Publications by authors named "Alberto Vera"

18 Publications

  • Page 1 of 1

A Comprehensive Model to Predict Atrial Fibrillation in Cryptogenic Stroke: The Decryptoring Score.

J Stroke Cerebrovasc Dis 2022 Jan 21;31(1):106161. Epub 2021 Oct 21.

Cardiology Department, Hospital Universitario de La Princesa, Universidad Autónoma de Madrid. IIS-IP, CIBER-CV, Madrid, Spain. Electronic address:

Objetive: Cryptogenic stroke (CS) represents up to 30% of ischemic strokes (IS). Since atrial fibrillation (AF) can be detected in up to 30% of CS, there is a clinical need for estimating the probability of underlying AF in CS to guide the optimal secondary prevention strategy. The aim of the study was to develop the first comprehensive predictive score including clinical conditions, biomarkers, and left atrial strain (LAS), to predict AF detection in this setting.

Methods: Sixty-three consecutive patients with IS or transient ischemic attack with ABCD2 scale ≥ 4 of unknown etiology were prospectively recruited. Clinical, laboratory, and echocardiographic variables were collected. All patients underwent 15 days wearable Holter-ECG monitoring. Main objective was the Decryptoring score creation to predict AF in CS. Score variables were selected by a univariate analysis and, thereafter, score points were derived according to a multivariant analysis.

Results: AF was detected in 15 patients (24%). Age > 75 (9 points), hypertension (1 point), Troponin T > 40 ng/L (8.5 points), NTproBNP > 200 pg/ml (0.5 points), LAS reservoir < 25.3% (24.5 points) and LAS conduct < 10.4% (0.5 points) were included in the score. The rate of AF detection was 0% among patients with a score of < 10 and 80% among patients with a score > 35. The comparison of the predictive validity between the proposed score and AF-ESUS score resulted in an AUC of 0.94 for Decryptoring score and of 0.65 for the AF-ESUS score(p < 0.001).

Conclusion: This novel score offers an accurate AF prediction in patients with CS; however these results will require validation in an independent cohort using this model before they may be translated into clinical practice.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2021.106161DOI Listing
January 2022

The Role of Cost-Effectiveness Analysis in Patient-Centered Cancer Care in the Era of Precision Medicine.

Cancers (Basel) 2021 Aug 25;13(17). Epub 2021 Aug 25.

Department of Radiology, New York Presbyterian, Columbia University Irving Medical Center, New York, NY 10032, USA.

Over the last few decades, changes in diagnostic and treatment paradigms have greatly advanced cancer care and improved outcomes [...].
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http://dx.doi.org/10.3390/cancers13174272DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8428334PMC
August 2021

Electrocardiographic biomarkers to predict atrial fibrillation in sinus rhythm electrocardiograms.

Heart 2021 11 4;107(22):1813-1819. Epub 2021 Jun 4.

Cardiology Department, Hospital Universitario de la Princesa, Madrid, Spain.

Objective: Early prediction of atrial fibrillation (AF) development would improve patient outcomes. We propose a simple and cheap ECG based score to predict AF development.

Methods: A cohort of 16 316 patients was analysed. ECG measures provided by the computer-assisted ECG software were used to identify patients. A first group included patients in sinus rhythm who showed an ECG with AF at any time later (n=505). A second group included patients with all their ECGs in sinus rhythm (n=15 811). By using a training set (75% of the cohort) the initial sinus rhythm ECGs of both groups were analysed and a predictive risk score based on a multivariate logistic model was constructed.

Results: A multivariate regression model was constructed with 32 variables showing a predictive value characterised by an area under the curve (AUC) of 0.776 (95% CI: 0.738 to 0.814). The subsequent risk score included the following variables: age, duration of P-wave in aVF, V4 and V5; duration of T-wave in V3, mean QT interval adjusted for heart rate, transverse P-wave clockwise rotation, transverse P-wave terminal angle and transverse QRS complex terminal vector magnitude. Risk score values ranged from 0 (no risk) to 5 (high risk). The predictive validity of the score reached an AUC of 0.764 (95% CI: 0.722 to 0.806) with a global specificity of 61% and a sensitivity of 55%.

Conclusions: The automatic assessment of ECG biomarkers from ECGs in sinus rhythm is able to predict the risk for AF providing a low-cost screening strategy for early detection of this pathology.
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http://dx.doi.org/10.1136/heartjnl-2021-319120DOI Listing
November 2021

Association of CHADS-VASc Score With Remodeling of Left Atrial Appendage Assessed by Cardiac Computed Tomography.

Cardiol Res 2021 Apr 23;12(2):126-128. Epub 2021 Feb 23.

Department of Cardiology, Hospital Universitario de La Princesa, Madrid, Spain.

Background: CHADS-VASc score (congestive heart failure; hypertension; ages ≥ 74 years (2 points); diabetes; stroke, transient ischemic attack, or systemic embolism (2 points); vascular disease; ages 65 - 74 years; sex (female)) is a widely used clinical scale to estimate the risk of stroke in patients with non-valvular atrial fibrillation (AF). However, the relationship between the increase in CHADS-VASc score and atrial remodeling remains unsettled.

Methods: Twenty-five consecutive patients undergoing cardiac computed tomography (CT) were recruited. The systolic and diastolic volumes of left atrium and left atrial appendage (LAA) were measured. Risk of stroke was estimated using the CHADS-VASc score. The relationship of the CHADS-VASc score with morphological and functional variables was analyzed by Pearson's correlation.

Results: A positive correlation was documented between the CHADS-VASc score and systolic (r = 0.419, P = 0.037) and diastolic (r = 0.415, P = 0.039) LAA volumes. Atrial volumes and left atrial ejection fraction showed no significant correlations with CHADS-VASc.

Conclusions: This study shows, for the first time, a positive correlation between CHADS-VASc score and LAA remodeling.
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http://dx.doi.org/10.14740/cr1192DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7935638PMC
April 2021

Spontaneous coronary artery dissection in old patients: clinical features, angiographic findings, management and outcome.

Eur Heart J Acute Cardiovasc Care 2021 Oct;10(8):926-932

Servicio de Cardiología, Hospital Universitario La Princesa, Madrid, Spain.

Aims: Spontaneous coronary artery dissection (SCAD) is a relatively rare but well-known cause of acute coronary syndrome. Clinical features, angiographic findings, management and outcomes of SCAD in old patients (>65 years of age) remain unknown.

Methods And Results: The Spanish multicentre prospective SCAD registry (NCT03607981), included 318 consecutive patients with SCAD. Data were collected between June 2015 and April 2019. All angiograms were analysed in a centralized corelab. For the purposes of this study, patients were classified according to age in two groups <65 and ≥65 years old and in-hospital outcomes were analysed. Fifty-five patients (17%) were ≥65 years old (95% women). Older patients had more often hypertension (76% vs. 29%, P < 0.01) and dyslipidaemia (56% vs. 30%, P < 0.01), and less previous (4% vs. 18%, P < 0.001) or current smoking habit (4% vs. 33%, P < 0.001). An identifiable trigger was less often present in old patients (27% vs. 43%, P = 0.028). They also had more often severe coronary tortuosity (36% vs. 11%, P = 0.036) and showed more frequently coronary ectasia (24% vs. 9%, P < 0.01). Older patients were more often managed conservatively (89% vs. 75%, P = 0.025), with no significant differences in major adverse cardiac events during index admission (7% vs. 8%, P = 0.858). There were no differences between groups in terms of in-hospital stay, new acute myocardial infarction, unplanned coronary angiography or heart failure.

Conclusion: Older patients with SCAD show different clinical and angiographic characteristics compared with younger patients. Initial treatment strategy was different between groups, though in-hospital outcomes do not significantly differ (NCT03607981).
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http://dx.doi.org/10.1093/ehjacc/zuaa029DOI Listing
October 2021

Baseline CHA DS -VASc score and prognosis in octogenarians with non-ST segment elevation acute coronary syndrome.

Int J Clin Pract 2021 Jun 17;75(6):e14082. Epub 2021 Mar 17.

Cardiology Department, Hospital Universitario La Princesa, Madrid, Spain.

Background: CHA DS -VASc Score is widely used to predict thromboembolic risk in patients with Atrial Fibrillation (AF). We sought to study if this score predicts outcomes in elderly patients with Non-ST segment Elevation Acute Coronary Syndromes (NSTEACS).

Methods: The multicenter LONGEVO-SCA prospective registry included 532 unselected patients with NSTEACS aged ≥80 years. Data to calculate CHA DS -VASc Score were available in 523 patients (98.3%). They were classified according to CHA DS -VASc Score: group 1 (score ≤ 4), and 2 (5-9). We studied outcomes in terms of mortality or readmission at 6 months follow-up.

Results: A total of 266 patients (51%) had a high CHA DS -VASc Score (group 2). They were more often women, with more cardiovascular risk factors, such as hypertension or diabetes mellitus, and history of previous stroke and cardiovascular disease and heart failure (all, P = .001). Geriatric syndromes (Barthel Index, Lawton Brody, cognitive impairment, and frailty) and Charlson Index were worse in this group (all, P = .001). They had poorer clinical status on admission, with worse Killip class and lower left ventricle ejection fraction (all, P = .001), and developed new-onset AF more often during admission (12.4% vs. 6.6%, P = .024). At six months follow-up, patients in group 2 had higher reinfarction, all-cause mortality, and mortality or readmission rates. A CHA DS -VASc Score > 4 was associated with mortality or readmission at 6 months (HR 2.07, P < .001). However, after adjusting for potential confounders, this last association was not significant (P = .175).

Conclusions: A CHA DS -VASc Score > 4 is present in half of octogenarians with NSTEACS and is associated with poorer outcomes. However, it is not an independent predictor of events and should not replace recommended tools for risk prediction in this setting.
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http://dx.doi.org/10.1111/ijcp.14082DOI Listing
June 2021

Coronary Plaque Erosion after Abemaciclib Treatment Onset: An Unknown Side Effect?

Thromb Haemost 2021 Jul 1;121(7):976-978. Epub 2020 Dec 1.

Instituto de Investigación Sanitaria (IIS-IP), Hospital Universitario de la Princesa, CIBERCV, Madrid, Spain.

The current article describes a 72-year-old woman who suffered an acute myocardial infarction due to plaque erosion (PE) 2 weeks after abemaciclib treatment onset due to advanced breast cancer. Abemaciclib is a cyclin-dependent kinase 4 and 6 inhibitor that has recently demonstrated efficacy and safety in advanced breast cancer. Of major concern, however, reported thromboembolic rates in randomized clinical trials testing this drug range from 0.6 to 5%. To the best of our knowledge this is the first thrombotic coronary side effect ever reported. We suggest that a treatment that increases thromboembolic risk, such abemaciclib, may have triggered PE in our patient, 15 days after abemaciclib initiation. New molecules are promising in cancer treatment; however, care must be paid to their potential cardiotoxic effects.
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http://dx.doi.org/10.1055/a-1326-7028DOI Listing
July 2021

Mitral Regurgitation and Prognosis After Non-ST-Segment Elevation Myocardial Infarction in Very Old Patients.

J Am Geriatr Soc 2019 08 2;67(8):1641-1648. Epub 2019 May 2.

Hospital Universitario de La Princesa, Madrid, Spain.

Background/objetctives: Mitral regurgitation (MR)after an acute coronary syndrome is associated with a poor prognosis. However,the prognostic impact of MR in elderly patients with non-ST-segment elevation myocardialinfarction (NSTEMI) has not been well addressed.

Design: Prospective registry.

Setting And Participants: The multicenter LONGEVO-SCA prospective registry included 532 unselected NSTEMI patients aged ≥80 years.

Measurements: MR was quantified using echocardiography during admission in 497 patients. They were classified in two groups: significant (moderate or severe) or not significant MR (absent or mild). We evaluated the impact of MR status on mortality or readmission at 6 months.

Results: Mean age was 84.3±4.1 years, and 308 (61.9%) were males. A total of 108 patients (21.7%) had significant MR. Compared with those without significant MR, they were older and showed worse baseline clinical status, with higher frailty, disability, and risk of malnutrition. They also had lower systolic blood pressure, higher heart rate, worse Killip class, lower left ventricular ejection fraction, and higher pulmonary pressure on admission, as well as more often new onset atrial fibrillation (all p values = 0.001). Patients with significant MR also had higher in-hospital mortality (4.6% vs. 1.3%, p = 0.04), longer hospital stay (median 8 [5-12] vs. 6 [4-10] days, p = 0.002), and higher mortality/readmission at 6 months (hazard ratio 1.54, 95% confidence interval 1.09-2.18, p = 0.015). However, after adjusting for potential confounders, this last association was not significant.

Conclusions: Significant MR is seen in one fifth of octogenarians with NSTEMI. Patients with significant MR have a poor prognosis, mainly determined by their baseline clinical characteristics. J Am Geriatr Soc 67:1641-1648, 2019.
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http://dx.doi.org/10.1111/jgs.15926DOI Listing
August 2019

Laser-interstitial thermal therapy compared to craniotomy for treatment of radiation necrosis or recurrent tumor in brain metastases failing radiosurgery.

J Neurooncol 2019 Apr 17;142(2):309-317. Epub 2019 Jan 17.

Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA.

Purpose: Many publications report laser-interstitial thermal therapy (LITT) as a viable alternative treatment to craniotomy for radiation necrosis (RN) and re-growing tumor occurring after stereotactic radiosurgery (SRS) for brain metastases. No studies to-date have compared the two options. The aim of this study was to retrospectively compare outcomes after LITT versus craniotomy for regrowing lesions in patients previously treated with SRS for brain metastases.

Methods: Data were collected from a single-institution chart review of patients treated with LITT or craniotomy for previously irradiated brain metastasis.

Results: Of 75 patients, 42 had recurrent tumor (56%) and 33 (44%) had RN. Of patients with tumor, 26 underwent craniotomy and 16 LITT. For RN, 15 had craniotomy and 18 LITT. There was no significant difference between LITT and craniotomy in ability to taper off steroids or neurological outcomes. Progression-free survival (PFS) and overall survival (OS) were similar for LITT versus craniotomy, respectively: %PFS-survival at 1-year = 72.2% versus 61.1%, %PFS-survival at 2-years = 60.0% versus 61.1%, p = 0.72; %OS-survival at 1-year = 69.0% versus 69.3%, %OS-survival at 2-years = 56.6% versus 49.5%, p = 0.90. Craniotomy resulted in higher rates of pre-operative deficit improvement than LITT (p < 0.01). On subgroup analysis, the single factor most significantly associated with OS and PFS was pathology of the lesion. About 40% of tumor lesions needed post-operative salvage with radiation after both craniotomy and LITT.

Conclusions: LITT was as efficacious as craniotomy in achieving local control of recurrent irradiated brain metastases and facilitating steroid taper, regardless of pathology. Craniotomy appears to be more advantageous for providing symptom relief in those with pre-operative symptoms.
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http://dx.doi.org/10.1007/s11060-019-03097-zDOI Listing
April 2019

Calcified neoatherosclerosis causing in-stent restenosis: prevalence, predictors, and implications.

Coron Artery Dis 2019 01;30(1):1-8

Cardiology Department.

Background: Neoatherosclerosis has emerged as a major cause of in-stent restenosis (ISR). Although this entity has been described as a unique process, optical coherence tomography (OCT) enables depiction of distinct morphologic patterns, including the presence of calcified sheets within the stent. We sought to assess prevalence, predictors, and implications of calcified neoatherosclerosis (cNA) as the cause of ISR.

Methods And Results: From January 2014 to August 2016, 75 consecutive patients with 81 ISR lesions with a clinical indication for revascularization were evaluated by OCT before reintervention. In 13 (16%) lesions, cNA was the predominant pattern of ISR, all of them presenting as very-late (>3 years) ISR. Patients with cNA were older (71±9 vs. 66±10 years, P=0.0157), had worse low-density lipoprotein control (97±29 vs. 81±30 mg/dl, P=0.0746), and received treatment with statins (54 vs. 85%, P=0.006) and angiotensin-converting-enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB) (31 vs. 65%, P=0.003) less frequently compared with patients with other patterns of ISR. Time from stent implantation to ISR [odds ratio (OR)=1.3; 95% confidence interval (CI): 1.1-1.6; P=0.01] and absence of treatment with statins (OR=11.3; 95% CI: 1.7-74; P=0.012) or ACEi/ARB (OR=7.4; 95% CI: 1.3-43; P=0.026) were associated independently with the presence of cNA. During reinterventions, ISR lesions with cNA obtained poorer angiographic (postintervention minimal lumen diameter 1.8±0.4 vs. 2.2±0.5 mm, P=0.0174) and OCT (final stent expansion 83±11 vs. 88±9%, P=0.0896) results.

Conclusion: In our cohort of consecutive patients with clinical ISR, one-sixth showed underlying cNA as the predominant substrate of restenosis. This unique underlying substrate is related to the time elapsed from stent implantation and the absence of previous treatment with statins or ACEi/ARB and is associated with poorer acute results after reintervention.
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http://dx.doi.org/10.1097/MCA.0000000000000669DOI Listing
January 2019

Response by Cecconi et al to Letter Regarding Article, "Wide QRS Complex Tachycardia: What the Algorithms Fear".

Circulation 2018 09;138(11):1174-1175

Department of Cardiology, Hospital Universitario de La Princesa, Instituto de Investigacion Sanitaria, Madrid, Spain.

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http://dx.doi.org/10.1161/CIRCULATIONAHA.118.036214DOI Listing
September 2018

Spontaneous Coronary Artery Dissection and Hypothyroidism.

Rev Esp Cardiol (Engl Ed) 2019 Aug 7;72(8):625-633. Epub 2018 Aug 7.

Servicio de Cardiología, Hospital Universitario de La Princesa, Madrid, Spain.

Introduction And Objectives: Thyroid hormone affects the metabolism of all tissues in the body. The aim of this study was to analyze the prevalence and implications of thyroid disorders in a cohort of consecutive patients with spontaneous coronary artery dissection (SCAD).

Methods: A total of 73 patients with SCAD were analyzed. Baseline characteristics and clinical outcomes were compared between euthyroid and hypothyroid patients. Subsequently, the prevalence of thyroid function abnormalities and the clinical characteristics of SCAD patients were compared with those in 73 patients with acute coronary syndrome but without SCAD, matched by age, sex, and presentation.

Results: Mean age was 55 ± 12 years and 26% had hypothyroidism. Compared with patients with normal thyroid function, patients with SCAD and hypothyroidism were all women (100% vs 69%, P = .01), more frequently had dissection in distal (74% vs 41%, P = .03) and tortuous coronary segments (68% vs 41%, p = .03), and more frequently received conservative medical management (79% vs 41%, P = .007). During a mean clinical follow-up of 4.1 ± 3.8 years, 23% of the patients had adverse cardiac events irrespective of thyroid function status. The prevalence of hypothyroidism was higher in patients with SCAD than in matched patients with acute coronary syndrome without SCAD (26% vs 8%, P = .004).

Conclusions: There is a high prevalence of hypothyroidism in patients with SCAD. Patients with SCAD and hypothyroidism are more frequently women, more frequently have distal dissections in tortuous vessels, and are more frequently managed with a conservative medical strategy.
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http://dx.doi.org/10.1016/j.rec.2018.06.031DOI Listing
August 2019

[Late atrial dissection and mitral annular pseudoaneurysm after valve replacement. Aetiological characteristics using multidetector CT].

Arch Cardiol Mex 2018 12 1;88(5):517-520. Epub 2018 Jun 1.

Servicio de Cardiología, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa (IIS-IP), Universidad Autónoma de Madrid, Madrid, España.

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http://dx.doi.org/10.1016/j.acmx.2018.05.006DOI Listing
December 2018

Wide QRS Complex Tachycardia: What the Algorithms Fear.

Circulation 2018 03;137(13):1407-1409

Department of Cardiology, Hospital Universitario de La Princesa, Instituto de Investigacion Sanitaria, Madrid, Spain.

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http://dx.doi.org/10.1161/CIRCULATIONAHA.118.033936DOI Listing
March 2018

Micra Implantation After Transcatheter Aortic Valve Implantation.

Rev Esp Cardiol (Engl Ed) 2018 Jun 31;71(6):485. Epub 2017 Oct 31.

Servicio de Cardiología, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria, Hospital Universitario de La Princesa (IIS-IP), Universidad Autónoma de Madrid, Madrid, Spain. Electronic address:

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http://dx.doi.org/10.1016/j.rec.2017.10.002DOI Listing
June 2018

Inflammation-dependent cerebrospinal fluid hypersecretion by the choroid plexus epithelium in posthemorrhagic hydrocephalus.

Nat Med 2017 Aug 10;23(8):997-1003. Epub 2017 Jul 10.

Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, USA.

The choroid plexus epithelium (CPE) secretes higher volumes of fluid (cerebrospinal fluid, CSF) than any other epithelium and simultaneously functions as the blood-CSF barrier to gate immune cell entry into the central nervous system. Posthemorrhagic hydrocephalus (PHH), an expansion of the cerebral ventricles due to CSF accumulation following intraventricular hemorrhage (IVH), is a common disease usually treated by suboptimal CSF shunting techniques. PHH is classically attributed to primary impairments in CSF reabsorption, but little experimental evidence supports this concept. In contrast, the potential contribution of CSF secretion to PHH has received little attention. In a rat model of PHH, we demonstrate that IVH causes a Toll-like receptor 4 (TLR4)- and NF-κB-dependent inflammatory response in the CPE that is associated with a ∼3-fold increase in bumetanide-sensitive CSF secretion. IVH-induced hypersecretion of CSF is mediated by TLR4-dependent activation of the Ste20-type stress kinase SPAK, which binds, phosphorylates, and stimulates the NKCC1 co-transporter at the CPE apical membrane. Genetic depletion of TLR4 or SPAK normalizes hyperactive CSF secretion rates and reduces PHH symptoms, as does treatment with drugs that antagonize TLR4-NF-κB signaling or the SPAK-NKCC1 co-transporter complex. These data uncover a previously unrecognized contribution of CSF hypersecretion to the pathogenesis of PHH, demonstrate a new role for TLRs in regulation of the internal brain milieu, and identify a kinase-regulated mechanism of CSF secretion that could be targeted by repurposed US Food and Drug Administration (FDA)-approved drugs to treat hydrocephalus.
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http://dx.doi.org/10.1038/nm.4361DOI Listing
August 2017

Cytomegalovirus encephalitis in a hemodialysis patient: a rare association.

New Microbiol 2017 Jan 7;40(1):70-71. Epub 2016 Nov 7.

Nephrology Department, Hospital Universitario de la Princesa, Madrid, España.

Haemodialysis patients are at greater risk of infections than individuals not on dialysis due to their immunosuppressive state caused by several factors (uraemia, vascular access, inflammation, malnutrition). However, infections affecting the central nervous system are not frequent in this population. We present the case of a 77-year-old man with end-stage renal disease who was admitted to the emergency department for a decreased level of consciousness and fever. Although the initial clinical suspicion oriented to a urinary infection, the lack of improvement forced us to perform a lumbar puncture. Five days after cerebrospinal fluid was cultured, cytomegalovirus was isolated and ganciclovir initiated.
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