Early released lipid-soluble cardiodepressant factor and elevated oestrogenic substances in human septic shock

Severe malaria: lessons learned from the management of critical illness in children

Two hypotheses have recently been raised to explain the metabolic acidosis (increased blood acidity) of severe malaria, and both are relevant to treatment. The first suggests that a decreased blood volume (hypovolaemia) has an important role in severe malaria; following this, treatment should be based on the current standard paediatric management of acidosis in children with features of cardiovascular compromise. The second hypothesis contends that acidosis in malaria has a metabolic cause and proposes treatment with dichloroacetate. Both hypotheses are plausible and are not mutually exclusive. In truth, the risks and benefits of either treatment are uncertain, and will remain so until large multicentre, randomised controlled trials provide appropriate supportive evidence. As both views involve complex physiological rationales, beyond the usual scope of this journal, I attempt here to present the largely academic aspects of these hypotheses within the practical and contextual aspects of childhood severe malaria.

Role of interleukin 6 in myocardial dysfunction of meningococcal septic shock

BACKGROUND

Myocardial failure has a central role in the complex pathophysiology of septic shock and contributes to organ failure and death. During the sepsis-induced inflammatory process, specific factors are released that depress myocardial contractile function. We aimed to identify these mediators of myocardial depression in meningococcal septic shock.

METHODS

We combined gene-expression profiling with protein and cellular methods to identify a serum factor causing cardiac dysfunction in meningococcal septic shock. We identified genes that were significantly upregulated in blood after exposure to meningococci. We then selected for further analysis those genes whose protein products had properties of a myocardial depressant factor--specifically a 12-25 kDa heat-stable protein that is released into serum shortly after onset of meningococcal infection.

FINDINGS

We identified 174 significantly upregulated genes in meningococcus-infected blood: six encoded proteins that were of the predicted size and had characteristics of a myocardial depressant factor. Of these, interleukin 6 caused significant myocardial depression in vitro. Removal of interleukin 6 from serum samples of patients with meningococcaemia and from supernatants of inflammatory cells stimulated by meningococci in vitro abolished the negative inotropic activity. Furthermore, concentrations in serum of interleukin 6 strongly predicted degree of myocardial dysfunction and severity of disease in children with meningococcal septic shock.

INTERPRETATION

Interleukin 6 is a mediator of myocardial depression in meningococcal disease. This cytokine and its downstream mediators could be a target for future treatment strategies.

Characterization of a myocardial depressant factor in meningococcal septicemia

OBJECTIVE

Identification and characterization of myocardial depressant factors present in meningococcal septicemia.

DESIGN

Laboratory investigation of myocardial depression that used isolated cardiac myocytes as an model of cardiac contractile function.

SETTING

University hospital and laboratories.

PATIENTS

Children with severe meningococcal septic shock requiring intensive care.

ANIMALS

Myocytes obtained from adult male Sprague-Dawley rats.

INTERVENTIONS

Serum samples obtained from the acute phase of sepsis were evaluated for the presence of myocardial depressant activity. Further characterization of the myocardial depressant factor was undertaken by using cell culture supernatants from whole blood and peripheral blood mononuclear cells that had been exposed to heat-killed meningococci.

MEASUREMENTS AND MAIN RESULTS

Myocardial depressant activity was measured by using isolated rat left-ventricular myocytes. Changes in amplitude of contraction and in the speed of contraction and relaxation were determined after cells were exposed to various stimuli. Serum from patients with meningococcal disease had myocardial depressant activity. This activity was also present in whole blood and peripheral blood mononuclear cells exposed to meningococci. Myocardial depressant activity was found to be heat stable, proteinaceous, and of a molecular weight range of 10-25 kDa. The activity did not elevate concentrations of cyclic guanylic acid. Lipopolysaccharide-binding protein augmented the release of myocardial depressant factor by peripheral blood mononuclear cells exposed to meningococci.

CONCLUSIONS

Myocardial depression in meningococcal sepsis is mediated in part by circulating myocardial depressant factors. Myocardial depressant factors are also released when whole blood or peripheral blood mononuclear cells of healthy donors are exposed to heat-killed meningococci. Release of the factors appears to be mediated through endotoxin-induced activation of peripheral blood mononuclear cells, since lipopolysaccharide-binding protein augments release in a dose-responsive manner. Partial physicochemical characterization of the factors has been achieved.

Myocardial dysfunction in septic shock

Over the last decade, it has become clear that myocardial depression, like vascular dysfunction, is typical of human septic shock. Human septic myocardial depression is characterized by reversible biventricular dilatation, decreased ejection fraction, and decreased response to fluid resuscitation and catecholamine stimulation (in the presence of overall hyperdynamic circulation). A circulating myocardial depressant substance, not myocardial hypoperfusion, is responsible for this phenomenon. This substance has been shown to represent low concentrations of TNF-alpha and IL-1 beta acting in synergy on the myocardium through mechanisms that include NO and cGMP generation. Despite major advances in our understanding of the hemodynamics and pathogenesis of cardiac dysfunction in sepsis, successful attempts to modulate these mechanisms to improve clinical outcomes in human trials have not been demonstrated to date. For the moment, the therapeutic approach to the patient with cardiac dysfunction in distributive or septic shock must be primarily aimed at reestablishing adequate organ perfusion and oxygen delivery by vigorous fluid resuscitation and vasopressor or inotropic support. In the long term, however, only continued research regarding the cellular mechanisms of organ dysfunction, including septic myocardial depression, will lead to successful therapeutic strategies. These strategies will likely involve direct manipulation of intracellular signaling processes that lead to organ dysfunction as manifested by septic myocardial dysfunction and septic shock.

Tumor necrosis factor alpha and interleukin 1beta are responsible for in vitro myocardial cell depression induced by human septic shock serum

Previous studies have demonstrated the presence of myocardial depression in clinical and experimental septic shock. This depression is associated with the presence of a circulating myocardial depressant substance with physical characteristics consistent with cytokines. The present study utilized an in vitro myocardial cell assay to examine the role of various human recombinant cytokines, including tumor necrosis factor (TNF)alpha and interleukin (IL)1beta, in depression of cardiac myocyte contractile function induced by serum from humans with septic shock. The extent and velocity of electrically paced rat cardiac myocytes in tissue culture was quantified by a closed loop video tracking system. Individually, TNF-alpha and IL-1beta each caused significant concentration-dependent depression of maximum extent and peak velocity of myocyte shortening in vitro. In combination, TNF-alpha and IL-1beta induced depression of myocardial cell contractility at substantially lower concentrations consistent with a synergistic effect. Using immunoabsorption, removal of both TNF-alpha and IL-1beta (but not either alone) from the serum of five patients with acute septic shock and marked reversible myocardial depression resulted in elimination of serum myocardial depressant activity. IL-2, -4, -6, -8, -10, and interferon gamma failed to cause significant cardiac myocyte depression over a wide range of concentrations. These data demonstrate that TNF-alpha and IL-1beta cause depression of myocardial cell contraction in vitro and suggest that these two cytokines act synergistically to cause sepsis-associated myocardial depression in humans.

Systemic inflammatory response syndrome: septic shock

The systemic inflammatory response syndrome (SIRS) is the body's response to a multitude of chemical mediators. Conditions inciting the release of these mediators include bacterial sepsis, viremia, pancreatitis, trauma, neoplasia, heat stroke, and many others. The key to the successful management of SIRS lies in anticipation and not reaction. Resuscitation of the patient to supranormal levels, coupled with aggressive monitoring and support of target organs are essential.

Serum steroids and prolactin during and after major surgical trauma

Serum levels of cortisol, dehydroepiandrosterone (DHA) and its sulfate (DHAS), 4-androstene-3,17-dione (A-4), 17-alfa-hydroxy-progesterone (17 OHP), testosterone (T, only in males), unconjugated (E1) and total estrone (tE1 greater than 85% estrone sulfate) were studied in six male and two female patients before, during and up to 30 days after aortic graft surgery. All steroids except 17 OHP decreased following induction of anesthesia but, except for testosterone, rose again during surgery to preoperative levels or slightly above. Extremely high peak values for E1 and tE1 and a less pronounced peak for cortisol were noted on postoperative day 2; after that, the levels of these steroids returned to normal. The levels of 17-OHP, DHA and DHAS decreased after surgery and were below preoperative values from postoperative day 4 to day 16 or (DHAS) day 30. In males, 17 OHP showed a pronounced peak 30 min after initiation of surgery, but decreased after that to below preoperative values. Testosterone levels decreased further during surgery and remained very low until postoperative day 16. Major surgical trauma has a rapid, profound and long-lasting effect on gonadal activity, as judged from decreased testosterone levels, while the effect on adrenal steroids is less pronounced. Adrenal delta 4 and delta 5-steroids showed different patterns in the postoperative period, indicating differences in their regulation. The highly elevated estrogen levels on postoperative day 2 probably reflect either transiently elevated peripheral aromatization or decreased estrogen metabolism rather than increased levels of substrate steroids (A-4). The biological significance of this remains to be elucidated.

Effect of the aromatase inhibitor, 4 hydroxyandrostenedione, on the endotoxin-induced changes in steroid hormones in male rats

The increase in circulating estrogen concentrations that follows injection of Escherichia coli endotoxin (Endo) may be due to increased aromatase activity. We have therefore analysed the effect of the aromatase inhibitor, 4 hydroxyandrostenedione (4OHA) on the steroid hormone response of male rats, particularly the dramatic increase in estrogens and decrease in androgens, induced by Endo. The concentrations of corticosterone (B), progesterone (P4), 17 alpha hydroxyprogesterone (17 alpha OHP4), androstenedione (delta 4), testosterone (T), estrone (E1) and estradiol (E2) were determined 2 hours after injection of increasing doses of 4OHA with and without Endo. The increase in serum estrogen concentrations and drop in serum androgen levels in response to Endo were blocked by a single dose of 4OHA. The effect of 4OHA appeared to be dose dependent. Low doses (30 mg/kg and 50 mg/kg) induced significant changes in the estrogen and androgen responses, but the high dose (100 mg/kg) blocked all changes in sex steroids induced by Endo. 4OHA did not alter the Endo-induced changes in other steroids.

Endotoxin induced changes in serum estrogen in male rats: influence of testicular maturation

The influence of acute endotoxin (Endo) administration on adrenal and testicular serum hormones, corticosterone (B), progesterone (P4), 17 alpha OH progesterone (17 alpha OH P4), androstenedione (delta 4), testosterone (T), estrone (E1) and estradiol (E2) was studied in male rats aged 8, 12 and 15 weeks. The present study confirms that the concentrations of circulating steroid hormones in male rats vary with age, and indicate that the adrenal glands mature before the testes. The steroid response to Endo is age-dependent. B, P4, 17 alpha OH P4 was increased and T decreased in all animals. But, there was a very significant increase in estrogens (E1 and E2) and a decrease in delta 4 only in male rats aged 12 weeks and over. The lack of an estrogen response to Endo injection in 8 week-old rats may indicate that the reduced sensitivity (refractory period) to Endo (which has been reported to last until 21 days of age) continues longer. The reduced sensitivity to Endo which occurs in young rats could be due in part to the absence of adrenal-testicular cooperation as a result of partial testicular immaturity.

Influence of prostacyclin and two metabolites on the contractility of cultured rat heart cells

Heart cells were cultured from newborn rats, and the contractile activity (CA) and beating frequency (BF) were recorded using an electrooptical technique. Myocardial cells were found to be highly sensitive to Prostacyclin (PGI2) since a 10(-11) M concentration increased the BF and CA. Increasing the concentration (2.7 x 10(-10) to 2.7 x 10(-8) M) resulted in a dose-dependent decrease in CA and BF. The stable product of the non-enzymatic degradation of PGI2 (6 Keto PGF1 alpha) was found to be completely ineffective, and the stable product of the enzymatic PGI2 metabolism (6 Keto PGE1) exerted only a dose-dependent (10(-6) to 10(-5) M) positive inotropic effect. PGI2 was also effective in the presence of serum instead of culture medium but the decrease in CA was less marked than in culture medium, probably due to protein-binding of the drug. When the CA was decreased by PGI2, perfusion with the intracellular calcium-releasing and phosphodiesterase inhibiting agent, caffeine, reversed the PGI2-induced negative inotropic effect. These results suggest that PGI2 participates in the regulation of the heart cell contractility. Its metabolite 6 Keto PGEI could also influence heart cell contractility but higher concentrations are needed. Moreover myocardial intracellular calcium availability seems to be influenced by PGI2.

Elevated oestrogen and reduced testosterone levels in the serum of male septic shock patients

The variations in oestrogen levels which occur in men with septic shock were determined and analysed in terms of the changes seen in the levels of other steroid hormones of testicular and adrenal origin. The concentrations of the hormones, oestrone (E1), oestradiol (E2), testosterone (T), delta 4-androstenedione (delta 4), cortisol (F) and progesterone (P4) were determined by radioimmunoassay. The serum levels of cholesterol, triglycerides, phospholipids and non-esterified fatty acids (NEFAs) were also determined. Two groups of male septic shock patients were studied within the first 24 h following the admission to the Intensive Care Unit. Group I (n = 24) patients died. Group II (n = 22) patients recovered. Both groups were compared to a control group (n = 44) of healthy men. In group I patients, serum E1 levels were 3900 +/- 900 pmol/l, 12-fold higher than controls (296 +/- 22 pmol/l) [P less than 0.001], serum E2 levels were 880 +/- 170 pmol/l, 6-fold above control levels (158 +/- 30 pmol/l) [P less than 0.001] and serum T levels were 1.7 +/- 0.3 nmol/l, 11-fold lower than in controls (18.7 +/- 1.9 nmol/l) [P less than 0.001]. Serum P4 and F levels were slightly increased (P less than 0.05) and delta 4 androstenedione levels were unchanged. Groups II serum estrogen levels (814 +/- 350 pmol/l) [P less than 0.01] were higher than controls and serum T levels were 2-3 times less than control levels (5.5 +/- 2 nmol/l) [P less than 0.01]. The group II serum P4, F and delta 4 androstenedione levels did not differ from control levels. The levels of cholesterol, triglycerides, phospholipids and NEFAs were all decreased to similar, significant, degrees in both groups of shock patients. The dramatic increase in E1 levels associated with the decrease in T suggests an adrenal-testicular relationship with possible potentiation of aromatization of adrenal or testicular androgens in men in septic shock. The determination of serum E1 and T during septic shock in men could form the basis for prognostic estimations of septic shock severity and for a new therapeutic approach to shock.

Endotoxin-induced changes in sex steroid hormone levels in male rats

Intravenous administration of Escherichia coli endotoxin (ENDO) was found to induce profound time and dose dependent changes in the serum steroid hormones, oestrone (E1), oestradiol (E2), corticosterone (B), progesterone (P4), 17 alpha-OH progesterone (17 alpha OHP4), and testosterone (T) of intact male rats. These changes were rapid, with a maximal response at 2 h and a return to close to normal values by 4 h. Non-lethal doses (0.01-2 mg/kg) of ENDO induced large increases in oestrogens (3-9-fold), P4 (4-fold) and B (2-3-fold) and decreased serum T (2-fold). The greatest increase in E2 level was seen with an ENDO dose of 2 mg/kg. Serum E1, E2 and T did not change in response to lethal ENDO doses (4-8 mg/kg); B, P4 and 17 alpha OHP4 levels alone were moderately elevated. Systemic mean arterial pressure was unchanged, except at the highest ENDO dose used. Thus, the hormonal responses are unlikely to be the result of hemodynamic changes. Low doses of ENDO did not produce an increase in serum E1 and E2 in adrenalectomized or orchidectomized rats. These results indicate that oestrogens are largely produced in the testis. The aromatization of the testicular and adrenal androgens can be stimulated by glucocorticoid.

Considerations in the therapy of septic shock

In summary, gram-negative sepsis is unique among infectious illnesses in that it is a disorder that recruits endogenous physiologic processes to mediate tissue injury. This host damage frequently occurs in the absence of microbial invasion of affected organs. The resultant hypotension, coagulation defects, and organ dysfunction may be associated with serious morbidity or may contribute to mortality. Ultimately, however, mortality in patients with septic shock depends on the nature of the infectious process and the severity of the underlying illnesses. Unfortunately, attempts to aggressively treat septic patients with a formidable array of antimicrobial and pharmaceutical agents have not remarkably reduced mortality. Nor does it seem likely that future elucidation of the inflammatory mechanisms of sepsis will lead to the generation of therapeutic agents that will significantly improve survival. On the other hand, prophylactic or therapeutic modalities that deter colonization or invasion by pathogenetic organisms or that alter the ability of pathogens to evoke adverse host responses may be more likely to impact on the incidence and morbidity of gram-negative bacillary infections. Until modifications in the initial interactions of gram-negative pathogens with human hosts can be realized, the mortality of gram-negative sepsis is likely to remain high.

Total and unbound cortisol-, progesterone-, oestrone- and transcortin-binding activities in sera from patients with myocardial infarction: evidence for differential responses of good and bad prognostic cases

Day-of-admission sera from myocardial infarction patients (MI) and patients with cardiopathies other than MI (non-MI) were analysed for total and unbound cortisol (F), progesterone (P4), oestrone (E1), and corticosteroid binding activities (CBG). The MI who survived (n = 28) showed high increases of F, P4 and E1 compared to healthy controls. By contrast, the MI who died within 10 days of admission (n = 6) had unchanged F and less increased P4 and E1 than survivors. The non-MI (n = 6) had higher F and E1 than controls but normal P4. The unbound steroids were increased in all patients: however, the MI who died showed much smaller rises than survivors (P less than 0.001 for unbound F and E1 increases in survivors vs. deceased). The CBG activity was in all MI lower than in normals (P less than 0.001) but unchanged in non-MI. These results are discussed in terms of the potential significance of unbound plasma steroids as predictors of MI severity.