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Introduction Spondyloarthritis is a group of chronic inflammatory diseases that mainly affect the axial skeleton, and also the peripheral joints. In bone metabolism studies on these patients, it has been observed that there are lower levels of vitamin D in patients with spondyloarthritis. Objective To estimate the prevalence of vitamin D deficiency/insufficiency, as well as calcium/phosphate metabolism and their implications in a cohort of patients with spondyloarthritis. Methodology Observational, descriptive, and cross-sectional study. A retrospective review of the databases was carried out on patients with spondyloarthritis who were treated in the outpatient clinics of the Rheumatology Department of the General University Hospital of Ciudad Real between June 2018 and June 2019. Variables are described using frequency and central tendency/dispersion measurements as appropriate. Results The study included 115 patients, of whom 64 were men and 51 women, with a mean age of 45.97 years (±13.41 SD). They included 59 patients with ankylosing spondylitis, 24 with psoriatic arthropathy, 9 arthritis associated with inflammatory bowel disease, 12 non-radiographic axial spondyloarthritis, and 11 reactive arthritis. Vitamin D levels were 23.81 ng/mL (±10.5 SD), with 77.4% of patients with vitamin D deficiency/insufficiency levels. Grouped by the spondyloarthritis subtype, and according to vitamin D deficiency/insufficiency, 45 patients had ankylosing spondylitis, 19 psoriatic arthropathy, 9 arthritis associated with inflammatory bowel disease, 7 non-radiographic axial spondyloarthritis, and 9 reactive arthritis. Furthermore, vitamin D deficiency ( Conclusions An optimization of vitamin D levels may lead to an improvement in the clinical situation of the patients, as measured by both BASDAI and DAPSA, as well as by PCR and ESR. Therefore, vitamin D monitoring and supplementation is recommended in patients with vitamin D deficiency.

RESUMEN Introducción: Las espondiloartritis son un grupo de enfermedades inflamatorias crónicas con afectación principalmente del esqueleto axial y también de articulaciones periféricas. En cuanto al metabolismo óseo de estos pacientes, se ha observado en algunos estudios que existen niveles más bajos de vitamina D en pacientes con espondiloartritis. Objetivo: Estimar la prevalencia de déficit/insuficiencia de vitamina D, el metabolismo fosfocálcico y sus implicaciones en una cohorte de pacientes con espondiloartritis. Metodología: Estudio observacional, descriptivo y transversal. Se llevó a cabo una revisión retrospectiva de la base de datos de pacientes con espondiloartritis que fueron atendidos en las consultas externas del Servicio de Reumatología del Hospital General Universitario de Ciudad Real entre junio del 2018 y junio del 2019. Las variables se describieron usando medidas de frecuencia o medidas de tendencia central/dispersión según correspondiera. Resultados: Se analizaron 115 pacientes, de los cuales 64 fueron hombres y 51 mujeres, con una edad media de 45,97 años (± 13,41 DE). Del total de los pacientes, 59 presentaron espondilitis anquilosante, 24 artropatía psoriásica, 9 artritis asociada a enfermedad inflamatoria intestinal, 12 espondiloartritis axial no radiográfica y 11 artritis reactiva. Los niveles de vitamina D fueron de 23,81 ng/ml (±10,5 DE), con un 77,4% de los pacientes con cifras de déficit/insuficiencia de vitamina D. Agrupados por el subtipo de espondiloartritis y según las cifras de déficit/insuficiencia de vitamina D, 45 pacientes tenían espondilitis anquilosante, 19 artropatía psoriásica, 9 artritis asociada a enfermedad inflamatoria intestinal, 7 espondiloartritis axiales no radiográficas y 9 artritis reactivas. Además, el déficit de vitamina D (< 20 ng/ml) se presentaba la mayoría de las veces en las estaciones de primavera e invierno, con 31 y 26 pacientes respectivamente. Conclusiones: Una optimización de los niveles de vitamina D puede implicar una mejoría en la situación clínica del paciente, medida tanto por BASDAI y DAPSA como por PCR y VSG. En consecuencia, se recomienda la monitorización y suplementación de vitamina D en pacientes con hipovitaminosis D. ABSTRACT Introduction: Spondyloarthritis is a group of chronic inflammatory diseases that mainly affect the axial skeleton, and also the peripheral joints. In bone metabolism studies on these patients, it has been observed that there are lower levels of vitamin D in patients with spondyloarthritis. Objective: To estimate the prevalence of vitamin D deficiency / insufficiency, as well as calcium/ phosphate metabolism and their implications in a cohort of patients with spondyloarthritis. Methodology: Observational, descriptive, and cross-sectional study. A retrospective review of the databases was carried out on patients with spondyloarthritis who were treated in the outpatient clinics of the Rheumatology Department of the General University Hospital of Ciudad Real between June 2018 and June 2019. Variables are described using frequency and central tendency / dispersion measurements as appropriate. Results: The study included 115 patients, of whom 64 were men and 51 women, with a mean age of 45.97 years (± 13.41 SD). They included 59 patients with ankylosing spondylitis, 24 with psoriatic arthropathy, 9 arthritis associated with inflammatory bowel disease, 12 non-radiographic axial spondylarthritis, and 11 reactive arthritis. Vitamin D levels were 23.81 ng/ml (± 10.5 SD), with 77.4% of patients with vitamin D deficiency / insufficiency levels. Grouped by the spondylarthritis subtype, and according to vitamin D deficiency / insufficiency, 45 patients had ankylosing spondylitis, 19 psoriatic arthropathy, 9 arthritis associated with inflammatory bowel disease, 7 non-radiographic axial spondyloarthritis, and 9 reactive arthritis. Furthermore, vitamin D deficiency (< 20 ng/ml) mainly occurred in the spring and winter seasons, with 31 and 26 patients, respectively. Conclusions: An optimization of vitamin D levels may lead to an improvement in the clinical situation of the patients, as measured by both BASDAI and DAPSA, as well as by PCR and ESR. Therefore, vitamin D monitoring and supplementation is recommended in patients with vitamin D deficiency.

Resumen Nuestro hospital es el hospital de referencia en medicina nuclear para la realizacion de la sinoviortesis radioisotopica para toda Castilla La-Mancha. Objetivo Describir la experiencia en la realizacion de la sinoviortesis radioisotopica en las artritis refractarias a otros tratamientos en nuestro hospital. Metodologia Estudio observacional, descriptivo y transversal protocolizado a traves de la revision de la base de datos de las sinoviortesis radioisotopicas realizadas entre 2007 y 2017. Se recopilaron datos clinicos previos (edad, sexo, proceso patologico, tratamientos previos, infiltracion previa y articulacion afectada) y evolutivos a los 6 meses tras administrar el isotopo. Se creo una base de datos Excel para un analisis de frecuencias con SPSS 21. Resultados Se realizaron 30 radiosinoviortesis, siendo las enfermedades mas frecuentes, por este orden: sinovitis villonodular pigmentada (40%), artritis reumatoide (23,3%), espondiloartritis (13,3%), osteoartritis (10%) y artritis inespecificas (6,7%), seguido de lupus eritematoso sistemico y gota. Tras 6 meses un 56,7% de los pacientes mejoraron frente a un 36,7% que seguian igual. Asi mismo, ninguno de ellos presento complicaciones relacionadas con el procedimiento. A un 6,6% de los pacientes se les perdio el seguimiento. Discusion y conclusiones En los pacientes con episodios de artritis de repeticion con derrame articular asociado en una o 2 articulaciones, refractarias a tratamientos sistemicos, a las infiltraciones locales con corticoides y en aquellos pacientes en los que otros tratamientos puedan estar contraindicados, debemos considerar la posibilidad de realizar una radiosinoviortesis isotopica, pues es una tecnica sencilla, segura y con una tasa de exito superior al 50%.

Our hospital is the nuclear medicine referral hospital for radioisotopic synoviorthesis for all of Castilla-La Mancha. Objective To describe the experience in the performance of radioisotopic synoviorthesis for arthritis refractory to other treatments in our hospital. Methodology Observational, descriptive and cross-sectional study protocolised through the review of the database of radioisotopic synoviorthesis performed between 2007 and 2017. Previous clinical data were collected (age, sex, pathology, previous treatments, previous infiltration and affected joint), and progress at 6 months after administering the isotope. An Excel database was created for a frequency analysis with SPSS 21. Results 30 radiosynovitis interventions were performed. The most frequent pathologies in this order were: pigmented villonodular synovitis (40%), rheumatoid arthritis (23.3%), spondyloarthritis (13.3%), osteoarthritis (10%) and nonspecific arthritis (6.7%), followed by systemic lupus erythematosus and gout. After 6 months, 56.7% of the patients improved compared to 36.7% who remained the same. Likewise, none of them presented complications related to the procedure. Six point six percent of the patients were lost to follow-up. Discussion and conclusions In patients with episodes of recurrent arthritis with associated joint effusion in one or two joints, refractory to systemic treatments, to local infiltrations with corticosteroids and for patients for whom other treatments may be contraindicated, we must consider the possibility of performing an isotope radiosinoviortesis, as it is a simple, safe technique with a success rate of more than 50%.

Resumen Objetivo Describir las diferentes caracteristicas clinicas de los pacientes ingresados en el Servicio de Reumatologia por manifestaciones reumaticas como primera expresion de un proceso tumoral no conocido. Pacientes y metodos Estudio observacional retrospectivo y descriptivo protocolizado por la revision de las historias clinicas de los ingresados en Reumatologia del Hospital Universitario de Ciudad Real desde enero de 2007 hasta agosto de 2017 por manifestaciones iniciales reumaticas, con sospecha al alta de un tumor no conocido. Resultados De mas de 500 ingresos, se obtuvieron 64 casos. Las manifestaciones reumaticas mas frecuentes fueron lumbalgia inflamatoria, poliartralgias, sindrome de cadera, dorsalgia, cervicalgia, poliartritis y polimialgia reumatica. Un 44% presentaban anemia, un 70% elevacion de los reactantes de fase aguda, un 62% alteracion en los marcadores tumorales y un 76% lesiones metastasicas. En el 20%, el tumor primario fue de origen pulmonar y solo el 26,56% recibio tratamiento paliativo. El 64% fallecieron. Discusion Es importante plantearse en el diagnostico diferencial la posibilidad de un proceso tumoral subyacente, dado que su diagnostico temprano puede ser determinante para el pronostico.

Resumen Introduccion El Servicio de Reumatologia del Hospital de Ciudad Real tiene implementado un modelo de autogestion de citaciones de consultas sucesivas desde hace mas de 10 anos, en el que son los facultativos del propio servicio los que gestionan las citas de revision de los pacientes en funcion de su enfermedad, evolucion, pruebas complementarias… El proposito del presente estudio es valorar y comparar el modelo de autogestion de citas sucesivas del Servicio de Reumatologia del Hospital de Ciudad Real frente al modelo de gestion externa de citas implantado en 8 de los 15 servicios medicos del hospital. Material y metodos Se realizo un analisis comparativo y multivariante para la identificacion de variables con diferencias estadisticamente significativas, en terminos de indicadores de actividad/rendimiento y de calidad percibida por los usuarios, entre el modelo de autogestion de citas sucesivas del Servicio de Reumatologia del Hospital de Ciudad Real, y el modelo de gestion externa de citas de 8 servicios medicos del hospital, entre el 1 de enero y el 31 de mayo de 2016. Resultados En una base de datos con mas de 100.000 registros de las citaciones del conjunto de servicios incluidos en el estudio, el tiempo medio de espera y los numeros de incomparecencias y reprogramaciones para consultas sucesivas del servicio de reumatologia fueron significativamente inferiores al resto de servicios. El numero de pacientes atendidos en consultas externas de reumatologia fue de 7.768 y, de estos, se le realizo una encuesta a un total de 280 pacientes (tasa de respuesta del 63,21%), donde destaca una gran satisfaccion global, ademas de una tasa de incidencia de reclamaciones baja. Conclusion Nuestros resultados denotan que el modelo de autogestion de citaciones tiene mejores resultados, tanto en indicadores de actividad como en la calidad percibida por los usuarios, a pesar de la intensa actividad, por lo que este estudio puede ser fundamental para la toma de decisiones en la mesogestion de organizaciones sanitarias.

The heterogenous nature of colorectal cancer (CRC) renders it a major clinical challenge. Increasing genomic understanding of CRC has improved our knowledge of this heterogeneity and the main cancer drivers, with significant improvements in clinical outcomes. Comprehensive molecular characterization has allowed clinicians a more precise range of treatment options based on biomarker selection. Furthermore, this deep molecular understanding likely extends therapeutic options to a larger number of patients. The biological associations of consensus molecular subtypes (CMS) with clinical outcomes in localized CRC have been validated in retrospective clinical trials. The prognostic role of CMS has also been confirmed in the metastatic setting, with CMS2 having the best prognosis, whereas CMS1 tumors are associated with a higher risk of progression and death after chemotherapy. Similarly, according to mesenchymal features and immunosuppressive molecules, CMS1 responds to immunotherapy, whereas CMS4 has a poorer prognosis, suggesting that a CMS1 signature could identify patients who may benefit from immune checkpoint inhibitors regardless of microsatellite instability (MSI) status. The main goal of these comprehensive analyses is to switch from "one marker-one drug" to "multi-marker drug combinations" allowing oncologists to give "the right drug to the right patient." Despite the revealing data from transcriptomic analyses, the high rate of intra-tumoral heterogeneity across the different CMS subgroups limits its incorporation as a predictive biomarker. In clinical practice, when feasible, comprehensive genomic tests should be performed to identify potentially targetable alterations, particularly in RAS/BRAF wild-type, MSI, and right-sided tumors. Furthermore, CMS has not only been associated with clinical outcomes and specific tumor and patient phenotypes but also with specific microbiome patterns. Future steps will include the integration of clinical features, genomics, transcriptomics, and microbiota to select the most accurate biomarkers to identify optimal treatments, improving individual clinical outcomes. In summary, CMS is context specific, identifies a level of heterogeneity beyond standard genomic biomarkers, and offers a means of maximizing personalized therapy.

In this study, a relationship between low levels of vitamin D and other markers of inflammation is observed in patients with spondyloarthritis. Therefore, insufficient levels of vitamin D could be used as a marker of inflammation, so they would help to have a better follow-up of the patient. The aim of this study is to determine the association between 25-hydroxyvitamin D deficiency and level of disease activity in patients suffering from spondyloarthritis. This study is an observational, descriptive and transversal study. A retrospective review of patients with spondyloarthritis under treatment at the Rheumatology Department of Hospital General Universitario de Ciudad Real between September 2016 and September 2018 is under consideration. The association between 25-hydroxyvitamin D deficiency and levels of disease activity was calculated using odds ratio (OR) with a 95% confidence level. Initial study developments are reported. A group of 147 patients was analyzed. The average disease activity was 4.3 (according to BASDAI) and 11.4 (according to DAPSA). Twenty-eight percent of patients showed increased levels of acute-phase reactants, and 82% exhibited 25-hydroxyvitamin D deficiency/insufficiency. Analysis of the association between vitamin D deficiency/insufficiency and BASDAI/DAPSA activity degree revealed an OR of 7.9 (CI95%: 2.92–21.23, p =

RESUMEN Objetivo: Determinar el riesgo cardiovascular y la prevalencia de factores de riesgo cardiovascular (RCV) en los pacientes con artritis reumatoide. Materiales y métodos: Estudio observacional, descriptivo y transversal, realizado en el Hospital General de Ciudad Real, entre junio de 2013 y mayo de 2014. Se realizó una analítica completa, se elaboró un perfil clínico, se calculó el SCOREm y se estratificó el RCV. Finalmente, se determinó la presencia de aterosclerosis subclínica mediante la realización de una ecografía carotídea. Resultados: 119 pacientes aceptaron participar en el estudio. Hubo una prevalencia del 73,1% de los factores de riesgo tradicionales, 6,72% había presentado un evento cardiovascular al momento del estudio, 22,68% poseía un infradiagnóstico de diabetes mellitus o nefropatía. La distribución final del RCV fue: riesgo bajo 46 (38,7%), riesgo intermedio 33 (27,7%), riesgo alto 2 (1,7%), riesgo muy alto 38 (31,9%). Conclusiones: Existe una alta prevalencia de factores de RCV y riesgo elevado infradiagnosticado en esta población. Por lo que si bien la artritis reumatoide se manifiesta de forma más aparente a nivel articular, ha de considerarse una enfermedad sistémica asociada a una mayor incidencia de eventos cardiovasculares. ABSTRACT Objective: To determine the cardiovascular risk and the prevalence of cardiovascular risk (CVR) factors in patients with rheumatoid arthritis. Material and methods: Observational, descriptive and cross-sectional study performed in the General Hospital of Ciudad Real from June 2013 to May 2014. A complete laboratory analysis was performed, a clinical profile was prepared, the Systematic COronary Risk Evaluation (SCOREm) was calculated, and the CVR was stratified. Finally, the presence of sub-clinical atherosclerosis was determined by performing a carotid ultrasound. Results: 119 patients accepted to participate in the study. There was a prevalence of 73.1% of traditional risk factors; 6.72% having had a cardiovascular event at the time of the study, and 22.68% had an underdiagnosis of diabetes mellitus and/or nephropathy. The final distribution of the CVR was: Low risk 46 (38.7%), intermediate risk 33 (27.7%), high risk 2 (1.7%), very high risk 38 (31.9%). Conclusions: There is a high prevalence of CVR factors and an elevated risk of underdiagnosis in the rheumatoid arthritis population. Therefore, although rheumatoid arthritis manifests itself more in the joints, it should be considered a systemic disease associated with a higher incidence of cardiovascular events.

Resumen Objetivo Determinar el riesgo cardiovascular y la prevalencia de factores de riesgo cardiovascular (RCV) en los pacientes con artritis reumatoide. Materiales y metodos Estudio observacional, descriptivo y transversal, realizado en el Hospital General de Ciudad Real, entre junio de 2013 y mayo de 2014. Se realizo una analitica completa, se elaboro un perfil clinico, se calculo el SCOREm y se estratifico el RCV. Finalmente, se determino la presencia de aterosclerosis subclinica mediante la realizacion de una ecografia carotidea. Resultados 119 pacientes aceptaron participar en el estudio. Hubo una prevalencia del 73,1% de los factores de riesgo tradicionales, 6,72% habia presentado un evento cardiovascular al momento del estudio, 22,68% poseia un infradiagnostico de diabetes mellitus o nefropatia. La distribucion final del RCV fue: riesgo bajo 46 (38,7%), riesgo intermedio 33 (27,7%), riesgo alto 2 (1,7%), riesgo muy alto 38 (31,9%). Conclusiones Existe una alta prevalencia de factores de RCV y riesgo elevado infradiagnosticado en esta poblacion. Por lo que si bien la artritis reumatoide se manifiesta de forma mas aparente a nivel articular, ha de considerarse una enfermedad sistemica asociada a una mayor incidencia de eventos cardiovasculares.

Background: Spondyloarthritis is a group of chronic inflammatory diseases with involvement of the axial skeleton (mainly), and also of peripheral joints. Patients with spondyloarthritis have a significant prevalence of vitamin D levels below normal and that would correlate with the degree of activity of the disease. Objectives: To determine the association between vitamin D deficiency and the degree of activity of the disease (inflammatory activity) in a cohort of patients with spondyloarthritis. Methods: Observational, extensive and transversal study. We propose a retrospective review of the database of patients with spondyloarthritis who were treated in the outpatient clinics of the Rheumatology Service of the General University Hospital of Ciudad Real during September 2016 to September 2018. Patients with the data will be selected. necessary for the analysis of the variables under study. The variables evaluated will be described using measures of frequency and measures of central tendency/dispersion as appropriate. To assess the association between vitamin D deficit and activity index, the odds ratio (OR) will be calculated. All analyzes were performed with a confidence level of 95% using SPSS 21.0. Results: The first advances of the results of the study are presented. 101 patients were analyzed, of which 58 were men and 43 women, with an average age of 46.33 years (+/- 13.05 DE). 15 (14.85%) were non-radiographic axial spondyloarthritis, 48 (47.52%) ankylosing spondylitis, 24 (23.76%) psoriatic arthropathy, 3 (2.97%) spondyloarthropathy associated with inflammatory bowel disease, and 11 (10, 89%) were other types of spondyloarthritis. The average of the activity was a BASDAI of 4.355 (+/- 2.376 SD), 64 patients were in activity (BASDAI> or = 4) and 31 patients (30.69%) with an elevation of acute phase reactants. Vitamin D levels were 24.52 (+/- 9.21 SD). 77 patients (76.24%) presented figures of vitamin D deficiency or insufficiency. When performing the association analysis, the vitamin D deficit/insufficiency presented an OR 12.46 (95% CI: 4.07-38.08)., p = Conclusion: In our study, patients with spondyloarthritis who have a vitamin D deficit correlate with presenting disease activity (BASDAI> or = 4). Therefore, inflammation along with increased bone turnover and low levels of vitamin D could be related to the pathophysiology of osteoporosis related to spondyloarthritis, and may adversely affect the patient’s functional status and quality of life. Disclosure of Interests: None declared

Objective To describe the different clinical characteristics of patients admitted to the Rheumatology Department due to rheumatic manifestations as the first expression of an unknown malignant process. Patients and methods Retrospective and descriptive observational study involving the review of the medical records of those admitted to rheumatology in the University Hospital of Ciudad Real between January 2007 and August 2017 for initial rheumatic manifestations with a suspicion at discharge of an unknown tumor. Results In all, 64 patients were identified from more than 500 admissions. The most common rheumatic manifestations were inflammatory low back pain, polyarthralgia, hip pain, thoracic spine pain, cervical pain, polyarthritis and polymyalgia rheumatica. Forty-four percent had low haemoglobin, 70% had elevation of acute-phase reactants, 62% had abnormal tumor markers, 76% had metastatic lesions. In 20% the primary tumor was of pulmonary origin and only 26.56% received palliative treatment; 64% died. Discussion It is important to consider the possibility of an underlying malignant process in the differential diagnosis since its early identification can be determinant for prognosis.

Introduction The rheumatology service of Ciudad Real Hospital, located in an autonomous community of that same name that is nearly in the center of Spain, implemented a self-management model of successive appointments more than 10 years ago. Since then, the physicians of the department schedule follow-up visits for their patients depending on the disease, its course and ancillary tests. The purpose of this study is to evaluate and compare the self-management model for successive appointments in the rheumatology service of Ciudad Real Hospital versus the model of external appointment management implemented in 8 of the hospital's 15 medical services. Material and methods A comparative and multivariate analysis was performed to identify variables with statistically significant differences, in terms of activity and/or performance indicators and quality perceived by users. The comparison involved the self-management model for successive appointments employed in the rheumatology service of Ciudad Real Hospital and the model for external appointment management used in 8 hospital medical services between January 1 and May 31, 2016. Results In a database with more than 100,000 records of appointments involving the set of services included in the study, the mean waiting time and the numbers of non-appearances and rescheduling of follow-up visits in the rheumatology department were significantly lower than in the other services. The number of individuals treated in outpatient rheumatology services was 7768, and a total of 280 patients were surveyed (response rate 63.21%). They showed great overall satisfaction, and the incidence rate of claims was low. Conclusion Our results show that the self-management model of scheduling appointments has better results in terms of activity indicators and in quality perceived by users, despite the intense activity. Thus, this study could be fundamental for decision making in the management of health care organizations.

Resumen Si bien la neumonitis por hipersensibilidad es la complicacion pulmonar mas frecuentemente descrita durante el tratamiento con metotrexato, existen otras complicaciones de tipo linfoproliferativo e infeccioso que hay que tener en cuenta dentro del diagnostico diferencial ante una neumopatia en el contexto de dicho tratamiento. La existencia de un riesgo incrementado de desarrollar procesos infecciosos o reactivaciones de microorganismos latentes puede ser similar al observado a lo largo del tratamiento con antagonistas del factor de necrosis tumoral y corticoides. Dentro de ellas, la neumonia por citomegalovirus es una complicacion muy severa a tener en cuenta, ya que el diagnostico acertado y el tratamiento oportuno evitaran un desenlace potencialmente mortal.

Reportamos el caso de un varón de 50 años con antecedente de tuberculosis pulmonar que presenta síndrome febril durante 66 días, sin tos, hemoptisis o dolor torácico. La presencia de fiebre y síntomas generales (disnea, baja de peso) se ha asociado a menos del 7% de casos de aspergiloma pulmonar, y el síndrome febril prolongado como única forma de presentación no ha sido descrita adecuadamente con anterioridad. Por lo que el caso que presentamos constituye una forma de presentación infrecuente de aspergiloma pulmonar. Al paciente se le practicó lobectomía superior derecha como tratamiento definitivo con remisión del cuadro febril. We report the case of a 50-year-old male with antecedent of pulmonary tuberculosis who presents with fever syndrome for 66 days, without cough, hemoptisis or thoracic pain. The presence of fever and general symptoms (dyspnea, loss of weight) has been associated with less than 7 % of cases of pulmonary aspergilloma, and the long fever syndrome as the only way of presentation has not been described adequately before. Therefore, this case constitutes a form of infrequent presentation of pulmonary aspergiloma. An upper right lobectomy was practiced as definitive treatment with remission of the fever.

Objective To investigate the validity, reproducibility, and responsiveness of a simplified power Doppler ultrasound (PDUS) assessment of joint inflammation compared with a comprehensive 44-joint PDUS assessment in patients with rheumatoid arthritis (RA) who started therapy with a biologic agent. Methods A total of 160 patients with active RA who started a biologic agent were prospectively recruited in 18 Spanish centers. The patients underwent clinical and laboratory assessment and blinded PDUS examination at baseline and 6 months. A PDUS examination of 128 synovial sites in 44 joints was performed. US synovitis and PD signal were semiquantitatively graded from 1 to 3 in all synovial sites. US count and index for synovitis and PD signal were obtained. PDUS intraobserver and interobserver reliability were evaluated. A process of data reduction based on the frequency of involvement of synovial sites by both synovitis and PD signal was conducted. Construct and discriminant validity of a simplified PDUS assessment was investigated. Results A PDUS simplified assessment including 24 synovial sites from 12 joints detected 100% of patients with synovitis and 91% of patients with PD signal. There was a highly significant correlation between the 44-joint count and index for synovitis and PD signal and the 12-joint count and index for synovitis and PD signal at baseline and 6 months (r = 0.84–0.90, P < 0.0005). The smallest detectable difference was lower than the mean change in simplified PDUS variables. Conclusion A 12-joint PDUS assessment of RA joint inflammation may be a valid, feasible method for multicenter monitoring of therapeutic response to biologic agents.

Although hypersensitivity pneumonitis is the most common pulmonary complication described during treatment with methotrexate, other complications like lymphoproliferative and infectious disease may be considered in the study of respiratory disease associated to methotrexate. The existence of an increased risk to developing infectious diseases may be similar to that observed during treatment with antagonists of tumor necrosis factor and corticosteroids, where Cytomegalovirus pneumonia is a serious complication; early diagnosis and treatment will prevent a potentially fatal outcome.

The liver abscess (LA) continues to cause a high morbidity and mortality worldwide.To determine demographic characteristics, clinical presentation, imaging and management at the Arzobispo Loayza Hospital in 5 years.A descriptive retrospective study, based on medical records of patients diagnosed with LA between January 2003 to December 2007.Of 106 medical records reviewed, 46 entered the study. The mean age was 47.8 years (95% CI 41.9-53.8 years), 21 patients were over 50 years (45.6%) and 52.2% were male. The main symptoms were fever (95.6%) and right upper quadrant pain (73.5%). The average time of disease was 2.5 weeks. We found high frequency of hypoalbuminemia, elevated alkaline phosphatase, leukocytosis and anemia. The diagnosis was mostly based on ecography (97.8%), AH were mainly a single abscess (73%) located in the right lobe (77%), with an average diameter of 70 mm (p25-75: 44-90 mm), and 69.6% had more than 5 cm in diameter. Antibiotics were administered for 18.6 days (range: 3-30), being the combination administered more frequently metronidazole and ciprofloxacin. Seventeen patients (36.9%) underwent surgery, 7 patients (15.2%) received external drainage by percutaneous catheter and 10.9% (5 patients) was aspirated directly.LA is an acute or subacute disease of middle age without gender bias, whose main symptoms are fever and right upper quadrant pain. It is necessary to protocolize the management of this condition.

La endocarditis infecciosa en válvulas derechas es predominantemente en la válvula tricuspídea, mientras la válvula pulmonar es excepcionalmente afectada (menos de 1,5%), por lo que son pocos los casos reportados en la literatura mundial. Las manifestaciones clínicas de endocarditis en válvula pulmonar no son las clásicas de endocarditis infecciosa, como son los síntomas de embolismo séptico pulmonar. La endocarditis aislada de válvula pulmonar nativa es inusual en personas que no consumen drogas intravenosas. Se presenta el caso de un paciente varón con diabetes mellitus tipo 2 y sin otro factor predisponente. Right sided endocarditis usually involves the tricuspid valve, while pulmonary valve is affected exceptionally (less than 1,5%), there fore few cases reported in the literature. The clinical of pulmonary valve endocarditis are not the classics of infectious endocarditis, as they are the symptoms of lung septic embolism. Isolated pulmonary native valve endocarditis is an unusual clinical entity in non-users of intravenous drugs. We present a case of a male patient with diabetes mellitus type 2 and without other predisposing factor.

Introduction Hashimoto's encephalopathy is a neurological disorder of unknown cause associated with thyroid autoimmunity. The disease occurs primarily in the fifth decade of life and may present in two types - a sudden vasculitic type or a progressive subacute type associated to cognitive dysfunction, confusion and memory loss. Case presentation We report the case of a 62-year-old Hispanic woman, previously healthy, who developed a subacute onset of declining upper brain function. Serologic studies demonstrated high levels of antithyroid antibodies. Electroencephalographic and magnetic resonance image findings were consistent with Hashimoto's encephalopathy. Conclusion Hashimoto's encephalopathy is a diagnosis of exclusion. This unusual disorder is often under-recognized because of the multiple and protracted neurocognitive manifestations; therefore, it is important to be aware of the clinical manifestations to make a correct diagnosis.

We report a 72-year-old patient with chronic diarrhoea and histologic evidence of gastrointestinal histoplasmosis. He had no history of HIV or of taking immunosuppressive drugs. The patient was found to be a carrier of Human T-lymphotropic virus-1, a condition associated with inflammatory, lymphoproliferative, and opportunistic infectious diseases. To our knowledge, there are only three previous cases reporting this coinfection and this is the first documented case with gastrointestinal involvement.