Prevalence of latent tuberculosis infection (LTBI) in healthcare workers in Latin America and the Caribbean: systematic review and meta-analysis.

Background: Tuberculosis remains a significant global health concern, and healthcare workers (HCWs) face a high risk of acquiring latent tuberculosis infection (LTBI) through occupational exposure. In the Latin American and Caribbean (LAC) region, where the burden of tuberculosis is substantial, understanding the prevalence of LTBI among HCWs is crucial for effective infection control measures. Therefore, we conducted a systematic review and meta-analysis to estimate the prevalence of LTBI among HCWs in LAC countries. Methods: Our search included MEDLINE, Scopus, EMBASE, Web of Science, and Google Scholar databases, focusing on relevant English-language records. We looked for observational studies from inception until December 2023. Results: Our analysis included 38 studies representing 15,236 HCWs and 6,728 LTBI cases. These studies spanned the period from 1994 to 2023 and were conducted in Brazil, Peru, Cuba, Colombia, Trinidad and Tobago, Mexico, and Chile. The mean prevalence of LTBI among HCWs was 35.32% (range 17.86-56.00%) for interferon-gamma release assay (IGRA) and 43.67% (range 6.68-70.29%) for tuberculin skin test (TST). The pooled prevalence of LTBI among HCWs was 34.5% (95% CI 25.4-44.1%) for IGRA and 43.0% (95% CI 35.5-50.7%) for TST. When considering both IGRA and TST tests, the overall prevalence of LTBI among HCWs was 40.98% (95% CI 34.77-47.33%). LTBI was associated with longer lengths of employment and exposure to patients, family members, or any person with TB. Additionally, older HCWs faced a higher risk of LTBI. Specific professional roles (such as nurses, nurse technicians, or physicians), smoking, and deficient TB infection control measures increased the likelihood of LTBI. However, information regarding gender and BCG vaccination status showed discordance among studies. Conclusion: Our findings underscore a substantial burden of LTBI among HCWs in LAC countries. Implementing adequate infection control measures is essential to prevent and control transmission within healthcare settings.

Conscious prone positioning in nonintubated COVID-19 patients with acute respiratory distress syndrome: systematic review and meta-analysis.

OBJECTIVE: To systematically review the effect of the prone position on endotracheal intubation and mortality in nonintubated COVID-19 patients with acute respiratory distress syndrome. METHODS: We registered the protocol (CRD42021286711) and searched for four databases and gray literature from inception to December 31, 2022. We included observational studies and clinical trials. There was no limit by date or the language of publication. We excluded case reports, case series, studies not available in full text, and those studies that included children < 18-years-old. RESULTS: We included ten observational studies, eight clinical trials, 3,969 patients, 1,120 endotracheal intubation events, and 843 deaths. All of the studies had a low risk of bias (Newcastle-Ottawa Scale and Risk of Bias 2 tools). We found that the conscious prone position decreased the odds of endotracheal intubation by 44% (OR 0.56; 95%CI 0.40 - 0.78) and mortality by 43% (OR 0.57; 95%CI 0.39 - 0.84) in nonintubated COVID-19 patients with acute respiratory distress syndrome. This protective effect on endotracheal intubation and mortality was more robust in those who spent > 8 hours/day in the conscious prone position (OR 0.43; 95%CI 0.26 - 0.72 and OR 0.38; 95%CI 0.24 - 0.60, respectively). The certainty of the evidence according to the GRADE criteria was moderate. CONCLUSION: The conscious prone position decreased the odds of endotracheal intubation and mortality, especially when patients spent over 8 hours/day in the conscious prone position and treatment in the intensive care unit. However, our results should be cautiously interpreted due to limitations in evaluating randomized clinical trials, nonrandomized clinical trials and observational studies. However, despite systematic reviews with meta-analyses of randomized clinical trials, we must keep in mind that these studies remain heterogeneous from a clinical and methodological point of view.

Effect of calcium-channel blockers on the risk of active tuberculosis and mortality: systematic review and meta-analysis.

Introduction: Recent studies suggest that calcium channel blockers (CCBs) could reduce the risk of active tuberculosis and improve clinical outcomes. We aimed to synthesize the evidence regarding the effect of CCBs on the risk of developing active tuberculosis and mortality. Methods: We systematically searched for observational studies and clinical trials published in six databases until 31 August 2023, following a PECO/PICO strategy. Results: We included eight observational studies, 4,020,830 patients, among whom 241,761 had diabetes mellitus and 30,397 had active tuberculosis. According to our results, CCBs reduce the risk of developing active tuberculosis by 29% (RR 0.71; 95% CI 0.67-0.75) in patients with and without diabetes mellitus. However, CCBs do not show any benefit in terms of tuberculosis-related mortality (RR 1.00; 95% CI 0.98-1.02). For both outcomes, no statistical heterogeneity was found (I2 = 0, p > 0.10). This protective effect of CCBs on the risk of active tuberculosis remained independent of the type of patient (with diabetes mellitus vs. general population) or the class of CCB administered (DHP-CCB vs. non-DHP-CCB) (test for subgroup differences I2 = 0, p > 0.10). However, this beneficial effect was more significant among the general population (RR 0.70; 95% CI 0.66-0.74) compared to patients with diabetes mellitus (RR 0.72; 95% CI 0.61-0.86) and among those patients treated with DHP-CCBs (RR 0.69; 95% CI 0.63-0.74) compared to patients treated with non-DHP-CCBs (RR 0.72; 95% CI 0.67-0.78). Conclusion: CCBs may reduce the risk of active TB in patients with diabetes and the general population. On the contrary, CCBs do not seem to have a protective effect on tuberculosis-related mortality. However, more evidence is still needed. We recommend developing clinical trials to verify these findings, including more diverse populations. Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=352129].

Conscious prone positioning in nonintubated COVID-19 patients with acute respiratory distress syndrome: systematic review and meta-analysis / Pronação consciente em pacientes com COVID-19 não intubados e com síndrome do desconforto respiratório agudo: revisão sistemática e metanálise

ABSTRACT Objective: To systematically review the effect of the prone position on endotracheal intubation and mortality in nonintubated COVID-19 patients with acute respiratory distress syndrome. Methods: We registered the protocol (CRD42021286711) and searched for four databases and gray literature from inception to December 31, 2022. We included observational studies and clinical trials. There was no limit by date or the language of publication. We excluded case reports, case series, studies not available in full text, and those studies that included children < 18-years-old. Results: We included ten observational studies, eight clinical trials, 3,969 patients, 1,120 endotracheal intubation events, and 843 deaths. All of the studies had a low risk of bias (Newcastle-Ottawa Scale and Risk of Bias 2 tools). We found that the conscious prone position decreased the odds of endotracheal intubation by 44% (OR 0.56; 95%CI 0.40 - 0.78) and mortality by 43% (OR 0.57; 95%CI 0.39 - 0.84) in nonintubated COVID-19 patients with acute respiratory distress syndrome. This protective effect on endotracheal intubation and mortality was more robust in those who spent > 8 hours/day in the conscious prone position (OR 0.43; 95%CI 0.26 - 0.72 and OR 0.38; 95%CI 0.24 - 0.60, respectively). The certainty of the evidence according to the GRADE criteria was moderate. Conclusion: The conscious prone position decreased the odds of endotracheal intubation and mortality, especially when patients spent over 8 hours/day in the conscious prone position and treatment in the intensive care unit. However, our results should be cautiously interpreted due to limitations in evaluating randomized clinical trials, nonrandomized clinical trials and observational studies. However, despite systematic reviews with meta-analyses of randomized clinical trials, we must keep in mind that these studies remain heterogeneous from a clinical and methodological point of view.

RESUMO Objetivo: Revisar sistematicamente o efeito da posição prona na intubação endotraqueal e na mortalidade em pacientes com COVID-19 não intubados com síndrome do desconforto respiratório agudo. Métodos: Registramos o protocolo (CRD42021286711) e pesquisamos quatro bancos de dados e literatura cinzenta desde o início até 31 de dezembro de 2022. Incluímos estudos observacionais e ensaios clínicos. Não houve limite de data ou idioma de publicação. Excluímos relatos de casos, séries de casos, estudos não disponíveis em texto completo e estudos que incluíram pacientes < 18 anos de idade. Resultados: Incluímos 10 estudos observacionais, 8 ensaios clínicos, 3.969 pacientes, 1.120 eventos de intubação endotraqueal e 843 mortes. Todos os estudos tinham baixo risco de viés (ferramentas Newcastle-Ottawa Scale e Risk of Bias 2). Observamos que a pronação consciente reduziu as chances de intubação endotraqueal em 44% (RC 0,56; IC95% 0,40 - 0,78) e a mortalidade em 43% (RC 0,57; IC95% 0,39 - 0,84) em pacientes com COVID-19 não intubados com síndrome do desconforto respiratório agudo. Esse efeito protetor sobre a intubação endotraqueal e a mortalidade foi mais robusto naqueles que passaram > 8 horas por dia na pronação consciente (RC 0,43; IC95% 0,26 - 0,72 e OR 0,38; IC95% 0,24 - 0,60, respectivamente). A certeza da evidência, de acordo com os critérios GRADE, foi moderada. Conclusão: A pronação consciente diminuiu as chances de intubação endotraqueal e mortalidade, especialmente quando os pacientes passaram > 8 horas por dia na pronação consciente e tratamento na unidade de terapia intensiva. Contudo, nossos resultados devem ser interpretados com cautela devido às limitações na avaliação de ensaios clínicos randomizados, ensaios clínicos não randomizados e estudos observacionais. Não obstante, apesar das revisões sistemáticas com metanálises de ensaios clínicos randomizados, devemos ter em mente que esses estudos permanecem heterogêneos do ponto de vista clínico e metodológico.

Latent tuberculosis infection (LTBI) in health-care workers: a cross-sectional study at a northern Peruvian hospital.

Background: Healthcare workers (HCWs) have a higher risk of latent tuberculosis infection (LTBI) and active tuberculosis than the general population. In HCWs, the risk of tuberculosis infection depends on the local tuberculosis prevalence, HCWs' characteristics, the healthcare facility, and prevention and control measures. We aimed to estimate the prevalence and risk factors for LTBI in HCWs at a northern Peruvian hospital. Methods: This study had two phases: (1) a cross-sectional phase involving recruitment, history taking, and sampling for the Interferon-Gamma Release Assays (IGRA test), and (2) a prospective follow-up of IGRA-positive participants. We enrolled direct and non-direct patient caregivers among HCWs. We defined an LTBI case if the IGRA test was positive and clinical, laboratory, and radiological evaluations for active tuberculosis were negative. Results: We recruited 308 participants between November 2022 and May 2023. The mean age was 38.6 ± 8.3 years. Over 75% of the participants were female. The most common job category was technicians (30.5%), physicians (22.7%), nurses (20.5%), and other HCWs groups (17.5%). Most participants worked in hospital wards (28.2%), diagnostics departments (16.9%), and critical care departments (15.6%). The LTBI prevalence among HCWs was 17.86% (95% CI 13.84-22.70). In multivariate analysis, after adjusting for age, time working in our hospital, and family history of tuberculosis, males had a higher risk of LTBI (aPR 1.69, 95% CI 1.01-2.77) than females. Working for more than 10 years increased the risk of LBTI (aPR 2.4, 95% CI 1.44-3.97) compared to working for ≤10 years. Even further, participants who had worked for more than 20 years had an aPR of 4.31 (95% CI 1.09-13.65) compared to those with ≤10 years. Similarly, occupational exposure increased the risk of LTBI (aPR 2.21, 95% CI 1.27-4.08) compared to those HCWs not occupationally exposed. Conclusion: The LTBI prevalence in HCWs at a northern Peruvian hospital was lower compared to other Peruvian cities. Males, more experienced, and occupational exposed HCWs are at higher risk of LTBI. LTBI prevalence in Peruvian HCWs is still high. More studies are needed to address some aspects this study has not examined.

Droplet digital PCR vs. quantitative real time-PCR for diagnosis of pulmonary and extrapulmonary tuberculosis: systematic review and meta-analysis.

Tuberculosis is a rising global public health emergency. Then, it is a priority to undertake innovations in preventive, diagnostic, and therapeutic methods. Improved diagnostic methods for tuberculosis are urgently needed to address this global epidemic. These methods should be rapid, accurate, affordable, and able to detect drug-resistant tuberculosis. The benefits of these new diagnostic technics include earlier diagnosis and treatment, improved patient outcomes, and reduced economic burden. Therefore, we aimed to systematically review the diagnostic performance of droplet digital PCR (ddPCR)-a third-generation PCR-compared with quantitative Real Time-PCR (qPCR) for diagnosing pulmonary and extrapulmonary tuberculosis. We included 14 diagnostic accuracy test studies performed in Asia, Europe, and Latin America, 1,672 participants or biological samples, and 975 events (pulmonary or extrapulmonary tuberculosis). Most of the included studies had a low risk of bias (QUADAS-C tool). Sensitivity and specificity were lower for ddPCR [0.56 (95% CI 0.53-0.58) and 0.97 (95% CI 0.96-0.98), respectively] than for qPCR [0.66 (95% CI 0.60-0.71) and 0.98 (95% CI 0.97-0.99), respectively]. However, the area under the ROC curve (AUC) was higher for ddPCR than for qPCR (0.97 and 0.94, respectively). Comparing both AUCs using the Hanley & McNeil method, we found statistically significant differences (AUC difference of 4.40%, p = 0.0020). In the heterogeneity analysis, we found significant differences between both techniques according to the continent of origin of the study and the location of tuberculosis (pulmonary or extrapulmonary disease). The AUCs of both methods were similar in pulmonary tuberculosis. However, for extrapulmonary tuberculosis, the AUC was higher for ddPCR. We found some limitations: (1) significant heterogeneity of the studies, and (2) we could not perform subgroup analyses according to other relevant variables, such as the age and sex of the participants. Nonetheless, this study is the first meta-analysis that shows that ddPCR has a comparable diagnostic performance than qPCR for pulmonary tuberculosis. However, for extrapulmonary tuberculosis, ddPCR has a better discriminant capacity to differentiate between patients with and without extrapulmonary tuberculosis. We conclude that ddPCR is likely the best diagnostic technic for tuberculosis diagnosis, especially for extrapulmonary tuberculosis. More studies are still needed yet. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022382768, CRD42022382768.

Acute Coronary Syndrome, Stroke, and Mortality after Community-Acquired Pneumonia: Systematic Review and Meta-Analysis.

One-third of adult inpatients with community-acquired pneumonia (CAP) develop acute coronary syndrome (ACS), stroke, heart failure (HF), arrhythmias, or die. The evidence linking CAP to cardiovascular disease (CVD) events is contradictory. We aimed to systematically review the role of CAP as a CVD risk factor. We registered the protocol (CRD42022352910) and searched for six databases from inception to 31 December 2022. We included 13 observational studies, 276,109 participants, 18,298 first ACS events, 12,421 first stroke events, 119 arrhythmic events, 75 episodes of new onset or worsening HF, 3379 deaths, and 218 incident CVD events. CAP increased the odds of ACS (OR 3.02; 95% CI 1.88-4.86), stroke (OR 2.88; 95% CI 2.09-3.96), mortality (OR 3.22; 95% CI 2.42-4.27), and all CVD events (OR 3.37; 95% CI 2.51-4.53). Heterogeneity was significant (I2 = 97%, p < 0.001). Subgroup analysis found differences according to the continent of origin of the study, the follow-up length, and the sample size (I2 > 40.0%, p < 0.10). CAP is a significant risk factor for all major CVD events including ACS, stroke, and mortality. However, these findings should be taken with caution due to the substantial heterogeneity and the possible publication bias.

SGLT-2 inhibitors and prevention of contrast-induced nephropathy in patients with diabetes undergoing coronary angiography and percutaneous coronary interventions: systematic review and meta-analysis.

Introduction: SGLT2 inhibitors (SGLT2Is) have demonstrated cardioprotective and nephroprotective effects in patients with and without diabetes. Recent studies suggest that SGLT2Is may reduce the risk of contrast-induced nephropathy (CIN) in patients with diabetes undergoing coronary arteriography (CAG) or percutaneous coronary interventions (PCI). However, the evidence is still inconclusive. We aimed to systematically review the evidence regarding the potential nephroprotective role of SGLT2Is in preventing CIN in this population. Methods: We searched for studies in six databases published up to September 30, 2023, following a PECO/PICO strategy. Initially, we meta-analyzed five studies, but due to several reasons, mainly methodological concerns, we excluded one RCT. In our final meta-analysis, we included four observational studies. Results: This meta-analysis comprised 2,572 patients with diabetes undergoing CAG or PCI, 512 patients treated with SGLT2Is, and 289 events of CIN. This is the first meta-analysis demonstrating that SGLT2Is may reduce the risk of developing CIN by up to 63% (RR 0.37; 95% CI 0.24-0.58) in patients with diabetes undergoing CAG or PCI, compared to not using SGLT2Is. Statistical heterogeneity was not significant (I2 = 0%, p = 0.91). We assessed the certainty of the evidence of this systematic review and meta-analysis, according to the GRADE criteria, as moderate. Conclusion: SGLT2Is significantly reduce the risk of CIN by up to 63% in patients with diabetes undergoing CAG or PCI. Clinical trials are needed; several are already underway, which could confirm our findings and investigate other unresolved issues, such as the optimal dose, type, and duration of SGLT2 inhibitor therapy to prevent CIN. Systematic Review: PROSPERO, identifier CRD42023412892.

Periodontal disease as a non-traditional risk factor for acute coronary syndrome: a systematic review and meta-analysis.

Objectives: Previous observational studies have suggested an association between periodontal disease (PD) and cardiovascular and cerebrovascular diseases. Nonetheless, evidence linking PD with coronary heart disease (CHD) and acute coronary syndrome (ACS) is still contradictory. We aim to systematically review the role of PD as a risk factor for ACS (myocardial infarction and unstable angina). Methods: The protocol was registered in PROSPERO (CRD42021286278) and we followed the recommendations of the PRISMA and AMSTAR 2 guidelines. We systematically searched for 7 databases and electronic thesis repositories from inception to February 2022. We included articles without language restriction following the PECO strategy (population: "adult participants"; exposure: "periodontal disease"; comparator: "no periodontal disease"; outcome: "acute coronary syndrome" OR "acute myocardial infarction" OR "unstable angina"). Odds ratios (OR) with 95% confidence intervals (95% CI) were pooled using random effects and heterogeneity was quantified by Cochran's Q and Higgins' I2 statistics. Subgroup analyses were carried out according to the participants' sex, type of diagnosis of PD, type of study, and continent of origin of studies. Results: We included 46 papers (17 cohort, 25 case-control, and 4 cross-sectional studies) that met the inclusion criteria. This meta-analysis includes a total of 6,806,286 participants and at least 68,932 ACS events, mainly myocardial infarction (MI). In accordance with our results, PD is associated with a higher risk of ACS (OR 1.35; 95% CI 1.25-1.45). However, clinical and methodological heterogeneity was significant (I2=86%, p<0.05). In the sensitivity analysis, the exclusion of some studies with "extreme" results (outliers) did not significantly affect the overall estimate or heterogeneity. In subgroup analysis, we found no statistically significant differences between men and women according to subgroup difference tests (I2=0%, p=0.67). Conversely, there were differences according to the type of diagnosis of PD (clinical or self-reported diagnosis), type of study (cohort, case-control, or cross-sectional study), and the continent of origin (North America, South America, Asia, or Europe) of the studies (I2=79%-96%, p<0.10). Of the 46 studies, only 4 had a high risk of bias. Additionally, the funnel plot suggested publication bias. Conclusion: PD may be an important non-traditional risk factor for ACS. Although, this meta-analysis brings together more studies, and therefore more evidence, than any other previous similar study, its results should be interpreted with caution due to the great heterogeneity and the potential presence of bias.

Effect of Oral Antidiabetic Drugs on Tuberculosis Risk and Treatment Outcomes: Systematic Review and Meta-Analysis.

Tuberculosis and diabetes mellitus are two global pandemics and rising public health problems. Recent studies suggest that oral antidiabetic drugs (OADs) could reduce the risk of tuberculosis and improve clinical outcomes. However, the evidence is controversial. Therefore, we aimed to assess the effect of OADs on the risk of tuberculosis and treatment outcomes. We systematically searched for six databases from inception to 31 August 2022. We followed a predefined PICO/PECO strategy and included two randomized controlled trials and sixteen observational studies. This study collects 1,109,660 participants, 908,211 diabetic patients, and at least 13,841 tuberculosis cases. Our results show that metformin decreases the risk of active tuberculosis by 40% (RR 0.60; 95% CI 0.47-0.77) in diabetic patients. In addition, metformin exhibits a dose-response gradient (medium doses reduce the risk of active tuberculosis by 45%, while high doses reduce this risk by 52%). On the other hand, DPP IV inhibitors increase the risk of active tuberculosis by 43% (RR 1.43; 95% CI 1.02-2.02). Subgroup analysis showed that study design and metformin dose accounted for the heterogeneity. We conclude that metformin significantly protects against active tuberculosis among diabetic patients. On the contrary, DPP IV inhibitors could increase the risk of developing active tuberculosis.

Hipokalemia y muerte súbita cardiaca en personas sin enfermedad cardiaca estructural: Presentación de caso y revisión sistemática / Hypokalemia and sudden cardiac death in people without structural heart disease: Case presentation and systematic review

Introducción: El objetivo de este estudio fue sintetizar la evidencia sobre las causas de muerte súbita cardiaca (MSC) asociada a hipokalemia en individuos de ≥15 a <65 años de edad sin cardiopatía estructural. Reporte de caso. Reportamos un caso y recopilamos casos de MSC siguiendo la estrategia PECO. Realizamos una búsqueda bibliográfica hasta el 30 de noviembre del 2021. Incluimos 25 casos. La edad media fue 33,8 ± 2,4 años. Del total de casos, 60% fueron varones y 60% correspondieron a etiologías adquiridas. La tirotoxicosis fue la etiología del 8% de casos. El intervalo QTc estuvo prolongado en 90% de casos en los que se pudo registrar. El 60% de casos fueron extrahospitalarios. Solo el 24% de los episodios resultaron en muerte. Conclusiones. La tirotoxicosis es una causa rara de parada cardiaca súbita (PCS) hipokalémica. La PCS parece asociarse a mejores clínicos comparada con la PCS asociada a kiperkalemia o normokalemia.

Introduction: The aim of this study was to synthesize the evidence on the causes of sudden cardiac death (SCD) associated with hypokalemia in individuals ≥15 to <65 years of age without structural heart disease. Case report. We reported a case and collected SCD cases following the PECO strategy. We conducted a bibliographic search of the literature published up to November 30, 2021. We included 25 cases. The mean age was 33.8 ± 2.4 years. Of the total cases, 60% were male and 60% corresponded to acquired etiologies. Thyrotoxicosis was the etiology of 8% of cases. The QTc interval was prolonged in 90% of the cases in which it could be recorded. Sixty percent of cases occurred out of hospital. Only 24% of episodes resulted in death. Conclusions. Thyrotoxicosis is a rare cause of hypokalemic sudden cardiac arrest (SCA). Hypokalemic SCA seems to be associated with better clinical results compared to SCA associated with hyperkalemia or normokalemia.

Tetanus secondary to oral and odontogenic infections: a case report and systematic literature review.

Objectives: Tetanus is a potentially lethal infection and remains a priority public health problem in countries with low vaccination coverage. We aim to synthesize the evidence on the clinical-epidemiologic characteristics of oral (odontogenic) tetanus. Methods: We report a case of oral tetanus. Furthermore, we collected eligible articles about oral tetanus published to date. We performed a systematic review with an exhaustive search of the literature published up to June 30, 2022, in Medline (PubMed), Google Scholar, Scopus, EMBASE, Web of Science, and ScienceDirect. Results: We analyzed 19 studies that enrolled 26 cases of oral tetanus. The mean age was 51.60 ± 21.95 (range 10-77) years. The frequency and lethality of odontogenic tetanus were higher in males than females. More than 60% of cases occurred in North America. Almost three-quarters of cases were associated with a dental procedure - mainly dental extraction - meanwhile, tooth decay accounted for 23% of cases. The median incubation period was 8.0 (IQR 10.0) days. The time between trismus and death was 4.25±1.89 (range 3-7) days. Clostridium tetani was isolated in only 11.54% of cases. Administration of anti-tetanus immunoglobulin alone or combined with anti-tetanus toxoid was reported in at least 42% of cases, and antibiotics in 32% of cases. Patients required tracheostomy and mechanical ventilation in 12% and 8% of cases, respectively. The mean hospital stay was 18.38±14.97 (range 4-53) days. The lethality of odontogenic tetanus was (30.77%). Conclusion: Since the diagnosis of tetanus is merely clinical, it is crucial to have a high index of suspicion to diagnose this disease correctly. Although odontogenic tetanus is rare, it is potentially life-threatening.

Toxic epidermal necrolysis associated with anticonvulsants / Necrólisis epidérmica tóxica asociada a anticonvulsivantes

ABSTRACT Background and Objectives: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are considered as a continuum of the same process. TEN or Lyell Syndrome is the most severe form. Both entities involve an acute mucocutaneous blistering reaction associated with systemic inflammation. Materials and Methods: We present a case of a young woman who developed TEN following concomitant treatment with valproate, lamotrigine, and phenobarbital. Despite the extensive mucocutaneous detachment (over 90%), prognostic evaluation was favorable (SCORTEN score 2; probability of survival 88%), and this patient evolved satisfactorily. Five days after admission, valproate was reinitiated without any subsequent adverse reaction. Results: Causality evaluation identified both lamotrigine and phenobarbital as "very probable" (ALDEN score = 6) causes and valproate as "very unlikely" (ALDEN score = 0) cause of TEN. Conclusions: SJS and TEN are true life-threatening medical emergencies. This case emphasizes the importance of early diagnosis and treatment, including the discontinuation of the causative agent, which can be lifesaving.

RESUMEN Antecedentes y objetivos: El síndrome de Stevens-Johnson (SSJ) y la necrólisis epidérmica tóxica (NET) se consideran un continuum del mismo proceso. La NET o síndrome de Lyell es la forma más grave. Ambas entidades implican una reacción ampollosa mucocutánea aguda asociada con inflamación sistémica. Materiales y métodos: Presentamos el caso de una mujer joven que desarrolló NET posterior al tratamiento concomitante con valproato, lamotrigina y fenobarbital. A pesar del extenso desprendimiento mucocutáneo (más del 90%), la evaluación pronóstica fue favorable (puntuación SCORTEN 2; probabilidad de supervivencia 88%), y esta paciente evolucionó satisfactoriamente. Cinco días después de su ingreso, se reinició el valproato sin ninguna reacción adversa posterior. Resultados: La evaluación de causalidad identificó tanto la lamotrigina como el fenobarbital como causas "muy probables" (puntuación ALDEN = 6) y el valproato como causas "muy improbables" (puntuación ALDEN = 0) de NET. Conclusiones: El SJS y la NET son verdaderas emergencias médicas potencialmente letales. Este caso enfatiza la importancia del diagnóstico y tratamiento tempranos, incluida la interrupción del agente causal, lo cual puede salvar la vida del paciente.