Diagnostic-therapeutic algorithm for thrombotic microangiopathy. A report of two cases.

Thrombotic microangiopathies (TMA) are a group of clinical syndromes associated with haemolytic anaemia, thrombocytopenia and organ dysfunction, mainly renal or neurological. They are associated with significant morbidity and mortality, so early diagnosis and treatment are essential. In this article we report two cases of TMA; a patient with thrombotic thrombocytopenic purpura (TTP) and a patient with atypical haemolytic uraemic syndrome (aHUS).

Algoritmo diagnóstico-terapéutico de las microangiopatías trombóticas. A propósito de 2 casos / Diagnostic-therapeutic algorithm for thrombotic microangiopathy. A report of two cases

Las microangiopatías trombóticas (MAT) son un conjunto de síndromes clínicos que asocian anemia hemolítica, trombocitopenia y disfunción orgánica, principalmente renal o neurológica. Están asociados a una morbimortalidad significativa, por lo que su diagnóstico y tratamiento precoz son esenciales. En este artículo detallamos 2 casos de MAT; una paciente con una púrpura trombocitopénica trombótica (PTT) y otra paciente con un síndrome hemolítico urémico atípico (SHUa).(AU)

Thrombotic microangiopathies (TMA) are a group of clinical syndromes associated with haemolytic anaemia, thrombocytopenia and organ dysfunction, mainly renal or neurological. They are associated with significant morbidity and mortality, so early diagnosis and treatment are essential. In this article we report two cases of TMA; a patient with thrombotic thrombocytopenic purpura (TTP) and a patient with atypical haemolytic uraemic syndrome (aHUS).(AU)

Diagnostic-therapeutic algorithm for thrombotic microangiopathy. A report of two cases. / Algoritmo diagnóstico-terapéutico de las microangiopatías trombóticas. A propósito de 2 casos.

Thrombotic microangiopathies (TMA) are a group of clinical syndromes associated with haemolytic anaemia, thrombocytopenia and organ dysfunction, mainly renal or neurological. They are associated with significant morbidity and mortality, so early diagnosis and treatment are essential. In this article we report two cases of TMA; a patient with thrombotic thrombocytopenic purpura (TTP) and a patient with atypical haemolytic uraemic syndrome (aHUS).

Manejo perioperatorio de pacientes con sospecha o infección grave por coronavirus SARS-CoV-2 programados para implante de dispositivos electrónicos para el control de dolor crónico / Perioperative management of patients with suspected or severe infection with SARS-CoV-2 coronavirus programmed for the implementation of electronic devices for the control of chronic pain

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Analgesia regional en el paciente crítico posquirúrgico / Regional analgesia in postsurgical critically ill patients

La analgesia regional, intrínsecamente y en base a sus efectos fisiológicos, es de uso habitual para el tratamiento perioperatorio del dolor relacionado con procedimientos quirúrgicos. Sin embargo, en otros ámbitos no quirúrgicos, como es el tratamiento del dolor agudo del paciente en situación crítica, no ha sido objeto de estudios prospectivos específicos. Si nos atenemos a los efectos fisiológicos que el bloqueo nervioso tiene en una situación de estrés, las indicaciones de la anestesia regional en este grupo de pacientes se extienden al manejo de una gran variedad de situaciones tanto médicas como posquirúrgicas, al paciente politraumatizado o a otros procedimientos dolorosos realizados en la misma cama del paciente. El paciente crítico, sin duda, debe ser analizado de forma individualizada, dado que su propia afectación primaria de carácter vital, como las desarrolladas de forma asociada, pueden aumentar potencialmente el riesgo de toxicidad sistémica o de morbilidad, como serían las coagulopatías, infecciones, estados de inmunodepresión, sedación y problemas relacionados con la ventilación mecánica. Esta revisión intenta evaluar el papel de la analgesia regional en el paciente crítico, situarla dentro del árbol de decisión de los profesionales responsables de los pacientes en las unidades de cuidados críticos, todo ello en base a la evidencia de beneficios potenciales según la bibliografía publicada (AU)

Regional analgesia intrinsically, based on its physiological effects, is routinely used for the perioperative treatment of pain associated with surgical procedures. However, in other areas such as the non-surgical treatment of acute pain for patients in a critical condition, it has not been subjected to specific prospective studies. If we confine ourselves to the physiological effects of the nerve block, in a situation of stress, the indications for regional anaesthesia in this group of patients extend to the management of a wide variety of medical as well as postsurgical conditions, of trauma patients and of other painful procedures performed in the patient's bed. The critical patient certainly must be analyzed individually as their own primary conditions is of vital importance, as well as any associated conditions they have developed that can potentially increase the risk of systemic toxicity or morbidity, such as, coagulopathies, infection, immunosuppressive states, sedation and problems associated with mechanical ventilation. This review aims to assess the role of regional analgesia in critically ill patients, placing it within the algorithm decision tree of the professional responsible for patients in critical care units, all based on the evidence of potential benefits according to the published literature (AU)

Regional analgesia in postsurgical critically ill patients. / Analgesia regional en el paciente crítico posquirúrgico.

Regional analgesia intrinsically, based on its physiological effects, is routinely used for the perioperative treatment of pain associated with surgical procedures. However, in other areas such as the non-surgical treatment of acute pain for patients in a critical condition, it has not been subjected to specific prospective studies. If we confine ourselves to the physiological effects of the nerve block, in a situation of stress, the indications for regional anaesthesia in this group of patients extend to the management of a wide variety of medical as well as postsurgical conditions, of trauma patients and of other painful procedures performed in the patient's bed. The critical patient certainly must be analyzed individually as their own primary conditions is of vital importance, as well as any associated conditions they have developed that can potentially increase the risk of systemic toxicity or morbidity, such as, coagulopathies, infection, immunosuppressive states, sedation and problems associated with mechanical ventilation. This review aims to assess the role of regional analgesia in critically ill patients, placing it within the algorithm decision tree of the professional responsible for patients in critical care units, all based on the evidence of potential benefits according to the published literature.

Taxanes-induced cutaneous eruption: another histopathologic mimicker of malignancy.

BACKGROUND: Paclitaxel and docetaxel are antineoplastic drugs that bind the microtubules, producing the arrest of mitoses, which may be seen histopathologically. These histopathologic changes may simulate an intraepidermal keratinocytic malignant neoplasm, and an accurate diagnosis may be only established by clinicopathological correlation. OBJECTIVES: We report six cases of cutaneous eruptions by taxanes in which a striking cytotoxic effect was evident histopathologically. METHODS: Cutaneous biopsies were obtained in each patient. RESULTS: Atypical starburst-like or ring-like mitoses and dyskeratosis on basal and suprabasal layers of the epidermis. Areas of squamous syringometaplasia were also seen in one case. DISCUSSION: These findings were interpreted as expression of mitotic arrest due to taxanes. Similar changes have been described in association with other chemotherapeutic drugs such as vincristine, podophyllin and its derivative etoposide; colchicine, busulfan and maytansine, but cases like ours due to taxanes are exceptional or under-reported. CONCLUSION: Dermatopathologists should be aware of these effects in order to interpret carefully cutaneous biopsy specimens of patients receiving taxanes.

Amyophatic dermatomyositis presenting as a flagellated skin eruption with positive MDA5 antibodies and thyroid cancer: a real association?

Amyopathic dermatomyositis (ADM) is characterized clinically by typical skin lesions with hypomyopathy or no muscular involvement. ADM has been recently reported to be complicated by rapidly progressive interstitial lung disease (ILD), especially in patients with positive antibodies against melanoma differentiation-associated gene 5 (MDA5). These patients may have a low risk of cancer, but no clinical, histological or laboratory markers completely specific for paraneoplastic DM have been identified to date. We report a case of flagellate erythema as the initial presentation of ADM associated with ILD, positive MDA5 antibodies and a concomitant diagnosis of thyroid cancer. We discuss the unusual clinical features and associations that make this case particularly interesting.

Effectiveness of egg yolk immunoglobulin against the intracellular salmonid pathogen Piscirickettsia salmonis.

AIMS: To produce and characterize egg yolk immunoglobulin (IgY) against the fish intracellular pathogen Piscirickettsia salmonis as well as to evaluate the antibacterial activity of IgY in vitro and the availability in the serum of fish immunized orally. METHODS AND RESULTS: Specific IgY was produced by immunizing hens with P. salmonis proteins. The IgY was obtained from egg yolks using the ammonium sulphate precipitation method and it was characterized by SDS-PAGE, Western-blot and ELISA, demonstrating that anti-P. salmonis IgY strongly reacted specifically against P. salmonis proteins. In an in vitro neutralization assay, IgY inhibited the growth of P. salmonis in liquid medium at concentrations ranging from 128 to 256 µg ml(-1) in a dose-dependent manner. Interestingly, IgY against P. salmonis also generates a strong protective effect on the infection of P. salmonis in salmon head kidney-1 cells. In addition, the bacteriostatic function of IgY appears to result possibly from agglutination by the interaction of IgY with surface components of the pathogen. Finally, to confirm this IgY as an alternative for salmonid treatment, Atlantic salmon (Salmo salar) specimens were orally inoculated with IgY. The analysis of the sera demonstrates that IgY was effectively transported by fish intestine and that this immunoglobulins maintains its properties and recognizes several proteins of P. salmonis up to 12 h after inoculation of IgY against P. salmonis. CONCLUSIONS: Specific IgY effectively inhibited the growth of P. salmonis and this immunoglobulin can be released in the Atlantic salmon sera when administered orally to fish. SIGNIFICANCE AND IMPACT OF THE STUDY: We propose that this specific IgY against this fastidious micro-organism could be a useful strategy for the treatment of piscirickettsiosis.

Peptidoglycan and lipopolysaccharide synergistically enhance bone resorption and osteoclastogenesis.

BACKGROUND AND OBJECTIVE: Peptidoglycan (PGN) and lipopolysaccharide (LPS) are bacterial cell wall constituents that are able to induce bone resorption by stimulating Toll-like receptor (TLR) 2 and TLR4, respectively. The fragments of PGN also stimulate inflammatory responses via nucleotide-binding oligomerization domain (NOD) 1 and NOD2, although there are differences in the NOD-stimulatory activities between gram-positive and gram-negative PGNs. The TLR and NOD signaling pathways are known to engage in cross-talk to enhance the production of inflammatory cytokines. In the present study, we investigated the effects of gram-negative and gram-positive PGNs on bone resorption and osteoclastogenesis in the presence or absence of LPS. MATERIAL AND METHODS: We injected Escherichia coli PGN or Staphylococcus aureus PGN with or without LPS into mouse gingiva, and histopathologically assessed alveolar bone resorption by tartrate-resistant acid phosphatase staining. We also stimulated osteoclast precursors from mouse bone marrow macrophages with these PGNs in vitro and assessed osteoclastogenesis. The cells were also stimulated with synthetic ligands for NOD1; γ-D-glutamyl-meso-DAP NOD2; muramyl dipeptide or TLR2; Pam(3) CSK(4) with or without LPS to analyse the signaling cross-talk. RESULTS: S. aureus PGN, but not E. coli PGN, induced alveolar bone resorption, as did LPS. However, PGN from both sources significantly enhanced the bone resorption in the mice co-injected with LPS. Both types of PGNs induced osteoclastogenesis and accelerated osteoclastogenesis when the cells were co-stimulated with LPS in vitro. All synthetic ligands synergistically induced osteoclastogenesis by co-stimulation with LPS. CONCLUSION: Gram-positive or gram-negative PGN worked synergistically with LPS to induce bone resorption and osteoclastogenesis, possibly by co-ordinating the effects of TLR2, NOD1, NOD2 and TLR4 signaling.

Pioderma gangrenoso: revisión de cinco casos / No disponible

Describimos cinco pacientes con pioderma gangrenoso derivados desde la consulta de Atención Primaria al servicio de Dermatología de referencia. Tres de ellos presentaban patología sistémica ya conocida, y en otro paciente se diagnosticó durante el estudio una gammapatía monoclonal. El pioderma gangrenoso es una dermatosis neutrofílica no infecciosa que se manifiesta como una úlcera dolorosa de rápida evolución, que puede asociarse a enfermedad inflamatoria intestinal, discrasias sanguíneas malignas, artritis reumatoide y otras enfermedades sistémicas. Ante la presencia de una lesión ulcerosa cutánea que no mejora con el tratamiento local, con cultivos negativos y sin respuesta al tratamiento antibiótico, se debe sospechar la existencia de pioderma gangrenoso, lo que obliga a descartar patología sistémica asociada y remitir a estos pacientes a consultas de Dermatología de referencia (AU)

We describe five patients with pyoderma gangrenosum who were refered from General Practicer to one Dermatology Department. Three of them presented previously known systemic pathology, and in another patient monoclonal gammapathy was disclosed. Pyoderma gangrenosum is a noninfectious neutrophilic dermatosis that manifests as a painful festering wound with rapid evolution that may be associated to inflammatory bowel disease, hematologic malignancy, rheumatoid arthritis and other internal disorders. Pyoderma gangrenosum should be suspected whenever there is festering skin ulcer that does not improve with the local treatment, with negative cultures and without response to the antibiotic treatment. A diagnosis of pyoderma gangrenosum should be followed by a search of systemic associated disorder and the patient should be sent in consultation to the corresponding Dermatology department (AU)

Foliculitis por candida albicansen drogadicto intravenoso / Folliculitis due to candida albicans in an intravenous drug-abuser

La foliculitis candidiásica es casi exclusiva de los consumidores de heroína marrón por vía intravenosa. Es debida a una infección sistémica por Candidaalbicans.Describimos el caso de un varón de 42 años de edad, HIV negativo, adicto a drogas por vía parenteral, que consultó por la presencia de pápulas y pústulasfoliculares dolorosas localizadas en regiones pilosas, la barba, el cuero cabelludo, zona centrotorácica y genital, de 48 horas de evolución, junto afiebre, malestar general y artromialgias desde hacía una semana. En el estudio oftalmológico se demostró la existencia de retinitis bilateral candidiásicajunto a uveítis anterior aguda en el ojo izquierdo. En el estudio histopatológico de las lesiones cutáneas se demostró la presencia de microabcesosfoliculares, y un leve infiltrado inflamatorio perifolicular compuesto por linfocitos y polimorfonucleares. En el cultivo de las lesiones cutáneas enmedios Saboreaud, se aisló Candida albicans.En la década de los noventa la incidencia de la candidiasis sistémica, en drogadictos intravenosos disminuyó notablemente, siendo en la actualidaduna entidad excepcional que aún hoy, hay que tenerla presente (AU)

Candidiasic folliculitis is an almost exclusive disease of intravenous brown heroin abusers. This entity is due to a systemic infection by Cándida albicans.A 42 year- old man, HIV negative and intravenous drug abuser, who was referred with painful, follicular papules and pustules located on hairs regions,of the beard, scalp, thoracic and genital areas is reported. The patient had also fever, general discomfort and arthromialgias. The ophthalmologicexamination demostrated bilateral, candidiasic retinitis and left acute anterior uveitis. Histopathological study showed follicular microabcess andslight inflammatory infiltrate with perifollicular arrangement and composed of lymphocytes and neutrophils. Culture of the biopsy specimen isolatedCandida albicans.In the decade of the nineties the incidence of the systemic candidiasis, diminished notably, being at present an exceptional entity although still it is necessaryto be aware the process (AU)

[Proliferative cutaneous epithelioid angiomatous nodule]. / Nódulo angiomatoso epitelioide cutáneo proliferativo.

The cutaneous epithelioid angiomatous nodule is an uncommon benign vascular proliferation that has only recently been described. Clinically, it usually presents as a solitary, fast-growing, small reddish papulous or nodular lesion on the trunk or limbs of adults. Histopathologic study reveals a proliferation of epithelioid cells and predominantly solid, well delimited, unilobular growth in the superficial dermis. Well defined vessels are often found permeating the lesion, which also shows a certain degree of inflammatory infiltration. The cells contain abundant pink cytoplasm, often with vacuoles, and vesicular nuclei with prominent nucleoli. The morphology of these cells is relatively uniform, without atypia or pleomorphism, although mitoses are not uncommon. We report 2 new cases of cutaneous epithelioid angiomatous nodules, the first in a 28-year-old pregnant woman and the second in a 27-year-old man. In both cases, the usual characteristics of this entity were present, but with the peculiarity of a high mitotic index. We discuss the differential diagnosis of cutaneous epithelioid angiomatous nodules with other vascular proliferations that exhibit epithelioid cytology.

[Trichilemmal horn: a new case and review of the literature]. / Cuerno tricolémico: presentación de un nuevo caso y revisión de la literatura.

Trichilemmal horn, or trichilemmal keratosis, is an uncommon benign neoplasm of follicular lineage with trichilemmal differentiation. The essential characteristics of this tumor are its clinical presentation in the form of a cutaneous horn with trichilemmal keratinization apparent in the histology study (with a hyperplastic epithelium giving rise to dense, orthokeratotic eosinophilic keratin). We present a new case of this type of tumor in an 82-year-old woman who developed a solitary lesion on her scalp after surgical removal of a trichilemmal cyst. On the basis of the pathology report, the tumor was diagnosed as trichilemmal horn. We review the 33 reports of this tumor in the literature to date.

Nódulo angiomatoso epitelioide cutáneo proliferativo / Proliferative Cutaneous Epithelioid Angiomatous Nodule

El nódulo angiomatoso epitelioide cutáneo es una proliferación vascular poco frecuente de naturaleza benigna y de reciente descripción. Clínicamente es una lesión rojiza, pequeña, papulosa o nodular, habitualmente única, de crecimiento rápido en el tronco o las extremidades de una persona adulta. Histopatológicamente se trata de una proliferación de células de hábito epitelioide y crecimiento predominantemente sólido, bien delimitada, unilobular, localizada en la dermis superficial. Es común encontrar vasos bien conformados salpicando la lesión, así como cierto infiltrado inflamatorio acompañante. Las células muestran amplios citoplasmas rosados, muchas veces con vacuolas, y núcleos vesiculosos con nucléolos prominentes. La morfología de las células es relativamente uniforme y no se encuentran atipias ni pleomorfismo, aunque no son raras las mitosis. Describimos dos nuevos casos de nódulo angiomatoso epitelioide cutáneo, el primero en una mujer embarazada de 28 años y el segundo en un varón de 27 años, ambos con todos los rasgos descritos como propios de esta entidad, pero con la peculiaridad de que presentaban un elevado índice mitósico. Discutimos el diagnóstico diferencial entre el nódulo angiomatoso epitelioide cutáneo y otras proliferaciones vasculares con citología epitelioide (AU)

The cutaneous epithelioid angiomatous nodule is an uncommon benign vascular proliferation that has only recently been described. Clinically, it usually presents as a solitary, fast-growing, small reddish papulous or nodular lesion on the trunk or limbs of adults. Histopathologic study reveals a proliferation of epithelioid cells and predominantly solid, well delimited, unilobular growth in the superficial dermis. Well defined vessels are often found permeating the lesion, which also shows a certain degree of inflammatory infiltration. The cells contain abundant pink cytoplasm, often with vacuoles, and vesicular nuclei with prominent nucleoli. The morphology of these cells is relatively uniform, without atypia or pleomorphism, although mitoses are not uncommon. We report 2 new cases of cutaneous epithelioid angiomatous nodules, the first in a 28-year-old pregnant woman and the second in a 27-year-old man. In both cases, the usual characteristics of this entity were present, but with the peculiarity of a high mitotic index. We discuss the differential diagnosis of cutaneous epithelioid angiomatous nodules with other vascular proliferations that exhibit epithelioid cytology (AU)

Cuerno tricolémico: presentación de un nuevo caso y revisión de la literatura / Trichilemmal Horn: a New Case and Review of the Literature

El cuerno tricolémico o queratosis tricolemal es una neoplasia benigna, poco frecuente, de estirpe folicular y diferenciación tricolémica. Las características fundamentales de este tumor son su presentación clínica en forma de cuerno cutáneo que histológicamente muestra queratinización tricolémica (con un epitelio hiperplásico que da lugar a una queratina eosinófila, compacta y ortoqueratósica). En este artículo presentamos un nuevo caso de este tumor en una paciente de 82 años que desarrolló una lesión solitaria en el cuero cabelludo, tras la manipulación de un quiste tricolémico. El estudio histológico permitió llegar al diagnóstico de cuerno tricolémico. Realizamos una revisión de los 33 ejemplos de este tumor descritos en la literatura hasta la fecha (AU)

Trichilemmal horn, or trichilemmal keratosis, is an uncommon benign neoplasm of follicular lineage with trichilemmal differentiation. The essential characteristics of this tumor are its clinical presentation in the form of a cutaneous horn with trichilemmal keratinization apparent in the histology study (with a hyperplastic epithelium giving rise to dense, orthokeratotic eosinophilic keratin). We present a new case of this type of tumor in an 82-year-old woman who developed a solitary lesion on her scalp after surgical removal of a trichilemmal cyst. On the basis of the pathology report, the tumor was diagnosed as trichilemmal horn. We review the 33 reports of this tumor in the literature to date (AU)

[Importance of heterotrimeric G proteins in prostate cancer molecular biology]. / Importancia de las proteínas G heterotriméricas en la biología molecular del cáncer de próstata.

OBJECTIVE: To deep in the knowledge of the involvement of G-protein alphas and alphai subunits in human prostate cancer. METHODS: Prostate tissue from 9 patients undergoing radical prostatectomy for prostate cancer and 5 controls undergoing cystoprostatectomy for bladder carcinoma. G-protein alphas and alphai subunits were studied for expression (mRNA by RT-PCR and protein by Western-blot), functionality (adenylyl cyclase activity, AC) and possibility of mutations (analysis with restriction enzymes and cDNA sequentiation). RESULTS: At mRNA level, the expression of alphas, alphai1, alphai2 y alphai3 was detected in healthy and cancerous tissues. At protein level, the expression of alphas y alphai1,2 diminished (25% and 40%, respectively) in prostate cancer. The expression of alphai3/0 also diminished, whereas that of beta subunit was not modified. Basal AC activity in adenocarcinoma membranes was 40% inferior to the control. Digestion with restriction enzymes Eag I or AlwN I did not allow to locate mutations in alphas. However, digestion at alphai2 level with BstU I enzyme served to observe a change of Gln205 (CAG triplet) to Pro (CCG). CONCLUSIONS: The functionality and expression of heterotrimeric G proteins are selectively modified in human prostate adenocarcinoma, occurring in addition some punctual mutation. The observed substitution of Gln205 by Pro may result in a low GTPase activity for alphai2 that, therefore, is stabilized in its active form.