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(b) The same area showing positivity for CD 56 with immunohistochemistry that corresponds with a neuroendocrine cell hyperplasia (asterisk, objective magnification 60×). (c) Paratracheal lymph node of case number 1 stained with hematoxylin and eosin technique showing a little focus of neuroendocrine epithelial cells that corresponds with a metastatic typical carcinoid marked with an asterisk (objective magnification 20×). Insert: immunohistochemical technique using cytokeratins, which highlights the metastatic neuroendocrine cells. (d) CT of case number 2. We can observe a subcentimeter nodule in the middle lobe (arrow) and a bilateral mosaic pattern.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Eva García-Fontán, Montserrat Blanco Ramos, Jose Soro García, Rommel Carrasco, Miguel Ángel Cañizares, Ana González Piñeiro" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Eva" "apellidos" => "García-Fontán" ] 1 => array:2 [ "nombre" => "Montserrat" "apellidos" => "Blanco Ramos" ] 2 => array:2 [ "nombre" => "Jose Soro" "apellidos" => "García" ] 3 => array:2 [ "nombre" => "Rommel" "apellidos" => "Carrasco" ] 4 => array:2 [ "nombre" => "Miguel Ángel" "apellidos" => "Cañizares" ] 5 => array:2 [ "nombre" => "Ana" "apellidos" => "González Piñeiro" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020618305461?idApp=UINPBA00004N" "url" => "/23870206/0000015200000003/v1_201901290746/S2387020618305461/v1_201901290746/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2387020618305333" "issn" => "23870206" "doi" => "10.1016/j.medcle.2018.02.033" "estado" => "S300" "fechaPublicacion" => "2019-02-01" "aid" => "4452" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Med Clin. 2019;152:98-101" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Brief report</span>" "titulo" => "Infecciones de transmisi¢n sexual con afectaci¢n anorrectal: agentes causales, coinfecciones, infecci¢n por el VIH y conductas de riesgo" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "98" "paginaFinal" => "101" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Infecciones de transmisión sexual con afectación anorrectal: agentes causales, coinfecciones, infección por el VIH y conductas de riesgo" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Daniel Morgado-Carrasco, Mercè Alsina Gibert, Jordi Bosch Mestres, Miriam Álvarez Martínez, José Luís Blanco Arévalo, Irene Fuertes de Vega" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Daniel" "apellidos" => "Morgado-Carrasco" ] 1 => array:2 [ "nombre" => "Mercè" "apellidos" => "Alsina Gibert" ] 2 => array:2 [ "nombre" => "Jordi" "apellidos" => "Bosch Mestres" ] 3 => array:2 [ "nombre" => "Miriam" "apellidos" => "Álvarez Martínez" ] 4 => array:2 [ "nombre" => "José Luís" "apellidos" => "Blanco Arévalo" ] 5 => array:2 [ "nombre" => "Irene" "apellidos" => "Fuertes de Vega" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775318301532" "doi" => "10.1016/j.medcli.2018.02.014" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775318301532?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020618305333?idApp=UINPBA00004N" "url" => "/23870206/0000015200000003/v1_201901290746/S2387020618305333/v1_201901290746/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial article</span>" "titulo" => "Anorectal sexually transmitted infections. An infradiagnosticated epidemic" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "102" "paginaFinal" => "103" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Alfonso Cabello, Miguel Górgolas" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Alfonso" "apellidos" => "Cabello" "email" => array:1 [ 0 => "acabello@fjd.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Miguel" "apellidos" => "Górgolas" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "División de Enfermedades Infecciosas, Hospital Universitario Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Infecciones de transmisión sexual anorrectales. Una epidemia infradiagnosticada" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Recently, antigenic and molecular diagnostic techniques have improved our ability to detect the pathogens responsible for various infections.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> This has been accompanied by an increase in the incidence and prevalence of some entities, making us doubt, at times, whether they are really increasing or we have simply increased our diagnostic capacity.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Sexually transmitted infections (STIs) are an example of the diseases where these two realities have converged. Despite this, there is no author who doubts the sustained increase of most STIs in recent decades.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">2,3</span></a> This increase has occurred mainly in certain groups, such as men who have sex with men (MSM) and sex workers.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3–5</span></a> The causes are multiple and varied, however, numerous authors agree that two of the causes are a lower perception of the risk of acquiring the human immunodeficiency virus (HIV) – mainly due to the introduction of highly effective antiretroviral treatments – and changes in habits and practices.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The close relationship between HIV and other STIs is well known; they share transmission mechanisms, risk factors and incidence curves in certain groups.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">2,7,8</span></a> MSM represent the highest rate of new HIV diagnoses reported in our country,<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a> and it is not surprising that they are the majority in the study presented by the authors.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a> This study presents a series of cases of STIs with anorectal involvement (STI-AR), all occurring in MSM, to outline a focused and very useful perspective on anorectal disease, whose diagnosis requires not only clinical suspicion, but also detection through anal inspection and a microbiological study of the rectal samples. About 80% of the subjects diagnosed had symptoms of proctitis, which was more than 10% of the global cohort of patients who were attended to during this period. These figures show the importance and frequency of proctitis in the MSM group and the need to understand it so it can be dealt with effectively.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> The diagnosis of proctitis can be done through symptoms, based on a good anamnesis and a correlation with risk factors. Furthermore, exploration by conventional anoscopy or proctoscopy provides very useful information for the establishment of an empirical treatment<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> and can offer adequate samples for study.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Not being aware of this disease favours a delay in diagnosis and treatment<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a> given the similarities between the rectal lesions that appear with ulcerative colitis and lymphogranuloma venereum (LGV)<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a> or that of a severe proctitis due to LGV or gonococcus and a haemorrhoid condition or anal fissure.</p><p id="par0025" class="elsevierStylePara elsevierViewall">New molecular tests have made it possible to more accurately detect the main causative agents, often with a single exudate sample, facilitating and simplifying the empirical treatment subsequently prescribed.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a> Furthermore, they improve the early detection of asymptomatic cases, preventing progression of the lesions and epidemic transmission.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The study carried out by Morgado-Carrasco et al.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a> is worth noting as it offers very useful data for the prescription of empirical antibiotic treatment when there is a suspicion of anal or perianal infection. This is done according to symptoms, ensuring the simplification of international guideline recommendations, whose objective seems to be more aimed at covering all pathogens.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> The authors recommend giving empirical coverage against anal LGV when clinical suspicion is high (anal ulcer and associated proctitis), even when the <span class="elsevierStyleItalic">Chlamydia trachomatis</span> serotype L1-3 diagnostic technique is not available. Meanwhile, the presence of an anal ulcer without associated proctitis would indicate a possible lues, a disease responsible for up to 20% of the diagnoses.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Finally, focusing on sexual habits and epidemiological aspects is essential, as also pointed out by Morgado-Carrasco et al. Certain sexual practices, including so-called chemsex<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a> (the combination of drugs and sex in order to facilitate or lengthen the latter), have been associated with the MSM group, unprotected sexual relationships and having multiple partners. In addition, several studies describe its establishment mainly in large cities and European capitals (as this study does), and that participants are educated subjects with relevant purchasing power.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a> There is also a high percentage of foreign patients who are well trained and have a high social-economic level, resulting in them being easily able to change residence while continuing their personal and professional development without dispensing with certain sexual practices or habits. The different meeting events arranged by these groups, also pointed out by the authors, entail a great mobilisation of people, especially within the European framework, exponentially increasing the possibilities of STI-AR transmission.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a> We should remember this when new outbreaks are reported in our context,<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a> assuming that the chances of them reaching large cities are high, whether in the form of outbreaks or multiresistant variants of some specific germs.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">STI-AR is a frequent entity in MSM, mainly in subjects with HIV infection. The sexual habits and the mobilisation of this group by these events facilitate their dispersion throughout the main European cities. Studies such as those carried out by Morgado-Carrasco et al. can help to focus more precisely on the empirical treatment of these infections, while also assist in discovering other unknown diseases, or those that are underestimated by many doctors, but very present among those patients they often attend to.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Cabello A, Górgolas M. Infecciones de transmisión sexual anorrectales. Una epidemia infradiagnosticada. 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