Hemophagocytic syndrome: a dilemma chasing the intensivists.

Hemophagocytic lymphohistiocytosis or hemophagocytic syndrome is represented by an uncontrolled inflammatory response characterized by marked histiocyte activation and a cytokine storm. The entity may present a primary or genetic type, and the secondary type is usually triggered by infectious diseases of any kind, autoimmune disease, or neoplasia. This entity, although well described and with definite diagnostic criteria, still remains misdiagnosed because of the overlap presentation with other inflammatory processes. The authors present the case of a 13-year-old girl who was submitted to an appendicectomy complicated with a pericolic abscess, which required a second operation in order to be drained surgically. During the postoperative period of this second surgical procedure, the patient remained febrile, developing cytopenias, and multiple organ failure. Unfortunately, she died despite the efforts of the intensive care staff. The autopsy findings were characteristic of hemophagocytic syndrome. The authors report the case to call attention to this diagnosis whenever unexpected outcomes of infections are experienced.

[Incidence and endoscopic characteristics of airway injuries associated endotracheal intubation in children]. / Incidência e caracteristicas endoscópicas de lesões das vias aéreas associadas à intubação traqueal em crianças.

OBJECTIVE: Describe the incidence and endoscopic characteristics of airway injuries in children submitted to intubation. METHODS: During a two-year period (October/1999-October/2001) we conducted a prospective study in which all patients that required intubation, excluding those who deceased before extubation and newborns (NB) weighing less than 1.250 g, were submitted to airway endoscopy at extubation. The endoscopic findings were classified as minor, moderate or severe. Descriptions were made through proportions and medians, comparisons were done through chi-square for proportions. RESULTS: We studied 61 NB and 154 children. In 89.8%, 55 NB and 138 children (P=0.89), it was detected at least one lesion in a total of 507. Patients with minor lesions were 54.8% (IC95%: 48.1-61.5), those with moderate were 24.2% (IC95%: 18.5-30.0) and severe injury occurred in 10.7% (IC95%: 6.6-14.8). Lesions at the glottis (48.1% of lesions) and subglottis (35.1%) presented the highest incidence. Erosions had the highest incidence in both age groups (P=0.88). Vocal folds edema was the main moderate lesion in both groups (P=0.96), followed by ulcerations (P=0.92). Fibrous nodules at vocal folds and adhesions were the main severe injuries in both groups (P=0.12). Subglottic stenosis was detected in 2.8% of the patients without difference between groups (P=0.35). CONCLUSIONS: We observed a high incidence of airway injury, without statistical significant difference between age groups in regard to the incidence and characteristics of the injuries. Minor injury was detected in the majority of the population. Lesions were mainly noticed at the glottis and were characterized by erosions, edema and ulcerations.

Incidência e características endoscópicas de lesões das vias aéreas associadas à intubação traqueal em crianças / Incidence and endoscopic characteristics of airway injuries associated with endotracheal intubation in children

OBJETIVO: Descrever a incidência e características endoscópicas de lesões das vias aéreas em crianças submetidas à intubação. MÉTODOS: Durante o período de dois anos (outubro/99 a outubro/01) foi conduzido estudo prospectivo no qual todo paciente intubado, excetuando-se aqueles que evoluíram para óbito e recém-nascidos (RN) com peso inferior a 1.250g, foi submetido à endoscopia respiratória na extubação. Achados endoscópicos foram classificados em leves, moderados ou graves. Descrições foram realizadas por meio de proporções e medianas, comparações feitas por teste qui-quadrado para proporções. RESULTADOS: Foram estudados 61 RN e 154 crianças. Em 89,8 por cento dos pacientes, sendo 55 RN e 138 crianças (p=0,89), foi detectada pelo menos uma lesão somando 507. Pacientes com lesões leves corresponderam a 54,8 por cento (IC95 por cento: 48,1-61,5), aqueles com lesões moderadas foram 24,2 por cento (IC95 por cento: 18,5-30,0) enquanto as graves ocorreram em 10,7 por cento dos pacientes (IC95 por cento: 6,6-14,8). Locais principalmente acometidos foram glote (48,1 por cento das lesões) e subglote (34,9 por cento das lesões). Erosões foram as mais incidentes em ambos os grupos etários (p=0,88). Edema de prega vocal foi a principal lesão moderada em ambos os grupos (p=0,96), seguida por ulcerações (p=0,92). Nódulos fibrosos em pregas vocais e sinéqüias foram as principais lesões graves em ambos os grupos etários (p=0,12). Estenose subglótica foi detectada em 2,8 por cento da população sem diferença entre as faixas etárias (p=0,35). CONCLUSÕES: Verificou-se elevada incidência de lesões em vias aéreas, sem diferença significante entre os grupos etários com relação à incidência e características das lesões. Houve predomínio de lesões leves, lesões na glote e caracterizadas por erosões, edema e ulcerações.