Spontaneous pneumomediastinum: An extra muscular manifestation of anti-MDA5 dermatomyositis. Report of 2 cases.

The use of specific antibodies in inflammatory myopathies has improved the characterization of this disease, identifying different clinical phenotypes. Patients with dermatomyositis (DM) and anti-MDA5 antibodies display typical skin symptoms, lesser muscular involvement, and a prevalence of interstitial lung disease (ILD) of up to 91%. Beyond ILD, spontaneous pneumomediastinum (SN) has been identified as a rare but potentially fatal pulmonary manifestation. Two cases of this complication in patients with anti-MDA5 DM are reported.

Gestational diabetes mellitus early prediction by maternal body fat index: A cohort study.

OBJECTIVES: To compare the performance of maternal body fat index (BFI) assessed during the first 20+6 weeks among 138 pregnant women in an ultrasound outpatient clinic as a predictor of gestational diabetes mellitus (GDM) later in pregnancy. METHOD: Maternal visceral and subcutaneous fat was measured with a convex ultrasound probe placed in two locations on the maternal abdominal surface: the first in the mid-sagittal epigastric region, visualising epigastric fat, and the second 2cm above the maternal umbilical scar, visualising periumbilical fat. Ultrasound callipers measured the distance from dermal edge to the linea alba and after from the linea alba to the anterior hepatic surface (epigastric fat). Periumbilical fat was measured from the dermal edge to the linea alba and after from the linea alba to the anterior aortic surface. The BFI formula was [visceral adipose tissue (mm)×subcutaneous adipose tissue (mm)]/maternal height (cm). RESULTS: The best thresholds for predicting GDM outcome for epigastric and periumbilical BFI were 1.2 and 4.8, respectively. Odds ratio, sensitivity and specificity were 5.88 (95% CI 1.86-18.6), 80.9%, 58.0% for the epigastric site and 6.31 (95% CI 1.73-22.94), 84.2%, 54.2% for the periumbilical site. Pre-pregnancy body mass index compatible with adult obesity shows inadequate predictive performance for GDM outcome. Only epigastric BFI above 1.2 maintained statistical significance for GDM in the logistic regression analysis, when compared to periumbilical BFI above 4.8. CONCLUSION: Epigastric BFI above 1.2 during the first half of pregnancy may help identify women at risk of developing GDM later in pregnancy.

Complications and inappropriate shocks in pediatric patients receiving a subcutaneous implantable cardioverter defibrilator.

INTRODUCTION AND OBJECTIVES: There is limited evidence regarding the use of subcutaneous implantable cardioverter-defibrillators (S-ICD) in pediatric patients. The aim of this study was to determine the incidence of complications in these patients at our center, according to the type of ICD and patient size. METHODS: We included all patients aged<18 years who received an S-ICD since 2016 at our center. As a control group, we also included contemporary patients (since 2014) who received a transvenous ICD (TV-ICD). The primary endpoint was a composite of complications and inappropriate shocks. RESULTS: A total of 26 patients received an S-ICD (median age, 14 [5-17] years; body mass index [BMI], 20.2 kg/m2). Implantation was intermuscular in 23 patients (88%) and subserratus in the remainder. Two incisions were used in 24 patients (92%). In all patients, 2 zones were programmed: a conditional zone set at 230 (220-230) bpm, and a shock zone set at 250 bpm. Nineteen patients received a TV-ICD (median age, 11 [range, 5-16] years; BMI, 19.2 kg/m2, 79% single-chamber). Survival free from the primary endpoint at 5 years was 80% in the S-ICD group and 63% in the TV-ICD group (P=.54). Survival free from inappropriate shocks was similar (85% vs 89%, P=.86), while survival free from complications was higher in the S-ICD group (96% vs 57%, cloglog P=.016). There were no therapy failures in the S-ICD group, and no increased complication rates were observed in patients with BMI ≤20 kg/m2. CONCLUSIONS: With contemporary implantation techniques and programming, S-ICD is a safe and effective therapy in pediatric patients. The number of inappropriate shocks is similar to TV-ICD, with fewer short- and mid-term complications.

Desfibrilador subcutáneo. Primeros casos en el Instituto Nacional de Cardiología, incluyendo dos pacientes pediátricos / Use of subcutaneous cardioverter-defibrillator. First cases reported from National Institute of Cardiology Ignacio Chávez-Mexico

Resumen Introducción: El desfibrilador automático implantable (DAI) transvenoso es el tratamiento de elección para la prevención de muerte súbita (MS) cardiaca por arritmias ventriculares malignas. Su uso se puede ver limitado cuando existe infección del sistema de estimulación o en población pediátrica donde representa un reto por diversas razones, incluyendo: las mínimas dimensiones del sistema venoso de los niños, la longitud de los electrodos, el tamaño del generador, así como por la complejidad anatómica en casos de cardiopatía congénita asociada. Objetivo: El presente artículo tiene por objetivo presentar la primera serie de casos de pacientes mexicanos a los cuales se les implantó un DAI subcutáneo (DAI-SC) como terapia para la prevención de MS. Métodos: Se presentan los cuatro primeros casos que fueron implantados en el Instituto Nacional de Cardiología Ignacio Chávez con un DAI-SC (Emblem, Boston Scientific, EE.UU.), tres de ellos eran pacientes pediátricos, incluyendo el primer implante de este tipo de dispositivo en un paciente pediátrico en América Latina. Las técnicas de tres y dos incisiones fueron empleadas bajo anestesia general. Resultados: Se realizó el implante exitoso con técnica de tres incisiones en los dos primeros casos y con técnica de dos incisiones en los dos últimos casos. Se corroboró el adecuado funcionamiento del dispositivo en sala, con la verificación de terapia apropiada (65 J) de la fibrilación ventricular inducida mediante estimulación a 50 Hz. No hubo complicaciones inmediatas. Un paciente presentó descargas apropiadas a los dos meses del implante. En el seguimiento, un niño desarrolló erosión de la piel a nivel de la curva del electrodo en el esternón, sin datos de infección. En quirófano se resecó la piel dañada, se retiró el barril y la seda de fijación, se realizó lavado quirúrgico y se volvió a cerrar la piel, logrando así evitar el retiro del sistema. Conclusiones: El DAI-SC es una terapia alternativa al DAI endovenoso y puede ser considerado de primera elección en aquellos casos que no requieran de estimulación ventricular, incluyendo pacientes pediátricos. Pueden ocurrir complicaciones cutáneas, pero no representan una amenaza como las complicaciones venosas de los DAI convencionales.

Abstract Introduction: The transvenous implantable cardioverter defibrillator (ICD) is the treatment of choice for the prevention of sudden cardiac death (SCD). Its use could be restricted when device-related infections occurs or in the pediatric population. In the later, an ICD represents a challenge, due to the minimal dimensions of the venous system in children, the length of the electrodes, the size of the generator, as well as the anatomical complexity in cases with associated congenital heart disease. Objective: This article presents the first Mexican patients with a subcutaneous ICD (SC-ICD) implant as a therapy for the prevention of SCD. Methods: The first four cases were implanted at the Ignacio Chávez National Institute of Cardiology with a SC-ICD (Emblem, Boston Scientific, USA), three of them were pediatric patients, including the first implant of this type of device in a pediatric patient in Latin America. The 3-incision and 2-incision techniques were used under general anesthesia. Results: A successful implantation was obtained with the 3-incision technique in the first 2 cases and the last 2 with the 2-incision technique. Proper functioning of the device was corroborated in the operating room with proof of appropriate therapy (65 J) for ventricular fibrillation induced with 50 Hz stimulation. No immediate complications were observed. One patient had appropriate shocks two months after the implant. During follow-up, one child developed skin erosion at the level of the curve of the electrode on the sternum, with no signs of infection. In the operating room, the damaged skin was resected, the barrel and the fixation silk were removed, surgical lavage was performed, and the skin was closed again, thus avoiding removal of the system. Conclusions: The SC-ICD is an alternative therapy to the transvenous ICD. It can be considered first choice in subjects who do not require ventricular pacing, including pediatric patients. Skin complications can occur but do not pose a threat as venous complications of conventional ICDs.

Neumorraquis y neumomediastino espontáneo asociado a crisis asmática en el adulto

Introducción: la forma más frecuente del síndrome de fuga de aire en la crisis asmática es el neumomediastino, siendo habitualmente de curso benigno. La neumorraquis es una complicación poco descrita en la literatura. Presentamos el caso clínico de un paciente de 35 años, portador de asma intermitente, y que ingresa a terapia intensiva por crisis bronco obstructiva severa, enfisema subcutáneo cervical y cara anterior de tórax. La tomografía de tórax demostró neumomediastino extenso y neumorraquis. No se documentó neumotórax ni compromiso hemodinámico por la crisis. Presentó evolución satisfactoria con ventilación mecánica invasiva, broncodilatadores y corticoides sistémicos.

A case report: Pneumomediastinum is the most common form of air leak syndrome in asthmatic crisis and is usually benign in nature. Pneumorrhachis is a complication that is rarely described in the literature. We present the clinical case of a 35-year-old patient with intermittent asthma who was admitted to the Intensive Care Unit due to a severe bronchoobstructive crisis, cervical subcutaneous emphysema, and anterior chest wall emphysema. Chest computed tomography revealed extensive pneumomediastinum and pneumorrhachis Pneumothorax or hemodynamic compromise due to the crisis was not documented. The patient showed a satisfactory outcome with invasive mechanical ventilation, bronchodilators, and systemic corticosteroids.

Relato de caso: O pneumomediastino é a forma mais comum de síndrome de presença de ar no mediastino em crises de asma, geralmente com curso benigno. A pneumorráquis é uma complicação raramente descrita na literatura. Apresentamos o caso clínico de um paciente de 35 anos, com asma intermitente, admitido na Unidade de Cuidados Intensivos por crise bronco-obstrutiva grave, enfisema subcutâneo cervical e de parede torácica anterior. A tomografia de tórax mostrou extenso pneumomediastino e pneumorraque. Não se observou pneumotórax ou comprometimento hemodinâmico devido à crise. Apresentou evolução satisfatória com ventilação mecânica invasiva, broncodilatadores e corticoides sistêmicos.

Use of subcutaneous cardioverter-defibrillator. First cases reported from National Institute of Cardiology Ignacio Chávez-Mexico.

INTRODUCTION: The transvenous implantable cardioverter defibrillator (ICD) is the treatment of choice for the prevention of sudden cardiac death (SCD). Its use could be restricted when device-related infections occurs or in the pediatric population. In the later, an ICD represents a challenge, due to the minimal dimensions of the venous system in children, the length of the electrodes, the size of the generator, as well as the anatomical complexity in cases with associated congenital heart disease. OBJECTIVE: This article presents the first Mexican patients with a subcutaneous ICD (SC-ICD) implant as a therapy for the prevention of SCD. METHODS: The first four cases were implanted at the Ignacio Chávez National Institute of Cardiology with a SC-ICD (Emblem, Boston Scientific, USA), three of them were pediatric patients, including the first implant of this type of device in a pediatric patient in Latin America. The 3-incision and 2-incision techniques were used under general anesthesia. RESULTS: A successful implantation was obtained with the 3-incision technique in the first 2 cases and the last 2 with the 2-incision technique. Proper functioning of the device was corroborated in the operating room with proof of appropriate therapy (65 J) for ventricular fibrillation induced with 50 Hz stimulation. No immediate complications were observed. One patient had appropriate shocks two months after the implant. During follow-up, one child developed skin erosion at the level of the curve of the electrode on the sternum, with no signs of infection. In the operating room, the damaged skin was resected, the barrel and the fixation silk were removed, surgical lavage was performed, and the skin was closed again, thus avoiding removal of the system. CONCLUSIONS: The SC-ICD is an alternative therapy to the transvenous ICD. It can be considered first choice in subjects who do not require ventricular pacing, including pediatric patients. Skin complications can occur but do not pose a threat as venous complications of conventional ICDs.

INTRODUCCIÓN: El desfibrilador automático implantable (DAI) transvenoso es el tratamiento de elección para la prevención de muerte súbita (MS) cardiaca por arritmias ventriculares malignas. Su uso se puede ver limitado cuando existe infección del sistema de estimulación o en población pediátrica donde representa un reto por diversas razones, incluyendo: las mínimas dimensiones del sistema venoso de los niños, la longitud de los electrodos, el tamaño del generador, así como por la complejidad anatómica en casos de cardiopatía congénita asociada. OBJETIVO: El presente artículo tiene por objetivo presentar la primera serie de casos de pacientes mexicanos a los cuales se les implantó un DAI subcutáneo (DAI-SC) como terapia para la prevención de MS. MÉTODOS: Se presentan los cuatro primeros casos que fueron implantados en el Instituto Nacional de Cardiología Ignacio Chávez con un DAI-SC (Emblem, Boston Scientific, EE.UU.), tres de ellos eran pacientes pediátricos, incluyendo el primer implante de este tipo de dispositivo en un paciente pediátrico en América Latina. Las técnicas de tres y dos incisiones fueron empleadas bajo anestesia general. RESULTADOS: Se realizó el implante exitoso con técnica de tres incisiones en los dos primeros casos y con técnica de dos incisiones en los dos últimos casos. Se corroboró el adecuado funcionamiento del dispositivo en sala, con la verificación de terapia apropiada (65 J) de la fibrilación ventricular inducida mediante estimulación a 50 Hz. No hubo complicaciones inmediatas. Un paciente presentó descargas apropiadas a los dos meses del implante. En el seguimiento, un niño desarrolló erosión de la piel a nivel de la curva del electrodo en el esternón, sin datos de infección. En quirófano se resecó la piel dañada, se retiró el barril y la seda de fijación, se realizó lavado quirúrgico y se volvió a cerrar la piel, logrando así evitar el retiro del sistema. CONCLUSIONES: El DAI-SC es una terapia alternativa al DAI endovenoso y puede ser considerado de primera elección en aquellos casos que no requieran de estimulación ventricular, incluyendo pacientes pediátricos. Pueden ocurrir complicaciones cutáneas, pero no representan una amenaza como las complicaciones venosas de los DAI convencionales.

Manejo de reações adversas dermatológicas em pacientes submetidos à terapia quimioterápica antineoplásica / Management of dermatological adverse reactions in patients undergoing antineoplastic chemotherapy

Objetivo: o presente estudo tem como objetivo reunir recomendações de cuidados considerando a prevenção e tratamento de lesões de pele induzidas pelo tratamento com quimioterápicos antineoplásicos, de acordo com os estudos e consensos atuais. Metodologia: realizou-se um estudo bibliográfico para levantamento das relações entre os principais fármacos antineoplásicos e suas intercorrências dermatológicas, bem como seus respectivos manejos, para subsidiar a orientação e aconselhamento aos profissionais de saúde que acompanham o paciente oncológico. Resultado: os principais problemas dermatológicos decorrentes do uso de antineoplásicos correspondem às lesões de pele, tais como a descoloração, hiperpigmentação, fotossensibilidade, eritemas, descamação e prurido. Também são recorrentes os efeitos adversos que acometem os pelos e cabelos, resultando em alopecia, e a modificação do crescimento e lesões nas unhas. Tratamentos específicos para cada caso são capazes de amenizar ou reverter os problemas. Conclusão: as reações adversas aos medicamentos envolvendo quimioterapia são frequentes na prática oncológica, e variam em termos de frequência e gravidade, atingindo diversos anexos cutâneos. O adequado manejo destes efeitos melhora a integridade da pele e demais estruturas, proporcionando a esses pacientes a melhoria da autoestima e da qualidade de vida.

Objective: the present study aims to gather care recommendations considering the prevention and treatment of skin lesions induced by treatment with antineoplastic chemotherapy, according to current studies and consensus. Methodology: a bibliographical study was carried out to survey the relationships between the main antineoplastic drugs and their dermatological intercurrences, as well as their respective management, to subsidize the guidance and counselling of health professionals who treat cancer patients. Result: the main dermatological problems arising from the use of antineoplastic agents correspond to skin lesions, such as discoloration, hyperpigmentation, photosensitivity, erythema, scaling and pruritus. Adverse effects that affect hair and body hair are also recurrent, resulting in alopecia, and the modification of growth and lesions on the nails. Specific treatments for each case can alleviate or reverse the problems. Conclusion: adverse drug reactions involving chemotherapy are frequent in oncology practice, and vary in terms of frequency and severity, affecting various skin appendages. Proper management of these effects improves the integrity of the skin and other structures, providing these patients with improved self-esteem and quality of life.

Hidatidosis subcutánea primaria

La hidatidosis o equinococosis quística es una zoonosis parasitaria endémica causada por el estadio larvario del cestode Echinococcus granulosus. El hígado y el pulmón son los órganos con afección más frecuente. Su ubicación subcutánea es una entidad rara, poco descrita, y por ende un reto diagnóstico. Describimos el caso de una mujer, de 18 años de edad, procedente de un área endémica, que presentó un quiste hidatídico primario supraclavicular.

Hydatid disease or cystic echinococcosis is an endemic parasitic zoonosis caused by the larval stage of the cestode Echinococcus granulosus, the liver and lung being the most frequently affected organs. Its subcutaneous location is a rare entity, little described, and therefore a diagnostic challenge. We describe the case of an 18-year-old woman from an endemic area who presented with a primary supraclavicular hydatid cyst.

Is adipose tissue metabolic activity a predictor of pathological responses to neoadjuvant treatment in breast cancer.

INTRODUCTION AND OBJECTIVE: Prediction of the pathologic response to neoadjuvant chemotherapy (NAC) in patients with locally advanced breast cancer is essential for optimal treatment strategy. The current approach of adjuvant or neoadjuvant treatment is based on the molecular subtype. Obesity may have affected chemotherapy response. This study aims to evaluate the relationship between metabolic activity of adipose tissue (AT) and pathological responses to NAC. And to define the association with body mass index (BMI) and metabolic parameters of standardized uptake value (SUV) of adipose tissue measured by positron emission computed tomography (PET/CT). MATERIAL AND METHODS: One-hundred and sixteen consecutive patients with stage II and III breast cancer who underwent PET/CT before receiving NAC, were evaluated in the study. Metabolic parameters of visceral adipose tissue (VAT-SUV), subcutaneous adipose tissue (SAT-SUV), and calculated SUV of visceral-to-subcutaneous ratio (V/S-ratio) were regarded. The relationship between SUV of AT and pathologic response was evaluated from medical records retrospectively. RESULTS: Univariate-analysis revealed that good pathological response was significantly associated with clinical stage (P<.001), HER-2 positivity (P<.001), VAT-SUV (P=.037), VAT-density (P=.043) and V/S-ratio (P=.003). In multivariate-analysis clinical stage, HER-2 positivity and V/S-ratio were found to have statistically effect on pathological response. VAT-volume (P<.001), VAT-SUV (P=.016), SAT-volume (P<.001) and SAT-SUV (P<.001) has positive correlation with BMI value. On the other hand, V/S-ratio (P=.039) and SAT-density (P=.003) has negative correlation with BMI. CONCLUSION: Metabolic activity of AT is associated with BMI and effected chemotherapy responses. LowV/S ratio was associated with high BMI and poor pathological response to NAC. V/S ratio may be a useful marker for the prediction of NAC responses.

Neumotórax espontáneo bilateral en primigestante adolescente, reporte de un caso / Spontaneous bilateral pneumothorax in a primigestant adolescent, a case report

El neumotórax espontáneo es una patología extremadamente rara durante la gestación. Se define como la presencia de aire dentro de la cavidad pleural que puede generar principalmente dolor torácico y disnea. Esta patología tiene unas bajas incidencia y prevalencia en el embarazo, pero es relevante por una alta tasa de recurrencia, con un buen pronóstico para la madre y el feto si es tempranamente diagnosticada y oportunamente manejada. Se relaciona con factores de riesgo como las maniobras de Valsalva efectuadas durante el trabajo de parto, además de con comorbilidad como el tabaquismo, y con el biotipo longilíneo, entre otros, por lo que son muy importantes una adecuada anamnesis y la evaluación de la exploración física. El obstetra debe sospecharlo ante la clínica de dolor torácico asociado a disnea en gestantes en el trabajo de parto y el parto, y tenerlo en cuenta como diagnóstico diferencial. Es de vital importancia tener un manejo multidisciplinario compuesto por ginecoobstetra, internista, neumólogo y neonatólogo, incluido el apoyo por una unidad de cuidado intensivo para evitar complicaciones materno-perinatales que se puedan asociar al neumotórax espontáneo.

Spontaneous pneumothorax is an extremely rare pathology during pregnancy. It is defined as the presence of air inside the pleural cavity that can mainly generate chest pain and dyspnea. This pathology has a low incidence and prevalence in pregnancy, but a high rate of recurrence with a good prognosis for the mother and the fetus if it is diagnosed early and managed early. It is related to risk factors such as Valsalva maneuvers performed during labor, in addition to comorbidities such as smoking, longilinear biotype, among others, so it is very important to have an adequate history and evaluation of the physical examination. The obstetrician must be attentive to chest pain symptoms associated with dyspnea in pregnant women during labor and delivery, suspect this pathology and take it into account as a differential diagnosis. It is vitally important to have a multidisciplinary management composed of the gynecologist-obstetrician, internist, pulmonologist, neonatologist, including the support of an intensive care unit to avoid maternal-perinatal complications that may be associated with spontaneous pneumothorax.

Enfisema subcutáneo masivo asociado a lesión traqueal posterior a intubación endotraqueal de urgencia: reporte de un caso / Massive subcutaneous emphysema associated with tracheal injury after emergency endotracheal intubation: a case report

El enfisema subcutáneo se produce como complicación frecuente en intervenciones quirúrgicas, técnicas invasivas, ventilación mecánica, lesiones traqueales y neumotórax. La progresión fuera del tórax con afectación facial, abdominal e incluso inguinal puede producir un síndrome compartimental con compresión de estructuras aledañas como la tráquea y vasos del cuello, tal situación se ha denominado enfisema subcutáneo masivo. En este documento se reporta el caso de un paciente que desarrolló un enfisema subcutáneo masivo como signo precoz de lesión traqueal asociada a la intubación y ventilación a presión positiva.

Subcutaneous emphysema occurs as a frequent complication in surgical interventions, invasive techniques, mechanical ventilation, tracheal injuries and pneumothorax. Progression outside the thorax with facial, abdominal, and even inguinal involvement can produce compartment syndrome with compression of surrounding structures such as the trachea and neck vessels. This situation has been called massive subcutaneous emphysema.This document reports the case of a patient who developed massive subcutaneous emphysema as an early sign of tracheal injury associated with intubation and positive pressure ventilation.

Lesión laringotraqueal secundaria a traumatismo cerrado de cuello / Laryngotracheal injury secondary to blunt neck trauma

Resumen Los traumatismos contusos en la tráquea pueden provocar un compromiso agudo de las vías respiratorias, con implicaciones poten cialmente mortales. Representan el 5-10% de todos los casos traumatológicos, y se acompañan de una mortalidad de aproximadamente el 1-7%, siendo necesario su diagnóstico y manejo precoz. Los órganos frecuentemente lesionados son: estructuras vasculares, en un 20%, y se estima que el tracto aéreo y digestivo se encuentran comprometidos en un 10% de los casos.

Abstract Blunt trauma to the trachea can cause acute airway involvement, with life-threatening implications. They represent 5-10% of all trauma cases, and are accompanied by a mortality of approximately 1-7%, requiring early diagnosis and management. The organs frequently injured are: vascular structures, in 20%, and it is estimated that the air and digestive tracts are compromised in 10% of cases.

Neumomediastino espontáneo. Reporte de un caso

RESUMEN El neumomediastino espontáneo se caracteriza por la presencia de aire en el mediastino. Es una enfermedad generalmente benigna, que evoluciona de forma satisfactoria entre 2 y 15 días, no asociada a causa directa conocida. Es infrecuente en la tercera edad. Se presenta principalmente con dolor torácico, disnea y enfisema subcutáneo. El diagnóstico se realiza sobre la base del cuadro clínico, la radiografía de tórax y la tomografía axial computarizada de tórax, siendo esta última importante, además, para establecer el diagnóstico diferencial con el síndrome de Boerhaave de manera oportuna. Se presentó el caso de un paciente masculino de 67 años de edad, fumador con antecedente de enfermedad pulmonar obstructiva crónica, que acude al cuerpo de guardia por dolor torácico, disnea y enfisema subcutáneo después de un episodio de tos intensa. Se le realizaron radiografías de tórax posteroanterior y lateral, en las que se observan la presencia de aire en el mediastino, se descartan otras enfermedades agudas, y se corrobora el diagnóstico de neumomediastino mediante tomografía axial computarizada de tórax. Recibió tratamiento con oxígeno, broncodilatadores, esteroides y antibióticoterapia, obteniéndose una mejoría evidente. La literatura reporta que no es habitual la presencia de este cuadro en pacientes de la tercera edad, y que debe sospecharse en aquellos que presenten una exacerbación de la enfermedad pulmonar obstructiva crónica, fundamentalmente después de un episodio de tos.

ABSTRACT The spontaneous pneumomediastinum is characterized by the air presence in the mediastinum. It is a generally benign disease which evolves in a satisfactory way between 2 and 15 days, that is not associated to any directly known cause. It is infrequent in the old age. It mainly presents with chest pain, dyspnea and subcutaneous emphysema. Diagnosis realizes on the base of clinical characteristics, thorax radiography and thorax axial computed tomography, being the last one also important to establish the differential diagnosis with Boerhaave syndrome in an opportune way. The case presented is the case of a male patient aged 67 years, who smokes and has antecedents of chronic obstructive pulmonary disease. He assisted to the consultation due to thoracic pain, dyspnea and subcutaneous emphysema after an episode of intense cough. Posteroanterior and lateral thorax radiography were done, finding air presence in the mediastinum; other acute diseases were discarded and the diagnosis of pneumomediastinum was corroborated through thorax computed tomography scan. He was treated with oxygen, bronchodilators, steroids and antibiotics therapy, obtaining an evident improvement. The literature reports that the presence of these characteristics in old-aged patients is not common and that it must be suspected in those presenting an aggravation of the chronic obstructive pulmonary disease, mainly after a cough episode.

Lipoatrophia semicircularis: Clinical study and follow-up of 76 cases in Madrid, Spain. Classification proposal. / Lipoatrofia semicircular: estudio y seguimiento clínico de 76 casos en Madrid, España. Propuesta de clasificación.

INTRODUCTION: The clinical presentations of Lipoatrophia semicircularis (LS) vary, and diagnostic criteria are unclear. Several etiopathogenic factors, including occupational environmental ones, have been suggested. We aimed to describe a cluster of cases of suspected LS that started to appear in May 2008 among employees of the city council of Madrid, Spain. We report the actions taken by the council's Occupational Health Service and propose clinical categories with prognostic implications. MATERIAL AND METHOD: Retrospective observational case series study including prospectively collected data from patients evaluated between 2008 and 2021 at the Madrid City Council STI/Dermatology Department. Information on measures taken by the Occupational Health Service is detailed. The recording of clinical variables for statistical analysis and the proposal of defined clinical patterns were carried out. RESULTS: We studied the cases of 75 women and one man, most of whom attended follow-up visits for a median of 37 months. Local symptoms were observed in just 14.5% of patients. The cases were classified into 4 groups: typical LS, unilateral LS, band-like lipoatrophy in the lower limbs, and nonspecific LS. Clinical outcomes were more often favorable in the first 2 groups, in which 76% of patients achieved total or partial improvement of lesions (vs. 25.8% in the last 2 groups). LS was negatively associated with the presence of hypertrophic subcutaneous adipose tissue (P<.001). DISCUSSION: Typical LS, which can often be unilateral, generally has a satisfactory outcome. The clinical characteristics of this form distinguish it from other types of lipoatrophy. Measures taken by the Occupational Health Service contributed to favorable outcomes. In this series, LS was not associated with marked subcutaneous adipose tissue hypertrophy in the thighs. Our proposed categories may help distinguish between cases of LS with a favorable prognosis and other cases presenting with skin surface depressions, which are often persistent.

Terapia de presión negativa para pacientes con enfisema subcutáneo y neumomediastino masivo / Negative pressure therapy for patients with subcutaneous emphysemaand massive pneumomediastinum

Se han descrito diversas técnicas para el tratamiento del enfisema subcutáneo y del neumomediastino. Algunos pacientes con pequeñas perforaciones traqueales pueden ser manejados de forma expectante, salvo que requieran ventilación mecánica. Se presentan las imágenes de un paciente con enfisema subcutáneo y neumomediastino no candidato a cirugía y quien fue tratado exitosamente con terapia de presión negativa.

Different techniques have been described for the treatment of subcutaneous emphysema and pneumomediatinum. Some patients with small tracheal perforations can be managed expectantly, unless they require mechanical ventilation. Images of a patient with subcutaneous emphysema and pneumomediastinum not a candidate for surgery and who was successfully treated with negative pressure therapy are presented.

Drenaje subcutáneo por técnica de Beck para enfisema subcutáneo masivo en paciente pediátrico: reporte de caso / Subcutaneous drainage using Beck's technique for massive subcutaneous emphysema in a pediatric patient: a case report

RESUMEN Diversas terapias son empleadas para el manejo del enfisema subcutáneo en adultos, pero no se ha encontrado alguna referencia del drenaje subcutáneo mediante la técnica de Beck en pacientes pediátricos. Presentamos el caso clínico de una paciente de catorce años de edad con un trauma cerrado debido a una caída desde una altura de diez metros. Al ingreso, la paciente muestra pérdida de conciencia y desarrolla un síndrome de distrés respiratorio, por lo que se le indica ventilación mecánica. Siete días después se produce un enfisema subcutáneo y se realiza una inserción con angiocatéter fenestrado empleando la técnica de Beck. El enfisema en la zona superior del tórax y el rostro disminuyó a las 24 horas, y a las 72 horas la resolución fue completa.

ABSTRACT Several therapies are used for the management of subcutaneous emphysema in adults, but no reference to subcutaneous drainage using Beck's technique has been found in pediatric patients. This is the clinical case of a 14-year-old female patient who presented a blunt force trauma that resulted from a ten-meter-high fall. On admission, she was unconscious and developed respiratory distress syndrome, thus mechanical ventilation was indicated. Seven days later, subcutaneous emphysema occurred, and a fenestrated angiocatheter was inserted using Beck's method. At 24 hours, the emphysema was reduced in the upper chest and face, and, at 72 hours, complete resolution was observed.

Neumomediastino espontáneo asociado a episodio grave y persistente de hipo / Spontaneous pneumomediastinum associated with severe and persistent episode of hiccups

Resumen Introducción: El neumomediastino espontáneo es la presencia de aire libre en el mediastino que no ocurre por un trauma torácico o esofágico directo. Es un padecimiento muy raro, que usualmente ocurre en pacientes con asma, infecciones respiratorias o aspiración de cuerpo extraño. Se reportan pocos casos asociados a eventos de singultos por reflujo grave. Caso clínico: Se presenta el caso de una paciente de 10 años con neumomediastino espontáneo y extensión al cuello secundario a un episodio grave y persistente de hipo sin antecedentes de asma, trauma, cirugía, infección aguda, aspiración de cuerpo extraño ni ejercicio intenso con Vasalva. Conclusiones: La irritación del tercio distal del esófago produjo los episodios graves y persistentes de hipo que incrementaron la presión intratorácica, que a su vez por efecto Macklin, desencadenó el neumomediastino. El diagnóstico se realiza con estudios de imagen. El tratamiento es conservador, con resolución del cuadro clínico entre 5 y 7 días después de la hospitalización.

Abstract Background: Spontaneous pneumomediastinum is the presence of free air in the mediastinum that does not occur from direct thoracic or esophageal trauma. It is a very rare condition usually related to patients with asthma, respiratory infections, or foreign body aspiration. Only a few cases are reported to be associated with severe reflux events. Case report: We present the case of a 10-year-old female with spontaneous pneumomediastinum extending to the neck secondary to severe and persistent hiccups, with no history of asthma, trauma, surgery, acute infection, foreign body aspiration, and intense exercise with Vasalva. Conclusions: The irritation of the distal third of the esophagus produced severe and persistent episodes of hiccups that increased the intrathoracic pressure, which in turn triggered the pneumomediastinum by Macklin effect. The diagnosis is made with imaging studies. The treatment is conservative with resolution of the clinical picture between five and seven days after hospitalization.

[Spontaneous pneumomediastinum associated with severe and persistent episode of hiccups.] / Neumomediastino espontáneo asociado a episodio grave y persistente de hipo.

Background: Spontaneous pneumomediastinum is the presence of free air in the mediastinum that does not occur from direct thoracic or esophageal trauma. It is a very rare condition usually related to patients with asthma, respiratory infections, or foreign body aspiration. Only a few cases are reported to be associated with severe reflux events. Case report: We present the case of a 10-year-old female with spontaneous pneumomediastinum extending to the neck secondary to severe and persistent hiccups, with no history of asthma, trauma, surgery, acute infection, foreign body aspiration, and intense exercise with Vasalva. Conclusions: The irritation of the distal third of the esophagus produced severe and persistent episodes of hiccups that increased the intrathoracic pressure, which in turn triggered the pneumomediastinum by Macklin effect. The diagnosis is made with imaging studies. The treatment is conservative with resolution of the clinical picture between five and seven days after hospitalization.

Introducción: El neumomediastino espontáneo es la presencia de aire libre en el mediastino que no ocurre por un trauma torácico o esofágico directo. Es un padecimiento muy raro, que usualmente ocurre en pacientes con asma, infecciones respiratorias o aspiración de cuerpo extraño. Se reportan pocos casos asociados a eventos de singultos por reflujo grave. Caso clínico: Se presenta el caso de una paciente de 10 años con neumomediastino espontáneo y extensión al cuello secundario a un episodio grave y persistente de hipo sin antecedentes de asma, trauma, cirugía, infección aguda, aspiración de cuerpo extraño ni ejercicio intenso con Vasalva. Conclusiones: La irritación del tercio distal del esófago produjo los episodios graves y persistentes de hipo que incrementaron la presión intratorácica, que a su vez por efecto Macklin, desencadenó el neumomediastino. El diagnóstico se realiza con estudios de imagen. El tratamiento es conservador, con resolución del cuadro clínico entre 5 y 7 días después de la hospitalización.

Enfisema subcutáneo relacionado con trauma facial en un adulto / Subcutaneous emphysema related to facial trauma in an adult

Se describe el caso clínico de un paciente de 45 años de edad, blanco, quien fue atendido en el cuerpo de guardia médica del Hospital Universitario Dr. Antonio Luaces Iraola, provincia de Ciego de Ávila, por presentar trauma facial, debido a caída por un resbalón y golpe en la cara con el borde de cemento de una piscina. Al realizar el examen físico se halló un enfisema cervicofacial. Se indicó tomografía axial computarizada, la cual mostró fractura de las paredes medial y lateral del seno maxilar izquierdo. Se decidió utilizar la técnica conservadora para extracción de aire mediante la colocación de agujas. El paciente evolucionó favorablemente y no tuvo recidivas.

The case report of a 45 years white patient is described who was assisted in the emergency department of Dr. Antonio Luaces Iraola University Hospital, Ciego de Ávila province, presenting a facial trauma, due to a fall by a slip and hit in the face with a swimming pool cement border. A cervicofacial emphysema was found when the physical exam was carried out. Computerized axial tomography was indicated, which showed fracture of the medial and lateral walls of the left maxillary sinus. It was decided to use the conservative technique for air extraction by means of the needles placement. The patient had a favorable clinical course and he didn't have relapses.

Finding the bubble: atypical and unusual extrapulmonary air in the chest.

OBJECTIVE: To describe the radiologic findings of extrapulmonary air in the chest and to review atypical and unusual causes of extrapulmonary air, emphasizing the importance of the diagnosis in managing these patients. CONCLUSION: In this article, we review a series of cases collected at our center that manifest with extrapulmonary air in the thorax, paying special attention to atypical and uncommon causes. We discuss the causes of extrapulmonary according to its location: mediastinum (spontaneous pneumomediastinum with pneumorrhachis, tracheal rupture, dehiscence of the bronchial anastomosis after lung transplantation, intramucosal esophageal dissection, Boerhaave syndrome, tracheoesophageal fistula in patients with esophageal tumors, bronchial perforation and esophagorespiratory fistula due to lymph-node rupture, and acute mediastinitis), pericardium (pneumopericardium in patients with lung tumors), cardiovascular (venous air embolism), pleura (bronchopleural fistulas, spontaneous pneumothorax in patients with malignant pleural mesotheliomas and primary lung tumors, and bilateral pneumothorax after unilateral lung biopsy), and thoracic wall (infections, transdiaphragmatic intercostal hernia, and subcutaneous emphysema after lung biopsy).