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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">El antimoniato de meglumina &#40;AM&#41;&#40;Glucantime&#174;&#44; Sanofi-Aventis&#44; S&#46;A&#46;&#44; Espa&#241;a&#41; es el tratamiento de primera elecci&#243;n en la leishmaniasis cut&#225;nea &#40;LC&#41;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#8211;4</span></a>&#46; Se utiliza tanto por v&#237;a intramuscular &#40;i&#46;m&#46;&#41; como intralesional &#40;i&#46;l&#46;&#41; y se considera un medicamento eficaz y seguro&#46; La v&#237;a i&#46;l&#46; se utiliza en lesiones &#250;nicas menores de 3-4 cm y la v&#237;a i&#46;m&#46; se reserva para las lesiones m&#250;ltiples&#44; complicadas o con datos de diseminaci&#243;n linf&#225;tica<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;3&#44;4</span></a>&#46; La dosis recomendada para la v&#237;a i&#46;m&#46; es 10-20 mg&#47;kg&#47;d de antimonio &#40;75 mg&#47;kg&#47;d de AM&#41; en ciclos de 10 d&#237;as<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;5&#8211;7</span></a>&#46; Por v&#237;a i&#46;l&#46; se utilizan dosis mucho m&#225;s bajas de entre 0&#44;2 y 1 mL&#47;lesi&#243;n en pautas variables&#44; cada 0&#44;5-1-2 semanas<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;3&#44;8</span></a>&#46; Es bien conocido que su uso por v&#237;a sist&#233;mica puede producir alteraciones electrocardiogr&#225;ficas<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Una mujer de 82 a&#241;os consult&#243; por una placa eritemato-edematosa e infiltrada de 3&#44;5 cm&#44; sin ulceraci&#243;n ni costra&#44; localizada en la frente&#44; persistente y de meses de evoluci&#243;n &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; Como antecedentes&#44; la paciente padec&#237;a una artritis reumatoide&#44; en tratamiento con etanercept y prednisona&#44; osteoporosis&#44; escoliosis&#44; anemia leve&#44; dermatitis seborreica&#44; que trataba con corticoides t&#243;picos&#44; y una delgadez severa &#40;IMC 15 kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#46; Una biopsia cut&#225;nea de la lesi&#243;n objetiv&#243; una dermatitis granulomatosa con la presencia de amastigotes&#44; por lo que se diagnostic&#243; de leishmaniasis&#46; La paciente no hab&#237;a viajado fuera de Espa&#241;a&#46; Se decidi&#243; tratar con itraconazol oral durante seis semanas&#44; con una buena tolerancia cl&#237;nica y anal&#237;tica&#44; pero sin mejor&#237;a&#46; Una semana despu&#233;s se administr&#243; AM intralesional&#44; con una dosis de 0&#44;6-1 mL en los d&#237;as 0&#44; 7 y 21&#44; previa administraci&#243;n de lidoca&#237;na&#47;piloca&#237;na&#46; Desde el momento del diagn&#243;stico se retiraron los corticoides t&#243;picos y etanercept&#46; En un electrocardiograma &#40;ECG&#41; realizado tras la tercera dosis se detect&#243; una prolongaci&#243;n del intervalo QT &#40;QTc 510 ms&#41;&#44; un descenso no significativo del segmento ST y un crecimiento de la onda P &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#44; por lo que se suspendi&#243; el tratamiento&#46; La paciente no refer&#237;a s&#237;ncopes&#46; Un control del ECG&#44; realizado por cardiolog&#237;a tres semanas despu&#233;s&#44; estaba en el rango de la normalidad&#46; El cuadro cut&#225;neo se resolvi&#243; con las tres dosis ya administradas&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Se han descrito m&#250;ltiples efectos adversos del AM usado de forma sist&#233;mica&#58; mialgias&#44; artralgias&#44; alteraciones gastrointestinales &#40;n&#225;useas&#44; dolor abdominal&#41;&#44; cefalea&#44; elevaci&#243;n de enzimas hep&#225;ticas y pancre&#225;ticas&#44; leucopenia&#44; alteraciones del ECG y arritmias graves<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;5</span></a>&#46; El uso intralesional de AM&#44; al utilizar dosis m&#225;s bajas y espaciadas&#44; produce unos efectos secundarios leves y generalmente locales &#40;dolor&#44; edema&#44; prurito y eritema transitorio en la zona de inyecci&#243;n&#41;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;4&#44;5&#44;7&#8211;10</span></a>&#46; Se han descrito por esta v&#237;a tambi&#233;n efectos adversos sist&#233;micos como n&#225;useas&#44; v&#243;mitos&#44; disnea&#44; mareo&#44; urticaria&#44; mialgias&#44; artralgias&#44; cefalea e incluso <span class="elsevierStyleItalic">shock</span> anafil&#225;ctico<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a>&#46; Con respecto a la cardiotoxicidad por antimoniales sist&#233;micos&#44; se trata de un efecto adverso bien conocido que en la ficha t&#233;cnica se indica que puede aparecer cuando se utilizan a dosis altas y durante periodos prolongados&#46; Puede producir una prolongaci&#243;n del intervalo QT en el ECG&#44; con el desarrollo potencial de una arritmia grave&#44; que puede tener un desenlace mortal&#46; Los cambios en el ECG generalmente son dosis-dependiente y habitualmente reversibles&#46; En la mayor&#237;a de los casos&#44; las alteraciones como la inversi&#243;n de la onda T y la prolongaci&#243;n del intervalo QT preceden a la aparici&#243;n de arritmias graves y alertan de su posible aparici&#243;n&#46; Se recomienda la realizaci&#243;n de un ECG basal y de seguimiento cada 7-10 d&#237;as y suspender el tratamiento si el intervalo QTc &#62; 450 ms<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;6&#44;9</span></a>&#46; Ribeiro et al&#46; demostraron la presencia de cambios en el ECG &#40;prolongaci&#243;n del QT&#41; tambi&#233;n con la terapia sist&#233;mica i&#46;m&#46; a dosis bajas &#40;10 mg&#47;kg&#41; y en tratamientos cortos &#40;10 d&#237;as&#41; con implicaciones potenciales graves&#44; por lo que sugieren monitorizar a estos pacientes mediante un ECG<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a>&#46; Con respecto a la terapia intralesional&#44; un estudio cl&#237;nico brasile&#241;o reciente de 53 pacientes&#44; a los que se realiz&#243; ECG semanalmente&#44; encontr&#243; una prolongaci&#243;n del intervalo QT sin repercusi&#243;n cl&#237;nica en el 25&#37; de los casos<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a>&#46; Este efecto se encontr&#243; asociado al tabaquismo<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a>&#46; Sin embargo&#44; se trata de un efecto adverso poco documentado al no realizarse habitualmente ECG en el seguimiento cl&#237;nico de la terapia intralesional&#46; En este ensayo se utilizaban dosis semanales muy superiores a las utilizadas en nuestro caso&#46; El hecho de haber detectado esta alteraci&#243;n en una paciente sin criterios de riesgo cardiol&#243;gico en tratamiento con AM intralesional a dosis bajas nos hace reflexionar sobre la conveniencia de monitorizar el ECG tambi&#233;n en estos pacientes&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">En conclusi&#243;n&#44; antes de iniciar la terapia con antimoniales en cualquier modalidad&#44; se debe preguntar por antecedentes personales de enfermedad cardiaca &#40;infarto&#44; bradicardia&#44; palpitaciones o s&#237;ncopes&#46;&#46;&#46;&#41; y de muerte s&#250;bita en familiares&#46; Se deben vigilar y corregir factores que puedan favorecen la prolongaci&#243;n del QT&#44; tales como desequilibrios electrol&#237;ticos&#44; y evitar su asociaci&#243;n con otros f&#225;rmacos que tambi&#233;n puedan prolongar el QT &#40;<a href="http://www.qtdrugs.org/">www&#46;qtdrugs&#46;org</a>&#41; &#40;antiarr&#237;tmicos&#44; antidepresivos tric&#237;clicos&#44; eritromicina&#44; tetracicilinas&#44; trimetropina&#47;sulfametoxazol&#44; antipsic&#243;ticos&#46;&#46;&#46;&#41;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a>&#46; Parece recomendable monitorizar a los pacientes de alto riesgo y vigilar la aparici&#243;n de prolongaci&#243;n del intervalo QT&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicto de intereses</span><p id="par0025" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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CARTA CIENTÍFICO-CLÍNICA
Alteraciones electrocardiográficas por Glucantime® intralesional, un evento adverso potencialmente grave
Electrocardiographic Alterations Related to Intralesional Glucantime® Treatments: A Potentially Severe Adverse Event
B. García Bracamonte
Corresponding author
beagarcia50@hotmail.com

Autor para correspondencia.
, S. Burillo Martínez, C. Morales Raya, P. Ortiz Romero
Hospital Universitario 12 de Octubre, Madrid, Madrid
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">El antimoniato de meglumina &#40;AM&#41;&#40;Glucantime&#174;&#44; Sanofi-Aventis&#44; S&#46;A&#46;&#44; Espa&#241;a&#41; es el tratamiento de primera elecci&#243;n en la leishmaniasis cut&#225;nea &#40;LC&#41;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#8211;4</span></a>&#46; Se utiliza tanto por v&#237;a intramuscular &#40;i&#46;m&#46;&#41; como intralesional &#40;i&#46;l&#46;&#41; y se considera un medicamento eficaz y seguro&#46; La v&#237;a i&#46;l&#46; se utiliza en lesiones &#250;nicas menores de 3-4 cm y la v&#237;a i&#46;m&#46; se reserva para las lesiones m&#250;ltiples&#44; complicadas o con datos de diseminaci&#243;n linf&#225;tica<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;3&#44;4</span></a>&#46; La dosis recomendada para la v&#237;a i&#46;m&#46; es 10-20 mg&#47;kg&#47;d de antimonio &#40;75 mg&#47;kg&#47;d de AM&#41; en ciclos de 10 d&#237;as<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;5&#8211;7</span></a>&#46; Por v&#237;a i&#46;l&#46; se utilizan dosis mucho m&#225;s bajas de entre 0&#44;2 y 1 mL&#47;lesi&#243;n en pautas variables&#44; cada 0&#44;5-1-2 semanas<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;3&#44;8</span></a>&#46; Es bien conocido que su uso por v&#237;a sist&#233;mica puede producir alteraciones electrocardiogr&#225;ficas<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Una mujer de 82 a&#241;os consult&#243; por una placa eritemato-edematosa e infiltrada de 3&#44;5 cm&#44; sin ulceraci&#243;n ni costra&#44; localizada en la frente&#44; persistente y de meses de evoluci&#243;n &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; Como antecedentes&#44; la paciente padec&#237;a una artritis reumatoide&#44; en tratamiento con etanercept y prednisona&#44; osteoporosis&#44; escoliosis&#44; anemia leve&#44; dermatitis seborreica&#44; que trataba con corticoides t&#243;picos&#44; y una delgadez severa &#40;IMC 15 kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#46; Una biopsia cut&#225;nea de la lesi&#243;n objetiv&#243; una dermatitis granulomatosa con la presencia de amastigotes&#44; por lo que se diagnostic&#243; de leishmaniasis&#46; La paciente no hab&#237;a viajado fuera de Espa&#241;a&#46; Se decidi&#243; tratar con itraconazol oral durante seis semanas&#44; con una buena tolerancia cl&#237;nica y anal&#237;tica&#44; pero sin mejor&#237;a&#46; Una semana despu&#233;s se administr&#243; AM intralesional&#44; con una dosis de 0&#44;6-1 mL en los d&#237;as 0&#44; 7 y 21&#44; previa administraci&#243;n de lidoca&#237;na&#47;piloca&#237;na&#46; Desde el momento del diagn&#243;stico se retiraron los corticoides t&#243;picos y etanercept&#46; En un electrocardiograma &#40;ECG&#41; realizado tras la tercera dosis se detect&#243; una prolongaci&#243;n del intervalo QT &#40;QTc 510 ms&#41;&#44; un descenso no significativo del segmento ST y un crecimiento de la onda P &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#44; por lo que se suspendi&#243; el tratamiento&#46; La paciente no refer&#237;a s&#237;ncopes&#46; Un control del ECG&#44; realizado por cardiolog&#237;a tres semanas despu&#233;s&#44; estaba en el rango de la normalidad&#46; El cuadro cut&#225;neo se resolvi&#243; con las tres dosis ya administradas&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Se han descrito m&#250;ltiples efectos adversos del AM usado de forma sist&#233;mica&#58; mialgias&#44; artralgias&#44; alteraciones gastrointestinales &#40;n&#225;useas&#44; dolor abdominal&#41;&#44; cefalea&#44; elevaci&#243;n de enzimas hep&#225;ticas y pancre&#225;ticas&#44; leucopenia&#44; alteraciones del ECG y arritmias graves<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;5</span></a>&#46; El uso intralesional de AM&#44; al utilizar dosis m&#225;s bajas y espaciadas&#44; produce unos efectos secundarios leves y generalmente locales &#40;dolor&#44; edema&#44; prurito y eritema transitorio en la zona de inyecci&#243;n&#41;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;4&#44;5&#44;7&#8211;10</span></a>&#46; Se han descrito por esta v&#237;a tambi&#233;n efectos adversos sist&#233;micos como n&#225;useas&#44; v&#243;mitos&#44; disnea&#44; mareo&#44; urticaria&#44; mialgias&#44; artralgias&#44; cefalea e incluso <span class="elsevierStyleItalic">shock</span> anafil&#225;ctico<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a>&#46; Con respecto a la cardiotoxicidad por antimoniales sist&#233;micos&#44; se trata de un efecto adverso bien conocido que en la ficha t&#233;cnica se indica que puede aparecer cuando se utilizan a dosis altas y durante periodos prolongados&#46; Puede producir una prolongaci&#243;n del intervalo QT en el ECG&#44; con el desarrollo potencial de una arritmia grave&#44; que puede tener un desenlace mortal&#46; Los cambios en el ECG generalmente son dosis-dependiente y habitualmente reversibles&#46; En la mayor&#237;a de los casos&#44; las alteraciones como la inversi&#243;n de la onda T y la prolongaci&#243;n del intervalo QT preceden a la aparici&#243;n de arritmias graves y alertan de su posible aparici&#243;n&#46; Se recomienda la realizaci&#243;n de un ECG basal y de seguimiento cada 7-10 d&#237;as y suspender el tratamiento si el intervalo QTc &#62; 450 ms<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;6&#44;9</span></a>&#46; Ribeiro et al&#46; demostraron la presencia de cambios en el ECG &#40;prolongaci&#243;n del QT&#41; tambi&#233;n con la terapia sist&#233;mica i&#46;m&#46; a dosis bajas &#40;10 mg&#47;kg&#41; y en tratamientos cortos &#40;10 d&#237;as&#41; con implicaciones potenciales graves&#44; por lo que sugieren monitorizar a estos pacientes mediante un ECG<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a>&#46; Con respecto a la terapia intralesional&#44; un estudio cl&#237;nico brasile&#241;o reciente de 53 pacientes&#44; a los que se realiz&#243; ECG semanalmente&#44; encontr&#243; una prolongaci&#243;n del intervalo QT sin repercusi&#243;n cl&#237;nica en el 25&#37; de los casos<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a>&#46; Este efecto se encontr&#243; asociado al tabaquismo<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a>&#46; Sin embargo&#44; se trata de un efecto adverso poco documentado al no realizarse habitualmente ECG en el seguimiento cl&#237;nico de la terapia intralesional&#46; En este ensayo se utilizaban dosis semanales muy superiores a las utilizadas en nuestro caso&#46; El hecho de haber detectado esta alteraci&#243;n en una paciente sin criterios de riesgo cardiol&#243;gico en tratamiento con AM intralesional a dosis bajas nos hace reflexionar sobre la conveniencia de monitorizar el ECG tambi&#233;n en estos pacientes&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">En conclusi&#243;n&#44; antes de iniciar la terapia con antimoniales en cualquier modalidad&#44; se debe preguntar por antecedentes personales de enfermedad cardiaca &#40;infarto&#44; bradicardia&#44; palpitaciones o s&#237;ncopes&#46;&#46;&#46;&#41; y de muerte s&#250;bita en familiares&#46; Se deben vigilar y corregir factores que puedan favorecen la prolongaci&#243;n del QT&#44; tales como desequilibrios electrol&#237;ticos&#44; y evitar su asociaci&#243;n con otros f&#225;rmacos que tambi&#233;n puedan prolongar el QT &#40;<a href="http://www.qtdrugs.org/">www&#46;qtdrugs&#46;org</a>&#41; &#40;antiarr&#237;tmicos&#44; antidepresivos tric&#237;clicos&#44; eritromicina&#44; tetracicilinas&#44; trimetropina&#47;sulfametoxazol&#44; antipsic&#243;ticos&#46;&#46;&#46;&#41;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a>&#46; Parece recomendable monitorizar a los pacientes de alto riesgo y vigilar la aparici&#243;n de prolongaci&#243;n del intervalo QT&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicto de intereses</span><p id="par0025" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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Article information
ISSN: 00017310
Original language: Spanish
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