arlos Pérez C

Endocarditis infecciosa: análisis de 261 casos y resultados del tratamiento con un enfoque multidisciplinario

Background: Early diagnosis, an effective treatment and prompt recognition of complications are essential to improve the prognosis of infective endocarditis (IE) Aim: To report the results of a multidisciplinary approach to diagnosis and management of patients with IE at the Universidad Catolica de Chile Hospital. Patients and methods: The clinical history, diagnosis, treatment and outcome of 261 episodes (Duke criteria) of IE admitted between January 1980 and January 1999 were analyzed. These included 185 episodes of native, 73 of prosthetic valve and 3 of nonvalvular IE. Results: Sixty nine percent of patients were men and the mean age was 49 ± 16 years. Seventy five percent had a definite diagnosis of IE (Duke). S. viridans, staphylococci and enterococci together constituted 85% of the isolated bacterial strains. Twenty seven had culture-negative IE, related to a high incidence of antibiotic therapy prior to diagnosis. Transesophageal echocardiography was performed in 102 cases and it detected vegetations in 91% of aortic and 96% of mitral IE, rupture or prosthesis dehiscence in 67% of aortic and 52% of mitral IE and abscesses in 51% of aortic and 15% of mitral IE. Fifty one percent developed heart failure and 34% had embolic events. S. aureus IE was associated to a higher incidence of embolic events, complications which contraindicated surgery and increased mortality rate (27%). Of all patients, 40% were treated exclusively with antibiotics, 52% were operated on and 8% had surgical indication but were nonoperable because of serious complications. The overall mortality was 16.3%: 13% in the medical, 9% in the surgical and 81% in the non-operable groups. The type of treatment and mortality rates did not differ between IE of native valves and prosthetic valves. Long term follow up showed survival rates of 73% at 5 years and 66% at 10 years. Conclusion: A multidisciplinary approach may be very helpful to improve the prognosis of IE. (Rev Med Chile 2000; 128: 708-20).

Craniectomía descompresiva en una paciente con encefalitis herpética asociada a hipertensión intracraneana refractaria

Herpetic encephalitis is the most common cause of viral encephali-tis in our country. Pathological studies show progressive necrosis and edema in specific territo-ries of the brain. The mortality of herpetic encephalitis was reduced from 70% to 20% with theuse of intravenous aciclovir in the first three days of illness. However, almost 50% of patientsdevelop a neurological deficit. One of the most important causes of death in herpetic encephali-tis is the refractory intracranial hypertension. There are anecdotal reports of patients with re-fractory intracranial hypertension due to herpetic encephalitis that were treated with decom-pressive craniectomy with good results. We report a 21 years old female patient with herpeticencephalitis and refractory intracranial hypertension that was successfully treated with a de-compressive craniectomy (Rev Med Chile 2003; 131: 1434-8).(

Encefalitis herpética: Serie clínica de 15 casos confirmados por reacción de polimerasa en cadena

Resumen La encefalitis herpetica es la causa mas frecuentede encefalitis esporadica en el mundo occidental.Para conocer las principales caracteristicas clinicasde esta enfermedad en nuestro medio, se efectuo unanalisis de casos confirmados por reaccion depolimerasa en cadena en dos hospitales universita-rios de Santiago. Un total de 15 casos pudo seridentificado con un promedio de edad de 41 anos (5-78 anos) y 80% ≥ 30 anos, el primero de ellos el ano1998. La mayor parte se presento con fiebre y com-promiso de conciencia (80% cada uno) o cefalea(67%). Las convulsiones y la focalizacion fueroninfrecuentes (≤ 15%) y solo 2 casos (13%) tuvieronademas una manifestacion herpetica extracerebral.La duracion promedio de los sintomas fue de 3,8dias. La mayor parte estuvo asociada al serotipo 1(86,7%). El 91,7% de los casos evaluados presentoalteraciones electroencefalograficas, 81,8% altera-ciones en la resonancia magnetica y solo 13,3% enla tomografia axial computarizada. La totalidad de lospacientes fue tratada con aciclovir y la letalidad fuede 13,3%, aunque el deceso en un paciente conSIDA y linfoma del SNC no pudo ser atribuido a lainfeccion herpetica. Seis pacientes (40%) presenta-ban secuelas neurologicas al momento del egreso.La muerte o alteraciones neurologicas al alta estu-vieron asociadas significativamente a un inicio deltratamiento > 3 dias desde el inicio de los sintomas.(p = 0,01 prueba bilateral de Fisher).

Coinfecciones por virus hepatitis B, virus hepatitis C, Treponema pallidum y Toxoplasma gondii en la cohorte de pacientes VIH positivos en control en la Pontificia Universidad Católica de Chile

Three hundred ninety five patients (aged 16 to 89 years, 359males) were included in the review. Seventy nine percent had been tested for HBV status with HBsAg,and the global HIV-HBV co-infection prevalence was 6.1%. A subgroup of 190 individuals were testedfor HBV infection with HBsAg and IgM/IgG anti-HBc markers. Of these, 46% fulfilled co-infectioncriteria: eight with acute hepatitis B, 11 with chronic hepatitis B and 69 with inactive HBV infection.The frequency of HIV-HBV co-infection was 48% and 22% among men and women respectively (NS).HCV-HIV co-infection was detected in 3%, syphilis-HIV co-infection in 21% and T gondii-HIV co-infection in 26%.

Reconocimiento de influenza-A como etiología de síndrome febril e insuficiencia respiratoria en adultos hospitalizados durante brote en la comunidad

: Adults subjects, with Influenza A confirmed by antigen detection test, hospitalized in theclinical hospital of the «Hospital Clinico de la Universidad Catolica de Chile» between May and June,with fever or respiratory symptoms were studied. A special record was designed to register clinical,microbiological and therapeutic data.

Etiología de la neumonía en pacientes chilenos infectados por el virus de la inmunodeficiencia humana

Objetivos: Establecer la etiologia de la neumonia y comparar el rendimiento de diferentes tecnicas para el diagnostico de las infecciones por Pneumocystis jiroveci y Mycobacterium tuberculosis en pacientes con infeccion por virus de inmunodeficiencia humana (VIH). Material y Metodos: De cada paciente se obtuvo esputo inducido y se efectuo LBA. A las muestras obtenidas se les realizo tinciones de Gram, Ziehl-Neelsen, plata e inmunofluores-cencia (IF) para P. jiroveci y M. tuberculosis; reaccion de polimerasa en cadena (RPC) para ambos microorganismos; cultivos aerobicos, fungicos, para micobacterias, virus respiratorios y citomegalovirus. Tambien se realizo determinacion de IgM de Mycoplasma pneumoniae y Chlamydophyla pneumoniae y antigeno urinario de Legionella pneumophila. Resultados: Se incluyeron 60 pacientes, lograndose diagnostico etiologico en 97% de los casos. Pneumocystis jiroveci fue la etiologia mas frecuente (58%), seguida por Streptococcus pneumoniae (12%) y Mycobacterium avium complex (MAC) (12%). Mycobacterium tuberculosis fue encontrado en 5%. Conclusiones: La comparacion de los metodos diagnosticos para P. jiroveci mostro una mayor sensibilidad de la IF y tincion de plata en LBA que en esputo; sin embargo, la RPC fue igualmente sensible en ambos tipos de muestras. Con esta estrategia se logro establecer etiologia en la gran mayoria de los pacientes. La etiologia mas comun fue P. jiroveci. IF en LBA sigue siendo el estandar para el diagnostico de la neumonia por P. jiroveci.

Enfermedad de Hansen: Revisión a propósito de un caso

Leprosy is a granulomatous disease affecting the skin and peripheral nerves caused by Mycobacterium leprae. The range of clinical forms varying from tuberculoid to lepromatous leprosy results from variations in the cellular immune response to the mycobacterium. Despite available combined drug-therapy, it continues to be a significant public health problem, carrying a strong stigma. Although recently there has been no native cases in Chile, a few imported cases have been diagnosed. We present a 56-year-old man who had lived in Paraguay for 8 years, and presented with leprosy 6 years after returning to Chile. The biology of leprosy, clinical features of the disease, current diagnostic criteria and approaches to treatment are discussed.

Cirugía valvular reparadora en endocarditis infecciosa

Background: Valve replacement has been the treatment of choice for patients with valvular complications of infectious endocarditis (IE). However, excellent results with valve repair allowed it to become a new therapeutic alternative for these patients. Aim: To evaluate the results of valve repair in patients with valvular complications of IE. Patients and Methods: From January 1991 to December 2000, 14 patients with valvular complications of IE underwent valve repair. Mean age was 37.9 ± 14.9. Results: New York Heart Association (NYHA) class was 2.8 ± 0.9. IE was located in the aortic in 6 (42%), in the mitral valve in 4 (29%) and in both valves in 4 cases (29%). Surgical indication was hemodynamic in 50% of the cases, echocardiographic in 29% and septic in 21%. Five aortic valves were bicuspid, 3 mitral valves were myxomatous and the rest were normal. The most common septic lesions were vegetations and leaflet perforations. A total of 23 aortic and 21 mitral valve repair procedures were performed. There were no deaths. Only 1 patient had a surgical complication (renal failure and prolonged mechanical ventilation). Follow-up was 100% complete. There was not late mortality. One patient with bone marrow aplasia required reoperation for a new episode of IE 19 months later. At the end of the follow-up NYHA class was 1.3 ± 0.6 and echocardiography showed a mild or absence of valve regurgitation in most patients. Conclusions: Valve repair surgery in IE has good results, with advantages over valve replacement (Rev Med Chile 2004; 132: 307-15). (Key Words: Cardiovascular surgical procedures; Endocarditis, bacterial; Surgical procedures, operative)

Diagnóstico de la infección por Treponema pallidum en pacientes con sífilis temprana y neurosífilis mediante reacción de la polimerasa en cadena

Syphilis is a sexually transmitted disease caused by Treponema pallidum. The diagnosis is based mainly in clinical presentation and non-specific assays. PCR-based diagnosis has been suggested as an attractive alternative method. The aim of this study was the validation of a PCR-based test for the diagnosis of early syphilis (ES) and neurosyphilis (NS). Clinical samples of mucocutaneous lesions and cerebrospinal fluid (CSF) specimens from patients previously diagnosed for ES and NS respectively using an enlarged gold standard, were tested by PCR. The reaction was done using primers targeting the tpN47 gene. Twenty out of 21 mucocutaneous samples from patients diagnosed with ES were positive by PCR, with a clinical sensitivity of 95%. Four out of 8 CSF samples from patients previously diagnosed with NS were positive by PCR, with a clinical sensitivity of 50%. The clinical specificity for both ES and NS was 100%. The PCR sensitivity and specificity for mucocutaneous samples allowed us to implement this assay in our laboratory for routine diagnosis. Although the sensitivity of the PCR in CSF was low, it may be useful to support clinical diagnosis.

Usefulness of the determination of IgG and IgM antibodies by ELISA and immunocapture in a clinical series of human brucellosis

INTRODUCTION The diagnostic difficulties of brucellosis makes the evaluation of new diagnostic tests necessary. OBJECTIVES Evaluation of different commercial tests in the serological diagnosis of brucellosis by ELISA and immunocapture antibodies in a clinical series of patients with brucellosis of the Health Network of the Catholic University of Chile. METHODS All the serums received in the Laboratory of Microbiology for suspicion of brucellosis during five years were studied. Two groups were obtained, one that fulfilled diagnostic criteria for brucellosis [clinical evidence, and/or positive blood culture and/or seroagglutination test (SAT) in titers > 1/160] and the control group. Each serum sample was analyzed using irnmunocapture-agglutination test (Brucellacapt), ELISA IgM and IgG. RESULTS Of 10 patients with brucellosis, the serologic results were: 8/10 positives for ELISA IgG, 7/10 for Brucellacapt and SAT, and 5/10 for ELISA IgM. DISCUSSION ELISA IgG alone was superior than SAT. The combination ELISA IgG/ Brucellacapt reaches the best detection performance (9/10) and can be an alternative to SAT.