V. Lorenzo Zúñiga

Epidemiología del síndrome de abstinencia alcohólica: Mortalidad y factores de mal pronóstico

INTRODUCTION: Patients with alcoholism and alcohol withdrawal syndrome (AWS) have a worse prognostic. METHODS: We have performed a retrospective analysis of the hospital discharges in with diagnosis include AWS from 1 of January of 1997 to the 31 of December of 2002. RESULTS: We identified 924 hospital stays with 2.4% of mortality (1.6% in Internal Medicine). Mortality is associated with greater age (57 years +/-15 vs. 49+/- 13, p < 0.005), with the diagnostic of hepatic cirrhosis (6.2 vs. 1.8%, p < 0.005), bacteraemia (10 vs. 1.8%, p < 0.001) and respiratory infection (9.6 vs. 1.8%, p < 0,001), with a lower mortality when AWS was secondary diagnosis (1.2 vs. 4.2%, p < 0.005). In multivariant analysis were associated with more mortality age (OR 1.03), hepatic cirrhosis (OR 3.4), bacteriemia (OR 4.5) and respiratory infection (OR 3.6). CONCLUSION: Alcohol withdrawal syndrome mortality could to benefit from treatment in an Internal Medicine Service.

Endocarditis por Stenotrophomonas maltophilia: presentación de un caso y revisión de la literatura

We report a case of a 65 year-old woman with late endocarditis of prosthetic aortic valve and paravalvular abscess by Stenotrophomonas maltophilia, which had an acute presentation for the memtionated abscess broken, with fever, bacteremia and congestive heart failure secondary to severity aortic regurgitation. Itacute;s a rare cause of endocarditis with only 22 cases descripted in medical literature, the most of them in parenteral drug addict and as complication of cardiac valve replacement. The literature is reviewed and relate the epidemiology, clinical and prognosis characteristics of this disease, the same as his treatment and prevention.

Análisis epidemiológico de los pacientes ingresados en un servicio de Medicina Interna

Objetives: To study the characteristics of the entered patients in an Internal Medicine department. Patients and Methods: Descriptive and observational study with the admissions elder than 65 years old in an Internal Medicine Department during the year 2002. The variables analized were: age, sex, intake date, discharge date, days of hospital stay, chronic disease previous, reason for admission (guide symptom), deceased and diagnosis at discharge. The statistical analysis was performed with measures of central tendency and of standard deviation, Chi-cuadrado, Mann-Whitney-Wilcoxon. Results: 770 patients were accepted for the study. The distribution in sex is similar, although the women show bigger median age. The most frequent chronic disease was isquemic hipertensive heart disease (25.7%) and the 64.9% of the patients have someone cardiovascular risk factor. The men show more cardiovascular risk factor and more chronic disease (p < 0.01). The most frequent was the dyspnea (42.7%). The most frequent diagnosis was the cardiac failure (20.6%). The 16.6% of the patients died in the hospital, and the most frequent diagnosis was respiratory tract infection (49.5%). Conclusions: The most frequents pathologies are the cardiopulmonary chronic disease of developed countries. The primary and secondary prevention and an improvement of chronic cardiopulmonary disease would be an effective way of cost control in these disease.

Patología digestiva alta en pacientes de edad avanzada con anemia ferropénica: comparación entre usuarios y no usuarios de anti-inflamatorios no esteroideos

Background: Iron-deficency anemia is common in the elderly. Chronic upper gastrointestinal bleeding is its most frequent cause. The use of non-steroidal antinflamatory drugs (NSAID) is common in older people. Gastrointestinal complications of NSAID may be also more frequent among the elderly. Aims: The study was aimed to evaluate if a history of regular NSAID use in elderly patients with iron-deficiency anemia is associated to characteristic findings on esophagogastroduodenoscopy. Materials and methods: A total of 91 patients (40% of males and 60% females) older than 65 years (mean age 77 years, range 65-90 years) entered the study. All of them had been admited to our Hospital for study of iron-deficien cy anemia. Thirty-eight patients were regular users of NSAID. Esophagogastroduodenoscopy was performed in all patients. Results: The prevalences of peptic ulcer, erosive gastritis/duodenitis, and esophagitis were similar in NSAID users and non-users (13 vs 11%, 18 vs 15%, and 26 vs 26%, respectively). A trend to a higher prevalence of gastric adenocarcinoma was observed the group of NSAID non-users (8% vs 23%, p=0.05). Esophagogastroduodenoscopy was entirely normal in 39% of NSAID users and 34% of NSAID non-users. Conclusions: Upper gastrointestinal lesions in elderly patients with iron-deficiency anemia are similar in NSAID users and non-users, with the exception of gastric adenocarcinoma which can be more common in NSAID non-users.

Bacteriemia por Leuconostoc spp. en paciente sin factores de riesgo

: Leuconostoc spp are gram-positive coccobacilli, catalase and oxidase negative, vancomycin resistant. Causes of infection have been reported previously but it has not been described confirmed bacteremia due to Leuconostoc spp in patient without other immunological disorders. We describe a case of bacteremia in a 64-years-old man with a prosthetic valve 7 months before to begin fever of unknown origin. We confirmed bacteremia due Leuconostoc spp and the treatment with respective antibiotics permits the cure. Leuconostoc spp should be considered as a potential cause of bacteraemia, but we would be observant to the bacteremias due vancomycin resistant germs, because in most cases the laboratory do not find the sensitivity to this antibiotic.

Correlación entre el mantoux y la fracción tuberculínica de la prueba de hipersensibilidad retardada, en una cohorte de pacientes VIH+, en función de su nivel de inmunodeficiencia, e incidencia de tuberculosis activa

OBJECTIVES: The aim of this work was to assess cellular immunity using the multitest CMI and relate its results with lymphocyte CD4 counts, and the risk to developed active tuberculosis if the multi-tests tuberculosis papula was positive. METHODS: Prospective longitudinal follow-up of 342 IDU patients, 210 infected with HIV-1 and seronegative 132 patients. The cohort study was 165 IDU HIV-1 positive patients (128 men, 37 female). Ages was 18 to 45 years. Study time were 25 months (8-25). Tuberculin skin tests and multitest IMC were performed at baseline and each three months, and screening from active tuberculosis were performed all study when necessary was considered. RESULTS: Actived tuberculosis developed in 9.25 cases per one hundred persons and year from follow-up in the ranges with better immunologic status (Score from PHR > 10 mm). There are an significative correlation between tuberculosis skin test diameter and PHR tuberculin fraction papula. CONCLUSIONS: PHR performed with Multitest IMC is an useful test to evaluate cellular immune system, and HIV-1 positive patients with energy in this test or positive tuberculine fraction must be considered to isoniazid (9 months) prophylaxis.

Grado de control de hipertensión arterial en población mayor de 65 años ingresada en un servicio de Medicina Interna

Objectives: To investigate hypertension control in elderly patients. To identify the cardiovascular risk factors and cardiovascular diseases associated with poor control of hypertension. To evaluate the pharmacologic treatment needed for the good control of hypertension. To analyse the existence of date in the medical history to evaluate the cardiovascular risk. Methods: A coss-sectional study of elderly hypertensive patients intaked between 1 to January 2002 to 31 December 2002 in a Internal Medicine Service. Blood pressure was measured in the standard manner. Blood pressure control was regarded as optimum if pressure averaged less than 140/90 mmHg or, in diabetics, less than 130/80 mmHg. Results: The study included 484 hipertensive patients. In the hypertensive patients, both systolic and diastolic blood pressures were well controlled in 53.9% of patients, systolic blood pressure alone in 2,1% and diastolic blood pressure alone in 30.8%. The isolated systolic arterial hypertension prevalence is bigger in the group with poor control, p < 0.001. The 77% of hypertensive patients associated other cardiovascular risk factor, and the 69% associated any cardiovascular disease. The 64% of hypertensive patients needed pharmacologic treatment. Conclusions: Arterial blood pressure control was optimum in only one out of two hypertensive patients. Diabetes is the most influential variable in poor control. The diuretics are the active ingredients more used in the hypertension therapeutic.

Diagnóstico por tomografía axial computarizada de sinusitis esfenoidal

Sphenoidal sinusitis is an uncommon pathology potencially dange condition, what we can find in young population. Clinically it is very difficult the diagnosis because of its nonspecific symptoms, but cranial computer tomography proves the diagnosis. The most cases were trated with antbiotics and recovered completely. We present a young-man with isolated sphenoidal sinusitis who were managed in our medical centre, and a review the literature.

Hepatomegalia pseudotumoral como forma de presentación de amiloidosis

Sr. Director: Como es sabido, la afectación hepática resulta un hecho frecuente en la amiloidosis. Suele mostrar una expresividad clínica variable con función hepática habitualmente conservada en la que, excepcionalmente, puede presentarse de forma similar a una hepatomegalia de carácter tumoral. Ello conlleva a una dificultad diagnóstica con entidades de índole neoplásica (1-6). Recientemente, tuvimos la oportunidad de diagnosticar un caso de amiloidosis que se presentó con importante hepatomegalia y a continuación se comenta: Se trataba de un varón de 63 años con antecedentes de etilismo crónico (consumo habitual de 80-100 g de etanol/día) y miocardiopatía en fibrilación auricular a tratamiento con digital y ácido acetilsalicílico. En la anamnesis el paciente refería, desde hacía cuatro meses, anorexia, astenia, adelgazamiento cuantificado en 5 kg de peso, sensación de plenitud postprandial y molestias en hipocondrio derecho. A la exploración destacaba auscultación arrítmica sin soplos y hepatomegalia de unos 15 cm bajo arcada costal en línea media clavicular, dura e irregular de borde liso y no dolorosa. En los datos complementarios: hemograma normal. VSG de 40 mm a la primera hora. GGT 500 UI/L (N: 1-39), Fosfatasa alcalina 465 UI/L (N: 230-460), Colesterol total 282 mg/dl (N: 145-255), Triglicéridos 255 mg/dl (N: 35-150), el resto de los parámetros bioquímicos fueron normales. Fibrinógeno 495 mg/dL (N: 200-450) y los otros parámetros de coagulación estaban dentro de los límites de la normalidad. En el análisis elemental de orina se evidenció proteinuria superior a 3 g/l. En el proteinograma se halló elevación de las alfa2 y beta globulinas siendo normales las determinaciones de inmunoglobulinas, cadenas ligeras y alfaproteína. El EKG presentaba fibrilación auricular con frecuencia ventricular media de 80 lpm y datos de HVI. La ecografía y una TAC abdominal pusieron de manifiesto una marcada hepatomegalia homogénea, sin datos de hipertensión portal, bazo de tamaño normal y litiasis biliar única. Ante la sospecha de cirrosis hepática y/o hígado tumoral se realizó biopsia hepática percutánea, tras la cual obtuvimos el diagnóstico histopatológico de Amiloidosis hepática con afectación, fundamentalmente, periportal y mediazonal. Se inició tratamiento a base de colchicina (1,2 mg/día) observándose al cabo de seis meses mejoría del estado general y ligera reducción de la hepatomegalia así como marcada disminución de la proteinuria, normalizándose asimismo los parámetros enzimáticos de colestasis. En la expresividad clínica de la amiloidosis hepática es común la sintomatología inespecífica, la presencia de hepatomegalia y las alteraciones analíticas con moderada elevación de las enzimas de colestasis (3,4). Por ello, y debido a la presencia de una hepatomegalia inexplicada, está indicada la realización de biopsia (4). Los casos que cursan con colestasis intrahepática severa, hipertensión portal o insuficiencia hepática severa son menos frecuentes habiéndose descrito, incluso, procesos de evolución fatal (1,4,7,8). En este caso, y con el fin de llegar al diagnóstico definitivo, fue preciso efectuar una biopsia hepática que cursó sin complicaciones. No obstante, cabe destacar que la toma de la muestra, en estos enfermos, parece incrementar (3%) el riesgo de hemorragía postpunción e, incluso, de forma espontánea, como consecuencia de anormalidades en la coagulación incluyendo deficit de factor X y por la infiltración del amiloide en la pared vascular (4,9). Para concluir, en todo paciente con expresividad clínica inespecífica y gran hepatomegalia, pese a su carácter excepcional de presentación, debe tenerse en cuenta la amilodosis en el diagnóstico diferencial.