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{\info{\author Webmaster}}
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\paperw11893\paperh16840\margl666\margr133\margt666\margb346
\pard\li3586\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3586\ri0\sl-213\slmult0 \fs
18\cf0\par\pard\li3586\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3586\ri0\sl-453\s
lmult0 \fs30\cf0\f0\charscalex100 {ANEMIA PERNICIOSA }\par\pard\li1040\ri0\sl-21
3\slmult0 \fs18\cf0\par\pard\li1040\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1040
\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1040\ri0\sl-213\slmult0 \fs18\cf0\par\p
ard\li1040\ri0\sl-253\slmult0 \fs24\cf0\f0\charscalex100 {Hablamos de anemia mac
roctica cuando en una anemia el volumen }\par\pard\li1040\ri0\sl-266\slmult0 \fs2
4\cf0\f0\charscalex100 {corpuscular medio est elevado (}\fs24\cf0\f0\charscalex10
0 {>100)}\fs24\cf0\f0\charscalex100 { y existen macrocitos en sangre }\par\pard\
li1040\ri0\sl-266\slmult0 \fs24\cf0\f0\charscalex100 {perifrica.}\fs24\cf0\f0\cha
rscalex100 { La causa ms comn de anemia macroctica es la anemia }\par\pard\li1040\r
i0\sl-266\slmult0 \fs24\cf0\f0\charscalex100 {megaloblstica,}\fs24\cf0\f0\charsca
lex100 { en la que existe una sntesis anormal de ADN por los }\par\pard\li1040\ri
0\sl-266\slmult0 \fs24\cf0\f0\charscalex100 {precursores eritroides y mieloides,
}\fs24\cf0\f0\charscalex100 { lo que da lugar a hematopoyesis ineficaz }\par\par
d\li1040\ri0\sl-266\slmult0 \fs24\cf0\f0\charscalex100 {(}\fs24\cf0\f0\charscale
x100 {anemia,}\fs24\cf0\f0\charscalex100 { leucopenia y trombopenia)}\fs24\cf0\f
0\charscalex100 { y cuyas causas ms frecuentes son el }\par\pard\li1040\ri0\sl-26
6\slmult0 \fs24\cf0\f0\charscalex100 {dficit de vitamina B12 y el de cido flico.}\f
s24\cf0\f0\charscalex100 { Las manifestaciones clnicas y }\par\pard\li1040\ri0\sl
-266\slmult0 \fs24\cf0\f0\charscalex100 {hematolgicas son similares en ambos caso
s.}\par\pard\li1040\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1040\ri0\sl-333\slmu
lt0 \fs24\cf0\f0\charscalex100 {La causa ms frecuente de anemia megaloblstica en n
uestro medio es }\par\pard\li1040\ri0\sl-266\slmult0 \fs24\cf0\f0\charscalex100
{consecuencia de un dficit de vitamina B12 debido a su vez a la disminucin }\par\p
ard\li1040\ri0\sl-266\slmult0 \fs24\cf0\f0\charscalex100 {de factor intrnseco (}\
fs24\cf0\f0\charscalex100 {FI}\fs24\cf0\f0\charscalex100 {)}\fs24\cf0\f0\charsca
lex100 { por atrofia de la mucosa gstrica o por destruccin }\par\pard\li1040\ri0\s
l-266\slmult0 \fs24\cf0\f0\charscalex100 {autoinmune de las clulas parietales.}\f
s24\cf0\f0\charscalex100 { Es la anemia perniciosa.}\par\pard\li1040\ri0\sl-213\
slmult0 \fs18\cf0\par\pard\li1040\ri0\sl-333\slmult0 \fs24\cf0\f0\charscalex100
{En adultos es una enfermedad de origen autoinmune.}\fs24\cf0\f0\charscalex100 {
En un 90% de los }\par\pard\li1040\ri0\sl-266\slmult0 \fs24\cf0\f0\charscalex10
0 {casos se asocia a la presencia de anticuerpos anti-clulas parietales }\par\par
d\li1040\ri0\sl-266\slmult0 \fs24\cf0\f0\charscalex100 {(}\fs24\cf0\f0\charscale
x100 {productoras del FI}\fs24\cf0\f0\charscalex100 {)}\fs24\cf0\f0\charscalex10
0 {.}\fs24\cf0\f0\charscalex100 { Existe atrofia gstrica,}\fs24\cf0\f0\charscalex
100 { lo que origina un descenso o }\par\pard\li1040\ri0\sl-266\slmult0 \fs24\cf
0\f0\charscalex100 {ausencia de produccin de cido y FI}\fs24\cf0\f0\charscalex100
{ y una posterior alteracin en la }\par\pard\li1040\ri0\sl-266\slmult0 \fs24\cf0\
f0\charscalex100 {absorcin de la vitamina B12.}\fs24\cf0\f0\charscalex100 { En u
n 50% de casos se asocia a anticuerpos }\par\pard\li1040\ri0\sl-266\slmult0 \fs
24\cf0\f0\charscalex100 {anti FI}\fs24\cf0\f0\charscalex100 {,}\fs24\cf0\f0\char
scalex100 { cuya presencia en otras enfermedades autoinmunes es excepcional.}\pa
r\pard\li1040\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1040\ri0\sl-333\slmult0 \f
s24\cf0\f0\charscalex100 {Existe una posible predisposicin gentica.}\fs24\cf0\f0\c
harscalex100 { Tpicamente existe una atrofia }\par\pard\li1040\ri0\sl-280\slmult0
\fs24\cf0\f0\charscalex100 {de la mucosa gstrica que respeta al antro.}\fs24\cf
0\f0\charscalex100 { Existe una anemia perniciosa }\par\pard\li1040\ri0\sl-266\s
lmult0 \fs24\cf0\f0\charscalex100 {j}\fs24\cf0\f0\charscalex100 {uvenil que apar
ece en menores de 10 aos en los que el FI}\fs24\cf0\f0\charscalex100 { no es acti
vo y }\par\pard\li1040\ri0\sl-266\slmult0 \fs24\cf0\f0\charscalex100 {no se obse

rvan anticuerpos.}\par\pard\li1040\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1040\

ri0\sl-333\slmult0 \fs24\cf0\f0\charscalex100 {Suele asociarse a otras enfermeda
des de origen autoinmune: }\par\pard\li1400\ri0\sl-213\slmult0 \fs18\cf0\par\par
d\li1400\ri0\sl-320\slmult0 \*\tx1760\fs20\cf0\f1\charscalex100 {\uc1\u61623X}\t
ab \fs24\cf0\f0\charscalex100 {Tiroiditis de Hashimoto }\par\pard\li1386\ri0\sl
-213\slmult0 \fs18\cf0\par\pard\li1386\ri0\sl-320\slmult0 \*\tx1760\fs20\cf0\f1\
charscalex100 {\uc1\u61623X}\tab \fs24\cf0\f0\charscalex100 {Vitligo }\par\pard\
li1386\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1386\ri0\sl-306\slmult0 \*\tx1760
\fs20\cf0\f1\charscalex100 {\uc1\u61623X}\tab \fs24\cf0\f0\charscalex100 {Tiroto
xicosis (}\fs24\cf0\f0\charscalex100 {Enfermedad de Graves)}\par\pard\li1386\r
i0\sl-213\slmult0 \fs18\cf0\par\pard\li1386\ri0\sl-306\slmult0 \*\tx1760\fs20\cf
0\f1\charscalex100 {\uc1\u61623X}\tab \fs24\cf0\f0\charscalex100 {Diabetes Melli
tus }\par\pard\li1386\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1386\ri0\sl-320\s
lmult0 \*\tx1760\fs20\cf0\f1\charscalex100 {\uc1\u61623X}\tab \fs24\cf0\f0\chars
calex100 {Enfermedad de Addison }\par\pard\li1386\ri0\sl-213\slmult0 \fs18\cf0\
par\pard\li1386\ri0\sl-306\slmult0 \*\tx1760\fs20\cf0\f1\charscalex100 {\uc1\u61
623X}\tab \fs24\cf0\f0\charscalex100 {Hipoparatiroidismo }\par\pard\li1386\ri0\
sl-213\slmult0 \fs18\cf0\par\pard\li1386\ri0\sl-306\slmult0 \*\tx1760\fs20\cf0\f
1\charscalex100 {\uc1\u61623X}\tab \fs24\cf0\f0\charscalex100 {Aganmaglobulinemi
a }\par\pard\li1386\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1386\ri0\sl-320\slm
ult0 \*\tx1760\fs20\cf0\f1\charscalex100 {\uc1\u61623X}\tab \fs24\cf0\f0\charsca
lex100 {LES }\par\pard\sect\sectd\sbkpage\pgwsxn11893\pghsxn16840\marglsxn666\ma
rgrsxn133\margtsxn666\margbsxn613\pard\li1040\ri0\sl-213\slmult0 \fs18\cf0\par\p
ard\li1040\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1040\ri0\sl-213\slmult0 \fs18
\cf0\par\pard\li1040\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1040\ri0\sl-426\slm
ult0 \fs24\cf0\f0\charscalex100\ul {CL}\ul0 \fs24\cf0\f0\charscalex100\ul {NI}\ul
0 \fs24\cf0\f0\charscalex100\ul {CA}\ul0 \fs24\cf0\f0\charscalex100\ul { }\ul0 \
par\pard\li1466\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1466\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li1466\ri0\sl-386\slmult0 \*\tx1760\fs20\cf0\f1\charscalex100
{\uc1\u61623X}\tab \fs24\cf0\f0\charscalex100 {Anemi}\fs24\cf0\f0\charscalex100
{a Megal}\fs24\cf0\f0\charscalex100 {obl}\fs24\cf0\f0\charscalex100 {st}\fs24\cf
0\f0\charscalex100 {i}\fs24\cf0\f0\charscalex100 {ca}\fs24\cf0\f0\charscalex100
{: Astenia,}\fs24\cf0\f0\charscalex100 { palpitaciones,}\fs24\cf0\f0\charscalex1
00 { sudoracin,}\fs24\cf0\f0\charscalex100 { mareo,}\par\pard\li1826\ri0\sl-213\s
lmult0 \fs18\cf0\par\pard\li1826\ri0\sl-306\slmult0 \fs24\cf0\f0\charscalex100 {
insuficiencia cardiaca de instauracin lenta y con buena tolerancia }\par\pard\li1
826\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1826\ri0\sl-306\slmult0 \fs24\cf0\f0
\charscalex100 {por parte del paciente.}\par\pard\li1466\ri0\sl-213\slmult0 \fs1
8\cf0\par\pard\li1466\ri0\sl-320\slmult0 \*\tx1760\fs20\cf0\f1\charscalex100 {\u
c1\u61623X}\tab \fs24\cf0\f0\charscalex100 {Di}\fs24\cf0\f0\charscalex100 {gest}
\fs24\cf0\f0\charscalex100 {i}\fs24\cf0\f0\charscalex100 {va}\fs24\cf0\f0\charsc
alex100 {: Anorexia,}\fs24\cf0\f0\charscalex100 { diarrea,}\fs24\cf0\f0\charscal
ex100 { estomatitis angular,}\fs24\cf0\f0\charscalex100 { lengua lisa }\par\pard
\li1826\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1826\ri0\sl-306\slmult0 \fs24\cf
0\f0\charscalex100 {depapilada,}\fs24\cf0\f0\charscalex100 { dolorosa al tacto y
de color roj}\fs24\cf0\f0\charscalex100 {o intenso (}\fs24\cf0\f0\charscalex100
{glositis de }\par\pard\li1826\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1826\ri0
\sl-306\slmult0 \fs24\cf0\f0\charscalex100 {Hunter)}\fs24\cf0\f0\charscalex100 {
.}\par\pard\li1466\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1466\ri0\sl-320\slmul
t0 \*\tx1760\fs20\cf0\f1\charscalex100 {\uc1\u61623X}\tab \fs24\cf0\f0\charscale
x100 {Neurol}\fs24\cf0\f0\charscalex100 {gi}\fs24\cf0\f0\charscalex100 {ca}\fs24\
cf0\f0\charscalex100 { (}\fs24\cf0\f0\charscalex100 {Las alteraciones neurolgicas
pueden aparecer sin que }\par\pard\li1826\ri0\sl-213\slmult0 \fs18\cf0\par\pard
\li1826\ri0\sl-306\slmult0 \fs24\cf0\f0\charscalex100 {exista anemia ni macrocit
osis)}\par\pard\li2186\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li2186\ri0\sl-320\s
lmult0 \*\tx2480\fs20\cf0\f3\charscalex100 {o}\tab \fs24\cf0\f0\charscalex100 {D
egeneracin combinada subaguda medular (}\fs24\cf0\f0\charscalex100 {Mielosis }\pa
r\pard\li2546\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li2546\ri0\sl-306\slmult0 \f
s24\cf0\f0\charscalex100 {cunicular)}\fs24\cf0\f0\charscalex100 {: Alteracin de l
os cordones posteriores,}\fs24\cf0\f0\charscalex100 { parestesias,}\par\pard\li2

546\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li2546\ri0\sl-306\slmult0 \fs24\cf0\f0

\charscalex100 {ataxia,}\fs24\cf0\f0\charscalex100 { tendencia a cadas en la oscu
ridad.}\fs24\cf0\f0\charscalex100 { El signo ms }\par\pard\li2546\ri0\sl-213\slmu
lt0 \fs18\cf0\par\pard\li2546\ri0\sl-320\slmult0 \fs24\cf0\f0\charscalex100 {pre
coz en la exploracin es la disminucin de la sensibilidad }\par\pard\li2546\ri0\sl
-213\slmult0 \fs18\cf0\par\pard\li2546\ri0\sl-306\slmult0 \fs24\cf0\f0\charscale
x100 {vibratoria en las extremidades inferiores.}\par\pard\li2186\ri0\sl-213\sl
mult0 \fs18\cf0\par\pard\li2186\ri0\sl-320\slmult0 \*\tx2480\fs20\cf0\f3\charsca
lex100 {o}\tab \fs24\cf0\f0\charscalex100 {Alteracin de la va piramidal: paresia,}
\fs24\cf0\f0\charscalex100 { espasticidad,}\par\pard\li2546\ri0\sl-213\slmult0 \
fs18\cf0\par\pard\li2546\ri0\sl-306\slmult0 \fs24\cf0\f0\charscalex100 {hiperref
lexia,}\fs24\cf0\f0\charscalex100 { alteracin de los esfnteres,}\fs24\cf0\f0\chars
calex100 { Romberg y Babinsky }\par\pard\li2546\ri0\sl-213\slmult0 \fs18\cf0\par
\pard\li2546\ri0\sl-306\slmult0 \fs24\cf0\f0\charscalex100 {positivos y alteraci
ones mentales (}\fs24\cf0\f0\charscalex100 {irritabilidad,}\fs24\cf0\f0\charscal
ex100 { demencia,}\par\pard\li2546\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li2546\
ri0\sl-306\slmult0 \fs24\cf0\f0\charscalex100 {depresin)}\fs24\cf0\f0\charscalex1
00 {.}\par\pard\li1040\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1040\ri0\sl-213\s
lmult0 \fs18\cf0\par\pard\li1040\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1040\ri
0\sl-213\slmult0 \fs18\cf0\par\pard\li1040\ri0\sl-240\slmult0 \fs24\cf0\f0\chars
calex100\ul {PRUEBAS DI}\ul0 \fs24\cf0\f0\charscalex100\ul {AGNSTI}\ul0 \fs24\cf0
\f0\charscalex100\ul {CAS}\ul0 \fs24\cf0\f0\charscalex100\ul { }\ul0 \par\pard\l
i1040\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1040\ri0\sl-213\slmult0 \fs18\cf0\
par\pard\li1040\ri0\sl-386\slmult0 \fs24\cf0\f0\charscalex100 {Las pruebas de in
ters diagnstico son: }\par\pard\li1466\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li146
6\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1466\ri0\sl-386\slmult0 \*\tx1760\fs20
\cf0\f1\charscalex100 {\uc1\u61623X}\tab \fs24\cf0\f0\charscalex100 {Niveles sric
os de vitamina B12 (}\fs24\cf0\f0\charscalex100 {< 100 pg/}\fs24\cf0\f0\charscal
ex100 {ml)}\fs24\cf0\f0\charscalex100 { y cido flico (}\fs24\cf0\f0\charscalex100
{>4 }\par\pard\li1826\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1826\ri0\sl-293\sl
mult0 \fs24\cf0\f0\charscalex100 {ng/}\fs24\cf0\f0\charscalex100 {ml)}\par\pard\
sect\sectd\sbkpage\pgwsxn11893\pghsxn16840\marglsxn666\margrsxn133\margtsxn666\m
argbsxn466\pard\li1466\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1466\ri0\sl-213\s
lmult0 \fs18\cf0\par\pard\li1466\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1466\ri
0\sl-213\slmult0 \fs18\cf0\par\pard\li1466\ri0\sl-426\slmult0 \*\tx1760\fs20\cf0
\f1\charscalex100 {\uc1\u61623X}\tab \fs24\cf0\f0\charscalex100 {La determinacin
de anticuerpos anti FI}\fs24\cf0\f0\charscalex100 { (}\fs24\cf0\f0\charscalex100
{sensibilidad: 66%;}\par\pard\li1826\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li18
26\ri0\sl-306\slmult0 \fs24\cf0\f0\charscalex100 {especificidad: 95%)}\fs24\cf0\
f0\charscalex100 { y el nivel srico de gastrina (}\fs24\cf0\f0\charscalex100 {si
est disponible)}\par\pard\li1826\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1826\ri0
\sl-306\slmult0 \fs24\cf0\f0\charscalex100 {permiten el diagnstico del 90-95% cas
os.}\par\pard\li1466\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1466\ri0\sl-320\slm
ult0 \*\tx1760\fs20\cf0\f1\charscalex100 {\uc1\u61623X}\tab \fs24\cf0\f0\charsca
lex100 {Anticuerpos anti-clulas parietales (}\fs24\cf0\f0\charscalex100 {sensibil
idad: 80%;}\fs24\cf0\f0\charscalex100 { especificidad: }\par\pard\li1826\ri0\sl213\slmult0 \fs18\cf0\par\pard\li1826\ri0\sl-306\slmult0 \fs24\cf0\f0\charscalex
100 {baj}\fs24\cf0\f0\charscalex100 {a,}\fs24\cf0\f0\charscalex100 { 3-10% perso
nas sin anemia perniciosa lo tienen elevado)}\fs24\cf0\f0\charscalex100 {.}\par\
pard\li1466\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1466\ri0\sl-320\slmult0 \*\t
x1760\fs20\cf0\f1\charscalex100 {\uc1\u61623X}\tab \fs24\cf0\f0\charscalex100 {N
iveles de cido metilmalnico y homocistena plasmticos: ambos }\par\pard\li1826\ri0\sl
-213\slmult0 \fs18\cf0\par\pard\li1826\ri0\sl-306\slmult0 \fs24\cf0\f0\charscale
x100 {aumentan en el dficit de vitamina B12 de forma precoz (}\fs24\cf0\f0\charsc
alex100 {incluso }\par\pard\li1826\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1826\
ri0\sl-306\slmult0 \fs24\cf0\f0\charscalex100 {antes de la aparicin de la anemia
y con dficit mnimos de B12)}\fs24\cf0\f0\charscalex100 {.}\par\pard\li1826\ri0\sl213\slmult0 \fs18\cf0\par\pard\li1826\ri0\sl-306\slmult0 \fs24\cf0\f0\charscalex
100 {Podran estar indicados en situaciones dudosas,}\fs24\cf0\f0\charscalex100 {
con cifras lmite de }\par\pard\li1826\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li182

6\ri0\sl-320\slmult0 \fs24\cf0\f0\charscalex100 {vitamina B12.}\par\pard\li1466\

ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1466\ri0\sl-320\slmult0 \*\tx1760\fs20\c
f0\f1\charscalex100 {\uc1\u61623X}\tab \fs24\cf0\f0\charscalex100 {Test de Schil
ling (}\fs24\cf0\f0\charscalex100 {patrn oro en diagnstico;}\fs24\cf0\f0\charscale
x100 { en la anemia perniciosa }\par\pard\li1826\ri0\sl-213\slmult0 \fs18\cf0\p
ar\pard\li1826\ri0\sl-306\slmult0 \fs24\cf0\f0\charscalex100 {se corrige en la s
egunda fase)}\par\pard\li1466\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1466\ri0\s
l-306\slmult0 \*\tx1760\fs20\cf0\f1\charscalex100 {\uc1\u61623X}\tab \fs24\cf0\f
0\charscalex100 {Gastroscopia: Para valorar la atrofia de mucosa gstrica (}\fs24\
cf0\f0\charscalex100 {suele }\par\pard\li1826\ri0\sl-213\slmult0 \fs18\cf0\par\p
ard\li1826\ri0\sl-306\slmult0 \fs24\cf0\f0\charscalex100 {respetar el antro)}\fs
24\cf0\f0\charscalex100 { y las lesiones gstricas (}\fs24\cf0\f0\charscalex100 {pl
ipos y/}\fs24\cf0\f0\charscalex100 {o carcinoma }\par\pard\li1826\ri0\sl-213\slm
ult0 \fs18\cf0\par\pard\li1826\ri0\sl-320\slmult0 \fs24\cf0\f0\charscalex100 {as
ociados a la anemia perniciosa)}\fs24\cf0\f0\charscalex100 {.}\par\pard\li1040\r
i0\sl-213\slmult0 \fs18\cf0\par\pard\li1040\ri0\sl-333\slmult0 \fs24\cf0\f0\char
scalex100 {Otras pruebas tiles en el seguimiento y diagnstico diferencial: }\par\p
ard\li1040\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1040\ri0\sl-333\slmult0 \fs24
\cf0\f0\charscalex100 {Hemat}\fs24\cf0\f0\charscalex100 {i}\fs24\cf0\f0\charscal
ex100 {met}\fs24\cf0\f0\charscalex100 {r}\fs24\cf0\f0\charscalex100 {a}\fs24\cf0\
f0\charscalex100 {: }\par\pard\li1466\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li14
66\ri0\sl-333\slmult0 \*\tx1760\fs20\cf0\f1\charscalex100 {\uc1\u61623X}\tab \fs
24\cf0\f0\charscalex100 {Anemia macroctica con ovalocitosis y poiquilocitosis.}\f
s24\cf0\f0\charscalex100 { VCM aumentado }\par\pard\li1826\ri0\sl-266\slmult0 \f
s24\cf0\f0\charscalex100 {(}\fs24\cf0\f0\charscalex100 {signo ms precoz)}\fs24\cf
0\f0\charscalex100 {.}\fs24\cf0\f0\charscalex100 { Reticulocitos disminuidos.}\p
ar\pard\li1466\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1466\ri0\sl-320\slmult0 \
*\tx1760\fs20\cf0\f1\charscalex100 {\uc1\u61623X}\tab \fs24\cf0\f0\charscalex100
{Leucopenia.}\fs24\cf0\f0\charscalex100 { Neutrfilos polisegmentados,}\fs24\cf0\
f0\charscalex100 { envej}\fs24\cf0\f0\charscalex100 {ecidos y con }\par\pard\li1
826\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1826\ri0\sl-306\slmult0 \fs24\cf0\f0
\charscalex100 {desviacin a la derecha.}\fs24\cf0\f0\charscalex100 { El hallazgo
de ms de 6 segmentaciones es }\par\pard\li1826\ri0\sl-213\slmult0 \fs18\cf0\par\p
ard\li1826\ri0\sl-306\slmult0 \fs24\cf0\f0\charscalex100 {muy indicativo.}\par\p
ard\li1466\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1466\ri0\sl-320\slmult0 \*\tx
1760\fs20\cf0\f1\charscalex100 {\uc1\u61623X}\tab \fs24\cf0\f0\charscalex100 {Tr
ombopenia.}\par\pard\li1040\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1040\ri0\sl320\slmult0 \fs24\cf0\f0\charscalex100 {Si}\fs24\cf0\f0\charscalex100 {gnos secu
ndari}\fs24\cf0\f0\charscalex100 {os de heml}\fs24\cf0\f0\charscalex100 {i}{ }\fs
24\cf0\f0\charscalex100 {s}\fs24\cf0\f0\charscalex100 {: Descenso de la haptoglo
bina y }\par\pard\li1040\ri0\sl-266\slmult0 \fs24\cf0\f0\charscalex100 {aumento
de la LDH,}\fs24\cf0\f0\charscalex100 { bilirrubina indirecta y ferritina.}\par\
pard\li1040\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1040\ri0\sl-333\slmult0 \fs2
4\cf0\f0\charscalex100 {Hormonas t}\fs24\cf0\f0\charscalex100 {i}\fs24\cf0\f0\ch
arscalex100 {roi}\fs24\cf0\f0\charscalex100 {deas}\fs24\cf0\f0\charscalex100 {:
Puede asociarse a tiroiditis autoinmune.}\fs24\cf0\f0\charscalex100 { En 5-10% }
\par\pard\li1040\ri0\sl-280\slmult0 \fs24\cf0\f0\charscalex100 {casos existe hip
otiroidismo y en <5% hipertiroidismo.}\par\pard\sect\sectd\sbkpage\pgwsxn11893\p
ghsxn16840\marglsxn666\margrsxn133\margtsxn666\margbsxn506\pard\li1040\ri0\sl-21
3\slmult0 \fs18\cf0\par\pard\li1040\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1040
\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1040\ri0\sl-213\slmult0 \fs18\cf0\par\p
ard\li1040\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1040\ri0\sl-213\slmult0 \fs18
\cf0\par\pard\li1040\ri0\sl-266\slmult0 \fs24\cf0\f0\charscalex100\ul {DI}\ul0 \
fs24\cf0\f0\charscalex100\ul {AGNSTI}\ul0 \fs24\cf0\f0\charscalex100\ul {CO DI}\u
l0 \fs24\cf0\f0\charscalex100\ul {FERENCI}\ul0 \fs24\cf0\f0\charscalex100\ul {AL
}\ul0 \fs24\cf0\f0\charscalex100\ul { }\ul0 \par\pard\li1040\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li1040\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1040\ri0\sl-38
6\slmult0 \*\tx7093\fs24\cf0\f0\charscalex100 {Anemi}\fs24\cf0\f0\charscalex100
{a megal}\fs24\cf0\f0\charscalex100 {obl}\fs24\cf0\f0\charscalex100 {st}\fs24\cf0
\f0\charscalex100 {i}\fs24\cf0\f0\charscalex100 {ca por df}\fs24\cf0\f0\charscale

x100 {i}{ }\fs24\cf0\f0\charscalex100 {t}\fs24\cf0\f0\charscalex100 { de ci}\fs24

\cf0\f0\charscalex100 {do f}\fs24\cf0\f0\charscalex100 {l}\fs24\cf0\f0\charscalex
100 {i}\tab \fs24\cf0\f0\charscalex100 {: ingesta inadecuada }\par\pard\li1040\r
i0\sl-266\slmult0 \fs24\cf0\f0\charscalex100 {(}\fs24\cf0\f0\charscalex100 {las
reservas de flico cubren las necesidades hasta 4 meses)}\fs24\cf0\f0\charscalex10
0 {,}\fs24\cf0\f0\charscalex100 { alcoholismo,}\par\pard\li1040\ri0\sl-280\slmul
t0 \fs24\cf0\f0\charscalex100 {sndromes de malabsorcin (}\fs24\cf0\f0\charscalex10
0 {enfermedad de Crohnn,}\fs24\cf0\f0\charscalex100 { enfermedad celaca)}\fs24\cf
0\f0\charscalex100 {,}\par\pard\li1040\ri0\sl-253\slmult0 \fs24\cf0\f0\charscale
x100 {frmacos (}\fs24\cf0\f0\charscalex100 {barbitricos,}\fs24\cf0\f0\charscalex10
0 { difenilhidantoina,}\fs24\cf0\f0\charscalex100 { etanol,}\fs24\cf0\f0\charsca
lex100 { sulfasalazina,}\par\pard\li1040\ri0\sl-266\slmult0 \fs24\cf0\f0\charsca
lex100 {colestiramina,}\fs24\cf0\f0\charscalex100 { zidovudina,}\fs24\cf0\f0\cha
rscalex100 { hidroxiurea,}\fs24\cf0\f0\charscalex100 { anticonceptivos orales,}\
fs24\cf0\f0\charscalex100 { metotrexate,}\par\pard\li1040\ri0\sl-280\slmult0 \fs
24\cf0\f0\charscalex100 {pentamidina)}\fs24\cf0\f0\charscalex100 {,}\fs24\cf0\f0
\charscalex100 { aumento de las necesidades (}\fs24\cf0\f0\charscalex100 {embara
zo,}\fs24\cf0\f0\charscalex100 { lactancia,}\par\pard\li1040\ri0\sl-266\slmult0
\fs24\cf0\f0\charscalex100 {crecimiento,}\fs24\cf0\f0\charscalex100 { neoplasias
,}\fs24\cf0\f0\charscalex100 { hipertiroidismo,}\fs24\cf0\f0\charscalex100 { hem
odilisis,}\fs24\cf0\f0\charscalex100 { trastornos }\par\pard\li1040\ri0\sl-266\sl
mult0 \fs24\cf0\f0\charscalex100 {exfoliativos de la piel)}\fs24\cf0\f0\charscal
ex100 { y aumento de la excrecin (}\fs24\cf0\f0\charscalex100 {insuficiencia card
iaca }\par\pard\li1040\ri0\sl-266\slmult0 \fs24\cf0\f0\charscalex100 {congestiva
,}\fs24\cf0\f0\charscalex100 { hepatitis aguda)}\fs24\cf0\f0\charscalex100 {.}\p
ar\pard\li1040\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1040\ri0\sl-333\slmult0 \
fs24\cf0\f0\charscalex100 {Anemi}\fs24\cf0\f0\charscalex100 {a megal}\fs24\cf0\f
0\charscalex100 {obl}\fs24\cf0\f0\charscalex100 {st}\fs24\cf0\f0\charscalex100 {i
}\fs24\cf0\f0\charscalex100 {ca por df}\fs24\cf0\f0\charscalex100 {i}{ }\fs24\cf0
\f0\charscalex100 {t}\fs24\cf0\f0\charscalex100 {/ al}\fs24\cf0\f0\charscalex100
{t}\fs24\cf0\f0\charscalex100 {eraci}\fs24\cf0\f0\charscalex100 {n de vi}\fs24\c
f0\f0\charscalex100 {t}\fs24\cf0\f0\charscalex100 {ami}\fs24\cf0\f0\charscalex10
0 {na B12}\fs24\cf0\f0\charscalex100 {: }\par\pard\li1466\ri0\sl-213\slmult0 \fs
18\cf0\par\pard\li1466\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1466\ri0\sl-386\s
lmult0 \*\tx1760\fs20\cf0\f1\charscalex100 {\uc1\u61623X}\tab \fs24\cf0\f0\chars
calex100 {Disminucin de la absorcin: gastrectomizados,}\fs24\cf0\f0\charscalex100
{ ausencia congnita o }\par\pard\li1826\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1
826\ri0\sl-306\slmult0 \fs24\cf0\f0\charscalex100 {anomala funcional.}\par\pard\l
i1466\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1466\ri0\sl-306\slmult0 \*\tx1760\
fs20\cf0\f1\charscalex100 {\uc1\u61623X}\tab \fs24\cf0\f0\charscalex100 {Alterac
iones de las proteasas: pancreatitis crnica,}\fs24\cf0\f0\charscalex100 { sndrome
de }\par\pard\li1826\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1826\ri0\sl-306\slm
ult0 \fs24\cf0\f0\charscalex100 {Zollinger Ellison }\par\pard\li1466\ri0\sl-213
\slmult0 \fs18\cf0\par\pard\li1466\ri0\sl-320\slmult0 \*\tx1760\fs20\cf0\f1\char
scalex100 {\uc1\u61623X}\tab \fs24\cf0\f0\charscalex100 {Alteraciones del I}\fs2
4\cf0\f0\charscalex100 {leon terminal: esprue tropical,}\fs24\cf0\f0\charscalex1
00 { EEI}\fs24\cf0\f0\charscalex100 {,}\fs24\cf0\f0\charscalex100 { TBC,}\fs24\c
f0\f0\charscalex100 { reseccin }\par\pard\li1826\ri0\sl-213\slmult0 \fs18\cf0\par
\pard\li1826\ri0\sl-306\slmult0 \fs24\cf0\f0\charscalex100 {intestinal }\par\pa
rd\li1466\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1466\ri0\sl-320\slmult0 \*\tx1
760\fs20\cf0\f1\charscalex100 {\uc1\u61623X}\tab \fs24\cf0\f0\charscalex100 {Com
peticin por la cobalamina: sobrecrecimiento bacteriano.}\par\pard\li1466\ri0\sl-2
13\slmult0 \fs18\cf0\par\pard\li1466\ri0\sl-306\slmult0 \*\tx1760\fs20\cf0\f1\ch
arscalex100 {\uc1\u61623X}\tab \fs24\cf0\f0\charscalex100 {Frmacos: colchicina,}\
fs24\cf0\f0\charscalex100 { neomicina.}\fs24\cf0\f0\charscalex100 {.}\fs24\cf0\f
0\charscalex100 {.}\par\pard\li1040\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1040
\ri0\sl-333\slmult0 \fs24\cf0\f0\charscalex100 {Ot}\fs24\cf0\f0\charscalex100 {r
as causas de macroci}\fs24\cf0\f0\charscalex100 {t}\fs24\cf0\f0\charscalex100 {o
si}\fs24\cf0\f0\charscalex100 {s no megal}\fs24\cf0\f0\charscalex100 {obl}\fs24\
cf0\f0\charscalex100 {st}\fs24\cf0\f0\charscalex100 {i}\fs24\cf0\f0\charscalex100

{cas}\fs24\cf0\f0\charscalex100 {: Alcoholismo,}\par\pard\li1040\ri0\sl-266\slm
ult0 \fs24\cf0\f0\charscalex100 {hepatopatas,}\fs24\cf0\f0\charscalex100 { hipoti
roidismo,}\fs24\cf0\f0\charscalex100 { hipopituitarismo,}\fs24\cf0\f0\charscalex
100 { reticulocitosis,}\fs24\cf0\f0\charscalex100 { anemia }\par\pard\li1040\ri0
\sl-266\slmult0 \fs24\cf0\f0\charscalex100 {aplsica,}\fs24\cf0\f0\charscalex100 {
sndrome mielodisplasico.}\fs24\cf0\f0\charscalex100 {.}\fs24\cf0\f0\charscalex10
0 {.}\par\pard\li1040\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1040\ri0\sl-213\sl
mult0 \fs18\cf0\par\pard\li1040\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1040\ri0
\sl-213\slmult0 \fs18\cf0\par\pard\li1040\ri0\sl-226\slmult0 \fs24\cf0\f0\charsc
alex100\ul {TRATAMI}\ul0 \fs24\cf0\f0\charscalex100\ul {ENTO}\ul0 \fs24\cf0\f0\c
harscalex100\ul { }\ul0 \par\pard\li1040\ri0\sl-213\slmult0 \fs18\cf0\par\pard\l
i1040\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1040\ri0\sl-386\slmult0 \fs24\cf0\
f0\charscalex100 {El tratamiento tiene como obj}\fs24\cf0\f0\charscalex100 {etiv
os: Corregir la anemia y posibles }\par\pard\li1040\ri0\sl-266\slmult0 \fs24\cf0
\f0\charscalex100 {alteraciones epiteliales,}\fs24\cf0\f0\charscalex100 { reduci
r los trastornos neurolgicos y prevenir su }\par\pard\li1040\ri0\sl-266\slmult0 \
fs24\cf0\f0\charscalex100 {aparicin y normalizar los depsitos de vitamina B12.}\pa
r\pard\li1040\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1040\ri0\sl-333\slmult0 \f
s24\cf0\f0\charscalex100 {Tratamiento va oral:}\fs24\cf0\f0\charscalex100 { Dosis
muy elevadas de vitamina B12 oral pueden }\par\pard\li1040\ri0\sl-266\slmult0 \
fs24\cf0\f0\charscalex100 {corregir el dficit de B12 en pacientes con dficit de FI
}\fs24\cf0\f0\charscalex100 {.}\fs24\cf0\f0\charscalex100 { Si la causa es }\par
\pard\li1040\ri0\sl-280\slmult0 \fs24\cf0\f0\charscalex100 {carencial,}\fs24\cf0
\f0\charscalex100 { dieta con: 50-150 mg/}\fs24\cf0\f0\charscalex100 { da.}\par\p
ard\sect\sectd\sbkpage\pgwsxn11893\pghsxn16840\marglsxn666\margrsxn133\margtsxn6
66\margbsxn560\pard\li1040\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1040\ri0\sl-2
13\slmult0 \fs18\cf0\par\pard\li1040\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li104
0\ri0\sl-373\slmult0 \fs24\cf0\f0\charscalex100 {Tratamiento va intramus}\fs24\cf
0\f0\charscalex100 {c}\fs24\cf0\f0\charscalex100 {ular}\fs24\cf0\f0\charscalex10
0 {: Es la va indicada como primera eleccin.}\par\pard\li1040\ri0\sl-266\slmult0 \
fs24\cf0\f0\charscalex100 {Existen varias pautas,}\fs24\cf0\f0\charscalex100 { u
na de ellas consiste en administrar 1 mg/}\fs24\cf0\f0\charscalex100 { I}\fs24\c
f0\f0\charscalex100 {M/}\par\pard\li1040\ri0\sl-266\slmult0 \fs24\cf0\f0\charsca
lex100 {semana/}\fs24\cf0\f0\charscalex100 { 6 semanas y posteriormente 1 mg/}\
fs24\cf0\f0\charscalex100 { I}\fs24\cf0\f0\charscalex100 {M/}\fs24\cf0\f0\charsc
alex100 { 2-3 meses durante toda la }\par\pard\li1040\ri0\sl-266\slmult0 \fs24\c
f0\f0\charscalex100 {vida.}\par\pard\li1040\ri0\sl-213\slmult0 \fs18\cf0\par\par
d\li1040\ri0\sl-333\slmult0 \fs24\cf0\f0\charscalex100 {La eficacia del tratamie
nto se controla con la cifra de reticulocitos que }\par\pard\li1040\ri0\sl-266\
slmult0 \fs24\cf0\f0\charscalex100 {alcanzan su valor mximo hacia el 10 da tras la
primera dosis.}\fs24\cf0\f0\charscalex100 { El paciente }\par\pard\li1040\ri0\s
l-280\slmult0 \fs24\cf0\f0\charscalex100 {suele encontrar mej}\fs24\cf0\f0\chars
calex100 {ora a las 48 horas de la instauracin del tratamiento.}\par\pard\li1040\r
i0\sl-213\slmult0 \fs18\cf0\par\pard\li1040\ri0\sl-333\slmult0 \fs24\cf0\f0\char
scalex100 {En la anemia perniciosa el tratamiento corrige por completo las alter
aciones }\par\pard\li1040\ri0\sl-266\slmult0 \fs24\cf0\f0\charscalex100 {hematolg
icas,}\fs24\cf0\f0\charscalex100 { no as las alteraciones neurolgicas (}\fs24\cf0\
f0\charscalex100 {que pueden persistir o }\par\pard\li1040\ri0\sl-266\slmult0 \f
s24\cf0\f0\charscalex100 {no)}\fs24\cf0\f0\charscalex100 { ni la atrofia gstrica
.}\par\pard\li1040\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1040\ri0\sl-333\slmul
t0 \fs24\cf0\f0\charscalex100 {Debe realizarse un estudio endoscpico preferente s
i aparece anemia }\par\pard\li1040\ri0\sl-266\slmult0 \fs24\cf0\f0\charscalex100
{ferropnica,}\fs24\cf0\f0\charscalex100 { dispepsia o cualquier otro sntoma suges
tivo de alteracin }\par\pard\li1040\ri0\sl-266\slmult0 \fs24\cf0\f0\charscalex100
{gstrica (}\fs24\cf0\f0\charscalex100 {4% de pacientes con anemia perniciosa des
arrollan carcinoma }\par\pard\li1040\ri0\sl-266\slmult0 \fs24\cf0\f0\charscalex1
00 {gstrico a lo largo de su vida)}\fs24\cf0\f0\charscalex100 {.}\par\pard\li1040
\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1040\ri0\sl-213\slmult0 \fs18\cf0\par\p
ard\li1040\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1040\ri0\sl-213\slmult0 \fs18
\cf0\par\pard\li1040\ri0\sl-226\slmult0 \fs24\cf0\f0\charscalex100\ul {BI}\ul0 \

fs24\cf0\f0\charscalex100\ul {BLI}\ul0 \fs24\cf0\f0\charscalex100\ul {OGRAF}\ul0

\fs24\cf0\f0\charscalex100\ul {A}\ul0 \fs24\cf0\f0\charscalex100\ul { }\ul0 \par
\pard\li1400\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1400\ri0\sl-346\slmult0 \*\
tx1760\fs20\cf0\f1\charscalex100 {\uc1\u61623X}\tab \fs24\cf0\f0\charscalex100 {
Babior BM,}\fs24\cf0\f0\charscalex100 { Bunn HF.}\fs24\cf0\f0\charscalex100 { Me
galoblastic anemias.}\fs24\cf0\f0\charscalex100 { En: Harrrisons }\par\pard\li176
0\ri0\sl-253\slmult0 \fs24\cf0\f0\charscalex100 {Principles of I}\fs24\cf0\f0\ch
arscalex100 {nternal Medicine.}\fs24\cf0\f0\charscalex100 { Dennos L.}\fs24\cf0\
f0\charscalex100 { Harper (}\fs24\cf0\f0\charscalex100 {Editors)}\fs24\cf0\f0\ch
arscalex100 {.}\fs24\cf0\f0\charscalex100 { 16th.}\fs24\cf0\f0\charscalex100 { e
d.}\par\pard\li1760\ri0\sl-266\slmult0 \fs24\cf0\f0\charscalex100 {New York: McG
raw-Hill;}\fs24\cf0\f0\charscalex100 { 2005.}\fs24\cf0\f0\charscalex100 { p.}\fs
24\cf0\f0\charscalex100 {601-607 }\par\pard\li1400\ri0\sl-280\slmult0 \*\tx1760
\fs20\cf0\f1\charscalex100 {\uc1\u61623X}\tab \fs24\cf0\f0\charscalex100 {Carmel
R.}\fs24\cf0\f0\charscalex100 { Megaloblastic Anemias: Disorders of impaired DN
A }\par\pard\li1760\ri0\sl-253\slmult0 \fs24\cf0\f0\charscalex100 {synthesis.}\f
s24\cf0\f0\charscalex100 { En: Wintrobes Clinical Hematology.}\fs24\cf0\f0\charsc
alex100 { 11}{\super \fs14\up3\cf0\f0\charscalex100 {th}}\fs24\cf0\f0\charscalex
100 {.}\fs24\cf0\f0\charscalex100 { ed.}\fs24\cf0\f0\charscalex100 { Philadelphi
a: }\par\pard\li1760\ri0\sl-266\slmult0 \fs24\cf0\f0\charscalex100 {Lippincott W
illiams & Wilkins;}\fs24\cf0\f0\charscalex100 { 2004.}\fs24\cf0\f0\charscalex100
{ p.}\fs24\cf0\f0\charscalex100 {1367-1388.}\par\pard\li1400\ri0\sl-280\slmult0
\*\tx1760\fs20\cf0\f1\charscalex100 {\uc1\u61623X}\tab \fs24\cf0\f0\charscalex1
00 {Colon\uc1\u339XOtero G ,}\fs24\cf0\f0\charscalex100 { Menke D ,}\fs24\cf0\f0
\charscalex100 { Hook CC.}\fs24\cf0\f0\charscalex100 { A practical approach to t
he }\par\pard\li1760\ri0\sl-253\slmult0 \fs24\cf0\f0\charscalex100 {differential
diagnosis and evaluation of the adult patient with }\par\pard\li1760\ri0\sl-266
\slmult0 \fs24\cf0\f0\charscalex100 {macrocytic anemia.}\fs24\cf0\f0\charscalex1
00 { Med Clin North Am.}\fs24\cf0\f0\charscalex100 { 1992 May;}\fs24\cf0\f0\char
scalex100 {76(}\fs24\cf0\f0\charscalex100 {3)}\fs24\cf0\f0\charscalex100\ul { [}
\ul0 \fs24\cf1\f0\charscalex100\ul {Medline}\ul0 \fs24\cf0\f0\charscalex100 {]
}\par\pard\li1400\ri0\sl-280\slmult0 \*\tx1760\fs20\cf0\f1\charscalex100 {\uc1\u
61623X}\tab \fs24\cf0\f0\charscalex100 {Duffy TP.}\fs24\cf0\f0\charscalex100 { N
onhemolitic normochromic,}\fs24\cf0\f0\charscalex100 { normocytic anemias.}\fs24
\cf0\f0\charscalex100 { En: Cecil }\par\pard\li1760\ri0\sl-266\slmult0 \fs24\cf0
\f0\charscalex100 {Textbook of Medicine.}\fs24\cf0\f0\charscalex100 { Lee Goldma
n (}\fs24\cf0\f0\charscalex100 {edit.}\fs24\cf0\f0\charscalex100 {)}\fs24\cf0\f0
\charscalex100 {.}\fs24\cf0\f0\charscalex100 { Philadelphia: Saunders;}\par\pard
\li1760\ri0\sl-266\slmult0 \fs24\cf0\f0\charscalex100 {2004.}\fs24\cf0\f0\charsc
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