Usefulness of delta neutrophil index for early prediction of overt disseminated intravascular coagulopathy in patients with venomous snakebite

OBJECTIVE: Clinically, consumptive coagulopathy, such as disseminated intravascular coagulopathy (DIC), is the most important among the common venomous snakebite complications owing to the serious hemorrhage risk associated with this condition. We evaluated the predictive value of the delta neutrophil index (DNI)—a new indicator for immature granulocytes—for DIC diagnosis. METHODS: This retrospective observational study consecutively assessed adult patients with venomous snakebites for over 51 months. Patients were categorized into the no DIC and DIC groups. DNI values were measured within 24 hours after snakebite. RESULTS: Thirty patients (26.3%) developed DIC. The DIC group had significantly higher median initial DNI than the no DIC group (0% vs. 0.2%, P < 0.001). When the DIC group was divided into early and late groups (within and over 24 hours after snakebite, respectively), the DNI of the former was significantly higher than that of the latter and no DIC group. The late DIC group had significantly higher DNI than the no DIC group. Furthermore, DNI positively correlated with the DIC score (r=0.548, P < 0.001). The initial DNI (odds ratio, 4.449; 95% confidence interval, 1.738 to 11.388; P=0.002) was an early DIC predictor. The area under the curve based on the initial DNI’s receiver operating characteristic curve was 0.724. CONCLUSION: DNI values were significantly higher in the DIC group. Additionally, DNI was an early predictor of DIC development in patients with venomous snakebites in the emergency department.

Postoperative excessive blood loss after cardiac surgery can be predicted with International Society on Thrombosis and Hemostasis scoring system / A perda sanguínea excessiva no pós-operatório de cirurgia cardíaca pode ser prevista com o sistema de classificação da Sociedade Internacional de Trombose e Hemostasia (ISTH)

Abstract Background and objective Prediction of postoperative excessive blood loss is useful for management of Intensive Care Unit after cardiac surgery. The aim of present study was to examine the effectiveness of International Society on Thrombosis and Hemostasis scoring system in patients with cardiac surgery. Method After obtaining approval from the institutional review board, the medical records of patients undergoing elective cardiac surgery using Cardio-Pulmonary Bypass between March 2010 and February 2014 were retrospectively reviewed. International Society on Thrombosis and Hemostasis score was calculated in intensive care unit and patients were divided with overt disseminated intravascular coagulation group and non-overt disseminated intravascular coagulation group. To evaluate correlation with estimated blood loss, student t-test and correlation analyses were used. Results Among 384 patients with cardiac surgery, 70 patients with overt disseminated intravascular coagulation group (n = 20) or non-overt disseminated intravascular coagulation group (n = 50) were enrolled. Mean disseminated intravascular coagulation scores at intensive care unit admission was 5.35 ± 0.59 (overt disseminated intravascular coagulation group) and 2.66 ± 1.29 (non-overt disseminated intravascular coagulation group) and overt disseminated intravascular coagulation was induced in 29% (20/70). Overt disseminated intravascular coagulation group had much more EBL for 24 h (p = 0.006) and maintained longer time of intubation time (p = 0.005). Conclusion In spite of limitation of retrospective design, management using International Society on Thrombosis and Hemostasis score in patients after cardiac surgery seems to be helpful for prediction of the post- cardio-pulmonary bypass excessive blood loss and prolonged tracheal intubation duration.

Resumo Justificativa e objetivo A previsão de perda sanguínea excessiva no pós-operatório é útil para o manejo em Unidade de Terapia Intensiva (UTI) após cirurgia cardíaca. O objetivo do presente estudo foi examinar a eficácia do sistema de classificação da Sociedade Internacional de Trombose e Hemostasia (International Society on Thrombosis and Hemostasis - ISTH) em pacientes submetidos à cirurgia cardíaca. Método Após obter a aprovação do Comitê de Pesquisa Institucional, os prontuários de pacientes submetidos à cirurgia cardíaca eletiva com circulação extracorpórea (CEC) entre março de 2010 e fevereiro de 2014 foram retrospectivamente revisados. O escore ISTH foi calculado na UTI e os pacientes foram alocados em dois grupos: grupo com coagulação intravascular disseminada (CID) manifesta e grupo com CID não manifesta. Para avaliar a correlação com a Perda Estimada de Sangue (PES), o teste t de Student e as análises de correlação foram usados. Resultados Dentre os 384 pacientes submetidos à cirurgia cardíaca, 70 com CID manifesta (n = 20) ou CID não manifesta (n = 50) foram incluídos. As médias dos escores CID na admissão na UTI foram 5,35 ± 0,59 (Grupo CID manifesta) e 2,66 ± 1,29 (Grupo CID não manifesta) e induzida CID manifesta em 29% (20/70). O grupo CID manifesta apresentou PES superior durante 24 horas (p = 0,006) e um tempo maior de intubação (p = 0,005). Conclusão Apesar da limitação do desenho retrospectivo, o uso do escore ISTH para o manejo de pacientes após cirurgia cardíaca parece ser útil para prever a perda sanguínea excessiva pós-CEC e o prolongamento da intubação traqueal.

An Unusual Presentation of Vasculotoxic Snake Bite.

In India, viper bites are more common than any other poisonous snake bites. In these patients, the cardinal features are local pain, swelling and mild coagulation abnormalities; but gangrenous changes involving bilateral upper and lower limbs are uncommon. We are reporting a case of a 62-year-old man bitten by a Russell viper on the right thumb. He experienced local pain, swelling and later developed disseminated intravascular coagulopathy, pre-renal azotemia, sepsis, acute respiratory distress syndrome (ARDS) and peripheral gangrenous changes involving bilateral upper and lower limbs. He succumbed to his ailment 5 months after the bite. There have been very few cases of gangrenous changes involving distal part of extremities associated with snake bite.

A Case of Intestinal Hemangioma Complicated with Thrombocytopenia (Kasabach-Merritt syndrome) in Premature Infant

Kasabach-Merritt syndrome is a rare thrombocytopenic consumptive coagulopathy associated with a giant hemangioma. We experienced a case of unexplained ascites with thrombocytopenia in a 32 week premature infant. An exploratory laparotomy was performed to determine the cause of the refractory ascites and thrombocytopenia. An intestinal hemangioma was found, but, surgical removal was not performed due to the extensive involvement. Hemangioma was confirmed by SPECT (single-photon emission computed tomography) and the thrombocytopenia was treated with steroid therapy. It is recommended that hemangioma of the visceral organs should be suspected when unexplained thrombocytopenia and disseminated intravascular coagulopathy persist.

Intracranial Hemorrhage in Patients with Hematologic Disorders

OBJECTIVE: Spontaneous intracranial hemorrhage is still common cause of death in the hematologic disorder including leukemia. The authors examine laboratory & radiological findings in patients with intracranial hemorrhage caused by hematologic disorder. METHODS: From March 1998 to May 2002, 42 patients with hematologic disease complicated by intracranial hemorrhage were transferred from hematology department. The patients were normotensive and had not trauma history. In all patients, intracranial hemorrhages were diagnosed with the brain computerized tomography. Surgical treatment was performed in one case. RESULTS: Underlying hematologic disorders included aplastic anemia (4), acute myeloblastic leukemia (20), acute lymphoblastic leukemia (6), chronic myeloblastic leukemia (8), myelodysplastic syndrome (2), multiple myeloma (1), and polycythemia vera (1). Intracranial hemorrhage subtypes consisted of intracerebral hemorrhage (39) including mainly subcortical lobar hemorrhage (28), and subarachnoid hemorrhage (3). Twenty (48%) of the 42 patients had multifocal hematomas. Thirty six patients (86%) had moderate and severe thrombocytopenia (less than 100x10(9)/L). Twenty four patients (57%) had moderate and severe leukocytosis (greater than 20x109/L). CONCLUSION: It showed that (1) the risk factors of intracranial hemorrhage in hematologic disorders are thrombocytopenia, leukocytosis and disseminated intravascular coagulopathy ; (2) intracerebral hemorrhage in hematologic disorders occur preferentially in the subcortical portion ; (3) intracranial hemorrhage in hematologic disorders consist of various combinations of subcortical lobar hemorrhage, subarachnoid hemorrhage, subdural hemorrhage and intraventricular hemorrhage ; (4) intracerebral hemorrhage in hematologic disorders tend to be multiple.

A Death Resulting from Inadvertent Intravenous Injection of Antidiarrheal: A Case Report / 대한법의학회지

Although medication errors in hospital are common, medication errors that result in death rarely occur. We report a case of inadvertent intravenous injection of SMECTA(TM), a kind of oral antidiarrheal, in a 4-year-old boy, who underwent orthopedic surgery of foot to correct congenital malformation. After this medical accident seizure suddenly developed, mental change, and disseminated intravascular coagu-lopathy followed. The diagnostic confirmation of this fatal error was made after thrombi and foreign materials were identified the histopathologic examination in the lung, as well as by analyzing the components of the antidiarrheal such as magnesium, aluminum etc. We propose to make it a rule to keep the strategies, for examples, oral liquids should not be put in Luer-lock syringes for IV administration, avoid drugs with similar names or packages form placing in the same area to reduce errors.

Portal Vein, Splenic Vein, and Superior Mesenteric Vein Thrombosis and Small Bowel Necrosis in the Patient with Hypereosinophilia: A Case Report

Eosinophils are only a small minority of peripheral blood leucocytes and, in normal subjects, most are found in the tissues of the lung and gastrointestinal tract. Peripheral blood eosinophilia is occurred by various causes, allergic diseases, parasite infection, clonal disorder, and drug. Moderate to severe eosinophilia may be caused by the idiopathic hypereosinophilic syndrome (HES), but the commonest cause of eosinophilia worldwide is helminthic infection and, in industrialized nations, atopic disease. Whatever the cause for the eosinophilia, in certain circumstances the eosinophils produce damage to various organs by activation of eosinophils, thrombotic events, release of eosinophil granule contents, and deposition of eosinophil proteins. Clinical manifestations are characterized by thromboembolic events of the involved organ, such as the heart, lungs, or nervous system. To our knowledge, the association between hypereosinophilia and intraabdominal multivessel (portal, splenic and superior mesenteric vein) thrombosis has never previously been reported. Thus, we report a case with portal, splenic and superior mesenteric venous thrombosis simultaneously with disseminated intravascular coagulapathy in the patient with hypereosinophilia.

Clinical Characteristics and Atypical Cases of Subacute Necrotizing Lymphadenitis / 감염

BACKGROUND: Subacute necrotizing lymphadenitis (SNL) or Kikuchi-Fujimoto disease, first described in 1972, is a benign process of lymphatic system that consists of lymphadenopathy which may be accopanied by fever, rash and some hematologic alterations. It affects usually young people, mostly women. Even though this disease is self-limited, many cases are misidentified as malignant lymphoma. The purpose of this study is to report the clinical characteristics, many laboratory tests and pathologic finding and to elaborate the criteria that are useful in distinguishing from fever cause. We are going to present some rare cases and fatal cases. METHODS: Authors evaluated 116 patients, who were diagnosed as Subacute necrotizing lymphadenitis on excisional biopsy with retrospective chart review at Yonsei Medical Center from January 1993 to May 2000. RESULTS: The mean age was 26.4+/-0.9 years (range : 5~63 years) and the male to female ratio was 1 : 2.28. The most common symptoms were cervical lymphadenopathy (89.7%) and fever (57.8%), and the duration of symptom was generally less than 8 weeks. Leukopenia (74.4%), relative lymphocytosis (33.3%) and DIC (7 cases) were hematologic abnormalities. Recently, we experienced patients showing atypical clinical findings which were pancytopenia, DIC (disseminated intravascular coagulopathy), hypotension or debilitating symptoms. Steroid pulse or high dose steroid and immunosuppressant therapy were performed in atypical cases. Sj gren some cases were rarely associated with systemic diseases such as systemic lupus erythematosus (4 cases), Sj gren disease (2 cases), rheumatoid arthritis (3 cases), aseptic meningitis (2 cases) or adult Still's disease (1 case). Thirteen cases (10.9%) were recurrent, and two cases died. CONCLUSION: Subacute necrotizing lymphadenitis should be considered in the differential diagnosis of fever cause in the patients which had localized cervical adenopathy, unresponsive to antibiotic therapy, especially in young women. We report atypical or fatal cases and need clinical attention to this kind of possibility.

A Case of Tsutsugamushi Disease Complicated with Adult Respiratory Distress Syndrome and Disseminated Intravascular Coagulopathy / 감염

Tsutsugamushi disease is an acute febrile illness caused by Orientia tsutsugamushi. It is characterized by fever, myalgia, lymphadenopathy, and rash. And it can be easily diagnosed by characteristic eschar and serologic testing. Nearly all of the patients with tsutsugamushi disease improve with antibiotics such as doxycycline. However, the fatality rate of untreated cases is seven to ten percent. The well-known causes of mortality are respiratory failure associated with pulmonary edema or adult respiratory distress syndrome. We report a case of tsutsugamushi disease complicated with acute respiratory distress syndrome and disseminated intravascular coagulopathy, despite of doxycycline treatment. A 78-year old woman was admitted to the hospital because of fever. Twelve days before admission she had suffered myalgia and some days later she developed a rash. Despite of management at a local clinic, her condition deteriorated and she was transferred to our hospital. On admission she presented with altered consciousness and two eschars on her right arm and right thigh. Under the initial diagnosis of scrub typhus, doxycycline was administered. Her fever subsided with the initiation of doxycycline. However, her hypoxia worsened progressively and she died on the fifth hospital day.