Plasma exchange as a complementary approach to snake bite treatment: an academic emergency department's experiences.

Snake bites are leading causes of morbidity and mortality worldwide, especially in rural areas. Therapeutic plasma exchange has been used in the treatment of many different conditions such as immunologic diseases, toxicologic disorders, and snake envenomation. The aim of this study is to evaluate the efficacy of plasma exchange treatment on clinical status, outcomes, and discharge of patients who were bitten by venomous snakes. The study was conducted retrospectively in the Emergency Department of Gaziantep University from January 2002 to December 2011. Thirty-seven patients were included in the present study. Routine biochemical and hematologic laboratory parameters were studied before and after plasma exchange. Demographic data, clinical status, and outcomes of patients were recorded. Plasma exchange was performed by using centrifugation technology via an intravenous antecubital or subclavian vein catheter access. Human albumin/fresh frozen plasma was used as replacement fluids. A significant correlation was seen between therapeutic plasma exchange and improvement of laboratory results. None of the study patients lost their limbs. Eight patients were sent to the intensive care unit. The mean length of the hospital stay was 12.2 days (4-28). All patients were discharged with good recovery. No complications were seen during the 3 months following discharge. Plasma exchange appears to be an effective treatment intervention for snake bite envenomations, especially in the management of hematologic problems and in limb preservation/salvage strategies. In addition to traditional treatment methods, plasma exchange should be considered by emergency physicians in cases of snake bite envenomation as a therapeutic approach to facilitate rapid improvement.

Plasma exchange therapy in HELLP syndrome: a single-center experience.

BACKGROUND/AIMS: The aim of this study was to investigate the effectiveness of plasma exchange therapy in patients with various forms of hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. METHODS: During a three-year period, 13 patients with HELLP syndrome were treated with one or two sessions of plasma exchange after delivery. Diagnosis of hemolysis, elevated liver enzymes, and low platelets syndrome was made according to Sibai's criteria, and the severity of illness was categorized according to platelet counts. Among patients, nine were in class-1 and the remaining four were in class-2. Patients with very high levels of aspartate aminotransferase (AST) (>2000 U/L) and lactate dehydrogenase (LDH) (>3000 U/L) were defined as fulminant type (2 cases). RESULTS: Rapid improvement in platelet counts was observed after treatment with plasma exchange. All patients survived except the two fulminant hemolysis, elevated liver enzymes, and low platelets syndrome cases. CONCLUSION: In our study, plasma exchange therapy was effective in patients with severe hemolysis, elevated liver enzymes, and low platelets syndrome, but fulminant cases did not appear to respond to this therapy.

Immunomodulation therapy in children with chronic hepatitis B.

PURPOSE: The aim of this study is to investigate the effects of HBsAg vaccine and levamisole on virological indicators in naive patients suffering from chronic hepatitis B (CHB) and in healthy carriers of hepatitis B. METHOD: Vaccination and treatment with levamisole were applied to 93 minor patients in total, 43 of them inactive CHB carriers and 50 patients suffering from CHB. RESULTS: 15 (30%) of 50 patients who had high ALT values in the beginning of the study had normal values after treatment. In nine (12%) patients, posttreatment ALT values were higher than pretreatment values, and six (10%) patients showed HBV-DNA loss. In spite of the presence of 50 (54%) HBeAg-positive patients before treatment, 17 (34%) patients proved to be HBeAg-negative after treatment. HBeAg sero-conversion was seen in 10 (20%) cases. In two (2%) patients, HBsAg sero-conversion occurred. CONCLUSION: It was found that treatment with levamisole and vaccine had positive effects on CHB patients and healthy carriers with respect to HBV DNA loss, HBeAg sero-conversion and ALT normalization. The viral load increases and ALT increases that occurred in certain cases were thought to be related to the early immune response. It was determined that combined levamisole and vaccine therapy had no additional positive effect.

The use of therapeutic plasmapheresis in the treatment of poisoned and snake bite victims: an academic emergency department's experiences.

The objective of this study is to describe the clinical status, procedural interventions, and outcomes of critically ill patients with poisoning and snake bite injuries presenting to a tertiary-care emergency department for treatment with therapeutic plasmapheresis. Records of 20 patients who presented to our academic emergency department over a 2-year period and who underwent plasmapheresis for poisoning or snake bite were retrospectively reviewed. Plasmapheresis was performed using centrifugation technology via an intravenous antecubital venous or subclavian vein catheter access. Human albumin or fresh frozen plasma were used as replacement fluids. Data extracted from the patient record included demographic data, clinical status, and outcome measures. Sixteen patients underwent plasmapheresis because of toxicity from snake bite. Three patients were treated for drug poisoning (phenytoin, theophylline, bipyridene HCl) and one patient for mushroom poisoning. Haematologic parameters such as platelet count, PT, and INR resolved rapidly in victims of snake bite injuries after treatment with plasmapheresis. Loss of limbs did not occur in these cases. Seven patients required admission to the intensive care unit. One patient with mushroom poisoning died. Mean length of hospital stay was 14.3 days (range 3-28 days) for all cases. Plasmapheresis was a clinically effective and safe approach in the treatment of snake bite envenomation and other drug poisoning victims especially in the management of hematologic problems and in limb preservation/salvage strategies. In addition to established conventional therapies, emergency physicians should consider plasmapheresis among the therapeutic options in treatment strategies for selected toxicologic emergencies.

A rare cause of anemia and thrombocytopenia in a newborn: congenital malaria.

A newborn with fever and jaundice was referred to our hospital with anemia and thrombocytopenia of unknown origin. The patient's mother suffered from malaria infection during the third trimester of her pregnancy, but she did not accept medical therapy. On physical examination the newborn showed mild splenomegaly and jaundice. Laboratory tests revealed marked anemia with a hemoglobin value of 7.7 g/L and thrombocytopenia with platelet numbers of 17,000/mm3. Plasmodium vivax was detected in blood smear. Oral therapy with chloroquine and primaquine was started. This patient is the second case of congenital malaria reported from Turkey, and shows that the diagnosis of congenital malaria should be considered in infants with suspected congenital infection who are born to mothers with a history of malarial disease. We emphasize the importance of adequate antenatal medical therapy during pregnancy.

Immunomodulatory effects of HBsAg vaccine and levamisole in chronic hepatitis B and hepatitis B carrier children.

BACKGROUND/AIMS: Pathogenesis of chronic hepatitis B and hepatitis B carrier status is related to deficiencies in the immune system. Thus, treatments regulating the immune system are under discussion. The aim of this study was to investigate the effects of HBsAg vaccine and levamisole on lymphocyte subgroups and immunoglobulins in children with chronic hepatitis B and hepatitis B carriers. METHODS: A total of 93 naive children (43 chronic hepatitis B carriers, 50 chronic hepatitis B patients) were treated in three groups with HBsAg vaccine, levamisole or levamisole plus HBsAg vaccine. Levamisole (ketrax) was delivered as 2.5 mg/kg/day per os, three times per week for three months; the vaccine (Gen HevacB) was administered subcutaneously as 20, 30, 40 microg at one-month intervals. Both medications were delivered at same dosages in the combined group. The examinations were performed at pre-treatment and at the end of the third month when the treatment concluded. RESULTS: After treatments, CD3, CD4 and CD4/CD8 significantly increased and CD8 significantly decreased in chronic hepatitis B patient groups, except in the levamisole treated group. IgG and IgA were significantly decreased in all groups of chronic hepatitis B patients. CONCLUSIONS: It was found that HBsAg vaccine induced cellular immunostimulation in children with chronic hepatitis B; however, levamisole did not. The immune cells of hepatitis B carriers did not manifest a significant change in any treatment group. Although there was no change in B-cell, significant decreases were determined in immunoglobulins (IgG, IgA), especially in chronic hepatitis B patients.

Association of asthma with gastroesophageal reflux disease in children.

BACKGROUND: The objective in this study was to assess the association of gastroesophageal reflux disease (GERD) with asthma in pediatric patients. METHODS: Thirty-six pediatric patients who were diagnosed as having bronchial asthma were included in the study. The male-to-female ratio was 2 to 1. The diagnosis of GER was made by 24-hour pH monitoring. RESULTS: GER was present in 27 of 36 (75%) patients, of whom 19 (70%) were male and 8 (30%) were female patients. The GER frequency was found to be different between the supine and upright positions (p < 0.05). GER was more frequent in the upright position. However, duration of GER was longer in the supine position than the upright position (p < 0.05). Overall reflux duration was similar in both positions (p > 0.05). CONCLUSIONS: Demonstration of the relationship between asthma and GER suggests that GER is involved substantially in the pathogenesis and/or symptomatology of asthma. The patients with asthma should be evaluated for the presence of GER even in the absence of GER-related symptoms.