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&#225;reas de necrosis y fractura patol&#243;gica esternal&#44; sin compromiso del par&#233;nquima pulmonar&#46; Bas&#225;ndonos en los hallazgos tomogr&#225;ficos se decidi&#243; la toma de biopsia quir&#250;rgica y se envi&#243; muestras para cultivo&#44; KOH&#44; PCR para tuberculosis &#40;Xpert&#174; MTB&#47;RIF&#41; y anatom&#237;a patol&#243;gica&#44; resultando todo negativo&#46; La herida continu&#243; sin cicatrizar a pesar de los m&#250;ltiples intentos de cierre&#44; apareci&#243; fiebre &#40;38<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#44; por lo que se inici&#243; tratamiento antibi&#243;tico de amplio espectro por v&#237;a endovenosa y se disminuy&#243; la dosis de prednisona &#40;7&#44;5<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#237;a&#41;&#44; con resultados cl&#237;nicos parciales &#40;desaparici&#243;n de la fiebre&#44; pero sin cierre de la herida&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Ante la evoluci&#243;n estacionaria y por la alta sospecha de lesi&#243;n tumoral esternal maligna&#44; se solicit&#243; una nueva tomograf&#237;a&#44; donde se evidenci&#243; un aumento en el tama&#241;o de la lesi&#243;n&#46; Se le realiz&#243; una resecci&#243;n completa del tumor esternal m&#225;s la reconstrucci&#243;n de la pared anterior del t&#243;rax con colgajo bilateral del pectoral mayor y se remiti&#243; la pieza quir&#250;rgica a anatom&#237;a patol&#243;gica&#44; cuyo informe report&#243; una reacci&#243;n granulomatosa con formaci&#243;n de granulomas caseificantes&#44; PCR para tuberculosis &#40;Xpert&#174; MTB&#47;RIF&#41; positivo&#46; Los resultados de los cultivos de tuberculosis confirmaron el diagn&#243;stico &#40;crecimiento de 17 colonias&#41;&#44; resultando sensibles a rifampicina &#40;R&#41;&#44; pirazinamida &#40;Z&#41;&#44; etambutol &#40;E&#41; e isoniazida &#40;H&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">La paciente fue tratada con el esquema 2<span class="elsevierStyleHsp" style=""></span>HREZ 4<span class="elsevierStyleHsp" style=""></span>HR&#44; con mejor&#237;a de la sintomatolog&#237;a a las pocas semanas de su inicio&#46; En la actualidad ha completado la primera fase del tratamiento&#44; manteniendo una evoluci&#243;n favorable y con cierre completo de la herida&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">La tuberculosis esternal es una entidad poco frecuente&#44; en la literatura se ha reportado alrededor de 25 casos&#46; Veinte de ellos en pa&#237;ses en v&#237;as de desarrollo&#44; sobre todo en la India y 5 casos en los pa&#237;ses desarrollados&#46; Es m&#225;s frecuente en varones &#40;16 varones frente a 9 mujeres&#41; y 6 casos se asociaron a comorbilidades importantes&#46; La edad de presentaci&#243;n fue variable&#44; desde un ni&#241;o de 9 meses hasta una paciente de 74 a&#241;os&#46; La mayor&#237;a de los casos est&#225; relacionada con infecciones pulmonares&#44; cirug&#237;as cardiacas&#44; vacunaci&#243;n con la BCG e inmunosupresi&#243;n como es el caso de nuestra paciente<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">1&#8211;5</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Se considera la infecci&#243;n esternal como secundaria a la diseminaci&#243;n hemat&#243;gena de un foco primario pulmonar&#44; pero solo en 4 casos se pudo identificar otra localizaci&#243;n adem&#225;s de la esternal&#46; En este caso existe la posibilidad &#40;aunque no confirmada&#41; que la etiolog&#237;a de la insuficiencia suprarrenal sea tambi&#233;n tuberculosa<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">La mayor&#237;a de pacientes acude a consulta con s&#237;ntomas cl&#237;nicos de meses de evoluci&#243;n&#44; caracterizados por una tumoraci&#243;n esternal dolorosa&#44; en ciertos casos con formaci&#243;n de f&#237;stulas&#44; fiebre&#44; sudoraci&#243;n profusa&#44; p&#233;rdida de peso o fracturas esternales espont&#225;neas como es el caso de nuestra paciente<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">La radiograf&#237;a tor&#225;cica no suele ser de gran utilidad&#44; siendo la tomograf&#237;a y la resonancia magn&#233;tica &#40;RM&#41; las t&#233;cnicas de imagen m&#225;s &#250;tiles para caracterizar la lesi&#243;n&#44; con engrosamiento cortical con reacci&#243;n peri&#243;stica&#44; osteomielitis y tumores heterog&#233;neos de tejidos blandos que se puede observar en las tomograf&#237;as&#44; adem&#225;s de inflamaci&#243;n de la m&#233;dula del estern&#243;n que se caracteriza por im&#225;genes de baja intensidad en T2 en la RM&#46; El diagn&#243;stico definitivo se realiza con al an&#225;lisis del tejido esternal&#44; suele ser complicado y muchas veces se requiere m&#225;s de un m&#233;todo complementario&#46; En los casos comunicados el diagn&#243;stico fue histopatol&#243;gico en 11 ocasiones&#44; por reacci&#243;n en cadena de la polimerasa en 5 &#40;90&#37; de sensibilidad y 80&#37; de especificidad&#41;&#44; por cultivos en 5 y por baciloscopia positiva en 4 casos<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">2&#8211;11</span></a>&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">El tratamiento tiene como objetivo curar la tuberculosis y evitar las deformaciones &#243;seas&#46; Se basa en el empleo de rifampicina &#40;R&#41;&#44; pirazinamida &#40;Z&#41;&#44; etambutol &#40;E&#41; e isoniazida &#40;H&#41; en un esquema de 2<span class="elsevierStyleHsp" style=""></span>HREZ m&#225;s 4 a 10 meses de HR&#46; En general se mantiene el mismo esquema de la tuberculosis pulmonar con o sin desbridamiento quir&#250;rgico de las lesiones &#40;solo 7 casos registrados requirieron cirug&#237;a&#41;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">1&#8211;14</span></a>&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">En conclusi&#243;n&#44; presentamos el caso de una paciente inmunosuprimida que present&#243; tuberculosis esternal sin foco pulmonar&#44; una presentaci&#243;n muy rara&#44; pero que debemos tener en cuenta en el diagn&#243;stico diferencial de las tumoraciones esternales&#46;</p></span>"
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Carta Científica
Lesión lítica esternal por tuberculosis
Lytic Lesion of the Sternum Due to Tuberculosis
Nathalie Pinos Véleza,b,
Corresponding author
nathaliepinos@hotmail.com

Autor para correspondencia.
, Oswaldo León Cabrerac,d, Mateo Torracchi Carrascod,e, Jhonatan Vazquez Albornozf, Juan Carlos Ortiz Calleg
a Unidad de Pulmonar, Hospital José Carrasco Arteaga, Cuenca, Ecuador
b Unidad de Cirugía Torácica, Hospital Universitario del Río, Cuenca, Ecuador
c Unidad de Medicina Interna, Hospital José Carrasco Arteaga, Cuenca, Ecuador
d Unidad de Medicina Interna, Universidad del Azuay, Cuenca, Ecuador
e Unidad de Neumología, Hospital Universitario del Río, Cuenca, Ecuador
f Unidad de Cirugía plástica, Hospital José Carrasco Arteaga, Cuenca, Ecuador
g Unidad de Cirugía General, Hospital José Carrasco Arteaga, Cuenca, Ecuador
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        "titulo" => "Lytic Lesion of the Sternum Due to Tuberculosis"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Presentamos el caso de una mujer de 61 a&#241;os con insuficiencia suprarrenal de 10 a&#241;os de evoluci&#243;n&#44; osteoporosis e hipercolesterolemia&#44; tratada con dosis medias de prednisona &#40;20<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#237;a&#41;&#46; La paciente acudi&#243; por presentar tumoraci&#243;n preesternal de consistencia blanda&#44; m&#243;vil y dolorosa&#44; de 4 meses de evoluci&#243;n&#46; Se le realiz&#243; una ecograf&#237;a que objetiv&#243; una imagen nodular hipoecog&#233;nica&#44; sin presencia de vascularizaci&#243;n&#44; de 29<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>21<span class="elsevierStyleHsp" style=""></span>mm&#44; sugerente de fibrolipoma&#46; Se procedi&#243; a la resecci&#243;n quir&#250;rgica de la masa&#44; y se confirm&#243; con estudio anatomopatol&#243;gico la presencia de un lipoma&#46; A los 7 d&#237;as del procedimiento se evidenci&#243; una apertura espont&#225;nea de la herida con supuraci&#243;n&#46; Se procedi&#243; a realizar una curaci&#243;n con toma de muestras para cultivos&#44; y se inici&#243; antibioterapia oral&#46; Los resultados de los cultivos fueron negativos&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Ante la falta de cicatrizaci&#243;n de la herida y la persistente eliminaci&#243;n de l&#237;quido purulento&#44; se solicit&#243; una tomograf&#237;a de t&#243;rax &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#44; en la cual se observ&#243; un tumor de partes blandas localizado en la regi&#243;n pre y retroesternal de 55<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>45<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>46<span class="elsevierStyleHsp" style=""></span>mm&#44; con realce heterog&#233;neo al contraste&#44; &#225;reas de necrosis y fractura patol&#243;gica esternal&#44; sin compromiso del par&#233;nquima pulmonar&#46; Bas&#225;ndonos en los hallazgos tomogr&#225;ficos se decidi&#243; la toma de biopsia quir&#250;rgica y se envi&#243; muestras para cultivo&#44; KOH&#44; PCR para tuberculosis &#40;Xpert&#174; MTB&#47;RIF&#41; y anatom&#237;a patol&#243;gica&#44; resultando todo negativo&#46; La herida continu&#243; sin cicatrizar a pesar de los m&#250;ltiples intentos de cierre&#44; apareci&#243; fiebre &#40;38<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#44; por lo que se inici&#243; tratamiento antibi&#243;tico de amplio espectro por v&#237;a endovenosa y se disminuy&#243; la dosis de prednisona &#40;7&#44;5<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#237;a&#41;&#44; con resultados cl&#237;nicos parciales &#40;desaparici&#243;n de la fiebre&#44; pero sin cierre de la herida&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Ante la evoluci&#243;n estacionaria y por la alta sospecha de lesi&#243;n tumoral esternal maligna&#44; se solicit&#243; una nueva tomograf&#237;a&#44; donde se evidenci&#243; un aumento en el tama&#241;o de la lesi&#243;n&#46; Se le realiz&#243; una resecci&#243;n completa del tumor esternal m&#225;s la reconstrucci&#243;n de la pared anterior del t&#243;rax con colgajo bilateral del pectoral mayor y se remiti&#243; la pieza quir&#250;rgica a anatom&#237;a patol&#243;gica&#44; cuyo informe report&#243; una reacci&#243;n granulomatosa con formaci&#243;n de granulomas caseificantes&#44; PCR para tuberculosis &#40;Xpert&#174; MTB&#47;RIF&#41; positivo&#46; Los resultados de los cultivos de tuberculosis confirmaron el diagn&#243;stico &#40;crecimiento de 17 colonias&#41;&#44; resultando sensibles a rifampicina &#40;R&#41;&#44; pirazinamida &#40;Z&#41;&#44; etambutol &#40;E&#41; e isoniazida &#40;H&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">La paciente fue tratada con el esquema 2<span class="elsevierStyleHsp" style=""></span>HREZ 4<span class="elsevierStyleHsp" style=""></span>HR&#44; con mejor&#237;a de la sintomatolog&#237;a a las pocas semanas de su inicio&#46; En la actualidad ha completado la primera fase del tratamiento&#44; manteniendo una evoluci&#243;n favorable y con cierre completo de la herida&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">La tuberculosis esternal es una entidad poco frecuente&#44; en la literatura se ha reportado alrededor de 25 casos&#46; Veinte de ellos en pa&#237;ses en v&#237;as de desarrollo&#44; sobre todo en la India y 5 casos en los pa&#237;ses desarrollados&#46; Es m&#225;s frecuente en varones &#40;16 varones frente a 9 mujeres&#41; y 6 casos se asociaron a comorbilidades importantes&#46; La edad de presentaci&#243;n fue variable&#44; desde un ni&#241;o de 9 meses hasta una paciente de 74 a&#241;os&#46; La mayor&#237;a de los casos est&#225; relacionada con infecciones pulmonares&#44; cirug&#237;as cardiacas&#44; vacunaci&#243;n con la BCG e inmunosupresi&#243;n como es el caso de nuestra paciente<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">1&#8211;5</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Se considera la infecci&#243;n esternal como secundaria a la diseminaci&#243;n hemat&#243;gena de un foco primario pulmonar&#44; pero solo en 4 casos se pudo identificar otra localizaci&#243;n adem&#225;s de la esternal&#46; En este caso existe la posibilidad &#40;aunque no confirmada&#41; que la etiolog&#237;a de la insuficiencia suprarrenal sea tambi&#233;n tuberculosa<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">La mayor&#237;a de pacientes acude a consulta con s&#237;ntomas cl&#237;nicos de meses de evoluci&#243;n&#44; caracterizados por una tumoraci&#243;n esternal dolorosa&#44; en ciertos casos con formaci&#243;n de f&#237;stulas&#44; fiebre&#44; sudoraci&#243;n profusa&#44; p&#233;rdida de peso o fracturas esternales espont&#225;neas como es el caso de nuestra paciente<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">La radiograf&#237;a tor&#225;cica no suele ser de gran utilidad&#44; siendo la tomograf&#237;a y la resonancia magn&#233;tica &#40;RM&#41; las t&#233;cnicas de imagen m&#225;s &#250;tiles para caracterizar la lesi&#243;n&#44; con engrosamiento cortical con reacci&#243;n peri&#243;stica&#44; osteomielitis y tumores heterog&#233;neos de tejidos blandos que se puede observar en las tomograf&#237;as&#44; adem&#225;s de inflamaci&#243;n de la m&#233;dula del estern&#243;n que se caracteriza por im&#225;genes de baja intensidad en T2 en la RM&#46; El diagn&#243;stico definitivo se realiza con al an&#225;lisis del tejido esternal&#44; suele ser complicado y muchas veces se requiere m&#225;s de un m&#233;todo complementario&#46; En los casos comunicados el diagn&#243;stico fue histopatol&#243;gico en 11 ocasiones&#44; por reacci&#243;n en cadena de la polimerasa en 5 &#40;90&#37; de sensibilidad y 80&#37; de especificidad&#41;&#44; por cultivos en 5 y por baciloscopia positiva en 4 casos<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">2&#8211;11</span></a>&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">El tratamiento tiene como objetivo curar la tuberculosis y evitar las deformaciones &#243;seas&#46; Se basa en el empleo de rifampicina &#40;R&#41;&#44; pirazinamida &#40;Z&#41;&#44; etambutol &#40;E&#41; e isoniazida &#40;H&#41; en un esquema de 2<span class="elsevierStyleHsp" style=""></span>HREZ m&#225;s 4 a 10 meses de HR&#46; En general se mantiene el mismo esquema de la tuberculosis pulmonar con o sin desbridamiento quir&#250;rgico de las lesiones &#40;solo 7 casos registrados requirieron cirug&#237;a&#41;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">1&#8211;14</span></a>&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">En conclusi&#243;n&#44; presentamos el caso de una paciente inmunosuprimida que present&#243; tuberculosis esternal sin foco pulmonar&#44; una presentaci&#243;n muy rara&#44; pero que debemos tener en cuenta en el diagn&#243;stico diferencial de las tumoraciones esternales&#46;</p></span>"
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                          "etal" => true
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                        0 => array:2 [
                          "etal" => false
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                            0 => "R&#46;M&#46; Santos"
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                        ]
                      ]
                    ]
                  ]
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                    0 => array:1 [
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                        "fecha" => "2006"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17273613"
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            10 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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Article information
ISSN: 03002896
Original language: Spanish
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