El megaesófago se presenta entre el 5 % y el 20 % de pacientes con acalasia, un trastorno motor esofágico primario reconocido hace más de 300 años, a considerarse en todo paciente con disfagia no explicada por un proceso obstructivo o inflamatorio luego de un estudio endoscópico detallado. Se presenta el caso de un paciente con disfagia progresiva, en quien se documentó megaesófago como complicación de una acalasia de largo tiempo de evolución, no tratada. Se descartó la enfermedad de Chagas mediante enzimoinmunoensayo (ELISA) e inmunofluorescencia indirecta (IFI), tal como recomiendan las guías actuales. Ante la baja frecuencia de esta entidad en nuestro medio y las implicaciones terapéuticas que tiene para los pacientes con acalasia, se realizó una revisión narrativa en la literatura sobre su diagnóstico y alternativas de manejo.

One of the essential therapeutic objectives in the approach to the septic patient is to impact early on the course of the underlying vasoplegia using medication with vasoactive potential. Multimodal management is paramount, including appropriate monitoring techniques and personalized approaches, since excessive vasoconstriction can worsen multiple organ failure, and some inodilators may be deleterious to the hemodynamic profile of patients with septic shock. We offer an updated critical review of the evidence of vasoactive agents managing patients with sepsis. Uno de los objetivos terapéuticos más importantes en el abordaje del paciente séptico es impactar tempranamente en el curso de la vasoplejia subyacente, por medio de medicamentos con potencial vasoactivo. Si bien se plantea un manejo multimodal que incluya técnicas de monitoreo apropiadas y enfoques personalizados, la vasoconstricción excesiva puede empeorar la insuficiencia orgánica múltiple, así como algunos inodilatadores ser deletéreos para el perfil hemodinámico de pacientes con choque séptico. Ofrecemos una revisión actualizada de la evidencia en el uso de vasoactivos en pacientes con sepsis.

Ascites is defined as the accumulation of fluid in the peritoneal cavity, following an imbalance between production and reabsorption; it is detectable from 50 mL on ultrasound. Three mechanisms have been classically implicated, according to Starling's forces: an increase in the hydrostatic pressure gradient (increased portal venous pressure), a reduction in the oncotic pressure gradient (loss of total proteins, especially albumin), and an increase in peritoneal capillary permeability. This latter mechanism, plus the difference between lymph production and excretion (which favors the accumulation of exudate), explains some of the most notable causes of non-hypertensive ascites (according to the serum albumin in ascites gradient (SAAG)), including peritoneal carcinomatosis and tuberculosis. We present the case of a young man, originally from a tuberculosis endemic area, in whom the study of ascitic fluid guided the workup and the definitive diagnosis, which was unexpected for his age. Finally, a practical approach to non-hypertensive ascites is provided.

Pulmonary coinfection by Pneumocystis jirovecii and Histoplasma capsulatum in patients with human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS) is common. However, coinfection by extrapulmonary pneumocystis and disseminated histoplasmosis is not. We report a 33-year-old Colombian male patient with a recent diagnosis of HIV/AIDS infection presented with mild flu-like symptoms, chronic diarrhea, cachexia, pale conjunctiva, oral ulcers, and painful hepatomegaly for about 15 days. Pancytopenia without jaundice was documented. Computed tomography showed ground-glass and micronodular miliary patterns suggestive of P. jirovecii pneumonia, pulmonary involvement due to miliary tuberculosis, or histoplasmosis. Histological samples of bronchoalveolar lavage and laparoscopic liver biopsy revealed structures of P. jirovecii, which are verified by polymerase chain reaction. Histoplasma urine antigen was positive. H. capsulatum infection was confirmed by fungal isolation from blood culture and matrix-assisted laser desorption ionization time of flight mass spectrometry. The patient was treated with clindamycin, oral primaquine, and intravenous amphotericin B plus maintenance therapy with itraconazole, and the clinical response was excellent. This case report highlights that despite effective, highly active antiretroviral therapy (ART), rare instances of extrapulmonary coinfection by P. jirovecii and H. capsulatum can still occur. It is therefore important to have a high suspicion index of extrapulmonary pneumocystosis and initiating treatment to prevent mortality. Factors such as severe immunosuppression (CD4+ T-lymphocyte counts <40/mm³) in patients with undiagnosed HIV, treatment-naïve individuals, those who discontinue ART and the absence of P. jirovecii prophylaxis may increase clinicians' suspicion of extrapulmonary manifestations in HIV-infected patients.

La amiloidosis AL (antes denominada amiloidosis primaria) es una entidad sistémica poco frecuente, con incidencia desconocida en el mundo, que puede llegar a presentar compromiso cardíaco en casi la mitad de los pacientes, llevando a una cardiomiopatía restrictiva por depósito de tejido amiloide. A continuación, presentamos 3 casos de pacientes que consultaron por falla cardíaca aguda y síncope, en quienes finalmente se confirmó el diagnóstico de amiloidosis AL. Al final, se realiza una breve revisión de la literatura, enfatizando en los elementos clínicos para un diagnóstico temprano.