When the symptoms do not fit!

When the symptoms do not fit!


Herrero S. “!Cuando los síntomas no cuadran!”  Journal of Pearls in Intensive Care Medicine 2011 Volumen 1. Nº 31


J Pearls Int Care Med © 2011 ·Todos los derechos reservados. All rights reserved

When the symptoms do not fit!

Medicine is not a mathematical science!
This term is often heard, because the medicine is not the product of 2 × 1 = 2 or a logic equation!
For this reason, that medicine is about “art” as a combination of practice and pure knowledge.

The art is, according to Aristotle, doing something knowing why it does what it does (techne). One way to get to the causes and effects, giving an explanation of the processes. Medicine is an art that is closer to the intuitive, from subjective elements. Diseases can “play” when we are aware of how the incidence, although sometimes we do not know how it ends. Play a disease is relatively easy, when we know the causal agent. For example “infections.” Today the only items or drugs that are able to cure is antibiotics. Other drugs may alter the natural laws of the disease, but not the direct solution.

The art of healing, it is a practice of a single element. Medicine is science “so reproducible” which are some of their illnesses. To become art, is not only necessary to know the medical rules, but rather to justify an “all material”.

The diseases have the patient in a sequence of signs and symptoms. Often they are reproducible when a product works only as single disease.

For example, a typical pneumonia:

  • Sudden onset
  • Chills
  • High fever thermometers (> 38.5 ° C).
  • Cough irritative initially isolated and subsequently be
  • Yellowish expectoration muco followed by purulent (green), dark (or rusty) or mucosanguinolentas
  • Impact of general or prostration
  • Dyspnea or respiratory distress
  • Flank pain (pleuritic)
  • State of confusion
  • Cyanosis due to decreased arterial oxygenation.
  • Rx. Thorax: pictures of lobar condensation

Well, these symptoms would add up to a common pathology as a typical pneumonia in a patient who comes from the community (listed in the common area of any person). Community Acquired Pneumonia (CAP) remains a common condition with significant mortality and morbidity, since it is not a notifiable disease and is difficult to obtain reliable data on mortality.

However there is another type of pneumonia, atypical: Most common in children, young adults, but also the elderly may suffer or even older. Common symptoms are:

  • General malaise
  • Musculoskeletal pain, or musculoskeletal pain
  • Distermia Feeling (perceive fever)
  • Fever> 38.5 ° C
  • Irritative cough and low
  • Expectoration may or may not occur and even if it appears, may not be purulent
  • Headache
  • Pharyngeal discomfort
  • CXR: bilateral interstitial infiltrate

Well, we have seen two ways of pneumonia occurs in the community (there is another type of pneumonia, nosocomial pneumonia and even worse yet, but these I leave out for now).

The community-acquired pneumonia (CAP), is considered the sixth leading cause of death and the first among infectious diseases in the United States until 1994 (1).

Pneumonia is acute lung parenchyma of the Inflammation of Various etiologies and variable duration, characterized by a localized inflammatory exudate in the distal portions of terminal bronchioles and alveoli, alveolar sacs Including.

The differences between a typical with an atypical pneumonia, is given by the casual agent (the organism as a bacterium, virus, etc.).

Recognized as the main organisms causing community-acquired pneumonia (CAP) are Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, Legionella pneumophila, Chlamydia pneumoniae, Moraxella catarrhalis, Staphylococcus aureus, Gram negative stand of Klebsiella, Pseudomonas aeruginosa, Escherichia coli. Viruses rare in adults except in outbreaks of influenza, respiratory syncytial also.

But beware! On more than one third of cases of CAP does not identify the causative agent …

But things get complicated when we have not all patients are equal … we must determine the risk factors and others who are poor prognostic factors:

RISK FACTORS  Community-acquired pneumonia (CAP):

  • Alcoholism
  • Psychiatric
  • Chronic obstructive airway disease
  • Influenza
  • HIV
  • Senility
  • Acute pulmonary edema
  • Immunosuppression
  • Viral
  • Diabetes Mellitus
  • Other

Poor prognostic factors:

  • Age: over 65 years
  • Associated pathology: Diabetes mellitus, renal failure, alcoholism.
  • Recent hospitalization.
  • Fever> 38.5 *.
  • Tachypnea, hypoxemia (pO2 <50 mm Hg).
  • Bacteremia.
  • Immunosuppression.
  • Staphylococcus, Gram negative.
  • Radiological progression.

The diagnosis is based on details obtained from the patient history, detailed physical examination, appropriate laboratory tests and some procedures. The clinical history, physical examination and chest radiograph are obtained before any laboratory test, so the determination of the initial pathogen depends on the clinical and x-ray, which may subsequently be confirmed or not by the tests laboratory can also be added that in approximately 50% of cases is not the causative agent, the difficulties in tear tests, cultures, serological tests and more invasive techniques are not home tests.

Many patients with CAP are treated on an outpatient basis and require further study a chest radiograph to establish the diagnosis, some laboratory tests to determine the extent and the associated pathologies and microbiological study.

The treatment of pneumonia in theory is deceptively easy, we simply must make the diagnosis, determine the etiologic agent and then select the antibiotic to which the agent is sensitive. In practice however this is not possible. And it is not possible, because we can not wait for the outcome of which is the etiologic agent or germ … here comes what we call EMPIRICAL TREATMENT!


This treatment applies without knowledge of the causative agent, since diseases such as pneumonia or other can not wait days to find the agent who produced it.

Spain is a developed country with more antibiotic use, higher rates of bacterial resistance in community pathogens and exporting them worldwide, creating a true public health problem (2.3). Over 90% of antibiotic prescribing in primary care is performed, and in this clinical environment in which their use is incorrect regarding the indications, the choice of antibiotic, dosage used, the failure of treatment and self-medication (4).

The serious public health problem associated with bacterial resistance has prompted scientific societies to agree to make recommendations on the use of antibiotics and has developed policies to rationalize their use.

Empiric treatment is based on a recommendation guidelines which have been identified risk factors, prognostic factors, typical and atypical causative agent with which the doctor can begin medical treatment each patient as appropriate antibiotic … eg for pneumonia:

  •     Patients aged 65 years or younger
  •     Depending on whether or not there is respiratory failure
  •     Comorbidity (risk factors and poor prognosis)
  •     Re-assessment at 48-72 hours and change the antibiotic if worsening.
  •     If the patient is living in endemic areas or geographic outbreaks of Legionella pneumophila levofloxacin 1 g / 24 hours, oral, 10 days.
  •     Amoxicillin treatment of choice for b. 1 g / 8 hours, vo, 7 days or amoxicillin-clavulanate c. 1000/125 mg / 8 hours, vo, 7 days + macrolide (500 mg/12 hours Claritromicina., po, 7 days or azithromycin. 500 mg / 24 hours, po, 5 days).



The Hippocratic physician worked in close relationship with the patient. The patient, family and even the environment, should all cooperate with the doctor’s action. To exercise his art the Hippocratic physician should be a mental representation of the patient’s condition throughout the time course: in the past, present and future. This representation is indeed the outcome, the “prognosis”. Access was looking to the past questioning the patient as a reminder of the beginning of his condition, that is, was looking through the “history”. The present state, the diagnosis, the “diagnosis”, was established using all its means of perception of the “seméix”, ie, signs and symptoms of disease, whose study is semiotics.

An error in medicine is based on the assumption, ignoring objectivity. The fixation of subjectivity is an invalid option for the start of patient care.

The value of the Hippocratic Concept:

THIS EXAMPLE IS THE TYPICAL AND WRITTEN IN THE HISTORY OF MEDICINE, the description of the Hippocratic facies, which is usually observed in a dysenteric box:

In acute diseases it should be noted carefully: first, the patient’s face, if it is similar to that of healthy people, and especially if he looks like himself. This would be the best, and the opposite of normal appearance, the most dangerous. It may look like this: sharp nose, sunken eyes, depressed temples, ears cold and contracted, and diverted earlobes, the skin of the forehead, hard, tense and dry, and the skin around the face, yellow or dark (Forecast, 2)

By hypothesis and medical deductions represented the future course of the disease, in particular outcome. To develop this representation was difficult and for this the doctor turned to his knowledge, experience and intelligence, not only to analyze the facts collected, but especially for integration into a coherent picture. This intellectual capacity for integration, not reproduced in the artificial intelligence is a fundamental part of the medical art, and not infrequently manifest that capacity rapidly, ie, as an intuition.


The progress of medicine has shifted a bit to the famous “clinical eye” test for categorical and more selective. The tests, they understood the multiple analysis, the different imaging techniques and other techniques to practice on a patient, helps give the doctor an essential and invaluable when evaluating a patient. In fact, some tests, by themselves, can be used to develop a diagnosis and appropriate treatment; Take for instance a chest radiograph in a young patient with pneumonia acquired outside the hospital, or a CT scan in a patient following trauma head has a subdural hematoma. This type of medicine “direct” to characterize in some way, is often confused with scientific medicine, because people – secular, profane and sometimes not – believes that science is about testing and equipment, the more the merrier.

I refuse to believe that doctors, before medicine instrumentalized as the current (CT, Nuclear Magnetic Resonance Analysis, directed, etc.) were unable to bring their knowledge to current standards!

One of the few things that have changed in the last 40 years is the knowledge of physiology. With more or less detail, the doctor once had more knowledge of physiology, that current doctors, who base their knowledge of course you have online. No need to memorize a formula or concept of physiology because what you have on your Palm, iPad, iPhone or Tablet. Current is a mistake, because every formula physiological response to a synopsis, which we leave to study.

Another factor that proves, if it is true that we have more information today than 20 years ago, it is also true that medicine is more subjective, because the doctor thinks that the diagnosis was given a CT analysis and therefore should not Further research on objective facts. Sometimes you forget to look at the patient’s face! and only memorize signs and symptoms that tell us, without looking for more information! That’s the fear that I have today by young doctors. They have all their medical logic in what they provide diagnostic tests rather than enable your “personal research to understand what happens to the patient from a pathophysiological rationale.”

EVENTS assume, without reaching a correct diagnosis!

It is true that sometimes reach a diagnosis is difficult, sometimes so entangled that they can be symptoms, others because we assume that the patient has a “disease” although we have not reached their logical interpertación … for example, is a real patient!

A 79-year-old has a few months more or less complex disturbances of gait, has “oversights” but still in time and space alert. It is a patient who has been taking chronically “prednisone” 20 years ago by a “rheumatoid arthritis”. Has in the past 10 years chronic refractory sideroblastic anemia (a form of myelodysplastic syndrome). Note gradual loss of strength (although there are occasional moments that is fine). It takes you to a neurologist, who after a test of TAC, a condition is not clear in the images (the neurologist suspected NPH or incipient dementia, perhaps, Alzheimer’s). The patient is taken to the hospital for health impairment and psychomotor agitation. Patient follow-up days before is not very clear because his wife, also greater, can not serve you. You will be given “neuroleptics” and sedatives until at one point the patient has hypotension, still agitated and intubated (administered midazolam, fentanyl and muscle relaxants before intubation). After intubation, the patient remains hypotensive and begin to administer vasoactive amines. Septic shock is labeled, because in an analysis of PCT (procalcitonin) is high (9.02 ug / ml). However, the focus of sepsis is attributed to “possible aspiration” for mishandling respiratory secretions.

Here are several circumstances concur:

On the one hand the patient is labeled “senile dementia or Alzheimer’s,” which will translate that whatever happens, will not decide to extend the picture much, if not better.
A diagnosis of “septic shock” based on a high PCT.
Is attributed to a possible source of sepsis “bronchial pneumonia”, although the chest radiograph is normal after intuabción.

Perhaps with this, many doctors have been satisfied. But if we are responsible and we decided to clarify the process, we should ask ourselves these questions:

Is there a clear diagnosis of “dementia”? No one patient had a “mini mental test” and … say it is “insane” because there is a “presumptive diagnosis” that’s really insane!
Does the pre-intubation hypotension is cleared? Maybe play a role sedatives and neuroleptics?
Is saying septic shock, only because there is a circulatory failure and adds a PCT analysis as high, but because the evidence says it is highly likely diagnosis of sepsis, septic shock?
There may be aspiration, but we can not make the diagnosis of pneumonia, because no images compatible with alveolar condensation.

Results: The patient was given antibiotics following admission as “Piperacillin-tazobactam” and amines hypotension, fluids and steroids. At 24 hours there is a leukemoid reaction (67,000 leukocytes mainly lymphocytosis) that after the removal of the steroid, begins to decrease. Hematology recommended for Vancomycin for the sepsis. As an immunosuppressed patient after bronchoscopy for bronchoalveolar lavage and brushing, was treated with cotrimoxazole.

On the other hand, the words “shock”, “dementia”, “immunocompromised” are the words “cross out or labeled” the patient for the entire world and is held in our subconscious …

But … So far we have been very subjective! We should not settle for this! There are signs and symptoms that do not fit!

The patient data are no bacteria in the body despite multiple bacteriological checks! Therefore “septic shock” remains very empty of content, although they all imagine that the picture was “septic shock” because data had indeed shock, but the fact of believing a fact that a high value of procalcitonin (PCT ) is invariably target of sepsis-septic shock us out of a potential vision is to give the high value of PCT to another interpretation, here comes the Differential Diagnosis!

The first 3 questions are:

  • 1 º What causes shock, but even if it seems infectious, it is not!
  • 2 ° What can cause loss of strength and simulate a dementia before entering the shock!
  • 3 ° What role immunosuppression plays here!

Replies …. I have no idea, it seems what is the income, a great-grandfather with loss of strength, restlessness, possible aspiration and septic shock bronchopulmonary!

The truth, even you think seriously? IS WHAT SEEMS TO INCOME? ….

NO response to what seems to believe!

There is a TV series called House, I guess you all know whom I mean! Well, truth be told, House has that Inquisitor, which many doctors we love, the power to decide what you think and do, mistake or not, but always with an answer on … if we put the paw!

His most famous words: Everybody lies!

Seriously, no more than a series, but it’s a fabulous character! The case surrounds him, and seen from afar, yet up close and always creates a dilemma! Outside …. OUT of the fictional characters, we all like to be a bit HOUSE!

When symptoms of Frames!

There is a saying which is that “when a symptom does not fit” do not take the more simple!

Our case is still on! Remember the questions? Reemphasizes!

The first 3 questions are:

  • 1 º What causes shock, but even if it seems infectious, is not it?
  • 2 ° What can cause loss of strength and simulate a dementia before entering the shock?
  • 3 º What is the role here immunosuppression ‘

The first question will come the following processes!

If shock, but is not infectious … I’ll take my pearls to remember the shock!

Causes of septic shock-like

First is a shock vasodilatation! (Hyperdynamic)


  • Anaphylaxis (Allergy?) … Do not think!
  • Spinal shock? … No trauma, do not think!
  • The third would lead to septic shock again … and not what it seems!
  • Shock drug? Here there are only two: neuroleptics and sedatives … Sedatives the discard! Neuroleptics in some patients, tachycardia and hypotension have occurred, but shock? does not appear!
  • ?????

What can simulate septic shock is not? …. We ask the question in reverse, for example: What exists in septic shock and is in this patient, but not septic? … THERE IS A REASON !!!!!!!!!!

We know that the septic shock, can go in the acute phase, relative adrenal insufficiency! This patient was a chronic drinker prednisone. Prednisone is a synthetic corticosteroid drug that is usually taken orally in patients with rheumatoid arthritis (this patient has been taking almost 20 years)!
We know that suppression of adrenal function occurs if prednisone is administered for more than seven days, so that the body is unable to synthesize natural corticosteroids and becomes dependent on the prednisone taken by the patient. For this reason, prednisone should not be stopped abruptly and if taken chronically, and while the patient took a very low dose, although this needs to be reduced slowly, this reduction may take days if the course of prednisone was short, but it may take weeks or months if the patient has been treated for a long time.

A sudden drop in dose taking would lead to secondary adrenal insufficiency!

It seems that the patient could potentially lead time without taking prednisone (no one could say that were not) and perhaps the patient developed adrenal insufficiency that led to other symptoms such as loss of strength (asthenia first symptom or weakness ). To confirm this finding we made a study EMG (electromyogram) and we discovers he has a mixed neuropathy (sensory-motor), predominantly axonal (The axon is a long, thin extension of the neurons that originates in a specialized region called the axon or axon hillock eminence. The axon is shaped like a cone that is tapering towards the periphery). On its surface are observed circular periodic constrictions called nodes of Ranvier (orange).

Chronic axonal peripheral neuropathies are usually secondary to:
1. Metabolic (diabetes, uremia, etc.).
2. Toxic substances (alcohol, drugs, etc.).
3. Deficiency (Enf.celiaca, Vitamin B1, B6, B12)
4. Infectious diseases (leprosy, syphilis, HIV, etc.).
5. Hereditary (Enf.de Friedrich, CMT2, etc.).
6. Veins (vasculitis, lupus, arthritis
rheumatoid arthritis, etc.).
7. Immunological (Sgro, dysproteinemia, etc.).
8. Paraneoplastic (lung, etc.).

Interestingly the word out Rheumatoid arthritis as a potential cause of this neuropathy … Now also here there is little of dementia … The evidence is that there are two explanations!

  1. Potential secondary adrenal insufficiency
  2. Axonal neuropathy predominantly mixed (vascular or rheumatoid arthritis)
  3. The third (which raises the PCT?) Or, what is capable of raising the PCT (procalcitonin) and is not infectious?

ANSWER: Adrenal insufficiency may also induce pathological elevation of PCT

The answer is:
TO A PATIENT, YOU EVERYONE blames septic shock, which is really what happens is not seen directly, but that presents as septic shock, adrenal insufficiency, the cause of many patients can not improve a septic shock, but here is the primary cause  … TRUTH IS A little mess?

THEN the patient is improving, because we gave cortisone NEW AND WITH THAT CAME THE SHOCK




  1. Campbell-GD. Overview of community acquired pneumonia. Prognosis and clinical features. Med Clin North Am. 1994;78(5):1035-104
  2. Palop V, Melchor A, Martínez-Mir I. Reflexiones sobre la utilización de antibióticos en atención primaria. Aten Primaria 2003; 32: 42-7; Smith RD, 2002
  3. Smith RD, Coast J. Ant imicrobial resistance: a global response. Bulletin of the World Health Organization 2002; 80: 126-33
  4. Palop Larrea V, Catalán Oliver C, Gonzálvez Perales JL, Belenguer Varea A, Martínez-Mir I. Utilización clínica de antibióticos en atención primaria. En: J Merino y V Gil. Práctica Clínica en Atención Primaria de Salud. 4. Enfermedades infecciosas – Universitat Miguel Hernández. Barcelona: Doyma SA; 1999. p.158-84.
  5. El arte hipocrático. PONTIFICIA UNIVERSIDAD CATOLICA DE CHILE FACULTAD DE MEDICINA http://www.elgotero.com/Archivos%20zip/La%20Medicina%20Prehipocr%C3%A1tica.pdf


Herrero S. “!Cuando los síntomas no cuadran!”  Journal of Pearls in Intensive Care Medicine 2011 Volumen 1. Nº 31   http://wp.me/p19kQl-hd

J Pearls Int Care Med © 2011 ·Todos los derechos reservados. All rights reserved


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