Blood pressure control aims to reduce the risk of long-term cardiovascular events. Olmesartan medoxomil is an oral prodrug that belongs to the angiotensin II receptor blockers (ARBs) family and blocks the renin-angiotensin-aldosterone system by antagonizing the angiotensin II (AT) type 1 receptor. 1 Olmesartan-associated enteropathy (OAE), was described for the first time in 2012 by Rubio-Tapia et al. in 22 patients with chronic diarrhea and weight loss treated with olmesartan. Serological screening tests for celiac disease were negative, and there was no response to a gluten-free diet. Endoscopic biopsy showed villous atrophy and mucosal inflammation similar to sprue-like enteropathy. Clinical response was demonstrated in all patients after drug discontinuation. In July 2013 the U.S. Food and Drug Administration issued a postmarketing warning highlighting the importance of this new entity. 2 We present a case of a 76-year-old man with a history of arterial hypertension treated with olmesartan/hydrochlorothiazide 40/12.5mg/daily during 2 years, who presented with 2-month history of weight loss of 15 kg, vomiting and watery diarrhea, up to 4 stools per day, without bleeding, mucus or pus, and afebrile. Stool sample culture found no microbiological isolations. Laboratory tests showed hemoglobin 14 g/dL, white blood cells 9,100/mcL, platelets 259,000/mcL, creatinine 0.7 mg/dL with no electrolyte imbalance, albumin 3.0 g/dL, C-reactive protein 1.5 mg/dL, thyroid-stimulation hormone 0.5 mUI/L and T4-free 1.3 nanogram/dL. Biomarkers were normal. Autoimmune tests with anti-nuclear antibodies and anti-DNA antibodies were negative. Serological tests for celiac disease (CD) were negative. Human leukocyte antigen (HLA) DQ2 typing was positive. Abdominal computed tomography showed a diffuse thickening throughout the entire colon and terminal ileum. Gastroscopy and colonoscopy evinced villous atrophy in duodenum and unspecific recto-colon-ileitis, respectively. Biopsy samples from gastric, ileum and colon showed no malignancy but severe chronic nonspecific inflammatory damage with the presence of lymphocytes, plasma cells and granulocytic infiltration. Helicobacter pylori was not visualized (Figure 1).During hospitalization, watery diarrhea persisted in spite of a gluten-free diet. Parenteral nutrition was required initially due to severe weight loss and oral intolerance. Clinical remission was observed after withdrawal of olmesartan. Control

La asociación entre síndrome de Good y aplasia de células rojas es extremadamente rara. Presentamos el caso de una paciente con un timoma que presentaba concomitantemente estos dos síndromes paraneoplásicos. A pesar de la resección quirúrgica del timoma, ninguno de los dos trastornos autoinmunes mejoró.

Texto en Español:Varón de 87 años, con antecedentes de hipertensión arterial y cardiopatía isquémica. Ingresa en box vital de Urgencias por epigastralgia intensa, súbita, opresión precordial con irradiación a zona interescapular, sudoración profusa, asociada a sensación de disnea y palpitaciones. Se procede a la recogida de constantes, monitorización y colocación de vía periférica. Destaca el registro de cifras tensionales variables en posición de semisedestación, tanto en el miembro superior izquierdo como en la extremidad contralateral. Se registran en miembro superior izquierdo cifras de 220/80 mmHg, posteriormente 100/50 mmHg y finalmente 170/95 mmHg. En miembro superior derecho tensión arterial de 180/40 mmHg seguida de 120/70 mmHg. Pulsos proximales y distales presentes, sin objetivarse masa pulsátil en abdomen. Ante la sospecha de un síndrome aórtico, se realiza una tomografía computarizada con contraste, que evidencia una hernia de hiato esofágico gigante por deslizamiento que condiciona colapso parcial de la aurícula izquierda y venas lobares inferiores (Fig 1-4). El paciente es trasladado a zona de observación, donde se coloca sonda nasogástrica, presentando mejoría parcial sintomática, con posterior persistencia de náuseas y vómitos, así como tendencia a la hipertensión. Tras ser valorado por cirugía general, se decide la realización de reducción del contenido herniario a cavidad abdominal y fundoplicatura posterior con fundus residual (tipo Toupet). No hubo complicaciones perioperatorias. Tras varios días de hospitalización, el paciente fue remitido a su domicilio sin más incidencias. Palabras clave: hernia hiatal; estómago; atrios cardíacos. Texto en Inglés:87 years old male with a history of hypertension and ischemic cardiopathy. He arrives to the Emergency department with sudden intense epigastralgia, precordial oppression with irradiation to the interscapular area, profuse sweating, associated sensation of dyspnoea and palpitations. The patient is monitored and a venous peripheral access is placed. It is remarkable the variable blood pressure measures in the semistationary position, both in the upper left limb as in the contralateral limb. In the upper left limb we registrered 220/80 mmHg, followed by 100/50 mmHg and finally 170/95 mmHg. In the upper right limb, blood pressure was 180/40 mmHg and afterwards 120/70 mmHg. Proximal and distal pulses are present and no pulsatile epigastric mass can be found. Given the suspicion of an aortic syndrome, a CT scan with intravenous contrast is performed which shows a large hiatal hernia compromising partially the left atrium and inferior lobar veins (Fig 1-4). The patient is transferred to the observation area, where a nasogastric tube is placed, presenting partial symptomatic improvement, with persistent nausea and vomiting, as well as a tendency to hypertension. After being evaluated by general surgery, it was decided to make an hernia content reduction to the abdominal cavity and posterior fundoplication with residual fundus (Toupet type). There were n...

Texto en Español:Varón de 87 años, con antecedentes de hipertensión arterial y cardiopatía isquémica. Ingresa en box vital de Urgencias por epigastralgia intensa, súbita, opresión precordial con irradiación a zona interescapular, sudoración profusa, asociada a sensación de disnea y palpitaciones. Se procede a la recogida de constantes, monitorización y colocación de vía periférica. Destaca el registro de cifras tensionales variables en posición de semisedestación, tanto en el miembro superior izquierdo como en la extremidad contralateral. Se registran en miembro superior izquierdo cifras de 220/80 mmHg, posteriormente 100/50 mmHg y finalmente 170/95 mmHg. En miembro superior derecho tensión arterial de 180/40 mmHg seguida de 120/70 mmHg. Pulsos proximales y distales presentes, sin objetivarse masa pulsátil en abdomen. Ante la sospecha de un síndrome aórtico, se realiza una tomografía computarizada con contraste, que evidencia una hernia de hiato esofágico gigante por deslizamiento que condiciona colapso parcial de la aurícula izquierda y venas lobares inferiores (Fig 1-4). El paciente es trasladado a zona de observación, donde se coloca sonda nasogástrica, presentando mejoría parcial sintomática, con posterior persistencia de náuseas y vómitos, así como tendencia a la hipertensión. Tras ser valorado por cirugía general, se decide la realización de reducción del contenido herniario a cavidad abdominal y fundoplicatura posterior con fundus residual (tipo Toupet). No hubo complicaciones perioperatorias. Tras varios días de hospitalización, el paciente fue remitido a su domicilio sin más incidencias. Palabras clave: hernia hiatal; estómago; atrios cardíacos. Texto en Inglés:87 years old male with a history of hypertension and ischemic cardiopathy. He arrives to the Emergency department with sudden intense epigastralgia, precordial oppression with irradiation to the interscapular area, profuse sweating, associated sensation of dyspnoea and palpitations. The patient is monitored and a venous peripheral access is placed. It is remarkable the variable blood pressure measures in the semistationary position, both in the upper left limb as in the contralateral limb. In the upper left limb we registrered 220/80 mmHg, followed by 100/50 mmHg and finally 170/95 mmHg. In the upper right limb, blood pressure was 180/40 mmHg and afterwards 120/70 mmHg. Proximal and distal pulses are present and no pulsatile epigastric mass can be found. Given the suspicion of an aortic syndrome, a CT scan with intravenous contrast is performed which shows a large hiatal hernia compromising partially the left atrium and inferior lobar veins (Fig 1-4). The patient is transferred to the observation area, where a nasogastric tube is placed, presenting partial symptomatic improvement, with persistent nausea and vomiting, as well as a tendency to hypertension. After being evaluated by general surgery, it was decided to make an hernia content reduction to the abdominal cavity and posterior fundoplication with residual fundus (Toupet type). There were n...