Aspergilosis invasora multisistémica en un niño inmunocompetente: comunicación de un caso / Invasive multisystemic aspergillosis in an immunocompetent child: case report

La aspergilosis invasora es una patología grave, con una incidencia en aumento, que generalmente afecta a pacientes con inmunosupresión, existiendo escasa información en pacientes pediátricos inmunocompetentes. Reportamos el caso de un escolar de 8 años, previamente sano, que cursó con una aspergilosis invasora multisistémica de origen abdominal, en relación a una laparotomía contenida, evolucionando hacia una falla orgánica múltiple, con un desenlace fatal, a pesar de recibir terapia con anfotericina B deoxicolato más voriconazol y drenaje quirúrgico amplio. El estudio anátomo-patológico reveló elementos de hifas características dentro de diversos parénquimas e invasión vascular. La aspergilosis invasora debe tenerse presente entre las causas de infecciones emergentes en pacientes críticos, incluso en inmunocompetentes; se asocia a una elevada mortalidad a pesar de un adecuado y oportuno tratamiento.

Coqueluche grave con hipertensión pulmonar tratado con exanguineotransfusión / Severe Pertussis with pulmonary hypertension: cardiorespiratory improvement after exchange transfusion

Introducción: La infección grave causada por Bordetella pertussis en la infancia produce una alta mortalidad, a pesar del uso de soporte vital avanzado. Su mal pronóstico está ligado al desarrollo de hipertensión pulmonar refractaria, cuya etiopatogenia es pobremente entendida. La presencia de hiperleucocitosis en estos niños es un factor de riesgo conocido para la génesis de hipertensión pulmonar, sugiriéndose recientemente el empleo de terapias cito reductoras, entre ellas la exanguineotransfusión. Caso clínico: Comunicamos una lactante de 4 meses de edad, no vacunada que ingresa por coqueluche, con marcado compromiso de intercambio gaseoso, shock cardiogénico e hipertensión pulmonar grave asociados a leucocitosis de 78,800/µl. Ante fracaso de la terapia habitual se decide realizar exanguineotransfusiones, obteniéndose una buena respuesta hemodinámica y de intercambio gaseoso, temporalmente asociadas a la terapia, inexplicable por el curso natural de la enfermedad. Conclusión: El caso presentado sugiere que la exanguineotransfusión precoz puede ser una terapia útil en el tratamiento del coqueluche grave con hiperleucocitosis.

Septic shock secondary to scrub typhus: characteristics and complications.

Scrub typhus is an acute febrile illness caused by infection with Orientia tsutsugamushi transmitted by the bite of larval trombiculid mites (chiggers). A prospective study was conducted in septic shock patients in Maharat Hospital, Nakhon Ratchasima Province, Thailand, from 12 November 2001 to 5 January 2002. Of the 51 septic shock patients studied during the 7 week period, 18 (35.3%) were found to have evidence of scrub typhus infection; 3 patients (16.7%) died. In this study, septic shock caused by Orientia tsutsugamushi is the most prominent (35.3%) in endemic area of scrub typhus. Scrub typhus with septic shock patients results in organ failure: respiratory failure, DIC were predominant, followed by renal and hepatic involvement. Two deaths were due to respiratory failure and one death was as a result of combined respiratory and renal failure. Fever was the most common symptom, followed by headache, myalgia and dyspnea; lymphadenophathy and eschar are common signs. Laboratory findings revealed that almost all of the patients had a mild leukocytosis, reduced hematocrit and thrombocytopenia; SGOT, ALP, direct bilirubin (DB), total billirubin (TB), BUN, Cr were elevated; hypoalbuminemia was noted. Urinalysis showed that 88.9% of the patients had albuminuria. 77.8% of patients had abnormal chest X-rays.

Dístrés respiratorio debido a hemorragia pulmonar por leptospirosis / [Respiratory distress due to pulmonary hemorrhage in leptospirosis]

Two patients who lived in Buenos Aires suburbs died from leptospirosis in July 2000 and March 2001. They developed a nonspecific febrile illness followed by hemorrhagic pneumonia and respiratory distress in absence of typical manifestations such as jaundice, nephropathy, thrombocitopenia or hemorrhages in other organs. In the house and surroundings of one patient rodents were captured and three strains of leptospira, serogroup Icterohaemorrhagiae were isolated. Laboratory guinea pigs were inoculated and they were sacrificed as soon as respiratory symptoms appeared. Necropsy showed primary lung injury, which was similar to the histopathological lesions found in one of the patients. Neither jaundice, nor renal damage was found. Pericardiac hemorrhages were considered as a possible cause of cardiopulmonary collapse. This clinical form has not been reported previously in this region, where conditions are indeed suitable for the human illness to appear.

Causa de ingreso de pacientes VIH-SIDA a medicina intensiva: una experiencia nacional / Causes of admission to intensive care of HIV-SIDA patients: a national experience

Se revisa la experiencia de los autores, en la asistencia de 52 pacientes de VIH-SIDA, asistidos en nuestro medio. Se analizan las causas de ingreso, poniendo especial énfasis en el manejo de la insuficiencia respiratoria y las etiologías infecciosas desencadenantes de la misma, con particular atención a las neumonías por Pneumocystis carinii, neumococo y Mycobacterium tuberculosis. Se destaca el aporte que ha significado como método ventilatorio la CPAP con máscara. Resulta llamativo en esta serie la frecuente presencia de endocarditis en portadores. Se discute la posibilidad de pautar cuales de estos pacientes se benefician del ingreso a áreas de medicina intensiva

Nosocomial infections in respiratory failure patients in intensive care unit

The subjects of this study were 20 ventilated patients with acute respiratory failure and chronic obstructive disease [COD] admitted to the General Intensive Care Unit of Zagazig University Hospital and needed ventilation. Sputum samples from patients and swabs from different parts of ventilators were cultured on Blood agar and MacConkey's agar. Then these cultures were examined for bacterial growth, colonial morphology and cultural characteristics, Gram stained films were done and examined microscopically to identify the organism. As regards ventilated patients 9 patients out of 20 [45%] were already infected before ventilation. After 24 hours the incidence of infection increased to 11 patients [55%]. While after 48 hours 16 patients out of 20 [80%] were infected and increased to 18 patients [90%] after 72 hours. The most predominate organisms isolated from endotracheal secretion were Gram-negative bacilli. [40%]. The use ventilators limb were found to be the main source of contamintion. Only one ventilator [5%] was found to be contaminated from limbs before use. After 24 hours 8 ventilators [50%] and after 48 hours ventilators [45%] were contaminated 10 ventilators [50%] were contaminated from limb after 72 hours. The most prevalent organisms isolated from ventilators were Gram-negative bacilli. The antibiotic sensitivity of the isolated organisms was done

Bombay experience in intensive respiratory care over 6 years.

The experience of the intensive respiratory care in 930 cases treated from 1983 for 4 years and in 404 cases over the next 2 years is reported. The background operational problems are stressed. Those between age 10 and 50 years did significantly better (p less than 0.05). The survival over the first 4 years in IPPR cases was 16.3% and in non IPPR group 71.8%; over the next 2 years, the former group, survival was 32.4 and 36.3%. The survival in asthmatic patients was high (76%). In cases with organophosphorus poisoning (without IPPR), survival was 81% while in IPPR group it was 29%. In 1988, the results in this group were better due to more aggressive management. In autopsy data on 85 cases, infection was not a major feature in those dying within 24 hours. The survival in COPD cases showed significant relation to age (p less than 0.05), initial arterial pO2 below 60 mm (p less than 0.01) and arterial pH below 7.3 (p less than 0.01). In cases with pneumonia (also asthma) younger cases did better (p less than 0.05) as also those with pneumonia and initial pO2 above 60 mm (p less than 0.01) and pH above 7.3 (p less than 0.001). When pneumonia was community acquired, survival (64.8%) was better than when it was hospital acquired (24%; p less than 0.01). Only the need for IPPR affected survival in trauma group. The major cause of death was infection with Klebsiella, Pseudomonas, Staphylococci and other gram--ve organisms. It is concluded that with proper planning and training, the IRCU does provide a useful mode of treatment in selected patients with respiratory problems.