Tuberculosis miliar, un hallazgo clínico-radiológico: a propósito de un caso / Miliary tuberculosis, a clinical-radiological finding: about a case

La tuberculosis es una enfermedad granulomatosa, con espectro clínico variable. El objetivo es presentar un caso con tuberculosis miliar, una de las formas clínicas menos frecuente de la enfermedad y la utilización del método clínico proporcionó el diagnóstico certero. Se presenta un paciente masculino de 54 años, no fumador, alcohólico atendido en el Hospital Clínico Quirúrgico Hermanos Ameijeiras por referir historia de tos poco productiva, cefalea, fiebre, pérdida de apetito y de peso de dos meses de evolución. En la radiografía y tomografía de tórax se evidencia un patrón miliar y la baciloscopía directa confirma la presencia del Mycobacterium tuberculosis. La TB miliar es muy poco frecuente, pero se puede sospechar ante un patrón radiológico miliar y confirmar mediante análisis microbiológico.

Tuberculosis is a granulomatous disease with a variable clinical spectrum. The objective is to present a case with miliar tuberculosis, one of the least frequent clinical forms of the disease, and the use of the clinical method provided an accurate diagnosis. We present a 54-year-old male, non-smoker, alcoholic who attended in the Ameijeiras Brothers Surgical Clinical Hospital for referring to a history of unproductive cough, headache, fever, loss of appetite, and weight two months of evolution. Chest X-ray and CT showed a miliar pattern and direct bacilloscopy confirmed the presence of Mycobacterium tuberculosis. Miliar TB is very rare but can be suspected by a miliar radiological pattern and confirmed by microbiological analysis.

Nimotuzumab combinado con quimioradioterapia en pacientes con carcinoma epidermoide esofágico avanzado en el mundo real / Nimotuzumab combined with chemoradiotherapy in patients with advanced esophageal squamous cell carcinoma in the real world

Introducción: La supervivencia global de pacientes con cáncer de esófago continúa siendo baja a pesar de los avances terapéuticos realizados en las últimas décadas. Objetivo: Evaluar respuesta al tratamiento y supervivencia global. Métodos: Se realizó un estudio retrospectivo y observacional en pacientes con carcinoma epidermoide esofágico avanzado, tratados con nimotuzumab combinado con quimioradioterapia, atendidos en el Servicio de Oncología Clínica del Hospital Ameijeiras, entre enero 2013 y junio de 2019 (n = 94). Se utilizó chi-cuadrado para la asociación de variables, con un valor p< 0,05. Se evaluó supervivencia global por el método de Kaplan Meier, y la prueba de Log-Rank para la comparación de las curvas. Resultados: La tasa de respuesta objetiva y de control de enfermedad fue 64,9 por ciento y 83 por ciento, respectivamente. El esquema de quimioterapia con cisplatino/fluouracilo fue el empleado con más frecuencia. Las variables con mayor respuesta y significación estadística fueron: ECOG cero, color de piel no blanca, tratamiento radiante ≥ 50 Gy, y más de catorce dosis de nimotuzumab. La mediana de supervivencia fue 13,03 meses (IC95 por ciento -10,9; 15,2), y las variables asociadas a una mayor probabilidad de supervivencia fueron: ECOG cero, dosis de quimioterapia > 75 por ciento de lo planificado, tratamiento radiante ≥ 50 Gy, más de catorce dosis de nimotuzumab, y alcanzar una respuesta objetiva (p< 0,05). Solo 5,8 por ciento de los pacientes presentaron toxicidades clasificadas como grado 3-5. Conclusiones: En condiciones de práctica clínica, este esquema de combinación obtuvo óptimas tasas de respuesta objetiva y supervivencia con buen perfil de toxicidad(AU)

Introduction: Overall survival of esophageal cancer patients remains low despite the therapeutic advances achieved in the last decades. Objective: Evaluate response to treatment and overall survival. Methods: An observational retrospective study was conducted of patients with advanced esophageal squamous cell carcinoma treated with nimotuzumab combined with chemoradiotherapy at the Clinical Oncology Service of Ameijeiras Hospital from January 2013 to June 2019 (n = 94). Association of variables was analyzed with the chi-square test, using a value of p < 0.05. Overall survival was evaluated with the Kaplan-Meier method, whereas the Log-Rank test was used to compare the curves. Results: Objective response and disease control rates were 64.9 percent and 83 percent, respectively. The chemotherapy scheme with cisplatin / fluorouracil was the most commonly applied. The variables with the greatest response and statistical significance were ECOG zero, skin color not white, radiation therapy ≥ 50 Gy and more than 14 doses of nimotuzumab. Median survival was 13.03 months (CI 95 percent -10,9; 15,2), whereas the variables associated to a greater probability of survival were ECOG zero, chemotherapy dose > 75% of plan, radiation therapy ≥ 50 Gy, more than 14 doses of nimotuzumab, and achieving an objective response (p< 0.05). Only 5.8 percent of the patients presented toxicities classified as grades 3-5. Conclusions: In clinical practice conditions, this combination scheme achieved optimum objective response and survival rates with a good toxicity profile(AU)

Acute cellular rejection grading scheme for human gastric allografts.

The control of acute cellular rejection (ACR) in multivisceral transplantation improves long-term survival, but monitoring this process can be challenging because different allografts can display varying forms and degrees of rejection. Criteria for ACR of small bowel and liver have been established, but a systematic analysis for ACR in stomach is lacking. For this reason we have developed a comprehensive grading scheme for the evaluation of gastric allograft rejection. The grading scheme was designed to individually grade a variety of changes in the surface epithelium, lamina propria, and glandular structures. The individual values are cumulated, and the final score determines assignment of the rejection grade. The ACR grades range from no evidence of acute cellular rejection to severe rejection. We performed a retrospective study based on 70 gastric allograft biopsies from 20 patients who received multivisceral transplantation from 1995 to 2001. We found that the scoring system showed no significant interobserver variability and allowed for an accurate designation of the ACR grade to the gastric allografts. We found with this grading system that neither clinical symptoms nor gastric endoscopic findings could serve as specific indicators of gastric ACR. Our results also showed that there were differences in the occurrence and intensity of acute rejection between the stomach and other transplanted organs, suggesting that ACR can occur independently among different allografts of the same host. In conclusion, we find that this scheme for grading ACR in gastric transplants is objective and reproducible. This grading system will likely allow for improved correlation between gastric ACR grade and clinical symptoms, as well as improve interobserver uniformity within and between institutions.

Hallazgos por imagen de tumor carcinoide bronquial en hospital de la habana / Imaging findings of bronchial carcinoid tumor in haban-hospital

Se presenta un caso de adolescente sin comorbilidades, quien cursó durante tres meses con infecciones respiratorias a repetición sin mejoría a pesar de manejo médico apropiado. En imagen de control posterior a la hospitalización, se documenta en estudios de imagen lesión del lóbulo inferior derecho con crecimiento endoluminal y mediante broncoscopía se confirma la presencia de una masa tumoral en la luz del bronquio para dicho lóbulo. Se realiza biopsia y el estudio anatomopatológico reporta tumor carcinoide variedad típica. A pesar que es una entidad poco frecuente, el tumor carcinoide es una neoplasia neuroendócrina que se puede presentar en el sistema respiratorio en este grupo poblacional y se debe considerar en el contexto de infecciones respiratorias a repetición. Los estudios de imagen deberían ser parte de la evaluación de todo paciente que cursa con complicaciones de infecciones respiratorias y en el diagnóstico diferencial de otras entidades respiratorias.

It is present a case of teenager without comorbidities, who had recurrent respiratory infections during three months without improving besides proper medical treatment. Imaging post-hospitalization control documented in imaging studies a right lower lobe lesion with endobronchial grow and bronchoscopy confirmed a growing into the lumen tumoral mass of such lobular bronchi. A biopsy was performed and an pathological study reported carcinoid tumor typical type. Even though it is a rare entity, carcinoids tumors are neuroendocrine neoplasms that can be found in the respiratory system among this population group and it should be considered in a repetitive respiratory infections scene. Imaging studies should be part of every patient evaluation that course with complications as well as a tool for other entities differential diagnosis.

Neumonía por citomegalovirus en el adulto inmunocompetente / Cytomegalovirus pneumonia in immunocompetent adult patient

Introducción: la Neumonía por Citomegalovirus (CMV) es una entidad rara en los pacientes inmunocompetentes, pero cuando se asocia con otras enfermedades como la neumonía, puede ser altamente letal. Objetivo: presentar un caso infrecuente de infección primaria por Citomegalovirus complicado con neumonía. Presentación del caso: se presenta el caso de una paciente de 36 años de edad, que trabajaba directamente con pacientes trasplantados renales, y que acudió a consulta por presentar fiebre de 38 oC en un período de más de 10 días, precedida de escalofríos, dolor de garganta, tos seca al inicio y luego expectoración de color verde claro; examen físico negativo; todo lo anterior acompañado de astenia marcada durante todo el día y anorexia. La falta de respuesta adecuada al tratamiento con Levofloxacino y Azitromicina nos hizo sospechar la presencia de una Neumonía viral por un germen de etiología no habitual, por lo que se le indicaron exámenes de anticuerpos anti-virales, resultando positivo para Citomegalovirus. Conclusiones: existen procesos inflamatorios pulmonares agudos reversibles de causa infecciosa sin manifestaciones auscultatorias, es decir con disociación clínico-radiológica, que en su mayoría corresponden a procesos de índole viral, y que además no son exclusivos de pacientes inmunodeprimidos...

Introduction: Cytomegalovirus pneumonia is a rare disease in immunocompetent patients, but when associated to other diseases such as pneumonia, it becomes deadly. Objective: to present an uncommon case of primary Cytomegalovirus infection complicated with pneumonia. Case presentation: this is the case of a 36years-old patient who directly worked with renal transplanted patients and went to the doctor´s because of 38o fever for more than 10 days, thrills, throat ache, dry cough at the beginning and clear green colored sputum, negative physical examination results, and marked asthenia during the day and anorexia. The inadequate response to Levofloxacine and Azitromycin treatment made us suspect of viral pneumonia caused by an infrequent germ. Anti-viral antibodies tests were indicated to reveal positive results for Cytomegalovirus. Conclusions: there are reversible acute pulmonary inflammatory processes of infective origin without any manifestation on physical exam, that is, a clinical-radiological dissociation; the majority of these processes are of viral origin but they do not occur only in immunodepressed patients...

Abundance and distribution of Legionellaceae in Puerto Rican waters.

Waters in marine and freshwater areas of Puerto Rico were analyzed for the presence of Legionella spp. by direct fluorescent antibody assay with guinea pig confirmation. Several species, including L. bozemanii, L. dumoffii, L. gormanii, L. longbeachae, L. micdadei, and L. pneumophila, were widely distributed among all sites. Legionellaceae, including L. pneumophila, were found in high densities in water collected in the rain forest from epiphytes in trees 30 ft. (about 9.25 m) above the ground. Both interspecific and intersite variations were significant. L. pneumophila was the most abundant species at all sites, with average densities of 10(4) cells ml-1, very close to the range which is potentially pathogenic for humans. Densities of L. pneumophila were highest in sewage-contaminated coastal waters. These are the highest densities of Legionella spp. ever reported for marine habitats. Densities of L. pneumophila were positively correlated with concentrations of sulfates, phosphates, and pH. A survey of 88 fatal atypical pneumonia cases at a Puerto Rico hospital showed that 15% of the patients had L. pneumophila infections. This study establishes L. pneumophila as a relatively common cause of atypical pneumonia in Puerto Rico and suggests natural aquatic habitats as possible sources or reservoirs of pathogenic Legionella spp. in the tropics.

Utilidad de la osteosonometría del calcáneo en el diagnóstico imagenológico del riesgo de fractura / Usefulness of the calcaneus osteosonometry imaging in the diagnosis of fracture risk

El aumento de la esperanza de vida en países desarrollados ha favorecido el incremento de la incidencia de afecciones crónicas como la osteoporosis, que actualmente constituye un problema de salud pública de magnitud creciente. Su consecuencia principal es la producción de fracturas. Predomina el sexo femenino, después de la menopausia; su prevalencia asciende al aumentar la edad, alcanzando el 52% en mayores de 70 años. Cerca de 200 millones de personas sufren de osteoporosis en el mundo. Cuba con población cada vez más envejecida no escapa de esta situación...