Neuroartropatía diabética en fase aguda: un dilema diagnóstico. A propósito de dos casos y revisión de la bibliografía

INTRODUCTION

Charcot's neuroarthropathy is a progressive deterioration of bones and joints, mainly the ankle and foot of the diabetic patients suffering severe neuropathy. Its pathogeny is not well known, although mechanical, vascular and neurological factors are thought to be involved, generally with a precipitating minor traumatic even. Charcot's foot acute phase is inflammatory, and it is often confused with other diseases such as arthritis, cellulitis and deep venous thrombosis (DVT). This leads to delays or errors in the diagnosis, the patient coming to the hospital too late with severe foot deformation.

OBJECTIVE

Thus, it must always be posed as differential diagnosis in a diabetic patient who comes with a warm and inflamed foot, generally without fever, even more if he has a severe autonomic or somatic neuropathy. In the acute onset, the only treatment has been complete and long term off-loading with a total contact cast that should be initiated immediately after diagnosis. More recent studies show promising results with biphosphonates to decrease bone turnover in acute phase.

CONCLUSION

We present two cases of acute Charcot's foot and we briefly review the bibliography.

[Infectious complications of heart transplantation. A prospective study for the first 6 years of a transplantation program]

OBJECTIVE

To study the infectious complications, mortality, and associated factors in heart transplant recipients.

METHODS

Prospective study of the first 69 heart transplantations performed from January 1991 until December 1996 in a university hospital. Description of clinical features of infectious complications during the first year after transplantation. Univariate and multivariate analyses of the risk factors associated with mortality and development of infectious complications.

RESULTS

Seventy-three percent of patients had at least one infectious complication; the incidence was 1.13 episodes per patient-year. The etiology of complications was bacterial (50%), viral (31%), Pneumocystis carinii (5%), fungal (4%), and protozoal (4%). The opportunist organisms accounted for 42% of cases. Pneumonia was the most common complication (28%), followed by mucocutaneous herpetic reactivation (19%), bacteremia (13%), urinary tract infection (13%), cytomegalovirus disease (11.5%), pleural empyema (5%) and surgical wound infection (5%). Nosocomial pneumonia accounted for 50% of cases. Gram-negative rods accounted for 41% of pneumonia cases. A total of 62.5% of deaths were directly related to infectious complications. Factors independently associated with mortality were hospital origin at transplantation (RR = 4.5 [2-9], p = 0.034), development of infectious complications in the post-heart transplantation period (RR = 3.2 [1.2-12], p = 0.04) and a more prolonged hospital stay at ICU (p = 0.0004). The factor which was independently associated with the development of infectious complications was one or more severe episodes of acute rejection (RR = 1.5 [1.1-2.2], p = 0.04). Patients who developed infectious complications had a more prolonged accumulated annual hospital stay (p = 0.004) than those without infectious complications.

CONCLUSIONS

Infectious complications are very common, prolong hospital stay, and are the first cause of mortality during the first year after transplantation. Bacteria are the most common etiology and pneumonia is the most common infection.

[Q fever-induced endocarditis. An analysis of 6 cases]

Endocarditis by Q fever is a diagnostic and therapeutic challenge given the diagnostic delay and elevated morbidity and mortality it carries. Six cases of endocarditis by Q fever attended over the last 7 years were retrospectively studied. Five patients had been previously diagnosed of valvular involvement and three had prosthesis. Five patients presented a febrile syndrome of prolonged duration with negative hemocultures and progressive valvular changes. One patient presented acute valvular failure requiring emergency surgery. The most significant laboratory data were anemia, thrombocytopenia, high ESR and hypergammaglobulinemia. In the echocardiograms valvular vegetations were observed in 4 cases. All the patients received medical treatment with doxicylin, one associated with rifampicin and another cotrimoxazol. In 4 patients valvular reposition was required due to a severe hemodynamic alteration. After a minimum follow up of 2 years all the patients remain asymptomatic. The serologic evolution is described.

[Candida albicans spondylodiscitis]

Infections by Candida sp. have increased notably and cause not only local but also systemic infections. It is rarely mentioned as an etiologic agent of osteomyelitis. Two cases of candidiasic spondylodiscitis are presented with the first being in a 33 year old intravenous drug using male who consulted for mechanical lumbar pain. Spondylodiscitis L2-L3 was observed upon radiological study. Aspiration puncture was carried out and the cultures were negative. Surgical biopsy was performed with spondylodiscitis and an abscess in the spine being observed. C. albicans was isolated in the culture. Pathological study confirmed the diagnosis. Cutaneous and sternocostal involvement was also concommitantly presented. The patient was treated with amphotericin B with a favorable evolution. The second case was in a 35 year old male with burns over 65% of his body due to a laboral accident. Three months after admission the patient presented lumbar pain irradiating to the groin and thigh. Bone destruction of the second lumbar vertebra and an abscess of the right psoas were observed upon CT scan. Puncture biopsy was performed and C. albicans was isolated. Histopathologic study demonstrated osteomyelitis by Candida sp. Treatment with amphotericin B was started. Posteriorly urea and creatinine was raised. Treatment was continued with fluconazole with good therapeutic response.

[Pyomyositis caused by Staphylococcus aureus]

BACKGROUND

An evaluation of the clinical characteristics and profitability of the diagnostic methods of myositis by Staphylococcus aureus was undertaken in favor of earlier diagnosis and treatment.

METHODS

Twenty-eight cases of pyomyositis by S. aureus attended over the last nine years were studied. Inclusion criteria were: 1) compatible clinical manifestations, 2) demonstration of an abscess in CT and/or surgery, 3) isolation of S. aureus in abscess, hemoculture and/or neighboring tissue.

RESULTS

Age: 36 +/- 18 years (limits 9-70). Sex: 23 males (82%). Neighboring pathology existed in 11 cases (39%). 5 sacroiliitis (18%), 4 spondyliodiscitis, 2 osteomyelitis. Favoring/predisposing factors: intravenous drug addiction in 11, staphylococcal sepsis in 6, diabetes mellitus in 4, previous surgery in 3, penetrating muscle injury in 3, and parametritis in 1. Fourteen cases (50%) corresponded to primary pyomyositis. The muscle most frequently involved was the psoas/iliacpsoas, followed by near the forearm muscle, spinal, gluteal, and upper pectoral muscles. In 16 cases (57%), only one muscle was involved, in 10 two muscles, and in 2 three groups. The time of clinical manifestation prior to consultation oscillated between 1.5-30 days, being less in cases of primary pyomyositis (p less than 0.0005). All the patients referred fever and local pain, with functional impotence in 26 (93%), general involvement, shivering and perspiration in 24 (86%). All the patients presented pain upon palpation. In 19 (68%) there was an increase in local temperature and in 18 a palpable mass. S. aureus was isolated in 16 hemocultures (sensitivity 57%), in 12 of 13 cultures of neighboring tissue (92%) and in all those aspirated from abscesses (100%). CT demonstrated muscular (thickening and/or destructuration or abscess) and neighboring pathology (if existent) in all cases. All the patients received medical treatment. Evacuating puncture was carried out in 7 cases, and surgical drainage in 23 (82%). Two cases were cured exclusively with medical treatment. Complications were seen in 8 cases (29%) and two patients died of staphylococcal sepsis.

CONCLUSIONS

1) In myositis by Staphylococcus aureus the percentage of primary pyomyositis is considerable. 2) In secondary pyomyositis the most frequent neighboring processes were sacroiliitis and spondylitis. 3) intravenous drug addiction was the most frequent predisposing factor. 4) The time of clinical evolution is variable although less in case of primary pyomyositis. 5) The performance of hemocultures was found to be greater than described and even greater in primary pyomyositis. 6) Abscess cultures and CT are the most efficient microbiological and imaging techniques in the early diagnosis of myositis by S. aureus.