Foot ischaemia and toe skin necrosis associated with interleukin-2 infusion in an HIV-infected patient.

A 39-year-old white man developed a severe left toe foot ischaemia and toe skin necrosis following his 12 courses of interleukin (IL)-2 (4.5 MIU twice a day, subcutaneously) for five days every two months. He had no known general risk factors for thrombosis other than HIV infection. An arterial Doppler ultrasound examination of the leg confirmed the permeability of the posterior tibial artery and its digital pulse. A diagnosis of foot ischaemia and toe skin necrosis was made. The suspected causative agent was IL-2 since this was the only drug that the patient was taking before the symptoms appeared. The patient was empirically treated with an aspirin and pentoxifylline in order to improve local microcirculation. We observed a satisfactory response with a quick resolve of skin lesions. The most possible cause of foot ischaemia and toe skin necrosis was considered to be IL-2 because of the temporal relationship between the exposure to the drug and onset of symptoms. Based on the Naranjo probability scale, IL-2 could be considered the probable cause of the foot ischaemia and toe skin necrosis. If clinical evaluation leads to the suspicion of ischaemic process, therapy with IL-2 should be discontinued immediately.

[Community-acquired pneumonia among the elderly: differences between patients living at home and in nursing homes]. / La neumonía adquirida en la comunidad de los ancianos: diferencias entre los que viven en residencias y en domicilios particulares.

OBJECTIVE: The etiology, presentation, and prognosis of community-acquired pneumonia (CAP) among nursing home residents are believed to differ from those of other groups. However, few Spanish studies have confirmed those assumptions or studied regional differences in CAP etiology. PATIENTS AND METHODS: A prospective study which included all patients over 65 years of age admitted to our hospital with CAP was carried out over a period of 18 months (2002-2003). We examined clinical, analytical, and radiographic characteristics paying particular attention to functional status--using the Eastern Cooperative Oncology Group (ECOG) scale and Barthel and Karnofsky indices--and comorbidity. Two blood cultures, a Legionella antigen test in urine, and serology for atypical bacteria were used for the etiologic diagnosis; bacterial cultures of respiratory samples were also used in certain cases. RESULTS: Ninety-one patients, 25 of whom were nursing home residents, were enrolled. The nursing home residents were older than the other patients (mean [SD] age of 82 [4] compared with 73 [5]; P=.0001) and had greater comorbidity (P=.0001)--with a significantly greater presence of diabetes mellitus, cerebrovascular disease, congestive heart failure, and dementia. They also had a poorer functional status (ECOG, 2.09 [0.9] compared with 0.93 [1.1], P=.001; Barthel Index, 19 [33] compared with 77 [35], P=.001; Karnofsky In-dex, 51 [17] compared with 78 [23], P=.001). Regarding clinical characteristics, significant differences were found for respiratory rate (39 [11] compared with 27 [7] breaths/min; P=.001), blood pressure (69.5 [20] compared with 79.2 [18] mm Hg; P=.029), and temperature (36.6 [1.2] compared with 37.7 [1.1] degrees C; P=.001). CAP patients from nursing homes presented a greater number of affected lobules in chest x-rays (P=.004), more hypoxemia, acidosis, anemia, hypoalbuminemia, and greater scores of urea and creatinine. Fine Scale scores were also greater (134 [26] compared with 95 [28]; P=.001) as was mortality (7/25 compared with 3/66; P=.005). Few patients had an etiologic diagnosis and no significant differences were observed between the groups. The variable that predicted mortality in elderly patients in this series, according to stepwise logistic regression, was urea (adjusted R2=0.452). CONCLUSIONS: In our sample population, nursing home residents were older, had greater comorbidity, and severe functional impairment. Under these circumstances the severity of CAP increases and becomes an important cause of mortality despite the fact that the etiologic agents do not appear to differ from those of the other patients.

[Systemic candidiasis and infliximab therapy]. / Candidiasis sistémica y tratamiento con infliximab.

The use of infliximab in patients with luminal or fistulizing Crohn's disease refractory to medical treatment (steroids and immunomodulatory drugs) is increasingly widespread. Although the incidence of serious infections in patients undergoing infliximab treatment is not higher than that of controls, systemic fungal infections in patients treated with this antibody have been anecdotally described. We report a case of systemic candidiasis in a patient with refractory Crohn's disease who was treated with infliximab associated with corticosteroids and azathioprine and discuss the role that infliximab could have played in the development of this complication.

[Hypertransaminasemia: indication for the diagnosis of celiac disease]. / Hipertransaminasemia: sospecha para el diagnóstico de enfermedad celíaca.

A high percentage of diagnosed cases of coeliac disease are oligosymptompatic. Various atypical manifestations such as hypertransaminasemia may guide diagnosis when the disease is suspected. We present two cases of coeliac disease, which were diagnosed on the basis of hypertransaminasemia of unknown origin. One of the patients lacked the gastrointestinal symptoms suggestive of disease. We also retrospectively review (January 1990-December 1998) all the cases of coeliac disease diagnosed in our center in order to establish the frequency of liver enzyme alterations in patients with coeliac disease and their evolution on a gluten-free diet. The importance of sprue suspicion in guiding diagnosis in patients with cryptogenic hypertransaminasemia is highlighted as is the need to rule out underlying liver disease in coeliac patients with persistent hypertransaminasemia after withdrawing gluten from the diet.

[Clinical manifestations of Stenotrophomas (Xanthomonas) maltophilia infection]. / Espectro clínico de la infección por Stenotrophomonas (Xanthomonas) maltophilia.

OBJECTIVE: Stenotrophomonas maltophilia (SM) is a gram-negative bacillus whose incidence like nosocomial pathogen has been incremented in the last years, especially in immunocompromised patients, subjected to invasive procedures and those receiving broad-spectrum antimicrobial therapy. METHOD: We report 15 isolations of SM between 1994-1996. RESULTS: The criteria for SM infection were fulfilled by 9 patients (60%), and 6 patients (40%) were colonized. The mean age of the patient was 60 +/- 12 years. Major predisposing factors in infections included venous catheterization (100%), prior surgery (86%), residence in ICU (80%), prior antibiotic therapy (80%) and intubation (66%). The most common underlying disease were heart disease (60%), treatment with immunosuppressors and/or steroids (46%) and chronic lung disease (46%). Ten cases (66%) had polymicrobial culture. The mortality rate was 40%. Risk factors associated with fatal outcome included the following: chronic lung disease (p = 0.043), nasogastric catheterization (p = 0.01), urinary tract catheterization (p = 0.02), intubation (p = 0.04) and the presence of pneumonia or sepsis by SM (p = 0.02). The most active agents were colistina (100%), cotrimoxazol (71%) and ceftazidima (53%). The isolates were highly resistant to first and second-generation cephalosporins (100%) tetracyclines (86%), aztreonam (91%) and imipenem (71%). CONCLUSION: SM cause a wide range of clinical syndromes and is more likely to cause infection or colonization in patients who have underlying disease. Due to its inherent multiple-antimicrobial resistance, it would appear its potential as a nosocomial pathogen will continue to increase. Therapy of patients should include cotrimoxazole.

[Langerhans cell histiocytosis of lymph node]. / Histiocitosis de células de Langerhans de presentación ganglionar.

Langerhans cell Histiocytosis or Histiocytosis X encompasses the syndromes of Letterer-Siwe disease, Hand-Schuller-Christian disease and eosinophilic granuloma. The localized disease usually consisted of isolated bone involvement as osteolytic areas. The isolated lymph node disease is uncommon. A case study of eosinophilic granuloma of lymph node in a 27 years-old woman who underwent several recurrences as lymphadenitis is presented. This case is presented in light of the cytologic, histologic and immunohistochemical findings of node-based eosinophilic granuloma and the favorable prognosis of this localized form treated with steroids.

Traditional knowledge of medicinal plants in the Serra de Mariola Natural Park, South-Eastern Spain.

The present study aims to inventory and analyse the ethnobotanical knowledge about medicinal plants in the Serra de Mariola Natural Park. In respect to traditional uses, 93 species reported by local informants were therapeutic, 27 food, 4 natural dyes and 13 handcrafts. We developed a methodology that allowed the location of individuals or vegetation communities with a specific popular use. We prepared a geographic information system (GIS) that included gender, family, scientific nomenclature and common names in Spanish and Catalan for each species. We also made a classification of 39 medicinal uses from ATC (Anatomical, Therapeutic, Chemical classification system). Labiatae (n=19), Compositae (n=9) and Leguminosae (n=6) were the families most represented among the plants used to different purposes in humans. Species with the most elevated cultural importance index (CI) values were Thymus vulgaris (CI=1.431), Rosmarinus officinalis (CI=1.415), Eryngium campestre (CI=1.325), Verbascum sinuatum (CI=1.106) and Sideritis angustifolia (CI=1.041). Thus, the collected plants with more therapeutic uses were: Lippia triphylla (12), Thymus vulgaris and Allium roseum (9) and Erygium campestre (8). The most repeated ATC uses were: G04 (urological use), D03 (treatment of wounds and ulcers) and R02 (throat diseases). These results were in a geographic map where each point represented an individual of any species. A database was created with the corresponding therapeutic uses. This application is useful for the identification of individuals and the selection of species for specific medicinal properties. In the end, knowledge of these useful plants may be interesting to revive the local economy and in some cases promote their cultivation.

Hyperhidrosis related to nevirapine therapy.

A 70-year-old white man presented to the internal medicine outpatient clinic with symptoms of significant hyperhidrosis. He had been started on antiretroviral therapy (ART) with tenofovir, lamivudine and nevirapine. The patient complained of excessive sweating following severe asthenia after taking nevirapine. Based on these findings, we suspected that the causative agent was nevirapine and a diagnosis of hyperhidrosis due to nevirapine was made. Nevirapine treatment was stopped and was substituted with efavirenz: the patient continued on therapy with tenofovir and lamivudine. The hyperhidrosis symptoms resolved in 2-3 days. No relapse was observed with the new ART regimen. Drugs that induce hyperhidrosis can cause patient discomfort and embarrassment. In our patient, this adverse drug reaction also caused severe asthenia that decreased the patient's physical and emotional quality of life. There was a temporal relationship between the developments of symptoms and starting nevirapine therapy. Once nevirapine was suspended and switched to efavirenz, excessive sweating resolved. An objective causality assessment revealed that the adverse effect was probable. Until further data are available, clinicians should consider discontinuation of nevirapine therapy in patients who develop severe hyperhidrosis.

[Lipid lowering goals in high risk and very high cardiovascular risk patients: a reasonable challenge?]. / Objetivos del tratamiento hipolipemiante en pacientes con alto riesgo y muy alto riesgo cardiovascular: un reto posible?

OBJECTIVE: The last modifications of the National Cholesterol Education Program (NCEP) indicate some lower therapeutic targets of low density protein cholesterol (LDL-c) in patients with very high vascular risk. Our study aims to establish the degree of compliance of the therapeutic targets defined by these modifications. PATIENTS AND METHOD: Descriptive and cross sectional study of patients from a cardiovascular clinic. Low-density lipoprotein cholesterol (LDL-c) was calculated and targets were established according the new update of NCEP-ATP III. RESULTS: 836 patients, 625 (75%) with HR and 211(25%) with VHR were studied 45% of HR and 67% of VHR were receiving treatment with statins (p < 0.001) but only 38% of HR and 15% of VHR achieved target LDL-c levels. The percentage of patients who could achieve LDL-goals using the maximum approved dose of the statins plus other lipid lowering drug was calculated: The 31% of HR and 51% of VHR were unable to achieve the LDL-c targets. CONCLUSIONS: Only 15% of very high risk patients achieve target levels of LDL-c according to the new NCEP-ATP III recommendations. Even using maximum dose of statins in combination with other lipid lowering drugs, less than half of the patients will be able to achieve LDL-c goal (< 70 mg/dl).

[The prognostic value of plasma triglycerides in human immunodeficiency virus infection]. / Valor pronóstico de los triglicéridos plasmáticos en la infección por virus de la inmunodeficiencia humana.

BACKGROUND: Infection with the human immunodeficiency virus (HIV) is associated with an increased prevalence of hypertriglyceridemia, which is more common in advanced stages of disease. Nevertheless, the role of hypertriglyceridemia as a predictive marker of progression of disease and/or mortality is not fully elucidated. METHODS: One-hundred nineteen patients with HIV infection attended at our Outpatient Clinic or hospitalized in our Service were retrospectively studied. At the beginning of the study and every six months a complete medical history and physical examination were obtained, with a complete blood count, serum biochemistry, total lymphocytes and CD4 subpopulations, cholesterol, triglycerides and IgA. With comparative purposes cholesterol and triglyceride values were also determined in a control group of healthy subjects with the same age and gender. The relationship between triglyceride levels and the other clinical and analytical parameters was evaluated by means of the Pearson linear correlation. The risk for developing clinical disease and survival were studied by the method proposed by Kaplan and Meier. RESULTS: The mean age of patients was 27 +/- 6 years and the male/female ratio was 86/33. Eighty-three percent (99) of patients consumed drugs parenterally. Compared with the control group, patients with HIV infection had hypertriglyceridemia (159 +/- 80 mg/dl vs 79 +/- 53 mg/dl) and hypocholesterolemia (143 +/- 41 mg/dl vs 174 +/- 36 mg/dl) (p < 0.05). There was a positive correlation between triglycerides and IgA levels (p < 0.01) and a negative correlation with serum albumin (p < 0.05). A higher risk towards progression of disease was not observed among patients with hypertriglyceridemia (TG > 143 mg/dl) in non-AIDS infected patients, nor mortality in the overall group. CONCLUSIONS: HIV infected patients have a higher prevalence of hypertriglyceridemia and hypocholesterolemia. Plasma triglycerides were not useful as a prognostic factor for the development of disease nor as mortality risk.