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Derrame pleural leucémico: aproximación diagnóstica y controversias en pleurodesis
Leukemic Pleural Effusion: Diagnostic Approach and Controversies in Pleurodesis
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"identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Josep Miquel" "apellidos" => "Bauça" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Bernardo" "apellidos" => "López Andrade" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Análisis Clínicos, Hospital Universitario Son Espases, Palma de Mallorca, España" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Hematología, Hospital Universitario Son Espases, Palma de Mallorca, España" "etiqueta" => "b" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Autor para correspondencia." ] ] ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Leukemic Pleural Effusion: Diagnostic Approach and Controversies in Pleurodesis" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 713 "Ancho" => 951 "Tamanyo" => 175381 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Examen microscópico de líquido pleural, donde se observan células con una cromatina laxa e inmadura, una relación núcleo-citoplasma elevada y nucléolos visibles, siendo compatibles con blastos mieloides (tinción May-Grünwald/Giemsa, 1000×).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Las causas más frecuentes de derrame pleural en pacientes con leucemia aguda mieloide son las infecciones (bacterianas o virales), otros procesos neoplásicos, la quimioterapia y las derivadas del proceso neoplásico. La supervivencia está determinada por la respuesta al tratamiento de la patología hematológica<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>.</p><p id="par0010" class="elsevierStylePara elsevierViewall">El diagnóstico de malignidad en líquido pleural, cuando se realiza por un estudio microscópico citomorfológico, precisa un mínimo de 60 mililitros de muestra<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>.</p><p id="par0015" class="elsevierStylePara elsevierViewall">En casos de derrame pleural refractario al tratamiento de la enfermedad de base es necesaria la realización de una pleurodesis para el control de los síntomas respiratorios.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Presentamos el caso de un paciente de 76 años diagnosticado de leucemia aguda mieloide hacía 2 meses por inmunofenotipo compatible en médula ósea, con estudio citogenético normal (46,XY[15]), tratado con 3 ciclos de 5-azacitidina.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Ingresó por disnea, fiebre de 38<span class="elsevierStyleHsp" style=""></span>°C y taquicardia(120 lpm). Presentaba leucocitosis(45<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/L), anemia(hemoglobina 88<span class="elsevierStyleHsp" style=""></span>g/L), trombocitosis(719<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/L) y niveles séricos de lactato deshidrogenasa(LDH) de 1663 IU/L (normal:125-220 IU/L). La radiografía y la TC torácica mostraban un derrame pleural izquierdo importante.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Mediante toracocentesis se obtuvieron 90 mililitros de líquido pleural que contenía 1.200 linfocitos/μL(normal:<<span class="elsevierStyleHsp" style=""></span>200/μL),glucosa 52<span class="elsevierStyleHsp" style=""></span>mg/dL(normal:70-110<span class="elsevierStyleHsp" style=""></span>mg/dL), LDH 1.724 IU/L(normal:125-220 IU/L) y un pH de 7,38. Los cultivos microbiológicos fueron negativos. Se realizó citocentrifugación y tinción May-Grünwald/Giemsa del líquido pleural para examen microscópico (<a class="elsevierStyleCrossRef" href="#fig0005">fig. 1</a>). El inmunofenotipado por citometría de flujo (CD34, CD33, CD13 y CD117, pero no CD14 ni CD15) confirmaba la presencia de células mieloblásticas en líquido pleural. El estudio citogenético con técnicas de bandas G resultó normal, coincidiendo con el fenotipo celular de su leucemia mieloide aguda.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Se estableció el diagnóstico de derrame pleural leucémico realizándose un drenaje pleural con escasa respuesta. Una semana más tarde, precisó pleurodesis con bleomicina para controlar la disnea derivada del empeoramiento del derrame pleural. El cuadro respiratorio empeoró de manera progresiva hasta el fallecimiento del paciente a los 15 días.</p><p id="par0040" class="elsevierStylePara elsevierViewall">En caso de derrame pleural leucémico, se debe comprobar la línea clonal celular mediante un análisis de hibridación <span class="elsevierStyleItalic">in situ</span> por fluorescencia (FISH)<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>.</p><p id="par0050" class="elsevierStylePara elsevierViewall">En la selección rutinaria de estos pacientes para indicación de pleurodesis no existe una clara correlación entre el valor de pH del líquido pleural y la supervivencia, siendo el estado clínico el mejor predictor de supervivencia pospleurodesis.</p><p id="par0055" class="elsevierStylePara elsevierViewall">En pacientes sin pleurodesis previas no se han encontrado diferencias significativas entre el drenaje pleural permanente con catéter y la pleurodesis con talco en la mejora del control de la disnea<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Tanto la bleomicina como el talco han demostrado ser buenos agentes esclerosantes, con eficacia similar en pleurodesis para el control de derrames pleurales malignos sintomáticos. Aunque en nuestro paciente se usó la bleomicina, es importante tener en cuenta que el talco es más económico y podría tener una tasa de éxito superior en la reducción de la recidiva del derrame pleural maligno, frente tanto a la bleomicina como a otros agentes esclerosantes, pese a que esa diferencia no se ha demostrado estadísticamente significativa<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Se han documentado muchos agentes esclerosantes para realización de pleurodesis (povidona yodada, doxiciclina, nitrato de plata, interferón alfa-2b, etc.) demostrando buenos resultados, pero la disparidad en el diseño de dichos estudios dificulta su comparación. Son necesarios futuros estudios que ayuden a consensuar el mejor método de pleurodesis en estos pacientes.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 713 "Ancho" => 951 "Tamanyo" => 175381 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Examen microscópico de líquido pleural, donde se observan células con una cromatina laxa e inmadura, una relación núcleo-citoplasma elevada y nucléolos visibles, siendo compatibles con blastos mieloides (tinción May-Grünwald/Giemsa, 1000×).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliografía" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pleural effusions in patients with acute leukemia and myelodysplastic syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.A. 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Treasure" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ejcts.2005.12.025" "Revista" => array:7 [ "tituloSerie" => "Eur J Cardiothorac Surg" "fecha" => "2006" "volumen" => "29" "paginaInicial" => "829" "paginaFinal" => "838" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16626967" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S1470204509700038" "estado" => "S300" "issn" => "14702045" ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "es" "url" => "/03002896/0000005000000008/v1_201407200016/S0300289614000842/v1_201407200016/es/main.assets" "Apartado" => array:4 [ "identificador" => "9222" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Letters to the Director / Cartas al Director" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/03002896/0000005000000008/v1_201407200016/S0300289614000842/v1_201407200016/es/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289614000842?idApp=UINPBA00003Z" ]
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| 2024 November | 15 | 1 | 16 |
| 2024 October | 256 | 29 | 285 |
| 2024 September | 239 | 10 | 249 |
| 2024 August | 208 | 43 | 251 |
| 2024 July | 205 | 34 | 239 |
| 2024 June | 212 | 23 | 235 |
| 2024 May | 210 | 24 | 234 |
| 2024 April | 123 | 32 | 155 |
| 2024 March | 175 | 23 | 198 |
| 2024 February | 115 | 50 | 165 |
| 2023 May | 3 | 2 | 5 |
| 2023 March | 27 | 2 | 29 |
| 2023 February | 185 | 26 | 211 |
| 2023 January | 144 | 22 | 166 |
| 2022 December | 148 | 32 | 180 |
| 2022 November | 233 | 30 | 263 |
| 2022 October | 241 | 37 | 278 |
| 2022 September | 171 | 26 | 197 |
| 2022 August | 206 | 40 | 246 |
| 2022 July | 153 | 44 | 197 |
| 2022 June | 191 | 37 | 228 |
| 2022 May | 209 | 38 | 247 |
| 2022 April | 254 | 55 | 309 |
| 2022 March | 214 | 48 | 262 |
| 2022 February | 193 | 76 | 269 |
| 2022 January | 262 | 42 | 304 |
| 2021 December | 193 | 45 | 238 |
| 2021 November | 186 | 57 | 243 |
| 2021 October | 200 | 54 | 254 |
| 2021 September | 155 | 49 | 204 |
| 2021 August | 150 | 43 | 193 |
| 2021 July | 184 | 36 | 220 |
| 2021 June | 228 | 48 | 276 |
| 2021 May | 261 | 52 | 313 |
| 2021 April | 418 | 103 | 521 |
| 2021 March | 312 | 26 | 338 |
| 2021 February | 216 | 35 | 251 |
| 2021 January | 184 | 39 | 223 |
| 2020 December | 193 | 31 | 224 |
| 2020 November | 271 | 19 | 290 |
| 2020 October | 206 | 19 | 225 |
| 2020 September | 191 | 20 | 211 |
| 2020 August | 202 | 21 | 223 |
| 2020 July | 204 | 36 | 240 |
| 2020 June | 170 | 22 | 192 |
| 2020 May | 213 | 22 | 235 |
| 2020 April | 151 | 16 | 167 |
| 2020 March | 129 | 23 | 152 |
| 2020 February | 177 | 23 | 200 |
| 2020 January | 187 | 20 | 207 |
| 2019 December | 200 | 20 | 220 |
| 2019 November | 149 | 33 | 182 |
| 2019 October | 183 | 25 | 208 |
| 2019 September | 201 | 24 | 225 |
| 2019 August | 119 | 25 | 144 |
| 2019 July | 140 | 27 | 167 |
| 2019 June | 195 | 19 | 214 |
| 2019 May | 236 | 28 | 264 |
| 2019 April | 205 | 17 | 222 |
| 2019 March | 133 | 15 | 148 |
| 2019 February | 128 | 27 | 155 |
| 2019 January | 139 | 20 | 159 |
| 2018 December | 126 | 22 | 148 |
| 2018 November | 236 | 20 | 256 |
| 2018 October | 224 | 21 | 245 |
| 2018 September | 121 | 14 | 135 |
| 2018 July | 1 | 0 | 1 |
| 2018 June | 1 | 0 | 1 |
| 2018 May | 78 | 1 | 79 |
| 2018 April | 126 | 4 | 130 |
| 2018 March | 133 | 5 | 138 |
| 2018 February | 116 | 10 | 126 |
| 2018 January | 229 | 6 | 235 |
| 2017 December | 218 | 11 | 229 |
| 2017 November | 108 | 3 | 111 |
| 2017 October | 120 | 7 | 127 |
| 2017 September | 111 | 7 | 118 |
| 2017 August | 120 | 10 | 130 |
| 2017 July | 98 | 4 | 102 |
| 2017 June | 135 | 11 | 146 |
| 2017 May | 161 | 16 | 177 |
| 2017 April | 109 | 10 | 119 |
| 2017 March | 100 | 6 | 106 |
| 2017 February | 301 | 3 | 304 |
| 2017 January | 117 | 6 | 123 |
| 2016 December | 101 | 1 | 102 |
| 2016 November | 188 | 9 | 197 |
| 2016 October | 169 | 16 | 185 |
| 2016 September | 229 | 11 | 240 |
| 2016 August | 200 | 13 | 213 |
| 2016 July | 92 | 13 | 105 |
| 2016 June | 128 | 31 | 159 |
| 2016 May | 114 | 17 | 131 |
| 2016 April | 87 | 1 | 88 |
| 2016 March | 72 | 3 | 75 |
| 2016 February | 72 | 2 | 74 |
| 2016 January | 65 | 12 | 77 |
| 2015 December | 88 | 20 | 108 |
| 2015 November | 168 | 15 | 183 |
| 2015 October | 156 | 4 | 160 |
| 2015 September | 85 | 0 | 85 |
| 2015 August | 115 | 0 | 115 |
| 2015 July | 116 | 0 | 116 |
| 2015 June | 77 | 0 | 77 |
| 2015 May | 101 | 0 | 101 |
| 2015 April | 76 | 0 | 76 |
| 2015 March | 71 | 0 | 71 |
| 2015 February | 77 | 0 | 77 |
| 2015 January | 52 | 0 | 52 |
| 2014 December | 76 | 0 | 76 |
| 2014 November | 120 | 0 | 120 |
| 2014 October | 10 | 0 | 10 |
| 2014 September | 16 | 0 | 16 |
| 2014 August | 27 | 0 | 27 |
| 2014 July | 18 | 0 | 18 |
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