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Neu C, Wissuwa B, Thiemermann C, Coldewey SM. Cardiovascular impairment in Shiga-toxin-2-induced experimental hemolytic-uremic syndrome: a pilot study. Front Immunol 2023; 14:1252818. [PMID: 37809105 PMCID: PMC10556238 DOI: 10.3389/fimmu.2023.1252818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 09/01/2023] [Indexed: 10/10/2023] Open
Abstract
Introduction Hemolytic-uremic syndrome (HUS) can occur as a systemic complication of infection with Shiga toxin (Stx)-producing Escherichia coli (STEC). Most well-known aspects of the pathophysiology are secondary to microthrombotic kidney disease including hemolytic anemia and thrombocytopenia. However, extrarenal manifestations, such as cardiac impairment, have also been reported. We have investigated whether these cardiac abnormalities can be reproduced in a murine animal model, in which administration of Stx, the main virulence factor of STEC, is used to induce HUS. Methods Mice received either one high or multiple low doses of Stx to simulate the (clinically well-known) different disease courses. Cardiac function was evaluated by echocardiography and analyses of biomarkers in the plasma (troponin I and brain natriuretic peptide). Results All Stx-challenged mice showed reduced cardiac output and depletion of intravascular volume indicated by a reduced end-diastolic volume and a higher hematocrit. Some mice exhibited myocardial injury (measured as increases in cTNI levels). A subset of mice challenged with either dosage regimen showed hyperkalemia with typical electrocardiographic abnormalities. Discussion Myocardial injury, intravascular volume depletion, reduced cardiac output, and arrhythmias as a consequence of hyperkalemia may be prognosis-relevant disease manifestations of HUS, the significance of which should be further investigated in future preclinical and clinical studies.
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Affiliation(s)
- Charles Neu
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
- Septomics Research Center, Jena University Hospital, Jena, Germany
- Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | - Bianka Wissuwa
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
- Septomics Research Center, Jena University Hospital, Jena, Germany
| | - Christoph Thiemermann
- William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Sina M. Coldewey
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
- Septomics Research Center, Jena University Hospital, Jena, Germany
- Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
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2
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Liboiron M, Malone MP, Brown CC, Prodhan P. Extracorporeal Membrane Oxygenation and Hemolytic Uremic Syndrome in Children: Outcome Review of a Multicenter National Database. J Pediatr Intensive Care 2023. [DOI: 10.1055/s-0042-1758478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
AbstractHemolytic uremic syndrome (HUS) is a triad of hemolytic anemia, thrombocytopenia, and acute renal failure. In critically ill children with HUS, extrarenal manifestations may require intensive care unit admission and extracorporeal membrane oxygenation (ECMO) support. Outcomes specific to HUS and ECMO in children have not been well investigated. The primary aim of this project was to query a multicenter database to identify risk factors associated with mortality in HUS patients supported on ECMO. A secondary aim was to identify factors associated with ECMO utilization in children with HUS. Utilizing the Pediatric Health Information System database (January 2004 and September 2018), this retrospective, multicenter cohort study identified the index HUS hospitalization among children aged 0 to 18 years. Univariate analysis was used to compare demographics, clinical characteristics, and procedures to identify risk factors associated with adverse outcomes. Among 4,144 subjects, 37 were supported on ECMO. Survival for those on ECMO support was 54%. Among nonsurvivors, 59% of deaths occurred within 14 days of hospitalization. The mean hospital LOS was 15.9 days in nonsurvivors versus 53.9 days for survivors (p < 0.001). When comparing subjects supported on ECMO to those who were not, patients with ECMO support had statistically longer hospital LOS and higher rates of extrarenal involvement (p < 0.001). This study found a mortality rate of 46% among HUS patients requiring ECMO. The investigated clinical risk factors were not associated with mortality among the ECMO population. The study identifies risk factors associated with ECMO utilization in children with HUS.
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Affiliation(s)
- Mireille Liboiron
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Matthew P. Malone
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Clare C. Brown
- Department of Health Policy and Management, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Parthak Prodhan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
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Tanné C, Javouhey E, Boyer O, Recher M, Allain-Launay E, Monet-Didailler C, Rouset-Rouvière C, Ryckewaert A, Nobili F, Gindre FA, Rambaud J, Duncan A, Berthiller J, Bacchetta J, Sellier-Leclerc AL. Cardiac involvement in pediatric hemolytic uremic syndrome. Pediatr Nephrol 2022; 37:3215-3221. [PMID: 35286451 DOI: 10.1007/s00467-022-05427-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 12/14/2021] [Accepted: 12/14/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Cardiac involvement is a known but rare complication of pediatric hemolytic uremic syndrome (HUS). We conducted a nationwide observational, retrospective case-control study describing factors associated with the occurrence of myocarditis among HUS patients. METHODS Cases were defined as hospitalized children affected by any form of HUS with co-existent myocarditis in 8 French Pediatric Intensive Care Units (PICU) between January 2007 and December 2018. Control subjects were children, consecutively admitted with any form of HUS without coexistent myocarditis, at a single PICU in Lyon, France, during the same time period. RESULTS A total of 20 cases of myocarditis were reported among 8 PICUs, with a mean age of 34.3 ± 31.9 months; 66 controls were identified. There were no differences between the two groups concerning the season and the typical, Shiga toxin-producing Escherichia coli (STEC-HUS), or atypical HUS (aHUS). Maximal leukocyte count was higher in the myocarditis group (29.1 ± 16.3G/L versus 21.0 ± 9.9G/L, p = 0.04). The median time between admission and first cardiac symptoms was of 3 days (range 0-19 days), and 4 patients displayed myocarditis at admission. The fatality rate in the myocarditis group was higher than in the control group (40.0% versus 1.5%, p < 0.001). Thirteen (65%) children from the myocarditis group received platelet transfusion compared to 19 (29%) in the control group (p = 0.03). CONCLUSION Our study confirms that myocarditis is potentially lethal and identifies higher leukocyte count and platelet transfusion as possible risk factors of myocarditis. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Corentin Tanné
- Department of Pediatric Nephrology, Hopital Femme-Mere-Enfant, Lyon, France.,Service de Pédiatrie Et Néonatalogie, Hôpitaux du Pays du Mont Blanc, Sallanches, France
| | - Etienne Javouhey
- Pediatric Intensive Care Unit, Hôpital Femme Mère Enfants, Hospices Civils of Lyon, Lyon, France.,Université de Lyon, Lyon, France
| | - Olivia Boyer
- Service de Néphrologie Pédiatrique, Centres de Référence MARHEA Et MAT, Hôpital Necker-Enfants Maladies, Assistance Publique-Hôpitaux de Paris, Paris, France.,Institut IMAGINE, INSERM U1163, Université de Paris, Paris, France
| | - Morgan Recher
- CHU Lille, Department of Paediatric Intensive Care Unit, Jeanne de Flandre Hospital, 59000, Lille, France
| | | | - Catherine Monet-Didailler
- Service de Pédiatrie, Unité de Néphrologie Pédiatrique, CHU de Bordeaux, France.,Service de Pédiatrie, Centre Hospitalier de La Côte Basque, Bayonne, France
| | | | | | | | | | - Jérôme Rambaud
- Service de Réanimation Pédiatrique Et Néonatal, Hôpital Armand-Trousseau, assistance publique des Hôpitaux de Paris (APHP), Sorbonne Université, Paris, France
| | - Anita Duncan
- Department of Pediatric Nephrology, Hopital Femme-Mere-Enfant, Lyon, France
| | - Julien Berthiller
- Service d'Epidémiologie Et de Recherche Clinique. Pôle de Santé Publique Des Hospices Civils de Lyon, Lyon, France
| | - Justine Bacchetta
- Department of Pediatric Nephrology, Hopital Femme-Mere-Enfant, Lyon, France.,Université de Lyon, Lyon, France
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Sanders E, Brown CC, Blaszak RT, Crawford B, Prodhan P. Cardiac Manifestation among Children with Hemolytic Uremic Syndrome. J Pediatr 2021; 235:144-148.e4. [PMID: 33819463 PMCID: PMC8316308 DOI: 10.1016/j.jpeds.2021.03.067] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 03/25/2021] [Accepted: 03/29/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The primary objectives of the study were to describe the association between cardiac manifestations and in-hospital mortality among children with hemolytic uremic syndrome. STUDY DESIGN Using the Pediatric Health Information System database, this retrospective, multicenter, cohort study identified the first hemolytic uremic syndrome-related inpatient visit among children ≤18 years (years 2004-2018). The frequency of selected cardiac manifestations and mortality rates were calculated. Multivariate analysis identified the association of specific cardiac manifestations and the risk of in-hospital mortality. RESULTS Among 3915 patients in the analysis, 238 (6.1%) had cardiac manifestations. A majority of patients (82.8%; n = 197) had 1 cardiac condition and 17.2% (n = 41) had ≥2 cardiac conditions. The most common cardiac conditions was pericardial disease (n = 102), followed by congestive heart failure (n = 46) and cardiomyopathy/myocarditis (n = 34). The percent mortality for patients with 0, 1, or ≥2 cardiac conditions was 2.1%, 17.3%, and 19.5%, respectively. Patients with any cardiac condition had an increased odds of mortality (OR, 9.74; P = .0001). In additional models, the presence of ≥2 cardiac conditions (OR, 9.90; P < .001), cardiac arrest (OR, 38.25; P < .001), or extracorporeal membrane oxygenation deployment (OR, 11.61; P < .001) were associated with increased risk of in-hospital mortality. CONCLUSIONS This study identified differences in in-hospital mortality based on the type of cardiac manifestations, with increased risk observed for patients with multiple cardiac involvement, cardiac arrest, and extracorporeal membrane oxygenation deployments.
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Affiliation(s)
- Emily Sanders
- Pediatrics, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, Arkansas
| | - Clare C. Brown
- Department of Health Policy and Management, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Richard T Blaszak
- Nephrology; Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, Arkansas
| | - Brendan Crawford
- Nephrology; Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, Arkansas
| | - Parthak Prodhan
- Pediatric Cardiology/Pediatric Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, Arkansas
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Yesilbas O, Yozgat CY, Akinci N, Sonmez S, Tekin E, Talebazadeh F, Jafarov U, Temur HO, Yozgat Y. Acute Myocarditis and Eculizumab Caused Severe Cholestasis in a 17-Month-Old Child Who Has Hemolytic Uremic Syndrome Associated with Shiga Toxin-Producing Escherichia coli. J Pediatr Intensive Care 2020; 10:216-220. [PMID: 34395040 DOI: 10.1055/s-0040-1713111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 05/02/2020] [Indexed: 10/23/2022] Open
Abstract
Cardiovascular involvement is uncommon in pediatric patients with hemolytic uremic syndrome associated with Shiga toxin-producing Escherichia coli (STEC-HUS). In this case report we presented a case of 17-month-old toddler who had a sporadic type of STEC-HUS complicated by acute myocarditis. The patient was successfully treated by a single dose of eculizumab after six doses of therapeutic plasma exchange (TPE) were inefficient to prevent the cardiac complication. Hepatotoxicity was observed after a single dose of eculizumab. Hepatic and cholestatic enzyme levels slowly returned to normal within 6 months. To the best of our knowledge, this is the first case of myocarditis/cardiomyopathy treated with eculizumab in STEC-HUS. This case illustrates the need for vigilance regarding myocardial involvement and eculizumab-induced hepatotoxicity in STEC-HUS.
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Affiliation(s)
- Osman Yesilbas
- Department of Pediatric Critical Care Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | | | - Nurver Akinci
- Department of Pediatric Nephrology, Bezmialem Vakif University, Istanbul, Turkey
| | - Sirin Sonmez
- Department of Pediatrics, Bezmialem Vakif University, Istanbul, Turkey
| | - Eser Tekin
- Department of Pediatrics, Bezmialem Vakif University, Istanbul, Turkey
| | - Faraz Talebazadeh
- Department of Pediatrics, Bezmialem Vakif University, Istanbul, Turkey
| | - Uzeyir Jafarov
- Department of Pediatrics, Bezmialem Vakif University, Istanbul, Turkey
| | - Hafize Otcu Temur
- Department of Radiology, Bezmialem Vakif University, Istanbul, Turkey
| | - Yilmaz Yozgat
- Department of Pediatric Cardiology, Bezmialem Vakif University, Istanbul, Turkey
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Yesilbas O, Yozgat CY, Akinci N, Talebazadeh F, Jafarov U, Guney AZ, Temur HO, Yozgat Y. Sudden Cardiac Arrest and Malignant Ventricular Tachycardia in an 8-Year-Old Pediatric Patient Who Has Hemolytic Uremic Syndrome Associated with Shiga Toxin-Producing Escherichia coli. J Pediatr Intensive Care 2020; 9:290-294. [PMID: 33133747 DOI: 10.1055/s-0040-1708553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 02/16/2020] [Indexed: 10/24/2022] Open
Abstract
Gastrointestinal, neurological, pancreatic, hepatic, and cardiac dysfunction are extrarenal manifestations of hemolytic uremic syndrome associated with Shiga toxin-producing Escherichia coli (STEC-HUS). The most frequent cause of death for STEC-HUS is related to the central nervous system and cardiovascular system. Cardiac-origin deaths are predominantly related to thrombotic microangiopathy-induced ischemia and the immediate development of circulatory collapse. STEC-HUS cardiac related deaths in children are rare with only sporadic cases reported. In our literature search, we did not come across any pediatric case report about STEC-HUS causing sudden cardiac arrest and malignant ventricular tachycardia (VT). Herein, we report the case of an 8-year-old female child with a typical clinical manifestation of STEC-HUS. On the seventh day of pediatric intensive care unit admission, the patient had a sudden cardiac arrest, requiring resuscitation for 10 minutes. The patient had return of spontaneous circulation with severe monomorphic pulsed malignant VT. Intravenous treatment with lidocaine, amiodarone and magnesium sulfate were promptly initiated, and we administered multiple synchronized cardioversions, but VT persisted. Furthermore, we were not able to ameliorate her refractory circulation insufficiency by advanced cardiopulmonary resuscitation. Thus, inevitably, the patient lost her life. This case illustrates the need for aggressive management and the dilemma that pediatric critical care specialists, cardiologists, and nephrologists have to face when dealing with STEC-HUS that is worsened by a sudden cardiac arrest accompanied with VT.
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Affiliation(s)
- Osman Yesilbas
- Department of Pediatric Critical Care Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | | | - Nurver Akinci
- Department of Pediatric Nephrology, Bezmialem Vakif University, Istanbul, Turkey
| | - Faraz Talebazadeh
- Department of Pediatrics, Bezmialem Vakif University, Istanbul, Turkey
| | - Uzeyir Jafarov
- Department of Pediatrics, Bezmialem Vakif University, Istanbul, Turkey
| | | | - Hafize Otcu Temur
- Department of Radiology, Bezmialem Vakif University, Istanbul, Turkey
| | - Yilmaz Yozgat
- Department of Pediatric Cardiology, Bezmialem Vakif University, Istanbul, Turkey
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Extrarenal manifestations of the hemolytic uremic syndrome associated with Shiga toxin-producing Escherichia coli (STEC HUS). Pediatr Nephrol 2019; 34:2495-2507. [PMID: 30382336 DOI: 10.1007/s00467-018-4105-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 09/26/2018] [Accepted: 09/27/2018] [Indexed: 10/28/2022]
Abstract
Hemolytic uremic syndrome is commonly caused by Shiga toxin-producing Escherichia coli (STEC). Up to 15% of individuals with STEC-associated hemorrhagic diarrhea develop hemolytic uremic syndrome (STEC HUS). Hemolytic uremic syndrome (HUS) is a disorder comprising of thrombocytopenia, microangiopathic hemolytic anemia, and acute kidney injury. The kidney is the most commonly affected organ and approximately half of the affected patients require dialysis. Other organ systems can also be affected including the central nervous system and the gastrointestinal, cardiac, and musculoskeletal systems. Neurological complications include altered mental status, seizures, stroke, and coma. Gastrointestinal manifestations may present as hemorrhagic colitis, bowel ischemia/necrosis, and perforation. Pancreatitis and pancreatic beta cell dysfunction resulting in both acute and chronic insulin dependant diabetes mellitus can occur. Thrombotic microangiopathy (TMA) in cardiac microvasculature and troponin elevation has been reported, and musculoskeletal involvement manifesting as rhabdomyolysis has also been described. Extrarenal complications occur not only in the acute setting but may also be seen well after recovery from the acute phase of HUS. This review will focus on the extrarenal complications of STEC HUS. To date, management remains mainly supportive, and while there is no specific therapy for STEC HUS, supportive therapy has significantly reduced the mortality rate.
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Extrarenal manifestations of the hemolytic uremic syndrome associated with Shiga toxin-producing Escherichia coli (STEC HUS). PEDIATRIC NEPHROLOGY (BERLIN, GERMANY) 2019. [PMID: 30382336 DOI: 10.1007/s00467-018-4105-1)] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Hemolytic uremic syndrome is commonly caused by Shiga toxin-producing Escherichia coli (STEC). Up to 15% of individuals with STEC-associated hemorrhagic diarrhea develop hemolytic uremic syndrome (STEC HUS). Hemolytic uremic syndrome (HUS) is a disorder comprising of thrombocytopenia, microangiopathic hemolytic anemia, and acute kidney injury. The kidney is the most commonly affected organ and approximately half of the affected patients require dialysis. Other organ systems can also be affected including the central nervous system and the gastrointestinal, cardiac, and musculoskeletal systems. Neurological complications include altered mental status, seizures, stroke, and coma. Gastrointestinal manifestations may present as hemorrhagic colitis, bowel ischemia/necrosis, and perforation. Pancreatitis and pancreatic beta cell dysfunction resulting in both acute and chronic insulin dependant diabetes mellitus can occur. Thrombotic microangiopathy (TMA) in cardiac microvasculature and troponin elevation has been reported, and musculoskeletal involvement manifesting as rhabdomyolysis has also been described. Extrarenal complications occur not only in the acute setting but may also be seen well after recovery from the acute phase of HUS. This review will focus on the extrarenal complications of STEC HUS. To date, management remains mainly supportive, and while there is no specific therapy for STEC HUS, supportive therapy has significantly reduced the mortality rate.
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9
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Hsu CT, Hsiao PJ, Liu CH, Chou YL, Chen BH, Liou JT. Acute myocarditis complicated with permanent complete atrioventricular block caused by Escherichia coli bacteremia: A rare case report. Medicine (Baltimore) 2019; 98:e17833. [PMID: 31689871 PMCID: PMC6946433 DOI: 10.1097/md.0000000000017833] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Acute myocarditis complicated with complete atrioventricular block (CAVB) is rare in clinical scenario. We report an uncommon case of myocarditis complicated with permanent CAVB caused by Escherichia coli (E coli) bacteremia. PATIENT CONCERNS A 77-year-old woman presented at the emergency department with chest pain, dizziness, nausea, and cold sweats of 1-day duration. She had histories of type 2 diabetes mellitus, hyperlipidemia, and chronic kidney disease with regular medical therapy. DIAGNOSIS Both blood and urine cultures were positive for E coli. Regional inferior wall motion abnormalities on echocardiography, unexplained life-threatening arrhythmias, newly abnormal electrocardiogram, elevated cardiac troponins, and healthy coronary arteries on angiography were consistent with E coli-induced myocarditis. INTERVENTIONS The patient received implantation of a dual-chamber pacemaker because of irreversible CAVB. OUTCOMES The patient was discharged on day 8 and remained asymptomatic at 15 months of follow-up, with ST-segment normalization and normal left ventricular function. LESSONS This extremely rare case of E coli-induced myocarditis masquerading as acute STEMI and with permanent CAVB sequelae, highlights the importance of sensitivity to non-ischemia etiologies of ST-segment elevation and the potential impact of E coli sepsis on the cardiac conduction system.
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Affiliation(s)
- Ching-Tsai Hsu
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei
- Division of Cardiology, Department of Internal Medicine, Taoyuan Armed Forces General Hospital, Taoyuan
| | - Po-Jen Hsiao
- Division of Nephrology, Department of Internal Medicine, Taoyuan Armed Forces General Hospital, Taoyuan
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei
- Department of Life Sciences, National Central University, Taoyuan City
- Division of Nephrology, Department of Medicine, Fu Jen Catholic University Hospital, School of Medicine, Fu Jen Catholic University, New Taipei City
| | - Ching-Han Liu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung
| | - Yen-Lien Chou
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei
| | - Bo-Hau Chen
- Department of Pediatrics, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
| | - Jun-Ting Liou
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei
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10
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Balgradean M, Croitoru A, Leibovitz E. An outbreak of hemolytic uremic syndrome in southern Romania during 2015-2016: Epidemiologic, clinical, laboratory, microbiologic, therapeutic and outcome characteristics. Pediatr Neonatol 2019; 60:87-94. [PMID: 29807724 DOI: 10.1016/j.pedneo.2018.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Revised: 03/16/2018] [Accepted: 04/30/2018] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND AND AIMS To describe the epidemiologic, clinical, microbiological, therapeutic and outcome characteristics of a HUS outbreak occurring in southern Romania from 2015 to 2016. METHODS We retrospectively collected data from the medical records of all HUS cases hospitalized at the pediatric nephrology department of Marie Curie Children's Hospital of Bucharest, Romania. RESULTS There were 32 HUS cases (19 girls/13 boys, 87.6% <2 years), all associated with diarrhea (bloody in 13, 40.6%). Thirteen (40.6%) and 4 (12.5%) patients had oliguria and anuria at admission. Extreme pallor, generalized edema, vomiting, dehydration, fever and seizures were found in 100%, 56.3%, 31.3%, 31.3%, 25% and 9.4% of patients, respectively. E. coli and STEC were identified in the stools of 6 and 8 patients, respectively; E. coli O26 and O157 infection were documented serologically in 10 and 3 children, respectively. There were 15/32 (46.9%) patients with confirmed HUS. Eighteen (56.3%) patients were hypertensive; other complications included infections, left ventricular hypertrophy, cardiopulmonary arrest, seizures and encephalopathy in 62.5%, 37.5%, 28.3%, 18.8% and 12.5%, respectively. Peritoneal dialysis and hemodialysis were performed in 23 (72%) and 2 patients, respectively. Three patients (9.4%) died early during hospitalization. A 6-12-month follow-up of 26 patients revealed that 65.4% had post-HUS sequelae (persistent hypertension and chronic renal failure in 34.6% and 30.8%, respectively). CONCLUSIONS The principal STEC serotype involved was O26:H11 and the number of confirmed HUS cases reached half of the patients. Compared with the medical literature, this outbreak had a higher rate of complications and renal sequelae and was associated with a high fatality rate.
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Affiliation(s)
- Mihaela Balgradean
- Nephrology & Dialysis Department, Children's Emergency Hospital " M. S. Curie", "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Anca Croitoru
- Nephrology & Dialysis Department, Children's Emergency Hospital " M. S. Curie", "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Eugene Leibovitz
- Pediatric Infectious Disease Unit, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.
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11
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HUS-induced cardiac and circulatory failure is reversible using cardiopulmonary bypass as rescue. Pediatr Nephrol 2017; 32:2155-2158. [PMID: 28780656 DOI: 10.1007/s00467-017-3736-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 06/19/2017] [Accepted: 06/20/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Extra-renal involvement in hemolytic uremic syndrome (HUS) includes gastrointestinal, pancreatic, hepatic, neurological and cardiac manifestations. The current 3-5% mortality rate in HUS patients is primarily attributed to complications related to the central nervous system and the heart. In this brief report, we illustrate that severe cardiac involvement in a patient with HUS is potentially reversible using cardiopulmonary bypass as rescue. CASE-DIAGNOSIS/TREATMENT A 12-year-old boy was diagnosed with enterohemorrhagic Escherichia coli-induced HUS related to E. coli serotypes O55:H7 and O121:H19. The patient developed anuria and hypertension of 150/105 mmHg and had neurological symptoms, with lethargy, confusion and later a tonic-clonic seizure successfully treated with midazolam. Laboratory tests on blood samples revealed acute renal failure, with a creatinine level of 3.98 mg/dL, thrombocytopenia of 47 × 109/L, lactate dehydrogenase level of 3620 IU/L, low haptoglobin (<20 mg/dL), anemia (10.0 g/dL) and schistocytes on blood smears. Peritoneal dialysis was initiated without complications. Serum potassium level was normal. At day 3, the patient suffered cardiac arrest on two separate occasions. Troponin-T, creatine kinase and creatine kinase-MB levels were significantly increased. The second episode of cardiac arrest could not be reversed with advanced cardiopulmonary resuscitation, and a cardiopulmonary bypass circuit was established. Declining cardiac pump function to a near non-contractile state with an ejection fraction of <10% was observed on echocardiography. This persisted during the following days. After the patient had been on the cardiopulmonary bypass (CPB) circuit for 7 days, the myocardium slowly recovered function. Three days later, the CPB was successfully discontinued; the echocardiography showed near-normal ejection fraction, and electrocardiography (ECG) showed sinus rhythm. CONCLUSIONS Fatal outcome in patients with HUS may be the result of severe cardiac involvement. The present case illustrates the need for intensive supportive care, including the use of CPB, as the cardiac symptoms in HUS patients may be reversible. We suggest the monitoring of cardiac-specific enzymes, ECG and echocardiography in high-risk patients.
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12
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Rigamonti D, Simonetti GD. Direct cardiac involvement in childhood hemolytic-uremic syndrome: case report and review of the literature. Eur J Pediatr 2016; 175:1927-1931. [PMID: 27659663 DOI: 10.1007/s00431-016-2790-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 09/12/2016] [Accepted: 09/14/2016] [Indexed: 11/28/2022]
Abstract
UNLABELLED Overhydration, hypertension, anemia, or dyselectrolytemias sometimes cause cardiovascular impairment in childhood hemolytic-uremic syndrome. Here, we report the case of a 4.5-year-old boy with hemolytic-uremic syndrome and sudden onset, 6 h later, of hemodynamic compromise secondary to a cardiac thrombotic micro-angiopathy. The child died. In the literature, we found 18 further cases with cardiac compromise ≤25 days after diagnosis. The following causes were found: micro-angiopathy, pericardial blood causing tamponade, and myocarditis. CONCLUSION We were able to document only 19 cases of childhood hemolytic-uremic syndrome complicated by a direct cardiac compromise. Nonetheless, we speculate that a direct cardiac compromise accounts for many cases of childhood hemolytic-uremic syndrome complicated by sudden death during the initial hospitalization. Hence, we propose to always measure troponin in children with hemolytic-uremic syndrome to detect a latent myocardial damage. What is Known: • Overhydration, hypertension, anemia, or dyselectrolytemias sometimes cause cardiovascular impairment in childhood hemolytic-uremic syndrome. What is New: • This study documents 19 cases of childhood hemolytic-uremic syndrome complicated by a direct cardiac compromise ≤ 25 days after diagnosis. • The Following causes were found: micro-angiopathy, pericardial blood causing tamponade, and myocarditis.
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Affiliation(s)
- Davide Rigamonti
- Pediatric Department of Southern Switzerland, Via Ospedale, CH-6500, Bellinzona, Switzerland
| | - Giacomo D Simonetti
- Pediatric Department of Southern Switzerland, Via Ospedale, CH-6500, Bellinzona, Switzerland. .,Division of Pediatric Nephrology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, CH-3010, Bern, Switzerland.
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13
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Abstract
Post-infectious hemolytic uremic syndrome (HUS) is caused by specific pathogens in patients with no identifiable HUS-associated genetic mutation or autoantibody. The majority of episodes is due to infections by Shiga toxin (Stx) producing Escherichia coli (STEC). This chapter reviews the epidemiology and pathogenesis of STEC-HUS, including bacterial-derived factors and host responses. STEC disease is characterized by hematological (microangiopathic hemolytic anemia), renal (acute kidney injury) and extrarenal organ involvement. Clinicians should always strive for an etiological diagnosis through the microbiological or molecular identification of Stx-producing bacteria and Stx or, if negative, serological assays. Treatment of STEC-HUS is supportive; more investigations are needed to evaluate the efficacy of putative preventive and therapeutic measures, such as non-phage-inducing antibiotics, volume expansion and anti-complement agents. The outcome of STEC-HUS is generally favorable, but chronic kidney disease, permanent extrarenal, mainly cerebral complication and death (in less than 5 %) occur and long-term follow-up is recommended. The remainder of this chapter highlights rarer forms of (post-infectious) HUS due to S. dysenteriae, S. pneumoniae, influenza A and HIV and discusses potential interactions between these pathogens and the complement system.
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Affiliation(s)
- Denis F. Geary
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario Canada
| | - Franz Schaefer
- Division of Pediatric Nephrology, University of Heidelberg, Heidelberg, Germany
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14
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Igarashi T, Ito S, Sako M, Saitoh A, Hataya H, Mizuguchi M, Morishima T, Ohnishi K, Kawamura N, Kitayama H, Ashida A, Kaname S, Taneichi H, Tang J, Ohnishi M. Guidelines for the management and investigation of hemolytic uremic syndrome. Clin Exp Nephrol 2016; 18:525-57. [PMID: 25099085 DOI: 10.1007/s10157-014-0995-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Takashi Igarashi
- National Center for Child Health and Development (NCCHD), 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan,
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15
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Dilated Cardiomyopathy Several Months after Hemolytic Uremic Syndrome. JOURNAL OF PEDIATRIC NEPHROLOGY 2016. [DOI: 10.20286/jpn-040145] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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16
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Shiga Toxin/Verocytotoxin-Producing
Escherichia coli
Infections: Practical Clinical Perspectives. Microbiol Spectr 2014; 2:EHEC-0025-2014. [DOI: 10.1128/microbiolspec.ehec-0025-2014] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
ABSTRACT
Escherichia coli
strains that produce Shiga toxins/verotoxins are rare, but important, causes of human disease. They are responsible for a spectrum of illnesses that range from the asymptomatic to the life-threatening hemolytic-uremic syndrome; diseases caused by
E. coli
belonging to serotype O157:H7 are exceptionally severe. Each illness has a fairly predictable trajectory, and good clinical practice at one phase can be inappropriate at other phases. Early recognition, rapid and definitive microbiology, and strategic selection of tests increase the likelihood of good outcomes. The best management of these infections consists of avoiding antibiotics, antimotility agents, and narcotics and implementing aggressive intravenous volume expansion, especially in the early phases of illness.
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17
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Diamante Chiodini B, Davin JC, Corazza F, Khaldi K, Dahan K, Ismaili K, Adams B. Eculizumab in anti-factor h antibodies associated with atypical hemolytic uremic syndrome. Pediatrics 2014; 133:e1764-8. [PMID: 24843055 DOI: 10.1542/peds.2013-1594] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a life-threatening multisystemic condition often leading to end-stage renal failure. It results from an increased activation of the alternative pathway of the complement system due to mutations of genes coding for inhibitors of this pathway or from autoantibodies directed against them. Eculizumab is a monoclonal antibody directed against complement component C5 and inhibiting the activation of the effector limb of the complement system. Its efficacy has already been demonstrated in aHUS. The present article reports for the first time the use of eculizumab in a patient presenting with aHUS associated with circulating anti-complement Factor H autoantibodies and complicated by cardiac and neurologic symptoms. Our observation highlights the efficacy of eculizumab in this form of aHUS not only on renal symptoms but also on the extrarenal symptoms. It also suggests that eculizumab should be used very promptly after aHUS presentation to prevent life-threatening complications and to reduce the risk of chronic disabilities. To obtain a complete inhibition of the effector limb activation, the advised dosage must be respected. After this initial therapy in the autoimmune aHUS form, a long-term immunosuppressive treatment should be considered, to prevent relapses by reducing anti-complement Factor H autoantibody plasma levels.
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Affiliation(s)
| | - Jean-Claude Davin
- Departments of Pediatric Nephrology, andDepartment of Pediatric Nephrology, Emma Children's Hospital-Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Francis Corazza
- Department of Immunology, CHU Brugmann Hospital (ULB), Brussels, Belgium; and
| | - Karim Khaldi
- Pediatric Cardiology, Hôpital Universitaire des Enfants-Reine Fabiola, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Karin Dahan
- Center for Human Genetics, Université Catholique de Louvain, Brussels, Belgium
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18
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Mele C, Remuzzi G, Noris M. Hemolytic uremic syndrome. Semin Immunopathol 2014; 36:399-420. [PMID: 24526222 DOI: 10.1007/s00281-014-0416-x] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Accepted: 01/19/2014] [Indexed: 12/25/2022]
Abstract
Hemolytic uremic syndrome (HUS) is a thrombotic microangiopathy defined by thrombocytopenia, nonimmune microangiopathic hemolytic anemia, and acute renal failure. The most frequent form is associated with infections by Shiga-like toxin-producing bacteria (STEC-HUS). Rarer cases are triggered by neuraminidase-producing Streptococcus pneumoniae (pneumococcal-HUS). The designation of aHUS is used to refer to those cases in which an infection by Shiga-like toxin-producing bacteria or S. pneumoniae can be excluded. Studies performed in the last two decades have documented that hyperactivation of the complement system is the pathogenetic effector mechanism leading to the endothelial damage and the microvascular thrombosis in aHUS. Recent data suggested the involvement of the complement system in the pathogenesis of STEC-HUS and pneumococcal-HUS as well. Clinical signs and symptoms may overlap among the different forms of HUS; however, pneumococcal-HUS and aHUS have a worse prognosis compared with STEC-HUS. Early diagnosis and identification of underlying pathogenetic mechanism allows instating specific support measures and therapies. In clinical trials in patients with aHUS, complement inhibition by eculizumab administration leads to a rapid and sustained normalization of hematological parameters with improvement in long-term renal function. This review summarizes current concepts about the epidemiological findings, the pathological and clinical aspects of STEC-HUS, pneumococcal-HUS, and aHUS, and their diagnosis and management.
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Affiliation(s)
- Caterina Mele
- IRCCS Istituto di Ricerche Farmacologiche "Mario Negri", Clinical Research Center for Rare Diseases "Aldo e Cele Daccò", Via Camozzi, 3, Ranica, Bergamo, 24020, Italy
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19
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Hofer J, Rosales A, Fischer C, Giner T. Extra-renal manifestations of complement-mediated thrombotic microangiopathies. Front Pediatr 2014; 2:97. [PMID: 25250305 PMCID: PMC4157546 DOI: 10.3389/fped.2014.00097] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 08/25/2014] [Indexed: 12/19/2022] Open
Abstract
Thrombotic microangiopathies (TMA) are rare but severe disorders, characterized by endothelial cell activation and thrombus formation leading to hemolytic anemia, thrombocytopenia, and organ failure. Complement over activation in combination with defects in its regulation is described in an increasing number of TMA and if primary for the disease denominated as atypical hemolytic-uremic syndrome. Although TMA predominantly affects the renal microvasculature, extra-renal manifestations are observed in 20% of patients including involvement of the central nerve system, cardiovascular system, lungs, skin, skeletal muscle, and gastrointestinal tract. Prompt diagnosis and treatment initiation are therefore crucial for the prognosis of disease acute phase and the long-term outcome. This review summarizes the available evidence on extra-renal TMA manifestations and discusses the role of acute and chronic complement activation by highlighting its complex interaction with inflammation, coagulation, and endothelial homeostasis.
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Affiliation(s)
- Johannes Hofer
- Department of Pediatrics I, Innsbruck Medical University , Innsbruck , Austria
| | - Alejandra Rosales
- Department of Pediatrics I, Innsbruck Medical University , Innsbruck , Austria
| | - Caroline Fischer
- Department of Pediatrics I, Innsbruck Medical University , Innsbruck , Austria
| | - Thomas Giner
- Department of Pediatrics I, Innsbruck Medical University , Innsbruck , Austria
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20
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21
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Chen TC, Lu PL, Lin CY, Lin WR, Chen YH. Escherichia coli urosepsis complicated with myocarditis mimicking acute myocardial infarction. Am J Med Sci 2010; 340:332-4. [PMID: 20601856 DOI: 10.1097/maj.0b013e3181e92e71] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Myocarditis is defined clinically as inflammation of the heart muscle, which can be caused by infectious agents, toxins or immunologic reactions. Most recognized cases of acute myocarditis are secondary to cardiotropic viral infections. Escherichia coli rarely cause myocarditis. The authors report a 25-year-old woman with E coli-induced acute pyelonephritis and septic shock that was complicated with acute myocarditis. Her symptoms mimicked acute myocardial infarction. The authors discuss the possible mechanism of bacterial sepsis-induced myocarditis.
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Affiliation(s)
- Tun-Chieh Chen
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung City, Taiwan
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22
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Donoso Fuentes A, Arriagada Santis D, Bertrán Salinas K, Cruces Romero P, Díaz Rubio F. [Myocardial infarction during classic haemolytic uraemic syndrome]. An Pediatr (Barc) 2010; 72:362-3. [PMID: 20399160 DOI: 10.1016/j.anpedi.2009.12.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2009] [Revised: 09/25/2009] [Accepted: 12/21/2009] [Indexed: 11/16/2022] Open
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23
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Sallée M, Daniel L, Piercecchi MD, Jaubert D, Fremeaux-Bacchi V, Berland Y, Burtey S. Myocardial infarction is a complication of factor H-associated atypical HUS. Nephrol Dial Transplant 2010; 25:2028-32. [PMID: 20305136 DOI: 10.1093/ndt/gfq160] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Cardiac complications are frequently seen in thrombotic thrombocytopaenic purpura related to ADAMTS13 deficiency. We describe the case of a 43-year-old woman who was diagnosed with an atypical haemolytic-uraemic syndrome (aHUS) associated with a pathogenic mutation in the factor H gene (C623S). After 15 days of treatment, she suffered a sudden cardiac arrest and died despite intensive resuscitation attempts. She showed only one cardiovascular risk factor, hypercholesterolaemia. Her sudden death was secondary to cardiac infarction related to a coronary thrombotic microangiopathy. This is the first case of aHUS related to a mutation in the factor H gene associated with cardiac microangiopathy. This case emphasizes the need to screen for cardiac complication during the treatment of aHUS.
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Affiliation(s)
- Marion Sallée
- Centre de néphrologie et transplantation rénale, AP-HM, Hôpital de la Conception, Université de la Méditerranée, Marseille, France
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24
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25
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Mohammed J, Filler G, Price A, Sharma AP. Cardiac tamponade in diarrhoea-positive haemolytic uraemic syndrome. Nephrol Dial Transplant 2008; 24:679-81. [PMID: 19033247 DOI: 10.1093/ndt/gfn649] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The spectrum of extra-renal involvement secondary to diarrhoeal (D+) haemolytic uraemic syndrome (HUS) includes neurological, gastrointestinal, hepatic, pancreatic and cardiac complications. Among the cardiac complications, myocardial injury has been more commonly reported with HUS. Literature is scarce on HUS-associated pericardial involvement. We report a HUS-induced significant pericardial effusion that resulted in a cardiac tamponade. We also discuss the diagnostic and therapeutic implications of this complication.
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Affiliation(s)
- Javed Mohammed
- Department of Paediatrics, Children's Hospital at London Health Science Centre, University of Western Ontario, London, Ontario, Canada
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26
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Alexopoulou A, Dourakis SP, Zovoilis C, Agapitos E, Androulakis A, Filiotou A, Archimandritis AJ. Dilated cardiomyopathy during the course of hemolytic uremic syndrome. Int J Hematol 2008; 86:333-6. [PMID: 18055340 DOI: 10.1532/ijh97.e0713] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
A 47-year-old woman presented with severe hemolytic uremic syndrome (HUS) followed by heart failure. An echocardiogram showed an ejection fraction of 20%, and a cardiac catheterization followed by a myocardial histologic evaluation demonstrated dilated cardiomyopathy. Plasma exchange and hemodialysis were performed regularly. The later outcomes of renal function and cardiomyopathy were favorable. A review of the literature confirmed the rare and severe nature of cardiac lesions occurring in the course of HUS. This case indicates the importance of cardiac monitoring in HUS and the need for prolonged support.
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Affiliation(s)
- Alexandra Alexopoulou
- 2nd Department of Medicine, University of Athens Medical School, Hippokration General Hospital, Greece.
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27
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Abstract
Cardiovascular dysfunction in patients with hemolytic-uremic syndrome (HUS) may be related to secondary issues such as volume overload, hypertension or electrolyte disturbances including hyperkalemia. Additionally, primary myocardial involvement has been increasingly recognized as a potential comorbid feature of HUS. We report a 9-month-old child with HUS who developed clinical signs of poor myocardial function with depressed myocardial function noted by echocardiography. Supportive care including mechanical ventilation and inotropic agents were necessary for approximately 10 days. Follow-up echocardiography revealed return of normal ventricular function. Previous reports of primary cardiac involvement with HUS have included thrombotic microangiopathy of the coronary vasculature resulting in myocardial ischemia, myocardial infarction or depressed myocardial function, myocarditis, congestive heart failure with dilated cardiomyopathy and pericardial effusion with tamponade. Given the potential for morbidity and mortality during the preoperative period in patients with HUS, anesthesiologists involved in the care of such patients should be aware of the potential for myocardial involvement in this disease process. Preoperatively, the routine evaluation of myocardial function may be indicated.
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Affiliation(s)
- Joseph D Tobias
- Department of Anesthesiology, University of Missouri, Columbia, MO 65212, USA.
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28
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Affiliation(s)
- Abiodun A Omoloja
- Nephrology Department, The Children's Medical Center, Dayton, Ohio, USA
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29
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Oakes RS, Siegler RL, McReynolds MA, Pysher T, Pavia AT. Predictors of fatality in postdiarrheal hemolytic uremic syndrome. Pediatrics 2006; 117:1656-62. [PMID: 16651320 DOI: 10.1542/peds.2005-0785] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Describe the cause of deaths among patients with postdiarrheal hemolytic uremic syndrome (HUS) and identify predictors of death at the time of hospital admission. METHODS Case-control study of 17 deaths among patients with HUS identified from the Intermountain HUS Patient Registry (1970-2003) compared against all nonfatal cases. RESULTS Of the 17 total deaths, 15 died during the acute phase of disease. Two died because treatment was withdrawn based on their preexisting conditions, and 1 died because of iatrogenic cardiac tamponade; they were excluded from analysis. Brain involvement was the most common cause of death (8 of 12); congestive heart failure, pulmonary hemorrhage, and hyperkalemia were infrequent causes. Presence of prodromal lethargy, oligoanuria, or seizures and white blood cell count (WBC) >20 x 10(9)/L or hematocrit >23% on admission were predictive of death. In multivariate analysis, elevated WBC and elevated hematocrit were independent predictors. The combination of prodromal dehydration, oliguria, and lethargy and admission WBC values >20 x 10(9)/L and hematocrit >23% appeared in 7 of the 12 acute-phase deaths. CONCLUSIONS Diarrheal HUS patients presenting with oligoanuria, dehydration, WBC >20 x 10(9)/L, and hematocrit >23% are at substantial risk for fatal hemolytic uremic syndrome. Such individuals should be referred to pediatric tertiary care centers.
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Affiliation(s)
- Robert S Oakes
- Pediatric Nephrology, University of Utah School of Medicine, Salt Lake City, Utah, USA.
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Askiti V, Hendrickson K, Fish AJ, Braunlin E, Sinaiko AR. Troponin I levels in a hemolytic uremic syndrome patient with severe cardiac failure. Pediatr Nephrol 2004; 19:345-8. [PMID: 14685841 DOI: 10.1007/s00467-003-1343-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2003] [Revised: 09/10/2003] [Accepted: 09/18/2003] [Indexed: 10/26/2022]
Abstract
Troponins are highly sensitive and specific biochemical markers of myocardial injury that are released into the circulation during myocardial ischemia. We describe changes in cardiac troponin I (cTnI) prior to and following clinical evidence of severe myocardial dysfunction in a child with hemolytic uremic syndrome (HUS). A previously healthy, 22-month-old girl presented with typical HUS and stool cultures positive for Escherichia coli O157:H7. She required dialysis, blood and platelet transfusions, and insulin for HUS-related diabetes mellitus. On the 6th hospital day she had sudden circulatory collapse with a blood pressure of 70/40 mmHg and an oxygen saturation of 88%. She responded rapidly to emergency resuscitation but had diminished left ventricular function (ejection fraction 18%). Four days after the acute event an echocardiogram showed normal ventricular size and contractility. She underwent hemodialysis for 22 days, and renal function was normal after 33 days. cTnI levels were measured with a microparticle enzyme immunoassay. cTnI was normal (>0.4 microg/l) 32 h prior to cardiac collapse, mildly increased (2.1 microg/l) 8 h before the cardiac collapse, severely elevated shortly after the cardiac event (43.1 microg/l), and peaked (140.6 microg/l) at 24 h. It then fell gradually and was normal at discharge. These results suggest that measurement of cTnI may be a useful predictor of cardiac involvement in severely affected children with HUS.
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Affiliation(s)
- Varvara Askiti
- Division of Nephrology, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN 55455, USA
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31
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Abstract
Two cases of unexpected childhood death due to hemolytic uremic syndrome are reported. A 21-month-old girl who was discovered dead in bed following a short illness was found at autopsy to have overwhelming sepsis resulting from transmural colitis. Escherichia coli serotype 0157A was isolated from the intestine, and renal changes of hemolytic uremic syndrome were found. A 4-year-old girl died suddenly in hospital from intracranial hemorrhage while being treated for hemolytic uremic syndrome-related renal failure. Culture of urine and feces grew verocytotoxin producing E. coli. These cases demonstrate that hemolytic uremic syndrome may be a rare cause of unexpected childhood death and that the diagnosis may not be established prior to autopsy. Postmortem culture of tissues and fluids in cases of suspected sepsis in children may be essential in establishing this diagnosis, because histologic evaluation may be compromised by profound sepsis and tissue putrefaction. Accuracy in diagnosis may have significant public health and medicolegal consequences.
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Affiliation(s)
- N Manton
- Department of Histopathology, Women's and Children's Hospital, Adelaide, Australia
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