Hiponatremia sintomática secundaria a tratamientos con oxcarbacepina / Symptomatic hyponatremia after the use of oxcarbazepine

La oxcarbacepina es un análogo de la carbamacepina utilizada para el tratamiento de la epilepsia y el dolor neuropático. Su espectro de efectos secundarios es sensiblemente inferior a la carbamacepina. Sin embargo, tiene una capacidad mayor de producir hiponatremia. Generalmente esta hiponatremia, que es dosis-dependiente, es asintomática cuando aparece y está favorecida por otras circunstancias concomitantes que pueden disminuir los niveles de sodio, como ocurre con la toma de ciertos fármacos (diuréticos). En raras ocasiones esta hiponatremia inducida por oxcarbacepina puede provocar síntomas que potencialmente pueden llevar al paciente a estados de encefalopatía si no se detectan a tiempo. Presentamos el caso de una paciente con hiponatremia provocada por la asociación de oxcarbacepina e hidroclorotiazida. En este caso se pudo constatar por las circustancias que se dieron que la disminución de los niveles de sodio era debida al efecto de los dos fármacos en conjunto y no por separado (AU)

Oxcarbazepine is a ketoanalogue of carbamazepine used for the treatment of epilepsy and neuropatic pain. However, oxcarbazepine is more likely to cause hyponatremia. Generally, hyponatremia is dose-dependant and asymptomatic, and is favoured by circumstances that cause a decrease in sodium levels, as the use of certain drugs (diuretics). If undetected, hyponatremia might occasionally cause severe symptoms leading to encephalopathy. A case of a patient with hyponatremia caused by the association of oxcarbazepine and hidroclorotiazide is reported. In this instance, the decrease of sodium levels was due to the association both drugs and not to the effect of each one separatedly (AU)

[Vascular Aspergillus infection in two recipients of kidneys from the same donor]. / Infección vascular por Aspergillus en dos receptores de injertos renal del mismo donante.

We describe a clinical case of two patients who received a cadaveric renal graft from the same donor in a multi-organ extraction procedure. The donor was a 39-years-old woman who died of intracranial tumour. A benign ganglioma was shown in biopsy. The two recipients received the same immunosuppressive regimen. Induction comprised cyclosporin A, steroids and basiliximab while cyclosporin A and steroids were used in maintenance immunosuppression. The A patient was a 53-year-old woman with chronic renal failure due to chronic pyelonephritis. She had been undergoing periodic haemodialysis for five years. She was hospitalised for sciatic pain refractory to rest and analgesics 35 days after transplantation. Two days later, her graft function deteriorated. Ultrasonography ruled out a urinary tract obstruction. Cyclosporine levels was normal. It was interpreted as an acute rejection episode and was treated with boluses of methylprednisolone (500 mg for 3 days). At the same time, her right leg began to show paraesthesia, coldness and a decreased arterial pulse. A spinal magnetic nuclear resonance was performed. It showed an aneurysm of right common iliac artery (fig. 1). An arteriography confirmed the existence of a pseudoaneurysm and an arteriovenous fistula to inferior vena cava (fig. 2). The B recipient was a 56-year-old woman with chronic renal failure due to chronic pyelonephritis. She required haemodialysis for two years. In the 4th month after transplantation her graft function deteriorated. Graft biopsy did not show acute cellular rejection, so she was kept on immunosuppressive treatment. A second graft biopsy was taken and no changes with the previous one was observed. Renal function deteriorated and haemodialysis was required. During the 6th month she began to show paraesthesia, coldness and decreased arterial pulse in her right leg. Ultrasonography showed pyelocaliectasis with an adjacent solid-liquid mass, abdominal CT scan confirmed. Arteriography proved the presence of a pseudoaneurysm of the right common iliac artery (fig. 3). Transplantectomy and pseudoaneurysm resection was performed in the two cases. Culture analysis revealed fungi identified as Aspergillus in both pseudoaneurysms. Medical treatment was started immediately with liposomal amphotericin B. The clinical evolution of the two recipients were different. While recipient A died, B patient recovered, requiring haemodialysis.

Infección vascular por Aspergillus en dos receptores de injertos renal del mismo donante / Vascular aspergillus infection in two renal recipients from the same donor

El caso clínico aquí descrito es el de dos pacientes que recibieron un injerto renal procedente del mismo donante, una mujer de 39 años fallecida a consecuencia de un tumor cerebral benigno. Los dos receptores iniciaron tratamiento inmunosupresor con ciclosporina A, esteroides y basiliximab, manteniéndose posteriormente con ciclosporina A y esteroides. La paciente A, una mujer de 53 años, padecía una insuficiencia renal crónica terminal (IRCT) secundaria a pielonefritis crónica, llevando en el momento del trasplante cinco años en programa de hemodiálisis. A los 35 días post-trasplante comenzó con clínica de ciatalgia derecha homolateral al injerto, refractaria a tratamiento analgésico. El día 37, presentó deterioro de la función renal que fue interpretado como un episodio de rechazo agudo y tratado como tal. Al mismo tiempo refirió parestesias con frialdad y disminución del pulso arterial periférico en la pierna derecha. Se le realizó una resonancia magnética donde se apreció la existencia de un pseudoaneurisma en la arteria ilíaca con una fístula arteriovenosa a cava inferior, que posteriormente fue confirmado mediante la realización de arteriografía. La paciente B, se trata de una mujer de 56 años, con IRCT secundaria a pielonefritis crónica en hemodiálisis previa durante 2 años. En el cuarto mes posttrasplante presentó un deterioro de la función renal. Se descartó la existencia de rechazo agudo mediante la realización de biopsia renal, manteniéndose el mismo tratamiento inmunosupresor. Debido al deterioro de la función renal, la paciente volvió a programa de hemodiálisis. Al sexto mes, desarrolló un cuadro de parestesias, frialdad y disminución del pulso arterial periférico en la pierna derecha homolateral al injerto. Mediante ecografía se apreció ectasia renal y una masa adyacente. Se realizó una tomografía que confirmó la existencia de una masa sólido-líquida. Mediante arteriografía se identificó como un pseudoaneurisma. En los dos casos se realizó nefrectomía del injerto, junto con resección del pseudoaneurisma y ligadura de la arteria ilíaca. El estudio histológico de los pseudoaneurismas reveló la presencia de Aspergillus y se inició tratamiento con anfotericina B liposomal. La evolución clínica de las dos pacientes fue diferente. La paciente A falleció debido a complicaciones secundarias a una segunda intervención quirúrgica por recibida del aneurisma. La paciente B presentó una evolución favorable manteniéndose en la actualidad en programa de hemodiálisis (AU)

We describe a clinical case of two patients who received a cadaveric renal graft from the same donor in a multi-organ extraction procedure. The donor was a 39-years-old woman who died of intracraneal tumour. A benign ganglioma was shown in biopsy. The two recipients received the same inmunosupressive regimen. Induction comprised cyclosporin A, steroids and basiliximab while cyclosporin A and steroids were used in maintenance immunosupression. The A patient was a 53-years-old woman with chronic renal failure due to chronic pyelonephritis. She had been undergoing periodic haemodialysis for five years. She was hospitalised by sciatic pain refractive to rest and analgesics 35 days after transplantation. Two days later, her graft function deteriorated. Ultrasonography ruled out a urinary tract obstruction. Cyclosporine levels was normal. Was interpreted as an acute rejection episode and was treated with boluses of methylprednisolone (500 mg for 3 days). At the same time, her right leg began to show paraesthesia, coldness and a decreased of arterial pulse. A spinal magnetic nuclear resonance was performed. It showed an aneurysm of right common iliac artery (fig. 1). An arteriography confirmed the existence of a pseudoaneurysm and an arteriovenous fistula to inferior vena cava (fig. 2). The B recipient was a 56-years-old woman with chronic renal failure due to chronic pyelonephritis. She required haemodialysis for two years. In the 4th month after transplantation her graft function deteriorated. Graft biopsy did not show acute cellular rejection. So she was kept on immunosupressive treatment. A second graft biopsy was taken and no changes with the previous one was observed. Renal function deteriorated and haemodialysis was required. During the 6th month she began to show paraesthesia, coldness and decreased of arterial pulse in her right leg. Ultrasonography showed pyelocaliectasis with an adjacent solidliquid mass, abdominal CT scan confirmed. Arteriography proved the presence of a pseudoaneurysm of the right common iliac artery (fig. 3). Transplantectomy and pseudoaneurysm resection was taken in the two cases. Culture analysis revealed fungi identified as Aspergillus in both pseudoaneurysm. Medical treatment was started immediately with liposomal amphotericin B. The clinical evolution of the two recipients were different. While recipient A died, B patient recovered requiring haemodialysis (AU)

[Psychologic morbidity in thyroidectomized patients]. / Morbilidad psíquica en pacientes tiroidectomizados.

To study psychological disorders and personality in a series of patients scheduled to undergo thyroidectomy under general anesthesia. We selected 33 patients who were to undergo thyroidectomy during the second half of 1993. Socio-demographic data were collected and the patients were given the following battery of psychometric tests: Cognitive Mini-Test (CMT), which explores the main cognitive areas; Goldberg's General Health Questionnaire (GHQ-28), which is a tool for screening out probable cases of mental illness (mainly involving affective disorders); and Cattell's Personality Questionnaire 16-PF. With the GHQ-28 we detected a 29.6% prevalence of mental illness before surgery; this figure increased to 33.31% after surgery with a cut-off point of 5/6. Some 3.7% of this series of patients presented general cognitive disorders when evaluated with the CMT. One in 3 patients shows signs of significant mental illness and could benefit from some type of psychological or psychopharmacological support, or even psychiatric treatment in the worst cases. We propose that the anesthetist learn to use these simple instruments for psychopathological evaluation in order to detect problems.

Intraoperative anaphylaxis caused by a hydatid cyst.

The incidence of the hydatid disease is still high in some regions of the Mediterranean. A serious, but rare, peroperative complication is IgE-mediated anaphylaxis, as a result of passing of the highly antigenic hydatid cyst content into the bloodstream. We present here a case of anaphylactic reaction in a patient who underwent surgical treatment of hydatid cyst.

[Intraoperative hydatid anaphylactic shock]. / Shock anafiláctico hidatídico intraoperatorio.

Certain parts of Spain continue to have a high incidence of hydatid disease. Anaphylaxis mediated by IgE, due to the high concentration of antigens in the blood stream, is a serious but fortunately infrequent complication of surgery. We present two cases of anaphylactoid reaction in patients undergoing surgery for excision of hydatid cysts and one case of a patient scheduled for cholecystectomy with unsuspected hydatid disease. This represents three cases presenting vascular collapse accompanied by metabolic acidosis, from among a total of 53 surgical patients handled by our department between January 1992 and May 1993. Early, essentially clinical, diagnosis and immediate start of treatment with adrenaline, suspension of inhaled anesthetics, administration of 100% oxygen, and restoration of intravascular volume with colloids or crystalloids were decisive in assuring the favorable outcome for these patients. Hydatid disease must be considered as a differential diagnosis in cases of shock during surgery in areas where it is endemic. Although infrequent, the possibility of anaphylaxis must be kept in mind whenever there is sudden hemodynamic deterioration during surgery for removal of a hydatid cyst. Early diagnosis and appropriate treatment are essential for a favorable outcome.

Autonomic nervous system in haemodialysis.

Fifty-two patients with terminal chronic renal failure on haemodialysis were assessed for the existence of autonomic neuropathy using the Valsava index. The values in the patients were lower than in the controls. Only a few symptoms could be related to the autonomic neuropathy. No correlation was found between Valsalva index and orthostatic or intradialysis hypotension, motor-nerve conduction velocity or plasma intact parathyroid hormone. Having demonstrated the existence of autonomic neuropathy, eight healthy subjects and ten patients on haemodialysis were studied to locate the segment of the autonomic reflex are affected. Heart rate and intraarterial pressure were monitored during the following tests: phenylephrine; hyperventilation; cold pressor; atropine; tyramine and adrenaline. An alteration was observed in baroreceptors, together with adrenergic hyperexcitability (reflected in the hypersensitivity of the sympathetic efferent pathway) and a greater response to the stimulus for the release of extra-adrenal adrenaline. The lower response to atropine is indicative of vagal alteration.

[A study of the urinary acidifying capacity of patients chronically treated with anticonvulsants (author's transl)]. / Estudio de la capacidad de acidificación de la orina en enfermos con ingestón crónica de anticonvulsivantes.

The subjects of this study were 18 patients with essential or secondary epilepsy under treatment with anticonvulsant drugs (hydantoins and phenobarbital) for periods of time varying between 8 months and 22 years. In all of them the serum levels of calcium, phosphorus, alkaline phosphatase, and the renal tubular capacity to acidify the urine were measured. Mean serum calcium and phosphorus levels were normal, while alkaline phosphatase was significantly elevated (p less than 0.0005). The renal threshold for bicarbonate was lowered to a mean of 23.01 +/- 2.86 (p less than 0.01). Distal tubular function was normal in all cases. When the patients are divided into two groups according to the duration of treatment (more or less than 100 months), the group with longest therapy shows an elevation of alkaline phosphatase (p less than 0.0005), a lowering of serum calcium (p less than 0.025) and a reduction of the renal threshold for bicarbonate (p less than 0.005) when compared to the group with shortest therapy.