[Pneumonia caused by Fusobacterium necrophorum: is Lemierre syndrome still current?]. / Fusobacterium necrophorum'un Neden Oldugu Pnömoni: Lemierre Sendromu Hala Güncel mi?

Fusobacterium necrophorum is a non-spore-forming gram-negative anaerobic bacillus that may be the causative agent of localized or severe systemic infections. Systemic infections due to F.necrophorum are known as Lemierre's syndrome, postanginal sepsis or necrobacillosis. The most common clinical course of severe infections in humans is a progressive illness from tonsillitis to septicemia in previously healthy young adults. A septic thrombophlebitis arising from the tonsillar veins and extending into the internal jugular vein leads to septicemia and septic emboli contributing to the development of necrotic abscesses especially in lungs and other tissues such as liver, bone and joints. In this case report, a previously healthy man with pneumonia and empyema due to F.necrophorum has been presented. A 22 year-old man suffering from sore throat for seven days was admitted to emergency department with ongoing fever and dysphagia for three days. On admission he was already taking amoxicillin-clavulanic acid and his complaints were relieved with continuation of therapy to a total of 10 days. However, five days after the cessation of treatment he developed productive cough, fever and generalized myalgia. On physical examination, there were crackles on right lower lung, and chest X-ray revealed pulmonary consolidation on the right middle lobe. Levofloxacin therapy was started based on the diagnosis of pneumonia. While polymorphonuclear leucocytes and intracellular gram-negative bacilli were seen in Gram stained sputum smear, sputum culture was reported as normal flora. Although the patient's status had started to improve with treatment, his condition deteriorated with development of fever and dyspnea. Chest X-ray revealed consolidation, pulmonary infiltrates, pleural effusion and air-fluid level on the right. Meropenem, clarithromycin and linezolid were initiated and a chest tube was inserted with the preliminary diagnosis of necrotizing pneumonia, empyema and type-1 respiratory failure. While there was no growth on bronchoalveolar lavage fluid culture, thoracentesis material inoculated into thioglycolate broth revealed turbidity. Further inoculation onto Schaedler agar which was incubated under anaerobic conditions, yielded growth of catalase negative, indol positive, gram-negative anaerobic bacilli identified as F.necrophorum by BBL Crystal system (Becton Dickinson, USA). The detailed history of the patient revealed that fish bone had stuck in his throat a week ago. Clarithromycin and linezolid were discontinued and he was recovered within six weeks of meropenem treatment. F.necrophorum infection should be considered in the differential diagnosis of persistent head and neck infections with rapidly progressive metastatic necrotic lesions especially in healthy young adults and clindamycin or metranidazol should be added to the treatment protocols.

Splenic artery embolization: An alternative approach in a critically ill patient with autoimmune hemolytic anemia.

Assessment of general health status and hematological parameters usually precedes the use of invasive diagnostic and therapeutic procedures in critically ill patients. Angiography can be effective and safe as a substitute for major surgical procedures, or as a bridging therapy in such cases. We present a critically ill patient with hemolytic anemia that underwent splenic artery embolization as a bridging therapy. We aimed to emphasize that minimally invasive approaches and multidisciplinary care can be utilized in the treatment of critically ill patients with accompanying hematological disease.

[Current strategies for the diagnosis and treatment of acute respiratory distress syndrome]. / Akut solunum sikintisi sendromu tanisi ve tedavisinde güncel yaklasimlar.

Acute respiratory distress syndrome is a frequently encountered condition in the intensive care units, with high mortality rates despite cumulating knowledge on its pathogenesis. It is important that cardiac pulmonary edema should be ruled out for diagnosis. Different mechanical ventilation strategies, as well as agents for the control of inflammation are being tested. Currently, low tidal volume ventilation with high PEEP and plateau pressures below 30 cmH(2)O is the only intervention that has been shown to improve survival significantly. Low dose steroids, nitric oxide inhalation, surfactant, antioxidants, Beta(2) adrenergic agents, HMG-CoA reductase inhibitors are promising agents. Fluid restriction and immunonutrition should be considered when these patients are being cared for.

Successful heparin desensitization after anaphylactic shock due to heparin.

A successful desensitization protocol in a patient with low molecular weight heparin induced anaphylactic reaction is being presented. A 72-years-old patient who was known to have multiple drug allergies and asthma was admitted with acute renal insufficiency. She had an anaphylactic reaction with a low molecular weight heparin during a hemodialysis session. Peritoneal dialysis was not feasible. Anticoagulation with warfarin was not considered appropriate; alternative anticoagulants were not available. Therefore a desensitization protocol was planned and applied, comprising of IV administration of diluted heparin by gradually increasing doses (0.1 to 5000 units), at 15 minute intervals, completing 8 hours before the procedure. By this way, IV heparin could be administered during the subsequent hemodialysis sessions with no reactions. The Naranjo probability scale revealed a probable adverse reaction associated with nadroparin for this patient. Anaphylactic reaction to low molecular weight heparins is reported rarely in the literature. To the best of our knowledge, this is the third case of successful heparin desensitization. When other anticoagulants are not available and anticoagulation is indispensible, heparin desensitization can be an option.

Ventilator-associated pneumonia caused by high risk microorganisms: a matched case-control study.

UNLABELLED: To determine the impact of ventilator-associated pneumonia (VAP) caused by high risk microorganisms (HRM) on patient outcome. DESIGN: Matched case-control study. The study was conducted in a medical intensive care unit (ICU) of a university hospital. Thirty-five patients with VAP caused by HRM, including Pseudomonas aeruginosa, Acinetobacter spp., Stenotrophomonas maltophilia and/or methicillin-resistant Staphylococcus aureus were accepted as the case the patients. Thirty-five control patients, who did not develop VAP were matched to the case patients, according to APACHE II score, age, date of admission and duration of mechanical ventilation (MV). ICU and hospital mortality rates were similar between the case and the control patients (p= 0.58 and p= 1.00, respectively). However, length of ICU stay was longer in the case patients than in the control patients [20 (11-30) days (median-interquartile range-) and 13 (8-19) days, respectively; p< 0.01]. Length of hospital stay was also longer in the case patients than in the control patients [29 (20-44) days and 22 (13-37) days, respectively; p= 0.05]. In addition, duration of MV was longer in the case patients than in the control patients [18 (10-25) days and 8 (6-11) days, respectively; p< 0.01]. VAP caused by HRM independently prolonged ICU (OR: 6) and hospital stay (OR: 4) and duration of MV (OR: 11). VAP caused by HRM was not significantly associated with mortality. However, it was an independent risk factor, increasing length of ICU stay and hospital stay by seven days, and duration of MV by 10 days.