Edema pulmonar por reexpansión. Reporte de Caso / Pulmonary edema due to re-expansion. Case Report

Introducción. El edema pulmonar por reexpansión es una complicación poco frecuente, secundaria a una rápida reexpansión pulmonar posterior al drenaje por toracentesis o toracostomía cerrada. Al día de hoy, se ha descrito una incidencia menor al 1 % tras toracostomía cerrada, con mayor prevalencia en la segunda y tercera década de la vida. Su mecanismo fisiopatológico exacto es desconocido; se ha planteado un proceso multifactorial de daño intersticial pulmonar asociado con un desequilibrio de las fuerzas hidrostáticas. Caso clínico. Presentamos el caso de un paciente que desarrolló edema pulmonar por reexpansión posterior a toracostomía cerrada. Se hizo una revisión de la literatura sobre esta complicación. Resultados. Aunque la clínica sugiere el diagnóstico, la secuencia de imágenes desempeña un papel fundamental. En la mayoría de los casos suele ser autolimitado, por lo que su manejo es principalmente de soporte; sin embargo, se han reportado tasas de mortalidad que alcanzan hasta el 20 %, por tanto, es importante conocer los factores de riesgo y las medidas preventivas. Conclusión. El edema pulmonar de reexpansión posterior a toracostomía es una complicación rara en los casos con neumotórax, aunque es una complicación que se puede presentar en la práctica diaria, por lo cual debe tenerse en mente para poder hacer el diagnóstico y un manejo adecuado.

Introduction. Re-expansion pulmonary edema is a rare complication secondary to rapid pulmonary re-expansion after drainage by thoracentesis and/or closed thoracostomy. As of today, an incidence of less than 1% has been described after closed thoracostomy, with a higher prevalence in the second and third decades of life. Its exact pathophysiological mechanism is unknown; a multifactorial process of lung interstitial damage associated with an imbalance of hydrostatic forces has been proposed. Clinical case. We present the case of a patient who developed pulmonary edema due to re-expansion after closed thoracostomy, conducting a review of the literature on this complication. Results. Although the clinic suggests the diagnosis, the sequence of images plays a fundamental role. In most cases, it tends to be a self-limited disease, so its management is mainly supportive. However, mortality rates of up to 20% have been recorded. Therefore, it is important to identify patients with major risk factors and initiate preventive measures in these patients. Conclusions. Re-expansion pulmonary edema after thoracostomy is a rare complication in cases with pneumothorax; however, it is a complication that can occur in daily practice. Therefore, it must be kept in mind to be able to make the diagnosis and an adequate management.

Fisiología respiratoria. Neumología de altura: saturación de oxígeno, edema pulmonar y pruebas de función pulmonar / Respiratory physiology - High -altitude pneumology: oxygen saturation, pulmonary edema and pulmonary function tests

En las alturas, sobre todo a 2500 metros sobre el nivel del mar, la cantidad absoluta de oxígeno va decreciendo y por lo tanto la cantidad disponible para el intercambio gaseoso disminuye, produciéndose una vasoconstricción hipóxica pulmonar (VHP). La VHP asociada a la hipoxia hipobárica de la altura produce un aumento de la presión pulmonar que es mayor en los lactantes y a mayores alturas. No hay valores únicos de saturación de oxígeno (SatO2) en la altura, porque ésta va disminuyendo según el mayor nivel de altura, aumenta con la edad, y la brecha entre la vigilia y sueño es grande (sobre todo en los primeros meses de vida). El 25% de los niños sanos que viven en altura tienen valores de SatO2 significativamente menores que el 75% restante. Los valores normales de los índices de apnea/hipopnea son distintos a los de nivel del mar. El edema pulmonar de las alturas es una patología frecuente, que se produce por un incremento desproporcionado en la VHP reflejando una hiperactividad del lecho vascular pulmonar ante la exposición aguda a la hipoxia hipobárica. Tiene cuatro fenotipos, es infrecuente en menores de 5 años y rara vez es mortal, la sospecha clínica y el manejo oportuno con oxigeno es la clave. Finalmente, en la altura los valores normales de la función pulmonar de la espirometría, oscilometría de impulso y capacidad de difusión son distintos que a nivel del mar.

At high altitude, especially > 2,500 meters above sea level, the absolute amount of oxygen decreases and therefore the amount available for gas exchange decreases, producing hypoxic pulmonary vasoconstriction (VHP). VHP associated with high-altitude hypobaric hypoxia produces an increase in pulmonary pressure that is greater in infants and at higher altitudes. There are no single values of oxygen saturation (SatO2) at altitude, because it decreases with the highest level of altitude, increases with age, and the gap between wakefulness and sleep is large (especially in the first months of life). Around 25% of healthy children living at altitude have SatO2 values significantly lower than the remaining 75%. The normal values of the apnea/hypopnea indices are different from those at sea level. High altitude pulmonary edema is a frequent pathology that is produced by a disproportionate increase in VHP reflecting hyperactivity of the pulmonary vascular bed in the face of acute exposure to hypobaric hypoxia, it has four phenotypes, it is uncommon in children under 5 years of age, and it is rarely fatal, the clinical suspicion and timely management with oxygen is the key. Finally, at high altitude, the normal values of lung function from spirometry, impulse oscillometry, and diffusing capacity are different from those at sea level.

Edema pulmonar posobstructivo en niños: ¿por qué debería pensarlo el otorrinolaringólogo? / Post obstructive pulmonary edema in children: Why should the otolaryngologist think about it?

Introducción: el edema pulmonar posobstructivo (EPPO), o por presión negativa, es una entidad potencialmente mortal, que se desarrolla inmediatamente luego de una obstrucción severa de la vía aérea superior. Materiales y métodos: descripción de una serie de 4 casos de EPPO ocurridos en niños, 3 de ellos secundarios a aspiración de un cuerpo extraño y el otro como complicación de una adenoamigdalectomía. Discusión: la causa más frecuente de la obstrucción de la vía aérea es el laringoespasmo asociado con la manipulación de la vía aérea durante la intubación o las intervenciones quirúrgicas de la vía aérea. Tanto la adenoamigdalectomía, como la extracción de cuerpos extraños en la vía aérea constituyen unas de las intervenciones más frecuentes de la práctica otorrinolaringológica para el tratamiento de la obstrucción de la vía aérea; sin embargo, puede potencialmente desarrollar EPPO. Conclusión: Destacamos la importancia de que el otorrinolaringólogo tenga presente esta afección en niños que presentan dificultad respiratoria tras cualquier obstrucción o intervención quirúrgica de la vía aérea.si bien los cuerpos extraños en la vía aérea en niños suelen presentarse con crisis de asfixia, tos paroxística o dificultad respiratoria luego del evento, también debería pensarse la posibilidad de un evento de aspiración de un cuerpo extraño no presenciado ante un cuadro de edema pulmonar sin causa conocida. Si bien la adenoamigdalectomía es una de las cirugías más frecuente en la práctica otorrinolaringológica, esta potencialmente puede complicarse con EPPO.

Introduction: Post-obstructive pulmonary edema (POPE) or by Negative Pressure, is a potentially fatal entity that develops immediately after a severe obstruction of the upper airway. Materials and methods: Description of a series of four cases of POPE in children, three of them secondary to foreign body aspiration and the remaining one as a complication of adenotonsillectomy. Discussion: The most common etiology of airway obstruction is laryngospasm associated to airway manipulation during intubation or airway surgery. Both adenotonsillectomy and removal of foreign bodies in the airway are one of the most common procedures in otorhinolaryngology practice for management of airway obstruction, however, they can potentially develop EPPO. Conclusion: Although airway foreign bodies in children usually present with sudden episode of choking, paroxysmal cough and/or respiratory distress, the likelihood of an unwitnessed foreign body aspiration event in the presence of unexplained pulmonary edema should also be considered. Although adenotonsillectomy is one of the most common surgeries in ENT practice, it can potentially be complicated by EPPO. We emphasize the importance of the otorhinolaryngologist keeping this condition in mind in children who present respiratory distress after any obstruction or surgical intervention of the airway.

Pectus excavatum em uma ninhada de Buldogue Francês: relato de caso / Pectus excavatum in a French Bulldog Litter: case report

RESUMO O pectus excavatum é considerado uma patologia da parede torácica, onde há convexidade no aspecto ventral do esterno, o que gera complicações secundárias, como alongamento ventrodorsal do tórax e aumento da pressão intratorácica, entre outras. No presente caso, o corpo de um cachorro Buldogue Francês nasceu com sinais prévios de decaimento e baixo consumo de leito materno, além de uma avaliação médica forense. De acordo com a avaliação patológica, foi encontrada uma fenda no peito esternal relacionada às esternas caudais próximas à cartilagem xifóide, conteúdo espumoso na cartilagem epiglótica da laringe e sinais graves de enfisema nos lobos caudal, craniano e médio pulmonar. Na avaliação cardiológica, foi observada assimetria morfológica invaginante no septo interventricular na mesma área em que a fenda esternal ocorre, por sua vez, na avaliação radiográfica, evidencia uma depressão dorsal do terço caudal do esterno com alterações consideráveis na silhueta cardíaca. Na Colômbia não há relatos de ninhadas completas que apresentem esta alteração, portanto, pretende-se que este seja o primeiro relatório anatomopatológico e de imagem que descreva a patologia em caninos.

ABSTRACT Pectus excavatum is considered a pathology of the chest wall where there is convexity in the ventral aspect of the sternum, which generates secondary complications, such as ventrodorsal stretching of the chest and increased intrathoracic pressure, among others. In the present case, the body of a French bulldog dog was born with previous signs of decay and low consumption of maternal waste, in addition to a forensic medical evaluation. According to the pathological evaluation, a crack was found in the sternal chest related to the caudal sternum close to the xiphoid cartilage, frothy content in the laryngeal epiglottis cartilage and severe signs of emphysema in the caudal, cranial and middle lung lobes. In the cardiological evaluation, an invaginating morphological asymmetry was observed in the interventricular septum in the same area in which the sternal cleft occurs, in turn, in the radiographic evaluation, it shows a dorsal depression of the caudal third of the sternum with considerable changes in the cardiac silhouette. In Colombia there are no reports of complete litters that present this alteration, so it is intended that this is the first anatomopathological and imaging report that describes the pathology in canines.

Incidence of post-anesthetic respiratory complications in pediatrics. Observational, single-center study in Medellin, Colombia / Incidencia de complicaciones respiratorias postanestésicas en pacientes pediátricos. Estudio observacional en un hospital en Medellín, Colombia

Abstract Introduction: Post-anesthetic complications, particularly respiratory complications, continue to be a source of concern due to their high frequency, particularly in pediatrics. Objective: To describe the incidence of respiratory complications in the post-anesthesia care unit of an intermediate complexity center during a six-month period, and to explore the variables associated with major respiratory complications. Materials and Methods: Retrospective cohort study based on clinical record reviews. The records of the post-anesthesia care unit of an intermediate complexity pediatric institution located in Medellin, Colombia, were reviewed. This center uses a nursing-based care model that includes patient extubation in the post-anesthesia care unit. Results: The records of 1181 patients were analyzed. The cumulative incidences of major complications were bronchospasm 1.44%, laryngospasm 0.68% and respiratory depression 0.59%. There were no cases of cardiac arrest or acute pulmonary edema. A history of respiratory infection less than 15 days before the procedure, rhinitis and female sex were associated with major respiratory complications. Conclusions: A low frequency of respiratory complications was found during care provided by nursing staff trained in anesthesia recovery and pediatric airway in the post-anesthesia care unit.

Resumen Introducción: Las complicaciones postanestésicas, especialmente las respiratorias, siguen siendo causa de preocupación por su alta frecuencia, en particular, en la población pediátrica. Objetivo: Describir la incidencia de complicaciones respiratorias en la unidad de cuidados postanestésicos de una institución de mediana complejidad, en un período de seis meses y explorar las variables relacionadas con las complicaciones respiratorias mayores. Materiales y métodos: Estudio de cohorte retrospectivo, basado en la valoración de historias clínicas. Se revisaron los registros de la unidad de cuidados postanestésicos de una institución pediátrica de mediana complejidad ubicada en Medellín. Esta institución utiliza un modelo de atención -basado en enfermería- que incluye la extubación del paciente en la unidad de cuidados postanestésicos. Resultados: Se analizaron los registros de 1181 pacientes. La incidencia acumulada de complicaciones mayores fue: broncoespasmo 1,44 %, laringoespasmo 0,68 % y depresión respiratoria 0,59 %. No se presentaron casos de paro cardiaco ni de edema agudo de pulmón. El antecedente de infección respiratoria menor a 15 días, rinitis y sexo femenino se asociaron con complicaciones respiratorias mayores. Conclusiones: Durante la atención en la unidad de cuidados postanestésicos por parte del personal de enfermería entrenado en la recuperación de la anestesia y de la vía aérea de los pacientes pediátricos, se encontró una baja frecuencia de complicaciones respiratorias.

Variante de SARS-CoV-2 VUI 202012/01 (B-1-1-7) en paciente pediátrico, primer reporte de caso en Ecuador / SARS-CoV-2 variant VUI 202012/01 (B-1-1-7) in pediatric patient, first case report in Ecuador

Introducción: Los virus de RNA son conocidos por tener altas tasas de variabilidad genética. El SARS-CoV-2 ha producido diversas variantes en la actualidad que pueden cambiar la presentación clínica. Se presenta el primer caso clínico de la variante B.1.1.7 con estado clínico crítico en un paciente pediátrico y nos alerta sobre la vigilancia de nuevas variantes y la relación de casos críticos en pacientes pediátricos. Caso clínico: Paciente pediátrica con antecedente de parálisis cerebral infantil, atrofia subcortical severa completa, síndrome de Lennox-Gastaut y neumonía recurrente. Presentó una evolución tórpida con necesidad de terapia intensiva por SDRA en relación con la variante B 1.1.7 del SARS-CoV-2. Evolución: Inicialmente fue atendido en un hospital privado, en el cual debido al SDRA necesitó de cuidados intensivos, fue trasladado a un hospital público en el cual posterior a 38 días fue dada de alta por evolución favorable de su cuadro infeccioso. Conclusión: Las nuevas variantes de SARS-CoV-2 pueden mostrar nuevos comportamientos clínicos. A pesar de los antecedentes del paciente estudiado, no se había observado previamente una evolución clínica hacia síntomas graves en pacientes pediátricos con COVID-19. Eso podría estar relacionado con la infección por SARS-CoV-2 variante B.1.1.7 que presentó este paciente.

Introduction: RNA viruses are known to have a high genetic variability. To date, SARS-CoV-2 has produced several variants that can change the clinical presentation of COVID-19. The first clinical case of variant B.1.1.7 with a critical clinical status in a pediatric patient is presented. It indicates that surveillance of new variants and their relationship to critical cases in pediatric patients are required. Clinical case: A pediatric patient with a history of infantile cerebral palsy, complete severe subcortical atrophy, Lennox−Gastaut syndrome, and recurrent pneumonia. She had a slow evolution requiring intensive therapy for acute respiratory distress syndrome (ARDS) that was related to SARS-CoV-2 variant B 1.1.7. Evolution: Initially, she was treated at a private hospital because she required intensive care due to ARDS, and she was then transferred to a public hospital. She was discharged after 35 days due to a favorable evolution of her infectious etiology. Conclusions: New SARS-CoV-2 variants may show new clinical behaviors. Despite this patient's history, a clinical course towards severe symptoms had not been previously observed in pediatric patients with COVID-19. The severe symptoms could be related to the SARS-CoV-2 variant B.1.1.7 infection in this patient.

Caracterização do comprometimento pulmonar associado à COVID-19 em pacientes com necessidade de ventilação mecânica / Characterization of pulmonary impairment associated with COVID-19 in patients requiring mechanical ventilation

RESUMO Objetivo: Detectar precocemente a instabilidade respiratória e hemodinâmica para caracterizar o comprometimento pulmonar em pacientes com COVID-19 grave. Métodos: Analisamos retrospectivamente os dados colhidos de pacientes com COVID-19 que apresentaram insuficiência respiratória aguda com necessidade de intubação e ventilação mecânica. Utilizamos a avaliação da termodiluição transpulmonar por meio do dispositivo PiCCO™. Foram coletados os dados demográficos, respiratórios, hemodinâmicos e ecocardiográficos dentro das primeiras 48 horas após a admissão. Para resumir os dados, utilizamos estatística descritiva. Resultados: Entre 22 de março e 7 de abril de 2020, foram admitidos 23 pacientes com COVID-19 grave. Foram monitorados com o dispositivo PiCCO™ 12 (22,6%) deles. Quando da admissão, o volume diastólico final global indexado era normal (média de 738,8mL ± 209,2) e, na hora 48, encontrava-se moderadamente aumentado (879mL ± 179), enquanto o índice cardíaco se achava abaixo do normal (2,84 ± 0,65). Todos os pacientes revelaram a presença de água extravascular pulmonar acima de 8mL/kg na admissão (17,9 ± 8,9). Não identificamos qualquer evidência de origem cardiogênica. Conclusão: No caso de pneumonia grave por COVID-19, o quadro hemodinâmico e respiratório é compatível com edema pulmonar sem evidência de origem cardiogênica, o que favorece o diagnóstico de síndrome do desconforto respiratório agudo.

ABSTRACT Objective: To detect early respiratory and hemodynamic instability to characterize pulmonary impairment in patients with severe COVID-19. Methods: We retrospectively analyzed data collected from COVID-19 patients suffering from acute respiratory failure requiring intubation and mechanical ventilation. We used transpulmonary thermodilution assessment with a PiCCO™ device. We collected demographic, respiratory, hemodynamic and echocardiographic data within the first 48 hours after admission. Descriptive statistics were used to summarize the data. Results: Fifty-three patients with severe COVID-19 were admitted between March 22nd and April 7th. Twelve of them (22.6%) were monitored with a PiCCO™ device. Upon admission, the global-end diastolic volume indexed was normal (mean 738.8mL ± 209.2) and moderately increased at H48 (879mL ± 179), and the cardiac index was subnormal (2.84 ± 0.65). All patients showed extravascular lung water over 8mL/kg on admission (17.9 ± 8.9). We did not identify any argument for cardiogenic failure. Conclusion: In the case of severe COVID-19 pneumonia, hemodynamic and respiratory presentation is consistent with pulmonary edema without evidence of cardiogenic origin, favoring the diagnosis of acute respiratory distress syndrome.

An aqueous pomegranate peel extract (Punica granatum) protect against Elastase-induced pulmonary emphysema in Sprague Dawley rats model

We investigated the effect of Punica granatum peel aqueous extract (PGE), on pulmonary inflammation and alveolar degradation induced by intratracheal administration of Elastase in Sprague Dawley rats. Lung inflammation was induced in rats by intratracheal instillation of Elastase. On day 1 and 2, animals received an intraperitoneal injection of PGE (200 mg/mL), three hours later, they were intratracheally instilled with 25U/kg pancreatic porcine Elastase. Animals were sacrificed 7 days later. Bronchoalveolar lavage (BAL) were collected and cellularity, histology and mRNA expression of Monocyte chemotactic protein 1(MCP-1), Tumor Necrosis Factor-Alpha (TNF-α), Interleukin 6 (IL-6), and Matrix Metalloproteinase-2 (MMP-2) were studied. In addition, activity of TNF- α, IL-6 and MCP-1 on BAL were also analyzed by ELISA Kit. Elastase administration increased: BAL cellularity, neutrophils recruitment and BAL MCP1, IL-6 expressions. It also increased lung TNF-α, MCP-1, MMP-2 expressions, platelets recruitment, histological parameters at 7th day of elastase treatment. Intraperitoneal injection of 200 mg/kg of PGE reduced, significantly, BAL cellularity, and neutrophils recruitment. However, in animal treated with PGE, MCP-1, MMP-2 and IL-6 on day 7, were similar to the Sham group. Treatment with PGE (200 mg/ kg) also significantly reduced lung TNF-α, and MCP-1 expression. This study reveals that PGE Punica granatum protects against elastase lung inflammation and alveolar degradation induced in rats

Agenesia pulmonar como hallazgo infrecuente en adultos: reporte de caso / Pulmonary agenesis as a rare finding in adults: case report

La agenesia pulmonar es una malformación infrecuente que se caracteriza por la ausencia de uno o ambos parénquimas pulmonares, estructuras bronquiales y vasculares. Posee una incidencia de un caso por cada 10 000 a 15 000 nacidos vivos. Generalmente, el diagnóstico es realizado durante la niñez, aunque puede llegar a presentarse asintomático hasta la edad adulta, lo cual su diagnóstico resulta un hallazgo incidental durante exámenes de rutina. Habiendo pocos casos descritos. Reportamos el caso de una paciente femenina 40 años de edad, quien fue referida al servicio de emergencia de nuestro Hospital del Tórax por presentar dolor torácico, disnea de medianos esfuerzos y fiebre de un mes de evolución.

Pulmonary agenesis is a rare malformation characterized by the absence of one or both pulmonary parenchyma, bronchial and vascular structures. Has an incidence of one case per 10 000 to 15 000 live births. Generally, the diagnosis is made during childhood, although it can be asymptomatic until adulthood, which makes its diagnosis an incidental finding during routine examinations. Few cases have been described. We report the case of a 40-yearold female patient, who was referred to the emergency department of our Hospital del Tórax for presenting chest pain, dyspnea of medium efforts and fever of one month of evolution

Edema agudo pulmonar Postextubación / Edema agudo pulmonar Postextubación

El edema pulmonar agudo posextubación constituye un evento poco frecuente en la práctica anestésica. Cuando ocurre es necesario administrar tratamiento adecuado, ya que las complicaciones del mismo pueden traducirse en mayor estancia hospitalaria y lesiones serias del aparato respiratorio, como edema pulmonar intersticial, elevación de la presión hidrostática capilar y aumento de la presión transmural de las cámaras cardiacas, lo que puede conducir a fallo del aparato cardiovascular y a la muerte subsecuente del paciente. Se presenta el caso de un paciente con clasificación del estado físico ASA (American Society of Anesthesiologist) II, sin patología pulmonar previa, quien al momento de la emersión anestésica presenta un episodio agudo de dificultad respiratoria, con evidencia de edema pulmonar posextubación confirmado por clínica e imágenes con ulterior resolución satisfactoria.

Post-extubation acute pulmonary edema is a rare event in anesthetic practice. When it occurs, it requires adequate treatment, since its complications may result in longer hospital stay and serious respiratory system lesions, such as interstitial pulmonary edema, increased capillary hydrostatic pressure and increased transmural pressure of the cardiac chambers, which may progress to cardiopulmonary arrest and death of the patient. We present the case of a patient who was classified with the (American Society of Anesthesiologist (ASA) II physical status, without a history of pulmonary disease, who upon emergence of general anesthesia developed an acute episode of respiratory distress, with evidence of post-extubation pulmonary edema confirmed by clinical and imaging findings with subsequent satisfactory resolution.

Edema pulmonar neurogênico - revisão da literatura e relato de caso / Pulmonary neurogenic edema - revision of literature and case repor

O objetivo deste trabalho foi o de relatar um caso de edema pulmonar de etiologia neurogênica (EPN), que ocorreu nos pós-operatório imediato (POI) de uma neurocirurgia (pós-clipagem de aneurisma intracraniano). O controle adequado no POI deste edema pode ser difícil, e seu tratamento é diferente do edema pulmonar de origem cardiogênica. Houve maior tempo de internamento (tanto da UTI como hospitalar) pela própria característica do edema e as complicações resultantes que ocorreram. O paciente permaneceu na UTI por 154 dias, com vários episódios de sepse. A sua alta hospitalar foi possível, mas à custa de cuidados pós-hospitalares assistenciais

The aim of this work was to describe a case with pulmonary edema of neuronic ethnology (NPE) that occurred in the immediate postoperative period of a neurosurgery (clipping a cerebral aneurysm). The proper identification of this event can be difficult in he immediate postoperative care, and the its treatment is different from the cardiogenic pulmonary edema. Longer hospital stay (both ICU and hospital) by the very characteristic of the edema and the complications that occurred. The patient stayed at the ICU for 154 days, with multiple cases of sepsis. His hospital discharge was possible, but at the expense of post-hospital care

Autopsias en fallecidos de la tercera edad / Autopsies in elderly deceased elderly

Introducción: La Organización Mundial de la Salud promueve un compromiso con el envejecimiento saludable. La autopsia constituye el método más completo para el estudio de las enfermedades, y en los fallecidos de la tercera edad se evidencian sus problemas de salud. Objetivo: Mostrar las particularidades en edad, sexo, enfermedades crónicas, en particular los tumores malignos, la sepsis y causas de muerte que se encuentran en las autopsias de fallecidos de la tercera edad. Método: se realizó un estudio retrospectivo, longitudinal, entre los años 1987-2017 de las autopsias en fallecidos de la tercera edad. Se agrupan por edades: edad avanzada, anciana y grande longeva. Se exploran las variables de edad y sexo, enfermedades crónicas, infección y causas de muerte. Resultados: Los fallecidos de la tercera edad constituyen más de las tres cuartas partes de las autopsias en la institución. El sexo femenino muestra mayor longevidad. La hipertensión arterial, diabetes y el cáncer decrecen con la edad, mientras la sepsis se incrementa. Aumentan progresivamente en las causas de muerte directa, la sepsis y el tromboembolismo, mientras disminuyen el choque, edema pulmonar e infarto cardiaco. Aumenta en las causas básicas la aterosclerosis cerebral y generalizada, disminuye la coronaria, la enfermedad hipertensiva y los tumores malignos. La no coincidencia clínico patológica aumenta con la edad, discretamente. Conclusiones: Existen particularidades en el estudio de los pacientes de la tercera edad, evidenciado por los resultados de autopsia, por lo que se recomienda la geriatrización de los servicios(AU)

Introduction: The World Health Organization promotes a commitment to healthy aging. The autopsy is the most complete method for the study of the diseases and in the elderly deceased their health problems are evidenced. Objective: To show the particularities in ages, sex, chronic diseases, in particular malignant tumors, sepsis and causes of death found in the autopsies of the deceased elderly people. Method: A retrospective, longitudinal study was carried out between the years 1987-2017 of autopsies in elderly deceased. They were grouped by age: advanced age, elderly and long-lived. The variables age, sex, chronic diseases, infection and causes of death were explored. Results: The elderly deceased were more than three quarters of the autopsies in the institution. The female sex showed greater longevity. Hypertension, diabetes and cancer decreased with age, while sepsis increased. Sepsis and thromboembolism were progressively increasing in the direct causes of death, while shock, pulmonary edema and cardiac infarction decreased. In basic causes, cerebral and generalized atherosclerosis increased and coronary atherosclerosis, hypertensive disease and malignant tumors decreased. The clinical - pathology no coincidence, increased slightly with age. Conclusions: There are particularities in the studies of elderly patients evidenced by the results of autopsy, so that geriatrification of services is necessary(AU)

Tiger stripes sign in acute coronary syndrome / Signo manchas de tigre en síndrome coronario agudo

Abstract The incidence of mitral regurgitation in acute myocardial syndromes is variable. Echocardiographic evaluation is fundamental in making a proper diagnosis of mechanical complications and to offer timely treatment. We present a case of a 64-year-old male who was admitted to the ER in acute pulmonary edema. The electrocardiogram showed negative ST-segment deviation from V4-V6, positive ST-segment deviation in aVR. Multivessel disease with severe mitral regurgitation was seen in catheterization. A transthoracic echocardiogram revealed important mitral regurgitation showing the "tiger stripes" sign, seen in the presence of intracardial oscillating structures, in this case, suspected papillary muscle rupture. Echocardiographic evaluation is necessary in every case of myocardial infarction who present with new-onset mitral regurgitation. Treatment is complex and must be determined with an interdisciplinary group.

Endocarditis bacteriana a propósito de un caso / Bacterial endocarditis case report

OBJETIVO: informar acerca de un caso de endocarditis bacteriana. Paciente varón de 34 años de edad, con único antecedente de rinitis alérgica con tratamiento irregular. Él es procedente de Valparaiso Chile, se encuentra en sus vacaciones en la ciudad de La Paz, acude al servicio de medicina interna ­ emergencias, con clínica compatible con edema agudo de pulmón de la altura y edema cerebral de la altura, asociado a sepsis de foco pulmonar, que progresa a choque séptico, durante su internación intercurre con alzas térmicas continuas, asociado a hallazgo ecocardiográfico de vegetación en ventrículo derecho con hemocultivo positivo, por lo que se llega al diagnóstico de endocarditis bacteriana, se realizó el tratamiento correspondiente, y resolución del cuadro.

OBJECTIVE: to report a case of bacterial endocarditis A 34-year-old male patient with a unique history of allergic rhinitis with irregular treatment. He comes from Valparaiso Chile, is on vacation in the city of La Paz, goes to the service of internal medicine - emergencies with compatible clinical with acute pulmonary edema of height and cerebral edema of height, associated with sepsis of focus pulmonary disease, which progresses to septic shock, during internment with continuous hyperthermia, associated vegetation in right ventricle for echocardiography, also positive blood culture, so that a diagnosis of bacterial endocarditis is reached, Corresponding treatment was carried out, and resolution of pathology..

Edema pulmonar de las alturas. A propósito de un caso / High Altitude Pulmonary Edema: About a Case

El edema pulmonar de las alturas es una condición clínica que se desarrolla en individuos que han estado en regiones a nivel del mar y que posteriormente ascienden rápidamente a altitudes por encima de los 2500 metros. Se describe el caso de un paciente de 26 años con cuadro clínico y hallazgos radiológicos típicos de esta patología, en quién inicialmente se sospechó infección por coronavirus dada la sintomatología y el contexto de pandemia actual

High altitude pulmonary edema is a clinical condition that develops in individuals who have been in regions at sea level and who subsequently have a rapid ascent to altitudes above 2500 meters. We present the case of a 26-year-old male with clinical presentation and radiological findings typical of this entity, in whom coronavirus infection was initially suspected given the signs and symptoms in context of the current pandemic

Takayasu arteritis: differential diagnosis in a teenager with severe acute kidney injury - a case report / Arterite de Takayasu: diagnóstico diferencial em adolescente com lesão renal aguda grave - relato de caso

ABSTRACT Takayasu arteritis (TA) is a chronic granulomatous inflammatory condition of unknown cause that involves large vessels - particularly the aorta and its branches - such as the carotid, coronary, pulmonary, and renal arteries. The left subclavian artery is the most frequently involved vessel. Stenosis of the renal artery has been reported in 23-31% of the cases and may result in malignant hypertension, ischemic renal disease, decompensated heart failure, and premature death. Involvement of both renal arteries is uncommon. Early onset anuria and acute kidney injury are rare and have been reported only in a few cases in the literature. This report describes the case of a 15-year-old female with constitutional symptoms evolving for a year, combined with headache, nausea, and vomiting, in addition to frequent visits to emergency services and insufficient clinical examination. The patient worsened significantly six months after the onset of symptoms and developed acute pulmonary edema, oliguria, acute kidney injury, and difficult-to-control hypertension, at which point she was admitted for intensive care and hemodialysis. Initial ultrasound examination showed she had normal kidneys and stenosis-free renal arteries. The patient was still anuric after 30 days of hospitalization. A biopsy was performed and revealed her kidneys were normal. Computed tomography angiography scans of the abdominal aorta presented evidence of occlusion of both renal arteries. The patient met the diagnostic criteria for Takayasu arteritis and had a severe complication rarely described in the literature: stenosis of the two renal arteries during the acute stage of ischemic renal disease.

RESUMO A Arterite de Takayasu (AT) é uma doença inflamatória crônica, granulomatosa, de causa desconhecida, que afeta grandes vasos, principalmente a aorta e seus ramos, incluindo artérias carótidas, coronárias, pulmonares e renais, sendo a artéria subclávia esquerda o vaso mais acometido. A estenose da artéria renal é relatada em 23-31% dos casos e pode resultar em hipertensão maligna, insuficiência renal por isquemia, descompensação cardíaca e morte prematura. O acometimento bilateral de artérias renais é incomum, sendo rara a presença de anúria súbita e lesão renal aguda como sintoma inicial da doença, com poucos relatos na literatura. O caso reporta uma adolescente de 15 anos com sintomas constitucionais durante um ano de evolução, associados a problemas como cefaleia, náuseas e vômitos, com idas frequentes a serviços de emergência, sem adequada investigação clínica. Após 6 meses do início dos sintomas, a paciente evoluiu de forma grave, com quadro de edema agudo de pulmão, oligúria, lesão renal aguda e hipertensão arterial de difícil controle, sendo necessário suporte em Unidade de Terapia Intensiva e hemodiálise. A ultrassonografia inicial mostrava rins normais e artérias renais sem sinais de estenose. Após 30 dias de internamento, paciente permanecia anúrica, sendo realizada biópsia renal que se mostrou dentro dos padrões da normalidade. Angiotomografia de aorta abdominal evidenciou oclusão bilateral de artérias renais. A paciente descrita fechou critérios diagnósticos para arterite de Takayasu e manifestou uma complicação grave pouco descrita na literatura: estenose bilateral de artérias renais, ainda na fase aguda da nefropatia isquêmica.

El ultrasonido pulmonar en cardiología: realidades y promesas / Lung ultrasound in cardiology: realities and promises

Resumen El ultrasonido pulmonar es una herramienta de fícil reproducibilidad en pacientes estables y críticos que se utiliza para valorar el estado de congestón y comprobar la causa de la disnea. En este texto se revisan los fundamentos de la ecografía pulmonar, los protocolos de adquisición y su interpretación, así como la evidencia que sustenta su uso en el paciente cardiovascular críticamente enfermo y en el paciente estable. Esta herramienta debe emplearse como complemento de la exploración física regular para poder instituir un tratamiento oportuno en los pacientes con congestión pulmonar.

Abstract Lung ultrasound is an easily available, reproducible examination tool, both in ambulatory and critically-ill patients, which is used to evaluate congestion status and to differentiate the etiology of dyspnea. In this review, we explain lung ultrasound technique, acquisition protocols and their interpretation, as well as the evidence that shows its effectiveness among stable and critically-ill patients. Lung ultrasound should be used as an add-on to traditional physical examination in order to give an accurate diagnosis and a rapid treatment to patients with pulmonary congestion.

Edema agudo de pulmón por mal de altura: caso pediátrico / Acute pulmonary edema due to altitude sickness: pediatric case

Resumen: El edema pulmonar por mal de altura es una entidad no cardiogénica que se debe a hipoxia hipobárica y falta de adaptación pulmonar en los pacientes que retornan a altitudes mayores de 2.500 m luego de haber permanecido a nivel del mar por varios días. Esta entidad, frecuente en los niños, debido a sus características anatómicas y fisiológicas, suele ser subdiagnosticada o confundida con otras patologías que cursan con insuficiencia respiratoria. Presentamos el caso de un paciente de sexo masculino, 4 años de edad, atendido en Emergencias por dificultad respiratoria severa por mal de altura.

Abstract: Pulmonary edema by altitude sickness is a non-cardiogenic entity, due to lack of pulmonary adaptation and hypobaric hypoxia in patients who return to altitudes higher than 2,500 meters after staying for several days at sea level. This entity is frequent in children, given their physiological and anatomical characteristics. It tends to be underdiagnosed or confused with other pathologies associated with shortness of breath. We present the case of a four-year-old male patient, who attended the emergency department for severe respiratory distress caused by altitude sickness.