Secondary Hemophagocytic Lymphohistiocytosis Due to Typhoid Fever.

Hemophagocytic lymphohistiocytosis (HLH) is a potentially fatal hyper-inflammatory state that is caused by a highly activated but ineffective immune system. It can be primary or secondary to triggers like infections, malignancies, and autoimmune conditions. The authors present the case of a young male with a fever and abdominal pain due to typhoid. He continued to have a high-spiking fever and developed dyspnea, requiring oxygen therapy despite being treated with appropriate antibiotics. Laboratory evaluation revealed cytopenias and deranged liver function tests, and abdominal imaging revealed hepatosplenomegaly. These clinical and laboratory findings raised suspicion of HLH secondary to typhoid fever. Further investigations were suggestive of hyperferritinemia and hypofibrinogenemia, and bone marrow aspirates showed hemophagocytes. The patient was treated with immunosuppression (dexamethasone) and antibiotics and showed remarkable recovery. Hemophagocytic lymphohistiocytosis should be suspected in patients with tropical infections like enteric fever, tuberculosis, malaria, dengue, etc. that worsen despite appropriate treatment, as late diagnosis is associated with greater mortality.

Modified Nutrition Risk in Critically Ill Score, A Prognostic Marker of Morbidity and Mortality in Mechanically Ventilated Patients: A Prospective Observational Study.

BACKGROUND: Critically ill (CI) patients, especially those requiring mechanical ventilation (MV) are at a higher risk of malnutrition, which in turn is associated with increased hospitalization and excess mortality. The modified Nutrition Risk in Critically Ill (mNUTRIC) score, a predictor of mortality, has not been validated adequately in CI Indian patients. Thus, this study evaluated the mNUTRIC score as a prognostic marker of morbidity and mortality in CI patients requiring MV. MATERIALS AND METHODS: This prospective observational study was performed, between January 2018 and June 2019, in the intensive critical care unit (ICCU) of the medicine department of a tertiary care hospital. A total of 250 patients aged above 12 years, admitted in ICCU, and requiring MV for >48 hours were included. Based on the data collected, mNUTRIC score was calculated and patients were classified as at low (0-4) and high (5-9) nutritional risk. Mortality was the outcome variable. RESULTS: More than a quarter of patients had a high mNUTRIC score (28.4%) and the overall mortality was 35.6%. A significantly greater proportion of non-survivors had a high mNUTRIC score (p-value<0.0001). Likewise, the mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Sequential Organ Failure Assessment (SOFA) score, and mNUTRIC score (all p-values<0.0001) were significantly higher among the non-survivors than the survivors. On receiver operator characteristic (ROC) curve analysis, a cutoff value of >2 predicted mortality [area under the curve (AUC): 0.83; 95% confidence interval: 0.778-0.874] with a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 80.9, 76.4, 65.5, and 87.9%, respectively. CONCLUSION: At a cutoff of >2, mNUTRIC score had high sensitivity and specificity in the prediction of mortality.

Comparison of Acute Physiology and Chronic Health Evaluation II, Modified Computed Tomography Severity Index, and Bedside Index for Severity in Acute Pancreatitis Score in Predicting the Severity of Acute Pancreatitis.

AIMS OF THIS STUDY: Severe acute pancreatitis has been defined recently based on the persistence of organ failure at 48 hours of admission. The bedside index for severity in acute pancreatitis (BISAP) score, a simplified scoring system to predict severity of acute pancreatitis, is proposed to be useful in early risk stratification of acute pancreatitis. Our aim was to prospectively compare BISAP score with the already established acute physiology and chronic health evaluation II (APACHE II) and modified computed tomography severity index (CTSI) scores in predicting the severity of acute pancreatitis. MATERIALS AND METHODS: A total of 87 consecutive cases presenting with the first attack of acute pancreatitis were included in the study. Acute physiology and chronic health evaluation II and BISAP scores were calculated from the worst parameters in the first 24 hours, and modified CTSI was reported at 48 hours of admission. Receiver-operating characteristic (ROC) curves were plotted, and predictive accuracy of each score was calculated from the area under the curve. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for each score. RESULTS: A total of 20 patients (23%) had severe acute pancreatitis with a total of 11 mortalities (12.64%), 10 of them in the severe acute pancreatitis group. Acute physiology and chronic health evaluation II, modified CTSI, and BISAP score all correlated well with each other. Modified CTSI and BISAP score also correlated with duration of hospital stay. Areas under the curve for APACHE II (≥8), modified CTSI (≥8), and BISAP score (≥2) were 0.826, 0.806, and 0.811, respectively, suggesting similar predictive accuracy. CONCLUSION: The BISAP score was similar to APACHE II and modified CTSI in terms of accuracy, sensitivity, specificity, and NPV. It is much easier to calculate and a useful risk stratification tool. It should be used for early triage and referral to a high dependency unit. HOW TO CITE THIS ARTICLE: Chatterjee R, Parab N, Sajjan B, Nagar VS. Comparison of Acute Physiology and Chronic Health Evaluation II, Modified Computed Tomography Severity Index, and Bedside Index for Severity in Acute Pancreatitis Score in Predicting the Severity of Acute Pancreatitis. Indian J Crit Care Med 2020;24(2):99-103.

Complements Spurned: Our Experience with Atypical Hemolytic Uremic Syndrome.

Atypical hemolytic uremic syndrome (aHUS) is a rare disorder resulting from a dysregulated activation of the alternative pathway of the complement system. It results in significant morbidity and mortality if not diagnosed and treated promptly. It lends itself to myriad renal and extrarenal manifestations, all potentially disabling. Eculizumab, a monoclonal antibody to complement C5 is now the widely accepted norm for treatment. However, in resource-limited settings, plasma exchange if instituted early may be as beneficial. We report a case of aHUS treated with extended plasma exchange with excellent results. Critical care monitoring is essential for the management of the disease in view of a tendency to develop multiple complications. Long-term immunosuppression may be successful in maintaining remission.

Subacute Sclerosing Panencephelitis in Pregnancy.

Subacute sclerosing panencephalitis (SSPE) is a rare delayed complication of measles virus infection in infancy. We present here 7 month pregnant lady who had SSPE. She delivered low birth-weight baby prematurely which died on 3rd day of delivery. Patient died due to sepsis one month after admission.