Respiratory failure caused by tuberculous pneumonia requiring extracorporeal membrane oxygenation.

While a common pathogen, Mycobacterium tuberculosis (TB) pneumonitis is only rarely reported as a cause for respiratory failure in developed countries. We report an adolescent with TB pneumonitis and respiratory failure requiring extracorporeal membrane oxygenation (ECMO) with eventual survival. With the incidence of TB rising globally, TB should be suspected and treated as early as possible. ECMO should be considered as a treatment option if conventional ventilatory support is inadequate. ECMO survival with TB pneumonia and anti-TB antimicrobial therapy is possible.

Emergency department use of ketamine in pediatric status asthmaticus.

The objective of this study was to evaluate the effects of adding ketamine to standard emergency department (ED) therapy for patients with status asthmaticus. This was a prospective observational study. Ten patients with an acute exacerbation of asthma who were unresponsive to standard therapy were enrolled in the ED. Upon enrollment, children received ketamine at a loading dose of 1 mg/kg intravenously (i.v.), followed by a continuous infusion of 0.75 mg/kg/hr (12.5 microg/kg/min) for 1 hr. Clinical asthma score (CAS), vital signs, and peak expiratory flow (PEF) measurements were obtained prior to ketamine administration, within 10 min after ketamine administration was completed, and 1 hr after infusion. Median CAS on ED arrival was 15 (range 7-23) and did not significantly change immediately prior to infusion of ketamine (median 14, range 8-21). Median CAS decreased to 10.5 immediately after infusion and to 9.51 hr post ketamine infusion (37% reduction, p < 0.05 by ANOVA vs. preketamine CAS). Median respiratory rate (RR) also decreased from 39 prior to ketamine to 30 immediately following ketamine administration (25% decrease vs. preketamine; p < 0.05). Oxygen saturation significantly improved after ketamine infusion, although 5 patients remained on oxygen. Median PEF improved after infusion, but was not statistically significant. Four patients experienced mild side effects including mild hallucinations, diffuse flushing, and moderate hypertension. Side effects resolved with benzodiazepines or with discontinuation of the infusion. Addition of ketamine to standard therapy was associated with improved indices of acute asthma severity. Side effects were transitory and comparable to previous studies. However, a double-blinded randomized controlled trial needs to be conducted to determine if improvement is attributable to the addition of ketamine to standard asthma therapy.

Enteritis necroticans (pigbel) in a diabetic child.

BACKGROUND AND METHODS: Enteritis necroticans (pigbel), an often fatal illness characterized by hemorrhagic, inflammatory, or ischemic necrosis of the jejunum, occurs in developing countries but is rare in developed countries, where its occurrence is confined to adults with chronic illnesses. The causative organism of enteritis necroticans is Clostridium perfringens type C, an anaerobic gram-positive bacillus. In December 1998, enteritis necroticans developed in a 12-year-old boy with poorly controlled diabetes mellitus after he consumed pig intestines (chitterlings). He presented with hematemesis, abdominal distention, and severe diabetic ketoacidosis with hypotension. At laparotomy, extensive jejunal necrosis required bowel resection, jejunostomy, and ileostomy. Samples were obtained for histopathological examination. Polymerase-chain-reaction (PCR) assay was performed on paraffin-embedded bowel tissue with primers specific for the cpa and cpb genes, which code for the alpha and beta toxins produced by C. perfringens. RESULTS: Histologic examination of resected bowel tissue showed extensive mucosal necrosis, the formation of pseudomembrane, pneumatosis, and areas of epithelial regeneration that alternated with necrotic segments--findings consistent with a diagnosis of enteritis necroticans. Gram's staining showed large gram-positive bacilli whose features were consistent with those of clostridium species. Through PCR amplification, we detected products of the cpa and cpb genes, which indicated the presence of C. perfringens type C. Assay of ileal tissue obtained during surgery to restore the continuity of the patient's bowel was negative for C. perfringens. CONCLUSIONS: The preparation or consumption of chitterlings by diabetic patients and other chronically ill persons can result in potentially life-threatening infectious complications.

Do pediatric intensivists and radiologists concur on the interpretation of chest radiographs?

BACKGROUND: Therapeutic decisions in the pediatric intensive care unit are made by pediatric intensivists (PI) based on their interpretation of chest radiographs before the formal interpretation by a pediatric radiologist (PR). This study was designed to determine the adequacy of chest radiograph interpretations by pediatric intensivists and the effects on patient care. The PI recorded their chest radiograph interpretations, documenting support devices and thoracic abnormalities. Concordance and discordance were determined by the pediatric pulmonologist who was not involved in the care of the patient by comparing the interpretations of the PI and PR. Clinically significant discordance was defined as interpretations by the radiologist that differed to those from the PI that may have required therapeutic intervention. RESULTS: The evaluation of 291 chest radiographs demonstrated an overall concordance rate of 82.5% (240 out of 291; P < 0.05). There was no significant difference in the ability of critical care medicine physicians to identify atelectasis, infiltrates, pleural effusions, or airleaks (P > 0.05). Support devices were correctly identified in 100% of the cases. Discordant interpretations included 20 that were clinically significant, 17 insignificant findings and 14 films over-interpreted by the PI. A chart review of the patients with discordant findings revealed only one finding that required an alteration in therapy. CONCLUSIONS: These findings demonstrate significant agreement between the interpretation of chest radiographs by PI and PR in selected clinical situations. These data support the current practice of the PI making therapeutic decisions based on their interpretations of chest radiographs.

[Iatrogenic bronchial obstruction: study of 4 atopic children with bronchial obstruction induced by acetyl salicylic acid]. / Broncostruzione iatrogena: studio di 4 bambini atopici con broncostruzione scatenata da ASA.

The authors have studied the modification of the spirometric parameters in four atopic children, during nonallergic diet, after administration of ASA (400 mg). The examination of the respiratory functionality has showed a fall of parameters starting four hours after the challenge and with an increase of respiratory resistance. This bronchospastic reaction persisted for about eighteen hours to diminish 24 h. after administration of 400 mg of ASA. The study of spirometric values has showed a remarkable fall of MMEF, sign of small airways obstruction, but also of FEV1-CV for the involvement of the higher airways. The authors attribute the reaction to the metabolites of arachidonic acid (Leukotrienes) and to their different receptor site on the bronchial mucous membrane target cells. The authors conclude showing the gravity of injury that will induce imprudent administration of ASA in hypersensitive subject.

Collagen accumulation in the neonatal rat skin: absence of fibrillar collagen degradation during normal growth.

Collagen-bound collagenase activity was assayed in the entire skins of growing neonatal rats. The levels of fibrillar collagen degradation were found to be extremely low throughout the first six days of life. Less than one percent of the collagen accumulated during one day's growth could be degraded by the collagenase bound to the extracellular fibrils of the skin. Control experiments, which included the addition of purified rat uterine collagenase to the skins both before and after homogenization, showed that collagenase activity is easily detectable in the tissue when it is present. It therefore appears that the vast majority of skin collagen, once deposited as fibrils in the skin, fails to turn over during growth. Support for this concept was provided by experiments in which neonatal animals were injected with the potent synthetic glucocorticoid, triamcinolone. Very low levels of collagen-bound collagenase, comparable to those observed in control animals, were found in the steroid-treated animals. Furthermore, the inhibition of collagen synthesis in these animals resulted in a constant chemical content of collagen as well as a constant amount of proteinaceous [14C]-hydroxyproline after injection of [14C]-proline over a 72-hour period. Our results strongly suggest that the bulk of fibrillar collagen does not participate in a dynamic equilibrium between synthesis and degradation during normal neonatal growth. In addition, the results in steroid-treated animals suggest that the rate of collagen accumulation during this period appears to be essentially a function only of collagen synthesis.