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1.
BMC Infect Dis ; 20(1): 817, 2020 Nov 10.
Artículo en Inglés | MEDLINE | ID: mdl-33167878

RESUMEN

BACKGROUND: Gastrointestinal (GI) mucormycosis is a rare and often deadly form of mucormycosis. Delayed diagnosis can lead to an increased risk of death. Here, we report a case of GI mucormycosis following streptococcal toxic shock syndrome in a virologically suppressed HIV-infected patient. CASE PRESENTATION: A 25-year-old Thai woman with a well-controlled HIV infection and Grave's disease was admitted to a private hospital with a high-grade fever, vomiting, abdominal pain, and multiple episodes of mucous diarrhea for 3 days. On day 3 of that admission, the patient developed multiorgan failure and multiple hemorrhagic blebs were observed on all extremities. A diagnosis of streptococcal toxic shock was made before referral to Siriraj Hospital - Thailand's largest national tertiary referral center. On day 10 of her admission at our center, she developed feeding intolerance and bloody diarrhea due to bowel ischemia and perforation. Bowel resection was performed, and histopathologic analysis of the resected bowel revealed acute suppurative transmural necrosis and vascular invasion with numerous broad irregular branching non-septate hyphae, both of which are consistent with GI mucormycosis. Peritoneal fluid fungal culture grew a grayish cottony colony of large non-septate hyphae and spherical sporangia containing ovoidal sporangiospores. A complete ITS1-5.8S-ITS2 region DNA sequence analysis revealed 100% homology with Rhizopus microsporus strains in GenBank (GenBank accession numbers KU729104 and AY803934). As a result, she was treated with liposomal amphotericin B. However and in spite of receiving appropriate treatment, our patient developed recurrent massive upper GI bleeding from Dieulafoy's lesion and succumbed to her disease on day 33 of her admission. CONCLUSION: Diagnosis of gastrointestinal mucormycosis can be delayed due to a lack of well-established predisposing factors and non-specific presenting symptoms. Further studies in risk factors for abdominal mucormycosis are needed.


Asunto(s)
Tracto Gastrointestinal/microbiología , Enfermedad de Graves/complicaciones , Infecciones por VIH/complicaciones , Mucormicosis/complicaciones , Rhizopus/genética , Choque Séptico/complicaciones , Infecciones Estreptocócicas/complicaciones , Streptococcus pyogenes/aislamiento & purificación , Adulto , Anfotericina B/uso terapéutico , Antifúngicos/uso terapéutico , ADN de Hongos/genética , Resultado Fatal , Femenino , Infecciones por VIH/virología , Humanos , Mucormicosis/diagnóstico , Mucormicosis/tratamiento farmacológico , Mucormicosis/microbiología , Choque Séptico/diagnóstico , Choque Séptico/microbiología , Infecciones Estreptocócicas/diagnóstico , Infecciones Estreptocócicas/microbiología , Síndrome , Tailandia
3.
Pan Afr Med J ; 35(Suppl 2): 141, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-33193956

RESUMEN

Novel coronavirus 2019 (COVID-19) is a severe respiratory infection leading to acute respiratory distress syndrome [ARDS] accounting for thousands of cases and deaths across the world. Several alternatives in treatment options have been assessed and used in this patient population. However, when mechanical ventilation and prone positioning are unsuccessful, venovenous extracorporeal membrane oxygenation [VV-ECMO] may be used. We present a case of a 62-year-old female, diabetic, admitted to the intensive care unit with fever, flu-like symptoms and a positive COVID-19 test. Ultimately, she worsened on mechanical ventilation and prone positioning and required VV-ECMO. The use of VV-ECMO in COVID-19 infected patients is still controversial. While some studies have shown a high mortality rate despite aggressive treatment, such as in our case, the lack of large sample size studies and treatment alternatives places healthcare providers against a wall without options in patients with severe refractory ARDS due to COVID-19.


Asunto(s)
Betacoronavirus , Terapia de Reemplazo Renal Continuo/métodos , Infecciones por Coronavirus/complicaciones , Enfermedad Crítica , Oxigenación por Membrana Extracorpórea/instrumentación , Neumonía Viral/complicaciones , Lesión Renal Aguda/etiología , Lesión Renal Aguda/terapia , Antibacterianos/uso terapéutico , Antivirales/uso terapéutico , Bacteriemia/complicaciones , Terapia Combinada , Terapia de Reemplazo Renal Continuo/instrumentación , Infecciones por Coronavirus/tratamiento farmacológico , Enfermedad Crítica/terapia , Síndrome de Liberación de Citoquinas/etiología , Diabetes Mellitus Tipo 2/complicaciones , Resultado Fatal , Femenino , Infecciones por Bacterias Grampositivas/complicaciones , Humanos , Persona de Mediana Edad , Marruecos , Pandemias , Respiración Artificial , Síndrome de Dificultad Respiratoria del Adulto/etiología
4.
BMJ Case Rep ; 13(10)2020 Oct 31.
Artículo en Inglés | MEDLINE | ID: mdl-33130584

RESUMEN

During the global pandemic of COVID-19 accurate diagnosis of the infection by demonstrating SARS-CoV-2 viral RNA by PCR in specimens is crucial for therapeutic and preventative interventions. There have been instances where nasal and throat swabs have been negative despite the patient having typical clinical and radiological findings compatible with the disease. We report a case of a man in his late 50s, brought to the hospital following a cardiac arrest and prolonged unsuccessful resuscitation. The history was typical for COVID-19 with fever for 10 days and worsening shortness of breath. His throat and nasal swabs (after death) were negative for SARS-CoV-2. A limited diagnostic autopsy was performed after 27 days, and lung swabs confirmed presence of SARS-CoV-2. This case highlights the importance of lung swabs when initial upper respiratory tract swabs are negative and proves that the virus can be detected from dead human tissue almost a month later.


Asunto(s)
Técnicas de Laboratorio Clínico/métodos , Infecciones por Coronavirus/diagnóstico , ADN Viral/análisis , Pulmón/virología , Paro Cardíaco Extrahospitalario/terapia , Faringe/virología , Neumonía Viral/diagnóstico , Autopsia , Reanimación Cardiopulmonar/métodos , Servicio de Urgencia en Hospital , Reacciones Falso Negativas , Resultado Fatal , Humanos , Masculino , Persona de Mediana Edad , Pandemias , Reacción en Cadena de la Polimerasa/métodos
5.
J Infect Dev Ctries ; 14(10): 1138-1145, 2020 Oct 31.
Artículo en Inglés | MEDLINE | ID: mdl-33175709

RESUMEN

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic is spreading rapidly. Critically ill cases of COVID-19 can rapidly progress to acute respiratory distress syndrome and multiple organ failures. However, no effective drugs have been available till now, leading to more than 300,000 deaths up to 29 April 2020. Here, we present a critically ill case utilizing umbilical cord blood-derived mesenchymal stem cells (UCB-MSCs). CASE PRESENTATION: A 72-year-old man was admitted, with the diagnosis of COVID-19, ARDS, type-2 diabetes, diabetic nephropathy, renal insufficiency, and hypertension. His clinical condition continually developed to be life-threatening even receiving various treatment options including antiviral therapy and extracorporeal membrane oxygenation. Between 28 February and 8 March 2020, the patient was given 5-time intravenous infusions of UCB-MSCs. His hematological and biochemical indexes, including lymphocytes and renal function improved. Pulmonary static compliance increased significantly and PaO2/FiO2 ratio maintained stable. On March 10, he received lung transplantation. CONCLUSIONS: Our current findings suggested that UCB-MSCs therapy may show some positive effect in treating critical COVID-19 to some extent, for its delaying deterioration of the disease and efficacy in respiratory and renal function, though limited.


Asunto(s)
Infecciones por Coronavirus/terapia , Sangre Fetal/citología , Trasplante de Células Madre Mesenquimatosas , Neumonía Viral/terapia , Anciano , Betacoronavirus , Enfermedad Crítica , Resultado Fatal , Humanos , Trasplante de Pulmón , Masculino , Pandemias
6.
BMC Med Genet ; 21(1): 200, 2020 10 12.
Artículo en Inglés | MEDLINE | ID: mdl-33046013

RESUMEN

BACKGROUND: Dedifferentiated liposarcoma (DDLPS), which accounts for an estimated 15-20% of liposarcomas, is a high-grade and aggressive malignant neoplasm, exhibiting a poor response to available therapeutic agents. However, genetic alteration profiles of DDLPS as well as the role of NF1 mutations have not been studied extensively. CASE PRESENTATION: The current study reports a patient presenting with rapidly growing DDLPS accompanied by multiple lung and pleural metastases, in whom whole-exome sequencing revealed a NF1 truncating mutation of the known pathogenic variant, c.C7486T, p.R2496X, as well as multiple copy number alterations (CNAs), including the well-known 12q13-15 amplification, and multiple chromothripsis events encompassing potential cancer-related genes. CONCLUSIONS: Our results suggest that, in addition to the 12q13-15 amplification, NF1 inactivation mutation and other CNAs may contribute to DDLPS tumorigenesis accompanied by aggressive clinical features.


Asunto(s)
Variaciones en el Número de Copia de ADN , Liposarcoma/genética , Neoplasias Pulmonares/genética , Mutación , Neurofibromina 1/genética , Anciano de 80 o más Años , Resultado Fatal , Humanos , Liposarcoma/patología , Liposarcoma/cirugía , Neoplasias Pulmonares/secundario , Masculino , Secuenciación del Exoma Completo/métodos
7.
Medicine (Baltimore) ; 99(42): e22793, 2020 Oct 16.
Artículo en Inglés | MEDLINE | ID: mdl-33080751

RESUMEN

RATIONALE: Thrombocytepenia, anasarca, fever, renal insufficiency, and organomegaly (TAFRO) syndrome is a novel disease entity characterized by a constellation of symptoms (thrombocytopenia, anasarca, fever, renal insufficiency, and organomegaly). Here, we describe the development of TAFRO syndrome-like features during the treatment of rheumatoid arthritis with a Janus kinase (JAK) inhibitor. PATIENT CONCERNS: In this report, a 74-year-old woman treated with a JAK inhibitor (tofacitinib) for rheumatoid arthritis was admitted because of fever and thrombocytopenia. DIAGNOSES: On laboratory examination, marked thrombocytopenia and elevated creatinine and C-reactive protein levels were present. A computed tomography scan revealed lymphadenopathy, hepato-splenomegaly, and anasarca. A left axillary lymph node biopsy revealed Castleman's disease-like features. These clinical features satisfied the proposed diagnostic criteria for TAFRO syndrome. Since autoimmune disorders should be excluded when diagnosing TAFRO syndrome, it is not strictly correct to diagnose her as TAFRO syndrome. Therefore, we diagnosed her as rheumatoid arthritis complicated by TAFRO syndrome-like features. INTERVENTIONS: The patient was treated with high-dose glucocorticoid, tacrolimus, eltrombopag, intravenous immunoglobulin, and rituximab. OUTCOMES: Her condition was refractory to the above-mentioned treatment, and she eventually died because of multi-organ failure 6 months after the first admission. LESSONS: TAFRO syndrome-like features can develop during treatment with a JAK inhibitor for rheumatoid arthritis. Patients with autoimmune diseases complicated by TAFRO syndrome-like features can follow a fatal clinical course, and thus, an intensive combined treatment is warranted for such patients, especially in cases refractory to glucocorticoid.


Asunto(s)
Artritis Reumatoide/tratamiento farmacológico , Enfermedad de Castleman/inducido químicamente , Inhibidores de las Cinasas Janus/efectos adversos , Piperidinas/efectos adversos , Pirimidinas/efectos adversos , Pirroles/efectos adversos , Trombocitopenia/inducido químicamente , Anciano , Resultado Fatal , Femenino , Humanos , Insuficiencia Multiorgánica/etiología
8.
J Coll Physicians Surg Pak ; 30(10): 112-114, 2020 10.
Artículo en Inglés | MEDLINE | ID: mdl-33115582

RESUMEN

Coronavirus disease-2019 (COVID-19) characteristics and clinical spectrum are currently evolving with the collaboration of clinicians.Arterial thromboembolic events due to COVID-19 are extremely rare; and all reported cases so far were of ischemic strokes and pulmonary embolism. In this case report,we present a case of superior mesenteric artery (SMA) thrombosis in a patient of COVID-19 pneumonia. To our knowledge, this is the first case that demonstrates acute mesenteric ischemia in a patient with COVID-19 pneumonia. Key Words: COVID-19, Mesenteric ischemia, Thrombosis.


Asunto(s)
Infecciones por Coronavirus/complicaciones , Arteria Mesentérica Superior , Neumonía Viral/complicaciones , Trombosis/etiología , Anciano de 80 o más Años , Betacoronavirus , Infecciones por Coronavirus/terapia , Resultado Fatal , Femenino , Humanos , Pandemias , Neumonía Viral/terapia , Trombosis/terapia
10.
J Card Surg ; 35(10): 2808-2810, 2020 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-33043653

RESUMEN

Hemorrhagic extension along the pulmonary arteries should be recognized as a complication of Stanford type A aortic dissection. Radiologists and other physicians with an interest in cardiothoracic imaging should be aware of this rare but life-threatening pathology. The anatomical concept of the pathology is outlined in this text, through high-quality electrocardiogram-gated computerized tomography images.


Asunto(s)
Aneurisma Disecante/complicaciones , Aneurisma Disecante/diagnóstico por imagen , Aneurisma de la Aorta/complicaciones , Aneurisma de la Aorta/diagnóstico por imagen , Electrocardiografía , Hematoma/diagnóstico por imagen , Hematoma/etiología , Arteria Pulmonar , Tomografía Computarizada por Rayos X/métodos , Anciano de 80 o más Años , Resultado Fatal , Femenino , Humanos , Arteria Pulmonar/diagnóstico por imagen , Negativa del Paciente al Tratamiento
11.
Medicine (Baltimore) ; 99(43): e22925, 2020 Oct 23.
Artículo en Inglés | MEDLINE | ID: mdl-33120847

RESUMEN

RATIONALE: Apatinib is a novel anti-angiogenic agent that targets vascular endothelial growth factor receptor-2, thereby inhibiting tumor angiogenesis, and is effective in the treatment of brain metastases (BM) and peritumoral brain edema (PTBE). There are no previous reports of combination therapy with apatinib and fractionated stereotactic radiotherapy (FSRT) for BM from primary lung mucoepidermoid carcinoma (MEC). PATIENT CONCERNS: A 63-year-old man underwent left lower lobectomy and mediastinal lymph node dissection in April 2018. DIAGNOSES: Postoperative pathology demonstrated high-grade MEC. The patient developed 3 BM with PTBE 3 months after undergoing surgery. INTERVENTIONS: The patient received a combination of FSRT and apatinib (250-500 mg/d) as maintenance therapy. OUTCOMES: The 3 BM showed nearly complete responses, and the PTBE areas shrank visibly. A new BM lesion occurred 7 months after the first FSRT and was treated with a second dose of FSRT. The patient developed extensive metastasis and atelectasis 9 months later. He died of pulmonary infection in December 2019. The overall survival time was 20 months. LESSONS: Limited BM from primary lung MEC may be treated effectively with combination therapy with apatinib and FSRT when chemotherapy alone is not effective or tolerated. Further studies are needed to investigate the clinical outcomes and toxicities associated with the treatment.


Asunto(s)
Neoplasias Encefálicas/secundario , Neoplasias Encefálicas/terapia , Inhibidores de Proteínas Quinasas/uso terapéutico , Piridinas/uso terapéutico , Radiocirugia/métodos , Edema Encefálico/terapia , Carcinoma Mucoepidermoide/complicaciones , Carcinoma Mucoepidermoide/cirugía , Terapia Combinada , Resultado Fatal , Humanos , Neoplasias Pulmonares/patología , Masculino , Persona de Mediana Edad , Clasificación del Tumor/métodos , Inhibidores de Proteínas Quinasas/administración & dosificación , Piridinas/administración & dosificación
12.
Medicine (Baltimore) ; 99(43): e22934, 2020 Oct 23.
Artículo en Inglés | MEDLINE | ID: mdl-33120850

RESUMEN

INDUCTION: Liver transplantation (LT) is the only final therapy for patients with acute liver failure (ALF) that cannot be controlled by conservative treatment. Acute pancreatitis (AP) is a recognized complication of ALF. The pathogenesis of AP in ALF patients has not yet been elucidated. The appearance of AP complicates the patients condition and causes a significantly increased risk of mortality. PATIENT CONCERNS: We report 2 fatal cases who were both admitted with yellowing of skin and sclera with general weakness lasting for 2 weeks. DIAGNOSIS: After admission, the laboratory examination of case 1 showed liver dysfunction with serum levels of total bilirubin (TB) 270 µmol/l, alanine aminotransferase (ALT) 106 U/l. Abdominal computed tomography (CT) showed pelvic and peritoneal cavity fluids, occupation of left lateral lobe of liver and unclear margin of pancreas. The clinical laboratory findings of case 2 revealed TB 351.1 µmol/l, ALT 252 U/l, blood lactic acid 18 mmol/l, ammonia 209 µmol/l. And abdominal CT showed pancreatic exudation. They were both diagnosed with acute liver failure, hepatic encephalopathy and AP which was confirmed during the operation. INTERVENTIONS: They were both received a routine orthotopic LT. OUTCOMES: After the surgery, their liver functions recovered well, and they received conventional conservative treatment for pancreatitis. However, the treatment was not adequately effective, and the infection was too serious and both died of multiple organ failure despite emergency rescue efforts on day 21 and day 19 after LT. CONCLUSION: AP is a serious complication that can contribute to prohibitive morbidity and mortality in LT patients. For this reason, the vulnerable state of the pancreas and the scoring system must be defined to help clinicians decide whether a patient is suitable for liver transplantation, and the clinical experience in the treatment of pancreatitis after LT needs to be summarized as an optimal treatment guideline to facilitate better treatment.


Asunto(s)
Fallo Hepático Agudo/etiología , Fallo Hepático Agudo/terapia , Trasplante de Hígado/mortalidad , Pancreatitis/complicaciones , Anciano , Alanina Transaminasa/sangre , Bilirrubina/sangre , Tratamiento Conservador/métodos , Resultado Fatal , Encefalopatía Hepática/diagnóstico , Humanos , Periodo Intraoperatorio , Masculino , Persona de Mediana Edad , Pancreatitis/diagnóstico , Pancreatitis/terapia , Pronóstico , Tomógrafos Computarizados por Rayos X
13.
Medicine (Baltimore) ; 99(42): e22509, 2020 Oct 16.
Artículo en Inglés | MEDLINE | ID: mdl-33080685

RESUMEN

INTRODUCTION: Proton pump inhibitors (PPIs) are widely prescribed and generally well tolerated but can rarely cause severe allergic reactions, such as drug rash with eosinophilia and systemic symptoms (DRESS). We report a case of DRESS and renal injury induced by PPIs, and describe the therapeutic process. PATIENT CONCERNS: The patient was a 66-year-old female who complained of fever, pruritus, desquamation, erythema multiforme, and anuria caused by omeprazole taken for 2 weeks to treat abdominal distention. DIAGNOSIS: The clinical history revealed a similar episode of PPI-induced fever, eosinophilia, and acute kidney injury more than 1 year ago. The present laboratory tests revealed eosinophilia and oliguric renal failure. The renal biopsy was performed subsequently and proved the diagnosis of PPI-induced DRESS. INTERVENTIONS: After the suspected diagnosis of PPI-induced DRESS, omeprazole was discontinued and methylprednisolone infusion (40 mg qd) was initiated. Because of oliguric renal failure, the patient received intermittent hemodialysis. OUTCOMES: The patient initially responded to omeprazole discontinuation, hemodialysis, and glucocorticoids but later died from severe infection during the tapering of glucocorticoid therapy. CONCLUSION: Clinicians should remain on high alert for potential life-threatening complications when prescribing PPIs. If unexplained renal injury develops in a patient taking a PPI, renal biopsy may help in identifying the pathogenesis and might facilitate timely intervention.


Asunto(s)
Lesión Renal Aguda/inducido químicamente , Síndrome de Hipersensibilidad a Medicamentos/etiología , Omeprazol/efectos adversos , Inhibidores de la Bomba de Protones/efectos adversos , Anciano , Resultado Fatal , Femenino , Humanos
14.
Pan Afr Med J ; 36: 286, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-33117480

RESUMEN

With the major spread of SARS-COV-2 around the world, its association with various pathologies has been reported. However, hemopathy has rarely been revealed during a coronavirus infection. The authors of this article aim to emphasize the diagnostic and therapeutic challenges faced while treating COVID/hemopathy patients.


Asunto(s)
Betacoronavirus , Infecciones por Coronavirus/diagnóstico , Leucemia Linfocítica Crónica de Células B/diagnóstico , Neumonía Viral/diagnóstico , Anciano , Infecciones por Coronavirus/sangre , Infecciones por Coronavirus/complicaciones , Resultado Fatal , Humanos , Hallazgos Incidentales , Masculino , Pandemias , Neumonía Viral/sangre , Neumonía Viral/complicaciones , Evaluación de Síntomas
15.
Sarcoidosis Vasc Diffuse Lung Dis ; 37(2): 231-233, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-33093788

RESUMEN

Background: A subgroup of patients with fibrotic ILD experience progression and several risk factors for ILD progression have been reported, such as male sex, older age, lower baseline pulmonary function, and a radiological or pathological pattern of usual interstitial pneumonia. Objective: To describe a possible new phenotype of rapidly non IPF progressive fibrosing with an IPF-like outcome. Methods: Three previously fit and well patients who developed a rapidly progressive ILD and died within 6 to 7 months from the initial development of respiratory symptoms. Results: Unlike what is currently known, our patients developed a severe fibrosing ILD with an IPF-like outcome despite a) being younger than the average patient with IPF, b) having received a non-IPF MDT diagnosis, c) having a non-UIP pattern on HRCT. Moreover and similarly to IPF, they failed to respond to immunosuppressive treatment which is the preferred treatment option in these cases. Conclusion: We believe that patients who present with similar characteristics should be considered as likely to develop a phenotype of rapidly progressive ILD and be treated with antifibrotic medications instead of immunosuppressive ones according to the favourable treatment response to antifibrotic therapy observed in clinical trials of patients with progressive fibrosing ILDs. (Sarcoidosis Vasc Diffuse Lung Dis 2020; 37 (2): 231-233).


Asunto(s)
Enfermedades Pulmonares Intersticiales/diagnóstico , Pulmón/diagnóstico por imagen , Fibrosis Pulmonar/diagnóstico , Tomografía Computarizada por Rayos X , Adulto , Antibacterianos/uso terapéutico , Progresión de la Enfermedad , Resultado Fatal , Volumen Espiratorio Forzado , Humanos , Inmunosupresores/uso terapéutico , Pulmón/efectos de los fármacos , Pulmón/inmunología , Pulmón/fisiopatología , Enfermedades Pulmonares Intersticiales/tratamiento farmacológico , Enfermedades Pulmonares Intersticiales/inmunología , Enfermedades Pulmonares Intersticiales/fisiopatología , Masculino , Persona de Mediana Edad , Fenotipo , Fibrosis Pulmonar/tratamiento farmacológico , Fibrosis Pulmonar/inmunología , Fibrosis Pulmonar/fisiopatología , Índice de Severidad de la Enfermedad , Factores de Tiempo , Insuficiencia del Tratamiento , Capacidad Vital
16.
Rev. esp. enferm. dig ; 112(10): 784-787, oct. 2020. ilus, tab
Artículo en Inglés | IBECS | ID: ibc-194291

RESUMEN

COVID-19 is associated with severe coagulopathy. We present three cases of colonic ischemia that can be attributed to the hypercoagulable state related with SARS-CoV2 and disseminated intravascular coagulation. Three males aged 76, 68 and 56 with respiratory distress presented episodes of rectal bleeding, abdominal distension and signs of peritoneal irritation. Endoscopy (case 1) and computed tomography angiography revealed colonic ischemia. One patient (case 2) in which a computed tomography (CT) scan showed perforation of the gangrenous cecum underwent surgery. D-dimer levels were markedly increased (2,170, 2,100 and 7,360 ng/ml) in all three patients. All three patients died shortly after diagnosis


No disponible


Asunto(s)
Humanos , Masculino , Persona de Mediana Edad , Anciano , Infecciones por Coronavirus/complicaciones , Neumonía Viral/complicaciones , Pandemias , Colitis Isquémica/virología , Infecciones por Coronavirus/diagnóstico , Neumonía Viral/diagnóstico , Colitis Isquémica/diagnóstico , Resultado Fatal , Índice de Severidad de la Enfermedad
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