Austrian Syndrome: Community-Acquired Pneumonia in an Unusual Triad.

Austrian syndrome corresponds to the triad of meningitis, pneumonia, and endocarditis caused by Streptococcus pneumoniae, there is no global or local incidence given the infrequency of entity. Scarce cases are published in Latin America, with none of them in Colombia. A case of Austrian syndrome by penicillin-resistant S. pneumoniae in an immunocompetent patient is presented. Aortic valve is the most frequent site involved in Austrian syndrome; this patient had an unusual localization of the vegetation on the right coronary artery ostium. The prognosis is poor with a mortality rate of 30% or higher, this patient survived despite systemic complications. Vaccination status impacts in prevention and severity of cases because responsible serotypes are often included in available vaccines. The patient had a serotype covered by available vaccines; however, her vaccination status was unknown. Thus, we present the first case reported in Colombia of Austrian syndrome by a penicillin-resistant S. pneumoniae, in a patient with no identified comorbidities or toxicological history, with a successful evolution.

Tromboembolismo pulmonar asociado a COVID-19 en paciente con síndrome de May-Thurner / COVID-19-associated Pulmonary Thromboembolism in a Patient with May-Thurner Syndrome

Introducción: El síndrome de May-Thurner es una enfermedad cuya prevalencia real es desconocida. Suele ser asintomática y las manifestaciones clínicas aparecen en el contexto de las complicaciones asociadas a la enfermedad. La aproximación diagnóstica se realiza por medio de imágenes, donde se identifican alteraciones patognomónicas que permiten descartar diagnósticos diferenciales. Se ha demostrado que la COVID-19 genera un estado protrombótico, que en contexto del síndrome de May-Thurner puede derivar en complicaciones tromboembólicas. Objetivo: Comparar la clínica y la posible relación de la enfermedad tromboembólica venosa en el curso de la COVID-19 en pacientes con SMT. Caso clínico: Mujer de 24 años, secretaria de profesión y residente en Bucaramanga. Presentó un cuadro clínico de 20 días de evolución que inició con rinorrea hialina, tos ocasional y mialgias; cinco días después manifestó fiebre no cuantificada y tos con expectoración hemoptoica. Conclusiones: Dentro de la fisiopatología de la infección por SARS-CoV-2 se desarrollan mecanismos procoagulantes, lo cual incrementa el riesgo de eventos trombóticos en pacientes con o sin factores de riesgo(AU)

Introduction: May-Thurner syndrome is a disease whose actual prevalence is unknown. It is usually asymptomatic and clinical manifestations appear in the context of complications associated with the disease. The diagnostic approach is performed by imaging, where pathognomonic alterations are identified to rule out differential diagnoses. It has been demonstrated that COVID-19 generates a prothrombotic state, which particularly in patients with May-Thurner syndrome would lead to thromboembolic complications. Objective: To compare the clinical and possible relationship of venous thromboembolic disease in the course of COVID-19 in patients with May-Thurner syndrome. Clinical case: 24-year-old woman, secretary by profession and resident in Bucaramanga, Colombia. She presented a clinical picture of 20 days of evolution that began with hyaline rhinorrhea, occasional cough and myalgias; five days later she manifested unquantified fever and cough with hemoptotic expectoration. Conclusions: Within the pathophysiology of SARS-CoV-2 infection, procoagulant mechanisms develop, which increases the risk of thrombotic events in patients with or without risk factors(AU)

Características de pacientes con exacerbación aguda grave de enfermedad pulmonar obstructiva crónica que requirieron ventilación mecánica invasiva en un hospital de Santander durante 2014-2020

Introducción: la enfermedad pulmonar obstructiva crónica es una limitación del flujo de aire por anomalías alveolares. En una exacerbación aguda, la ventilación mecánica no invasiva es la primera línea en el manejo, sin embargo, existen ciertos factores de riesgo que hacen más probable el uso de ventilación mecánica invasiva en estos pacientes, que no están apropiadamente descritos en la literatura científica y que pueden guiar hacia una elección de soporte ventilatorio apropiado. Objetivo: describir los factores que se asociaron con mayor necesidad de ventilación mecánica no invasiva en una cohorte de pacientes hospitalizados con exacerbación aguda de la enfermedad pulmonar obstructiva crónica. Métodos: estudio observacional analítico de corte transversal, con muestreo no probabilístico que incluye todos los pacientes que consultaron a urgencias y fueron hospitalizados por exacerbación aguda de la enfermedad pulmonar obstructiva crónica en un hospital de tercer nivel de Santander, Colombia, durante el período 2014-2020. Resultados: fueron incluidos 81 pacientes, 36 requirieron ventilación mecánica no invasiva y 12 ventilación mecánica invasiva; 25 % de los pacientes con ventilación mecánica no invasiva fallaron a la terapia inicial y demandaron el uso de ventilación mecánica invasiva. Las comorbilidades más frecuentes fueron hipertensión arterial (70,3 %) y cardiopatía (49,38 %); 70 % había tenido exposición al tabaquismo como fumador directo. Conclusiones: el uso de ventilación mecánica invasiva estuvo relacionado de forma estadísticamente significativa en pacientes con perfil de disnea severa, acidosis por parámetros gasométricos, escalamiento antibiótico, uso de corticoides intravenosos, requerimiento de unidad de cuidado intensivo, infecciones asociadas al cuidado de la salud y estancia hospitalaria prolongada.

Introduction: Chronic obstructive pulmonary disease is airflow limitation due to alveolar abnormalities. In an acute exa- cerbation, non-invasive mechanical ventilation is the first line of management, however, there are certain risk factors that make the use of invasive mechanical ventilation more likely in these patients, which are not adequately described in the scientific literature and that can guide towards a choice of appropriate ventilatory support. Objective: To describe the factors that were associated with an increased need for invasive mechanical ventilation in a cohort of hospitalized patients with an acute exacerbation of chronic obstructive pulmonary disease. Methods: Cross-sectional analytical observational study, with non-probabilistic sampling including all patients who consulted the emergency room and were hospitalized for acute exacerbation of chronic obstructive pulmonary disease in a tertiary care hospital in Santander-Colombia during the period 2014-2020. Results: 81 patients were included, 36 required non-invasive mechanical ventilation and 12 invasive me- chanical ventilation. 25 % of the patients with non-invasive mechanical ventilation failed the initial therapy and demanded the use of invasive mechanical ventilation. The most frequent comorbidities were arterial hypertension (70.3 %) and heart disease (49.38 %). 70 % had been exposed to smoking as direct smokers. Conclusions: The use of invasive mechanical ven- tilation was associated in a statistically significant way in patients with a profile of: severe dyspnea, acidosis by gasometric parameters, antibiotic escalation, use of intravenous corticosteroids, intensive care unit requirement, infections associa- ted with health care and prolonged hospital stay.

Hemorragia alveolar en síndrome febril tropical: reporte de caso de leptospirosis con compromiso pulmonar / Alveolar hemorrhage in febril-tropical syndrome: case report of leptospirosis with lung commitment

Resumen La leptospirosis en una enfermedad infecciosa importante en el diagnóstico diferencial de un paciente con síndrome ictérico hemorrágico, especialmente en países de ubicación tropical como Colombia. A continuación, se presenta el caso de un paciente masculino de 21 años, con cuadro clínico agudo caracterizado por presencia de fiebre y elevación de bilirrubinas, asociado a diarrea y trombocitopenia. Inicialmente se hizo diagnóstico presuntivo de dengue, sin embargo, durante su evolución presentó hemorragia y dificultad respiratoria asociada a secreción hemática con necesidad de intubación endotraqueal, por lo que se solicitó serologia IgM seriada de leptospira pensando en esta entidad como diagnóstico diferencial luego de indagar antecedentes epidemiológicos, la cual tuvo reporte positivo. Es importante conocer este tipo de casos debido a la presentación de compromiso pulmonar como una manifestación rara pero altamente asociada a mortalidad. Finalmente, con manejo de soporte y antibiótico adecuado se obtuvo una buena evolución clínica de este paciente.

Abstract Leptospirosis is a relevant infectious disease when there is a patient with an ictero-hemorrhagic syndrome, especially in tropical countries such as Colombia. The following is the case of a 21-year-old male patient, with an acute clinical picture given by fever, elevated bilirubin, associated with diarrhea and thrombocytopenia. Initially, a presumptive diagnosis of dengue was made. However, during his evolution, he presented hemorrhage and respiratory distress with a hematic secretion that required endotracheal intubation. After inquiring about the epidemiological data, leptospirosis was considered a differential diagnosis. Serial serology for leptospira IgM was requested and was positive. It is essential to know this type of case due to pulmonary affections as a rare manifestation but highly associated with mortality. Finally, with adequate antibiotic and supportive management, a good clinical evolution of this patient was obtained.

Nódulo pulmonar / Pulmonary nodule

Introducción: El nódulo pulmonar es un hallazgo generalmente incidental. Su detección ha aumentado observándose hasta en 13 por ciento de las tomografías. El diagnóstico diferencial plantea un desafío. Objetivo: Describir el caso de un paciente con nódulos pulmonares múltiples y su abordaje a partir de recomendaciones basadas en la evidencia. Caso clínico: Se presenta el caso de un paciente de 35 años con sintomatología inespecífica y nódulos pulmonares múltiples incidentales en estudios cervicotorácicos. Se analizaron etiologías posibles según datos clínicos, epidemiológicos, radiológicos y probabilidad de malignidad. Las recomendaciones basadas en la evidencia dirigieron el manejo. Dada la probabilidad intermedia de malignidad se indicó seguimiento escanográfico en 3 a 6 meses. Conclusiones: El caso presentado pretende reforzar destrezas clínicas en el manejo de esta entidad repercutiendo favorablemente en la morbimortalidad. Busca además impulsar el desarrollo de estrategias de tamizaje en poblaciones de riesgo(AU)

Introduction: The pulmonary nodule is a generally incidental finding. Its detection has increased, being observed in up to 13 percent of CT scans. Differential diagnosis poses a challenge. Objective: To describe the case of a patient with multiple pulmonary nodules and the approach to it based on evidence-based recommendations. Clinical case report: The case of a 35-year-old patient with nonspecific symptoms and incidental multiple pulmonary nodules in cervicothoracic studies is reported. Possible etiologies were analyzed according to clinical, epidemiological, radiological data and probability of malignancy. Evidence-based recommendations guided management. Given the intermediate probability of malignancy, a scan follow-up was indicated in 3 to 6 months. Conclusions: This case aims to reinforce clinical skills in the management of this entity, favourably impacting on morbidity and mortality. It also seeks to promote the development of screening strategies in populations at risk(AU)

Vasculitis inusual asociada a anticuerpos anticitoplasma de neutrófilos / Unusual vasculitis associated with antineutrophil cytoplasmic antibodies

Introducción: Las vasculitis asociadas a autoanticuerpos citoplasmáticos de neutrófilos son afecciones infrecuentes con una incidencia reportada de 46 a 184 casos por millón de personas y aparecen, generalmente, en edades tardías de la vida. Objetivo: Describir los hallazgos de una paciente en la que se diagnosticó vasculitis pauciinmune tipo poliangeítis microscópica tardíamente. Caso clínico: Se presenta el caso de una paciente de 60 años con antecedente de enfermedad renal crónica y compromiso respiratorio manifestado por disnea, tos productiva, malestar general y fiebre. En las imágenes se evidenció bronquiectasias y en los exámenes de laboratorio factor reumatoideo alto, autoanticuerpos citoplasmáticos antineutrófilos perinucleares positivos, anticuerpos antinucleares negativos y hemosiderófagos en el lavado broncoalveolar. Se instauró manejo con corticoides sistémicos con franca mejoría clínica. Sin embargo, una malformación arteriovenosa que originó una hemorragia en la fosa posterior, le ocasionó la muerte. Conclusiones: El diagnóstico de las vasculitis es complejo y depende en gran medida del criterio clínico, por lo que el médico debe estar presto a la interpretación de las manifestaciones clínicas y de los hallazgos paraclínicos(AU)

Introduction: Vasculitis associated with neutrophil cytoplasmic autoantibodies are infrequent conditions with a reported incidence of 46 to 184 cases per million people and it generally appears late in life. Objective: To describe the findings of a patient in whom microscopic polyangiitis-type pauciimmune vasculitis was late diagnosed. Clinical case report: We report a case of a 60-year-old patient with history of chronic kidney disease and respiratory compromise exhibited by dyspnea, productive cough, general malaise and fever. The images showed bronchiectasis and laboratory tests revealed high rheumatoid factor, positive perinuclear antineutrophil cytoplasmic autoantibodies, negative antinuclear antibodies, and bronchoalveolar lavage exposed hemosiderophages. Management with systemic corticosteroids was established with clear clinical improvement. However, an arteriovenous malformation that caused a hemorrhage in the posterior fossa caused his death. Conclusions: The diagnosis of vasculitis is complex and depends largely on clinical criteria, so physicians must be ready to interpret the clinical manifestations and paraclinical findings(AU)

Hemorragia alveolar por consumo de cocaína / Cocaine-induced alveolar hemorrhage

La hemorragia pulmonar por inhalación de cocaína o alguno de sus derivados (crack-cocaina) resulta en un síndrome raro conocido como "pulmón de crack", cuya presentación es aguda y potencialmente fatal. Del 25 al 60% de las personas que consumen cocaína reportan síntomas respiratorios después de la inhalación, pero menos del 5% consultan por esta causa. Los síntomas aparecen dentro de las primeras 5 horas luego del consumo y la presentación clínica puede ser variable con posibilidad de progresión. En los estudios radiograficos se pueden apreciar frecuentemente areas de afectación intersticial difusa de localización subpleural o peribronquial. El analisis del lavado broncoalveolar juega un papel importante en el diagnostico y exclusion de condiciones diferenciales. La presencia de hemosiderofagos en recuento significativo determina la hemorragia aveolar por inhalacion de cocaina. El diagnóstico y tratamiento oportuno es crucial en esta entidad. Se revisó un caso de hemorragia pulmonar por inhalación de crack ­ cocaina que resolvio satisfactoriamente.

Acute respiratory involvement in Colombian patients with systemic lupus erythematosus undergoing chest computed tomography.

INTRODUCTION: Systemic lupus erythematosus (SLE) is an inflammatory disease which affects multiple organs. The respiratory system is compromised in 1.6% to 36% of the patients with SLE. The objective of this study was to know the prevalence of these alterations, their associated variables, and outcomes in patients with SLE between 2012 and 2017. METHODS: A cross-sectional study of 200 patients with SLE underwent chest computed tomography (CT). The primary outcome was acute respiratory involvement (ARI). A descriptive, bivariate and multivariate analysis were performed using Stata 12.0 software. RESULTS: ARI was present in 40% of the SLE patients undergoing chest CT. The most frequent ARI was pleural effusion in 33%, followed by pneumonia (16.5%), lupus pneumonitis (9%), pulmonary embolism (3%) and pulmonary hemorrhage (2.5%). In bivariate and multivariate analysis a statistically significant association between ARI and nephropathy, hematological impairment, active disease, dead, readmission and prolonged hospital stay was found. CONCLUSION: This is the first Colombian study that evaluates ARI in patients with SLE. ARI is an important and frequent condition in patients with SLE, pleural effusion being the most prevalent cause of ARI. There are some variables (nephropathy, hematological impairment and activity disease) that are associated with ARI and could be the basis of intervention.

Signo de Chilaiditi como hallazgo incidental en un paciente con enfermedad respiratoria: reporte de caso / Chilaiditi sign as an incidental finding in a patient with respiratory disease: a case report

Resumen El signo de Chilaiditi es un hallazgo radiográfico infrecuente que consiste en la interposición de un asa intestinal entre el hígado y el diafragma. No existe etiología claramente establecida; sin embargo, se han planteado varias hipótesis que explican su presencia, entre ellos la hiperlaxitud de los ligamentos suspensorios del hígado, el aumento de la presión intraabdominal y la redundancia colónica. Al asociarse este hallazgo con síntomas gastrointestinales o respiratorios se denomina síndrome de Chilaiditi, y su tratamiento principalmente es sintomático, en casos excepcionales requiere abordaje quirúrgico. Este signo se encuentra usualmente de manera incidental y se ha visto una relación con enfermedad respiratoria crónica; pudiendo afectar su curso clínico, motivando a profundizar en el estudio integral. Se presenta el caso de un paciente adulto mayor, en seguimiento médico por enfermedad pulmonar obstructiva crónica, cuya radiografía de tórax evidencia la interposición de un asa intestinal entre la cúpula diafragmática derecha y el hígado. MÉD.UIS. 2018;31(3):57-61.

Abstract The Chilaiditi sign is a rare radiographic finding, which consists in the interposition of an intestinal handle between the liver and the diaphragm. There is no clear etiology established, however, several hypotheses have been proposed to explain its presence, including the hyper-laxity of the liver suspensory ligaments, an increase on the intra-abdominal pressure and colonic redundancy. When this finding is associated with gastrointestinal or respiratory symptoms is called "Chilaiditi syndrome", and its treatment is mainly symptomatic; in exceptional cases a surgical approach is required. The Chilaiditi sign is usually an incidental finding, and a connection with chronic respiratory disease has been seen, and it could affect this pathology's clinical course, being this a motivation to deepen in an integral study. We present a case of an elder patient, being followed due to chronic obstructive pulmonary disease, whose chest X-ray shows interposition of an intestinal handle between the right diaphragmatic dome and the liver. MÉD.UIS. 2018;31(3):57-61.

Systemic lupus erythematosus, gender differences in Colombian patients.

The objective of this study was to compare the clinical and immunological presentation of SLE between males and females in a Colombian SLE population. A cross-sectional, retrospective study was performed that evaluated patients with SLE over 6 years. The dependent variables were systemic complications, duration of hospitalization, readmission, and death. Descriptive, group comparison, bivariate, and multivariate analysis were performed using Stata 12.0 software 200 patients were included in this study, 84.5% were females and 15.5% males. Longer hospitalizations, readmissions, respiratory compromise, higher activity disease (ECLAM score), smoking, and use of cyclophosphamide in the past 3 months were more prevalent in males. In the bivariate and multivariate analysis, we found an increased risk in males of respiratory symptoms (OR 3.35), anti-DNA antibody (OR 2.46), smoking (OR 4.2), cyclophosphamide use (OR 3.23), chronic pulmonary alterations (OR 2.51), readmission (OR 2.88), long hospitalization (OR 3.12), and death (OR: 3.31). This is the first study that shows the differences related to gender in Colombian SLE patients. Males with SLE have more disease activity compare with females. Also, we found that males have more risk of pulmonary impairment, longer hospitalizations, hospital readmissions, and deaths.

Hemoptisis relacionada a una aspergilosis pulmonar cavitaria cónica: presentación de un caso / Hemoptysis related to chronic cavitary aspergillosis of the lung: case report

RESUMEN Introducción: la aspergilosis pulmonar crónica es una patología infrecuente, su prevalencia aumenta en asociación con alteraciones estructurales, esto resalta la importancia de su conocimiento teniendo en cuenta la elevada incidencia de tuberculosis en Colombia. Por el carácter angioinvasivo del hongo la posibilidad de desarrollar hemoptisis es alta, pudiendo llegar a comprometer la vida de quien la padece. Objetivo: estudiar la forma de presentación y abordaje diagnóstico de la aspergilosis y su asociación con secuelas de tuberculosis pulmonar. Presentación de caso: se presenta el caso de un paciente masculino de 44 años, con secuelas pulmonares por tuberculosis, que requirió hospitalización por hemoptisis recurrente; con hallazgos imagenológicos sugestivos de aspergilosis pulmonar, requirió estabilización clínica, embolización arterial selectiva y resección de la lesión. Conclusión: la aspergilosis es una enfermedad inusual y se requiere de la integración de aspectos clínicos e imagenológicos representativos para hacer un diagnóstico acertado. MÉD.UIS. 2017;30(1):79-86.

ABSTRACT Introduction: the chronic pulmonary aspergillosis is an uncommon condition, its prevalence increases in association with structural alterations, this highlights the importance of its knowledge bearing in mind the high incident of tuberculosis in Colombia. for the angioinvasive behavior of the fungus, the possibility of developing hemoptysis is high even life threatening. Objective: to study the form of presentation and diagnostic approach of the aspergilosis and his association with sequels of pulmonary tuberculosis. Case Report: we present a case of a 44-year-old masculine patient, with pulmonary sequels for tuberculosis who required hospitalization because of recurring hemoptysis; some imagenologic findings were found suggesting of pulmonary aspergillosis, he required clinical stabilization, selective arterial embolization and finally resection of the lesion. Conclusion: the aspergillosis is an unusual disease and requires integration of non-accurate clinical aspects and some representative imagenologic findings to make a proper diagnostic. MÉD.UIS. 2017;30(1):79-86.