Preterm Labor Caused by Hemolysis, Elevated Liver Enzymes, Low Platelet Count (HELLP) Syndrome and Postpartum Infection Complicated with Actinomyces Species: A Case Report

HELLP syndrome at <23 weeks' gestation: a systematic literature review

OBJECTIVE

We performed a systematic review to evaluate the clinical presentation and maternal and fetal outcomes in pregnancies with early-onset HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome.

DATA SOURCES

PubMed, Ovid MEDLINE, Scopus, CINAHL, Cochrane Library, and ClinicalTrials.gov were queried from inception through January 1, 2023 with the following terms: "HELLP syndrome," "HELLP," "hemolysis, elevated liver enzymes, low platelets," "hemolysis, elevated liver enzymes, low platelets syndrome," "pre-viable," "peri-viable," "previable," "periviable," "first trimester," "second trimester," "before 23 weeks," "<23 weeks," "<23 week gestation," and "before 23 weeks gestation." We also included an additional case from our institution.

STUDY ELIGIBILITY CRITERIA

Abstracts, unpublished studies, and review articles were excluded, yielding 46 studies that met our inclusion criteria.

METHODS

Two reviewers (N.S.I. and M.H.M.) performed the study selection and subsequent data extraction independently, after which the results were reviewed together. PRISMA guidelines were followed, and our study was registered at PROSPERO (CRD42021292692).

RESULTS

A total of 55 patients had 58 pregnancies complicated by early-onset HELLP syndrome, including 3 with recurrent HELLP. The most common presenting signs/symptoms were abdominal pain (35/45; 78%), hypertension (32/49; 65%), nausea/vomiting (16/45; 36%), headache (13/45; 29%), and edema (8/45; 18%). Lactate dehydrogenase ≥600 IU/L was observed in 21 of 31 (68%) cases, whereas liver enzyme abnormalities and thrombocytopenia were reported in 48 of 51 (94%) and 50 of 54 (93%) cases, respectively. Maternal complications were encountered in 25 of 56 (45%) cases. The most common complications were hepatic (13/56; 23%), central nervous system-related (11/56; 20%), and respiratory (11/56; 20%). In 36 of 57 (63%) cases, pregnancy was terminated. Of the 21 continued pregnancies, early fetal death (at <20 weeks' gestation) was reported in 10 (48%), stillbirth in 6 (28%), and neonatal demise in 2 (10%). Living neonates were reported in 3 of 21 (14%) cases, all delivered at 23 weeks. The perinatal mortality rate was 73% (8/11). One case (2%) reported maternal death. Antiphospholipid syndrome was diagnosed in 14 of 29 (48%) cases.

CONCLUSION

Early-onset HELLP syndrome presents with symptoms similar to those observed in later gestation. Maternal complications are life-threatening, with the most common complications being hepatic, central nervous system-related, and respiratory. Fetal outcomes are poor.

Clinical Characteristics of Actinomyces viscosus Bacteremia

Background and Objectives: Actinomyces species are part of the normal flora of humans and rarely cause disease. It is an uncommon cause of disease in humans. The clinical features of actinomycosis have been described, and various anatomical sites (such as face, bones and joints, respiratory tract, genitourinary tract, digestive tract, central nervous system, skin, and soft tissue structures) can be affected. It is not easy to identify actinomycosis because it sometimes mimics cancer due to under-recognition. As new diagnostic methods have been applied, Actinomyces can now more easily be identified at the species level. Recent studies have also highlighted differences among Actinomyces species. We report a case of Actinomyces viscosus bacteremia with cutaneous actinomycosis. Materials and Methods: A 66 years old male developed fever for a day with progressive right lower-leg erythematous swelling. Blood culture isolates yielded Actinomyces species, which was identified as Actinomyces viscosus by sequencing of the 16S rRNA gene. In addition, we searched for the term Actinomyces or actinomycosis cross-referenced with bacteremia or "blood culture" or "blood stream" from January 2010 to July 2020. The infectious diseases caused by species of A. viscosus from January 1977 to July 2020 were also reviewed. Results: The patient recovered well after intravenous ampicillin treatment. Poor oral hygiene was confirmed by dental examination. There were no disease relapses during the following period. Most cases of actinomycosis can be treated with penicillin. However, clinical alertness, risk factor evaluation, and identification of Actinomyces species can prevent inappropriate antibiotic or intervention. We also compiled a total of 18 cases of Actinomyces bacteremia after conducting an online database search. Conclusions: In summary, we describe a case of fever and progressive cellulitis. Actinomyces species was isolated from blood culture, which was further identified as Actinomyces viscosus by 16S rRNA sequencing. The cellulitis improved after pathogen-directed antibiotics. Evaluation of risk factors in patients with Actinomyces bacteremia and further identification of the Actinomyces species are recommended for successful treatment.

A Premature Infant With Neonatal Actinomyces odontolyticus Sepsis

We describe the presentation, diagnosis and management of a premature newborn with Actinomyces odontolyticus bacteremia; this is the first case report of neonatal sepsis secondary to this bacteria. Maternal dental infection was the likely source of the pathogen. The outcome was favorable, with good response to antimicrobial therapy with ampicillin/amoxicillin.