[ECMO support in a child with cardiogenic shock due to Kingella Kingae endocarditis]. / ECMO en un lactante con shock cardiogénico secundario a endocarditis por Kingella Kingae.

INTRODUCTION: Endocarditis is a rare disease in children, especially in those without previous heart disease, and Kingella Kingae (KK) is rarely identified as the cause. Extracorporeal membrane oxyge nation (ECMO) is a support for both heart and respiratory failure. OBJECTIVE: To report the first case of infectious endocarditis (IE) due to KK which required ECMO support secondary to refractory cardiogenic shock. CLINICAL CASE: 19-months-old previously healthy female patient, with a 2-day his tory of fever, and diagnosed with hand-foot-and-mouth disease. The patient developed refractory cardiogenic shock, multiorgan failure, acute respiratory distress syndrome, and deep hemodynamic compromise that required veno-arterial ECMO support. The echography showed an image compa tible with mitral valve vegetation, confirming IE with transthoracic echocardiography. Blood culture was positive for KK. She had an ischemic stroke and required two heart surgeries, the first one for the mass resection and the second one for mitral valve repair, which had a posterior ring pseudoa neurysm. The patient had a favorable evolution and was discharged 73 days after admission. At one year of follow-up, she had no cardiological symptoms, but a mild right brachial-crural hemiparesis persisted. CONCLUSION: This is the first reported case of IE due to KK that required extracorporeal life support. KK endocarditis is an uncommon pathology that can cause multiorgan failure, which can be successfully supported with ECMO.

ECMO en un lactante con shock cardiogénico secundario a endocarditis por Kingella Kingae / ECMO support in a child with cardiogenic shock due to Kingella Kingae endocarditis

Resumen: Introducción: La endocarditis es una enfermedad poco frecuente en niños, especialmente en los sin patología cardiaca previa, y de manera extraordinaria se identifica a Kingella Kingae (KK) como la causa. La oxigenación por membrana extracorpórea (ECMO) es una forma de soporte tanto para fa lla cardiaca como respiratoria. Objetivo: Reportar el primer caso de endocarditis infecciosa (EI) por KK que requiere soporte con ECMO por shock cardiogénico refractario. Caso clínico: Lactante de 19 meses, previamente sana, que consultó por cuadro de 2 días de fiebre, diagnosticándose síndrome pie mano boca. Evolucionó con shock, falla multiorgánica, síndrome de distress respiratorio agudo y compromiso hemodinámico profundo, por lo que se le dio soporte con ECMO veno arterial. La ecoscopía mostró imagen compatible con vegetación en válvula mitral, confirmando EI con ecocardiografía transtorácica. El hemocultivo fue positivo a KK. Presentó accidente cerebrovascular isquémico. Requirió dos cardiocirugías -la primera para resección de la masa y la segunda para la reparación de la válvula mitral, que había quedado con un pseudoaneurisma del anillo- velo posterior. La paciente tuvo una evolución favorable, siendo dada de alta a los 73 días desde el ingreso. Al año de seguimien to se encontraba asintomática cardiaca, pero persistía una hemiparesia braquiocrural derecha leve. Conclusión: Este es el primer caso reportado de EI por KK que requirió soporte vital extracorpóreo. La EI por KK es una patología infrecuente, que puede provocar falla orgánica múltiple, la que puede ser soportada exitosamente con ECMO.

Abstract: Introduction: Endocarditis is a rare disease in children, especially in those without previous heart disease, and Kingella Kingae (KK) is rarely identified as the cause. Extracorporeal membrane oxyge nation (ECMO) is a support for both heart and respiratory failure. Objective: To report the first case of infectious endocarditis (IE) due to KK which required ECMO support secondary to refractory cardiogenic shock. Clinical case: 19-months-old previously healthy female patient, with a 2-day his tory of fever, and diagnosed with hand-foot-and-mouth disease. The patient developed refractory cardiogenic shock, multiorgan failure, acute respiratory distress syndrome, and deep hemodynamic compromise that required veno-arterial ECMO support. The echography showed an image compa tible with mitral valve vegetation, confirming IE with transthoracic echocardiography. Blood culture was positive for KK. She had an ischemic stroke and required two heart surgeries, the first one for the mass resection and the second one for mitral valve repair, which had a posterior ring pseudoa neurysm. The patient had a favorable evolution and was discharged 73 days after admission. At one year of follow-up, she had no cardiological symptoms, but a mild right brachial-crural hemiparesis persisted. Conclusion: This is the first reported case of IE due to KK that required extracorporeal life support. KK endocarditis is an uncommon pathology that can cause multiorgan failure, which can be successfully supported with ECMO.

Value of Serum Cholinesterase Activity in the Diagnosis of Septic Shock Due to Bacterial Infections.

BACKGROUND: We aimed to investigate whether serum cholinesterase (SChE) activity can be helpful for the diagnosis of septic shock and to evaluate its usefulness in comparison with procalcitonin (PCT) and C-reactive protein (CRP). METHODS: A prospective single-blinded study conducted in an intensive care unit of university hospital. Patients were classified as having cardiogenic shock, septic shock, or hemorrhagic shock. We also included a control group without neither hemodynamic instability nor sepsis. For all included patients, SChE, PCT, and CRP were simultaneously sampled. RESULTS: The comparison of sepsis markers between all groups showed that the mean values of PCT and CRP were significantly higher in patients with septic shock. However, SChE activity was significantly lower in this group. The SChE activity was found to be more accurate than PCT and CRP for the diagnosis of septic shock. In fact, an SChE activity ≤ 4000 UI/L predicted the diagnosis of septic shock with a sensitivity of 78%, a specificity of 89%, a predictive negative value of 97%, and a predictive positive value of 65%. However, the prognostic value of SChE activity was poor in multivariate analysis. CONCLUSION: The SChE activity level was significantly decreased in patients with septic shock. However, its prognostic value is poor. Our results suggest that SChE activity is useful for the diagnosis of septic shock. Further studies are warranted to confirm our findings.

Peroperative cardiogenic shock suggesting acute coronary syndrome as initial manifestation of Lyme carditis.

Carditis can complicate Lyme disease in an estimated <5% of cases, and cardiogenic shock and severe cardiac arrhythmias are described with electrocardiographic abnormalities that could be suggestive of coronary manifestations. We report a case of severe persistent biventricular heart failure complicated by cardiac arrhythmias as initial manifestation of a Lyme disease developing peroperatively electrocardiographic abnormalities suggesting acute transmural myocardial infarction.

External coronary artery compression due to prosthetic valve bacterial endocarditis.

Acute coronary syndromes in the setting of infective endocarditis may be the result of coronary compression secondary to periannular aortic valve complications, coronary embolism, obstruction of the coronary ostium due to a large vegetation, coronary atherosclerosis, and severe aortic insufficiency. External coronary artery compression as a result of infective endocarditis is a rare and lethal finding with few reported cases available in the medical literature. We present a rare occurrence of an acute coronary syndrome occurring in the setting of a bioprosthetic aortic valve abscess in which there was no complete coronary occlusion visualized and given the patient's recent unremarkable catheterization and findings of diffuse tapering of the proximal left coronary system, the most likely etiology was external compression secondary to the known aortic root abscess, which caused myocardial ischemia, and was confirmed during surgery. Although uncommon, external compression should be considered in the differential diagnosis of acute coronary syndrome in this setting and coronary angiography can be diagnostic of this entity.

Nosocomial infections in adult cardiogenic shock patients supported by venoarterial extracorporeal membrane oxygenation.

BACKGROUND: Incidence and impact on adult patients' outcomes of nosocomial infections (NIs) occurring during venoarterial extracorporeal membrane oxygenation (VA-ECMO) support for refractory cardiogenic shock have rarely been described. METHODS: We retrospectively reviewed the charts of a large series of patients who received VA-ECMO in our intensive care unit (ICU) from January 2003 through December 2009. Incidence, types, risk factors, and impact on outcomes of NIs occurring during ECMO support were analyzed. RESULTS: Among 220 patients (49 ± 16 years old, simplified acute physiology score (SAPS) II 61 ± 20) who underwent ECMO support for >48 hours for a total of 2942 ECMO days, 142 (64%) developed NIs. Ventilator-associated pneumonia (VAP), bloodstream infections, cannula infections, and mediastinitis infections occurred in 55%, 18%, 10% and 11% of the patients, respectively. More critical condition at ICU admission, but not antibiotics at the time of ECMO cannulation, was associated with subsequently developing NIs (hazard ratio, 0.73; 95% confidence interval [CI], .50-1.05; P = .09). Infected patients had longer durations of mechanical ventilation, ECMO support, and hospital stays. Independent predictors of death were infection with severe sepsis or septic shock (odds ratio, 1.93; 95% CI, 1.26-2.94; P = .002) and SAPS II, whereas immunosuppression and myocarditis as the reason for ECMO support were associated with better outcomes. CONCLUSIONS: Cardiogenic shock patients who received the latest generation VA-ECMO still had a high risk of developing NIs, particularly VAP. Strategies aimed at preventing these infections may improve the outcomes of these critically ill patients.

[Tubercular myocarditis: two case reports and review of the literature]. / Myocardites tuberculeuses: à propos de deux observations et revue de la littérature.

We report here the cases of two patients developing tubercular myocarditis with a different clinical presentation, the first one with a myopericarditis, the second one presenting as pseudo-infarction complicated by cardiogenic shock. We discuss here the different anatomical and clinical presentations, the diagnostic approach, the indications of myocardic biopsy and the prognosis of this pathology.

Necrotizing fasciitis causing severe myocardial dysfunction with ST-segment elevation in a young man.

Necrotizing fasciitis is a life-threatening infection of the fascia and subcutaneous tissues. We report on a 30-year-old man with history of intramuscular injection resulted in gluteal abscess that progressed to necrotizing fasciitis. On admission, the patient developed circulatory collapse, severe left ventricular dysfunction, and ST-segment elevation in the inferior leads. Wound and blood cultures indicated staphylococcal infection. The clinical, laboratory, echocardiographic, and electrocardiographic features are discussed.

Extracorporeal support in a patient with cardiogenic shock due to Aerococcus urinae endocarditis.

Aerococcus urinae is a newly identified Gram-positive coccus that causes serious infections. To date, only 15 cases of A. urinae infective endocarditis have been reported, but with a very high mortality. The case is reported of a patient with A. urinae double valve endocarditis. Following aortic and mitral valve replacement, the patient suffered from refractory cardiogenic shock; extracorporeal membrane oxygenation was used successfully as a rescue mechanical support.

Acute fulminant myocarditis in scrub typhus.

Scrub typhus is a zoonotic disease caused by Orientia tsutsugamushi in which humans are accidental hosts. It is a febrile illness which is confined to rural Asia and the Western Pacific islands. Severe complications are very rare. We report four cases of acute fulminant myocarditis in children with scrub typhus. This complication led to severe cardiogenic shock and death in two of them. We believe this is the first report of fulminant myocarditis complicating scrub typhus in children.

Exchange transfusion to reverse severe pertussis-induced cardiogenic shock.

Severe pertussis has a high mortality risk, especially in those with high white blood cell counts and pulmonary hypertension. Exchange transfusion can reduce the leukocyte mass in blood. We report 3 young infants with severe pertussis and hyperleukocytosis who developed cardiogenic shock and pulmonary hypertension. Exchange transfusion was performed. The white blood cell count decreased accompanied by improvement in the cardiopulmonary condition and survival in the 3 infants. Exchange transfusion should be considered in patients with severe pertussis with hyperleukocytosis.

Right ventricular inflow obstruction from massive fungal vegetation presenting as neonatal circulatory collapse.

Occurrence of neonatal circulatory collapse imposes effective differential diagnosis and expeditious therapeutic intervention. We report a case of neonatal cardiogenic shock, caused by a massive intra-cardiac fungal vegetation.

Atrioventricular block in a toxic child: do not forget diphtheria.

We describe a 4.5-year-old girl who presented with severe febrile throat infection and who, after a few days, developed ventricular tachycardia followed by atrioventricular block. Although a pacemaker was inserted, she died of cardiogenic shock. Throat cultures were positive for Corynebacterium diphtheriae.

Effect of cardiogenic shock on pharmacokinetics and tissue distribution of ampicillin-sulbactam.

A reversible cardiogenic shock model in pigs investigated shock-induced changes in the pharmacokinetics and tissue distribution of ampicillin-sulbactam and the efficacy of this antibiotic regimen in eliminating enteric bacterial translocation. Sixteen pigs were randomly allocated to 3 groups: group I (shock, ampicillin-sulbactam, n = 6), group II (no shock, ampicillin-sulbactam, n = 6), and group III (shock, no ampicillin-sulbactam, n = 4). Nalidixic acid-resistant E. coli (60 x 10(6) CFU) were instilled into a jejunal loop created in each pig, and bacterial cultures were taken from thoracic duct lymph, periportal, and mesenteric lymph nodes. Ampicillin-sulbactam was administered intravenously at a standard dose of 3 g. Results showed that 1) ampicillin and sulbactam concentrations generally increase during cardiogenic shock; 2) cardiogenic shock does not increase ampicillin concentrations in jejunum and liver; 3) during resuscitation, thoracic duct lymph ampicillin concentrations decrease; and 4) during and immediately after cardiogenic shock, standard doses of ampicillin-sulbactam appear efficacious in eliminating translocated bacteria.

[A case of cardiogenic shock caused by Vibrio parahaemolyticus].

A case of a 53 year old healthy female complaining of diarrhea and abdominal pain after taking raw fish is presented. She immediately went into shock and unconsciousness. Central venous pressure was 8 cmH2O and her ECG showed a first-degree AV block and ST-T changes in almost all leads. After mechanical ventilation and administration of dopamine, dobutamine, cefotiam, ciprofloxacin, she became alert and recovered from her critical condition. V. parahaemolyticus which produces thermostable direct hemolysin (TDH) was cultured from the feces on admission. Kanagawa phenomenon was positive. Arterial blood culture was negative and the titer of serum endotoxin was low. The diagnosis of cardiogenic shock due to exotoxin produced by V. parahaemolyticus was made. Serological examination by ELISA showed elevation of IgG class antibody against TDH and TRH (TDH related hemolysin). And antibody against TDH was normalized after 180 days. By review of literature, there are some case reports of cardiogenic shock complicated with V. parahaemolyticus infection, but few showed elevation of antibody against TDH and TRH in the serum of the survived patient.