Loxosceles venom-induced cytokine activation, hemolysis, and acute kidney injury.

Herein, we describe a confirmed case of Loxosceles spider bite that illustrates the critical complications seen in loxoscelism, including skin necrosis, rhabdomyolysis, hemolysis, coagulopathy, acute kidney failure, and electrolyte disorders. Upon initial assessment, laboratory studies revealed the following: the white blood cell count was 29,400 WBCs/mm(3), hemoglobin was 9.2g/dL, and the platelet count was 218,000 cells/mm(3). Coagulation studies revealed the following: international normalized ratio, 1.83; activated partial-thromboplastin time, 62 s; D-dimer, 600 ng/mL (normal range <500 ng/mL); free protein S, 37% (normal range=64-114%); protein C, negative; and antithrombin III, negative. Various serum levels were abnormal: urea, 110 mg/dL; creatinine, 3.1mg/dL; indirect bilirubin, 3.8 mg/dL; creatine kinase, 1631 U/L; lactate dehydrogenase, 6591 U/L; potassium 6.2 mmol/L. Urine tests were positive for hemoglobin and bilirubin. In addition, concentrations of interleukin-6 and tumor necrosis factor-alpha were notably elevated in the serum. In conclusion, physicians must be alert to the possibility of loxoscelism when a patient presents with the clinical and laboratory findings described above, especially if the patient resides in an endemic area. Advances in our understanding of multiple pathways and mediators that orchestrate the response to Loxosceles venom might reveal new possibilities for the management of loxoscelism.

Listeria monocytogenes pneumonia in a cirrhotic child.

A 13-year-old girl with cirrhosis and cyanotic heart disease was admitted with a three-day history of pneumonia. The chest roentgenogram revealed left-sided pleural effusion and cultures from the pleural fluid yielded Listeria monocytogenes. The authors discuss the epidemiologic, clinical, and pathophysiological aspects of L. monocytogenes pneumonia and its association with cirrhosis.

[Meningoencephalitis in the acute phase of measles. Report of 6 cases]. / Meningoencefalite na fase aguda do sarampo: relato de seis casos.

We present the clinical and laboratory manifestations of encephalitis following measles in six patients which were diagnosed during the epidemics that occurred in the city of São Paulo, Brazil, in 1997. We performed retrospective case analysis of the six patients diagnosed as having encephalitis due to measles. Encephalitis was diagnosed based on clinical grounds and on the cerebrospinal fluid (CSF) alterations. All the cases were serologically confirmed. Of 467 patients with measles who presented themselves for medical care at the Instituto de Infectologia Emílio Ribas six were diagnosed with encephalitis. Patient's age was 2 months to 28 years old. The most frequent symptoms were drowsiness and nuchal rigidity. CSF showed an increased of white cell count in all cases. Four patients were admitted to the intensive care unit. Two of them required mechanical ventilation. In only two patients did the computerized tomography show abnormalities. All showed good recovery without sequelae.

Acute lung injury in leptospirosis: clinical and laboratory features, outcome, and factors associated with mortality.

Forty-two consecutive patients with leptospirosis and acute lung injury who were mechanically ventilated were analyzed in a prospective cohort study. Nineteen patients (45%) survived, and 23 (55%) died. Multivariate analysis revealed that 3 variables were independently associated with mortality: hemodynamic disturbance (odds ratio [OR], 6.0; 95% confidence interval [CI], 0.9-38.8; P=. 047), serum creatinine level >265.2 micromol/L (OR, 10.6; 95% CI, 0. 9-123.7; P =.026), and serum potassium level >4.0 mmol/L (OR, 19.9; 95% CI, 1.2-342.8; P=.009). These observations can be used to identify factors associated with mortality early in the course of severe respiratory failure in leptospirosis.

Descending suppurative mediastinitis: nonsurgical approach to this unusual complication of retropharyngeal abscesses in childhood.

OBJECTIVE: To alert the pediatric emergency physician about suppurative mediastinitis as an unusual, life-threatening complication of retropharyngeal abscesses in children and to report an alternative therapeutic option for these cases. METHODS: We describe a case of suppurative mediastinitis secondary to a retropharyngeal abscess in a 19-month-old girl and discuss the pathophysiology, diagnosis, and treatment of this disease. RESULTS: Prompt diagnosis, based on clinical, radiographic, and CT findings, followed by immediate retropharyngeal drainage and appropriate antibiotic therapy, allowed conservative management of the mediastinal abscess, without the need for surgery. The child presented a good outcome and was discharged on hospital day 14. CONCLUSIONS: When evaluating a retropharyngeal abscess, the pediatric emergency physician should be aware of its complications. A chest radiograph should be prescribed for each patient presenting with an indolent course. Widening of the mediastinum should be considered as strong evidence of a mediastinal abscess for which the best therapeutic option is aggressive surgical drainage. In the rare cases in which marked improvement is achieved after retropharyngeal drainage, a nonsurgical approach to the mediastinal abscess could be attempted. CT scan and a simple chest radiograph have proved to be useful for diagnosis and follow-up.

Fatal group A Streptococcal toxic shock-like syndrome in a child with varicella: report of the first well documented case with detection of the genetic sequences that code for exotoxins spe A and B, in São Paulo, Brazil.

A previously healthy seven-year-old boy was admitted to the intensive care unit because of toxaemia associated with varicella. He rapidly developed shock and multisystem organ failure associated with the appearance of a deep-seated soft tissue infection and, despite aggressive treatment, died on hospital day 4. An M-non-typable, spe A and spe B positive Group A Streptococcus was cultured from a deep soft tissue aspirate. The criteria for defining Streptococcal toxic shock-like syndrome were fulfilled. The authors discuss the clinical and pathophysiological aspects of this disease as well as some unusual clinical findings related to this case.

[Fluid and electrolyte disorders] / Distúrbios hidroeletrolíticos.

OBJECTIVE: To review the major concepts involving electrolyte disorders in pediatrics, with special emphasis on the diagnosis and treatment.METHOD: Systematic literature review, searching through classic pediatric textbooks, periodic electronic databases, such as Medline, Lilacs and other sources. RESULTS: Electrolyte disorders are among the most common events in pediatric medical practice, specially in emergency care, where, depending upon the magnitude, they may represent significant risk to patient life or to the development of permanent sequelae. Dehydration, independent of etiology, has its importance defined by the severity of water deficit (mild, moderate or severe) and by the proportion of sodium waste in relation to water deficit (isotonic, hypotonic and hypertonic), and should be correctly recognized to guide adequate treatment. Sodium disorders have major risks of central nervous system compromise and potassium disorders are specially linked to cardiac arrhythmia, always deserving special attention and care. On the other hand, calcium, phosphorus and magnesium disorders are more related to neuromuscular function alterations and, although less threatening, they need adequate recognition and management.CONCLUSION: Knowledge of the several mechanisms involved in water and electrolyte metabolism is crucial to the correct comprehension, diagnosis and management of fluid and electrolyte disorders in pediatrics.

[Necrotizing fasciitis. Case report and review of literature]. / Fasciíte necrotizante. Relato de caso e revisão de literatura.

Necrotizing fasciits (NF) is a rapidly progressive disease characterized by extensive necrosis of the fascia, skin, and subcutaneous tissue, with characteristical sparing of the underlying muscle. It is considered to be a rare entity and is associated with a high mortality rate since early recognition and treatment are not provided. Extensive surgical debridement of all necrotic tissues and appropriate antimicrobial treatment are the cornerstones for a successful treatment. We present a case of NF in a 36-year-old man and discuss it's pathophysiology, clinical manifestations and the best therapeutic choice for this potential life threatening disease.

Acute disseminated encephalomyelitis: an unusual cause of encephalitic syndrome in childhood.

Acute disseminated encephalomyelitis is a rare central nervous system demyelinating disease that occurs most frequently in children. It usually runs a monophasic course, beginning with fever, headache, and meningeal signs and rapidly progressing to coma when appropriate diagnosis and treatment are not provided. We report a case of a 14-year-old patient to alert emergency physicians to consider acute disseminated encephalomyelitis when presented with any child with encephalitic signs with nonspecific cerebrospinal fluid findings, failure to detect any causative agent, and only mild alterations on computerized tomography scan. The role of magnetic resonance imaging for the diagnosis is emphasized.

Primary community-acquired pneumonia by Escherichia coli. Case report and review of the literature.

A two year old girl with chronic neurologic convulsive disease was admitted with a six day history of pneumonia and, despite treatment, died on hospital day 3. The X-ray revealed right upper lobar pneumonia. The results of pleural effusion and blood cultures drawn on admission yielded a non-typable Escherichia coli. No other source of infection was identified. The authors discuss the clinical and pathophysiological aspects of Escherichia coli pneumonia.

[Necrotizing tracheobronchitis in an infant]. / Traqueobronquite necrotisante: relato de um caso em lactente.

OBJECTIVE: To alert the pediatric emergency physician about an unusual cause of airways obstruction in children undergoing mechanical ventilation. METHODS: We report a case of necrotizing tracheobronchitis (NTB) in an 8-month-old boy and discuss the pathophysiology, diagnosis and treatment of this disease. RESULTS: This child presented a good outcome that was related to prompt diagnosis and treatment with bronchoscopic removal of necrotic tissue. CONCLUSIONS: The pediatric emergency physician must consider NTB in every children undergoing mechanical ventilation who presents acute episodes of airways obstruction, hypercarbia, lack of chest movement and pulmonary hyperinflation, even out of the perinatal period. This characteristic clinical presentation, when recognized, is an indication for emergency tracheobronchoscopy.

Outcome of acute renal failure in meningococcemia.

We studied 28 consecutive patients (18 males and 10 females), 1-32 years of age, admitted to the intensive care unit from January 1989 to July 1995, with acute renal failure (ARF) due to meningococcal septicemia. All patients were treated with dexamethasone, penicillin, and/or chloramphenicol. Twenty-two patients presented septic shock and needed fluid replacement and vasoactive drugs. Acute renal failure was oliguric in 67.8%. Maximum levels of blood urea and serum creatinine were 210.3 +/- 26.6 mg/dL and 6.9 +/- 1.3 mg/dL, respectively. Metabolic acidosis was observed in 89.3% and hyperkalemia in 43%. The fractional excretion of sodium on day 1 was high (9.9 +/- 0.6%). The urinalysis did not show trace protein, but hematuria was positive in 81%. The mortality rate was 63.3%. In the 10 survivors, oliguria was present for a period of 12.7 +/- 2.4 days, and the period to reach a normal serum creatinine level was 20.2 +/- 4.7 days, although in two female patients, 7 and 17 years old, the elevated serum creatinine persisted. Renal biopsy was performed in one of these patients which revealed bilateral cortical necrosis. These data show that acute renal failure in meningococcemia presents high mortality rate associated to shock; 80% of the survivors recover renal function; and bilateral cortical necrosis occurred in one patient in this series.