Hígado agudo graso del embarazo: reporte de caso / Acute fatty liver of pregnancy: case report

El hígado graso del embarazo es una patología poco frecuente en la especialidad obstétrica, cuyo diagnóstico se realiza basado en los criterios de Swansea, muchas veces es un diagnóstico que se realiza por exclusión; usualmente se presenta entre las semanas 30 y 35 del embarazo, y la cura definitiva se realiza con la interrupción expedita del mismo; con una tasa de recuperación casi del 100% si se realiza la interrupción oportuna y una tasa de mortalidad materno fetal actual del 10%. Es importante estar atentos a la ganancia ponderal de la embarazada durante el control prenatal, la epigastralgia, y los signos clínicos asociados a hipoglicemia(AU)

Fatty liver of pregnancy is a rare pathology in obstetrics, whose diagnosis is made based on the Swansea criteria, many times it is a diagnosis that is made by exclusion; It usually occurs between weeks 30 and 35, and the definitive cure is carried out with the expeditious interruption of pregnancy; with a recovery rate of almost 100% if timely interruption is made and a current maternal-fetal mortality rate of 10%. It is important to be attentive to the weight gain of the pregnant woman during prenatal control, epigastric pain, and clinical signs associated with hypoglycemia

Variante "no clásica" o "atípica" del síndrome de Stauffer en paciente con carcinoma renal de células claras: reporte de caso / "Non-classical" or "atypical" variant of Stauffer syndrome in a patient with clear cell renal carcinoma: a case report

La manifestación paraneoplásica conocida como síndrome de Stauffer tiene una presentación atípica, caracterizada por ictericia y colestasis intrahepática. Presentamos el caso de un paciente de 53 años de edad, con antecedente de una masa renal derecha en plan de resección quirúrgica programada, con cuadro de evolución de dolor abdominal en hipocondrio derecho e ictericia. A su ingreso se documentó hepatoesplenomegalia, elevación de bilirrubinas a expensas de la directa, y de fosfatasa alcalina junto con elevación de transaminasas. Se descartaron causas obstructivas a nivel de vía biliar intra y extrahepática. No se documentaron metástasis o lesiones focales a nivel de parénquima, ni lesiones de etiología vascular que explicaran el cuadro. También se descartó hepatitis B, C e infección por VIH, por lo cual se consideró un probable síndrome de Stauffer. Fue llevado a nefrectomía intrahospitalaria, con posterior diagnóstico patológico compatible con carcinoma de células claras. Luego del procedimiento se normalizó la bioquímica hepática y se corrigió la ictericia. Es importante reconocer que la afectación hepática en el contexto de neoplasias, no es solo atribuida a metástasis a distancia, sino también a la existencia de síndromes paraneoplásicos como condicionantes.

The paraneoplastic manifestation known as Stauffer syndrome has an atypical presentation, characterized by jaundice and intrahepatic cholestasis. We present the case of a 53-year-old patient, with a history of a right renal mass with a planned surgical resection, who developed abdominal pain in the right upper quadrant and jaundice. Upon admission, hepatosplenomegaly, elevated bilirubin, at the expense of direct bilirubin, alkaline phosphatase and elevated transaminases were documented. Intra- and extrahepatic bile ducts obstruction were ruled out. There were no documented metastases or focal lesions at the level of the parenchyma, or lesions of vascular etiology that could explain the condition. Hepatitis B, C and HIV infection were also ruled out, and a probable Stauffer syndrome was considered. In-hospital nephrectomy was performed, with subsequent pathology compatible with clear cell carcinoma. After the procedure, liver biochemistry was normalized and jaundice was corrected. It is important to recognize that liver involvement in the context of neoplasms is not only attributed to distant metastases but to the existence of paraneoplastic syndromes as determining factors.

Differential diagnoses in 83 dogs with icterus / Diagnósticos diferenciais em 83 cães com icterícia

Icterus (jaundice) is a yellowish pigmentation resulting from the depositing of bilirubin in tissues due to its high plasmatic concentration. The pathogenesis of icterus includes metabolic changes or obstructed bilirubin excretion and it is classified as pre-hepatic, hepatic and post-hepatic. This study aimed to evaluate and classify different causes of icterus in dogs during post mortem examination. These dogs were examined from 2014 to 2017, using macroscopic and histologic exams as well as ancillary tests. Eighty-three dogs were examined macroscopically and microscopically. They were separated into groups of icterus types: 24 (28.9%) dogs had pre-hepatic icterus, 45 (54.2%) had hepatic, 13 (15.7%) pre-hepatic and hepatic and one (1.2%) had post-hepatic icterus. Many factors were identified as a cause of icterus, including infectious agents (51/83), neoplasms (13/83), hepatic degeneration (11/83), chronic hepatic diseases (6/83), and obstructive causes (1/87). Among the infectious causes, leptospirosis, ehrlichiosis and disorders suggestive of septicemia were diagnosed. Neoplasms associated with icterus were cholangiocarcinoma, hemangiosarcoma and lymphoma. Other causes of icterus included degenerative diseases, such as lipidosis and glycogen degeneration. Hepatic fibrosis (cirrhosis) as a chronic disease and cholelithiasis also produced icterus. PCR was performed to confirm leptospirosis and ehrlichiosis. Samples of total DNA were used to amplify a fragment of a gene from Leptospira interrogans and Ehrlichia canis. In some dogs, co-infection of these agents was detected. The classification and identification of icterus etiologies in dogs is very important due to the number of diseases with this alteration, where ante mortem diagnosis is not always easily performed when some of these conditions are present.(AU)

Icterícia é a pigmentação amarelada decorrente da deposição de bilirrubina em tecidos devido à elevada concentração plasmática. A patogênese da icterícia inclui alterações no metabolismo ou na excreção de bilirrubina, sendo classificada em pré-hepática, hepática ou pós-hepática. O objetivo desse estudo foi identificar, avaliar e classificar as causas de icterícia em cães necropsiados de 2014 a 2017, associando as lesões macroscópicas, histológicas e exames complementares. Foram avaliados macro- e microscopicamente 83 cães com diferentes intensidades de icterícia. Os cães foram separados em grupos de acordo com o tipo de icterícia: 24 (28,9%) cães com icterícia pré-hepática, 45 (54,2%) cães com icterícia hepática, 13 (15,7%) com icterícia pré-hepática e hepática e um (1,2%) com icterícia pós-hepática. Foram identificadas várias etiologias associadas à icterícia, dentre elas pode-se destacar, agentes infecciosos (51/83), neoplasmas (13/83), processos degenerativos (11/83), crônicos (6/83) e obstrutivos (1/83). Dentre as causas infecciosas, destacam-se a leptospirose, a erliquiose e as lesões sugestivas de septicemia. Entre os neoplasmas associados com icterícia destacaram-se o colangiocarcinoma, hemangiossarcoma e linfoma. Outras causas de icterícia incluiriam os processos degenerativos como as degenerações gordurosa e glicogênica. Fibrose hepática (cirrose) e colelitíase foram também diagnosticados como causa de icterícia. A PCR foi utilizada para o diagnóstico confirmatório de leptospirose e erliquiose. Amostras de DNA total foram utilizadas para amplificar um fragmento dos genes de Leptospira interrogans e de Ehrlichia canis. Em alguns cães foi detectada co-infecção por estes agentes. A classificação e a identificação das causas de icterícia em cães são relevantes devido ao grande número de doenças que apresentam essa alteração, muitas vezes sem diagnóstico ante mortem.(AU)

Diagnóstico diferencial da icterícia obstrutiva na emergência / Differential diagnosis of obstructive jaundice in the emergency room

Neste breve artigo de revisão serão expostos os principais diagnósticos diferenciais do paciente que se apresenta ictérico no primeiro atendimento na emergência, abordando a apresentação clínica e aspectos relacionados aos exames subsidiários utilizados no diagnóstico dessas patologias, com ênfase na obstrução biliar extra-hepática.

These brief review article will expose the major differential diagnosis of patients who present with jaundice in the first emergency care, approaching the clinical presentation and aspects related to subsidiary tests used in the diagnosis of these diseases, with emphasis on extrahepatic biliary obstruction.

Disección del proceso uncinado y mesopáncreas como paso inicial durante la duodenopancreatectomía cefálica: adaptación de un procedimiento laparoscópico / Open pancreatoduodenectomy with initial dissection of the uncinate process and mesopancreas: adaptation from a laparoscopic procedure

Usualmente cuando un procedimiento laparoscópico es realizado, los pasos utilizados en la cirugía abierta son adaptados o modificados con la intención de hacerlo factible desde el punto de vista laparoscópico, la presentación de esta técnica quirúrgica demuestra la situación inversa. La disección de manera inicial del proceso uncinado pudiera permitir una mejor exposición de los vasos mesentéricos superiores y dirigir una correcta disección linfática y neurovascular del tejido conocido como mesopáncreas, con el propósito de obtener un mayor porcentaje de resecciones R0. Es así como se expone la técnica quirúrgica utilizada en un caso clínico(AU)

When a laparoscopic procedure is done, the surgical steps are adapted from open surgery in order to make it feasible, in this case presentation it shows the inverse situation. The dissection of the uncinate process and the neurovascular tissue known as mesopancreas, at the first steps in surgery could achieve better results for negative margins. The paper ilustrate the surgical technique performed in a clinical case presentation(AU)

Espectro morfológico de la biopsia hepática / Morphologic spectrum of liver biopsy

La biopsia hepática constituye un excelente método diagnóstico en el espectro de la patología hepática. Para algunos autores la biopsia hepática no es considerada como el "método más indicado" debido al error de muestreo y las variaciones interobservador, sin embargo, sigue considerándose por muchos el "método de elección". Se recopilaron y analizaron en forma retrospectiva, las preparaciones histológicas y las boletas de solicitud de biopsias de todos los casos de biopsias hepáticas, provenientes de la Sección de Patología Gastrointestinal y Hepática "Dr. Pedro Grases" del Instituto Anatomopatológico "Dr. José A. O’Daly" de la Universidad Central de Venezuela, en el lapso comprendido entre enero de 1996 y diciembre de 2006. Pacientes 50,8% eran mujeres y 46,8% hombres. El grupo etario más afectado (55,4%) fue entre 31 y 60 años. Los hallazgos clínicos más frecuentes fueron ictericia (7,9%) y dolor en hipocondrio derecho (5,3%). Frecuencia de los diagnósticos histopatológicos: esteatosis (15,1%), hepatitis por virus C (12,3%), tumores metastásicos (8,9%), cirrosis (8,1%), esteatohepatitis (6,6%), patologías vasculares (5,4%), tumores primarios hepáticos (4,1%). La biopsia hepática es una excelente herramienta para el diagnóstico y tratamiento, si se realiza una buena correlación clínico patológica

Liver biopsy is an excellent diagnostic method in the spectrum of liver pathology. For some authors liver biopsy is considered the "best method" due to sampling error and interobserver variations, however is still considered by many the "method of choice". We collected and analyzed retrospectively, the histological preparations and request ballots biopsies of all cases of liver biopsies, from the Section of Gastrointestinal and Liver Pathology "Dr. Pedro Grases "Institute of Pathology" Dr. José A. O’Daly "Central University of Venezuela, in the period between January 1996 and December 2006. 50.8% patients were female and 46.8% male. The most affected age group (55.4%) was between 31 and 60 years. The most frequent clinical findings were jaundice (7.9%) and right upper quadrant pain (5.3 %). Frequency of histopathological diagnoses: steatosis (15.1%), hepatitis C virus (12.3%), metastatic tumors (8.9%), cirrhosis (8.1%), steatohepatitis (6.7%), vascular diseases (5.4%), primary liver tumors (4.1%). Liver biopsy is an excellent tool for diagnosis and treatment, if you do a good clinicopathologic correlation

Investigação de icterícia / Investigation of jaudice

Este trabalho é uma revisão da literatura sobre como investigar a icterícia no paciente adulto. Para isso, é imprescindível entender o metabolismo da bilirrubina, a fisiopatologia da hiperbilirrubinema e reconhecer os principais diagnósticos diferenciais de icterícia no adulto.

This article is a literature review on jaundice investigation in adult patients. Therefore, it is necessary for the understanding, knowing about the metabolism of bilirubin and the pathophysiology of hyperbilirrubinemia as well as recognizing the main differential diagnoses of jaundice in adults.

Utilidad diagnóstica del método de Kramer para la detección clínica de la hiperbilirrubinemia neonatal / Usefullness of the Kramer’s index in the diagnosis of hyperbilirubinemia of the newborn

El objetivo de la presente investigación fue correlacionar los valores séricos de bilirrubina con el índice de Kramer en un grupo de pacientes con ictericia neonatal de tres diferentes etnias. Representa un estudio prospectivo, aleatorio, observacional descriptivo-analìtico, longitudinal, comparativo y controlado en 50 recién nacidos con ictericia neonatal sin complicaciones. Se dividieron en 3 grupos: A (Control), n = 25 de origen caucásico; B, n = 15 de origen indígena local Wayúu y C, n = 10 de origen Afro americano. Al ingreso, a cada neonato se le determinaron las zonas dérmicas de Kramer y se le tomó una muestra de sangre venosa braquial para medir la bilirrubina de ingreso. Los valores al ingreso fueron: bilirrubina sérica 12,02 ± 3,41 mg/dL y el 62,8% estaban en nivel 3 de Kramer. No hubo diferencias entre los grupos étnicos estudiados y la correlación bilirrubina sérica-índice de Kramer fue de r= 0,93 (p < 0,005). Al 3er día se empezó a notar el descenso de la bilirrubina y de los índices de Kramer. El método de Kramer ofrece múltiples ventajas en la evolución del RN ictérico. No se encontraron diferencias raciales. Se recomienda implementar la aplicación de este método de Kramer en todas las unidades de neonatos en los hospitales, preferentemente en aquellas que carezcan de bilirrubinómetros transcutáneos.

The objective of the present study was to correlate seric values of bilirubin with the Kramer’s index in a group of newborns with neonatal jaundice, from three different ethnic groups. This was a prospective, randomized, observational, descriptive-analytical, longitudinal, comparative and controlled study of 50 newborns with neonatal jaundice, without complications. They were divided into three groups: A (Control), n = 25, of Caucasian descent; B, n = 15, of local indigenous descent (Wayúu) and C, n = 10, of Afro-American descent. Each newborn was screened at the start of the study for their Kramer’s dermic areas and simultaneously, a venous blood sample from the arm was taken for bilirubin quantification. They were compared through a correlation-regression analysis. Values at the beginning of the study were: serum bilirubin 12.02 ± 3.41 mg/dL, and 62.8% of neonates were at Kramer’s level 3. There were no differences among the ethnic groups studied and the correlation bilirubin/Kramer’s index was r= 0.93 (p < 0.005). At the third day, both bilirubin and Kramer’s indexes started to decrease. There were no ethnic differences. In conclusion, the Kramer’s method offers multiple advantages to evaluate a jaundiced newborn; it is a safe, non-invasive method with no cost. Besides, it is of great help in the prevention of the kernicterus. It is recommended to implement the use of the Kramer method in all the newborns units in our Hospitals, preferably in those lacking transcutaneous bilirubinometers.

Prolonged jaundice attributed to super infection of hepatitis E virus in a case of resolving leptospirosis.

India is endemic for both Leptospira and hepatitis E virus (HEV). The clinical presentations of these diseases have overlapping features. We report a case of superinfection of HEV in a patient with resolving leptospirosis with underlying Hodgkin lymphoma. The diagnosis of HEV in our case was established by HEV-RNA PCR as our patient was immunosuppressed. The present study highlights the need for molecular diagnosis in the case of HEV infection with strong clinical suspicion and negative serological results.

Correlacionando icterícia, resultados de exames laboratoriais e diagnósticos de doenças / Correlating jaundice, laboratory test results and diagnosis of diseases

Para descobrir quais as doenças que mais comumente cursam com a icterícia em pacientes internados no Hospital Universitário Antônio Pedro (HUAP) e correlacioná-las com marcadores bioquímicos foram utilizados dados extraídos de prontuários de pacientes internados durante os anos de 2005 a 2007. 0s dados foram analisados usando métodos estatísticos como qui-quadrado e teste Z. Utilizamos a análise das dosagens de aspartato-aminotrans ferase (AST), alanina-aminotransferase (ALT), fosfatase alcalina (FA), gama-glutamiltransferase (gama-GT), bilirrubina (Bb) total e suas frações direta e indireta. Os sinais e sintomas mais comuns na amostra estudada foram: dor abdominal, vômitos e colúria, que estão presentes em cerca de 60% das queixas dos pacientes estudados. Na população entre nove e 85 anos de idade, a análise sugere que AST e ALT nos chamam atenção para uma possível lesão hepática associada aos casos de icterícia. Enquanto que FA e GGT são marcadores de colestase. A bilirrubina direta tem média mais elevada no grupo de pacientes entre nove e 85 anos e a bilirrubina indireta atinge níveis maiores no grupo com até dois meses de vida. As dosagens bioquímicas são armas muito importantes na pesquisa etiológica dos casos de icterícia.

To find out which diseases most commonly lead to jaundice in hospitalized patients in HUAP and correlate them with biochemical markers. We used data from medical records of patients hospitalized during the years 2005 to 2007. The data were analyzed using statistical methods to test and chi-square-Z. We used the analysis of the strengths of AST, ALI, FA, GGT, Bb and its fractions total direct and indirect. The most common signs and symptoms in the sample studied were abdominal pain, vomiting and choluria that are present in about 60% of complaints from patients. In the population between nine and 85 years of age, the analysis suggests that AST and ALT in calling attention to a possible liver damage linked to cases of jaundice. While FA and gamma-GT are markers of cholestasis. The direct bilirubin is highest average in the group of patients between nine and 85 years and indirect bilirubin levels higher in the group with up to two months of life. The biochemical doses are very important weapons in the etiological research of cases of jaundice.

Hepatite grave e icterícia durante a evolução de infecção pelo vírus da dengue: relato de caso / Severe hepatitis and jaundice during the evolution of dengue virus infection: case report

Apresentamos o caso de uma paciente do sexo feminino, que apresentou quadro de febre hemorrágica da dengue, evoluindo com icterícia e importantes alterações da coagulação. O diagnóstico de dengue foi realizado pela presença de anticorpos IgM antidengue (MAC-ELISA). Esta doença deveria ser considerada no diagnóstico diferencial das icterícias febris agudas.

We describe the case of a female patient who presented a condition of dengue hemorrhagic fever that evolved with jaundice and significant coagulation abnormalities. Dengue was diagnosed through the presence of anti-dengue IgM antibodies (MAC-ELISA). This disease needs to be taken into consideration in the differential diagnosis for acute febrile jaundice.

A Patient Diagnosed as Autoimmune Pancreatitis 6 Years after Onset of Jaundice / 대한소화기학회지

The clinical manifestations of autoimmune pancreatitis (AIP) are diffuse pancreatic swelling, diffuse irregular narrowing of the main pancreatic duct, and increased serum IgG or positive serum autoantibody. Clinically, AIP can be improved dramatically with oral steroid therapy. In this report, we describe a 62-year-old woman diagnosed as autoimmune pancreatitis six years after onset of jaundice, who presented with uncontrolled blood glucose levels. The laboratory tests revealed obstructive jaundice, and the computed tomography of the pancreas showed pancreatic swelling. After six years of onset, she was diagnosed with AIP and successfully treated with steroid treatment.

Clinical and regulatory protocol for the treatment of jaundice in adults and elderly subjects: a support for the health care network and regulatory system / Protocolo clínico e de regulação para o tratamento de icterícia no adulto e idoso: subsídio para as redes assistenciais e o complexo regulador

PURPOSE: Clinical interventions and controlled access to the health care system can be improved by a Regulatory System (RS) and Clinical and Regulatory Protocols (CRPs). The objective of the present paper is to present the methodology used for elaborating the CRPs. METHODS: The process used to elaborate the CPRs involved a scientific co-operation between university and health care system. Workshops were held and attended by primary care practitioners, RS team, and matrix team (university specialists supporting primary care practitioners). RESULTS: The treatment of jaundice in adults and elderly subjects is amongst the themes selected for elaborating the CRPs since jaundice is a medical sign frequently seen in four clinical scenarios involving distinctive diagnostic and therapeutic interventions which can be performed in different health care settings. Evaluation guidelines as well as the clinical and regulatory procedures were established for different health care settings. The most relevant clinical and regulatory interventions were expressed as algorithms in order to facilitate the use of CRPs by health care practitioners. CONCLUSION: It is expected that the implementation of this protocol will minimise the imbalance between the icteric patients' needs and the treatment modalities being offered, thus contributing to a more co-operative health care network.

OBJETIVO: As ações clínicas e de ordenação do acesso à rede de saúde podem ser aperfeiçoadas pelo Complexo Regulador (CR) e pelos Protocolos Clínicos e de Regulação (PCR). Nesse trabalho apresenta-se a metodologia de elaboração dos PCR mediante cooperação entre universidade e sistema de saúde. MÉTODOS: O processo utilizado para a elaboração dos PCR envolve oficinas com a participação de profissionais da atenção básica, do CR e das equipes matriciais (especialistas da universidade que dão suporte às equipes de atenção básica). RESULTADOS: Dentre os temas selecionados para elaboração dos PCR, incluiu-se a icterícia no adulto e no idoso. Trata-se de um sinal clínico que comporta quatro cenários de apresentação com distintos percursos diagnósticos e terapêuticos passíveis de serem executados em diferentes pontos da rede assistencial. As diretrizes de avaliação, bem como as decisões e ações clínicas e reguladoras cabíveis para os diferentes cenários foram estabelecidas desde a atenção básica até o hospital terciário. As ações clínicas e reguladoras mais relevantes foram colocadas em algoritmo para facilitar o emprego do protocolo pelos profissionais de saúde. CONCLUSÃO: Há a expectativa que a implementação desse protocolo possa minimizar o descompasso entre as necessidades dos pacientes ictéricos e a modalidade de serviço oferecida e, assim, contribuir para a configuração de uma rede assistencial mais cooperativa.

Transcutaneous bilirubin in the pre-term infants.

OBJECTIVE: 1) To evaluate the accuracy of transcutaneous bilirubin (T(C)B) measurement compared to total serum bilirubin level (TSB) in the pre-term infants and 2) To establish cut-off values of T(C)B that indicated need for TSB. MATERIAL AND METHOD: Premature infants whose birth weight was more than 1,000 grams and gestational age less than 36 weeks had paired T(C)B-TSB assessment when jaundice was observed. T(C)B was done using JM 103 (Minolta AirShields Jaundice Meter) on the forehead. T(C)B, which corresponded to TSB level that required phototherapy, was chosen as the cut-off point that indicated blood sampling for TSB. RESULTS: Two hundred and forty-nine paired T(CB)-TSB measurements from 196 premature neonates were obtained. Birth weight was 1,887 +/- 344.4 grams. TSB ranged from 4.5-17.6 mg/dL (mean 9.4, SD 2.2 mg/dL), T(C)B 4.1-17.7 mg/dL (mean 9.7, SD 2.4 mg/dL). The correlation coefficient between T(C)B and TSB was significant (r 0.79, p < 0.0001). T(C)B had a tendency to overestimate TSB with the mean difference of TSB- T(C)B = -0.3 +/- 1.5 mg/dL and 95% confidence interval of the mean -0.1 to -0.5 mg/dL. Of all the variables of birth weight, gestational age, and postnatal age, only postnatal age significantly influenced the correlation of T(C)B-TSB. In the early postnatal age of 1-4 days, the number of T(C)B reading overestimated TSB more than underestimated. However, at > or = 5 days of age, the number of underestimation was more than those of overestimation. The cut-off points of T(C)B that indicated the need for blood sampling for TSB were chosen as the same level of TSB of 6, 8, 10, 11, and 12 mg/dL when phototherapy was recommended. Screening with T(C)B would eliminate painful procedure of blood taking by 40%. CONCLUSION: Noninvasive T(C)B assessment demonstrated significant accuracy when compared to TSB. T(C)B can be adopted as a screening test to identify the need for blood sampling of serum bilirubin in premature infants.

Anemia hemolítica autoinmune por anticuerpos calientes: reporte de un caso pediátrico / Autoimmune hemolytic anemia, warm antibody: a case report pediatric

Las anemias hemolíticas autoinmunitarias se caracterizan por la presencia de inmunoglobulinas en la superficie eritrocitaria dirigidas contra los determinantes antigénicos de los hematíes. La anemia hemolítica autoinmune por anticuerpos calientes se caracteriza porque los autoanticuerpos actúan a la temperatura del organismo (37°C), son de clase IgG y la hemólisis es predominantemente extravascular, siendo el tipo más frecuente de anemia hemolítica autoinmune en los niños de 2-12 años de edad. Sus manifestaciones clínicas son postración, palidez, ictericia, fiebre y hemoglobinuria. El diagnóstico de las AHAI se establece con la prueba de Coombs. La administración de corticoesteroides constituye el tratamiento inicial de elección. Se presenta el caso de una preescolar femenina de tres años de edad procedente del medio rural, quien exhibe las características clínicas, paraclínica y epidemiológicas de anemia hemolítica autoinmune por anticuerpos calientes, con respuesta satisfactoria a la terapia con esteroides.

Síndromes coledocianos: ictericias febriles / Choledochus syndromes: feverish ictericias

El síndrome coledociano se caracteriza por la triada clásica de ictericia, dolor y fiebre, a la que se agrega el prurito propio del carácter colestasico. Sus causas principales son la coledocolitiasis, las estenosis de las vías biliares principales y el cáncer de cabeza de páncreas. Causas infrecuentes son el Síndrome de Mirizzi, la Enfermedad de Caroli y la Colangitis esclerosante. Cuadros clínicos parecidos se observan en la hepatitis aguda alcohólico y en las crisis hemolíticas violentas, así como en ciertas infecciones tales como la leptospirosis y la tifoiden.