Contexto Clínico:
Varón de raza negra atendido en urgencias del Centro de Salud en reiteradas ocasiones , por varios médicos de guardia, que ninguno es su médico habitual.
Motivo de consulta y anamnesis
Acude a urgencias en tres ocasiones por hematuria, disuria , sin fiebre y con molestias leves en hipogastrio a la presión . Barrera idiomática.
La exploración física:
El abdomen estaba blando y depresible, no defensa, dolor leve a la palpación profunda en hipogastrio.
Exploraciones complementarias :
Se le realizaron dos tiras urinarias en las que aparecían tres y cuatro cruces de sangre y resto normal.
Plan diagnóstico y terapéutico :
Fue tratado con en la primera consulta, según consta en el informe de cistitis aguda con amoxicilina clavulánico dosis correctas una semana, En la segunda ocasión, con diagnostico probable de uretritis con ciprofloxacino durante diez días, sin mejoría. Y en la tercera se le prescribió nolotil y se le recomendó por escrito en el apartado plan que acudiera su medico de cabecera para valorar la pertinencia de cultivo.
El paciente acude a mi consulta dos meses después de la primera consulta con los mismos síntomas, y tras ampliar la historia clínica solicito cultivo y serología: llegándose al diagnostico y derivándolo para su tratamiento.
Discusión del caso:
La decisiones diagnosticas iniciales que se tomaron en la consulta de urgencias se basa en los árboles de decisiones diagnosticas, que representa en forma secuencial condiciones y acciones, normalmente construidos a partir de la descripción de la narrativa de un problema. Pero estos se basan en la prevalencia de de la enfermedad en la población donde se realiza el estudio.
En nuestro medio las causas mas frecuentes de hematuria:
• Infección urinaria y uretritis,
• Estenosis del meato,
• Irritación perineal,
• Trauma,
• Urolitiasis,
• Otras causas menos comunes :Hipercalciuria, • Coagulopatía, • Tumores, • Glomerular: – Nefropatía IgA– Síndrome de Alport– Enfermedad de membranas finas– Glomerulonefritis aguda postinfecciosa Nefritis de Schönlein-Henoch– Lupus eritematoso sistémico.
Causando el posible diagnostico inicial o mejor dicho la hipótesis inicial. “Quien se equivoca según la norma es efectivo y eficiente”, puesto que evita que se produzcan pruebas innecesarias que aumenten la iatrogénica y el aumento del coste.
Pero en este caso se obviaron datos antecedentes del sujeto que podría haber alertado sobre otros diagnósticos diferenciales .
El sujeto era emigrante de Mali, había tenido episodios similares anteriores y las características de la hematuria era gotas de sangre al final de la micción.
Hematuria de inicio : sangre antes o durante la miclón, después normal o levemente teñida. Debemos pensar un problema debqjo del cuello vesical, uretra o próstata.
Sangre durante toda la micción con igual intensidad. Debemos pensar en un problema encima del cuello vesical(vejiga, uréter, riñón).
Chorro orina claro hasta el final de la micción, donde se aprecia la emisión de sangre mezclada con la orina o gotas de sangre al acabar la micción. Debemos pensar en un problema Cuerpo vesical. Como en nuestro caso.
En este caso se comete un error de probabilidad, al aplicar una probabilidad incorrecta de que se produzca el evento a este paciente, por una historia clínica incompleta, y al no establecer y sobre todo en la atención en urgencias una red de seguridad.
¿ Que deberíamos hacer si los síntomas persisten o empeoran?.
En este caso se sigue cometiendo el error de probabilidad ( ” algo con cuatro patas grande que corre por aquí es un caballo, no una cebra”), e induce un segundo error diagnóstico y de tratamiento al calificar el segundo encuentro con el diagnóstico de uretritis puesto que es una cistitis que no mejora.
Tres signos y un síntoma disminuyen la probabilidad de IU y uretritis:
• Ausencia de disuria. • Ausencia de dolor lumbar. • Ausencia de historia de flujo e irritación vaginal. • Evidencia al examen genital de flujo uretral.
Y por último se produce un error en seguimiento de las guías clínicas:
La cistitis espontánea en el varón es excepcional, excepto en homosexuales, pacientes no circuncidados y tras manipulación urológica reciente. Se ha de descartar ante sospecha de infección: uretritis, anomalía urológica y prostatitis crónica. Debe realizarse siempre urocultivo.
Se debía haber remitido en la primera consulta a su medico de cabecera. No así en las mujeres en estas cistitis, no complicadas ,no es necesario practicar un urocultivo.
Diagnostico final cerrado :
El paciente presentaba una esquistosomiasis que es endémica de la zona de donde provenía .
Las manifestaciones clínicas de la esquistosomiasis urogenital están relacionadas con los períodos de desarrollo del parásito, en este caso estaba en fase de enfermedad establecida, donde se produce la eliminación de los huevos por la orina, manifestándose por hematuria de tipo terminal, polaquiuria, disuria y molestias hipogástricas. El período de estado y aparición de complicaciones es consecuencia de la inflamación crónica y reacción fibrosa, que producen los huevos atrapados en la vejiga, da lugar a granulomas, ulceraciones y pólipos que son responsables de la hematuria.
Las complicaciones más frecuentes: anemia secundaria a la hematuria, litiasis, calcificación urétero-vesical, uropatía obstructiva, insuficiencia renal, reflujo urinario, hidronefrosis, infecciones urinarias de repetición por Escherichia coli y Salmonella. Además se relaciona con la aparición de cáncer de vejiga (tipo celular escamoso). Se trato por medicina interna donde lo remití con praziquantel, En dosis recomendada es de 40 mg/kg en dosis única o dividida en dos dosis en nuestro caso una dosis.
Conclusión :
La presencia de emigrantes y la facilidad de trasporte de este mundo globalizado, nos obliga a tener en cuenta enfermedades emergentes, que habían desaparecido en nuestro medio, y a adoptar una red de control, que posibilite el diagnostico de enfermedades infrecuentes en nuestro medio.
Bibliografía: Emergencias 2004;16:162-164; msc.com.guia del emigrante. Pagina de la semfyc infeccioso.
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