[Fatal spotted fever in Salta province]. / Fiebre manchada de evolución fatal en la provincia de Salta.

We describe the case of a 17-year-old male patient living in Salta city who, 10 days after visiting a rural area in Salta province, was hospitalized for febrile seizures. Shortly after admission, he developed an exanthema followed by a multiple organ dysfunction that evolved to irreversible septic shock followed by death 48 hours after admission. Serological diagnosis -high IgM and IgG anti-Rickettsia spp. antibody titres as detected by indirect immunofluorescence- arrived post mortem. Spotted fever group rickettsioses are tick-borne diseases distributed worldwide and continue being under diagnosed in several countries mainly due to a low clinical suspicion. In the north-western provinces of Argentina there is also the limitation of not counting with a regional laboratory to perform the etiological diagnosis. This is crucial because the severe forms of the disease, which are commonly caused by R. rickettsii, have been already documented in the region. Given that spotted fevers have broadly unspecific febrile presentations and the components of the enzootic cycle are present even in geographic areas not yet considered to be endemic for tick borne diseases, their diagnosis should not be underestimated. If the adequate antibiotic treatment is administered timely, the prognosis of this group of life-threatening diseases improves drastically.

Fiebre manchada de evolución fatal en la provincia de Salta / Fatal spotted fever in Salta province

Describimos el caso de un varón de 17 años oriundo de la ciudad de Salta quien, 10 días después de visitar una zona rural de la provincia homónima, ingresó a nuestro hospital por convulsiones febriles. Durante la internación presentó exantema seguido de disfunción orgánica múltiple, la que evolucionó rápidamente hacia shock séptico irreversible y muerte a las 48 horas de su admisión. El diagnóstico serológico -altos títulos de IgM e IgG anti-Rickettsia spp. por inmunofluorescencia indirecta- arribó post mortem. Las rickettsiosis del grupo de las fiebres manchadas son transmitidas por garrapatas, tienen distribución global y en varios países continúan siendo subdiagnosticadas debido a una baja sospecha clínica. En las provincias del noroeste argentino se agrega la carencia de un laboratorio regional capacitado para efectuar el diagnóstico etiológico. Esta limitación es crítica porque en esa región del país ya ha sido documentada la presencia de las formas graves de la enfermedad, usualmente debidas a R. rickettsii. Dado que las fiebres manchadas se presentan como sindromes febriles inespecíficos y los componentes del ciclo enzoótico están presentes en vastas áreas geográficas, incluso en algunas aún no consideradas endémicas para rickettsiosis, su diagnóstico nunca debe ser subestimado. Con el tratamiento antibiótico adecuado instaurado en tiempo oportuno, el pronóstico de este grupo de enfermedades potencialmente mortales mejora en forma drástica.

We describe the case of a 17-year-old male patient living in Salta city who, 10 days after visiting a rural area in Salta province, was hospitalized for febrile seizures. Shortly after admission, he developed an exanthema followed by a multiple organ dysfunction that evolved to irreversible septic shock followed by death 48 hours after admission. Serological diagnosis -high IgM and IgG anti-Rickettsia spp. antibody titres as detected by indirect immunofluorescence- arrived post mortem. Spotted fever group rickettsioses are tick-borne diseases distributed worldwide and continue being under diagnosed in several countries mainly due to a low clinical suspicion. In the north-western provinces of Argentina there is also the limitation of not counting with a regional laboratory to perform the etiological diagnosis. This is crucial because the severe forms of the disease, which are commonly caused by R. rickettsii, have been already documented in the region. Given that spotted fevers have broadly unspecific febrile presentations and the components of the enzootic cycle are present even in geographic areas not yet considered to be endemic for tick borne diseases, their diagnosis should not be underestimated. If the adequate antibiotic treatment is administered timely, the prognosis of this group of life-threatening diseases improves drastically.

Suggested Cut-Off Values for Vitamin D as a Risk Marker for Total and Cardiac Death in Patients with Suspected Acute Coronary Syndrome.

BACKGROUND: Several studies have demonstrated an association between low vitamin D levels and cardiovascular risk. Vitamin D cut-off levels are still under debate. OBJECTIVES: To assess two cut-off levels, 40 and 70 nmol/L, respectively, for vitamin D measured as 25-hydroxyvitamin D in chest pain patients with suspected acute coronary syndrome. METHODS: We investigated 1853 patients from coastal-Norway and inland Northern-Argentina. A similar database was used for pooling of data. Two-year follow-up data including all-cause mortality, cardiac death, and sudden cardiac death in the total patient population were analyzed, applying univariate and multivariable analysis. RESULTS: Two hundred fifty-five patients with known vitamin D concentrations died. In the multivariable analysis, there was a decrease in total mortality above a cut-off level of 40 nmol/L and a decrease in cardiac death above a cut-off level of 70 nmol/L [HRs of 0.66 (95% CI, 0.50-0.88), p = 0.004 and 0.46 (95% CI, 0.22-0.94), p = 0.034, respectively]. CONCLUSION: Vitamin D cut-off levels of 40 and 70 nmol/L were related to total mortality and cardiac death, respectively.

Borderline Values of Troponin-T and High Sensitivity C-Reactive Protein Did Not Predict 2-Year Mortality in TnT Positive Chest-Pain Patients, Whereas Brain Natriuretic Peptide Did.

BACKGROUND: Troponin-T (TnT), high-sensitive C-reactive protein (hsCRP), and Brain Natriuretic Peptide (BNP) have been shown to be independent prognostic indicators of total and cardiac death during short- and long-term follow-up. METHODS: We investigated prospectively the prognostic value of admission samples of TnT, hsCRP, and BNP in 871 chest-pain patients from South-Western Norway and 982 patients from Northern Argentina, based on a similar protocol and database setup. Follow-up was 2 years for the pooled population. The prognostic value of the selected biomarkers was investigated in quartiles of 239 patients with TnT values greater than 0.01 and up to and including 0.1 ng/mL, with continuous TnT as a potential confounder. RESULTS: After 24 months, 69 patients had died, of whom 38 died from cardiac causes. In the selected range of TnT, this biomarker was not significantly different between patients who died and survived (mean 0.0452 and 0.0457, p = 0.887). The BNP levels were significantly higher among patients dying than in long-term survivors [340 (142-656) versus 157 (58-367) pg/mL (median, 25 and 75% percentiles), p < 0.001]. In a multivariable Cox regression model for death within 2 years, the hazard ratio (HR) for BNP in the highest quartile (Q4) as compared to the lowest (Q1) was significantly related to total mortality [HR 2.84 (95% confidence interval (CI), 1.13-7.17)], p = 0.027, in addition to age (p ≤ 0.001) and hypercholesterolemia (p = 0.043). For cardiac death, the HR for BNP was 5.18 (95% CI, 1.06-25.3), p = 0.042. Several other variables (age, congestive heart failure, ST elevation myocardial infarction, and study country) were also significantly related to cardiac death. In a multivariable Cox regression model, hsCRP rendered no significant prognostic information for all-cause mortality (p = 0.089) or for cardiac mortality (p = 0.524). CONCLUSION: In patients with borderline TnT values (greater than 0.01 and up to and including 0.1 ng/mL), this biomarker as well as hsCRP did not render prognostic information, whereas BNP was found to be a strong prognostic indicator of 2-year total and cardiac mortality.

Vitamin d predicts all-cause and cardiac mortality in females with suspected acute coronary syndrome: a comparison with brain natriuretic Peptide and high-sensitivity C-reactive protein.

Vitamin D may not only reflect disease but may also serve as a prognostic indicator. Our aim was to assess the gender-specific utility of vitamin D measured as 25-hydroxy-vitamin D [25(OH)D] to predict all-cause and cardiac death in patients with suspected acute coronary syndrome (ACS) and to compare its prognostic utility to brain natriuretic peptide (BNP) and high-sensitivity C-reactive protein (hsCRP). Blood samples were harvested on admission in 982 patients. Forty percent were women (65.9 ± 12.6 years). Mortality was evaluated in quartiles of 25(OH)D, BNP, and hsCRP, respectively, during a 5-year follow-up, applying univariate and multivariate analyses. One hundred and seventy-three patients died; 78 were women. In 92 patients (37 women), death was defined as cardiac. In women, the univariate hazard ratio (HR) for total death of 25(OH)D in Quartile (Q) 2 versus Q1, Q3 versus Q1, and Q4 versus Q1 was 0.55 (95% CI 0.33-0.93), 0.29 (95% CI 0.15-0.55), and 0.13 (95% CI 0.06-0.32), respectively. In females, it was an independent predictor of total and cardiac death, whereas BNP and hsCRP were less gender-specific. No gender differences in 25(OH)D were noted in a reference material. Accordingly, vitamin D independently predicts mortality in females with suspected ACS.

Socioeconomic assessment and impact of social security on outcome in patients admitted with suspected coronary chest pain in the city of salta, Argentina.

Low socioeconomic status is associated with increased mortality from coronary heart disease. We assessed total mortality, cardiac death, and sudden cardiac death (SCD) in relation to socioeconomic class and social security in 982 patients consecutively admitted with suspected coronary chest pain, living in the city of Salta, northern Argentina. Patients were divided into three socioeconomic classes based on monthly income, residential area, and insurance coverage. Five-year follow-up data were analyzed accordingly, applying univariate and multivariate analyses. At follow-up, 173 patients (17.6%) had died. In 92 patients (9.4%) death was defined as cardiac, of whom 59 patients (6.0%) were characterized as SCD. In the multivariate analysis, the hazard ratios (HRs) for all-cause and cardiac mortality in the highest as compared to the lowest socioeconomic class were 0.42 (95% confidence interval (CI), 0.22-0.80), P = 0.008, and 0.39 (95% CI, 0.15-0.99), P = 0.047, respectively. Comparing patients in the upper socioeconomic class to patients without healthcare coverage, HRs were 0.46 (95% CI, 0.23-0.94), P = 0.032, and 0.37 (95% CI, 0.14-1.01), P = 0.054, respectively. In conclusion, survival was mainly tied to socioeconomic inequalities in this population, and the impact of a social security program needs further attention.

Serum 25(OH)D is a 2-year predictor of all-cause mortality, cardiac death and sudden cardiac death in chest pain patients from Northern Argentina.

BACKGROUND: Several studies have shown an association between vitamin D deficiency and cardiovascular risk. Vitamin D status is assessed by determination of 25-hydroxyvitamin D [25(OH)D] in serum. METHODS: We assessed the prognostic utility of 25(OH)D in 982 chest-pain patients with suspected acute coronary syndrome (ACS) from Salta, Northern Argentina. 2-year follow-up data including all-cause mortality, cardiac death and sudden cardiac death were analyzed in quartiles of 25(OH)D, applying univariate and multivariate analysis. RESULTS: There were statistically significant changes in seasonal 25(OH)D levels. At follow-up, 119 patients had died. The mean 25(OH)D levels were significantly lower among patients dying than in long-term survivors, both in the total population and in patients with a troponin T (TnT) release (n = 388). When comparing 25(OH)D in the highest quartile to the lowest quartile in a multivariable Cox regression model for all-cause mortality, the hazard ratio (HR) for cardiac death and sudden cardiac death in the total population was 0.37 (95% CI, 0.19-0.73), p = 0.004, 0.23 (95% CI, 0.08-0.67), p = 0.007, and 0.32 (95% CI, 0.11-0.94), p = 0.038, respectively. In patients with TnT release, the respective HR was 0.24 (95% CI, 0.10-0.54), p = 0.001, 0.18 (95% CI, 0.05-0.60), p = 0.006 and 0.25 (95% CI, 0.07-0.89), p = 0.033. 25(OH)D had no prognostic value in patients with no TnT release. CONCLUSION: Vitamin D was shown to be a useful biomarker for prediction of mortality when obtained at admission in chest pain patients with suspected ACS. TRIAL REGISTRATION: ClinicalTrials.gov NCT01377402.