Gliosarcoma: presentación de un caso y hallazgos por tomografía y resonancia magnética convencional y tractografía / Gliosarcoma: Case Report and Findings by Tomography and Conventional and DTI Magnetic Resonance Imaging

El gliosarcoma es un tumor raro del sistema nervioso central y de alto grado de malignidad. La OMS lo clasifica como variante del glioblastoma (grado IV) y es de mal pronóstico. Histológicamente se caracteriza por tener componentes gliales y mesenquimatosos. El cuadro clínico varía dependiendo de su localización y tamaño, los signos y síntomas más frecuentes son convulsiones, cefalea y déficit neurológico focal. El acercamiento diagnóstico inicial es la tomografía computarizada que aporta datos de sospecha; sin embargo, la resonancia magnética constituye el pilar diagnóstico, con importantes elementos de diagnóstico que se vuelven más significativos con el uso de secuencias funcionales como la tractografía. Se presenta un caso clínico con revisión de la literatura y los hallazgos más significativos en los estudios de imagen.

Gliosarcoma is a rare and highly malignant central nervous system tumor. It is classified by the WHO as a variant of glioblastoma (grade IV) and has a poor prognosis. Histologically it is characterized by having both glial and mesenchymal components. Clinically, it varies depending on the location and size of the tumor, the most frequent symptoms being seizures, headaches and focal neurological deficit. The initial diagnostic approach is computed tomography, which provides suspicionus data; however, magnetic resonance is the diagnostic pillar, providing important data that becomes more significant with the use of functional sequences such as tractography. A clinical case is presented with a literature review and the most significant findings in the imaging studies.

Invasive aspergillosis in critically ill patients: An autopsy study.

Autopsy studies show that IA is among the most commonly missed diagnoses in critically ill patients. And, because of lack of unequivocal diagnostic criteria, a timely diagnosis remains challenging. We investigate the epidemiology of and the clinical risk factors for IA in critically ill patients. We conducted a retrospective, observational study of all consecutive ICU patients with evidence of IA in the postmortem examination. During the period of the study (25 years), 893 postmortem examinations were performed in the ICU. Twenty-five patients (2.8%) were diagnosed with IA in autopsy. Only ten (40%) were classified as IA ante-mortem, based on the initiation of antifungal treatment. The most common comorbid conditions were corticosteroid treatment (n = 14, 56%), chronic obstructive pulmonary disease (COPD) (n = 11, 44%), immunosuppression (n = 6, 24%) and haematological malignancy (n = 5, 20%). Twenty-three patients (92%) had three or more risk factors for IA. Critically ill patients with pulmonary infiltrates, treated with high doses intravenous corticosteroids (even for a short period of time), particularly COPD patients who developed worsening respiratory insufficiency despite appropriate treatment were at the highest risk of IA.

[Bronchiectasis severity in adult patients with common variable immunodeficiency]. / Severidad de bronquiectasias en pacientes adultos con inmunodeficiencia común variable.

BACKGROUND: Common variable immunodeficiency (CVID) is the most common primary symptomatic humoral immunodeficiency in adults. Antibody deficiency entails higher susceptibility to sinopulmonary infections and bronchiectasis formation, which is related to increased mortality. Scales have been established to assess the degree of severity of bronchiectasis in order to predict outcomes such as mortality, exacerbations and hospitalizations. OBJECTIVE: To determine bronchiectasis severity in adult patients with common variable immunodeficiency using the Brief Symptom Inventory scale. METHOD: Cross-sectional study in adult population diagnosed with common variable immunodeficiency and attended to at the Mexican Institute of Social Security National Medical Center Siglo XXI Specialty Hospital. RESULTS: Bronchiectasis severity according to the Brief Symptom Inventory was mild in 60% of patients and moderate in 40%. Statistically significant differences were found for body mass index, number of affected lobes and type of bronchiectasis (p < 0.001). CONCLUSIONS: Using bronchiectasis severity scales in patients with common variable immunodeficiency is indispensable for clinical and therapeutic decision making; however, determining the most appropriate instrument to assess bronchiectasis severity in this population is necessary.

Antecedentes: La inmunodeficiencia común variable es la inmunodeficiencia primaria humoral sintomática más frecuente en el adulto. La deficiencia de anticuerpos conlleva mayor susceptibilidad a infecciones sinopulmonares y formación de bronquiectasias, que se relacionan con aumento de la mortalidad. Se han establecido escalas para evaluar el grado de severidad de las bronquiectasias para predecir desenlaces como mortalidad, exacerbaciones y hospitalizaciones. Objetivo: Determinar la severidad de las bronquiectasias en pacientes adultos con inmunodeficiencia común variable mediante la escala Brief Symptom Inventory. Método: Estudio transversal en población adulta con diagnóstico de inmunodeficiencia común variable atendida en el Hospital de Especialidades del Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social. Resultados: La severidad de las bronquiectasias de acuerdo con la escala Brief Symptom Inventory fue leve en 60 % de los pacientes y moderada en 40 %. Las diferencias estadísticas significativas fueron para el índice de masa corporal, la cantidad de lóbulos afectados y el tipo de bronquiectasias (p < 0.001). Conclusiones: Es indispensable utilizar escalas de severidad de bronquiectasias en pacientes con inmunodeficiencia común variable para la toma de decisiones clínicas y terapéuticas, sin embargo, es necesario determinar el instrumento más apropiado para evaluar la severidad de las bronquiectasias en esta población.

Autopsy-detected diagnostic errors over time in the intensive care unit.

We evaluate the evolution over time of discrepancies between clinical diagnoses and postmortem findings in critically ill patients and assess the factors associated with these discrepancies. We conducted a prospective study of all consecutive patients who underwent autopsy in a medical-surgical intensive care unit (ICU) between January 2008 and December 2015. Among 7655 patients admitted to our ICU, 671 (8.8%) died. Clinical autopsy was performed in 215 (32%) patients. Major missed diagnoses were noted in 38 patients (17.7%). Eighteen patients (8.4%) had class I discrepancies, and 20 patients (9.3%) had class II discrepancies. The most frequently missed diagnoses were invasive aspergillosis, intestinal ischemia, myocardial infarction, cancer, and intra-abdominal abscesses. We did not find a statistically significant correlation between any premortem factor, including age, sex, severity of illness, length of hospital stay before ICU admission, length of ICU stay before death, duration of mechanical ventilation, or admitting unit, and the level of agreement between clinical and pathological diagnosis. In the last decades, the discrepancies between clinical and autopsy diagnoses persisted despite advances in medical skills and technology. Specific clinical entities such as invasive aspergillosis, mesenteric ischemia, myocardial infarction, intra-abdominal abscesses, and neoplastic diseases remain a diagnostic challenge in critically ill patients. Clinical level of diagnostic certainty does not increase with specific premortem characteristics.

Type and location of bronchiectasis in a cohort of adults with common variable immunodeficiency / Tipo y localización de bronquiectasias en una cohorte de adultos con inmunodeficiencia común variable

Background: Bronchiectasis are permanent dilatations of the bronchi. Its prevalence in patients with variable common immunodeficiency (CVID) is high, however there is little information regarding the type and location of the same; therefore the objective of this study is to know the type and location of bronchiectasis in a cohort of adult patients with CVID. Methods: It has been made a transversal, observational and descriptive study that included 32 adult patients with diagnosis of CVID according to the criteria of the European Society of Immunodeficiencies (ESID). All patients underwent high resolution pulmonary computed tomography (HRCT), which were interpreted by an expert radiologist. The frequency, type and location of bronchiectasis were reported using descriptive statistics. Results: Thirty-two adult patients, ten men (31.25%) and 22 women (68.7%), were included. 40.6% had bronchiectasis. 23% had a lobe involvement, 15.3% two lobes, 46.1% 3 lobes and 15.3% complete involvement of the parenchyma. The types of bronchiectasis were distributed as follows: tubular 38.4%, varicose 23% and cystic and tubular combinations 15.3%, cystic and varicose 15.3% and cystic, tubular and varicose 7.6%. Conclusions: Our results show that 40% of adult patients with CVID have BQs, usually affecting three pulmonary lobes, located mainly in the right and middle lower lobe; The tubular type, is the most common. Their timely diagnosis and treatment can improve survival and reduce costs for patients and health care.

Introducción: Las bronquiectasias (BQs) son dilataciones permanentes de los bronquios. Su prevalencia en pacientes con inmunodeficiencia común variable (IDCV) es alta, sin embargo existe escasa información respecto al tipo y localización de las mismas. El objetivo de este estudio es conocer el tipo y localización de las bronquiectasias en una cohorte de pacientes adultos portadores de IDCV. Métodos: Estudio transversal, observacional y descriptivo que incluyó a 32 pacientes adultos con diagnóstico de IDCV de acuerdo con los criterios de la Sociedad Europea de Inmunodeficiencias. A todos se les realizó tomografía de alta resolución pulmonar, las cuales fueron interpretadas por un médico radiólogo experto. Se reportó la frecuencia, tipo y localización de las bronquiectasias mediante estadística descriptiva.Resultados: se incluyeron 32 pacientes adultos, diez hombres y 22 mujeres. El 40.6% presentaron bronquiectasias. El 23% tenía afección en un lóbulo, el 15.3% dos lóbulos, 46.1% 3 lóbulos y el 15.3% afectación completa del parénquima; distribuidos de la siguiente manera: tubulares 38.4%, varicosas 23% y las combinaciones quísticas y tubulares 15.3%, quísticas y varicosas 15.3% y quísticas, tubulares y varicosas 7.6%. Conclusión: Nuestros resultados muestran que el 40% de los pacientes adultos con IDCV tienen BQs, suelen afectar tres lóbulos pulmonares, el tipo más común fue el tubular. Su diagnóstico y tratamiento oportuno puede mejorar la supervivencia y reducir los costos para el paciente y las instituciones de salud.

[Diagnostic imaging of the small bowel]. / Estudio radiológico del intestino delgado.

This article describes the different imaging techniques used in the study of the small bowel. We define the technical requirements that conventional small bowel follow through studies must fulfill to be considered an efficacious examination (individualized study of each bowel loop by compression and fluoroscopy); we evaluate the different types of enteroclysis, giving special attention to the biphasic type, which is the most commonly employed; we discuss the advantages and disadvantages of biphasic enteroclysis with respect to conventional small bowel follow through studies; and finally we evaluate the role of modern techniques of image acquisition, tomodensitometry and magnetic resonance imaging used together with traditional techniques. Small bowel studies require accurate indications for radiologic study, thorough and meticulous examination, and careful interpretation of the images obtained. Although the modern techniques of magnetic resonance and computed tomography enteroclysis are no better than conventional small bowel follow through or enteroclysis at demonstrating the details of the intestinal mucosa, they are of great use in solving the problem of the superimposition of intestinal loops and provide information about the intestinal wall and possible extraluminal pathology.

Estudio radiológico del intestino delgado / Diagnostic imaging of the small bowel

En el presente artículo se describen las distintas técnicas radiológicas utilizadas en el estudio del intestino delgado, definiendo los requisitos técnicos que debe reunir el tránsito convencional para que se considere una exploración eficaz (estudio individualizado de cada asa intestinal mediante compresión y fluoroscopia), evaluando los distintos tipos de enteroclisis, especialmente la bifásica, modalidad más utilizada, sus ventajas y desventajas respecto al tránsito convencional, y valorando el papel de las modernas técnicas de formación de imagen, tomodensitometría y resonancia magnética en su utilización conjunta con las técnicas tradicionales. En conjunto la guía práctica para el estudio del intestino delgado implica una indicación precisa del estudio radiológico, un examen meticuloso y detallado y una cuidadosa interpretación de las imágenes obtenidas. Aunque las modernas técnicas de enteroclisis mediante tomografía axial computarizada y resonancia magnética no superan al tránsito o a la enteroclisis convencionales en la demostración del detalle mucoso intestinal, se muestran como modalidades de gran utilidad al solventar el problema de la superposición de las asas intestinales, aportando información sobre las características de la pared y de la posible patología extraluminal

This article describes the different imaging techniques used in the study of the small bowel. We define the technical requirements that conventional small bowel follow through studies must fulfill to be considered an efficacious examination (individualized study of each bowel loop by compression and fluoroscopy); we evaluate the different types of enteroclysis, giving special attention to the biphasic type, which is the most commonly employed; we discuss the advantages and disadvantages of biphasic enteroclysis with respect to conventional small bowel follow through studies; and finally we evaluate the role of modern techniques of image acquisition, tomodensitometry and magnetic resonance imaging used together with traditional techniques. Small bowel studies require accurate indications for radiologic study, thorough and meticulous examination, and careful interpretation of the images obtained. Although the modern techniques of magnetic resonance and computed tomography enteroclysis are no better than conventional small bowel follow through or enteroclysis at demonstrating the details of the intestinal mucosa, they are of great use in solving the problem of the superimposition of intestinal loops and provide information about the intestinal wall and possible extraluminal pathology