An 81 year old female patient with chronic heart failure and atrial fibrillation receiving anticoagulant therapy, was admitted with progressive pain on her right leg for the past 24 hours, associated to local erythema, edema and warmth. The lesion evolved at the same site where she presented a chronic ulcer for the previous 5 months managed only with local care. At admission a necrotic plaque on the affected site was perceived; there was no hypotension or mental confusion but signs of a deep venous thrombosis on the involved leg were found. She was febrile (37.8 o C) and with tachychardia (126 per minute). Laboratory evaluation revealed normal white blood cell count and a subtherapheutic anticoagulant INR value. A chest xray showed infiltrates on the left lower lung lobe. On the following hours the lesion evolved with increasing pain, haemorrhagic bullae and a purulent discharge through the ulcer, with the patient developing mental deterioration, hypotension, respiratory failure and shock. The patient received intravenous ciprofloxacin and clindamycin and was operated 15 hours after admission performing an over-the knee amputation. A cardiac catheterization demonstrated a low cardiac output (2.3 L/min), and both a high systemic vascular resistance (2888 din.s.cm -5 ) and pulmonary capillary wedge pressure (17 cm H 2 O), results compatible with cardiogenic shock. Evolution was progressively worse and she died of multiple organic failure 36 hours after admission. Two blood culture samples grew Serratia marcescens. No necropsy was performed and cultures taken from the leg remained negative. La paciente ingresó a comienzos de mayo de 2006, por un cuadro fulminante de 24 horas de evolución, con dolor progresivo en la pierna derecha, aumento de volumen y eritema en torno a la lesión ulcerada. Al examen físico destacaba la presencia de fiebre (37,6 ºC axilar), taquicardia (126 latidos por min) y un marcado edema en la pierna derecha, con calor local y una lesión ulcerada necrótica con halo eritematoso de 10 por 5 cm, en el tercio medio de la cara lateral externa. No había hipotensión arterial, compromiso de conciencia, ritmo de galope ni congestión pulmonar al ingreso. Los exámenes iniciales indicaron: leucocitos Introducción a fascitis necrosante es una infección poco frecuente que se caracteriza por necrosis del tejido subcutáneo y la fascia, con trombosis de la microcirculación. Puede progresar rápidamente con toxicidad sistémica y, eventualmente, causar la muerte si no se diagnostica y trata en forma rápida. La diferenciación con infecciones frecuentes como celulitis y abscesos es muy importante. Tradicionalmente, esta infección ha sido ligada a algunas variantes virulentas de Streptococcus pyogenes y, rara vez, a bacilos gramnegativos. Recientemente, observamos un caso fulminante asociado a Serratia marcescens que nos pareció de interés comunicar. Caso clínicoPaciente de sexo femenino, de 81 años, con antecedentes de hipertensión arterial, insuficiencia cardíaca
Popliteal artery aneurysm Popliteal artery aneurysms are uncommon, affecting 0.1% of the population. They are generally asymptomatic and rupture is unusual. The surgical indications of the condition are the presence of symptoms and a diameter over 2 cm. Surgical treatment of choice consists in aneurysm exclusion and revascularization with saphenous vein. Endovascular treatment is a therapeutic alternative in deteriorated patients.
Spontaneous dissection of superior mesenteric arteryIntroduction: Spontaneous dissection of the superior mesenteric artery (AMS) is a infrecuent pathology, representing the main frequency of isolated peripheral artery dissection, it is more common in males and occurs in the fifth decade of life. Materials and Methods: Retrospective cases analysis of patients with spontaneous dissection of AMS that were handled in our hospital, in last two years. Results: Two patients were diagnosed in this period, both active smoking and hypertensive pathology, appearing with severe abdominal and back pain. The diagnosis was made by CT angiogram of the abdomen and pelvis; establishing medical management of hypertension and standard heparin anticoagulation. Both patients had dissections at new imaging controls and one patient required exploratory laparotomy with bowel resection and intestinal anastomosis. Patients recovered satisfactorily and are in control. Conclusions: Spontaneous dissection of the SMA is a rare disease with uncertain evolution, it may occur in middle age of life, associated with smoking and hypertension. The suspected diagnosis is clinical and can be confirmed by CT angiography. Initial management remains conservative and occasionally is surgical.
median arcuate ligament syndrome background: Median arcuate ligament syndrome (SLAM) is caused by extrinsic compression of the celiac artery by fibrous bands of this ligament and periaortic lymph node tissue. case report: We report a 59 years old man with a history of weight loss, epigastric pain and a postprandial murmur. The syndrome was diagnosed by CT angiography. The patient was operated, performing a midline laparotomy and releasing the extrinsic compression. An early and sustained remission of symptoms was achieved. resumen introducción: El síndrome del ligamento arcuato medio (SLAM), es causado por la compresión extrínseca del tronco celíaco por bandas fibrosas de este ligamento y tejido ganglionar periaórtico. caso clínico: Reportamos el caso de un hombre de 59 años con historia de baja de peso, dolor postprandial y soplo epigástrico, al cual se le diagnostica SLAM por medio de angioTC. Se realiza abordaje quirúrgico, con laparotomía media y liberación de la compresión extrínseca, logrando remisión de los síntomas de forma inmediata y sostenida. El SLAM es una causa infrecuente de dolor abdominal, requiere estudio por imágenes para su diagnóstico, la resolución quirúrgica constituye su tratamiento.Palabras clave: Síndrome ligamento arcuato medio, clínica, diagnóstico, tratamiento quirúrgico.
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