Fascitis necrotizante y síndrome del shock tóxico por Streptococcus pyogenes tras inyección intramuscular

Sr. Editor: La fascitis necrotizante (FN) es una infección grave, rápidamente progresiva y de difícil diagnóstico en estadios tempranos. Afecta a la fascia muscular y al tejido celular subcutáneo, produce trombosis de la microcirculación subcutánea, necrosis y se asocia a elevada mortalidad. Presentamos un caso de FN y shock tóxico por Streptococcus pyogenes. Mujer de 47 años de edad con antecedentes de hipertensión que acudió al Servicio de Urgencias por náuseas, vómitos, sensación distérmica, dolor intenso y tumefacción del glúteo y muslo izquierdo desde que 24 horas antes le fuera administrada una inyección intramuscular de metilprednisolona por faringoamigdalitis. Presentaba eritema (3,5 x 3 cm) en región glútea izquierda, sin fluctuación ni tumefacción, ni datos de repercusión sistémica. Se recomendó hielo local y continuar tratamiento iniciado el día anterior con amoxicilina-clavulánico. Doce horas más tarde acudió de nuevo a Urgencias por aumento del dolor. Se objetivó TA: 73/40 mm Hg, FC: 110 lpm, Tª: 35,5ºC. Se realizó TC observando aumento de tamaño de la zona glútea con pérdida de las interfases y desflecamiento del contorno. Se inició tratamiento con ertapenem y fluidoterapia, mejorando el cuadro hemodinámico. Seis horas después comenzó de nuevo con hipotensión, taquicardia, hiperlactacidemia e hipoglucemia, con progresión de la afectación cutánea en muslo. Se modificó tratamiento a meropenem y daptomicina. Se realizaron fasciotomía y necrosectomía extensas, ingresando en el Servicio de Medicina Intensiva, donde presentó shock refractario a volumen, precisando altas dosis de noradrenalina, signos de coagulación intravascular diseminada y fallo renal ..

Telomeric Heterochromatin Propagation and Histone Acetylation Control Mutually Exclusive Expression of Antigenic Variation Genes in Malaria Parasites

SummaryMalaria parasites use antigenic variation to avoid immune clearance and increase the duration of infection in the human host. Variation at the surface of P. falciparum-infected erythrocytes is mediated by the differential control of a family of surface antigens encoded by var genes. Switching of var gene expression occurs in situ, mostly from telomere-associated loci, without detectable DNA alterations, suggesting that it is controlled by chromatin structure. We have identified chromatin modifications at telomeres that spread far into telomere-proximal regions, including var gene loci (>50 kb). One type of modification is mediated by a protein homologous to yeast Sir2 called PfSir2, which forms a chromosomal gradient of heterochromatin structure and histone hypoacetylation. Upon activation of a specific telomere-associated var gene, PfSir2 is removed from the promoter region and acetylation of histone occurs. Our data demonstrate that mutually exclusive transcription of var genes is linked to the dynamic remodeling of chromatin

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Long or redundant leaflet complicating transcatheter mitral valve replacement: Case vignettes that advocate for removal or reduction of the anterior mitral leaflet

Transcatheter mitral valve replacement (TMVR) procedures can be an alternative to surgical valve replacement for high surgical risk patients with bioprosthetic mitral valves, annuloplasty rings, or severe mitral annular calcification (MAC). TMVR can trigger acute left ventricular outflow tract (LVOT) obstruction from permanent displacement of the native anterior mitral leaflet toward the left ventricular septum, more often among patients undergoing valve-in-ring and valve-in-MAC procedures. Although acute LVOT obstruction is well described in the literature, there are important additional complications of TMVR related to the length and/or redundancy of the anterior mitral valve that have been recognized after mitral valve surgery and have not been previously reported in the setting of TMVR. These additional complications include acute mitral regurgitation secondary to prolapsing native leaflet through the TMVR, frozen TMVR leaflet secondary to overhanging native leaflet and late LVOT obstruction in the neo-LVOT secondary to long native leaflet. Preprocedural planning with imaging (echocardiography and computed tomography) and measurement of anterior mitral leaflet length is critical important in understanding the risk for these complications. As transcatheter mitral valve technology proliferates, interactions with the anterior mitral leaflet after TMVR may be more frequent than initially anticipated. We believe that there is no advantage to an intact anterior leaflet and advocate removal or reduction of the leaflet prior to TMVR. © 2017 Wiley Periodicals, Inc

Long or redundant leaflet complicating transcatheter mitral valve replacement: Case vignettes that advocate for removal or reduction of the anterior mitral leaflet

Transcatheter mitral valve replacement (TMVR) procedures can be an alternative to surgical valve replacement for high surgical risk patients with bioprosthetic mitral valves, annuloplasty rings, or severe mitral annular calcification (MAC). TMVR can trigger acute left ventricular outflow tract (LVOT) obstruction from permanent displacement of the native anterior mitral leaflet toward the left ventricular septum, more often among patients undergoing valve-in-ring and valve-in-MAC procedures. Although acute LVOT obstruction is well described in the literature, there are important additional complications of TMVR related to the length and/or redundancy of the anterior mitral valve that have been recognized after mitral valve surgery and have not been previously reported in the setting of TMVR. These additional complications include acute mitral regurgitation secondary to prolapsing native leaflet through the TMVR, frozen TMVR leaflet secondary to overhanging native leaflet and late LVOT obstruction in the neo-LVOT secondary to long native leaflet. Preprocedural planning with imaging (echocardiography and computed tomography) and measurement of anterior mitral leaflet length is critical important in understanding the risk for these complications. As transcatheter mitral valve technology proliferates, interactions with the anterior mitral leaflet after TMVR may be more frequent than initially anticipated. We believe that there is no advantage to an intact anterior leaflet and advocate removal or reduction of the leaflet prior to TMVR. © 2017 Wiley Periodicals, Inc