Mal de Pott. Reporte de Caso Clínico / Pott's disease. Clinical Case Report

Introducción: La Tuberculosis (TB) es una enfermedad endémica en Paraguay, en el año 2010 se reportaron 2313 casos. La presentación extrapulmonar se observa en un 10-20% de los casos y en pacientes inmunocomprometidos puede llegar al 60%. La tuberculosis vertebral puede afectar la columna vertebral, con mayor frecuencia las vértebras T8 hasta L3. Tiene su origen en un foco primario pulmonar, que favorece uno secundario a nivel óseo. El diagnostico oportuno de la TB delimita la progresión a esta complicación y a las consecuencias para la vida del paciente. Caso Clínico: Paciente de sexo femenino de 42 años, fumadora de larga data, consulta por dolor en columna dorsal de 3 meses de evolución y pérdida de peso progresiva de aproximadamente 5 kg, con deformidad ósea progresiva de la columna dorsal. Al cuadro se agrega tos de 2 meses de evolución, seca al inicio y volviéndose productiva 15 días antes de la consulta. Niega sensación febril. Al examen físico se observa cifosis dorsal marcada y relieves óseos prominentes. En la Rx de torax se observan infiltrados bilaterales difusos miliariformes y leve desviación de la columna. El diagnostico definitivo fue Tuberculosis vertebral por lo que se inicia el tratamiento con HRZE (Rifampicina, Pirazinamida, Isoniazida, Etambutol) y se la deriva a neurocirugía para corrección de la deformidad ósea. Actualmente la paciente se encuentra en fase de recuperación con buena evolución tras cirugía correctiva. Discusión: Como en la mayoría de los casos reportados el síntoma cardinal fue el dolor. La imagenología es un pilar fundamental del diagnostico, brinda evidencia de la extensión de la lesión vertebral para decidir conducta. El alivio sintomático solo se logra con la cirugía correctiva. Debemos pensar y buscar tuberculosis en todo paciente sintomático respiratorio; las complicaciones extrapulmonares pueden evitarse mediante el diagnostico precoz y tratamiento adecuado de esta enfermedad de elevada prevalencia en nuestro país. Palabras clave: Espondilitis; Tuberculosis espinal; Mal de Pott.

Introduction: Tuberculosis (TB) is an endemic disease in Paraguay; in 2010 2313 cases were reported. Extrapulmonary presentation occurred in about 10 to 20% of cases, and in immunocompromised patients can go up to 60%. Vertebral tuberculosis can affect the spine, and is more frequent from T8 to L3. It has its origin in a primary pulmonary nodule from which can seed a secondary process in these bones. Early diagnosis of TB limits this complication and improved the quality of life of these patients. Case: 42 years old female, smoker, came for an evaluation of pain on her dorsal spine for the past 3 months, progressive loss weight of about 5 kilos, and bone deformity of the dorsal spine. 2 months prior this visit, she started coughing, described as dry, and then becomes wet 15 days before this visit. She denies fever and on physical examination there is a severe dorsal kyphosis with prominent bony prominence. CXR showed a miliary, diffuse, bilateral infiltrates with a slight deviation of the dorsal spine. Final diagnosis was vertebral tuberculosis, and treatment with HRZE (Rifampin, Pyrazinamide, Isoniazid and Ethambutol) was started. The patient was sent to neurosurgery for correction of the spine deformity. Currently she is stable, after corrective spine surgery. Discussion: Lijke in most reported cases, de cardinal symptom was pain, and imaging is fundamental for making a diagnosis and helps determine the extension of the vertebral disease to decide the treatment approach. Pain is controlled only with corrective surgery. We should think and look for TB in every patient with respiratory symptoms; the extrapulmonary complications could be avoided throu and early diagnosis and appropriate treatment of this disease, which has a high prevalence in our country. Key words: Spondylitis, spinal tuberculosis,Pott´s disease.

[Effectiveness of PRECEDE model for health education in metabolic control and reduction of cardiovascular risk factors in patients with diabetes type 2]. / Eficacia del modelo PRECEDE, de educación para la salud, en el control metabólico y de los factores de riesgo cardiovascular en pacientes con diabetes mellitus tipo 2.

OBJECTIVE: To evaluate the effectiveness of PRECEDE model for health education, in the metabolic control and the reduction of cardiovascular risk factors, in type 2 diabetic patients followed for over two years in primary health care services. MATERIALS AND METHODS: PRECEDE model for health education was used in 318 patients with type 2 diabetes, from five primary health care centres. The study was conducted during two years of monitoring. RESULTS: After two years of follow-up was observed decrease in diastolic and systolic pressures (p < 0.05), as well as in levels of total cholesterol and LDL-cholesterol (p < 0.05). Patients with good metabolic control (glycated hemoglobin A1c < 7% and LDL cholesterol < 100 mg/dl), increased from 9.9% to 16.8% (p < 0,05). On the other hand, 27% of patients improved their level of therapeutic adherence, and there was a decreased in the number of patients with microalbuminuria from 8.4% to 6.3% (p = 0.05). Finally, we found no differences in levels of glycated hemoglobin A1c, BMI and cardiovascular risk. Mortality after two years was 0.7%. DISCUSSION: PRECEDE model for health education is a useful method in the management of type 2 diabetes, that reduce the levels of blood pressure both systolic and diastolic, decrease the lipid levels, and improve the level of therapeutic adherence in type 2 diabetic patients, followed for two years.

Multivariate analysis of factors associated with renal dysfunction in patients with obstructive jaundice.

BACKGROUND: The aim was to evaluate the factors determining preoperative renal dysfunction in patients with obstructive jaundice. METHODS: In a prospective cross-sectional observational study, 63 patients, 27 with benign and 36 with malignant obstructive jaundice, were investigated at admission and compared with 25 healthy control subjects. Variables analysed included extracellular body water (ECW) compartment, plasma levels of aldosterone, renin, atrial natriuretic peptide, vasopressin, nitric oxide, endothelin (ET) 1 and prostaglandin E2 (PGE2), urinary nitric oxide and PGE2, serum albumin and renal function. RESULTS: The metabolic profile of obstructive jaundice was characterized by a depletion of the ECW (P = 0.004), and increased plasma levels of atrial natriuretic peptide (P < 0.001), ET-1 (P = 0.044), vasopressin (P = 0.017), aldosterone (P = 0.005) and renin (P = 0.001). Increased plasma (P < 0.001) and urinary (P = 0.001) PGE2 levels were also found. Fifty-four per cent of patients had a creatinine clearance of less than 70 ml/min. In multivariate analysis, serum bilirubin, renin, ET-1, PGE2, decreased urinary sodium excretion and age were identified as predictors of renal dysfunction. CONCLUSIONS: Renal dysfunction in patients with obstructive jaundice was associated with the degree of biliary obstruction, age of the patient and reduced urinary sodium excretion. These alterations were closely related to derangements in sodium- and water-regulating hormones.

Randomized clinical trial of the effect of intravenous fluid administration on hormonal and renal dysfunction in patients with obstructive jaundice undergoing endoscopic drainage.

BACKGROUND: Renal dysfunction in patients with biliary obstruction is associated with extracellular water depletion. This study examined the effect of preoperative saline infusion before biliary drainage on hormonal and renal functional derangements in patients with obstructive jaundice. METHODS: In a randomized study, 49 patients with malignant obstructive jaundice were investigated at baseline, on the day of drainage, and at 24 h, 72 h and 7 days after internal endoscopic biliary drainage. Patients were randomized to receive (n = 22) or not to receive (n = 27) 3000 ml normal saline intravenously for 24 h before drainage. Variables analysed included extracellular water volume, creatinine clearance, and serum levels of aldosterone, renin, atrial natriuretic peptide (ANP), vasopressin and albumin. RESULTS: Preoperative saline infusion produced a rise in creatinine clearance, diuresis, ANP concentration and extracellular water volume but this did not translate into better recovery of renal function after operation. Drainage produced a fall in creatinine clearance in all patients, but hormonal and renal function had recovered by 2 days after restoration of bile flow, independently of preoperative hydration. CONCLUSION: Fluid administration expands the extracellular water compartment before drainage but fails to improve renal function after drainage. Definitive improvement in endocrine and renal function requires the restoration of bile flow into the duodenum.

Melatonin protects against renal oxidative stress after obstructive jaundice in rats.

The goals of this study were to analyze the renal oxidative status in experimental biliary obstruction and to evaluate the impact of melatonin on renal oxidative stress. Cholestasis was done by double ligature and section of the extra-hepatic biliary duct. Melatonin was injected i.p. (500 microg/kg/day). Malondialdehyde, reduced glutathione, catalase, superoxide dismutase, glutathione reductase, glutathione peroxidase and glutathione transferase were determined in the renal tissue. After biliary obstruction, an increase in malondialdehyde (P<0.0001) and a fall in reduced glutathione (P<0.0001) were seen. Moreover, the scavenger enzyme activity had significantly diminished. After melatonin administration, the malondialdehyde fell significantly (P<0.0001), whereas reduced glutathione showed an important increase (P<0.0001) compared with the ligated bile duct group. Experimental bile duct obstruction was associated to an increase of renal oxidative stress. Treatment with melatonin decreased the renal lipid peroxidation, and both the reduced glutathione as well as the scavenger enzyme activity recovered.

Factors predicting nutritional derangements in patients with obstructive jaundice: multivariate analysis.

Patients with obstructive jaundice (OJ) that requires surgery often have malnutrition associated with increased perioperative morbidity. This study investigated the factors influencing nutritional derangements in these patients. A series of 46 OJ patients were investigated prospectively (28 malignant tumors, 18 benign obstructions). A nutritional risk index of < 83.5 was used to define protein-calorie malnutrition. Liver function, cholecystokinin (CCK), tumor necrosis factor-alpha (TNFalpha), and endotoxin levels were determined. A multivariate analysis was performed, and an obstructive jaundice malnutrition index (OJMI) was obtained. Altogether, 22 (48%) OJ patients had malnutrition (33% with benign obstructions, 57% with malignant disease). Malnourished patients had higher serum bilirubin levels (258 +/- 120 vs. 154 +/- 62 mmol/L; p = 0.005), longer duration of jaundice (16 +/- 9 vs. 9 +/- 5 days; p = 0.03), and higher plasma levels of CCK (4.0 +/- 1.3 vs. 1.7 +/- 1.0 pmol/L; p = 0.005), alanine aminotransferase (ALT) (226 +/- 209 vs. 187 +/- 161 UI/L; p = 0.01), endotoxin (15 +/- 10 vs. 6.5 +/- 7.0 EU/L; p = 0.007), and TNFalpha (69 +/- 82 vs. 23 +/- 15 pg/ml; p = 0.008) than those without malnutrition. However, only serum bilirubin, CCK, ALT, and patient age were predictors for malnutrition by multivariate analysis. Malnutrition might be expected (95% confidence interval) in patients older than 68 years with increased bilirubin (> 290 mmol/L) and ALT (> 210 UI/L) levels that corresponded with an OJMI > 55. It was concluded that nutritional alterations in patients with obstructive jaundice were determined by the intensity of the biliary obstruction correlated with increased plasma CCK levels as well as with liver dysfunction and patient age.

Cytokines and acute-phase response markers derangements in patients with obstructive jaundice.

BACKGROUND/AIMS: Prolonged acute-phase response and increase of cytokines have been associated with higher mortality and surgical complications. This study investigated the status of cytokines and acute-phase response markers in patients with obstructive jaundice. METHODOLOGY: Forty-one patients were investigated. Endotoxin, tumor necrosis factor-alpha, interleukin-6, nitric oxide, C-reactive protein, liver enzymes, albumin and percentage of weight loss were determined at admission. RESULTS: Endotoxin, interleukin-6 and C-reactive protein were significantly elevated in both benign and malignant obstructive jaundice. Increased plasma levels of tumor necrosis factor-alpha were only detected in malignant tumors (68 vs. 24 pg/mL; P < 0.001). Patients with positive acute-phase response (C-reactive protein > mean + 2 SD of controls) had greater weight loss (P = 0.02), endotoxin (P = 0.03) and interleukin-6 plasma levels (P = 0.05) than those with no inflammatory response. Prolonged biliary obstruction (> 10 days) was associated with higher weight loss (P = 0.04), tumor necrosis factor-alpha (P = 0.003) and interleukin-6 (P = 0.05) plasma levels. CONCLUSIONS: A prolonged high-grade biliary tract obstruction prompted an increase in endotoxin levels, associated with a positive acute-phase response and cytokine elevation.

Nutritional assessment of patients with benign and malignant obstructions of the biliary tract.

OBJECTIVES: the aim of this study was to assess the severity and type of nutritional deficiencies observed in patients with benign and malignant obstructive jaundice (OJ). METHOD: in this prospective cross-sectional study 51 patients with OJ (21 with benign and with 30 malignant obstruction) were investigated. Nutritional status was assessed by anthropometric parameters (ideal body weight, midarm muscle area and skinfold thickness), visceral proteins, creatinine height index and total lymphocyte count. Observed values in patients with OJ were normalized to the percentage value of the lower limit of normal (obtained from 17 healthy subjects matched for age and sex) and averaged to obtain a total score for protein-energy malnutrition. RESULTS: forty-two (82%) patients with OJ had protein-calorie malnutrition (PCM). Malnutrition was mild in 55%, moderate in 35% and severe in 10%. Severity of PCM was associated with intensity (p < 0.05) and duration of jaundice (p < 0.01). Kwashiorkor (74%) was the dominant type of malnutrition. PCM was common in benign (71%) as well as in malignant obstruction (90%), but the total score (92 +/- 20 vs 80 +/- 19; p < 0.05) and the proportion of mild PCM in patients with benign obstruction (80% vs 41%, p < 0.01) was significantly higher than in patients with malignant tumors. CONCLUSIONS: a high percentage of patients with OJ had PCM. The degree of nutritional alteration was associated with the intensity of jaundice. Malnutrition was equally prevalent among patients with benign obstructions and patients with malignant causes of biliary obstruction, although it was more severe in the latter. Acute malnutrition (kwashiorkor) was the dominant type of malnutrition in both groups of patients.

Changes in the pattern of visceral protein concentrations after internal biliary drainage in patients with obstructive jaundice.

OBJECTIVE: To evaluate the influence of internal drainage on status of nutritional markers in patients with obstructive jaundice. DESSING: Prospective longitudinal study. SETTING: University hospital, Spain. SUBJECTS: 39 patients with obstructive jaundice (18 benign and 21 malignant obstructions). INTERVENTIONS: Nutritional state was assessed before and 10 days after endoscopic drainage. MAIN OUTCOME MEASURES: One anthropometric (body weight <95% of ideal) and two biochemical (albumin <35 g/L and prealbumin < 170 mg/L) as an indication of protein calorie malnutrition. Retinol binding protein and transferrin concentrations, total lymphocyte count, and nutritional prognostic index (NPI) were also measured. RESULTS: Thirty patients (77%) had protein calorie malnutrition. After internal drainage, 6 patients with benign obstruction and 11 with malignant tumours remained malnourished. No anthropometric variables or concentrations of proteins with long half-lives were affected by drainage. However, prealbumin (p < 0.01) and transferrin (p < 0.01) concentrations, and total lymphocyte count (p < 0.001) increased significantly in both groups. NPI also improved significantly after drainage from 43 (9) compared with 37 (5) in benign obstructions (p < 0.05) and 58.7 (14) compared with 52 (12) in malignant (p < 0.05), although in the latter group the mean nutritional risk index remained high. CONCLUSIONS: Concentrations of some of the visceral proteins studied (prealbumin and transferrin) improved 10 days after internal biliary drainage for both benign and malignant obstruction. However, many patients with malignant tumours remained malnourished with a high nutritional risk index.

Preoperative assessment of body fluid disturbances in patients with obstructive jaundice.

Postoperative renal dysfunction in obstructive jaundice (OJ) patients has been associated with hypovolemia and depletion of the extracellular water compartment (ECW). The aim of the study was to evaluate the preoperative status of body compartments in OJ patients measured by two methods. In a prospective study 39 OJ patients (11 benign and 28 malignant obstructions) were investigated, with 15 healthy subjects used as a control group (CG). Bioelectrical impedance analysis (BIA) determinations and values derived from anthropometric measurements were used to assess body compartment status. The coefficient of variation of BIA was below 4% in both OJ and CG subjects. No differences were found in intracellular water. However total body water (TBW) and ECW were reduced in OJ patients (50.5 +/- 4.6 vs. 56 +/- 8% body weight, p = 0.05; and 21 +/- 4.5 vs. 23.8 +/- 2.5% body weight, p < 0.05, respectively). There were no differences between benign and malignant obstructions. Seventy four percent of OJ patients had an ECW volume below the mean +/- 2 SD in the CG subjects. Anthropometric and BIA determinations correlated closely for TBW measurements in both CG (r = 0.92, p < 0.001) and OJ patients (r = 0.91, p < 0.001). Bland-Altman analysis also showed that for TBW the BIA was in agreement with anthropometry. In the present study, BIA offered a good correlation with anthropometric determinations and was a reliable method for body fluid disturbances assessment in jaundiced patients.

[Evaluation of anorexia in patients with bile duct obstruction]. / Evaluación de la anorexia en enfermos con obstrucción de la vía biliar.

INTRODUCTION: Obstructive jaundice is often accompanied by protein-caloric malnutrition. The objective of the present study is to analyze the incidence and the degree of alterations in the food ingestion of patients with obstructive jaundice. MATERIAL AND METHODS: In a prospective, cross-sectional study 50 patients with obstructive jaundice (19 benign and 31 malignant) were evaluated. The anorexia was evaluated using Welch's test (subjective evaluation) and by means of quantifying the caloric ingestion. An anthropometric parameter (ideal weigh < 95%) and two biochemical ones (albumin < 3.5 g/dl and pre-albumin < 17 mg/dl) were used to define the degree of malnutrition. RESULTS: 96% of the patients presented alterations in the Welch test and in 72% of the patients the caloric ingestion was below the estimated needs. Overall, the ingestion of food was reduced by 76.3 +/- 30% of the estimated needs (84.7 +/- 28% in the benign cases and 70.9 +/- 32% in the malignant cases). Both the Welch test (r = 0.59; p = 0.01) and the caloric ingestion (r = 0.53; p < 0.001) were inversely correlated with the serum bilirubin. In patients with malnutrition criteria, the caloric ingestion was reduced by 30% against the 12% reduction in the non-malnourished patients (p < 0.05). There was a direct correlation between the two methods used in the assessment of the anorexia (r = 0.71; p < 0.001). CONCLUSIONS: Obstructive jaundice is associated with an important reduction in the caloric ingestion, and this is manifested in both biliary obstructions of a benign origin, and in those of neoplasic origins.

[Prospective and randomized study on the usefulness of octreotide in the prevention of complications after cephalic duodeno-pancreatectomy]. / Estudio prospectivo y randomizado sobre la utilidad del Octreótido en la prevención de complicaciones tras duodeno-pancreatectomía cefálica.

OBJECTIVE: This study seeks to evaluate the role of the somatostatin analogue Octreotide as postoperative prophylaxis in the prevention of pancreatic fistula following Pancreaticoduodenectomy (PD). METHODS: A prospective and randomized study has been completed in 34 patients undergoing PD. Sixteen patients were randomly assigned to receive Octreotide 0.1 cc (100 mcg) three times daily subcutaneously during the first seven days of the post-operative period and the remaining 18 constituted the control group. All patients were fed parenterally until normal oral feeding was restored (mean 8 days). Fisher's exact test was used to compare complications in both groups. Pancreatic fistula was defined as the persistence of an amylase-rich discharge at least 50 ml daily during a minimum period of two weeks. RESULTS: The mortality rate was 3% and the morbidity 26%. No significant differences were observed regarding the total number of complications. The appearance of pancreatic fistula was considerably smaller (p = 0.03) in the Octreotide group than in control group. Postoperative hospital stay and the number of subsequent surgical interventions were significantly higher (p < 0.05) in the control group. CONCLUSION: Octreotide prevents the occurrence of pancreatic fistula after PD when it is administered prophylactically during the immediate postoperative period.

An unusual form of pneumatosis intestinalis associated with appendicitis.

A rare case of pneumatosis intestinalis is described in a patient with appendicitis. Gas in the colonic wall, epiploic appendices and mesentery caused a new appearance not previously reported on plain radiography or CT. The relevance of an associated redundant right colon is also discussed.

[Evaluation of body fluid compartments and their relationship with water-electrolyte changes in obstructive jaundice]. / Evaluación de los compartimientos corporales y su relación con las alteraciones hidroelectrolíticas en la ictericia obstructiva.

BACKGROUND: The alteration of the mechanisms of water and sodium preservation may be an important factor in the development of acute postoperative renal failure in obstructive jaundice (OJ). Experimental OJ has been associated with a depletion of the extracellular volume and alteration of the mechanisms of regulation of hydrosaline metabolism. The aim of this study was to evaluate the distribution of the body volumes and the regulating hormones of hydrosaline metabolism in human OJ. PATIENTS AND METHOD: A prospective, clinical study evaluating 18 patients with OJ (9 females and 9 males) with a mean age of 69 +/- 8.9 years was performed. The plasma levels of antinatriuretic peptide (ANP), aldosterone and renin were determined. The body volumes were evaluated by tetrapolar bioimpedanciometry. The results of the patients with OJ were compared with a control group (CG) of 12 healthy subjects, matched for age and sex (6 females and 6 males with a mean age of 64.5 +/- 14 years). RESULTS: High ANP values were observed in 87.5% of the patients. The results of the hormonal studies compared with the CG were: ANP (117.33 +/- 37.7 vs 41.31 +/- 16.8 pg/ml; p < 0.001), aldosterone (185.68 +/- 82.1 vs 44.3 +/- 21.6 pg/ml; p < 0.001) and renine (57.18 +/- 69.9 vs 16.08 +/- 9.7 microU/ml; p < 0.05). Depletion of extracellular volume was found in 75% of the patients. CONCLUSIONS: Human obstructive jaundice is associated with an important alteration in the hormonal mechanisms of water and sodium regulation. This alteration is accompanied by a marked depletion of extracellular volume.

[Prognostic factors in severe acute pancreatitis. Univariate and multivariate study]. / Factores pronósticos en la pancreatitis aguda severa. Estudio univariante y multivariante.

OBJECTIVES: The aim of this study was to analyze the prediction of mortality in patients with severe acute pancreatitis. PATIENTS AND METHODS: In a retrospective study 43 patients with severe acute pancreatitis were included. All patients required ICU admittance and surgical treatment. We evaluated severity according to Ranson's criteria, APACHE II score, CT scan classification (Hill), intraoperative findings (Vankemmel's classification) and number of organs failure. We performed a univariant and multivariant statistic study with lineal discriminant analysis. RESULTS: The overall mortality was 46.5%. Ranson's score and APACHE II did not correlate with mortality. Hill's classification did not reach significance either. However, only the Vankemmel's classification and the number of organs failure had statistic value (p < 0.01). After lineal discriminant analysis, the association of more than 4 Ranson's criteria, APACHE II up to 9 points, grades IV and V in Hill's classification and 4 organs failure had a predictive value for mortality. CONCLUSIONS: In our limited experience the Vankemmel's classification and the number of organs failure had a predictive value for mortality in patients with acute pancreatitis. The association of more than 4 Ranson's criteria. APACHE II up to 8 points, grades IV-V in Hill's classification and 4 organs failure disclosed poor prognosis.