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BACKGROUND High-risk pulmonary embolism (PE) occurs when the pulmonary circulation is suddenly occluded by a thrombus and is a life-threatening medical emergency. In young and otherwise healthy individuals, there may be undiagnosed underlying risk factors for PE that require investigation. This report presents the case of a 25-year-old woman admitted as an emergency with a high-risk large and occlusive PE, later diagnosed with primary antiphospholipid syndrome (APS) and hyperhomocysteinemia. CASE REPORT A 25-year-old woman presented with sudden-onset dyspnea after elective cholecystectomy. One year earlier, the patient had lower limb deep vein thrombosis without an identified predisposing cause, and she received anticoagulation for 6 months. On physical examination, she had right leg edema. Laboratory tests revealed elevated levels of troponin, pro-B-type natriuretic peptide, and D-dimer. Computed tomography pulmonary angiography (CTPA) demonstrated a large and occlusive PE, and an echocardiogram showed right ventricular dysfunction. Successful thrombolysis was performed with alteplase. On repeat CTPA, a significant reduction in filling defects in the pulmonary vasculature was observed. The patient evolved uneventfully and was discharged home on a vitamin K antagonist. Due to unprovoked recurrent thrombotic events, suspicion of underlying thrombophilia was raised, and hypercoagulability studies confirmed primary APS and hyperhomocysteinemia. CONCLUSIONS This report presents the case of a life-threatening high-risk PE in a previously healthy young woman and highlights the importance of emergency management followed by investigation and treatment of underlying risk factors for venous thromboembolism, including APS and hyperhomocysteinemia.

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Abdominal pregnancy is defined as one that occurs outside of the uterus and fallopian tubes in the abdominal cavity. We present the case of a 30-year-old Peruvian female patient from Lima with a surgical history of exploratory laparotomy due to tubal ectopic pregnancy and appendectomy without further relevant personal or family histories. She attended the emergency room of a social security hospital in Peru with a referral from a district hospital and a diagnosis of abdominal pregnancy at 14 weeks of gestational age without previous prenatal controls. Symptomatology at hospital admission was colic-type abdominal pain in the hypogastrium without vaginal bleeding, fluid loss or fever. During hospitalization, she underwent an exploratory laparotomy with embolization of the uterine artery, left salpingectomy, and removal of the abdominal ectopic pregnancy. The evolution was favorable after the surgery, and she was discharged. Without further complications, she continues her controls at the obstetrics and gynecology outpatient service without complications.

El embarazo abdominal es aquel embarazo que ocurre fuera del útero y las trompas de Falopio en la cavidad abdominal. Presentamos el caso de una paciente peruana de 30 años proveniente de la ciudad de Lima, con antecedentes quirúrgicos de laparotomía exploradora por embarazo ectópico tubárico y apendicectomía, sin otras patologías ni antecedentes familiares de importancia. La paciente acude al servicio de urgencias de un hospital del seguro social en Perú derivada de un hospital distrital con diagnóstico de embarazo abdominal a las 14 semanas de edad gestacional, sin controles prenatales previos. La sintomatología al ingreso hospitalario fue dolor abdominal de tipo cólico a nivel del hipogastrio, sin sangrado vaginal, pérdida de líquidos o fiebre. Durante su hospitalización se le realizó una laparotomía exploratoria con embolización de la arteria uterina, salpingectomía izquierda y extracción del embarazo abdominal. La evolución fue favorable tras la intervención quirúrgica, siendo dada de alta. Actualmente continúa sus controles en el servicio de consulta externa del servicio de ginecología y obstetricia sin complicaciones.

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RESUMO

Abdominal pregnancy is defined as one that occurs outside of the uterus and fallopian tubes in the abdominal cavity. We present the case of a 30-year-old Peruvian female patient from Lima with a surgical history of exploratory laparotomy due to tubal ectopic pregnancy and appendectomy without further relevant personal or family histories. She attended the emergency room of a social security hospital in Peru with a referral from a district hospital and a diagnosis of abdominal pregnancy at 14 weeks of gestational age without previous prenatal controls. Symptomatology at hospital admission was colic-type abdominal pain in the hypogastrium without vaginal bleeding, fluid loss or fever. During hospitalization, she underwent an exploratory laparotomy with embolization of the uterine artery, left salpingectomy, and removal of the abdominal ectopic pregnancy. The evolution was favorable after the surgery, and she was discharged. Without further complications, she continues her controls at the obstetrics and gynecology outpatient service without complications.

El embarazo abdominal es aquel embarazo que ocurre fuera del útero y las trompas de Falopio en la cavidad abdominal. Presentamos el caso de una paciente peruana de 30 años proveniente de la ciudad de Lima, con antecedentes quirúrgicos de laparotomía exploradora por embarazo ectópico tubárico y apendicectomía, sin otras patologías ni antecedentes familiares de importancia. La paciente acude al servicio de urgencias de un hospital del seguro social en Perú derivada de un hospital distrital con diagnóstico de embarazo abdominal a las 14 semanas de edad gestacional, sin controles prenatales previos. La sintomatología al ingreso hospitalario fue dolor abdominal de tipo cólico a nivel del hipogastrio, sin sangrado vaginal, pérdida de líquidos o fiebre. Durante su hospitalización se le realizó una laparotomía exploratoria con embolización de la arteria uterina, salpingectomía izquierda y extracción del embarazo abdominal. La evolución fue favorable tras la intervención quirúrgica, siendo dada de alta. Actualmente continúa sus controles en el servicio de consulta externa del servicio de ginecología y obstetricia sin complicaciones.

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Background: Primary aldosteronism is a disorder due to excessive aldosterone production in the presence of low renin levels. It is an underdiagnosed pathology despite its simple screening. Establishing the unilateral or bilateral location represents the greatest diagnostic challenge and is crucial to define the therapeutic approach. Adrenal venous catheterization (AVC) is the best test to establish the location, but it is invasive and expensive. New predictive markers of laterality are being developed. Case series presentation: We present a case series of 8 patients diagnosed with primary aldosteronism due to arterial hypertension with hypokalaemia, elevated aldosterone-renin ratio and compatible computed tomography. 4 patients underwent adrenal venous catheterization. Conclusion: In patients who underwent catheterization as well as in those who did not, the Küpers score adequately predicted lateralization in 75% of cases and it could be a useful tool to discriminate unilateral from bilateral aldosteronism.

Introducción: El hiperaldosteronismo primario es un desorden debido a una producción excesiva de aldosterona en presencia de niveles bajos de renina. Es una patología infradiagnosticada a pesar de su simple tamizaje. Definir la localización unilateral o bilateral representa el más importante desafío diagnóstico y es crucial para el abordaje terapéutico. El cateterismo venoso adrenal (CVA) es la mejor prueba para establecer la localización, pero es invasivo y costoso. Nuevos marcadores predictivos de unilateralidad se encuentran en desarrollo. Presentación de serie de casos: Presentamos una serie de casos de 8 pacientes diagnosticados con hiperaldosteronismo primario debido a hipertensión arterial con hipocalemia, radio aldosterona-renina elevado y tomografía compatible. 4 pacientes fueron sometidos a cateterismo venoso adrenal. Conclusión: Tanto en los pacientes que fueron sometidos a cateterismo venoso adrenal como en los que no, el score de Küpers predijo adecuadamente la lateralidad en 75% de los casos y puede ser una herramienta útil para diferenciar el hiperaldosteronismo unilateral del bilateral.

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Resumen La acromegalia es una enfermedad rara, causada principalmente por un tumor hipofisiario secretor de hormona de crecimiento (GH), se caracteriza por tener progresión lenta y asociarse a un compromiso multisistémico, siendo el aparato cardiovascular uno de los más comprometidos, llegando, incluso, desde hace más de 10 años a representar la principal causa de muerte. Las complicaciones cardiovasculares se desarrollan como resultado de las concentraciones sanguíneas elevadas de la GH y del factor de crecimiento similar a la insulina tipo 1 (IGF-1), los cuales ejercen efectos directos e indirectos sobre el endotelio, grandes vasos, riñón y los cardiomiocitos; produciendo hipertensión arterial, enfermedad valvular, arritmia cardiaca y una cardiopatía propia de la acromegalia denominada miocardiopatía acromegálica. Luego de la revisión bibliográfica actualizada relacionada con la fisiopatología, manifestaciones clínicas, diagnóstico y tratamiento del compromiso cardiovascular, encontramos que desde el punto de vista cardiovascular los pacientes con acromegalia pueden variar desde un estado asintomático hasta presentar disfunción cardiaca severa, siendo los marcadores bioquímicos y exámenes de imagen herramientas diagnósticas que permiten evaluar el grado de afección cardiovascular para poder brindar un tratamiento individualizado. La normalización de los valores de la GH y del IGF-1 mejora los parámetros cardiovasculares y, por tanto, su pronóstico.

Abstract Acromegaly is a rare disease, mainly caused by a pituitary tumor secreting growth hormone. It is characterized by slow progression and is associated with a multisystemic involvement, being the cardiovascular system, one of the most involved, even reaching, more than 10 years ago, to represent the main cause of death. Cardiovascular complications develop as a result of elevated blood concentrations of growth hormone and insulin-like growth factor 1, which exert direct and indirect effects on the endothelium, large vessels, kidney and cardiomyocytes; causing arterial hypertension, valve disease, cardiac arrhythmia and a specific heart disease called acromegalic cardiomyopathy. After the literature overview related to the pathophysiology, clinical manifestations, diagnosis and treatment of cardiovascular involvement, we found that from a cardiovascular point of view, patients with acromegaly can range from an asymptomatic state to severe cardiac dysfunction, being the biochemical markers and imaging studies diagnostic tools that allow assessment the degree of cardiovascular disease in order to provide individualized treatment. The normalization of growth hormone and insulin-like growth factor 1 levels improves cardiovascular parameters, and therefore its prognosis.

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This review provides an update on the epidemiology, pathophysiology, symptoms, diagnosis and treatment of neuroendocrine neoplasms (NENs) of the small bowel (SB). These NENs are defined as a group of neoplasms deriving from neuroendocrine cells. NENs are currently the most common primary tumors of the SB, mainly involving the ileum, making the SB the most frequently affected part of the gastrointestinal tract. SB NENs by definition are located between the ligament of Treitz and the ileocecal valve. They are characterized by small size and induce an extensive fibrotic reaction in the small intestine including the mesentery, resulting in narrowing or twisting of the intestine. Clinical manifestations of bowel functionality are related to the precise location of the primary tumor. The majority of them are non-functional NENs and generally asymptomatic; in an advanced stage, NENs present symptoms of mass effect by non-specific abdominal pain or carcinoid syndrome which appears in patients with liver metastasis (around 10%). The main manifestations of the carcinoid syndrome are facial flushing (94%), diarrhea (78%), abdominal cramps (50%), heart valve disease (50%), telangiectasia (25%), wheezing (15%) and edema (19%). Diagnosis is made by imaging or biochemical tests, and the order of request will depend on the initial diagnostic hypothesis, while confirmation will always be histological. All patients with a localized SB NEN with or without near metastasis in the mesentery are recommended for curative resection. Locoregional and distant spread may be susceptible to several therapeutic strategies, such as chemotherapy, somatostatin analogs and palliative resection.

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Obstetric tetanus is defined as a C. tetani infection that occurs during pregnancy or within six weeks of delivery. In Peru, there are no reports of obstetric tetanus cases. Here we report a sixth case of obstetric tetanus in a puerperal woman who underwent curettage for postpartum hemorrhage, despite immunization against tetanus.

RESUMO

Acromegaly is a rare disease, mainly caused by a pituitary tumor secreting growth hormone. It is characterized by slow progression and is associated with a multisystemic involvement, being the cardiovascular system, one of the most involved, even reaching, more than 10 years ago, to represent the main cause of death. Cardiovascular complications develop as a result of elevated blood concentrations of growth hormone and insulin-like growth factor 1, which exert direct and indirect effects on the endothelium, large vessels, kidney and cardiomyocytes; causing arterial hypertension, valve disease, cardiac arrhythmia and a specific heart disease called acromegalic cardiomyopathy. After the literature overview related to the pathophysiology, clinical manifestations, diagnosis and treatment of cardiovascular involvement, we found that from a cardiovascular point of view, patients with acromegaly can range from an asymptomatic state to severe cardiac dysfunction, being the biochemical markers and imaging studies diagnostic tools that allow assessment the degree of cardiovascular disease in order to provide individualized treatment. The normalization of growth hormone and insulin-like growth factor 1 levels improves cardiovascular parameters, and therefore its prognosis.

La acromegalia es una enfermedad rara, causada principalmente por un tumor hipofisiario secretor de hormona de crecimiento (GH), se caracteriza por tener progresión lenta y asociarse a un compromiso multisistémico, siendo el aparato cardiovascular uno de los más comprometidos, llegando, incluso, desde hace más de 10 años a representar la principal causa de muerte. Las complicaciones cardiovasculares se desarrollan como resultado de las concentraciones sanguíneas elevadas de la GH y del factor de crecimiento similar a la insulina tipo 1 (IGF-1), los cuales ejercen efectos directos e indirectos sobre el endotelio, grandes vasos, riñón y los cardiomiocitos; produciendo hipertensión arterial, enfermedad valvular, arritmia cardiaca y una cardiopatía propia de la acromegalia denominada miocardiopatía acromegálica. Luego de la revisión bibliográfica actualizada relacionada con la fisiopatología, manifestaciones clínicas, diagnóstico y tratamiento del compromiso cardiovascular, encontramos que desde el punto de vista cardiovascular los pacientes con acromegalia pueden variar desde un estado asintomático hasta presentar disfunción cardiaca severa, siendo los marcadores bioquímicos y exámenes de imagen herramientas diagnósticas que permiten evaluar el grado de afección cardiovascular para poder brindar un tratamiento individualizado. La normalización de los valores de la GH y del IGF-1 mejora los parámetros cardiovasculares y, por tanto, su pronóstico.

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Introducción: El síndrome de McCune-Albright (SMA) es una enfermedad rara caracterizada por la triada: manchas cutáneas de color café con leche, displasia fibrosa poliostótica y pubertad precoz. Puede afectar a diversos ejes hormonales, entre ellos el de la hormona de crecimiento (GH), pudiendo asociarse a acromegalia. Reporte de caso: describimos el caso de una mujer de 44 años, con pubertad precoz periférica, hemorragia uterina anormal, crecimiento de manos y pies, prognatismo, prominencia frontal, manchas café con leche y tumoraciones pétreas en cara y antebrazos. Resultados: Apoyados con exámenes laboratoriales y de imágenes, se llegaron a los diagnósticos de acromegalia, hipogonadismo hipogonadotropo y síndrome de McCune-Albright. La paciente fue sometida a tratamiento quirúrgico con persistencia de enfermedad clínica y laboratorial. Conclusión: El diagnóstico y tratamiento oportunos de la acromegalia y sus complicaciones brindará un mejor pronóstico a los pacientes con SMA.

Background: McCune-Albright syndrome (MAS) is a rare disease characterized by the triad: café-au-lait skin spots, polyostotic fibrous dysplasia, and precocious puberty. It can affect various hormonal axes, including growth hormone (GH), and may be associated with acromegaly. We describe the case Case report:of a 44-year-old woman with peripheral precocious puberty, abnormal uterinebleeding, growthof thehands and feet, prognathism, frontal prominence, café-au-lait spots, and stony tumorsonthefaceandforearms.Supportedby Results:laboratory and imaging tests, the diagnoses of acromegaly, hypogonadotropic hypogonadism and McCune-Albright syndrome were reached. The patient underwent surgical treatment with persistence of clinical and laboratory disease. Conclusion: Timely diagnosis and treatment of acromegaly and its complications will provide a better prognosis for patients with MAS

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BACKGROUND AND AIMS: The prevalence and incidence of infertility are increasing worldwide; they are associated with a significant economic and social impact. Infertility is defined as the inability to achieve pregnancy after 12 months or more of regular unprotected sex. In recent times, the male factor has gained importance and currently it contributes to approximately 50% of infertility cases. Multiple etiologies are stated, such as metabolic, anatomical, genetic or even idiopathic causes; however, the main cause is semen abnormalities. The aim of this manuscript is to provide a complete review of hormonal assessment of male infertility, as well as to review the physiology and pathophysiology related to the male gonadal axis. METHODS: This study is a narrative abstract carried out on basis of systematic bibliographic review, using articles indexed in PubMed/Medline, Scopus, Embase and Scielo, which were published during the last 20 years. RESULTS: The cornerstone of the evaluation of the hormonal status is semen analysis. Clinicians must rule out hypogonadism in those patients who present oligospermia and azoospermia, by determining levels of testosterone and gonadotropins, which provide the functionality status of the hypothalamic-pituitary-testicular axis. Evaluation of the adrenal, thyroid, and lactotroph axis are indicated in those patients with central hypogonadism. CONCLUSIONS: Despite advances in the diagnosis of male infertility, some causes are not fully understood, therefore, it is crucial to perform a timely hormonal evaluation of the male factor in infertile couples, in order to provide adequate treatment and improve fertility rates.

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