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Empiema por Actinomyces meyeri
Actinomyces Meyeri Empyema
Lucía Ferreiroa,b,
, María Luisa Pérez del Molinoc, Carlos Rábadea, Luis Valdésa,b
Corresponding author
a Servicio de Neumología, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, España
b Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, España
c Servicio de Microbiología, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, España
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En contraste a otras especies de <span class="elsevierStyleItalic">Actinomyces</span>, <span class="elsevierStyleItalic">Actinomyces meyeri (A. meyeri)</span> puede causar infecciones pulmonares, pero el empiema por este germen es muy poco frecuente. La actinomicosis se caracteriza porque puede producir fístulas en los tejidos que afecta, suele presentar supuración con aspecto de gránulos de sulfuro y su cultivo es técnicamente difícil.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Presentamos un caso de empiema por <span class="elsevierStyleItalic">A. meyeri</span> que hemos tratado recientemente en nuestro hospital. Se trata de un varón de 62 años, fumador de 40 paquetes/año y consumidor de 18 unidades diarias de alcohol, con hipoacusia neurosensorial grave como secuela de una meningitis que padeció en la adolescencia. Acudió al servicio de urgencias de nuestro hospital por dolor pleurítico izquierdo de tres semanas de evolución, acompañado de tos no productiva, sensación distérmica y pérdida de peso no cuantificada. Estaba hemodinámicamente estable, afebril y eupneico al aire ambiente. En la exploración física destacaba la presencia de halitosis por boca séptica con ausencia de varias piezas dentarias, la disminución de las vibraciones vocales en todo el hemitórax izquierdo con matidez a la percusión, así como hepatomegalia de dos traveses de dedo.</p><p id="par0015" class="elsevierStylePara elsevierViewall">En la analítica de sangre destacaba: hematíes 3,77<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">6</span>/μL, hemoglobina 11,5<span class="elsevierStyleHsp" style=""></span>g/dl, hematocrito 33,9%, VCM 100, leucocitos 8,87<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>/μL (85% neutrófilos), velocidad de sedimentación 120, bilirrubina total 2,4<span class="elsevierStyleHsp" style=""></span>mg/dl (directa 1,9<span class="elsevierStyleHsp" style=""></span>mg/dl), GOT 114 UI/l, GPT 129 UI/l, GGT 280 UI/l y fosfatasa alcalina 245 UI/l. Gasometría arterial (aire ambiente): pH 7,51, pCO<span class="elsevierStyleInf">2</span> 33,1<span class="elsevierStyleHsp" style=""></span>mmHg, pO<span class="elsevierStyleInf">2</span> 69,5<span class="elsevierStyleHsp" style=""></span>mmHg. En la radiografía de tórax se observaba un aumento de densidad aparentemente homogéneo que ocupaba gran parte del hemitórax izquierdo, de contorno superior nítido y convexo, que no se movilizaba en los decúbitos laterales. En la ecografía torácica se visualizaba abundante derrame pleural izquierdo hiperecogénico con septos en su interior. En la toracocentesis se obtuvo un líquido purulento con pH 6,80, leucocitos 173<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>/μL (75% neutrófilos), glucosa 15<span class="elsevierStyleHsp" style=""></span>mg/dl, LDH 20.000 UI/l, proteínas 4,7<span class="elsevierStyleHsp" style=""></span>g/dl, proteína C-reactiva 9,88<span class="elsevierStyleHsp" style=""></span>mg/dl, procalcitonina <0,020<span class="elsevierStyleHsp" style=""></span>ng/mL, interleucina-6 152.525<span class="elsevierStyleHsp" style=""></span>pg/ml y adenosina desaminasa 227 U/l. Se estableció el diagnóstico de empiema por lo que se inició tratamiento antibiótico empírico con amoxicilina/ácido clavulánico 2<span class="elsevierStyleHsp" style=""></span>g iv. cada 8 h, drenaje torácico (16F; 9 días) y uroquinasa intrapleural (100.000 UI/día, 3 días). La evolución fue favorable. Los hemocultivos fueron negativos. El cultivo del líquido pleural para micobacterias fue negativo, y en medios anaerobios resultó positivo para <span class="elsevierStyleItalic">A. meyeri</span>.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Dos meses más tarde el paciente está asintomático, continúa en tratamiento con amoxicilina oral (500<span class="elsevierStyleHsp" style=""></span>mg/8 h) y la TC de tórax demuestra un engrosamiento pleural a lo largo de la región lateral y posterior del hemitórax izquierdo con una mínima cantidad de líquido pleural asociado.</p><p id="par0025" class="elsevierStylePara elsevierViewall">La infección pleural por <span class="elsevierStyleItalic">A. meyeri</span> es muy poco frecuente ya que, hasta la actualidad, solamente se han publicado 12 casos (<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>)<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2–12</span></a>. La mala higiene bucal y el alcoholismo, como es nuestro caso, son factores predisponentes ya que la aspiración del germen desde la cavidad oral es su vía de llegada al parénquima pulmonar. La pleura se afecta, bien por contigüidad, o por diseminación hematógena<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1,13</span></a>. Suele tratarse de varones (11/13 casos; 84,6%) mayores de 40 años (12/13; 92,3%) en los que además de la pleura, hay otros órganos afectados (generalmente el pulmón) que pueden fistulizarse. Las características del líquido pleural son las de todo empiema, con valores elevados de LDH y de leucocitos (generalmente neutrófilos), y bajos de pH y glucosa. Algunos casos también pueden cursar con niveles altos de adenosina desaminasa y bajos de proteínas<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">La enfermedad puede coexistir con un cáncer de pulmón ya que <span class="elsevierStyleItalic">A. meyeri</span> es un germen que tiene tendencia a colonizar el tejido necrótico que suele producirse en las neoplasias<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a>. Por lo tanto, su aislamiento en esputo puede representar una simple colonización si no va acompañado de la observación de los gránulos de azufre característicos en el material purulento del tejido infectado. Si no es así, su aislamiento no es de utilidad diagnóstica. Por el contrario, el cultivo en el líquido pleural establece el diagnóstico y debe tenerse la precaución de llevarlo a cabo en medios anaeróbicos adecuados. El tratamiento de elección es amoxicilina/ácido clavulánico o penicilina G sódica (administrada por vía intravenosa durante 2-6 semanas seguida de amoxicilina por vía oral durante un periodo de 6-12 meses), dependiendo de la evolución clínica y radiológica. Otras alternativas son clindamicina, doxiciclina o eritromicina, si el paciente es alérgico a la penicilina o presenta intolerancia a la misma<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a>. Suele ser necesario colocar un drenaje torácico, administrar fibrinolíticos intrapleurales y, en ocasiones, es necesario recurrir a la decorticación pleural<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a>. La evolución suele ser favorable, aunque hay descrito un caso fatal<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a>, y puede quedar como secuela una paquipleuritis residual. Nuestro paciente solamente lleva dos meses de tratamiento, pero parece responder favorablemente desde el punto de vista clínico, a la espera de evaluar la posible secuela del engrosamiento pleural izquierdo que presenta, con pruebas de función pulmonar.</p><p id="par0035" class="elsevierStylePara elsevierViewall">La enseñanza de este caso es que ante un derrame pleural de evolución tórpida que no mejora con el tratamiento antibiótico habitual y que presenta los factores de riesgo reseñados, deben hacerse cultivos en medios adecuados para descartar un empiema por <span class="elsevierStyleItalic">A. meyeri</span>.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Autoría</span><p id="par0040" class="elsevierStylePara elsevierViewall">Lucía Ferreiro: autora y escritora. Concepción y diseño. Aprobación final del manuscrito.</p><p id="par0045" class="elsevierStylePara elsevierViewall">María Luisa Pérez del Molino: coautora. Aprobación final del manuscrito.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Carlos Rábade: coautor. Aprobación final del manuscrito.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Luis Valdés: autor y escritor. Concepción y diseño. Aprobación final del manuscrito.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Autoría" ] 1 => array:1 [ "titulo" => "Bibliografía" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Tabla 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Tabla " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">AB: antibiótico; ADA: adenosina desaminasa; DT: drenaje torácico; F. riesgo: factores de riesgo; H: hombre; LDH: lactato deshidrogenasa; Leuc.: leucocitos; LP: líquido pleural; M: mujer; NE: no especificado; Prot.: proteínas; ref: referencia; Tto.: tratamiento; UQ: uroquinasa.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Autor (ref.) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sexo/edad (años) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">F. riesgo \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Presentación clínica \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Tto. AB \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Duración tto. (meses) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">DT \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">UQ \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Leuc. LP (cel)/seg (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">pH \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Glucosa (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LDH (UI/l) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ADA (U/l) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Prot. (g/dl) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Evolución \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rose et al.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">H/49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Alcoholismo, mala higiene bucal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Empiema<br>Neumonía<br>Fístula broncopleural<br>Osteomielistis (esternón) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Penicilina G/clindamicina/tetraciclina \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 meses (hasta el éxitus) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sí \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Éxitus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">H/62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Alcoholismo, mala higiene bucal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Empiema<br>Neumonía<br>Absceso subcutáneo cadera izquierda \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Penicilina G/amoxicilina \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 meses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sí \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NE \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lentino et al.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">H/16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Empiema<br>Médula ósea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Clindamicina \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 meses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sí/toracotomía (decorticación) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">141<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>/83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Favorable \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Alemanni et al.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">H/58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Alcoholismo, mala higiene bucal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Empiema<br>Absceso muscular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Penicilina G \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Probablemente favorable \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Del Castillo et al.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">H/61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mala higiene bucal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Empiema \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Penicilina G/amoxicilina \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 meses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">6</span>/100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6,34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.367 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5,1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Favorable<br>Engrosamiento pleural \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vallet et al.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M/64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Alcoholismo \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Empiema<br>Fístula pleurosubcutánea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Penicilina \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 meses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sí/toracotomía (decorticación) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Favorable<br>Engrosamiento pleural \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fazili et al.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">H/45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mala higiene bucal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Empiema<br>Neumonía \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Penicilina G \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 meses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sí/toracotomía (decorticación) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pérdida seguimiento \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Porcel et al.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">H/49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Alcoholismo \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Empiema<br>Neumonía \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Clindamicina/doxiciclina \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 meses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sí \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sí \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">160<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/neutrof \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6,82 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17.700 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0,3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2,4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Favorable \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Attaway et al.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">H/61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Alcoholismo, mala higiene bucal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Empiema<br>Neumonía<br>Lumpy jaw \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ampicilina/penicilina G/doxiciclina \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 meses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Toracotomía (decorticación) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NE \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Alonso et al.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M/83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Absceso dentario \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Empiema \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Imipenem/doxiciclina \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 meses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sí \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">649<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>/neutrof \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16.300 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1,2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Jung et al.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">H/49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Alcoholismo \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Empiema<br>Neumonía \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Penicilina G/amoxicilina \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 meses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sí \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">56<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>/89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20.530 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Favorable \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sander et al.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">H/84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Empiema<br>Neumonía \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Amoxicilina/ácido clavulánico \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 meses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sí \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sí \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9,6<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>/36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6,80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.560 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">117 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Favorable \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Presente caso \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">H/62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Alcoholismo, mala higiene bucal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Empiema \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Amoxicilina/ácido clavulánico \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 meses<span class="elsevierStyleSup">¶</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sí \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sí \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">173<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>/75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6,80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20.000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">227 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4,7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Favorable<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">¶</span></a><br>Engrosamiento pleural \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1406806.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "<span class="elsevierStyleBold">*</span>" "nota" => "<p class="elsevierStyleNotepara" id="npar0005"><span class="elsevierStyleItalic">Actinomyces</span> spp.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "¶" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Continúa con el tratamiento.</p>" ] ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Casos de empiema pleural por <span class="elsevierStyleItalic">Actinomyces meyerii</span> descritos en la literatura</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliografía" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0080" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pulmonary actinomicosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "G.F. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 2 | 10 |
| 2024 October | 86 | 24 | 110 |
| 2024 September | 73 | 18 | 91 |
| 2024 August | 97 | 35 | 132 |
| 2024 July | 56 | 24 | 80 |
| 2024 June | 83 | 23 | 106 |
| 2024 May | 87 | 32 | 119 |
| 2024 April | 76 | 32 | 108 |
| 2024 March | 71 | 26 | 97 |
| 2024 February | 68 | 26 | 94 |
| 2023 July | 1 | 2 | 3 |
| 2023 March | 18 | 2 | 20 |
| 2023 February | 93 | 25 | 118 |
| 2023 January | 84 | 30 | 114 |
| 2022 December | 122 | 27 | 149 |
| 2022 November | 79 | 22 | 101 |
| 2022 October | 135 | 39 | 174 |
| 2022 September | 94 | 28 | 122 |
| 2022 August | 64 | 45 | 109 |
| 2022 July | 58 | 40 | 98 |
| 2022 June | 67 | 29 | 96 |
| 2022 May | 75 | 41 | 116 |
| 2022 April | 128 | 37 | 165 |
| 2022 March | 136 | 43 | 179 |
| 2022 February | 122 | 33 | 155 |
| 2022 January | 125 | 27 | 152 |
| 2021 December | 61 | 34 | 95 |
| 2021 November | 79 | 32 | 111 |
| 2021 October | 62 | 30 | 92 |
| 2021 September | 64 | 42 | 106 |
| 2021 August | 54 | 45 | 99 |
| 2021 July | 78 | 31 | 109 |
| 2021 June | 96 | 52 | 148 |
| 2021 May | 70 | 43 | 113 |
| 2021 April | 163 | 92 | 255 |
| 2021 March | 88 | 32 | 120 |
| 2021 February | 68 | 29 | 97 |
| 2021 January | 48 | 27 | 75 |
| 2020 December | 52 | 34 | 86 |
| 2020 November | 59 | 21 | 80 |
| 2020 October | 76 | 35 | 111 |
| 2020 September | 71 | 12 | 83 |
| 2020 August | 72 | 26 | 98 |
| 2020 July | 63 | 28 | 91 |
| 2020 June | 55 | 27 | 82 |
| 2020 May | 60 | 15 | 75 |
| 2020 April | 53 | 21 | 74 |
| 2020 March | 67 | 19 | 86 |
| 2020 February | 54 | 20 | 74 |
| 2020 January | 73 | 27 | 100 |
| 2019 December | 92 | 36 | 128 |
| 2019 November | 69 | 30 | 99 |
| 2019 October | 106 | 17 | 123 |
| 2019 September | 78 | 20 | 98 |
| 2019 August | 77 | 11 | 88 |
| 2019 July | 73 | 19 | 92 |
| 2019 June | 123 | 12 | 135 |
| 2019 May | 201 | 28 | 229 |
| 2019 April | 331 | 78 | 409 |
| 2019 March | 170 | 39 | 209 |
| 2019 February | 121 | 27 | 148 |
| 2019 January | 142 | 25 | 167 |
| 2018 December | 136 | 26 | 162 |
| 2018 November | 208 | 39 | 247 |
| 2018 October | 189 | 22 | 211 |
| 2018 September | 90 | 10 | 100 |
| 2018 August | 4 | 0 | 4 |
| 2018 July | 3 | 0 | 3 |
| 2018 June | 3 | 0 | 3 |
| 2018 May | 34 | 1 | 35 |
| 2018 April | 55 | 9 | 64 |
| 2018 March | 54 | 9 | 63 |
| 2018 February | 54 | 13 | 67 |
| 2018 January | 41 | 9 | 50 |
| 2017 December | 54 | 17 | 71 |
| 2017 November | 57 | 7 | 64 |
| 2017 October | 53 | 17 | 70 |
| 2017 September | 54 | 18 | 72 |
| 2017 August | 60 | 17 | 77 |
| 2017 July | 5 | 3 | 8 |
| 2017 June | 2 | 2 | 4 |
| 2017 May | 32 | 14 | 46 |
| 2017 April | 1 | 1 | 2 |
| 2017 March | 0 | 1 | 1 |
| 2017 February | 0 | 3 | 3 |
| 2017 January | 0 | 7 | 7 |
| 2016 December | 0 | 3 | 3 |
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