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SESIÓN CLÍNICA CERRADA - Servicio de Medicina Interna · The yield of diagnostic...
Transcript of SESIÓN CLÍNICA CERRADA - Servicio de Medicina Interna · The yield of diagnostic...
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SESIÓN CLÍNICA CERRADA
Modera: Dra. MÓNICA LÓPEZ RODRÍGUEZ Presenta: Dra. PALOMA ROMERO GALLEGO-ACHO
R4 DE MEDICINA INTERNA
Sesiones clínicas
Servicio de Medicina Interna
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Mujer de 70 años con diarrea, fiebre y dolor en costado derecho, a estudio.
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ANTECEDENTES PERSONALES
AF: Padre fallecido de cardiopatía. Madre ictus isquémico. Hermano enolismo y TCE. Hija con HTA e hipotiroidismo. Dos hijos con DL.
• FRCV: HTA. DL en tto dietético. Osteoporosis. • Enfermedades: 1. En 2005, diarrea de 1 mes de evolución, autolimitada, sin diagnóstico. 2. Desde hace > 1 año, 3-4 deposiciones diarreicas diarias, con
colonoscopia y gastroscopia sin alteraciones macroscópicas. 3. Hace 1 mes, ingreso en Cardiología con dg. de pericarditis idiopática
con derrame pericárdico y taponamiento cardiaco, que precisó toracotomía media. (Líq. Pericárdico con citología negativa para malignidad, frotis con intenso infiltrado inflamatorio y cultivos estériles para bacterias y micobacterias.
• Tratamiento habitual: AAS 500 mg/8 horas. Pantoprazol 40 mg/día. Mastical D en comida.
Intervenciones quirúrgicas: Apendicectomía. Toracotomía media. SB: IABVD. Viuda, vive con hija. Ha trabajado como bibliotecaria.
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ENFERMEDAD ACTUAL
• Mujer de 70 años, que presenta cuadro de 24 horas de dolor en costado derecho, que aumenta con inspiración profunda, fiebre de 38,3ºC y persistencia de deposiciones diarreicas.
• No disnea, tos ni expectoración.
INGRESO PARA ESTUDIO
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EXPLORACIÓN FÍSICA
TA: 124/73 FC: 95 lpm. Tª 36,5ºC. SatO2 basal 94%. Consciente y orientada en las 3 esferas. Palidez y
cianosis muco-cutánea. • C y C: Carótidas RR y SS. No IY. No adenopatías. • ACP: Rítmica sin soplos. MVC, hipoventilación con
crepitantes en base derecha. • Abdomen blando y depresible, no doloroso. No
masas ni megalias. RHA +, ligeramente aumentados.
• EEII: No edemas. Pulsos pedios conservados • NRL: Pupilas IC y NR. Pares conservados. Fuerza en
extremidades 5/5. No focalidad.
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PRUEBAS COMPLEMENTARIAS
Analítica urgente: Htíes 4,31. Hb 13,2. Htc 40%. VCM 93. HCM 30,6. Leucos 12100 (N 8350; L 2600; M 780; E 300; B 0). Plaq. 468.000. Coag.: TP 12,5. AP 89%. INR 1,1. Fbng 864. BQ: PCR 118. Glu 102. Urea 49. Cr 1,12. Na 135,4. K 4,6. GV: pH 7,34, HCO3 23.
Analítica diferida: Hemograma: Htíes 3,48. Hb 10,1. Htc 33,3%. VCM 95. HCM 28,9.
Leucos 8200 (N 5310; L 2060; M 390). Plaq. 349.000. VSG 102. Coagulación: AP 87%. INR 1,1. Fbng 814. Bioquímica: Na 141. K 4,1. Cl 110. Glu 90. Colesterol total 163. HDL
38. LDL 89. TGL 181. PT 5,3. Alb 2,6. Ca total 8,3. Fosfato 3,1. LDH 111. GOT 12. GPT 16. GGT 103. FAlc 108. Cr 1.BT 1. PCR 178.
Metabolismo del Fe/B12: Fe 25. IST 10%. Ferritina 506. Vit B12: 674.
Proteinograma: Sin bandas monoclonales. Hormonas tiroideas: TSH 1,11. T4L 1,44. Marcadores tumorales: CEA 1,27. CA125 76,2. CA15,3 27,4. AFP
3,75. DRAS: proteínas (+), resto normal.
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LÍQUIDO PLEURAL: Células 680 (N 16%; L 55%; E 5%; Macrófagos 24%).
BQ: Glu 78. Colesterol total 153. PT 5,6. Alb 3. Amilasa 32. ADA 31,4 (5-40). CA125 185,6.
Citología negativa para células tumorales malignas.
Baciloscopia: no se observan BAAR.
Cultivos estériles para bacterias y micobacterias
PRUEBAS COMPLEMENTARIAS
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PRUEBAS COMPLEMENTARIAS
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PRUEBAS COMPLEMENTARIAS
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FIBROBRONCOSCOPIA: Vía aérea superior de
aspecto normal. CV móviles, tráquea, carina principal y ambos árboles bronquiales sin lesiones endoluminales. BAL: Citología negativa para células tumorales malignas. No se puede hacer recuento por escasa celularidad del BAL.
PRUEBAS COMPLEMENTARIAS
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En resumen, mujer de 70 años, con antecedentes de diarrea crónica, con endoscopia normal e ingreso reciente por pericarditis idiopática con derrame pericárdico, que ingresa por neumonía basal derecha y derrame pleural ipsilateral, con características de exudado.
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POLISEROSITIS (derrame pleural + derrame pericárdico)
DIARREA CRÓNICA, con endoscopia normal, a estudio.
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DERRAME PLEURAL - Ofrece importante información clínica. Procedimiento realizado a pie de cama. - En >90% es útil para la toma de decisiones
Collins TR, Sahn SA. Thoracocentesis. Clinical value, complications, technical problems, and patient
experience. Chest 1987; 91:817
Pleural Effusion. Richard W. Light, M.D. N ENGL J MED 2002; 346:1971-1977
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LÍQUIDO PLEURAL:
Células 680 (N 16%; L 55%; E 5%; Macrófagos 24%).
BQ: Glu 78. Colesterol total 153. PT 5,6. Alb 3. Amilasa 32. ADA 31,4 (5-40). CA125 185,6.
Citología negativa para células tumorales malignas.
Baciloscopia: no se observan BAAR.
Cultivos estériles para bacterias y micobacterias
EXUDADO
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DERRAME PERICÁRDICO
Se realiza análisis de líquido pericárdico (ESC):
1. Taponamiento cardiaco
2. Sospecha de TBC, malignidad o pericarditis purulenta
3. Moderado- severo, sin causa justificable y que no responde a tratamiento antiinflamatorio.
Ben-Horin S, Bank I, Shinfeld A, et al. Diagnostic value of the biochemical composition of pericardial effusions in patients undergoing pericardiocentesis. Am J Cardiol 2007; 99:1294.
Maisch B, Seferović PM, Ristić AD, et al. Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. Eur Heart J 2004; 25:587.
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The yield of diagnostic pericardiocentesis has varied in different series, but in most, a definitive diagnosis has been made following pericardiocentesis in less than 40 percent of cases. When an etiology for the pericardial effusion was confirmed, malignancy, purulent infection, and tuberculosis were the most frequently identified causes.
Corey GR, Campbell PT, Van Trigt P, et al. Etiology of large pericardial effusions. Am J Med 1993; 95:209. Levy PY, Corey R, Berger P, et al. Etiologic diagnosis of 204 pericardial effusions. Medicine (Baltimore) 2003; 82:385. Permanyer-Miralda G, Sagristá-Sauleda J, Soler-Soler J. Primary acute pericardial disease: a prospective series of 231 consecutive patients. Am J Cardiol 1985; 56:623.
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Light RW, Erozan YS, Ball WC Jr. Cells in pleural fluid: their value in differential diagnosis. ARCH INTERN MED 1973;132:854-860
Yam LT. Diagnostic significance of lymphocytes in pleural effusions. ANN INTERN MED 1967;66:972-982
CÉLULAS
-N 16%
-L 55%
-E 5%
-Macrófagos 24%
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TUBERCULOSIS
-Reacción de hipersensibilidad retardada
-Unilaterales de leve-mod. cuantía
-¾ lesiones en LSD-Reactivación
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Análisis líquido pleural
- Exudado con predominio de linfocitos. - Prot >3gr/dl. - Glu 60 mg/dl - LDH elevada - pH >7.3 - Cultivo + 10-30% - Baciloscopia – - Biopsia pleural es dg 40-60% - Cultivo +biospia 90%
Berger HW, Mejía pleuresía tuberculosa E.. Chest 1973; 63:88.
Epstein DM, Kline LR, Albelda SM, Miller WT. Derrames
pleurales tuberculosos. Chest 1987; 91:106.
USO DE BIOMARCADORES
- ADA (corte 40 U/L)
- IFN-Y (S y E similar a ADA)
- PCR
Jiménez Castro D, Díaz Nuevo G, Pérez-Rodríguez E, Light RW. Diagnostic value of adenosine deaminase in nontuberculous lymphocytic pleural effusions. Eur Respir J 2003; 21:220.
Villegas MV, Labrada LA, Saravia NG. Evaluation of polymerase chain reaction, adenosine deaminase, and interferon-gamma in pleural fluid for the differential diagnosis of pleural tuberculosis. Chest 2000; 118:1355.
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TBC extrapericárdica + exudado linfocitario con ADA elevada + respuesta a antiTBC
Líquido pericárdico:
- Linfocitos/monocitos
- Baciloscopia y cultivo 20-60%
- ADA 30 U/L (S 94%, E 68%)
- IFN y PCR
Maisch B, Seferović PM, Ristić AD, et al. Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. Eur Heart J 2004; 25:587.
Reuter H, Burgess LJ, Carstens ME, Doubell AF. Adenosine deaminase activity--more than a diagnostic tool in tuberculous pericarditis. Cardiovasc J S Afr 2005; 16:143.
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- No factores epidemiológicos.
- Clínica poco sugestiva
- Radiología
- Análisis de líquido pleuro-pericárdico.
- Microbiología
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NEOPLASIAS-SEROSITIS
MM y Macroglobulinemia de Waldestrom
Neoplasias hematológicas
Carcinomas
Primarios cardiacos (rabdomiosarcoma, fibroma, teratoma, …)
Primarios pleuropulmonares (adenoCa pulmón, mesotelioma, …)
Otros: quilotórax, etc.
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NEOPLASIAS-SEROSITIS
Clínica y exploraciones complementarias poco compatibles.
Marcadores tumorales E 100%; S 30-60%
Citología:
- Negativas en ambos líquidos
- Citología pericárdica S 70-90%
- Citología pleural S 60%; E45% ?
Liang QL, Shi HZ, Qin XJ, et al. Diagnostic accuracy of tumour markers for malignant pleural effusion: a meta-analysis. Thorax 2008; 63:35. Porcel JM, Vives M, Esquerda A, et al. Use of a panel of tumor markers (carcinoembryonic antigen, cancer antigen 125, carbohydrate antigen 15-3, and cytokeratin 19 fragments) in pleural fluid for the differential diagnosis of benign and malignant effusions. Chest 2004; 126:1757.
Wiener HG, Kristensen IB, Haubek A, et al. The diagnostic value of pericardial cytology. An analysis of 95 cases. Acta Cytol 1991; 35:149
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Y volvemos al análisis celular…
Light RW, Erozan YS, Ball WC Jr. Cells in pleural fluid: their value in differential diagnosis. ARCH INTERN MED 1973;132:854-860
Yam LT. Diagnostic significance of lymphocytes in pleural effusions. ANN INTERN MED 1967;66:972-982
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-1-2%. Afectación extensa y manifestaciones extratorácicas.
-Pequeños y bilaterales
-Exudado linfocítico
-50% dg incidental por alteraciones en Rx tórax
-Dg por biopsia y de exclusión
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Iannuzzi MC et al. N Engl J Med 2007;357:2153-2165.
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OTRAS PATOLOGÍAS…
EMTC
Otras autoinmunes (Churg-Strauss/Wegener/ Sjögren)
FMF
Amiloidosis
Meigs
Uremia
IgG-4
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¿Y si la diarrea tiene algo que ver?
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ANTECEDENTES PERSONALES AF: Padre fallecido de cardiopatía. Madre ictus isquémico. Hermano enolismo y TCE. Hija con HTA e hipotiroidismo. Dos hijos con DL.
• FRCV: HTA. DL en tto dietético. Osteoporosis. • Enfermedades: 1. En 2005, diarrea de 1 mes de evolución, autolimitada, sin diagnóstico. 2. Desde hace > 1 año, 3-4 deposiciones diarreicas diarias, con
colonoscopia y gastroscopia sin alteraciones macroscópicas. 3. Hace 1 mes, ingreso en Cardiología con dg. de pericarditis idiopática
con derrame pericárdico y taponamiento cardiaco, que precisó toracotomía media. (Líq. Pericárdico con citología negativa para malignidad, frotis con intenso infiltrado inflamatorio y cultivos estériles para bacterias y micobacterias.
• Tratamiento habitual: AAS 500 mg/8 horas. Pantoprazol 40 mg/día. Mastical D en comida.
Intervenciones quirúrgicas: Apendicectomía. Toracotomía media. SB: IABVD. Viuda, vive con hija. Ha trabajado como bibliotecaria.
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ENFERMEDAD ACTUAL
• Mujer de 70 años,que presenta cuadro de 24 horas de dolor en costado derecho, que aumenta con inspiración profunda, fiebre de 38,3ºC y persistencia de deposiciones diarreicas.
• No disnea, tos ni expectoración.
INGRESO PARA ESTUDIO
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Síndrome de malabsorción intestinal (1) M.T. Pérez Fernández, R. Temiño López-Jurado, M. Fernández Gil y M. Calvo Moya Unidad de Aparato Digestivo. Fundación Hospital Alcorcón. Madrid.
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-Tropheryma whipplei (BGP)
-Varón blanco de mediana edad
-Etapa prodrómica/etapa establecida
-50% afectación pericárdica/35% pulmonar
-Simuladora
-Diagnóstico
Durand DV, Lecomte C, Cathébras P, et al. Whipple disease. Clinical review of 52 cases. The SNFMI Research Group on Whipple Disease. Société Nationale Française de Médecine Interne. Medicine (Baltimore) 1997; 76:170.
Riemer H, Hainz R, Stain C, et al. Severe pulmonary hypertension reversed by antibiotics in a patient with Whipple's disease. Thorax 1997; 52:1014.
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Enfermedad Inflamatoria Intestinal
CU/EC.
Patogenia no muy clara
Edad de distribución bimodal
Factores de riesgo
Asca/p-ANCA (S 40-60%; E 90%)
Loftus EV Jr. Clinical epidemiology of inflammatory bowel disease: Incidence, prevalence, and environmental influences. Gastroenterology 2004; 126:1504. Molodecky NA, Soon IS, Rabi DM, et al. Increasing incidence and prevalence of the inflammatory bowel diseases with time, based on systematic review. Gastroenterology 2012; 142:46. Kappelman MD, Rifas-Shiman SL, Kleinman K, et al. The prevalence and geographic distribution of Crohn's disease and ulcerative colitis in the United States. Clin Gastroenterol Hepatol 2007; 5:1424.
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Key Features of Major Forms of Inflammatory Bowel Disease.
Podolsky DK. N Engl J Med 2002;347:417-429.
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REVISANDO LA LITERATURA…
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COMO CONCLUSIONES…
-Poco frecuentes
-Subestimadas por el uso de antiinflamatorios
-Asociada a EII, infecciones asociadas o uso de fármacos
-Importante descartar otras patologías
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ANTECEDENTES PERSONALES AF: Padre fallecido de cardiopatía. Madre ictus isquémico. Hermano enolismo y TCE. Hija con HTA e hipotiroidismo. Dos hijos con DL.
• FRCV: HTA. DL en tto dietético. Osteoporosis. • Enfermedades: 1. En 2005, diarrea de 1 mes de evolució, autolimitada, sin diagnóstico. 2. Desde hace > 1 año, 3-4 deposiciones diarreicas diarias, con
colonoscopia y gastroscopia sin alteraciones macroscópicas. 3. Hace 1 mes, ingreso en Cardiología con dg. de pericarditis idiopática
con derrame pericárdico y taponamiento cardiaco, que precisó toracotomía media. (Líq. Pericárdico con citología negativa para malignidad, frotis con intenso infiltrado inflamatorio y cultivos estériles para bacterias y micobacterias.
• Tratamiento habitual: AAS 500 mg/8 horas. Pantoprazol 40 mg/día. Mastical D en comida.
Intervenciones quirúrgicas: Apendicectomía. Toracotomía media. SB: IABVD. Viuda, vive con hija. Ha trabajado como bibliotecaria.
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IMPRESIÓN DIAGNÓSTICA
Enfermedad Inflamatoria intestinal, probablemente tipo Crohn.
Serositis (derrame pleural y pericárdico), como manifestación infrecuente de la misma.
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PRUEBAS DIAGNÓSTICAS
Análisis inmunológicos (ANAs, C3, C4, antiRNP, FR). pANCA y ASCA.
Análisis heces (macro-micro, malabsorción, azúcares, …).
Biopsia grasa abdominal (Rojo Congo).
Colonoscopia con ileoscopia + toma de biopsias, ileal y colónicas.
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MUCHAS GRACIAS MUCHAS
GRACIAS