Influenza virus infection has a great and underestimated impact in the emergency department during influenza epidemics. High frequency of confusing symptoms, which overcome classical influenza syndrome in adult people with comorbidity, may explain this effect. Disproportionate prostration and cough are symptoms that independently predict its diagnosis in the global adult population, whereas in the elderly, fever and cough should arouse this suspicion whether or not they present classic symptoms. In our setting, individuals with high comorbidity are inadequately vaccinated.
A case of group A streptococcal meningitis is reported and the 51 cases reported in the literature since 1966 reviewed. A total of 24 men and 24 women were included in the study; the mean age (+/-SD) was 20.9+/-25.5 years. Fifty-eight percent of the patients had comorbid conditions, 80% had a distant focus of infection, and 65.8% had blood cultures positive for group A streptococci. Seventy-five per cent of the patients were treated with penicillin. The overall case-fatality rate was 12% (6 patients). Sequelae were more prevalent among children (44%) than among adults (7.7%) (OR=9.43; 95% CI, 1.02-438.95; P=0.03). Group A streptococcus is a rare cause of pyogenic meningitis, affecting mainly children or adults with comorbidity. Although the case-fatality rate is relatively low, neurological sequelae are frequent among survivors, especially children.
We describe a 54-year-old woman with diffuse myxoedematous infiltration at the site of a smallpox vaccination scar as the presenting symptom of Graves' disease. Associated features included acute ocular symptoms (vascular congestion of the sclera, epiphora and blurred vision) and transient erythema on both shins. However, there were no signs of pretibial myxoedema. A number of neoplastic, inflammatory and systemic diseases may localize to scar tissue in skin, including at smallpox vaccination sites, but this case demonstrates the unusual occurrence of myxoedematous infiltration at such a site and illustrates a most atypical cutaneous presentation of Graves'disease.
A 69-year-old woman suffering from exophthalmos and facial pain came to us referred for aetiological diagnosis of exophthalmos. Orbital MRI showed thinned extrinsic ocular musculature, intraconal fat infiltration, retro-ocular compression and thickening of maxillary and sphenoid sinus walls. She had been suffering from diabetes insipidus for the last 7 years. During our diagnosis process, she presented signs of cardiac tamponade. Transthoracic heart ultrasound revealed large pericardial effusion and a heterogeneous mass that compressed the right ventricle. No osteosclerotic lesions on appendicular bones were present. Pericardiocentesis temporarily controlled tamponade and corticoid therapy temporarily abated exophthalmos. Pericardiectomy definitively resolved tamponade. Histological examination of pericardial tissue was conclusive of Erdheim-Chester disease. Exophthalmos responded to pegylated interferon-alpha-2a. Facial bone pain disappeared after zoledronic acid and interferon treatment. During interferon therapy, the patient suffered from a severe generalised desquamative exanthema that slowly resolved after discontinuing interferon. Diabetes insipidus remains controlled with desmopressin.
In order to evaluate the effects of one-year antihypertensive treatment on plasma lipids and lipoproteins, 65 patients whose diastolic blood pressure was in the range 95-120 mmHg were randomly allocated to groups that received either hydrochlorothiazide or metoprolol, or both drugs when the response to one of them was insufficient to control blood pressure. Blood pressure was effectively reduced in all groups. Patients on hydrochlorothiazide showed a significant increase (P less than 0.01) in low-density lipoprotein cholesterol (LDL-C) after 3 months of treatment. A significant increase in triglycerides was observed after 6 and 12 months, together with a decrease in high-density lipoprotein cholesterol (HDL-C) after 12 months (P less than 0.05) of treatment in patients on metoprolol. In patients treated with both hydrochlorothiazide and metoprolol, total cholesterol increased after 3 (P less than 0.001) and 6 months (P less than 0.05), triglycerides increased after 6 (P less than 0.01) and 12 months (P less than 0.01), and LDL-C increased after 3 (P less than 0.05), 6 (P less than 0.001) and 12 months (P less than 0.01) of treatment, respectively. In 61% of the patients, three or more lipid parameters were affected during the study period. We conclude that long-term antihypertensive treatment with hydrochlorothiazide, metoprolol, and particularly with both drugs, can induce lipid effects that deserve recognition, because in some cases these might counteract the possible benefit of a reduction in blood pressure on the prevention of coronary heart disease.
RESUMENFudamentos: La primoinfección por el virus varicela-zoster en el adulto adquiere una inusitada gravedad debido a complicaciones entre las que la neumonía es la más frecuente. Se estudian nueve pacientes diagnosticados de neumonía varicelosa.Pacientes y métodos: Se revisan retrospectivamente las peculiaridades clínico-terapéuticas y evolutivas de una serie de pacientes, tanto inmunocompetentes como inmunodeprimidos, diagnosticados en los últi-mos diez años en el Hospital de Sant Pau de Barcelona. El diagnóstico de varicela se estableció por la aparición del típico rash en el contexto de una enfermedad febril. Se valoran los antecedentes de tabaquismo, embarazo y la presencia de enfermedades de base; analizando especialmente la gasometría arterial y la cifra plaquetar al ingreso.Resultados: Se estudian 9 pacientes, 4 hombres y 5 mujeres, con una edad media de 38 años. El 78% eran fumadores de más de 20 cigarrillos/día, uno cumplía criterios de bronquitis crónica, otro tenía una espondilitis anquilopoyética y tres se conocían portadores del virus de la inmunodeficiencia humana. Ninguna de las pacientes estaba embarazada. Los síntomas respiratorios se iniciaron entre el tercer y el quinto día de aparición del exantema, siendo los más frecuentes tos (89%), disnea (67%) y expectoración hemoptoica (22%). La gasometría arterial evidenció hipoxemia en cuatro (45%). Asimismo se objetivó trombocitopenia al ingreso en seis (66%). La radiografía de tórax mostró un patrón intersticial de predominio bibasal en todos los casos observándose un caso de derrame subpulmonar derecho. Se instauró terapia con aciclovir intravenoso en seis pacientes, foscarnet en uno y tratamiento sintomático en dos. Todos los pacientes siguieron una correcta evolución clínica no precisando ninguno de ellos ser ingresados en la U.C.I.Conclusiones: Los pacientes adultos con neumonía varicelosa que presentan insuficiencia respiratoria, trombopenia o son portadores de enfermedades de base deben recibir precozmente aciclovir por vía intravenosa. No obstante, si bien la mejoría clínica, biológica y radiológica serían más precoces con dicho tratamiento, la evolución parece igualmente favorable si sólo se instaura, por ejemplo, terapia sintomática con antitérmicos y antihistamínicos.
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