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Mujer de 34 años con inestabilidad en la marcha
A 34-year old woman with gait instability
A. Arévalo Gómeza, L. Bello Rodrígueza, E. Sánchez Vidala, D. Sousa Regueiroa, P. Varela Garcíaa, E. Miguez Reya, P. Llinares Modejara
a Unidad de Enfermedades Infecciosas. Hospital Juan Canalejo. La Coruña. España.
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    "textoCompleto" => "<p class="elsevierStylePara">Caso cl&#237;nico</p><p class="elsevierStylePara">Mujer de 34 a&#241;os&#44; sin h&#225;bitos t&#243;xicos ni antecedentes de inter&#233;s&#46; Desde hac&#237;a un mes y medio presentaba episodios vertiginosos y cefalea opresiva leve&#46; En los &#250;ltimos d&#237;as se a&#241;aden v&#243;mitos e inestabilidad al caminar&#46; No refer&#237;a otra focalidad neurol&#243;gica&#44; fiebre&#44; s&#237;ndrome general ni otra cl&#237;nica&#46; La exploraci&#243;n f&#237;sica general era normal&#44; y en la exploraci&#243;n neurol&#243;gica destacaba inestabilidad en la marcha en t&#225;ndem&#46; El hemograma&#44; la coagulaci&#243;n y la bioqu&#237;mica general no mostraban alteraciones&#44; ni tampoco la radiograf&#237;a de t&#243;rax&#46; En la tomograf&#237;a axial computarizada &#40;TAC&#41; craneal se apreciaba un proceso expansivo en hemisferio cerebeloso derecho&#44; con importante edema cerebral &#40;fig&#46; 1&#41;&#46;</p><p class="elsevierStylePara"><img src="65v207n08-13108759fig01.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Fig&#46; 1&#46; Tomograf&#237;a axial computarizada craneal&#58; dep&#243;sito tumoral s&#243;lido de 28</span> &#215; <span class="elsevierStyleItalic">20</span> &#215;<span class="elsevierStyleItalic">30 mm en el hemisferio cerebeloso derecho &#40;flecha&#41;&#46;</span></p><p class="elsevierStylePara">Evoluci&#243;n</p><p class="elsevierStylePara">La resonancia magn&#233;tica nuclear &#40;RMN&#41; cerebral mostr&#243; un dep&#243;sito tumoral s&#243;lido en el l&#243;bulo cuadrangular y semilunar superior del hemisferio cerebeloso derecho&#44; que realzaba a la inyecci&#243;n de contraste&#44; muy sugerente de un adenocarcinoma mucinoso&#44; o menos probablemente un absceso cerebral&#46; En busca de un tumor primario se realiz&#243; una TAC toracoabdominal que mostr&#243; peque&#241;os n&#243;dulos pulmonares en l&#243;bulos superiores&#44; la mayor&#237;a cavitados compatibles con met&#225;stasis&#46; Se decidi&#243; realizar la ex&#233;resis de la tumoraci&#243;n cerebral&#46;</p><p class="elsevierStylePara">En la biopsia intraoperatoria se identificaron granulomas necrotizantes tuberculosos&#46; Los cultivos en medio l&#237;quido de la lesi&#243;n y posteriormente del esputo fueron positivos para <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span>&#46; Se descartaron VIH y otras inmunodeficiencias&#46; Se inici&#243; tratamiento antituberculoso y la evoluci&#243;n fue favorable&#46; La paciente se encuentra actualmente asintom&#225;tica&#46;</p><p class="elsevierStylePara">Diagn&#243;stico</p><p class="elsevierStylePara">Tuberculosis diseminada&#58; tuberculosa cerebral&#44; tuberculosis pulmonar&#46;</p><p class="elsevierStylePara">Comentario</p><p class="elsevierStylePara">La tuberculosis del sistema nervioso central puede manifestarse como meningitis&#44; absceso epidural o granulomas inflamatorios intraparenquimatosos &#40;tuberculomas&#41;&#46; &#201;stos se comportan como cualquier otro proceso expansivo intracraneal y es frecuente confundirlos con met&#225;stasis <span class="elsevierStyleSup">1-3</span>&#46; Son raros en el mundo occidental <span class="elsevierStyleSup">4&#44;5</span> y fundamentalmente se presentan en inmunocomprometidos <span class="elsevierStyleSup"> 1&#44;6</span>&#46; En Espa&#241;a suponen el 0&#44;1&#37; de los procesos intracraneales <span class="elsevierStyleSup">7</span>&#46; Pueden encontrarse en personas de cualquier edad aunque es m&#225;s frecuente en j&#243;venes <span class="elsevierStyleSup">4&#44;7</span>&#46; Existe cierta preponderancia en mujeres&#46; La localizaci&#243;n infratentorial es para algunos autores la m&#225;s frecuente <span class="elsevierStyleSup">4</span>&#46;</p><p class="elsevierStylePara">Es necesario siempre descartar tuberculosis en otras localizaciones&#44; ya que en el 12&#37; de los casos coexisten con tuberculosis pulmonar activa <span class="elsevierStyleSup">2&#44;7-9</span>&#46; M&#225;s del 50&#37; presentan antecedentes de tuberculosis&#44; sobre todo pulmonar <span class="elsevierStyleSup">4</span>&#46; El diagn&#243;stico de sospecha se realiza mediante TAC y RMN&#44; en las que se aprecia una masa que realza en anillo <span class="elsevierStyleSup">1&#44;7&#44;10&#44;11</span>&#44; al igual que los tumores cerebrales&#44; pero es necesaria la confirmaci&#243;n histol&#243;gica y bacteriol&#243;gica <span class="elsevierStyleSup">7&#44;12</span>&#46; El tratamiento es quir&#250;rgico si la lesi&#243;n es &#250;nica y accesible&#44; y requiere adem&#225;s tratamiento antituberculoso con isoniacida&#44; rifampicina y pirazinamida entre 9 y 12 meses <span class="elsevierStyleSup">4&#44;10</span>&#46;</p>"
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