The potential impact of PCV-13, PCV-15 and PCV-20 vaccines in Colombia.

PURPOSE: To provide information about which pneumococcal vaccine could have greater coverage in Colombia. METHODS: This is a retrospective analysis of patients diagnosed with invasive pneumococcal disease (IPD) between 2015 and 2019 in Bogotá, Colombia. We compared the theoretical serotype coverage of the available anti-pneumococcal vaccines (i.e., PCV-10, PCV-10 SII, PCV-13, PCV-15, PCV-20, PCV-21, PCV24, PPSV-23) and the non-vaccine-covered serotypes stratified by age. RESULTS: 690 IPD cases were included. In children ≤5 y/o, of the approved vaccines PCV-20 showed the most theoretical protection (71.3 % [149/209]), while in adults aged 18-64 y/o was PCV-20 (61.8 % [164/265]), and in those ≥65 y/o was PPSV-23 (58.1 % [100/172]) followed by PCV-20 (55.2 % [95/172]). The non-covered serotypes represented one-third of the cohort (33.9 % [234/690]), being 6C (20.5 % [48/234]), 15A (12.8 % [30/234]), and 23A (11.5 % [27/234]) the most prevalent. CONCLUSION: Introducing PCV-20 for children and PCV-20 along with a PPSV-23 booster in adults may reduce IPD frequency in all ages in Colombia. The inclusion of non-covered serotypes is required for future vaccines.

Prevalence of pulmonary hypertension in children with obstructive sleep apnea living at high altitude.

Introduction: The prevalence of obstructive sleep apnea (OSA) is 1-4 %. Some reports describe its association with pulmonary hypertension (PH), but its prevalence is unknown. No studies at high altitude have determined the relationship between OSA and PH. The aim of this study was to establish the prevalence of PH in children diagnosed with OSA living in a high-altitude city at 2640 m above sea level. Methods: Children between 2 and 16 years of age referred to the Sleep Laboratory of the Fundación Neumológica Colombiana in Bogotá with a positive polysomnogram for OSA were included, and a two-dimensional transthoracic echocardiogram (TTE) was performed to evaluate PH. Statistical analysis was performed using median, interquartile range, chi-squared test, and Kruskall-Wallis test. Results: Of the 55 patients (n: 55), 63.6 % were male, with a median age of 6 years, 14 children (25.5 %) were overweight; 12 children (21.8 %) had mild OSA, 12 (21.8 %) had moderate OSA and 31 (56.4 %) severe OSA. In patients with severe OSA, the minimum saturation during events was 78 % with a desaturation index (DI) of 33.8/hour (p < 0.01). T90 and T85 increased proportionally with OSA severity (p < 0.05). Of the 55 patients with OSA, none had PH according to echocardiography; 4 patients (7.2 %) had pulmonary artery systolic pressure (PASP) at the upper limit of normal (ULN), and it was not related to a higher body mass index (BMI). Conclusions: We found no association between OSA and PH in children with OSA at high altitude.

Interpretación de gases arteriovenosos. Una guía práctica. Revisión de tema / Interpretation of arteriovenous gases. A practical guideline. A review

La evaluación del estado ácido base y de la oxigenación de un paciente es fundamental en cualquier escenario clínico, sea en consulta externa, en un servicio de urgencias, hospitalización, en cirugía o en la unidad de cuidado intensivo. El conocimiento de las bases fisiopatológicas es de suma importancia para el entendimiento y adecuada interpretación de estas condiciones. El objetivo de esta revisión es proveer las bases de conocimiento necesarias para el abordaje adecuado de los gases arteriovenosos y proponer un modelo para la compresión e interpretación de estos. Este artículo aborda las bases fisiopatológicas de las alteraciones ácido base, los modelos existentes en su compresión, el modelo propuesto para su abordaje diagnóstico, sus diagnósticos diferenciales, el enfoque de la hipoxemia, la interpretación de los gases arteriovenosos y las variables que se pueden obtener de estos, el enfoque de la acidosis láctica y unos ejemplos del modelo propuesto.

The evaluation of the acid-base status and the oxygenation of a patient is fundamental in any clinical setting, be it in an outpatient clinic, in an emergency service, hospitalization, in surgery or in the intensive care unit. Knowledge of the pathophysiological bases is of the utmost importance for the understanding and adequate interpretation of these conditions. The objective of this review is to provide the necessary knowledge for the adequate understanding of arteriovenous gases and to propose a model for their comprehension and interpretation. This article addresses the pathophysiological bases of acid-base disorders, the existing models in their comprehension, the model proposed for their diagnostic approach, their differential diagnoses, the diagnostic approach to hypoxemia, the interpretation of arteriovenous gases and the variables that can be obtained from them, the diagnostic approach of lactic acidosis and some examples of the proposed model.

Medicina prepagada: problemas bioéticos evidentes en la atención de sus pacientes / Prepaid medicine: Evident bioethical problems in patient care

El sistema de salud en Colombia hace parte del Sistema de Seguridad Social Integral (SGSS) creado por la Ley 100 de 1993. La medicina prepagada existe como un contrato comercial de seguro de personas desde antes del SGSS, para mejorar la comodidad y el lujo, con libertad de elección de profesionales, sin trámites burocráticos para autorizaciones, oportunidad de citas, resolución rápida, eficiencia por ahorro en tiempo, dinero, efectividad y calidad en la atención. La naturaleza del vínculo comercial da pie para que los usuarios puedan tomar ventaja ilegítima del contrato y cambien las relaciones de poder y líneas de autoridad, amparados por el derecho que sienten que les confiere la compra con el fin de ver su inversión en resultados. Se generan así relaciones no idóneas, que transforman la relación médico-paciente, dando lugar a toda clase de conflictos, perversiones y vicios con consecuencias nefastas desde el punto de vista clínico, bioético y jurídico. El caso, analizado desde la metodología de análisis en ética clínica de Diego Gracia para resolver dilemas bioéticos, se aplica para hacer evidentes los conflictos y problemas bioéticos que surgieron en este contexto.

The health system in Colombia is part of the General Social Security System (GSSS) created by Law 100 of 1993. Prepaid medicine exists as a Personal Insurance Commercial Contract since before the SGSS, to improve comfort, luxury, with freedom of choice of professionals, without bureaucratic procedures for authorizations, opportunity for appointments, decisiveness, efficiency due to savings in time, money, effectiveness, and quality of care. The nature of the commercial relationship allows users to take illegitimate advantage of the contract and change the power relationships and lines of authority protected by the right they feel the purchase confers on them to see their investment in results. Inappropriate relationships are thus generated, which transform the doctor-patient relationship, giving rise to all kinds of conflicts, perversions, and vices with disastrous consequences from the clinical, bioethical and legal point of view. The case, analyzed from Diego Gracia's clinical ethics analysis methodology to resolve bioethical dilemmas, is applied to make evident the conflicts and bioethical problems that arose in this context.

Actinomyces in the mediastinum. Surprise is key in all art.

Introduction: Actinomycosis is an unusual chronic granulomatous infectious disease. They are commensals in various sites of the human body but with little pathogenicity. Actinomyces israelii is the most prevalent species but more than 30 species have been described. Infection of the lower respiratory tract is unusual, the involvement of mediastinum being even rarer. Case report: A 63-year-old man, previously healthy and living in a rural area, presented with a 5-month history of hemoptysis, pleuritic pain, weight loss, and night sweats. Community-acquired pneumonia with a mediastinal mass was documented, for which he received antibiotic management. Thoracoscopy was carried out for diagnosis and resection of the mediastinal mass due to inconclusive findings in the percutaneous biopsy. Pathology reported the presence of filamentous Gram-positive bacteria visible in Grocott staining. Due to the pathology findings, and the fact that no other infectious agents were identified, a diagnosis of actinomycosis was established. Treatment with oral amoxicillin 1g TID for 6 months was initiated. Conclusions: As far as we are aware, we present the sixth case of mediastinal actinomycosis. We present this case to bring attention to this rare but clinically relevant presentation to be considered as a differential diagnosis of mediastinal masses and to emphasize the need for specific anaerobic cultures to improve the diagnostic yield.

Diagnóstico de sarcoidosis mediante el uso del Ultrasonido endoscópico bronquial (EBUS) / Diagnosis of sarcoidosis by use of bronchial endoscopic bronchial ultrasound (EBUS)

La sarcoidosis es una enfermedad multisistémica presente a nivel mundial que se caracteriza por el compromiso pulmonar y mediastinal en la mayoría de los pacientes. Para confirmar el diagnóstico, es importante contar con una biopsia que demuestre granulomas no caseificantes y la exclusión de otros diagnósticos diferenciales. Por lo tanto, la selección del método diagnostico para la confirmación histológica juega un rol fundamental en estos pacientes. Es así como, en los últimos años, el ultrasonido endoscópico bronquial (EBUS) ha mostrado ser un método seguro y con un alto rendimiento diagnóstico que debe considerarse en el abordaje de esta patología cuando existe compromiso mediastinal.

Sarcoidosis is a multisystemic disease present worldwide that is characterized by pulmonary and mediastinal involvement in most patients. To confirm the diagnosis, it is important to have a biopsy showing non-caseating granulomas and the exclusion of other differential diagnoses. Therefore, the selection of the diagnostic method for histological confirmation plays a fundamental role in these patients. Thus, in recent years, endoscopic bronchial ultrasound (EBUS) has shown to be a safe method with a high diagnostic yield that should be considered in the approach to this pathology when there is mediastinal involvement.

Hafnia alvei pneumonia: from bees to human beings.

INTRODUCTION: Hafnia alvei is an enterobacteria that is a common inhabitant of the gastrointestinal flora of bees, birds, fish, and mammals. In humans this enterobacteria has been recovered from the oropharynx and the gastrointestinal tract but it has been rarely reported as a pathogen and usually identified as hospital-acquired enterobacteria. CASE REPORT: We describe a case of a 57-year-old woman, previously healthy, with a 7-day history of cough with brown sputum, sudden onset of chills, subjective fever, malaise, and pleuritic pain in the right hemithorax. A diagnosis of community-acquired pneumonia (CAP) was suspected and empiric antibiotic treatment was started. However, the patient showed no response and developed hemoptysis. A diagnosis of CAP by Hafnia alvei was confirmed with bronchoalveolar lavage and the patient was treated with i.v. cefepime 2 g TID with a good response. CONCLUSIONS: We presented a case of community-acquired pneumonia by Hafnia alvei in a previously healthy patient that, as far as our knowledge reaches, is the third reported case of CAP secondary to this pathogen.

Lemierre's syndrome by Bacillus circulans, Fusobacterium nucleatum and Staphylococcus aureus with involvement of the internal and external jugular vein.

INTRODUCTION: Lemierre's syndrome refers to the septic thrombophlebitis of the internal jugular vein, secondary to a pharyngeal infection. Although it mainly affects the internal jugular vein, isolated cases have been described of involvement of the external jugular vein. The main etiological agent is Fusobacterium necrophorum. CASE REPORT: A 27-year-old male, previously healthy, presented with a 7-day history of sore throat and fever. He was diagnosed with Lemierre's syndrome, coinfection by Bacillus circulans, F. nucleatum and Staphylococcus aureus with an atypical presentation due to the involvement of the external jugular vein and the internal jugular vein. CONCLUSIONS: As far as we are aware, we present the first case of Lemierre's syndrome with these characteristics.

Subarachnoid racemose neurocysticercosis with cerebellar involvement: an old friend in an infrequent location?

Taenia solium is the most common parasitic infection of the central nervous system and it can cause parenchymal or extra-parenchymal lesions. Subarachnoid cysticercosis is a type of extra-parenchymal infection in which the prevalence is not known and racemose NC with cerebellar involvement has been rarely reported. The diagnosis is challenging because of its similarity to other infectious diseases or to subarachnoid involvement of systemic malignancies. Treatment usually requires cysticide drugs, however, there are no randomized studies concerning the anti-parasitic treatment in subarachnoid NC. We present a case of racemose NC in the cerebellar hemisphere to draw attention to this pathology, endemic in many parts of the world; and highlight all the current gaps in our understanding of this entity.

Enfermedad de Behçet frente a la enfermedad inflamatoria intestinal. Diferencias en la presentación clínica / Behçet's disease compared with inflammatory bowel disease. Differences in their clinical presentation

Resumen La enfermedad de Behçet es una enfermedad poco frecuente con un compromiso sistémico cuyas principales manifestaciones abarcan el sistema gastrointestinal, neurológico, vascular y articular, además de la piel y los ojos. Por su compromiso multisistémico, es frecuente confundirlo con otras entidades como la enfermedad inflamatoria intestinal, con la cual comparte gran parte de su presentación clínica, por lo que se describe un caso clínico y se aborda una revision narrativa desde el punto de vista epidemiológico de las manifestaciones clínicas con el fin de tener un mayor conocimiento para identificarla a tiempo.

Abstract Behçet's disease is a rare disease with systemic involvement whose main manifestations include the gastrointestinal, neurological, vascular, and articular systems, as well as the skin and eyes. Due to its multisystemic nature, it is often mistaken for other entities such as inflammatory bowel disease since they share multiple characteristics in their clinical presentation. A clinical case is described, and an epidemiological review of clinical manifestations is discussed to have better knowledge that allow identifying it on time.

Burden of invasive pneumococcal disease (IPD) over a 10-year period in Bogotá, Colombia.

BACKGROUND: Invasive pneumococcal disease (IPD) is the leading cause of infectious death worldwide. This study aimed to describe the epidemiology of IPD and the impact of pneumococcal conjugate vaccine-10 (PCV-10) over a 10-year period in Bogotá, Colombia. METHODS: This was a laboratory-based surveillance study of Streptococcus pneumoniae isolated from patients with IPD from 82 hospitals over 10 years in Bogotá, Colombia. Data were compared between two periods: 2007-2011 (before the introduction of PCV-10) and 2012-2017 (after the introduction of PCV-10). RESULTS: In total, 1670 patients with IPD were included in the study between 2007 and 2017. Between 2007 and 2011, the most common serotypes were 14, 1, 6B, 6A and 3. Between 2012 and 2017, the most common serotypes were 19A, 3, 14 and 1. A decrease in the incidence of IPD, particularly in children aged 0-4 years, was noted after the introduction of PCV-10. Importantly, this reduction in incidence was not observed in patients aged ≥50 years. CONCLUSIONS: The IPD burden in Bogotá remained stable between 2007 and 2017. The incidence of IPD decreased in children but not in older adults. The introduction of PCV-10 led to a change in the most prevalent serotypes to serotypes that are not included in PCV-10.

Ivermectina subcutánea en el tratamiento de un síndrome de hiperinfección por Strongyloides stercoralis / Subcutaneous ivermectin for the treatment of the hyperinfection syndrome by Strongyloides stercoralis

La estrongiloidiasis es una enfermedad causada por el nematodo Strongyloides stercoralis, endémico en las regiones rurales de los países tropicales y subtropicales. Los pacientes inmunosuprimidos tienen un mayor riesgo de infección con este parásito y pueden terminar desarrollando un síndrome de hiperinfección que conlleva un alto riesgo de muerte. En el tratamiento se utiliza la ivermectina, pero, ni en Colombia ni en el mundo, existe una presentación parenteral del medicamento para uso en humanos, lo cual es un problema en aquellos pacientes que puedan tener comprometida la absorción intestinal, como es el caso de aquellos con obstrucciones intestinales. Se reporta el caso de un síndrome de hiperinfección por S. stercoralis en Colombia tratado con ivermectina subcutánea; la idea al presentarlo es incentivar los estudios de farmacocinética y farmacodinamia que analicen esta vía de administración como alternativa para el tratamiento de pacientes con riesgo de fracaso terapéutico con la vía oral.

Strongyloidiasis is a disease caused by the nematode Strongyloides stercoralis that is endemic in rural regions in tropical and subtropical countries. Immunosuppressed patients have an increased risk of infection by this parasite and are at risk of developing a hyperinfection syndrome which involves a higher risk of death. The syndrome is treated with ivermectin, however, there is no parenteral presentation of this medication for human use in Colombia or the world, which is an important problem in patients who have compromised enteral absorption, for instance, those with intestinal obstructions. We present a case of hyperinfection syndrome by Strongyloides stercoralis in Colombia, which was treated with subcutaneous ivermectin. Our purpose is to encourage pharmacokinetic and pharmacodynamic studies to establish this route of administration in the future as an alternative for those patients who have a high risk of therapeutic failure with the oral route.

Colitis eosinofílica como causa de diarrea crónica / Eosinophilic colitis as a cause of chronic diarrhea

Resumen La colitis eosinofílica es una enfermedad rara e idiopática caracterizada por la infiltración eosinofílica del colon y que hace parte del espectro de la gastroenteritis eosinofílica. Esta entidad tiene síntomas inespecíficos y en la actualidad no hay estudios clínicos, por lo cual la evidencia científica se basa en series de casos o reportes aislados. Esta patología requiere de un enfoque diagnóstico adecuado para descartar otras causas de eosinofilia en el colon, para poder así ofrecer un manejo farmacológico y no farmacológico dirigido y especializado para lograr la remisión de la enfermedad, por lo cual para ofrecer una atención oportuna, se debe tener en cuenta dentro del diagnóstico diferencial de aquellos pacientes jóvenes con diarrea crónica para lograr mejorar el enfoque diagnóstico y promover la realización de estudios clínicos que mejoren la calidad de la evidencia científica actual. Presentamos el primer caso con compromiso exclusivo del colon reportado en Colombia de una mujer con antecedente de enfermedades atópicas. (Acta Med Colom 2019; 44: 47-50)

Abstract Eosinophilic colitis is a rare and idiopathic disease characterized by eosinophilic infiltration of the colon and is part of the spectrum of eosinophilic gastroenteritis. This entity has nonspecific symptoms and currently there are no clinical studies, so the scientific evidence is based on case series or isolated reports. This pathology requires an adequate diagnostic approach to rule out other causes of eosinophilia in the colon, in order to offer a directed and specialized pharmacological and non-pharmacological management to achieve remission of the disease, so that to offer timely care it should be considered in the differential diagnosis of those young patients with chronic diarrhea in order to improve the diagnostic approach and promote performance of clinical studies that improve the quality of current scientific evidence. This is the first case with exclusive involvement of the colon reported in Colombia of a woman with a history of atopic diseases. (Acta Med Colom 2019; 44: 47-50)

Síndrome de Mounier Kuhn en una paciente de 78 años con fibrosis pulmonar / Mounier Kuhn syndrome in a 78-year-old patient with pulmonary fibrosis

Resumen Se presenta el caso de una mujer de 78 años de edad con fibrosis pulmonar idiopàtica, quien consultó por exacerbación de sus síntomas respiratorios, a quien se le realizan estudios radiológicos, donde se evidencia dilatación de la vía aérea, previamente no descrita, y se realiza diagnóstico de síndrome de Mounier Kuhn. Hasta donde el conocimiento alcanza, es el primer caso reportado en Colombia y la tercera persona de mayor edad reportada en el mundo. Este es un hallazgo incidental, dado que desde el punto de vista fisiopatológico no hay ninguna relación causal entre la fibrosis pulmonar idiopática y el síndrome de Mounier Kuhn. Sin embargo, su presencia puedo afectar aún más el compromiso funcional, dado el eventual colapso de la vía aérea, lo cual puede llevar a intervenciones terapéuticas adicionales, como colocación de stent. (Acta Med Colomb 2017: 42-198-201).

Abstract The case of a 78-year-old woman with idiopathic pulmonary fibrosis who consulted for exacerbation of her respiratory symptoms is presented. Radiologic studies showed dilation of the airway that was not previously described, and for this reason the diagnosis of Mounier Kuhn Syndrome was made. To our knowledge, this is the first case reported in Colombia and the third oldest person reported in the world. This is an incidental finding, since from the pathophysiological point of view there is no causal relationship between idiopathic pulmonary fibrosis and Mounier Kuhn's syndrome. However, its presence may further affect the functional compromise, given the eventual collapse of the airway, which may lead to additional therapeutic interventions, such as stent placement. (Acta Med Colomb 2017: 42-198-201).

Síndrome de Löfgren Una variante clínica de la sarcoidosis caracterizada por eritema nodoso, artritis y adenomegalias mediastinales / Löfgren's syndrome A clinical variant of sarcoidosis characterized by erythema nodosum, arthritis, and mediastinal lymphadenopathy

Se presenta el caso de una paciente de 24 años que consulta por inflamación de los tobillos y eritema nodoso. Al realizar el estudio clínico y paraclínicos de la paciente se diagnosticó síndrome de Löfgren, entidad de baja prevalencia en nuestro país. Este caso permite realizar una discusión del diagnóstico del eritema nodoso y la sarcoidosis. (Acta Med Colomb 2015; 40: 345-348).

The case of a patient of 24 years who consulted for swollen ankles and erythema nodosum is presented. In conducting clinical and laboratory study of patient, Löfgren's syndrome diagnosis was made, entity of low prevalence in our country. This case allows to make a discussion of the diagnosis of erythema nodosum and sarcoidosis. (Acta Med Colomb 2015; 40: 345-348).