Successful Isavuconazole Salvage Therapy for a Cryptococcus deuterogattii (AFLP6/VGII) Disseminated Infection in a European Immunocompetent Patient.

Members of the Cryptococcus gattii species complex are notorious causes of cryptococcosis as they often cause severe, life-threatening infections. Here we describe a case of a severe disseminated C. deuterogattii infection in a previously healthy patient who was initially treated with amphotericin B, 5-fluorocytosine and fluconazole, which led to a good neurological response, but the infection in the lungs remained unaltered and was not completely resolved until switching the antifungal therapy to isavuconazole. The infection was likely acquired during a one-month stay at the Azores Islands, Portugal. Environmental sampling did not yield any cryptococcal isolate; therefore, the source of this apparent autochthonous case could not be determined. Molecular typing showed that the cultured C. deuterogattii isolates were closely related to the Vancouver Island outbreak-genotype.

Macroprolactinoma clival ectópico: una forma rara de presentación de adenoma hipofisario / Ectopic clival macroprolactinoma: a rare presentation of pituitary adenoma

Los adenomas pituitarios son los tumores hipofisarios más frecuentes siendo una entidad rara cuando se trata de adenomas ectópicos, es decir, sin conexión con la glándula pituitaria. Se cree que derivan de células residuales del tracto de migración embriológico desde la bolsa de Rathke. Su presentación clínica es muy variable porque depende de la producción hormonal y del efecto masa en estructuras adyacentes. Generalmente suponen un reto diagnóstico debido a su baja frecuencia, la clínica variable de presentación y que no presentan características específicas en las pruebas de imagen. Generalmente el diagnóstico se realiza de manera retrospectiva tras la resección quirúrgica. Presentamos el caso de un varón de 56 años que se presentó con unos valores de prolactina de 6647.5 ng/ml (2.2-17.7) con clínica de hipogonadismo aislada que se resolvió con tratamiento médico sin precisar resección quirúrgica, con una disminución de la densidad radiológica y estabilización del tamaño y sin clínica compresiva ni alteración visual.

Pituitary adenomas are the most common hypophyseal tumors being a rare entity when they are ectopic, without connection to the pituitary gland. They are thought to arise from residual cells in the migration tract from Rathke´s pouch. Its clinical presentation is variable depending on the hormonal production and the pressure effect on adjacent structures. They usually are a diagnostic challenge due to their low frequency, wide range of clinical presentation and not showing specific features on imaging techniques. The diagnosis is made usually retrospectively after surgical resection. We report the case of a 56 years old male that presented with a prolactine value of 6647.5 ng/ml (2.2-17.7) and isolated hypogonadism symptoms that resolved with medical treatment without surgery, diminishing the radiological density and stabilizing the size without having compresive symptoms nor visual disturbances.

Sobre un análisis incorrecto del concepto de ganglio centinela / On an incorrect analysis of the concept of sentinel node breast biopsy

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Utilidad y ventajas de la inyección subareolar única del trazador en la biopsia selectiva del ganglio centinela en el cáncer de mama / Utility and advantages of single tracer subareolar injection in sentinel lymph node biopsy in breast cancer

Introducción. La biopsia selectiva del ganglio centinela (BSGC) ha demostrado ser eficaz para determinar el estadio de los ganglios linfáticos en pacientes con cáncer de mama. Es un procedimiento mínimamente invasivo que permite evitar la linfadenectomía en pacientes sin afectación ganglionar. Presentamos el proceso de validación de la BSGC realizado con inyección subareolar única de 99mTc-nanocoloides. Material y método. Durante 2 años se estudió a 100 pacientes con cáncer de mama en estadios iniciales (T1 y T2). A todas ellas se les realizó, el mismo día de la intervención, una gammagrafía con inyección subareolar de 99mTc-nanocoloides para la localización del ganglio centinela (GC). Tras la visualización de los GC, y una vez realizado el marcaje en la piel, se procedió a la tumorectomía seguida de la BSGC utilizando una sonda detectora de rayos gamma. Una vez extirpado el GC se completó el vaciamiento axilar en todos los casos. En el análisis anatomopatológico del GC se utilizó la tinción con hematoxilina-eosina (HE), y con citoqueratinas (CK). Resultados. Se identificó el GC en todos los casos, y se extrajo una media de 1,95 ganglios por paciente. En 44 de ellas el GC presentaba metástasis, y en 15 de estos casos también se encontró extensión al resto de los ganglios axilares. En las 56 pacientes restantes el GC estaba libre de enfermedad, y tan sólo en 2 de ellos existía afectación ganglionar axilar (4,5% falsos negativos). La sensibilidad global de la técnica fue del 95,65% (44/46), y la especificidad del 100% (54/54), con un valor predictivo positivo de 100% y un valor predictivo negativo de 96,4% (54/56). Conclusiones. La BSGC en pacientes con cáncer de mama en estadios iniciales es un proceso seguro y eficaz que proporciona una estadificación al alza de la enfermedad y disminuye la morbilidad asociada a la cirugía axilar. La inyección subareolar presenta las siguientes ventajas: es única, no precisa otras técnicas de imagen para localizar el tumor, permite una rápida visualización del GC y evita la superposición de imágenes cuando el tumor está localizado cerca de la axila (AU)

Introduction. Sentinel lymph node (SLN) biopsy is a reliable technique for determining axillary status in patients with early breast cancer. This technique is a minimally invasive procedure that can avoid the use of lymphadenectomy in patients without axillary involvement. We present a validation study of SLN biopsy with subareolar injection of 99mTc-nanocolloids. Material and method. We studied 100 patients with early breast cancer (T1 and T2) over a 2-year period. All patients underwent deep subareolar-injection of 99mTc-nanocoloid for localization of the sentinel node. Images were obtained and when the sentinel node was seen, it was marked on the skin. All patients underwent tumor excision and radioguided SLN biopsy followed by complete lymphadenectomy. Histopathological analysis of sentinel nodes was performed by hematoxylin-eosin and immunohistochemistry with cytokeratins. Results. The sentinel node was identified in all patients, and a mean of 1.95 sentinel nodes per patient were found. Lymphatic metastases in the sentinel node were found in 44 patients and in 15 of these tumoral spread was also found in the remaining axillary nodes. In the 56 remaining patients the sentinel node was free of metastasis, but in two of them a non-sentinel node was found to be positive (4.5% false negative rate). Sensitivity was 95.7% (44/46), specificity was 100% (54/54), the positive predictive value was 100% and the negative predictive value was 96.4% (54/56). Conclusions. SLN biopsy is an accurate alternative to complete axillary lymph node dissection in patients with early-stage breast cancer. This technique improves the staging of these patients and decreases the morbidity associated with lymphadenectomy. The advantages of subareolar injection are that a single injection site is required, the tumor does not have to be located by other techniques, it allows rapid visualization of the sentinel node and avoids the "shine through phenomenon" when the tumor is located near the axilla (AU)

Perforación gástrica en adulto por tricobezoar (síndrome de Rapunzel) / Gastric perforation due to trichobezoar in an adult (Rapunzel syndrome)

El síndrome de Rapunzel o tricobezoar es una afección poco frecuente; la perforación gástrica secundaria a éste es excepcional y no se ha encontrado en la actualidad ningún caso en adultos en la literatura médica consultada. Presentamos el caso de un paciente adolescente con cuadro clínico de masa en el epigastrio y abdomen agudo; en el estudio radiológico se objetiva neumoperitoneo y una masa intragástrica. Entre los antecedentes destaca síndrome depresivo y ansiedad. En la laparotomía de urgencia se confirma el diagnóstico de perforación gástrica por tricobezoar que moldea completamente la cámara gástrica. Las imágenes radiológicas hacen sospechar el diagnóstico, pero sólo la laparotomía lo confirma (AU)

Rapunzel syndrome, or trichobezoar, is an uncommon entity and secondary gastric perforation is exceptional. We found no adult cases reported in the literature. Our patient is a teenager with clinical symptoms of epigastric mass and acute abdomen. Radiological study showed pneumoperitoneum and intragastric mass. Personal history revealed depressive syndrome and anxiety. Urgent laparotomy confirmed the diagnosis of gastric perforation due to a trichobezoar completely moulding the gastric chamber. The diagnosis was suspected on the basis of radiologic images but laparotomy was required to confirm it (AU)

Incidencia e impacto de los efectos adversos en dos hospitales / Incidence and impact of adverse events in two hospitals

Objetivos: Presentar los resultados preliminares del proyecto IDEA relativos a la incidencia e impacto de los efectos adversos (EA) en dos de los hospitales incluidos en el estudio. Material y método: Diseño: estudio de cohortes prospectivo realizado durante el primer trimestre de 2004 en dos servicios de dos hospitales de la Comunidad Valenciana. Muestreo consecutivo. Sujetos: pacientes de más de 14 años, ingresados más de 24 h en los servicios seleccionados, en total, 673 sujetos. Medidas principales: proporción de alerta de EA (formulario de cribado positivo) e incidencia acumulada de EA identificados (cuestionario modular para su confirmación y caracterización). Resultados: La incidencia de alertas fue de un 34,7% para el hospital A (servicio de cirugía general) y de un 31% en el hospital B (servicio de medicina interna). La incidencia de EA fue del 16,1 y el 5,6%, respectivamente. El 42,1% de los EA del hospital A y el 16,7% del hospital B fueron considerados evitables, independientemente de la gravedad de sus consecuencias. Conclusiones: Los sistemas de vigilancia de alerta de los EA se han mostrado muy diferentes en los servicios estudiados. La variabilidad en la práctica clínica condiciona la identificación de los EA al revisar las historias clínicas

Objectives: To present the preliminary results of the IDEA project relating to the effect and impact of adverse events in two of the hospitals included in the study. Material and method: Design: prospective cohort study carried out in the first quarter of 2004 in two wards of two hospitals of the Autonomous Community of Valencia (Spain). Sampling: consecutive. Subjects: patients more than 14 years old, hospitalized for more than 24 hours in the selected wards. The total number of subjects was 673. Main measurements: proportion of adverse event alerts (positive detection questionnaire) and the accumulated incidence of identified adverse events (modular questionnaire for confirmation of AE and their characterization). Results: The incidence of alerts was 34.7% in hospital A (general surgery ward) and 31% in hospital B (internal medicine ward). The incidence of adverse events was 16.1% and 5.6% respectively. A total of 42.1% of the adverse events in hospital A and 16.7% of those in hospital B were avoidable, independently of the seriousness of their consequences. Conclusions: The adverse event surveillance systems differed between the two wards studied. Variability in clinical practice affects identification of adverse events on reviewing medical records

[Utility and advantages of single tracer subareolar injection in sentinel lymph node biopsy in breast cancer]. / Utilidad y ventajas de la inyección subareolar única del trazador en la biopsia selectiva del ganglio centinela en el cáncer de mama.

INTRODUCTION: Sentinel lymph node (SLN) biopsy is a reliable technique for determining axillary status in patients with early breast cancer. This technique is a minimally invasive procedure that can avoid the use of lymphadenectomy in patients without axillary involvement. We present a validation study of SLN biopsy with subareolar injection of 99mTc-nanocolloids. MATERIAL AND METHOD: We studied 100 patients with early breast cancer (T1 and T2) over a 2-year period. All patients underwent deep subareolar-injection of 99mTc-nanocoloid for localization of the sentinel node. Images were obtained and when the sentinel node was seen, it was marked on the skin. All patients underwent tumor excision and radioguided SLN biopsy followed by complete lymphadenectomy. Histopathological analysis of sentinel nodes was performed by hematoxylin-eosin and immunohistochemistry with cytokeratins. RESULTS: The sentinel node was identified in all patients, and a mean of 1.95 sentinel nodes per patient were found. Lymphatic metastases in the sentinel node were found in 44 patients and in 15 of these tumoral spread was also found in the remaining axillary nodes. In the 56 remaining patients the sentinel node was free of metastasis, but in two of them a non-sentinel node was found to be positive (4.5% false negative rate). Sensitivity was 95.7% (44/46), specificity was 100% (54/54), the positive predictive value was 100% and the negative predictive value was 96.4% (54/56). CONCLUSIONS: SLN biopsy is an accurate alternative to complete axillary lymph node dissection in patients with early-stage breast cancer. This technique improves the staging of these patients and decreases the morbidity associated with lymphadenectomy. The advantages of subareolar injection are that a single injection site is required, the tumor does not have to be located by other techniques, it allows rapid visualization of the sentinel node and avoids the "shine through phenomenon" when the tumor is located near the axilla.

[Gastric perforation due to trichobezoar in an adult (Rapunzel syndrome)]. / Perforación gástrica en adulto por tricobezoar (síndrome de Rapunzel).

Rapunzel syndrome, or trichobezoar, is an uncommon entity and secondary gastric perforation is exceptional. We found no adult cases reported in the literature. Our patient is a teenager with clinical symptoms of epigastric mass and acute abdomen. Radiological study showed pneumoperitoneum and intragastric mass. Personal history revealed depressive syndrome and anxiety. Urgent laparotomy confirmed the diagnosis of gastric perforation due to a trichobezoar completely moulding the gastric chamber. The diagnosis was suspected on the basis of radiologic images but laparotomy was required to confirm it.