Cytomegalovirus infection as a rare cause of colitis.

A 62 year-old-man with low anterior rectal resection and protective ileostomy, for low rectal neo and neoadjuvant QT +RT. Then ileostomy closure without incidences. On the 3rd postoperative day, he started with fever peaks and diarrhea. An abdominal CT scan showed diffuse thickening of the wall of the descending colon compatible with colitis and colonoscopy showed deep rectal ulcers with punch-like morphology with hyperemic mucosa with erythematous stippling of erosive appearance, showing this ulcerative pattern with numerous lesions and intensely edematous and congestive mucosa covered with abundant fibrinopurulent exudate in the descending colon. Biopsies and stool cultures were negative, but serologies were positive for CMV. Suspected CMV infection in a immunosuppressed by chemotherapy patient, he was treated with ganciclovir. The patient presented clinical improvement, without fever or diarrhea and improvement of the punch ulcers in the endoscopic controls, so he could be discharged from the hospital with follow-up in the outpatient consulting offices.

Photodynamic Therapy for the Treatment of Complex Anal Fistula.

BACKGROUND AND OBJECTIVES: To validate and analyze the results of intralesional photodynamic therapy in the treatment of complex anal fistula. STUDY DESIGN/MATERIALS AND METHODS: This prospective multicentric observational study enrolled patients treated for complex anal fistula who underwent intralesional photodynamic therapy (i-PDT). The included patients were treated from January 2016 to December 2018 with a minimum follow-up of 1 year to evaluate recurrence, continence and postoperative morbidity. Intralesional 5-aminolevulinic acid (ALA) gel (2%) was injected directly into the fistula. The internal and external orifices were closed. After an incubation period of 2 hours, the fistula was irradiated using an optical fiber connected to a red laser (Multidiode 630 PDT) operating at 1 W/cm for 3 minutes (180 J). RESULTS: In total, 49 patients were included (61.2% male). The mean age was 48 years, and the mean duration of fistula was 13 months. Of the fistulas included, 75.5% were medium transphincteric, and 24.5% were high transphincteric. The median fistula length was 4 ± 1,14 cm (range: 3-5). A total of 41 patients (83.7%) had a previous history of fistula surgery. Preoperatively, some degree of anal incontinence was found in 5 patients (10.2%). No center reported any other procedure-related complications intraoperatively. Phototoxicity was found in one patient. In the first 48 hours after the procedure, fever was reported in 2 patients (4%). At the end of follow-up, total healing was observed in 32/49 patients (65.3%). No patient reported new incontinence postoperatively. CONCLUSION: i-PDT could be considered a good choice in patients with complex anal fistulas to avoid surgery and its complications. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

[Diagnosis of lymph node metastases from papillary thyroid carcinoma by measuring thyroglobulin in the puncture needle. Calculation of optimal cut-off point in our series]. / Diagnóstico de metástasis ganglionares de carcinoma papilar tiroideo midiendo tiroglobulina en la aguja de la punción. Cálculo de punto de corte optimo en nuestra serie.

Fine-needle aspiration cytology (FNAC), used in suspicious cervical lymph nodes of unknown origin is frequently inconclusive and prone to false negatives. In order to evaluate the usefulness of measuring thyroglobulin in the washing with saline solution of the puncture needle for the diagnosis of metastasis of papillary carcinoma of the thyroid, an optimal thyroglobulin cutting point has to be calculated, being positive or negative depending on whether the thyroglobulin levels are higher or lower than the cutting point. We have retrospectively studied 33 patients (19 women and 14 men) with an average age of 49.3 years, with papillary carcinoma of the thyroid and suspected lymph node metastasis. Of them 16 (47.1%) had a positive FNAC. To determine thyroglobulin predictive capacity with regards to the metastasis of papillary carcinoma of the thyroid a ROC analysis was carried out with an under curve area UCA: 0.987 (CI 95%: 0.808-1.000) obtaining, using Youden's J statistic, 0.4 ng/ml as the thyroglobulin cutting point with best predictive capacity. The study of the relationship between thyroglobulin and the preservation/non-preservation of the thyroid showed statistically significant differences (P=.023). Our results validate 0.4 ng/ml of thyroglobulin as an optimal cutting point of the presence of metastasis of papillary carcinoma of the thyroid in lymph nodes. When reviewing the bibliography, a great diversity of cutting points may be found, which is explained mainly by the great inter-observer and inter-assay variability. That is why we recommend calculating each laboratory's own optimal cutting point; and determine in subsequent studies two cutting points depending on whether or not thyroid is preserved.

Postoperative Diet with an Oligomeric Hyperproteic Normocaloric Supplement versus a Supplement with Immunonutrients in Colorectal Cancer Surgery: Results of a Multicenter, Double-Blind, Randomized Clinical Trial.

(1) Background: For normo-nourished colorectal cancer patients, the need for immunonutrients after elective surgery is not known. (2) Methods: Multicenter, randomized, double-blind, phase III clinical trial comparing the postoperative diet with 200 mL oligomeric hyperproteic normocaloric (OHN; experimental arm) supplement vs. 200 mL immunonutritional (IN) (active comparator) supplement twice a day for five days in 151 normo-nourished adult colorectal-resection patients following the multimodal rehabilitation ERAS protocol. The proportions of patients with complications (primary outcome) and those who were readmitted, hospitalized for <7 days, had surgical site infections, or died due to surgical complications (secondary outcome) were compared between the two groups until postoperative day 30. Tolerance to both types of supplement and blood parameters was also assessed until day 5. (3) Results: Mean age was 69.2 and 84 (58.7%) were men. Complications were reported in 41 (28.7%) patients and the incidence did not differ between groups (18 (25%) vs. 23 (32.4%) patients with OHN and IN supplement, respectively; p = 0.328). No significant differences were found for the rest of the variables. (4) Conclusions: IN supplement may not be necessary for the postoperative recovery of colorectal cancer patients under the ERAS regimen and with normal nutritional status at the time of surgery.

Parkinsonism as presenting symptom of primary hyperparathyroidism: Improvement after surgery.

INTRODUCTION: Hypercalcemia can cause different neurological disorders, depending on the calcium level. We report an exceptional case of primary hyperparathyroidism presenting as neurological alteration and it has favourable outcome after parathyroidectomy. CASE REPORT: A 74-year-old woman presented with progressive cognitive deterioration and impaired motor function. The complementary tests showed hypercalcemia due to a parathyroid adenoma. Parathyroidectomy was performed with symptomatic improvement. CONCLUSION: Cognitive impairment of the elderly due to a parathyroid adenoma is underdiagnosed, behavioral changes and alterations of motor functions are attributed to age, dementia and frailty, representing a diagnostic challenge.

INTRODUCCIÓN: La hipercalcemia puede causar diferentes trastornos neurológicos, dependiendo de las concentraciones de calcio. Aportamos un caso excepcional de hiperparatiroidismo primario que se manifestó con deterioro neurológico rápidamente evolutivo y se resolvió mediante paratiroidectomía. CASO CLÍNICO: Mujer de 74 años que consultó por deterioro cognitivo progresivo y alteración de las funciones motoras. Las pruebas complementarias evidenciaron hipercalcemia debida a un adenoma paratiroideo. Se realizó paratiroidectomía, con mejoría sintomática. CONCLUSIÓN: El deterioro cognitivo del anciano por un adenoma paratiroideo está infradiagnosticado, pues los cambios de conducta y las alteraciones de las funciones motoras se atribuyen a la edad, la demencia y la fragilidad, suponiendo un reto diagnóstico.

[Metástasis en el lóbulo frontal como primera manifestación clínica de un carcinoma folicular de tiroides]. / Frontal lobe metastases as the initial presentation of follicular thyroid carcinoma.

ANTECEDENTES: El carcinoma folicular de tiroides puede producir metástasis a distancia, siendo las localizaciones más habituales el pulmón y el hueso. Las metástasis cerebrales son inusuales, y es poco habitual que aparezcan como primera manifestación de cáncer. CASO CLÍNICO: Paciente varón de 80 años, que tras una caída al suelo comenzó con alteración del comportamiento, desorientación y pérdida del control de esfínteres. La tomografía computarizada cerebral evidenció una masa en el lóbulo frontal derecho. Se realizó la extirpación de la lesión cerebral, cuyo estudio histológico informó de metástasis de carcinoma folicular de tiroides. CONCLUSIÓN: La manifestación de la enfermedad con metástasis cerebrales es muy infrecuente, y empeora el pronóstico notablemente. BACKGROUND: Follicular thyroid carcinoma can produce distant metastases, generally occur to lung followed by bone. Brain metastases are unusual, and onset manifestation is little frequently. CLINICAL CASE: A 80-years old men presented disturbance behavior, desorientation and loss of sphincters after fallin to the ground. Computed tomography scan showed a lesion in the right frontal lobe. The patient underwent a craniotomy to remove the brain tumor, histopathology confirmed of follicular thyroid carcinoma metastases. CONCLUSION: At initial diagnosis brain metastasis are extremely rare, with adverse prognosis.

Parkinsonism as presenting symptom of primary hyperparathyroidism: Improvement after surgery. / Parkinsonismo como síntoma principal de hiperparatiroidismo: recuperación tras cirugía

Introduction: Hypercalcemia can cause different neurological disorders, depending on the calcium level. We report an exceptional case of primary hyperparathyroidism presenting as neurological alteration and it has favourable outcome after parathyroidectomy. Case report: A 74-year-old woman presented with progressive cognitive deterioration and impaired motor function. The complementary tests showed hypercalcemia due to a parathyroid adenoma. Parathyroidectomy was performed with symptomatic improvement. Conclusion: Cognitive impairment of the elderly due to a parathyroid adenoma is underdiagnosed, behavioral changes and alterations of motor functions are attributed to age, dementia and frailty, representing a diagnostic challenge.

Introducción: La hipercalcemia puede causar diferentes trastornos neurológicos, dependiendo de las concentraciones de calcio. Aportamos un caso excepcional de hiperparatiroidismo primario que se manifestó con deterioro neurológico rápidamente evolutivo y se resolvió mediante paratiroidectomía. Caso clínico: Mujer de 74 años que consultó por deterioro cognitivo progresivo y alteración de las funciones motoras. Las pruebas complementarias evidenciaron hipercalcemia debida a un adenoma paratiroideo. Se realizó paratiroidectomía, con mejoría sintomática. Conclusión: El deterioro cognitivo del anciano por un adenoma paratiroideo está infradiagnosticado, pues los cambios de conducta y las alteraciones de las funciones motoras se atribuyen a la edad, la demencia y la fragilidad, suponiendo un reto diagnóstico.

[Pneumoperitoneum due to splenic abscess: a diagnostic challenge. Case Report]. / Neumoperitoneo por absceso esplénico: un reto diagnóstico. Reporte de un caso.

BACKGROUND: Splenic abscess is a rare clinic entity, its incidence has increased due to the rising number of clinical conditions involving immunosuppression. Endocarditis is the most frequent cause, and gram-positive aerobes are the main causal agents. Its clinical presentation is non-specific and delays diagnosis. Computed tomography scan is the method of choice, and the treatment is based on antibiotics and drainage, radiological or surgical, involving splenectomy in special cases that require it. CLINICAL CASE: A 55-year-old man with abdominal pain and fever. The analysis revealed leukocytosis 14,000/mm3, prothrombin activity 53%, and metabolic acidosis. Computed tomography scan showed a peri-hepatic pneumoperitoneum, liquid fluid, and peri-splenic bubbles, and slight trabeculation of fat around the duodenal bulb with pneumoperitoneum in this area. Patient underwent a median laparotomy, finding a purulent peritonitis due to a ruptured abscess in the spleen, splenectomy was performed. Fluid culture showed polymorphonuclears, with no microorganisms identified. The patient progressed and was discharged on the 5th post-operative day. CONCLUSIONS: Splenic abscess is an uncommon condition, in which the diagnosis is delayed and mortality, in untreated patients, is high. Its association with pneumoperitoneum may confuse the diagnosis towards viscera perforation. Thus it must be suspected in the finding of unknown cause of pneumoperitoneum by complementary examinations. The treatment of choice is splenectomy, because the capsular rupture is the norm in all of them.

[Psoas abscess as a differential diagnosis in emergency department]. / Absceso de psoas como diagnóstico diferencial en la patología abdominal de urgencias.

BACKGROUND: A psoas (or iliopsoas) abscess is a rare clinical entity with a wide etiological range. It is defined as a collection of pus that begins and extends through the iliopsoas muscle and can reach up to the inguinal region. METHODS: We performed a retrospective descriptive study by reviewing medical records from the General Surgery department of Reina Sofía's General University Hospital. Information was collected from patients diagnosed with psoas abscess who were admitted to the General Surgery department from 2006 to 2011. RESULTS: Five cases were reported for 6 years: four males (80%) and one female (20%). Average age was 51.6 years (range: 35--75). All were admitted to the hospital through the Emergency Department. Lumbar pain, fever and rash were clinical features in three patients. Two patients initiated with septic shock. Each patient had computed tomography performed, which confirmed the diagnosis. Causes of the abscess were as follows: one perforated colon neoplasm, two left hip osteomyelitis, one Crohn's disease and one primary abscess. Surgery was the treatment in three cases and placement of pigtail drainage was the treatment in two patients. Two patients were admitted to the Intensive Care Unit and ultimately died. CONCLUSION: In our case series report, it is seen that treatment delay developed to septic shock and death. We should consider this entity in emergency practice in order to carry out timely treatment.

Antecedentes: el absceso del psoas es una colección de pus que se localiza en el músculo psoas iliaco. Se produce por continuidad desde estructuras adyacentes o por diseminación hematógena; su etiología es diversa. Objetivo: describir la atención ofrecida a los pacientes con absceso de psoas ingresados en un servicio de cirugía general. Material y métodos: estudio retrospectivo y descriptivo de pacientes ingresados al servicio de Cirugía General y del Aparato Digestivo del Hospital General Reina Sofía, Murcia, España, entre enero de 2006 y febrero de 2012 con diagnóstico compatible con absceso de psoas. Resultados: se reunieron 5 casos: 4 varones (80%) y 1 mujer (20%) con una media de edad de 51.6 años (límites: 35 y 75). Todos ingresaron al servicio de Cirugía General desde Urgencias. La clínica fue: dolor lumbar, fiebre y enrojecimiento de partes blandas en 3 pacientes. Dos iniciaron con choque séptico. A todos los pacientes se les realizó tomografía computada abdominal que confirmó el diagnóstico. Las causas del absceso fueron: 1 neoplasia de sigma perforada; 2 osteomielitis de cadera izquierda; 1 enfermedad de Crohn, y 1 absceso primario. El tratamiento fue el drenaje quirúrgico en 3 casos, y colocación de pig tail bajo control radiológico en 2 pacientes. Dos necesitaron atención en la unidad de cuidados intensivos, donde fallecieron. Conclusión: el retraso en el tratamiento suele desembocar en choque séptico con resultado de muerte en todos los casos. Es importante tener en mente esta posibilidad diagnóstica para poder establecer el diagnóstico diferencial en urgencias y tratarla lo más temprano posible.

[Peritoneal gliomatosis]. / Gliomatosis peritoneal.

BACKGROUND: Peritoneal gliomatosis is characterized by the presence of miliary implants of mature glia on the peritoneum of patients with ovarian teratomas, usually immature. CLINICAL CASE: We report the case of a woman operated on 5 years earlier due to a right mature ovarian teratoma. When she was operated on due to left ovarian tumor she presented a miliary glial dissemination in omentum and peritoneum. CONCLUSION: The association of peritoneal gliomatosis ovarian teratomas is rare. Although the primary treatment and patient monitoring is focused on the teratoma, control should be maintained of peritoneal implants because of the possibility of malignancy. We believe it would be beneficial to establish a protocol for monitoring these lesions.

ANTECEDENTES: la gliomatosis peritoneal se caracteriza por la existencia de implantes miliares de tejido glial diseminados dentro de la cavidad abdominal de pacientes con teratomas ováricos, generalmente inmaduros. Caso clínico: paciente femenina intervenida cinco años antes de un teratoma maduro del ovario derecho, que al ser operada de un tumor en el ovario izquierdo se encontró diseminación miliar de tejido glial en el epiplón y el peritoneo. CONCLUSIÓN: la asociación de gliomatosis peritoneal con teratomas ováricos es infrecuente y, aunque el tratamiento principal y seguimiento de los pacientes está enfocado al teratoma deben controlarse los implantes peritoneales, por la posibilidad de malignización. Consideramos que sería benéfico establecer un protocolo para el seguimiento de pacientes con estas lesiones.

Síndrome del cascanueces (nutcracker): una causa rara de dolor abdominal / Nutcracker syndrome: a rare cause of abdominal pain

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¿Es el neumomediastino y enfisema cervical un signo de mal pronóstico en la dehiscencia de anastomosis colorrectal? / Is pneumomediastinum and cervical emphysema a sign of poor prognosis in colorectal anastomosis leakage?

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