Hyperacute Liver Failure with Multi-organ Dysfunction Syndrome (MODS) by Leptospirosis: A Case Report

Introduction: Leptospirosis may have multi-organ involvement in its severe form with potentially life-threatening consequences. However, acute fulminant hepatic failure is very uncommonly reported. A case study is presented here with fulminant hepatic failure and a diagnostic dilemma for etiology. Case history: A 40-year-old man with no significant medical history presented with fever, muscle pain, weakness, and pain in the upper abdomen. On clinical work, he has developed multi-organ hepatic, respiratory, and renal failure. A timely workup was done, but due to the rapid progression of the disease, the patient succumbed to the disease in the intensive care unit by the time his report for positive leptospirosis test arrived. Conclusion: Leptospirosis must be considered as an important differential diagnosis of acute liver failure patients. An early suspicion for leptospirosis in patients with fulminant hepatic failure and multi-organ failure in India particularly in the rainy season is warranted owing to its high mortality rate.

Oxidative phosphorylation in septic organ injury / 国际儿科学杂志

Sepsis is a systemic inflammatory response syndrome caused by pathogenic microorganisms that infect the host.If treated improperly, it can progress to severe sepsis or even septic shock.As such, it′s one of the main reasons for the death of children in PICU.The inflammatory response of sepsis exerts great influence on a series of basic physiological functions of cells, including the oxidative phosphorylation of the mitochondria.Oxidative phosphorylation is a process during which oxygen is reduced to generate high-energy phosphate bonds in the form of adenosine triphosphate(ATP), which supplies energy for cells and produces a series of functional by-products.During sepsis, the process of oxidative phosphorylation in mitochondria undergoes a series of complex alterations, which in turn can further promote the development of septic organ injury.The present review aims to clarify the relationship between changes in oxidative phosphorylation and the impairment of various organs in sepsis.

Spectrum of microbial infection in an Intensive Care Unit: a single centre tertiary care experience in Southern Indian state of Karnataka

Background: There is an increased incidence of hospital acquired infection, especially in ICU setting, the most common being ICU acquired pneumonia which increases the morbidity, mortality, prolongs hospital stay and consuming more resources. Microbial etiology of intensive care unit (ICU)-acquired pneumonia (ICUAP) determines antibiotic treatment and outcomes which vary from centre to centre. Hence, a study of risk factors, clinical profile of patient, microorganisms and their resistance patterns to antibiotics are important for the diagnosis, prognosis of patient with ICU acquired pneumonia and also in the prevention of the same.Methods: Patients with ICUAP confirmed microbiologically were prospectively compared according to identification of 1 (monomicrobial) or more (polymicrobial) potentially pathogenic microorganism. Patients without microbiological confirmation were excluded from the study. We assessed clinical characteristics, microbiology and outcome variables.Results: In the present study 60 patients with ICU Pneumonia were included out of which 50 (83%) had mono-microbial infection. Most common organism isolated in mono microbial infection was Klebsiella species (26%), followed by Acinetobacter species (25%), out of which 20 percent was multidrug resistant. Multi-drug resistance was similarly frequent in both groups. Outcome variables like initial response to the empiric treatment, length of stay and mortality were similar in both monomicrobial and polymicrobial pneumonia. Mortality rates were higher with higher pneumonia scores (p value <0.002) and with multi organ dysfunction (p <0.008) irrespective of mono microbial or poly microbial infection.Conclusions: In this study mono microbial infection was more than polymicrobial, the most common organism being Kliebsiella species followed by Acinetobacter species. When empiric treatment is frequently appropriate, mortality rates were higher with higher pneumonia scores and MODS. In our study polymicrobial aetiology did not influence the outcome of ICUAP.

Assessment of Predictors for Severity in Scrub Typhus-A Case-Control Study

Objective: Scrub typhus is a rickettsial febrile condition caused by bacteria called Orientia tsusugamushi. It spreads to people through bites of infected larval mites. The objective of this study was to predict the severity of scrub typhus. Methods: A case-control study was done at Kasturba Medical College Hospital (2012-2015) retrospectively on patients admitted with scrub typhus. Patient demographics, lab parameters, investigations and treatment courses were noted. Subjects were divided into two groups, non-severe and severe group. Patient clinical details and laboratory parameters were compared in both the groups. The lab parameters associated with the severity of disease and mortality were also analyzed. A total of 210 patients out of which 140 controls (non-severe group) and 70 were cases (severe group). Results: The overall mortality due to scrub typhus infection was 14.3%. Eschar was present in 21.4% of the patients. Among the cases, the common symptoms were cough, chest pain, abdominal pain and distension, pedal edema and facial puffiness. Lymphadenopathy was observed with non-severe cases of scrub typhus and was statistically significant whereas, icterus, maculopapular rash, and hepatomegaly were associated with severe scrub typhus infection. Hemoglobin, platelet count and serum albumin were considerably lower in patients who died, whereas AST, aPTT, serum urea and creatinine were higher in them. Conclusion: Lower levels of hemoglobin, platelet count, serum albumin and higher levels of total leucocyte count, hepatic transaminases and serum creatinine correlated with severity. Doctors need to be watchful for such lab parameters and act quickly.

Towards safe motherhood to - are we moving in the right direction?: experience from an urban health facility in South India

Background: This study was designed to evaluate the institutional Maternal Mortality Ratio (iMMR) in our institution, a tertiary private medical college hospital and to suggest recommendations and possible interventions to reduce it.Methods: This retrospective descriptive study was conducted by reviewing the hospital records over a period of ten years from January 2009-December 2018. The case records were reviewed for maternal demographic characteristics and complications.Results: The total number of deaths during the study period was 21, giving an iMMR of 85.268 per 100000 live births. Most of the maternal deaths (>80%) occurred postpartum. Obstetric causes contributed to 57% of the deaths with hypertension and hemorrhage topping the list. Other causes were sepsis and non obstetric causes including one case of maternal suicide. 52.38% of the women died more than 48 hours after admission to the hospital, while 28.57% succumbed in less than six hours. Secondary complications noted were ICU admission, extended intubation, massive transfusion, operative intervention and multi organ dysfunction.Conclusions: The classical triad of Hypertension, Hemorrhage and Sepsis continues to be the major determinant of maternal mortality and are potentially preventable by promoting universal access to quality health care, strengthening of health services and ensuring accountability.

Clinical Profile and Outcome of H1N1 Influenza Infection at a Tertiary Care Teaching Hospital.

Background: The 2009 flu outbreak in humans, knownas "swine influenza" or H1N1 influenza A, refers toinfluenza A due to a new H1N1 strain called SwineOrigin Influenza Virus A (S-OIV). Global pandemicswith high mortality and morbidity occur when avirulent new viral strain emerges. Aim and Objectives:To study demography, clinical profile and outcome ofH1N1 influenza infection at a tertiary care teachinghospital. Material and Methods: This was aprospective observational study conducted at theteaching hospital during six month period. It was a timest bound study over a period of six months (from 1 Julyth 2018 to 30 December 2018). All suspects with throatswab/nasal swab positive for influenza H1N1 virus byReverse Transcriptase Polymerase Chain Reaction(RT-PCR) with age more than 15 years were includedin the present study. Data were analysed for mean,percentage, standard deviation and Chi square test forquantitative data by using Microsoft Excel spreadsheet. Results: A total 60 patients were admitted withconfirmed diagnosis of H1N1 infection. Out of the 21(35%) were males and 39 (65%) were females,predominated by female gender (p=0.001). The meanage in male (46.14 ± 20.058) was relatively morecompared to female gender (36.33 ± 11.50). The malegender had more co-morbidities and risk factorscompared to female patients (p=0.01) and wasstatistically significant. Out of total 21 male patients 7patients died because of bilateral pneumonia and AcuteRespiratory Distress Syndrome (ARDS) and MultiOrgan Dysfunction (MOD) with case fatality rate of33.33%. Out of total 39 female patients 5 patients diedwith case fatality rate of 12.82%. Conclusion: Thepresent study highlighted the disease burdenassociated with H1N1 infection. The advancing age,male gender, associated co-morbidities and delayedpresentation were the risk factors for mortality inpresent cohort study of H1N1 patients. The communityawareness, early case detection and timelymanagement can reduce the disease burden at large

Lung Involvement Is an Early Clue to Severe Dengue / 中山大学学报(医学科学版)

@#【Objective】To investigate the differences of lung involvement between dengue and severe dengue.【Methods】227 dengue patients admitted in The Third Affiliated Hospital of Sun Yat-sen University from July 2014 to October 2018 were enrolled. The clinical characteristics，treatment and outcome of the patients were analyzed to explore the differences of lung involvement between dengue and severe dengue （SD）. 【Results】 The rate of old age ，smoking ，hypertension，diabetes and cerebrovascular disease was higher in dengue with lung involvement group（DWLI）than dengue without lung involvement group（DWOLI）（χ2 were 25.146，3.847，10.326，7.177，and 5.355，P was 0.050 for smoking，the others were < 0.05）. The rate of cough and breathlessness was higher in DWLI（χ2 were 11.465 and 6.068，P were 0.001 and 0.014），as well as in SD subgroup（χ2 were 4.585 and 6.717，P were 0.032 and 0.010）. C-reactive protein and procalcitonin were increased in DWLI（Z were - 2.591 and - 3.033，P were 0.010 and 0.002）. The rate of pleural effusion was higher in SD subgroup（χ2 = 4.987，P = 0.026）. Bilateral lung infiltration was correlated with SD（χ2 = 5.910，P =0.015）. The rate of acute liver injury，acute kidney injury and multi-organ dysfunction syndrome（MODS）was higher in DWLI（χ2 were 7.044，7.059，and 11.315，P were 0.008，0.008 and 0.001）. The rate of anti-virus，anti-bacteria and combined therapy was higher in DWLI（χ2 were 13.156，32.845，and 12.684，P all were < 0.001）.【Conclusion】Dengue patients who were with old age，smoking，or suffered from underlying disease of hypertension，diabetes and cerebrovascular disease were vulnerable to lung involvement. Cough，breathlessness，pleural effusion and bilateral lung infiltration were signs of severe dengue. Attention should be paid to dengue with lung involvement.

Evaluation of complications and factors associated with multi-organ dysfunction in malaria: a cross sectional study

Background: Prevalence of complications in malaria continues to grow even with reducing number of malaria cases. Complications associated with malaria can involve multiple organs. There is paucity of literature on factors associated with multi organ dysfunction in different types of malaria.Methods: Our aim was to study the clinical profile of complications in different types of malaria with specific focus on multi-organ dysfunction (MODS). In this cross-sectional study confirmed cases of malaria were enrolled.Results: Plasmodium vivax malaria was the predominant type seen in 74.1% cases. The overall prevalence of thrombocytopenia was 61.5%, hepatic dysfunction 58%, cerebral malaria 16.1%, Hypoglycemia 7.5%, bleeding 34.5%, acute respiratory distress syndrome (ARDS) 5.7% and acute kidney injury (AKI) 49.4%. Hypoglycemia was significantly higher in mixed malaria (0.025, p = 0.025). Hepatic dysfunction and hyperbilirubinemia were significantly higher in mixed malaria (p=0.001). Mortality was seen in mixed malaria (p = 0.007). Only those with mixed malaria died (13%). Patients with MODS had higher prevalence of rashes (p <0.0001) and cerebral malaria (p = 0.000). Serum levels of urea, creatinine, Bilirubin, Serum glutamic oxaloacetic transaminase (SGOT) and Serum glutamic pyruvic transaminase (SGPT) were significantly higher in patients with MODS (p<0.0001 for all variables). On evaluating factors associated with multi-organ dysfunction presence of cerebral malaria [OR: 6.4 (95% CI): 2.4 to 17.4; p<0.0001], type of malaria (Vivax or Falciparum or both) [1.77 (1.03 to 3.03); p=0.0038], and hypoglycemia [4.4 (1.08 to 17.8); p=0.038] were statistically significant on multivariate analysis.Conclusions: The present study demonstrates the factors associated with multi organ dysfunction and its impact on clinical outcome in different types of malaria.

Clinical spectrum and outcome of paraquat poisoning in a tertiary care teaching hospital

Background: Paraquat is most common insecticide compound used for suicidal consumption in rural part of the Karnataka next to organo-phosphorous compound. It produces various local and systemic manifestations in the early course. It is very notorious to cause multi-organ dysfunction and mortality within 24 hours in severe amount of consumption. Lack of specific antidote and high-quality evidence based medicine makes the management of paraquat poisoning challenging. Hence, we took up the study to evaluate the clinical features, course and management option for the poisoning.Methods: It is an observational study conducted at HIMS, Hassan. History was collected from patient and bystanders. Clinical features, laboratory parameters were noted regularly and frequently. Patient’s complications were identified initially and treated accordingly. All the data collected were tabulated and statistically analysed.Results: Out of 110 patients, 72 were females and 38 were males; most of them were in the age group of 30-40 years. Mild poisoning was noted in 30, moderate in 56 and 24 patients were severe. Most common symptom was nausea and signs were oral cavity ulcers followed by tachycardia and tachypnoea. The overall mortality was 72%, 18% were recovered fully and 10% patients left against medical advice.Conclusions: Since there is a lack of antidote management of paraquat is challenging. Early gastric lavage, aggressive fluids, IV methyl prednisolone and N-Acetyl-Cysteine is beneficial.

Clinical characteristics and prognosis of novel bunyavirus infection: 68-case report / 中华传染病杂志

Objective To retrospectively analyze the clinical characteristics,prognosis and risk factors of novel bunyavirus infection.Methods The clinical data of 68 patients with novel bunyavirus infection confirmed by laboratory diagnosis at Wendeng Central Hospital of Weihai were retrospectively collected.Epidemiological characteristics,clinical manifestations,physical signs and laboratory results were analyzed.Results Twenty two patients (32.4 ％) had intimate contact with ermine (breeding ermine or ermine biting) ; 4 patients (5.9％) had been bitten by tick within 2 weeks,6 patients (7.4％) had intimate contact with patients with severe fever with thrombocytopenia syndrome (SFTS) ; and 25 patients (36.8 ％) had a history of fieldwork before the onset of the disease.Thirty-four patients (50.0 ％) were over 60 years old and 27 cases (39.7％) had underlying diseases.Initial symptoms in all patients were fever accompanied by loss of appetite,fatigue and other toxemic symptoms,followed by multi organ damage.Other clinical manifestations included nervous system damage (27 cases,39.7％),hemorrhage (4 cases,5.9％),rapid atrial fibrillation (10 cases,14.7％) and pneumonia (18 cases,26.5％).White blood cell count of 55 cases (80.9％) was less than or equal to 2.0 × 109/L,platelet count of 18 cases (26.5％) was less than or equal to 30 × 109/L.Abnormal hepatic function was found in 62 cases (91.2％); elevated myocardial enzymes was found in 68 cases (100.0％),prolonged activated partial thromboplastin time in 44 cases (64.7％),hyponatremia in 23 cases (33.8％),hypokalemia in 29 cases (42.6％),hypocalcemia in 36 cases (82.4％),hyperglycemia in 49 cases (72.1％).Serum nucleic acid quantitation of novel bunyavirus varied from 1.10 × 102 to 5.78 × 107 tissue culture infective dose (TCID)/ mL.Fifty five cases were cured,accounting for 80.9 ％,while 13 (19.1％) died eventually.Conclusions High risk factors of novel bunyavirus infection included intimate contact with ermine and infected patients,tick biting and fieldwork.Patients with elder age,underlying diseases,nervous system symptoms,hemorrhage,pneumonia,low platelet,high viral load and elevated myocardial enzymes may have poor progonsis.

Comparison of the Bama minipig and Juema minipig models of high altitude multi-organ dysfunction syndrome / 中国比较医学杂志

Objective To compare the Bama minipig and Juema minipig models of high altitude multi-organ dysfunction syndrome.Methods Six plateau-origin Juema minipigs and plain-origin Bama minpigs in each group received intravenous infusion of 0.35 mg/kg lipopolysaccharide ( LPS) , respectively.Blood samples were taken at 0 h, 3 h, 6 h, 12 h, 24 h, 48 h and 72 h after LPS infusion.Routine blood test was performed, blood CK, AST, ALT, TBIL, CRE were assayed, and histopathological examination of the lung tissues was performed at 24 h, 48 h after LPS infusion.Results The mortality of Bama minipigs was 33.3%, higher than that of 16.7%of Juema minipigs.The trend of physiological and biochemical changes was similar, but was milder in the Juema minipigs than in Bama minipigs.The lung injuries of the Bama minipigs at 24 h and 48 h were more severe than those in the Juema minipigs.Conclusions Both Bama and Juema minipig models of high altitude multi-organ dysfunction syndrome can be successfully established.Juema minipig models can be more closely and safely established, due to its own plateau biological properties, and avoid the influence by extrinsic injurious effects of plateau environment.

Analysis of the prevention effect of early individualized and comprehensive therapy on MODS in patients with severe acute pancreatitis / 重庆医学

Objective To investigate the effect of individualized and comprehensive therapy in treatment of severe acute pancrea-titis in early stage for preventing MODS .Methods 85 patients with severe acute pancreatitis treated in this Chengde medical college affiliated hospital from January 2008 to January 2012 were divided into two groups .The control group included 42 patients ,all used conventional basic treatment ;the test group included 43 patients ,and all used individualized and comprehensive therapy in early stage .The APACHEⅡ ,MODS and Ranson scores ,and serum inflammatory cytokines indexes of patients in each group before and after admission were all recorded .Results The APACHEⅡ and MODS scores after admission of test group were significantly low-er than the control group(P< 0 .05) .The TNF α,CRP and IL 10 after admission of two groups had significant difference (P<0 .05) .The MODS incidence of control group was 64 .3% (27/42) ,pancreatic encephalopathy incidence was21 .4% (9/43) ,the inci-dence of pancreatic infection was 33 .3% (14/42) ,hospital mortality incidence was 19 .1% (8/42) and length of hospital stay was (30 .4 ± 5 .7) d .The MODS incidence of test group was 27 .9% (12/43) ,pancreatic encephalopathy incidence was11 .6% (5/43) , pancreatic infection rate was 14 .0% (6/43) ,hospital mortality incidence was 4 .7% (2/43) and length of hospital stay was (23 .5 ± 4 .3) d .The incidence of MODS ,hospital mortality and pancreatic infection rates of test group were significantly lower than that of the control group (P<0 .05) .The average length of stay of test group were significantly lower than the control group (P<0 .05) . Conclusion To use individualized and comprehensive therapy in treatment of severe acute pancreatitis in early stage can reduce MODS ,protect organ function ,and reduce mortality .