RESUMEN
A 25-year-old man presented to the emergency department with a 3-day history of fever, anorexia, jaundice, and a generalized skin eruption. His liver function tests showed marked cholestatic and cytolytic abnormalities without liver insufficiency. A liver biopsy was performed, and morphology with routine stains was considered non-specific. Because of the dermatological findings, the non-specific biopsy morphology, and the absence of an identified infectious etiology, a diagnosis of Kawasaki disease was presumed. However, additional colorations on liver biopsy with Warthin-Starry stain revealed multiple thin and coiled microorganisms compatible with spirochetes. His serology for leptospirosis was found to be positive for IgM, supporting the diagnosis of acute leptospirosis with liver involvement. Our case illustrates the diagnostic challenge of leptospirosis and highlights the utility of conventional laboratory tests to confirm the diagnosis. Exceptionally, Warthin-Starry stain allowed the identification of leptospires in liver biopsy and confirmed liver involvement of systemic leptospirosis.
Un homme de 25 ans a consulté à l'urgence parce qu'il faisait de la fièvre depuis trois jours, de l'anorexie, un ictère et une éruption cutanée généralisée. Les tests de fonction hépatique ont révélé des anomalies cholestatiques et cytolytiques marquées, sans insuffisance hépatique. La coloration standard de la biopsie hépatique a révélé une morphologie cellulaire considérée comme non spécifique. Compte tenu des observations dermatologiques, de la morphologie non spécifique de la biopsie et de l'absence d'étiologie infectieuse établie, un diagnostic de maladie de Kawasaki a été présumé. Cependant, l'ajout d'une coloration de Warthin-Starry a révélé de multiples microorganismes minces et torsadés compatibles avec des spirochètes. La sérologie pour la leptospirose s'est avérée positive pour les anticorps IgM, appuyant un diagnostic de leptospirose aiguë avec atteinte hépatique. Ce cas illustre les difficultés diagnostiques de la leptospirose et fait ressortir l'utilité des tests de laboratoire traditionnels pour confirmer le diagnostic. Exceptionnellement, la coloration de WarthinStarry a permis d'observer des leptospires à la biopsie hépatique et confirmé la leptospirose systémique avec atteinte hépatique.
RESUMEN
OBJECTIVE: To determine whether mixed venous blood gas sampling obtained by pulmonary artery catheter (PAC) is influenced by the speed of withdrawal. DESIGN: Prospective, observational study. SETTING: Surgical intensive care unit at a university hospital. SUBJECTS: Twenty-five patients in the early postoperative period of cardiac surgery. MEASUREMENTS AND MAIN RESULTS: After verification of the adequate position of the PAC, measurements of mixed venous blood gas oxygen saturation, oxygen partial pressure (PO(2)), carbon dioxide partial pressure (PCO(2)), pH and bicarbonates were obtained at two different rates of withdrawal. A slow sampling was taken at a mean speed of 3 ml/min and a fast sampling at 18 ml/min for each patient. The mean difference in venous oxygen saturation between slow and fast samplings was -0.18+/-1.3%, venous PO(2): -0.2+/-1.3 mmHg, venous PCO(2): 0.1+/-0.9 mmHg, venous pH: 0+/-0.03, venous bicarbonates: 0.03+/-0.5 mmol/l. CONCLUSION: Using the Bland & Altman method, we showed a satisfactory agreement between slow and fast mixed venous blood gas sampling techniques when measuring PO(2), oxygen saturation, PCO(2), pH and bicarbonates though a PAC.
