{"id":6393,"date":"2009-02-13T08:45:46","date_gmt":"2009-02-13T12:45:46","guid":{"rendered":"http:\/\/piel-l.org\/blog\/?p=6393"},"modified":"2009-02-15T11:12:22","modified_gmt":"2009-02-15T15:12:22","slug":"consulta-a-un-colega-n-4-sindrome-de-superposicion-steven-johnson-necrolisis-epidermica-toxicalyell-por-medicamento-dipirona","status":"publish","type":"post","link":"https:\/\/piel-l.org\/blog\/6393","title":{"rendered":"Consulta a un Colega N\u00ba 4 (S\u00edndrome de Superposici\u00f3n: Steven Johnson-Necrolisis Epid\u00e9rmica T\u00f3xica\/Lyell por medicamento, Dipirona)"},"content":{"rendered":"<p><strong><em>Presentado por  Lolimar    Velasquez (medico internista e intensivista), Carmen Bastidas Montilla (m\u00e9dico dermat\u00f3logo), Rolando Hern\u00e1ndez P\u00e9rez (m\u00e9dico dermat\u00f3logo), Marisela Acosta Casanova (m\u00e9dico Anatomopat\u00f3logo)<br \/>\n Yajana Reyes  H **, Ada Anguinetti   **, Gustavo Perez.  **<br \/>\n ** Estudiantes del 6\u00ba  a\u00f1o de medicina, Facultad de Medicina Universidad de los Andes (Emergencia de  Adultos)<br \/>\n Hospital General  \u201cDr. Luis Razetti\u201d Barinas\/Venezuela<\/em><\/strong><\/p>\n<p><strong><span style=\"text-decoration: underline;\">Motivo de Consulta:<\/span><\/strong> Dolor de garganta y lesiones en  piel<\/p>\n<p><!--more--><br \/>\n <strong><span style=\"text-decoration: underline;\">Enfermedad actual: <\/span><\/strong> Paciente femenina, de 19 a\u00f1os  natural y procedente de  \u201cLa  Mula\u201d\/ Edo. Barinas,  quien inicia  enfermedad actual una  semana antes de su ingreso (<strong>viernes 16\/01\/2009<\/strong>),   caracterizada por fiebre continua no cuantificada, odinofagia y malestar  general,  motivo por el cual se automedic\u00f3 con  \u201cAdolen\u201d  (Acetaminofen 250 mgr, \u00e1cido acetilsalic\u00edlico  250 mgr y cafe\u00edna 65 mgr),  el  cuadro no respondi\u00f3,  por lo que acude a un centro asistencial local (CDI),  en  donde le  administraron Dipirona intravenosa,  posterior (dos d\u00edas despu\u00e9s) a  la administraci\u00f3n de dicho f\u00e1rmaco, present\u00f3, lesiones tipo m\u00e1culas rojas  oscuras y placas eritematosas, muy pruriginosas, que progresaron r\u00e1pidamente  a  la formaci\u00f3n de ves\u00edculas y ampollas centrales, con ruptura de las mismas y aparici\u00f3n  de peque\u00f1as zonas o \u00e1reas  de piel desprendidas o decoladas, sim\u00e9tricas, en  miembros superiores, tronco y cara, principalmente; <em>(<strong>FAVOR VER FOTO CL\u00cdNICA N\u00ba DSC02314.jpg-DSC02315.jpg<\/strong>)<\/em> signo  de Nikolsky positivo (desprendimiento de  la epidermis cuando se hace presi\u00f3n  digital y deslizamiento); hay claro compromiso de cavidad bucal, conjuntivas,  mucosa genital y anal, con marcado dolor y formaci\u00f3n de costras hemorr\u00e1gicas  que impiden abrir la boca y los ojos , as\u00ed como deglutir y manifestaciones sist\u00e9micas.<\/p>\n<figure id=\"attachment_6396\" aria-describedby=\"caption-attachment-6396\" style=\"width: 225px\" class=\"wp-caption alignnone\"><a href=\"http:\/\/piel-l.org\/blog\/wp-content\/uploads\/\/2009\/02\/dsc023141.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-medium wp-image-6396\" title=\"dsc02314.jpg\" src=\"http:\/\/piel-l.org\/blog\/wp-content\/uploads\/\/2009\/02\/dsc023141-225x300.jpg\" alt=\"dsc02314.jpg\" width=\"225\" height=\"300\" srcset=\"https:\/\/piel-l.org\/blog\/wp-content\/uploads\/2009\/02\/dsc023141-225x300.jpg 225w, https:\/\/piel-l.org\/blog\/wp-content\/uploads\/2009\/02\/dsc023141.jpg 576w\" sizes=\"auto, (max-width: 225px) 100vw, 225px\" \/><\/a><figcaption id=\"caption-attachment-6396\" class=\"wp-caption-text\">dsc02314.jpg<\/figcaption><\/figure>\n<figure id=\"attachment_6395\" aria-describedby=\"caption-attachment-6395\" style=\"width: 300px\" class=\"wp-caption alignnone\"><a href=\"http:\/\/piel-l.org\/blog\/wp-content\/uploads\/\/2009\/02\/dsc02315.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-medium wp-image-6395\" title=\"dsc02315\" src=\"http:\/\/piel-l.org\/blog\/wp-content\/uploads\/\/2009\/02\/dsc02315-300x225.jpg\" alt=\"dsc02315.jpg\" width=\"300\" height=\"225\" srcset=\"https:\/\/piel-l.org\/blog\/wp-content\/uploads\/2009\/02\/dsc02315-300x225.jpg 300w, https:\/\/piel-l.org\/blog\/wp-content\/uploads\/2009\/02\/dsc02315.jpg 1024w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a><figcaption id=\"caption-attachment-6395\" class=\"wp-caption-text\">dsc02315.jpg<\/figcaption><\/figure>\n<p>AP: Epigastralgia. Alergia novo   Dipirona. Asma.<\/p>\n<p>HP: No refiere<\/p>\n<p>AF: no refiere<\/p>\n<p>Examen f\u00edsico de ingreso: TArt.  110\/70 mmHg   FC: 90  Temp. 36.5 \u00baC<\/p>\n<p>Muestra de ampolla: numerosas  esporas<\/p>\n<p>RX de t\u00f3rax dentro de la  normalidad.<\/p>\n<p><br class=\"spacer_\" \/><\/p>\n<p><strong><span style=\"text-decoration: underline;\">Impresi\u00f3n Diagnostica<\/span><\/strong>:<\/p>\n<p>1 Reacci\u00f3n de hipersensibilidad Medicamentosa (Farmacodermia)<\/p>\n<p>2 S\u00edndrome d de Steven Johnson VS. Necrolisis Epid\u00e9rmica T\u00f3xica<\/p>\n<p>3 Shock t\u00f3xico por Estafilococo.<\/p>\n<p><br class=\"spacer_\" \/><\/p>\n<p><strong><span style=\"text-decoration: underline;\">Laboratorio<\/span><\/strong><\/p>\n<p>Leu::4.6              SEG:  88.6%          AST :66<\/p>\n<p>Hgb: 10.8 gr\/dl    MON:  3.4 %         ALT:  82<\/p>\n<p>Hcto: 30.5 %      GRAN  8 %            BUN 20<\/p>\n<p>Plt: 166 mil          GLU=  110mg\/dl    Creat:  1.1<\/p>\n<p>Se toma muestra para estudio  histopatol\u00f3gico: Favor ver foto histopatol\u00f3gica  <em><strong>DSCN4337.jpg,DSCN4332,jpg-DSCN4334.jpg-DSCN4335.jpg-DSCN4336.jpg)<\/strong><\/em>:  Necrosis total y extensa del epitelio, con queratinocitos apopt\u00f3sicos, clivaje  subepidermico, infiltrado inflamatorio mixto moderado.<\/p>\n<p><br class=\"spacer_\" \/><\/p>\n<figure id=\"attachment_6397\" aria-describedby=\"caption-attachment-6397\" style=\"width: 300px\" class=\"wp-caption alignnone\"><a href=\"http:\/\/piel-l.org\/blog\/wp-content\/uploads\/\/2009\/02\/dscn4337.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-medium wp-image-6397\" title=\"dscn4337\" src=\"http:\/\/piel-l.org\/blog\/wp-content\/uploads\/\/2009\/02\/dscn4337-300x225.jpg\" alt=\"dscn4337.jpg\" width=\"300\" height=\"225\" srcset=\"https:\/\/piel-l.org\/blog\/wp-content\/uploads\/2009\/02\/dscn4337-300x225.jpg 300w, https:\/\/piel-l.org\/blog\/wp-content\/uploads\/2009\/02\/dscn4337.jpg 1024w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a><figcaption id=\"caption-attachment-6397\" class=\"wp-caption-text\">dscn4337.jpg<\/figcaption><\/figure>\n<figure id=\"attachment_6400\" aria-describedby=\"caption-attachment-6400\" style=\"width: 300px\" class=\"wp-caption alignnone\"><a href=\"http:\/\/piel-l.org\/blog\/wp-content\/uploads\/\/2009\/02\/dscn4334.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-medium wp-image-6400\" title=\"dscn4334\" src=\"http:\/\/piel-l.org\/blog\/wp-content\/uploads\/\/2009\/02\/dscn4334-300x225.jpg\" alt=\"dscn4334.jpg\" width=\"300\" height=\"225\" srcset=\"https:\/\/piel-l.org\/blog\/wp-content\/uploads\/2009\/02\/dscn4334-300x225.jpg 300w, https:\/\/piel-l.org\/blog\/wp-content\/uploads\/2009\/02\/dscn4334.jpg 1024w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a><figcaption id=\"caption-attachment-6400\" class=\"wp-caption-text\">dscn4334.jpg<\/figcaption><\/figure>\n<figure id=\"attachment_6399\" aria-describedby=\"caption-attachment-6399\" style=\"width: 300px\" class=\"wp-caption alignnone\"><a href=\"http:\/\/piel-l.org\/blog\/wp-content\/uploads\/\/2009\/02\/dscn4332.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-medium wp-image-6399\" title=\"dscn4332\" src=\"http:\/\/piel-l.org\/blog\/wp-content\/uploads\/\/2009\/02\/dscn4332-300x225.jpg\" alt=\"dscn4332.jpg\" width=\"300\" height=\"225\" srcset=\"https:\/\/piel-l.org\/blog\/wp-content\/uploads\/2009\/02\/dscn4332-300x225.jpg 300w, https:\/\/piel-l.org\/blog\/wp-content\/uploads\/2009\/02\/dscn4332.jpg 1024w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a><figcaption id=\"caption-attachment-6399\" class=\"wp-caption-text\">dscn4332.jpg<\/figcaption><\/figure>\n<figure id=\"attachment_6401\" aria-describedby=\"caption-attachment-6401\" style=\"width: 300px\" class=\"wp-caption alignnone\"><a href=\"http:\/\/piel-l.org\/blog\/wp-content\/uploads\/\/2009\/02\/dscn4335.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-medium wp-image-6401\" title=\"dscn4335\" src=\"http:\/\/piel-l.org\/blog\/wp-content\/uploads\/\/2009\/02\/dscn4335-300x225.jpg\" alt=\"dscn4335.jpg\" width=\"300\" height=\"225\" srcset=\"https:\/\/piel-l.org\/blog\/wp-content\/uploads\/2009\/02\/dscn4335-300x225.jpg 300w, https:\/\/piel-l.org\/blog\/wp-content\/uploads\/2009\/02\/dscn4335.jpg 1024w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a><figcaption id=\"caption-attachment-6401\" class=\"wp-caption-text\">dscn4335.jpg<\/figcaption><\/figure>\n<figure id=\"attachment_6402\" aria-describedby=\"caption-attachment-6402\" style=\"width: 300px\" class=\"wp-caption alignnone\"><a href=\"http:\/\/piel-l.org\/blog\/wp-content\/uploads\/\/2009\/02\/dscn4336.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-medium wp-image-6402\" title=\"dscn4336\" src=\"http:\/\/piel-l.org\/blog\/wp-content\/uploads\/\/2009\/02\/dscn4336-300x225.jpg\" alt=\"dscn4336.jpg\" width=\"300\" height=\"225\" srcset=\"https:\/\/piel-l.org\/blog\/wp-content\/uploads\/2009\/02\/dscn4336-300x225.jpg 300w, https:\/\/piel-l.org\/blog\/wp-content\/uploads\/2009\/02\/dscn4336.jpg 1024w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a><figcaption id=\"caption-attachment-6402\" class=\"wp-caption-text\">dscn4336.jpg<\/figcaption><\/figure>\n<p><br class=\"spacer_\" \/><\/p>\n<p><strong><span style=\"text-decoration: underline;\">Tratamiento: (Deperatamento  de Emergencia)<\/span><\/strong><\/p>\n<ul type=\"disc\">\n<li>Hidrataci\u00f3n       Parenteral:250cc de Sol 0.9% alternada con Sol 0.45%  para 24H a raz\u00f3n de       28 gt`min<\/li>\n<li>KCL 15       mEq en frascos 1 y 3<\/li>\n<li><span lang=\"PT-BR\" xml:lang=\"PT-BR\">Vancomicina 1gr EV c\/12H<\/span><\/li>\n<li><span lang=\"PT-BR\" xml:lang=\"PT-BR\">Dexametasona 8gr EV c\/8H<\/span><\/li>\n<li>Clorotrimetron       1 ampolla EV c\/12H<\/li>\n<li>Acetaminofen        500mg VO OD SOS fiebre<\/li>\n<li><span lang=\"PT-BR\" xml:lang=\"PT-BR\">Garasone soluci\u00f3n oft\u00e1lmica<\/span><\/li>\n<li><span lang=\"PT-BR\" xml:lang=\"PT-BR\">Fluconazol 400mg EV c\/12H<\/span><\/li>\n<li>Gammaglobulina       2.5gr EV en infusi\u00f3n en 12 horas por 5 d\u00edas<\/li>\n<li>Ba\u00f1os       con manzanilla y colocaci\u00f3n de compresas en parpados<\/li>\n<\/ul>\n<p><br class=\"spacer_\" \/><\/p>\n<p><strong><span style=\"text-decoration: underline;\">Evoluci\u00f3n<\/span><\/strong>:<\/p>\n<p>Paciente quien es valorada por el <strong>Servicio de Dermatolog\u00eda<\/strong>, plantea el diagnostico de ERITEMA POLIMORFO  MEDICAMENTOSO MAYOR  VS. STEVEN JOHNSON VS. NECROLISIS EPIDERMICA T\u00d3XICA  (S\u00edndrome de Lyell) medicamentoso y se recomienda omitir antibi\u00f3ticos ,  analg\u00e9sicos y esteroides sist\u00e9micos y se plantea  el uso de Ganmaglobulina  humana intravenosa (400 mg\/Kg\/peso\/d\u00eda\/6 d\u00edas) . Se sugiere subir a Terapia  Intensiva e interconsulta con Oftalmolog\u00eda, ORL, Medicina Interna, Nutrici\u00f3n y  extremar los cuidados de enfermer\u00eda. Localmente soluciones d\u00e9biles jabonosa  para la limpieza de la piel, antibi\u00f3tico t\u00f3pico oft\u00e1lmico, soluci\u00f3n fisiol\u00f3gica  para la limpieza de las cavidades.<\/p>\n<p>La paciente permaneci\u00f3 en  Emergencia de adulto en ambiente aislada.-<\/p>\n<p>Paciente evoluciona  satisfactoriamente evidenci\u00e1ndose   27 d\u00edas (<strong>Favor ver foto cl\u00ednica  convalecencia: ( DSC02322.jpg-DSC02324.jpg- DSC00390.jpg-DSC00389.jpg) <\/strong><\/p>\n<figure id=\"attachment_6404\" aria-describedby=\"caption-attachment-6404\" style=\"width: 225px\" class=\"wp-caption alignnone\"><a href=\"http:\/\/piel-l.org\/blog\/wp-content\/uploads\/\/2009\/02\/dsc02322.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-medium wp-image-6404\" title=\"dsc02322\" src=\"http:\/\/piel-l.org\/blog\/wp-content\/uploads\/\/2009\/02\/dsc02322-225x300.jpg\" alt=\"dsc02322\" width=\"225\" height=\"300\" srcset=\"https:\/\/piel-l.org\/blog\/wp-content\/uploads\/2009\/02\/dsc02322-225x300.jpg 225w, https:\/\/piel-l.org\/blog\/wp-content\/uploads\/2009\/02\/dsc02322.jpg 576w\" sizes=\"auto, (max-width: 225px) 100vw, 225px\" \/><\/a><figcaption id=\"caption-attachment-6404\" class=\"wp-caption-text\">dsc02322.jpg<\/figcaption><\/figure>\n<figure id=\"attachment_6403\" aria-describedby=\"caption-attachment-6403\" style=\"width: 225px\" class=\"wp-caption alignnone\"><a href=\"http:\/\/piel-l.org\/blog\/wp-content\/uploads\/\/2009\/02\/dsc02324.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-medium wp-image-6403\" title=\"dsc02324\" src=\"http:\/\/piel-l.org\/blog\/wp-content\/uploads\/\/2009\/02\/dsc02324-225x300.jpg\" alt=\"dsc02324.jpg\" width=\"225\" height=\"300\" srcset=\"https:\/\/piel-l.org\/blog\/wp-content\/uploads\/2009\/02\/dsc02324-225x300.jpg 225w, https:\/\/piel-l.org\/blog\/wp-content\/uploads\/2009\/02\/dsc02324.jpg 576w\" sizes=\"auto, (max-width: 225px) 100vw, 225px\" \/><\/a><figcaption id=\"caption-attachment-6403\" class=\"wp-caption-text\">dsc02324.jpg<\/figcaption><\/figure>\n<figure id=\"attachment_6406\" aria-describedby=\"caption-attachment-6406\" style=\"width: 225px\" class=\"wp-caption alignnone\"><a href=\"http:\/\/piel-l.org\/blog\/wp-content\/uploads\/\/2009\/02\/dsc00390.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-medium wp-image-6406\" title=\"dsc00390\" src=\"http:\/\/piel-l.org\/blog\/wp-content\/uploads\/\/2009\/02\/dsc00390-225x300.jpg\" alt=\"dsc00390.jpg\" width=\"225\" height=\"300\" srcset=\"https:\/\/piel-l.org\/blog\/wp-content\/uploads\/2009\/02\/dsc00390-225x300.jpg 225w, https:\/\/piel-l.org\/blog\/wp-content\/uploads\/2009\/02\/dsc00390.jpg 576w\" sizes=\"auto, (max-width: 225px) 100vw, 225px\" \/><\/a><figcaption id=\"caption-attachment-6406\" class=\"wp-caption-text\">dsc00390.jpg<\/figcaption><\/figure>\n<figure id=\"attachment_6405\" aria-describedby=\"caption-attachment-6405\" style=\"width: 225px\" class=\"wp-caption alignnone\"><a href=\"http:\/\/piel-l.org\/blog\/wp-content\/uploads\/\/2009\/02\/dsc00389.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-medium wp-image-6405\" title=\"dsc00389\" src=\"http:\/\/piel-l.org\/blog\/wp-content\/uploads\/\/2009\/02\/dsc00389-225x300.jpg\" alt=\"dsc00389.jpg\" width=\"225\" height=\"300\" srcset=\"https:\/\/piel-l.org\/blog\/wp-content\/uploads\/2009\/02\/dsc00389-225x300.jpg 225w, https:\/\/piel-l.org\/blog\/wp-content\/uploads\/2009\/02\/dsc00389.jpg 576w\" sizes=\"auto, (max-width: 225px) 100vw, 225px\" \/><\/a><figcaption id=\"caption-attachment-6405\" class=\"wp-caption-text\">dsc00389.jpg<\/figcaption><\/figure>\n<p><strong>Dos \u00faltimas  fotos tomada el 12\/2\/02\/2009) :<\/strong><\/p>\n<p><strong><a href=\"http:\/\/piel-l.org\/blog\/wp-content\/uploads\/\/2009\/02\/imagen-142.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-medium wp-image-6407\" title=\"imagen-142\" src=\"http:\/\/piel-l.org\/blog\/wp-content\/uploads\/\/2009\/02\/imagen-142-225x300.jpg\" alt=\"imagen-142\" width=\"225\" height=\"300\" srcset=\"https:\/\/piel-l.org\/blog\/wp-content\/uploads\/2009\/02\/imagen-142-225x300.jpg 225w, https:\/\/piel-l.org\/blog\/wp-content\/uploads\/2009\/02\/imagen-142.jpg 576w\" sizes=\"auto, (max-width: 225px) 100vw, 225px\" \/><\/a><br \/>\n <\/strong><\/p>\n<p><strong> <a href=\"http:\/\/piel-l.org\/blog\/wp-content\/uploads\/\/2009\/02\/imagen-139.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-medium wp-image-6408\" title=\"imagen-139\" src=\"http:\/\/piel-l.org\/blog\/wp-content\/uploads\/\/2009\/02\/imagen-139-278x300.jpg\" alt=\"imagen-139\" width=\"278\" height=\"300\" srcset=\"https:\/\/piel-l.org\/blog\/wp-content\/uploads\/2009\/02\/imagen-139-278x300.jpg 278w, https:\/\/piel-l.org\/blog\/wp-content\/uploads\/2009\/02\/imagen-139.jpg 576w\" sizes=\"auto, (max-width: 278px) 100vw, 278px\" \/><\/a><\/strong><\/p>\n<p><strong>Comentarios<\/strong>: Pensamos en un <strong>S\u00edndrome de  Superposici\u00f3n<\/strong> (Sind. Steven Johonson &ndash; Necrolisis Epid\u00e9rmica  T\u00f3xica) por presentar una cuadro cl\u00ednico de S\u00edndrome de Steven Johnson  (lesiones con aspecto en diana at\u00edpicas color rojo oscuras, confluente en cara  y tronco superior, otras lesiones difusas en miembros superiores e inferiores,  con compromiso del 40% de la superficie corporal, afectaci\u00f3n intensa y severa  de mucosas, principalmente de la boca y ojos. Desprendimiento de peque\u00f1as zonas  de piel . Histopatol\u00f3gicamente: una dermatitis de interfase intensa, &nbsp;con  necrol\u00edsis, numerosos queratinocitos apopt\u00f3sicos, \u00e9ste aspecto histopatol\u00f3gico  habla a favor &nbsp;de necro\u00edsis epid\u00e9rmica t\u00f3xica.(NET O Sindrome de Lyell). &nbsp;Manifestaciones  sist\u00e9micas de moderadas a severa: deshidrataci\u00f3n, fiebre, dificultad para  tragar, lesiones exudativas y erosionadas en boca, genitales y ano;  conjuntivitis purulenta, fotofobia y pegamiento de las pesta\u00f1as. Estomatitis,  costras hemorr\u00e1gicas en labios y mucosa bucal. Por otra parte la evoluci\u00f3n  satisfactoria relativamente r\u00e1pida de 27 d\u00edas (ver secuencia fotogr\u00e1fica;  \u00faltima foto tomada el jueves 12\/02\/2009) son caracter\u00edsticas de S\u00edndrome de  Steven Johnson; de esta forma concluimos que por haber caracter\u00edsticas cl\u00ednicas,  histopatol\u00f3gicas, laboratoriales y evolutivas de ambas entidades, concluimos en  un S\u00edndrome de Superposici\u00f3n.<\/p>\n<p><strong>Pensamos que el medicamento  desencadenante fue la Dipirona.<\/strong><\/p>\n<p><strong>\u00bfCu\u00e1l es su comentario?<\/strong><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Presentado por Lolimar Velasquez (medico internista e intensivista), Carmen Bastidas Montilla (m\u00e9dico dermat\u00f3logo), Rolando Hern\u00e1ndez P\u00e9rez (m\u00e9dico dermat\u00f3logo), Marisela Acosta Casanova (m\u00e9dico Anatomopat\u00f3logo) Yajana Reyes H **, Ada Anguinetti **, Gustavo Perez. ** ** Estudiantes del 6\u00ba a\u00f1o de medicina, Facultad de Medicina Universidad de los Andes (Emergencia de Adultos) Hospital General \u201cDr. Luis Razetti\u201d &hellip;<\/p>\n","protected":false},"author":16,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[25],"tags":[282,281],"class_list":["post-6393","post","type-post","status-publish","format-standard","","category-consulte-a-un-colega","tag-necrolisis","tag-steven-johnson"],"_links":{"self":[{"href":"https:\/\/piel-l.org\/blog\/wp-json\/wp\/v2\/posts\/6393","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/piel-l.org\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/piel-l.org\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/piel-l.org\/blog\/wp-json\/wp\/v2\/users\/16"}],"replies":[{"embeddable":true,"href":"https:\/\/piel-l.org\/blog\/wp-json\/wp\/v2\/comments?post=6393"}],"version-history":[{"count":0,"href":"https:\/\/piel-l.org\/blog\/wp-json\/wp\/v2\/posts\/6393\/revisions"}],"wp:attachment":[{"href":"https:\/\/piel-l.org\/blog\/wp-json\/wp\/v2\/media?parent=6393"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/piel-l.org\/blog\/wp-json\/wp\/v2\/categories?post=6393"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/piel-l.org\/blog\/wp-json\/wp\/v2\/tags?post=6393"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}