Paracoccidioidomicosis con afectación mucocutánea. Reporte de un caso

Paracoccidioidomycosis is a systemic mycosis caused by the dimorphic fungus Paracoccidioides brasiliensis, with a high incidence in Brazil and Latin America. The disease is clinically, classified in a juvenile - acute form and a chronic adult form. The primary lesion starts in the lungs through the inhalation of Paracoccidioides brasiliensis through the respiratory tract. It may spread hematogenously and lymphatically to other organs, as well as the skin and mucous membranes. Skin and mucosa manifestations are characterized by the formation of granulomatous lesions, organized according to the type of host¨s pattern of immune response. People that works in agriculture and lives in rural areas are considered high risk of infection group. The diagnosis is based on direct identification of the fungus with the microscope, culture or histology sample of the clinical specimen. In addition, molecular biology techniques such as polymerase chain reaction (PCR) demonstrate high sensitivity, considered appropiate for diagnosis and follow-up treatment. The choice of treatment depends on the state of the disease and is medicated with azole derivatives such as amphotericin B and sulfonamides. It is reported the case of a male patient, a farmer, with no systemic contributor, who inhaled Paracoccidioides brasiliensis. He presented granulomatous lesions in oral cavity, clinical, imaging and histopathological examinations were carried out, to diagnose paracoccidioidomycosis with mucocutaneous affectation. He was successfully treated at the oral and maxillofacial surgery service of the National Hospital Hipólito Unanue (HNHU) Lima-Peru.La Paracoccidioidomicosis es una micosis sistémica causada por el hongo dimórfico Paracoccidioides brasiliensis, con alta incidencia en Brasil y América Latina. La enfermedad se clasifica clínicamente en una forma juvenil - aguda y una forma adulta crónica. La lesión primaria se inicia en los pulmones a través de la inhalación de Paracoccidioides brasiliensis por el tracto respiratorio. Puede extenderse por vía hematógena y linfática a otros órganos, así como la piel y las mucosas. Las manifestaciones en piel y mucosas se caracterizan por la formación de lesiones granulomatosas, organizadas de acuerdo con el tipo de patrón de respuesta inmune. Las personas que trabajan en la agricultura y viven en zonas rurales se encuentran en alto riesgo de infección. El diagnóstico se basa en la identificación directa del hongo con el microscopio, el cultivo o la histología del espécimen clínico. Además, las técnicas de biología molecular como la reacción en cadena de la polimerasa (PCR) demuestran una alta sensibilidad, adecuada para el diagnóstico y el seguimiento del tratamiento. La elección del tratamiento depende del estado de la enfermedad y se realiza con derivados de azol, como la anfotericina B y las sulfonamidas. Se reporta el caso de un paciente varón, agricultor, sin antecedentes sistémicos contributorios, que inhaló Paracoccidioides brasiliensis. Presentó lesiones granulomatosas en la cavidad oral, se realizó los exámenes clínicos, imagenológicos e histopatológicos, llegando al diagnóstico de paracoccidioidomicosis con afectación mucocutánea. Fue tratado con éxito en el servicio de cirugía bucal y maxilofacial del Hospital Nacional Hipólito Unanue Lima-Perú

Exéresis de odontoma complejo mediante osteotomía sagital de rama. Reporte de un caso

The odontoma is a benign tumor that comes from an alteration of differentiated epithelial and mesenchymal odontogenic cells capable of forming enamel, dentin and cement. The etiology is unknown, but it has been associated with infections, inherited abnormalities, odontoblastic hyperactivity and trauma. To small or average odontoma size, the acceptable treatment is tumor exeresis. The problem arises with large odontomas, whose removal involves the sacrifice of large amounts of bone, the potential for mandibular fracture and damage to the inferior alveolar nerve. To avoid these treatment complications, Rittersma and Van Gool introduced in 1979 the use of the sagittal-cut osteotomy technique of mandibular ramus. We report the case of a 37-year-old male patient, with no contributory systemic history, who presented increased volume of left side face associated with pain and purulent secretion; clinical, imaging and histopathological examinations were performed, arriving at the diagnosis of infected complex odontoma. It was successfully treated via sagittal osteotomy technique of the mandibular ramus at Hipólito Unanue Hospital´s Oral and Maxillofacial Surgery Service, Lima-Peru.El odontoma es un tumor benigno originado a partir de una alteración de células odontogénicas epiteliales y mesenquimatosas diferenciadas con capacidad de formar esmalte, dentina y cemento, siendo la diferencia entre ambos la organización del tejido dentario. La etiología es desconocida pero se ha asociado a infecciones, anomalías hereditarias, hiperactividad odontoblástica y traumatismos. Cuando el odontoma es de tamaño pequeño o promedio, el tratamiento aceptable es la exéresis del tumor. El problema surge con los odontomas grandes, cuya extirpación implica el sacrificio de grandes cantidades de hueso, el potencial de fractura mandibular y el daño del nervio alveolar inferior. Para evitar estas complicaciones en la extirpación de tumores grandes en la mandíbula, Rittersma y van Gool introdujeron en 1979 el uso de la técnica de osteotomía sagital de rama mandibular para tratar esta patología. Se reporta el caso de un paciente varón de 37 años, sin antecedentes sistémicos, que presentó aumento de volumen de hemicara izquierda asociado a dolor y secreción purulenta, se realizó los exámenes clínicos, imagenológico e histopatológicos, llegando al diagnóstico de odontoma complejo infectado. Fue tratado con la técnica osteotomía sagital de rama mandibular exitosamente en el servicio de cirugía bucal y maxilofacial del Hospital Nacional Hipólito Unanue, Lima-Perú

Comprehensive analysis and insights gained from long-term experience of the Spanish DILI Registry

Altres ajuts: Fondo Europeo de Desarrollo Regional (FEDER); Agencia Española del Medicamento; Consejería de Salud de Andalucía.Background & Aims: Prospective drug-induced liver injury (DILI) registries are important sources of information on idiosyncratic DILI. We aimed to present a comprehensive analysis of 843 patients with DILI enrolled into the Spanish DILI Registry over a 20-year time period. Methods: Cases were identified, diagnosed and followed prospectively. Clinical features, drug information and outcome data were collected. Results: A total of 843 patients, with a mean age of 54 years (48% females), were enrolled up to 2018. Hepatocellular injury was associated with younger age (adjusted odds ratio [aOR] per year 0.983; 95% CI 0.974-0.991) and lower platelet count (aOR per unit 0.996; 95% CI 0.994-0.998). Anti-infectives were the most common causative drug class (40%). Liver-related mortality was more frequent in patients with hepatocellular damage aged ≥65 years (p = 0.0083) and in patients with underlying liver disease (p = 0.0221). Independent predictors of liver-related death/transplantation included nR-based hepatocellular injury, female sex, higher onset aspartate aminotransferase (AST) and bilirubin values. nR-based hepatocellular injury was not associated with 6-month overall mortality, for which comorbidity burden played a more important role. The prognostic capacity of Hy's law varied between causative agents. Empirical therapy (corticosteroids, ursodeoxycholic acid and MARS) was prescribed to 20% of patients. Drug-induced autoimmune hepatitis patients (26 cases) were mainly females (62%) with hepatocellular damage (92%), who more frequently received immunosuppressive therapy (58%). Conclusions: AST elevation at onset is a strong predictor of poor outcome and should be routinely assessed in DILI evaluation. Mortality is higher in older patients with hepatocellular damage and patients with underlying hepatic conditions. The Spanish DILI Registry is a valuable tool in the identification of causative drugs, clinical signatures and prognostic risk factors in DILI and can aid physicians in DILI characterisation and management. Lay summary: Clinical information on drug-induced liver injury (DILI) collected from enrolled patients in the Spanish DILI Registry can guide physicians in the decision-making process. We have found that older patients with hepatocellular type liver injury and patients with additional liver conditions are at a higher risk of mortality. The type of liver injury, patient sex and analytical values of aspartate aminotransferase and total bilirubin can also help predict clinical outcomes

The management of acute venous thromboembolism in clinical practice - study rationale and protocol of the European PREFER in VTE Registry

Background: Venous thromboembolism (VTE) is a major health problem, with over one million events every year in Europe. However, there is a paucity of data on the current management in real life, including factors influencing treatment pathways, patient satisfaction, quality of life (QoL), and utilization of health care resources and the corresponding costs. The PREFER in VTE registry has been designed to address this and to understand medical care and needs as well as potential gaps for improvement. Methods/design: The PREFER in VTE registry was a prospective, observational, multicenter study conducted in seven European countries including Austria, France Germany, Italy, Spain, Switzerland, and the UK to assess the characteristics and the management of patients with VTE, the use of health care resources, and to provide data to estimate the costs for 12 months treatment following a first-time and/or recurrent VTE diagnosed in hospitals or specialized or primary care centers. In addition, existing anticoagulant treatment patterns, patient pathways, clinical outcomes, treatment satisfaction, and health related QoL were documented. The centers were chosen to reflect the care environment in which patients with VTE are managed in each of the participating countries. Patients were eligible to be enrolled into the registry if they were at least 18 years old, had a symptomatic, objectively confirmed first time or recurrent acute VTE defined as either distal or proximal deep vein thrombosis, pulmonary embolism or both. After the baseline visit at the time of the acute VTE event, further follow-up documentations occurred at 1, 3, 6 and 12 months. Follow-up data was collected by either routinely scheduled visits or by telephone calls. Results: Overall, 381 centers participated, which enrolled 3,545 patients during an observational period of 1 year. Conclusion: The PREFER in VTE registry will provide valuable insights into the characteristics of patients with VTE and their acute and mid-term management, as well as into drug utilization and the use of health care resources in acute first-time and/or recurrent VTE across Europe in clinical practice. Trial registration: Registered in DRKS register, ID number: DRKS0000479