Two cases of systemic capillary leak syndrome associated with COVID-19 in Japan

Systemic Capillary Leak Syndrome (SCLS) is a rare disease that causes severe distributive shock provoked by infection or vaccination. SCLS is clinically diagnosed by a triad of distributive shock, paradoxical hemoconcentration, and hypoalbuminemia. SCLS associated with coronavirus disease (COVID-19) in adults has not been reported yet in Japan. Case 1: A 61-year-old woman with fever, sore throat, headache, and muscle pain was admitted to our emergency department with suspected COVID-19. She had been diagnosed with SCLS 3 years earlier. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antigen and polymerase chain reaction (PCR) tests were negative at admission. She went into shock in the emergency department and was treated for septic shock. The following day, the SARS-CoV-2 PCR test was positive. She did not respond to fluid resuscitation and catecholamine and finally died. Case 2: A 58-year-old man was admitted to our hospital for de-saturation due to COVID-19. He got into shock on day 3. SCLS was suspected, and 5 g of intravenous immunoglobulin and 5% albumin were administered for sepsis treatment. He responded to the aggressive fluid therapy within 48 h and was finally discharged. COVID-19 can trigger SCLS, and early recognition of SCLS is crucial for survival. Primary care physicians should consider SCLS when they observe distributive shock and paradoxical hemoconcentration deviations from the natural course of COVID-19.

Ultrasound findings and specific intrinsic blood volume expansion therapy for neonatal capillary leak syndrome: report from a multicenter prospective self-control study

OBJECTIVE

Capillary leak syndrome (CLS) is characterized by severe systemic edema without specific treatment, resulting in a high mortality rate. This study investigated whether there is organ edema in neonatal CLS patients and specific treatment strategies to improve patient prognosis.

METHODS

Thirty-seven newborns diagnosed with CLS were included in this study. (1) Routine point-of-care ultrasound (POCUS) was used to identify whether the patients had visceral edema or fluid collection. (2) All patients were treated with 3% NaCl intravenously, and the clinical manifestations, laboratory indices and outcomes were compared before and after treatment.

RESULTS

(1) Diffuse severe edema was found in 92.0% of the patients. (2) The POCUS examination revealed that CLS patients exhibited significant visceral edema in addition to diffuse severe edema, which included pulmonary edema in 67.6%, cerebral edema in 37.8%, severe intestinal edema in 24.3%, severe myocardial edema in 8.1%, pericardial effusion in 5.4%, pleural effusion in 29.7% and peritoneal effusion in 18.9%. Two patients (5.45%) had only myocardial edema without other manifestations. (3) Before and after the intravenous injection of 3% NaCl, there were no significant differences in the serum sodium or potassium levels of CLS patients, while the hemoglobin and hematocrit levels were significantly lower after treatment (p < 0.01). Her plasma ALB concentration and arterial pressure returned to normal levels after the treatment was completed. (4) All the patients survived, and no side effects or complications were observed during or after treatment with 3% NaCl.

CONCLUSIONS

(1) In addition to diffuse severe edema, visceral edema and effusion are common and important clinical manifestations of neonatal CLS and need to be detected by routine POCUS. (2) The intravenous injection of 3% NaCl is a safe, effective and specific treatment strategy for neonatal CLS, with a survival rate of 100% and no adverse effects.

[A case of brucellosis complicated with capillary leak syndrome and multiple organ dysfunction syndrome]

Brucellosis can lead to pathological changes of multiple systems. Capillary leak syndrome (CLS) is a clinical syndrome caused by different reasons, mainly characterized by hypotension, hypoproteinemia and systemic edema. The condition is critical and the clinical manifestations are complex, and multiple organ dysfunction syndrome (MODS) may occur in severe cases. CLS caused by brucellosis is extremely rare. The diagnosis and treatment of a patient with brucellosis complicated with CLS and MODS was analyzed in this paper, in order to improve the knowledge of clinicians about brucellosis and its complications.

Trauma-induced capillary leak syndrome after penetrating chest injury: Manifestation of massive ascites and pulmonary secretions aggravated by transfusion

Trauma with prolonged shock can cause systemic capillary leak syndrome regardless of the site of injury and a transfusion can aggravate it. The systemic capillary leak induces both an abdominal compartment syndrome and pulmonary edema, and a transfusion can aggra-vate these sequelae within hours. In our case, 21-year-old man with a penetrating injury in his left thorax experienced delay in rescue and definitive surgery. To manage life-threatening shock, massive blood transfusion and crystalloids had been infused. Cardiopulmonary cerebral resuscitations were performed 2 times during the surgery. Massive amount of pulmonary secretions emitted from his airways with severe hypoxia along with development of massive ascites causing abdominal compartment syndrome, while the surgery was underway. After temporary abdominal closure, he was moved to the intensive care unit and underwent venovenous extracorporeal membranous oxygenation. He recovered without any notable complications. It is important to prevent and correct the shock rapidly by appropriate rescue, controlling the source and infusing less amount of crystalloid and transfusion.

Bilateral simultaneous non-arteritic ischaemic optic neuropathy: a rare complication of idiopathic systemic capillary leak syndrome (SCLS)

We report a case of bilateral symmetrical superior visual field defects in a 72-year-old man first reported during the recovery from systemic capillary leak syndrome (SCLS). During the acute illness, he required extensive and prolonged fluid replacement and mechanical ventilation for severe hypotension, shock and multiorgan dysfunction. His visual field defect and optic nerve changes were consistent with a diagnosis of ischaemic optic neuropathy. These remained unchanged over 3 years and he retained excellent 6/7.5 visual acuity bilaterally. We hypothesised the mechanism of bilateral segmental infarction of the optic nerve head to be caused by the hypercoagulable and hypovolaemic state, in addition to pre-existing vascular disease and hypertension. This case highlights the importance of including optic nerve examination in the management plan of SCLS, particularly in individuals with underlying vascular risk factors.

[Idiopathic systemic capillary leak syndrome: 2 cases with misleading presentation]

INTRODUCTION

Idiopathic systemic capillary leak syndrome (ISCLS) also known as Clarkson syndrome is a rare and sudden life-threatening entity. Three consecutive phases are described. A first non-specific prodromal phase often manifests as "flu-like" symptoms and precedes capillary leak phase with major hypovolemic and distributive shock leading to serious and frequent multiorgan dysfunction syndrome (MODS). Severe hypovolemia contrasts with edema, and hemoconcentration with hypoalbuminemia. ISCLS is characterized by these two clinical and biological paradoxes. Subsequent recovery phase exhibits organ function restoration along with interstitial/intravascular volumes normalization. The latter occurs spontaneously and systematically in patients surviving from leak phase.

OBSERVATIONS

We report here two ISCLS cases admitted in intensive care unit (ICU) both enhancing initial misdiagnosis possibly lowering prognosis and outcome. Our first 28-year-old female patient was admitted for « polycythemia vera » although hemoconcentration was attributable to hypovolemia. She presented circulatory arrest during the second bloodletting session and complicated with MODS. In and out ICU favorable outcome was noted on intravenous immunoglobulin therapy. A second 57-year-old male patient was admitted in ICU for severe "myositis" (myalgia and rhabdomyolysis) although rectified diagnosis retained compartment syndrome (muscular severe edema following capillary leak). Rapid and refractory hypovolemic shock appeared with subsequent MODS leading to death.

CONCLUSION

ISCLS pathophysiology remains unknown but certainly implies transitory endothelial dysfunction. Impossibility of randomized controlled trial for this exceptional disease led to based-on-experience therapeutic guidelines implying symptomatic care (cardiac output surveillance, nephroprotection, prudent fluid intake, prudent vasoactive amine use) and specific therapies (intravenous aminophylline during severe flares). Although enhancing controversial and even deleterious effects during the acute phase, polyvalent immunoglobulins are effective for relapse prevention. Syndromic diagnosis is difficult, but its precocious finding constitutes a key-element in better outcome before organ failure.

Idiopathic systemic capillary leak syndrome (Clarkson's disease) presenting with recurrent hypovolemic shock

A 49-year old male with a past medical history of myocardial infarction and compartment syndromes requiring fasciotomies presented on five occasions with hypovolemic shock. We describe his admissions and presumptive diagnoses which required large volumes of intravenous fluids, admission to intensive care for vasopressors and renal replacement therapy. The presentations were always precipitated by a prodrome of fatigue and pre-syncopal episodes. On his last admission, a diagnosis of Idiopathic systemic capillary leak syndrome (ISCLS), also known as Clarkson's Disease, was reached. He is currently receiving high dose intravenous immunoglobulins on a monthly basis.

[Neonatal capillary leak syndrome]

Neonatal capillary leak syndrome is a clinical syndrome with definite etiology or predisposing factors and has the manifestations of hypotension, hemoconcentration, hypoproteinemia, and systemic edema. This disease often has critical conditions and may lead to multiple organ failure and even death. There are still controversies over the diagnosis and treatment of this disease. This article summarizes the recent advances in the diagnosis and treatment of neonatal capillary leak syndrome, in order to improve the diagnosis and treatment of this disease among clinicians.

Idiopathic systemic capillary leak syndrome presenting as septic shock: A case report

BACKGROUND

Idiopathic capillary leak syndrome (Clarkson's Disease) is a rare angiopathy with a heterogenous phenotype that may present as distributive shock refractory to resuscitative management.

OBJECTIVE

We report a case of idiopathic systemic capillary leak syndrome presenting as septic shock.

METHODS

Structured case report and review of the literature.

RESULTS

A 27-year old man admitted to our institution with coryzal symptoms rapidly deteriorated with presumed sepsis, leading to intensive care unit admission. Following further deterioration, Idiopathic systemic capillary leak syndrome was considered and intravenous immunoglobulin administered, resulting in rapid improvement in the patient's clinical status.

CONCLUSIONS

Idiopathic systemic capillary leak syndrome is a rare and potentially life-threatening angiopathy that may present as, and should be considered in, refractory distributive shock. Administration of intravenous immunglobulin resulted in rapid recovery in this patient, and has been associated with positive outcomes in previous cases.

Clarkson disease - systemic capillary leak syndrome in a 6-year-old girl: case report

Idiopathic systemic capillary leak syndrome is a rare and life-threatening disorder of unknown pathology. It results from leakage of plasma from the intravascular into the interstitial space and is characterised by recurrent episodes of shock, weight gain and generalised oedema. Recurrent episodes of this syndrome are reported in a 6-year-old girl who presented with the characteristic symptoms of shock, oedema and hypoalbuminaemia. She was treated effectively with fluid resuscitation, ionotropes and intravenous immunoglobin. Since systemic capillary leak syndrome is rare and the diagnosis is often missed, further research regarding its pathogenesis and treatment in children is warranted.

Systemic capillary leak syndrome revealing a diffuse large B-cell lymphoma

We report on a 75-year-old woman who presented with recurrent episodes of hypotension, anasarca, renal failure, hypoalbuminaemia without proteinuria, suggestive of systemic capillary leak syndrome (SCLS). Further investigations led to a diagnosis of diffuse large B-cell lymphoma. Secondary SCLS associated with non-Hodgkin lymphoma is reviewed.

[Fluid resuscitation in a patient with severe hypovolemic shock and severe pulmonary capillary leak]

A male patient undergoing extracorporeal ultrasound lithotripsy developed the symptoms of dyspnea, low blood pressure, palpitations, chest tightness, and sweating, and a clinical diagnosis of pulmonary capillary leak and hypovolemic shock was made. Pulse indicator continuous cardiac output (PiCCO) technique was used for resuscitation according to the measurements of extravascular lung water index (EVLWI) and global end-diastolic volume index (GEDI). The patient showed low levels of cardiac output (CO) and GEDI with a peak EVLWI of 32 ml/kg and profuse pink and thin sputum overflow from the trachea. The high ventilator support parameters failed to correct low oxygen saturation. Restricted fluid infusion was used to reduce pulmonary edema. Colloidal solution was given when GEDI was below 500 ml/m(2), and the volume and fluid infusion rate were reduced for a GEDI higher than 500 ml/m(2). Pulmonary edema was gradually reduced after the treatments with improvement of lactic acid level and liver and kidney functions. Vasopressors were withdrawn 6 days later, mechanical ventilation was discontinued 10 days later, and tracheal intubation was removed 25 days later, after which the patient was discharged. In the treatment of the patient, PiCCO monitoring played an important role.

Capillary leak syndrome in a 5-month-old infant associated with intractable diarrhoea

Systemic capillary leak syndrome (SCLS) is a rare disorder of unknown pathophysiology, characterised by episodic life-threatening hypotension, haemoconcentration and hypo-albuminaemia. A 5-month-old child presented with episodes of relapsing diarrhoea, vomiting and hyponatraemia and developed generalised oedema during treatment. Clinical and laboratory findings were consistent with acute SCLS. Treatment with careful fluid replacement, fresh frozen plasma and aminophylline in the acute phase and teophylline and gingko biloba in the chronic phase led to sustained remission during follow-up for over 1 year. To our knowledge, this is the youngest case of SCLS in the literature and is unusual in that it presented with diarrhoea.

Narrative review: the systemic capillary leak syndrome

The systemic capillary leak syndrome (SCLS) is a rare disease of reversible plasma extravasation and vascular collapse accompanied by hemoconcentration and hypoalbuminemia. Its cause is unknown, although it is believed to be a manifestation of transient endothelial dysfunction due to endothelial contraction, apoptosis, injury, or a combination of these. Fewer than 150 cases of SCLS have been reported, but the condition is probably underrecognized because of its nonspecific symptoms and signs and high mortality rate. Patients experience shock and massive edema, often after a nonspecific prodrome of weakness, fatigue, and myalgias, and are at risk for ischemia-induced organ failure, rhabdomyolysis and muscle compartment syndromes, and venous thromboembolism. Shock and edema reverse almost as quickly as they begin, at which time patients are at risk for death from flash pulmonary edema during rapid fluid remobilization. Diagnosis is made clinically and by exclusion of other diseases that cause similar symptoms and signs, most notably sepsis, anaphylaxis, and angioedema. Acute episodes are treated with vasopressor therapy and judicious fluid replacement, possibly with colloid solutions for their osmotic effects, to prevent the sequelae of underperfusion. Between episodes, patients may be treated with theophylline and terbutaline, which clinical experience suggests may reduce the severity and frequency of acute episodes. Prognosis is uncertain, but patients who survive an initial severe SCLS episode are estimated to have a 10-year survival rate greater than 70%. Much remains to be learned about SCLS, and clinicians should consider the diagnosis in patients with unexplained edema, increased hematocrit, and hypotension.

Narrative review: the systemic capillary leak syndrome

The systemic capillary leak syndrome (SCLS) is a rare disease of reversible plasma extravasation and vascular collapse accompanied by hemoconcentration and hypoalbuminemia. Its cause is unknown, although it is believed to be a manifestation of transient endothelial dysfunction due to endothelial contraction, apoptosis, injury, or a combination of these. Fewer than 150 cases of SCLS have been reported, but the condition is probably underrecognized because of its nonspecific symptoms and signs and high mortality rate. Patients experience shock and massive edema, often after a nonspecific prodrome of weakness, fatigue, and myalgias, and are at risk for ischemia-induced organ failure, rhabdomyolysis and muscle compartment syndromes, and venous thromboembolism. Shock and edema reverse almost as quickly as they begin, at which time patients are at risk for death from flash pulmonary edema during rapid fluid remobilization. Diagnosis is made clinically and by exclusion of other diseases that cause similar symptoms and signs, most notably sepsis, anaphylaxis, and angioedema. Acute episodes are treated with vasopressor therapy and judicious fluid replacement, possibly with colloid solutions for their osmotic effects, to prevent the sequelae of underperfusion. Between episodes, patients may be treated with theophylline and terbutaline, which clinical experience suggests may reduce the severity and frequency of acute episodes. Prognosis is uncertain, but patients who survive an initial severe SCLS episode are estimated to have a 10-year survival rate greater than 70%. Much remains to be learned about SCLS, and clinicians should consider the diagnosis in patients with unexplained edema, increased hematocrit, and hypotension.

A case report of systemic capillary leak syndrome (Clarkson's disease)

Systemic capillary leak syndrome (SCLS) is a very rare disorder also known as Clarkson's disease. The condition is characterized by recurrent episodes of severe capillary hyperpermeability resulting in severe hemoconcentration, hypoalbuminemia, hypovolemia and shock. We describe a 41-year-old previously healthy man who was admitted to hospital on several occasions with rapidly developing hypovolemic shock accompanied by extreme hemoconcentration and hypoalbuminemia. Our case is similar to other reports describing patients with SCLS where the initial suspicions have been pointing towards septic shock. He received a combination of prophylactic treatment with theophylline, beta-agonists, immunoglobulins and statins but eventually died after a severe episode of SCLS that ended with recurrent cardiac arrest. Clinical autopsy revealed pulmonary edema and acute and chronical organic fluid overload. SCLS should be kept in mind when treating patients suffering from attacks of severe idiopathic edema and mimics recurrent septic shock where no pathogen is found. The pathogenesis is unknown and the attacks may be lethal.

[Risk factors for capillary leak syndrome in children with tetralogy after operation]

OBJECTIVE

To determine risk factors of capillary leak syndrome(CLS) in children with tetralogy after operation.

METHODS

Clinical data were retrospectively collected and analyzed from 32 tetralogy cases with CLS and 50 cases without CLS(control group), who received operation under cardiopulmonary bypass (CBP) in our hospital from October 2002 to December 2006. Risk factors with statistical significance were screened with univariate logistic regression analysis, independent risk factors of CLS were determined with multivariate logistic regression analysis. Postoperative outcome was compared between CLS group and control group.

RESULT

Logistic analysis showed that the risk factors for CLS were age(OR=6.783), duration of CBP(OR=4.756)and MGoon index (OR=3.826). There were statistical differences in injection of colloid, time of inotropic drugs and ventilation between CLS and control groups(P<0.01). Eight CLS cases underwent peritoneal dialysis and 2 CLS cases died.

CONCLUSION

The risk factors of CLS in children with tetralogy after CBP are age, duration of CBP and MGoon index.

Idiopathic systemic capillary leak syndrome (SCLS): case report and systematic review of cases reported in the last 16 years

'Idiopathic systemic capillary leak syndrome (SCLS), or Clarkson's disease is an unusual entity first described 45 years ago. It presents with recurrent episodes of shock due to leakage of the plasma, which is reflected by accompanying hemo-concentration, hypo-albuminemia and edema. We report the case of a young man with multiple episodes of shock with generalized edema and pleural effusion. An initial diagnosis of sepsis was made, but the lack of fever and absence of a demonstrable organism or source led to a revision of diagnosis to SLCS. The last review of this syndrome which analyzed 24 cases was published in 1990. Since then, 75 more cases have been reported. This article reviews these cases.

Influence of Volume Replacement with Colloids versus Crystalloids in Neonates on Venoarterial Extracorporeal Membrane Oxygenation on Fluid Retention, Fluid Balance, and ECMO Runtime

In this retrospective study, we compared the effects of colloid versus crystalloid fluid replacement on the clinical signs of capillary leakage syndrome in 30 neonates with pulmonary hypertension due to meconium aspiration syndrome on venoarterial membrane oxygenation (VA-ECMO). Before 2000, 15 neonates received volume replacement with a pasteurized plasma protein solution (3.8% albumin); after 2000, 15 neonates received normal saline. Patient characteristics and pre-ECMO values did not differ between the two groups. Total fluid balance was also equal. Diuretic use was significantly higher in the colloid group (p < 0.001). The chest wall soft-tissue index was significantly higher in the crystalloid group (p < 0.005), as were the ventilator settings at the end of the ECMO runtime (p < 0.05). Serum colloid osmotic pressure, albumin, urea nitrogen, and creatinine were significantly higher in the colloid group (p < 0.0001, < 0.0001, < 0.001, and < 0.05, respectively). Duration of VA-ECMO, of artificial ventilation after ECMO treatment, and the mortality rate did not differ between the two groups. We conclude that volume replacement with crystalloids in neonates on VA-ECMO aggravated the edema in a preexisting situation of capillary leakage syndrome, whereas volume replacement with colloids could impair the kidney function.

Syndrome œdémateux réfractaire : penser au syndrome d'hyperperméabilité capillaire idiopathique

Systemic Capillary Leak Syndrome (SCLS) is a rare and recently discovered disease. The diagnosis must be evoked in front of an hypovolaemic shock associated with a refractory anasarca. We report an observation of SCLS and then discuss the diagnostic and therapeutic difficulties. SCLS is diagnosed when a patient meet a compatible clinical situation with an hypoalbuminemia in spite of relative hemoconcentration. Evidence of a monoclonal gammapathy constitute an additional clue.

[Clarkson syndrome: a rare clinical condition characterized by generalized edema associated to monoclonal gammopathy]

Generalized edema is commonly due to cardiac failure, renal changes, hepatic and metabolic disturbances, or it can be idiopathic, i.e. primitive lymphedema. Here we describe a patient with several episodes of fluid extravasation characterized by hypotension, hemoconcentration and functional renal insufficiency. These findings, associated to a monoclonal gammopathy, lead to the diagnosis of systemic capillary leak syndrome or Clarkson Syndrome. This rare and perplexing disorder, characterized by a typical three-phase clinical feature, is due to an endothelium permeability alteration, rather responsible of these paroxysmal manifestations. Interleukin-2-pathway is considered as one of the underlying mechanisms. During acute phase the patient underwent therapy with plasma-expanders and glucocorticoids, although in quiescent phase we administered aminophylline, salbutamol and prednisone. After three months, the patient is asymptomatic.

Systemisches Kapillarlecksyndrom als Ursache eines Kompartmentsyndroms beider Unterschenkel und eines Unterarms

Systemic capillary leak syndrome is a rare disorder which causes recurrent episodes of hypovolemic shock due to a markedly increased plasma shift into the interstitium. Hemoconcentration, hypoalbuminemia and a monoclonal gammopathy are characteristic laboratory findings. A rare manifestation of this disease is a compartment syndrome with rhabdomyolysis and acute renal failure. We describe a patient who suffers from a compartment syndrome of both lower legs and the left forearm secondary to systemic capillary leak syndrome, and discuss the pathophysiological background.

Idiopathic systemic capillary leak syndrome: cutaneous involvement can be misleading

BACKGROUND

Systemic capillary leak syndrome (SCLS) is a severe disorder characterized by unexplained rapid transfer of considerable volumes of plasma from the intravascular to the extravascular compartment. For some cases of SCLS, no aetiology is evident and these cases are reported as idiopathic (ISCLS).

OBJECTIVES

To describe the cutaneous findings in 3 patients with ISCLS.

RESULTS

Cutaneous involvement consisted in sclerosis, livedo, purpura and photodistributed maculopapular erythematous rash. Dermal mucinosis was proven by biopsy in 1 patient. No underlying disease was diagnosed during follow-up.

CONCLUSION

The above-mentioned cutaneous findings can be present during acute attacks of ISCLS. They seem specifically related to the ISCLS and not indicative of an underlying disease.

[A case report of systemic capillary leak syndrome. Effective treatment with immunoadsorption and leukotriene antagonist]

Systemic capillary leak syndrome (SCLS) is an unusual condition characterized by periodic leakage of plasma proteins through the capillary wall, leading to hypoalbuminaemia, hypovolaemia, haemoconcentration and shock. The pathogenesis is unknown and the mortality high. Various prophylactic treatments have been tried but are difficult to evaluate because of the unpredictable course of the disease. We describe one patient with frequent attacks of SCLS, that did not respond to any kind of treatment regimens over a period of nine years. Subsequently, therapy with regular immunoadsorption of plasma proteins and a leukotriene receptor antagonist was attempted. This treatment has now been given for six years and only one episode of capillary leakage has occurred. The effect may be due to removal of pathogenic immunoglobulins or immune complexes and/or inhibition of leukotriene-induced capillary leakage.

52-j�hrige Patientin mit rezidivierendem Schock unklarer Genese, H�mokonzentration und Hypalbumin�mie

Systemic capillary leak syndrome is a rare life threatening condition of unknown etiology. It was firstly described by Clarkson et al in 1960. It is characterised by recurrent attacks of severe hypovolemic shock, hemoconcentration and hypalbuminemia, caused by a sudden reversible increase in capillary permeability and shift of fluid and macromolecules to the extravascular compartment. A monoclonal paraprotein is always detectable in the serum of patients, without evidence of multiple myeloma. We describe the course of a patient, who died at a severe attack despite of prophylactic treatment after 25 months of illness. Application of cytostatics should be considered if prophylactic treatment fails even if there is no evidence of progression to multiple myeloma.

Vessel injury and capillary leak

OBJECTIVE

To understand the mechanism of pathologic capillary leak in the critically ill patient.

DESIGN

Review of normal and altered physiology of the microvasculature. Review of recent literature describing pathogenesis, mediators, and interventions influencing capillary leak and microvascular repair.

SETTING

In vitro and in vivo studies, the latter including animal and human subjects.

MEASUREMENTS AND MAIN RESULTS

Capillary leak with resultant edema develops in the critical care setting on the basis of perturbations in Starling's equation, primarily as a result of increased capillary permeability to larger molecules. This process is most likely fueled by inflammatory mediators or mechanical stress. Attempts to prevent or treat this process remain largely unsuccessful; resuscitation is more often symptomatic than therapeutic. Models of microvascular repair focus on discrete injury and may not be applicable to the recovery of capillary damage secondary to a systemic leak

CONCLUSIONS

Our understanding of capillary leak syndrome remains fragmented and weighted toward specific mediators contributing to the leak. The implications of extensive edema and the mechanism by which it resolves continue to be the subject of speculation rather than study.

Intraperitoneal photodynamic therapy causes a capillary-leak syndrome

BACKGROUND

In patients undergoing intraperitoneal (IP) photodynamic therapy (PDT), the combination of aggressive surgical debulking and light therapy causes an apparent systemic capillary-leak syndrome that necessitates significant intensive care unit (ICU) management after surgery.

METHODS

From May 1997 to May 2001, 65 patients underwent surgical debulking and PDT as part of an ongoing phase II trial for disseminated IP cancer. Perioperative data were reviewed retrospectively, and statistical analyses were performed to determine whether any identifiable factors were associated with the need for mechanical ventilation for longer than 1 day and with the occurrence of postoperative complications.

RESULTS

Forty-three women and 22 men (mean age, 49 years) were treated. Operative time averaged 9.8 hours, and mean estimated blood loss was 1450 mL. The mean crystalloid requirement for the first 48 hours after surgery was 29.3 L, and 49 patients required blood products. Twenty-four patients were intubated for longer than 24 hours, with a mean of 8.3 days for those intubated longer than 1 day. The median ICU stay was 4 days. Overall, 110 complications developed in 45 (69%) of the 65 patients. Significant complications included 6 patients with acute respiratory distress syndrome, 28 patients with infectious complications, and 4 patients with anastomotic complications. Statistical analyses revealed that surgery-related factors were significantly associated with these complication outcomes.

CONCLUSIONS

Patients who undergo surgical debulking and IP PDT develop a significant capillary-leak syndrome after surgery that necessitates massive volume resuscitation, careful ICU monitoring, and, frequently, prolonged ventilatory support.

Regulation of interleukin-2-induced vascular leak syndrome by targeting CD44 using hyaluronic acid and anti-CD44 antibodies

Previous studies from our laboratory demonstrated that CD44 knockout mice exhibit marked decrease in interleukin (IL)-2-induced vascular leak syndrome (VLS), thereby suggesting a role for CD44 in VLS. In the current study, we tested whether treatment with mAbs against CD44 or hyaluronic acid (HA), the ligand for CD44, can abrogate IL-2-induced VLS. Interestingly, administration of HA caused a marked increase in IL-2-induced VLS in the lungs and liver of C57BL/6 mice. In contrast, use of anti-CD44 mAbs reduced IL-2-induced VLS in the lungs and liver. Treatment with HA enhanced the IL-2-induced edema and lymphocytic infiltration in these organs and caused marked increase in IL-2-induced lymphokine-activated killer (LAK) cell activity, whereas administration of anti-CD44 mAbs caused a significant decrease in edema and LAK activity but similar levels of lymphocytic infiltration. Anti-CD44 mAbs, but not HA caused marked downregulation of CD44 expression on LAK cells. These studies demonstrate that molecular targeting of CD44 may serve as a useful tool to selectively alter the LAK activity and to prevent endothelial cell injury induced by IL-2.

Systemic capillary leak syndrome

Systemic capillary leak syndrome (SCLS) is characterized by recurrent hypovolemic shock attributable to increased systemic capillary leakage. A 46-year-old man was admitted to our hospital because of recurrent episodes of generalized edema with hypovolemic shock. Blood laboratory data revealed severe hypoproteinemia with a small monoclonal IgG-kappa protein. These findings suggested strongly the diagnosis of SCLS. A regimen with steroid pulse therapy was tried; however, intravascular overloading accompanied by the recruitment of the initially extravasated fluids resulted in acute pulmonary edema. Intensive care and careful monitoring of fluid volume are required in SCLS.

Systemic capillary leak syndrome

A 40-year-old woman was referred to our hospital with severe hypovolemic shock and anasarca. The laboratory findings showed marked hemoconcentration and a decrease in total serum protein with the presence of monoclonal IgG-lambda. She had had a similar episode of generalized edema 2 years previously. We diagnosed the patient as having typical systemic capillary leak syndrome (SCLS) and she improved gradually after infusion of albumin-containing fluid. SCLS is a very rare condition caused by unexplained episodic capillary hyperpermeability. Its treatment has remained largely supportive and the prognosis is generally poor. Awareness of SCLS is necessary for improvement of the outcome.

[Immunonutrition with omega-3-fatty acids. Are new anti-inflammatory strategies in sight?]

In the early phase of sepsis and SIRS an overwhelming activation of humoral and cellular mediator systems can alter vascular resistance and causes capillary leakage increasing the risk of organ dysfunction. omega-6-arachidonic acid is released from lipid pools of cellular membranes during inflammation and is metabolized to pro-inflammatory prostaglandins and leukotriens, which are key mediators in the pathogenesis of organ dysfunction. omega-3-eicosapentaenoic acid-derived lipid mediators present altered biologic effects. Thus, omega-3-fatty acid application enables anti-inflammatory intervention on the level of lipid mediators. The current article reviews experimental and clinical data on omega-3-fatty acids. Besides the decrease of pro-inflammatory mediators, fish oil supplementation lowered post operative infection rates and showed a tendency to reduce hospital stay in surgical patients. It is believed that the decreased formation of LTB4 and TXA2 during sepsis after administration of omega-3-fatty acids accounts for improved microcirculatory perfusion and declined lactate acidosis.