Ipsilateral proximal and shaft femoral fractures: Results of two treatment strategies. / [Artículo traducido] Fracturas ipsilaterales proximales y diafisarias del fémur: resultados de dos estrategias de tratamiento.

INTRODUCTION: Ipsilateral proximal and shaft femoral fractures typically occur in young adults after high-energy trauma. No consensus exists regarding the optimal internal fixation device or surgical strategy for these complex fractures. Our main objective is to identify differences on outcomes and complications between patients treated with one or combined implants. MATERIAL AND METHOD: This is a single-center retrospective cohort study in patients with associated fractures of the proximal (31 AO) and shaft femur (32 AO). We divided the patients into two groups according to the use of single (GroupI) or combined implants (GroupII). Demographic, clinical, radiological, surgical data and development of complications were collected. RESULTS: We identified 28 patients (19 men and 9 women) with an average age of 43years. We used an anterograde femoral nail in GroupI (17 patients) and a retrograde femoral nail or a plate associated with hip lag screws or sliding hip screw in GroupII (11 patients). Patients were followed up for 26.28 (9.12-62.88) months. Osteonecrosis of the femoral head, osteoarthritis, infection or nonunion was found in 9 patients (32%). No significant differences (P=.70) were found in complications between two groups or between definitive surgical fixation before or after the first 24h. CONCLUSIONS: No differences in the development of complications or timing of definitive fixation were found between the use of one or combined implants in ipsilateral proximal femur and shaft fractures. Regardless of the implant chosen, an appropriate osteosynthesis technique is crucial, even so high complication rates are expected.

Does the fracture of the lateral wall affect the degree of collapse and the degree of sliding of the cephalic plate, in pertrochanteric fractures treated by intramedullary interlocking? Radiological study and review of the literature. / ¿Afecta la fractura de la pared lateral al grado de colapso y al grado de deslizamiento de la lámina cefálica, en fracturas pertrocantéreas tratadas mediante enclavado intramedular? Estudio radiológico y revisión de la literatura.

BACKGROUND: Lateral wall fracture has been recognized as an important sign of instability of pertrochanteric fractures. The aim of the present study is to assess the relationship between lateral wall fractures, helical blade telescoping and neck shortening in fractures treated with intramedullary nailing. MATERIAL AND METHOD: A descriptive radiological study was performed at our institution. Patients who suffered a pertrochanteric fracture, treated at Hospital 12 de Octubre by intramedullary nailing were included. All fractures were classified according to Evans and AO systems. Preoperative and postoperative radiological assessment was carried out including a lateral wall fracture classification, helical blade telescoping and femoral neck shortening. RESULTS: 210 patients were included, 48% had a fracture of the femoral lateral wall. Helical blade telescoping was higher in lower lateral wall fractures with respect to higher fractures. Difference was statistically significant (p<0.05). Neck shortening was higher in fractures with femoral lateral wall disruption; despite not have found any significant differences comparing to fractures with intact lateral wall (P=.39). Multivariate analysis showed statistically significant association between helical blade telescoping, neck shortening and lateral wall fracture. CONCLUSIONS: There is evidence of a higher helical blade telescoping and neck shortening in pertrochanteric fractures with lateral wall fracture treated with intramedullary nails, especially in those with most unstable patterns such us fractures of the lateral wall distal to the vastus ridge.

Valoración de parámetros clínicos del paciente politraumatizado como predictores del gasto hospitalario y de su distribución / Assessment of clinical parameters of the polytraumatized patient as predictors of hospital expenditure and of its distribution

Introducción: La enfermedad traumática continúa representando un importante problema socio-sanitario. El objetivo del estudio es valorar predictores clínicos del gasto total, así como analizar que componentes del coste se modifican con cada parámetro clínico del politraumatizado. Material y métodos: Estudio retrospectivo de 131 politraumatizados registrados prospectivamente. Se llevó a cabo un análisis estadístico para valorar la relación entre parámetros clínicos, el coste total y el coste de los principales componentes del tratamiento. Resultados: El coste total del ingreso hospitalario fue de 3.791.879 euros. El gasto medio por paciente fue de 28.945 Euros. La edad y el género no fueron predictores del coste. Las escalas ISS, NISS y PS fueron predictores del coste total y del coste de diferentes facetas del tratamiento. El AIS de cráneo y tórax predijo un mayor coste de ingreso en UCI y de coste total. El AIS de miembros inferiores se asoció exclusivamente a un mayor gasto en las facetas de tratamiento relacionadas con la actividad quirúrgica. Discusión: Existen parámetros clínicos que son predictores del coste de tratamiento del paciente politraumatizado. En el estudio se describe como el tipo de traumatismo que presenta el paciente modifica el tipo de gastos que presentará en su ingreso hospitalario. Conclusiones: Los pacientes politraumatizados que presentan lesión multisistémica grave presentan incremento del gasto en múltiples componentes del coste de tratamiento. Los pacientes donde predomina el TCE o traumatismo torácico presentan un mayor coste por ingreso en la UCI y los que predomina el traumatismo ortopédico asocian un mayor gasto en actividad quirúrgica

Introduction: Traumatic pathology continues to represent an important socio-health problem. The aim of the study was to assess the clinical predictors of total expenditure, as well as to analyze which components of the cost are modified with each clinical parameter of the polytraumatized patient. Material and methods: Retrospective study of 131 polytrauma patients registered prospectively. A statistical analysis was carried out to assess the relationship between clinical parameters, the total cost and the cost of various treatment components. Results: The total cost of hospital admission was 3,791,879 euros. The average cost per patient was Euros 28,945. Age and gender were not predictors of cost. The scales ISS, NISS and PS were predictors of the total cost and of multiple treatment components. The AIS of Skull and Thorax predicted a higher cost of admission to ICU and Total Cost. The AIS of lower limbs was associated with greater spending on facets of treatment related to surgical activity. Discussion: There are clinical parameters that are predictors of the treatment cost of the polytraumatized patient. The study describes how the type of trauma that the patient suffers modifies the type of expenses that will present in their hospital admission. Conclusions: Polytraumatized patients with severe multisystem injury present increased costs in multiple components of the treatment cost. Patients with TBI or chest trauma present a higher cost for admission to ICU and those with orthopaedic trauma are associated with greater expenditure on surgical activity

Utilidad de los catéteres percutáneos para perfusión continua de anestésico local en el manejo del dolor postoperatorio en pacientes sometidos a artrodesis lumbar instrumentada. Estudio de cohortes prospectivas / Utility of percutaneous catheters for local anaesthetics infusion for postoperative pain control in lumbar arthrodesis. A prospective cohort study

Objetivo: Valorar si la administración asociada de levobupivacaína a través de dos catéteres percutáneos submusculares conectados a dos bombas elastoméricas en el postoperatorio de la artrodesis instrumentada lumbar es más eficaz que el uso aislado de analgesia intravenosa controlada por el paciente con cloruro mórfico y comparar sus efectos secundarios. Material y método: Estudio observacional, prospectivo, de cohortes. Se comparó la necesidad de analgesia de rescate entre ambos grupos, la valoración subjetiva del dolor mediante la escala visual analógica y la presencia de efectos adversos con una y otra técnica. Resultados: No se encontraron diferencias estadísticamente significativas en cuanto a las necesidades de analgesia de rescate. El dolor medido con la escala visual analógica fue significativamente menor (p = 0,032) en reposo a las 48h postoperatorias en el grupo tratado con catéteres. La escala visual analógica media en el resto de momentos presentó una tendencia a un menor dolor postoperatorio en el grupo tratado con catéteres, pero sin significación estadística. No hubo diferencias estadísticamente significativas en los efectos adversos, aunque en el grupo tratado con catéteres hubo 6 casos de efectos adversos frente a 11 casos del grupo tratado con analgesia convencional. Conclusiones: Se observó una tendencia en el grupo tratado con catéteres a presentar menor dolor postoperatorio con menos efectos indeseables, aunque las diferencias no fueron estadísticamente significativas

Objective: To evaluate whether postoperative continuous wound infiltration of levobupivacaine through two submuscular catheters connected to two elastomeric pumps after lumbar instrumented arthrodesis is more effective than intravenous patient-controlled analgesia. Material and methods: An observational, prospective cohorts study was carried out. The visual analogue scale, the need for additional rescue analgesia and the onset of adverse effects were recorded. Results: Pain records measured with visual analogue scale scale were significantly lower in the 48hours postoperative record at rest (p=.032). The other records of visual analogue scale showed a clear tendency to lower levels of pain in the group treated with the catheters. No statistically significant differences were found in the rescue analgesia demands of the patients. The adverse effects were lower in the catheter group (6 cases versus 11 cases) but without statistical differences. Conclusions: A trend to lower pain records was found in the group treated with catheters, although differences were not statistically significant

Assessment of clinical parameters of the polytraumatized patient as predictors of hospital expenditure and of its distribution. / Valoración de parámetros clínicos del paciente politraumatizado como predictores del gasto hospitalario y de su distribución.

INTRODUCTION: Traumatic pathology continues to represent an important socio-health problem. The aim of the study was to assess the clinical predictors of total expenditure, as well as to analyze which components of the cost are modified with each clinical parameter of the polytraumatized patient. MATERIAL AND METHODS: Retrospective study of 131 polytrauma patients registered prospectively. A statistical analysis was carried out to assess the relationship between clinical parameters, the total cost and the cost of various treatment components. RESULTS: The total cost of hospital admission was 3,791,879 euros. The average cost per patient was € 28,945. Age and gender were not predictors of cost. The scales ISS, NISS and PS were predictors of the total cost and of multiple treatment components. The AIS of Skull and Thorax predicted a higher cost of admission to ICU and Total Cost. The AIS of lower limbs was associated with greater spending on facets of treatment related to surgical activity. DISCUSSION: There are clinical parameters that are predictors of the treatment cost of the polytraumatized patient. The study describes how the type of trauma that the patient suffers modifies the type of expenses that will present in their hospital admission. CONCLUSIONS: Polytraumatized patients with severe multisystem injury present increased costs in multiple components of the treatment cost. Patients with TBI or chest trauma present a higher cost for admission to ICU and those with orthopaedic trauma are associated with greater expenditure on surgical activity.

Utility of percutaneous catheters for local anaesthetics infusion for postoperative pain control in lumbar arthrodesis. A prospective cohort study. / Utilidad de los catéteres percutáneos para perfusión continua de anestésico local en el manejo del dolor postoperatorio en pacientes sometidos a artrodesis lumbar instrumentada. Estudio de cohortes prospectivas.

OBJECTIVE: To evaluate whether postoperative continuous wound infiltration of levobupivacaine through two submuscular catheters connected to two elastomeric pumps after lumbar instrumented arthrodesis is more effective than intravenous patient-controlled analgesia. MATERIAL AND METHODS: An observational, prospective cohorts study was carried out. The visual analogue scale, the need for additional rescue analgesia and the onset of adverse effects were recorded. RESULTS: Pain records measured with visual analogue scale scale were significantly lower in the 48hours postoperative record at rest (p=.032). The other records of visual analogue scale showed a clear tendency to lower levels of pain in the group treated with the catheters. No statistically significant differences were found in the rescue analgesia demands of the patients. The adverse effects were lower in the catheter group (6 cases versus 11 cases) but without statistical differences. CONCLUSIONS: A trend to lower pain records was found in the group treated with catheters, although differences were not statistically significant.

[Femur fracture in a patient with dog-leg deformity secondary to arthrogryposis. Description of a unique osteosynthesis method]. / Fractura de fémur en un paciente con deformidad «dog-leg¼ secundaria a artrogriposis. Descripción de un método único de osteosíntesis.

The concept of arthrogryposis encompasses several conditions that share the presence of multiple congenital contractures. The knee is frequently involved and is an important cause of morbidity in these patients. Flexion contractures of the knee are the most common ones and have a worse prognosis than extension contractures. Different approaches are available to treat flexion contractures of the knee. Distal femoral extension osteotomy effectively corrects fixed flexion, but may lead to residual deformity. This iatrogenic deformity disrupts the anterior convexity of the femoral shaft and leads to serious problems in the subsequent management of orthopedic conditions. This is a case report of a patient with arthrogryposis and a femur deformity who sustained a supracondylar fracture. Managing the fracture was challenging due to a disruption in the normal architecture of the femur. This is a description of the osteosynthesis approach used to treat the fracture and the patients pre-existing deformity.

El concepto «artrogriposis¼ agrupa varias enfermedades cuya característica común es la presencia de múltiples contracturas congénitas. La rodilla se afecta con frecuencia y es causa importante de morbilidad en estos pacientes. Las contracturas en flexión de la rodilla son más comunes y tienen peor pronóstico que las contracturas en extensión. Existen diferentes técnicas de tratamiento para la contractura en flexión de la rodilla; la osteotomía distal de extensión femoral corrige eficazmente la flexión fija, pero puede dar lugar a una deformidad residual. Esta deformidad iatrogénica altera la convexidad anterior de la diáfisis femoral y conlleva problemas graves en el manejo posterior de patología ortopédica. Se presenta el caso de una paciente con artrogriposis y una deformidad en fémur con una fractura en la región supracondílea. El manejo de la fractura fue dificultoso por la presencia de una distorsión de la arquitectura normal del fémur. En nuestro trabajo se describe el método de osteosíntesis utilizado para hacer frente a la fractura y a la deformidad previa de la paciente.

Fractura de fémur en un paciente con deformidad « dog-leg ¼ secundaria a artrogriposis. Descripción de un método único de osteosíntesis / Femur fracture in a patient with dog-leg deformity secondary to arthrogryposis. Description of a unique osteosynthesis method

Resumen: El concepto «artrogriposis¼ agrupa varias enfermedades cuya característica común es la presencia de múltiples contracturas congénitas. La rodilla se afecta con frecuencia y es causa importante de morbilidad en estos pacientes. Las contracturas en flexión de la rodilla son más comunes y tienen peor pronóstico que las contracturas en extensión. Existen diferentes técnicas de tratamiento para la contractura en flexión de la rodilla; la osteotomía distal de extensión femoral corrige eficazmente la flexión fija, pero puede dar lugar a una deformidad residual. Esta deformidad iatrogénica altera la convexidad anterior de la diáfisis femoral y conlleva problemas graves en el manejo posterior de patología ortopédica. Se presenta el caso de una paciente con artrogriposis y una deformidad en fémur con una fractura en la región supracondílea. El manejo de la fractura fue dificultoso por la presencia de una distorsión de la arquitectura normal del fémur. En nuestro trabajo se describe el método de osteosíntesis utilizado para hacer frente a la fractura y a la deformidad previa de la paciente.

Abstract: The concept of arthrogryposis encompasses several conditions that share the presence of multiple congenital contractures. The knee is frequently involved and is an important cause of morbidity in these patients. Flexion contractures of the knee are the most common ones and have a worse prognosis than extension contractures. Different approaches are available to treat flexion contractures of the knee. Distal femoral extension osteotomy effectively corrects fixed flexion, but may lead to residual deformity. This iatrogenic deformity disrupts the anterior convexity of the femoral shaft and leads to serious problems in the subsequent management of orthopedic conditions. This is a case report of a patient with arthrogryposis and a femur deformity who sustained a supracondylar fracture. Managing the fracture was challenging due to a disruption in the normal architecture of the femur. This is a description of the osteosynthesis approach used to treat the fracture and the patient's pre-existing deformity.

[Evolution of the treatment of distal radius fractures in Spain. Is this the right way to go?]. / Evolución del tratamiento de las fracturas de radio distal en España. Es el camino correcto?

OBJECTIVE: To assess the changes in the treatment of distal radius fractures that have occurred in recent years at our center. To analyze the changes that have occurred and their possible causes. MATERIAL AND METHODS: We analyzed the hospital admission data from our center, both total admissions and those due to distal radius fractures. Surgical activity records show the evolution of the surgical treatment of distal radius fractures throughout time. Using the data from 2 research works done at our center we assessed the radiological and functional results obtained with an external fixator and nails and with buttress plates. We reviewed the updated bibliography trying to identify new evidence leading to treatment changes. RESULTS: Objective evidence shows a marked evolution towards the use of open reduction and internal fixation to treat distal radius fractures. We did not identify data in our studies that show poor results with the use of external fixators and nails or a clear superiority of the open reduction methods. These data are not available in the current bibliography. CONCLUSION: The treatment of distal radius fractures is being modified. This change is not based on contrasted clinical or bibliographic data. We need to ask whether this is due to commercial pressure or to a perception of surgeons that is yet to be proven in quality studies.

Hepatoesplenomegalia febril en un lactante / Febrile hepatosplenomegaly in an infant

La esplenomegalia febril es un desafío diagnóstico, y más aún desde la Atención Primaria. Describimos un caso de una lactante, con fiebre intermitente de varias semanas de evolución. El hallazgo dominante era una esplenomegalia llamativa de 7-8 cm y una hepatomegaliade menor tamaño. Se realizaron pruebas complementarias siguiendo el protocolo diagnóstico, y se encontraron cifras normales de leucocitos, con anemia y trombopenia leve, aumento de colesterol, triglicéridos y ferritina. Se recogieron cultivos (sangre, heces, orina),que fueron negativos y serologías de virus, bacterias atípicas y leishmania, también negativas.Ante la anemización progresiva se ingresó a la paciente durante una semana, sin llegar a un diagnóstico. Posteriormente, y cuando la paciente se encontraba en seguimiento en la consulta de Atención Primaria, se recibió el resultado positivo para PCR (Reacción en Cadenade la Polimerasa) de Leishmania sp. La paciente reingresó y fue tratada con Anfotericina B liposomal en dosis estándar, con desaparición de la fiebre y disminución progresiva de la esplenomegalia. Desde el inicio de los síntomas presentaba además una lesión costrosa en cuerocabelludo, que fue biopsiada dos meses después del ingreso, y que dio como resultado leishmaniasis cutánea. En poco tiempo la lesión evolucionó a alopecia cicatricial, y no fue necesario ningún otro tratamiento.El kala-azar o leishmaniasis visceral es endémico en el área mediterránea, y es habitualmente causado en nuestro medio por L. infantum. Cursa habitualmente con pancitopenia y fiebre en picos, incluso períodos de defervescencia, yes la esplenomegalia el hallazgo habitual. El tratamiento clásico incluye los antimoniales aunque, debido a las resistencias (sobre todo en lasformas de la India), se puede tratar con anfotericina B liposomal. Se han descrito casos de leishmaniasisviscerales y cutáneas concomitantes, sobre todo en inmunodeficiencias. Creemos interesante este caso en ef que describimos a una lactante, no inmunodeprimida, con ambos tipos de leishmaniasis: visceral y cutánea, que sería el primero descrito en nuestro país

Fever and splenomegaly are a diagnostic challenge, mainly from Primary Care Centres. We describe here the case of a female infant with intermittent fever over several weeks, in which a giant splenomegaly of 7-8 cm and a smaller hepatomegaly were the main symptoms. Diagnosticprotocol was followed, and normal accounts of leucocytes were found, but also anemia and mild thrombopenia, with increased cholesterol, triglicerydes and ferritine. The procedure included cultures (urine, blood, faeces) and serology from virus, atypical bacteria and leishmania, allof them negative. Increasing anemia was the cause of hospital admission for one week, although no diagnosis was reached. Afterwards, when the patient was being followed in our Primary Care Centre, a positive result for Leishmania sp PCR (Polimerase Chain Reaction) was informed. With a diagnose of visceral leishmaniasis, the patient then received standard doses of liposomal Amfotericin B disappearing afterwards fever and (slowly over a period of several months) splenomegaly. From the beginning of symptoms, our infant showed a scabbed lesionon her scalp, which was biopsied two months after treatment with amfotericin, being "cutaneousleishmaniasis" the new diagnose. The patient did not receive any other treatment and her lesion improved, although it remains as an atrophic scar.Kala-azar or visceral leishmaniasis is endemic in the Mediterranean countries, being L. infantumthe most prevalenfspecies in our afea. Pancytopenia and high fever are common, although afebrile periods of time can also be found in leishmaniasis case series. Splenomegaly is the most common symptom. Classic treatment included pentavalent antimonials but due torecent resistance of Indian species to this drug, visceralleishmaniasis can be treated with liposomalamfotericin B. Concomitant cutaneous and visceral leishmaniasis have been described, moreover among immunodepressed adults. We believe this is a very interesting case, where we describe a healthy infant with both types of leishmaniasis: visceral and cutaneous, which is the first one described in our country

Recomendaciones actuales de vacunación en población infantil VIH+ / Current recommendations for immunization in human immunodeficiency virus-infected children

Objetivos. La infección por virus de la inmunodeficiencia humana (VIH) continúa siendo la mayor causa de inmunodeficiencia en la población infantil española. La cobertura vacunal y la deficiente respuesta a las inmunizaciones podrían determinar parte de la morbimortalidad a largo plazo. Se pretende analizar aquí las recomendaciones actuales de vacunación en esta población ante la aparición constante de nuevas vacunas.Resultados. La efectividad de las vacunas está limitada, especialmente si existe inmunodepresión (linfocitos CD 4+ <15%) y sobremanera en vacunas contra la hepatitis B, triple vírica y gripe. Los calendarios de vacunación no difieren de forma especial de las recomendaciones del calendario oficial, añadiéndose varicela, neumococo y hepatitis A en zonas de riesgo. Es necesario conocer el grado de inmunodeficiencia antes de vacunar con vacunas de virus vivos (triple vírica y varicela). En la actualidad, no se recomienda en Europa la vacunación frente a bacilo de Calmette-Guérin (BCG) en población VIH+.Conclusión. La infección por VIH no contraindica por sí sola ninguna vacuna, siempre y cuando no exista inmunodepresión avanzada y la situación epidemiológica requiera la vacunación. Por otra parte, la vacunación (con el consiguiente estímulo linfocitario) no acelera la progresión de la enfermedad

Objectives. Human immunodeficiency virus (HIV) infection remains the most common cause of immunosuppression among Spanish children. Vaccine coverage and the poor response to immunization may play a role in long-term morbidity and mortality. In view of the constant introduction of new vaccines, we propose to analyze the current recommendations for vaccination in this population. Results. The efficacy of vaccines in HIV-infected children is especially limited in the presence of immunosuppression (CD4+ lymphocytes <15%). The hepatitis B virus, measles-mumps-rubella and influenza vaccines are particularly ineffective. The immunization schedules do not differ widely from those recommended by the health authorities for healthy children, although varicella, pneumococcal and hepatitis A vaccines are added in high-risk areas. Prior to administering live virus vaccines (measles-mumps-rubella and varicella), it is necessary to determine the degree of immunosuppression. At the present time, in Europe, immunization against bacillus Calmette-Guerin is not recommended in HIV-positive patients. Conclusion. HIV seropositivity itself does not contraindicate any vaccine in the absence of advanced immunosuppression. On the other hand, immunization (with the consequent lymphocyte stimulation) does not accelerate the progression of the disease

Trastornos neuropsiquiátricos asociados a estreptococo / Neuropsychiatric disorders associated with streptococci: a case report

Los trastornos neuropsiquiátricos compulsivos son frecuentes en la infancia, siendo el más común el síndrome de Gilles de la Tourette. Recientemente ha sido descrito el síndrome PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococci), de etiología incierta, pero asociado a infección reciente por estreptococo del grupo A (SGA). Niño de 3 años y 9 meses que inició bruscamente, tras un episodio de faringitis, un cuadro de tics consistentes en inclinación de la cabeza y elevación del hombro, junto con muecas faciales, coprolalia y posteriormente compulsiones como golpear objetos de manera compulsiva. Se realizó estudio bioquímico completo, incluyendo cobre y ceruloplasmina (normales), antiestreptolisina O y anti-DNAsa, que resultaron elevadas, y se realizó cultivo faríngeo, que fue positivo para SGA. Fue inicialmente tratado con ácido valproico, aunque su mejoría posterior coincidió con el tratamiento durante 10 días con penicilina. A los 3 meses, los valores de antiestreptolisina O (ASLO) disminuyeron, y en su seguimiento a los 6 meses se comprobó una mejoría mantenida, incluso tras la suspensión del ácido valproico. Se solicitaron estudios de inmunohistoquímica. El síndrome PANDAS fue descrito en 1998 en niños que presentaban: a) trastornos obsesivo-compulsivos y/o trastorno de tics; b) curso episódico con exacerbaciones bruscas; c) alteraciones neurológicas (movimientos coreiformes), y d) relación temporal entre infección por SGA y exacerbación de los síntomas. La etiología se discute actualmente, se postula la existencia de reacciones cruzadas entre antígenos del SGA y proteínas presentes en los ganglios de la base, encontrándose cierta evidencia serológica a favor de varios antígenos proteicos implicados (B8/17 y otros). Está recomendado tratar con penicilina en cada exacerbación en la que se demuestre SGA, e incluso utilizar tratamientos más agresivos (inmunoglobulina intravenosa o plasmaféresis) en caso de tics graves y discapacitantes. Creemos que es un caso interesante de posible síndrome PANDAS, y sería el primero descrito en España

Compulsive neuropsychiatric disorders are common in children and the most frequent is Gilles de la Tourette syndrome. Recently, a new disease has been described: the PANDAS syndrome (pediatric autoimmune neuropsychiatric disorders associated with streptococci). The etiology of this syndrome is uncertain but it has been associated with recent group A streptococcal infection (GAS). After an episode of pharyngitis, a boy aged 3 years and 9 months showed abrupt onset of a variety of neurobehavioral problems such as tics (consisting of elevation of the head and ipsilateral shoulder, winking, and grimaces) and compulsions (such as repeatedly hitting objects). A complete biochemical study was performed, including Cu and ceruloplasmin (which had normal values), antistreptolysin O (ASLO) and anti-DNAse (showing elevated values). Pharyngeal culture revealed GAS. The child was initially treated with valproic acid, but his subsequent improvement coincided with penicillin treatment for 10 days. Three months afterwards, ASLO values were reduced and at the 6-month follow-up the improvement was maintained even after suspension of valproic acid. Immunohistochemical studies were requested. PANDAS syndrome was first described in 1998 in a group of children who presented 1) obsessive compulsive disorders and/or tics, 2) episodic course with abrupt exacerbations, 3) abnormal results of neurologic examination (choreiform movements), and 4) temporal relation between GAS infection and onset of symptoms. The etiology of this syndrome is unclear, and it has been postulated that certain streptococcal antigens trigger antibodies which, through a process of molecular mimicry, cross-react with epitopes on the basal ganglia of susceptible hosts, such as the B8/17 antigen, among others. Current recommendations include penicillin treatment of each exacerbation with positive throat culture, and more aggressive therapies (intravenous immunoglobulin or plasmapheresis) when symptoms are severe. We believe that the case presented herein is a probable PANDAS syndrome, which would be the first case described in Spain