A 55-year-old woman with a history of smoking since she was 15 years old and COPD grade II.
In May 2012, a chest computed tomography (CT) was performed, which showed a 27 mm nodule in the right upper lobe, with probable inactive primary rib.
He was diagnosed with a Pancoast tumor with an initial staging T4N0M0.
In July 2012 she received concomitant chemotherapy and radiotherapy.
She had a complete response and in October 2012, a right upper lobectomy videothoracoscopic and lymphadenectomy was performed.
The postoperative course was chest discomfort with septic shock of respiratory origin, heart failure, acute renal failure and required admission to the ICU for respiratory failure requiring total parenteral nutrition (TPN).
The patient was admitted 2 months later, and then underwent an exploratory laparotomy.
After observing an ileitis with an infectious and necrotic component along with ischemic loops and abundant fluid free of appearance he left ileosoid iliac valve, resection of approximately 60 cm of terminal ileum was performed.
Cultures were positive for staphylococci and gram-positive bacilli. Empirical intravenous treatment with piperacillin-tazo were initiated 4 g every 8 hours and vancomycin 1 g every 12 hours.
The patient was discharged with oral diet, hyperproteic supplements of enteral nutrition and multivitamin complex with minerals.
One month after discharge, the patient returned to the hospital with significant dyspnea, fever, nausea, vomiting, fever, asthenia, hypoxia and decay, accompanied by high output (1,500-2,000 mL per ileostomy).
A CT scan showed an abundant postsurgical collection in the right hemithorax with probable bronchopleural fistula and was admitted to the Thoracic Surgery Service.
He remained fixed in empyema and two "pigtail" drains were placed.
Antibiotic therapy was initiated with 4 g piperacillin-talocalizeate every 8 hours and vancomycin 1 g every 12 hours through a peripherally inserted central catheter (PICC) in the left upper limb.
No other central access was possible, as she presented complete thrombosis of the right jugular vein due to her long stay in the IVU.
In the general biochemistry, hypocalcemia (without treatment with Natecal® 2 tablets a day), hypokalemia and hypomagnesemia that did not present previously stood out.
Intravenous treatment with daily gluconate was initiated with Nutrition 1 ampoule of 10 mL every 6 hours, magnesium sulfate 2 grams every 24 hours and oral supplements of potassium (1 Boi Magnesium® every 8 hours), calcium (Na).
The patient continued with abundant liquid diarrhea due to the ileostomy with 1500 mL/day, referring anorexia, asthenia, decay and cramps.
Despite oral supplementation, she continued with indectable magnesium levels (< 0.6 mg/dL).
Given the low intake and poor oral tolerance to magnesium supplements, it was decided to start central parenteral nutrition through the PICC.
After the hydroelectrolytic normalization and proper nutritional support, the patient underwent surgery for closure of the bronchopleural fistula.
One week after surgery, the patient was taking nutritional supplements and oral diet, improving cramps and mood, without the need for antidepressant treatment.
Isolated hypomagnesemia took 7 days to recover and was discharged with oral nutritional supplements and magnesium at a dose of 1 tablet every 8 hours.
As magnesium levels did not completely normalize and given the good tolerance, the dose was increased to 2 tablets every 8 hours, with salts returning to normal limits.
Urinary leakage was ruled out, with undetectable magnesium levels in urine (< 1.81 mg/dL), confirming the diagnosis of intestinal malabsorption.
