[Upper limb deep venous thrombosis. Risk factors, outcome, and posthrombotic syndrome]. / Trombosis venosa profunda de miembros superiores. Factores de riesgo, evolución y síndrome postrombótico.

OBJECTIVE: Our objective was that of describing a series of episodes of upper limb deep venous thrombosis, with special emphasis on the incidence of posthrombotic syndrome and its impact in the quality of life of the patients. METHODS: 33 episodes (29 patients) of upper limb deep venous thrombosis were studied, between January 1995 and January 2002; episodes until September 1999 (18 episodes) were considered retrospectively while those which took place starting in this date (15 episodes) were considered prospectively. In all, 24 patients were cared in hospital clinic. It was possible to obtain complete data in 16 cases, in which evolution toward posthrombotic syndrome, venous revascularization, and impact of the pathological process in the global quality of life of patients were studied. RESULTS: Average age of patients was 58.9 years. In 25 episodes (75.8%) some risk factor for venous thrombosis existed, the presence of a venous catheter being the most frequent. Subclavian axillary affectation was predominant (18 episodes, 55%) and in the left side (25 episodes, 76%). Twenty-eight episodes were diagnosed with echography (84.8%). Mean D-dimers concentration (N = 16) was 1,046 ng/ml (standard deviation [SD]: 826.9). One of the episodes (3%) was associated to lung thromboembolism. Treatment consisted on the administration of low molecular weight heparin during the acute phase in 70% of the cases. In 13 episodes (39%) additional treatment of thrombosis (endovascular in most) was carried out. In 29 episodes (88%) chronic treatment was administered with acenocoumarol, while in 4 episodes (12%) the administration of low molecular weight heparin was kept. No patient died during hospitalization. In 15 patients (52%) control of revascularizacion was performed. We detected complete revascularization in 6 patients (40%), revascularization with collateral circulation in 4 patients (27%), partial revascularization in other 4 patients (27%) and presence of permeability but with expansion and tortuosity of deep venous system in 1 case (6%). Posthrombotic syndrome was considered mild or nonexistent in 10 patients (62.5%) and moderate in 6 patients (37.5%). Quality of life of patients with moderate posthrombotic syndrome was significantly worse than that of patients with mild posthrombotic syndrome (73 vs 90, p < 0.035). CONCLUSIONS: Most of upper limb deep venous thrombosis are associated to the use of intravenous catheters. Echography is the primary diagnostic technique. At the time of the diagnosis, patients tend to show elevation in D-dimers levels. Evolution toward posthrombotic syndrome is frequent; this syndrome does not use to be serious but indeed influences the quality of life of patients.

Trombosis venosa profunda de miembros superiores. Factores de riesgo, evolución y síndrome postrombótico / Upper limb deep venous thrombosis

Objetivo. Nos propusimos describir una serie de episodios de trombosis venosa profunda de miembro superior, con especial énfasis en la incidencia posterior de síndrome postflebítico y surepercusión en la calidad de vida de los pacientes. Métodos. Se estudiaron 33 episodios (29 pacientes) de trombosis venosa profunda del miembro superior entre enero de 1995 y enero de 2002, incluidos retrospectivamente hasta septiembre de 1999 (18 episodios) y prospectivamente a partir de esta fecha (15 episodios). Se analizaron los factores de riesgo, la clínica, los procedimientos diagnósticos y el tratamiento administrado. Fueron controlados en la policlínica24 pacientes. Se dispuso de datos completos evaluables en16 casos, estudiándose la evolución a síndrome postflebítico, la repermeabilización venosa y la repercusión del proceso en la calidad de vida global de los pacientes. Resultados. La edad media fue de 58,9 años. En 25 episodios(75,8%) se apreció algún factor de riesgo para trombosisvenosa, siendo el más frecuente la presencia de un catéter venoso. Predominó la afectación axilosubclavia (18 episodios,55%) y del lado izquierdo (25 episodios, 76%). Veintiocho episodios (84,8%) se diagnosticaron con ecografía. La media de los niveles de D-dímeros (n=16) fue de 1.046 ng/ml.(DE: 862,9). En un episodio (3%) se asoció tromboembolismo pulmonar. El 70% de los casos se trató con heparina de bajo peso molecular en la fase aguda. En 13 episodios (39%) se practicó tratamiento adicional de la trombosis (endovascularla mayoría). En 29 episodios (88%) se administró tratamiento crónico con acenocumarol y en 4 (12%) se continuó con heparina de bajo peso molecular. No falleció ningún paciente durante el ingreso hospitalario. Se practicó control de repermeabilización en15 pacientes (52%). Detectamos repermeabilización completa en6 pacientes (40%), repermeabilización con circulación colateral en 4 (27%), repermeabilización parcial en otros 4 pacientes(27%) y eje permeable pero con dilatación y tortuosidad del sistema venoso profundo en un caso (6%). El síndrome postflebítico se clasificó como leve o ausente en 10 pacientes(62,5%) y moderado en 6 (37,5%). La calidad de vida de los pacientes con síndrome posflebítico moderado fue significativamente peor que la de los pacientes con síndrome postflebítico leve (73 frente a 90, p<0,035).Conclusiones. Las trombosis venosas profundas de miembros superiores más frecuentes se asocian al uso de catéteres intravenosos. La ecografía es la técnica diagnóstica predominante. Los D-dímeros se elevan al diagnóstico. La evolución a síndrome postflebítico es frecuente, pero éste no suele ser grave. aunque sí repercute en la calidad de vida de los pacientes

Objective. Our objective was that of describing a series of episodes of upper limb deep venous thrombosis, with special emphasis on the incidence of posthrombotic syndrome and its impact in the quality of life of the patients. Methods. 33 episodes (29 patients) of upper limb deep venous thrombosis were studied, between January 1995 and January2002; episodes until September 1999 (18 episodes) were considered retrospectively while those which took place starting in this date (15 episodes) were considered prospectively. In all,24 patients were cared in hospital clinic. It was possible to obtain complete data in 16 cases, in which evolution toward posthrombotic syndrome, venous revascularization, and impact of the pathological process in the global quality of life of patients were studied. Results. Average age of patients was 58.9 years. In25 episodes (75.8%) some risk factor for venous thrombosis existed, the presence of a venous catheter being the most frequent. Subclavian axillary affectation was predominant(18 episodes, 55%) and in the left side (25 episodes, 76%).Twenty-eight episodes were diagnosed with echography (84.8%).Mean D-dimers concentration (N = 16) was 1,046 ng/ml(standard deviation [SD]: 826.9). One of the episodes (3%) was associated to lung thromboembolism. Treatment consisted on the administration of low molecular weight heparin during the acute phase in 70% of the cases. In 13 episodes (39%)additional treatment of thrombosis (endovascular in most)was carried out. In 29 episodes (88%) chronic treatment was administered with acenocoumarol, while in 4 episodes (12%)the administration of low molecular weight heparin was kept. No patient died during hospitalization. In 15 patients (52%)control of revascularización was performed. We detected complete revascularization in 6 patients (40%),revascularization with collateral circulation in 4 patients (27%),partial revascularization in other 4 patients (27%) and presence of permeability but with expansion and tortuosity of deep venous system in 1 case (6%). Posthrombotic syndrome was considered mild or nonexistent in 10 patients (62.5%) and moderate in 6 patients (37.5%). Quality of life of patients with moderate posthrombotic syndrome was significantly worse than that of patients with mild posthrombotic syndrome (73 vs 90,p<0,035).Conclusions. Most of upper limb deep venous thrombosis are associated to the use of intravenous catheters. Echography is the primary diagnostic technique. At the time of the diagnosis, patients tend to show elevation in D-dimers levels. Evolution toward posthrombotic syndrome is frequent; this syndrome does not use to be serious but indeed influences the quality of life of patients

[Malaria. Analysis of 31 cases (1993-2002)]. / Paludismo. Análisis de 31 casos (1993-2002).

The objective of this work is the study of malaria in the population of our hospital area. The characteristics of 31 cases of imported malaria diagnosed in the University Hospital La Fe of Valencia are described. The study included the period between 1993 and 2002. The predominance of males (81%), of the age group of 20-40 years (average: 37.68), and of the patients native from African countries (all except for a patient from Ecuador) of which 40% came from Equatorial Guinea, were outstanding results. The most prevalent species was Plasmodium falciparum (72%). Only 12.9% of the patients received antimalarial prophylaxis with mefloquine, without appropriate compliance. Malaria continues to be the most important protozoan infection in the world, and currently a possible reintroduction of this infection is observed in Spain. That is why is necessary to improve the information offered to the tourists who visit tropical countries. The clinical suspicion is also essential in patients who come from endemic areas.

[Antiphospholipid syndrome. The use of transesophageal echocardiography]. / Síndrome antifosfolípido. Utilidad de la ecocardiografía transesofágica.

Antiphospholipid syndrome (APS) is defined by the presence of arterial and venous thromboses, recurrent fetal death, cerebrovascular accidents, hemolytic anaemia, thrombocytopenia and various other manifestations in different organs. APS is a clinical entity that can appear commonly alongside systemic lupus erithemathous on it can occur as a primary disease. The syndrome is defined by the presence of antiphospholipid antibodies in serum, a group of immunoglobulins (IgG, IgM, IgA or an mixture of them) that adopt an hexagonal configuration when they are incubated at 37grades C. In APS, it is rather common to find cardiac lesions such as non-verrucous endocarditis, valvular lesions (especially of the mitral valve), microvascular cardiac disease and more risk of thrombosis at this level, myxomas that could be the cause of a systemic inflammation in relation to the production of antiphospholipid antibodies, intracardiac thrombii and congenital heart disease. We present the case of a woman with APS associated with interauricular communication whose initial diagnosis were pulmonary thromboembolism and cerebrovascular stroke. We were able to diagnose the cardiac abnormality by the use of transesophagic echocardiography. We propose the use of this imaging technique for patients with APS even though the transthoracic Doppler echocardiography was found to be normal. In this way we will be able to rule out cardiac lesions which could also be the cause of embolic manifestations.

Síndrome antifosfolípido. Utilidad de la ecocardiografía transesofágica / Antiphospholipid syndrome. The use of transesophagic echocardiography

El síndrome antifosfolípido (SAF) es una alteración inmune que produce trombosis venosas y arteriales, accidente cerebrovascular, aborto recurrente, anemia hemolítica, trombopenia y un sinfín de manifestaciones de órgano. El SAF es una entidad asociada en ocasiones al lupus eritematoso sistémico pudiendo también ser detectado sin enfermedad subyacente de base. El trastorno es debido a la presencia de unas inmunoglobulinas (IgG, IgA, IgM o una combinación de ellas) que adoptan una configuración hexagonal cuando se incuban a 37º. En el SAP es relativamente frecuente encontrar lesiones cardiacas como endocarditis no verrugosa, lesiones valvulares (especialmente de la válvula mitral), enfermedad microvascular cardiaca y mayor riesgo de trombosis a este nivel, mixomas que pueden inducir una inflamación sistémica en relación a la producción de anticuerpos antifosfolípidos , trombos intracardiacos y cardiopatias congénitas. Presentamos el caso de una mujer con SAP asociado a comunicación interauricular que había debutado anteriormente con tromboembolismo pulmonar y accidente cerebrovascular y que pudo ser diagnosticada tras examen con ecografía transesofágica. Proponemos el examen con esta técnica en pacientes con SAP aunque la ecocardiografía con doppler sea normal. Así podremos descartar lesiones cardiacas que puedan además ser causa de fenómenos embolígenos (AU)

Antiphospholipid syndrome (APS) is defined by the presence of arterial and venous thromboses, recurrent fetal death, cerebrovascular accidents, hemolytic anaemia, thrombocytopenia and various other manifestations in different organs. APS is a clinical entity that can appear commonly alongside systemic lupus erithemathous on it can occur as a primary disease. The syndrome is defined by the presence of antiphospholipid antibodies in serum, a group of immunoglobulins (IgG, IgM, IgA or an mixture of them) that adopt an hexagonal configuration when they are incubated at 37 ºC. In APS, it is rather common to find cardiac lesions such as non-verrucous endocarditis, valvular lesions (especially of the mitral valve), microvascular cardiac disease and more risk of thrombosis at this level, myxomas that could be the cause of a systemic inflammation in relation to the production of antiphospholipid antibodies, intracardiac thrombii and congenital heart disease. We present the case of a woman with APS associated with interauricular communication whose initial diagnosis were pulmonary thromboembolism and cerebrovascular stroke. We were able to diagnose the cardiac abnormality by the use of transesophagic echocardiography. We propose the use of this imaging technique for patients with APS even though the transthoracic Doppler echocardiography was found to be normal. In this way we will be able to rule out cardiac lesions which could also be the cause of embolic manifestations (AU)

[Stevens-Johnson syndrome associated with atypical pneumonia]. / Stevens-Johnson syndrome associated with atypical pneumonia.

Stevens-Johnson syndrome is characterized by generalized exanthema associated with high fever, catarrhal symptoms and mucositis. Various etiologies have been implicated, particularly numerous medications and certain agents of atypical pneumonia. Stevens-Johnson syndrome leads to death in up to 5% of cases. We describe the case of a 30-year-old woman with bilateral atypical pneumonia accompanied by severe generalized exanthema that required hospitalization in the serious burns unit of our hospital. She was diagnosed with Stevens-Johnson syndrome following atypical pneumonia caused by Mycoplasma pneumoniae with microbiological and pathological confirmation.

Síndrome de Stevens-Johnson asociado a neumonía atípica / Stevens-Johnson syndrome associated with atypical pneumonia

El síndrome de Stevens-Johnson se caracteriza por un exantema generalizado asociado a fiebre alta, síntomas catarrales y mucositis. Ha sido relacionado con varias etiologías, entre las que destacan numerosos fármacos y algunos agentes productores de neumonías atípicas, y puede llegar a ser mortal hasta en el 5 por ciento de las ocasiones. Presentamos el caso de una paciente joven con una neumonía atípica bilateral que se acompañó de un exantema generalizado muy importante y requirió ingreso en la Unidad de Grandes Quemados de nuestro hospital. Fue diagnosticada de síndrome de Stevens-Johnson tras neumonía atípica por Mycoplasma pneumoniae con confirmación microbiológica y anatomopatológica (AU)

Displasia epifisaria múltiple familiar / Multiple familial epiphyseal dysplasia

Revisamos la displasia epifisaria múltiple familiar a propósito del caso de una mujer diagnosticada a los 38 años tras ingresar en el servicio de Neurología por un accidente cerebrovascular. Esta entidad es un trastorno hereditario autosómico dominante con gran variabilidad clínica. Es característica la aparición de deformidades progresivas e indoloras en las articulaciones de las manos, codos, caderas, rodillas y pies. Puede asociarse a alteraciones cardiopulmonares como la broncopatía obstructiva y defectos cardíacos congénitos (AU)

Lesión cutánea papuloeritematosa tras punción con acícula de pino en paciente en tratamiento corticoideo / Erythematous papules on the skin after pine needle puncture in a patient receiving corticoid treatment

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