Cases reported "Shock, Septic"

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1/9. Postpartum clostridium sordellii infection associated with fatal toxic shock syndrome.

    Clostridium bacteria are anaerobic Gram positive spore-form-ing bacilli, known to cause distinct clinical syndromes such as botulism, tetanus, pseudomembranous colitis and myonecrosis. The natural habitats of Clostridium species are soil, water and the gastrointestinal tract of animals and humans. In 5-10% of all women, Clostridium species are also found to be normal inhabitants in the microbial flora of the female genital tract. In case of a non-sexually transmitted genital tract infection, Clostridium species are isolated in 4-20%, and clostridium welchii seems to be the most common isolate. clostridium sordellii is rarely encountered in clinical specimens (1% of Clostridium species), but it has been described as a human pathogen with fatal potential. Two toxins, a lethal and a hemorrhagic (that antigenically and pathophysiologically appear similar to clostridium difficile toxins B and A, respectively) are responsible for this potential. Reviewing the obstetric literature, only six cases of postpartum endometritis caused by C. sordellii, are described - all being fatal. In addition, one lethal case of spontaneous endometritis resulting from C. sordellii is reported. The clinical aspects of these cases include: - sudden onset with influenza-like symptoms in previously healthy women - progressive refractory hypotension - local and spreading tissue edema - absence of fever Laboratory findings include: - marked leukocytosis - elevated hematocrit. This paper reports the seventh fatal postpartum C. sorlellii associated toxic shock syndrome - the first recognized in scandinavia.
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2/9. ECG changes during septic shock.

    We have previously found that skeletal muscle becomes electrically inexcitable in septic patients. work in an animal model suggests that a decrease in the available sodium current underlies the loss of electrical excitability. We examined ECGs from patients during periods of septic shock to determine whether there were any ECG abnormalities that might suggest a similar loss of excitability in cardiac tissue during sepsis. Fourteen out of 17 patients had low or significantly decreased QRS amplitudes during septic shock; 8 of 17 had long or increased QRS duration with or without bundle branch block. The mean decrease in QRS amplitude in septic patients was 41%, significantly higher than in controls where no consistent decrease in QRS amplitude was found (p < 0.01). In patients who recovered from septic shock, the QRS amplitude and the increased QRS duration both returned to normal. We conclude that there is a loss of QRS amplitude during septic shock that may be due to altered cardiac excitability.
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3/9. chlamydophila abortus infection in a pregnant woman associated with indirect contact with infected goats.

    Reported here is the case of a pregnant woman who developed a severe chlamydophila abortus infection after indirect contact with infected goats resulting in preterm stillbirth. The woman fully recovered after treatment with doxycycline. In the goat herd with which her husband worked chlamydophila abortus was actively circulating, as shown by positive serology. When pregnant women present with rapidly worsening influenza-like illness, special attention should be given to possible contact (direct or indirect) with animals when recording the anamnesis. pregnant women, especially those who live in rural areas, should generally be made aware of the risks of zoonotic diseases and how to avoid them.
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4/9. naloxone and its use in neonatal septic shock.

    Current research suggests that the secretion of beta-endorphin from the pituitary gland may be associated with the refractory hypotension seen in patients with septic shock. Extensive animal research and a few clinical studies have demonstrated that naloxone, a narcotic antagonist, can increase MAP, cardiac output, and cardiac contractility and improve survival in victims of endotoxic shock. The ability of naloxone to improve MAP, however, appears to decrease with prolonged persistent hypotension (greater than eight hours). Studies also suggest that a synergistic effect exists between naloxone and the steroid methylprednisolone in improving the hemodynamics of these patients. In the future, naloxone may prove to be essential in the management of patients in the early stages of septic shock, but more complete clinical trials are warranted. It is imperative that nurses be involved in this type of clinical research.
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5/9. Pathophysiologic alterations in endotoxemia. Similarities to an animal model.

    The validity of animal models of human sepsis has been questioned. We describe a patient who experienced a short episode of endotoxemia (? bacteremia) with resultant pulmonary hypertension, pulmonary edema from increased alveolar capillary membrane permeability, hypoxemia, hypotension, and relative leukopenia, which mimics the pathophysiologic changes noted following infusion of pseudomonas bacteria into awake sheep. The similarity of abnormalities and their resolution suggests that pseudomonas infusion in sheep is a valid experimental model of human septic shock.
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6/9. Streptococcal toxic shock-like syndrome: evidence of superantigen activity and its effects on T lymphocyte subsets in vivo.

    Toxic shock-like syndrome is a serious complication of invasive streptococcal disease. The syndrome is believed to be the consequence of exposure to exotoxins produced by the infecting organisms which behave as superantigens. We describe two patients who fulfilled clinical criteria for this syndrome, one of whom died. Streptococci isolated from both patients were found to produce a mitogen specific for the V beta 2 T lymphocyte subset in vitro, which had the characteristics of a superantigen. The phenotype and function of lymphocytes collected from both patients during the acute phase of their illness demonstrated a marked reduction in circulating CD4 ('helper') and CD45RA ('naive') T lymphocytes expressing the V beta 2 chain, and an increase of those expressing CD8, CD45RO and the V beta 2 chain. This effect resolved within 4 weeks in the patient who survived. Proliferation assays demonstrated no T cell anergy in either patient. Stimulation of lymphocytes by superantigen in these clinical situations does not appear to cause permanent deletion of T cell subsets, as has been observed in animal models.
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7/9. Group B streptococcal toxic shock-like syndrome: report of a case and purification of an associated pyrogenic toxin.

    A patient with streptococcal toxic shock-like syndrome (TSLS) caused by streptococcus agalactiae (group B Streptococcus) is described. The patient had all of the defining criteria for toxic shock syndrome (TSS), including fever, hypotension, erythematous rash, desquamation, and involvement of multiple organs. Neither staphylococcus aureus nor group A streptococci were recovered, but vaginal and urine cultures yielded group B streptococci. The group B streptococcal isolate gave negative results in antibody tests for the production of TSS toxin 1, staphylococcal enterotoxins, and streptococcal scarlet fever toxins. However, the strain produced a novel pyrogenic toxin. This toxin, purified from culture fluids by ethanol precipitation, isoelectric focusing, and reverse-phase high-pressure liquid chromatography, had a molecular weight of 12,000 and an isoelectric point of approximately 7.0. The purified toxin was pyrogenic in rabbits, enhanced the susceptibility of the animals to lethal endotoxin shock, and caused the proliferation of rabbit splenocytes; these properties define pyrogenic toxins. When given to three rabbits via a subcutaneous miniosmotic pump, the toxin caused TSS-like symptoms ending in death. Three additional group B streptococcal strains from patients with TSLS were tested and were found to produce a toxin with similar properties.
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8/9. bacterial translocation as a cause of septic shock in humans: a report of two cases.

    While bacterial translocation has been reported to occur under numerous conditions in animal models, there has been no paper to date focusing on bacterial translocation as a direct cause of septic shock in humans. We present herein the cases of two patients who developed septic shock believed to have been directly caused by bacterial translocation. Neither of the patients had a focus of infection, the intestinal walls were intact in gross appearance, and the peritoneal cavity had not been contaminated by surgery. Moreover, in both patients, the same organisms were detected in the blood, ascites fluid, and mesenteric lymph nodes, and bacilli were found in the intestinal wall.
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9/9. actinobacillus equuli septicemia: an unusual zoonotic infection.

    We describe the isolation of actinobacillus equuli from the blood of a 53-year-old butcher with septicemia. This species of the genus Actinobacillus is primarily associated with animals and animal diseases, especially septicemia in foals. This is the first report of the isolation of A. equuli from a human with septicemia.
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