Necrotising soft tissue infections. / Nekrotiserende bløtdelsinfeksjoner.

Necrotising soft tissue infections can affect the skin, subcutaneous tissue, superficial fascia, deep fascia and musculature. The infections are severe, they spread quickly and can result in extensive tissue loss. Although rare, morbidity and mortality rates are high. Early clinical identification is crucial for the outcome, and rapid infection control through surgery and targeted antibiotic treatment is needed to save lives. Few prospective clinical trials have been conducted for the treatment of this type of infection. Specific challenges include rapid identification of the condition and the uncertain efficacy of the various treatment options. In this clinical review article, we describe clinical characteristics, diagnostics and treatment.

Myxedema coma complicated by bilateral hygromas.

SUMMARY: Myxedema coma is an important differential diagnosis in critically ill patients. Early diagnosis and treatment are paramount but challenging due to a lack of diagnostic criteria. We report a case about a patient who suffered from untreated hypothyroidism for several years. Before the correct diagnosis was made, he was admitted three times due to severe constipation. Eventually, he developed myxedema coma in connection with a urinary tract infection. The course was complicated by recurrent seizures, and neuroimaging showed bilateral hygromas. Hormone replacement therapy resulted in complete recovery and regression of hygromas. To the best of our knowledge, this is the first time hygroma is reported in association with myxedema coma. LEARNING POINTS: Myxedema coma is a difficult diagnosis to make due to a lack of diagnostic criteria. Cardinal features include hypothermia, bradycardia, gastrointestinal symptoms, pericardial/pleural effusions and affection of CNS. Anemia and hyponatremia are common. In case of suspected myxedema coma, neuroimaging should be a part of the evaluation in most cases. There is a possible association between longstanding/severe hypothyroidism and hygroma.

Necrotizing Soft Tissue Infections: Case Reports, from the Clinician's Perspectives.

Necrotizing soft tissue infections (NSTI) are rapidly spreading and life-threatening infections of skin and soft tissue. Essentially there are two types of NSTI, based on the invasive microorganisms. The speed of development and associated clinical features differ markedly depending on the bacterial etiology. Early recognition, extensive surgical debridement, and appropriate antimicrobials are pivotal for successful management. In this chapter, we present three cases from the INFECT-study population. This study was an international, multicenter, prospective cohort study of adult patients with NSTI. We describe the clinical presentations, pre-, peri-, and postoperative clinical findings, microbiology, and treatment in cases of monobacillary Streptococcus pyogenes necrotizing soft tissue infections NSTI, polymicrobial infection, and an unusual presentation of pelvic monobacillary S. pyogenes infection in an immunocompromised patient.

Transcapillary fluid flux and inflammatory response during neonatal therapeutic hypothermia: an open, longitudinal, observational study.

BACKGROUND: Therapeutic hypothermia is neuroprotective in asphyxiated neonates by counteracting mechanisms contributing to brain injury. Although an initial increased permeability is part of an inflammatory reaction and thereby a natural healing process, an excessive endothelial permeability with edema formation may result in impaired hemodynamics. Reduced permeability may, however, benefit healing. Although plasma and interstitial colloid osmotic pressure are accessible and essential parameters for understanding fluid imbalance, the mechanisms of fluid exchange remain poorly understood. The potential influence of therapeutic hypothermia on plasma and interstitial colloid osmotic pressure, and the relationship between inflammatory markers and colloid osmotic pressure in asphyxiated neonates, was investigated. METHODS: Seventeen neonates with moderate to severe hypoxic ischemic encephalopathy, born after 35 weeks gestation, received servo-controlled whole body cooling before 6 h of age, followed by gradual rewarming after 72 h. All infants were treated according to a national hypothermia protocol. Interstitial fluid in the skin was collected at 7, 13, 25, 49, and 73 h after birth by subcutaneous implantation of multifilamentous nylon wicks with 60 min of implantation time. Biomarkers of inflammation and colloid osmotic pressure were measured in serum and interstitial fluid. RESULTS: A modest decrease in serum and interstitial colloid osmotic pressure was measured, leaving an unaltered difference in colloid osmotic pressure gradient. A decline in mean arterial pressure was observed between 7 and 13 h of life, with a concomitant decrease in positive fluid balance within the same time frame. White blood cell count and leukocyte subclasses dropped significantly throughout treatment, with elevated interstitial interleukin (IL)-1α and decreased serum IL-1RA, IL-6, and IL-10 during treatment time points. CONCLUSIONS: Colloid osmotic pressures measured in serum and interstitial fluid during asphyxia is lower than previously reported, with small alteration of pressure differences across capillaries, reducing vascular filtration. An inherent local and systemic regulation of inflammation together with changes in colloid osmotic pressure may indicate a possible preventive mechanism of edema generation during neonatal asphyxia and therapeutic hypothermia. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01044940 . Date of registration: January 8, 2010.

Interstitial fluid colloid osmotic pressure in healthy children.

OBJECTIVE: The colloid osmotic pressure (COP) of plasma and interstitial fluid play important roles in transvascular fluid exchange. COP values for monitoring fluid balance in healthy and sick children have not been established. This study set out to determine reference values of COP in healthy children. MATERIALS AND METHODS: COP in plasma and interstitial fluid harvested from nylon wicks was measured in 99 healthy children from 2 to 10 years of age. Nylon wicks were implanted subcutaneously in arm and leg while patients were sedated and intubated during a minor surgical procedure. COP was analyzed in a colloid osmometer designed for small fluid samples. RESULTS: The mean plasma COP in all children was 25.6 ± 3.3 mmHg. Arbitrary division of children in four different age groups, showed no significant difference in plasma or interstitial fluid COP values for patients less than 8 years, whereas patients of 8-10 years had significant higher COP both in plasma and interstitial fluid. There were no gender difference or correlation between COP in interstitial fluid sampled from arm and leg and no significant effect on interstitial COP of gravity. Prolonged implantation time did not affect interstitial COP. CONCLUSION: Plasma and interstitial COP in healthy children are comparable to adults and COP seems to increase with age in children. Knowledge of the interaction between colloid osmotic forces can be helpful in diseases associated with fluid imbalance and may be crucial in deciding different fluid treatment options. TRIAL REGISTRATION: ClinicalTrials.gov NCT01044641.

Does insulin impact cold-induced fluid- and protein-extravasation?

BACKGROUND: Insulin has been shown to stabilize the endothelial barrier via inactivation of the endothelial contractile machinery and enhancement of cell-cell adhesions. Here we explored if insulin by its endothelial-stabilizing and anti-inflammatory properties could influence the increase of fluid- and protein-extravasation during hypothermia. METHODS: Two groups of animals (n=10, each) were cooled to 28°C, with insulin-infusion (I-group) or without (C-group), in a randomly controlled study. Fluid balance, hemodynamics, plasma volume (PV), colloid osmotic pressures in plasma (COPp) and interstitial fluid (COPi), hematocrit (Hct), cytokine profiles, serum-albumin- and protein-concentrations were measured and fluid extravasation rate (FER) and albumin-and protein-masses calculated. RESULTS: During 240 min of hypothermia the albumin- and protein-masses together with COPp decreased significantly in both groups. COPi remained essentially unchanged. Plasma volume decreased significantly in the C-group, whereas only a decreasing trend was present in the I-group. Hemoconcentration was significant in both study groups reflected by the Hct-values. A slight increasing trend of FER was seen in both groups from 0.10 (0.04) ml/kg/min and 0.09 (0.05) mg/kg/min, C-group and I-group, respectively, to 0.14 (0.05) mg/kg/min and 0.12 (0.03) mg/kg/min, during the hypothermic period. Between-group differences were absent for all listed parameters including FER. CONCLUSION: Insulin administration does not impact fluid and protein extravasation significantly in animals undergoing cooling and prolonged hypothermia.

Effect of topical anaesthetics on interstitial colloid osmotic pressure in human subcutaneous tissue sampled by wick technique.

OBJECTIVES: To measure colloid osmotic pressure in interstitial fluid (COP(i)) from human subcutaneous tissue with the modified wick technique in order to determine influence of topical application of anaesthetics, dry vs. wet wick and implantation time on COP(i). MATERIAL AND METHODS: In 50 healthy volunteers interstitial fluid (IF) was collected by subcutaneous implantation of multi-filamentous nylon wicks. Study subjects were allocated to two groups; one for comparing COP(i) obtained from dry and saline soaked wicks, and one for comparing COP(i) from unanaesthetized skin, and skin after application of a eutectic mixture of local anaesthetic (EMLA®, Astra Zeneca) cream. IF was sampled from the skin of the shoulders, and implantation time was 30, 60, 75, 90 and 120 min. Colloid osmotic pressure was measured with a colloid osmometer. Pain assessment during the procedure was compared for EMLA cream and no topical anaesthesia using a visual analogue scale (VAS) in a subgroup of 10 subjects. RESULTS: There were no significant differences between COP(i) obtained from dry compared to wet wicks, except that the values after 75 and 90 min. were somewhat higher for the dry wicks. Topical anaesthesia with EMLA cream did not affect COP(i) values. COP(i) decreased from 30 to 75 min. of implantation (23.2 ± 4.4 mmHg to 19.6 ± 2.9 mmHg, p = 0.008) and subsequently tended to increase until 120 min. EMLA cream resulted in significant lower VAS score for the procedure. CONCLUSION: COP(i) from subcutaneous tissue was easily obtained and fluid harvesting was well tolerated when topical anaesthetic was used. The difference in COP(i) assessed by dry and wet wicks between 75 min. and 90 min. of implantation was in accordance with previous reports. The use of topical analgesia did not influence COP(i) and topical analgesia may make the wick technique more acceptable for subjects who dislike technical procedures, including children. TRIAL REGISTRATION: ClinicalTrials.gov NCT01044979.

Hyperbaric oxygen treatment in three cases of necrotizing infection of the neck.

Necrotizing infections of the head and neck are rare conditions in our hospital. Clinical and microbiological characteristics of three consecutive cases treated in Haukeland University Hospital in western Norway in the year 2010 are described. Two cases of Lemierre's syndrome and one case with a descending necrotizing mediastinitis (DNM) were diagnosed. All three cases were treated with broad spectrum antibiotics and in two cases surgery was possible. Hyperbaric oxygen treatment (HBOT) with intensive care facilities became recently available at our hospital, and this treatment was used in all these patients regardless of surgery. In one case we describe the use of HBOT on the basis of strong clinical suspicion of anaerobic infection only. Bacterial identification by partial sequencing of the 16SrDNA gene proved to be a useful supplement to conventional culture techniques. All the cases all demonstrated a significant clinical improvement after introduction of HBOT. When HBOT is available, it should be considered as adjunctive treatment in extensive infections with anaerobes.

Integrin alphavbeta3 acts downstream of insulin in normalization of interstitial fluid pressure in sepsis and in cell-mediated collagen gel contraction.

The administration of insulin is recommended to patients with severe sepsis and hyperglycemia. Previously, we demonstrated that insulin may have direct anti-inflammatory properties and counteracted fluid losses from the circulation by normalizing the interstitial fluid pressure (P(IF)). P(IF) is one of the Starling forces determining fluid flux over the capillary wall, and a lowered P(IF) is one of the driving forces in early edema formation in inflammatory reactions. Here we demonstrate that insulin restores a lipopolysaccharide (LPS)-lowered P(IF) via a mechanism involving integrin alpha(v)beta(3). In C57 black mice (n = 6), LPS lowered P(IF) from -0.2 +/- 0.2 to -1.6 +/- 0.3 (P < 0.05) and after insulin averaged -0.8 +/- 0.2 mmHg (P = 0.098 compared with after LPS). Corresponding values in wild-type BALB/c mice (n = 5) were -0.8 +/- 0.1, -2.1 +/- 0.3 (P < 0.05), and -0.8 +/- 0.3 mmHg (P < 0.05 compared with LPS) after insulin administration. In BALB/c integrin beta(3)-deficient (beta(3)(-/-)) mice (n = 6), LPS lowered P(IF) from -0.1 +/- 0.2 to -1.5 +/- 0.3 mmHg (P < 0.05). Insulin did not, however, restore P(IF) in these mice (averaged -1.7 +/- 0.3 mmHg after insulin administration). Cell-mediated collagen gel contraction can serve as an in vitro model for in vivo measurements of P(IF). Insulin induced alpha(v)beta(3)-integrin-dependent collagen gel contraction mediated by C2C12 cells. Our findings suggest a beneficiary effect of insulin for patients with sepsis with regard to the fluid balance, and this effect may in part be due to a normalization of P(IF) by a mechanism involving the integrin alpha(v)beta(3).

Peritumoral TNFalpha administration influences tumour stroma structure and physiology independently of growth in DMBA-induced mammary tumours.

BACKGROUND: Systemic treatment of malignancies with high doses of tumour necrosis factor-alpha (TNFalpha) has an anticancer effect, but also serious side effects. The aim of the present study was to elucidate the effects of local TNFalpha administration alone or in combination with chemotherapy on tumour stroma structure and physiology in di-methyl-benz-anthracene (DMBA)-induced mammary carcinomas in rats. METHODS: TNFalpha (500 ng/mL in a volume of 5 microL) was given s.c. around the carcinoma and 5-fluorouracil (5-FU) (1.5 mg/kg, volume of 0.2 mL) was given i.p on days 1, 4, 7 and 10. RESULTS: Treatment with TNFalpha resulted in a significant reduction of tumour interstitial fluid pressure (TIFP: 75-87%, p < 0.02-0.001), as well as in the number of tumour-infiltrating macrophages, extracellular volume (ECV) and collagen fibril density in carcinoma. In addition, pH was lowered in tumours treated with TNFalpha, suggesting decreased aerobic metabolism. Treatment with TNFalpha, however, had no effect on tumour growth, arterial blood pressure, tumour vessel density, plasma volume or body weight. Concentrations of locally produced VEGF and IL-1beta in carcinoma interstitial fluid or in serum were not affected by TNFalpha. The study demonstrated that these cytokines are produced locally in the tumour. Furthermore, TNFalpha had no effect on efficacy of treatment with 5-FU. CONCLUSIONS: Locally administered TNFalpha did not affect DMBA-induced mammary tumour growth or vasculature, but reduced inflammation and ECM structure, suggesting the latter to be of importance in the observed reduction in TIFP.

Platelet-derived growth factor BB-mediated normalization of dermal interstitial fluid pressure after mast cell degranulation depends on beta3 but not beta1 integrins.

Interstitial fluid pressure (PIF) is one of the determinants of transcapillary fluid flux and thereby interstitial fluid volume. Cell-mediated control of PIF regulates fluid content in the loose interstitial connective tissues that surround the capillary bed. To maintain a normal PIF in dermis, beta1 integrins mediate the tensile strength applied by connective tissue cells on the extracellular matrix. Platelet-derived growth factor (PDGF)-BB normalizes anaphylaxis-induced reduction of PIF. Anti-beta3 integrin IgG and a cyclic RGD peptide that inhibits the alphaVbeta3 integrin blocked the ability of PDGF-BB to normalize the lowered PIF resulting from mast cell degranulation. PDGF-BB was unable to normalize PIF lowered as a result of mast cell degranulation in beta3-negative mice. Monoclonal anti-beta3 integrin IgG had no effect on PIF in normal mouse dermis. In contrast, administration of anti-beta1 integrin IgM lowered PIF in normal dermis but had no effect on PDGF-BB-induced normalization of PIF after anaphylaxis. Furthermore, collagen gel contraction mediated by wild-type mouse embryonal fibroblasts were only marginally affected by function-blocking anti-beta1 integrin antibodies, especially in the presence of PDGF-BB. In contrast, contraction mediated by alphaV-negative mouse embryonic fibroblasts was completely blocked by anti-beta1 integrin antibodies, even after stimulation with PDGF-BB. These results show a previously unrecognized in vivo function for the alphaVbeta3 integrin, as a participant in the control of PIF during inflammatory reactions. Furthermore, our data demonstrate that PDGF-BB induces connective tissue cells to generate tensile forces via alphaVbeta3 during such reactions.

A novel function of insulin in rat dermis.

In this study we present a novel function of insulin in rat dermis. We investigated local effects of insulin on interstitial fluid pressure (Pif), and capillary albumin leakage and pro-inflammatory cytokine production in skin and serum after intravenous lipopolysaccharide (LPS), tumour necrosis factor-alpha (TNF-alpha) and interleukin-1beta (IL-1beta) challenge treated with a glucose-insulin-potassium regimen (GIK). The main objective for this study was to investigate anti-inflammatory effects of insulin. Work by others shows that insulin stimulates cell adhesion, and that this effect is dependent upon phosphatidylinositol 3-kinase (PI3K) activity. Cytokines like platelet-derived growth factor BB (PDGF-BB) attenuate lowering of Pif, possibly via PI3K. LPS and pro-inflammatory cytokines contribute to oedema development during acute inflammation by lowering the Pif. Intravenous injection of LPS, TNF-alpha or IL-1beta to Wistar Møller rats caused a lowering of Pif, but after local injection of insulin in the paw, Pif increased back to control values. IL-1beta caused a lowering in control from -0.5 +/- 0.2 mmHg to -3.0 +/- 0.2 mmHg after 20 min (mean +/- S.E.M.) (P < 0.05). Within 50 min after insulin injection the pressure was increased to -0.6 +/- 0.2 mmHg (P > 0.05 compared with control). Insulin was given together with a PI3K inhibitor (wortmannin) locally in the skin, almost abolishing the effect of insulin on Pif. A GIK regimen was given as a continuous intravenous infusion, significantly attenuating the oedema formation after LPS or TNF-alpha/IL-1beta challenge. The same GIK regimen caused a significant reduction in pro-inflammatory cytokines in serum and in interstitial fluid in skin of endotoxaemic rats. These experiments show a possible role for insulin in the interstitium during inflammation induced by LPS and TNF-alpha/IL-1beta. Insulin can attenuate a lowering of Pif possibly via PI3K, and it has an anti-inflammatory effect by inhibiting production of pro-inflammatory cytokines.

Differential cytokine response in interstitial fluid in skin and serum during experimental inflammation in rats.

Tumour necrosis factor-alpha (TNF-alpha) and interleukin-1beta (IL-1beta) are important mediators produced during inflammation. We hypothesized that the pro-inflammatory cytokine response in the interstitial fluid (IF) is different from that in serum, and we aimed at quantifying the amount of TNF-alpha and IL-1beta in the IF. By centrifugation of rat skin at < 424 g pure IF is extracted. Using ELISA such fluid was analysed for cytokines in back and/or paw skin of pentobarbital-anaesthetized rats, after either induction of endotoxaemia or ischaemia-reperfusion (I/R) injury. During endotoxaemia, TNF-alpha increased in the IF from 0 in control to 640 +/- 100 pg ml(-1) (mean +/-s.e.m.) after 90 min, with the serum concentration being 5-10 times higher at all time points. The response pattern of IL-1beta after lipopolysaccharide (LPS) challenge differed greatly from that of TNF-alpha with a large increase in IF from 390 +/- 90 to 28 000 +/- 1500 pg ml(-1) after 210 min, and a significantly smaller increase in serum (600 +/- 45 pg ml(-1)). During reperfusion of the hind paw after 2 h of ischaemia, there was a gradual increase of TNF-alpha in both IF of the paw skin and serum after 3 min of reperfusion. Both declined after 20 min. The pattern for IL-1beta differed, increasing significantly less in serum (25 +/- 15 pg ml(-1) after 20 min of reperfusion) than in the IF (1100 +/- 200 pg ml(-1)). Immunostaining of the inflamed tissues showed increased expression of the two cytokines in cells of both epidermis and dermis compared to controls. Subdermal injections of TNF-alpha and IL-1beta at the same concentrations found in IF after LPS infusion affected interstitial fluid pressure significantly. Local TNF-alpha production dominates after I/R injury, whereas in endotoxaemia systemic production predominates. For IL-1beta local production dominates in both conditions. Thus, there is a differential pattern of cytokine production and the current method allows the study of the role of cytokines in IF during different inflammatory reactions.

Effect of alpha-trinositol on interstitial fluid pressure, edema generation, and albumin extravasation after ischemia-reperfusion injury in rat hind limb.

Reperfusion of ischemic tissue often leads to an acute inflammatory response, which acts directly to aggravate the injury in the reperfused zone, characterized by adhesion and subsequent infiltration of inflammatory cells that injure the tissue through the generation of oxygen-derived free radicals and release of various inflammatory mediators. The rapid edema formation associated with reperfusion injury is induced by increased microvascular permeability to plasma proteins and/or increased net filtration pressure across the microvascular wall, and the latter is at least in part induced by lowering of the interstitial fluid pressure (P(if)). We investigated the anti-inflammatory effect of alpha-trinositol (D-myo-inositol-1,2,6-trisphosphate) on edema formation, microvascular protein leakage, and P(if) in rat hind limb after ischemia-reperfusion (I/R) injury. There was significant increase of both albumin extravasation from 0.02 +/- 0.02 to 0.41 +/- 0.21 mL g dry weight-1 (P < 0.05) and total tissue water from 1.08 +/- 0.07 to 1.65 +/- 0.55 mL g dry weight(-1) (P < 0.05) in the skin of paws undergoing I/R injury. P(if) was significantly lowered from -0.51 +/- 0.34 to -5.00 +/- 1.53 mmHg (P < 0.05) concomitant with substantial edema formation. The edema formation, and lowering of P(if) during I/R injury was significantly lowered and nearly totally abolished in the animals treated with alpha-trinositol 30 min before reperfusion. We conclude that alpha-trinositol limits the increased vascular permeability and edema formation by preventing the decrease in P(if) as well as acting protective on the microvascular wall.

Different serotypes of endotoxin (lipopolysaccharide) cause different increases in albumin extravasation in rats.

Endotoxin (lipopolysaccharide [LPS] from cell membranes of gram-negative bacteria) is frequently used in experimental models of septic shock that are characterised by hypotension, peripheral vasodilation, and edema formation, as well as greatly enhanced flux of macromolecules and fluid from plasma to tissues. The edema formation and increased albumin extravasation (Ealb) could be caused by increased permeability and/or increased capillary net filtration pressure. We have measured interstitial fluid pressure (Pif) and Ealb after i.v. injection of two different serotypes of LPS in female Wistar Møller rats (200-250 g) in pentobarbital anaesthesia. Two experimental groups and one control group were studied (n = 8 in each group). Group 1, serotype 0111:B4, received 3 mg/kg LPS, Group 2, serotype 0127:B8, received 1.5 mg/kg LPS, and controls received saline vehicle (0.4 mL). Five minutes after injection of LPS or saline vehicle, human serum albumin labelled with 125I (125I-HAS; 0.05 MBq) was injected i.v. and was followed 55 min later by 131I-HSA (0.05 MBq). Five minutes thereafter the rats were killed and tissue samples were obtained from skin, muscle, and small intestine. Ealb was estimated as the difference between the plasma equivalent distribution volumes of 125I-HSA and 131I-HSA. The pattern of extravasation between the groups was the same in all the tissues studied. Group 1 serotype (0111:B4) and controls had much lower Ealb than Group 2 serotype (0127:B8; P < 0.05). Ealb differed among the tissues both in relative and absolute numbers, being largest in the intestine and smallest in skeletal muscle. We previously demonstrated a lowering of Pif after LPS injection using serotype (0127:B8). The present results demonstrate that the same serotype of LPS also causes a significant increase of Ealb, and is therefore likely caused by the lowering of Pif.