Peste septicémica rápidamente fatal secundaria a peste bubónica primaria inicialmente no diagnosticada: reporte de caso / Rapidly fatal septicemic plague secondary to undiagnosed primary bubonic plague: case report

RESUMEN La peste es una enfermedad reemergente causada por Yersinia pestis. Los humanos generalmente adquieren la enfermedad por picaduras de pulgas. La peste es una enfermedad sistémica fulminante, siendo la peste neumónica la forma más letal. El diagnóstico tardío es una de las principales causas de mortalidad y diseminación de la enfermedad, dado que limita la efectividad de las medidas de control. Presentamos el caso de un varón de 42 años, que previamente había viajado a una zona endémica de peste, y luego presentó hiperpirexia, hipotensión, y adenopatía inguinal inflamatoria. A pesar del cuadro clínico muy característico, nadie (antes del ingreso a nuestro hospital) sospechó peste. Se inició una combinación antibiótica efectiva y tratamiento intensivo recién al quinto día de enfermedad. El paciente evolucionó con shock séptico, falla respiratoria, y muerte. Se confirmó peste por reacción en cadena de polimerasa (PCR). Este caso enfatiza la importancia de tener un alto índice de sospecha para peste.

ABSTRACT Plague is a re-emerging disease caused by the bacteria Yersinia pestis. Humans usually get the disease through the bite of an infected flea. Plague is a fulminant systemic disease, with pneumonic plague being the most lethal form. Late diagnosis is one of the main causes of mortality and spread of the disease, as it limits the effectiveness of control measures. We present the case of a 42-year-old male, who had previously traveled to an endemic plague area and then presented hyperpyrexia, hypotension, and inflammatory inguinal adenopathy. Despite the very characteristic clinical picture, nobody (before admission to our hospital) suspected plague. An effective combination of antibiotics and intensive treatment was initiated only on the fifth day of illness. The patient went into septic shock, respiratory failure, and death. Plague was confirmed by polymerase chain reaction (PCR). This case emphasizes the importance of having a high suspicion rate for plague.

Surto de leptospirose em bezerros criados em resteva de arroz / Leptospirosis outbreak in calves maintained in a rice stubble field

A leptospirose é uma doença infecciosa causada por bactérias do gênero Leptospira, que afeta animais domésticos, selvagens e também humanos. De outubro a novembro de 2014, numa propriedade rural localizada em Glorinha, RS, em que bovinos eram mantidos em resteva de arroz, 13 bezerros manifestaram hemoglobinúria e apatia, nove dos quais morreram em menos de 24 horas após o início dos sinais clínicos. Foram necropsiados quatro bezerros (A, B, C e D). Fragmentos de tecido foram fixados em formalina a 10%. Amostras de rim, fígado e pulmão dos Bezerros B, C e D foram enviadas para análise de PCR para RNA ribossômico 16S e a proteína Lip 32 de Leptospira. No exame macroscópico foram observados mucosas e tecido subcutâneo amarelados, fígado alaranjado, pulmões com múltiplas petéquias, predominantemente nos lóbulos craniais. A cavidade torácica do Bezerro A estava repleta de um líquido vermelho-escuro. À avaliação microscópica foi observada hemorragia acentuada nos pulmões; no fígado havia necrose e vacuolização hepatocelular centrolobular difusa moderada, além de infiltrado linfocítico periportal discreto. Nos rins observou-se nefrite intersticial linfoplasmocítica discreta multifocal. A análise por PCR teve resultado positivo para os Bezerros B e D. O diagnóstico de leptospirose nos bezerros foi baseado nos achados epidemiológicos, clínicos e patológicos, associados ao resultado positivo na PCR. Este estudo demonstra a importância da investigação da doença quando animais jovens são criados em áreas inundadas e têm manifestações clínicas de doença septicêmica aguda.(AU)

Leptospirosis is an infectious disease caused by bacteria of the genus Leptospira, which affect domestic and wild animals, and also humans. From October to November 2014, in a rural property located in Glorinha, RS, where cattle were kept in the rice stubble, thirteen calves presented hemoglobinuria and apathy, nine of which died within less than 24 hours after the onset of clinical signs. Four calves were necropsied (A, B, C and D). Tissue samples were collected in 10% formalin. Samples of kidney, liver and lung from calves B, C and D were sent for PCR analysis for 16S ribosomal RNA and the protein Lip 32 genes of Leptospira. At macroscopic examination jaundiced mucosae and subcutaneous tissue, orange liver, and lungs with multiple petechiae, predominantly in cranial lobes, were observed. The thoracic cavity of calf A was filled with a reddish fluid. At microscopic examination, severe hemorrhage was observed in the lungs; in the liver there was moderate diffuse centrilobular hepatocellular necrosis and vacuolization, in addition to discrete periportal lymphocytic infiltrate. Discrete multifocal lymphoplasmocytic interstitial nephritis was observed in the kidneys. PCR analyzis resulted positive for calves B and D. The diagnosis of leptospirosis in the calves was based on epidemiological, clinical and pathological findings associated with positive PCR analysis. This study demonstrates the importance of investigation of the disease when young bovids are raised in flooded areas and have clinical signs of an acute septicemic disease.(AU)

The Use of Laboratory and Physiological Parameters in Predicting Mortality in Sepsis Induced Hypotension and Septic Shock Patients attending The Emergency Department

Introduction: In this study, we sought to determine whether laboratory and physiological parameters can be useful in predicting mortality in patients with sepsis-induced hypotension and septic shock. Methodology: This prospective cohort study was carried out in the emergency department at an academic medical center. A total of 51 patients met enrollment criteria during the study period and 41 of them were included in the study. Inclusion criteria were patients 18 years old or older, diagnosed to have either sepsis-induced hypotension or septic shock and investigated sepsis marker (blood lactate and leukocytes) measured. Other physiological variables were also measured in this study. The main outcome measure was 30-day mortality. Kaplan-Meier, Log-rank and Cox's methods were used for statistical analysis using SPSS version 12.0.1. Results: 61% were diagnosed to have sepsis-induced hypotension and 39% were diagnosed with septic shock. Twenty two (54%) deaths occurred within the 30 day follow up. The overall mean blood lactate level and leukocyte counts were 3.52 mmol/L (SD=2.29) and 11.37 x 109 (SD=6.38) respectively. A Cox Proportional Hazard Analysis revealed an increase in blood lactate levels in the ED was associated with an increased risk of death (B=0.35, HR=1.45, 95% CI 1.22,1.73, p<0.001). However no significant correlation between the physiological parameters and the 30-day mortality. Patients with septic shock state prior to initial presentation has a lower 30 day survival compared to any other septic conditions. Conclusion: Our results support blood lactate level as a promising risk stratification tool when compared with leukocytes counts and other physiological parameters. The multivariate analysis showed that for every increment of lactate value of 1 mmol/L, the hazards of dying are expected to increase by 1.5 times (p<0.001).

Leptospirosis in children: A review for family physicians.

Leptospirosis is an important cause of acute febrile illness in the monsoon season in India. It is a zoonotic disease that is spread primarily by rodents. There exist two clinical types: anicteric and icteric leptospirosis. Both have an initial septicemic phase followed by an immune phase. The clinical manifestations vary and the disease manifestations may range from a nonspecific febrile illness to one with severe multiorgan failure. Weil's disease is the severe form of the infection; which occurs in less than 10% of the patients and is associated with high mortality. The methods available for diagnosis and treatment of leptospirosis are discussed in this review. Crystalline penicillin is the drug of choice for treatment of leptospirosis in children. Avoidance of contact with flood waters and rodent control are vital for prevention of the disease. We also discuss the differences between childhood leptospirosis and adult disease. We used two methods to garner the information presented in this article: i) we searched the PubMed database (http://www.ncbi.nlm.nih.gov/pubmed/) using the keywords 'leptospirosis' and 'children,' with special emphasis given to articles from the Indian literature; and ii) we reviewed the chapters on leptospirosis in the standard textbooks of pediatric and infectious diseases.

Salmonelose septicêmica prolongada associada à esquistossomose: evolução do conhecimento e mecanismos imunopatogênicos: [revisão] / Schistosoma-associated chronic septicemic salmonellosis: evolution of knowledge and immunopathogenic mechanisms: [review]

A salmonelose septicêmica prolongada é uma entidade clinicamente individualizada caracterizada por febre prolongada com hepatoesplenomegalia que ocorre em indivíduos esquistossomóticos coinfectados com salmonelas. Os mecanismos imunopatogênicos são vários e dependem das peculiaridades das interações entre as salmonelas e várias espécies do gênero Schistosoma. As modificações ocasionadas no sistema imunitário pela infecção parasitária são responsáveis pela evolução do quadro da doença. Nesta revisão, analisamos a evolução do conhecimento sobre a entidade e discutimos os possíveis mecanismos imunofisiopatogênicos que concorrem para seu desenvolvimento.

Chronic septicemic salmonellosis is an individualized clinical entity characterized by prolonged fever with enlargement of the liver and spleen that occurs in Schistosoma-infected individuals who are coinfected with Salmonella. Several immunopathogenic mechanisms are involved, and they depend on the peculiarities of the interactions between Salmonella and various species of the genus Schistosoma. The modifications to the immune system that are caused by parasite infection are responsible for the evolution of the disease. In this review, we analyze the evolution of the knowledge on this entity and discuss the possible immuno-physiopathogenic mechanisms that contribute towards its development.

Septicemic melioidosis and meningitis: A case report.

Melioidosis predominantly affects the rice-farming community of north-eastern Thailand, and occurs mainly in patients with underlying diseases such as diabetes mellitus or chronic renal impairment. It may be asymptomatic or may present as acute septicaemic or chronic suppurative infection. Neurological involvement in melioidosis is uncommon. We report here on a patient with septicaemic melioidosis and meningitis. A 48-year-old man presented with a three-month history of fever, chillis and weight loss. He came from Udon Thani and was a known diabetic who had been on regular treatment for three years. Both Widal and Weil-Felix reactions were negative with normal X-ray of the chest. On the next day, the patient had severe headache with a stiff neck. The CSF contained elevated glucose and protein concentrations, polymorphonuclear cells and lymphocytes but revealed no growth on culture. Two days later, the patient developed a cough, dyspnoea with difficulty in swallowing. Culture frpm the blood and sputum yielded pure Burkholderia pseudomallei. The patient was treated with a combination of ceftriaxone and trimethoprim-sulphamethoxazle which was found to be sensitive in vitro. However, the patient died on day 7 of hospitalization. This case illustrate an urgent need for early diagnosis and identification of sensitive drugs for the treatment the melioidosis which is still quite common in north. Eastern Thailand.