S0001-600220020001 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022002000100001 El premio "Aportes al mejoramiento de la calidad de vida" Miranda Guido , 03 2002 2002 44 3 3
S0001-600220020001 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022002000100002 El papel de los anti-inflamatorios no esteroideos en la producción de fasceítis necrotizante Behm-López Bertrand Salas-Herrera lsaías ,Centro Nacional de Control del Dolor y Cuidados Paliativos San José ,Centro Nacional de Control del Dolor y Cuidados Paliativos 03 2002 2002 44 5 9

La fasceítis necrotizante es una infección que afecta tejidos blandos, producida por estreptococos beta hemolíticos grupo A. Su diagnóstico temprano es difícil, siendo más fácil conforme avanza el curso de la enfermedad. Para determinar si existía una relación entre los anti-inflamatorios no esteroideos y la aparición de fasceítis necrotizante, fue analizada la literatura médica de estudios clínicos en los últimos 41 años (base de datos de MEDLINE), los cuales evidenciaron que el tamaño de las muestras era pequeño , no eran randomizadas, no tenían grupos control y no lograron demostrar evidencia científica de causa-efecto entre los anti-inflamatorios no esteroideos y la fasceítis necrotizante, sin importar las vías de administración utilizadas. Con el fin de determinar si existe una asociación entre los anti-inflamatorios no esteroideos y fasceítis necrotizante, deben llevarse a cabo en el futuro estudios clínicos bien diseñados.

Necrotizing fasceiitis, as a severe group A streptococcus infection generally originating from localizad skin infections or disruptions has increased worldwide in recent years. Early diagnosis is often difficult due to the appearance of characteristic soft tissue changes only late in the course of the disease. The medical literatura was analized to determine a possible association between non-setroidal antiinflammatory drugs and necrotizing fasceiitis and possible factors involved in necrotizing fasceiitis. Sample sizes of the clinical studies reviewed were small, non-randomized, without control groups. Thus, no clinical studies showed scientific evidence of a cause and effect relationship between non-setroidal anti-inflammatory drugs and necrotizing fasceiitis, regardless of the route of administration. Further well-designed clinical trials should be carried out to determine if there is a possible association between nonsetroidal anti-inflan-irnatory drugs and necrotizing fasceitis.

 fasceítis necrotizante anti-inflamatorios no esteroideos infección inmunosupresión Bisno A Stevens D Streptocoecal infections of skin and soft tissues N Engl J Med 1996 334 Guy C Fulminating necrotizing fasciitis after intramuscular injection of a corticoid. Contributing role of non-steroidal anti-inflammatory agents Therapie 1993 48 Stevens DL Tiinner MH Winship J Swarts R Ries KM Schlievert PM Kaplan E Severe group A streptocoecal infections associated with a toxic shock-like syndrome and scarlet leve toxin A N Engl J Med 1989 321 Wilson CB Necrotizing fasciitis Am Surg 1952 18 Stevens DL Could nonsteroidal anti-inflammatory drugs (NSAID) enhance de progression of bacterial infections to toxic shock syndrome? Clin Infect Dis 1995 21 Brantigan CO Senkowsky J Group A beta hemolytie streptocoecal necrotizing fasciitis Wounds 1995 7 Descamps V Aitken J Lee MG Hippocrates on necrotising fasciitis Lancet 1994 344 Kahn LH Necrotizing soft tissue infections reported with nonsteroidal antiinflammatory drugs Ann Pharmacother 1997 31 ^s9 Kotrappa KS Bansal RS Amin NM Necrotizing Fasciitis Am Fain Physician 1996 53 Chapnick EL Abter El Infectious Disease Emergencies-Necrotizing soft tissue infections Infect Dis Clin North Am 1996 10 ^s4 Bergdoll MS Chesney PJ Toxic Shock Syndrome Toxic Shock Syndrome 1991 Boca Raton^eFL CRC Press Morantes M Lipsky BA "Flesh eating bacteria": return of an old nemesis Int J Dematol 1995 34 Katz AR Morens DM Severe streptococcal infections in historical perspective Clin Infect Dis 1992 14 Hoge CW Schwartz B Talkington DF Breiman RF MacNeill EM Englender SJ The changing epidemiology of invasive group A streptococcal infections and the emergence of streptococcal toxic shock-like syndrome: a retrospective population-based study JAMA 1993 269 Davies HD McGeer A Schwartz B Green K Cann D Simor AE Low DE Invasive group A streptococcal infections in Ontario, Canada N Engl J Med 1996 335 Group A beta-hemolytic streptococcal bacteremia: Colorado, 1989 MMWR 1990 39 O'Brien KL Levine OS Schwartz B The changing epidemiology of group A streptococcus infections Semin Pediatr Infect Dis 1997 8 Davies HD Matlow A Scriver SR Lovgren M Talbot JA Low DE Apparent lower rates of streptococcal toxic shock syndrome and lower mortality in children with invasive group A streptococcal infections compared with adults Pediat r lnfect Dis J 1994 13 Kaplan EL Recent epidemiology of group A streptococcal infections in North America and abroad: an overview Pediatrics 1996 97 ^s6 Cockerill FR MacDonald KL Thompson RL Roberson F Kohner PC Besser-Wiek J An outbreak of invasive group A streptococcal disease associated with high carriage rates of the invasive clone among school-aged children JAMA 1997 277 Wolf JE Rabinowitz LG Streptococcal toxic shock-like syndrome Arch Dermatol 1995 131 Bronze MS Dale JB The reemergence of serious group A streptococcal infections and acute rheumatic fever Am J Med Sci 1996 311 Stevens DL Tanner MH Winship J Swarts R Ries KM Schlievert PM Severe group A streptococcal infections associated with a toxic shock-like syndrome and scarlet fever toxin A N Engl J Med 1989 321 Schwartz B Facklam RR Breiman RF Changing epidemiology of group A streptococcal infection in the USA Lancet 1990 336 White J Herman A Pullen AM Kubo R Kappler JW Marrack P The Vbeta-specific superantigen staphylococcal enterotoxin B: stimulation of mature T cells and clonal deletion in neonatal mice Cell 1989 56 Leung DYM Travers JB Norris DA The role of superantigens in skin disease J Invest Dermatol 1995 105 Rosen H Superantigens Int J Dermatol 1997 36 Shimozato T lwata M Tamura N Suppression of tumor necrosis factor alpha production by a human immunoglobulin preparation for intravenous use Infect Immun 1990 58 Stevens DL Bryant AE Hackett SP Chang A Peer G Kosanke S Emerson T Hinshaw L Group A streptococcal bacteremia: The role of tumor necrosis factor in shock and organ failure J Infect Dis 1995 173 Solomon L Activation of latent infection by indomethacin: a report of three cases Br. Med. J 1996 1 Solberg CO Alfred CD HiII HR Influence of phenylbutazone on leukocyte chemiluminescence and function Acta Pathol Microbiol Immunol Scand 1978 86 Brun-Buisson CJ Saada M Trunet P Rapin M Roujeau JC Revuz J Haemolytic streptococcal gangrene and non-steroidal-anti-inflammatory drugs Br Med J 1985 290 Krige JE Spence RA Potter PC Terblanche J Necrotizing Fasciitis after diflunisal for minor injury Lancet 1985 2 Espersen GT Larsen K NSAID and fasciitis necroticans Ugeskr Lacger 1987 145 Rimailho A Riou B Richard C Auzepy P Fulminant necrotizing fasciitis and non-steroidal-antiinflammatory drugs J Infect Dis 1987 155 Smith RJ Berk SL Necrotizing fasciitis and Nonsteroidal Anti-inflammatory Drugs South Med J 1991 84 Chaplain A Acute cervical necrotizing fasciitis of pharyngeal origin: possible role of steroidal and non-steroidal anti-inflammatory agents Rev Laryngol Otol Rhinol (Bord) 1996 117 ^s5 Zerr DM Alexander ER Duchin JS Koutsky LA Rubens CE A casecontrol study of necrotizing fasciitis during primary varicella Pediatrics 1999 103 Kahn LH Necrotizing soft tissue infections reported with non-steroidal antiinflammatory drugs Ann Pharmacother 1997 31 ^s9 Streptococcal Infections: A Subject Review (RE9804) Streptococcal Infections: A Subject Review (RE9804) 1999 American Academy of Pediatrics Committee on Infectious Diseases Green RJ Dafoe DC Raffin TA Necrotizing Fasciitis Chest 1996 110 ^s1 Canadian Bacterial Surveillance Network Canadian Bacterial Surveillance Network 1999 Stone DR Gorbach SL Necrotizing fasciitis: The changing spectrum Dermatol Clin 1997 15 ^s2
S0001-600220020001 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022002000100003 Vertigo: una visión otorrinolaringológica para la medicina general Murillo-González Federico Maía Víquez Pineda Zita ,CCSS Hospital Nacional de Niños Servicio de Otorrinolaringología Heredia ,CCSS Clínica de Guararí 03 2002 2002 44 10 18

Muchos padecimientos se presentan con diversos síntomas que son descritos como "vértigo" o "mareo". Desde enfermedades inocentes hasta padecimientos potencialmente mortales pueden presentarlo, lo que genera cierta atmósfera de temor a enfrentarse con la tarea de llegar a un diagnóstico por parte del médico. Este trabajo trata de resumir la experiencia práctica del otorrinolaringólogo, dirigida a mejorar la capacidad resolutiva. Se describen las características y las causas del vértigo periférico y central, continuando con algunas recomendaciones para su tratamiento, y termina con la propuesta de un algoritmo general de cuatro pasos.

Many illnesses show themselves with various symptoms described as "vertigo" or "dizziness". From very mild ailments to potentially mortal discases can present with this symptoms this generales some fear to face the tasks of reaching a diagnosis. This paper tries lo summarize the practicar experience of an otolaryngologist, aimed to improved the general physician's ability lo solve the diagnostic challenge. Central and peripheral vertigo's causes and characteristic are describes, followed by basic treatment recommendations. Finally, a general four steps algorithm is proposed.

 Vértigo neuronitis vestibular vértigo postural paroxístico benigno Shepard Neil T Funcional operation of the balance ystem in daily activities Otolaryngol Clin North Am 2000 33 ^s3 Cohen NI Pacientes con vertigo: actualización sobre transtornos vestibulares Clin Med Nort Am 1991 Smith DB Dizzness: a clinical perpective Neurol Clin 1990 8 ^s2 Hard CW Hughes CB Clinical evaluation of the dizzy patient Clinical Otonlogy Clinical Otonlogy 1997 Thierme Brown JJ A systematic to the dizzy patient Neurol Clin 1990 8 ^s2 Deweese Parella M Diagnóstico diferencial del mareo y vértigo Otorrinolaringología Otorrinolaringología 1994 Ed Médica Panamericana Linstrom C Atención al paciente marcado Clin Otorrinol Nort Am 1992 Gillipie M, Boyd Prognosis in bilateral vestibular hypofuction Laryngoscopc 1999 109 ^s1 Kashlan Hussan Diagnosis and initiang treatement for peripherical system disorder: Imbalance and dizzness with normal hearing Otolaryngol Clin North Am 2000 33 ^s3 Cohen Helen Efficacy of treatement for posterior cana bening paroxystical vertigo Laryngoscopc 1999 109 ^s4 Merchant, sunil N Temporal bone studies of the human peripheral vestibular system: nonnative vestibular hair cell data Ann Otol Rinol Laryngol 2000 109 ^s181 Baloh RW Otología neurological Clin Neurol Nort Am 1996 1 Drachmann DA An approach to the dizzy patient Neurology 1972 22 ^s4 Velásquez Luis Temporal bone studies of the human peripheral vistibular: normativa Scarpa's ganglion cell data Ann Otol Rhinol Laryngol 2000 1095 ^s181 Tsuji Kojiro Temporal bone studies of the human peripheral vestibular: aminoglycoside ototoxity Ann Otology Rhinol Lariyngol 2000 1095 ^s181 Goycoolea Marcos Aspectos generales y justificación de alternativas quirúrgicas para tratar el vértigo periférico incapacitante Clin Otorrinol Nort Am 1994 2 Ruckenstein Michael J Balance function testing Otolaryngol Clin North Am 2000 33 ^s3 Forman Joseph Treatement of Bening positional vertigo using heelsover-head rotation Ann Otol Rhinol Laringol 1998 107 ^s12 Epley John Reposición de partículas para tratar el vértigo postural paroxístico benigno Clin Otorrinol Nort Am 1996 2 Walker Mark E Bedside vestibular examination Orolaryngol Clin North Am 2000 33 ^s3 La Rouse Michael Tratamiento quirúrgico de la enfermedad de Meniere Clin Otorrinol Nort Am 1996 2 Ruckenstein MJ Vertigo and dysequilibrium with associated hearing loss Otolaryngol Clin North Am 2000 33 ^s3 Brookles Kh Lee KJ El sistema vestibular y su patología Lo esencial en otorrinolaringología Lo esencial en otorrinolaringología 1995 Appleton and Lange Conlon, Bredan J Meniere's Disease: the incidence of hydrops in the contralateral asyntomatie car Laryngoscope 1999 109 ^s11 Tsuji Kojiro Temporal bone studies of the human peripheral vestibular: Meniere's disease Ann Otol Rhinology Laryngol 2000 109 ^s181 Wolfagan Arnold Herpes simplex virus antibodies in the periiynph of patients with Meniere disease Arch Otol Head Neck Surg 1997 123 ^s1 Kumar A Nadol JB Evaluation of the vestibular system Surgery of the car and temporal bone Surgery of the car and temporal bone 1993 Raven Prrs Escajadillo José Ramón Oído, nariz, garganta y cirugía de la cabeza y cuello Oído, nariz, garganta y cirugía de la cabeza y cuello 1991 Ed El Manuel Moderno Fitzgerald Dennis C Perylinfatic fistula: a Washington DC experience Ann Otol Phinol Laryngol 1997 106 ^s10 Lloyd, B. Minor Sound-and/or pressure-induced vertigo due to bone dehicense of the superior semicircular canal Arch Otolaryngol Head Neck Surg 1998 124 ^s3 Meyerhoff William L Fístula perilinfática Clin Otorrinol Nort Am 1994 4 Salomon David Distingishing and treating causes of central vertigo Otolaryngol Clin North Am 20033 ^s3 Whithey Susan L Physical therapy for migraine-related vestibulopathy and vestibular dysfuction with history of migraine Laryngoscope 2000 110 ^s9 Oliveira Carlos A Meniere's syndrome and migraine: incidence in one family Ann Otol Rhinol Laryngol 1997 10610 Grond Mastin Early intravenous thrombolysis with recombinant tissuc-type plaminogen activator in vertebro basilar ischemic stroke Arch Neurol 1998 55 ^s4 Wityk Robert J Proximal extracraneal vestibular artery disease in the New England Medical Center Posterior Circulation Registry Arch Neurol 1998 55 ^s4 River Yason Spontaneus vertebral artery dissection mirnicking acute vertigo Ann Otol Rhinol Laryngol 1999 10812 Wesh Louis Vertigo: analysis by magnetic resonance imaging and angiography Ann Otol Rhinol Laryngol 200109 ^s3 Welsh Louis Basilar artery and vertigo Ann Otol Rhinol Laryngol 2000 109 ^s7 Caplan Louis R Vertebro basilar disease and thrombolytic treatement Arch Neurol 1998 55 ^s4 Rosenberg Michael Neuro-otologic history Otolaryngol Clin North Am 2000 33 ^s3 Chaverri Julián Función vestibular Neuroeje 1985 3 ^s3 Goebel Joel A Manegement options for acute versus chronic vertigo Otolaringol Clin North Am 2000 33 ^s3 Whitney Susan Efficacy of vestibular rehabilitation Otolaryngol Clin North Arn 2000 33 ^s3 Shumway-Cook A rehabilitation strategies for patiens with vestibular deficit Neurol Clin 1990 8 ^s3 Tirelli Giancarlo Modified particle repositioning procedure Laryngoscope 2000 110 Paparella Michael M Reforzamiento del saco endolinfático Clin Otorrinol North Am 1994 2 Silverstein Herbert Sección del nervio singular para el tratamiento del vértigo paxoxístico postural Clin Otorrinol North Am 1994 2 Mc Donald Tbomas J Procedimiento de saculotomía Clin Otorrinol North Am 1994 2 Blakley Brian W Update on intraty-panic gentamicin for Meniere's disease Laryngoscope 2000 110 Hellstrom Sten Laberintectomía farmacológica Clin Otorrinol North Am 1994 2 Shea John J Perfusión de estreptomicina en el laberinto a través de la ventana redonda y administración por vía intavenosa Clin Otorrinol North Am 1994 2 Gacek Richard R Neurectomía del singular para el tratamiento del vértigo paroxístico postural Clin Otorrinol North Am 1994 2 Graham Malcolm D Laberintectomía: indicaciones y Técnica quirúrgica Clin Otorrinol North Am 1994 2 Yasdley Lucy Overview of psychologic effects of chronie dizznes and balance disorders Otolaryngologic Clin North Am 2000 33 ^s3 Staab Jeffrey Diagnosis and tratement of psychologic symptoms and psychiatric disorders in patients with dizzness and imbalance Otolaryngologic Clin North Am 2000 33 ^s3
S0001-600220020001 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022002000100004 Prevalencia de microsporidios en orinas de pacientes referidos para urocultivo en la Región Pacífico Central Valerio-Campos Idalia Cedeño-Saldaña Randolph Umaña-Bolaños Marisela Chinchilla-Carmona Misael ,Universidad de Ciencias Médicas Departamento de Investigación Cátedra de Parasitología Médica San José Costa Rica 03 2002 2002 44 19 23

Justificación: La mayoría de las infecciones por microsporidios en el ser humano se han reportado en el tracto gastrointestinal, sin embargo, es posible hallarlos parasitando otros sitios anatómicos como el tracto genitourinario, en donde las patologías pueden variar desde uretritis hasta falla renal. Tradicionalmente esas infecciones se deben al género Encephalitozoon, parásito contra el cual el Albendazol ha demostrado ser un medicamento efectivo. Objetivo: Determinar la prevalencia de microsporidios en personas que son referidas al laboratorio para urocultivo, dados los antecedentes clínicos que presentan. Métodos: El procesamiento de las muestras incluyó su toma con técnica aséptica, su cultivo en los medios de Agar Sangre, MacConkey y Manitol - sal para su estudio por presencia de bacterias y/u hongos y la realización del antibiograma, según los parámetros establecidos por la CCSS para los urocultivos. Adicional a esto se centrifugó una alícuota de 9 ml separando 50 microlitos del sedimento urinario, al cual se le añadió igual volumen de KOH al 5%. Se hicieron frotis los cuales se fijaron con alcohol metílico una vez secos, y se tiñeron con la técnica trierómica de Weber, obviando el paso de la decoloración y la deshidratación. Resultados: Se encontró un 25% de orinas positivas por microsporidios. Los pacientes con edades entre 26 y 55 años presentaron mayor positividad. Conclusiones: El porcentaje de prevalencia encontrado (25%) y el hecho de que estas infecciones pueden llegar a causar severos daños al ser humano, hacen imperativa la necesidad de realizar diagnósticos más certeros de esta parasitosis, para lo cual proponemos la tinción de Weber con la modificación presentada en este trabajo para el diagnóstico de las infecciones por microsporidios en el tracto urinario.

Urine samples from patients with clinical antecedents of suspicion genitourinary pathology were studied for bacteria, fungi and for the presence of microsporidia. Usual culture media and methods were used lo study bacteria and fungi organisms. To study for microsporidian parasites, nine ml were centrifuged and smears of the sediment were fixed, previous tratment with 5% KOH and then stained according to a modified Weber method. Groups of Microsporidia spores were foud in twenty five per cent of the samples, coming more frenquently from people between 26 to 55 five years old .

 Microsporidios urolcutivo diagnóstico epidemiología Didier E Snowden KF Shabduck JA Biology of Microsporidian Species Infecting Mammals Ady Parásitol 1998 40 Weber R Bryan R Schwartz D Owen L Human Microsporidial Infections Clin Microb Rev 1994 7 Weiss LM Vossbrinck CR Microsporidiosis: Molecular and Diagnostic Aspects Adv Parasitol 1998 40 Matsubayashi H Koike T Mikata T Hagiwara S A case of Encephalitozoon like body infection in man Arch Pathol 1959 67 Gutiérrez G Reyes L Chinchilla M Herrera G Rodríguez M Frajman Presencia de Parásitos Intestinales en Pacientes HIV Seropositivos. Primer Informe de Microsporidiosis Humana en Costa Rica Parasitol al Día 1997 21 Kotler D Orenstein J Clinical Syndromes Associated with Microsporidiosis Adv Parasitol 1998 40 Croft SL Williams J McGowan I Intestinal microsporidiosis Smin Gastroint Dis 1997 8 ^s1 MeDougall R Tandy M Robyn B Borcham R Stenzel D O'Donoghue P Incidental Finding of a Microsporidian Parasite from an AIDS Patient J Clin Microb 1993 31 ^s2 Chinchilla M Reyes L Guerrero OM Castro A Microsporidiosis; una parasitosis de reciente adaptación al hombre Rev Cost de Ciencias Médicas 1998 19 ^s3-4 Chinchilla M Reyes L Guerrero O Frajman M Morales MT Enterocytozoon bieneusi (Orden Microsporidia, Familia Enterocytozoonidae) in Costa Rica: Report of the first human case in Central America Parasitol al Día 1997 21 Ryan N Sutherland G Coughlan K Globan M Doultree J Marshall J Baird R Pedersen J Dwyer B A New Trichrome-Blue Stain for Detection of Microsporidial Species in Urine, Stool, and Nasopharyngeal Specimens J Clin Microb 1993 31 ^s12 Weber R Bryan R Owen R Wilcox M Gorelkin L Visvesvara G Im proved Light-Microscopical Detection of Microsporidia Spores in Stool and Duodenal Aspirates N Engl J Med 1992 326 ^s3 Didier E Visvesvara G Baker M Rogers L Bertucci D De Groote M Vossbrinck Ch A microsporidian Isolated From an AIDS Patient Corresponds to Encephalitozoon cuniculi III, Originally Isolated from Domestic Dogs J Clin Microb 1996 34 ^s11 Field A Marriott D Milliken S Brew B Canning E Kench J Darveniza P Harkness J Myositis Associated with a Newly Described Microsporidian, Trachipleistophora hominis, in a Patient with AIDS J Clin Microb 1996 34 ^s11 Lecuit M Oksenhendler E Safarti C Use of Albendazole for Dissemitated Microsporidian Infection in a Patient with AISD Clin Inf Dis 1994 19 Molina JM Oksenhendler E Beauvais B Sarfati C Jaccard A Derouin F Modai J Disseminated Microsporidiosis due to Albendazole therapy J Inf Dis 1995 171 Carter P MacPherson D McKenzie R Modified technique to recover microsporidian spores in sodium acetate-acetic acid-formalin-fixed fecal samples by light microscopy and correlation with transmission electron microscopy J Clin Microb 1996 34 Franzen C Muller A Molecular Techniques for Detection, Species Differentiation, and Phylogenetie Analysis of Microsporidia Clin Microb Rev 1999 12 Simon D Weiss L Tanowitz H Cali A Jones J Wittner M Light Microscopic Diagnosis of Human Mierosporidiosis and Variable Response to Octreotide Gastroenterology 1991 100 ^s1 Weber R Bryan R Microsporidial Infections in Immunodeficient and Immunocompetent Patients 1994 19 Sandford J Hannemann A Gelberblom H Stark K Owen R Ruf B Enterocytozoon bieneusi Infection in an Immunocompetent Patient who had acute diarrhea and who was not infected with the Human Inmunodeficiency Virus Clin Infect Dis 1994 19 Weber R Sauer B Spycher M Deplazes P Keller R Ammann R Briner J Luthy R Detection of Septata intestinalis in Stool Specimens and Coprodiagnostic Monitoring of Successful Treatment with Albendazole Clin Inf Dis 1994 19 Dieterich D Lew E Kotler D Poles M Orenstein J Treatrnent with Albendazole for Intestinal Discase Due to Enterocytozoon bieneusi in Patients with AIDS J Infect Dis 1994 169 Aguila C Izquierdo F Navajas R Aguila C Izquierdo F Navajas R Enterocytozoon bieneusi in Animals: Rabbits and Dogs as Hosts J Euka Mierob 1999 46 Goodgame R Understanding Intestinal spore-forming protozoa: Cryptosporidia, Microsporidia, Isospora, and Cyclospora Ann Intern Med 1996 124
S0001-600220020001 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022002000100005 Reconstrucción mamaria con colgajo recto abdominal: reporte de primeros 15 casos Chavarría-León Gustavo ,CCSS Hospital México Servicio de Cirugía Reconstructiva 03 2002 2002 44 24 26

Las opciones terapéuticas y reconstructivas disponibles hoy en día para las mujeres con cáncer mamario son numerosas. De los métodos disponibles para la reconstrucción mamaria autóloga el colgajo recto abdominal ha sido el más popular. Es un colgajo que incluye la piel, el tejido graso y el músculo recto abdominal, este conjunto es llevado con su irrigación de la arteria epigástrica superior hasta el defecto de la mastectomía, en el tórax. El colgajo recto abdominal (TRAM) ha sido calificado por algunos líderes en el campo de la Cirugía Plástica como el procedimiento más ingenioso realizado en esta especialidad. Entre abril de 1999 y diciembre 2000 realizamos 15 reconstrucciones mamarias utilizando el TRAM. La reconstrucción fue unilateral en catorce casos y bilateral en un caso. En trece pacientes se utilizó un pedículo contralateral y en dos el pedículo fue ipsilateral. Como complicaciones tuvimos dos hernias abdominales, una necrosis grasa parcial y un hematoma, todas fueron resueltas satisfactoriamente. La reconstrucción inmediata ofrece ventajas sobre la reconstrucción retardada . En nuestro país podemos realizar tanto la reconstrucción retardada como inmediata y en los equipos de trabajo (oncólogos, cirujanos generales, cirujanos plásticos, psiquiatras, etc) se debe fomentar la reconstrucción inmediata.

Today, the therapeutic and reconstructive options for mastectomized women are numerous. Of the different methods for autologous breast reconstruction, the transversus rectus abdominis muscle "TRAM" flap has been the most popular. The flap includes skin, subcutancous tissue and the rectus abdominis muscle. This flap irrigated by the superior epigastric artery is taken lo the mastectomy defect in the thorax.. From April 1999 to December 2000 we performed 15 breast reconstructions using the rectus abdominis flap. The reconstruction was unilateral in fourteen cases and bilateral in one. In thirteen patients we utilized a contralateral pedicle and in two patients the pedicle was ipsilateral. The complications were two abdominal hernial, one partial fat necrosis and one hematoma, all of them resolved . Inmediate reconstruction offers advantages over delayed reconstruction. In our country we performed immediate and delayed reconstruction. Immediate reconstruction by comprensive teams of oncology and general surgeons, plastie surgeons, psychiatrics, etc.

 Alexander JE Block LI Breast reconstruction following radical mastectomy Plast Reconstr Surg 1967 40 Cronin T Gerow F Braodbent T.R Augmentation mammoplasty: a new natural feel prosthesis Transactions of the third international Congress of Plastic Surgery Transactions of the third international Congress of Plastic Surgery 1964 Amsterdam Excerpta Medica Foundation Schneider WJ Hill HL Brown RG The latissimus dorsi myocutaneous flap for breast reconstruction BR J Plast Surg 1977 30 Hartrampf C Sheflan M Black PW Breast reconstruction with a transverse abdominal island flap Plast Reconstr Surg 1982 69 Hartrampf C Bennett GK Autogenous tissue reconstruction in the mastectomy patient: A critical review of 300 patients Ann Surg 1987 205 Shaw WW Breast reconstruction by superior gluteal microvascular free flaps without silicone implants Plast Reconstr Surg 1983 72 Paletta CE Bostwiek J Nahai F The inferior gluteal free flap in breast reconstruction Plast Reconstr Surg 1989 84 Hartrampf CR Noel RT Drazan L Ruben's fat pad for breast re-construction: A peri-iliac soft-tissue reconstruction Plast Reconstr Surg 1994 93 Giorgiade G Giorgiade N Mc Carthy KS Rationale for immediate reconstruction of the breast following modified radical mastectomy Ann Plast Surg 1982 8 Elkowitz A Colen S Slavin S Various methods of breastre construction after mastectomy: An economic comparison Plast Reconstr Surg 1993 92 Grotting JC Urist MM Maddox WA Conventional tram versus free microsurgical tram flap for immediate breast reconstruction Plast Reconstr Surg 1989 83 Shestak K.C Breast reconstruction with a pedicled tram flap Clin Plast Surg 1998 25
S0001-600220020001 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022002000100006 Diagnóstico directo de la mutación que causa el síndrome del cromosoma X frágil: experiencia en Costa Rica Cuenca-Berger Patricia Morales-Montero Fernando Castro-Volio Isabel ,Instituto de Investigaciones en Salud 03 2002 2002 44 27 33

Justificación y objetivo: el síndrome del cromosoma X frágil es la principal causa de retardo mental hereditario. Afecta a 1:4 000 varones y a 1:6 000 mujeres. La mayoría de las personas afectadas aún no han sido diagnosticadas y en sus familias suele haber más de un miembro con "retardo mental de origen oscuro". Si estas personas conocieran el diagnóstico y el carácter hereditario del padecimiento, el asesoramiento genético adecuado y oportuno, podría contribuir a reducir la ocurrencia o la recurrencia de esta patología en las familias. El objetivo por lo tanto fue hacer diagnóstico directo de la mutación que causa el síndrome, para confirmar o descartar el diagnóstico clínico o citogenético en los probandos, para encontrar a los portadores y portadoras en las familias de estas personas y de esa manera poder brindar prevención a través del asesoramiento genético. Métodos: se realizaron los análisis moleculares mediante hibridaciones de Southem, con las sondas Ox 1.9 y StB 12.3 previa digestión del ADN genómico con las enzimas Hind III, EcoRI y Eagl. Además de confirmar la presencia o ausencia de la mutación completa en los afectados por el retardo mental, se ha determinado el tamaño de la premutación en algunos portadores y confirmado a individuos libres de mutación mediante el uso de la reacción en cadena de la polimerasa. Resultados: se han realizado estudios moleculares en niños con examen citogenético positivo (grupo uno, N = 13), sus familiares cercanos (grupo dos, N = 30) y niños referidos por maestros, pediatras y sicólogos (grupo tres, N = 15). En nueve de los niños del grupo uno se confirmó la presencia de la mutación completa del gen FMRI, en los otros cuatro se descartó, al encontrarse resultados normales en todas las pruebas moleculares. En el grupo dos se encontraron dos mujeres con la mutación completa y doce personas con la premutación: un varón transmisor fenotípicamente normal y once mujeres portadoras. El resto de los familiares estudiados resultaron normales. En el grupo tres se detectó una niña con la mutación, el resto fueron normales, tanto mediante estudios citogenéticos como moleculares. Conclusión: el diagnóstico preciso de la mutación permite, por un lado el abordaje correcto de los niños afectados desde el punto de vista psicopedagógico. Por otro lado, la identificación de los portadores de premutaciones y de los individuos libres de la mutación en una familia donde está segregando la enfermedad permite un consejo genético preciso de acuerdo al hallazgo molecular. Los métodos moleculares, además de más exactos, resultan más baratos que los citogenéticos cuando se cuenta con un laboratorio equipado y el personal capacitado.

Fragile X syndrome is the most common hereditary type of mental retardation, affecting 1:4 000 males and 1:6 000 females. Unfortunately, most persons with this syndrome have not bcen diagnosed and are classified as cases of mental retardation of unknown origin. The correct etiological classification of these patients would allow their families lo avoid recurrence of this disease through adequate genetic counseling. As a result, this study intended to provide accurate molecular diagnosis of fragile X syndrome in mentally retarded patients with clinical or cytogenetic suspicion of the disease, to detect the normal transmitting males and female carriers in each of the proband's families and to promote prevention after proper genetic counseling. To achieve this, genomic DNA was digested with Hind 111, EcoRI and Eagl and Southern blotting was performed with probes Oxl.9 and StB 12.3. To asses the size of the trinucleotide repeat, PCR was used in some of the cases. Three groups were studied: group one with 13 children with the cytogenetic marker, 30 of their close relativas conformes group two and group three with 15 clinically suspicious fragile X syndrome children. Results: of the 13 probands, four proved not to be fragile X cases since their average repeat number was 30. In group two, two females with the full mutation, one normal transmitting male and eleven female carriers with the premutation were found. In group three an additional female with the full mutation was identified, the rest had normal DNA and cytogenetic test results. In summary, DNA studies are a better way to accurately asses the full mutation and premutation carriers. The right diagnosis renders benefits to fragile X cases in terms of the interventions they need and to carriers since this information is a must for proper genetic counseling and prevention. Moreover, molecular studies are cheaper than cytogenetie diagnosis in well equipped laboratories with trained personnel.

 genética humana diagnóstico molecular FRAXA cromosoma X retardo mental hereditario FMRI mutaciones inestables Turner G Webb T Wake S Robinson H Prevalence of fragile X syndrome Am.J.Med Genet 1996 64 Hagerman R Wells R Warren S T Sarmiento M Clinical and diagnostic aspects of fragile X syndrome Genetic instabilities and hereditary neurological diseases Genetic instabilities and hereditary neurological diseases 1998 New York Academic Press Imbert G Feng Y Nelson D L Warren S T Mandel Wells R Warren S T Sarmiento M FMRI and mutations in fragile X syndrome: Molecular biology, biochemistry, and genetics Genetic instabilities and hereditary neurological discases Genetic instabilities and hereditary neurological discases 1998 19 98 New York Academie Press Wührle D Salat U Gláser D Mücke J Meisel-Stosiek M Schindler D Unusual patterns of mutations in high functioning fragile X males and other cases may result from instability of expanded CGG repeats in the absence of methylation J.Med.Genet 1998 35 Lachiewicz A M Spiridigliozzi G A MeConkie-Rossell A Burhess D Feng Y Warren S T A fragile X male with a broad Smear on Southern blot analysis representing 100-500 CGG repeats and no-methylation at the Eagl site of the FMR- 1 gene Am. 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Genet 2001 9 ^s1 Verkerk A J M Pieretti M Sutcliffe J S Fu Y H Kuhl D P Pizzuti A Identification of a gene (FMR-1) contain ing a CGG repeat coincident with a breakpoint cluster region exhibiting length variation in fragile X syndrome Cell 1991 65 Oberlé I Rosseau E Heitz D Kretz C Deveys D Instability of a 550-base pair DNA segment and abnormal methylation in fragile X syndrome Science 1991 252 Fu Y H Kuhl D P A Pizutti A Pieretti M Sutcliffe J S Richards S Variation of the CGG repeat al the fragile X site results in genetic , instability: resolution of the Sherman paradox Cell 1991 67 Yu S Pritchard M Kremer E Lynch M Nancarraw J Baker E Fragile X genotype characterized by an unstable region of DNA Science 1991 252 Eichler E E Holden J J A Popovich B W Reiss A L Snow K Thibodeau S N Length of uninterrupted CGG repeats determines stability in the FMR1 gene Nature Genet 1994 8 Quan E Zonana J Gunter K Peterson K L Ma,,enis R.E Popovich B W An atipical case of fragile X syndrome calised by a deletion that includes the FMRI gene Am.J.Hum.Genet 1995 56 Jin P Warren ST Understanding the molecular basis of fragile X syndrome Hum Mol Genet 2000 9 Castro l Cuenca R Frecuencia del síndrome del cromosoma X frágil en la Escuela de Enseñanza Especial "Fernando Centeno Güell" Act Ped Cost 1996 10 ^s2 Tommerup N Davies K E Cytogenetics of the fragile site at Xq27 The fragile X syndrome The fragile X syndrome 1989 Oxford Oxford University Press Krawcsun M S Jenkins E C Brown W T Analysis of the fragile X chromosome: localization and detection of the fragile site in high resolution preparation Hum Genet 1985 69 Morton JE Bundey S Webb TP MacDonald F RindI PM Bullock S Fragile X syndrome is less common than previously estimated J Med Genet 1997 34 Rousseau F Rouillard P Morel M L Khandjian E W Morgan K Prevalence of carriers of premutation.size alleles of the FMRI gene and implicacions for the population genetics of the fragile X syndrome Am J Hum Genet 1995 57 Falik-Zaccai T C Shachak E Yalon M Lis Z Borochowitz Z MacPherson J N Predisposition to the fragile X syndrome in Jews of Tunisian descent is due to the absence of AGG interruptions on a rare Mediterranean haplotype Am J Hum Genet 1997 60 Turner G Robinson H Wake S Laing S Partington M Case finding for the fragile syndrome and its consequences B M J 1997 315 Sutherland GR Gedeon A Korman L Donnelly A Byard RW Mulley J C Prenatal diagnosis of fragile X syndrome by direct detection of unstable DNA sequence N Engl J Med 1991 325 Spiridigliozzi G A Lachiewicz M MacMurdo C S Vizoso A D O'Donnel C M McConkie-Rossel A Educating boys with fragile X syndrome. 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S0001-600220020001 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022002000100007 Torsión de un apéndice epiploico. Reporte de 2 casos: características ecográficas y tomográficas Sayago-Castro Daniel ,Clínica Santa Catalina Departamento de Imágenes Desamparados 03 2002 2002 44 34 35

El infarto de una apéndice epiploica produce un proceso inflamatorio que se localiza en la región del colon afectada así como a la porción correspondiente del omento mayor. La apendagitis epiploica tiene hallazgos sonográficos y de TAC característicos los cuales contribuyen al diagnostico rápido y por lo tanto ayudan con el manejo del paciente. Se presentan aquí dos casos.

Acute infarction of an appendix epiploica results in an inflammatory process localizad to the affected portion of the colon and the adjacent greater omentum. The primary epiploic apendagitis has fairly characteristic US and CT features that contribute to a rapid diagnosis and help in the hand ling of the patient. We present here two cases recently seen by the author that illustrate this condition.

 Rioux M Langis P Primary epiploic appendagitis: clinical. US, and CT findings in 14 cases Radiology 1994 191 Julien B.C.M Puylaert. When in doubt, sound it out Radiology 1994 191 Kelvin Danielson Mark M Chermin Case Report. Epiploic Appendicitis: CT Characteristics Journal of computer assisted tomography 1986 10 ^s1 Patrick M. Rao Jack Wittenherg Nash Lawrason. Primary Epiploic Appendagitis: Evolutianary Changes in Ct appearanco Radiology 1997 204 Gary G Ghahremani E Maureen White Frederick L Appendices Epiploicae of the colon: Radiologic and Pathologic features Radiographics 1992 12
S0001-600220020001 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022002000100008 Neumotórax hipertensivo por inhalación de cocaína González Cogollo William José ,CCSS Hospital Dr. Tony Facio Castro Limón Costa Rica 03 2002 2002 44 36 38

El uso de la cocaína causa complicaciones pulmonares, cardiacas, músculo esqueléticas, obstétricas y gastrointestinales. Se describe el caso de un varón joven quien presento barotrauma (neumotórax hipertensivo) posterior a la inhalación de cocaína. Basados en este caso y en una revisión de la literatura medica se recomienda interrogar exhaustivamente acerca del uso de drogas en todo paciente adulto o adolescente con neumotórax "espontáneo".

The use of cocaine causes pulmonary, cardiac, obstetric, muskuloskeletal and gastrointestinal complications. The case of a young man who sustained barotrauma (hipertensive pneumotorax) associated with the use of cocaine is presentes here. Based on this case and a review of the literature it is recommended that a careful drug abuse history be obtained when "spontaneous" pneumotorax is encountered in an adult or adolescent patient.

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