Persistent fever as the only symptom of familial Mediterranean fever.

We describe a 54-year-old man who suffered from familial Mediterranean fever, but the fever has been the only symptom during a 10-year period. During this period, results of laboratory tests and roentgenographic studies were negative. On the basis of these findings we propose that familial Mediterranean fever can be included in the causes of persistent fever in patients with long periods of fever.

Survival after massive (>2000) Africanized honeybee stings.

We report the clinical case of a man who survived a massive attack of Africanized bees (>2000 bee stings). The man experienced anaphylactic shock and multisystem organ failure (neurologic, hepatic, renal, and hematologic failure). He was treated with administration of dopamine hydrochloride, antihistaminic agents, corticosteroids, fluid and electrolyte replenishment, peritoneal dialysis, and plasmapheresis. No sequelae have been observed during follow-up.

An IgG antibody response to the antigen 85 complex is associated with good outcome in Mexican Totonaca Indians with pulmonary tuberculosis.

SETTING: It is generally accepted that antibodies do not protect against Mycobacterium tuberculosis infection, as this role relies upon T-cell reactivity. Hence, most studies on antimycobacterial antibodies have been aimed at developing serologic tests, and few explore their role in disease pathogenesis. OBJECTIVE: To determine the IgG antimycobacterial antibody response of 55 Mexican Totonaca Indians with pulmonary tuberculosis and its correlation with some features of the disease. DESIGN: Study of the profile of antigen recognition by immunoblot and ELISA with isolated antigen 85 complex (Ag85) and whole culture filtrate proteins. Correlation of immunoblot and ELISA results with BCG vaccination, tuberculin reactivity, extent of the disease, clinical setting, and response to treatment. RESULTS: On immunoblot, band reactivity was very poor and the most frequently recognized antigen was the 30-32 kDa, antigen 85 complex (45.8% of serum samples). ELISA with this antigen showed a sensitivity of 72% and a specificity of 100%. Positive antibody titers to Ag85 were observed in 79.4% of patients with non-cavitary tuberculosis (P = 0.012) and in 95.8% of patients who were cured with anti-tuberculosis chemotherapy (P = 0.0001). By contrast, an antibody response to whole culture filtrate antigens had no correlation with the presence of cavitations or with prognosis. CONCLUSIONS: Our data show that an antibody response to Ag85, aside from having great potential to develop a serologic test for tuberculosis, was associated with a positive outcome in a cohort of tuberculous Mexican Indians.

Thyroid function and abdominal surgery. A longitudinal study.

Surgical trauma produces complex metabolic changes and may be an excellent model for studying the effects of an acute insult on the circulating thyroid hormone concentrations. Abnormalities in thyroid function tests in patients with nonthyroidal illness can be divided into a low T3 syndrome, low T3 and T4 syndrome in more severe cases and elevated T4 syndrome. In this study 30 patients undergoing elective or urgent abdominal surgery were longitudinally evaluated with pre- and postoperative thyroid function tests. Comparing with preoperative values, a significant reduction in total T3 serum values in the immediate postoperative period was seen (p < 0.005). The rest of the variables did not show significant statistical differences between the three periods. Over half of the patients undergoing urgent surgery had a low T3 syndrome, whereas only a sixth of the patients scheduled for elective surgery suffered from this syndrome. In the late postoperative period half the patients submitted to urgent surgery persisted with alterations in thyroid function tests, whereas most of the patients scheduled for elective surgery showed an improvement in their thyroid hormone level in the same period of time. Abnormalities in thyroid hormone metabolism were more frequent in patients admitted for urgent surgery, reflecting the severity of their illness and favoring the concept that these syndromes can be used as prognostic markers.

Circadian variation of human acute phase response.

Circadian variation of temperature, both normal and febrile, is a well known fact. Mediators of fever are also regulators of acute phase response and are associated with stimulation of pituitary hormone production related with defervescence and with a circadian pattern of secretion. Acute phase response may consequently have circadian variations in its components. Measurements of temperature, erythrocyte sedimentation rate, complete blood cell count, serum cortisol and fibrinogen were made at 7:00, 15:00, and 23:00 h during two consecutive days in 35 patients with fever and acute infection, 15 patients with clinically active ankylosing spondylitis without fever and 10 healthy volunteers. Temperature curves showed statistically significant circadian rhythms, with higher values at night and lower ones during early morning. Erythrocyte sedimentation rate, leukocyte count and fibrinogen also showed statistically significant circadian rhythms, but with higher values at 15:00 h. Serum cortisol also showed statistically significant circadian rhythmicity but with a higher rhythm adjusted mean (MESOR), and a 100 degrees (6 h) phase shift in patients with fever, as compared to patients with ankylosing spondylitis and healthy controls. In conclusion, components of acute phase response, including fever, have circadian rhythmicity, but asynchronically. Differences between fever and ankylosing spondylitis can be due to the intensity of acute phase response stimulation.

Protease inhibitor-associated hyperglycemia in Mexican patients with HIV infection.

BACKGROUND: The use of protease inhibitors has revolutionized the treatment of HIV infection. These agents are well tolerated, although the Federal Drug Administration (FDA) has warned U.S. doctors that protease inhibitors may precipitate hyperglycemia and diabetes (DM), based on isolated reports from physicians. METHODS: Sixty-one patients with HIV infection with criterion of non-DM from the onset of the protease inhibitor therapy participated in the study. Plasma glucose levels were obtained every month during a 6-month period, with a basal determination prior to protease inhibitor therapy. RESULTS: All Mexican patients enrolled in this study had the same Hispanic-American ethnic origin. Four patients (6.55%) developed hyperglycemia related with saquinavir. One had family history of DM type II. These patients were controlled with diet. CONCLUSIONS: Based on present data, we believe the benefits of these drugs to patients suffering from HIV infection outweigh the various risks of taking protease inhibitors. However, physicians who use these drugs have to be on the alert for hyperglycemia in the Mexican population, while patients should know the warning symptoms of hyperglycemia and diabetes.

Familial Mediterranean fever and primary antiphospholipid syndrome, a rare association. A case report.

The authors present the case of a twenty-one-year-old woman with familial Mediterranean fever who during her first pregnancy developed a primary antiphospholipid syndrome. This is an association not reported previously.

Pyoderma gangrenosum and extensive caval thrombosis associated with the antiphospholipid syndrome--a case report.

Pyoderma gangrenosum is a rare cutaneous disorder frequently associated with systemic diseases. The authors report the case of a 28-year-old man with pyoderma gangrenosum and inferior cava vein syndrome due to thrombosis. The search for pyoderma gangrenosum-associated conditions (gastrointestinal, rheumatic, neoplasic, and infectious diseases) was negative. A prolonged partial thromboplastin time and a positive test for circulating anticardiolipin antibodies strongly suggested the diagnosis of the antiphospholipid syndrome. There are reports of at least three other cases of pyoderma gangrenosum associated with the antiphospholipid syndrome. This clinical case adds further evidence to the possible link between these disorders and warrants a search for anticardiolipin antibodies in patients with pyoderma gangrenosum.

[Treatment of enteropathy in AIDS with a gluten-free diet. Preliminary communication]. / Tratamiento de la enteropatía del SIDA con una dieta sin gluten. Comunicación preliminar.

We present five patients with AIDS and enteropathy in whom the chronic diarrheal syndrome disappeared with a gluten-free diet. We hypothesize on the interrelations between celiac disease and enteropathy in AIDS, and propose that in similar cases, it may be a useful therapeutic alternative.

[Tuberculous pancreatic abscess as initial manifestation of acquired immunodeficiency syndrome (AIDS)]. / Absceso pancreático tuberculoso como manifestación inicial del síndrome de inmunodeficiencia adquirida (SIDA).

INTRODUCTION: Tuberculosis is frequently the form of presentation of HIV infection, even in patients who have not developed AIDS. Nevertheless, pancreatic affection is rare, and focal pancreatic affection is even rarer. CASE REPORT: We present the case of a 49 years old man with antecedents of 25 heterosexual partners and exploratory laparotomy three years before because of an hepatic lesion during which he was multitransfunded. He had a one year history of fever, diaphoresis and abdominal pain, in whom ultrasonography detected an image compatible with pancreatic abscess, so he went through laparotomy for drainage; biopsy reported tuberculosis. He persisted with fever and abdominal pain, and a computed tomography scan demonstrated persistent pancreatic abscess. The determination of HIV antibodies was positive, and the CD4 count in 110/mm3. Antituberculous therapy was started and eight weeks later, the computed tomography showed improvement; also, he had clinical improvement. After a two-years follow up, he remains asymptomatic, only with antiretroviral therapy. DISCUSSION: Pancreatic tuberculosis is an infrequent complication of this infection. It is considered the result of the dissemination of the infection from near lymphatic nodes. When needle aspiration of a pancreatic abscess is made, it is necessary to effect a culture in order to diagnose tuberculosis. The recommended treatment comprises a four antifimic scheme for 72 doses followed by a triple intermittent scheme for 60 more doses.

[Gastric neuroendocrine tumor]. / Tumor neuroendocrino gástrico.

Gastric carcinoid tumors arise from enterochromaffin-like (ECL) cells, these tumors represent 2-41% of all neuroendocrine tumors and 0.3% of malignant gastric neoplasias, being more common in men than in women, and commonly affecting people over 60 years old. These tumors arise from accelerated proliferation of the ECL cells as a consequence of the hypersecretion of gastrin, situation that can be present in atrophic gastritis and the Zollinger-Ellison syndrome. We report the case of a 51 year old hispanic female who presented with a 3 month history of abdominal pain, meteorism and constipation; she was treated with ranitidine and metoclopramide without clinical improvement, thus she underwent upper gastrointestinal endoscopy which showed an atrophic gastritis and gastric polyps. Histopathologic examination revealed a neuroendocrine gastric tumor which was positive to serotonine and gastrin stainings. Hormonal screening showed normal serum levels of LH, FSH, estradiol, ACTH, progesterone, calcitonin and cortisol. The serum level of gastrin was elevated with 500 pg/mL. Gammagraphic scanning with octreotide was negative for metastasis.

[POEMS syndrome. Report of a case]. / Síndrome de POEMS. Informe de un caso.

POEMS syndrome is a multisystem disorder with signs such as peripheral neuropathy, organomegaly, endocrinopathy, monoclonal protein, skin lesions, papilledema, and increased cerebrospinal fluid proteins, which can also evolve with renal and cardiac affection. It is considered a result of a plasma cell cyscrasia with the production of a monoclonal protein. A 46-year old man was seen as an outpatient referring progressive weakness of legs and arms, fever, impotence, inguinal and cervical lymphadenopathies, peripheral edema, hepatomegaly and skin hyperpigmentation. In laboratory test, platelet count was between 528 x 10(9)/L and 599 x 10(9)/L, creatinine clearance 27.2 ml/min, proteinuria 0.8 g/dl, IgA 455 mg/dl, T3 30 ng/100 ml, T4 2.6 vg/dl, T4F 0.5 ng/dl, TSH 12.4 vU/ml; testosterone 1.56 ng/ml. The electromyography showed a mixed sensitive-motor pattern. On the pelvis radiography, an osteosclerotic lesion on the left sacroiliac joint was identified. Bone biopsy of the site of the sclerotic lesion revealed plasma cell dyscrasia. The patient was treated with diuretics, digitalis and prednisone. Diagnosis of this disorder is difficult because of the multipathology it is necessary to establish differential diagnosis.

[Captopril reduction of albuminuria in type-II diabetics with diabetic nephropathy]. / Reducción de albuminuria por captopril en diabéticos tipo II con nefropatía diabética.

This study was to search if captopril (C) reduces albuminuria in a group of type II diabetics with diabetic nephropathy (DN). Eleven type II diabetics with DN and hypertension, with albuminuria over 0.30 g/L/24th, fasten blood glucose under 250 mg/dL, serum albumin over 3 g/dL, without infection, cardiac failure or diuretic treatment, were treated with C for six months, as the only treatment for hypertension and albuminuria. Every month, albuminuria in a 24h urinary collection, medium arterial pressure (MAP), serum creatinine and fasten blood glucose were measured. Ten women and one man with 60 (50-70) years of average age (0 to 100th percentile), with 18 (8-35) years of diabetic disease, and 4 (1-7) years of clinic hypertension were studied. Before the treatment with C they had albuminuria of 6.9 (0.7 to 12.5) g/L/24h, MAP of 119.7 (93.2 to 139) mmHg, serum creatinine of 2.2 (0.7 to 7.5) mg/dL and glucose of 168 (78 to 250) mg/dL. After 6 months with C, they had albuminuria of 3.5 (0.2 to 9.6) g/L/24h (p less than 0.01), MAP of 113.4 (92.9 to 132.4) mmHg (p = 0.5), serum creatinine of 2.3 (0.5 to 6.4) mg/dL (p = 0.23) and glucose of 133 (87.5 to 239) mg/dL (p = 0.32). The MAP showed a predictive relation over albuminuria (p = less than 0.004). During the six months of study, C reduced albuminuria in type II diabetics with hypertension and diabetic nephropathy.

[Usefulness of the ASA scale and thoracic radiography as indicators of perioperative cardiovascular risk]. / La utilidad de la escala de ASA y de la radiografía de tórax como indicadores de riesgo cardiovascular perioperatorio.

This paper evaluates the usefulness of ASA physical status classification and the multifactorial index of cardiac risk in the preoperative assessment, without considering arterial blood gases. With the results of this study we propose to add the ASA physical status classification, the radiologic diagnosis of chronic obstructive pulmonary disease and the multifactorial index of cardiac risk. This strategy increases the diagnostic certainty of Goldman's index of cardiac risk, is practical, not expensive and favors a better establishment of the risk of perioperative cardiovascular morbidity.

[Taking advantage of information sources for clinical practice]. / El aprovechamiento de las fuentes de información para la práctica clínica.

Information sources are the books, journals and electronic systems which support the academic work of physicians. Doctors have not taken enough advantage of these sources for their clinical decisions because they trend to rely on a routine undue confidence in experience, and because they do not have the skills for so-called health documentation. Many patients, consequently, have access to the best alternatives for solving their medical problems. The proper use of these sources implies some skills such as reflexive practice, the ability for recovering information, and critical reading and enough determination to apply the results of scientific research to individual patients, taking into consideration the patient's circumstances and the evaluation of outcomes. In this way, there is real integration of medical care, research, and continuing medical education.

[Thyroid function tests in healthy and ill elderly]. / Pruebas de función tiroidea en ancianos sanos y enfermos.

Thyroid function in the elderly has been a matter of discussion. The universe of the present study includes males and females 36 hospitalized with an average age of 72.97 +/- 8.70 years (group I) and 36 ambulatory asymptomatic elderly with 69.81 +/- 8.55 years of age (group II). Serum levels of T3, T4, T4L and TSH were measured in both groups. Mean values of T3 were significantly lower in the hospitalized patients than in the control group. The difference persisted on both, males and females, analyzed separately. Mean values of T4L were significantly lower in women of group II, while mean values of T3 were significantly lower in men of group I. The comparison of thyroid function tests in male and female showed that serum values of T3 and T4 were significantly lower in men of group I. By dividing results in age categories, serum levels of T4L in group II were significantly lower in the age group of 70 to 79 and 80 to 89. Thyroid function tests in asymptomatic ambulatory elderly tend to be normal, whereas the hospitalized patients showed a high proportion of alterations.

[Migrant erythema as clinical presentation of cutaneous larva migrans in Mexico City]. / Eritema migratorio como presentación clínica de larva migrans cutánea en la ciudad de México.

Cutaneous larva migrans (CLM) is a ubiquitous self-limited skin eruption, most frequently caused by the larvae of dog and cat hookworms. Although CLM is most frequent in tropical climates, the infection is becoming more common in urban areas. CLM has been frequently misdiagnosed and/or treated inappropriately, and mimics rheumatic, infectious, vascular, or dermatologic diseases. We here in report the clinical presentation and management of 18 cases of CLM.

[Preoperative assessment in adults]. / La valoración preoperatoria en el adulto.

UNLABELLED: The scope of this work is to analyze the usefulness and indications of preoperative evaluation. PATIENTS AND METHODS: 791 consecutive patients candidate for surgical treatment, were studied prospectively under the next inclusion criteria: 40 years old or less than 40 years old. Blood count cell, glucose, urea, creatinine, sodium, potassium, prothrombin time, partial thromboplastin time, platelets count, liver function tests, chest x-ray and electrocardiograph made before entry. In the the post liver, lung, bleeding, infectious or metabolic complications was done, while visiting the patients every day until discharge. Relative risk (RR) was calculated for every variable, analyzing differences with X2 and Fisher's Test. Those variables with statistical significance value were analyzed with logistic regression. Only 751 patients were studied, there were 335 male (44%) and 416 female (56%), with mean age of 63.9 years. Metabolic disorders (16.9%) and postoperative infections (7.0%) were the more frequent complications. Hemorrhage during of after surgery occurred in 2.2% of the patients. There were seventeen deaths (2.2%) related directly with surgery, with systemic illness or with postoperative complications. Selection of auxiliary tests for preoperative evaluation must be agree with clinical evaluation. The major objective of clinical evaluation is to estimate risk factors for surgery.

Infarto talámico bilateral secundario a oclusión de la arteria de Percherón / Bilateral thalamic infarct secondary to Percheron's artery occlusion

Resumen: La arteria de Percherón es una variante vascular que se caracteriza por una arteria tálamo-perforante dominante originada en el segmento P1 de la arteria cerebral posterior y se bifurca para irrigar a ambos tálamos en su porción paramedial. Su obstrucción se traduce en infartos talámicos bilaterales en el sitio paramedial. Se comunica el caso de un paciente de 85 años de edad con alteraciones en el estado de conciencia, con poca interacción con el medio y parálisis vertical de la mirada, al que se le realizó una resonancia magnética que evidenció infartos talámicos bilaterales. Las lesiones talámicas bilaterales son poco frecuentes. Los infartos talámicos representan 11% de los eventos vasculares y los bilaterales de 22 a 35% de los eventos vasculares talámicos; generalmente son de origen embólico y en raras ocasiones se asocian con hipoperfusión. La tríada típica incluye alteraciones del estado de conciencia, alteraciones de la memoria y parálisis vertical de la mirada. Aunque es una enfermedad infrecuente, es importante considerar la realización de estudios de imagen en pacientes con alteraciones del estado de conciencia que permitan descartar infartos talámicos como parte del diagnóstico diferencial.

Abstract: The Percheron's artery is a vascular variant characterized by the presence of a dominant thalamic-perforating artery originated in the P1 segment of the posterior cerebral artery; it forks to irrigate both thalamus in its paramedial portion. Its obstruction results in bilateral thalamic infarcts in the paramedial site. This paper reports the case of an 85-year-old man evaluated for alterations in the state of consciousness, associated with little interaction with the environment and vertical paralysis of the gaze. MRI evidenced bilateral thalamic stroke. The presentation of bilateral thalamic lesions is rare. The thalamic infarcts represent 11% of the vascular events, and the bilateral events 22 to 35% of the thalamic vascular events; they usually have an embolic origin and they are rarely associated with hypoperfusion. The typical triad includes alterations of the state of consciousness, alterations of the memory and vertical paralysis of the gaze. Although this is an infrequent disease, it is important to consider the performance of imaging studies in patients with alterations of the state of consciousness that allow to discard thalamic infarctions as part of the differential diagnosis.

Fiebres recurrentes / Recurrent fevers

Resumen: Las fiebres recurrentes corresponden a una proporción significativa pero menospreciada (18-42%) de las fiebres de origen desconocido. Un grupo de fiebres recurrentes, conocidas como enfermedades autoinflamatorias o síndromes hereditarios de fiebre periódica ocurren debido a una respuesta disregulada de la inmunidad innata, en donde ocurre una reacción autoinflamatoria que causa daño tisular. A diferencia de las enfermedades autoinmunitarias, las enfermedades autoinflamatorias no se asocian con autoanticuerpos específicos o complejos mayores de histocompatibilidad (CMHs), pero ocurren debido a la activación aberrante de las células de la inmunidad innata, como macrófagos y neutrófilos. Aunque la mayoría de los casos inicia durante la infancia, varios suelen ser diagnosticados años después de su inicio o comienzan durante la edad adulta, lo que justifica la necesidad de que el internista esté familiarizado con estas afecciones. En esta revisión discutimos la epidemiología, fisiopatología, manifestación clínica, diagnóstico y tratamiento de las principales enfermedades autoinflamatorias.

Abstract: Recurrent fevers make up a significant yet underappreciated proportion (18-42%) of fevers of unknown origin. A group of recurrent fevers, known as autoinflammatory diseases or hereditary periodic fever syndromes occur due to a deregulated response of innate immunity, whereby an autoinflammatory reaction occurs resulting in tissue damage. Unlike autoimmune diseases, the autoinflammatory diseases are not associated to specific autoantibodies or major histocompatibility complexes (MHCs), but rather result from an aberrant activation of innate immune cells such as macrophages and neutrophils. Although the majority of cases begin during childhood, several are often diagnosed years after their debut or begin during adult life, justifying the need for internists to be familiar with these diseases. In this review we discuss the epidemiology, pathophysiology, clinical presentation, diagnosis and management of the main autoinflammatory diseases.