Francisco Félix Rodríguez-Vidigal

Motivo de ingreso en pacientes infectados por el virus de la inmunodeficiencia humana en un área rural. Papel de la hepatopatía crÓnica

Objetivos Conocer si tras la introduccion del tratamiento antirretroviral de gran actividad (TARGA) ha existido una modificacion en las causas de ingreso de los pacientes infectados por el virus de la inmunodeficiencia humana (VIH) y evaluar la influencia de la infeccion por el virus de la hepatitis C (VHC). MEtodos Se estudiaron retrospectivamente las causas de ingreso en pacientes infectados por el VIH en nuestro hospital, desde el 1 de enero de 1994 hasta el 31 de diciembre de 1997 (grupo 1, ningun caso con TARGA) y desde el 1 de enero de 1998 hasta el 30 de junio de 2001 (grupo 2, 63% con TARGA). Se analizaron parametros epidemiologicos, virologicos, inmunologicos y los datos de infeccion por el VHC. Resultados Los ingresos del grupo 2 correspondian a pacientes de mayor edad media (34,7 ± 6,3 frente a 30,6 ± 4,6 anos; p = 0,0037) y mayor recuento de linfocitos CD4+ (256 ± 243 frente a 146 ± 178; p = 0,044) y sus estancias eran significativamente menores (7,7 ± 6,3 frente a 17,5 ± 16,7; p = 0,003). En el grupo 2 se redujo la proporcion de ingresos por enfermedades definitorias de sida (29% frente a 50%; p = 0,046) y aumento la proporcion de ingresos por hepatopatia descompensada (22% frente a 0%; p = 0,007). Entre los pacientes que fallecieron durante el ingreso existia una mayor frecuencia de recuento bajo de linfocitos CD4 (77,8% frente a 43,3%; p = 0,05), infeccion activa por el VHC (100% frente a 57,9%; p = 0,02) y de enfermedad definitoria de sida o hepatopatia descompensada como motivo de ingreso (81,8% frente a 45%; p = 0,02) que entre los supervivientes. El recuento bajo de linfocitos CD4 se asocio de modo independiente con la mortalidad (odds ratio, 1.063,1; intervalo de confianza del 95% [IC 95%], 1,3-838.855,5). Conclusiones En nuestro medio, desde la introduccion del TARGA, ha disminuido la frecuencia de infecciones oportunistas y ha aumentado la frecuencia de hepatopatia descompensada como causa de ingreso.

Mortalidad hospitalaria en el Servicio de Medicina Interna de un hospital de primer nivel

BACKGROUND AND OBJECTIVE: Hospital mortality is a indicator of quality of care, and their study may improve assistance of hospitalized patients. Our objective was to know the most frequent death causes of hospitalized patients, to identify clinical and analytical variables associated with each cause, and to determine gender differences. MATERIAL AND METHODS: A systematic and retrospective revision of 113 medical reports of death patients was carried out; it corresponded 26% of all deaths occurred between March 2002 to November 2004. At each case, epidemiological variables, previous clinical reports, biochemical and haematological parameters, death cause and in-hospital complications were registered. RESULTS: Mean age was 79 +/- 10 years and 58.4% of cases were males. Thirty eight percent had previous admission, and 45% had functional class III-IV. Men died with less age that women (76.6 +/- 10.3 versus 82.3 +/- 8.0 p < 0.002) and they had more frequent antecedents of chronic bronchopulmonary disease (43% versus 19%, p <0.04); however, women had worse ventilatory situation at admission. The main death causes were cardiopulmonary (56% whole, 34% because of respiratory insufficience, 14% because of pneumonia, and 8% because of acute lung oedema), followed by neurological causes (25% whole, 23% because of stroke) and 19% because another reason (neoplasia, multiorganic failure, hepatic insufficience and renal failure). Patients died from cardiopulmonary cause had a more frequent previous hospitalization (p < 0.04). Patients died from neurological cause had higher systolic and diastolic blood pressure at admission (p < 0.0001), higher rate of hypertension (p < 0.0001) and more frequent nosocomial fever (p = 0.0001). CONCLUSIONS: In our Service, male patients died with less age that women, the main death causes were cardiorespiratory diseases and subsequently neurologic diseases. Hypertension at admission was most frequent in patients died from neurologic cause.

Infección por el virus de la hepatitis C en un hospital de primer nivel de ámbito rural: estudio descriptivo en la década 1991-1999

INTRODUCTION: To assess epidemiology, clinical manifestations and prognostic factors in subjects diagnosed with hepatitis C virus (HCV) infection in a first level rural hospital. METHODS: This retrospective study includes 142 patients diagnosed with HCV infection at the Hospital de Llerena, from August 1991 to December 1999. Epidemiological and clinical parameters were collected at a mean of 2.7 years after diagnosis and prognostic factors were analyzed. RESULTS: HCV infection predominated in males (69%) and the mean age of patients was 48.3 6 19.3 years. Mechanisms of transmission included unknown (46.5%), intravenous drug use (39.4%), and transfusions (14.1%). Human immunodeficiency virus coinfection was present in 23% of patients and hepatitis B virus (HBV) coinfection in 5.6%. At the time of diagnosis, 111 patients (78.2%) were asymptomatic; 26 (18.3%) presented with complications of portal hypertension and 5 (3.5%) with extrahepatic symptoms. Ultrasonographic signs of portal hypertension were observed in 32.4% of cases. Hepatocarcinoma was detected in 17 patients (12.0%) and extrahepatic neoplasms in 14 (9.9%). Twenty-eight patients died (19.7%). Independent risk factors for mortality included HBV coinfection (OR 26.9; 95% CI 2.19-331.47), ultrasonographic signs of portal hypertension (OR 11.0; 95% CI 3.38-32.61) and diagnosis of hepatocarcinoma (OR 182.7; 95% CI 14.85-2248.21). CONCLUSIONS: Between 1990 and 1999 in our hospital HCV infection was frequently diagnosed in advanced stages and was associated with high mortality, particularly when ultrasonographic signs of portal hypertension or HBV coinfection were present.

Mycobacterium mageritense meningitis in an immunocompetent patient with an intrathecal catheter

Mycobacterium mageritense is a non-pigmented rapidly growing microorganism identified as a new species in the year 1997 in Madrid, Spain.1 Since 2002, there are several published papers of clinical infections caused by M. mageritense (e.g., sinusitis, pneumonia, skin and soft tissue infections, and catheterrelated bacteraemia).2–6 Different antimicrobials (doxicicline, ciprofloxacine, amykacine, imipenem, linezolid and trimethoprim/sulfamethoxazole) have been used for the treatment of these infections. We report here our experience with an immunecompetent patient diagnosed of M. mageritense meningitis likely associated to an intrathecal catheter. In July 2008, a 39-year-old woman was admitted at her reference hospital because of fever. She was carrier of an intrathecal catheter (with a reservoir for epidural analgesia); also, she was taking several psychotropic drugs because of posttraumatic back pain and left radiculopathy (following a car crash). There was a purulent discharge in the reservoir area. Therefore, both the epidural catheter and the reservoir were removed. Microbial cultures (three set of blood, the exudates and the catheter tip) were all negative. An empirical combination of intravenous (IV) vancomycin and gentamicin was prescribed during 14 days. There was total resolution of fever and the patient was discharged from her reference hospital. Twenty days later (August 2008), she developed a new fever (38.5 ◦C), headache and somnolence, and the back pain increased significantly. She was remitted to our hospital. The cerebrospinal fluid (CSF) study showed a count of 246 leukocyte/ L (60% of mononuclear’s cells), 33 mg/dL of glucose, 155 mg/dL of protein, and the adenosinedeaminase (ADA) was 29 U/L (normal range: <9 U/L). CSF usual stains, bacterial cultures and LCR serology (VDRL, Brucella sp., Listeria monocytogenes, Coxiella burnetii, Leptospira sp., and Borrelia sp.) were all negative. A Mantoux test was negative. Chest X-ray was within normal limits. Empirical treatment with rifampin, isoniazid, pyrazinamide and ethambutol in standard doses was prescribed. Twelve days after, the patient developed a sudden facio-braquio-crural hemiplegy. NMR study showed several ischaemic infarcts (at the protuberance and right intern capsule). The first CSF culture in Löwenstein medium (August 2008) was positive for a mycobacterium. The isolate was sent to the National Reference Laboratory for Mycobacteria and identified by phenotypic methods as colonies non-pigmented after 3 days of incubation at 22, 30, 37 and 42 ◦C, negative for Tween Hydrolysis and heat-stable catalase test, positive for arylsulfatase activity at 3 days, and for nitrate reductase. Furthermore, it was identified as M. mageritense by PCR-RFLP of hsp65 gene.8 The strain showed three fragments (240, 130 and 85 bp) by BstEII restriction enzyme digestion and three fragments (145, 120 and 60 bp) by HaeIII restriction enzyme digestion. In addition, the identification was confirmed by sequencing of 16S rRNA gene. Susceptibility testing was made by the proportions method (on Agar 7H10) that showed resistance to isoniazide, streptomycin, ethambutol, rifampicin, P.A.S., kanamycin, cycloserine and ethionamide. Pirazinamide susceptibility on MGIT 960 was made following the manufacturer recommendations. The susceptibility to other drugs (amikacin, norfloxacin, ofloxacin, ciprofloxacin, imipenen, linezolid, trimetil-sulfametoxazol, capreomycin, doxiciclin, claritromycin, amoxicillin-clavulanic and tobramycin) was made by E-TEST (on Mueller-Hinton agar). Table 1 Mycobacterium mageritense infections.

Epidemiología del carcinoma hepatocelular en un área rural: Papel de los virus hepatotropos en la supervivencia

BACKGROUND: Chronic hepatitis C and B are the main causes of hepatocellular carcinoma (HCC) worldwide. It is not clear whether chronic hepatitis C or B virus (HCV or HBV) infection is a prognostic factor for HCC. This study aimed to asses epidemiology of HCC in a rural area and to determine if chronic HCV or HBV infection had any impact on survival after the diagnosis of HCC. MATERIAL AND METHODS: Fifty-one consecutive patients were retrospectively studied. All of them were diagnosed of HCC between january 1994 and december 2002 in a First Level Hospital. The following variables were analysed: age, sex, HCV and HBV infection, chronic alcohol abuse (daily intake upper 80 g), clinical presentation, Child stage, number ol liver nodules, therapeutic options and survival. RESULTS: The mean age at diagnosis of HCC was 68,5 years old (age range 45-90) and 45 patients (88,6%) were male. Heavy alcohol intake (66%) and chronic HCV infection (42,8%) were the most prevalent etiologic factors. Chronic HBV was found in 11,9%. Chronic HCV or HBV infection was present in 48,9%. Twenty-five percent were asymptomatic and 66% were in Child stage A. The rate single lesion / multilobular HCC was 52/48. Only 6% of all patients could be treated with a curative intention. The mean survival was 10,9 +/- 9,1 months, and there were no differences in age, sex, Child stage and number of nodules. There was a significantly higher survival in patients with chronic HCV or HBV infection (16,7 +/- 13,1 months versus 4,75 +/- 5,3 months in seronegative patients; p=0.02). On multivariate analysis, only chronic HCV or HBV infection was associated with survival longer than 10 months (OR 22,3; CI 95% 1,8-277,9). CONCLUSIONS: In our area, heavy alcohol abuse and HCV infection were the most prevalent etiologic factors of HCC. Chronic HCV or HBV infection was associated with longer survival in patients with HCC.

Patogenia de la lipodistrofia y de las alteraciones metabólicas asociadas a la infección por el VIH

La lipodistrofia y las alteraciones metabolicas (dislipemia, insulinorresistencia) asociadas a la infeccion por el virus de la inmunodeficiencia humana (VIH) conforman un sindrome multifactorial por la interaccion de factores relacionados con el hospedador (inmunidad celular, dieta, mutaciones en determinados genes), el virus (sintesis de citocinas, deplecion de acidos grasos poliinsaturados) y los farmacos antirretrovirales (inhibicion de la ADN polimerasa mitocondrial, inhibicion de la lipolisis, reduccion de la sintesis de adiponectina). El propio VIH puede intervenir en la diferenciacion de los adipocitos y en el metabolismo de los lipidos, efecto debido a ciertas citocinas proinflamatorias (factor de necrosis tumoral), con la participacion de otros factores (farmacos, dieta) y el particular contexto genetico del hospedador. El adipocito (y diversos receptores celulares, acidos grasos, proteinas de membrana y citocinas) parece desempenar un papel primordial en la patogenia de la lipodistrofia asociada al VIH.

Infecciones por gonococo

Introduccion. La gonorrea o gonococia es una inflamacion purulenta de las superficies mucosas del tracto genital, recto, orofaringe y/o conjuntiva, causada por Neisseria gonorrhoeae (gonococo). Ocasionalmente puede pasar a la sangre y causar infeccion gonococica diseminada (gonococemia). Taxonomia y microbiologia. N. gonorrhoeae es un diplococo gramnegativo, muy labil, de crecimiento lento y requerimientos nutritivos especiales, precisando medios de cultivo enriquecidos. Se visualizan al microscopio de luz como diplococos dentro de los polimorfonucleares neutrofilos. Patogenia y estructura antigenica. N. gonorrhoeae es un parasito exclusivo del ser humano. No forma parte de la flora habitual. Sus mecanismos de virulencia son la adhesion e invasion de las celulas mediante las moleculas de su membrana externa, principalmente los pili o fimbrias, las proteinas de membrana externa I, II y III y los lipooligosacaridos. Epidemiologia. La gonococia tiene una distribucion mundial. El riesgo aumenta con el numero de parejas sexuales y con la presencia de otras enfermedades de transmision sexual. Es mas frecuente en el varon, pero las complicaciones son mas comunes en la mujer.

Infecciones por enterobacterias productoras de betalactamasas de espectro extendido tras cirugía cardiaca: su impacto en la mortalidad

Introduction Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ES BLEE) increasingly cause nosocomial infections. It is controversial whether they are associated to a worse prognosis. The motivation for this study is to analyse if infections caused by ES BLEE after a cardiac surgery show a worse diagnosis that those caused by non-multidrug-resistant enterobacteriaceae.

Cirugía cardiovascular del adulto − Artículo originalInfecciones por enterobacterias productoras de betalactamasas de espectro extendido tras cirugía cardiaca: su impacto en la mortalidadExtended-spectrum beta-lactamase-producing Enterobacteriaceae infections after cardiac surgery: their impact on mortality

Introduction Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ES BLEE) increasingly cause nosocomial infections. It is controversial whether they are associated to a worse prognosis. The motivation for this study is to analyse if infections caused by ES BLEE after a cardiac surgery show a worse diagnosis that those caused by non-multidrug-resistant enterobacteriaceae.

Linezolid, Staphylococcus coagulasa-negativa y el problema de las resistencias

El linezolid es una oxazolidinona eficaz frente a cocos grampositivos por inhibir la sı́ntesis proteica mediante su unión a la subunidad 50S del ribosoma bacteriano. Se emplea con frecuencia en infecciones nosocomiales causadas por Staphylococcus aureus (S. aureus), Staphylococcus coagulasa-negativa (SCN) y especies de Enterococcus. Los SCN, especialmente Staphylococcus epidermidis (S. epidermidis), son actualmente la causa más frecuente de bacteriemia primaria. En una elevada proporción son resistentes a meticilina. Hace apenas una década, los SCN eran mayoritariamente sensibles a linezolid, sin embargo, a partir de 2006 se ha demostrado una frecuencia creciente de resistencias. Se define la resistencia a linezolid como la concentración mı́nima inhibitoria igual o superior a 8 mg/ml. La resistencia se ha asociado a clones portadores del gen cfr (chloramphenicol florfenicol resistance). Este gen determina una mutación puntual en el dominio V del 23S ARNr bacteriano (expresada por una actividad metilasa en la posición A2503). Los brotes nosocomiales descritos se han asociado al uso de linezolid durante los 3 meses previos al aislamiento bacteriano. En nuestro centro (un hospital terciario de referencia), más del 10% de las cepas de SCN aisladas son resistentes a linezolid. Con la intención de conocer si los pacientes diagnosticados de una infección nosocomial por SCN resistente a linezolid (SCNRL) presentaban unas caracterı́sticas clı́nicas y pronósticas diferentes a los infectados por una cepa sensible (SCNSL), analizamos de