Understanding yellow fever-associated myocardial injury: an autopsy study

BACKGROUND

Yellow fever (YF) is a viral hemorrhagic fever, endemic in parts of South America and Africa. There is scarce evidence about the pathogenesis of the myocardial injury. The objective of this study is to evaluate the cardiac pathology in fatal cases of YF.

METHODS

This retrospective autopsy study included cases from the São Paulo (Brazil) epidemic of 2017-2019. We reviewed medical records and performed cardiac tissue histopathological evaluation, electron microscopy, immunohistochemical assays, RT-qPCR for YF virus (YFV)-RNA, and proteomics analysis on inflammatory and endothelial biomarkers.

FINDINGS

Seventy-three confirmed YF cases with a median age of 48 (34-60) years were included. We observed myocardial fibrosis in 68 (93.2%) patients; cardiomyocyte hypertrophy in 68 (93.2%); endothelial alterations in 67 (91.8%); fiber necrosis in 50 (68.5%); viral myocarditis in 9 (12.3%); and secondary myocarditis in 5 (6.8%). Four out of five patients with 17DD vaccine-associated viscerotropic disease presented with myocarditis. The cardiac conduction system showed edema, hemorrhages and endothelial fibrinoid necrosis. Immunohistochemistry detected CD68-positive inflammatory interstitial cells and YFV antigens in endothelial and inflammatory cells. YFV-RNA was detected positive in 95.7% of the cardiac samples. The proteomics analysis demonstrated that YF patients had higher levels of multiple inflammatory and endothelial biomarkers in comparison to cardiovascular controls, and higher levels of interferon gamma-induced protein 10 (IP-10) in comparison to sepsis (p = 0.01) and cardiovascular controls (p < 0.001) in Dunn test.

INTERPRETATION

Myocardial injury is frequent in severe YF, due to multifactorial mechanisms, including direct YFV-mediated damage, endothelial cell injury, and inflammatory response, with a possible prominent role for IP-10.

FUNDING

This study was funded by Fundação de Amparo à Pesquisa do Estado de São Paulo, Bill and Melinda Gates Foundation, Conselho Nacional de Desenvolvimento Científico e Tecnológico, Coordenação de Aperfeiçoamento de Pessoal de Nível Superior.

Optimization of Antimicrobial Stewardship Programs Using Therapeutic Drug Monitoring and Pharmacokinetics-Pharmacodynamics Protocols: A Cost-Benefit Review

PURPOSE

Antimicrobial stewardship programs are important for reducing antimicrobial resistance because they can readjust antibiotic prescriptions to local guidelines, switch intravenous to oral administration, and reduce hospitalization times. Pharmacokinetics-pharmacodynamics (PK-PD) empirically based prescriptions and therapeutic drug monitoring (TDM) programs are essential for antimicrobial stewardship, but there is a need to fit protocols according to cost benefits. The cost benefits can be demonstrated by reducing toxicity and hospital stay, decreasing the amount of drug used per day, and preventing relapses in infection. Our aim was to review the data available on whether PK-PD empirically based prescriptions and TDM could improve the cost benefits of an antimicrobial stewardship program to decrease global hospital expenditures.

METHODS

A narrative review based on PubMed search with the relevant studies of vancomycin, aminoglycosides, beta-lactams, and voriconazole.

RESULTS

TDM protocols demonstrated important cost benefit for patients treated with vancomycin, aminoglycosides, and voriconazole mainly due to reduce toxicities and decreasing the hospital length of stay. In addition, PK-PD strategies that used infusion modifications to meropenem, piperacillin-tazobactam, ceftazidime, and cefepime, such as extended or continuous infusion, demonstrated important cost benefits, mainly due to reducing daily drug needs and lengths of hospital stays.

CONCLUSIONS

TDM protocols and PK-PD empirically based prescriptions improve the cost-benefits and decrease the global hospital expenditures.

Septic shock, hyperferritinemic syndrome, and multiple organ dysfunction without respiratory failure in a patient with disseminated histoplasmosis and advanced HIV disease

AIDS-related disseminated histoplasmosis (DH) can cause septic shock and multiorgan dysfunction with mortality rates of up to 80%. A 41-year-old male presented with fever, fatigue, weight loss, disseminated skin lesions, low urine output, and mental confusion. Three weeks before admission, the patient was diagnosed with HIV infection, but antiretroviral therapy (ART) was not initiated. On day 1 of admission, sepsis with multiorgan dysfunction (acute renal failure, metabolic acidosis, hepatic failure, and coagulopathy) was identified. A chest computed tomography showed unspecific findings. Yeasts suggestive of Histoplasma spp. were observed in a routine peripheral blood smear. On day 2, the patient was transferred to the ICU, where his clinical condition progressed with reduced level of consciousness, hyperferritinemia, and refractory septic shock, requiring high doses of vasopressors, corticosteroids, mechanical ventilation, and hemodialysis. Amphotericin B deoxycholate was initiated. On day 3, yeasts suggestive of Histoplasma spp. were observed in the bone marrow. On day 10, ART was initiated. On day 28, samples of peripheral blood and bone marrow cultures revealed Histoplasma spp. The patient stayed in the ICU for 32 days, completing three weeks of intravenous antifungal therapy. After progressive clinical and laboratory improvement, the patient was discharged from the hospital on oral itraconazole, trimethoprim-sulfamethoxazole, and ART. This case highlights the inclusion of DH in the differential diagnosis of patients with advanced HIV disease, septic shock and multiorgan dysfunction but without respiratory failure. In addition, it provides early in-hospital diagnosis and treatment and comprehensive management in the ICU as determining factors for a good outcome.

Phylogeographic patterns of the yellow fever virus around the metropolitan region of São Paulo, Brazil, 2016–2019

From 2016 to 2019, the largest outbreak caused by the Yellow Fever virus (YFV) in the 21^st century in the Americas occurred in southeastern Brazil. A sylvatic cycle of transmission was reported near densely populated areas, such as the large metropolitan area of the city of São Paulo. Here, we describe the origin, spread, and movement of the YFV throughout the state of São Paulo. Whole-genome sequences were obtained from tissues of two patients who died due to severe yellow fever, during 2018–2019. Molecular analysis indicated that all analyzed tissues were positive for YFV RNA, with the liver being the organ with the highest amount of viral RNA. Sequence analysis indicates that genomes belonged to the South American genotype I and were grouped in the epidemic clade II, which includes sequences from the states of Goiás, Minas Gerais, and São Paulo of previous years. The analysis of viral dispersion indicates that the outbreak originated in Goiás at the end of 2014 and reached the state of São Paulo through the state of Minas Gerais after 2016. When the virus reached near the urban area, it spread towards both the east and south regions of the state, not establishing an urban transmission cycle in the metropolitan region of São Paulo. The virus that moved towards the east met with YFV coming from the south of the state of Rio de Janeiro, and the YFV that was carried to the south reached the Brazilian states located in the south region of the country.

The Yellow Fever virus (YFV) has caused serious public health issues in Africa and the Americas. YFV infections can vary from asymptomatic to severe clinical conditions, which may culminate in death. In Brazil, the main viral origin of YFV outbreaks is the states located in the Amazon Basin. In the present study, we detected YFV RNA in several tissues, including the heart, lung, brain, kidney, spleen, pancreas, liver, and testicle in two human cases. The YFV characterized in the present study belong to the South American genotype I, clade II, and they are associated with viral spread throughout the state of São Paulo after intense viral circulation in the metropolitan region in 2018. Future investigations are necessary for a better understanding of the complex ecological factors involved in viral dispersion from the Amazon Basin.

PULSOTERAPIA COM METILPREDNISOLONA NA SÍNDROME DE HIPERFERRITINEMIA DA COVID-19. RELATO DE DOIS CASOS

Introdução

Hiperferritinemia à admissão é reconhecida como determinante de desfecho desfavorável em COVID-19. Mas a ferritina plasmática é também um sensível biomarcador de grande utilidade na monitorização da atividade inflamatória nestes pacientes.

Relato de caso

Apresentamos dois casos nos quais a monitorização contínua deste biomarcador permitiu a detecção de Sd. Hiperferritinêmica que responderam favoravelmente à pulsoterapia com metilprednisolona. Caso 1 - Paciente do sexo masculino, 28 anos, previamente hígido. Negava comorbidades. Internado em nosso serviço no sexto dia de sintomas da COVID-19, evoluindo para SRAG. Cursou ao longo dos dias com piora expressiva do padrão respiratório, sendo necessária a realização de intubação orotraqueal. Concomitantemente à deterioração respiratória, exames laboratoriais evidenciaram aumento abrupto de proteína C reativa e de ferritina. Suscitada a hipótese de síndrome hiperferritinêmica. Assim, optou-se pela instituição de pulsoterapia com Metilprednisolona 1g/dia EV por 05 dias. Paciente evoluiu com melhora do padrão respiratório e queda da ferritina, sendo extubado dez dias depois. Caso 2 - Paciente do sexo feminino, 49 anos. Apresentava sobrepeso e hipertensão arterial sistêmica. Internada no nosso serviço no sétimo dia de sintomas da COVID-19. Evoluiu para SRAG, realizada intubação orotraqueal de urgência. Ao longo da internação, cursou com múltiplas complicações como infecção de corrente sanguínea, candidemia, pneumonia associada à ventilação, insuficiência renal aguda, infecção intestinal por Schistosoma mansoni e Giardia lamblia e TRALI - lesão pulmonar aguda associada à transfusão. Além da deterioração clínica progressiva, apresentou aumento significativo dos níveis de ferritina, caracterizando uma síndrome hiperferritinêmica, o que motivou a instituição de pulsoterapia com Metilprednisolona 1g EV ao dia por três dias. Após quarenta e quatro dias em ventilação mecânica, foi possível a transição para nebulização em traqueostomia. Recebeu alta após cinquenta e sete dias de internação hospitalar, confortável em ar ambiente, com sequela de tremor de extremidades e marcha atáxica.

Discussão

A partir desses dois relatos de casos, propomos uma discussão sobre a associação entre COVID-19 grave e síndrome hiperferritinêmica, com suas possíveis abordagens terapêuticas.

POSIÇÃO PRONA EM PACIENTES COM COVID-19 EM VENTILAÇÃO MECÂNICA AUMENTA OS NÍVEIS SÉRICOS DE CREATINA-FOSFOQUINASE (CPK)

Introdução/Objetivo

A pandemia do Coronavirus colocou a posição prona em evidência como uma ferramenta de auxílio no manejo de hipoxemias graves. No entanto, de modo análogo ao relatado em outras situações que utilizam a manobra, tais como neurocirurgias e cirurgias ortopédicas, chama a atenção que pacientes ventilados mecanicamente na unidade de terapia intensiva (UTI) em posição prona costumam apresentar níveis séricos mais elevados de Creatina-fosfoquinase (CPK) posteriormente. Assim, o objetivo do presente estudo foi avaliar a diferença entre valores de CPK sérica antes e após a pronação em pacientes diagnosticados com COVID-19 em uso de ventilação mecânica na UTI.

Método

Estudo analítico em que 15 pacientes graves com diagnóstico de COVID-19 foram avaliados quanto a seus níveis séricos de CPK antes e depois de serem pronados. Todos os pacientes tinham resultado positivo para COVID-19 e estavam em ventilação mecânica na UTI. Os dados sobre os níveis séricos de CPK foram coletados até 24 horas antes e após o posicionamento dos pacientes em prona. Em seguida, o Teste do Sinal para Pares Combinados (unilateral) foi usado para testar a hipótese de aumento dos níveis séricos de CPK até 24 horas após a posição prona. A significância estatística foi estabelecida em p < 0,05.

Resultados

O presente estudo teve tamanho amostral de 15 pacientes, todos em posição prona: 8 mulheres (53,33%) e 7 homens (46,67%), com mediana de idade de 51 anos. Nesse contexto, 12 pacientes (80%) apresentaram aumento dos níveis séricos de CPK até 24 horas após o posicionamento, o que, após ser testado com o Teste de Sinal de Pares Combinados (unilateral), resultou em uma diferença significativa entre os níveis séricos de CPK antes e após a manobra (p valor = 0,0176).

Conclusão

Houve um aumento estatisticamente significativo nos níveis séricos de CPK até 24 horas após o posicionamento em prona de pacientes com COVID-19 ventilados mecanicamente na UTI. Mais estudos devem avaliar se e como esses achados podem afetar os resultados clínicos desses pacientes, especialmente considerando o papel da CPK nos desfechos de paciente com COVID-19.

Intensive care unit staff preparedness as an independent factor for death of patients during COVID-19 pandemic: An observational cohort study

The pandemic of COVID-19 brought to the world an unprecedented challenge. This single center observational study aimed to evaluate the impact of staff preparedness by comparing the outcomes between two intensive care units (ICUs) from a hospital that had to expand ICU beds to deal with an incremented volume of critical patients. Patients consecutively admitted to these ICUs with suspected COVID-19, from March 1st until April 30th, 2020, were included. Both ICUs attended a similar population and had the same facilities, what differed was the staff: one previously well-established (ICU-1) and another recently assembled (ICU-2). 114 patients with severe respiratory syndrome were included. In-hospital mortality was 40%. Compared with patients in the well-established ICU-1, patients in the recently assembled ICU-2 were older (54 versus 61.5, p=0.045), received more antibiotics (93% versus 98%, p=0.001) and chloroquine/hydroxychloroquine 6% versus 30%, p=0.001), had a higher proportion of invasive mechanical ventilation (44% versus 52%, p=0.008) and had greater in-hospital mortality (30% versus 50%, p=0.017). The proportion of patients considered at high risk for death according to PSI was similar between the two ICU populations. Age ≥ 60 years (adjusted OR 2.33; 95% CI 1.02-5.31), need of invasive mechanical ventilation (adjusted OR 2.79; 95% CI 1.22-6.37), and ICU type (recently assembled) (adjusted OR 2.38; 95% CI 1.04-5.44) were independently associated with in-hospital mortality . This finding highlights the importance of developing support strategies to improve preparedness of staff recently assembled to deal with emergencies.

Epidemiology, clinical aspects, outcomes and prognostic factors associated with Trichosporon fungaemia: results of an international multicentre study carried out at 23 medical centres

BACKGROUND

Trichosporon fungaemia (TF) episodes have increased in recent years and mortality rates remain high despite the advances in the management of sepsis. New concepts about its clinical course, treatment and microbiology need to be investigated for the better management of this infection.

OBJECTIVES

To describe the aetiology, natural history, clinical management and prognostic factors of TF.

METHODS

TF episodes documented between 2005 and 2018 in 23 South American centres were retrospectively investigated by using a standard clinical form. Molecular identification, antifungal susceptibility testing and biofilm production were also performed.

RESULTS

Eighty-eight TF episodes were studied. Patients had several underlying conditions, including haematological diseases (47.7%), post-operative status (34%), solid organ transplants (n = 7, 7.9%), among others. Seventy-three (82.9%) patients had a central venous catheter (CVC) at TF diagnosis. The 30 day mortality rate was 51.1%. Voriconazole-based therapy was given to 34 patients (38.6%), with a 30 day mortality rate of 38.2%. Multivariate predictors of 30 day mortality were age (OR 1.036), mechanical ventilation (OR 8.25) and persistent neutropenia (OR 9.299). CVC removal was associated with over 75% decreased risk of 30 day mortality (OR 0.241). Microbiological analyses revealed that 77.7% of the strains were identified as Trichosporon asahii, and voriconazole showed the strongest in vitro activity against Trichosporon spp. Most of the strains (63%) were considered medium or high biofilm producers.

CONCLUSIONS

Older age, mechanical ventilation and persistent neutropenia were associated with poor prognosis. CVC may play a role in the pathogenicity of TF and its removal was associated with a better prognosis.

Awake Proning as an Adjunctive Therapy for Refractory Hypoxemia in Non-Intubated Patients with COVID-19 Acute Respiratory Failure: Guidance from an International Group of Healthcare Workers

Non-intubated patients with acute respiratory failure due to COVID-19 could benefit from awake proning. Awake proning is an attractive intervention in settings with limited resources, as it comes with no additional costs. However, awake proning remains poorly used probably because of unfamiliarity and uncertainties regarding potential benefits and practical application. To summarize evidence for benefit and to develop a set of pragmatic recommendations for awake proning in patients with COVID-19 pneumonia, focusing on settings where resources are limited, international healthcare professionals from high and low- and middle-income countries (LMICs) with known expertise in awake proning were invited to contribute expert advice. A growing number of observational studies describe the effects of awake proning in patients with COVID-19 pneumonia in whom hypoxemia is refractory to simple measures of supplementary oxygen. Awake proning improves oxygenation in most patients, usually within minutes, and reduces dyspnea and work of breathing. The effects are maintained for up to 1 hour after turning back to supine, and mostly disappear after 6-12 hours. In available studies, awake proning was not associated with a reduction in the rate of intubation for invasive ventilation. Awake proning comes with little complications if properly implemented and monitored. Pragmatic recommendations including indications and contraindications were formulated and adjusted for resource-limited settings. Awake proning, an adjunctive treatment for hypoxemia refractory to supplemental oxygen, seems safe in non-intubated patients with COVID-19 acute respiratory failure. We provide pragmatic recommendations including indications and contraindications for the use of awake proning in LMICs.

Potential autoimmune encephalitis following yellow fever vaccination: A report of three cases

Meningoencephalitis following yellow fever vaccination is considered a viral neuroinvasive disease. We describe three patients with typical autoimmune encephalitis syndromes that developed 1-27 days following yellow fever vaccination. Anti-N-methyl-d-aspartate-r antibodies were identified in the CSF and serum of two patients and the other case was associated with anti-neurexin-3 antibodies. One case was confirmed as vaccine-associated neurotropic disease due to reactive CSF yellow fever IgM, which suggested an infectious-autoimmune overlap mechanism. Two aditional cases of Anti-N-methyl-d-aspartate-r encephalitis were identified in the literature review. Antibody-positive autoimmune encephalitis should be included in the differential diagnosis of neurologic adverse events following yellow fever vaccination.

Disseminated Mycobacterium avium on HIV/AIDS: Historical and Current Literature Review

Combination antiretroviral therapy (cART) has changed Mycobacterium avium epidemiology. A significant decrease in the incidence of disseminated M. avium complex: (DMAC) infection was observed between pre-cART and post-cART periods. In contrast, diagnoses of DMAC more than doubled from 1990 to 1996. During this time, DMAC prevalence in people living with AIDS (PLHA) in developed countries reached 20-23% overall and >40% in groups with CD4 cell counts <10 cells/mm3. At present, DMAC in PLHA has an incidence of two events per 1000 patient years. Recently, the centers for disease control changed the criteria for MAC primary prophylaxis, where only patients without immediate cART and CD4 cell counts <50 cells/mm3 are prescribed 1200 mg of azithromycin weekly. Treatment is discontinued when patients initiate effective cART. Diagnosing a disseminated M. avium infection is difficult due to the low accuracy of fluid cultures and a lack of diagnostic processes. However, the usefulness of newer molecular techniques such as whole-genome sequencing has not been evaluated for DMAC and HIV/AIDS. As DMAC has a high mortality rate if not properly diagnosed and treated, we performed a literature review of HIV/AIDS and DMAC epidemiology, risk factors, prophylaxis, clinical manifestation, diagnosis, prognosis, and treatment.

Severe Yellow Fever and Extreme Hyperferritinemia Managed with Therapeutic Plasma Exchange

A 43-year-old man was admitted to the intensive care unit and diagnosed with yellow fever. He presented with refractory bleeding, extreme hyperferritinemia, and multiple organ dysfunction syndrome, requiring renal replacement therapy, mechanical ventilation, and treatment with vasoactive drugs. Because the bleeding did not respond to fresh-frozen plasma administration, the patient received therapeutic plasma exchange, which was accompanied by a marked improvement of the clinical and biochemical parameters, including a significant decline in serum ferritin levels.

Yellow Fever: Factors Associated with Death in a Hospital of Reference in Infectious Diseases, São Paulo, Brazil, 2018

Faced with the reemergence of yellow fever (YF) in the metropolitan region of São Paulo, Brazil, we developed a retrospective study to describe the cases of YF attended at the Institute of Infectology Emilio Ribas from January to March 2018 and analyze the factors associated with death, from the information obtained in the hospital epidemiological investigation. A total of 72 cases of sylvatic YF were confirmed, with 21 deaths (29.2% lethality rate). Cases were concentrated in males (80.6%) and in the age group of 30 to 59 years (56.9%). Two logistic regression models were performed, with continuous variables adjusted for the time between onset of symptoms and hospitalization. The first model indicated age (odds ratios_adjusted [OR_adj]: 1.038; CI 95%: 1.008-1.212), aspartate aminotransferase (AST) (OR_adj: 1.038; CI 95%: 1.005-1.072), and creatinine (OR_adj: 2.343; CI 95%: 1.205-4.553) were independent factors associated with mortality. The second model indicated age (OR_adj: 1.136; CI 95%: 1.013-1.275), alanine aminotransferase (ALT) (OR_adj: 1.118; CI 95%: 1.018-1.228), and creatinine (OR_adj: 2.835; CI 95%: 1.352-5,941). The risk of death in the model with continuous variables was calculated from the increase of 1 year (age), 1 mg/dL (creatinine), and 100 U/L for AST and ALT. Another logistic regression analysis with dichotomous variables indicated AST > 1,841 IU/L (OR_adj: 12.92; CI 95%: 1.50-111.37) and creatinine > 1.2 mg/dL (OR_adj: 81.47; CI 95%: 11.33-585.71) as independent factors associated with death. These results may contribute to the appropriate clinical management of patients with YF in health-care services and improve the response to outbreaks and public health emergencies.

Severe gastrintestinal bleeding as an unusual presentation of pediatric tuberculosis: a situation for injectable antituberculous drugs use?

Disseminated tuberculosis is a severe disease with high-mortality that requires early diagnosis and treatment. Intestinal tuberculosis accounts for only 2% of tuberculosis cases worldwide and is extremely rare in children. We report a case of a 4-year-old girl admitted due to disseminated tuberculosis with extensive intestinal involvement characterized by massive intestinal bleeding and hemorrhagic shock. The severity of the intestinal involvement precluded the exclusive use of oral anti-tuberculosis drugs and the patient was successfully treated with a combination of injectable and oral anti-tuberculosis agents. We discuss the importance of a regimen with injectable drugs for treating severe forms of tuberculosis in which the intestinal involvement impaired the use of oral drugs.

Efficacy of sofosbuvir as treatment for yellow fever: protocol for a randomised controlled trial in Brazil (SOFFA study)

INTRODUCTION

An ongoing outbreak of yellow fever (YF) has been reported in Brazil with 1261 confirmed cases and 409 deaths since July 2017. To date, there is no specific treatment available for YF. Recently published papers describing in vitro and animal models suggest a potential effect of antiviral drugs (approved for the treatment of hepatitis virus) against flaviviruses, including YF. The primary aim of this study is to analyse the effect of sofosbuvir on viral kinetics and clinical outcomes among patients presenting with YF. This is a multicentre open-label randomised controlled trial with 1:1 individual allocation, stratified by severity and by recruiting centre.

METHODS AND ANALYSIS

Adults with suspected or confirmed YF infection and symptoms lasting up to 15 days are screened. Eligible and consenting patients are randomised to receive oral sofosbuvir 400 mg daily for 10 days or to receive standard clinical care. Viral kinetics are measured daily and the reduction in YF plasma viral load from the sample at inclusion to 72 hours after randomisation will be compared between active and control groups. Clinical outcomes include severity meeting criteria for intensive care support, liver transplantation, in-hospital mortality and mortality within 60 days.

ETHICS AND DISSEMINATION

Ethics approval was obtained at the participating sites and at the national research ethics committee (CAAE 82673018.6.1001.0068). The trial has been submitted for ethical approval at additional potential recruiting centres. Results of the study will be published in journals and presented at scientific meetings.

TRIAL REGISTRATION

Brazilian Clinical Trials Registry (RBR-93dp9n).

Hemodiafiltration Decreases Serum Levels of Inflammatory Mediators in Severe Leptospirosis: A Prospective Study

Background

Leptospirosis is a health problem worldwide. Its most severe form is a classic model of sepsis, provoking acute respiratory distress syndrome (ARDS) and acute kidney injury (AKI), with associated mortality that remains unacceptably high. We previously demonstrated that early initiation of sustained low-efficiency dialysis (SLED) followed by daily SLED significantly decreases mortality. However, the mode of clearance can also affect dialysis patient outcomes. Therefore, the objective of this study was to compare the effects of SLED with traditional (diffusive) clearance, via hemodialysis, and SLED with convective clearance, via hemodiafiltration (SLEDf), in patients with severe leptospirosis.

Methods

In this prospective study, conducted in the intensive care unit (ICU) from 2009 through 2012, we compared two groups—SLED (n = 19) and SLEDf (n = 20)—evaluating demographic, clinical, and biochemical parameters, as well as serum levels of interleukins, up to the third day after admission. All patients received dialysis early and daily thereafter.

Results

During the study period, 138 patients were admitted to our ICU with a diagnosis of leptospirosis; 39 (36 males/3 females) met the criteria for ARDS and AKI. All patients were on mechanical ventilation and were comparable in terms of respiratory parameters. Mortality did not differ between the SLEDf and SLED groups. However, post-admission decreases in the serum levels of interleukin (IL)-17, IL-7, and monocyte chemoattractant protein-1 were significantly greater in the SLEDf group. Direct bilirubin and the arterial oxygen tension/fraction of inspired oxygen ratio were significantly higher in the SLED group. We identified the following risk factors (sensitivities/specificities) for mortality in severe leptospirosis: age ≥ 55 years (67%/91%); serum urea ≥ 204 mg/dl (100%/70%); creatinine ≥ 5.2 mg/dl (100%/58%); Acute Physiology and Chronic Health Evaluation II score ≥ 39.5 (67%/88%); Sequential Organ Failure Assessment score ≥ 20.5 (67%/85%); and inspiratory pressure ≥ 31 mmHg (84%/85%).

Conclusions

The mode of dialysis clearance might not affect outcomes in severe leptospirosis.

Rapid identification of moulds and arthroconidial yeasts from positive blood cultures by MALDI-TOF mass spectrometry

Moulds and arthroconidial yeasts are potential life-threatening agents of fungemia in immunocompromised patients. Fast and accurate identification (ID) of these pathogens hastens initiation of targeted antifungal therapy, thereby improving the patients' prognosis. We describe a new strategy that enabled the identification of moulds and arthroconidial yeasts directly from positive blood cultures by MALDI-TOF mass spectrometry (MS). Positive blood cultures (BCs) with Gram staining showing hyphae and/or arthroconidia were prospectively selected and submitted to an in-house protein extraction protocol. Mass spectra were obtained by Vitek MS™ system, and identifications were carried out with in the research use only (RUO) mode with an extended database (SARAMIS™ [v.4.12] plus in-house database). Fusarium solani, Fusarium verticillioides, Exophiala dermatitidis, Saprochaete clavata, and Trichosporon asahii had correct species ID by MALDI-TOF MS analysis of positive BCs. All cases were related to critically ill patients with high mortality fungemia and direct ID from positive BCs was helpful for rapid administration of targeted antifungal therapy.

Purulent pericarditis caused by Neisseria meningitidis serogroup C and confirmed through polymerase chain reaction

We here report the case of a previously healthy 20-y-old male with disseminated meningococcal disease and purulent pericarditis. Polymerase chain reaction was used to identify Neisseria meningitidis serogroup C as the causative agent in the pericardial fluid.

Myocardial infarction after meningococcal infection: a potential inflammatory link or a challenging puzzle?

There is evidence that systemic inflammatory response and infectious diseases are associated with an increased risk of vascular events such as stroke and myocardial infarction in humans. However, the potential triggering effect of infectious diseases in carciovascular phenomena is typically underreported, overlooked and unexplored. The remarkable discovery of the link between cytokine networks and the pathophysiology of infectious diseases, together with studies of the CD14+ Toll-like receptor 4 (TLR4), has increased our knowledge of the inflammatory cascade within the vascular compartment as well as of coronary artery disease. In addition, meningococcal sepsis can trigger an important host inflammatory response characterized by systemic production of cytokines and chemokines, as well as activation of complement and nitric oxide pathways. However, the exact mechanism involved and the multiple pathogenic links by which infection influences acute cardiovascular events have not been explored, presenting a challenging puzzle for researchers. Determining cytokine concentrations could prove to be a valuable tool in evaluating the pathophysiology of myocardial infarction during infectious processes. The knowledge gained could guide the development of new strategies for reducing the occurrence of adverse cardiovascular events.

Severe myalgia of the lower extremities as the first clinical feature of meningococcal purpura fulminans

In patients with meningococcal infection, devastating presentations, such as purpura fulminans, which can progress to extensive tissue necrosis of the limbs and digits, have a significant social impact. The case presented herein illustrates such a phenomenon in a patient who developed bilateral necrosis of the lower extremities as a result of infection with Neisseria meningitis. We emphasize that severe myalgia was the first clinical manifestation of meningococcal purpura fulminans in our case. However, myalgia has typically been overlooked and undervalued as an early clinical feature of meningococcal sepsis. Early recognition and prompt initial antibiotic therapy continue to be the cornerstones of the successful management of this dramatic disease, reducing morbidity and mortality.

Interleukin-6 activation in ischemic stroke caused by Neisseria meningitidis serogroup C

We report an unusual phenomenon in a patient with meningococcal meningitis who developed a brain infarct. Concentrations of interleukin-6 were notably elevated in the cerebrospinal fluid. We also discuss some clinical and pathophysiological features of cerebrovascular injury in meningococcal disease.

Cytokine activation in purulent pericarditis caused by Neisseria meningitidis serogroup C

Herein, we report a case of purulent pericarditis caused by Neisseria meningitidis serogroup C in a previously healthy 5-year-old boy, which was detected in pericardial fluid by polymerase chain reaction. The concentrations of interleukin-6, interferon-gamma and interleukin-10 in pericardial fluid were notably increased compared with serum. The role of polymerase chain reaction, counterimmunoelectrophoresis and latex agglutination test in the diagnosis, as well as the participation of cytokines in the pathogenesis of meningococcal pericarditis, are discussed.

Compartmentalization of interleukin-6 response in a patient with septic meningococcal peritonitis

We report the first case of Neisseria meningitidis-induced septic peritonitis diagnosed by PCR assay of peritoneal fluid. Concentrations of interleukin-6 were notably higher in the peritoneal fluid than in the blood. PCR diagnosis of septic meningococcal peritonitis and the pathogenesis of the disease are discussed.

Peripheral nerve palsy in a case of leptospirosis

We describe an unusual case of leptospirosis in a 54-year-old man presenting peripheral nerve palsy. The diagnosis of leptospirosis was confirmed by ELISA IgM and the microscopic agglutination test. Electrophysiological studies showed that no response could be obtained from the right fibular nerve. At 7 months after the initiation of treatment, additional electrophysiological studies and a neurological examination showed, respectively, a chronic axonal lesion of right fibular nerve with signs of re-innervation and a nearly complete clinical recovery. We feel that this case may serve to remind clinicians that peripheral nerve palsy is a potential clinical feature of leptospirosis.

Leptospirosis-induced meningitis and acute renal failure in a 19-month-old male child

An unusual case of leptospirosis is described in a 19-month-old male child presenting with meningitis and acute renal failure without jaundice. Some aspects concerning the pathogenesis and treatment of this potentially life-threatening disease are also discussed. Leptospirosis was diagnosed on the basis of history and serological tests.

Listeria monocytogenes pneumonia in a cirrhotic child

A 13-year-old girl with cirrhosis and cyanotic heart disease was admitted with a three-day history of pneumonia. The chest roentgenogram revealed left-sided pleural effusion and cultures from the pleural fluid yielded Listeria monocytogenes. The authors discuss the epidemiologic, clinical, and pathophysiological aspects of L. monocytogenes pneumonia and its association with cirrhosis.

Eosinophilic meningoencephalitis due to Toxocara canis: case report and review of the literature

Toxocariasis is usually manifested as visceral larva migrans. Nervous system involvement is a rare complication. In this report, we describe one case of meningoencephalitis due to Toxocara canis and review the literature. We report a previously healthy two-year-old boy who was admitted after 24 hours of severe neurologic symptoms with marked eosinophilic pleocytosis in the cerebrospinal fluid and a single subcortical lesion detected by cerebral magnetic resonance imaging. Both serum and spinal fluid tested positive for T. canis. Initial treatment with thiabendazole was ineffective. After marked improvement in clinical and laboratory results were achieved using albendazole and corticosteroids, the child was discharged.

Tuberculous brain abscess in a patient with AIDS: case report and literature review

Tuberculous brain abscesses in AIDS patients are considered rare with only eight cases reported in the literature. We describe the case of a 34-year-old woman with AIDS and previous toxoplasmic encephalitis who was admitted due to headache and seizures. A brain computed tomography scan disclosed a frontal hypodense lesion with a contrast ring enhancement. Brain abscess was suspected and she underwent a lesion puncture through a trepanation. The material extracted was purulent and the acid-fast smear was markedly positive. Timely medical and surgical approaches allowed a good outcome. Tuberculous abscesses should be considered in the differential diagnosis of focal brain lesions in AIDS patients. Surgical excision or stereotactic aspiration, and antituberculous treatment are the mainstay in the management of these uncommon lesions.

Pseudomonas aeruginosa septic shock associated with ecthyma gangrenosum in an infant with agammaglobulinemia

Ecthyma gangrenosum (EG) due to Pseudomonas aeruginosa is a rare and invasive infection that can be associated with agammaglobulinemia. The cornerstone of the treatment is based on prompt recognition with appropriate antibiotic coverage and intravenous immunoglobulin. The authors report a case of EG emphasizing the clinical and therapeutic aspects of this condition.

Acute abdomen due to late retroperitoneal extravasation from a femoral venous catheter in a newborn

CONTEXT

The use of parenteral nutrition via a central venous catheter is a common practice in the neonatal intensive care setting. Extravasation of the infusate leading to an acute abdomen is a complication that has only rarely been documented. This report describes the case of a premature infant with a femoral catheter placed in the inferior vena cava, who developed an acute abdomen as a result of late retroperitoneal extravasation of parenteral nutrition.

CASE REPORT

A pre-term infant receiving total parenteral nutrition via a femoral venous catheter developed an acute abdomen five days after the catheter placement. Extravascular catheter migration to the retroperitoneal space and extravasation of the infusate was diagnosed by contrast injection. Withdrawal of the catheter was followed by prompt cessation of the signs and full recovery from the acute abdomen, without the need for surgery. A review of the literature is presented, emphasizing the clinical and therapeutic aspects of this unusual complication from femoral venous catheterization and parenteral nutrition.

[Meningoencephalitis in the acute phase of measles. Report of 6 cases]

We present the clinical and laboratory manifestations of encephalitis following measles in six patients which were diagnosed during the epidemics that occurred in the city of São Paulo, Brazil, in 1997. We performed retrospective case analysis of the six patients diagnosed as having encephalitis due to measles. Encephalitis was diagnosed based on clinical grounds and on the cerebrospinal fluid (CSF) alterations. All the cases were serologically confirmed. Of 467 patients with measles who presented themselves for medical care at the Instituto de Infectologia Emílio Ribas six were diagnosed with encephalitis. Patient's age was 2 months to 28 years old. The most frequent symptoms were drowsiness and nuchal rigidity. CSF showed an increased of white cell count in all cases. Four patients were admitted to the intensive care unit. Two of them required mechanical ventilation. In only two patients did the computerized tomography show abnormalities. All showed good recovery without sequelae.

Acute lung injury in leptospirosis: clinical and laboratory features, outcome, and factors associated with mortality

Forty-two consecutive patients with leptospirosis and acute lung injury who were mechanically ventilated were analyzed in a prospective cohort study. Nineteen patients (45%) survived, and 23 (55%) died. Multivariate analysis revealed that 3 variables were independently associated with mortality: hemodynamic disturbance (odds ratio [OR], 6.0; 95% confidence interval [CI], 0.9-38.8; P=. 047), serum creatinine level >265.2 micromol/L (OR, 10.6; 95% CI, 0. 9-123.7; P =.026), and serum potassium level >4.0 mmol/L (OR, 19.9; 95% CI, 1.2-342.8; P=.009). These observations can be used to identify factors associated with mortality early in the course of severe respiratory failure in leptospirosis.

[Fluid and electrolyte disorders]

OBJECTIVE: To review the major concepts involving electrolyte disorders in pediatrics, with special emphasis on the diagnosis and treatment.METHOD: Systematic literature review, searching through classic pediatric textbooks, periodic electronic databases, such as Medline, Lilacs and other sources. RESULTS: Electrolyte disorders are among the most common events in pediatric medical practice, specially in emergency care, where, depending upon the magnitude, they may represent significant risk to patient life or to the development of permanent sequelae. Dehydration, independent of etiology, has its importance defined by the severity of water deficit (mild, moderate or severe) and by the proportion of sodium waste in relation to water deficit (isotonic, hypotonic and hypertonic), and should be correctly recognized to guide adequate treatment. Sodium disorders have major risks of central nervous system compromise and potassium disorders are specially linked to cardiac arrhythmia, always deserving special attention and care. On the other hand, calcium, phosphorus and magnesium disorders are more related to neuromuscular function alterations and, although less threatening, they need adequate recognition and management.CONCLUSION: Knowledge of the several mechanisms involved in water and electrolyte metabolism is crucial to the correct comprehension, diagnosis and management of fluid and electrolyte disorders in pediatrics.

Descending suppurative mediastinitis: nonsurgical approach to this unusual complication of retropharyngeal abscesses in childhood

OBJECTIVE

To alert the pediatric emergency physician about suppurative mediastinitis as an unusual, life-threatening complication of retropharyngeal abscesses in children and to report an alternative therapeutic option for these cases.

METHODS

We describe a case of suppurative mediastinitis secondary to a retropharyngeal abscess in a 19-month-old girl and discuss the pathophysiology, diagnosis, and treatment of this disease.

RESULTS

Prompt diagnosis, based on clinical, radiographic, and CT findings, followed by immediate retropharyngeal drainage and appropriate antibiotic therapy, allowed conservative management of the mediastinal abscess, without the need for surgery. The child presented a good outcome and was discharged on hospital day 14.

CONCLUSIONS

When evaluating a retropharyngeal abscess, the pediatric emergency physician should be aware of its complications. A chest radiograph should be prescribed for each patient presenting with an indolent course. Widening of the mediastinum should be considered as strong evidence of a mediastinal abscess for which the best therapeutic option is aggressive surgical drainage. In the rare cases in which marked improvement is achieved after retropharyngeal drainage, a nonsurgical approach to the mediastinal abscess could be attempted. CT scan and a simple chest radiograph have proved to be useful for diagnosis and follow-up.

Fatal group A Streptococcal toxic shock-like syndrome in a child with varicella: report of the first well documented case with detection of the genetic sequences that code for exotoxins spe A and B, in São Paulo, Brazil

A previously healthy seven-year-old boy was admitted to the intensive care unit because of toxaemia associated with varicella. He rapidly developed shock and multisystem organ failure associated with the appearance of a deep-seated soft tissue infection and, despite aggressive treatment, died on hospital day 4. An M-non-typable, spe A and spe B positive Group A Streptococcus was cultured from a deep soft tissue aspirate. The criteria for defining Streptococcal toxic shock-like syndrome were fulfilled. The authors discuss the clinical and pathophysiological aspects of this disease as well as some unusual clinical findings related to this case.

Acute disseminated encephalomyelitis: an unusual cause of encephalitic syndrome in childhood

Acute disseminated encephalomyelitis is a rare central nervous system demyelinating disease that occurs most frequently in children. It usually runs a monophasic course, beginning with fever, headache, and meningeal signs and rapidly progressing to coma when appropriate diagnosis and treatment are not provided. We report a case of a 14-year-old patient to alert emergency physicians to consider acute disseminated encephalomyelitis when presented with any child with encephalitic signs with nonspecific cerebrospinal fluid findings, failure to detect any causative agent, and only mild alterations on computerized tomography scan. The role of magnetic resonance imaging for the diagnosis is emphasized.

[Necrotizing fasciitis. Case report and review of literature]

Necrotizing fasciits (NF) is a rapidly progressive disease characterized by extensive necrosis of the fascia, skin, and subcutaneous tissue, with characteristical sparing of the underlying muscle. It is considered to be a rare entity and is associated with a high mortality rate since early recognition and treatment are not provided. Extensive surgical debridement of all necrotic tissues and appropriate antimicrobial treatment are the cornerstones for a successful treatment. We present a case of NF in a 36-year-old man and discuss it's pathophysiology, clinical manifestations and the best therapeutic choice for this potential life threatening disease.