Síndrome da angústia respiratória aguda associada à varicela em paciente adulto: exemplo de suporte respiratório extracorpóreo em doenças endêmicas brasileiras / Varicella associated acute respiratory distress syndrome in an adult patient: an example for extracorporeal respiratory support in Brazilian endemic diseases

Descreveu-se aqui o caso de um homem de 30 anos de idade com quadro de varicela grave, hipoxemia refratária, vasculite do sistema nervoso central e insuficiência renal anúrica. Foi necessário transporte por ambulância com suporte respiratório extracorpóreo veno-venoso, sendo este utilizado até a recuperação do paciente. Discute-se o potencial uso de oxigenação por membrana extracorpórea em países em desenvolvimento para o controle de doenças comuns nestas áreas.

A case of a 30 year-old man presenting with severe systemic chickenpox with refractory hypoxemia, central nervous system vasculitis and anuric renal failure is described. Ambulance transportation and support using veno-venous extracorporeal membrane oxygenation were necessary until the patient recovered. Ultimately, the potential use of extracorporeal membrane oxygenation support in low-middle income countries to manage common diseases is discussed.

Efectos de la ventilación en posición prono extendida en SDRA secundario a influenza A(H1N1) / Impact of extended prone position ventilation in patients with severe ARDS secondary to influenza A(H1N1)

Introducción: Durante la pandemia por influenza A(H1N1), Chile alcanzó una de las tasas de casos más alta del mundo. Nuestro hospital recibió numerosos afectados el 2009 y 2010. Evaluamos el impacto de ventilación en posición prono (VPP) extendida, en las variables respiratorias de pacientes con SDRA grave secundario a influenza, y comparamos estos resultados con los obtenidos en otras series de VPP. Métodos: Estudio prospectivo, intervencional en UCI. Los pacientes recibieron oseltamivir y antibióticos y fueron manejados según protocolos (ventilatorio y no ventilatorio). Aquellos con criterios de SDRA grave fueron pronados hasta un índice de oxigenación <10. Se registraron parámetros de intercambio gaseoso, ventilatorios y desenlaces clínicos. Resultados: 12 pacientes con SDRA grave (edad 46+/-12 años, 7 hombres, APACHE II 17+/-6, SOFA 9+/-3) requirieron VPP, que se instauró a las 14(7-39) horas de ventilación mecánica (VM) y se mantuvo por 72(54-96) horas. Ningún paciente experimentó complicaciones mayores. La PaO2:FiO2 mejoró de 82(63-101) mmHg a 145(138-223) mmHg, (p<0.001). El tiempo en VM fue 20+/-13 días y en UCI 22+/-13 días. La mortalidad hospitalaria fue 25 por ciento y no cambió en el seguimiento de más de 8 meses. Este comportamiento con VPP fue similar al observado en otras series de SDRA grave. Conclusión: Los resultados obtenidos sugieren que la VPP resultó segura y se asoció a mejoría del intercambio gaseoso en pacientes con SDRA por influenza A(H1N1). Aunque el número reducido de pacientes no permite sacar mayores conclusiones, la VPP extendida podría ser de utilidad en los casos más graves causados por esta nueva influenza.

Introduction: During pandemic for influenza A(H1N1), Chile achieved one of the highest rates of infection worldwide. On 2009 and 2010, our hospital received a large number of infected patients. We evaluated the impact of extended prone position ventilation (PPV) on respiratory variables from severe ARDS patients secondary to this influenza. We also compared these results with those obtained with PPV in other series. Methods: Prospective, interventional study, performed in a mixed-ICU. Patients received oseltamivir and antibiotics, and were treated according to protocols (ventilatory and non-ventilatory). Severe ARDS patients were proned until oxygenation index was < 10. Oxygen exchange, ventilatory parameters and clinical outcomes were registered. Results: 12 severe ARDS patients (46+/-12 y.o., 7 men, APACHE II 17+/-6, SOFA 9+/-3) required PPV, which was started 14(7-39) hours after mechanical ventilation (MV) initiation, and it was maintained for 72(54-96) straight hours. No major complication was described. Three patients needed two periods of PPV. PaO2:FiO2 improved significantly with PPV from 82(63-101) mmHg to 145(138-223) mmHg, (p<0.001). Time on MV was 20+/-13 days, and LOS in UCI was 22+/-13 days. Hospital mortality was25 percent and remained unchanged for at least 8 month of follow-up. PPV had the same effect than in other severe ARDS series. Conclusion: Our results suggest PPV is safe and it was associated with improvement in oxygen exchange in ARDS secondary to A(H1N1) influenza. Although the small number of patients does not allow drawing any major conclusion, we believe PPV can be useful to treat severe ARDS cases due to influenza infection.

Follow-up after acute respiratory distress syndrome caused by influenza a (H1N1) virus infection

BACKGROUND: There are no reports on the long-term follow-up of patients with swine-origin influenza A virus infection that progressed to acute respiratory distress syndrome. METHODS: Four patients were prospectively followed up with pulmonary function tests and high-resolution computed tomography for six months after admission to an intensive care unit. RESULTS: Pulmonary function test results assessed two months after admission to the intensive care unit showed reduced forced vital capacity in all patients and low diffusion capacity for carbon monoxide in two patients. At six months, pulmonary function test results were available for three patients. Two patients continued to have a restrictive pattern, and none of the patients presented with abnormal diffusion capacity for carbon monoxide. All of them had a diffuse ground-glass pattern on high-resolution computed tomography that improved after six months. CONCLUSIONS: Despite the marked severity of lung disease at admission, patients with acute respiratory distress syndrome caused by swine-origin influenza A virus infection presented a late but substantial recovery over six months of follow-up.

Identificación de otros agentes infecciosos en casos sospechosos de síndrome cardiopulmonar por hantavirus / Identification of infectious agents in cases suspicious of Hantavirus infection but with negative serology

Background: The diagnosis of acute respiratory illness caused by Hantavirus is based in the rapid and progressive clinical course, epidemiological background and the serological confirmation of the virus. When the presence of the virus is not confirmed a differential diagnosis must be made with other infections. Between 1999 and 2001, the Chilean Public Health Institute received 1063 blood samples from patients with a suspicious clinical picture, to study the presence of Andes strain of Hantavirus. In 134 of these samples, the presence of the virus was confirmed. Aim: To study the presence of other infections in sera from patients with suspected Hantavirus acute respiratory illness but serologically negative for Hantavirus. Material and methods: A retrospective study of 98 serum samples, received at the National Public Health Institute, of patients with negative serology for Hantavirus. The presence of antibodies against influenza virus, Mycoplasma pneumoniae, Leptospira and Streptococcus pneumoniae was determined using Latex techniques. Results: Leptospira was detected in 23 patients, influenza virus in 13, Streptococcus pneumoniae in six and Mycoplasma pneumoniae in one case. Leptospira infections were confirmed in four cases by ELISA determination of IgM antibodies. Influenza virus infection was confirmed in three cases by Hemmaglutation Inhibition Assay. Conclusions: In suspected cases of Hantavirus acute respiratory infection, but with negative serology, other infectious agents such as Leptospira, influenza virus and Streptococcus pneumoniae, must be sought.

Diagnóstico rápido de los principales virus respiratorios en Ciudad de la Habana, 1995-97 / Rapid diagnosis of principal respiratory viruses in the city of Havana, 1995-97

Acute respiratory diseases (ARD) are the most common infections in humans and difficult to prevent. Viruses have been recognized as predominant ethiological agents. In Cuba, ARD constitute a major problem of health and are the first cause of morbidity and important cause of mortality. In this paper, rapid diagnosis was performed to 516 clinical samples which arrived to the Reference Respiratory Viruses Laboratory of the Pedro KourÝ Institute of Tropical Medicine (IPK) from different parts of Havana City during 1995, 1996 and 1997. The results obtained have shown 218 positive samples (Influenza A, 89; respiratory syncytial virus 52; Influenza B, 45; Adenovirus, 13; human parainfluenza virus(HPIV)-1, 6; HPIV-2, 3 and HPIV-3, 10). Influenza A was the virus most frequently found in adults, whereas in closed population of teen-agers and adults, Influenza B was frequently found. Furthermore, respiratory syncytial virus was the most important pathogen in children's under 1 year of age.