[Primary hepatic sarcomatoid carcinoma, an unusual case]. / Carcinoma sarcomatoide hepático primario metastásico, una neoplasia infrecuente.

Primary hepatic sarcomatoid carcinoma is a very aggressive tumor, representing 0.4-0.7% of all primary hepatic neoplasms. The disease is associated with liver disease due to hepatotropic viruses and is more prevalent in Asians. Histology shows sarcomatous and carcinoma components. It does not have pathognomonic clinical or imaging characteristics and its diagnosis is based on the pathological and immunohistochemistry findings. Surgery could prolong survival in localized stages. We report the case of a 72-year-old Korean patient with a history of chronic liver disease due to B virus, who was diagnosed with primary hepatic sarcomatoid carcinoma with bone and lymph node metastases.

El carcinoma sarcomatoide primario hepático es un tumor agresivo que representa el 0.4-0.7% de todas las neoplasias primarias hepáticas. Se asocia a hepatopatía por virus hepatotropos, es más prevalente en la población asiática y en su histología se evidencian componentes de carcinoma y sarcoma. No posee características clínicas ni imagenológicas patognomónicas y su diagnóstico se realiza en base a los hallazgos de la anatomía patológica e inmunohistoquímica. La cirugía en estadio localizado representa la única modalidad terapéutica con impacto en la sobrevida. Reportamos el caso de una paciente de 72 años, coreana, con antecedentes de hepatopatía crónica por virus B, a quien se le diagnosticó un carcinoma sarcomatoide hepático primario con metástasis ósea y ganglionares.

Type 1 diabetes and subcutaneous insulin resistance syndrome treated with pancreas transplantation.

We present a case of subcutaneous insulin resistance syndrome, a rare entity, consisting of subcutaneous and intramuscular insulin resistance, with normal or almost normal sensitivity to insulin when administered intravenously. Its cause is unknown and its treatment is challenging. Our patient required a pancreas transplant.

Presentamos un caso de síndrome de resistencia subcutánea a la insulina, entidad infrecuente, que consiste en resistencia a la insulina por vía subcutánea e intramuscular, con sensibilidad normal o casi normal a la insulina cuando se aplica por vía intravenosa. Se desconoce su causa y su tratamiento es un desafío. Nuestra paciente requirió trasplante de páncreas.

Type 1 diabetes and subcutaneous insulin resistance syndrome treated with pancreas transplantation / Diabetes tipo 1 y síndrome de resistencia subcutánea a la insulina tratada con trasplante de páncreas

Abstract We present a case of subcutaneous insulin resistance syndrome, a rare entity, consisting of subcutaneous and intramuscular insulin resistance, with normal or almost normal sensitivity to insulin when administered intravenously. Its cause is unknown and its treatment is challenging. Our patient required a pancreas transplant.

Resumen Presentamos un caso de síndrome de resistencia subcutánea a la insulina, entidad in frecuente, que consiste en resistencia a la insulina por vía subcutánea e intramuscular, con sensibilidad normal o casi normal a la insulina cuando se aplica por vía intravenosa. Se desconoce su causa y su tratamiento es un desafío. Nuestra paciente requirió trasplante de páncreas.

[Acquired paraneoplastic hemophilia secondary to Vater's ampulla adenocarcinoma]. / Hemofilia paraneoplásica adquirida secundaria a adenocarcinoma de la ampolla de Vater.

Acquired hemophilia A is an unusual bleeding disorder of autoimmune origin resulting in the formation of autoantibodies directed against coagulation factor VIII. These autoantibodies can act by partially or completely neutralizing the activation or function of the factor, or they can also accelerate its elimination from the circulation. The global incidence of the disease is 1.5 cases per million inhabitants per year. In nearly 50% of cases, an underlying disease that is presumed responsible to produce autoantibodies can be detected. We report a case with acquired hemophilia A, in a patient with Vater's ampulla adenocarcinoma.

La hemofilia adquirida A es un desorden hemorrágico inusual de origen autoinmune que resulta en la formación de autoanticuerpos dirigidos contra el factor VIII de la coagulación. Estos autoanticuerpos pueden actuar neutralizando parcial o completamente la activación o función del factor, o también pueden acelerar su eliminación de la circulación. La incidencia mundial de la enfermedad es de 1.5 casos por millón de habitantes por año. En cerca del 50% de los pacientes se puede detectar una enfermedad subyacente que se presume responsable de la producción de los autoanticuerpos. Se presenta el caso de un varón con hemofilia adquirida A, en contexto de adenocarcinoma de la ampolla de Vater.

Hemofilia paraneoplásica adquirida secundaria a adenocarcinoma de la ampolla de Vater / Acquired paraneoplastic hemophilia secondary to Vater's ampulla adenocarcinoma

Resumen La hemofilia adquirida A es un desorden hemorrágico inusual de origen autoinmune que resulta en la formación de autoanticuerpos dirigidos contra el factor VIII de la coagulación. Estos autoanticuer pos pueden actuar neutralizando parcial o completamente la activación o función del factor, o también pueden acelerar su eliminación de la circulación. La incidencia mundial de la enfermedad es de 1.5 casos por millón de habitantes por año. En cerca del 50% de los pacientes se puede detectar una enfermedad subyacente que se presume responsable de la producción de los autoanticuerpos. Se presenta el caso de un varón con hemofilia adquirida A, en contexto de adenocarcinoma de la ampolla de Vater.

Abstract Acquired hemophilia A is an unusual bleeding disorder of autoimmune origin resulting in the formation of autoantibodies directed against coagulation factor VIII. These autoantibodies can act by partially or completely neutralizing the activation or function of the factor, or they can also accelerate its elimination from the circulation. The global incidence of the disease is 1.5 cases per million inhabitants per year. In nearly 50% of cases, an underlying disease that is presumed responsible to produce autoantibodies can be detected. We report a case with acquired hemophilia A, in a patient with Vater's ampulla adenocarcinoma.

Tibial brown tumor as a presentation of primary hyperparathyroidism / [Tumor pardo tibial como forma de presentación de un hiperparatiroidismo primario]

Cystic fibrous osteitis is a complication of a very evolved hyperparathyroidism. Because the determination of calcium, parathyroid hormone and vitamin D have become routine studies, this bone complication is uncommon in western countries. However, it should be considered in the differential diagnosis of hypercalcemia and lytic bone lesions. The treatment is to suppress the excess parathyroid hormone by parathyroidectomy and osteosynthesis in pathological fracture. We present the case of a female patient with primary hyperparathyroidism and a brown tumor in the right tibia.

La osteítis fibrosa quística es la complicación de un hiperparatiroidismo muy evolucionado. Debido a que la determinación del calcio, hormona paratiroides y vitamina D han pasado a ser estudios rutinarios, esta complicación ósea es infrecuente en los países occidentales. Sin embargo, debe ser considerada en el diagnóstico diferencial de hipercalcemia y lesiones óseas líticas. El tratamiento de esta entidad va dirigido a suprimir el exceso de hormona paratiroides mediante la paratiroidectomia y osteosíntesis en los casos de fracturas patológicas. Se presenta el caso de una paciente con hiperparatiroidismo primario y un tumor pardo en la tibia derecha.

Phenotypic Diversity and Association Mapping of Ascorbic Acid Content in Spinach.

Ascorbic acid (AsA), or vitamin C, is an essential nutrient for humans. In plants, AsA functions as an antioxidant during normal metabolism or in response to stress. Spinach is a highly nutritious green leafy vegetable that is consumed fresh, cooked or as a part of other dishes. One current goal in spinach breeding programs is to enhance quality and nutritional content. However, little is known about the diversity of nutritional content present in spinach germplasm, especially for AsA content. In this study, a worldwide panel of 352 accessions was screened for AsA content showing that variability in spinach germplasm is high and could be utilized for cultivar improvement. In addition, a genome-wide association study for marker-trait association was performed using three models, and associated markers were searched in the genome for functional annotation analysis. The generalized linear model (GLM), the compressed mixed linear model (CMLM) based on population parameters previously determined (P3D) and the perMarker model together identified a total of 490 significant markers distributed across all six spinach chromosomes indicating the complex inheritance of the trait. The different association models identified unique and overlapping marker sets, where 27 markers were identified by all three models. Identified high AsA content accessions can be used as parental lines for trait introgression and to create segregating populations for further genetic analysis. Bioinformatic analysis indicated that identified markers can differentiate between high and low AsA content accessions and that, upon validation, these markers should be useful for breeding programs.

Agranulocitosis febril y artropatía reactiva asociada a consumo de cocaína en un paciente HLA B27 positivo / Febrile agranulocytosis and reactive arthropathy associated with cocaine consumption in an HLA B27 positive patient

Resumen La agranulocitosis asociada al consumo de cocaína es un fenómeno vinculado a la presencia de levamisol, un agente antihelmíntico e inmunomodulador, usado como adulterante de la cocaína. Esta reacción puede presentarse con mayor frecuencia en personas con HLA B27. Además de la agranulocitosis, las personas que consumen cocaína adulterada con levamisol pueden desarrollar fiebre, lesiones en piel, artralgias y, menos frecuentemente, artritis y entesitis inflamatoria. Presentamos el caso de un paciente consumidor de cocaína, con genotipo HLA B27, que desarrolló agranulocitosis febril y artropatía reactiva. En sangre se detectó la presencia de ANCA p, ANCA atípico y MPO, y fueron excluidas otras causas de agranulocitosis. Fue tratado con corticoides y posteriormente metotrexato, terapia de deshabituación, con buena evolución.

Abstract Agranulocytosis associated with cocaine use is a phenomenon linked to the presence of levamisole, an anthelminthic and immunomodulating agent, used as an adulterant to cocaine. This reaction has been associated with the presence of HLA B27. In addition to agranulocytosis, people who use levamisole-adulterated cocaine may develop fever, skin lesions, arthralgias, and less frequently, inflammatory enthesitis and arthritis. We present the case of a cocaine-consuming patient with HLA B27 genotype, who developed febrile agranulocytosis and inflammatory arthropathy. The presence of p ANCA, atypical ANCA and MPO was detected in blood, and other causes of agranulocytosis were excluded. He was treated with corticosteroids and later methotrexate, therapy for addiction, with good evolution.

[Febrile agranulocytosis and reactive arthropathy associated with cocaine consumption in an HLA B27 positive patient]. / Agranulocitosis febril y artropatía reactiva asociada a consumo de cocaína en un paciente HLA B27 positivo.

Agranulocytosis associated with cocaine use is a phenomenon linked to the presence of levamisole, an anthelminthic and immunomodulating agent, used as an adulterant to cocaine. This reaction has been associated with the presence of HLA B27. In addition to agranulocytosis, people who use levamisole-adulterated cocaine may develop fever, skin lesions, arthralgias, and less frequently, inflammatory enthesitis and arthritis. We present the case of a cocaine-consuming patient with HLA B27 genotype, who developed febrile agranulocytosis and inflammatory arthropathy. The presence of p ANCA, atypical ANCA and MPO was detected in blood, and other causes of agranulocytosis were excluded. He was treated with corticosteroids and later methotrexate, therapy for addiction, with good evolution.

La agranulocitosis asociada al consumo de cocaína es un fenómeno vinculado a la presencia de levamisol, un agente antihelmíntico e inmunomodulador, usado como adulterante de la cocaína. Esta reacción puede presentarse con mayor frecuencia en personas con HLA B27. Además de la agranulocitosis, las personas que consumen cocaína adulterada con levamisol pueden desarrollar fiebre, lesiones en piel, artralgias y, menos frecuentemente, artritis y entesitis inflamatoria. Presentamos el caso de un paciente consumidor de cocaína, con genotipo HLA B27, que desarrolló agranulocitosis febril y artropatía reactiva. En sangre se detectó la presencia de ANCA p, ANCA atípico y MPO, y fueron excluidas otras causas de agranulocitosis. Fue tratado con corticoides y posteriormente metotrexato, terapia de deshabituación, con buena evolución.

Emphysematous cystitis in an 87 year old man. / [Cistitis enfisematosa en un varón de 87 años.]

Emphysematous cystitis is a complicated form of urinary tract infection, characterized by the presence of air inside the wall and in the light of the bladder, affecting more diabetics, elderly and immunosuppressed. The microorganisms that most frequently cause this entity are Escherichia coli and Klebsiella pneumoniae. Its treatment is based on broad-spectrum antibiotics, bladder catheterization and partial or total cystectomy in severe cases.

La cistitis enfisematosa es una forma complicada de infección urinaria, que se caracteriza por la presencia de aire dentro de la pared y en la luz de la vejiga, que afecta más a diabéticos, ancianos e inmunosuprimidos. Los microorganismo que con mayor frecuencia causan esta entidad son Escherichia coli y Klebsiella pneumoniae. Su tratamiento se basa en antibióticos de amplio espectro, sondaje vesical y cistectomía parcial o total en los casos graves.

Agranulocytosis Induced by Vancomycin. Case Report and Literature Review.

BACKGROUND Vancomycin has been used for decades to treat infections by Gram-positive bacteria, particularly those caused by methicillin-resistant staphylococci. Agranulocytosis is an infrequent complication of this antibiotic, postulated in its genesis a mechanism immune-mediated by antineutrophil antibodies and antineutrophil cytoplasm antibodies (ANCA). Treatment includes discontinuing vancomycin, and granulocyte colony-stimulating factor administration. CASE REPORT We present the case of a patient who developed agranulocytosis secondary to vancomycin during the treatment of an infectious endocarditis, which was reversed when the antibiotic was stopped. Concomitantly to neutropenia, he had ANCA positivity, which subsequently became negative. CONCLUSIONS Agranulocytosis induced by vancomycin is infrequent and generally occurs after day 12 of treatment. In most cases, like in our case, it is caused by an immune-mediated mechanism. More studies are needed to determine the pathogenic mechanism and the ANCA role in this adverse effect.

Fitz-Hugh-Curtis Syndrome Caused by Gonococcal Infection in a Patient with Systemic Lupus Erythematous: A Case Report and Literature Review.

BACKGROUND Fitz-Hugh-Curtis (FHC) syndrome is a perihepatitis linked to inflammatory pelvic disease. It can be caused by Neisseria gonorrhoeae or Chlamydia trachomatis infections. FHC syndrome usually presents with pain in the right hypochondrium and fever, associated with symptoms and signs of pelvic infection in women. CASE REPORT We present the case of a 22-year-old woman with systemic lupus erythematous (SLE) who presented with polyarthritis, cutaneous lesions, and abdominal pain. The diagnosis of FHC syndrome was based on the findings of abdominal computerized tomography (CT) and the isolation of Neisseria gonorrhoeae (NG) in blood cultures. The association of arthritis and cutaneous lesions was diagnosed as a syndrome of arthritis-dermatitis, also caused by systemic NG infection. The patient had a favorable outcome with antibiotic treatment. CONCLUSIONS FHC syndrome should be considered in sexually active young patients, mainly women, with pelvic infection and perihepatitis. It may be caused by disseminated gonococcal infection. An important risk factor is the serum complement deficit, which may predispose to severe forms. Low serum complement level is a frequent manifestation of active SLE. CT images showing the typical findings of perihepatitis allow making the correct diagnosis.

Takotsubo Myocardiopathy and Hyperthyroidism: A Case Report and Literature Review.

BACKGROUND Takotsubo cardiomyopathy (TM), also called stress myocardiopathy or transient left ventricular apical ballooning syndrome, is characterized by acute left ventricular dysfunction with reversible wall motion abnormalities. TM resembles acute coronary syndrome (ACS) in the absence of coronary artery disease (CAD). In several reports, TM has been described in association with hyperthyroidism, suggesting the potential role of thyrotoxicosis in the pathophysiology. CASE REPORT We present the case of a 34-year-old man with TM associated with hyperthyroidism caused by Graves' disease. In this case, TM was also preceded by an emotional trigger. The diagnosis of TM was based on clinical manifestations, electrocardiographic and echocardiographic abnormalities, and the absence of coronary artery disease (CAD) in the angiography. A diagnosis of hyperthyroidism was made based on hormonal and antibody measurements. The patient had a favorable outcome, and the cardiac and thyroid disorders resolved. CONCLUSIONS Our case illustrates that thyroid disease, mainly hyperthyroidism, should be considered in patients with TM with or without previous emotional triggers. As in our patient, the outcome in TM is usually favorable, with reversibility of cardiac abnormalities.