Septic shock: an atypical complication of alimentary tract duplication

Alimentary tract duplications are heterogenous congenital anomalies of the digestive tract. Their form of presentation is varied, and they may lead to different complications, depending on their natural course. Infection is a rare complication, but it cannot be ignored because of its severity. Here we describe the case of an otherwise healthy 2-year-old girl with an atypical complication of alimentary tract duplication: septic shock. She initially consulted due to abdominal distension and pain associated with a palpable abdominal mass. The imaging studies showed a partial fluid septation in the right side of the abdomen. During hospitalization, an intratumoral infection developed, which progressed to septic shock. The patient responded favorably to medical treatment for shock, and surgical resection was subsequently performed. The pathology report confirmed the presence of alimentary tract duplication.

Septic Shock After Endoscopic Sleeve Gastroplasty: A Post-procedural Complication?

BACKGROUND

ESG is a safe and effective technique in the obesity management, usually indicated in class I and II obesity. It is also an acceptable treatment in patients with class III obesity who have high surgical risk or refuse surgery. This procedure results in a significant weight loss and important improvement in metabolic comorbidities. Nevertheless, there are several procedure-related complications. Few cases of gastric perforation following ESG have been reported. We present a case of septic shock after ESG with preoperative diagnostic uncertainties.

METHODS

We present the case of a 54-year-old male with a BMI of 43.6 kg/m2 who underwent ESG 7 days before in an external center. The patient came to the emergency department presenting abdominal pain, nausea, and vomiting since the day after the procedure. Physical examination revealed hemodynamic instability, altered level of consciousness, diffuse abdominal pain, and a painful umbilical lump due to a complicated umbilical hernia. Emergent surgery was decided after preoperative assessment.

RESULTS

Intraoperative gastroscopy was performed, viewing a gastric ischemic ulcer covered with fibrin and a mucosal defect and suspecting a covered gastric perforation. Firstly, we performed an open approach to the complicated umbilical hernia. Subsequently, an exploratory laparoscopy was performed through the hernial ring, where a fibrin-covered area was evidenced in the anterior face of the gastric body, adhered to the round ligament by a transmural suture of the ESG. Additionally, multiple transmural sutures were observed adhered to the greater omentum and lesser sac and an intramural hematoma in the greater gastric curvature. No intra-abdominal free fluid was evidenced. A laparoscopic barbed suture of the area covered with fibrin was performed, after its release from the round ligament. The adhesions of the sutures and metallic material from the ESG were released. Finally, two abdominal drains were placed in the anterior and posterior gastric face. The patient presented superficial incisional surgical site infection and was discharged 6 days after laparoscopic surgery.

CONCLUSIONS

ESG is a novel procedure, which has proven to be an effective alternative in the treatment of obesity. However, this technique may have major complications that can require urgent surgery.

A woman in her fifties with a post-operative infection, generalised rash and organ failure

Background

Toxic shock syndrome (TSS) is a rare but potentially life-threatening disease caused by superantigen-producing Gram-positive bacteria such as Staphylococcus aureus and Streptococcus pyogenes. Staphylococcal TSS received special attention from 1978 to 1981, when an epidemic was observed associated with the use of hyper-absorbent tampons. Today the disease is rare and generally not related to menstruation, but can occur postpartum or in post-surgical wounds, intrauterine devices (IUDs), burns or other soft tissue injuries, mastitis or other focal infections. The annual incidence of staphylococcal TSS is around 0.5/100 000 and around 0.4/100 000 for streptococcal TSS. The mortality in menstrual-related cases is < 5 % and up to 22 % in non-menstrual related cases.

Case presentation

This article presents a case of a middle-aged woman who developed symptoms of toxic shock syndrome five days after elective breast cancer surgery, with high fever, multiorgan failure and a characteristic desquamation of the palms.

Interpretation

Toxic shock syndrome is a potentially lethal, toxin-mediated disease. Symptoms develop quickly, within hours. Early recognition and appropriate surgical management, intensive care and antibiotics are therefore important to reduce mortality and sequelae.

Pylephlebitis combined with septic shock secondary to acute nonperforated appendicitis: a case report

Pylephlebitis, which is a type of septic thrombophlebitis of the portal vein, is a rare and life-threatening complication that commonly occurs following appendicitis. However, nonspecific abdominal complaints and fever can impede the diagnosis of pylephlebitis. Timely use of appropriate antibiotics and anticoagulants is paramount for treating this condition. We present a case of pylephlebitis and septic shock caused by acute nonperforated appendicitis. A 32-year-old man presented with migratory right lower abdominal pain. Blood cultures showed the presence of Escherichia coli. Blood test results showed increased bilirubin concentrations and coagulation factor abnormalities. A computed tomographic abdominal scan showed that the portal vein had a widened intrinsic diameter. After intensive care treatment with antibiotics, antishock therapy, anticoagulants, and other supportive treatments, the infection was monitored, the abdominal pain disappeared, and the jaundice subsided. Laparoscopic appendectomy was performed. Histopathology showed acute suppurative appendicitis, and no abnormalities were observed during the follow-up period after discharge. A multidisciplinary approach is mandatory for the decision-making process in the presence of pylephlebitis caused by appendicitis to obtain a correct diagnosis and prompt treatment. Similarly, the timing of appendectomy is important for minimizing intra- and postoperative complications.

Rare case of septic shock combined with meningitis caused by Pasteurella multocida without a history of cat and dog bites

BACKGROUND

Pasteurella multocida is a zoonotic pathogen that mainly causes local skin and soft tissue infections in the human body through cat and dog bites. It rarely causes bacteraemia (or sepsis) and meningitis. We reported a case of septic shock and meningitis caused by P. multocida in a patient without a history of cat and dog bites.

CASE PRESENTATION

An 84-year-old male patient was urgently sent to the emergency department after he was found with unclear consciousness for 8 h, accompanied by limb tremors and urinary incontinence. In the subsequent examination, P. multocida was detected in the blood culture and wound secretion samples of the patient. However, it was not detected in the cerebrospinal fluid culture, but its DNA sequence was detected. Therefore, the patient was clearly diagnosed with septic shock and meningitis caused by P. multocida. The patient had no history of cat or dog contact or bite. The patient was subsequently treated with a combination of penicillin G, doxycycline, and ceftriaxone, and he was discharged after 35 days of hospitalisation.

CONCLUSION

This report presented a rare case of septic shock and meningitis caused by P. multocida, which was not related to a cat or dog bite. Clinical doctors should consider P. multocida as a possible cause of sepsis or meningitis and should be aware of its potential seriousness even in the absence of animal bites.

Prognostic Factors and Outcomes in Patients With Septic Shock After Allogeneic Hematopoietic Stem Cell Transplantation

Septic shock remains a potentially life-threatening complication among allogeneic hematopoietic stem cell transplant (allo-HSCT) recipients. There is a paucity of information on the clinical characteristics, outcome and prognostic factors of septic shock patients after allo-HSCT. We aimed to describe the clinical characteristics of septic shock after allo-HSCT and its associated health outcomes and to evaluate the role of patient demographics, transplantation-related laboratory and clinical variables associated with the short-term mortality of septic shock after allo-HSCT. We retrospectively studied 242 septic shock patients from 6105 consecutive patients allografted between 2007 and 2021. We assessed 29 risk factors as candidate predictors and used multivariable logistic regression to establish clinical model. The primary outcome was 28-day mortality. The median age of the subjects was 34 (IQR 24 to 45) years. A total of 148 patients (61.2%) had positive blood cultures. Gram-negative bacilli accounted for 61.5% of the positive isolates, gram-positive cocci accounted for 12.2%, and fungi accounted for 6.1%. Coinfections were found in 30 (20.3%) patients. Escherichia coli was the dominant isolated pathogen (31.1%), followed by Pseudomonas spp. (12.8%) and Klebsiella pneumoniae (10.1%). With a median follow-up of 34 (IQR: 2 to 528) days, a total of 142 (58.7%) patients died, of whom 118 (48.8%) died within the first 28 days after septic shock diagnosis, 131 (54.1%) died within 90 days, and 141 (58.3%) died within 1 year. A large majority of deaths (83.1% [118/142]) occurred within 28 days of septic shock diagnosis. Finally, 6 independent predictive variables of 28-day mortality were identified by multivariable logistic regression: time of septic shock, albumin, bilirubin, PaO2/FiO2, lactate, and sepsis-induced coagulopathy. Patients with late onset shock had higher 28-day mortality rates (64.6% versus 25.5%, P < .001) and more ICU admission (32.6% versus 7.1%, P < .001) than those with early onset shock. We highlight the poor survival outcomes in patients who develop septic shock, emphasizing the need for increasing awareness regarding septic shock after allo-HSCT. The information from the current study may help to assist clinicians in identifying high-risk patients.

Resuscitation With Early Adrenaline Infusion for Children With Septic Shock: A Randomized Pilot Trial

OBJECTIVES

In children with septic shock, guidelines recommend resuscitation with 40-60 mL/kg of fluid boluses, yet there is a lack of evidence to support this practice. We aimed to determine the feasibility of a randomized trial comparing early adrenaline infusion with standard fluid resuscitation in children with septic shock.

DESIGN

Open-label parallel randomized controlled, multicenter pilot study. The primary end point was feasibility; the exploratory clinical endpoint was survival free of organ dysfunction by 28 days.

SETTING

Four pediatric Emergency Departments in Queensland, Australia.

PATIENTS

Children between 28 days and 18 years old with septic shock.

INTERVENTIONS

Patients were assigned 1:1 to receive a continuous adrenaline infusion after 20 mL/kg fluid bolus resuscitation (n = 17), or standard care fluid resuscitation defined as delivery of 40 to 60 mL/kg fluid bolus resuscitation prior to inotrope commencement (n = 23).

MEASUREMENTS AND MAIN RESULTS

Forty of 58 eligible patients (69%) were consented with a median age of 3.7 years (interquartile range [IQR], 0.9-12.1 yr). The median time from randomization to inotropes was 16 minutes (IQR, 12-26 min) in the intervention group, and 49 minutes (IQR, 29-63 min) in the standard care group. The median amount of fluid delivered during the first 24 hours was 0 mL/kg (IQR, 0-10.0 mL/kg) in the intervention group, and 20.0 mL/kg (14.6-28.6 mL/kg) in the standard group (difference, -20.0; 95% CI, -28.0 to -12.0). The number of days alive and free of organ dysfunction did not differ between the intervention and standard care groups, with a median of 27 days (IQR, 26-27 d) versus 26 days (IQR, 25-27 d). There were no adverse events reported associated with the intervention.

CONCLUSIONS

In children with septic shock, a protocol comparing early administration of adrenaline versus standard care achieved separation between the study arms in relation to inotrope and fluid bolus use.

Management of Vasoplegic Shock in the Cardiovascular Intensive Care Unit after Cardiac Surgery

Vasoplegic shock after cardiac surgery is characterized by hypotension, a high cardiac output, and vasodilation. Much of the understanding of this pathologic state is informed by the understanding of septic shock. Adverse outcomes and mortality are increased with vasoplegic shock. Early recognition and a systematic approach to its management are critical. The need for vasopressors to sustain an adequate blood pressure as well as pharmacologic adjuncts to mitigate the inflammatory inciting process are necessary. The rationale behind vasopressor escalation and consideration of adjuncts are discussed.

[A Case of Postoperative Anastomotic Leakage with Septic Shock after Esophageal Cancer Surgery Treated by Two Stage Operation Using Ileocolic Reconstruction]

The patient was a 60s male. He underwent esophagectomy and gastric tube reconstruction for Barrett's esophageal cancer( pT3N1M0, pStage Ⅲ). Postoperatively, anastomotic leakage and mediastinitis resulted in septic shock. On the 8th day after first surgery, he transferred to our hospital. At the time of admission, qSOFA was 3 points. We judged to be difficult to treat with conservative treatment. Emergency right thoracotomy drainage underwent with resection of the esophagogastric anastomosis and cervical esophagostomy construction. He was discharged on the 55th postoperative day with home enteral nutrition. He underwent presternal ileocolic reconstruction on the 97th day after right thoracotomy drainage. On the 19th day after reconstruction, oral intake was started. The general condition is good without recurrence, and oral intake is sufficient at 1 year after reconstruction. We report a case of anastomotic leakage with septic shock after esophageal cancer surgery successfully treated by 2 stage ileocolic reconstruction.

Case report: A pregnant woman with Crohn disease who used ustekinumab to the 3rd trimester developed severe infection

RATIONALE

Crohn disease (CD) and pregnancy often impact each other, which poses challenges for women with CD to successfully give birth to a healthy baby. The latest guideline recommends that patients with active inflammatory bowel disease delay pregnancy to induce remission and optimize disease control. Research data has showed that the incidence of infection and severe infection in patients treated with ustekinumab (UST) did not increase compared to those treated with a placebo.

PATIENT CONCERNS

This report describes the entire process of a pregnant woman with CD who has undergone ileostomy and long-term enteral nutrition and requires biological agents to control the disease, from conception to delivery. This case was pregnant during CD period and regularly treated with UST to the third trimester, with the onset of sepsis and septic shock at 38 weeks gestation.

DIAGNOSES

The patient was pathologically diagnosed with CD 16 years ago and admitted to our department at 38 weeks gestation.

INTERVENTIONS

After admission to our department, fetal heart monitoring indicated fetal distress, so we immediately terminated the pregnancy by cesarean section. After the diagnosis of septic shock, the patient was transferred to intensive care unit for active anti-infection and symptomatic supportive treatment.

OUTCOMES

The mother only experienced an infection in the third trimester, and cured by active treatment. The newborn was delivered at full term and confirmed to be low birth weight.

LESSONS

Her experience suggests that although pregnant during Crohn active period, a good outcome can be achieved through positively controlling with medication and closely monitoring it. The use of UST during pregnancy appears to be safe for both the mother and fetus but may be associated with severe infections.

Maternal septic shock due to Acinetobacter lwoffii infection:a case report

The incidence of Acinetobacter infections has increased in recent years. Acinetobacter infections are resistant to most antibiotics and can be found in hospitalized patients. Pregnancies complicated by severe sepsis or septic shock are associated with a higher rate of preterm labor and delivery, fetal infection, and operative delivery. This case report describes septic shock due to Acinetobacter lwoffii infection in the 31st week of gestation. A 47-year-old woman, with a gestation of 31 weeks and one day, presented with a fever, and signs of bacterial infection on laboratory tests. Although the patient was started on tazobactam/piperacillin, she went into septic shock, and was transferred to our hospital. Cesarean section was performed at a gestation of 31 weeks and 4 days because of severe maternal pneumonia and non-reassuring fetal status. A. lwoffii was detected in blood cultures collected at the previous hospital, and susceptibility to piperacillin and meropenem to A. lwoffii was confirmed. The pneumonia responded to antibiotic treatment and there were no findings of infection in the neonate. Maternal sepsis is an infrequent but important complication, causing significant maternal and fetal morbidity and fetal and neonatal mortality; therefore, early antibiotic therapy is required to improve the clinical outcome.

Progressive multiple organ dysfunction syndrome in adolescent pregnancy: Case report

Introduction

Adolescent pregnancy is a physiological process, but it can evolve with premature delivery, severe obstetric or clinical pathologies, mortality, or sequelae for mother and child. We aim to report the progressive multiple organ dysfunction syndrome secondary to pyelonephritis and sepsis during prepartum, delivery, and puerperium of adolescent pregnancy and its sequelae.

Case report

A 14-year-old adolescent with a pregnancy of 27 weeks of gestation controlled from 8 to 25 weeks. She was urgently admitted to the high-risk obstetric unit due to signs of preterm labor, pyelonephritis, and acute renal injury. Treatment was started with intravenous cefazolin and betamethasone for lung maturation, oral nifedipine, and magnesium sulfate to prevent preterm labor and fetal neuronal protection, evolving with sustained hypotension and septic shock. At 13 hours after admission, she was transferred to the intensive care unit, where she evolved with persistent and progressive multiple organ failure for 28 days, progressively affecting the cardiovascular, hematologic, respiratory, and gastrointestinal systems. She was treated with vasoactive drugs, antibiotics, invasive mechanical ventilation, ultrafiltration, hemodialysis, pleural drainage, and cholecystectomy. Twenty-four hours after admission to intensive care, preterm vaginal delivery occurred. She developed chronic kidney disease stage KDIGO 5 (Kidney Disease Improving Global Outcomes V) and is awaiting renal transplantation. On the other hand, the preterm newborn presented severe neonatal asphyxia, bronchopulmonary dysplasia, and hypoxic-ischemic encephalopathy.

Conclusion

Complicated adolescent pregnancy is a health emergency. Avoiding delays in the diagnosis and treatment of pyelonephritis, septic shock and the progressive multiple organ dysfunction syndrome can prevent mortality and permanent sequelae, both maternal and neonatal.

Staphylococcus epidermidis induced toxic shock syndrome (TSS) secondary to influenza infection

BACKGROUND

To date, few cases of TSS caused by coagulase negative (CoN) staphylococci have been reported in the literature. Recent data show that CoN staphylococci are capable of secreting a number of enterotoxins and cytotoxins, normally produced by S. aureus. Herewith, we describe a case of TSS caused by Staphylococcus epidermidis with a favorable outcome.

CASE PRESENTATION

We report a case of a 46-year-old man who developed TSS from S. epidermidis. The patient was admitted for a 7-day history of general malaise and headache following a recent influenza infection and a 3-day history of vomiting, diarrhea, diffuse erythroderma, and fever. The main laboratory findings on admission were leukopenia (WBC 800/mm3), thrombocytopenia (Plt count 78.000/mm3), elevated urea, creatine levels and increased inflammatory markers (CRP 368 mg/ml). The patient had clinical and radiological evidence of pneumonia with chest computed tomography (CT) showing diffuse bilateral airspace opacifications with air bronchogram. On the second day, a methicillin resistant S. epidermidis (MRSE) strain was detected in both sets of blood cultures, but the organism was unavailable for toxin testing. All other cultures and diagnostic PCR tests were negative. His clinical signs and symptoms fulfilled at that stage four out of five clinical criteria of TSS with a fever of 39 °C, diffuse erythroderma, multisystem involvement and hypotension. On the same day the patient was admitted to the ICU due to acute respiratory failure. The initial treatment was meropenem, vancomycin, levofloxacin, clindamycin, IVIG and steroids. Finger desquamation appeared on the 9th day of hospitalization, fulfilling all five clinical criteria for TSS.

CONCLUSIONS

To our knowledge, this is the first adult case with TSS induced by CoNS (MRSE) secondary to an influenza type B infection, who had favorable progression and outcome. Further research is warranted to determine how TSS is induced by the CoNS infections.

Meningitis with septic shock resulting from odontogenic infection misdiagnosed as closed-lock in temporomandibular disorder: A case report and literature review

RATIONALE

Infections that spread to the pterygomandibular muscle can be misdiagnosed as temporomandibular disorder (TMD) because of the resulting difficulty in opening the mouth. Importantly, infection of the pterygomandibular space can extend to the skull base in the early stages, and a delay in therapeutic intervention can lead to severe complications.

PATIENT CONCERNS

A 77-year-old Japanese man with trismus after pulpectomy was referred to our department. This case report describes a rare instance of meningitis with septic shock caused by an odontogenic infection, initially misdiagnosed as TMD due to similar symptoms, leading to life-threatening complications.

DIAGNOSIS

The patient was diagnosed with sepsis and meningitis resulting from cellulitis in the pterygomandibular space caused by iatrogenic infection after pulpectomy of the right upper second molar.

INTERVENTIONS

After emergency hospitalization, the patient developed septic shock and required blood purification. Subsequently, abscess drainage and extraction of the causative tooth were performed. However, the patient developed hydrocephalus secondary to meningitis and underwent ventriculoperitoneal shunting to alleviate the condition.

OUTCOMES

The infection was controlled and the patient level of consciousness improved following treatment for hydrocephalus. The patient was transferred to a hospital for rehabilitation on the 106th day of hospitalization.

LESSONS

Infections of the pterygomandibular space may be misdiagnosed as TMD, owing to the main symptoms of restricted mouth opening and pain on mouth opening. A prompt and appropriate diagnosis is crucial because these infections can lead to life-threatening complications. A detailed interview, along with additional blood tests and computed tomography (CT) scans, can aid in making an accurate diagnosis.

Development and validation of the UCSS score, a novel method to predict septic shock after PCNL

OBJECTIVE

To develop an objective and easily recognizable model to predict septic shock following percutaneous nephrolithotomy (PCNL).

SUBJECTS AND METHODS

First, we identified differences between 431 patients who underwent PCNL with or without septic shock. These data were used to develop existing models and examine their improvement. Multivariate analysis was applied to identify risk factors of septic shock after PCNL based on the scores allocated to the PCNL postoperative test indicators. Finally, we developed a predictive nomogram using the selected factors and compared its performance with that of the existing nomograms SOFA, qSOFA, and SIRS.

RESULTS

Twelve (2.8%) of the patients met the criteria for postoperative septic shock after PCNL. Baseline data analysis revealed differences in sex, preoperative drainage, urinary culture, and urinary leukocyte between groups. After transforming patient data into measurement-level data, we investigated each index score in these conditions, and found that the incidence of septic shock generally increased with the score. Multivariate analysis and early optimization screening revealed that septic shock factors could be predicted using platelets, leukocytes, bilirubin, and procalcitonin levels. We further compared the prediction accuracy of urinary calculi-associated septic shock (UCSS), SOFA, qSOFA, and SIRS scores using the AUC of the ROC curve. As compared to SIRS [AUC 0.938 (95% CI 0.910-0.959)] and qSOFA [AUC 0.930 (95% CI 0.901-0.952)], UCSS [AUC 0.974 (95% Cl 0.954-0.987)] and SOFA [AUC 0.974 (95% CI 0.954-0.987)] scored better at discriminating septic shock after PCNL. We further compared the ROC curves of UCSS with SOFA (95% CI - 0.800 to 0.0808, P = 0.992), qSOFA (95% CI - 0.0611 to 0.0808, P = 0.409), and SIRS (95% CI - 0.0703 to 0.144, P = 0.502), finding that UCSS was non-inferior to these models.

CONCLUSIONS

UCSS, a new convenient and cost-effective model, can predict septic shock following PCNL and provide more accurate discriminative and corrective capability than existing models by including only objective data. The predictive value of UCSS for septic shock after PCNL was greater than that of qSOFA or SIRS scores.

Clinical Characteristics of Pediatric Patients With Septic Shock Caused by Acute Appendicitis: A Case Series

OBJECTIVES

This study aimed to explore the clinical characteristics of septic shock in pediatric patients caused by acute appendicitis.

METHODS

This case series included patients with septic shock caused by acute appendicitis in Beijing Children's Hospital between January 2015 and December 2020.

RESULTS

Six patients with septic shock caused by acute appendicitis were enrolled. One patient was an infant with extremely low weight; 2 patients were obese. The diagnosis was delayed in 4 patients (the time from onset to diagnosis was 5 days in 3 children and 4 days in 1 child). All patients had abnormally raised inflammatory markers (C-reactive protein 119.17 ± 48.36 mg/L, procalcitonin 129.95 ± 86.09 ng/mL). Severe abdominal infection was found in all patients. There was appendix perforation in 4 patients and diffused peritonitis in 3 patients. Two patients had metabolic diseases (Wilson disease and decreased biotinase activity, respectively). Five patients had an appendectomy and 1 patient received conservative treatment. Five patients were discharged in stable condition, while 1 patient died.

CONCLUSIONS

Children with delayed diagnosis, abnormal body weight, significant elevation in inflammatory markers, and underlying metabolic disease may be at greater risk of complicated appendicitis and septic shock.

EVIDENCEBASED MEDICINE

Level of Evidence: IV.

First report on severe septic shock associated with human Parvovirus B19 infection after cardiac surgery

Background

Human Parvovirus B19 (PB19) is a single-stranded DNA virus. Septic shock from viremia is rare with PB19; however, this infection can progress to life-threatening conditions. We report the first case of severe septic shock associated with a PB19 infection after cardiac surgery.

Case Presentation

A 50-year-old Chinese woman received elective double metal valve replacement, including the aortic valve and the mitral valve, under cardiopulmonary bypass (CPB) and suffered severe septic shock on postoperative day (PD) 30. Through the detection of PB19-specific nucleic acids in blister fluid and serum samples via metagenomic next-generation sequencing (mNGS), positive serum PB19 IgM and no other proven infection, acute PB19 infection was confirmed. After five days of combined treatment, no further fever or abdominal discomfort was noted, and the patient’s circulation gradually became stable without vasoactive medications.

Conclusion

PB19 may be an unrecognized cause of septic shock, rash, fever of unknown origin or multiple systemic signs and symptoms, especially in immunosuppressed and immunocompetent critically ill patients. Investigations for viral aetiology are needed.

Antiphospholipid syndrome after streptococcal toxic shock syndrome later diagnosed as Behcet's disease

Streptococcal toxic shock syndrome is a severe complication of group A streptococci. The production of antiphospholipid antibodies has been associated with streptococcal infections and with autoimmune diseases. Furthermore, streptococcal infections could be a trigger of Behcet's disease. We report a case of a boy who presented antiphospholipid syndrome after streptococcal toxic shock syndrome later he was diagnosed with Behcet's disease.

Fluid management of the critically Ill child

PURPOSE OF REVIEW

This review summarizes current literature pertaining to fluid management for critically ill children. It includes an overview on crystalloid fluid used throughout the critical illness course, management of fluid output and complications with fluid overload.

RECENT FINDINGS

Observational paediatric studies and adult randomized trials show mixed results regarding risk of mortality and kidney injury with 0.9% saline and crystalloid fluid. A recent adult randomized trial suggests that a fluid restrictive strategy may be well tolerated in critically ill adults with septic shock, but further randomized trials are needed in paediatrics. Fluid overload has been associated with increased morbidity and mortality. Trials exploring ways to decrease fluid accumulation must be done in paediatrics.

SUMMARY

Additional high-quality studies are needed to precisely define the type, timing and rate of intravenous fluid critically ill children should receive throughout their clinical illness course.

Citrobacter freundii induces sepsis with new-onset status seizure in an adult: A case report and literature review

RATIONALE

Sepsis with brain abscess induced by Citrobacter freundii in adults has rarely been reported and is extremely pathogenic with a high mortality rate. Early diagnosis of the infection still remains challenging.

PATIENT CONCERNS

A 27-year-old woman was transferred to our emergency department for fever, status seizure and refractory hypotension. Administration of midazolam, propofol and sodium valproate could not attenuate the seizure except for the addition of vecuronium. The blood white blood cell count was 42.91 (109/L) with 80% neutrophils, and procalcitonin was 22.46ng/mL.

DIAGNOSES

Both deoxyribonucleic acid and ribonucleic acid of C freundii were detected in blood by metagenomic next-generation sequencing of pathogens,the diagnosis of septic shock and brain abscess caused by C freundii was highly suspected.

INTERVENTIONS

On day 1, antibiotics of cefoperazone sodium and sulbactam sodium 6g/day, immunoglobulin, and hydrocortisone were used with suspected septic shock. Continuous renal replacement therapy was used to eliminate excessive lactate, ammonia, myohemoglobin and creatinine. On day 2, a brain computed tomography scan revealed multiple patchy slightly low densities in the brain, antibiotics were adjusted to meropenem intravenously 3g/day.

OUTCOMES

On day 2, a brain computed tomography scan revealed multiple patchy slightly low densities in the brain, she died on day 3.

LESSONS

Clinicians should consider the possibility of brain abscess when evaluating a patient with new-onset dizziness, fever, seizure, or other neurologic symptoms or signs, especially for patients whose mental status changes. metagenomic next generation sequencing and resistance genes could be considered when cerebrospinal fluid or blood results are negative and clinical manifestations are highly suspected of infection or when the treatment time is limited.

Delayed diagnosis and management of necrotizing fasciitis of the left lower leg: A case report

INTRODUCTION

Necrotizing fasciitis (NF) is a rare, severe soft tissue infection, characterized by rapid and extensive necrosis of the skin, subcutaneous tissue, and superficial and deep fascia. It is frequently misdiagnosed as other infectious diseases, leading to inappropriate treatment and potentially serious consequences. It may be complicated by septic shock and multiple organ failure with a fatal outcome.

PATIENT CONCERNS

A 73-year-old woman presented with continuous itching, skin lesions, pain, and swelling of the outer side of her left leg. The patient was diagnosed with septic shock and multiorgan failure caused by left leg NF.

DIAGNOSIS

Septic shock and multiorgan failure caused by left leg NF.

INTERVENTIONS

Two surgeries were performed on the patient's leg, which effectively treated her septic shock and multiple organ dysfunction.

OUTCOMES

The patient was followed up three times after her discharge. She had a good recovery, was generally well with no significant sequelae, and returned to her regular life.

CONCLUSION

NF is an acute severe illness with high mortality. It is easily misdiagnosed, leading to delayed or erroneous treatment and serious (or potentially fatal) outcomes. Rapid and accurate diagnosis of NF is essential for patient recovery. In difficult cases, multidisciplinary consultations may be helpful. The management of NF includes early and thorough surgical debridement, antibiotics, and symptomatic treatment.

Septic Emboli Resulting From Severe Trauma: A Primer on Care

INTRODUCTION

Trauma nursing requires specialized knowledge and skills. This article describes the case of a patient who was involved in a motor vehicle accident and presented to the emergency department with hypovolemic shock secondary to a splenic laceration. In the hospital, the patient experienced prolonged hypotension.

CLINICAL FINDINGS

The patient sustained a variety of insults to the cardiovascular, respiratory, endocrine, and musculoskeletal systems. Microbiological data and laboratory test results did not reveal the defining characteristics of sepsis or systemic inflammatory response syndrome typical of trauma patients, making it challenging to identify the source of the sepsis.

DIAGNOSIS

The patient was diagnosed with nontraumatic cerebral septic emboli, a condition that is less common in trauma patients and more common in cases of endocarditis, septic thrombophlebitis, and central venous catheter infections. The condition has a 50% mortality rate if not detected promptly and appropriate treatment administered.

OUTCOMES

The patient survived the 4-week hospitalization owing to timely management of his conditions by the health care team and their persistence in identifying the cause of his atypical sepsis.

CONCLUSION

To provide adequate care to trauma patients, critical care nurses require specialized knowledge of this unique population. Trauma critical care nursing should involve hands-off communication, thoughtful review of laboratory test and imaging results, and engagement in interdisciplinary care rounds.

[Predictive value of D-dimer for deep venous thrombosis of lower extremity in adult burn patients]

Objective: To investigate the predictive value of D-dimer for deep venous thrombosis (DVT) of lower extremity in adult burn patients. Methods: A retrospective case series study was conducted. The clinical data of 3 861 adult burn patients who met the inclusion criteria and were admitted to the Department of Burns of Zhengzhou First People's Hospital from January 1, 2015 to December 31, 2019 were collected. The patients were divided into DVT group (n=77) and non-DVT group (n=3 784) according to whether DVT of lower extremity occurred during hospitalization or not. Data of patients in the two groups were collected and compared, including the gender, age, total burn area, D-dimer level, with lower limb burn and inhalation injury or not on admission, with sepsis/septic shock, femoral vein indwelling central venous catheter (CVC), history of surgery, and infusion of concentrated red blood cells or not during hospitalization. Data were statistically analyzed with independent sample t test, Mann-Whitney U test, and chi-square test. The indicators with statistically significant differences between the two groups were analyzed with multivariate logistic regression analysis to screen the independent risk factors for DVT of lower extremity in 3 861 adult burn patients. The receiver operating characteristic (ROC) curve of the independent risk factors predicting DVT of lower extremity in 3 861 adult burn patients were drawn, and the area under the curve (AUC), the optimal threshold value, and the sensitivity and specificity under the optimal threshold value were calculated. The quality of the AUC was compared by Delong test, and the sensitivity and specificity under the optimal threshold value were compared using chi-square test. Results: There were no statistically significant differences in gender, occurrence of sepsis/septic shock or history of surgery during hospitalization between patients in the two groups (P>0.05), while there were statistically significant differences in age, total burn area, D-dimer level, lower limb burn and inhalation injury on admission, and femoral vein indwelling CVC and infusion of concentrated red blood cells during hospitalization between patients in the two groups (t=-8.17, with Z values of -5.04 and -10.83, respectively, χ2 values of 21.83, 5.37, 7.75, and 4.52, respectively, P<0.05 or P<0.01). Multivariate logistic regression analysis showed that age, total burn area, and D-dimer level were the independent risk factors for DVT of lower extremity in 3 861 adult burn patients (with odds ratios of 1.05, 1.02, and 1.14, respectively, 95% confidence intervals of 1.04-1.06, 1.00-1.03, and 1.10-1.20, respectively, P<0.05 or P<0.01). The AUCs of ROC of age, total burn area, and D-dimer level for predicting DVT of lower extremity in 3 861 adult burn patients were 0.74, 0.67, and 0.86, respectively (with 95% confidence intervals of 0.68-0.80, 0.60-0.74, and 0.83-0.89, respectively, P values<0.01), the optimal threshold values were 50.5 years old, 10.5% total body surface area, and 1.845 mg/L, respectively, the sensitivity under the optimal threshold values were 71.4%, 70.1%, and 87.0%, respectively, and the specificity under the optimal threshold values were 66.8%, 67.2%, and 72.9%, respectively. The AUC quality and sensitivity and specificity under the optimal threshold value of D-dimer level were significantly better than those of age (z=3.29, with χ2 values of 284.91 and 34.25, respectively, P<0.01) and total burn area (z=4.98, with χ2 values of 326.79 and 29.88, respectively, P<0.01), while the AUC quality and sensitivity and specificity under the optimal threshold values were similar between age and total burn area (P>0.05). Conclusions: D-dimer level is an independent risk factor for DVT of lower extremity in adult burn patients, its AUC quality and sensitivity and specificity under the optimal threshold value are better than those of age and total burn area, and it has good predictive value for DVT of lower extremity in adult burn patients.

Clinical Characteristics and Death Risk Factors of Severe Sepsis in Children

Sepsis is a systemic inflammatory response syndrome caused by viral infection. The circulatory dysfunction caused by sepsis is also called septic shock or septic shock. The main characteristics are rapid onset, rapid changes, and involvement. Multiple organs in the body make diagnosis difficult, which seriously threatens the survival of patients. As many as one million people worldwide die every year because of SIRS, it is also the leading cause of death among children in hospital ICUs. This article is aimed at studying the clinical characteristics of severe sepsis in children and the risk factors for death. Based on the analysis of the pathogenesis of sepsis and the treatment of septic shock, 65 cases of children with PICU sepsis admitted to a hospital were selected. Data, to study its clinical characteristics and risk factors for death. The results of the study showed that despite the interaction among the removal factors of the three indexes of serum lactic acid value, PCIS level, and the number of organs involved in MODS, they are still related to the mortality of children with severe sepsis.

Effect of 12 mg vs 6 mg of Dexamethasone on the Number of Days Alive Without Life Support in Adults With COVID-19 and Severe Hypoxemia: The COVID STEROID 2 Randomized Trial

IMPORTANCE

A daily dose with 6 mg of dexamethasone is recommended for up to 10 days in patients with severe and critical COVID-19, but a higher dose may benefit those with more severe disease.

OBJECTIVE

To assess the effects of 12 mg/d vs 6 mg/d of dexamethasone in patients with COVID-19 and severe hypoxemia.

DESIGN, SETTING, AND PARTICIPANTS

A multicenter, randomized clinical trial was conducted between August 2020 and May 2021 at 26 hospitals in Europe and India and included 1000 adults with confirmed COVID-19 requiring at least 10 L/min of oxygen or mechanical ventilation. End of 90-day follow-up was on August 19, 2021.

INTERVENTIONS

Patients were randomized 1:1 to 12 mg/d of intravenous dexamethasone (n = 503) or 6 mg/d of intravenous dexamethasone (n = 497) for up to 10 days.

MAIN OUTCOMES AND MEASURES

The primary outcome was the number of days alive without life support (invasive mechanical ventilation, circulatory support, or kidney replacement therapy) at 28 days and was adjusted for stratification variables. Of the 8 prespecified secondary outcomes, 5 are included in this analysis (the number of days alive without life support at 90 days, the number of days alive out of the hospital at 90 days, mortality at 28 days and at 90 days, and ≥1 serious adverse reactions at 28 days).

RESULTS

Of the 1000 randomized patients, 982 were included (median age, 65 [IQR, 55-73] years; 305 [31%] women) and primary outcome data were available for 971 (491 in the 12 mg of dexamethasone group and 480 in the 6 mg of dexamethasone group). The median number of days alive without life support was 22.0 days (IQR, 6.0-28.0 days) in the 12 mg of dexamethasone group and 20.5 days (IQR, 4.0-28.0 days) in the 6 mg of dexamethasone group (adjusted mean difference, 1.3 days [95% CI, 0-2.6 days]; P = .07). Mortality at 28 days was 27.1% in the 12 mg of dexamethasone group vs 32.3% in the 6 mg of dexamethasone group (adjusted relative risk, 0.86 [99% CI, 0.68-1.08]). Mortality at 90 days was 32.0% in the 12 mg of dexamethasone group vs 37.7% in the 6 mg of dexamethasone group (adjusted relative risk, 0.87 [99% CI, 0.70-1.07]). Serious adverse reactions, including septic shock and invasive fungal infections, occurred in 11.3% in the 12 mg of dexamethasone group vs 13.4% in the 6 mg of dexamethasone group (adjusted relative risk, 0.83 [99% CI, 0.54-1.29]).

CONCLUSIONS AND RELEVANCE

Among patients with COVID-19 and severe hypoxemia, 12 mg/d of dexamethasone compared with 6 mg/d of dexamethasone did not result in statistically significantly more days alive without life support at 28 days. However, the trial may have been underpowered to identify a significant difference.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04509973 and ctri.nic.in Identifier: CTRI/2020/10/028731.

Streptococcal Toxic Shock Syndrome Induced by Group A Streptococcus with the emm28 Genotype That Developed after a Uterine Cancer Test

A 69-year-old woman without pre-existing disease visited our hospital due to general malaise, diarrhea, and arthralgia 3 days after a uterine cancer test. We diagnosed her with sepsis of unknown focus and started treatment immediately, but she died 20 hours after the first visit due to multi-organ failure and septic shock. Later, group A streptococcus was detected from the blood culture, and streptococcal toxic shock syndrome (STSS) was diagnosed. The strain had the emm28 genotype and a mutation in csrR with increased NADase activity. These virulence factors were considered to be related to STSS development in this patient.

Hemodialysis Patient with Diffuse Liver Calcification After Septic Shock

BACKGROUND Calcification in arteries is sometimes observed in patients undergoing hemodialysis; however, ectopic calcification in other organs is uncommon. In particular, diffuse liver calcification is very rare. We report a case of rapidly developing diffuse liver calcification in a patient undergoing hemodialysis. CASE REPORT An 82-year-old woman started hemodialysis because of diabetic nephropathy, and her renal function worsened due to acute coronary syndrome. Percutaneous coronary intervention was conducted, and she was referred to our hospital. However, she subsequently contracted various infections, including a urinary tract infection and pneumonia. On day 43 of hospitalization, she developed septic shock and liver dysfunction due to catheter-induced infection. Although she did not have any medical history of liver disease, hypoperfusion of the liver resulted in liver dysfunction, and a computed tomography scan conducted 3 months later showed diffuse calcification in her liver. Despite recovering from septic shock, she ultimately died of multiple organ failure 21 months after admission to our hospital. CONCLUSIONS Diffuse liver calcification is extremely rare; however, it can be observed in patients undergoing hemodialysis who experience liver hypoperfusion. The precise mechanisms underlying this disorder remain unknown, but a critically ill status and specific characteristics of hemodialysis patients may play important roles in liver calcification.

An O-GlcNAcylomic Approach Reveals ACLY as a Potential Target in Sepsis in the Young Rat

Sepsis in the young population, which is particularly at risk, is rarely studied. O-GlcNAcylation is a post-translational modification involved in cell survival, stress response and metabolic regulation. O-GlcNAc stimulation is beneficial in adult septic rats. This modification is physiologically higher in the young rat, potentially limiting the therapeutic potential of O-GlcNAc stimulation in young septic rats. The aim is to evaluate whether O-GlcNAc stimulation can improve sepsis outcome in young rats. Endotoxemic challenge was induced in 28-day-old rats by lipopolysaccharide injection (E. Coli O111:B4, 20 mg·kg⁻¹) and compared to control rats (NaCl 0.9%). One hour after lipopolysaccharide injection, rats were randomly assigned to no therapy, fluidotherapy (NaCl 0.9%, 10 mL·kg⁻¹) ± NButGT (10 mg·kg⁻¹) to increase O-GlcNAcylation levels. Physiological parameters and plasmatic markers were evaluated 2h later. Finally, untargeted mass spectrometry was performed to map cardiac O-GlcNAcylated proteins. Lipopolysaccharide injection induced shock with a decrease in mean arterial pressure and alteration of biological parameters (p < 0.05). NButGT, contrary to fluidotherapy, was associated with an improvement of arterial pressure (p < 0.05). ATP citrate lyase was identified among the O-GlcNAcylated proteins. In conclusion, O-GlcNAc stimulation improves outcomes in young septic rats. Interestingly, identified O-GlcNAcylated proteins are mainly involved in cellular metabolism.

Obesity is independently associated with septic shock, renal complications, and mortality in a multiracial patient cohort hospitalized with COVID-19

BACKGROUND

Obesity has emerged as a risk factor for severe coronavirus disease 2019 (COVID-19) infection. To inform treatment considerations the relationship between obesity and COVID-19 complications and the influence of race, ethnicity, and socioeconomic factors deserves continued attention.

OBJECTIVE

To determine if obesity is an independent risk factor for severe COVID-19 complications and mortality and examine the relationship between BMI, race, ethnicity, distressed community index and COVID-19 complications and mortality.

METHODS

A retrospective cohort study of 1,019 SARS-CoV-2 positive adult admitted to an academic medical center (n = 928) and its affiliated community hospital (n-91) in New York City from March 1 to April 18, 2020.

RESULTS

Median age was 64 years (IQR 52-75), 58.7% were men, 23.0% were Black, and 52.8% were Hispanic. The prevalence of overweight and obesity was 75.2%; median BMI was 28.5 kg/m2 (25.1-33.0). Over the study period 23.7% patients died, 27.3% required invasive mechanical ventilation, 22.7% developed septic shock, and 9.1% required renal replacement therapy (RRT). In the multivariable logistic regression model, BMI was associated with complications including intubation (Odds Ratio [OR]1.03, 95% Confidence Interval [CI]1.01-1.05), septic shock (OR 1.04, CI 1.01-1.06), and RRT (OR1.07, CI 1.04-1.10), and mortality (OR 1.04, CI 1.01-1.06). The odds of death were highest among those with BMI ≥ 40 kg/m2 (OR 2.05, CI 1.04-4.04). Mortality did not differ by race, ethnicity, or socioeconomic distress score, though Black and Asian patients were more likely to require RRT.

CONCLUSIONS AND RELEVANCE

Severe complications of COVID-19 and death are more likely in patients with obesity, independent of age and comorbidities. While race, ethnicity, and socioeconomic status did not impact COVID-19 related mortality, Black and Asian patients were more likely to require RRT. The presence of obesity, and in some instances race, should inform resource allocation and risk stratification in patients hospitalized with COVID-19.

High pyocyanin production and non-motility of Pseudomonas aeruginosa isolates are correlated with septic shock or death in bacteremic patients

Studies of the outcome of Pseudomonas aeruginosa bacteremia (Pab) have focused mainly on antibiotic appropriateness. However, P. aeruginosa possesses many virulence factors whose roles in outcomes have not been examined in humans, except for the type III secretion system (T3SS) toxins. The purpose of this study was to examine the role of virulence factors other than the T3SS toxins. Bacterial isolates were collected from 75 patients who suffered from Pa blood stream infections. Host factors such as neutropenia, immunosuppression, comorbidities, time to effective antibiotics, source of bacteremia, and presence of multidrug resistant (MDR) isolate were studied. The isolates were analyzed for the presence of toxin genes, proteolytic activity, swimming and twitching motility, and pyocyanin production. The data were analyzed to ascertain which virulence factors correlated with poor outcomes defined as septic shock or death (SS) within 7 days. Septic shock or death occurred in 25/75 patients. Univariate analysis identified age as a host factor that exerted a significant effect on these outcomes. Ineffective antibiotics administered during the first 24 hours of treatment or MDR P. aeruginosa did not influence the frequency of SS, nor did the presence of lasB, exoA, exoS exoU, plcH genes and proteolytic activity. However, 6/8 patients infected with non-motile isolates, developed SS, p = 0.014 and 5/6 isolates that produced large amounts of pyocyanin (>18ug/ml), were associated with SS, p = 0.014. Multivariate analysis indicated that the odds ratio (OR) for development of SS with a non-motile isolate was 6.8, with a 95% confidence interval (CI) (1.37, 51.5), p = 0.030 and with high pyocyanin producing isolates, an OR of 16.9, 95% CI = (2.27, 360), p = .017. This study evaluating the role of microbial factors that significantly effect outcomes following Pa bloodstream infection suggests that P. aeruginosa strains showing high pyocyanin production and the lack of motility independently increase the risk of SS.

Genetic Predisposition to the Mortality in Septic Shock Patients: From GWAS to the Identification of a Regulatory Variant Modulating the Activity of a CISH Enhancer

The high mortality rate in septic shock patients is likely due to environmental and genetic factors, which influence the host response to infection. Two genome-wide association studies (GWAS) on 832 septic shock patients were performed. We used integrative bioinformatic approaches to annotate and prioritize the sepsis-associated single nucleotide polymorphisms (SNPs). An association of 139 SNPs with death based on a false discovery rate of 5% was detected. The most significant SNPs were within the CISH gene involved in cytokine regulation. Among the 139 SNPs associated with death and the 1311 SNPs in strong linkage disequilibrium with them, we investigated 1439 SNPs within non-coding regions to identify regulatory variants. The highest integrative weighted score (IW-score) was obtained for rs143356980, indicating that this SNP is a robust regulatory candidate. The rs143356980 region is located in a non-coding region close to the CISH gene. A CRISPR-Cas9-mediated deletion of this region and specific luciferase assays in K562 cells showed that rs143356980 modulates the enhancer activity in K562 cells. These analyses allowed us to identify several genes associated with death in patients with septic shock. They suggest that genetic variations in key genes, such as CISH, perturb relevant pathways, increasing the risk of death in sepsis patients.

Native Hip Septic Arthritis in the Setting of Postpartum Gynecologic Infection: A Case Report

CASE

A 34-year-old healthy G3P3 woman, 1.5 weeks postpartum, presented with hip pain, fever, and a rash. Clinical examination, laboratory testing, and microbiologic cultures identified bacterial arthritis of the right hip; obstetric/gynecologic examination and cultures identified endometrial, vaginal, and urinary tract infections caused by the same pathogen, group A streptococcus, likely contracted from her 5-year-old son who had streptococcal pharyngitis. She underwent successful surgical decompression of the hip with concurrent medical management of toxic shock syndrome (TSS).

CONCLUSIONS

Hematogenously spread septic arthritis may occur in the absence of positive blood cultures during the postpartum period, increasing the risk of developing TSS.

Pneumococcal septic shock after neonatal respiratory syncytial virus bronchiolitis: A case report and literature review

BACKGROUND

Bronchiolitis is a common cause of hospitalisation of infants less than a year old, with most infants recovering without complications. Respiratory syncytial virus (RSV) is a leading cause of bronchiolitis. Antimicrobial stewardship programmes do not recommend antibiotics for viral infections in neonates unless documented evidence of secondary bacterial infection is present.

CASE REPORT

We present the case of a 7-day-old infant admitted to hospital with chest retractions and fever. The baby was hospitalised, empirical antibiotic therapy was administered, and non-invasive ventilation was started. When the viral aetiology was identified and clinical conditions improved, antibiotics were discontinued. However, after 48 hours, the newborn's condition worsened because of pneumococcal septic shock. Intravenous fluids, catecholamine support, and wide-spectrum antibiotics were administered. Non-invasive ventilation was re-started and continued until the full recovery.

CONCLUSIONS

There is increasing evidence that RSV and S. pneumoniae co-infect and interact with each other, thus increasing respiratory diseases' severity. We provide a brief overview of the main international guidelines for managing bronchiolitis. Guidelines suggest avoidance of antibiotics use when the diagnosis of viral bronchiolitis is confirmed. We discuss the uncertainties regarding antibiotic use, especially in younger infants, who are more exposed to risks of bacterial superinfection.

COVID-19: should we consider it as a septic shock? (The treatment of COVID-19 patients in the ICU)

PURPOSE OF REVIEW

The severe acute respiratory syndrome coronavirus 2 associated coronavirus disease 2019 (COVID-19) illness combines a syndrome of viral replication and a host dysregulated inflammatory response. Despite sharing a similar etiology, COVID-19 patients present different patterns from asymptomatic to severely hypoxemic patients. In some patients, patterns of multiorgan failure have been observed similarly to patients with bacterial sepsis. This review aimed to analyze the currently available data on the treatment of COVID-19, specifically the most studied antiviral agents and therapies targeting the immune system including those that have been investigated in sepsis.

RECENT FINDINGS

In the last months, several trials have been conducted worldwide to try to identify optimal antiviral treatments against COVID-19. Antiviral agents such as lopinavir/ritonavir, remdesivir, hydroxychloroquine have been investigated as well as specific and non-specific immunomodulators in order to determine their potential efficacy against SARS-Cov2.

SUMMARY

To date, the vast majority of the studied antiviral and immunomodulatory agents have failed to improve outcomes of patients with COVID-19 except for dexamethasone. Many other trials are currently underway with new antiviral agents and various immunomodulatory agents with potential clinical benefit for COVID-19 patients. Despite these emerging data, robust controlled clinical trials assessing patient-centered outcomes remain imperative.

The Significance of Asymptomatic Kidney Stones as a Predictive Factor for Sepsis in Critically Ill Older Adults

OBJECTIVE

The objective of this study was to investigate the impact of kidney stones (KSs) on critically ill older adults (CIOA) staying longer than 24 hours in the ICU. Sepsis is one of the leading causes of mortality for ICU patients. KS disease is a well-known risk factor for bacteriuria and urinary tract infection.

METHODS

A total of 256 CIOA were initially evaluated from April 2017 through February 2019. Patients who had urinary ultrasonography and computed tomography within 12 months prior to ICU admission were included. Patients with an additional urological pathology, under the age of 65 years, and with ICU stays of 24 hours or less were excluded. Consequently, 151 patients were eligible and constituted the study group. These patients were divided into 2 subgroups, according to the presence or absence of KSs. These 2 groups were compared with regard to urine culture (UC) results, presence of urosepsis, and septic shock.

RESULTS

The mean age was 80.66 (±7.76) years. There were 18 patients with KSs and 133 without KSs. A total of 71 patients had a positive UC. Repeat UC positivity (p = 0.002) and resistant microorganisms (p = 0.034) were significantly more frequent in the KS group. The incidences of both urosepsis (p<0.001) and septic shock (p<0.001) were also significantly higher in patients with KSs.

CONCLUSION

The presence of KSs in CIOA is frequently associated with urosepsis and septic shock. Large prospective trials are required to evaluate the impact of KSs on the prognosis of patients in the ICU.

Septic shock due to Granulicatella adiacens after endoscopic ultrasound-guided biopsy of a splenic mass: A case report

BACKGROUND

Endoscopic ultrasound-guided fine needle aspiration or biopsy (EUS-FNA or FNB) has become a popular method for diagnosing various lesions of the gastrointestinal tract and surrounding tissue due to the accuracy and safety. To the best of our knowledge, no case report of severe infection after EUS-FNB of a solid lesion in the spleen has been described. Herein, we report a rare case of septic shock after EUS-FNB of a splenic mass.

CASE SUMMARY

A 45-year-old male patient presented to the outpatient clinic due to an incidentally detected splenic mass. A definitive diagnosis could not be established based on the abdominal magnetic resonance imaging. EUS of the spleen showed a 6 cm-sized, relatively well-demarcated, heterogeneous mass, and EUS-FNB with a 22G needle was performed. Ten days after the procedure patient developed septic shock and a splenic abscess was identified. Blood culture revealed growth of Granulicatella adiacens. After the treatment with antibiotics the patient underwent surgical resection, and the pathological examination showed diffuse large B-cell lymphoma. The patient received chemotherapy and he is in complete remission.

CONCLUSION

Infection of a splenic mass after EUS-FNB is a rare complication and prophylactic antibiotics might be considered.

Extracorporeal cytokine adsorption: Significant reduction of catecholamine requirement in patients with AKI and septic shock after cardiac surgery

Background

Extracorporeal cytokine adsorption is an option in septic shock as an additional measure to treat a pathological immune response. Purpose of this study was to investigate the effects of extracorporeal cytokine adsorption on hemodynamic parameters in patients with acute kidney injury (AKI) on continuous renal replacement therapy (CRRT) and septic shock after cardiac surgery.

Methods

In this retrospective study, a total of 98 patients were evaluated. Hemoadsorption was performed by the CytoSorb® adsorber. In all patients cytokine adsorption was applied for at least 15 hours and at least one adsorber was used per patient. To compare cumulative inotrope need in order to maintain a mean arterial pressure (MAP) of ≥ 65 mmHg, we applied vasoactive score (VAS) for each patient before and after cytokine adsorption. A paired t-test has been performed to determine statistical significance.

Results

Before cytokine adsorption the mean VAS was 56.7 points. This was statistically significant decreased after cytokine adsorption (27.7 points, p< 0.0001). Before cytokine adsorption, the mean noradrenalin dose to reach a MAP of ≥ 65 mmHg was 0.49 μg/kg bw/min, the mean adrenalin dose was 0.12 μg/kg bw/min. After cytokine adsorption, significantly reduced catecholamine doses were necessary to maintain a MAP of ≥ 65 mmHg (0.24 μg/kg bw/min noradrenalin; p< 0.0001 and 0.07 μg/kg bw/min adrenalin; p < 0.0001). Moreover, there was a significant reduction of serum lactate levels after treatment (p< 0.0001). The mean SOFA-score for these patients with septic shock and AKI before cytokine adsorption was 16.7 points, the mean APACHE II-score was 30.2 points. The mean predicted in-hospital mortality rate based on this SOFA-score of 16.7 points was 77,0%, respectively 73,0% on APACHE II-score, while the all-cause in-hospital mortality rate of the patients in this study was 59.2%.

Conclusion

In patients with septic shock and AKI undergoing cardiac surgery, extracorporeal cytokine adsorption could significantly lower the need for postoperative inotropes. Additionally, observed versus SOFA- and APACHE II-score predicted in-hospital mortality rate was decreased.

In-hospital mortality from severe COVID-19 in a tertiary care center in Mexico City; causes of death, risk factors and the impact of hospital saturation

Background

As the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has remained in Latin America, Mexico has become the third country with the highest death rate worldwide. Data regarding in-hospital mortality and its risk factors, as well as the impact of hospital overcrowding in Latin America has not been thoroughly explored.

Methods and findings

In this prospective cohort study, we enrolled consecutive adult patients hospitalized with severe confirmed COVID-19 pneumonia at a SARS-CoV-2 referral center in Mexico City from February 26th, 2020, to June 5th, 2020. A total of 800 patients were admitted with confirmed diagnosis, mean age was 51.9 ± 13.9 years, 61% were males, 85% were either obese or overweight, 30% had hypertension and 26% type 2 diabetes. From those 800, 559 recovered (69.9%) and 241 died (30.1%). Among survivors, 101 (18%) received invasive mechanical ventilation (IMV) and 458 (82%) were managed outside the intensive care unit (ICU); mortality in the ICU was 49%. From the non-survivors, 45.6% (n = 110) did not receive full support due to lack of ICU bed availability. Within this subgroup the main cause of death was acute respiratory distress syndrome (ARDS) in 95% of the cases, whereas among the non-survivors who received full (n = 105) support the main cause of death was septic shock (45%) followed by ARDS (29%). The main risk factors associated with in-hospital death were male sex (RR 2.05, 95% CI 1.34–3.12), obesity (RR 1.62, 95% CI 1.14–2.32)—in particular morbid obesity (RR 3.38, 95%CI 1.63–7.00)—and oxygen saturation < 80% on admission (RR 4.8, 95%CI 3.26–7.31).

Conclusions

In this study we found similar in-hospital and ICU mortality, as well as risk factors for mortality, compared to previous reports. However, 45% of the patients who did not survive justified admission to ICU but did not receive IMV / ICU care due to the unavailability of ICU beds. Furthermore, mortality rate over time was mainly due to the availability of ICU beds, indirectly suggesting that overcrowding was one of the main factors that contributed to hospital mortality.

Stercoral perforation of the colon: a mortal consequence of chronic constipation in the elderly (a case report)

The stercoral perforation is a mortal condition. It affects elderly patients who have a long history of chronic and severe constipation as well as constitutes a surgical emergency whose prognosis, often grim, depends on the early diagnosis and treatment. We report the case of a stercoral colon perforation which occurred in an 89-year-old patient. The clinical symptomatology was that of an acute peritonitis evolving for four days. The diagnosis was only made intraoperatively and the surgical gesture was a resection of the involved left colon segment and Bouilly Volkmann colostomy. The consequences were unfortunately marked by a resistant septic shock resulting in the death of the patient on the 1st postoperative day. The diagnosis of stercoral colon perforation, which is often difficult and delayed, must be known by all physicians who manage an increasingly older patient population.

Fatal outcome of anti-MDA5 juvenile dermatomyositis in a paediatric COVID-19 patient: a case report

Anti-melanoma differentiation-associated gene 5 juvenile dermatomyositis (anti-MDA5 JDM) is associated with high risk of developing rapidly progressive interstitial lung disease (RP-ILD). Here we report an 11-year-old girl with anti-MDA5 JDM and RP-ILD which led to a fatal outcome, further aggravated by SARS-CoV-2 infection. She was referred to our hospital after being diagnosed with anti-MDA5 JDM and respiratory failure due to RP-ILD. On admission, fibrobronchoscopy with bronchoalveolar lavage (BAL) revealed Pneumocystis jirovecii infection so treatment with intravenous trimethoprim-sulfamethoxazole was initiated. Due to RP-ILD worsening, immunosuppressive therapy was intensified using methylprednisolone pulses, cyclophosphamide, tofacitinib and intravenous immunoglobulin without response. She developed severe hypoxemic respiratory failure, pneumomediastinum and pneumothorax, further complicated with severe RP-ILD and cervical subcutaneous emphysema. Three real-time RT-PCR for SARS-CoV-2 were made with a negative result. In addition, she was complicated with a secondary hemophagocytic lymphohistiocytosis and a fourth real-time PCR for SARS-CoV-2 performed in BAS sample was positive. Despite aggressive treatment of RP-ILD due to anti-MDA5 JDM, there was no improvement of respiratory failure in the following days and patient developed refractory septic shock and died. Anti-MDA5 JDM patients with RP-ILD have a poor prognosis with a high mortality rate. For this reason, intensive immunosuppressive therapy is essential including the use of promising drugs such as tofacitinib. COVID-19 in children with underlying health conditions like anti-MDA5 JDM may still be at risk for disease and severe complications.

Sepsis and septic shock after craniotomy: Predicting a significant patient safety and quality outcome measure

OBJECTIVES

Sepsis and septic shock are important quality and patient safety metrics. This study examines incidence of Sepsis and/or septic shock (S/SS) after craniotomy for tumor resection, one of the most common neurosurgical operations.

METHODS

Multicenter, prospectively collected data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was used to identify patients undergoing craniotomy for tumor (CPT 61510, 61521, 61520, 61518, 61526, 61545, 61546, 61512, 61519, 61575) from 2012-2015. Univariate and multivariate logistic regression models were used to identify risk factors for S/SS.

RESULTS

There were 18,642 patients that underwent craniotomy for tumor resection. The rate of sepsis was 1.35% with a mortality rate of 11.16% and the rate of septic shock was 0.65% with a 33.06% mortality rate versus an overall mortality rate of 2.46% in the craniotomy for tumor cohort. The 30-day readmission rate was 50.54% with S/SS vs 10.26% in those without S/SS. Multiple factors were identified as statistically significant (p <0.05) for S/SS including ascites (OR = 33.0), ventilator dependence (OR = 4.5), SIRS (OR = 2.8), functional status (OR = 2.3), bleeding disorders (OR = 1.7), severe COPD (OR = 1.6), steroid use (OR = 1.6), operative time >310 minutes (OR = 1.5), hypertension requiring medication (OR = 1.5), ASA class ≥ 3 (OR = 1.4), male sex (OR = 1.4), BMI >35 (OR = 1.4) and infratentorial location.

CONCLUSIONS

The data indicate that sepsis and septic shock, although uncommon after craniotomy for tumor resection, carry a significant risk of 30-day unplanned reoperation (35.60%) and mortality (18.21%). The most significant risk factors are ventilator dependence, ascites, SIRS and poor functional status. By identifying the risk factors for S/SS, neurosurgeons can potentially improve outcomes. Further investigation should focus on the creation of a predictive score for S/SS with integration into the electronic health record for targeted protocol initiation in this unique neurosurgical patient population.