[Intestinal pneumatosis and pneumoperitonum: not always a surgical indication]. / Neumatosis intestinal y neumoperitoneo: no siempre una indicación quirúrgica.

Pneumatosis intestinalis and pneumoperitoneum are not pathological entities in themselves, they are radiological signs that result from some underlying condition. In general, these are associated with serious intra-abdominal processes that result in emergency surgeries with bowel resections. Below, we present the case of an 80-year-old woman, diagnosed with stage IV breast cancer under treatment with fulvestrant and ribociclib, who was admitted to our center due to abdominal pain and vomiting. She was diagnosed with intestinal pneumatosis and pneumoperitoneum, so she underwent exploratory laparotomy for suspected intestinal ischemia. There was no evidence of intestinal necrosis or perforation, so resection was not performed. She progressed satisfactorily during hospitalization and in the tomographic control one month after discharge there was complete resolution of the condition. Although this condition has been described in relation to episodes of increased intra-abdominal pressure, such as emesis, it has also been described in patients with neoplasms, mainly of the digestive tract, either due to local damage or toxicity associated with chemotherapy. We found no reports in the literature of pneumatosis intestinalis linked to this antineoplastic medication in humans. Probably in our case the etiology was multifactorial. It is possible that ribociclib played a role, either through an indirect mechanism associated with vomiting and immunosuppression or directly on the enterocyte due to its non-specific cellular mechanism of action.

La neumatosis intestinal y el neumoperitoneo no son entidades patológicas en sí mismas, son signos radiológicos que resultan de alguna condición subyacente. En general, estos se asocian con procesos graves intraabdominales que resultan en cirugías de urgencias con resecciones de intestino. A continuación, presentamos el caso de una mujer de 80 años, con diagnóstico de cáncer de mama estadio IV en tratamiento con fulvestrant y ribociclib, que ingresó a nuestro centro por dolor abdominal y vómitos. Se diagnosticó neumatosis intestinal y neumoperitoneo por lo que se procedió a laparotomía exploradora por sospecha de isquemia intestinal. No hubo evidencia de necrosis o perforación intestinal por lo que no se realizó resección. Evolucionó durante la internación de forma satisfactoria y en el control tomográfico al mes del egreso hubo resolución completa del cuadro. Si bien está descrito esta afectación en relación a los episodios de aumento de presión intraabdominal, como en la emesis, también se describió en pacientes con neoplasias, principalmente del tubo digestivo, ya sea por daño local o por toxicidad asociada a la quimioterapia. No encontramos reportes en la literatura de neumatosis intestinal vinculada a esta medicación antineoplásica en humanos. Probablemente en nuestro caso la etiología haya sido multifactorial. Es posible que el ribociclib haya jugado un rol, ya sea por un mecanismo indirecto asociado a los vómitos y la inmunosupresión o directo sobre el enterocito debido a su mecanismo de acción celular no específico.

Síndrome confusional agudo y confusional subsindromático en terapia intensiva: evolución intrahospitalaria y a los tres meses del alta / Delirium and subsyndromal delirium in the intensive care unit: In-hospital outcomes and prognosis at discharge

Antecedentes y objetivo Las características y la evolución de los pacientes con confusional subsindromático (CSS) en la internación aún continúa en discusión. El objetivo fue describir la incidencia de síndrome confusional agudo (SCA) y CSS en terapia intensiva (UTI), analizar su asociación con la presencia de factores de riesgo y explorar diferencias en la evolución hospitalaria y a los tres meses del alta. Pacientes y métodos Estudio prospectivo con seguimiento telefónico tres meses luego del alta. Se aplicó el CAM-ICU para definir tres grupos: sin delirio (de referencia), CSS y SCA. Resultados En 270 pacientes, el 22,96% presentaron SCA y el 17,03%, CSS. Factores relacionados con mayor riesgo de SCA: deterioro cognitivo (p=0,000), edad ≥75años (p=0,019), motivo de ingreso neurológico (p=0,003), shock (p=0,043), escaras (p=0,010), polifarmacia (0,017), ARM (p=0,001) y reposo digestivo (p=0,028); con mayor riesgo de CSS: baja escolaridad (p=0,014), Charlson >5 (p=0,028), AIVD <8 (p=0,001), alimentación enteral (p=0,000) y motivo de ingreso no cardiovascular (p=0,019). La mortalidad global fue del 6% en el grupo sin delirio, del 8% en CSS (p=0,516) y del 30% en SCA (p=0,000). La mediana de internación en UTI fue de 2días (rango 1-2) en el grupo sin delirio, 3 (2-4) días en CSS (p=0,0001) y 3 (2-7) días en SCA (p=0,0001). A los tres meses del alta, las AIVD estaban conservadas en el 50% del grupo sin delirio, en el 30% de CSS (p=0,026) y en el 26% de SCA (p=0,005). Conclusiones El CSS presentó un pronóstico intermedio entre el grupo sin delirio y el SCA. Se aconseja su diagnóstico para mejor clasificación de riesgo (AU)

Background and objective The characteristics and outcomes of patients with subsyndromal delirium (SSD) at hospitalization are still under discussion. The objectives were to describe the incidence of delirium and SSD in the intensive care unit (ICU), to analyze the association with risk factors and to explore outcomes of delirium and SSD at hospitalization and three months after discharge. Patients and methods A prospective study, with telephone follow-up three months after discharge. The study included 270 patients over one year. Delirium and SSD were assessed with the CAM-ICU. Results 22.96% developed delirium and 17.03% SSD. The main risk factors associated with the development of delirium were cognitive impairment (P=.000), age ≥75years (P=.019), neurological admission (P=.003), shock (P=.043), bedsores (P=.010), polypharmacy (P=.017), ARM (P=.001) and fast (P=.028), and with the development of SSD were low schooling (P=.014), Charlson >5 (P=.028), AIVD <8 (P=.001), enteral feeding (P=.000) and non-cardiovascular admission (P=.019). Overall mortality was 6% in the group without delirium (reference), 8% in SSD (P=.516) and 30% in delirium (P=.000). Median ICU length of stay was 2 (IQR, 1-2) days in the group without delirium, 3 (IQR, 2-4) days in SSD (P=.0001), and 3 (IQR, 2-7) days in delirium group (P=.0001). Three months after discharge, instrumental ADL were preserved in 50% of the group without delirium, 30% of SSD (P=.026) and 26% of delirium (P=.005). Conclusions The SSD group presented an intermediate prognosis between no delirium and delirium groups. It is advisable to promote its diagnosis for better risk classification (AU)

Delirium and subsyndromal delirium in the intensive care unit: In-hospital outcomes and prognosis at discharge. / Síndrome confusional agudo y confusional subsindromático en terapia intensiva: evolución intrahospitalaria y a los tres meses del alta.

BACKGROUND AND OBJECTIVE: The characteristics and outcomes of patients with subsyndromal delirium (SSD) at hospitalization are still under discussion. The objectives were to describe the incidence of delirium and SSD in the intensive care unit (ICU), to analyze the association with risk factors and to explore outcomes of delirium and SSD at hospitalization and three months after discharge. PATIENTS AND METHODS: A prospective study, with telephone follow-up three months after discharge. The study included 270 patients over one year. Delirium and SSD were assessed with the CAM-ICU. RESULTS: 22.96% developed delirium and 17.03% SSD. The main risk factors associated with the development of delirium were cognitive impairment (P=.000), age ≥75years (P=.019), neurological admission (P=.003), shock (P=.043), bedsores (P=.010), polypharmacy (P=.017), ARM (P=.001) and fast (P=.028), and with the development of SSD were low schooling (P=.014), Charlson >5 (P=.028), AIVD <8 (P=.001), enteral feeding (P=.000) and non-cardiovascular admission (P=.019). Overall mortality was 6% in the group without delirium (reference), 8% in SSD (P=.516) and 30% in delirium (P=.000). Median ICU length of stay was 2 (IQR, 1-2) days in the group without delirium, 3 (IQR, 2-4) days in SSD (P=.0001), and 3 (IQR, 2-7) days in delirium group (P=.0001). Three months after discharge, instrumental ADL were preserved in 50% of the group without delirium, 30% of SSD (P=.026) and 26% of delirium (P=.005). CONCLUSIONS: The SSD group presented an intermediate prognosis between no delirium and delirium groups. It is advisable to promote its diagnosis for better risk classification.

[Sporotrichoid nocardiosis by Nocardia brasiliensis]. / Nocardiosis esporotricoide por Nocardia brasiliensis.

Nocardia brasiliensis is a gram-positive, branched, aerobic, acid-resistant, rod-shaped bacillus that inhabits in soil, rotten organic matter and waters. Cutaneous nocardiosis in immunocompetent individuals can manifest in three different forms: actinomycetoma, superficial skin infection or lymphocutaneous infection. A case of an 85-year-old woman with an ulcerated lesion on the back of her left hand with erythematous papules in the lymphatic tract infected by N. brasiliensis is described. The microorganism was presumptively identified by conventional and inexpensive methods for a medium complexity laboratory at the species level. The morphological characteristics of colonies, the mold smell, a positive Kinyoun stain and the presence of aerial mycelium were the key tests to identify the genus. Species level identification was confirmed by mass spectrometry (MALDI-TOF MS). The trimethoprim-sulfamethoxazole treatment was effective as this agent was active in the susceptibility testing.

[Hypoxic hepatitis in a patient with endomyocardial fibrosis]. / Hepatitis hipóxica en paciente con endomiocardiofibrosis.

Endomyocardial fibrosis is a restrictive cardiomyopathy with high morbidity and mortality rates, prevalent in the sub-Saharan Africa region but infrequent in our population. It has a close relation with blood hypereosinophilia. Hypoxic hepatitis is frequently observed in intensive care units and its diagnosis is clinical. It shows a typical enzyme pattern with high mortality too. There are multiple mechanisms responsible for this condition, such as ischemia, passive congestion and dysoxia. We described the case of a 35 year-old cocaine addict woman diagnosed with endomyocardial fibrosis and hypereosinophilic syndrome who developed cardiogenic shock with hypoxic hepatitis. The patient evolved favorably with the appropriate treatment.

La endomiocardiofibrosis es una causa de miocardiopatía restrictiva frecuente en la región de áfrica subsahariana, aunque poco frecuente en nuestra población. Posee estrecha relación con la presencia de hipereosinofilia en sangre y tiene alta morbimortalidad. La hepatitis hipóxica es una afección clínica con un patrón enzimático característico, muy prevalente en unidades de cuidados intensivos y elevada mortalidad. Se reconocen múltiples mecanismos fisiopatológicos, como la isquemia, la congestión venosa y la alteración en la utilización de oxígeno del hepatocito. Describimos el caso de u na paciente de 35 años, consumidora de cocaína, con diagnóstico de endomiocardiofibrosis secundario a síndrome hipereosinofílico idiopático que presentó shock cardiogénico y hepatitis hipóxica asociada. Evolucionó favorablemente con el tratamiento de sostén adecuado.

Hepatitis hipóxica en paciente con endomiocardiofibrosis / Hypoxic hepatitis in a patient with endomyocardial fibrosis

La endomiocardiofibrosis es una causa de miocardiopatía restrictiva frecuente en la región de África subsahariana, aunque poco frecuente en nuestra población. Posee estrecha relación con la presencia de hipereosinofilia en sangre y tiene alta morbimortalidad. La hepatitis hipóxica es una afección clínica con un patrón enzimático característico, muy prevalente en unidades de cuidados intensivos y elevada mortalidad. Se reconocen múltiples mecanismos fisiopatológicos, como la isquemia, la congestión venosa y la alteración en la utilización de oxígeno del hepatocito. Describimos el caso de u na paciente de 35 años, consumidora de cocaína, con diagnóstico de endomiocardiofibrosis secundario a síndrome hipereosinofílico idiopático que presentó shock cardiogénico y hepatitis hipóxica asociada. Evolucionó favorablemente con el tratamiento de sostén adecuado.

Endomyocardial fibrosis is a restrictive cardiomyopathy with high morbidity and mortality rates, prevalent in the sub-Saharan Africa region but infrequent in our population. It has a close relation with blood hypereosinophilia. Hypoxic hepatitis is frequently observed in intensive care units and its diagnosis is clinical. It shows a typical enzyme pattern with high mortality too. There are multiple mechanisms responsible for this condition, such as ischemia, passive congestion and dysoxia. We described the case of a 35 year-old cocaine addict woman diagnosed with endomyocardial fibrosis and hypereosinophilic syndrome who developed cardiogenic shock with hypoxic hepatitis. The patient evolved favorably with the appropriate treatment.

Hemofagocitosis secundaria a dengue / Hemophagocytosis secondary to dengue fever

La infección por el virus del dengue constituye un problema de salud pública mundial. Causada por un virus de la familia Flaviviridae, presenta un amplio espectro clínico, desde formas asintomáticas frecuentes hasta las formas graves de fiebre hemorrágica y shock por fuga capilar. Existen cuatro serotipos; los serotipos 2 y 3 están asociados a las formas graves de la enfermedad. El diagnóstico definitivo de infección por dengue depende del aislamiento del virus en sangre, de la detección del antígeno viral o el ARN viral en suero o tejido, o detección de anticuerpos específicos. El síndrome hemofagocítico se produce ante la desregulación del sistema inmune que lleva a la activación macrofágica descontrolada, y se manifiesta con alteraciones clínicas, hematológicas, bioquímicas e histológicas. La asociación entre ambas entidades se encuentra descripta como una forma inusual y grave de presentación que responde a la tormenta de citocinas liberadas durante la enfermedad. Presentamos el caso de un paciente adulto con dengue, hemofagocitosis y valores inusualmente elevados de ferritina en sangre que evolucionó favorablemente con tratamiento de soporte.

Dengue virus infection constitutes a major public health problem worldwide. It is caused by a virus belonging to the Flaviviridae family. It produces a wide range of clinical presentations, from asymptomatic infection to severe forms of the disease with hemorrhagic fever or shock secondary to capillary leak syndrome. Four serotypes have been described; serotype 2 and serotype 3 are associated with the most severe forms of the disease. The diagnosis is based on laboratory tests aimed to detect antibodies, viral RNA, or antigens in serum. The hemophagocytic syndrome is generated by a dysfunction of the immune system with clinical, hematological, biochemical and histological manifestations. The association between these two entities is described as an unusual and severe presentation of dengue fever. We present a case of an adult patient with this association and very high blood levels of ferritin, who responded favorably to supportive care.

[Hemophagocytosis secondary to dengue fever]. / Hemofagocitosis secundaria a dengue.

Dengue virus infection constitutes a major public health problem worldwide. It is caused by a virus belonging to the Flaviviridae family. It produces a wide range of clinical presentations, from asymptomatic infection to severe forms of the disease with hemorrhagic fever or shock secondary to capillary leak syndrome. Four serotypes have been described; serotype 2 and serotype 3 are associated with the most severe forms of the disease. The diagnosis is based on laboratory tests aimed to detect antibodies, viral RNA, or antigens in serum. The hemophagocytic syndrome is generated by a dysfunction of the immune system with clinical, hematological, biochemical and histological manifestations. The association between these two entities is described as an unusual and severe presentation of dengue fever. We present a case of an adult patient with this association and very high blood levels of ferritin, who responded favorably to supportive care.

[KPC-producing Klebsiella pneumoniae colonization at a University Hospital]. / Colonización por Klebsiella pneumoniae productora de carbapenemasa tipo KPC en un Hospital Universitario.

A surveillance study was conducted at a University Hospital in Buenos Aires City aimed to assess the rates of colonization with carbapenemase-producing strains of Klebsiella pneumoniae, which are bacteria of utmost epidemiological importance. To this end, rectal swabs collected from all inpatients were cultured for the presence of these bacteria. Two point prevalence surveys showed high prevalence rates (up to 25%). The following variables were evaluated in all inpatients: place of origin (home or other chronic care center), age, prolonged hospitalization, antibiotics for at least 72 hours prior to swabbing, intensive care unit requirements for at least 24 hours, mechanical ventilation assistance for more than 4 days, hemodialysis requirements, need for surgery, enteral feeding through a nasogastric tube, and functional evaluation according to the Karnofsky performance scale. The variable associated with the highest statistical significance was the use of nasogastric enteral feeding. Also, the length of stay was significantly higher and the functional status was significantly worse in colonized patients. As for the prior use of antibiotics, results were close to statistical significance but without reaching it. Measures were implemented in order to control the spread of the microorganism in the acute setting and beyond. Upon implementation of such measures, a third prevalence survey was performed that showed a decrease in the horizontal transmission of the microorganism.

Colonización por Klebsiella pneumoniae productora de carbapenemasa tipo KPC en un hospital universitario / KPC-producing Klebsiella pneumoniae colonization at a University Hospital

Se realizó un estudio de vigilancia en un Hospital Universitario de la Ciudad Autónoma de Buenos Aires con el fin de determinar la prevalencia de colonización por cepas de Klebsiella pneumoniae productora de carbapenemasa, bacterias de gran importancia epidemiológica. A tal fin, se investigó su presencia en cultivos de hisopados rectales de todos los pacientes internados. Se realizaron dos cortes de prevalencia en los cuales se encontraron tasas de hasta 25%. Además, se analizaron las siguientes variables en toda la población estudiada: procedencia (domicilio u otro centro de cuidados crónicos), edad, internación prolongada, uso de antibióticos por al menos 72 horas previas al hisopado, internación en unidad de terapia intensiva, requerimientos de hemodiálisis, necesidad de cirugía, alimentación enteral mediante sonda nasogástrica, asistencia respiratoria mecánica por más de 4 días y evaluación funcional según escala de Karnofsky. La variable asociada a la colonización con mayor significación estadística fue el uso de sonda nasogástrica para alimentación enteral. Además, se observó que el tiempo de internación fue significativamente mayor y la clase funcional fue peor en los pacientes colonizados. En cuanto al uso previo de antibióticos se obtuvieron valores cercanos a la significación estadística, aunque sin alcanzarla. Con base en las variables evaluadas se implementaron medidas de contingencia con el fin de controlar la diseminación del microorganismo. Finalmente, se realizó un tercer corte de prevalencia durante la implementación de dichas medidas, el cual mostró una disminución en la transmisión horizontal del microorganismo.

A surveillance study was conducted at a University Hospital in Buenos Aires City aimed to assess the rates of colonization with carbapenemase-producing strains of Klebsiella pneumoniae, which are bacteria of utmost epidemiological importance. To this end, rectal swabs collected from all inpatients were cultured for the presence of these bacteria. Two point prevalence surveys showed high prevalence rates (up to 25%). The following variables were evaluated in all inpatients: place of origin (home or other chronic care center), age, prolonged hospitalization, antibiotics for at least 72 hours prior to swabbing, intensive care unit requirements for at least 24 hours, mechanical ventilation assistance for more than 4 days, hemodialysis requirements, need for surgery, enteral feeding through a nasogastric tube, and functional evaluation according to the Karnofsky performance scale. The variable associated with the highest statistical significance was the use of nasogastric enteral feeding. Also, the length of stay was significantly higher and the functional status was significantly worse in colonized patients. As for the prior use of antibiotics, results were close to statistical significance but without reaching it. Measures were implemented in order to control the spread of the microorganism in the acute setting and beyond. Upon implementation of such measures, a third prevalence survey was performed that showed a decrease in the horizontal transmission of the microorganism.

Clinical impact of a 2-week psychotropic medication washout in unipolar depressed inpatients.

BACKGROUND: Short-term discontinuation of psychiatric medications is required in many types of research studies. Yet there are few studies of the clinical impact of psychotropic discontinuation. We studied the impact of a short-term medication washout in unipolar depressed patients consecutively admitted to hospital for neuroimaging and cerebrospinal fluid (CSF) studies. METHOD: Patients (n=51) with unipolar depression who were taking antidepressant or mood stabilizing medication at or within 1 week of admission, and who had not been responding satisfactorily, were assessed for severity of psychopathology within 1 week of hospital admission and 41 of the group were reassessed following an approximately 2-week medication washout. RESULTS: On average, patients remained stable during the washout or improved on clinical measures. No serious adverse clinical changes were observed. LIMITATIONS: Potential sample bias, small sample size. CONCLUSION: The results suggest that similar studies can be conducted without causing undue worsening of symptoms. The benefit of medication washout may be related to the fact that many of the patients had been responding poorly to the medication they were taking. There is a need for further research on the effects of medication washout, for example in outpatients or those who are responding well to treatment, but have intolerable side-effects.