Septic death in adults at Surin Hospital: an investigation of real-life clinical practice vs. empirical guidelines.

OBJECTIVE: To explore the cause of death from sepsis and to evaluate the hospital practice in septic patients. MATERIAL AND METHOD: A cross-sectional, retrospective study was conducted between October 2004 and September 2005, at Surin Hospital. The present study included 119 adults (> or = 15 year of age) who were admitted with community-acquired sepsis. RESULTS: According to the ACCP/SCCM definition, 85.7% of the patients had severe sepsis and up to 71.4% had septic shock. The overall hospital mortality was 73.9% for septic patients and 88.2% for patients in septic shock. The factors that were significantly associated with death from sepsis were age > or = 60 years, presence of co-morbidity, septic shock, organ dysfunctions > or = 3, and acidosis (HCO3 < 20 mEq/L). During hospitalization, 5.9% of patients received ICU care, 29.4% adequate fluid resuscitation, but none had been monitored for Svo2 or Scvo2, and 36.4% had more than a 1-hr delay in the administration of antibiotics. The main cause of death was refractory hypotension (77.3%), in which the amount of fluid therapy during initial resuscitation was significantly associated with the survival of septic shock. CONCLUSION: Septic shock is the most common cause of death in septic patients. Delayed and inadequate hemodynamic management, including a delay in the administration of antibiotics are the main problems in real-life clinical management of septic patients.

HIV-associated primary pulmonary hypertension: a first case report in Thailand and literature review.

A 32-year-old woman had asymptomatic HIV infection diagnosed with primary pulmonary hypertension simultaneously. She presented after a three-month rapid progression of symptoms and hemodynamic change. Physical examination and laboratory findings were compatible with pulmonary hypertension. No sensible cause could be found for the pulmonary hypertension except the HIV seropositivity; therefore, HIV-associated primary pulmonary hypertension was diagnosed. She was treated with diltiazem and oral anti-coagulation. After four months, her functional status improved from a NYHA functional class of II to I and improved in right venticular function. Since HIV is epidemic, the authors recommend HIV testing in cases of primary pulmonary hypertension.

Benign form of herpes simplex encephalitis.

A 34-year-old woman who presented with only severe headache for 12 days was reported. She was initially diagnosed with cerebral infarction of the right temporal lobe and treated with aspirin, without improvement. On admission, she had bilateral papilledema. Other findings were unremarkable. CT scan and MRI of the brain revealed an area of cerebritis at the right temporal lobe. Lumbar puncture showed high opening pressure with normal CSF profiles. The patient was treated with intravenous acyclovir which gave a favorable outcome.

Eosinophilic pleural effusion in adults at Srinagarind Hospital.

The presence of pleural eosinophilia remains a controversy in etiology and prognosis. We conducted this study to evaluate the etiology of eosinophilic pleural effusion and to define the factors that determine malignancy in eosinophilic pleural effusion. Between 1 August 1994 and 1 July 2000, 50 patients were diagnosed with eosinophilic pleural effusion; 35 men and 15 women averaging 56.4 years of age. Most (96%) had exudative pleural effusion. Malignancy was the most common (46%) established cause followed by tuberculosis (10%), parapneumonic effusion (8%), and empyema thoracis (2%). We encountered only one case of pneumothorax and parasitic pleural effusion (from Strongyloides stercoralis). Unknown causes constituted 22% of cases. The etiology of those who had previously undergone thoracocentesis did not differ from those having their first thoracocentesis. Patients with malignant pleural effusion had significant longer duration of clinical symptoms (> or = 1 month) and weight loss than benign pleural effusion. The median duration of symptoms in benign pleural effusion was 14 days. Fever was more characteristic in patients with benign than in those with malignant pleural effusion. The percentage of eosinophils in pleural fluid and blood did not differ between the two groups. Pleural fluid eosinophils in malignant vs benign pleural effusion were 26.6% (range 10% to 63%), and 30.6% (range 10% to 93%), respectively. We concluded that, pleural eosinophilia did not indicate benign conditions which would spontaneously resolve. Malignant pleural effusion should be considered especially in areas malignancy is prevalent.

Actinomycotic meningitis: report of a case.

A 73-year-old man who presented with acute fever, drowsiness and confusion was reported. Two weeks prior to admission, he attended the Outpatient Department with symptoms of fever and headache for 2 weeks. Eosiophilic meningitis was initially diagnosed, which, in fact, was lymphocytic CSF pleocytosis. He was treated with a high dose of prednisolone. His symptoms improved for 1 week, then he experienced symptoms of fever and headache again. On admission, he had stiffness of the neck. Lumbar puncture showed purulent CSF with gram-positive branching filamentous organisms. CSF grew Actinomyces israelii. The patient died from brain herniation.