[Symmetrical rib fractures associated with chronic cough. Report of one case]. / Fracturas costales simétricas asociadas a tos.

Cough may be associated with complications such as syncope, urinary incontinence, pneumothorax, and less frequently, pulmonary hernia and costal fractures. Chronic cough is a cause of rib fractures and when they occur it is likely to affect more than one rib. We report a 53 year-old obese male in treatment with enalapril 10 mg for hypertension with a dry cough lasting five months. He consulted for bilateral chest pain and a Chest X ray examination showed symmetrical fractures in the seventh left and right ribs. Enalapril was discontinued, cough and pain subsided in two weeks.

[Isolated intestinal angioedema induced by enalapril]. / Angioedema intestinal aislado inducido por enalapril.

Angioedema induced by angiotensin converting enzyme inhibitors is a rare entity characterized by skin and mucosal edema, due to increased vascular permeability caused by inhibition of the converting enzyme and subsequent increase in bradykinin. It frequently presents with facial and mucosal involvement, being uncommon the intestinal or airway compromise. Intestinal angioedema may be associated with facial or isolated angioedema, the latter being exceptional. It is associated with recurrent episodes of pain, abdominal distention and watery diarrhea which complete recovery in two or three days. Although it is a rare entity, the fact that it is associated with frequently used drugs makes us include it in the differential diagnosis of recurrent abdominal pain. We report a case of isolated intestinal angioedema associated with the use of enalapril.

[Approach to patients with vertigo]. / Enfoque del paciente con vértigo.

Vertigo is defined as an abnormal sensation of body motion or of its surrounding objects. It is a common chief complaint in emergency departments comprising 2 to 3% of these consultations worldwide. Vertigo is classified as peripheral or central, according to its origin, and can also be occasionally mixed, the most common cause of peripheral involvement being benign paroxysmal positional vertigo. The initial findings on clinical evaluation of patients are the clues for making a correct diagnosis. The differentiation between central and peripheral vertigo can be optimized by analysing nystagmus, by using the skew test and the head impulse test (HINTS), as also by performing the appropriate tests to evaluate the integrity of the vestibular-cerebellar pathway. In addition, tonal threshold audiometry could raise the diagnostic sensibility from 71 to 89% on initial approach. Appropriate diagnosis is the principal key for managing this clinical condition.

[Síndrome de Paget-Schrötter: presentación de cuatro casos]. / Paget-Schrötter syndrome: description of four cases.

Deep vein thrombosis (DVT) of the upper limb is a rare entity, estimated to account for 10% of all cases of DVT. Classically, they are classified into primary (idiopathic, due to subclavian vein compression or exercise related) and secondary (cancer, thrombophilia, trauma, shoulder surgery, associated to venous catheters or due to hormonal causes). The Paget- Schrötter syndrome is a primary thrombosis of the subclavian vein in the subclavian-axillary junction, related either to repetitive movements or to exercise; leading to microtrauma in the endothelium with consequent activation of the coagulation cascade. Clinically, it presents abruptly with pain, edema and feeling of heaviness in the affected limb. The treatment varies from thrombolytics and anticoagulation to surgical intervention, depending on the time of evolution. We present four cases of exercise-related subclavian vein thrombosis.

[Saints in medicine during the great wars of the twentieth century]. / Santos y beatos de la medicina en las grandes guerras del siglo XX.

In the political and social context of World War periods and unstoppable technological advances, health professionals in the early twentieth century tried to orientate the practice of medicine towards a modern anthropological concept close to the biomedical perspective, which defends the dignity of a person. Threatened by the risks represented by collectivism and the meanness of the prevailing repressive governments, a personal struggle for the defense of life aroused, which was socially expressed by the advent of bioethics, psychoanalytic theories and the concept that environment has an important role in people’s health and welfare. And above all, the appearance of a paradoxical claim of religious ideals as support of science in times of overall crisis.

[Intravascular lymphoma: Report of one case]. / Linfoma intravascular, un desafio diagnóstico: Caso clínico.

Intravascular lymphoma is a rare subtype of extranodal diffuse large B-cell lymphoma characterized by clonal proliferation of lymphocytes inside of small and medium caliber vessels. Its incidence is estimated at one case per million. The clinical picture is very variable, but frequently has skin and central nervous system involvement. It is diagnosed by demonstrating pathological blood vessel infiltration by lymphoma cells. We report a 44 years old male presenting with fever, malaise and erythematous lesions in the abdominal wall. An abdominal wall biopsy showed dilated vascular vessels with atypical cells in their lumen, compatible with large B-cell intravascular lymphoma. He was treated with rituximab, cyclophosphamide, adriamycin, vincristine and prednisone and an autologous hematopoietic stem cell transplantation, achieving a complete remission that has lasted two years.

[Hughes-Stovin Syndrome, a case report]. / Síndrome de Hughes-Stovin.

The Hughes-Stovin syndrome is a rare entity characterized by deep vein thrombosis and pulmonary artery aneurysms of unknown etiology and pathogenesis. Some authors considered a variant of Behcet's disease. Its natural course is usually fatal. The symptoms are cough, dyspnea, hemoptysis, chest pain and fever. The treatment goes from steroids and cytotoxic agents to surgery. We present the case of a 41 year old man who shows dyspnea, hemoptysis, and chest pain leading to the diagnosis of deep venous thrombosis of the right leg, lung thromboembolism and pulmonary artery aneurysms. He was treated with high-dose corticosteroids and 6 cyclophosphamide pulses of 1 gram each per 6 months with complete regression of aneurysms and symptomatology.

[Sensory neuronopathy. Its recognition and early treatment]. / Neuronopatía sensitiva. Su reconocimiento y tratamiento temprano.

Sensory neuronopathies or ganglionopathies, or dorsal root ganglion disorders, represent a subgroup of peripheral nervous system diseases, frequently associated with dysinmune or neoplastic disorders and with toxic agents. A degeneration of both central and peripheral sensory proyections is present. Patients typically show early ataxia, loss of deep tendon reflexes and positive sensory symptoms present both in proximal and distal sites of the body. We retrospectively studied 10 cases with a final diagnosis of sensory neuronopathy. Sensory neuropathy was the presenting symptom and the course was subacute in all cases. Paresthesias in upper limbs were a predominant manifestation (100%). Other manifestations included: hypoesthesia (10/10), gait ataxia (8/10), autonomic symptoms (3/10) and perioral paresthesias (3/10). Electrophysiology showed sensory axonal neuronal pattern, with normal motor responses. Final diagnosis was acquired sensory neuronopathy in all patients, associated with Sjögren's syndrome in 2, with lupus erythematosus in 1, with rheumatoid arthritis in 1, with a cancer in 2 (paraneoplastic) and idiopathic in 4. In paraneoplastic cases, the tumor was small cell lung cancer in 1 (with positive anti-Hu antibodies), and epidermoid lung cancer in the other. Eight patients were treated with immunotherapy, high dose intravenous methylprednisolone and/or intravenous immunoglobulin; with poor response in 4 cases, neurologic improvement in 5, and without any change in 1 patient. The present work shows the typical clinical and electrophysiological pattern of subacute sensory neuronopathy, and the relevance of early treatment.

[Frederic Chopin (1810-1849), and his disease]. / Federico Chopin (1810-1849) y su enfermedad.

Frédéric Chopin - a great Polish composer and pianist-suffered from a chronic disease. Both during his life and after his death, physicians disagreed on Chopin's diagnosis. His contemporaries accepted the diagnosis of tuberculosis, a common disease in the 18th century. Description of new clinical entities provoked new dilemmas in the 21th century. Although other alternative diagnoses to tuberculosis have emerged, such as cystic fibrosis or alpha-1 antitrypsin deficiency, we still sustain that the first diagnosis is the most probable. In this paper we report F. Chopin's case history and discuss cons and pros for different diseases as the cause of F. Chopin's suffering and death.

[Subglottic tracheal stenosis in Wegener disease. Report of two cases]. / Estenosis subglótica y granulomatosis con poliangeítis (Wegener) en dos casos.

Granulomatosis with polyangiitis (GPA) or Wegener's disease is characterized by a granulomatous vasculitis of the upper and lower airways and kidney. It involves the lower respiratory tract causing subglottic tracheal stenosis, which occurs in approximately 22% of patients. We report two females aged 40 and 52 years, admitted to the hospital with a subglottic tracheal stenosis. Their symptoms and management are reviewed. The first patient responded to rituximab. The second patient required a tracheostomy.

[Armand Trousseau (1801-1867), his history and the signs of hypocalcemia]. / Armand Trousseau (1801-1867), su historia y los signos de hipocalcemia.

Armand Trousseau (1801-1867) was born in Tours, France on October 14, 1801. He graduated as a physician in the same city under the direction of Pierre Bretonneau and received his doctorate in 1825 in Paris. He was the first physician to practice tracheotomy in diphtheria and perform thoracenteses to remove air or fluid from the pleural space. He recommended tracheal intubation in different scenarios. He described the first cases of laryngeal tuberculosis and the presence of carpopedal spasm in hypocalcemia, a sign that has his name. He also described the association between migratory thrombophlebitis and neoplasia, which is known as Trousseau's syndrome. Ironically, on January 1, 1867 he diagnosed in himself a deep vein thrombosis of the left upper limb and told one of his disciples "I am lost; I have no doubt about the nature of my disease". He died of gastric cancer at the age of 66 years on June 23, 1867. He carried out an educational and medical work. He instructed his students about the rather instantaneous thought process in clinical medicine. He always conducted his clinical work with the certainty of a sound scientific background. Contemporary physicians should take advantage of the example and lessons of Armand Trousseau.

[Hiccup, a diagnostic challenge]. / Hipo, un desafío diagnóstico.

Hiccup is a spasmodic involuntary contraction of the diaphragm which triggers a sudden inspiration and an abrupt closure of the glottis with a characteristic sound. Regarding its duration, it is classified as hiccup attack, persistent hiccup or rebellious or intractable hiccup. We present the case of a 75 old male with rebellious hiccup which prevented him to fall asleep by day or by night, associated with belches lasting for three years, refractory to chlorpromazine. An extensive evaluation led to the diagnosis of right ethmoid sinus tumor. The tumor resection was performed and after subsequent local radiotherapy the hiccup disappeared. We consider this a rare cause of rebellious hiccup that generated a diagnostic and therapeutic challenge.

[Stress (Takotsubo) cardiomyopathy in a patient with anorexia nervosa]. / Cardiomiopatía inducida por estrés (Takotsubo) en una paciente con anorexia nerviosa.

We report the case of a woman with anorexia nervosa who developed takotsubo cardiomyopathy triggered by emotional stress and electrolyte disturbances. The patient improved with conservative management. Descriptions of stress-cardiomyopathy in association with eating disorders are often of higher severity and related to QT prolongation because of electrolyte abnormalities, ventricular arrhythmias and hypoglycemia. A review of cardiovascular compromise in patients with anorexia nervosa is performed.

[The portrait of medicine and Gustav Klimt (1862-1918)]. / Gustav Klimt (1862-1918) y su cuadro sobre la medicina.

Gustav Klimt was an Austrian Symbolist painter and one of the most important representatives of the modernist movement of the Viennese Secession. The most notable works carried out at his golden age were the "Portrait of Adele Bloch-Bauer I" and "The kiss". In 1901 he paints "Medicine" where he returns to the entanglement of floating bodies -the lifetime- among which appears the skeleton of death; a female figure stands out from the column to represent freedom from pain. The figure of Hygeia or Hygieia, daughter of Aesculapius, who personifies medicine, is shown in the foreground. In 1911, thanks to "The life and death", a picture related to medicine, he was awarded the first prize at the Universal Exhibition of Rome. A number of his artworks were confiscated by the Nazi dictatorship. During the advance of enemy troops, and fearing that these works would become spoils of war, it was decided to burn the castle where they remained confiscated. Therefore, countless artworks were lost. The progressive development of symbolic or abstract motifs already emphasized the freedom of spirit that permeated all the avant-garde of early twentieth century.

[Rod of Asclepius. Symbol of medicine]. / La vara de Esculapio, símbolo de la medicina.

Symbolism is one of the most archaic forms of human thoughts. Symbol derives from the Latin word symbolum, and the latter from the Greek symbolon or symballo, which means "I coincide, I make matches". The Medicine symbol represents a whole series of historical and ethical values. Asclepius Rod with one serpent entwined, has traditionally been the symbol of scientific medicine. In a misconception that has lasted 500 years, the Caduceus of Hermes, entwined by two serpents and with two wings, has been considered the symbol of Medicine. However, the Caduceus is the current symbol of Commerce. Asclepius Rod and the Caduceus of Hermes represent two professions, Medicine and Commerce that, in ethical practice, should not be mixed. Physicians should be aware of their real emblem, its historical origin and meaning.

[Lethargic encephalitis. Report of one case]. / Enfermedad de Von Economo: Caso clínico.

Lethargic encephalitis (LE) is a Central Nervous System disorder following an upper respiratory tract infection, characterized by sleep disturbances, clinical symptoms corresponding to basal ganglia involvement and in some cases, neuropsychiatric sequelae. We report a 18-year-old mole with a history of sinusitis treated with azithromycin, two weeks before, presenting with fever, headache, confusion and myoclonus. Urine analysis was positive for cannabis. Cerebro spinal fluid analysis showed mononuclear pleiocytosis (109xmm³) and an increase in protein concentration of l.6 g/dl. Forty eight hours after admission, the patient required mechanical ventilation and subsequently a status epilepticus appeared. Ten days later, fever, rigidity and resting tremor appeared. A magnetic resonance imaging showed hyperintensities in FLALR sequence in the right insular cortex. The patient continued with extreme rigidity, catatonia and mutism. Considering the possibility ofa LE, methyl prednisolone 1 g/day was administered for five consecutive days followed by prednisone 40 mg l day, observing a dramatic improvement of rigidity and tremors.

[Agranulocytosis induced by levamisole in association to cocaine]. / Agranulocitosis por levamisol asociado a cocaína.

Agranulocytosis in cocaine users is a worldwide recently recognized condition. It is due to the utilization as cutting agent of levamisole, an ancient antiparasitic and immunomodulator drug. We describe the case of a patient with agranulocytosis induced by levamisole in association to cocaine and we review clinical and biochemical characteristics of the clinical picture, as well as the management of these patients. We also analyze the reasons related to a more and more frequent practice, the addition of levamisole to cocaine. This is the first case described in our country, although it is probable that there are many not recognized or not described cases related to this pathology.

[Ergotism and HIV]. / Ergotismo y HIV.

Ergotism is a complication of acute intoxication and/or chronic abuse of ergot derivatives. It expresses itself through a vasomotor syndrome with peripheral vascular disease which frequently involves extremities. We report four cases of HIV-1 infected patients treated with antiretroviral drugs including boosted-protease inhibitors who had self-treated themselves with ergotamine. They developed peripheral vascular disease symptoms and their pulses where diminished or absent in the physical examination. Arterial Doppler confirmed diffused arterial spasm in two of them. Ergotism following ergotamine-protease inhibitors association was diagnosed. Patients were treated through the discontinuity of involved drugs (protease inhibitors and ergotamine), calcium blockers; antithrombotic prophylaxis with enoxaparine, antiaggregant therapy with acetylsalicylic acid, and one of them received pentoxifylline and vasodilator prostaglandins infusion, with amelioration of the symptoms. We discuss the clinical presentation of this drug interaction, difficult to diagnose properly without a strong suspicion of its existence.

[Stiff person syndrome associated with thymoma]. / Síndrome de la persona rígida asociado a timoma.

Stiff-person syndrome is a rare neurological condition characterized by muscular rigidity of the trunk and extremities and muscle spasms triggered by sensory or emotional stimuli, which progresses towards prostration. It has a pathophysiogenic mechanism with an immunological basis, in which autoantibodies, such as antiGAD65, play a central role. Likewise, the detection of these antibodies corroborates the diagnosis in a patient with a suggestive clinical picture. Four to 6% of cases have underlying neoplasms. Treatment is based on symptomatic, immunomodulatory, and underlying disease management in paraneoplastic cases. We report a case of classic stiff person syndrome associated with thymoma and review the main characteristics of this entity.

El síndrome de persona rígida es un cuadro neurológico infrecuente caracterizado por rigidez muscular de tronco y extremidades y espasmos musculares gatillados por estímulos sensoriales o emocionales, que progresa hacia la postración. Cuenta con un mecanismo fisiopatogénico con base inmunológica, en el cual los autoanticuerpos, como el antiGAD65, cumplen un rol central. Asimismo, la detección de dichos anticuerpos corrobora el diagnóstico ante un paciente con cuadro clínico sugestivo. Un 4 a 6% de los casos tienen neoplasias subyacentes. El tratamiento se basa en el manejo sintomático, inmunomodulador y de la enfermedad de base en los casos paraneoplásicos. Reportamos un caso de síndrome de persona rígida clásico asociado a timoma y describimos las características principales de esta entidad.