ISQUEMIA AGUDA DE LA EXTREMIDAD INFERIOR COMO POSIBLE COMPLICACION DE COVID-19.

Introduction Acute arterial ischemia in lower extremities is a vascular emergency with a high risk of limb loss and elevated morbidity and mortality associated. SARS-COV2 virus infection is usually not related to acute arterial ischemia and its incidence is unknown. World references have been documented such as superficial and deep vein thrombosis and peripheral arterial thrombosis. Case description We present the case of a 69-year-old patient, previous smoker for 15 years, who presented with acute pain in the left lower limb followed by absence of distal and popliteal pulses. Complementary imaging studies demonstrated the absence of left arterial patency from the left femoral artery, raising a diagnosis of acute arterial ischemia of the left lower limb. Threatening acute marginal ischemia (Rutherford IIA) associated with SARS-COV2 infection was considered, for which selective femoral and popliteal embolectomy was performed with further control arteriography. The patient recovers arterial patency in the left lower extremity and was discharged with anticoagulation and analgesia. Postsurgical popliteal wound developed lymphorrhea that subsides with compression measures. In follow-up, the patient has a satisfactory evolution, without signs of ischemia. Conclusion In the medical literature of our country, this is our first case of acute arterial ischemia located in the lower extremities. Diagnosis requires a high degree of clinical suspicion and correct identification. Recommended treatment are surgical and/or pharmacological.

SÍNDROME DE TAKOTSUBO Y ESTRÉS AGUDO.

Introduction Takotsubo Syndrome (STk) is characterized by a transient systolic regional dysfunction on the left ventricle, usually diagnosed in 2% of the patients presenting with clinical suspicion of ST elevating myocardial infarction (STAMI). Main etiology is still unclear, correlating with pericardial artery spasm, microvascular alterations, viral myocarditis, heightened catecholamine levels with alteration of sympathetic system, and anatomical variations of the anterior descendent artery. Several emotional and physical triggers are linked to its development, but symptoms can arise in their absence. Most common signs and symptoms include: acute chest pain, dyspnea and syncope, initially indistinct to those of an acute myocardial infarction. Its presence varies according to the trigger: on those with a strong emotional trigger chest pain and palpitations, while on physical stress, underlying disease predominates (stroke, seizure). Case description A 58 year old female, without medical history of cardiovascular disease, was admitted to the hospital because of left sided chest pain, beginning 2 hours ago, most likely caused by emotional distress. On arrival, initial diagnosis was Acute Coronary Disorder (ACD). Coronarography, and anterior oblique right ventriculography confirming the diagnosis. Requiring mainly low-molecular-weight heparin anticoagulation during admission and novel anticoagulants for outpatient care, added to anxiety treatment. Follow-up started October 2019 and went on during 2020. Conclusion STk has similar characteristics to those of ACD on postmenopausal women. The present Clinical Case meets 3 of the 4 Mayo Criteria, and has 61 points on the InterTak score. Acute chest pain, dyspnea and syncope plus several additional studies can confirm STk. EKG showing ST elevation (90%), negative T wave on precordial leads (44%), Q wave present (15-27%). Elevation of the ST segment on V4 to V6 is higher than V1 to V3, with absence of Q anomaly. Heightened troponin levels, but lower than AMI; Heghtened BPN or proBPN could be present. Myocardial stunning could be liked to catecholamine levels 2 to 3 times higher than AMI with Killip III. The recovery does not require treatment, but could require diuretics, beta blockers, ACEs, angiotensin-II receptor blockers, statins and acetylsalicylic acid. Prognosis is favorable with mortality under the 2%.

LINFAGIOMA QUÍSTICO DE EPIPLÓN COMO CAUSA DE ABDOMEN AGUDO PEDIÁTRICO. ACTUALIZACIÓN DEL TRATAMIENTO: REPORTE DE CASO.

Introduction Mesenteric lymphagioma is a rare, benign, congenital cystic tumor of the lymphatic vessels, which occurs in 2-5% of cases at the abdominal level (75% cervical, 20% axillary), which occurs more frequently during the childhood. It occurs with an incidence of 1: 250,000 during childhood (60% cases before one year of age), the ratio of women to men is 2: 1. They are located mainly in the subperitoneal space, in the mesentery (59% - 68%), omentum (20% - 27%) and retroperitoneum (12% - 14%). This should be suspected as a differential diagnosis of acute abdomen and pediatric abdominal masses. Its complete excision with negative microscopic margins is the treatment of choice, either by conventional means by exploratory laparotomy or by other less invasive techniques such as laparoscopy. Case description A 6-year-old boy presented with abdominal pain and peritonism. Physical exam: positive rebound sign. Paraclinical: leukocytosis, neutrophilia. Ultrasound shows abundant free fluid in the abdomen and pelvis. Patient undergoes an exploratory laparotomy, finding a multicystic mass dependent on the greater omentum, a sample of peritoneal fluid is taken for cytochemical, bacteriological, culture and histopathology. Complete excision of the cyst plus partial omentectomy and incidental appendectomy is performed. Patient with favorable evolution tolerates diet at 24 hours with progression from liquid to soft, undergoes antibiotic treatment for 48 days based on cefazolin (suspended due to negative culture at 48 hours and negative BARR), with hospital discharge on the fourth day. Result of fibrin-filled peritoneal fluid, transudate and negative histopathology for malignancy. Histopathology report: Macroscopic: irregular tissue fragment measuring 10 x 6 cm, greyish-yellow, cystic areas measuring 1.5 and 4 cm; When cut, it drains mucinous material, the rest of the irregular yellowish areas. Microscopic: fibrofatty tissue with congestive vessels and mixed inflammatory infiltrate (lymphocytes and polymorphonuclear cells), compatible with cystic lymphagioma (Fig. 3). Immunohistochemistry positive for marker D 2-40. Patient with follow-up at 7 days; In months 1, 3, 6 and year with favorable evolution, a control ultrasound was performed at the sixth month and at one year without evidence of recurrence. Conclusion: Mesenteric cystic lymphagioma can present with symptoms of acute abdomen. Complete resection is the treatment of choice, minimally invasive procedures are currently performed with favorable results in children, ultrasound is sufficient for long-term follow-up.

REPORTE DE CASO: ARTERITIS DE TAKAYASU EN ECUADOR

Introduction Takayasu's arteritis is a panarteritis, characterized by chronic inflammation, that affects large vessels, especially the Aorta and its main branches. This pathology is extremely rare, has a higher incidence in Japan, presenting low incidence in Latin America. Case description We present the case of a young adult, with no significant medical history, who presents a 3 months of evolution intense headache initially classified as trigeminal neuralgia and cluster headache. Asymmetric pulses and variation in blood pressure between both upper extremities where observed which allowed several presumptive diagnoses to be considered. In the complementary examinations, the patient showed sustained elevation of acute phase reactants. Our patient met four diagnostic criteria of the American College of Rheumatology for Takayasu arteritis and the diagnosis was confirmed by magnetic Angio resonance of the neck, chest and abdomen, where involvement of the entire route of the aorta was observed. In context to treatment, the first-line therapy is high-dose steroids. In patients in whom the suspension of steroids is difficult, combined therapy with immunosuppressive agents is used. In the case of our patient, combined therapy with prednisone and methotrexate was chosen, which presented a favorable evolution. Conclusion Takayasu arteritis is an infrequent vasculitis, however, it is important to make an early diagnosis and treatment in order to improve the prognosis, stop the progression of the disease and improve the quality of life of patients suffering from this pathology.

INFORME DE UN CASO: QUISTE PARASITARIO MESENTÉRICO SUMADO A INSUFICIENCIA RENAL CRÓNICA SECUNDARIO A LUPUS ERITEMATOSO SISTÉMICO EN ADOLESCENTE.

Introduction Mesenteric cysts are abdominal tumors with a low incidence, the clinical presentation depends on the location and size of the cyst, the recommended treatment is surgical resolution. In next pages. Case description We present the case of a 17-year-old female adolescent with no significant personal pathological history, who initially presented nausea and incoercible vomiting, accompanied by fever and abdominal pain of 5 days of evolution, which caused moderate dehydration and consequently acute kidney injury and later chronic kidney failure that is aggravated by systemic lupus erythematosus that the patient develops during the clinical course. Concomitantly, the patient presents significant abdominal distention, so it is performed a CT scan (Tomography), which reveals the presence of a mesenteric cyst that displaces intra-abdominal organs, so it is made a reference to general surgery. Patient remains awaiting renal biopsy to determine histopathological classification for underlying autoimmune disease. The patient remains awaiting surgical resolution. Conclusion Mesenteric cyst is a rare entity, surgery is the treatment of choice and the only definitive diagnostic method for mesenteric cysts, the patient remains awaiting surgical resolution.

SERIE DE CASOS: MIELOMA MÚLTIPLE DIFERENCIACIÓN CLÍNICA, DIAGNOSTICA Y TERAPÉUTICAS EN TIEMPOS DE PANDEMIA 2020.

Introduction Multiple myeloma is a neoplasm caused by the proliferation of a clone of plasma cells that in most cases produce a monoclonal protein. Due to its decreased incidence of 4-5 cases per 100,000 inhabitants. Case description The General Hospital San Francisco Quito-Ecuador was diagnosed during this time of pandemic: three cases of Multiple Myeloma, with diverse presentation both in clinical manifestations, laboratories and radiographs, taking us to carry out a series of clinical cases with the objective of differentiating the type of clinic, diagnosis and therapy in times of pandemic in 2020. Finding different diagnoses at admission such as acute coronary syndrome, acute pancreatitis and heart failure, which were later discarded and evidenced in general bone pain, hyperamylasemia and hyperglobulinemia, with image changes both in bone punches and pathological fractures that led to the suspicion of Multiple Myeloma and performance of a medullogram for definitive diagnosis. The subspecialty treatment will run without complications. Conclusion The main characteristics are pathological fractures that can present in the form of acute or chronic pain, as well as related to other pathologies; and since the rest of the clinical manifestations mentioned in the literature were not present. It is also worth mentioning that hyperamylasemia was a factor found in our cases that future studies could be related as a prognostic factor and mortality in multiple myeloma

CUERPO EXTRAÑO PUNZANTE LOCALIZADO EN APÉNDICE CECAL, DE DOS MESES DE EVOLUCIÓN. EXTRACCIÓN POR COLONOSCOPIA - INFORME DE CASO.

Introduction Ingestion of foreign bodies implies a 35% risk of possible complications, which are associated with their type (blunt or sharp) and their size. Although in most of them, it is expected that they pass along the gastrointestinal tract without difficulty or complications, the management will depend on the characteristics of the swallowed object, time of evolution and symptoms of the patient. Case description We present the clinical case of a 58-year-old female patient with a recent gastric bypass surgical history, who accidentally ingested a piece of dental equipment two months earlier during a dental procedure, remaining asymptomatic until she came to our office. In radiographic controls for confirmation, location and evolution, the presence of a 2 cm sharp object was evidenced, apparently located in the cecal appendix, which does not progress distally. For the management, initial expectant management was proposed, which was completed with therapeutic colonoscopy for its extraction, the technique recommends that the sharp object should be grasped by the pointed end, distal to the wall, which reduces the risk of perforation related to the procedure or damage of the mucosa during extraction, the case is completed with successful resolution and without complications. Conclusion Less invasive therapeutic management such as colonoscopy should be considered first line in this type of case, when there are no signs or radiological findings of perforation or clinical instability, due to its low incidence of complications and a high success rate.

MANEJO Y SEGUIMIENTO CLÍNICO DE PACIENTE CON SINDROME DE ALPORT FASE IV

Introduction Alport syndrome (AS) is a hereditary disease of the basement membranes caused by mutations in type IV collagen. This disease is characterized by the presence of progressive hereditary nephropathy associated with sensory deafness, as well as ocular lesions. AS has an incidence of 1 in every 50,000 live births, constituting 1 to 2% of the cause of chronic kidney disease (CKD) in Europe and 3% of CKD in the American pediatric population; it is considered to be the cause of terminal uremia in 0.6 to 4.6% of terminal patients in the United States and Europe. At the moment there is no casuistry in this regard in Ecuador. At present there is no specific treatment for Alport Syndrome, however the drugs Angiotensin Converting Enzyme Inhibitors (ACEI) and angiotensin II receptor antagonists (ARBs) have demonstrated efficacy and safety over blocking the system. renin angiotensin aldosterone, thus reducing the presence of proteinuria and slowing the deterioration of CKD. Case description A 28-year-old male patient with a personal history of HT and 6-member SA relatives: 2 nephews, 1 brother and 3 carrier nieces. The physical examination revealed the presence of moderate bilateral hearing loss. He presents kidney disease from the age of 10 without adequate control. Alport Syndrome was diagnosed in 2012 by means of a renal biopsy, evidence of hematuria and by family history. He is currently receiving Hemodialysis treatment in a daily short session modality, which consists of 5 weekly sessions from Monday to Friday of 2 hours each; he is kept under hypotensive treatment of 10mg QD of Amlodipine (Calcium Channel Blocker), and 10mg BID of Carvedilol (Beta Blocker), together with 12.5mg BID of Losartan (Angiotensin II Receptor Antagonist), The patient was followed up throughout the year 2020 until January 2021, calculating the Glomerular Filtration Rate month by month to be able to show whether there is a significant progressive deterioration of his residual kidney function. Conclusion It is mentioned that the residual renal function has not been affected thanks to the control of the Arterial Hypertension of the patient where an ARA II drug (Losartan) is added, which slows the progressive renal deterioration that is typical of Alport Syndrome. The incorporation of the patient to the modality of daily short session of hemodialysis has helped to have a compensation of the renal function, obtaining a continuous clearance, resembling the function of a healthy kidney as closely as possible. In order for a hemodialysis treatment to have better results compensating for residual renal function, consecutive and longer sessions should be established, however this is a complicated issue depending on the availability of time and tolerance of the patient.

FÍSTULA VESICOSIGMOIDEA EN ENFERMEDAD DIVERTICULAR, REPORTE DE CASO Y REVISIÓN DE LITERATURA.

Introduction Colovesical fistulas (CVF) are pathologic communications between bowel and bladder. They represent 1 in 3000 surgical hospital admissions per year. Imaging studies play a crucial role establishing the site, course and complexity of the fistulas, and in identifying their etiology. The management of CVF depends on the underlying pathology, the site of the intestinal injury, and the preoperative state of the patient. A surgical and non-surgical approach can be performed. Case description A clinical case of an 82-year-old patient with multiple comorbidities is reported, who suddenly presented dysuria, stranguria and fecaluria. The abdominal and pelvic tomography revealed diverticulitis with the presence of a fistulous tract from the colon to the bladder. During his hospitalization, the patient presented septic shock of urinary focus due to colovesical fistula, which required management by intensive therapy. Broad-spectrum antibiotic therapy was started. Once stable, we opted for surgical resolution with partial cystectomy plus fistulectomy and Hartmann-type colostomy. After the procedure, the patient evolved favorably with resolution of the condition. Conclusion The nonsurgical approach may be a viable option in patients with poor preoperative condition, an inability to tolerate general anesthesia, or in cancer patients with a short life expectancy. Spontaneous closure of fistulas occurs in approximately 2% of patients and, since up to 75% may have septic complications, the presence of a FCV is an indication for surgery in all patients without contraindications for it. The most widely used surgical approach consists of resection of the compromised intestinal segment with primary anastomosis, without a protective stoma, and closure of the bladder defect. At present, there is no consensus on which is the best surgical strategy due to the lack of clinical trials. An updated review of the subject and its therapeutic management is carried out.

SINDROME ANTISINTETASA EN TIEMPO DE PANDEMIA

Introduction Introduction: The Antisynthetase Syndrome is a rare entity that is included within the idiopathic inflammatory myopathies, characterized by the presence of antisynthetase antibodies, they can be found in 39.1% of the patients with these myopathies. The affectation is systemic being the main ones at the articular level in 40% -80%. Lung damage occurs in 60% -80%, the most frequent findings being ground glass, predominantly crosslinking in lower segments, probably with a pattern of non-specific interstitial pneumonia, organized pneumonia, or mixed patterns. Regarding muscle involvement, it occurs in 60% -80%. Treatment is based on the use of corticosteroids, immunosuppressants, and biological agents. Case description A 38-year-old female patient with no significant clinical or family history was approached, single (no children), who presented gradual and intermittent joint pain and muscle weakness associated with progressive dyspnea, in the context of The current pandemic was swabbed for SARS-COV-2 on two occasions as well as antibodies for the same virus being negative, with tomographic findings compatible with an alternative pattern, despite the aforementioned, it was treated in a particular way with a scheme directed towards COVID -19, with partial resolution of the symptoms and subsequent exacerbation of the same, for which he went to hospital care, where the swab was repeated obtaining negativity of the same, deciding on this occasion an evaluation by the Pneumology Service and hospitalization. During his stay, an immunological panel was performed where a weak elevation of rheumatoid factor is evidenced, due to logistical issues Myositis panel we are waiting, however, due to the lack of specific etiology, it was decided to perform a lung biopsy reporting a concordant pattern of organized pneumonia With the tomographic diagnosis, the evolution of the patient was favorable with supportive treatment until the results of the external immunological panel were received, evidencing a marked elevation of the anti-Jo antibody, added to the clinical and image manifestations, the picture is cataloged as an Antisynthetase Syndrome. Thus, with the support of rheumatology, treatment with corticosteroids (methylprednisolone), immunosuppressants (mycophenolate) and biological agent (rituximab) is started; with which there was significant clinical improvement, decrease in o2 support as well as lung lesions, with which we proceeded to discharge with the respective follow-up by the services involved. Conclusions: As we evidenced in the clinical case, in a retrospective way, we can assert that it complied with the clinical manifestations of the disease, although we are experiencing a pandemic where lung involvement is important, once it has been ruled out, other diagnostic possibilities must be addressed. As in the patient, it culminated in the presentation of a rheumatological picture with lung damage.