Two cases of systemic capillary leak syndrome associated with COVID-19 in Japan

Systemic Capillary Leak Syndrome (SCLS) is a rare disease that causes severe distributive shock provoked by infection or vaccination. SCLS is clinically diagnosed by a triad of distributive shock, paradoxical hemoconcentration, and hypoalbuminemia. SCLS associated with coronavirus disease (COVID-19) in adults has not been reported yet in Japan. Case 1: A 61-year-old woman with fever, sore throat, headache, and muscle pain was admitted to our emergency department with suspected COVID-19. She had been diagnosed with SCLS 3 years earlier. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antigen and polymerase chain reaction (PCR) tests were negative at admission. She went into shock in the emergency department and was treated for septic shock. The following day, the SARS-CoV-2 PCR test was positive. She did not respond to fluid resuscitation and catecholamine and finally died. Case 2: A 58-year-old man was admitted to our hospital for de-saturation due to COVID-19. He got into shock on day 3. SCLS was suspected, and 5 g of intravenous immunoglobulin and 5% albumin were administered for sepsis treatment. He responded to the aggressive fluid therapy within 48 h and was finally discharged. COVID-19 can trigger SCLS, and early recognition of SCLS is crucial for survival. Primary care physicians should consider SCLS when they observe distributive shock and paradoxical hemoconcentration deviations from the natural course of COVID-19.

Periodic generalized edema following COVID-19 infection

The unprecedented impact and sequelae of COVID-19 infection are not yet fully understood, and better understanding of the pathophysiology of these infections is needed. Endothelial dysfunction might be common sequelae associated with COVID-19, and increased inflammatory responses, oxidative stress, proinflammatory cytokines, and impaired mitochondrial function also contribute to the pathophysiology of post COVID-19 medical disorders. Systemic capillary leak syndrome following COVID-19 infection, both new onset and exacerbation of a prior disorder, has been reported. The pathophysiology of SCLS is uncertain; it likely develops during transient vascular endothelial dysfunction or endotheliopathy and inflammation resulting from circulating humoral factors. Here, we report a case of adult patient with 2 episodes of systemic capillary leak syndrome following prior COVID-19 infection. This patient had a transient response to intravenous IgG.

[Veno-venous extracorporeal membrane oxygenation for capillary leak syndrome during induction chemotherapy in acute myeloid leukemia]

A 44-year-old woman was diagnosed with acute myeloid leukemia (RUNX1::RUNX1T1 translocation) and received induction chemotherapy with idarubicin hydrochloride and cytosine arabinoside. The pneumonia that had been present since admission worsened, and a drug-induced skin rash appeared. On day 17, she presented with respiratory failure and shock, complicated by hemoconcentration and hypoalbuminemia. This was considered capillary leak syndrome due to pneumonia and drug allergy, so she was started on pulse steroid therapy and IVIG, and was intubated on the same day. On day 18, venovenous-extracorporeal membrane oxygenation (VV-ECMO) was started due to worsening blood gas parameters despite ventilatory management. Bronchoalveolar lavage fluid was serous, and both blood and sputum cultures yielded negative. The patient was weaned from VV-ECMO on day 26 as the pneumonia improved with recovery of hematopoiesis. She was disoriented, and a CT scan on day 28 revealed cerebral hemorrhage. Her strength recovered with rehabilitation. After induction chemotherapy, RUNX1::RUNX1T1 mRNA was not detected in bone marrow. The patient received consolidation chemotherapy, and has maintained complete remission. Severe respiratory failure during induction chemotherapy for acute leukemia can be fatal, but VV-ECMO may be lifesaving.

A ligand-independent Tie2-activating antibody reduces vascular leakage in models of Clarkson disease

Vascular dysfunction resulting from endothelial hyperpermeability is a common and important feature of critical illness due to sepsis, trauma, and other conditions associated with acute systemic inflammation. Clarkson disease [monoclonal gammopathy-associated idiopathic systemic capillary leak syndrome (ISCLS)] is a rare, orphan disorder marked by spontaneous and recurrent episodes of hypotensive shock and peripheral edema due to widespread vascular leakage in peripheral tissues. Mortality from acute flares approaches 30% due to lack of effective therapies. We evaluated a monoclonal antibody (4E2) specific for the endothelial receptor tyrosine kinase Tie2 in ISCLS models. 4E2 activated Tie2 in ISCLS patient-derived endothelial cells and reduced baseline and proinflammatory mediator-induced barrier dysfunction. 4E2 also reduced mortality and/or vascular leakage associated with systemic histamine challenge or influenza infection in the SJL/J mouse model of ISCLS. These findings support a critical role for Tie2 dysregulation in ISCLS and highlight a viable therapeutic approach to this catastrophic disorder.

Polycythemia as an Uncommon Finding in 2 Children, One With Systemic Capillary Leak Syndrome and the Other With Protein-losing Enteropathy Caused by CD55 Deficiency

We report 2 children with distinct causes of polycythemia, 1 from systemic capillary leak syndrome (SCLS) and the other from protein-losing enteropathy (PLE) caused by CD55 deficiency. There is only a single case series about polycythemia in children with SCLS, but none on polycythemia in children with PLE. We present a 10-year-old girl with hypoalbuminemia, polycythemia, and edema who died as a result of an SCLS attack and a 1-year-old girl with PLE who was successfully treated with eculizumab. Our experience suggests that hematologists should be alert for SCLS and PLE in children with relative polycythemia.

Pericardial effusion and systemic capillary leak syndrome late post-SARS-CoV-2 vaccination

We report an interesting case of pericardial effusion associated with idiopathic systemic capillary leak syndrome (ISCLS) following administration of SARS-CoV-2 vaccine. This patient initially presented with dyspnoea and chest pain, with non-pitting oedema and clear lung fields. The diagnosis of ISCLS was made based on the clinical syndrome and laboratory evidence of polycythaemia and hypoalbuminaemia. An enlarging pericardial effusion was diagnosed on transthoracic echocardiogram. Daily point-of-care ultrasound (POCUS)-guided volume management and serial transthoracic echocardiograms contributed to avoidance of refractory shock, cardiac tamponade and critical care admission.

Trauma-induced capillary leak syndrome after penetrating chest injury: Manifestation of massive ascites and pulmonary secretions aggravated by transfusion

Trauma with prolonged shock can cause systemic capillary leak syndrome regardless of the site of injury and a transfusion can aggravate it. The systemic capillary leak induces both an abdominal compartment syndrome and pulmonary edema, and a transfusion can aggra-vate these sequelae within hours. In our case, 21-year-old man with a penetrating injury in his left thorax experienced delay in rescue and definitive surgery. To manage life-threatening shock, massive blood transfusion and crystalloids had been infused. Cardiopulmonary cerebral resuscitations were performed 2 times during the surgery. Massive amount of pulmonary secretions emitted from his airways with severe hypoxia along with development of massive ascites causing abdominal compartment syndrome, while the surgery was underway. After temporary abdominal closure, he was moved to the intensive care unit and underwent venovenous extracorporeal membranous oxygenation. He recovered without any notable complications. It is important to prevent and correct the shock rapidly by appropriate rescue, controlling the source and infusing less amount of crystalloid and transfusion.

Bilateral simultaneous non-arteritic ischaemic optic neuropathy: a rare complication of idiopathic systemic capillary leak syndrome (SCLS)

We report a case of bilateral symmetrical superior visual field defects in a 72-year-old man first reported during the recovery from systemic capillary leak syndrome (SCLS). During the acute illness, he required extensive and prolonged fluid replacement and mechanical ventilation for severe hypotension, shock and multiorgan dysfunction. His visual field defect and optic nerve changes were consistent with a diagnosis of ischaemic optic neuropathy. These remained unchanged over 3 years and he retained excellent 6/7.5 visual acuity bilaterally. We hypothesised the mechanism of bilateral segmental infarction of the optic nerve head to be caused by the hypercoagulable and hypovolaemic state, in addition to pre-existing vascular disease and hypertension. This case highlights the importance of including optic nerve examination in the management plan of SCLS, particularly in individuals with underlying vascular risk factors.

[Idiopathic systemic capillary leak syndrome: 2 cases with misleading presentation]

INTRODUCTION

Idiopathic systemic capillary leak syndrome (ISCLS) also known as Clarkson syndrome is a rare and sudden life-threatening entity. Three consecutive phases are described. A first non-specific prodromal phase often manifests as "flu-like" symptoms and precedes capillary leak phase with major hypovolemic and distributive shock leading to serious and frequent multiorgan dysfunction syndrome (MODS). Severe hypovolemia contrasts with edema, and hemoconcentration with hypoalbuminemia. ISCLS is characterized by these two clinical and biological paradoxes. Subsequent recovery phase exhibits organ function restoration along with interstitial/intravascular volumes normalization. The latter occurs spontaneously and systematically in patients surviving from leak phase.

OBSERVATIONS

We report here two ISCLS cases admitted in intensive care unit (ICU) both enhancing initial misdiagnosis possibly lowering prognosis and outcome. Our first 28-year-old female patient was admitted for « polycythemia vera » although hemoconcentration was attributable to hypovolemia. She presented circulatory arrest during the second bloodletting session and complicated with MODS. In and out ICU favorable outcome was noted on intravenous immunoglobulin therapy. A second 57-year-old male patient was admitted in ICU for severe "myositis" (myalgia and rhabdomyolysis) although rectified diagnosis retained compartment syndrome (muscular severe edema following capillary leak). Rapid and refractory hypovolemic shock appeared with subsequent MODS leading to death.

CONCLUSION

ISCLS pathophysiology remains unknown but certainly implies transitory endothelial dysfunction. Impossibility of randomized controlled trial for this exceptional disease led to based-on-experience therapeutic guidelines implying symptomatic care (cardiac output surveillance, nephroprotection, prudent fluid intake, prudent vasoactive amine use) and specific therapies (intravenous aminophylline during severe flares). Although enhancing controversial and even deleterious effects during the acute phase, polyvalent immunoglobulins are effective for relapse prevention. Syndromic diagnosis is difficult, but its precocious finding constitutes a key-element in better outcome before organ failure.

Idiopathic systemic capillary leak syndrome (Clarkson's disease) presenting with recurrent hypovolemic shock

A 49-year old male with a past medical history of myocardial infarction and compartment syndromes requiring fasciotomies presented on five occasions with hypovolemic shock. We describe his admissions and presumptive diagnoses which required large volumes of intravenous fluids, admission to intensive care for vasopressors and renal replacement therapy. The presentations were always precipitated by a prodrome of fatigue and pre-syncopal episodes. On his last admission, a diagnosis of Idiopathic systemic capillary leak syndrome (ISCLS), also known as Clarkson's Disease, was reached. He is currently receiving high dose intravenous immunoglobulins on a monthly basis.

Clinical features of 47 secondary hemophagocytic lymphohistiocytosis patients complicated with capillary leak syndrome

The clinical features of patients with secondary hemophagocytic lymphohistiocytosis (sHLH) complicated with capillary leak syndrome (CLS) remain controversial. The data of 259 sHLH patients were retrospectively analyzed. The clinical manifestations, laboratory findings, treatment, and prognosis of the CLS-sHLH group and non-CLS-sHLH group were compared. The levels of fibrinogen, albumin, and serum calcium in the CLS-sHLH group were lower than in the non-CLS-sHLH group, and serum triglycerides in the CLS-sHLH group were higher than in the non-CLS-sHLH group (P < 0.05). Univariate analysis showed that fibrinogen level was an independent prognostic factor in sHLH patients complicated with CLS. The median survival time was significantly shorter in patients with fibrinogen ≤ 1.3 g/L than in patients with fibrinogen > 1.3 g/L (P < 0.05). Patients with improved CLS conditions in the CLS-sHLH group had significantly increased albumin and serum calcium after treatment (P < 0.05); patients without improved conditions in the CLS-sHLH group also had significantly increased albumin after treatment (P < 0.05), but the serum calcium did not change significantly (P > 0.05). sHLH patients complicated with CLS had significantly worse prognosis than without CLS. Significant reduction in fibrinogen may be an independent prognostic factor for poor prognosis in sHLH patients complicated with CLS.

Effects of Fusu mixture (Wen-Shen-Qian-Yang Method) on sepsis-induced acute respiratory distress syndrome

INTRODUCTION

Sepsis is the most common etiology of acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). Capillary leakage caused by lung endothelial injury is the central cause of ARDS. The results of research in modern medicine in reducing endothelial damage and restoring endothelial functions are limited. In the previous clinical observations, we found that the Fusu mixture not only improves the clinical symptoms but also reduces the leakage of pulmonary capillaries. Therefore, the purpose of this study is to determine the clinical efficacy of the Fusu mixture combined with Western medicine in the treatment of ARDS caused by sepsis and to explore the mechanism of traditional Chinese medicine.

METHODS

This is a prospective, single-center, randomized, single-blind, and controlled clinical study involving 620 eligible patients. The patients will be randomly divided into 2 groups: the Western medicine treatment group and the combination of Chinese and Western medicine treatment group. After 14 days of intervention, the clinical efficacy and safety of the Fusu mixture on sepsis-induced ARDS patients will be observed. The primary outcome will be measured as 28-day mortality. The secondary outcome indices include inflammatory markers (CRP, PCT, IL-6, TNF - α), APACHE II score, SOFA score, days without a ventilator, blood gas analysis (Lac, PaO2 / FiO2), intensive care unit hospital stay time, intensive care unit mortality. Simultaneously, the analysis of the exploratory results will be carried out to analyze the possible mechanism of Fusu mixture in the treatment of sepsis-induced ARDS by the high-throughput sequencing and bioinformatics.

DISCUSSION

The purpose of this study is to evaluate the clinical efficacy of Fusu mixture in the treatment of sepsis-induced ARDS and explore its possible mechanism of action. If successful, it will provide evidence-based adjuvant therapy for the clinical treatment of ARDS.

Multiple limb compartment syndrome as a manifestation of capillary leak syndrome secondary to metformin and dipeptidyl peptidase IV inhibitor overdose: A case report

RATIONALE

Capillary leak syndrome is a condition that increases systemic capillary permeability and causes characteristic manifestations such as recurrent hypovolemia, systemic edema, and hemoconcentration. Acute limb compartment syndrome is a possible complication of severe capillary leak syndrome. However, timely diagnosis and prompt treatment are challenging because of atypical presentation.

PATIENT CONCERNS

An 18-year-old woman with a history of clinical depression was admitted to our intensive care unit (ICU) because of metformin and vildagliptin overdose. She developed marked vasodilatory shock with recurrent severe hypovolemia and disseminated intravascular coagulation. After urgent hemodialysis and plasma exchange, she started to stabilize hemodynamically. However, her limbs became stone-hard with massive edema. Her serum creatinine kinase level increased to an extremely high level.

DIAGNOSIS

Extremities were distended, and her skin developed pallor with blistering. Intramuscular pressure in both forearms and lower legs was significantly elevated.

INTERVENTIONS

Decompressive fasciotomy was performed. Hemodialysis was continued because of rhabdomyolyses-induced acute kidney injury.

OUTCOMES

The patient was finally able to walk by herself at the time of hospital discharge on day 109.

LESSONS

The possibility of acute compartment syndrome should be considered in patients with marked capillary leakage, especially after aggressive fluid resuscitation. It is important to be aware of the compartment syndrome in an ICU setting because communication barriers often mask typical symptoms and make diagnosis difficult.

Hydrochlorothiazide-induced systemic capillary leak

Hypersensitivity reactions to drugs may cause very rapid physiologic derangements that can be fatal in the absence of adequate compensatory mechanisms or definitive treatment. For the most part, adverse drug reactions that progress over the course of minutes are mediated either by mast cell or complement activation. If a patient survives the acute event, appropriate long-term management requires the identification and future avoidance of the inciting drug. Here, we describe a patient who experienced two life-threatening multisystem reactions with cardiopulmonary compromise minutes after taking hydrochlorothiazide (HCTZ). The reactions were associated with systemic vascular leak resulting in hypotension and non-cardiogenic pulmonary edema.

Capillary leak syndrome and aseptic meningitis in a patient with Kawasaki disease: A case report

RATIONALE

Kawasaki disease (KD) is an acute vasculitis of childhood, coronary complications are the most serious and classic complications of this disease. However, simultaneous complications such as systemic capillary leak syndrome (CLS) and aseptic meningitis are rarely reported.

PATIENT CONCERNS

A 19-month-old boy had continuous fever for 6 days, rash for 3 days, and somnolence for 1 day.

DIAGNOSES

The boy was diagnosed with KD presenting with SCLS and aseptic meningitis.

INTERVENTIONS

He was treated with gamma globulin (2 g/kg) for 1 day, mannitol and furosemide to reduce intracranial pressure, human albumin to correct hypoproteinemia, methylprednisolone to control inflammation, and both aspirin and dipyridamole for anticoagulation.

OUTCOMES

After treatment, the patient recovered well. At one year follow-up, the patient was asymptomatic and showed no recurrence of skin rash.

LESSONS

The incidence of KD has recently increased and cardiovascular complications are frequently reported. This may be combined with systemic damage, however, the combination of SCLS and aseptic meningitis is rarely reported, therefor, children who have SCLS, aseptic meningitis and unexplained fever >5 days, KD should be taken into account. Early diagnosis and timely treatment can reduce complications induced by KD.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

Structured case report and review of the literature.

RESULTS

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

CONCLUSIONS

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

Systemic capillary leak syndrome: a case-report

We report a case of a patient presenting with episodic hypotension, tachycardia and oedema, with an elevated serum IgG kappa paraprotein level. She was diagnosed as having systemic capillary leak syndrome and upon commencing oral theophylline has had no further presentations. The patient has since progressed to multiple myeloma.

[Risk factors for capillary leak syndrome in children with hematological malignancies]

OBJECTIVE

To investigate the risk factors for capillary leak syndrome (CLS) in children with malignant hematologic diseases.

METHODS

Thirty children with hematological malignancies complicated with CLS were analyzed with multiple logistic regression analysis.

RESULTS

At the test level of 0.05, hypoxemia and septicemia were found to significantly correlate with CLS in these children, and the number of white blood cells before CLS and severe bone marrow suppression were near the test level.

CONCLUSION

Hypoxemia and septicemia are risk factors for CLS in children with malignant hematologic diseases.

Systemic capillary leak syndrome revealing a diffuse large B-cell lymphoma

We report on a 75-year-old woman who presented with recurrent episodes of hypotension, anasarca, renal failure, hypoalbuminaemia without proteinuria, suggestive of systemic capillary leak syndrome (SCLS). Further investigations led to a diagnosis of diffuse large B-cell lymphoma. Secondary SCLS associated with non-Hodgkin lymphoma is reviewed.

[Fluid resuscitation in a patient with severe hypovolemic shock and severe pulmonary capillary leak]

A male patient undergoing extracorporeal ultrasound lithotripsy developed the symptoms of dyspnea, low blood pressure, palpitations, chest tightness, and sweating, and a clinical diagnosis of pulmonary capillary leak and hypovolemic shock was made. Pulse indicator continuous cardiac output (PiCCO) technique was used for resuscitation according to the measurements of extravascular lung water index (EVLWI) and global end-diastolic volume index (GEDI). The patient showed low levels of cardiac output (CO) and GEDI with a peak EVLWI of 32 ml/kg and profuse pink and thin sputum overflow from the trachea. The high ventilator support parameters failed to correct low oxygen saturation. Restricted fluid infusion was used to reduce pulmonary edema. Colloidal solution was given when GEDI was below 500 ml/m(2), and the volume and fluid infusion rate were reduced for a GEDI higher than 500 ml/m(2). Pulmonary edema was gradually reduced after the treatments with improvement of lactic acid level and liver and kidney functions. Vasopressors were withdrawn 6 days later, mechanical ventilation was discontinued 10 days later, and tracheal intubation was removed 25 days later, after which the patient was discharged. In the treatment of the patient, PiCCO monitoring played an important role.

Capillary leak syndrome in a 5-month-old infant associated with intractable diarrhoea

Systemic capillary leak syndrome (SCLS) is a rare disorder of unknown pathophysiology, characterised by episodic life-threatening hypotension, haemoconcentration and hypo-albuminaemia. A 5-month-old child presented with episodes of relapsing diarrhoea, vomiting and hyponatraemia and developed generalised oedema during treatment. Clinical and laboratory findings were consistent with acute SCLS. Treatment with careful fluid replacement, fresh frozen plasma and aminophylline in the acute phase and teophylline and gingko biloba in the chronic phase led to sustained remission during follow-up for over 1 year. To our knowledge, this is the youngest case of SCLS in the literature and is unusual in that it presented with diarrhoea.

A case report of systemic capillary leak syndrome (Clarkson's disease)

Systemic capillary leak syndrome (SCLS) is a very rare disorder also known as Clarkson's disease. The condition is characterized by recurrent episodes of severe capillary hyperpermeability resulting in severe hemoconcentration, hypoalbuminemia, hypovolemia and shock. We describe a 41-year-old previously healthy man who was admitted to hospital on several occasions with rapidly developing hypovolemic shock accompanied by extreme hemoconcentration and hypoalbuminemia. Our case is similar to other reports describing patients with SCLS where the initial suspicions have been pointing towards septic shock. He received a combination of prophylactic treatment with theophylline, beta-agonists, immunoglobulins and statins but eventually died after a severe episode of SCLS that ended with recurrent cardiac arrest. Clinical autopsy revealed pulmonary edema and acute and chronical organic fluid overload. SCLS should be kept in mind when treating patients suffering from attacks of severe idiopathic edema and mimics recurrent septic shock where no pathogen is found. The pathogenesis is unknown and the attacks may be lethal.

Treatment of hepatocellular carcinoma in a mouse xenograft model with an immunotoxin which is engineered to eliminate vascular leak syndrome

Vascular leak syndrome (VLS) is the major dose-limiting toxicity of immunotoxin and interleukin-2 therapy. It has been evidenced that VLS-inducing molecules share a three-amino acid consensus motif, (x)D(y), which may be responsible for initiating VLS. Here we have constructed a recombinant immunotoxin (SMFv-PE38KDEL) by genetically fusing PE38KDEL to a single-chain antibody derived from SM5-1 monoclonal antibody, which has a high specificity for melanoma, hepatocellular carcinoma and breast cancer. In order to eliminate VLS induced by this PE38KDEL-based immunotoxin, a panel of mutants were generated by changing amino acid residues adjacent to its three (x)D(y) motifs in the three-dimensional structure. One of the SMFv-PE38KDEL mutants, denoted as mut1, displayed a similar protein synthesis inhibitory in a reticulocyte lysate translation assay compared to the wild-type SMFv-PE38KDEL (wt). The in vitro cytotoxicity assay indicated that mut1 specifically killed SM5-1 binding protein-positive tumor cells, although its cytotoxicity was slightly less than wt. In contrast, mut1 was shown to be much weaker in inducing VLS in mice than wt. The LD(50) values of wt and mut1 in mice were investigated with the result that the LD(50) of mut1 was about tenfold higher than that of wt. The in vivo antitumor activity of wt and mut1 were also compared in tumor-bearing nude mice. Both wt and mut1 were effective in inhibiting the tumor growth but mut1 showed improved therapeutic efficacy. These studies suggest mut1 may be a novel PE-based immunotoxin with much less toxicity for clinical use.

Current insights in intra-abdominal hypertension and abdominal compartment syndrome

A compartment syndrome exists when increased pressure in a closed anatomic space threatens the viability of the tissue within the compartment. When this occurs in the abdominal cavity it threatens not only the function of the intra-abdominal organs, but it can have a devastating effect on distant organs as well. Recent animal and human data suggest that the adverse effects of elevated intra-abdominal pressure (IAP) can occur at lower levels than previously thought and even before the development of clinically overt abdominal compartment syndrome (ACS). The ACS is not a disease but truly a syndrome, a spectrum of symptoms and signs that can and mostly does have multiple causes. It is only recently that this condition received a heightened awareness. This article reflects the current state of knowledge on intra-abdominal pressure regarding etiology, epidemiology, diagnosis, IAP measurement, organ dysfunction, prevention and treatment.

Acitretin induces capillary leak syndrome in a patient with pustular psoriasis

Capillary leak syndrome is a rare and potentially life-threatening condition caused by a shift of intravascular fluid and proteins to the interstitial space. We describe a patient with pustular psoriasis in whom capillary leak syndrome developed after the start of acitretin. Immediate withdrawal of retinoic acid is necessary and corticosteroid therapy should be considered.

Systemic capillary leak syndrome associated with compartment syndrome

Systemic capillary leak syndrome is characterized by recurrent hypovolemic shock attributable to increased systemic capillary leakage. A 26-year-old woman was admitted because of recurrent episodes of hypovolemic shock. Hemoconcentration, hypoalbuminemia, and monoclonal gammopathy were observed. We diagnosed systemic capillary leak syndrome. Three years later, she again had an attack of systemic capillary leak syndrome complicated with pretibial compartment syndrome. This case emphasizes the importance of muscle compartment pressure monitoring during volume resuscitation in patients with systemic capillary leak syndrome.

Idiopathic systemic capillary leak syndrome (SCLS): case report and systematic review of cases reported in the last 16 years

'Idiopathic systemic capillary leak syndrome (SCLS), or Clarkson's disease is an unusual entity first described 45 years ago. It presents with recurrent episodes of shock due to leakage of the plasma, which is reflected by accompanying hemo-concentration, hypo-albuminemia and edema. We report the case of a young man with multiple episodes of shock with generalized edema and pleural effusion. An initial diagnosis of sepsis was made, but the lack of fever and absence of a demonstrable organism or source led to a revision of diagnosis to SLCS. The last review of this syndrome which analyzed 24 cases was published in 1990. Since then, 75 more cases have been reported. This article reviews these cases.

Systemic capillary leak syndrome associated with compartment syndrome and rhabdomyolysis

Systemic capillary leak syndrome (SCLS) is a rare disorder characterized by recurrent spontaneous episodes of hypovolaemic shock due to marked plasma shifts from the intravascular to the extravascular space. This presents as the characteristic triad of hypotension, haemoconcentration and hypoalbuminemia often with an associated monoclonal gammopathy. We describe a patient with SCLS who required aggressive fluid resuscitation and emergency fasciotomies for compartment syndrome with rhabdomyolysis. At presentation the patient was considered to have severe erythrocytosis and was therefore initially referred to a haematologist, which appears to be a frequent sequence of presentation for patients with SCLS. This patient also highlights the importance of muscle compartment pressure monitoring during volume resuscitation in patients with SCLS.

Systemic capillary leak syndrome presenting as recurrent shock

OBJECTIVE

To report a case of systemic capillary leak syndrome (SCLS) in a child.

DESIGN

Case report.

SETTING

Pediatric intensive care unit.

PATIENT

A 6-yr-old girl was admitted twice to the pediatric intensive care unit, at a 10-month interval, in severe shock with important edema.

RESULTS

The patient presented with acute symptoms of abdominal pain, vomiting, and syncope in the hour preceding the shock. During both episodes necessary management included aggressive intravenous fluid rehydration, mechanical ventilation, and use of inotropes/vasopressors. Suspicion of a lower limb fasciitis necessitated surgical exploration, but pathology reports were negative on both occasions revealing only subcutaneous tissue edema. The patient recovered within 24 hrs on both episodes. Investigation ruled out cardiogenic shock and septic shock due to bacterial etiology. On the first episode, a nasopharyngeal aspirate was positive for influenza A (H3N2) by both viral immunofluorescence and culture. The presumed diagnosis was toxic shock syndrome associated with influenza virus. On the second episode, all bacterial and virology cultures remained negative. Hypovolemic shock was suspected, but there was no history of dehydration, bleeding, or gastrointestinal losses (persistent vomiting or diarrhea). Noninfectious causes of hypovolemic shock with edema were ruled out, leading us to believe that she suffered from SCLS.

CONCLUSIONS

Although well described in the adult literature, there have been few reports of SCLS in pediatric patients. SCLS should be considered in the differential diagnosis of recurrent hypovolemic shock without identifiable cause. The only therapeutic intervention is to obtain vascular access when initial manifestations occur and give aggressive fluid reanimation.

[Monoclonal gammopathies]

Monoclonal gammopathies can induce clinical or biological symptoms, independent of any associated hemopathy. Cryoglobulins types I and II are responsible for cutaneous lesions, peripheral neuropathy, and membranoproliferative glomerulopathy. Peripheral neuropathies associated with monoclonal gammopathy are chronic, distal, symmetrical and progressive, in two thirds of the cases the monoclonal component reacts with a neuronal antigen principally myelin associated glycoprotein. POEMS syndrome is characterized by: polyneuropathy, organomegaly, endocrine disorder, monoclonal component, and skin diseases. Deposits of light chains of immunoglobulins are responsible for a glomerulopathy, and sometimes affect other organs (skin, heart). Other manifestations are described: angioneurotic oedema, acquired Willebrand disease, systemic capillary leak syndrome, Fanconi syndrome. Treatment of the gammopathy can control associated affections.

Prognostic value of a simple evolving disseminated intravascular coagulation score in patients with severe sepsis

OBJECTIVE

We postulated that the coagulopathy initiated by the inflammatory response to severe sepsis would be reflected by changes in the platelet count and prothrombin time that convey prognostic information. To examine this hypothesis, we looked at the utility of a simple evolving disseminated intravascular coagulation (DIC) score that awarded 1 point for each of the following: a) an absolute platelet count <100 x 10/L; b) a prothrombin time >15.0 secs; c) a 20% decrease in platelets; and d) a >0.3-sec increase in prothrombin time in predicting outcome in patients with severe sepsis.

DESIGN

Prospective observational study.

SETTING

Intensive care units of university medical center.

PATIENTS

Patients were 163 critically ill severe sepsis patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were clinically classified as having capillary leak syndrome (n = 24), multiple organ failure with death from sepsis (n = 37), or multiple organ failure with recovery (n = 57) or as well (n = 45) if they showed rapid improvement in their modified Multiple Organ Dysfunction Syndrome (MODS) score (which did not score for thrombocytopenia). Patients with capillary leak syndrome had the highest Acute Physiology and Chronic Health Evaluation II score, modified MODS, and prothrombin time and the lowest platelet counts, whereas well patients had the most normal values. The simple evolving DIC score increased with worsening clinical class and was associated with worsening organ failure (increased modified MODS). Mortality rate increased from 10% for a simple evolving score of 0 to 73% for a score of 4 (p < .01). Overall, 86% of those with a score < or =1 survived, whereas 85% of those with a score of > or =2 developed multiple organ failure and half of them died from sepsis.

CONCLUSIONS

The simple evolving DIC score calculated in the first 48 hrs from two readily available global coagulation markers appears to reflect the severity of the underlying disorder. It can be easily calculated at the bedside and provides useful prognostic information for the patient with severe sepsis.

Systemisches Kapillarlecksyndrom als Ursache eines Kompartmentsyndroms beider Unterschenkel und eines Unterarms

Systemic capillary leak syndrome is a rare disorder which causes recurrent episodes of hypovolemic shock due to a markedly increased plasma shift into the interstitium. Hemoconcentration, hypoalbuminemia and a monoclonal gammopathy are characteristic laboratory findings. A rare manifestation of this disease is a compartment syndrome with rhabdomyolysis and acute renal failure. We describe a patient who suffers from a compartment syndrome of both lower legs and the left forearm secondary to systemic capillary leak syndrome, and discuss the pathophysiological background.

[The renal failure and capillary leak during the acute stage of (Dobrava) DOB and PUU (Puumala) infection]

The target organ for Puumala (PUU) and Dobrava (DOB) viruses is the kidney, but the impact on renal function seems far more important in DOB infection than in PUU infections. Aim of study was to estimate the renal failure and capillary leak during the acute stage of DOB-infection and PUU-infection. 50 patients with serological conformed diagnosis of acute hantavirus infection were included in the study. Diuresis, serum urea and creatinine were measured. Size of kidneys and presence of ascites was followed by ultrasonography. Enlargement of both kidneys were found in all (100%) patients. Ascites was present in 8/25 (32%) DOB patients; in 1/25 (4%) PUU patient and pleural effusion in four 4/25 (16%) DOB patients. The statistically significant difference in the mean urinary output was during 5th, 6th and 7th day of hospitalization (P<0,05). Serum creatinine and urea levels were at significantly higher levels for DOB than for PUU patients (P<0,05). Acute haemodialysis was needed in 7/25 (28 %) of the DOB patients. One DOB patient died. DOB virus infection is associated with a more severe kidney function disorders than PUU virus infection. Capillary leak, which caused swollen of kidney and ascites is probably the pathogenesis key factor.

Decreased hepatic uptake of gallium-67 citrate in haemophagocytic syndrome occurring concomitantly with capillary leak syndrome

We describe a 4-year-old girl with haemophagocytic syndrome (HPS) in whom hepatic gallium-67 citrate (Ga-67) uptake was suppressed when the disease was in its acute phase and returned to normal when the disease was in remission. The prominent clinical feature of this case was the occurrence of systemic capillary leak syndrome (CLS). Because extravasation of plasma proteins may be the result of vascular endothelial injury in CLS, loss of hepatic Ga-67 uptake may reflect insult to the hepatic sinusoidal endothelium. This case suggests a possible role of sinusoidal endothelial cells in the mechanism of hepatic Ga-67 uptake and indicates the need for further study of Ga-67 uptake in patients with HPS.

Fluid therapy in sepsis with capillary leakage

Sepsis is associated with a profound intravascular fluid deficit due to vasodilatation, venous pooling and capillary leakage. Fluid therapy is aimed at restoration of intravascular volume status, haemodynamic stability and organ perfusion. Circulatory stability following fluid resuscitation is usually achieved in the septic patient at the expense of tissue oedema formation that may significantly influence vital organ function. The type of fluid therapy, crystalloid or colloid, in sepsis with capillary leakage remains an area of intensive and controversial discussion. The current understanding of the physiology of increased microvascular permeability in health and sepsis is incomplete. Furthermore, there is a lack of appropriate clinical study end-points for fluid resuscitation. This review considers critically the clinical and experimental data analysing the assessment of capillary leakage in sepsis and investigating the effects of different fluid types on increased microvascular permeability in sepsis.

Capillary leakage syndrome: a case report and a review

Capillary leakage Syndrome (CLS) is a rare clinical syndrome, that was first described in 1960, characterized by acute episodes of generalized edema, hemoconcentration, hypoproteinemia and monoclonal gammopathy, in the vast majority of cases. We describe a 39-year-old man with anasarca, bilateral pleural and pericardial effusions, ascites and diffuse alveolo-intersticial edema. Clinical and laboratory findings were consistent with an acute episode of CLS. Treatment with prednisone, furosemide and aminophylline was started, which lead to a gradual improvement in 48 hours. Pathophysiologically there is an increase in capillary permeability with the extravasation of fluid and plasmatic proteins to the extravascular space that can lead to hypovolaemic shock. In the second phase there is a reentry of the fluid overload leading to pulmonary edema. The etiology of this hyperpermeability still remains unclear. The role of cytokines has become central in the comprehension of pathophysiology of CLS. Adhesion molecules are probably also involved in the genesis of capillary leakage. CLS treatment remains empirical. However, at present it seems that the association of steroids with furosemide, aminophylline and terbutaline are capable of controlling the clinical manifestation of the acute episodes in most cases. To our knowledge no prophylatic therapy has clearly proven its efficacy. There are only a few series analyzing the long-term evolution of patients with CLS. Further studies are necessary with the objective to collect enough patients with CLS to observe natural history of the disease and evaluate the efficacy of empiric treatments.

Hydroxyethyl starch and modified fluid gelatin maintain plasma volume in a porcine model of septic shock with capillary leakage

OBJECTIVE

To compare the effects of different volume replacement therapies on maintenance of plasma volume in septic shock and capillary leakage syndrome.

DESIGN AND SETTING

Prospective randomized, controlled animal laboratory study in a university animal laboratory.

MEASUREMENTS AND RESULTS

Twenty-five fasted, anaesthetized, mechanically ventilated and multi-catheterized pigs (20.8+/-1.8 kg) received 1 g/kg body weight faeces into abdominal cavity to induce sepsis and were observed over 8 h. Five animals each received volume replacement therapy with modified fluid gelatin 4% or 8% (MFG4%, MFG8%), 6% HES 200/0.5, or Ringer's solution and were compared to controls receiving 6% HES 200/0.5. Infusion rate was titrated to maintain a central venous pressure of 12 mmHg. Plasma volume was determined using (51)Cr-labelled erythrocytes and standard formulae. Albumin escape rate was calculated using technetium (99m)Tc-labelled albumin. Colloid osmotic pressure, systemic haemodynamics and oxygenation were obtained before and 4 and 8 h after induction of sepsis. Plasma volume was reduced in the Ringer's solution group (-46%) but was maintained in HES (+/-0%), MFG4% (+4%), MFG8% (+23%) groups. Albumin escape rate increased in HES (+52%), MFG4% (+47%), MFG8% (+54%) and the Ringer's solution group (+41%) compared to controls.

CONCLUSION

In this porcine septic shock model with concomitant capillary leakage syndrome, confirmed by an increased albumin escape rate, the artificial colloids HES, MFG4%, and MFG8% maintained plasma volume and colloid osmotic pressure. These results suggest the intravascular persistency of artificial colloids in the presence of albumin leakage. An editorial regarding this article can be found in the same issue (http://dx.doi.org/10.1007/s00134-002-1283-9)

[Systemic capillary leak syndrome presenting remarkable erythrocytosis]

Systemic capillary leak syndrome (SCLS) is a disorder characterized by hypotension, edema, and an increased hematocrit (Ht) due to sudden leakage of plasma into the extravascular space through some unknown mechanism, in which monoclonal gammopathy is observed. A 30-year-old man visited our emergency department because of abdominal pain, and was admitted to our hematology department because of a markedly increased hemoglobin concentration reaching 26.2 g/dl. The polycythemia was thought to be pseudo-polycythemia due to hemoconcentration, and we diagnosed the patient as having SCLS based on the triad of increased hematocrit, whole-body edema which was especially marked in the lower extremities, and monoclonal gammopathy. The patient recovered after administration of extracellular fluids and albumin, but the attacks recurred. Prophylaxis with terbutaline sulfate, theophylline and corticosteroid reduced the frequency of severe attacks. Because there is possibility that patients with SCLS may be admitted to hematology departments due to severe erythrocytosis, we report this case to increase the awareness of hematologists that SCLS is one of the important differential diagnoses of erythrocytosis.