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Castillo-Campos L, Bachiller-Carnicero L, Megía-Sevilla MJ, González-Tomé MI. Secondary asplenia as a complication of severe Meningococcal Sepsis. BMJ Case Rep 2017; 2017:bcr-2016-217167. [PMID: 28069783 DOI: 10.1136/bcr-2016-217167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We report the case of an 11-month-old infant who had a medical history of meningococcal septicaemia 6 months prior to this admission and presented to hospital with an episode of fever due to Streptococcus pneumoniae bacteraemia. During this second admission, an abdominal ultrasound scan revealed secondary asplenia.
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Haruta M, Yoshida Y, Yamakawa R. Pediatric endogenous Haemophilus influenzae endophthalmitis with presumed hyposplenism. Int Med Case Rep J 2017; 10:7-9. [PMID: 28115875 PMCID: PMC5221797 DOI: 10.2147/imcrj.s123524] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background Endogenous bacterial endophthalmitis is a rare but potentially devastating intraocular infection that can have severe sight-threatening complications. Most patients with endogenous bacterial endophthalmitis have underlying infectious conditions, such as diabetes or malignancy, which predispose them to infection. Case report A 1-year-old girl presented with cloudiness of the right eye. Ocular examination showed a cloudy cornea in the right eye with conjunctival injection and hypopyon. The intraocular pressure was 43 mmHg, and the fundus could not be visualized. She had an 8-day history of fever, and cerebrospinal fluid analysis showed typical findings of bacterial meningitis. She was clinically diagnosed with bacterial meningitis and endophthalmitis in the right eye and was treated with intravenous, topical, and intravitreal antibiotics and vitrectomy. Haemophilus influenzae was isolated from the blood and cerebrospinal fluid cultures, but not from the aqueous and vitreous cultures. Four months later, her pediatrician diagnosed Streptococcus pneumoniae meningitis, but she had no clinical signs of endophthalmitis. Seven years after the initial presentation, the best-corrected visual acuity was 20/40 in the right eye. Discussion Endophthalmitis caused by H. influenzae is generally associated with poor visual outcomes; however, the patient in the current case responded well to the treatment. The patient had recurrent bacterial meningitis caused by H. influenzae and S. pneumoniae within a 4-month period. Magnetic resonance imaging was performed to search for underlying infectious causes and revealed that the patient had an extremely small spleen for her age. Because the spleen is critical for clearing encapsulated bacteria such as H. influenzae or S. pneumoniae, we speculated that hyposplenism led to the bloodstream infection of H. influenza and then endogenous endophthalmitis in the right eye.
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Affiliation(s)
- Masatoshi Haruta
- Department of Ophthalmology, Kurume University School of Medicine, Kurume, Japan
| | - Yumiko Yoshida
- Department of Ophthalmology, Kurume University School of Medicine, Kurume, Japan
| | - Ryoji Yamakawa
- Department of Ophthalmology, Kurume University School of Medicine, Kurume, Japan
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104
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Meier ER, Rampersad A. Pediatric sickle cell disease: past successes and future challenges. Pediatr Res 2017; 81:249-258. [PMID: 27706129 DOI: 10.1038/pr.2016.204] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Accepted: 09/30/2016] [Indexed: 02/06/2023]
Abstract
Once a fatal disease of childhood, more than 95% of patients born today with sickle cell disease (SCD) in developed countries are expected to survive into adulthood, largely because of improvements in supportive and preventive care (newborn screening, penicillin prophylaxis, transcranial Doppler (TCD) screening). Hydroxyurea (HU) therapy, the only oral medication currently available to prevent SCD complications, has become more widespread over the past 20 y. The NHLBI recommends that HU be offered to all patients with HbSS beginning at 9 mo of age, and the recently published Abnormal TCD with Transfusions Changing to HU (TWiTCH) trial has shown HU as an acceptable alternative to transfusion therapy for patients at high risk of stroke. While hematopoietic stem cell transplant (HSCT) is a curative option for SCD, less than 25% of patients have a suitable donor. Alternative stem cell sources from unrelated donors and haplo-identical donors are currently under investigation as are gene therapy trials. This review will focus on early efforts to elucidate SCD pathophysiology as well as supportive and preventive care improvements. Findings from recent multi-center studies (Silent Infarct Transfusion (SIT) Trial and TWiTCH) will be summarized. Finally, HSCT trials and gene therapy will be reviewed.
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Affiliation(s)
- Emily Riehm Meier
- Pediatric Hematology, Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana
| | - Angeli Rampersad
- Pediatric Hematology, Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana
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105
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Dai MH, Shi N, Xing C, Liao Q, Zhang TP, Chen G, Wu WM, Guo JC, Liu ZW, Zhao YP. Splenic preservation in laparoscopic distal pancreatectomy. Br J Surg 2016; 104:452-462. [PMID: 28004852 DOI: 10.1002/bjs.10434] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 07/10/2016] [Accepted: 10/26/2016] [Indexed: 12/19/2022]
Abstract
Abstract
Background
Laparoscopic spleen-preserving distal pancreatectomy (LSPDP) is designed principally for the removal of benign and low-grade malignant lesions in the left pancreas. The aims of this study were to compare LSPDP with laparoscopic distal pancreatectomy with splenectomy (LDPS), compare two splenic preservation techniques (splenic vessel preservation and Warshaw technique) and investigate factors that influence splenic preservation.
Methods
Information from patients who underwent laparoscopic distal pancreatectomy between December 2004 and January 2016 at a single institution was reviewed. Data were extracted from a prospectively developed database. Intention-to-treat and propensity score matching analyses were employed. Univariable and multivariable analyses were used to investigate factors affecting splenic preservation.
Results
There were 206 patients in total (126 planned LSPDP and 80 planned LDPS procedures), of whom 108 underwent LSPDP and 98 LDPS. In intention-to-treat analysis, the duration of surgery was significantly shorter in the LSPDP group than in the LDPS group (mean 191·0 versus 220·5 min respectively; P < 0·001). Tumour size was an independent risk factor for splenic vessel resection in planned splenic vessel preservation operations, and a cut-off value of 3 cm provided optimal diagnostic accuracy. After a median follow-up of 35·9 months, there were no clinically significant splenic infarctions and no patient developed gastrointestinal bleeding after LSPDP.
Conclusion
Planned LSPDP had a high splenic preservation rate and was associated with significantly shorter operating time than LDPS. Splenic vessel preservation could be predicted using a tumour cut-off size of 3 cm.
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Affiliation(s)
- M-H Dai
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - N Shi
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - C Xing
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Q Liao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - T-P Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - G Chen
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - W-M Wu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - J-C Guo
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Z-W Liu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Y-P Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Marrie TJ, Tyrrell GJ, Majumdar SR, Eurich DT. Asplenic patients and invasive pneumococcal disease-how bad is it these days? Int J Infect Dis 2016; 51:27-30. [PMID: 27590561 DOI: 10.1016/j.ijid.2016.08.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 07/28/2016] [Accepted: 08/24/2016] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES Most are aware of pneumococcal infection as a complication of splenectomy and the increased risk of severe invasive pneumococcal disease (IPD) in asplenic patients. However little is known of the current status of this entity in a population with an active pneumococcal conjugate vaccine program for children. METHODS All IPD cases reported from 2000 to 2014 in Northern Alberta, Canada were collected prospectively. Socio-demographic variables, clinical characteristics, and IPD-related outcomes were compared between patients with and without a spleen using the Student t-test, Chi-square test, or Fisher's exact test, as appropriate. RESULTS Thirty-seven of 2435 patients with IPD (1.5%) were asplenic. Asplenic patients were significantly more likely to require mechanical ventilation or admission to the intensive care unit and had more complications (e.g., acute kidney injury). However, in-hospital mortality rates were similar in those with and without a spleen (19% vs. 16%, p=0.58). Pneumococcal serotype 22B was 33-fold higher in asplenic patients compared to those with a spleen. CONCLUSIONS In patients with IPD, those who are asplenic have a more severe infection than those with a spleen; however, the mortality rate is not significantly different. The reason for the predominance of serotype 22B requires further investigation and if replicated may warrant attention to current vaccination strategies.
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Affiliation(s)
- Thomas J Marrie
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Gregory J Tyrrell
- Division of Diagnostic and Applied Microbiology, Department of Laboratory Medicine and Pathology, University of Alberta, and The Provincial Laboratory for Public Health, Edmonton, Alberta, Canada
| | - Sumit R Majumdar
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Dean T Eurich
- School of Public Health, University of Alberta, 2-040 Li Ka Shing HRIF, Edmonton, Alberta, T6G 2E1, Canada.
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Fatal purpura fulminans and Waterhouse-Friderichsen syndrome from fulminant Streptococcus pneumoniae sepsis in an asplenic young adult. IDCases 2016; 6:1-4. [PMID: 27583208 PMCID: PMC4995527 DOI: 10.1016/j.idcr.2016.08.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 08/10/2016] [Accepted: 08/10/2016] [Indexed: 11/23/2022] Open
Abstract
Asplenic patients are at increased risk for sepsis and fulminant infection. Sepsis in these patients is typically secondary to encapsulated bacteria, with Streptococcus pneumoniae being the most frequent pathogen. Rare complications of severe sepsis include purpura fulminans and bilateral adrenal hemorrhage (Waterhouse-Friderichsen syndrome). We present the case of a 36-year-old woman, healthy except for splenectomy years prior for idiopathic thrombocytopenic purpura treatment, who presented with fever. Upon presentation to our hospital, three hours after symptoms onset, she had purpura fulminans and shock. Despite timely antimicrobials and maximal resuscitative efforts, her disease progressed and she expired 12 hours after symptoms onset. Autopsy revealed bilateral adrenal hemorrhage; acute adrenal crisis likely contributed to her refractory shock. Prior to her presentation, she had not received guideline-based post-splenectomy care. Sepsis in asplenic patients can be fulminant and rapidly fatal. Streptococcus pneumoniae remains the most frequent cause, despite decreasing rates in recent years related to widespread pneumococcal vaccination. Guideline-based vaccinations and "pill-in-pocket" therapy can be life-saving for asplenic patients. Purpura fulminans represents an extreme manifestation of disseminated intravascular coagulation, is more common in asplenic patients, and portends a poor prognosis. Waterhouse-Friderichsen syndrome can be seen concurrently with purpura fulminans and further portends a poor prognosis; pre-mortem diagnosis requires a high index of suspicion.
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108
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109
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Bone and Joint Infections due to Haemophilus parainfluenzae: Case Report and Review of the Literature. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2016; 2016:4503025. [PMID: 27516778 PMCID: PMC4969501 DOI: 10.1155/2016/4503025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 12/15/2015] [Indexed: 11/17/2022]
Abstract
Haemophilus parainfluenzae is a normal inhabitant of the human respiratory tract. However it is an increasingly recognized pathogen in invasive infections, particularly in the immunocompromised host and where there is disruption of the normal skin or mucosal barriers. We present a case of a 56-year-old female with a history of asplenia who developed H. parainfluenzae septic arthritis of the hip following an intra-articular steroid injection. We also summarize previously reported cases of bone and joint infections caused by H. parainfluenzae.
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110
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O'Neal HR, Niven AS, Karam GH. Critical Illness in Patients With Asplenia. Chest 2016; 150:1394-1402. [PMID: 27068019 DOI: 10.1016/j.chest.2016.03.044] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 02/29/2016] [Accepted: 03/27/2016] [Indexed: 10/22/2022] Open
Abstract
The critically ill, asplenic patient presents a variety of management challenges. Historically, the focus of the care of the asplenic population has been the prevention and management of infection, including the often-fatal overwhelming postsplenectomy infection with encapsulated organisms such as Streptococcus pneumoniae. Recently, however, there has been increasing recognition of the spleen's function in areas outside of immunity because the asplenic state has been identified as a risk factor for such vascular complications as thrombosis and pulmonary hypertension resulting from dysregulated inflammation and coagulation. Because of the relatively small size of this population and the relative infrequency with which critical illness occurs in it, there are few controlled trials that can serve as a basis for therapeutic maneuvers; thus, optimal management requires an astute clinician with an understanding of the pathogenetic mechanisms underlying the reported consequences of splenectomy. The purpose of this review is to explore the pathophysiology of the asplenic state-impairment in adaptive immunity, loss of blood filtration, endothelial dysfunction, and dysregulated coagulation-and how it leads to infection, thrombosis, and pulmonary hypertension as well as to discuss the implications of these conditions on the management of the critically ill, splenectomized patient.
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Affiliation(s)
- Hollis R O'Neal
- LSU Health Sciences Center - Baton Rouge, Department of Internal Medicine, Baton Rouge, LA
| | - Alexander S Niven
- Uniformed Services University of the Health Sciences, Department of Medicine, Bethesda, MD
| | - George H Karam
- LSU Health Sciences Center - Baton Rouge, Department of Internal Medicine, Baton Rouge, LA.
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112
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Ward R, Simpson E, Verhovsek M. A 19-year-old woman with sickle cell disease and pain. CMAJ 2016; 188:745-746. [PMID: 26833738 DOI: 10.1503/cmaj.150512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Richard Ward
- Division of Medical Oncology and Hematology (Ward), University Health Network; and Division of Hematology (Ward), University of Toronto, Toronto General Hospital, Toronto, Ont.; Division of Hematology/Oncology (Simpson), Children's Hospital of Eastern Ontario; and Faculty of Medicine (Simpson), University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ont.; Division of Hematology and Thromboembolism (Verhovsek), McMaster University, St. Joseph's Healthcare, Hamilton, Ont.
| | - Ewurabena Simpson
- Division of Medical Oncology and Hematology (Ward), University Health Network; and Division of Hematology (Ward), University of Toronto, Toronto General Hospital, Toronto, Ont.; Division of Hematology/Oncology (Simpson), Children's Hospital of Eastern Ontario; and Faculty of Medicine (Simpson), University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ont.; Division of Hematology and Thromboembolism (Verhovsek), McMaster University, St. Joseph's Healthcare, Hamilton, Ont
| | - Madeleine Verhovsek
- Division of Medical Oncology and Hematology (Ward), University Health Network; and Division of Hematology (Ward), University of Toronto, Toronto General Hospital, Toronto, Ont.; Division of Hematology/Oncology (Simpson), Children's Hospital of Eastern Ontario; and Faculty of Medicine (Simpson), University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ont.; Division of Hematology and Thromboembolism (Verhovsek), McMaster University, St. Joseph's Healthcare, Hamilton, Ont
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Hu L, Liu X, Zhang X, Yu L, Sha H, Zhou Y, Tian M, Shi J, Wang W, Liu C, Guo K, Lv Y, Wang B. Child-to-Adult Liver Transplantation With Donation After Cardiac Death Donors: Three Case Reports. Medicine (Baltimore) 2016; 95:e2834. [PMID: 26886643 PMCID: PMC4998643 DOI: 10.1097/md.0000000000002834] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Development of organ transplantation is restricted by the discrepancy between the lack of donors and increasing number of patients. The outcome of pediatric donors transplanted into adult recipients especially with donation after circulatory death (DCD) pattern has not been well studied. The aim of this paper is to describe our experience of 3 successful DCD donor child-to-adult liver transplantations lately. Three DCD donors were separately 7, 5, and 8 years old. The ratio between donor graft weight and recipient body weight was 1.42%, 1.00%, and 1.33%, respectively. Ratio between the volume of donor liver and the expected liver volume was 0.65, 0.46, and 0.60. Splenectomy was undertaken for the second recipient according to the portal vein pressure (PVP) which was observed during the operation. Two out of 3 of the recipients suffered with acute kidney injury and got recovered after renal replacement therapy. The first recipient also went through early allograft dysfunction and upper gastrointestinal bleeding. The hospital course of the third recipient was uneventful. After 1 year of follow-up visit, the first and second recipients maintain good quality of life and liver function. The third patient was followed up for 5 months until now and recovered well. DCD child-to-adult liver transplantation should only be used for comparatively matched donor and recipient. PVP should be monitored during the operation. The short-term efficacy is good, but long-term follow-up and clinical study with large sample evaluation are still needed.
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Affiliation(s)
- Liangshuo Hu
- From the Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
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114
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Long-term outcomes after pediatric splenectomy. Surgery 2016; 159:1583-1590. [PMID: 26832988 DOI: 10.1016/j.surg.2015.12.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Revised: 12/15/2015] [Accepted: 12/17/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Splenectomy is performed frequently for various and primarily hematologic indications in children and adolescents. We analyzed the long-term outcome after splenectomy (median, 8.7 years) focusing on sepsis, portal vein thrombosis (PVT), and retained accessory spleen. METHODS In total, 141 consecutive children after open (n = 89; 63%) or laparoscopic (n = 52; 37%) splenectomy from 1991 to 2010 were followed up through nationwide registries for septic infections, PVT, and causes of death. Sixty-six patients (58% of survivors) answered a structured questionnaire on infections, abdominal symptoms, and general health, and 64 (laparoscopic n = 26, open n = 38) consented to ultrasonography of the portal venous system. RESULTS Median operation age was 8.8 years (range, 1.0-22). Reoperations were required for bleeding after open procedures (n = 1) and retained accessory spleen after laparoscopic procedures (n = 3). Postsplenectomy sepsis occurred after a median of 1.7 years (range, 0.2-5.9) in 11 patients (8%), of whom 10 had an underlying immunodeficiency. No cases of PVT were observed, although the median portal vein flow was 1,130 mL/min (range, 440-2200) and diameter was 9.9 mm (range, 7-15) at a median follow-up of 9.5 years (range, 2.0-22) after splenectomy. Twenty-seven patients (19%) died after 8.7 years (0.03-23.00). The most common cause of death was the underlying malignancy (n = 15), with sepsis being an additional cause of death in 5 patients. CONCLUSION Postsplenectomy sepsis was associated almost exclusively with an underlying immunodeficiency with a high mortality rate. No PVT was observed. The overall risk of retained accessory spleen was around 7%, and was slightly greater after laparoscopic operation.
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115
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Theilacker C, Ludewig K, Serr A, Schimpf J, Held J, Bögelein M, Bahr V, Rusch S, Pohl A, Kogelmann K, Frieseke S, Bogdanski R, Brunkhorst FM, Kern WV. Overwhelming Postsplenectomy Infection: A Prospective Multicenter Cohort Study. Clin Infect Dis 2015; 62:871-878. [PMID: 26703862 DOI: 10.1093/cid/civ1195] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 12/14/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Recent population-based cohort studies have questioned the role of pneumococci as the most frequent pathogen causing severe infection in patients after splenectomy. The aim of the study was to define the causative pathogens and clinical presentation of patients with overwhelming postsplenectomy infection (OPSI). METHODS In a prospective cohort study in 173 German intensive care units, we searched for patients with and without asplenia and community-acquired severe sepsis/septic shock. Clinical and laboratory variables and survival of patients were assessed. RESULTS Fifty-two patients with severe sepsis or septic shock with asplenia and 52 without asplenia were included. OPSI patients more often had a history of malignancy (38% vs 17%; P = .016) and had a lower body mass index (24 kg/m(2) vs 28 kg/m(2); P = .004). Streptococcus pneumoniae was detected more frequently in OPSI patients (42% vs 12% without asplenia; P < .001) and more frequently manifested as bloodstream infection (31% vs 6%; P = .002). Gram-negative infection was similar in both groups (12% vs 19%; P = .157). Pneumococcal vaccine coverage of OPSI patients was low overall (42% vs 8% among patients without asplenia; P < .001). Purpura fulminans was a frequent complication, developing in 19% of OPSI patients vs 5% of patients without asplenia (P = .038). The interval between splenectomy and OPSI was 6 years (range, 1 month-50 years). On multivariable Poisson regression, asplenia was the only predictive variable independently associated with pneumococcal sepsis (adjusted relative risk, 2.53 [95% confidence interval, 1.06-6.08]). CONCLUSIONS Pneumococcal infections remain the most important cause of severe sepsis and septic shock following splenectomy.
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Affiliation(s)
- Christian Theilacker
- Center for Chronic Immunodeficiency.,Division of Infectious Diseases, Department of Medicine
| | | | | | | | - Jürgen Held
- Institute for Microbiology and Hygiene.,Mikrobiologisches Institut, Universitätsklinikum Erlangen und Friedrich-Alexander-Universität Erlangen-Nürnberg
| | - Martin Bögelein
- Center for Chronic Immunodeficiency.,Division of Infectious Diseases, Department of Medicine.,Clinical Research Unit, Freiburg University Medical Center
| | | | - Stephan Rusch
- Clinical Research Unit,Freiburg University Medical Center
| | - Annette Pohl
- Center for Chronic Immunodeficiency.,Clinical Research Unit, Freiburg University Medical Center
| | | | | | - Ralph Bogdanski
- Klinikum rechts der Isar, Technical University, Munich, Germany
| | - Frank M Brunkhorst
- Center for Sepsis Control and Care.,Paul Martini Sepsis Research Group, Jena University Hospital
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116
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Affiliation(s)
- Maurizio Miano
- Clinical and Experimental Haematology Unit; Department of Haematology/Oncology; IRCCS Istituto Giannina Gaslini; Genoa Italy
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117
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Meningococcemia Presenting as a Myocardial Infarction. Case Rep Crit Care 2015; 2015:953826. [PMID: 26640720 PMCID: PMC4658401 DOI: 10.1155/2015/953826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 11/02/2015] [Indexed: 11/23/2022] Open
Abstract
Neisseria meningitidis is an encapsulated gram negative diplococcus that colonizes the nasopharynx and is transmitted by aerosol or secretions with the majority of cases occurring in infants and adolescents. Meningococcemia carries a high mortality which is in part due to myocarditis. Early recognition and prompt use of antibiotics improve morbidity and mortality. We report a 55-year-old male presenting to the emergency department with chest pain, shortness of breath, and electrocardiogram changes suggestive of ST elevation MI who developed cardiogenic shock and multisystem organ failure from N. meningitidis. We present this case to highlight the unique presentation of meningococcemia, the association with myocardial dysfunction, and the importance of early recognition and prompt use of antibiotics.
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118
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Bacterial Infections Following Splenectomy for Malignant and Nonmalignant Hematologic Diseases. Mediterr J Hematol Infect Dis 2015; 7:e2015057. [PMID: 26543526 PMCID: PMC4621170 DOI: 10.4084/mjhid.2015.057] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 10/03/2015] [Indexed: 01/19/2023] Open
Abstract
Splenectomy, while often necessary in otherwise healthy patients after major trauma, finds its primary indication for patients with underlying malignant or nonmalignant hematologic diseases. Indications of splenectomy for hematologic diseases have been reducing in the last few years, due to improved diagnostic and therapeutic tools. In high-income countries, there is a clear decrease over calendar time in the incidence of all indication splenectomy except nonmalignant hematologic diseases. However, splenectomy, even if with different modalities including laparoscopic splenectomy and partial splenectomy, continue to be a current surgical practice both in nonmalignant hematologic diseases, such as Immune Thrombocytopenic Purpura (ITP), Autoimmune Hemolytic Anemia (AIHA), Congenital Hemolytic Anemia such as Spherocytosis, Sickle Cell Anemia and Thalassemia and Malignant Hematological Disease, such as lymphoma. Today millions of people in the world are splenectomized. Splenectomy, independently of its cause, induces an early and late increase in the incidence of venous thromboembolism and infections. Infections remain the most dangerous complication of splenectomy. After splenectomy, the levels of antibody are preserved but there is a loss of memory B cells against pneumococcus and tetanus, and the loss of marginal zone monocytes deputed to immunological defense from capsulated bacteria. Commonly, the infections strictly correlated to the absence of the spleen or a decreased or absent splenic function are due to encapsulated bacteria that are the most virulent pathogens in this set of patients. Vaccination with polysaccharide and conjugate vaccines again Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis should be performed before the splenectomy. This practice reduces but does not eliminate the occurrence of overwhelming infections due to capsulated bacteria. At present, most of infections found in splenectomized patients are due to Gram-negative (G-) bacteria. The underlying disease is the most important factor in determining the frequency and severity of infections. So, splenectomy for malignant diseases has the major risk of infections.
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119
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Minden K, Speth F, Huppertz HI, Borte M. [Immunization in children and adolescents with rheumatic and musculoskeletal diseases]. Z Rheumatol 2015; 73:878-89. [PMID: 25479932 DOI: 10.1007/s00393-014-1396-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Children and adolescents with inflammatory rheumatic diseases have a disease and treatment-related increased risk of infections. This risk includes vaccine-preventable diseases; therefore, vaccinations represent an important preventive measure against infection in these patients. However, approximately one in three patients with a juvenile rheumatic disease is nowadays still inadequately vaccinated, mostly due to uncertainty regarding the efficacy and safety of vaccination in these patients. OBJECTIVES This paper summarizes the available evidence regarding the efficacy and safety of vaccinations in children and adolescents with rheumatic diseases and gives recommendations for the clinical practice. RESULTS AND PERSPECTIVES Almost 2000 children and adolescents with rheumatic diseases were examined in the more than 30 previously published vaccination studies, comprising nearly all standard vaccinations in the immunization schedule. The immunogenicity was usually sufficient and there was no evidence of a relevant aggravation of the underlying disease. Recommendations for the clinical practice are given also considering data beyond pediatric rheumatology; however, a final benefit-risk assessment is not yet possible.
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Affiliation(s)
- K Minden
- Universitätskinderklinik Charité, Campus Virchow, Otto-Heubner-Centrum, SPZ, Deutsches Rheuma-Forschungszentrum Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland,
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120
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Trip AK, Sikorska K, van Sandick JW, Heeg M, Cats A, Boot H, Jansen EPM, Verheij M. Radiation-induced dose-dependent changes of the spleen following postoperative chemoradiotherapy for gastric cancer. Radiother Oncol 2015; 116:239-44. [PMID: 26253953 DOI: 10.1016/j.radonc.2015.07.036] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 07/23/2015] [Accepted: 07/26/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND PURPOSE Abdominal (chemo-)radiotherapy is associated with dose-limiting toxicity of various normal structures. The purpose of this retrospective study was to investigate radiation-induced changes of the spleen and their clinical consequences. PATIENTS AND METHODS In gastric cancer patients treated with postoperative chemoradiotherapy, the spleen size and its functions were assessed at follow-up by spleen volume on CT-scan, serum leucocytes/thrombocytes, and the occurrence of infectious events consisting of pneumonia and fatal sepsis. To evaluate the effect of radiation dose, mixed effects and Cox regression models were used. RESULTS Forty-six out of 90 consecutive patients treated from 2006 to 2011 were evaluable. All patients received 45 Gy in 25 fractions with concurrent capecitabine (n=8), and capecitabine/cisplatin (n=38). Median Dmean to the spleen was 40 Gy (range 32-46). Mean relative spleen volume reduced to 37% (95% CI 32-42%) at 4-year follow-up, which was most strongly associated to the V44 (p<0.001). Median follow-up time was 67 (95% CI 57-78) months. Eleven patients had 13 pneumonias and 3 fatal sepsis. No association with dosimetric parameters was observed. CONCLUSIONS In postoperative chemoradiotherapy for gastric cancer, the spleen received a high radiation dose. This resulted in a progressive, radiation dose-dependent reduction of spleen volume. Pneumonia and fatal sepsis occurred frequently, possibly as a result of functional hyposplenia.
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Affiliation(s)
| | | | | | - Maarten Heeg
- Department of Radiation Oncology, The Netherlands
| | - Annemieke Cats
- Department of Gastroenterology and Hepatology, The Netherlands
| | - Henk Boot
- Department of Gastroenterology and Hepatology, The Netherlands
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122
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Huebner ML, Milota KA. Asplenia and fever. Proc (Bayl Univ Med Cent) 2015; 28:340-1. [PMID: 26130882 DOI: 10.1080/08998280.2015.11929267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
A 45-year-old-man presented with the abrupt onset of a fever over 30 years after surgical splenectomy. He presented with symptoms and findings that seemed consistent with influenza. He rapidly developed fulminant meningitis that resulted in his death.
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Affiliation(s)
- Mitchell L Huebner
- Dallas Diagnostic Association Park Cities, Dallas, Texas (Huebner) and the Department of Critical Care Services, Children's Health System, Dallas, Texas (Milota)
| | - Kristin A Milota
- Dallas Diagnostic Association Park Cities, Dallas, Texas (Huebner) and the Department of Critical Care Services, Children's Health System, Dallas, Texas (Milota)
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123
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Handlogten KS, Anderson BW, Mohabbat AB. 72-Year-Old Man With Fever and Malaise. Mayo Clin Proc 2015; 90:e69-73. [PMID: 26141341 DOI: 10.1016/j.mayocp.2014.12.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 12/05/2014] [Accepted: 12/10/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Kathryn S Handlogten
- Resident in Internal Medicine, Mayo School of Graduate Medical Education, Rochester, MN
| | - Bradley W Anderson
- Resident in Internal Medicine, Mayo School of Graduate Medical Education, Rochester, MN
| | - Arya B Mohabbat
- Advisor to residents and Consultant in General Internal Medicine, Mayo Clinic, Rochester, MN.
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124
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Mohkam K, Farges O, Pruvot FR, Muscari F, Régimbeau JM, Regenet N, Sa Cunha A, Dokmak S, Mabrut JY. Toward a standard technique for laparoscopic distal pancreatectomy? Synthesis of the 2013 ACHBT Spring workshop. J Visc Surg 2015; 152:167-78. [DOI: 10.1016/j.jviscsurg.2015.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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125
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Dactylitis, early onset of drepanocytosis and a predictor of a poor prognosis. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2015. [DOI: 10.1016/j.anpede.2015.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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126
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Rice HE, Englum BR, Rothman J, Leonard S, Reiter A, Thornburg C, Brindle M, Wright N, Heeney MM, Smithers C, Brown RL, Kalfa T, Langer JC, Cada M, Oldham KT, Scott JP, St. Peter S, Sharma M, Davidoff AM, Nottage K, Bernabe K, Wilson DB, Dutta S, Glader B, Crary SE, Dassinger MS, Dunbar L, Islam S, Kumar M, Rescorla F, Bruch S, Campbell A, Austin M, Sidonio R, Blakely ML. Clinical outcomes of splenectomy in children: report of the splenectomy in congenital hemolytic anemia registry. Am J Hematol 2015; 90:187-92. [PMID: 25382665 DOI: 10.1002/ajh.23888] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 10/29/2014] [Indexed: 11/10/2022]
Abstract
The outcomes of children with congenital hemolytic anemia (CHA) undergoing total splenectomy (TS) or partial splenectomy (PS) remain unclear. In this study, we collected data from 100 children with CHA who underwent TS or PS from 2005 to 2013 at 16 sites in the Splenectomy in Congenital Hemolytic Anemia (SICHA) consortium using a patient registry. We analyzed demographics and baseline clinical status, operative details, and outcomes at 4, 24, and 52 weeks after surgery. Results were summarized as hematologic outcomes, short-term adverse events (AEs) (≤30 days after surgery), and long-term AEs (31-365 days after surgery). For children with hereditary spherocytosis, after surgery there was an increase in hemoglobin (baseline 10.1 ± 1.8 g/dl, 52 week 12.8 ± 1.6 g/dl; mean ± SD), decrease in reticulocyte and bilirubin as well as control of symptoms. Children with sickle cell disease had control of clinical symptoms after surgery, but had no change in hematologic parameters. There was an 11% rate of short-term AEs and 11% rate of long-term AEs. As we accumulate more subjects and longer follow-up, use of a patient registry should enhance our capacity for clinical trials and engage all stakeholders in the decision-making process.
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Affiliation(s)
- Henry E. Rice
- Duke University Medical Center; Durham North Carolina
| | | | | | - Sarah Leonard
- Duke University Medical Center; Durham North Carolina
| | - Audra Reiter
- Duke University Medical Center; Durham North Carolina
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Kerri Nottage
- St. Jude Children's Research Hospital; Memphis Tennessee
| | | | | | | | | | | | | | | | | | | | | | | | | | - Mary Austin
- University of Texas/MD Anderson Cancer Center; Houston Texas
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127
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Rituximab plus standard of care for treatment of primary immune thrombocytopenia: a systematic review and meta-analysis. LANCET HAEMATOLOGY 2015; 2:e75-81. [DOI: 10.1016/s2352-3026(15)00003-4] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 01/13/2015] [Indexed: 01/19/2023]
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Heitkamp AC, Dickhoff C, Nederhoed JH, Franschman G, de Vries JI. Saved from a fatal flight: A ruptured splenic artery aneurysm in a pregnant woman. Int J Surg Case Rep 2015; 8C:32-4. [PMID: 25617728 PMCID: PMC4353936 DOI: 10.1016/j.ijscr.2015.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 01/05/2015] [Accepted: 01/06/2015] [Indexed: 11/17/2022] Open
Abstract
Although rupture of a splenic artery aneurysm is rare, its consequences can be devastating for both mother and child. Early recognition and prompt multidisciplinary treatment might save the life of mother and child. There is a difficulty in recognizing hemodynamic instability in pregnancy due to the increase in circulating volume.
Introduction The reported prevalence of a SAA varies between 0.01 and 10.4% [1], and since SAAs often remain asymptomatic, the true prevalence is uncertain. The reported SAAs occur more frequently in younger patients, with 58% diagnosed in women of childbearing age; 95% of these are diagnosed during pregnancy. Presentation of case A 26-year-old woman, thirty-one weeks pregnant, was about to board an airplane for a three hour flight from the Netherlands to Turkey. Just before entering the plane, she suddenly felt a severe abdominal pain. Ultrasound guided aspiration of the abdominal fluid showed blood and supported the decision to perform urgent laparotomy. A caesarean section was performed. After further inspection a ruptured SAA was encountered. The splenic artery was ligated proximally and distally to the rupture in order to stop the bleeding. As the hilar localization of the aneurysm interfered with a primary vascular reconstruction, a splenectomy was performed. The mother and baby survived. Discussion Although rupture of a SAA is rare, its consequences can be devastating for both mother and child. The literature shows a higher incidence of ruptured SAA in pregnant women, although there is a difficulty in recognizing hemodynamic instability in pregnancy due to the increase in circulating volume. Conclusion In case of pregnant women with acute abdomen and hypovolemia, emergency physicians, surgeons, anesthesiologists, and gynecologists should be aware of the possibility of a ruptured SAA, apart from more common causes like placental abruption, placenta percreta, or uterine rupture. Early recognition and prompt multidisciplinary treatment might save the life of mother and child.
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Affiliation(s)
- Anke C Heitkamp
- Department of Obstetrics and Gynecology, VU University Medical Center, P.O. Box 7057, 1007MB Amsterdam, The Netherlands.
| | - Chris Dickhoff
- Department of Surgery, VU University Medical Center, P.O. Box 7057, 1007MB Amsterdam, The Netherlands
| | - Johanna H Nederhoed
- Department of Surgery, VU University Medical Center, P.O. Box 7057, 1007MB Amsterdam, The Netherlands
| | - Gaby Franschman
- Department of Anesthesiology, VU University Medical Center, P.O. Box 7057, 1007MB Amsterdam, The Netherlands
| | - Johanna I de Vries
- Department of Obstetrics and Gynecology, VU University Medical Center, P.O. Box 7057, 1007MB Amsterdam, The Netherlands
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Yamane H, Fukuda N, Nishino K, Yoshida K, Ochi N, Yamagishi T, Honda Y, Kawamoto H, Monobe Y, Mimura H, Naomoto Y, Takigawa N. Non-occlusive mesenteric ischemia after splenic metastasectomy for small-cell lung cancer. Intern Med 2015; 54:743-7. [PMID: 25832935 DOI: 10.2169/internalmedicine.54.3545] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 68-year-old man presented with severe abdominal pain. Seven months earlier, he had received systemic chemotherapy for small-cell lung cancer with solitary metastasis to the spleen, followed by splenectomy. Abdominal computed tomography and abdominal arterial angiography showed diffuse ischemia of the mesenteric artery without apparent occlusion. The patient also suffered from septicemia caused by Enterococcus faecium. Therefore, a diagnosis of non-occlusive mesenteric ischemia (NOMI) induced by septicemia was supposed. Although treatment with antibiotics and papaverine hydrochloride was administered and the necrotic tissue in the intestinal tract was resected, the patient died. Physicians should be aware that patients undergoing splenectomy are likely to be affected by septicemia, which may subsequently induce NOMI.
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Affiliation(s)
- Hiromichi Yamane
- Department of General Internal Medicine 4, Kawasaki Medical School, Japan
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130
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Brunkhorst FM, Patchev V. [Sepsis-associated Purpura Fulminans International Registry--Europe (SAPFIRE)]. Med Klin Intensivmed Notfmed 2014; 109:591-5. [PMID: 25348051 DOI: 10.1007/s00063-014-0402-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 09/16/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Purpura fulminans is a rare life-threatening condition which is characterized by disseminated thrombosis in dermal and systemic microcirculation, cutaneous hemorrhages with progressing necrosis and multiple organ failure. The underlying pathogenesis is based on the disruption of the intrinsic anticoagulation cascade, with protein C deficiency being considered the leading factor in this process. In the majority of cases, the condition emerges as consumptive coagulopathy associated with severe sepsis. OBJECTIVES Epidemiological data on sepsis-associated purpura fulminans (SAPF) are scarce and evidence-based treatment guidelines have not been established yet. While restoration of the balance in the coagulation cascade is a declared therapeutic goal, evaluations of the efficacy of different therapeutic approaches in randomized clinical trials are still lacking. The causal role of individual microbial pathogens also requires comprehensive evaluation. METHODS A prospective multicenter Sepsis-Associated Purpura Fulminans International Registry-Europe (SAPFIRE) will be established in the first quarter of 2015. For the first time, participating centers will systematically collect information on etiology, clinical course, biomarkers, treatment, morbidity, and mortality of SAPF. RESULTS The SAPFIRE data will be periodically evaluated and disseminated. Retrospective analysis of each center's data and regular access to aggregated information collected by other centers will enable the participants to monitor and update care quality standards.
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Affiliation(s)
- F M Brunkhorst
- Center of Sepsis Control and Care (CSCC), Klinik für Anaesthesiologie und Intensivtherapie, Universitätsklinikum Jena, Salvador-Allende-Platz 29, 07747, Jena, Deutschland,
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Solé-Ribalta A, Vilà-de-Muga M, Català-Temprano A, Luaces-Cubells C. [Dactylitis, early onset of drepanocytosis and a predictor of a poor prognosis]. An Pediatr (Barc) 2014; 82:267-8. [PMID: 25217384 DOI: 10.1016/j.anpedi.2014.07.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Revised: 07/30/2014] [Accepted: 07/31/2014] [Indexed: 10/24/2022] Open
Affiliation(s)
- A Solé-Ribalta
- Departamento de Pediatría, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, España.
| | - M Vilà-de-Muga
- Departamento de Urgencias de Pediatría, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, España
| | - A Català-Temprano
- Departamento de Hematología y Oncología Pediátrica, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, España
| | - C Luaces-Cubells
- Departamento de Urgencias de Pediatría, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, España
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