Coma as a presenting sign of Epstein-Barr encephalitis.

Among the many different manifestations of Epstein-Barr virus (EBV) infection, neurologic disturbances are less frequently observed, and they are diverse in nature. A young woman was admitted with acute hyperthermia, mydriasis, nystagmus, respiratory insufficiency, muscular hypertonia, evolving to decerebrate posturing, and bilateral facial epileptic contractions. The appearance of atypical blood lymphocytes, hepatitis, migrating skin rash, positive heterophile antibody tests, and specific serologic tests for EBV led to a diagnosis of EBV encephalitis. Under treatment with intravenously administered acyclovir, the patient recuperated almost completely. This case illustrates a less frequent manifestation of EBV infection.

Encephalomyelitis-associated antimyelin autoreactivity induced by streptococcal exotoxins.

OBJECTIVE: After implicating Streptococcus pyogenes as causing acute disseminated encephalomyelitis (ADEM) in a child, we wanted to prove that in vivo activation of autoreactive T lymphocytes by superantigens of this Streptococcus contributed to the dramatic demyelination. BACKGROUND: ADEM is a demyelinating disorder of the CNS sharing many similarities with MS. Demyelination in MS is considered to be the result of an autoimmune process mediated by autoreactive T lymphocytes with specificity for myelin antigens. METHODS: Phenotypic analysis and proliferation assays on blood monocytes, as well as isolation of myelin basic protein (MBP)-reactive T-cell lines/clones; and TCR repertorium analysis by PCR-ELISA and cytokine production. RESULTS: 1) The blood T-cell receptor (TCR) repertoire was compatible with in vivo expansion induced by S. pyogenes exotoxins. 2) TCR expression analysis indicated clonal expansion of CD8+ MBP-reactive T cells, suggesting in vivo activation. MBP-reactive T cells showed crossreactivity to S. pyogenes supernatant and exotoxins. 3) Cytokine mRNA quantification of the mononuclear cells revealed a Th2-biased profile. CONCLUSION: In vivo exposure to S. pyogenes may have induced activation of pathogenic myelin reactive T cells, contributing to the dramatic inflammatory demyelination.

Safety and tolerance data from the Belgian multicentre study of anisoylated plasminogen streptokinase activator complex versus heparin in acute myocardial infarction.

In the European Multicentre Study (EMS), the safety and efficacy of a single 30U intravenous injection of anisoylated plasminogen streptokinase activator complex (APSAC) was studied in patients with acute myocardial infarction. The present study discusses the Belgian data on safety and tolerance from the EMS study. 87 patients were randomised to treatment with APSAC or heparin. The reperfusion rate was 60.5% (APSAC) versus 20.5% (heparin control), and reocclusion occurred in 21% of the reperfused APSAC patients. Drug-related adverse events consisted of bleeding problems (7 events in patients on APSAC and 1 event in a patient on heparin and moderate allergic reactions (12 events in 9 patients on APSAC and 1 event in a heparin patient). There was 1 drug-related death in the APSAC group (hypovolaemic shock due to central vein puncture during lytic state) which could have been avoided. It is concluded that thrombolytic treatment of acute myocardial infarction with APSAC is effective and safe, as long as the standard precautions for thrombolytic treatment are respected. Bleeding and allergic-type events are infrequent, usually well tolerated and easily treated.

Haemodynamic monitoring. Problems, pitfalls and practical solutions.

The synthesis of adenosine triphosphate (ATP) depends on the coordinated interaction of oxygen delivery and glucose breakdown in the Krebs cycle. Cellular oxygen depots are non-existent, therefore the peripheral cells are totally dependent on the circulation for sufficient oxygen delivery. Shock is the clinical manifestation of cellular oxygen craving. The commonly measured variables--blood pressure, heart rate, urinary output, cardiac output and systemic vascular resistance--are not sensitive or accurate enough to warn of impending death in acutely ill patients nor are they appropriate for monitoring therapy. Calculated oxygen transport and oxygen consumption parameters provide the best available measures of functional adequacy of both circulation and metabolism. In order to optimise oxygen delivery (DO2), 4 interacting factors must be taken into account: cardiac output, blood haemoglobin content, haemoglobin oxygen saturation and avidity of oxygen binding to haemoglobin. For viscosity reasons, the optimal haemoglobin concentration is in the vicinity of 90 to 100 g/L, but for optimising the oxygen transport 100 to 115 g/L or a haematocrit of 30 to 35% seems better. The p50 (the pO2 at which haemoglobin is 50% saturated) describes the oxygen-haemoglobin dissociation curve; normally its value is +/- 27 mm Hg. It can be influenced by attaining normal body temperature, pH, pCO2 and serum phosphorous levels. In order to obtain an arterial blood saturation (SaO2) of more than 90% with acceptable haemodynamics, the ventilation mode and inspired oxygen fraction (FiO2) must be adapted; care must be taken not to stress the labile circulation with haemodynamic compromising ventilation techniques [e.g. high positive end expiratory pressure (PEEP) levels, inverse-ratio ventilation, etc.]. The factor most amenable to manipulation is the cardiac output, with its 4 determinants--preload, afterload, contractility and heart rate. In daily clinical practice, heart rate should be between 80 and 120 beats/min; small variations are acceptable. Important deviations must be treated by chemically [isoprenaline (isoproterenol)] or electrically (pacing techniques) accelerating the heart, or with the different antiarrhythmic drugs. A wide variety of agents is available to decrease the preload: diuretics [especially furosemide (frusemide)], venodilators like nitroglycerin (glyceryl trinitrate), isosorbide dinitrate (sorbide nitrate) and sodium nitroprusside, ACE inhibitors, phlebotomy, and haemofiltration techniques (peritoneal or haemodialysis, continuous arteriovenous haemofiltration). To increase the preload, volume loading using a rigid protocol ('rule of 7 and 3'), preferably with colloids, or vasopressor agents [norepinephrine (noradrenaline), epinephrine (adrenaline), dopamine] are useful. Arterial vasopressors are needed to improve perfusion pressure of 'critical' (coronary and cerebral) arteries. Afterload can be decreased by arterial vasodilators. Predominantly arterial dilators are hydralazine and clonidine, while sodium nitroprusside, nitroglycerin and isosorbide dinitrate have combined arterial and venous dilating actions.(ABSTRACT TRUNCATED AT 400 WORDS)

Cardiac arrest due to aberrant left coronary artery originating from the right sinus of Valsalva in a young girl.

We report a 14-year-old girl who sustained a syncope followed by cardiac arrest. She was kept alive for three days by full cardiocirculatory support using left and right ventricular assist devices, but subsequently died in multiple organ failure. Autopsy revealed an anomalous origin of the left coronary artery (LCA) from the right sinus of Valsalva (RSV) and a major left anterior wall infarction. A cyclo-ergometric stress test performed two years before having been negative, we discuss its value in preventing sudden death due to coronary anomalies.

Propylene glycol-induced side effects during intravenous nitroglycerin therapy.

Propylene glycol, an alcohol frequently used as a solvent in medical preparations, is considered non-toxic. We found that this solvent, used in a commercially available IV nitroglycerin solution, may cause hyperosmolality, hemolysis and lactic acidosis. The influence of kidney function as the main determinant in causing accumulation of this solvent and consequently hyperosmolality is emphasized. A review of the literature dealing with propylene glycol is given. The possible mechanisms of neurological disturbances occurring during IV nitroglycerin therapy are discussed.

European Resuscitation Council Guidelines 2000 for Adult Basic Life Support. A statement from the Basic Life Support and Automated External Defibrillation Working Group(1) and approved by the Executive Committee of the European Resuscitation Council.

The European Resuscitation Council (ERC) last issued guidelines for Basic Life Support (BLS) in 1998 [1]. These were based on the "Advisory Statements" of the International Liaison Committee on Resuscitation (ILCOR) published in 1997 [2]. Following this, the American Heart Association, together with representatives from ILCOR, undertook a series of evidence-based evaluations of the science of resuscitation [3] which culminated in the publication of "Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care" in August 2000 [4,5]. The Basic Life Support and Automated External Defibrillation Working Group (BLS&AED Group) has considered this document and has recommended changes in the ERC BLS guidelines. These are presented in this paper.

European Resuscitation Council Guidelines 2000 for Automated External Defibrillation. A statement from the Basic Life Support and Automated External Defibrillation Working Group(1) and approved by the Executive Committee of the European Resuscitation Council.

The European Resuscitation Council (ERC) last issued guidelines for Automated External Defibrillators (AEDs) in 1998 [1]. The American Heart Association, together with representatives from the International Liaison Committee on Resuscitation (ILCOR), then undertook a series of evidence-based evaluations of the science of resuscitation [2] which culminated in the publication of "Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care" in August 2000 [3,4]. The Basic Life Support and Automated External Defibrillation Working Group (BLS&AED Working Group of the ERC) has considered this document and has recommended changes in the ERC AED guidelines. These are presented in this paper.

Successful recovery after ventricular fibrillation in a patient with Kawasaki disease.

Kawasaki disease (KD) is an uncommon cause of sudden death in young adults in Europe. Angiographically, the disease is characterized by coronary artery aneurysms which can be fully obstructed by acute thrombosis or by progression of the disease. If diagnosis of KD is made, immediate investigation should be made to determine whether ischemia is occurring and if so, to establish optimal time for revascularisation or cardiac transplantation. We describe an 18-year-old Caucasian male who was not previously known to have KD and who suffered from an acute myocardial infarction complicated by ventricular fibrillation, caused by acute thrombosis of a coronary artery aneurysm.

Semi-automatic external defibrillation and implanted cardiac pacemakers: understanding the interactions during resuscitation.

Many emergency medical service (EMS) systems are currently implementing semi-automatic external defibrillation (AED) by emergency medical technicians. Surprisingly little information is available on the possible interactions between AEDs and implanted cardiac pacemakers. Therefore, at present there are no clear guidelines for the use of AEDs on patients having a cardiac pacemaker. During resuscitation, multiple interactions between pacemakers and AEDs are possible. External defibrillation can cause damage to several functions of the pacemaker. On the other hand, the presence of pacemaker spikes during cardiac arrest might prohibit recognition of the ventricular fibrillation by the AED. We report on two resuscitation attempts in which the interaction between the ventricular fibrillation, an implanted dual chamber pacemaker and the AED was decisive for the defibrillation success. A clear understanding of these possible interactions is necessary for the further refining of diagnostic algorithms and clinical strategies of prehospital defibrillation.

Liver rupture after cardiopulmonary resuscitation in a patient receiving thrombolytic therapy.

A patient with an acute myocardial infarction had to be resuscitated due to recurring ventricular fibrillation. After stabilisation, she received thrombolytic treatment with anistreplase. Fourteen hours later, clinical signs of hemoperitoneum developed and the diagnosis of liver rupture was made. After abdominal surgery and coronary revascularisation, the subsequent clinical course was uncomplicated. The literature on liver trauma after CPR as well as thrombolysis in association with CPR is reviewed. This observation suggests that there are no convincing arguments to withhold thrombolytic therapy in acute myocardial infarction after CPR in the absence of gross trauma. We stress that a high degree of clinical alertness is necessary to diagnose this life-threatening condition because of its frequent subacute evolution in patients that are per se hemodynamically unstable.

Knowledge, skills and counselling behaviour of Belgian general practitioners on CPR-related issues.

General practitioners (GP) can identify potential cardiac arrest victims. They have the opportunity to inform cardiac patients and their families about the risk of sudden cardiac death and can motivate family members to attend a CPR-course. To study actual counselling practices concerning basic CPR-training a questionnaire was mailed to a representative sample of Belgian GPs (n = 1119). The level of CPR-training of the GPs was fairly good: 67% had received BLS training on a manikin and 63% had already attended a cardiac arrest event. A discrepancy was observed between the positive attitude towards CPR and the counselling of family members to attend a CPR-course (9%). GPs feared to inflict additional stress to the patient (32%) or the family (43%) or did not know where CPR courses were organised (37%). GPs are a primary target group for CPR-training and should learn how to counsel potential bystanders of a cardiac arrest to attend a CPR-course without inflicting additional anxiety on the patient or his family.

A rule for early outcome classification of out-of-hospital cardiac arrest patients presenting with ventricular fibrillation.

The aim of the study was to develop a scoring system for outcome classification at the start of prehospital first tier resuscitation for patients with cardiac arrest from ventricular fibrillation (VF). We studied a consecutive sample of 100 out-of-hospital cardiac arrest patients, presenting with VF of presumed cardiac etiology on arrival of the first tier (in a two-tiered urban Emergency Medical Services system). The number of patients discharged was 29 ('survivors') and 71 died ('non-survivors'). The electrocardiography (ECG) tracings recorded during resuscitation using a semi-automatic defibrillator were retrospectively analysed. For each patient, VF amplitude in mV (VF_a) and the number of base-line crossings per second (VF_blc) were calculated. Fisher's linear discriminant analysis was applied to discriminate between survivors and non-survivors using the variables VF_a, VF_blc and age. Patients were classed as potential survivors or non-survivors using a survival index = 0.6*(VF_a) + 0.4*(VF_blc)-4.0. If for a given patient the survival index is < 0, he is classified in the non-survivor group, if the survival index is > 0, he is classified in the survivor group. Using this index 79% of the survivors and 70% of the non-survivors could be classified correctly. Adding age to the formula increased the correct classification of survivors to 86 and 73% for the non-survivors. The survival index provides a research tool for the discrimination between potential survivors and non-survivors, which opens the possibility for the development of alternative treatment protocols in cardiac arrest.

Quality and efficiency of bystander CPR. Belgian Cerebral Resuscitation Study Group.

Incorrectly performed bystander CPR might compromise survival of the cardiac arrest patient. We therefore evaluated the outcome in 3306 out-of-hospital primary cardiac arrests of which 885 received bystander CPR. bystanders performed CPR correctly in 52%, incorrectly in 11%, 31% performed only external chest compressions (ECC) and 6% only mouth-to-mouth ventilation (MMV). The initial ECG in cases without bystander CPR was ventricular fibrillation in 28% (95% confidence interval: 27-30%); 45% (41-50%) and 39% (29-48%), respectively when bystander CPR was performed correctly or incorrectly; 43% (37-49%) when only ECC was applied and 22% (11-33%) when only MMV was practiced. Long term survival, defined as being awake 14 days after CPR, was 16% (13-19%) in patients with correct bystander CPR; 10% (7-14%) and 2% (0-9%), respectively when only ECC or only MMV was performed; 7% (6-8%) when no bystander was involved; 4% (0-8%) when bystander CPR was performed incorrectly. Bystander CPR might have a beneficial effect on survival by maintaining the heart in ventricular fibrillation by ECC. A negative effect of badly performed bystander CPR was not observed compared to cases which had not received bystander CPR.

Venopulmonary fistula: a rare complication of central venous catheterization.

Venopulmonary fistula occurred in a 13-year-old girl, 2 weeks after insertion of a silicone parenteral nutrition catheter. "TPN pneumonia" evolved to life-threatening respiratory failure. Complete resolution of the respiratory insufficiency followed removal of the catheter.

Respiratory insufficiency in acid maltase deficiency: the effect of high protein diet.

A 27-yr-old woman with the myopathic form of acid maltase deficiency (AMD) developed severe respiratory insufficiency after a crash diet resulting in a 6-kg weight loss. While being maintained on home ventilation, an hypercaloric high-protein, low-carbohydrate diet (1800-2000 cal; 28% carbohydrates, 55% fat, 17% protein with 1.7 g protein/kg body weight) was instituted. This ameliorated her condition up to a level where useful life was possible and ventilation could be diminished.

Differential diagnosis of anesthesia induced rhabdomyolysis. A case report.

A four year old boy suffered from a prolonged cardiac arrest during anesthesia. Laboratory examination subsequently demonstrated extensive rhabdomyolysis. The possibility of an underlying muscle disease in this family was investigated by muscle biopsy, histological examination and in-vitro contracture testing. The latter test result was consistent with malignant hyperthermia susceptibility. This case history illustrates the differential diagnosis of anesthesia induced rhabdomyolysis.

Purulent pericarditis due to methicillin-resistant Staphylococcus aureus. A case report.

Purulent pericarditis is an infrequent complication of infections originating in another body location. Symptoms and signs are often absent; a high index of awareness is required for its diagnosis. A patient recovering from extensive necrotic-hemorrhagic pancreatitis presented with tamponade due to methicillin-resistant Staphylococcus aureus (MRSA) purulent pericarditis, further complicated by MRSA endocarditis. Treatment included pericardectomy, IV vancomycin and teicoplanin.

An unusual poisoning with the unusual pesticide amitraz.

Amitraz, 1,5 di-(2,4-dimethylphenyl)-3-methyl-1,3,5-triaza-penta-1,4-diene, a formamidine pesticide, is used worldwide. It causes side-effects in animals that resemble those caused by pure alpha 2-adrenergic agonist drugs such as clonidine. Data on poisonings in humans are scanty. We report on a case of human poisoning with amitraz with typical signs of alpha 2-adrenoreceptor stimulation.