Ruptured arterial aneurysm in Wegener's granulomatosis: a case report.

BACKGROUND: Aneurysm formation is a possible, but rare, complication of granulomatosis with polyangiitis, known as Wegener's granulomatosis. Urgent diagnosis and therapy is very important because a ruptured aneurysm could be life threatening. CASE PRESENTATION: We, therefore, present the case of a 63-year-old Greek man who was diagnosed with granulomatosis with polyangiitis and retroperitoneal hematoma due to ruptured aneurysm in renal artery and upper pancreaticoduodenal artery. His clinical course was complicated by acute renal failure and acute respiratory failure due to alveolar hemorrhage. Emergency coil embolization was performed. Postembolization recovery was uneventful; no bleeding occurred. The patient underwent mechanical ventilation and continuous veno-venous hemofiltration and received combined immunosuppression and supportive therapy, but eventually died 30 days after admission to hospital from severe septic shock and multiple organ failure. CONCLUSION: Endovascular treatment is the therapy of choice, especially for patients with ruptured aneurysms that are hemodynamically stable. Early diagnosis is very important, as urgent embolization and early initiation of immunosuppression therapy are the treatment of choice.

Reversible stress cardiomyopathy in Guillain-Barré syndrome: a case report.

BACKGROUND: Guillain-Barré syndrome is an autoimmune disorder in which autoantibodies mainly affect the peripheral nervous system. Autonomic dysfunction is a common and severe complication of Guillain-Barré syndrome. Cardiomyopathy, though, is a rare complication in Guillain-Barré syndrome, with only a few cases reported in the literature. CASE PRESENTATION: We present a case of a 65-year-old Greek woman with Guillain-Barré syndrome who developed cardiomyopathy shortly after admission to the intensive care unit due to respiratory deterioration. Her estimated left ventricular ejection fraction upon admission was 20%. The result of coronary angiography was negative for coronary artery disease, and cardiac magnetic resonance imaging excluded myocarditis. Her clinical condition improved with supportive therapy, and her estimated left ventricular ejection fraction at discharge was normal. CONCLUSIONS: Clinicians should be aware of this potentially lethal complication of Guillain-Barré syndrome and the therapeutic options, because early diagnosis can improve prognosis. Routine electrocardiographic and echocardiographic assessments should be performed in patients with Guillain-Barré syndrome presenting with hemodynamic instability.

Increase of circulating endocan over sepsis follow-up is associated with progression into organ dysfunction.

How circulating inflammatory mediators change upon sepsis progression has not been studied. We studied the follow-up changes of circulating vasoactive peptides and cytokines until the improvement or the worsening of a patient and progression into specific organ dysfunctions. In a prospective study, concentrations of tumor necrosis factor-alpha (TNFα), interleukin (IL)-6, IL-8, IL-10, interferon-gamma (IFNγ), endocan and angiopoietin-2 (Ang-2) were measured in serum by an enzyme immunoassay in 175 patients at baseline; this was repeated within 24 h upon progression into new organ dysfunction (n = 141) or improvement (n = 34). Endocan and Ang-2 were the only parameters that were significantly increased among patients who worsened. Any increase of endocan was associated with worsening with odds ratio 16.65 (p < 0.0001). This increase was independently associated with progression into acute respiratory distress syndrome (ARDS) as shown after logistic regression analysis (odds ratio 2.91, p: 0.002). Changes of circulating cytokines do not mediate worsening of the critically ill patients. Instead endocan and Ang2 are increased and this may be interpreted as a key-playing role in the pathogenesis of ARDS and septic shock. Any increase of endocan is a surrogate of worsening of the clinical course.

Clinical factors affecting costs in patients receiving systemic antifungal therapy in intensive care units in Greece: Results from the ESTIMATOR study.

Invasive fungal infections are common in intensive care units (ICUs) but there is a great variability in factors affecting costs of different antifungal treatment strategies in clinical practice. To determine factors affecting treatment cost in adult ICU patients with or without documented invasive fungal infection receiving systemic antifungal therapy (SAT) we have performed a prospective, multicentre, observational study enrolling patients receiving SAT in participating ICUs in Greece. During the study period, 155 patients received SAT at 14 participating ICUs: 37 (23.9%) for proven fungal infection before treatment began, 10 (6.5%) prophylactically, 77 (49.7%) empirically and 31 (20.0%) pre-emptively; 66 patients receiving early SAT (55.9%) were subsequently confirmed to have proven infection with Candida spp. (eight while on treatment). The most frequently used antifungal drugs were echinocandins (89/155; 57.4%), fluconazole (31/155; 20%) and itraconazole (20/155; 12.9%). Mean total cost per patient by SAT strategy was €20 458 (proven), €15 054 (prophylaxis), €23 594 (empiric) and €22 184 (pre-emptive). Factors associated with significantly increased cost were initial treatment failure, length of stay (LOS) in ICU before starting SAT (i.e. from admission until treatment start), fever and proven candidaemia (all P≤.05). CONCLUSION: Early administration of antifungal drugs was not a substantial component of total hospital costs. However, there was a significant adverse impact on costs with increasing LOS in febrile patients in ICU for whom diagnosis of fungaemia was delayed before starting SAT, and with initial treatment failure. Awareness of potential candidaemia and initiation of pre-emptive or empirical strategy as early appropriate treatment may improve ICU patient outcomes while reducing direct medical costs.

Validation of the new Sepsis-3 definitions: proposal for improvement in early risk identification.

OBJECTIVES: Sepsis-3 definitions generated controversies regarding their general applicability. The Sepsis-3 Task Force outlined the need for validation with emphasis on the quick Sequential Organ Failure Assessment (qSOFA) score. This was done in a prospective cohort from a different healthcare setting. METHODS: Patients with infections and at least two signs of systemic inflammatory response syndrome (SIRS) were analysed. Sepsis was defined as total SOFA ≥2 outside the intensive care unit (ICU) or as an increase of ICU admission SOFA ≥2. The primary endpoints were the sensitivity of qSOFA outside the ICU and sepsis definition both outside and within the ICU to predict mortality. RESULTS: In all, 3346 infections outside the ICU and 1058 infections in the ICU were analysed. Outside the ICU, respective mortality with ≥2 SIRS and qSOFA ≥2 was 25.3% and 41.2% (p <0.0001); the sensitivities of qSOFA and of sepsis definition to predict death were 60.8% and 87.2%, respectively. This was 95.9% for sepsis definition in the ICU. The sensitivity of qSOFA and of ≥3 SIRS criteria for organ dysfunction outside the ICU was 48.7% and 72.5%, respectively (p <0.0001). Misclassification outside the ICU with the 1991 and Sepsis-3 definitions into stages of lower severity was 21.4% and 3.7%, respectively (p <0.0001) and 14.9% and 3.7%, respectively, in the ICU (p <0.0001). Adding arterial pH ≤7.30 to qSOFA increased sensitivity for prediction of death to 67.5% (p 0.004). CONCLUSIONS: Our analysis positively validated the use of SOFA score to predict unfavourable outcome and to limit misclassification into lower severity. However, qSOFA score had inadequate sensitivity for early risk assessment.

Improving outcomes of severe infections by multidrug-resistant pathogens with polyclonal IgM-enriched immunoglobulins.

The emergence of infections by multidrug-resistant (MDR) Gram-negative bacteria, which is accompanied by considerable mortality due to inappropriate therapy, led to the investigation of whether adjunctive treatment with one polyclonal IgM-enriched immunoglobulin preparation (IgGAM) would improve outcomes. One hundred patients in Greece with microbiologically confirmed severe infections by MDR Gram-negative bacteria acquired after admission to the Intensive Care Unit and treated with IgGAM were retrospectively analysed from a large prospective multicentre cohort. A similar number of patient comparators well-matched for stage of sepsis, source of infection, appropriateness of antimicrobials and co-morbidities coming from the same cohort were selected. All-cause 28-day mortality was the primary end point; mortality by extensively drug-resistant (XDR) pathogens and time to breakthrough bacteraemia were the secondary end points. Fifty-eight of the comparators and 39 of the IgGAM-treated cases died by day 28 (p 0.011). The OR for death under IgGAM treatment was 0.46 (95% CI 0.26-0.85). Stepwise regression analysis revealed that IgGAM was associated with favourable outcome whereas acute coagulopathy, cardiovascular failure, chronic obstructive pulmonary disease and chronic renal disease were associated with unfavourable outcome. Thirty-nine of 62 comparators (62.9%) were infected by XDR Gram-negative bacteria and died by day 28 compared with 25 of 65 cases treated with IgGAM (38.5%) (p 0.008). Median times to breakthrough bacteraemia were 4 days and 10 days, respectively (p <0.0001). Results favour the use of IgGAM as an adjunct to antimicrobial treatment for the management of septic shock caused by MDR Gram-negative bacteria. A prospective randomized trial is warranted.

Predictors of mortality in patients with bloodstream infections caused by KPC-producing Klebsiella pneumoniae and impact of appropriate antimicrobial treatment.

Bloodstream infections (BSIs) caused by Klebsiella pneumoniae carbapenemases (KPC)-producing K. pneumoniae (KPC-KP) are associated with high mortality rates. We investigated outcomes, risk factors for mortality and impact of appropriate antimicrobial treatment in patients with BSIs caused by molecularly confirmed KPC-KP. All consecutive patients with KPC-KP BSIs between May 2008 and May 2010 were included in the study and followed-up until their discharge or death. Potential risk factors for infection mortality were examined by a case-control study. Case-patients were those who died from the BSI and control-patients those who survived. Appropriate antimicrobial therapy was defined as treatment with in vitro active antimicrobials for at least 48 h. A total of 53 patients were identified. Overall mortality was 52.8% and infection mortality was 34%. Appropriate antimicrobial therapy was administered to 35 patients; mortality due to infection occurred in 20%. All 20 patients that received combination schemes had favourable infection outcome; in contrast, seven of 15 patients given appropriate monotherapy died (p 0.001). In univariate analysis, risk factors for mortality were age (p <0.001), APACHE II score at admission and infection onset (p <0.001) and severe sepsis (p <0.001), while appropriate antimicrobial treatment (p 0.003), combinations of active antimicrobials (p 0.001), catheter-related bacteraemia (p 0.04), prior surgery (p 0.014) and other therapeutic interventions (p 0.015) were significantly associated with survival. Independent predictors of mortality were age, APACHE II score at infection onset and inappropriate antimicrobial treatment. Among them, appropriate treatment is the only modifiable independent predictor of infection outcome.

Community-acquired pneumonia and bacteremia due to methicillin-resistant Staphylococcus aureus carrying Panton-Valentine-leukocidin gene in Greece: two case reports and literature review.

We report the first two cases of community-acquired necrotizing pneumonia and bacteremia complicated by acute respiratory distress syndrome (ARDS) due to Panton-Valantine leukocidin-producing methicillin-resistant Staphylococcus aureus (MRSA-PVL) in Greece, together with a short literature review. Diagnosis was made by culture and broad spectrum PCR of respiratory secretions and blood. One patient received appropriate therapy and recovered fully. The other one died rapidly due to septic shock and life-threatening hemoptysis. Clinicians should be suspicious of community-acquired pneumonia due to MRSA-PVL strain, because rigorous microbiological diagnosis, early and appropriate therapy is essential for favorable outcome.

C Reactive protein, moderate alcohol consumption, and long term prognosis after successful coronary stenting: four year results from the GENERATION study.

OBJECTIVES: To determine the impact of moderate alcohol consumption on long term prognosis after successful coronary stenting, and whether it could be related to preprocedural plasma C reactive protein (CRP). DESIGN: Part of the prospectively designed GENERATION study which investigated the impact of several biochemical factors, including plasma CRP, on long term prognosis after coronary stenting. SETTING: Tertiary referral centre. PATIENTS: 483 consecutive patients with stable or unstable coronary artery disease who underwent successful coronary stenting and were followed for up to four years. Information about alcohol consumption was collected prospectively. INTERVENTIONS: Successful coronary stenting. MAIN OUTCOME MEASURES: The incidence of the composite end point of readmission to hospital for unstable angina, non-fatal myocardial infarction, or cardiac death, whichever occurred first. RESULTS: By the end of follow up the incidence of the composite end point was 22.8%. Patients with a baseline plasma CRP concentration of < 0.68 mg/dl (defined by ROC analysis) did not show any difference in the composite end point (p = 0.9) or its components, regardless of the amount of alcohol consumed during follow up. However, among patients with plasma CRP concentration of > or = 0.68 mg/dl, those who drank moderately had a lower incidence of the composite end point (p < 0.001) or its components. CONCLUSIONS: Moderate alcohol consumption may have a beneficial impact on the long term prognosis following successful coronary stenting. The extent of this effect is positively related to preprocedural inflammatory status. An anti-inflammatory action of moderate alcohol consumption cannot be excluded.

Aspergillus bronchitis causing atelectasis and acute respiratory failure in an immunocompromised patient.

Aspergillus tracheobronchitis is an uncommon clinical form of invasive aspergillosis with fungal infection limited entirely or predominantly to the tracheobronchial tree. We report a case of Aspergillus fumigatus bronchitis, diagnosed by fiberoptic bronchoscopy, with fungal growth completely occluding the left main bronchus leading to lung collapse and acute respiratory failure in a 60-year-old male with erythroleukemia and profound granulocytopenia.

The diagnostic value of gram stain of bronchoalveolar lavage samples in patients with suspected ventilator-associated pneumonia.

Ventilator-associated pneumonia (VAP) is one of the most common causes of morbidity and mortality in intensive care unit patients. However, the diagnosis is quite difficult. Gram stain (GS) of bronchoalveolar lavage (BAL) sample is a time-saving diagnostic method for VAP. However, its clinical significance has not been adequately investigated. The aim of this study was to determine its sensitivity and specificity for VAP diagnosis. We prospectively performed GS and quantitative bacterial cultures (QBC) of BAL samples, obtained through fiberoptic bronchoscope, in 75 consecutive postoperative and/or multiple trauma patients with suspected VAP. We considered BAL-GS as positive for VAP diagnosis when (i) polymorphonuclear neutrophils were > 25 per optic field at a magnification x 100 (p.o.f x 100); (ii) squamous epithelial cells were < 1% p.o.f x 100; and (iii) one or more microorganisms were seen p.o.f. at a magnification x 1,000 (p.o.f. x 1,000). VAP was diagnosed with criteria similar to those used in previous studies. Pneumonia was the final diagnosis in 22/75 (29%) patients. The BAL-GS was positive in 17/22 patients with VAP and in 7/53 patients without VAP. Accordingly, the sensitivity of BAL-GS for VAP diagnosis was 77%, the specificity 87%, the positive predictive value 71% and the negative predictive value 90%. Our data suggest that BAL-GS has good sensitivity and high specificity for VAP diagnosis. It could therefore constitute a useful complementary tool in the task of early diagnosis and treatment of VAP.

Conditional evaluation of broncho-alveolar lavage in mechanically ventilated patients with suspected unilateral lobar pneumonia.

OBJECTIVE: In an attempt to improve our ability to diagnose the cause of ventilator-associated pneumonia (VAP), we explore the usefulness of the conditional evaluation of bronchoalveolar lavage (BAL) samples from the involved and non-involved areas in patients with suspected unilateral lobar VAP (UL-VAP). DESIGN: Prospective study. SETTING: University teaching hospital intensive care unit. PATIENTS: We studied 19 consecutive patients with suspected UL-VAP. MEASUREMENTS AND MAIN RESULTS: Nine of the 12 patients (47%) developed UL-VAP. There was a significant difference between the involved and non-involved areas in UL-VAP patients (P < 0.001) in respect of the quantitative bacterial cultures (QBCs) of BAL samples for each micro-organism, whereas there was no difference in patients without UL-VAP. When we applied the criterion of usual BAL (one micro-organism in concentrations > 10(5) colony-forming units per millilitre) for UL-VAP diagnosis, the sensitivity was 100%, the specificity 70%, the positive predictive value 75%, and the negative predictive value 100%. When we used the conditional evaluation of the BAL results for UL-VAP diagnosis, in the involved and non-involved areas, the sensitivity was 78%, the specificity 90%, the positive predictive value 87.5% and the negative predictive value 82%. A statistically significant difference was found when we compared the difference in QBCs between the BAL samples for each micro-organism, between the involved and non-involved areas in patients with and without VAP (P < 0.001). CONCLUSION: These data suggest that utilisation of the conditional evaluation of the QBCs of BAL samples improves significantly our ability to diagnose the cause of UL-VAP.

Pneumocystis carinii pneumonia in a HIV-seronegative patient with untreated rheumatoid arthritis and CD4+ T-lymphocytopenia.

Pneumocystis carinii pneumonia (PCP) usually occurs in immunocompromised patients, and it is a life-threatening infection. We report the case of a human immunodeficiency virus (HIV)-seronegative patient with untreated rheumatoid arthritis (RA), who developed fatal PCP related to uncommon CD4+ T-lymphocytopenia. Although extremely rare and of uncertain aetiology, suppression of cellular immunity and subsequent opportunistic infections should be suspected in such patients.

Respiratory effects of tracheal gas insufflation in spontaneously breathing COPD patients.

OBJECTIVE: To evaluate the effect of tracheal gas insufflation (TGI) in spontaneously breathing, intubated patients with chronic obstructive pulmonary disease (COPD) undergoing weaning from the mechanical ventilation. DESIGN: A prospective study in humans. SETTING: Polyvalent intensive care unit (14-bed ICU) in a 700-bed general university hospital. PATIENTS: Twelve patients with chronic obstructive pulmonary disease (COPD) who required intubation and mechanical ventilation were studied. All patients met standard criteria for weaning from mechanical ventilation. Seven patients (group 1) had been transorally intubated during episodes of acute respiratory failure. Five patients, all men (group 2), had previously undergone tracheostomy and had a transtracheal tube in place. INTERVENTIONS: Intratracheal, humidified, O2-mixture insufflation (TGI) was given via a catheter placed in distal or proximal position. Gas delivered through the intratracheal catheter was blended to match the fractional of inspired gas through the endotracheal tube. Continuous flows of 3 and 6 l/min in randomized order were used in each catheter position. Prior to data collection at each stage, an equilibration period of at least 30 min was observed, and thereafter blood gases were analyzed every 5 min. A new steady state was assumed to have been established when values of both PaCO2 and V CO2 changed by less than 5% between adjacent measurements. The last values of blood gases were taken as representative. The new steady state was confirmed within 35-50 min. Baseline measurements with zero Vcath were made at the beginning and end of the experiment. RESULTS: This study shows that VT, MV, PaCO2, and VD/VT are reduced in a flow-dependent manner when gas is delivered through an oral-tracheal tube (group 1). The distal catheter position was more effective than the proximal one. In contrast, when gas was delivered through tracheostomy (group 2), TGI was ineffective in the proximal position and less effective than in group 1 in distal position. CONCLUSION: Under the experimental conditions, tracheal gas insufflation decreased dead space, increased alveolar ventilation and possibly reduced work of breathing. From the preliminary data reported here, we believe that TGI may help patients experiencing difficulty during weaning.