Transmission of malaria from donors to solid organ transplant recipients: A case report and literature review.

Malaria is a febrile and potentially fatal infection. It is typically transmitted to humans through the bite of Anopheles mosquitoes and less frequently can be contracted through blood transfusions, sharing contaminated needles and syringes, mother-to-child transmission, or after solid organ transplantation. Posttransplant malaria has rarely been reported in the literature, even in endemic areas. We report the cases of three solid organ recipients in which Plasmodium vivax infection was documented during postsurgical evaluation 30 days after transplant surgery. The diagnosis of donor-derived malaria was confirmed in all patients by demonstrating Plasmodium in a peripheral blood smear and by polymerase chain reaction (PCR). All recipients had symptoms. The liver transplant recipient had myalgia, arthralgia, and thrombocytopenia; the kidney transplant recipient developed acute renal failure; and the heart transplant recipient had fever, cephalalgia, and tonic-clonic seizures. Pre-transplant screening of donors and recipients from endemic regions may not be sufficient to safely rule out persistent malaria. In Colombia, according to legislation, no mandatory testing is required for the diagnosis of malaria in organ donors in nonendemic areas. Therefore, donor screening by questionnaire is the only tool for preventing transplant-borne malaria. The migratory trend from Venezuela to Colombia has increased the number of imported cases of malaria, and the infection may be present in endemic and nonendemic regions. Although donor evaluation is not standardized in current guidelines, we suggest that donors be tested for malaria with a peripheral blood smear, detection of specific IgG antibodies against Plasmodium, and techniques such as PCR, if possible.

Disseminated bronchiectasis in an adult with common variable immunodeficiency.

Primary immunodeficiencies (PID) are traditionally considered childhood diseases; however, adults account for 35% of all patients with PID. Antibody deficiencies, especially Common Variable Immunodeficiency (CVID), which have their peak incidence in adulthood, require a high suspicion index. Even though the estimated frequency of CVID is not high (1:25,000), high rates of under diagnosis and under reporting are very likely. The delay in diagnosis increases the morbidity and mortality; therefore, adult physicians should be able to suspect, identify and initiate management of individuals with PID. Here we report the case of a 37 year-old man presenting to the emergency room with dyspnea, fever and cough; he developed respiratory failure requiring mechanical ventilation. He complained of recurring pneumonia associated with widespread bronchiectasis since he was 18 years old. Serum immunoglobulins quantification showed severe hypogammaglobulinemia (total IgG <140 mg/dL; total IgA, 2.9 mg/dL; and total IgM <5 mg/dL). Treatment with Human Intravenous Immunoglobulin (IVIG) 10% was started, and with antibiotic treatment for severe pneumonia (during 14 days) was also prescribed. His clinical evolution has been favorable after one year follow-up. Common Variable Immunodeficiency (CVID) diagnosis was made.

Las inmunodeficiencias primarias (IDP) son patologías que tradicionalmente se consideran de la niñez sin embargo los adultos representan el 35% del total de pacientes con IDP. Las deficiencias de anticuerpos, en especial la Inmunodeficiencia Común Variable (IDCV) tienen su pico de incidencia en la edad adulta, requiere un alto índice de sospecha y si bien su frecuencia estimada no es alta (1:25,000), es muy posible que el subregistro y subdiagnóstico si lo sean. El retraso en el diagnóstico aumenta la morbi-mortalidad razón por la cual los médicos de adultos deben estar en capacidad de sospechar, identificar e iniciar el manejo de las personas con IPD. Presentamos el caso de un hombre de 37 años de edad atendido en la sala de urgencias con disnea, fiebre y tos, desarrolla falla respiratoria requiriendo ventilación mecánica. Refería neumonías a repetición desde los 18 años de edad asociadas con bronquiectasias generalizadas. La cuantificación de inmunoglobulinas séricas evidenció hipogammaglobulinemia severa (IgG total <140 mg/dL, IgA total 2.9 mg/dL, IgM total <5 mg/dL), se inició inmunoglobulina humana endovenosa (IGIV) al 10%, y recibió tratamiento antibiótico por 14 días para neumonía severa, su evolución clínica ha sido favorable hasta ahora (un año de seguimiento), se estableció el diagnostico de Inmunodeficiencia Común Variable (IDCV).

Disseminated bronchiectasis in an adult with common variable immunodeficiency / Bronquiectasias diseminada en un adulto con inmunodeficiencia común variable

Primary immunodeficiencies (PID) are traditionally considered childhood diseases; however, adults account for 35% of all patients with PID. Antibody deficiencies, especially Common Variable Immunodeficiency (CVID), which have their peak incidence in adulthood, require a high suspicion index. Even though the estimated frequency of CVID is not high (1:25,000), high rates of under diagnosis and under reporting are very likely. The delay in diagnosis increases the morbidity and mortality; therefore, adult physicians should be able to suspect, identify and initiate management of individuals with PID. Here we report the case of a 37 year-old man presenting to the emergency room with dyspnea, fever and cough; he developed respiratory failure requiring mechanical ventilation. He complained of recurring pneumonia associated with widespread bronchiectasis since he was 18 years old. Serum immunoglobulins quantification showed severe hypogammaglobulinemia (total IgG <140 mg/dL; total IgA, 2.9 mg/dL; and total IgM <5 mg/dL). Treatment with Human Intravenous Immunoglobulin (IVIG) 10% was started, and with antibiotic treatment for severe pneumonia (during 14 days) was also prescribed. His clinical evolution has been favorable after one year follow-up. Common Variable Immunodeficiency (CVID) diagnosis was made.

Las inmunodeficiencias primarias (IDP) son patologías que tradicionalmente se consideran de la niñez sin embargo los adultos representan el 35% del total de pacientes con IDP. Las deficiencias de anticuerpos, en especial la Inmunodeficiencia Común Variable (IDCV) tienen su pico de incidencia en la edad adulta, requiere un alto índice de sospecha y si bien su frecuencia estimada no es alta (1:25,000), es muy posible que el subregistro y subdiagnóstico si lo sean. El retraso en el diagnóstico aumenta la morbi-mortalidad razón por la cual los médicos de adultos deben estar en capacidad de sospechar, identificar e iniciar el manejo de las personas con IPD. Presentamos el caso de un hombre de 37 años de edad atendido en la sala de urgencias con disnea, fiebre y tos, desarrolla falla respiratoria requiriendo ventilación mecánica. Refería neumonías a repetición desde los 18 años de edad asociadas con bronquiectasias generalizadas. La cuantificación de inmunoglobulinas séricas evidenció hipogammaglobulinemia severa (IgG total <140 mg/dL, IgA total 2.9 mg/dL, IgM total <5 mg/dL), se inició inmunoglobulina humana endovenosa (IGIV) al 10%, y recibió tratamiento antibiótico por 14 dias para neumonía severa, su evolución clínica ha sido favorable hasta ahora (un año de seguimiento), se estableció el diagnostico de Inmunodeficiencia Común Variable (IDCV).

Colecistectomía laparoscópica difícil, estrategias de manejo / Difficult laparoscopic cholecystectomy, management strategies

La colecistectomía laparoscópica es uno de los procedimientos quirúrgicos practicados más frecuentemente por el cirujano general y en un importante número de casos se efectúa en pacientes mayores con gran inflamación vesicular, lo que pone a prueba los conocimientos y habilidades del cirujano. Es perfectamente posible reconocer, antes del acto quirúrgico, en cuáles pacientes este resultará difícil en mayor o menor grado, para así diseñar estrategias de manejo intraoperatorio que nos permitan resolver favorablemente estos casos. En este artículo, el cual se presenta acompañado de videos de casos clínicos publicados en la página electrónica de la Asociación Colombiana de Cirugía (http://www.ascolcirugia.org), se pretende mostrar cuáles son las opciones de manejo en aquellos pacientes cuyas colecistectomías son muy difíciles por el grado de inflamación o por las enfermedades subyacentes y que constituyen alternativas de manejo viables para la colecistectomía laparoscópica clásica o para evitar la conversión a cirugía abierta; aunque también, se llama fuertemente la atención sobre la necesidad de una conversión temprana y oportuna antes de tener complicaciones o alteraciones iatrogénicas de la vía biliar u otro órgano vecino.

Laparoscopic cholecystectomy is one of the most commonly performed procedures by the general surgeon and an important number of cases occur in elderly patients with major inflammation of the gallbladder, a condition that challenges the knowledge and ability of the surgeon. It is perfectible possible to recognize, prior to surgery, which patients will present major or minor difficulties so as to design intraoperative strategies in order to favorably resolve such situations. This article is complemented wit uploaded YouTube videos in the web page of the Asociación Colombiana de Cirugía, http://www.ascolcirugia.org. It intends to show the different management options in those patients with very difficult cholecystectomies because of the degree of inflammation or the underlying pathology that constitute viable alternatives to the classic laparoscopic cholecystectomy or to avoid conversion open surgery; however, it also strongly calls attention to the need of early and timely conversion so as to avoid complications or iatrogenic lesion of the bile duct or neighbor organs.

Acquisition of a multifunctional IgA+ plasma cell phenotype in the gut.

The largest mucosal surface in the body is in the gastrointestinal tract, a location that is heavily colonized by microbes that are normally harmless. A key mechanism required for maintaining a homeostatic balance between this microbial burden and the lymphocytes that densely populate the gastrointestinal tract is the production and transepithelial transport of poly-reactive IgA (ref. 1). Within the mucosal tissues, B cells respond to cytokines, sometimes in the absence of T-cell help, undergo class switch recombination of their immunoglobulin receptor to IgA, and differentiate to become plasma cells. However, IgA-secreting plasma cells probably have additional attributes that are needed for coping with the tremendous bacterial load in the gastrointestinal tract. Here we report that mouse IgA(+) plasma cells also produce the antimicrobial mediators tumour-necrosis factor-α (TNF-α) and inducible nitric oxide synthase (iNOS), and express many molecules that are commonly associated with monocyte/granulocytic cell types. The development of iNOS-producing IgA(+) plasma cells can be recapitulated in vitro in the presence of gut stroma, and the acquisition of this multifunctional phenotype in vivo and in vitro relies on microbial co-stimulation. Deletion of TNF-α and iNOS in B-lineage cells resulted in a reduction in IgA production, altered diversification of the gut microbiota and poor clearance of a gut-tropic pathogen. These findings reveal a novel adaptation to maintaining homeostasis in the gut, and extend the repertoire of protective responses exhibited by some B-lineage cells.

Membrane vesicles released by intestinal epithelial cells infected with rotavirus inhibit T-cell function.

Rotavirus (RV) predominantly replicates in intestinal epithelial cells (IEC), and "danger signals" released by these cells may modulate viral immunity. We have recently shown that human model IEC (Caco-2 cells) infected with rhesus-RV release a non-inflammatory group of immunomodulators that includes heat shock proteins (HSPs) and TGF-ß1. Here we show that both proteins are released in part in association with membrane vesicles (MV) obtained from filtrated Caco-2 supernatants concentrated by ultracentrifugation. These MV express markers of exosomes (CD63 and others), but not of the endoplasmic reticulum (ER) or nuclei. Larger quantities of proteins associated with MV were released by RV-infected cells than by non-infected cells. VP6 co-immunoprecipitated with CD63 present in these MV, and VP6 co-localized with CD63 in RV-infected cells, suggesting that this viral protein is associated with the MV, and that this association occurs intracellularly. CD63 present in MV preparations from stool samples from 36 children with gastroenteritis due or not due to RV were analyzed. VP6 co-immunoprecipitated with CD63 in 3/8 stool samples from RV-infected children, suggesting that these MV are released by RV-infected cells in vivo. Moreover, fractions that contained MV from RV-infected cells induced death and inhibited proliferation of CD4(+) T cells to a greater extent than fractions from non-infected cells. These effects were in part due to TGF-ß, because they were reversed by treatment of the T cells with the TGF-ß-receptor inhibitor ALK5i. MV from RV-infected and non-infected cells were heterogeneous, with morphologies and typical flotation densities described for exosomes (between 1.10 and 1.18 g/mL), and denser vesicles (>1.24 g/mL). Both types of MV from RV-infected cells were more efficient at inhibiting T-cell function than were those from non-infected cells. We propose that RV infection of IEC releases MV that modulate viral immunity.

Characterization of rotavirus specific B cells and their relation with serological memory.

We quantified circulating total, rotavirus (RV) and Tetanus toxin (TT) memory B cells (mBc) in healthy adults using a limiting dilution assay (LDA) and a flow cytometry assay (FCA) that permit evaluation of both CD27+ and CD27- mBc. RV mBc were enriched in the CD27-, IgG+ and in the CD27+, IgM+ subsets. The numbers of RV mBc were higher by FCA than by LDA and results of the two assays did not correlate. TT IgGmBc and RV IgA mBc determined by FCA and by LDA correlated with TT plasma IgG and RV plasma IgA, respectively. The mean ratio of specific mBc/mug/ml of the corresponding plasma immunoglobulin was lower for TT IgG than for RV IgA mBc. Our studies contribute to understand the relationship between circulating mBc and serological memory, and enhance our capacity to develop better correlates of protection against RV disease.

Evaluation of circulating intestinally committed memory B cells in children vaccinated with attenuated human rotavirus vaccine.

In a double blind trial, 319 fully immunized children received two doses of either placebo or 10(6.7) focus-forming units of the attenuated RIX4414 human rotavirus (RV) vaccine ("all-in-one" formulation). Plasma RV-specific IgA (RV IgA), stool RV IgA, and circulating total and RV memory B cells (CD19+ IgD+/- CD27+) with an intestinal homing phenotype (alpha4beta7+ CCR9+/-) were measured, after the first and second doses, as potential correlates of protection. After the first and/or second dose, 54% of vaccinees and 13% of placebo recipients had plasma RV IgA. Before vaccination, most (95%) of the children (of both study groups) were breast-fed and had stool RV IgA (68.64%). Coproconversion (4-fold increase) after the first and/or second dose was observed in 32.7% of vaccinees and 17.4% of placebo recipients. No significant difference was seen when comparing the frequencies of any subset of memory B cells between vaccinees and placebo recipients. Statistically significant weak correlations were found between plasma RV IgA titers and coproconversion, and several subsets of memory B cells. The vaccine provided 74.8% protection (95% confidence interval, 30.93-92.62) against any RV gastroenteritis and 100% protection (95% confidence interval, 14.53-100) against severe RV gastroenteritis. When vaccinees and placebo recipients were considered together, a correlation was found between protection from disease and plasma RV IgA measured after dose 2 and RV memory (IgD- CD27+ alpha4beta7+ CCR9+) circulating B cells measured after dose 1. However, the correlation coefficients for both tests were low (<0.2), suggesting that other factors are important in explaining protection from disease.

Enfermedad vesicular: Diagnostico y tratamiento / Gallblader disease: Diagnosis and treatment

Se revisaron las historias clinicas de 153 pacientes operados en 1983 poe enfermedad vesicular; 61% eran mayores de 40 anos y las mujeres predominaron sobre los hombres en proporcion de 5:1. El sintoma y signo mas frecuente fue el dolor en el cuadrante superior derecho del abdomen. Hubo leucocitosis en 35% de los pacientes e ictericia en 15%. La colecistografia oral, solo, solo se practico a 50% de los enfermos y ecografia a 26.8%. Tenian colecistitis aguda, en sus difernetes formas de presentacion 45% de los pacienteas. A 3% se les extirpo la vesicula siendo normal. La colecistitis acalculosa aparecio en 9.2%. Los germenes mas comunmente aislados fueron Eschericha coli y Klebsiella pneumoniae. Tan solo se dejo un drenaje subhepatico en 5% de los casos. Hubo complicaciones post-operatorios en 13% y las mas frecuentes fueron: infeccion de la herida y litiasis desapercibida en el coledoco. La mortalidad fue 1.3%

Absceso intraabdominal: Estudio de 47 pacientes en el Hospital Universitario del Valle / Intraabdominal abscess: Study of 47 Patients in Hospital Universitario del Valle

Se revisan las historias clinicas de 47 pacientes con absceso intraabdominal intervenidos quirurgicamente en el Hospital Universitario del Valle, entre julio 1 y diciembre 31 de 1984. Casi 66% de los pacientes estaban en el grupo entre 15 y 44 anos de edad. Presentaron leucocitosis 70% de los pacientes e ictericia 15%. Las radiografias simples de abdomen fueron importantes para hacer el diagnostico en 36% de los casos y se encontraron alteraciones en la radiografia de torax en 7%. La ecografia y la gammagrafia se hizo en muy pocos pacientes y a ninguno se le practico TAC

Apendicitis Aguda: Diagnostico y Tratamiento / Acute Appendicitis: Diagnosis and Treatment

Se analizaron las historias clinicas de 524 persoas que ingresaron al Hospital Universitario del Valle entre enero 1 y diciembre 31 de 1983. Fueron hombres 55% de los pacientes; la mayor proporcion de casos con apendicitis aguda se presento en el grupo entre 10 y 19 anos. La enfermedad es rara en los extremos de la vida. El analisis permitio estudiar las distintas variables segun la fase inflamatoria de la enfermedad. Los sintomas y signos que se presentaron en la casi totalidad de los pacientes fueron dolor abdominal, nauseas, vomito, anorexia y signo de Blumberg positivo. Alrededor de 70% de los enfermos tenian el leucograma alterado. La cifra de laparotomias innecesarias fue de 4.4% en 5 pacientes en quienes el cirujano juzgo que el apendice estaba sano; la patologia informo apendicitis aguda. El apendice se extirpo a los 524 pacientes del estudio. Se utilizaron antibioticos pre y post-operatorios en todos los pacientes con perforacion apendicular; la combinacion mas utilizada fue gentamicina y cloranfenicol. Solo se utilizaron drenajes de la cavidad peritoneal en 5% de los casos. A la casi totalidad de los pacienes con apendicitis aguda complicada se les dejaron descubiertos el tejido celular subcutaneo y la piel para prevenir la infeccion severa de la herida. El germen mas comunmente aislado fue Escherichia coli. En el Hospital no se hacen cultivos sistematicos para bacterias anaerobicas. Las complicaciones mas frecuentes fueron septicas. El porcentaje global de mortalidad fue 1.5%

Diagnostico y tratamiento de la sepsis intraabdominal: Estudio de 240 pacientes en el Hospital Universitario del Valle. Cali / Diagnosis and treatment of intraabdominal sepsis: Study of 240 patients in Hospital Universitario del Valle. Cali

Se analizan las historias clinicas de 240 pacientes que ingresaron al Hospital Universitario del Valle con sepsis intraabdominal durante el segundo semestre de 1984. Buena proporcion de pacientes, 48.3%, pertenecia al grupo entre 15 y 44 anos. Hubo leucocitosis en 66.7% de los casos e ictericia en 7.5%. Los estudios radiologicos simples, de abdomen y torax, se hicieron en menos de 20% de los pacientes. Aunque el ultrasonido se efectuo en 8% de los enfermos en estos pocos casos fue de gran ayuda para el diagnostico. La tomografia axial computadorizada no se realizo a ningun paciente. Las principales causas de la sepsis intraabdominal fueron: 1) apendicitis aguda perforada; 2) perforacion de viscera hueca; 3) trauma abdominal; 4) enfermedades de vesicula y vias biliares; y 5) enfermedades ginecoobstetricas. Todos los pacientes fueron atendidos con cirugia; 51% recibieron una asociacion de gentamicina y cloramfenicol y el resto distintas combinaciones para cubrir germenes aerobios y anaerobios. El germen mas comun fue la Escherichia coli. La mortalidad global fue 10.8% y el promedio de estancia hospitalaria fue 13.3 dias