Recurrent undifferentiated shock: Idiopathic Systemic Capillary Leak Syndrome

Effects of Indwelling Pleural Catheter on Severe Acute Pancreatitis: A Retrospective Study

Background. Pleural effusion (PE) is an important predictor for severity and prognosis of severe acute pancreatitis (SAP). However, there are few studies focused on the effects and timing of indwelling pleural catheter (IPC) on SAP. Considering this, we designed a retrospective study to verify the relationship between PE and severity of SAP and observe the effects and timing of IPC in SAP. Methods. A total of 309 SAP patients were enrolled. Based on the presence or absence of PE and IPC and IPC time, the enrolled patients were divided into 6 groups. Then, baseline parameters, disease severity, critical complications, ventilator supporting time (VST), length of stay (LOS), and 60-day mortality were compared between each two groups. Results. PE was a risk factor for death of SAP, but not an independent risk factor. SAP patients with PE rather without PE had higher critical complication rates ( $p<0.001$ ), along with longer VST ( $p<0.001$ ) and LOS ( $p<0.001$ ). And the critical complication rates were lower in group 1 (IPC within 1 week of onset) than group 2 (IPC after 1 week of onset). Further, patients in group 1 also had shorter LOS ( $p=0.042$ ) and VST ( $p=0.001$ ) than those in group 2. In addition, the survival analysis showed the risk of death in the PE group was higher than the non-PE group (HR 6.6, 95% CI, 3.67–11.86, and $p<0.001$ ). And the risk of death in group 1 was lower than group 2 (HR 0.26, 95% CI, 0.08–0.84, and $p=0.025$ ). Conclusions. PE is a risk factor for death of SAP, but not an independent risk factor. IPC, especially IPC within 1 week of onset, has clinical practical value in SAP.

Autonomic biomarkers of shock in idiopathic systemic capillary leak syndrome

OBJECTIVE

The term Idiopathic Systemic Capillary Leak Syndrome (ISCLS) refers to an uncommon condition of severe distributive shock, resulting from an abrupt shift of fluids and proteins from the intravascular to the interstitial compartment. We hypothesise that the autonomic nervous system (ANS) fails in regulating the response to hypovolemia in acute ISCLS and that ANS variables characterise the progression to the recovery.

DESIGN

Prospective cohort study of patients admitted to ICU for severe ISCLS flares.

SETTING

Single, referral center in Italy for ISCLS.

PATIENTS

Analysis of cardiovascular signals recorded during seven severe ISCLS attacks and one prodromal period in five patients.

INTERVENTIONS

ANS was studied non-invasively by means of heart rate variability (HRV) and blood pressure variability analysis, as an estimation of vagal and sympathetic modulation directed to the heart and vessels. Heart rate and systolic arterial pressure (SAP) variability were also used to assess baroreflex sensitivity. ANS variables were measured during the subsequent phases which characterise ISCLS flares, namely the acute phase, the post-acute phase, and the recovery phase.

MEASUREMENTS AND MAIN RESULTS

HRV was severely depressed during the acute phase accounting for the loss of ANS modulation during massive capillary extravasation. This phase was characterised by shock and impaired baroreflex control, which allowed SAP to oscillate driven by respiratory activity. Impending shock and transition from shock to a post-acute phase were marked by change of baroreflex spectral variables. The baroreflex control was fully restored during recovery.

CONCLUSIONS

ANS modulation and baroreflex control are severely impaired during the acute haemodynamic instability which characterises ISCLS crises and their progressive restoration may be a clue of improvement. ANS indices during ISCLS flares might serve as useful biomarkers, able to timely announce the transition from one phase to the subsequent one, thus helping to adapt therapy accordingly.

Paroxysmal Permeability Disorders: Development of a Microfluidic Device to Assess Endothelial Barrier Function

Background: Paroxysmal Permeability Disorders (PPDs) are pathological conditions caused by periodic short lasting increase of endothelial permeability, in the absence of inflammatory, degenerative, ischemic vascular injury. PPDs include primary angioedema, idiopathic systemic capillary leak syndrome and some rare forms of localized retroperitoneal-mediastinal edema.

Aim: to validate a microfluidic device to study endothelial permeability in flow conditions.

Materials and Methods: we designed a microchannel network (the smallest channel is 30μm square section). Human Umbilical Vein Endothelial Cells (HUVECs) were cultured under constant shear stress in the networks. Endothelial permeability assessment was based on interaction of biotinylated fibronectin used as a matrix for HUVECs and FITC-conjugated avidin. The increase in endothelial permeability was identified as changes in fluorescence intensity detected by confocal fluorescent microscopy.

Results: The microchannels were constantly perfused with a steady flow of culture medium, ensuring a physiologically relevant level of shear stress at the wall of ~0.2 Pa. Our preliminary results demonstrated that circulation of culture medium or plasma from healthy volunteers was associated with low fluorescence of fibronectin matrix. When bradykinin diluted in culture medium was perfused, an increase in average fluorescence was detected.

Conclusion: Our microvasculature model is suitable to study endothelial functions in physiological flow conditions and in the presence of factors like bradykinin known as mediator of several PPDs. Therefore, it can be a promising tool to better understand the mechanisms underlying disorders of endothelial permeability.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

Structured case report and review of the literature.

RESULTS

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

CONCLUSIONS

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

Idiopathic systemic capillary leak syndrome (Clarkson disease)

In 1960, Dr Bayard Clarkson described a woman experiencing sporadic recurrent episodes of shock and anasarca. Plasma from an acute attack induced a shock-like syndrome when injected into rats. The enigmatic systemic capillary leak syndrome (SCLS) named for Dr Clarkson is characterized by transient and severe but reversible hemoconcentration and hypoalbuminemia caused by leakage of fluids and macromolecules into tissues. Although less than 500 cases of SCLS have been reported in the literature since 1960, the condition is probably underdiagnosed because of a lack of awareness and a high mortality without treatment. Allergists should be vigilant of this diagnosis because its presentation can resemble more common plasma leakage syndromes, including angioedema or systemic anaphylaxis. Although the precise molecular cause of SCLS remains unknown, substantial advances over the last 5 years have increased our understanding of SCLS pathogenesis.