Diagnóstico tardío de la infección por el virus de la inmunodeficiencia humana: oportunidades diagnósticas perdidas / Late diagnosis of HIV infection: missed diagnostic opportunities

Fundamento: Analizar el porcentaje de pacientes con diagnóstico tardío (DT) de infección por VIH, sus factores de riesgo y las oportunidades perdidas para un diagnóstico más precoz. Material y métodos: Se incluyó a 165 pacientes diagnosticados de infección por VIH entre 2009 y 2013 en Navarra. Mediante regresión logística se estudiaron los factores asociados con DT (CD4 <350 células/mm3 o enfermedad definitoria de sida al diagnóstico). Se analizó la presencia de factores de riesgo e indicadores clínicos de una posible infección por VIH en los 5 años previos al diagnóstico. Resultados: La prevalencia global de DT fue del 55% (90/165). Este porcentaje fue mayor en los pacientes inmigrantes que en los españoles, y en aquellos sin serología realizada previamente. Se observó una interacción entre la edad y el origen del paciente. En los españoles el riesgo de DT aumentó con la edad a partir de los 40 años (OR: 3,72; IC95%: 1,52-9,12) pero esto no ocurrió en los inmigrantes. De los 132 pacientes con atención médica en los años previos al diagnóstico, 20 (15%) tenían factores de riesgo clásicos documentados en la historia, 14 (11%) procedían de regiones con alta prevalencia de VIH y 46 (35%) habían presentado indicadores clínicos sin la realización de la serología. Conclusiones: A pesar de los múltiples contactos con nuestro sistema sanitario, más de la mitad de los nuevos diagnósticos de infección por VIH se realizan tarde. Es necesario una mayor atención a los signos clínicos de la infección y, sobre todo, una mejor valoración del riesgo en pacientes asintomáticos (AU)

Background: To analyse the percentage of patients with a late diagnosis (LD) of HIV infection, their risk factors and the missed opportunities for an earlier diagnosis. Methods: One hundred and sixty-five patients diagnosed with HIV infection in Navarre between 2009 and 2013 were included. Logistic regression was used to study the factors associated with LD (CD4 <350 cells/ mm3 or AIDS defining disease at diagnosis). The presence of risk factors and clinical indicators of possible HIV infection in the 5 years preceding the diagnosis were analyzed. Results: The global prevalence of LD was 55% (90/165). This percentage was greater in immigrant patients than in Spanish patients, and in those without previous serology tests. An interaction was observed between the age and origin of patients. In Spaniards the risk of LD rose with age after 40 years (OR: 3.72; 95%CI: 1.52-9.12) but this did not occur in immigrant patients. Of the 132 patients who had received medical care in the years prior to diagnosis, 20 (15%) had classical risk factors recorded in their history, 14 (11%) proceeded from regions with a high prevalence of HIV, and 46 (35%) had presented clinical indicators without a serology test being realized. Conclusions: In spite of multiple contacts with our health system, over half of the new cases of HIV infection are diagnosed late. Greater attention to clinical signs is needed and, above all, a better evaluation of the risk in asymptomatic patients (AU)

[Late diagnosis of HIV infection: missed diagnostic opportunities]. / Diagnóstico tardío de la infección por el virus de la inmunodeficiencia humana: oportunidades diagnósticas perdidas.

BACKGROUND: To analyse the percentage of patients with a late diagnosis (LD) of HIV infection, their risk factors and the missed opportunities for an earlier diagnosis. METHODS: One hundred and sixty-five patients diagnosed with HIV infection in Navarre between 2009 and 2113 were included. Logistic regression was used to study the factors associated with LD (CD4 < 350 cells/mm3 or AIDS defining disease at diagnosis). The presence of risk factors and clinical indicators of possible HIV infection in the 5 years preceding the diagnosis were analyzed. RESULTS: The global prevalence of LD was 55% (90/165). This percentage was greater in immigrant patients than in Spanish patients, and in those without previous serology tests. An interaction was observed between the age and origin of patients. In Spaniards the risk of LD rose with age after 40 years (OR: 3.72; 95%CI: 1.52-9.12) but this did not occur in immigrant patients. Of the 132 patients who had received medical care in the years prior to diagnosis, 20 (15%) had classical risk factors recorded in their history, 14 (11%) proceeded from regions with a high prevalence of HIV, and 46 (35%) had presented clinical indicators (only 24 of them 1 year before diagnosis) without a serology test being realized. CONCLUSIONS: In spite of multiple contacts with our health system, over half of the new cases of HIV infection are diagnosed late. Greater attention to clinical signs is needed and, above all, a better evaluation of the risk in asymptomatic patients.

Fibrosis retroperitoneal postraumática como causa de dolor lumbar / Post traumatic retroperitoneal fibrosis as a cause of low-back pain

We present the case of a male patient with posttraumatic retroperitoneal fibrosis whose main clinical expression was low-back pain. Diagnosis was establis hedusing CAT-scan and MRI, which revealed a largemass of soft tissue that almost entirely enveloped the abdominal aorta. Treatment with 40 mg of prednisone every 24 hours was established. This dose was reduced gradually, and progressive remission of clinical sign sand symptoms was achieved, with a significant improvement of subsequent imaging-test results. Treatment was continued for one year. Two and a half years later the patient remains symptom-free, with no recurrence of his condition (AU)

Se presenta el caso de un paciente varón afecto de una fibrosis retroperitoneal postraumática, a cuyo diagnóstico se llegó a partir de dolor lumbar como síntoma principal. El diagnóstico se efectuó en base a los estudios mediante CT y RM, los cuales demostraron una gran masa de tejido de partes blandas que rodeabanla aorta. El tratamiento consistió en dosis de prednisonaque inicialmente se instauró a 40 mg cada 24 horas, y posteriormente se fue reduciendo de forma gradual hasta la remisión de los signos y síntomas, y consecuentemente de los estudios de imagen. El tratamiento con corticoides se mantuvo durante un año. Dos años y medio el paciente está libre de síntomas sin recidivade su proceso (AU)

Post traumatic retroperitoneal fibrosis as a cause of low-back pain.

We present the case of a male patient with post traumatic retroperitoneal fibrosis whose main clinical expression was low-back pain. Diagnosis was established using CAT-scan and MRI, which revealed a large mass of soft tissue that almost entirely enveloped the abdominal aorta. Treatment with 40 mg of prednisone every 24 hours was established. This dose was reduced gradually, and progressive remission of clinical signs and symptoms was achieved, with a significant improvement of subsequent imaging-test results. Treatment was continued for one year. Two and a half years later the patient remains symptom-free, with no recurrence of his condition.

[Vertebral osteomyelitis caused by Streptococcus agalactiae in healthy adults. Description of 2 new cases]. / Osteomielitis vertebral por Streptococcus agalactiae en adultos sanos: descripción de 2 nuevos casos.

The importance of Streptococcus agalactiae as a pathogen in nonpregnant adults has been widely recognized in recent years, especially in the elderly or immunocompromised patients. Two cases of vertebral osteomyelitis caused by S. agalactiae in young patients with no known underlying diseases or predisposing factor to infection are reported. A systematic review of the literature (MEDLINE, 1976-May 2008) was performed, 10 cases previously reported in the literature of vertebral osteomyelitis due to S. agalactiae being found in adults under 65 years of age with no predisposing risk factors for infection, most of which have been reported over the last 10 years. We believe that this microbial etiology should be considered in patients of any age and immunological status. Other factors, other than increasing the number of patients with chronic diseases, explaining the increased rate of S. agalactiae infections in adults need to be studied.

Osteomielitis vertebral por Streptococcus agalactiae en adultos sanos: descripción de 2 nuevos casos / Vertebral osteomyelitis caused by Streptococcus agalactiae in healthy adults. Description of 2 new cases

La importancia de Streptococcus agalactiae como patógeno en adultos fuera del período gestacional ha quedado bien demostrada en los últimos años, afectando a pacientes de edad avanzada o con inmunodepresión. Se describen 2 casos de osteomielitis vertebral por S. agalactiae en pacientes jóvenes sin enfermedad de base conocida ni factor predisponente de infección. Se realiza una revisión sistemática de la literatura (MEDLINE, 1976-Mayo 2008), encontrando 10 casos previamente publicados de osteomielitis vertebral por S. agalactiae en adultos menores de 65 años y sin ningún factor predisponente de infección, la mayoría publicados en los últimos 10 años. Consideramos que esta etiología microbiana debe ser tenida en cuenta en pacientes de cualquier edad y estado inmunológico. Otros factores, distintos al aumento del número de pacientes con enfermedades crónicas, que expliquen el incremento en la incidencia de las infecciones por S. agalactiae en adultos deben ser estudiados (AU)

The importance of Streptococcus agalactiae as a The importance of Streptococcus agalactiae as a pathogen in nonpregnant adults has been widely recognized in recent years, especially in the elderly or immunocompromised patients. Two cases of vertebral osteomyelitis caused by S. agalactiae in young patients with no known underlying diseases or predisposing factor to infection are reported. A systematic review of the literature (MEDLINE, 1976-May 2008) was performed, 10 cases previously reported in the literature of vertebral osteomyelitis due to S. agalactiae being found in adults under 65 years of age with no predisposing risk factors for infection, most of which have been reported over the last 10 years. We believe that this microbial etiology should be considered in patients of any age and immunological status. Other factors, other than increasing the number of patients with chronic diseases, explaining the increased rate of S. agalactiae infections in adults need to be studied (AU)

Síndrome de Lemierre y Mycoplasma pneumoniae / Lemierre´s syndrome and mycoplasma pneumoniae

Se ha sugerido que una infección faríngea previa viral o bacteriana puede favorecer el desarrollo del síndrome de Lemierre, una entidad hoy en día poco frecuente. Se describe un caso de síndrome de Lemierre en el que coexiste una infección por Mycoplasma pneumoniae, hecho comunicado en la literatura sólo en otros 2 casos. Se trata de una adolescente de 16 años con tromboflebitis yugular izquierda, bacteriemia por Fusobacterium necrophorum y émbolos sépticos en pulmón, que requirió ventilación mecánica por insuficiencia respiratoria grave. A pesar del tratamiento precoz con penicilina G y clindamicina, persistió la fiebre y parte de la afectación pulmonar hasta la introducción, tras la confirmación serológica de infección por M. pneumoniae, de un antibiótico activo frente a este patógeno. Los clínicos debemos saber reconocer fácilmente esta enfermedad porque su presentación clínica es muy característica, y debemos considerar la posibilidad de coinfección con otros microorganismos, incluido M. pneumoniae

It has been suggested that a previous viral or bacterial pharyngitis may predispose to Lemierre´s syndrome, an uncommon entity nowadays. A case of Lemierre´s syndrome and co-infection with Mycoplasma pneumoniae is described, association published before in only 2 other cases. A 16-year-old girl with trombophlebitis of the left jugular vein, Fusobacterium necrophorum bacteremia and septic emboli in the lung requiring mechanical ventilation due to severe respiratory insufficiency. Despite early treatment with penicillin G and clindamycin, fever and part of pulmonary affectation persisted until that an antibiotic agent active against M. pneumoniae was instaurated, after its serological confirmation. The physicians should be easily recognized this disease because of its characteristic clinical findings, and co-infection with other organisms including M. pneumoniae, should be considered

[Lemierre's syndrome and Mycoplasma pneumoniae]. / Síndrome de Lemierre y Mycoplasma pneumoniae.

It has been suggested that a previous viral or bacterial pharyngitis may predispose to Lemierre's syndrome, an uncommon entity nowadays. A case of Lemierre's syndrome and co-infection with Mycoplasma pneumoniae is described, association published before in only 2 other cases. A 16-year-old girl with trombophlebitis of the left jugular vein, Fusobacterium necrophorum bacteremia and septic emboli in the lung requiring mechanical ventilation due to severe respiratory insufficiency. Despite early treatment with penicillin G and clindamycin, fever and part of pulmonary affectation persisted until that an antibiotic agent active against M. pneumoniae was instaurated, after its serological confirmation. The physicians should be easily recognized this disease because of its characteristic clinical findings, and co-infection with other organisms including M. pneumoniae, should be considered.

[Giant cell arteritis and polymyalgia rheumatica: diagnosis and evolution of 90 cases]. / Arteritis de células gigantes y polimialgia reumática: diagnóstico y evolución de 90 casos.

OBJECTIVE: To compare the clinical features of giant cell arteritis (GCA) and polymyalgia rheumatic (PMR), and to evaluate the criteria proposed by the American College of Rheumatology in our results. PATIENTS AND METHODS: A retrospective analysis of 90 patients with GCA (n = 57.55 of whom were diagnosed by biops) and PMR (n = 33) diagnosed over the last 10 years. RESULTS: Headache was present in 45 patients (78.94%) with GCA and in 7 (21.21%) with PMR (p < 0.001); polymyalgic syndrome was observed in 15 patients (26.31%) with GCA and in 33 (100%) with PMR (p < 0.001); jaw or tongue claudication was observed in 14 patients (24.57%) with GCA and in 2 (6.06%) with PMR (p < 0.05), and visual disturbances were only present in 9 patients (15.79%) with GCA. The erythrocyte sedimentation rate (ESR) was > or = 50 mm/h in 84 patients (93.33%), and > or = 100 mm/h in 43 of them (51.19%). The ESR became normal (20 Pounds mm/h) in less of 8 weeks after the treatment was started in 64 patients (76.19%). At the time of diagnosis, 61 patients (61.67%) had anemia, which was severe (Hb < 10 g/dl) in 17 cases (27.86%). After steroid treatment 43 patients (70.49%) improved their anemia in less of 12 weeks, and 25 of them (58.13%) in less of 8 weeks. CONCLUSIONS: The cranial symptoms were predictive for a positive temporal artery biopsy. The anemia and its quick normalization after steroid treatment can help to the diagnostic.

Arteritis de células gigantes y polimialgia reumática: diagnóstico y evolución de 90 casos / Giant cell arteritis and polymyalgia rheumatica: diagnosis and evolution of 90 cases

Objetivo: Comparar el cuadro clínico de la arteritis de células gigantes (ACG) y el de la polimialgia reumática (PMR). Valorar los criterios diagnósticos del American College of Rheumatology contrastándolos con nuestros resultados. Pacientes y métodos: Estudio retrospectivo de 90 enfermos diagnosticados de ACG (n = 57,55 diagnosticados por biopsia) y de PMR (n = 33) en los últimos 10 años.Resultados: Presentaron cefalea 45 enfermos (78,94 por ciento) con ACG y 7 (21,21 por ciento) con PMR (p<0,001), síndrome polimiálgico 15 (26,31 por ciento) con ACG y 33 (100 por ciento) con PMR (p<0,001), claudicación mandibular o lingual 14 (24,57 por ciento) con ACG y 2 (6,06 por ciento) con PMR (p<0,05) y alteraciones visuales 9 (15,79 por ciento) con ACG. La VSG fue 50 mm/h en 84 enfermos (93,33 por ciento) y 100 mm/h en 43 de ellos (51,19 por ciento). La VSG se normalizó (£ 20 mm/h) en menos de 8 semanas en 64 enfermos (76,19 por ciento). En el momento del diagnóstico 61 enfermos (61,77 por ciento) presentaron anemia, 17 de ellos (27,86 por ciento) de grado severo (Hb < 10 g/dl). Tras tratamiento esteroideo se recuperaron de la anemia 43 enfermos (70,49 por ciento), todos en menos de 12 semanas y 25 (58,13 por ciento) en menos de 8 semanas. Conclusiones: Los síntomas cefálicos orientaron el diagnóstico en la ACG y son predictivos de biopsia de arteria temporal positiva. La anemia y su rápida normalización tras tratamiento exclusivo con glucocorticoides son datos que pueden ayudar en el diagnóstico de estas entidades. (AU)

[Invasive aspergillosis: a study of 20 cases]. / Aspergilosis invasiva: estudio de 20 casos.

OBJECTIVE: To assess the epidemiology of invasive aspergillosis (IA) and the frequency of recognition of this clinical entity. PATIENTS AND METHODS: Retrospective analysis of patients with the diagnosis of IA in the last three years. The diagnostic criteria of the American Institute of Infectious Diseases Mycoses Group were followed. RESULTS: During this period, 20 patients were diagnosed of IA: 9 (45%) had a hematologic malignancy, 14 (70%) had received corticosteroids, five (25%) had neutropenia, and three (15%) had no factors for immunosuppression. The disease was suspected in 15 cases (75%). Aspergillus spp. was recovered from sputum samples of the 16 patients who had the sample obtained. Seventeen patients (85%) died, 12 of them in spite of receiving antifungal therapy. Time relapsed since the beginning of symptoms and therapy was 14 days. CONCLUSIONS: The proportion of patients without neutropenia or severe immunosuppression is higher than usually thought. IA is a clinical entity of difficult diagnosis and occasionally it is diagnosed only at post-mortem examination. The high sensitivity of sputum culture may be due to the selection of cases with more severe infections as stringent diagnostic criteria were used. To improve the prognosis of IA it is necessary to initiate antifungal therapy early in the course of the disease and therefore, a high suspicion index is required, not only of the immunocompromised but also of the immunocompetent patient.

Aspergilosis invasiva: estudio de 20 casos / Invasive aspergillosis: study of 20 cases

Fundamento. Conocer la epidemiología de la aspergilosis invasiva (AI) y la frecuencia con la que reconocemos esta entidad. Material y métodos. Análisis retrospectivo de los pacientes diagnosticados de AI en los últimos tres años. Se siguieron los criterios diagnósticos del Grupo de Micosis del Instituto Americano de Enfermedades Infecciosas. Resultados. En este período 20 pacientes fueron diagnosticados de AI: 9 (45 por ciento) tenían una neoplasia hematológica, 14 (70 por ciento) habían recibido esteroides, 5 (25 por ciento) presentaban neutropenia y en 3 (15 por ciento) no existía ningún factor de inmunodepresión. La enfermedad fue sospechada en 15 casos (75 por ciento). Se aisló Aspergillus spp. en esputo en los 16 pacientes en los que se obtuvo dicha muestra. Fallecieron 17 pacientes (85 por ciento), 12 a pesar del tratamiento antifúngico. El tiempo transcurrido entre el inicio de los síntomas y el del tratamiento fue de 14 días. Conclusiones. La proporción de pacientes sin neutropenia o severa inmunodepresión es mayor que la habitualmente reconocida. La AI es una entidad de difícil diagnóstico clínico que incluso a veces sólo se diagnostica tras el estudio necrópsico. La elevada sensibilidad del cultivo de esputo puede deberse a haber seleccionado los casos con infección más severa al haber usado criterios diagnósticos estrictos. Para mejorar el pronóstico de la AI es necesario el inicio precoz del tratamiento antifúngico y para ello es imprescindible tener un alto índice de sospecha, no sólo en el paciente inmunocomprometido, sino también en el inmunocompetente. (AU)

[Fever of unknown origin and tuberculous aortitis]. / Fiebr de origen desconocido y aortitis tuberculosa.

We present the case of a silicotic patient, with recurrent febrile episodes during the past three years, who was hospitalized for the study of prolonged fever. In addition to compliance with the criteria of fever from unknown origin (FUO), the patient presented semiology and echocardiogram compatible with infectious endocarditis. Later on, he developed a severe aortic failure refractary to medical treatment and hence, he underwent surgery. The surgical intervention showed an abscess in the aortic root, which resulted to be of a tuberculous origin and an intact aortic valve. The review of the echocardiographic study allowed the detection of an image compatible with aortic abscess. We comment on the characteristic of this rare entity and the peculiarities of this case, which fulfill the criteria of what has been recently named recurrent or episodic FUO and among whose causes Mycobacterium tuberculosis had not been detected up to now.

[Still's disease: atypical manifestations and potential markers of severe visceral disease]. / Enfermedad de Still: manifestaciones atípicas y posibles marcadores de afectación visceral severa.

We present two patients with Still's disease which, in addition to the typical clinical manifestations, showed rare visceral alterations. The first case referred abdominal pain and a sustained hyperamilasemia was detected. The second case suffered a severe multiple organic failure, characterized by hepatic failure, with electric signs of encephalopathy, hydroelectrolytic disorder, rhabdomyolysis and disseminated intravascular coagulation. During this episode, we detected hyponatremia, reduction of leukocytes and normalization of GSR, modifications already described by other authors in cases similar to these ones, although without considered relevant until now. We comment these results and their value as markers of visceral affectation.