[Caso clínico: síndrome de DRESS por hidroxicloroquina]

Background

DRESS syndrome (Drug reaction with eosinophilia and systemic symptoms) is an idiosyncratic reaction characterized by peripheral eosinophilia and systemic symptoms: fever, exanthema, lymphadenopathy, hepatitis, atypical lymphocytes and elevated liver enzymes. The incidence is 1 per 10,000 exposures, mortality 10-20%. Treatment is based on suspension of the suspected drug and steroids.

Case report

A 42-year-old male with the following important antecedents. AHF: mother and father with Diabetes Mellitus type 2. APP: Arterial Hypertension, Diabetes Mellitus type 2, and bee sting allergy. Current Condition: He started 8 days after ingestion of hydroxychloroquine for probable SARS-COV-2 infection, with headache, facial and neck edema, desquamative dermatosis on trunk and upper extremities, went to private clinic with torpid evolution sent to third level for increased facial and neck edema, which merited orotracheal intubation, management with intravenous steroids and antihistamines.

Labs on admission

Leukocytes 20090, platelets 322 thousand, eosinophilia (5%), elevated liver enzymes and acute kidney injury, fulfilling J-SCAR criteria. The patient was discharged due to adequate evolution with follow-up by Allergy and Clinical Immunology, the patient persists with desquamative lesions after 4 weeks and normalization of laboratory parameters.

Conclusions

DRESS is a delayed adverse reaction. It is important the diagnostic presumption and the causal relationship with the drugs due to the high mortality rate.

Consequences of a low protein diet on the liver and longissimus dorsi transcriptome of Duroc × Iberian crossbred pigs

Low protein diets supplied during the growing period of pigs can diminish their growth rate and increase the intramuscular fat (IMF) content which affects the sensorial and technological characteristics of the products. In the present study, the effects of a low protein diet supplied during the growing period of Duroc × Iberian crossbred pigs on several phenotypic traits and on liver and longissimus dorsi transcriptome were analysed at the beginning (EARLY) and at the end (LATE) of the growing period. Two experimental groups of 10 crossbred pigs each were fed two isocaloric diets with different protein content: control diet (C) with 16.5% protein and 0.8% lysine and low protein diet (LP) with 11% CP and 0.6% lysine. Animals fed LP diet have a slower growth than those fed C diet, but no effect of LP diet was observed on the IMF content. The transcriptomes of liver and longissimus dorsi were characterised and quantified through RNA-sequencing (RNA-seq). In liver, 134 and 480 differentially expressed annotated genes and new isoforms (DEGs) were detected between C and LP diets for EARLY and LATE animals, respectively. In muscle, 128 and 68 DEGs were detected at EARLY and LATE time-points. Functional interpretation revealed that LP diet may inhibit immune system molecules and processes in both tissues at EARLY stage. In liver, the DEGs mainly affect lipid and cholesterol metabolic processes, while in muscle, the expression changes would be involved in growth, development and meat quality. In conclusion, a low protein diet supplied during the growing period seems to slow down the growth of Duroc × Iberian crossbred pigs, but it also seems to affect multiple biological processes that could compromise the immune system of Duroc × Iberian crossbred pigs. Therefore, these results question the adequacy of this type of regime in Duroc × Iberian pigs that must be studied in greater depth before being implemented.

HLA-G 3'UTR Polymorphisms Are Linked to Susceptibility and Survival in Spanish Gastric Adenocarcinoma Patients

HLA-G is a non-classical class I HLA molecule that induces tolerance by acting on receptors of both innate and adaptive immune cells. When overexpressed in tumors, limits surveillance by the immune system. The HLA-G gene shows several polymorphisms involved in mRNA and protein levels. We decided to study the implication of two polymorphisms (rs371194629; 14bp INS/DEL and rs1063320; +3142 C/G) in paired tissue samples (tumoral and non-tumoral) from 107 Spanish patients with gastric adenocarcinoma and 58 healthy control individuals, to assess the possible association of the HLA-G gene with gastric adenocarcinoma susceptibility, disease progression and survival. The presence of somatic mutations involving these polymorphisms was also analyzed. The frequency of the 14bp DEL allele was increased in patients (70.0%) compared to controls (57.0%, p=0.025). In addition, the haplotype formed by the combination of the 14bp DEL/+3142 C variants is also increased in patients (54.1% vs 44.4%, p=0.034, OR=1.74 CI95% 1.05-2.89). Kaplan-Meier analysis revealed that 14bp DEL/DEL patients showed lower 5-year life-expectancy than INS/DEL or INS/INS (p=0.041). Adjusting for TNM staging (Cox regression analysis) disclosed a significant difference in death risk (p=0.03) with an expected hazard 2.6 times higher. Finally, no somatic mutations were found when comparing these polymorphisms in tumoral vs non-tumoral tissues, which indicates that this is a preexisting condition in patients and not a de novo, tumor-restricted, event. In conclusion, the variants predominant in patients were those increasing HLA-G mRNA stability and HLA-G expression, clearly involving this molecule in gastric adenocarcinoma susceptibility, disease progression and survival and making it a potential target for immunotherapeutic approaches.

Changes in the rumen and colon microbiota and effects of live yeast dietary supplementation during the transition from the dry period to lactation of dairy cows

The first objective of this study was to evaluate the dynamics and their potential association with animal performance of the microbiota in both the rumen and colon of dairy cows as they move from a nonlactation to a lactation ration. The second objective was to assess the potential effects on the microbiota of live yeast supplementation. Twenty-one Holstein cows were split in 2 treatments consisting of 1 × 10¹⁰ cfu/d of live yeast (LY; n = 10) or no supplementation (control; n = 11) starting 21 d before until 21 d after calving. At 14 d before and 7 and 21 d after calving, samples of rumen and colon digesta were obtained from each cow using an endoscope. Total DNA was extracted and submitted to high-throughput sequencing. Shannon diversity index, in both the rumen and colon, was unaffected by LY; however, in the rumen it was lowest 7 d after calving and returned to precalving values at 21 d in milk, whereas in the colon it was greatest 14 d before calving but decreased after calving. In the rumen, LY supplementation increased the relative abundance (RA) of Bacteroidales (group UCG-001), Lachnospiracea (groups UCG-002 and UCG-006), and Flexilinea 14 d before calving, and increased RA of Streptococcus 21 d after calving compared with control cows. However, changes in the ruminal microbiota were more drastic across days relative to calving than as influenced by the dietary treatment, and the effect of LY in the colon was milder than in the rumen. The ruminal RA of several genera was associated with postcalving DMI, and that of Gastranaerophilales was the only order positively associated with milk yield. Several genera were positively correlated with feed efficiency, with Clostridiales (unclassified) being the only genus negatively associated with feed efficiency. In the colon, Prevotellaceae (group Ga6A1) was the only genus positively associated with feed efficiency. The ruminal RA of Prevotella 7 and Ruminobacter 14 d precalving was negatively correlated with dry matter intake and milk yield postcalving. The RA of Parabacteroides in the colon 14 d before calving was negatively correlated with milk yield, whereas the RA of Eggerthellaceae (unclassified) and Erysipelotrichaceae (groups c and unclassified) were positively correlated with feed efficiency. Interestingly, LY supplementation doubled the RA of Eggerthellaceae (unclassified) in the colon. It is concluded that microbial diversity in the rumen experiences a transient reduction after calving, whereas in the colon, the reduction is maintained at least until 21 d in milk. Most of the effects of LY on rumen microbiota were observed before calving, whereas in the colon, LY effects were more moderate but consistent and independent of the stage of production. The microbial community of the rumen after calving is more associated with feed intake, milk yield, and feed efficiency than that of the colon. However, the colon microbiota before calving is more associated with feed efficiency after calving than that of the rumen.

Extracolonic Cancer in Inflammatory Bowel Disease: Data from the GETECCU Eneida Registry

OBJECTIVES

The objective of this study was (a) To know the prevalence and distribution of extracolonic cancer (EC) in patients with inflammatory bowel disease (IBD); (b) To estimate the incidence rate of EC; (c) To evaluate the association between EC and treatment with immunosuppressants and anti-tumor necrosis factor (TNF) agents.

METHODS

This was an observational cohort study.

INCLUSION CRITERIA

IBD and inclusion in the ENEIDA Project (a prospectively maintained registry) from GETECCU.

EXCLUSION CRITERIA

Patients with EC before the diagnosis of IBD, lack of relevant data for this study, and previous treatment with immunosuppressants other than corticosteroids, thiopurines, methotrexate, or anti-TNF agents. The Kaplan-Meier method was used to evaluate the impact of several variables on the risk of EC, and any differences between survival curves were evaluated using the log-rank test. Stepwise multivariate Cox regression analysis was used to investigate factors potentially associated with the development of EC, including drugs for the treatment of IBD, during follow-up.

RESULTS

A total of 11,011 patients met the inclusion criteria and were followed for a median of 98 months. Forty-eight percent of patients (5,303) had been exposed to immunosuppressants or anti-TNF drugs, 45.8% had been exposed to thiopurines, 4.7% to methotrexate, and 21.6% to anti-TNF drugs. The prevalence of EC was 3.6%. In the multivariate analysis, age (HR=1.05, 95% CI=1.04-1.06) and having smoked (hazards ratio (HR)=1.47, 95% confidence interval (CI)=1.10-1.80) were the only variables associated with a higher risk of EC.

CONCLUSIONS

Neither immunosuppressants nor anti-TNF drugs seem to increase the risk of EC. Older age and smoking were associated with a higher prevalence of EC.

Preliminary characterization of dexamethasone-loaded cross-linked hyaluronic acid films for topical ocular therapy

The aim of this work was to design and characterize cross-linked hyaluronic acid (HA)-itaconic acid (IT) films loaded with dexamethasone sodium phosphate salt (DEX) for topical therapy of inflammatory ocular surface diseases. Films were chemically cross-linked with polyethylene glycol diglycidyl ether (PEGDE), then physical and mechanical characterization by stress-strain, X-ray diffraction, X-ray fluorescence spectrometry and swelling assays was conducted. A sequential in vitro therapeutic efficacy model was designed to assess changes in interleukin (IL)-6 production in an inflamed human corneal epithelial (HCE) cell line after film exposure. Changes in cell proliferation after film exposure were assessed using the alamarBlue(®) proliferation assay. Experimental findings showed desirable mechanical properties and in vitro efficacy to reduce cell inflammation. A moderately decreased proliferation rate was induced in HCE cells by DEX-loaded films, compared to commercial DEX eye drops. These results suggest that DEX and HA have opposite effects. The sequential in vitro therapeutic efficacy model arises as an efficient tool to study drug release from delivery systems by indirect measurement of a biological response.

Ectopic origin of coronary arteries from the aorta in Syrian hamsters (Mesocricetus auratus)

An ectopic origin of the coronary artery from the aorta beyond the sinotubular junction, a condition commonly referred to as 'coronary artery high take-off', has been described in man and C57BL/6 mice. The present paper reports this congenital coronary artery anomaly in the Syrian hamster (Mesocricetus auratus). Hearts from 14 individuals, aged 53-350 days, were examined by means of a corrosion-cast technique, scanning electron microscopy or histological and immunohistochemical techniques. In 11 hamsters, the right coronary artery was the ectopic vessel. In the other three animals there was a solitary coronary ostium in the aorta. In all cases, the ectopic coronary artery originated at an acute angle and a valve-like ridge was in front of the coronary artery ostium. The ectopic arteries examined microscopically showed an intramural trajectory within the aortic wall. In the hearts with a solitary ostium in the aorta, the left main coronary artery coursed between the aorta and the pulmonary artery. In man, all of these anomalous conditions place the individual at risk of myocardial ischaemia and sudden death. However, none of the affected hamsters had clinical signs of disease. Intimal thickenings of increasing size with age were present in the intramural coronary artery segment of eight hamsters aged 106 days or older, examined histologically. The present findings fit with the notion that coronary arteries with acute angle take-off and an intramural course are subjected to unusual wear and tear, leading to tissue changes in the vessel wall.

[Subarachnoid anesthesia for cesarean section in a patient with Ehlers-Danlos syndrome type II]

A 32 year-old woman with full-term pregnancy and a history of Ehlers-Danlos syndrome type II underwent cesarean delivery owing to breech presentation and the presence of oligohydramnios. Anesthesia was provided with a subarachnoid block with 6.5 mg of bupivacaine and 32.5 microg of fentanyl to T4. Depth of anesthesia was adequate and hemodynamic stability was good. The intervention was uneventful and the outcomes were excellent for both mother and fetus. A subarachnoid block with low doses of local anesthetic and fentanyl is an appropriate, safe alternative to general anesthesia for cesarean section in women with Ehlers-Danlos who have normal coagulation tests and no history of bleeding.

Omentum flap versus pectoralis major flap in the treatment of mediastinitis

The outcome of mediastinal reconstruction during the past 10 years at the "Instituto Nacional de Cardiología Ignacio Chávez" (INCIC), Mexico City was compared. A total of 7136 patients were submitted to open heart surgery. Eighty-two patients (1.15 percent) developed mediastinitis, and 33 patients (0.46 percent) developed sternal osteomyelitis. Only patients who developed mediastinitis with sternal osteomyelitis were included in the study. Reconstruction was performed either with a major omentum flap (12 patients) or a pectoralis major flap (21 patients). The sepsis-related mortality rate was higher in the pectoralis group (28.6 percent) than in the omentum group (0 percent) (p < 0.05). All of the postoperative deaths of the pectoralis group were caused by septic shock; in the omentum group, there were no such deaths. It is concluded that mediastinal reconstruction using the omentum flap in patients with mediastinitis secondary to open heart surgery is associated with fewer septic complications than using the pectoralis major flap.

[Microscopic characteristics of epidural filter pores]

OBJECTIVE

The increased use of the epidural route for administering opioids to treat chronic pain and the need to reduce complications as much as possible, has led some authors to recommend using micro filters to reduce catheter contamination. This study was motivated by the lack of technical information documenting epidural filters used routinely, as well as by the scarcity of literature describing their characteristics. Our aim was to investigate the true nature of the membrane pores, their characteristics and dimensions.

MATERIAL AND METHOD

Samples from 30 epidural filters labelled "Porosity: 0.2 microns" from three different manufacturers were studied. Filters from Vygon, Braun and Abbot were labelled A, B and C, respectively. The samples were placed in six groups of five filters each, and 15 random studies were made of each sample. Three of the six groups were used to study prefiltration surfaces and the others to study postfiltration surfaces. Each sample was metalized with gold and its center was then studied by scanning electron microscope. Given that the pores were anfractuous, they were measured by taking the diameter of the largest circle fitting inside that could predict the size of the smallest spherical non elastic body that might be retained. The samples for measuring thickness were cryofractured for determining the number of filtration planes in the 15 filters.

RESULTS

Prefiltration surface: Pore diameters were 0.70 (0.66 to 0.74), 0.45 (0.41 to 0.49), and 2.077 (2.01 to 2.15) microns on the filtration surfaces of manufacturers A, B and C, respectively. The differences were significant (p < 0.01) and the pore shapes were also different. Postfiltration surface: The function pores of filters from manufacturers A and B measured 0.26 (0.25 to 0.28) and 0.26 (0.24 to 0.28) microns, and the differences were not significant. The pores of filters from company C were significantly larger (p < 0.01), measuring 0.46 (0.43 to 0.49) microns. There were significant differences (p < 0.001) in pore size on the pre- and postfiltration surfaces from all three manufacturers. Gauge: The five A, B and C filters averaged 130, 118 and 165 microns thick, respectively, with an average number of 140, 220 and 210 filtration planes, respectively.

CONCLUSION

The pores of filters for epidural use labelled "0.2 microns" actually had much larger pores on their prefiltration surfaces and throughout the membrane thickness. On the postfiltration surface, however, the diameters of pores on filters manufactured by Vygon and Braun approached 0.2 microns. Pores on filters manufactured by Abbot, however, were approximately 0.46 microns. We believe that in the future manufacturers should include more information in the documentation accompanying their filters.

[Electron microscopy of the lesions produced in the human dura mater by Quincke beveled and Whitacre needles]

INTRODUCTION

Comparisons of Quincke needles and non traumatic "pencil point" needles in recent years have reported lower rates of post dural puncture headache using the later type. Our new understanding of the morphology of the human dura mater motivated us to study dural lesions caused by the Whitacre 25 G and Quincke 26 G needles, using scanning electron microscopy with the aim of determining whether there is an anatomic basis for the different outcomes.

METHOD

The dura mater from three fresh cadavers of individuals aged 65, 70 and 72 years were punctured 40 times at an angle of 90 degrees each time. The Whitacre 25 G needle was used for 20 punctures and the Quincke 26 G needle was used for the other 20. Half the punctures were performed with the bevel in the parallel alignment and the other half with the bevel perpendicular to the spinal column. Fifteen min after causing the punctures, specimens were fixed in solutions of glutaraldehyde phosphate buffer and dehydrated in acetone. After critical point removal of the acetone, after the specimens were treated with carbon and metallized with gold. The lesions were examined externally and internally and expressed as the ratio of area of lesion to diameter of the needle that had caused them.

RESULTS

Whitacre needle: each lesion consisted in the superimposition of multiple damaged layers that started to close individually. After 15 min the outermost layers were 90% closed and the innermost ones had closed entirely. Layers in the arachnoid surface of the dura mater had closed from 86 to 88%, while deeper layers in the thick part had closed 97 to 98%. Quincke needle: lesions were V-shaped or half-moon shaped, much like the opening formed by a can opener, on both the external and internal surfaces. Alignment of the bevel of the needle parallel to the spinal column did not lead to a different shape of puncture. After 15 min the lesions had closed 94 to 95% on the epidural surface and 95 to 96% on the arachnoid side, a difference attributable to the retraction of the arachnoid layers over the spinal column.

CONCLUSION

Non traumatic beveled dural needles, termed "pencil point needles", only partially separate dural fibers, and lesions caused by these needles develop in a more complex way. The Quincke 26G needle produced a puncture that is morphologically different from that caused by the Whitacre 25G needle, although lesions produced by both types close more than 94% after 15 min. We believe the size of the lesion caused by these needles does not explain the difference in post dural puncture headache due to loss of spinal fluid.

[Predictive value of IGE in the newborn infant]

To study the relationship of IgE titles to development of allergy disease in the nursing, it was quantified the levels of this immunoglobulin in blood of the umbilical cord in healthy term eutrofic infants born consecutively in a period of two months. A total of 74 infants were followed for six with monthly appointments. The mean of IgE was 0.08 IU/ml with standard deviation of 0.15. Only two infants developed allergy, this determined a negative predictive value for IgE of 94%. Our outputs agree with that of other authors with respect to high negative predictive value of the low or normal levels of IgE in blood of the umbilical cord and the development of allergy. We concluded that its determination should limit to infants with family antecedent of atopy in order to improve the capacity of prediction of this illness.

[Analysis of the external and internal surface of human dura mater with scanning electron microscopy]

INTRODUCTION

In recent years several studies have raised questions about the anatomy of the human dura mater. Our objective has therefore been to examine its tridimensional structure with the aid of the scanning electron microscope.

METHOD

Samples were taken from 4 human cadavers (70, 72, 77 and 78 years old) between 8 and 12 hours after death. After fixing in glutaraldehyde phosphate buffer, dehydration in acetone and elimination of the acetone at the critical point, treatment with carbon and metallization with gold, the external and internal surfaces were examined.

RESULTS

The external, or epidural, surface of the dura mater is made up of thin collagen fibers joined in bands running in different directions. The outer surface and lower layers of the dura contain elastic, interwoven fibers surpassing 2 microns in diameter. The inner surface, which is smooth and glossy, is formed of thin ribbons of arachnoids that are fused and tightly attached to the structure of the dura mater.

CONCLUSION

The outer surface of the dura mater consists mainly of collagen fibers which alone or in groups run in different directions: longitudinally, horizontally or obliquely, depending on the are studied. These findings contradict the classical descriptions of the dura mater as having parallel, longitudinally placed collagen fibers in the tangential plane.

[Structural analysis of the thickness of human dura mater with scanning electron microscopy]

INTRODUCTION

The only references to the thickness of the human dura mater, reporting its size at various levels, are now 50 years old. Our aim was to study its tridimensional structure with the aid of the scanning electron microscope.

METHOD

The samples, which were taken 8-12 h after death from 4 human cadavers between 70 and 78 years old, were examined on 2 orthogonal planes (radial longitudinal and transversal).

RESULTS

The architectural structure of the external membrane of the meninges was unusual. The dura mater is made up of elastic collagen fibers organized in successive parallel planes on the surface of the medulla. Each plane constitutes a unit which we will call a sub-laminae. The sub-laminae are found in groups of 8 to 12 that form larger units called laminae, which are between 4 and 5 microns thick. The full thickness of the dura mater at the level of the third lumbar vertebrate contains from 78 to 82 laminae which together measure 270 microns.

CONCLUSION

The dura mater is made up of a large number of sublaminae that are concentrically parallel to the surface of the medulla. The fibers in general run in all directions and are oriented differently in each sub-lamina. The orientation of fibers that can be seen on the outer or epidural surface corresponds only to the fibers of the outermost lamina, which has a thickness of 78 to 82 microns. A needle that pierces the dura mater passes through some 700 to 800 sublaminae, each with its own particular distribution of fibers.

[Iatrogenic spinal epidermoid tumors. A late complication of spinal puncture]

INTRODUCTION. Epidermoid tumors in the spinal canal are rare. Whether congenitally or iatrogenically caused, they form as the result of epidermal cells implanted within the spinal channel. Such implantation can occur during a variety of procedures and events such as bullet wounds, surgery, myelography or punctures for diagnosis, anesthesia or treatment. Although this complication is not discussed in books or journals on anesthesiology, we have found it mentioned in over 100 published cases reporting iatrogenically caused spinal epidermoid tumors. ETIOPATHOGENESIS. Iatrogenic epidermoid tumors of the spine derive from the implantation of epidermal tissue transported inside the spinal canal during lumbar punctures without guidance or with inadequate guidance. There is ample evidence that such tumors are iatrogenic. All cases occur in patients with a history of lumbar puncture. They are rarely associated with congenital anomalies. They are extramedullary. They tend to develop near sites of earlier lumbar puncture, usually near the conus medullaris and the cauda equina. Iatrogenic epidermoid tumors of the spine have been reproduced experimentally in two studies in which autologous skin fragments were implanted in the spinal canal. CLINICAL SIGNS. These tumors are well tolerated by patients for extended periods of time, ranging from 2 to 10 years. At the cauda equinus, tumors can grow slowly for long periods without signs of nerve compression. Symptoms are directly related to tumor size and site. All patients with tumors at the cauda equinus report severe pain radiating toward the roots of compressed nerves. Nuclear magnetic resonance makes it possible to detect the tumor without administration of intrathecal contrast. At present gadolinium-DTPA improves the image so that these tumors can be distinguished from other types. The prognosis for epidermoid tumors of the spine is good, as they are histologically benign. Treatment is always surgical. CONCLUSION. Although the causal relation between epidermoid spinal tumors and lumbar puncture is well documented, anesthesiologists are not sufficiently aware of this possible complication. Between 1977 and 1995, 28 new cases were published. We believe that a deeper understanding of such rare complications will show us how to prevent them while providing appropriate use of epidural and subarachnoid anesthesia.