Manejo de Crohn colónico refractario a corticoides y sulfazalazina: primer caso de uso pediátrico de infliximab en el Perú / Management of colonic Crohn disease with no response to corticoids and sulfazalazine: first case of pediatric use of infliximab in Peru

Presentamos el primer caso pediátrico peruano de uso de infliximab para inducir remisión en enfermedad de Crohn. Caso: niña de 9 años, con presencia de fístulas perianales desde los 8 meses de edad, además de diarreas recurrentes y pobre ganancia ponderal. Se le realizó una colostomía a los 4 años de edad, sin variación. A esa edad, una biopsia mostró colitis crónica severa superficial y profunda extensiva a la muscularis mucosae con áreas de fibrosis y atrofia glandular, planteándose enfermedad de Crohn. Recibió manejo con corticoides, sulfasalazina y antibióticos sin mejoría. A los 8 años de edad presentaba desnutrición crónica reagudizada, además de anemia moderada. Se decidió iniciar terapia con infliximab, 100 mg por dosis aplicada (5,5 mg/kg/dosis). A la cuarta infusión todas las fístulas perianales estaban inactivas, sin embargo, presentó exacerbación de la enfermedad a los 8 meses de tratamiento. Se decidió agregar azatriopina a 2 mg/kg/d VO y se acortaron las infusiones de mantenimiento a cada 4 semanas. Toda la sintomatología gastrointestinal se resolvió. Hasta el momento la niña no presenta eventos adversos a la administración de la terapia médica. Conclusión: El caso presentado corresponde a una presentación temprana, rara y agresiva de enfermedad de Crohn. El infliximab se constituye en herramienta clave para alcanzar la remisión.

We present the first Peruvian pediatric case of induction of remission and maintenance of Crohn's disease with infliximab. Case: 9-year old female who presented with perianal fistulas, intermittent diarrhea and poor weight gain since 8 months of age. Due to lack of improvement with medical therapy she had a colostomy at 4 years of age. A surgical biopsy showed chronic colitis with inflammation extending to the muscularis mucosae, with areas of glandular atrophy. A diagnosis of Crohn's disease was made. She received prednisone, sulfasalazine and antibiotics without significant improvement. She became undernourished, stunted, and anemic. Consequently, at 8 years of age we started infliximab, 100 mg per doses (5.5 mg/kg/doses). After 4 infusions her perianal fistulas closed. However, after 8 months of treatment she had a disease exacerbation with abdominal pain and diarrhea. Therefore, we added azathioprine (2 mg/kg/d PO) and shortened maintenance infliximab infusions from every 8 to every 4 weeks. Gastrointestinal symptoms resolved. So far the patient has had no adverse events secondary to therapy. Conclusion: This patient has a rare early onset and aggressive form of Crohn's disease that responded to infliximab, who needed the addition of azathioprine to maintain remission.

Fraturas do fêmur proximal no idoso: estudo de custo da doença sob a perspectiva de um hospital público no Rio de Janeiro, Brasil / Hip fractures in the elderly: cost of illness study in a public hospital perspective, Rio de Janeiro, Brazil

O artigo visa a estimar o custo direto médico do tratamento hospitalar de pacientes idosos com fraturas de fêmur proximal, no Hospital Municipal Lourenço Jorge, na cidade do Rio de Janeiro. Estudo observacional, prospectivo, para estimar a utilização de recursos e custos diretos médicos associados à hospitalização por fratura de fêmur proximal em idosos, em 2007 e 2008, sob a perspectiva do prestador de serviços. Foi utilizado um instrumento de coleta de dados através do qual foram registrados recursos identificados na revisão prospectiva dos prontuários. Aos recursos utilizados foram atribuídos custos em reais (R$) baseando-se em valores do ano 2010. Foram realizadas análises descritivas dos custos e utilização de recursos, bem como avaliada a associação de variáveis clínicas e demográficas com o custo final observado. Foram incluídos 82 pacientes, 81,7 por cento do sexo feminino, idade média de 76,96 anos, hospitalização média de 12,66 dias. A mediana de custo por paciente foi de R$ 3.064,76 (IC95 por cento: 2.817,63 a 3.463,98). Hospitalização clínica e procedimento cirúrgico foram responsáveis por 65,61 por cento e 24,94 por cento dos custos, respectivamente. Pacientes submetidos ao tratamento cirúrgico até o quarto dia de hospitalização apresentaram mediana de custos menor do que pacientes submetidos após o quarto dia (R$ 2.136,31 e R$ 3.281,45, p<0,00001). Observou-se também diferença significativa nos custos finais por tipo de procedimento cirúrgico realizado. O custo do tratamento das fraturas de fêmur proximal no idoso foi significativamente maior nos pacientes submetidos à cirurgia após o quarto dia de hospitalização. Hospitalização clínica e procedimento cirúrgico foram os principais componentes do custo final observado.

This paper aims to assess direct medical costs associated to hospital treatment of hip fractures in the elderly in the Municipal Hospital Lourenço Jorge (HMLJ), Rio de Janeiro. Observational, prospective study to assess resource utilization and direct medical costs associated to elderly hip fracture hospitalization in 2007 and 2008, under the health care provider perspective. A standard data collection instrument was used to register identified resources during prospective medical charts review. The resource utilization was converted into Brazilian Real (R$), based on 2010 prices. Descriptive analysis of costs and resource utilization and their association with clinical and demographic variables were performed. Eighty two patients were included, 81.7 percent female, mean age of 76.96 years, hospitalization mean time of 12.66 days. Median total costs per patient were R$ 3,064.76 (IC95 percent: 2,817.63 - 3,463.98). Clinical hospitalization and surgical procedure were responsible for 65.61 percent and 24.94 percent of costs, respectively. Median costs for patients submitted to surgical procedure until the fourth day of hospitalization were lower than median costs for patients submitted after the fourth day (R$ 2,136.45 and R$ 3,281.45, respectively, p<0.00001). A significant difference in average costs per type of surgical procedure was also observed. Cost associated to inpatient treatment of hip fractures in the elderly was higher in patients who performed surgery after the fourth day of hospitalization. Clinical hospitalization and surgical procedure were the main cost components observed.

The effect of 677C>T and 1298A>C MTHFR polymorphisms on sulfasalazine treatment outcome in rheumatoid arthritis

Despite the availability of several new agents for the treatment of rheumatoid arthritis (RA), sulfasalazine remains the mainstay because of both cost and experience with its use. Methylenetetrahydrofolate reductase (MTHFR) is involved in folate metabolism and several polymorphisms have been described in the MTHFR gene. Of these, the 677C>T and 1298A>C polymorphisms have been associated with altered enzyme activity. To examine the association between 677C>T and 1298A>C MTHFR polymorphisms and sulfasalazine efficacy for the treatment of RA, a total of 117 RA patients treated with sulfasalazine (1 g daily; duration of treatment 17 ± 5 months) were analyzed. The 677C>T and 1298 A>C polymorphisms were detected using a PCR-RFLP method. RA was diagnosed according to the criteria of the American College of Rheumatology (ACR). The remission of RA symptoms was evaluated according to the ACR 20% response criteria. Allele and genotype frequencies were compared by the two-sided Fisher exact test. The frequency of remission was 47.2% and 44.6% in carriers of 677T and 1298C alleles, compared to 40.7% and 42.0% in carriers of 677C and 1298A alleles, respectively. These differences were statistically non-significant. When the multivariate analysis was additionally adjusted for patients' age, gender and RA duration, the association of the MTHFR 677T allele with increased frequency of remission was statistically significant. Although RA remission rate in carriers of the MTHFR 677T and 1298C alleles was more frequently observed, it does not seem that 677C>T and 1298A>C MTHFR polymorphisms have a major influence on treatment outcome in RA patients treated with sulfasalazine.

Doença de Behçet na adolescência: relato de um caso com boa resposta à sulfasalazina / Behçet's disease in adolescence: case report with a good response to sulfasalazine

As autoras relatam a história, o diagnóstico e a evolução de um caso de um menino de 14 anos com doença de Behçet. Trata-se de uma vasculite crônica, multissistêmica, de causa desconhecida, que se caracteriza por úlceras orais recorrentes, úlceras genitais, uveíte e lesões de pele. O tratamento desta doença varia de acordo com os autores, dependendo das manifestações clínicas do paciente. Dentre as drogas utilizadas incluem-se esteróides tópicos, colchicina e agentes citotóxicos tais como azatioprina, clorambucil e ciclofosfamida. O interferon e, mais recentemente, um bloqueador TNF-α também vêm sendo prescritos. Os benefícios da sulfasalazina no tratamento da vasculite intestinal têm sido relatados há bastante tempo (2,19,20,21). No entanto, na literatura revisada, não se encontrou nenhum artigo que referisse o uso desta droga em adolescentes portadores de Behçet. A boa resposta à sulfasalazina e a baixa ocorrência de efeitos colaterais motivaram o relato deste caso (AU)

The authors report a case of Behçet's disease in a 14 year-old boy with history, diagnosis and evolution of this pathology. Behçet's disease is a multistemic vasculitis of unknow cause, with recurrent oral and genital ulcers, uveitis and skin lesions. The treatment varies according to different authors, taking into consideration the patients' clinical manifestations. The drugs that can be used in these cases are topic steroids, colchicine, cytotoxic agents such as azatioprine, clorambucil and ciclofosfamide. Interferon and a TNF-α blocker have also been used. The benefits of sulfasalazine in the treatment of patients with intestinal vasculitis have been reported before (2,19,20,21). Nevertheless, no data was found referring to the use of this drug in adolescents with Behçet's disease. The satisfactory response to sulfalazine and the rare occurrence of side effects were the motivations to report this case (AU)

Primer caso confirmado de enfermedad de Crohn en el Hospital General San Juan de Dios, Guatemala, C. A / First confirmed case of Crohn's disease at the San Juan de Dios General Hospital in Guatemala, Central America

Una paciente guatemalteca de 47 años consultó al hospital por diarrea crónica asociada a pérdida de peso. El estudio de colonoscopía y anatomía patológica estableció el diagnóstico de Enfermedad de Crohn. Tratamiento con metronidazol y sulfasalacina fue efectivo para el control de los síntomas. Esta enfermedad es sumamente rara en nuestra población, en general se presenta con mayor frecuencia en áreas templadas y particularmente en personas de raza blanca especialmente judíos

Psoriasis: tratamiento de 20 casos con sulfazalazina / Psoriasis: treatment of 20 cases with sulfasalazine

La sulfasalazina es un fármaco auxiliar en el tratamiento de la colitis ulcerativa crónica inespecifíca, enfermedad de Crohn, artritis reumatoide y psoriásica. Ha demostrado su utilidad en el tratamiento de lesiones cutáneas de psoriasis. Reportamos 20 pacientes con psoriasis en placas tratadas con 3-4 g/d de sulfasalazina durante 8 semanas. Nueve pacientes mostraron desaparición de sus lesiones y mejoría de más del 50 por ciento. Los efectos secundarios fueron náuseas en 8 pacientes y erupción macular en uno. La sulfasalazina es un fármaco que puede considerarse de elección en el tratamiento inicial de la psoriasis en placas

Colitis colágena: una buena razón para tomar biopsias de recto en pacientes con diarrea crónica

El motivo de presentar esta paciente es hacer consciencia entre el cuerpo médico de la existencia de esta entidad, de la cual hay muy pocos casos reportados en la literatura y sólo informe reciente en nuestro país. La colitis colágena es una entidad de etiología no aclarada que se caracteriza histológicamente por la presencia de una banda de colágeno mayor de 7 micras a nivel subepitelial de la mucosa colorrectal y clínicamente por diarrea crónica acuosa profusa, que puede asociarse con dolor abdominal tipo cólico, y estudios tanto de laboratorio como endoscópicos negativos. Se presenta un caso de esta entidad manejado recientemente en el Hospital Universitario del Valle, en quien se tomaron las biopsias aún en presencia de cambios endoscópicos. La respuesta terapéutica a la sulfasalazina y esteroides ha sido aceptable. Finalmente, sugerimos como recomendación que en pacientes con diarrea crónica no explicada, deben tomarse biopsias de colon y recto, a pesar de no presentar cambios endoscópicos