COVID-19–Associated Acute Asymmetric Hemorrhagic Necrotizing Encephalopathy: A Case Report

Background: Coronavirus disease 2019 (COVID-19) has been associated with many neurological complications affecting the central nervous system. Purpose: Our aim was to describe a case of COVID-19 associated with a probable variant of acute necrotizing encephalopathy (ANE). Results: A 60-year-old man who presented with a 3-day history of dyspnea, fever, and cough tested positive for severe acute respiratory syndrome–coronavirus 2 (SARS-CoV-2). Five days following his admission, the patient was intubated secondary to respiratory failure. Following his extubation 16 days later, he was found to have a left-sided weakness. Magnetic resonance imaging (MRI) of the brain showed hemorrhagic rim-enhancing lesions involving the right thalamus, left hippocampus, and left parahippocampal gyrus. These lesions showed decreased relative cerebral blood flow on MR perfusion and restricted on diffusion-weighted imaging. These neuroimaging findings were consistent with ANE. The left-sided weakness gradually improved over the subsequent weeks. Conclusions: We concluded that COVID-19 can be associated with ANE, a condition believed to be the result of an immune-mediated process with activation of the innate immune system. Future studies must address whether biological drugs targeting the pro-inflammatory cytokines could prevent the development of this condition.

Surgery Management of Pancreatitis with Complication: A Review Article

Introduction: Acute pancreatitis is an inflammatory disease of the pancreas with clinical manifestations that vary from mild to severe manifestations to death. The incidence of pancreatitis varies in various countries in the world and depends on the cause such as alcohol, gallstones, and metabolic factors. The clinical picture and the main symptom in patients with acute pancreatitis is abdominal pain. Abdominal pain varies from mild to severe and excruciating. Abdominal pain that is felt is constant and dull, and is usually felt in the epigastrium and periumbilicus and often spreads to the back, chest, waist, and lower abdomen. Discussion: The onset of acute pancreatitis, the patient should be evaluated for hemodynamic status immediately and receive the necessary resuscitation measures. Patients with acute pancreatitis should receive aggressive intravenous rehydration (250 - 500 ml/hour with isotonic crystalloid fluid) as early as possible with close monitoring, unless contraindicated with cardiovascular and/or renal comorbidities. It is most effective within the first 12-24 hours, but after that the benefits may diminish. Debridement (necrosectomy) is the gold standard in infected acute necrotizing pancreatitis and peripancreatic necrosis. Indications for intervention either through radiological, endoscopic or surgical procedures in necrotizing pancreatitis are suspected or proven infected necrotizing pancreatitis with clinical deterioration, especially after the necrotic tissue has been encapsulated with thick walls (walled-off necrosis). Sterile necrotizing pancreatitis with persistent organ failure several weeks after the onset of acute pancreatitis, particularly after the necrotic tissue has been encapsulated with thick walls (walled-off necrosis). Conclusion: Surgical management is often used in pancreatitis associated with gallstones. Cholecystectomy within 48 hours of the complaint can increase healing time. In addition, cholecystectomy performed early may not increase the risk of complications secondary to surgery. Surgery is not performed in acute necrotizing pancreatitis until the inflammation is reduced and the fluid accumulation no longer increases in size.

Clinical Manifestations and Pathogenesis of Acute Necrotizing Encephalopathy: The Interface Between Systemic Infection and Neurologic Injury

Acute necrotizing encephalopathy (ANE) is a devastating neurologic condition that can arise following a variety of systemic infections, including influenza and SARS-CoV-2. Affected individuals typically present with rapid changes in consciousness, focal neurological deficits, and seizures. Neuroimaging reveals symmetric, bilateral deep gray matter lesions, often involving the thalami, with evidence of necrosis and/or hemorrhage. The clinical and radiologic picture must be distinguished from direct infection of the central nervous system by some viruses, and from metabolic and mitochondrial disorders. Outcomes following ANE are poor overall and worse in those with brainstem involvement. Specific management is often directed toward modulating immune responses given the potential role of systemic inflammation and cytokine storm in potentiating neurologic injury in ANE, though benefits of such approaches remain unclear. The finding that many patients have mutations in the nucleoporin gene RANBP2, which encodes a multifunctional protein that plays a key role in nucleocytoplasmic transport, may allow for the development of disease models that provide insights into pathogenic mechanisms and novel therapeutic approaches.

ESOFAGITIS NECROTIZANTE AGUDA (ENA): REPORTE DE CASO

Introducción: La esofagitis necrotizante aguda (ENA) es una entidad patológica sumamente rara, cuya patogénesis no se ha identificado hasta la actualidad, pero se la asocia con la hipoperfusión tisular en pacientes de la tercera edad con antecedentes de patologías cardiovasculares (CV) o metabólicas. La ENA es identificada por endoscopia digestiva en ciertos pacientes con antecedentes de riesgo CV, quienes han presentado sintomatología como sangrado digestivo alto, disfagia súbita, epigastralgía intensa, vómitos, entre otros. Objetivo: describir un caso clínico de esofagitis necrotizante aguda, una entidad clínica poco estudiada, el manejo y la evolución clínica de la paciente. Caso clínico: paciente de 87 años con antecedentes de diabetes e hipertensión arterial, ingresada al Servicio de Medicina Interna por descompensación glicémica, quien en su estancia hospitalaria presentó disfagia súbita por lo que se realizó endoscopía digestiva alta, encontrándose un cuadro compatible con esofagitis necrotizante aguda, fue manejada con dieta absoluta, nutrición parenteral total, hidratación e inhibidores de la bomba de protones, siendo su evolución satisfactoria. Conclusiones: Se debería sospechar de ENA en pacientes adultos mayores quienes presentan sintomatología esófago-gástrica aguda y comorbilidades asociadas. Palabras clave: enfermedades del esófago, esofagitis, endoscopia, estenosis esofágica ABSTRACT Introduction: Acute necrotizing esophagitis (ENA) is an extremely rare pathological entity, the pathogenesis of which has not been identified to date, but it is associated with tissue hypoperfusion in elderly patients with a history of Cardiovascular disease (CVD) or metabolic pathologies. ENA is identified by digestive endoscopy in certain patients with a history of CVD risk, who have presented symptoms such as upper gastrointestinal bleeding, sudden dysphagia, intense epigastric pain, vomiting, among others. Objective: to describe a clinical case of acute necrotizing esophagitis, a little-studied clinical entity, the management and the clinical evolution of the patient. Clinical case: 87-year-old patient with a history of diabetes and arterial hypertension, admitted to the Internal Medicine Service due to glycemic decompensation, who during his hospital stay presented sudden dysphagia for which an upper gastrointestinal endoscopy was performed, finding a picture compatible with acute necrotizing esophagitis, was managed with absolute diet, total parenteral nutrition, hydration and proton pump inhibitors, and her evolution was satisfactory. Conclusions: ENA should be suspected in older adult patients who present acute esophageal-gastric symptoms and associated comorbidities. Keywords: diseases of the esophagus, esophagitis, endoscopy, esophageal stricture