Management of Sepsis and Septic Shock: What Have We Learned in the Last Two Decades?

Sepsis is a clinical syndrome encompassing physiologic and biological abnormalities caused by a dysregulated host response to infection. Sepsis progression into septic shock is associated with a dramatic increase in mortality, hence the importance of early identification and treatment. Over the last two decades, the definition of sepsis has evolved to improve early sepsis recognition and screening, standardize the terms used to describe sepsis and highlight its association with organ dysfunction and higher mortality. The early 2000s witnessed the birth of early goal-directed therapy (EGDT), which showed a dramatic reduction in mortality leading to its wide adoption, and the surviving sepsis campaign (SSC), which has been instrumental in developing and updating sepsis guidelines over the last 20 years. Outside of early fluid resuscitation and antibiotic therapy, sepsis management has transitioned to a less aggressive approach over the last few years, shying away from routine mixed venous oxygen saturation and central venous pressure monitoring and excessive fluids resuscitation, inotropes use, and red blood cell transfusions. Peripheral vasopressor use was deemed safe and is rising, and resuscitation with balanced crystalloids and a restrictive fluid strategy was explored. This review will address some of sepsis management's most important yet controversial components and summarize the available evidence from the last two decades.

COVID-19-Associated Acute Myocarditis: Risk Factors, Clinical Outcomes, and Implications for Early Detection and Management.

Background The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus causing acute respiratory distress with multisystem complications, including cardiac complications. Acute myocarditis is one possible complication of coronavirus disease 2019 (COVID-19). Previous studies revealed that mortality from COVID-19 was higher in patients with cardiac complications. Objectives We aim to identify if patients with COVID-19 develop myocarditis and if this condition is associated with an increased incidence of ventilatory support and mortality. We also aim to identify if preexisting cardiac conditions are associated with an increased incidence of ventilatory support and mortality in those who developed COVID-19. Methods This is a multicenter, retrospective study including patients aged 18 years and older. Statistical analysis was performed to compare the incidence of in-hospital mortality and ventilatory support in COVID-19-positive patients with and without myocarditis. In this study, we defined myocarditis using elevated troponin-T (TnT) and brain natriuretic peptide (BNP) levels as proxy. Results A total of 8,162 patients with a positive COVID-19 polymerase chain reaction (PCR) test were identified. Of those, 1,643 (20.1%) were found to have new-onset acute myocarditis. The risk of ventilation and mortality in these patients was significantly elevated (p<0.001) compared to patients without acute myocarditis. Underlying heart failure was associated with increased odds of in-hospital mortality, which was 1.6 times greater when compared to patients without heart failure. The odds of in-hospital mortality were 2.33 times as likely for those who had non-ischemic cardiomyopathy as opposed to those who did not. Conclusion Myocarditis is a serious and potentially fatal complication of COVID-19. The results of this study highlight the importance of routine testing of troponin-T and BNP levels to identify those at risk. Furthermore, underlying heart conditions are associated with a worse outcome, and those patients should be watched closely.

Adult-Onset Mitochondrial Encephalopathy, Lactic Acidosis, and Stroke-Like Episodes (MELAS) in a Patient Without Significant Family History.

This case reports a 53-year-old Caucasian female previously diagnosed with viral encephalitis and Fahr's Syndrome who presented with altered mental status. Shortly after arrival, she displayed severe lactic acidosis and was transferred to the intensive care unit (ICU), where she had a brief seizure. Neurological workup was performed including carotid ultrasound, magnetic resonance angiography (MRA) brain, and computed tomography (CT) angiogram of the neck, all of which were unremarkable. Initial magnetic resonance imaging (MRI) performed showed small, acute ischemic foci in the bilateral occipital lobes and medial left thalamus. Subsequent diffusion-weighted imaging (DWI) MRI of the bilateral occipital lobes showed vasogenic edema, a common finding in Mitochondrial Encephalopathy, Lactic Acid, and Stroke-like episodes (MELAS). The patient was given Levetiracetam and managed supportively. She was progressively extubated and her seizure symptoms and lactic acidosis resolved. Our case represents a unique case in which a patient with non-contributory family history is first diagnosed with MELAS after age 40 after her symptoms were initially attributed to other pathologies.

A Case of Posttraumatic Pott's Disease.

Tuberculosis infection, which is caused by the bacterium Mycobacterium tuberculosis (Mtb), most commonly manifests in patients with respiratory systems. However, it can also colonize other tissues including skeletal. In our case, a 77-year-old Caucasian male presented to the emergency department following a rollover motor vehicle collision with chief complaints of neck and lower back pain. After clinical improvement and a preliminary negative workup, the patient was deemed stable for discharge. Four months later, the patient was subsequently admitted for worsening back pain with workup suspicious for T9 and T10 discitis osteomyelitis and abscess formation on computed tomography (CT). During this admission, spinal Mtb was confirmed by acid-fast stain and real-time polymerase chain reaction of a CT-guided disc space aspirate of a left paraspinal cystic collection at approximately T9-T10. Given these findings, the patient was subsequently put on standard four-drug therapy for Mtb. Our case demonstrates the importance of considering Pott's disease in the diagnosis of lumbar spinal pain, especially in patients living in areas with high international migration and travel.

Critical Limb Ischemia in a Young Patient With a Mechanical Aortic Valve Leading to Bilateral Above-Knee Amputation.

This case reports a 24-year-old female with prior aortic insufficiency who underwent a mechanical aortic valve replacement with subsequent transient ischemic attacks and documented subtherapeutic international normalized ratio (INR). She presented with pain and bilateral lower extremity pulselessness. Workup showed a supratherapeutic INR, no thrombus on echocardiogram, and computed tomography angiography demonstrating no flow in the bilateral common femoral arteries. Patient failed repeated thrombectomies and had a bilateral above-knee amputation. The patient was suspected to have acute on chronic emboli from the mechanical aortic valve and further testing did not elucidate contributory causes of her critical limb ischemia. We believe this is the first documented case of bilateral lower extremity ischemia due to mechanical valve complications.

Adrenal Crisis Secondary to Influenza and Tetanus Vaccination in an Adult Without Known Adrenal Insufficiency: A Case of Autoimmune Adrenalitis.

Adrenal crisis (AC) is a rare but known life-threatening condition in patients with adrenal insufficiency (AI). We report the case of a 21-year-old without known AI who developed AC after routine vaccinations. Workup revealed that the patient had underlying, undiagnosed autoimmune adrenalitis. This is the first report of AC induced by influenza and diphtheria, tetanus, and acellular pertussis (DTaP) vaccinations in a patient without known AI.

Perception of HIV Testing and Counseling among Integrated Counseling and Testing Center Clients of Tertiary Level Hospitals.

BACKGROUND: The purpose of establishing integrated counseling and testing center (ICTC) is to detect HIV at the earliest time, providing information on modes of transmission and prevention of HIV by promoting behavioral change and reducing vulnerability, and informing individuals on HIV prevention, care, and treatment services. OBJECTIVE: To know the awareness of the clients about ICTC before pretest counseling. METHODS: This facility-based cross-sectional study was conducted among 105 pretest counseling clients who visited ICTC for the first time in 3 ICTCs of tertiary care hospitals attached to a medical college in Mangalore. RESULT: Majority of the clients were pregnant women (n = 57, 54.30%), and most of the clients were referred by the treating doctor (n = 91, 86.7%). Most of the clients, being unaware of ICTC, are not aware of its functions and activities. CONCLUSION: Although ICTCs have been functional for nearly a decade, the awareness of ICTC and its functions among the people is poor.