Cases reported "Sepsis"

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1/47. Substituting dexamethasone for prednisone complicates remission induction in children with acute lymphoblastic leukemia.

    BACKGROUND: The authors report the occurrence of fatal or near-fatal sepsis in 16 of 38 children with newly diagnosed acute lymphoblastic leukemia (ALL) treated with a new induction regimen that differed from its predecessor by the substitution of dexamethasone for prednisone. methods: The frequency of septic deaths among 38 children who received multiagent remission induction therapy, including dexamethasone (6 mg/m(2)) daily for 28 days (pilot protocol 91-01P), was compared with the frequency of septic deaths among children previously treated (protocol 87-01) and subsequently treated (protocol 91-01) in consecutive Dana-Farber Cancer Institute (DFCI) ALL trials with induction therapy that included 21 and 28 days of prednisone (40 mg/m(2)), respectively. Except for dexamethasone in protocol 91-01P, the remission induction agents used were identical in substance to those used in protocol 87-01. Protocol 91-01, the successor 91-01P, was also similar, with the exception of the deletion of a single dose of L-asparaginase. RESULTS: Sixteen of the 38 children (42%) treated on the DFCI 91-01P had documented gram positive or gram negative sepsis (17 episodes) during remission induction, including 4 toxic deaths (11%). In contrast, there were 4 induction deaths among 369 children (1%) treated on protocol 87-01 (P = 0.0035) and 1 induction death among 377 children (<1%) treated on protocol 91-01 (P = 0.0003). CONCLUSIONS: Substitution of dexamethasone for prednisone or methylprednisolone in an otherwise intensive conventional induction regimen for previously untreated children with ALL resulted in an alarmingly high incidence of septic episodes and toxic deaths. awareness of this complication, considering that the substitution has no apparent benefit in the efficacy of remission induction, argues against its routine use in intensive induction regimens for children with ALL.
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2/47. Hypercapnic respiratory failure and partial upper airway obstruction during high frequency oscillatory ventilation in an adult burn patient.

    PURPOSE: To present a case of severe hypercapnic respiratory failure in an adult burn patient and to describe our clinical problem solving approach during support with an unconventional mode of mechanical ventilation. CLINICAL FEATURES: A 19-yr-old male with smoke inhalation and flame burns to 50% total body surface area was admitted to the Ross Tilley Burn Centre. High frequency oscillatory ventilation (HFOV) was initiated on day three for treatment of severe hypoxemia. By day four, the patient met consensus criteria for acute respiratory distress syndrome. On day nine, alveolar ventilation was severely compromised and was characterized by hypercapnea (PaCO(2) 136 mmHg) and acidosis (pH 7.10). Attempts to improve CO(2) elimination by a decrease in the HFOV oscillatory frequency and an increase in the amplitude pressure failed. An intentional orotracheal tube cuff leak was also ineffective. A 6.0-mm nasotracheal tube was inserted into the supraglottic hypopharynx to palliate presumed expiratory upper airway obstruction. After nasotracheal tube placement, an intentional cuff leak of the orotracheal tube improved ventilation (PaCO(2) 81 mmHg) and relieved the acidosis (pH 7.30). The improvement in ventilation (with normal oxygen saturation) was sustained until the patient's death from multiple organ dysfunction four days later. CONCLUSION: During HFOV in burn patients, postresuscitation edema of the supraglottic upper airway may cause expiratory upper airway obstruction. The insertion of a nasotracheal tube, combined with an intentional orotracheal cuff leak may improve alveolar ventilation during HFOV in such patients.
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3/47. Fatal bowel infarction and sepsis: an unusual complication of systemic strongyloidiasis.

    A 58 year old Chinese male, one week after arriving in canada from hong kong, presented with acute abdominal pain and diarrhoea which was rapidly followed by escherichia coli infection causing septicaemia and meningitis. His past history revealed bronchial asthma for 15 years treated with steroids. At laparotomy, 7 days after the onset of symptoms, he was found to have extensive haemorrhagic infarction of the small bowel and right colon. Examination of the fibrosed mesenteric vessels revealed numerous filariform larvae of strongyloides stercoralis, within the walls, and in all layers of bowel wall. The role of the parasite in the production of obliterative arteritis in this fatal case of haemorrhagic enteropathy is discussed. Clinical strongyloidiasis, in uncomplicated cases, varies from mild to severe with gastroenteritis, nausea, colicky abdominal pain, electrolyte imbalance and symptoms of malabsorption syndrome (MARCIAL-ROJAS, 1971). In malnourished individuals and patients with debilitating infections, either newly acquired or asymptomatic latent infection with S. stercoralis can assume severe dimensions (BROWN and perna, 1958; HUGHTON and HORN, 1959). Similarly, in patients on steroid (CRUZ et al., 1966; WILLIS and MWOKOLO, 1966; NEEFE et al., 1973) and immunosuppressive therapy for lymphomatous diseases or deficient in immune response (ROGERS and NELSON, 1966; RIVERA et al., 1970), systemic strongyloidiasis is often fatal. The increased frequency of auto-infection in such patients with a breached immune barrier is, however, unclear. Further complications of this infection due to severe enterocolitis result in sepsis, bacteraemia and meningitis (BROWN and perna, 1958; HUGHTON and HORN, 1959). This paper presents a fatal case of S. stercoralis infection which illustrates an uncommon if not unique, mechanism in its production of haemorrhagic enteropathy leading to sepsis and death.
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4/47. Anaerobic infections in surgery: clinical review.

    Anaerobic bacteria are being recognized with increasing frequency as important micro-organisms in surgical infections. clostridium, Bacteriodes, fusobacterium, and peptostreptococcus are the clinically prominent pathological anaerobes. All are commensals and, consequently, most anaerobic infections are endogenous in origin. In the colon, anaerobes are 1,000 times more prevalent than aerobes. This has important implications regarding the management of gastrointestinal tract operations and the treatment of infections originating from the bowel. Typical anaerobic infections include gas gangrene, brain abscess, oral infections, putrid lung abscesses, intra-abdominal abscesses, and wound infections following gynecologic and bowel surgery, perirectal abscesses, postabortal infections, and septic thrombophlebitis. Infections with anaerobic organisms must be suspected when there is feculent odor and/or gas production following gynecologic or bowel surgery, when there are organisms on gram staining but no growth on aerobic cultures, or when septicemia is associated with repeatedly negative blood cultures. debridement and drainage constitute the main stay of treatment. All anaerobes are sensitive to chloramphenicol and clindamycin and all but bacteroides fragils are sensitive to penicillin. Identification of anaerobes requires proper specimen sampling, immediate culturing on prereduced media, and careful gram staining of clinical material. The frequency of anaerobic organisms in surgical infections generally is not recognized by many surgeons; their importance needs to be stressed in the future.
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5/47. Use of activated protein c (drotrecogin alfa) in a patient with sepsis and respiratory failure on ultra high frequency jet ventilation.

    Drotreocogin alfa is a recombinant form of human activated protein c that has recently been found to reduce mortality significantly when used in patients with severe sepsis. Bleeding is reported to be the most common adverse effect associated with the use of this drug. patients with sepsis on Ultra High Frequency Jet Ventilator may develop necrotizing tracheobronchitis and may be at an increased risk of bleeding when treated with drotreocogin alfa. We describe a patient with sepsis and respiratory failure on Ultra High Frequency Jet Ventilator, who was started on drotrecogin alfa, without the development of any significant bleeding.
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keywords = high frequency, frequency
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6/47. Report of a case series of ultra low-frequency oscillations in cardiac output in critically ill adults with sepsis, systemic inflammatory response syndrome, and multiple organ dysfunction syndrome.

    Healthy physiological systems exhibit irregular variability whereas diseased systems display decreased signal variability or greater regularity. The objective of this article is to report a case series of critically ill adults who displayed ultra low-frequency periodic sinusoidal oscillations in cardiac output (ULF-CO) that were discovered during a clinical study testing software for continuous physiological monitoring. Data were collected from 13 critically ill surgical and trauma patients who required continuous cardiac output monitoring. Physiologic data were collected from clinical monitors. The computerized time series of cases displaying CO oscillations were manually reviewed. Ten patients with sepsis or the systemic inflammatory response syndrome exhibited 18 episodes of ultra low-frequency periodic oscillations (ULF-CO) with frequencies ranging from 0.0028 to 0.000053 Hz (periods, 6 to 316 min). intensive care unit mortality rate was 50%. The amplitude and coefficient of variation of cardiac output during ULF-CO ranged from 0.1-4.6 L and 3.9-14.3%, respectively. Duration of ULF-CO ranged from 4-108.1 h. ULF-CO could not be explained as a result of patterned artifact from measurement error or therapeutic intervention. ULF-CO may be a pathophysiologic marker that might serve the diagnosis, prognosis, and treatment of critical illness.
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7/47. Aeromonas veronii biovar veronii septicaemia and acute suppurative cholangitis in a patient with hepatitis b.

    Gram-negative bacilli of the genus Aeromonas are widespread in aquatic environments and can be responsible for human infections. Although Aeromonas extraintestinal and systemic infections have been reported with growing frequency in recent years, Aeromonas septicaemia remains an uncommon finding, often associated with serious underlying disease and predominantly related to the species aeromonas hydrophila, Aeromonas veronii biovar sobria and aeromonas caviae. Here, a case of A. veronii biovar veronii septicaemia and acute suppurative cholangitis is reported in a patient with chronic hepatitis b.
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8/47. Enlarged effects of adenosine in a septic patient with multiple myeloma and atrial flutter.

    We report the history of a 60-year-old patient with a multiple myeloma and staphylococcus aureus associated sepsis to whom adenosine in a dose of 6 mg was administered, when a regular, narrow QRS complex tachycardia at a heart rate of 120 beats/minute started. adenosine led to a complete AV-block and revealed atrial flutter. atrial flutter waves persisted for about 15 seconds and were followed by atrial and ventricular asystole for about 20 seconds. Repeated nonsustained polymorphic ventricular tachycardias followed and after about 90 seconds sinus rhythm was restored.
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keywords = wave
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9/47. Occult gallbladder perforation: an unusual complication of gallstone lithotripsy.

    Three days following extracorporeal shock-wave lithotripsy of a solitary, calcified gallstone, a 69-year-old white male patient was re-admitted with E. coli sepsis and fever of up to 39.4 degrees C. Ultrasound and CT both revealed a smooth-rimmed hypodense paravasate in the middle portion of the left liver lobe adjacent to the gallbladder, with a density identical to gallbladder fluid. The evidence for perforation was based on CT scanning, and a diagnosis of occult gallbladder perforation was made. Conservative treatment was performed successfully. Following elective cholecystectomy two months thereafter, gallbladder histology showed signs of chronic cholecystitis and E. coli was isolated in bile cultures. The paravasate had granulated and finally cicatrized. By combining ESWL and chemical dissolution, treatment of multiple, calcified and pigment gallstones is possible and this approach has become an attractive alternative therapy modality for a selected group of gallstone patients. Further assessments of the efficacy and safety of this technique are necessary. Conservative treatment of occult gallbladder perforation is possible and should be performed in high-risk patients.
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10/47. Fatal yersinia enterocolitica biotype 4 serovar O:3 sepsis after red blood cell transfusion.

    BACKGROUND: Although posttransfusion bacterial sepsis is rare, this complication is associated with a high mortality rate. CASE REPORT: A fatal case of septic shock was observed in a 71-year-old patient following transfusion of contaminated red blood cells (RBCs) for refractory anemia. yersinia enterocolitica was isolated from the patient's blood sample and the transfused RBCs. Both strains were of bioserotype 4/O:3 and had the same NotI pulsotype. High titers of antibodies against Y. enterocolitica were detected in the donor's plasma sample 1 month after blood donation. The donor reported abdominal discomfort 3.5 months before blood collection but had no clinical signs of intestinal infection at the time of donation. CONCLUSION: Y. enterocolitica has been identified with increased frequency as a causative agent of posttransfusion septic shock. This nationwide investigation of these cases led to an estimated incidence of one case per 6.5 million RBC units distributed in france. Although rare, this often fatal complication remains nonpreventable worldwide owing to the lack of practical means for screening RBCs before transfusion.
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