Cerebral hemodynamics and optic nerve sheath diameter acquired via neurosonology in critical patients with severe coronavirus disease: experience of a national referral hospital in Peru.

Aim: We aimed to describe the neurosonological findings related to cerebral hemodynamics acquired using transcranial Doppler and to determine the frequency of elevated ICP by optic nerve sheath diameter (ONSD) measurement in patients with severe coronavirus disease (COVID-19) hospitalized in the intensive care unit of a national referral hospital in Peru. Methods: We included a retrospective cohort of adult patients hospitalized with severe COVID-19 and acute respiratory failure within the first 7 days of mechanical ventilation under deep sedoanalgesia, with or without neuromuscular blockade who underwent ocular ultrasound and transcranial Doppler. We determine the frequency of elevated ICP by measuring the diameter of the optic nerve sheath, choosing as best cut-off value a diameter equal to or >5.8 mm. We also determine the frequency of sonographic patterns obtained by transcranial Doppler. Through insonation of the middle cerebral artery. Likewise, we evaluated the associations of clinical, mechanical ventilator, and arterial blood gas variables with ONSD ≥5.8 mm and pulsatility index (PI) ≥1.1. We also evaluated the associations of hemodynamic findings and ONSD with mortality the effect size was estimated using Poisson regression models with robust variance. Results: This study included 142 patients. The mean age was 51.39 ± 13.3 years, and 78.9% of patients were male. Vasopressors were used in 45.1% of patients, and mean arterial pressure was 81.87 ± 10.64 mmHg. The mean partial pressure of carbon dioxide (PaCO2) was elevated (54.08 ± 16.01 mmHg). Elevated intracranial pressure was seen in 83.1% of patients, as estimated based on ONSD ≥5.8 mm. A mortality rate of 16.2% was reported. In the multivariate analysis, age was associated with elevated ONSD (risk ratio [RR] = 1.07). PaCO2 was a protective factor (RR = 0.64) in the cases of PI ≥ 1.1. In the mortality analysis, the mean velocity was a risk factor for mortality (RR = 1.15). Conclusions: A high rate of intracranial hypertension was reported, with ONSD measurement being the most reliable method for estimation. The increase in ICP measured by ONSD in patients with severe COVID-19 on mechanical ventilation is not associated to hypercapnia or elevated intrathoracic pressures derived from protective mechanical ventilation.

Urea como opción terapéutica en síndrome de antidiuresis inadecuada

El síndrome de antiduresis inadecuada (SADI) se produce por una alteración en el eje hipotálamo-neurohipófisis, por una falla en la respuesta regulatoria osmótica o por factores no osmóticos, con complicaciones en relación directa al grado de hiponatremia e impacto en la calidad de vida y mortalidad del paciente. El tratamiento consiste en la normalización de la natremia, y la búsqueda de la etiología. Presentamos el caso de un paciente adulto con el diagnóstico de SADI idiopático y trastorno neurocognitivo asociado, con respuesta favorable al tratamiento con urea.

Syndrome of Inappropriate Antidiuresis (SIAD), is produced by an alteration in the hypothalamus-neurohypophysis axis due to a failure in the osmotic regulatory response or non-osmotic factors, with complications directly related to the degree of hyponatremia and impact on quality of life and patient mortality. Management consists of normalization of natremia, and the search for the underlying etiology. We present the case of an adult patient diagnosed with idiopathic SIAD and associated neurocognitive disorder, with a favorable response to treatment with urea.

Risk factors for in-hospital complications in patients with acute ischemic stroke: Retrospective cohort in a national reference hospital in Peru.

Objective: To describe the clinical and demographic characteristics of patients with acute cerebral infarction treated at a national reference hospital in Peru and determine the risk factors for in-hospital complications. Methods: We conducted a retrospective cohort study including 192 patients with acute ischemic stroke in a national reference hospital in Peru from January to September 2021. Clinical, demographic and paraclinical information was recorded from medical records. We estimated risk ratios and 95% confidence intervals using regression models with Poisson family and robust variance for the bivariate and multivariate model, adjusting for age, sex and risk factors for stroke. Results: At least one in-hospital complication occurred in 32.3% of the patients. The most frequent complications were infectious in 22.4%, followed by 17.7% of neurological complications, with other complications, such as thromboembolism, immobility and miscellaneous, being much less frequent. Regression analysis showed that stroke severity (RR = 1.76; 95%CI:1.09-2.86) and albumin greater than 3.5 mg/dL (RR = 0.53; 95%CI: 0.36-0.79) were independent risk factors for the presence of in-hospital complications. Conclusions: A high rate of in-hospital complications were observed, among which infectious and neurological complications were the most frequent. Stroke severity was a risk factor and albumin greater than 3.5 mg/dL was a protective factor for the incidence of in-hospital complications. These results can serve as a starting point for establishing stroke care systems that consider differentiated flows for the prevention of in-hospital complications.

Oxigenoterapia de alto flujo y ventilación no invasiva en pacientes extubados por COVID-19 y riesgo de reintubación / High-flow oxygen therapy and non-invasive ventilation in extubated patients with COVID-19 and risk of reintubation

RESUMEN Introducción: La oxigenoterapia de alto flujo (OAF) y la ventilación no invasiva (VNI) son sistemas no invasivos que se administran post-extubación en pacientes COVID-19 para evitar la reintubación. Sin embargo, la evidencia sobre la elección de alguno de estos dispositivos no está muy clara. El objetivo fue determinar si el grupo que recibió OAF comparado con el grupo que recibió VNI se asocia a menor riesgo de reintubación en adultos con destete difícil y extubados por COVID-19. Material y métodos: Estudio cohorte retrospectivo en 206 registros de pacientes en destete difícil de ventilación mecánica en la Unidad de Cuidados Intensivos (UCI). El resultado primario fue reintubación en pacientes que fracasaron con OAF o VNI post-extubación y los resultados secundarios fueron estancia hospitalaria en UCI y mortalidad a los 90 días. Resultados: Doscientos seis pacientes cumplieron los criterios de inclusión, 102 pacientes en el grupo OAF y 104 pacientes en el grupo VNI. Durante el seguimiento de 72 horas, la tasa de reintubación en el grupo OAF fue mayor [n=24 (64,9%)] comparado con el grupo VNI [n=13 (35,1%)], mostrando en el análisis de Kaplan-Meier diferencias significativas (Log-Rank-Test p=0,005). La regresión de COX mostró mayor riesgo de reintubación en el grupo de OAF frente a VNI (HR 2,74; IC95% 1,42-5,68; p=0,007). No hubo diferencias en los días de hospitalización UCI (p=0,913) ni en mortalidad a los 90 días (Log-Rank-Test p=0,49). Conclusión: Este estudio observacional retrospectivo sugirió que la OAF frente al VNI se asoció a mayor riesgo de reintubación, pero no a mortalidad a los 90 días.

ABSTRACT Introduction: High flow oxygen therapy (HFO) and non-invasive ventilation (NIV) are non-invasive systems that are administered post-extubation in COVID-19 patients to avoid reintubation. However, the evidence on the choice of any of these devices is not very clear. The objective was to determine if the group that received OAF compared to the group that received NIV is associated with a lower risk of reintubation in adults with difficult weaning and extubated due to COVID-19. Material and methods: Retrospective cohort study in 206 records of patients in difficult weaning from mechanical ventilation in the Intensive Care Unit (ICU). The primary outcome was reintubation in patients who failed HFO or post-extubation NIV, and the secondary outcomes were ICU hospital stay and 90-day mortality. Results: Two hundred and six patients met the inclusion criteria, 102 patients in the OAF group and 104 patients in the NIV group. During the 72-h follow-up, the reintubation rate in the HFO group was higher [n=24 (64,9%)] compared to the NIV group [n=13 (35,1%)], showing in the analysis of Kaplan-Meier significant differences (Log-Rank-Test p=0,005). COX regression showed a higher risk of reintubation in the HFO group compared to NIV (HR 2,74; 95%CI 1,42-5,68; p=0,007). There were no differences in ICU hospitalization days (p=0,913) or in 90-day mortality (Log-Rank-Test p=0,49). Conclusion: This retrospective observational study suggested that HFO versus NIV was associated with a higher risk of reintubation, but not with 90-day mortality.

Mielopatía dorsal aguda como presentación atípica de una neurocisticercosis espinal / Acute dorsal myelopathy as an atypical presentation of spinal neurocysticercosis

La neurocisticercosis espinal es una enfermedad infecciosa poco frecuente. Su presentación puede ser extraespinal o intraespinal y la mayoría de casos es de evolución subaguda o crónica. Se presenta el caso de una paciente mujer de 55 años, natural y procedente de Lima, Perú, con cuadro clínico de una paraparesia aguda secundaria a una mielopatía dorsal por lesiones quísticas de cisticercosis espinal. La paciente recibió tratamiento médico y quirúrgico con una evolución clínica y de imágenes favorable. Es importante considerar en nuestro contexto epidemiológico, la cisticercosis espinal como diagnóstico diferencial, ante un cuadro clínico de mielopatía aguda, ya que el adecuado enfoque diagnóstico y tratamiento oportuno de esta rara entidad pueden mejorar el pronóstico de los pacientes.

Spinal neurocysticercosis is an infectious and rare disease. Its presentation can be extraspinal or intraspinal and most cases are of subacute or chronic evolution. We report the case of a 55-year-old female patient from Lima, Peru with a 2-day history of acute paraparesis secondary to dorsal myelopathy due to cystic lesions of spinal cysticercosis. The patient received medical and surgical treatment with a favorable clinical and imaging evolution. In our epidemiological context, it is important to consider a spinal cysticercosis as a differential diagnosis when faced with a clinical picture of acute myelopathy, since the appropriate diagnostic approach and timely treatment of this rare entity can improve the prognosis of patients.

Lesiones metabólicas bilaterales en núcleos basales: Serie de casos y Revisión de literatura

Introducción: Los núcleos basales son sustancias de materia gris, involucradas en la regulación de distintas funciones metabólicas y son vulnerables a situaciones de hipoxia y distintas situaciones patológicas. Los hallazgos imagenológicos no son específicos en la mayoría de los casos. Reporte de caso: Se reportan los casos de diez pacientes con lesiones metabólicas bilaterales en núcleos basales atendidos en un hospital de referencia nacional de Perú y se realiza una revisión de la literatura: 3 casos de Hipoparatiroidismo postquirúrgico, 2 de encefalopatía de Wernicke, 1 con degeneración hepatolenticular, 1 con mielinólisis extrapontina, 1 Intoxicación por metanol y 2 con encefalopatía Hipóxico-isquémica. Conclusión: Las lesiones bilaterales de núcleos basales producto de lesiones metabólicas son en gran parte inespecíficas, por lo que el contexto clínico es de vital importancia, así como las particularidades de los hallazgos imagenológicos, para el adecuado reconocimiento de las entidades etiológicas y su manejo oportuno.

Introduction: Basal nuclei are gray matter substances, involved in the regulation of different metabolic functions and are vulnerable to situations of hypoxia and different pathological situations. Imaging findings are not specific in most cases. Case of report: The cases of ten patients with bilateral metabolic lesions in the basal nuclei treated at a national reference hospital in Peru are reported, and a review of the literature is carried out: 3 cases of postoperative hypoparathyroidism, 2 of Wernicke's encephalopathy, 1 with hepatolenticular degeneration, 1 with extrapontine myelinolysis, 1 methanol intoxication and 2 with hypoxic-ischemic encephalopathy. Conclusion: Bilateral lesions of the basal nuclei as a result of metabolic lesions are nonspecific, so the clinical context is of vital importance, as well as the particularities of the imaging findings, for the adequate recognition of the etiological entities and their timely management.

Autoimmune encephalitis after BBIBP-CorV (Sinopharm) COVID-19 vaccination: a case report.

BACKGROUND: Vaccination is an important public health strategy; however, many neurological adverse effects are associated with COVID-19 vaccination, being encephalitis a rare manifestation. CASE PRESENTATION: We present the case of a 33-year-old woman who received the first dose of the BBIBP-CorV vaccine against COVID-19 on April 4 and the second dose on April 28, 2021. Three days after receiving the second dose, she experienced a subacute episode of headache, fever, insomnia, and transient episodes of environment disconnection. We obtained negative results for infectious, systemic, and oncological causes. Brain magnetic resonance imaging showed lesions in the bilateral caudate nucleus and nonspecific demyelinating lesions at the supratentorial and infratentorial compartments. The results of the neuronal autoantibodies panel were negative. She had an adequate response to immunoglobulin and methylprednisolone; however, she experienced an early clinical relapse and received a new cycle of immunosuppressive treatment followed by a satisfactory clinical evolution. CONCLUSIONS: We report the first case of severe encephalitis associated with BBIBP-CorV (Sinopharm) vaccination in Latin America. The patient had atypical imaging patterns, with early clinical relapse and a favorable response to corticosteroid therapy.

Case Report: Focal leptomeningeal disease, atypical cancer of unknown primary site.

Background: Leptomeningeal metastasis is an infrequent form of cancer expression, and it has a poor prognosis due to its torpid evolution and its challenging diagnosis. Case report: We report the case of a 68-year-old woman with rapidly progressing cognitive decline and focal epilepsy. Brain magnetic resonance imaging showed extensive gyriform hypersignal in the right precentral sulcus region, without mass effect, tenuous contrast uptake, and hydrocephalus with transependymal edema. The body tomographic study was negative for solid cancer and the 18F-FDG PET-CT revealed a severe hypermetabolism in the right lung upper lobe. These findings were suggestive of lung cancer with leptomeningeal metastasis. We performed a brain biopsy, finding atypical cells in the leptomeningeal region with positive immunohistochemical staining for CK7 and negative for CK20 corresponding to lung adenocarcinoma. The patient was evaluated in the oncology service and scheduled for radiotherapy and chemotherapy. Conclusions: Focal leptomeningeal disease is an entity that should be considered as a differential diagnosis in all cases of focal leptomeningitis. Timely diagnosis and adequate cancer management can increase patient survival.

Combining visual rating scales to identify prodromal Alzheimer's disease and Alzheimer's disease dementia in a population from a low and middle-income country.

Background: Many low- and middle-income countries, including Latin America, lack access to biomarkers for the diagnosis of prodromal Alzheimer's Disease (AD; mild cognitive impairment due to AD) and AD dementia. MRI visual rating scales may serve as an ancillary diagnostic tool for identifying prodromal AD or AD in Latin America. We investigated the ability of brain MRI visual rating scales to distinguish between cognitively healthy controls, prodromal AD and AD. Methods: A cross-sectional study was conducted from a multidisciplinary neurology clinic in Lima, Peru using neuropsychological assessments, brain MRI and cerebrospinal fluid amyloid and tau levels. Medial temporal lobe atrophy (MTA), posterior atrophy (PA), white matter hyperintensity (WMH), and MTA+PA composite MRI scores were compared. Sensitivity, specificity, and area under the curve (AUC) were determined. Results: Fifty-three patients with prodromal AD, 69 with AD, and 63 cognitively healthy elderly individuals were enrolled. The median age was 75 (8) and 42.7% were men. Neither sex, mean age, nor years of education were significantly different between groups. The MTA was higher in patients with AD (p < 0.0001) compared with prodromal AD and controls, and MTA scores adjusted by age range (p < 0.0001) and PA scores (p < 0.0001) were each significantly associated with AD diagnosis (p < 0.0001) but not the WMH score (p=0.426). The MTA had better performance among ages <75 years (AUC 0.90 [0.85-0.95]), while adjusted MTA+PA scores performed better among ages>75 years (AUC 0.85 [0.79-0.92]). For AD diagnosis, MTA+PA had the best performance (AUC 1.00) for all age groups. Conclusions: Combining MTA and PA scores demonstrates greater discriminative ability to differentiate controls from prodromal AD and AD, highlighting the diagnostic value of visual rating scales in daily clinical practice, particularly in Latin America where access to advanced neuroimaging and CSF biomarkers is limited in the clinical setting.

Post-Vaccinal Encephalitis with Early Relapse after BNT162b2 (COMIRNATY) COVID-19 Vaccine: A Case Report.

We describe the case of a 72-year-old man who received the first dose of the BNT162b2 (COMIRNATY) vaccine against COVID-19 on 18 May 2021, and the second dose on 9 September 2021. One day after receiving the first dose, he cursed with malaise, headache, fever, confusion, aggressiveness, and gait alterations. We performed serum and cerebrospinal fluid (CSF) tests (finding elevated proteins in CSF) with negative results for infectious, systemic, and neoplastic causes. We performed brain nuclear magnetic resonance imaging (MRI), finding circumscribed encephalitis at the anterior frontal and bilateral temporal lobes. We were unable to perform a panel of antineuronal antibodies. The patient was readmitted due to early clinical relapse four days after receiving his second dose. We found sequelae lesions at the frontal level but with new demyelinating lesions at the left temporal level in brain MRI. We indicated methylprednisolone, and he presented a favorable improvement. We report an encephalitis case of probable autoimmune etiology after vaccination with BNT162b2, which presented early clinical relapse after receiving the second dose and presented a favorable response to methylprednisolone.

Manejo de Encefalitis anti-NMDAR con Rituximab: Reporte de caso en un Hospital Público de Lima, Perú

Introducción: La encefalitis autoinmune comprende un amplio espectro de desórdenes inmunológicos, entre ellos el anti-NMDAR es el más frecuente. El manejo de esta patología es complejo debido a múltiples circunstancias. Reporte de caso: Mujer de 19 años que inicia cuadro subagudo con trastorno conductual y neurológico asociado: Alucinaciones, heteroagresividad, mutismo acinético, crisis epilépticas, discinesias orofaciales, fiebre y arritmia cardiaca transitoria reportada. La resonancia fue normal, el EEG registró ondas delta brush, Los estudios de LCR y séricos fueron negativos para causas secundarias. Se inició tratamiento con Aciclovir, medicamento anticrisis y psicofármacos, posteriormente se inicia metilprednisolona con inmunoglobulina sin respuesta satisfactoria. Inicia tratamiento con Rituximab presentando una respuesta favorable. El panel en LCR fue positivo a NMDA. Se indica control con desescalamiento progresivo de medicamentos anticrisis y psicofármacos. Conclusión: Es importante reconocer tempranamente las manifestaciones clínicas de esta entidad para así realizar un manejo oportuno que podría mejorar el pronóstico.

Introduction: Autoimmune encephalitis comprises a wide spectrum of immunological disorders, among them anti-NMDAR is the most frequent. The management of this pathology is complex due to multiple circumstances. Case report: A 19-year-old woman who started a subacute clinical picture with associated behavioral and neurological disorder: hallucinations, heteroaggressiveness, akinetic mutism, epileptic seizures, orofacial dyskinesias, fever and reported transient cardiac arrhythmia. MRI was normal, EEG recorded delta brush waves, CSF and serum studies were negative for secondary causes. Treatment was started with Acyclovir, an anti-crisis drug, and psychotropic drugs, later methylprednisolone with immunoglobulin was started without a satisfactory response. She starts treatment with Rituximab presenting a favorable response. The CSF panel was positive for NMDA. Control with progressive de-escalation of anti-crisis medications and psychotropic drugs is indicated. Conclusion: It is important to recognize early the clinical manifestations of this entity in order to carry out timely management that could improve the prognosis.

Cerebrovascular disease and mortality in hospitalized patients with COVID-19 in a Latin American country, Peru / Accidente cerebrovascular y mortalidad en pacientes hospitalizados con COVID-19 en un país de Latinoamérica, Perú

SUMMARY Objective : This study aimed at: 1) Assessment of the frequency of stroke and related mortality rate in patients hospitalized for COVID-19 in two major hospital referral centers in Peru; 2) Exploration of factors associated to mortality and dependency in these patients; 3) Comparisons of frequency of admissions of stroke patients and reperfusion treatments in similar periods of time prior to (2019) and during the pandemia occurrence. Material and Methods : A retrospective cohort study was conducted in two of the largest referral hospital centers for COVID-19 in Peru. The study included patient victims of stroke and COVID-19, hospitalized between April and August 2020. Demographic, clinical and laboratory data, radiological findings, and severity levels measured by the NIHSS scale were collected. Poisson regression models to evaluate associated factors to mortality and dependency were applied. Results : A 31% reduction of admissions for stroke, and of 81% of intravenous reperfusion treatment, respectively, were found in 2020 when compared with 2019. 1.37% of the patients with COVID-19 experienced a stroke, with an overall mortality rate of 40.6%, and a dependency rate of 68.3% at discharge time (Rankin > 2). An age increase of 10 years was found in mortality, associated with a 29% increase in mortality risk. As well, having hypertension, chronic kidney disease, inflammatory markers (D dimer and ferritin) and the severity of the stroke were associated with mortality. Finally, the severity of stroke, lymphopenia, and inflammatory markers (D dimer and fibrinogen) were associated with greater risk of dependency. Conclusions : The care system of stroke patients was affected by the COVID-19 pandemic in two of Perú's major public hospitals. There was a decrease in admissions and reperfusion treatments of stroke cases, and 1.37% of patients with COVID-19 presented a stroke. Age, hypertension, chronic kidney disease, inflammatory markers and severity of stroke were associated with mortality in these patients.

RESUMEN Objetivo : Los objetivos del presente trabajo fueron: 1) Evaluar la frecuencia de accidente cerebrovascular (ACV) y de la tasa de mortalidad en pacientes hospitalizados por COVID-19 en dos importantes centros hospitalarios de referencia en Perú, 2) Exploración de factores asociados a mortalidad y dependencia en estos pacientes, 3) Comparar la frecuencia de admisiones de pacientes con ACV y de los tratamientos de reperfusión en tiempo de pandemia y en periodos previos (2019). Material y Métodos : Se realizó un estudio retrospectivo en dos de los mayores centros hospitalarios de referencia en Perú, incluyendo pacientes con ACV y COVID-19 hospitalizados entre abril y agosto del 2020. Se recolectó información demográfica, clínica y de laboratorio, hallazgos radiológicos y niveles de severidad medidos por la escala NIHSS, y se utilizó un modelo de regresión de Poisson para evaluar los factores asociados a mortalidad y dependencia. Resultados : Se encontró una disminución del 31% de admisiones hospitalarias de pacientes con ACV (ictus) y del 81% de los tratamientos de reperfusión endovenosa en el 2020 con respecto al 2019. Un 1.37% de pacientes con COVID-19 experimentaron ACV, con una mortalidad global de 40.6% y dependencia al alta del 58.3% (rankin >2). Un incremento de 10 años en edad se asoció con un aumento del 29% en el riesgo de mortalidad. Hipertensión arterial, enfermedad renal crónica, marcadores inflamatorios (Dímero D y ferritina) y la gravedad del ictus se encontraron asociados con mortalidad. La gravedad del ictus, la linfopenia y los marcadores inflamatorios (Dimero D y fibrinógeno) estuvieron asociados a un mayor riesgo de dependencia. Conclusión : El sistema de atención de ACVs se vio afectado por la pandemia del COVID-19 en dos de los centros hospitalarios públicos más grandes del Perú. Se encontró una disminución en las admisiones hospitalarias y en los tratamientos de reperfusión de estos pacientes durante la pandemia. Edad, hipertensión, enfermedad renal crónica, marcadores inflamatorios y gravedad del ictus fueron factores asociados con la mortalidad de pacientes con COVID-19 y ACV.

Eventos cerebro vasculares en pacientes Covid-19: Experiencia en un hospital de referencia nacional del Perú / Stroke in patients with Covid-19: Experiencie in a national referral hospital in Peru

Introducción: Los eventos cerebro vasculares son una de las principales causas de mortalidad a nivel mundial y la actual pandemia por la COVID-19 ha producido un gran impacto en la atención de estos pacientes. El objetivo es describir las características de los pacientes con evento cerebro vascular en pacientes hospitalizados con COVID-19 en un hospital peruano de referencia. Material y Métodos. Estudio retrospectivo, se incluyó a pacientes mayores de 18 años hospitalizados con el diagnostico de COVID-19 y evento cerebro vascular. Resultados. Se incluyeron 26 pacientes con ECV y COVID-19, la edad promedio fue 69.8 años y la mediana del tiempo de admisión fue 24 horas. La mortalidad fue elevada (42.3%) y estuvo asociada a la edad y al compromiso respiratorio por COVID-19. La mayoría de sobrevivientes obtuvieron un pobre resultado funcional. Conclusión. Es necesaria la mejora en los procesos de atención para así realizar un diagnóstico precoz y un tratamiento oportuno.

Background: Stroke is one of the leading causes of mortality worldwide and the current COVID-19 pandemic has a great impact on the care of these patients. Aim: To describe the characteristics of patients with a cerebrovascular event in patients hospitalized with COVID-19 in the medical center with the highest hospital capacity in Peru. The Study: We conducted a retrospective study and included patients older than 18 years hospitalized with the diagnosis of COVID-19 and stroke. Findings: Atotal of 26 adults were included, the mean age was 69.8 years and the median time of admission was 24 hours. Mortality was high (42.3%) and was associated with age and respiratory compromise by COVID-19. The majority of survivors had a poor functional outcome. Conclusion: It is concluded that improvement in care processes is necessary in order to make an early diagnosis and timely treatment.

Factors associated with mortality in patients hospitalized with COVID-19: A prospective cohort in a Peruvian national referral hospital. / Factores asociados a mortalidad en pacientes hospitalizados con COVID-19: cohorte prospectiva en un hospital de referencia nacional de Perú.

OBJECTIVES: To describe and assess clinical characteristics and factors associated with mortality in adult patients with COVID-19 admitted to a national referral hospital in Peru. METHODS: We conducted a prospective cohort study that included hospitalized patients older than 18 years with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection diagnosis. Patients with a positive rapid serological test on admission but no respiratory symptoms nor compatible images were excluded. We collected the data from clinical records. RESULTS: A total of 813 adults were included, 544 (66.9%) with confirmed COVID-19. The mean age was 61.2 years (standard deviation: 15.0), and 575 (70.5%) were male. The most frequent comorbidities were hypertension (34.1%) and obesity (25.9%). On admission, the most frequent symptoms were dyspnea (82.2%) and cough (53.9%). A total of 114 (14.0%) patients received mechanical ventilation, 38 (4.7%) were admitted to the intensive care unit, and 377 (46.4%) died. The requirement for ventilatory support, greater lung involvement, and inflammatory markers were associated with higher mortality. It was found that for every 10-year age increase, the risk of dying increased 32% (relative risk: 1.32; 95% confidence interval: 1.25 to 1.38). Those who were admitted to the intensive care unit and and were placed on mechanical ventilation had 1.39 (95% confidence interval: 1.13 to 1.69) and 1.97 (95% confidence interval: 1.69 to 2.29) times the risk of dying compared to those who did not, respectively. CONCLUSION: We found a high mortality rate among hospitalized patients associated with older age, higher inflammatory markers, and greater lung involvement.

OBJETIVOS: Describir las características clínicas y evaluar los factores asociados con la mortalidad de los pacientes adultos con la nueva enfermedad causada por coronavirus 2019 (COVID-19) ingresados a un hospital de referencia nacional de Perú. MÉTODOS: Se realizó un estudio de cohorte prospectivo. Se incluyó a pacientes mayores de 18 años hospitalizados con el diagnóstico de infección por coronavirus 2 del síndrome respiratorio agudo severo (SARS-CoV-2). Se excluyó a quienes ingresaron con prueba rápida serológica positiva al ingreso, sin clínica sugestiva ni imágenes compatibles. Los datos se recolectaron a partir de la historia clínica. RESULTADOS: Se incluyó un total de 813 adultos, 544 (66,9%) tuvieron COVID-19 confirmado. La media de la edad fue de 61,2 años (desviación estándar: 15) y 575 (70,5%) fueron de sexo masculino. Las comorbilidades más frecuentes fueron hipertensión arterial (34,1%) y obesidad (25,9%). Los síntomas más frecuentes al ingreso fueron disnea (82,2%) y tos (53,9%). Un total de 114 (14%) pacientes recibieron ventilación mecánica, 38 (4,7%) ingresaron a unidad de cuidados intensivos y 377 (46,4%) fallecieron. Se asociaron a la mortalidad el requerimiento de soporte ventilatorio, el mayor compromiso pulmonar y los marcadores inflamatorios. Encontramos que por cada 10 años que aumentó la edad, el riesgo de morir se incrementó en 32% (riesgo relativo: 1,32; intervalo de confianza 95%: 1,25 a 1,38). Aquellos pacientes que requirieron ingreso a unidad de cuidados intensivos y ventilación mecánica tuvieron 1,39 (intervalo de confianza 95%: 1,13 a 1,69) y 1,97 (intervalo de confianza 95%: 1,69 a 2,29) veces el riesgo de morir, respectivamente. CONCLUSIÓN: La mortalidad encontrada en nuestro estudio fue alta y estuvo asociada a la edad, marcadores inflamatorios y compromiso respiratorio.

Factores asociados a mortalidad en pacientes hospitalizados con COVID-19: cohorte prospectiva en un hospital de referencia nacional de Perú / Factors associated with mortality in patients hospitalized with COVID-19: a prospective cohort in a Peruvian national referral hospital

Objetivos Describir las características clínicas y evaluar los factores asociados con la mortalidad de los pacientes adultos con la nueva enfermedad causada por coronavirus 2019 (COVID-19) ingresados a un hospital de referencia nacional de Perú. Métodos Se realizó un estudio de cohorte prospectivo. Se incluyó a pacientes mayores de 18 años hospitalizados con el diagnóstico de infección por coronavirus 2 del síndrome respiratorio agudo severo (SARS-CoV-2). Se excluyó a quienes ingresaron con prueba rápida serológica positiva al ingreso, sin clínica sugestiva ni imágenes compatibles. Los datos se recolectaron a partir de la historia clínica. Resultados Se incluyó un total de 813 adultos, 544 (66,9%) tuvieron COVID-19 confirmado. La media de la edad fue de 61,2 años (desviación estándar: 15) y 575 (70,5%) fueron de sexo masculino. Las comorbilidades más frecuentes fueron hipertensión arterial (34,1%) y obesidad (25,9%). Los síntomas más frecuentes al ingreso fueron disnea (82,2%) y tos (53,9%). Un total de 114 (14%) pacientes recibieron ventilación mecánica, 38 (4,7%) ingresaron a unidad de cuidados intensivos y 377 (46,4%) fallecieron. Se asociaron a la mortalidad el requerimiento de soporte ventilatorio, el mayor compromiso pulmonar y los marcadores inflamatorios. Encontramos que por cada 10 años que aumentó la edad, el riesgo de morir se incrementó en 32% (riesgo relativo: 1,32; intervalo de confianza 95%: 1,25 a 1,38). Aquellos pacientes que requirieron ingreso a unidad de cuidados intensivos y ventilación mecánica tuvieron 1,39 (intervalo de confianza 95%: 1,13 a 1,69) y 1,97 (intervalo de confianza 95%: 1,69 a 2,29) veces el riesgo de morir, respectivamente. Conclusión La mortalidad encontrada en nuestro estudio fue alta y estuvo asociada a la edad, marcadores inflamatorios y compromiso respiratorio.

Objectives To describe and assess clinical characteristics and factors associated with mortality in adult patients with COVID-19 admitted to a national referral hospital in Peru. Methods We conducted a prospective cohort study that included hospitalized patients older than 18 years with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection diagnosis. Patients with a positive rapid serological test on admission but no respiratory symptoms nor compatible images were excluded. We collected the data from clinical records. Results A total of 813 adults were included, 544 (66.9%) with confirmed COVID-19. The mean age was 61.2 years (standard deviation: 15.0), and 575 (70.5%) were male. The most frequent comorbidities were hypertension (34.1%) and obesity (25.9%). On admission, the most frequent symptoms were dyspnea (82.2%) and cough (53.9%). A total of 114 (14.0%) patients received mechanical ventilation, 38 (4.7%) were admitted to the intensive care unit, and 377 (46.4%) died. The requirement for ventilatory support, greater lung involvement, and inflammatory markers were associated with higher mortality. It was found that for every 10-year age increase, the risk of dying increased 32% (relative risk: 1.32; 95% confidence interval: 1.25 to 1.38). Those who were admitted to the intensive care unit and and were placed on mechanical ventilation had 1.39 (95% confidence interval: 1.13 to 1.69) and 1.97 (95% confidence interval: 1.69 to 2.29) times the risk of dying compared to those who did not, respectively. Conclusion We found a high mortality rate among hospitalized patients associated with older age, higher inflammatory markers, and greater lung involvement.

[Rapidly progressive dementia associated with leukoencephalopathy: A case report of lymphomatosis cerebri]. / Demencia rápidamente progresiva asociada a leucoencefalopatía: reporte de linfomatosis cerebri.

INTRODUCTION: Lymphomatosis cerebri is a rare form of primary central nervous system lymphoma characterized by an atypical clinical presentation and neuroimaging, with a poor short-term prognosis. CASE REPORT: A 51-year-old woman began with clinical manifestations characterized by rapidly progressing cognitive impairment associated with a behavioral disorder, myoclonus, and gait disturbance. The brain magnetic resonance image showed extensive signaling in the bilateral periventricular white matter. The 18F-FDG PET-CT showed severe dorsolateral neocortical hypometabolism in the absence of focal hypermetabolic lesion, a metabolic pattern indicative of cerebri lymphomatosis. A brain biopsy confirmed the diagnosis. The patient started chemotherapy achieving complete remission. Eighteen months after diagnosis, the patient had improved clinically and neuroimaging. CONCLUSION: This is the first report in Peru of an entity that should be considered in rapidly progressive dementia and leukoencephalopathy cases. Timely diagnosis and appropriate chemotherapy management can increase patient survival.

INTRODUCCIÓN: La linfomatosis cerebri es una forma infrecuente de linfoma primario del sistema nervioso central, caracterizado por una presentación clínica y de neuroimágenes atípicas con un mal pronóstico a corto plazo. REPORTE DE CASO: Mujer de 51 años que inició cuadro clínico caracterizado por deterioro cognitivo de rápido progreso asociado a trastorno conductual, mioclonías y alteración de la marcha. La resonancia cerebral presentó extensa hiperseñal en la sustancia blanca periventricular bilateral. La tomografía por emisión de positrones con fluoro dexosiglucosa evidenció severo hipometabolismo neocortical dorsolateral en ausencia de lesión hipermetabólica focal, con patrón metabólico sugestivo de linfomatosis cerebri. Se confirmó el diagnostico mediante biopsia cerebral. La paciente inició quimioterapia logrando remisión completa. A los 18 meses del diagnóstico la paciente presentó mejoría clínica y de neuroimágenes evidentes. CONCLUSIÓN: Es el primer reporte en Perú de una entidad que se debe de tener presente en casos de demencia rápidamente progresiva y leucoencefalopatía. El diagnóstico oportuno y manejo quimioterápico adecuado puede aumentar la sobrevida del paciente.

Neuroimágenes atípicas en pacientes con COVID-19 en el Perú: reporte de casos / Atypical neuroimaging in patients with COVID-19 in Peru: case report

RESUMEN El reporte de manifestaciones neurológicas en pacientes con COVID-19 se ha incrementado significativamente en los últimos meses. Sin embargo, los hallazgos de neuroimágenes han sido pobremente documentados debido a las restricciones por la necesidad de aislamiento de estos pacientes. Se reportan dos casos de pacientes con COVID-19 con clínica neurológica, a quienes se les realizó estudios de imagen cerebral y presentaron hallazgos atípicos en la resonancia magnética de encéfalo. Es necesario descripciones más detalladas y mejor documentadas de las manifestaciones neurológicas en los pacientes hospitalizados con COVID-19 y sus respectivos correlatos en neuroimágenes para lograr un mejor conocimiento de la enfermedad.

ABSTRACT Reports describing neurological manifestations in patients with COVID-19 have substantially increased in the past months. Nevertheless, findings from neuroimaging studies have been poorly documented because of restrictions due to the need for isolating such patients. Two cases of patients with COVID-19 and clinical neurological manifestations are reported. They underwent brain imaging studies and atypical findings were made in cerebral magnetic resonance imaging. It is necessary to have more detailed and better documented descriptions of neurological manifestations in patients hospitalized with COVID-19 and their respective neuroimaging correlates in order to obtain better knowledge of this condition.

Asma crítica asociada a aspergilosis broncopulmonar alérgica: reporte de un caso.

Critical asthma syndrome is the most severe consequence of an acute asthma exacerbation. Allergic bronchopulmonary aspergillosis is one of the most frequent pathologies that mimic critical asthma syndrome and is associated with a high mortality risk when timely diagnosis is not achieved in difficult-to-control asthmatic patients. We present the case of a 15-year-old male who was admitted to the intensive care unit with critical asthma signs and symptoms, where a diagnosis of allergic bronchopulmonary aspergillosis was made. He responded favorably with voriconazole and corticoids. In our context, the diagnosis of allergic bronchopulmonary aspergillosis should be considered in all patients with critical asthma or with a chronic lung disease that is difficult to control. Early diagnosis and treatment improve the quality of life and prognosis of patients.

El síndrome de asma crítica es la peor consecuencia de una exacerbación aguda de asma. La aspergilosis broncopulmonar alérgica es una de las patologías más frecuentes que se mimetizan con este síndrome y está asociada a un alto riesgo de mortalidad cuando no se realiza el diagnóstico oportuno en pacientes asmáticos de difícil control. Presentamos el caso de un varón de 15 años que ingresó a la unidad de cuidados intensivos con clínica de asma crítica, donde se hizo un diagnóstico de aspergilosis broncopulmonar alérgica y respondió favorablemente con voriconazol y corticoides. En nuestro medio se debe considerar el diagnóstico de aspergilosis broncopulmonar alérgica en todo paciente con clínica de asma crítica o con una enfermedad pulmonar crónica de difícil control; el diagnóstico y el tratamiento oportunos mejoran la calidad de vida y el pronóstico de los pacientes.

Asma crítica asociada a aspergilosis broncopulmonar alérgica: reporte de un caso

RESUMEN El síndrome de asma crítica es la peor consecuencia de una exacerbación aguda de asma. La aspergilosis broncopulmonar alérgica es una de las patologías más frecuentes que se mimetizan con este síndrome y está asociada a un alto riesgo de mortalidad cuando no se realiza el diagnóstico oportuno en pacientes asmáticos de difícil control. Presentamos el caso de un varón de 15 años que ingresó a la unidad de cuidados intensivos con clínica de asma crítica, donde se hizo un diagnóstico de aspergilosis broncopulmonar alérgica y respondió favorablemente con voriconazol y corticoides. En nuestro medio se debe considerar el diagnóstico de aspergilosis broncopulmonar alérgica en todo paciente con clínica de asma crítica o con una enfermedad pulmonar crónica de difícil control; el diagnóstico y el tratamiento oportunos mejoran la calidad de vida y el pronóstico de los pacientes.

ABSTRACT Critical asthma syndrome is the most severe consequence of an acute asthma exacerbation. Allergic bronchopulmonary aspergillosis is one of the most frequent pathologies that mimic critical asthma syndrome and is associated with a high mortality risk when timely diagnosis is not achieved in difficult-to-control asthmatic patients. We present the case of a 15-year-old male who was admitted to the intensive care unit with critical asthma signs and symptoms, where a diagnosis of allergic bronchopulmonary aspergillosis was made. He responded favorably with voriconazole and corticoids. In our context, the diagnosis of allergic bronchopulmonary aspergillosis should be considered in all patients with critical asthma or with a chronic lung disease that is difficult to control. Early diagnosis and treatment improve the quality of life and prognosis of patients.