Stridor and Horner's syndrome, weeks after attempted right subclavian vein cannulation

A 23-year-old woman presented with renal failure resulting from polycystic kidney disease (PKD) aggravated by tubulo-interstitial nephritis. Emergency haemodialysis was planned, and cannulation of the right subclavian vein was attempted, but failed. During this procedure, inadvertent arterial puncture occurred. Transient mild ischaemia of the right arm, and a transient Horner's syndrome were noted. Seven weeks later she presented with severe stridor with impending respiratory failure necessitating emergency intubation; the right-sided Horner's syndrome had recurred. CT imaging showed a large pseudo-aneurysm of the brachiocephalic artery resulting in severe compression of the trachea. Using a prosthetic graft, the operation for the pseudo-aneurysm was successful; there were mild neurological sequelae. Although her family history was negative, autosomal dominant PKD should be considered, and we discuss the possible role of a pre-existing PKD-associated aneurysm.

p38-MAPK inhibition and endotoxin induced tubular dysfunction in men

BACKGROUND

To evaluate the possibility of preventing endotoxin induced renal damage by p38-MAPK inhibition in a human model.

DESIGN AND METHODS

Twenty-one healthy young male volunteers received 4 ng/kg Escherichia coli endotoxin as a single dose. Four groups of volunteers received an oral dose of placebo or 350, 700 or 1400 mg RWJ-67657, a p38-MAPK inhibitor, 20 min before endotoxin infusion. Urine samples were collected at set time intervals. The urinary excretion rate of beta(2)-microglobulin and N-acetyl-beta-D-glucosaminidase, as indicators of tubular dysfunction was determined.

RESULTS

There was a significant increase of beta(2)-microglobulin and N-acetyl-beta-D-glucosaminidase urine excretion rate after endotoxin infusion in the placebo group. p38-MAPK inhibition prevented the increase of markers for tubulopathy.

CONCLUSIONS

Endotoxin infusion induces measurable tubular damage. Blocking the p38-MAPK may prevent this damage. The mechanism is unclear, but blocking TNF-alpha release is a possible explanation.

'Brugada ECG' elicited by imipramine overdose

The ECG hallmark of the Brugada syndrome is ST-segment elevation in the right precordial leads. However, a 'Brugada ECG' may also occasionally be caused by other conditions. We report a case of a Brugada ECG due to an overdose of imipramine, a tricyclic antidepressant. The patient, a 66-year-old woman, was admitted to the emergency unit in a comatose state, due to autointoxication with imipramine. In addition to other signs of massive sodium-channel blockade, the ECG showed typical ST-segment elevation in the right precordial and the inferior leads. The abnormalities resolved quickly after administration of sodium bicarbonate.

[Massive haemoptysis: primary care, diagnosis and treatment]

Massive haemoptysis is life-threatening because of asphyxiation from flooding of the central airways with blood. The first step in treatment includes airway protection, usually managed by intubation. Imaging may be inconclusive, and bronchoscopy--rigid or flexible--is essential to establish the site and cause of the bleeding. Bronchoscopy may be therapeutic in that a balloon catheter may be inserted in the bleeding airway in order to tamponade the source of bleeding. Embolisation of pathological bronchial arterial vessels is the treatment of choice in most cases; surgery is limited to causes that cannot be managed by the endovascular treatment modality, or to cases that fail to respond to embolisation.

ENDOTOXIN INCREASES PLASMA SOLUBLE TUMOR NECROSIS FACTOR-RELATED APOPTOSIS-INDUCING LIGAND LEVEL MEDIATED BY THE p38 MITOGEN-ACTIVATED PROTEIN KINASE SIGNALING PATHWAY

Despite extensive knowledge about the mechanisms behind sepsis, this syndrome still caries a large morbidity and mortality rate. Dysregulated immune and coagulation systems are held responsible. However, additional pathophysiological mechanisms such as uncontrolled apoptosis induced by death receptor ligands might well play a role. P38 mitogen-activated protein (MAP) kinase inhibitors are considered as potential drugs in inflammatory diseases. Therefore, the effect of endotoxin administration on the response of soluble(s) tumor necrosis factor-related apoptosis-inducing ligand (sTRAIL), a death receptor ligand, and the role of p38 MAP kinase inhibition was studied in 21 human volunteers. The volunteers received 30 min before the endotoxin infusion a single oral dose of placebo or the selective p38 MAP kinase inhibitor drug, RWJ-67657. Plasma sTRAIL increased 10-fold to 6564 +/- 511 pg/mL after 2.5 h. This increase was blocked completely by the highest dose of RW-J6765. This is the first report showing that endotoxin increases sTRAIL where the p38 MAP kinase signaling pathway is involved.

Recurrent splinter haemorrhages weeks after a tick bite

A 52-year-old man developed fever, headache, tinnitus, and painful joints. He reported a tick bite contracted during a summer holiday in the Netherlands, followed by erythema on his left arm three weeks earlier. Initial treatment with doxycycline had failed and he had now developed signs of meningoencephalitis. Laboratory tests showed an increased white cell count (16.1 x 10(9)/1), and elevated ESR (51/1h).

Cardiac troponin I release and cytokine response during experimental human endotoxaemia

OBJECTIVE

To study the relationship between cytokine levels and cardiac troponin I (cTnI).

DESIGN

Prospective experimental study.

SETTING

Intensive care unit of a university hospital.

PARTICIPANTS

Six healthy male volunteers. INTERVENTIONS. Endotoxin, 4 ng/kg, was given as a 1-min intravenous infusion.

MEASUREMENTS AND RESULTS

Circulating cardiac troponin I levels and proinflammatory cytokines tumour necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6) and interleukin-8 (IL-8) were analysed at various time points during a 24-h period. TNF-alpha appeared in the circulation 30 min after injection (T=0.5 h), reaching peak levels (5,665+/-1,910 pg/ml) 2 h after infusion. At T=24 h TNF-alpha was still elevated in the circulation compared to T=0. None of the six volunteers had a cTnI value higher than 0.1 microg/l at T=0, 6 h or 24 h.

CONCLUSION

The presence of significant amounts of TNF-alpha, IL-6 and IL-8 in the systemic circulation does not lead to increased levels of cTnI in experimental human endotoxaemia.

[Fulminant pneumococcal sepsis in two splenectomized patients]

Two 41-year-old women, who had previously been splenectomized, were admitted to the intensive-care unit due to fulminant sepsis. On admission, petechiae and ecchymoses characterised the clinical presentation of both patients. Laboratory tests revealed the presence of renal insufficiency and thrombocytopenia with disseminated intravascular coagulation. Streptococcus pneumoniae with serotypes (24 and 38) not included in the current polyvalent pneumococcal vaccine were found in blood cultures from both patients. One patient died as a result of a refractory septic shock. The other patient, who had never been vaccinated with the polyvalent pneumococcal vaccine, survived the sepsis. The clinical course of a fulminant Streptococcus pneumoniae sepsis in both asplenic patients underlines the importance of vaccination. It is also important to educate the patient about seeking immediate medical help if an infection is suspected on the basis of these symptoms. Vaccination does not provide complete protection.

Inhibition of p38 mitogen-activated protein kinase: dose-dependent suppression of leukocyte and endothelial response after endotoxin challenge in humans

OBJECTIVE

We studied the activity of a single oral dose of RWJ-67657, a synthetic p38 mitogen-activated protein kinase inhibitor, in preventing dual leukocyte/endothelial activation after endotoxin infusion in healthy volunteers.

DESIGN

Prospective placebo-controlled study.

SETTING

Intensive care unit at a university medical center.

SUBJECTS

Twenty-one healthy male volunteers.

INTERVENTIONS

Endotoxin (4 ng/kg) as a 1-min infusion. According to randomization, the volunteers received placebo (n = 6) or 1400 mg (n = 4), 700 mg (n = 6), or 350 mg (n = 5) of RWJ-67657.

MEASUREMENTS AND MAIN RESULTS

Neutrophil activation was investigated by analyzing the extent of membrane expression of adhesion markers by calibrated flow cytometry. Circulating intercellular adhesion molecule-1 and E-selectin were measured by enzyme-linked immunosorbent assays. The endotoxin-induced shedding of L-selectin was diminished in a dose-dependent manner (p <.0001). High-dose RWJ-67657 prevented up-regulation of the integrins CD11b (p <.01) and CD 66b (p <.01) on neutrophils. The endotoxin-induced increase in circulating intercellular adhesion molecule-1 and circulation E-selectin was almost completely prevented by high-dose RWJ-67657.

CONCLUSION

A single oral dose of RWJ-67657 prevented neutrophil and endothelial activation after endotoxin infusion.

Monocyte intracellular cytokine production during human endotoxaemia with or without a second in vitro LPS challenge: effect of RWJ-67657, a p38 MAP-kinase inhibitor, on LPS-hyporesponsiveness

In the present study, we investigated the effect of RWJ-67657, a p38 MAP kinase inhibitor, upon in vivo LPS-induced monocyte cytokine production and upon monocyte LPS-hyporesponsiveness. Thirty minutes before a single injection of LPS (4 ng/kg BW), healthy male volunteers received a single oral dose of RWJ-67657 at increasing dosages (0-1400 mg). Blood samples (pre-medication, 3, 6 and 24 h after LPS) were immediately incubated with LPS (reflecting LPS-hyporesponsiveness) or without LPS (reflecting in vivo monocyte stimulation) for 4 h at 37 degrees C. Following red blood cells lysis and white blood cell permeabilization, cells were labelled with alpha-CD14-FITC and alpha-IL-1beta, alpha-IL-12 or alpha-TNFalpha (PE-labelled), fixed, and analysed using flow cytometry. In vivo LPS injection resulted in an increased percentage of circulating monocytes producing IL-1beta, TNFalpha and IL-12 only at 3 h after the LPS injection. This was dose-dependently inhibited by RWJ-67657 treatment. LPS-hyporesponsiveness to in vitro LPS treatment was most prominent at 3 and 6 h after the in vivo LPS injection; compared with pre-medication monocytes, at these intervals a reduced percentage of monocytes produced IL-1beta, TNFalpha or IL-12 after the in vitro LPS stimulus. At t = 6 h, this LPS-hyporesponsiveness could dose-dependently be inhibited by RWJ-67657 treatment of the volunteers. We therefore conclude that p38 MAP kinase inhibition with RWJ-67657 inhibited monocyte production of cytokines following in vivo LPS injection. Treatment with RWJ-67657 also reversed the LPS-hyporesponsiveness. Whether this result can be extended to the clinical situation remains to be elucidated. Patients with sepsis or an otherwise high risk for multi-organ failure are potential study groups.

The influence of tumor necrosis factor-alpha and interleukin-10 gene promoter polymorphism on the inflammatory response in experimental human endotoxemia

In this study, we show that there is no correlation between tumor necrosis factor-alpha gene promoter polymorphism at position -308, interleukin-10 gene promoter polymorphism at position -1082, and the cytokine levels they produce in the human endotoxemia model.

Hormones in the critically ill patient: to intervene or not to intervene?

Critically ill patients show a variety of hormonal changes that appear to differ considerably in acute and prolonged critical illness. Whether these endocrine alterations serve as physiological adaptation or contribute to further deterioration remains an intriguing question. We review the recent literature and discuss whether measuring circulating hormone concentrations, performing stimulation tests, and intervening with hormone substitution could contribute to the recovery of critically ill patients.

[Relative adrenocortical insufficiency with sepsis, diagnosed and treated with hydrocortisone supplementation]

An 82-year-old woman was admitted to the ICU with septic shock and multiple organ failure. Despite the lack of a persistent septic focus she continued to be dependent on large doses of norepinephrine whilst receiving adequate antimicrobial therapy. After a trial treatment with hydrocortisone the norepinephrine infusion could be withdrawn within a few days and she made a full recovery. In the case of seriously ill patients the diagnosis 'relative adrenocortical insufficiency' is predominantly made on the basis of the clinical picture. The remarkable clinical response to the administration of hydrocortisone (400 mg in the first 24 h) confirmed the diagnosis. The dosage of vasopressors can be reduced remarkably quickly. The stimulatory test for adrenocorticotropin hormone (ACTH) has no added value as reference values for critically ill patients are not available and because the results do not predict the response to the treatment.