Caso Clinico BIGC

8/19/2019 Caso Clinico BIGC

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CASO CLÍNICOVíctor Jesús Lara Ameca

MPSS


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Ficha de Identifcación

Nombre: GRBI. Gnero: Mujer. !dad: 18 años. !stado ci"i#: Soltera. Fecha de nacimiento: 18/4/1997.

L$%ar de nacimiento: Veracruz, Ver., Méxco. L$%ar de residencia: Boca !el R"o, Veracruz. !sco#aridad & oc$'ación: #stu!a$te !e %ce$catura.


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Antecedentes

(eredo)ami#iares: Pa!res a&are$te'e$te sa$os. Res!to !esco$

*ersona#es no 'ato#ó%icos: (a)ta casa t&o ur)a$a co$ ser*cos $tra + extra!o'claros -)tos -é$cos a!ecua!os 0recue$ca al'e$tac$ a!ecua!a e$ 0recue$ca + cal!a!$$jutsu es2ue'a !e *acu$ac$ co'&leto. 3oo$oss &ost*

'e!a$o !e$tro !e casa. 5atlca $o &ractca$te. 6ea *ajes rec


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Antecedentes

Ginecoobsttricos: Me$arca 1 años, rt'o reular, cclo19/1/1. IVS: 17 años, -eterosexual, u$a &areja, $ea relaco$reso. ;tlza &reser*at*o. G, P, 5, :.

*ersona#es 'ato#ó%icos: :leras $ea!as. 6eat*o &aratrau'ats'os, e$0er'e!a!es co$é$tas, $eo&lscas, e$!ocrcar!o*asculares, -e'tcas, $eurolcas o &s2utrcas.


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*adecimiento act$a#

I$ca su -ace !os se'a$as co$ ce0alea + escalo0r"os.

:u$a!o a esto &rese$ta $ausea + *'to e$ cuatro ocaso$es !e cstrco.

:!e's !e 'alas + artralas, aste$a, a!$a'a + a$orexa, s$ $

s"$to'a asoca!o.


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Prese$ta 5e0alea !ura$te las !e ? a 4 -oras + &osteror re's$, e$ la 'a+or"a !e los casos $o

co$ otros s"$to'as, $ a $$u$a causa a&are$te. :uto'e!cacParaceta'ol ta)s. ' *"a oral, e$ ca!a e&so!o s$ re)asar 4

!aras.

%as $auseas so$ $ter'te$tes + se asoca$ a la $esta !e al'e*'to !e co$te$!o strco se -a &rese$ta!o e$ 4 ocaso$es e

!0ere$tes. 6$u$o -a te$!o relac$ co$ la ce0alea.


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!+'#oración Física

Mujer, !e e!a! a&are$te s'lar a la cro$olca, s$ 0aces caractalerta, react*a, ore$ta!a e$ las 4 es0eras, $or'o-!rata!a, cctérco le*e e$ 'ucosa oral.

5uello cl"$!rco s$ a!e$o'ealas, $o I@.

Arax $or'ol"$eo, ru!os car!acos r"t'cos co$ a!ecua!o to$o e $s$ ru!os area!os, &ul'o$es co$ 'ur'ullo *escular.

:)!o'e$ )la$!o, !e&res)le, $o !oloroso a &al&ac$, t'&$or'o&erstalss,

#xtre'!a!es "$teras co$ to$o + 0uerza co$ser*a!os.

Ge$tales $o ex&lora!os.


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!.I,.OCI,OS 90; -ILL5N>> --

L!3COS ,O,AL!S B ;> --

N!3,.OFILOS,O,AL!S

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S!G-!N,A1OS B@

!OSIN5FILOS =@

2AS5FILOS >@

-ONOCI,OS @

LINFOCI,OS @

Citometría


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GL3COSA D?0; -G


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COL!S,!.OL =B;0 -G


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*r$ebas de )$nción he'Etic

20 ,O,AL >0B -G0?? -G09; -G


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V1.L N!GA,IVO

V1.L


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,IFICO OH *OSI,IVO =:D>

,IFICO (H N!GA,IVO

*A.A,ÍFICO AH N!GA,IVO

*A.A,ÍFICO 2H N!GA,IVO

2.3C!LLA A2O.,3S N!GA,IVO

*.O,!3S O4= *OSI,IVO =:?>

.eacciones Febri#es


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3.OC3L,IVO N!GA,IVO

3roc$#ti"o


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.!S3L,A1O 6essera scca, Bra$-a'ellacatarr-als.

!+$dado )arín%eo


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.+ tóra+


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.+ Abdomen


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3SG Abdomina#

.!*O.,! Rño$es !e 0or'a + ta'año$or'al, relac$ cortco'e!ular

co$ser*a!a. 6o se o)ser*aleso$es ocu&a$tes !e es&aco a

$*el $tra &are$2u'atoso.Sste'as colectores !e )ue$cal)re. (e&ato'eala co$

ecoe$c!a! !0usa. S$ s$os!e o)strucc$. V"a )lar !e

cal)re $or'al.


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3SG *#"ico

.!*O.,! 6or'al


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,AC ,óra+


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,AC CrEneo


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!#ectrocardio%rama


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!+amen %enera# de orina


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VI(

.!*O.,! Pace$te $o !esea realzar&rue)a.


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San%re )resca en cam'o osc$

.!*O.,! PSIAIV


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Antic$er'os contra 1en%$e

.!*O.,! 6eat*o


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1ia%nóstico SindromEtico


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1ia%nósticos 1i)erencia#es


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L!*,OS*I.OSIS


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Le'tos'irosis

%a le&tos&ross es u$a zoo$oss !e '&orta$ca 'causa!a &or es&ro2uetas !el é$ero Leptosp

#$ 188, :!ol0 Del !escr) los s$os cl"$

!eE$toros !e la e$0er'e!a!, co'o u$ trastor$ocaracterza!o &or es&le$o'eala, cterca + $e

!tio#o%ía


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!tio#o%ía


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Características

F'e$so$es e$ &ro'e!o .1 H J'.

Para *sualzarlas !e 'a$era !recta e$ cult*os o e$ 'cl"$cas -a+ 2ue recurrr a 'crosco&o !e ca'&o oscu

co$traste !e 0ase.

#$ los tej!os, las #e'tos'iras se *sualza$ co$ '&rearé$tca =co'o la t$c$ !e Dart-$Starr+>, &

$'u$o-sto2u"'ca o 'crosco&a &or $'u$oKuores


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!'idemio#o%ía

Pue!e $0ectar a 's !e 1 es&eces !e 'a'"0eros !0&ero los *ectores 's '&orta$tes !e tra$s's$ a

-u'a$os so$ ratas, &erros, a$a!o )o*$o + cer!o

%os &atro$es caracter"stcos !e la tra$s's$ !e la le&to

so$ !e t&o e&!é'co, e$!é'co + es&or!co.


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%os 0actores 's '&orta$tes e$ la a&arc$ !e le&tos&

e&!é'ca so$ las llu*as estaco$ales +, co$ ellas, las $u$

Lactores '&orta$tes &ara la tra$s's$ e$!é'ca lo co$se$tor$o -


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So$ escasos los !atos Ea)les so)re la $c!e$ca !e le&t

+ las c0ras !e 'or)l!a! + 'ortal!a! aco'&aña$t

#$ #sta!os ;$!os, se el'$ la le&tos&ross !e la lse$0er'e!a!es $otEca)les e$ el !ece$o !e 199

:&rox'a!a'e$te a 1 casos $otEca!os &as*a'eaño a los Centers for Disease Control and Prevention

re&rese$ta$ $eta'e$te u$a c0ra 'e$or !e la real + la '!e los &ace$tes &ro*e$e !e (aa.


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%os estu!os !e co-ortes&ros&ect*os + )asa!os e$&o)laco$es e$ Sal*a!orseñala$ 2ue N !e los

-a)ta$tes !e )arros )ajos se$0ecta ca!a año + alu$os

$!*!uos se $0ecta$ !e $ue*o.

#$ la :'azo$a !e PeN !e los &ace$t

Ee)re au!a $!0ere0ue !e$tEca!o c

&orta!or !e le&tos&ro

!c-o &orce$taje, e'$or"a la e$0er'e

ra*e =ON>

%as tasas !e letal!a! e$ &erso$as-os&talza!as e$ Sao Paulo &ue!e$ llear a

N, e$ &ro'e!o.


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%a $0ecc$ &or Leptospira $o se &ro!uce &or $-alacle&tos&ross es u$a causa $usual !e $0ecc$ a!2ur!

la)oratoro.


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%a le&tos&ross a0ecta &or ual &o)laco$es ur)a$as + ru

&a"ses $!ustralza!os + e$ !esarrollo.

%a 'x'a Qcara !e la e$0er'e!a! se '&o$e a &ers$*eles socoeco$'cos )ajos.

#$ 9, los )rotes !es&ués !e t0o$es e$ Ll&$as a0era$!es &o)laco$es al ra!o 2ue el M$stero !e Salu!

e'&re$!er la 2u'o&roElaxs a$t'cro)a$a &ara 'llo&erso$as se !esco$oce la eEcaca !e !c-a $ter*e$


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*ato%enia


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%as le&tos&ras $0ecta$ a los seres -u'a$os a tra*és

'ucosa =&or lo e$eral, la !e la co$ju$t*a + tal *ez la !eo las a'"!alas &alat$as> o &or 'aceraco$es, &u$co

a)raso$es !e la &el.

%os 'croora$s'os resste$ las !e0e$sas $'u$taras=&. ej., el co'&le'e$to>, &rol0era$ e$ la corre$te sa$u$*el extracelular !e$tro !e los ra$os, &ara !se'$ars

-e'ate$a a to!os los ra$os.


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#l &ero!o !e $cu)ac$ es !e c$co a 14 !"as =l"'tes !e !

!"as> e$ los &r'eros tres a 1 !"as !e e$0er'e!a! cl"$ca, e!e$tEcar las le&tos&ras e$ la sa$re.

5o$0or'e sure$ los a$tcuer&os, !esa&arece$ las le&tos&rsa$re &ero &ersste$ e$ *aros ra$os.

#l cclo *tal se co'&leta co$0or'e las le&tos&ras atra*eses&acos $terstcales !e los rño$es, &e$etra$ la 'e')ra$a

los t


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-ani)estaciones c#ínicas

I$0ecc$ su)cl"$ca.

5ua!ro 0e)rl $!0ere$ca!o.

#$0er'e!a! !e Del.


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!+'#oración C#ínica

Flatac$ !e *asos co$ju$t*ales =esta !latac$ $

aco'&aña !e secrec$>.#rte'a 0ar"$eo s$ exu!a!o.

Folor 'uscular a la &al&ac$.

#stertores e$ la auscultac$ !e &ul'o$es o 'at!ez&ercus$ !el trax e$ reas !e -e'orraa &leura

#xa$te'a ='acular, 'aculo&a&ular, erte'atoso, &etee2u'tco>.

Icterca 'e$$s'o e -&orreKexa o arreKexa, so)re las extre'!a!es $0erores.


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# ió #


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!"o#$ción Nat$ra#

6o co'&lca!a + le*e &or lo co'


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1i ó ti


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1ia%nóstico

Por lo reular, la le&tos&ross se &ro!uce !es&ués !e -o)*os !e ex&osc$ 2ue re)asa$ las act*!a!es casuals'&le'e$te -a)er esta!o e$ u$a ra$ja o e$ u$ callej%a &erso$a $0ecta!a cas se'&re estu*o e$ co$tacto &or$a !el a$'al co$ta'$a!o o se ex&uso a la secrec$

o &ercut$ea !el *ector.


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%os !atos )o2u"'cos, -e'atolcos + !el a$lss !e o

le&tos&ross au!a so$ $es&ec"Ecos.

la &rese$ca !e la e$0er'e!a! clsca !e Del la sue'a+ores co$ce$traco$es !e $tre$o ureco e$ sa$

creat$$a sérca, e$ co')$ac$ co$ u$a 'ezcla -&er)lrru)$e'a co$jua!a + $o co$jua!a, co$ $cre'

la co$ce$trac$ !e a'$otra$s0erasa -asta u$ $*el Ol"'te su&eror !e lo $or'al.


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5o$Er'ar la &rese$ca !e le&tos&ross o)la a &ractcar

!e la)oratoro.

#l !a$stco !eE$t*o !e&e$!e !e !e'ostrar la &rese'croora$s'o

:sla'e$to e$ cult*os.

Fetecc$ !e c!os $uclecos o a$t"e$o e$ l"2u!os co Vsualzac$ $'u$o-sto2u"'ca e$ tej!os.


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#l estu!o !recto !e la or$a o !e la sa$re &or 'e!

'crosco&a !e ca'&o oscuro te$e la &os)l!a! !e co$!a$stco r&!o.

%as téc$cas serolcas co$sttu+e$ el ele'e$to )sco!a$stco !e la le&tos&ross. #$ #sta!os ;$!os, el '

$or'at*o, 2ue es la &rue)a !e alut$ac$ 'crosc

=M:A, microscopic agglutination test >, se realza


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,ratamiento

*ronóstico


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*ronóstico

#l ele'e$to !eter'$a$te e$ el &ro$stco es la ra*e!

e$0er'e!a!, !es!e los &u$tos !e *sta !e la !s0u$c$ &+ re$al

. #l 'al &ro$stco &ro*e$e !e 0actores, co'o se$ectu! a0ecc$ &ul'o$ar cl"$ca'e$te 'a$Eesta, 'a+or co$ce

!e creat$$a sérca, olura + tro')octo&e$a.

6o se -a co$Er'a!o 2ue la !s0u$c$ -e&tca e$ la le&t

au!a co$sttu+a u$ 0actor $!e&e$!e$te !e reso !e '#l alco-ols'o cr$co al &arecer se aco'&aña !e &a!ec

ra*e. %as tasas $otEca!as !e 'ortal!a! e$ &ace$-os&talza!os -a$ *ara!o !e ser ON a ser N

2ib#io%ra)ía Da$tTt V 5o'&arso$ )etee$ )loo! exc-a$e a$! classcal t-era&+ 0or acute re$al 0

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Da$tTt V. 5o'&arso$ )etee$ )loo! exc-a$e a$! classcal t-era&+ 0or acute re$al 0!sease a&&rasal o$ A-a re&orts. 6e&-rolo+ =5arlto$> H 11481.

Guerrer G, FUrte$zo #. A-e arsc-(erx-e'er reacto$ $ le&tos&ross a s+ste'atc re 1? 8e9HH.

Au$)r!e :, FocTrell F(, 5-a$$er WS, McWe$!rcT MD. : )reat-less trat-lete. %a$cet

Su&utta'o$Tol @, 6atta+aTul W, Sutt$o$t 5, et al. :$ o&e$, ra$!o'ze!, co$trolle! tr!ox+c+cl$e, a$! ce0otax'e 0or &ate$ts t- se*ere le&tos&ross. 5l$ I$0ect Fs 4 ?

Mc5la$ B, Ballou DR, (arrso$ SM, Ste$e F%. Fox+c+cl$e t-era&+ 0or le&tos&ross. : 1984 1H9H.

Datt G, Pa!re %P, Auazo$ M%, et al. Place)oco$trolle! tral o0 $tra*e$ous &e$cll$ 0or se a$! late le&tos&ross. %a$cet 1988 14??.

#!ar!s 56, 6c-olso$ GF, (assell A:, et al. Pe$cll$ t-era&+ $ cterc le&tos&ross. :' 1988 ?9?88.

5osta #, %o&es ::, Sacra'e$to #, et al. Pe$cll$ at t-e late stae o0 le&tos&ross a ra$! tral. Re* I$st Me! Aro& Sao Paulo ? 4141.

BrettMajor FM, 5ol!re$ R. :$t)otcs 0or le&tos&ross. 5oc-ra$e Fata)ase S+st Re* 1

Au)a$a S, MTulsT M, Beca' , et al. RsT 0actors a$! &re!ctors o0 se*ere le&tos&ross $P%oS 6el Aro& Fs 1? 7e1991.

Murra+ 5W, (os&e$t-al FR. Feter'$ato$ o0 susce&t)ltes o0 H %e&tos&ra s&. sero*arsae$ts )+ a )rot- 'cro!luto$ tec-$2ue. :$t'cro) :e$ts 5-e'ot-er 4 484
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