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BACKGROUND Brugada syndrome is characterized by specific electrocardiographic changes predisposing individuals to ventricular arrhythmias and sudden cardiac death. Cases of coexisting Brugada syndrome and ischemic stroke are seldom documented, and an underlying pathophysiological link is yet unknown. This article presents a case in which a patient exhibited both Brugada syndrome patterns and an ischemic stroke, prompting a comprehensive literature review to explore the potential association between Brugada syndrome and ischemic stroke. CASE REPORT A 49-year-old man, previously healthy, was admitted to the hospital after being discovered unconscious at his workplace. Physical exam showed low oxygen saturation, fever, and abnormal neurological findings. Head computed tomography revealed a significant posterior circulation ischemic stroke. An electrocardiogram revealed Brugada syndrome type II initially, progressing to type III pattern. Despite efforts, the patient's condition rapidly deteriorated, leading to death within 24 hours. As far as we're aware, Brugada patterns following a posterior circulation ischemic stroke have only been documented in 1 other instance, in which the patient was also diagnosed with atrial fibrillation. CONCLUSIONS Both our literature review and the presented case indicate that Brugada patterns may coexist with and even be associated with ischemic stroke. More extensive research is required to shed light on this potential association. The question of whether Brugada syndrome is a precursor to or a result of ischemic stroke remains unanswered. We propose that patients with ischemic stroke should undergo an evaluation for electrocardiographic signs indicative of Brugada syndrome, particularly if no clear causes, like cardioembolism, are evident.

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BACKGROUND: Tuberculous pericarditis (TP) remains a challenge for endemic countries. In developing countries, one to two percent of patients with pulmonary tuberculosis develops TP. CASE SUMMARY: A 49-year-old woman presented with dyspnea, chest pain and dry cough. On physical examination, veiled heart sounds were found. The electrocardiogram showed low-voltage complexes and the transthoracic echocardiography revealed a large and free-looking pericardial effusion. The patient was taken for an open pericardiotomy. The pericardial fluid revealed high levels of adenosine deaminase and Ziehl-Neelsen stain showed acid-fast bacilli. Polymerase chain reaction study for Mycobacterium tuberculosis in pericardial fluid was positive. The patient received tetra conjugate management with adequate clinical response after the first week of treatment and resolution of fever and chest pain. CONCLUSION: In cases of TP, obtaining pericardial fluid and/or pericardial biopsy is the most efficient strategy to confirm the diagnosis. Early diagnosis of this entity will allow physicians to initiate timely treatment, avoid complications and improve the patient's clinical outcome, so we consider the description of this case pertinent and its review in the literature.

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Resumen Introducción y objetivos: El ultrasonido endoscópico con punción-aspiración con aguja fina (USE-PAAF) en lesiones neoplásicas biliopancreáticas suele tener un rendimiento alto, que depende de características de la lesión; aspectos técnicos de la USE-PAAF y la experiencia del endoscopista. De los factores menos estudiados es la presencia de patólogo en sala. Se plantea la realización de USE-PAAF con patólogo en sala para disminuir el número de pases, la tasa de muestras inadecuadas y la necesidad de repetir el procedimiento. Material y métodos: Estudio observacional, retrospectivo, con recolección prospectiva de enero de 2018 a junio de 2019, en pacientes adultos sometidos a USE-PAAF. Las muestras obtenidas fueron extendidas y evaluadas en salas de endoscopia por médico patólogo con coloración Diff-Quick y cuando se obtenía una muestra suficiente se enviaba en frasco con formol para bloque celular o biopsias. Resultados: Se realizaron 48 USE-PAAF biliopancreáticas en individuos con una edad mediana de 64 años. Las indicaciones más frecuentes fueron punciones por masa o pseudomasa pancreática (71 % de casos); Se diagnosticaron 35 malignidades (77 % correspondientes a adenocarcinoma, y 14 % a tumores neuroendocrinos). La mediana de tamaño de lesiones fue de 28 mm; el número de pases promedio fue de 3. Se obtuvieron resultados diagnósticos en 89 % frente a 11 % de falsos negativos. Se presentó 1 complicación menor (2,1 %), que fue dolor abdominal. Conclusiones: La USE-PAAF con patólogo en sala tiene alto rendimiento diagnóstico, con escasos resultados falsos negativos. Se requiere una mediana de pases menor, que podría minimizar los riesgos del procedimiento y la necesidad de repetir la prueba.

Abstract Introduction: Endoscopic ultrasound with fine-needle aspiration (EUS-FNA) of pancreatobiliary neoplastic lesions usually has a high performance that depends on the characteristics of the lesion, technical aspects, and expertise of the endoscopist. One of the least studied factors is rapid on-site evaluation with a pathologist in the room. Objective: To perform EUS-FNA with a pathologist in the endoscopy room to reduce the number of passes, the rate of inadequate samples and the need to repeat the procedure. Material and methods: Observational retrospective study with a prospective data collection approach from January 2018 to June 2019 of adult patients undergoing EUS-FNA. The samples obtained were spread and evaluated in endoscopy rooms by a pathologist with Diff-Quick stain, and when a sufficient sample was obtained, it was sent in a vial with formalin for cell block and/or biopsy. Results: 48 pancreatobiliary EUS-FNA were performed in individuals with a median age of 64 years. The most frequent indication was aspiration due to pancreatic mass (71%); 35 malignancies were diagnosed (77% were adenocarcinomas and 14% were neuroendocrine tumors). The median size of the lesions was 28mm, and the average number of passes was 3. Diagnostic results were obtained in 89% vs. 11% of false negatives. There was 1 minor complication (2.1%), which was abdominal pain. Conclusions: EUS-FNA with an in-room pathologist has a high diagnostic performance, with few false negative results. Also, a lower median number of passes is required, minimizing the risks of the procedure and the need for repeating it.

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BACKGROUND: Health care delivery for cerebrovascular diseases is a complex process, which may be improved using telestroke networks. OBJECTIVE: The purpose of this work was to establish and implement a protocol for the management of patients with acute stroke symptoms according to the available treatment alternatives at the initial point of care and the transfer possibilities. METHODS: The review board of our institutions approved this work. The protocol was based on the latest guidelines of the American Heart Association and American Stroke Association. Stroke care requires human and technological resources, which may differ according to the patient's point of entry into the health care system. Three health care settings were identified to define the appropriate protocols: primary health care setting, intermediate health care setting, and advanced health care setting. RESULTS: A user-friendly web-based telestroke solution was developed. The predictors, scales, and scores implemented in this system allowed the assessment of the vascular insult severity and neurological status of the patient. The total number of possible pathways implemented was as follows: 10 in the primary health care setting, 39 in the intermediate health care setting, and 1162 in the advanced health care setting. CONCLUSIONS: The developed comprehensive telestroke platform is the first stage in optimizing health care delivery for patients with stroke symptoms, regardless of the entry point into the emergency network, in both urban and rural regions. This system supports health care personnel by providing adequate inpatient stroke care and facilitating the prompt transfer of patients to a more appropriate health care setting if necessary, especially for patients with acute ischemic stroke within the therapeutic window who are candidates for reperfusion therapies, ultimately contributing to mitigating the mortality and morbidity associated with stroke.

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RESUMEN Las garrapatas son artrópodos de gran impacto sobre la economía pecuaria y la salud humana debido a las pérdidas generadas en la producción, y a su capacidad de transmitir microorganismos. Pese a la evidencia de circulación de una gran diversidad de garrapatas en Colombia, no se cuenta con compilaciones actualizadas de la variedad de especies presentes, por lo cual los autores presentan una revisión de literatura sobre las garrapatas de la familia Ixodidae reportadas en Colombia incluyendo su distribución geográfica, sus hospederos y los microorganismos reportados en aquellas especies registradas en este país. En la recopilación se evidenció la presencia en Colombia de diferentes especies de garrapatas de los géneros Amblyomma, Ixodes, Haemaphysalis, Rhipicephalus y Dermacentor. El género con mayor variedad fue Amblyomma con 29 especies, seguido de Ixodes con 11 especies, y de los géneros Dermacentor, Haemaphysalis y Rhipicephalus se reportaron dos especies para cada uno. Las especies se distribuyeron en la mayoría de los departamentos de Colombia y en una amplia diversidad de hospederos entre los cuales se incluyen animales domésticos, sinantrópicos y silvestres. Adicionalmente se encontró que algunas garrapatas reportadas podrían jugar un papel como vectores potenciales de diversos microorganismos que pueden afectar a la salud publica y veterinaria. Esperamos que este trabajo sea un aporte para apoyar la investigación en garrapatas y el estudio de los agentes transmitidos por estas en Colombia.

ABSTRACT Ticks are arthropods with significant impact on the economy of livestock and public health, due to losses generated in production, and their ability to transmit microorganisms. Despite the evidence of circulation of different tick species in the country, there are no updates concerning the variety of existing species, therefore, the authors of this manuscript offer a literature review on ticks from the Ixodidae family reported in Colombia including their geographical distribution, their hosts and the microorganisms they carry and might transmit in Colombia. In this manuscript, we described the presence in the country of different species of ticks of the genera Amblyomma, Ixodes, Haemaphysalis, Rhipicephalus, and Dermacentor. The genus with the greatest variety was Amblyomma with 29 species, followed by Ixodes with 11 species, and of the genus Dermacentor, Haemaphysalis and Rhipicephalus two species were reported for each. These species are distributed in most departments and a wide variety of hosts, including domestic, synanthropic and wild animals. Additionally, it was found that some reported ticks could play a role as potential vectors of various microorganisms that could affect public and veterinary health. We expect that this work will be a contribution to support tick research and the study of tick-borne agents in Colombia.

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Abstract INTRODUCTION: In Colombia, there is insufficient epidemiological surveillance of zoonotic hemorrhagic viruses. METHODS: We performed a sero-epidemiological study in indigenous populations of Wayuü, Kankuamos, and Tuchin communities using Maciel hantavirus and Junin arenavirus antigens for IgG detection by ELISA. RESULTS IgG antibodies to hantavirus and arenavirus were found in 5/506 (1%) and 2/506 (0.4%) serum samples, respectively. CONCLUSIONS: Arenavirus and hantavirus circulate in indigenous populations from the Colombian Caribbean region, and the results indicate that the indigenous populations are exposed to these zoonotic agents, with unknown consequences on their health, despite low seroprevalence.

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Introducción. Los tumores neuroendocrinos comprenden una amplia familia tumoral, siendo de mayor frecuencia aquellos localizados en el tracto gastrointestinal, los pulmones, el timo y el páncreas. Ocurren con poca frecuencia y cursan con un comportamiento biológico variable. El objetivo del presente estudio fue describir las características demográficas y clínicas de los pacientes con esta entidad en un hospital de alta complejidad. Métodos. Estudio descriptivo con revisión de historias clínicas correspondientes a pacientes con tumor neuroendocrino, cuya muestra histológica fue analizada en el Departamento de Patología del Hospital Pablo Tobón Uribe, Medellín, Colombia, entre 2010 y 2015. Se describen frecuencias de localización, grado de diferenciación y perfil de inmunohistoquímica. Resultados. Se revisaron 111 historias, de las que el 51,5 % correspondió a pacientes masculinos, con una mediana de edad al momento del diagnóstico de 48 años. Las comorbilidades más frecuentes fueron: hipertensión arterial (38,6 %), hipotiroidismo (15,8 %) y diabetes mellitus (11,9 %). El antecedente de neoplasia estuvo presente en el 13,9 % de los casos. Un 59,4 % de las muestras correspondieron a tumores primarios, el 34,8 % estaban localizados en el páncreas. El hígado fue el órgano más comprometido por metástasis (73,3 %). De los tumores neuroendocrinos, el 27 % correspondió a tumores grado 1 del tracto gastrointestinal o del páncreas, el 36 % a grado 2 y el 27,9 % a grado 3. El 3,6 % correspondió a tumores pulmonares de grado bajo o intermedio y el 5,4 % a tumores pulmonares de alto grado. Los marcadores tumorales con mayor positividad fueron sinaptofisina (97,2 %), citoqueratinas AE1/AE3 (95 %), CD56 (91,3 %) y cromogranina (87,8 %). Discusión. Los tumores neuroendocrinos tienen características clínicas e histopatológicas diversas. Conocer las características de los pacientes afectados permite una aproximación de la epidemiología local aplicable a futuras investigaciones

Introduction. Neuroendocrine tumors comprise a broad family of tumors, the most common being those located in the gastrointestinal tract, lungs, thymus, and pancreas. They occur infrequently and have a variable biological behavior. The objective of this study was to describe the demographic and clinical characteristics of patients with this entity in a highly complex hospital.Methods. Descriptive study with review of medical records corresponding to patients with neuroendocrine tu-mors, whose histological sample was analyzed in the Pathology Department of the Pablo Tobón Uribe Hospital in Medellín between 2010 and 2015. Frequencies of location, degree of differentiation and immune-histochemistry profile are described.Results. One hundred eleven histories were reviewed, of which 51.5% corresponded to male patients, with a median age at diagnosis of 48 years. The most frequent comorbidities were arterial hypertension (38.6%), hypothyroidism (15.8%) and diabetes mellitus (11.9%). Medical history of neoplasia was present in 13.9% of the cases. 59.4% of the samples corresponded to primary tumors, 34.8% were located in the pancreas. The liver was the organ most compromised by metastasis (73.3%). Of the neuroendocrine tumors, 27% corresponded to grade 1 tumors of the gastrointestinal tract or pancreas, 36% to grade 2 and 27.9% to grade 3; 3.6% corresponded to low or intermediate grade lung tumors and 5.4% to high-grade lung tumors. The tumor markers with the highest positivity were synaptophysin (97.2%), cytokeratins AE1/AE3 (95%), CD56 (91.3%) and chromogranin (87.8%).Discusion. Neuroendocrine tumors have diverse clinical and histopathologic features. Knowing the characteristics of affected patients allows an approximation of local epidemiology applicable to future research

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INTRODUCTION: In Colombia, there is insufficient epidemiological surveillance of zoonotic hemorrhagic viruses. METHODS: We performed a sero-epidemiological study in indigenous populations of Wayuü, Kankuamos, and Tuchin communities using Maciel hantavirus and Junin arenavirus antigens for IgG detection by ELISA. RESULTS: IgG antibodies to hantavirus and arenavirus were found in 5/506 (1%) and 2/506 (0.4%) serum samples, respectively. CONCLUSIONS: Arenavirus and hantavirus circulate in indigenous populations from the Colombian Caribbean region, and the results indicate that the indigenous populations are exposed to these zoonotic agents, with unknown consequences on their health, despite low seroprevalence.

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BACKGROUND: Parathyroid cyst is an infrequent and unsuspected disease. There are more than 300 hundred cases reported in the world literature, a few of them are from Latin America. The experience of our centers and a review of the cases are presented. METHODS: Case report of a series of patients with parathyroid cyst from our institutions according to the CARE guidelines (Case Reports). A search of Medline, Embase, BIREME (Biblioteca Regional de Medicina) LILACS (Literatura Latinoamericana y del Caribe en Ciencias de la Salud), Google Scholar and Scielo (Scientific Electronic Library on Line) databases and telephonic or email communications with other experts from Latin-America was performed . RESULTS: Six patients with parathyroid cyst were found in our centers in Colombia. Most of them were managed with aspiration of the cyst. Two of them required surgery. Only one case was functional. Twelve reports from Latin America were found for a total of 18 cases in our region adding ours. CONCLUSIONS: Parathyroid cysts are uncommonly reported in Latin America. Most of them are diagnosed postoperatively. Suspicion for parathyroid cyst should be raised when a crystal clear fluid is aspirated from a cyst. The confirmation of the diagnosis may be easily done if parathyroid hormone (PTH) level is measured in the cyst fluid.

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Introducción: El rechazo celular agudo es una complicación del trasplante ortotópico de hígado (TOH). Se presenta entre 30 y 70% de los pacientes trasplantados en el primer año del procedimiento. Objetivo: Describir las principales variables asociadas al rechazo celular en pacientes con trasplante hepático en el Hospital Pablo Tobón Uribe de la ciudad de Medellín, en el periodo 2005-2010. Metodología: De forma retrospectiva se evaluaron las historias clínicas de 248 pacientes a quienes se les realizó TOH con donante cadavérico y se identificaron aquellos pacientes que presentaron pruebas histológicas, clínicas y bioquímicas de rechazo celular según los criterios universalmente aceptados. Resultados: En los 248 trasplantes de hígado realizados en el periodo 2005-2010 se confirmaron 44 episodios de rechazo celular en 34 pacientes, para una incidencia de 13,7%; 30 pacientes (88,2%) presentaron un episodio de rechazo; 2 (5,8%) tres episodios y 2 (5,8%) cuatro episodios. Conclusión: Se describen las características principales del rechazo celular agudo en esta serie y se comparan con la literatura internacional ya que no encontramos reportes nacionales. La mayoría de casos fueron rechazo celular agudo leve y moderado con buena respuesta al manejo médico y sin repercusiones para la supervivencia del injerto o del paciente.

Introduction: Acute cellular rejection is a complication of orthotopic liver transplantation (OLT) which occurs in between 30% and 70% of transplant patients in the first year after the procedure. Objective: The objective of this study was to describe the main variables associated with cellular rejection in liver transplant patients at the Hospital Pablo Tobon Uribe in Medellin from 2005 to 2010. Methods: Medical records of 248 patients who had undergone OLTs with cadaveric donor grafts were evaluated retrospectively. Patients with histological, clinical and biochemical evidence of cellular rejection were identified in accordance with universally accepted criteria. Results: 44 episodes of cellular rejection in 34 patients were confirmed from among 248 liver transplantations performed in from 2005 to 2010. The incidence of rejection was 13.7%. Thirty patients (88.2%) had one episode of rejection, two (5.8%) had three episodes and two others (5.8%) had four episodes. Conclusions: We describe the main features of acute cellular rejection in this series and compare them with reports in the international literature. No other reports from Colombia were found. Most cases were mild to moderate acute cellular rejection which responded well to medical management without implications for graft or patient survival.

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En este artículo se presenta el caso de una paciente en edad pediátrica, a quien se le diagnostic el síndrome de Letterer-Siwe por hallazgos clínicos, de imagen e histopatológicos, que evidenciaron una afectación multiorgánica por infiltración histiocitaria. Este síndrome es una entidad inusual y agresiva, parte del espectro clínico de las histiocitosis de células de Langerhans. Tiene el peor pronóstico de los tres tipos conocidos (granuloma eosinófilo, Hand-Schüller-Christian y Letterer- Siwe), por un compromiso infiltrativo más extenso, porque afecta un mayor número de órganos y porque tiende a aparecer en edades más tempranas. Los hallazgos clínicos de los síndromes que constituyen la histiocitosis de células de Langerhans están directamente relacionados con las alteraciones funcionales de los órganos afectados. En los casos crónicos, los pacientes evolucionan de forma rápida y progresiva a falla multiorgánica y con frecuencia fallecen por cuadros sépticos. Las imágenes diagnósticas son útiles; sin embargo, la apariencia de los hallazgos habitualmente no es específica, por lo que es necesario el estudio histológico.

A case of a female patient at pediatric age, who has been diagnosed with Letterer-Siwe is presented in this article. The diagnosis was based on clinical, imaging and histopatologic findings that exhibit multiorgan commitment caused by histiocytic infiltration. This syndrome is a rare andaggressive entity which is part of the Langerhans cell histicytosis clinical spectrum. It presents the worst prognosis of the three known types (eosinophilic granuloma, Hand-Schüller-Christian, and Letterer-Siwe syndromes) since it exhibits more extensive infiltrative comprise, involves a large number of organs and tends to occur at younger ages. The clinical findings of the syndromes thatconstitute Langerhans cells histiocytosis are directly related to functional alterations of the affected organs. In severe cases, patients promptly and progressively evolve into an organ failure and often die for septic issues. Diagnostic imaging is useful to see the compromise of most organs, howeverthe appearance of findings is usually not specific, so it is necessary a histological study.

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Introducción. El hepatocarcinoma es una neoplasia que, generalmente, se presenta en pacientes cirróticos y su manejo depende tanto del estado de la cirrosis como del tumor. Su incidencia se está incrementando a nivel mundial. El trasplante hepático es considerado por muchos la mejor alternativa para el manejo curativo en quienes cumplan los criterios de inclusión para dicho procedimiento.Materiales y métodos. Entre abril de 2004 y abril de 2008, se recolectaron de manera prospectiva todos los pacientes sometidos a trasplante hepático en el Hospital Pablo Tobón Uribe (Unidad de Trasplante Hepático Universidad de Antioquia-Hospital Pablo Tobón Uribe) de Medellín y se analizaron los resultados de las imágenes y de anatomopatología, de quienes se incluyeron en la lista de trasplantes con diagnóstico de hepatocarcinoma y de quienes en éste fue un hallazgo incidental.Resultados. De 153 trasplantes de hígado durante este período, 25 se hicieron con diagnóstico previo de hepatocarcinoma y en 3 fue un hallazgo incidental. Se incluyeron 21 hombres y 7 mujeres. La etiología de la cirrosis fue por hepatitis por virus B en 28,6% y hepatitis por virus C en 17,9%, seguidas por alcoholismo, enfermedad autoinmune y otras. Hubo 7 pacientes sin hallazgo de hepatocarcinoma en el hígado extraído del receptor, todos con imágenes previas que mostraban una lesión única diagnosticada como hepatocarcinoma; ninguno era Child A, por lo tanto, en todos la indicación de trasplante era una complicación de la cirrosis y no del tumor. La concordancia de las imágenes con la anatomopatología del hígado resecado fue mucho mejor para la resonancia magnética que para la tomografía computadorizada, 53,8% versus 38,8%.Discusión. El trasplante hepático es el tratamiento ideal para los pacientes con hepatocarcinoma y cirrosis. Es claro que esta terapia está restringida actualmente a pacientes con estadios tempranos del tumor, según los criterios de Milán. A pesar de los refinamientos en las técnicas de imágenes, todavía es frecuente encontrar discrepancias entre los hallazgos imaginológicos preoperatorios y los resultados definitivos de la anatomopatología en el hígado extraído del receptor, pero este hecho no es indicación para hacer, por el momento, ningún tipo de modificación en el manejo de estos pacientes, en vista de los buenos resultados encontrados en la supervivencia a 5 años.

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The authors report two cases of adrenal insufficiency secondary to infiltration of the adrenal glands by Paracoccidioides brasiliensis. The first patient had been treated for a chronic multifocal form of paracoccidiodomycosis 11 years ago. The diagnosis of the mycosis was done simultaneous with that of the adrenal insufficiency in the second patient. In both patients the diagnosis was done by direct visualization of fungus in adrenal biopsies. They were treated with hormonal supplements and itraconazol by 12 and six months, without relapses during the follow-up period.

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The authors report two cases of adrenal insufficiency secondary to infiltration of the adrenal glands by Paracoccidioides brasiliensis. The first patient had been treated for a chronic multifocal form of paracoccidiodomycosis 11 years ago. The diagnosis of the mycosis was done simultaneous with that of the adrenal insufficiency in the second patient. In both patients the diagnosis was done by direct visualization of fungus in adrenal biopsies. They were treated with hormonal supplements and itraconazol by 12 and six months, without relapses during the follow-up period.

Os autores apresentam dois casos de insuficiência supra-renal secundária à infiltração das adrenais pelo Paracoccidioides brasiliensis. O primeiro paciente tinha sido tratado de paracoccidioidomicose crônica multifocal 11 anos atrás. No segundo paciente, o diagnóstico da micose foi feito de forma simultânea com o da insuficiência adrenal. Em ambos os pacientes, o diagnóstico foi feito pela visualização direta do fungo nas biopsias adrenais. Eles foram tratados com suplementos hormonais com itraconazol por seis a 12 meses, sem recaídas durante o período de acompanhamento.

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