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Background: Disseminated cryptococcosis is a severe, high-mortality opportunistic infection with systemic effects, particularly in immunocompromised patients. Case Presentation: Herein, we report a rare case of fulminant disseminated cryptococcosis in a 32-year-old male with undiagnosed advanced human immunodeficiency virus/acquired immune deficiency syndrome who rapidly developed multi-organ failure, refractory shock, and cardiac arrest within 21 h of admission, necessitating veno-arterial extracorporeal membrane oxygenation. Despite resuscitative efforts, the patient died on Day 6. Conclusion: This case highlights the accelerated progression of disseminated cryptococcosis in patients with profound immunosuppression and the unique autopsy findings of extensive myocardial cryptococcal infiltration and microemboli, suggesting a contribution to acute refractory shock.
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BACKGROUND: Septic shock remains a critical condition with high mortality, necessitating reliable prognostic biomarkers and effective adjunct therapies. OBJECTIVES: This study explored prognostic biomarkers and the effect of vitamin C in septic shock. METHODS: This study analyzed 110 patients (January 2023-March 2024), stratified by 28-day outcome into survival (n=90) and death (n=20) groups. Compared to survivors, the death group exhibited significantly lower lymphocyte-to-high-density lipoprotein ratio (LHR), CD3+, CD3+CD4+, CD4+/CD8+ and higher interleukin 6 (IL-6), C-reactive protein (CRP), procalcitonin (PCT), CD3+CD8+. RESULTS: The receiver operating characteristic analysis showed the combination of LHR, IL-6, CRP, PCT and CD4+/CD8+ predicted death best [area under the receiver operating characteristic curve (AUC) =0.960], outperforming single markers. Patients were randomized to control (hydrocortisone) or observation (hydrocortisone with vitamin C) group. Post-treatment, both groups showed improved mean arterial pressure (MAP), central venous pressure (CVP) (increased), heart rate (HR) (decreased) and reduced PCT, tumor necrosis factor-α (TNF-α), IL-6 and Sequential Organ Failure Assessment (SOFA) score; however, improvements were significantly greater in the vitamin C group. CONCLUSION: The combination of LHR, IL-6, CRP, PCT and CD4+/CD8+ has prognostic value. Vitamin C adjunct therapy significantly enhances hemodynamic improvement, reduces inflammation, lowers SOFA scores and improves prognosis in septic shock patients.
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Ácido Ascórbico , Proteína C-Reactiva , Interleucina-6 , Lipoproteínas HDL , Polipéptido alfa Relacionado con Calcitonina , Choque Séptico , Subgrupos de Linfocitos T , Humanos , Polipéptido alfa Relacionado con Calcitonina/sangre , Proteína C-Reactiva/metabolismo , Ácido Ascórbico/uso terapéutico , Masculino , Femenino , Choque Séptico/tratamiento farmacológico , Choque Séptico/sangre , Choque Séptico/mortalidad , Choque Séptico/inmunología , Choque Séptico/diagnóstico , Persona de Mediana Edad , Interleucina-6/sangre , Biomarcadores/sangre , Pronóstico , Anciano , Subgrupos de Linfocitos T/efectos de los fármacos , Subgrupos de Linfocitos T/inmunología , Lipoproteínas HDL/sangreRESUMEN
Infection is one of the 2 most common complications associated with cesarean delivery. The principal infections, in descending order of frequency, are endometritis (organ space infection), wound infection (surgical site infection and incisional infection), and urinary tract infection. The major microorganisms that cause endometritis are anaerobic Gram-negative bacilli, anaerobic Gram-positive cocci, aerobic Gram-negative bacilli, aerobic Gram-positive cocci, and Ureaplasma urealyticum. The principal pathogens that cause wound infections are the organisms listed above plus the staphylococcal and streptococcal organisms that colonize the skin of the patient's abdomen, including methicillin-resistant Staphylococcus aureus. The dominant uropathogens are the aerobic Gram-negative bacilli Escherichia coli, Klebsiella pneumoniae, and Proteus species. Group B streptococci, enterococci, and Staphylococcus saprophyticus are less common, but still important, uropathogens. The principal risk factors for endometritis and wound infection are obesity, extended duration of labor and ruptured membranes, multiple vaginal examinations after membrane rupture, internal fetal monitoring, smoking, insulin-dependent diabetes, immunosuppressive disorders, use of immunosuppressive medications, extended duration of surgery, and excessive intraoperative blood loss. The key risk factors for urinary tract infection are the technique for insertion of the urinary catheter and the duration of bladder catheterization. The initial differential diagnosis of postoperative fever includes endometritis, lower respiratory tract infection, and acute pyelonephritis. When postoperative fever persists, the differential must be broadened to include resistant microorganism(s), wound infection, pelvic abscess, septic pelvic vein thrombophlebitis, retained products of conception, drug fever, and reactivation of connective tissue disease. The appropriate antibiotic therapy for endometritis is either a combination regimen, such as clindamycin plus gentamicin or metronidazole plus ampicillin plus gentamicin, or single agents such as extended-spectrum penicillins, cephalosporins, or carbapenems that provide coverage against the broad range of pelvic pathogens. For wound infection, the addition of a specific antistaphylococcal antibiotic such as vancomycin or linezolid, and, in some instances, surgical drainage are indicated. For a lower urinary tract infection, the oral antibiotics, nitrofurantoin monohydrate macrocrystals or trimethoprim-sulfamethoxazole, are preferred. For pyelonephritis, ceftriaxone is an excellent choice for therapy. Several measures are of great value in reducing the frequency of endometritis and wound infection: preoperative antibiotics, clipping (rather than shaving) the hair at the incision site, preparation of the skin with chlorhexidine (rather than povidone-iodine), removal of the placenta by traction on the cord (rather than by manual extraction), closure of the deep subcutaneous layer if it exceeds 2 cm in thickness, and closure of the skin with a thin monofilament suture (rather than with staples or with a multifilament suture). The key preventive measures for reducing the frequency of urinary tract infection are strict aseptic technique in inserting the catheter and removal of the catheter within 12 to 24 hours of surgery. This review focuses primarily on the pathophysiology, clinical manifestations, diagnosis, and treatment of endometritis, wound infection, and urinary tract infection. It also provides a brief overview of the diagnosis and management of the potentially very serious complications that may arise from the original infection at the operative site, namely pelvic abscess, septic pelvic vein thrombophlebitis, and septic shock. The review concludes with a summary of key measures to prevent postoperative infections.
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Cesárea , Endometritis , Infección de la Herida Quirúrgica , Infecciones Urinarias , Humanos , Femenino , Cesárea/efectos adversos , Infección de la Herida Quirúrgica/diagnóstico , Infección de la Herida Quirúrgica/fisiopatología , Infección de la Herida Quirúrgica/terapia , Infección de la Herida Quirúrgica/prevención & control , Embarazo , Endometritis/diagnóstico , Endometritis/fisiopatología , Endometritis/terapia , Endometritis/prevención & control , Endometritis/microbiología , Endometritis/etiología , Infecciones Urinarias/diagnóstico , Infecciones Urinarias/fisiopatología , Infecciones Urinarias/prevención & control , Infecciones Urinarias/terapia , Infecciones Urinarias/etiología , Factores de Riesgo , Antibacterianos/uso terapéuticoRESUMEN
BACKGROUND: Sepsis and septic shock are life-threatening conditions with high mortality, presenting challenges in predicting disease severity and outcomes. Cell-free mitochondrial DNA (mtDNA) has emerged as a potential mediator in sepsis pathogenesis, acting as a damage-associated molecular pattern (DAMP) that exacerbates inflammation. The present study aimed to assess cell-free mtDNA levels as predictors of mortality and disease severity, and to determine their correlation with established clinical markers. METHODS: A prospective study enrolled 150 participants, including healthy controls (n = 50) and patients (n = 100, of which 50 had sepsis and 50 had septic shock). Plasma cell-free mtDNA levels were quantified using RT-qPCR, and Receiver operating characteristic (ROC) curves were used to evaluate the predictive ability of cell-free mtDNA for 28-day mortality. The cell-free mtDNA correlated with clinical markers, including C-reactive protein (CRP), Sequential Organ Failure Assessment (SOFA), Acute Physiology and Chronic Health Evaluation (APACHE II), Procalcitonin (PCT), neutrophil-to-lymphocyte ratio (NLR), and lactate. RESULTS: Cell-free mtDNA levels were significantly elevated in sepsis and septic shock patients compared to controls, and higher in septic shock compared to sepsis patients. Non-survivors exhibited significantly higher cell-free mtDNA levels than survivors across both sepsis and septic shock subgroups. Cell-free mtDNA demonstrated a superior predictive value for 28-day mortality, area under the curve (AUC = 0.865) compared to clinical markers (CRP, SOFA, PCT, NLR, and Lactate). Furthermore, cell-free mtDNA levels showed a positive correlation with CRP, followed by SOFA, NLR, and PCT. CONCLUSION: Elevated circulating cell-free mtDNA levels were associated with severity and mortality in sepsis and septic shock, and may act as a valuable molecular tool for predicting disease outcomes. The study's findings warrant further investigation into the potential of cell-free mtDNA as a future component of clinical management strategies in sepsis.
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Ácidos Nucleicos Libres de Células , ADN Mitocondrial , Sepsis , Choque Séptico , Humanos , Femenino , Masculino , ADN Mitocondrial/sangre , Estudios Prospectivos , Choque Séptico/mortalidad , Choque Séptico/sangre , Ácidos Nucleicos Libres de Células/sangre , Persona de Mediana Edad , Sepsis/mortalidad , Sepsis/sangre , Anciano , Biomarcadores/sangre , Índice de Severidad de la Enfermedad , Curva ROC , Puntuaciones en la Disfunción de Órganos , Pronóstico , Estudios de Casos y Controles , Proteína C-Reactiva/metabolismo , APACHE , Valor Predictivo de las Pruebas , Polipéptido alfa Relacionado con Calcitonina/sangre , AdultoRESUMEN
A 54-year-old male with a history of poorly controlled diabetes mellitus presents to the emergency department after being found unresponsive at home. His last known well was approximately nine hours prior to arrival. He was intubated in the field for airway protection and transported emergently. His initial blood glucose was >600 mg/dL. On arrival, he was hypotensive (BP 67/56 mmHg) and hypothermic (35.7 °C). Examination revealed an unresponsive male with an endotracheal tube in place and a cold, pulseless left foot with necrotic wounds and palpable subcutaneous emphysema. He was immediately initiated on broad-spectrum antibiotics (vancomycin, piperacillin-tazobactam, and clindamycin), received a 30 mL/kg bolus of normal saline, and was started on norepinephrine, bicarbonate, and insulin drips. Vascular surgery was emergently consulted. Computed tomography imaging confirmed extensive lower extremity cellulitis, fasciitis, myositis, osteomyelitis, and air in soft tissues concerning for necrotizing infection. Labs confirmed an additional diagnosis of diabetic ketoacidosis. Due to the patient's unstable condition and anesthesiology deeming him unfit for the operating room, a bedside guillotine amputation of the foot and ankle was performed by vascular surgeon and emergency physician. The patient was admitted to the intensive care unit for ongoing management. The patient initially improved and became more responsive. However, after discussion with family regarding goals of care, the patient was transitioned to comfort care measures, terminally extubated, and ultimately expired. This case highlights the challenges of managing fulminant necrotizing infections in critically unstable patients and underscores the need for rapid, multidisciplinary intervention in the emergency department.
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Amputación Quirúrgica , Tobillo , Fascitis Necrotizante , Pie , Humanos , Fascitis Necrotizante/cirugía , Masculino , Persona de Mediana Edad , Amputación Quirúrgica/métodos , Servicio de Urgencia en Hospital , Pie/cirugía , Tobillo/cirugía , Antibacterianos/uso terapéuticoRESUMEN
The failed regimens for sepsis include but are not limited to steroids, antibiotic coverage for gram-negatives, and activated protein C. Reports of dramatic successes with vitamin C, its low cost and virtual absence of side effects in sepsis are encouraging despite some negative reports. I propose that this discrepancy in the results could be attributed to the altered status of essential fatty acid (EFA) metabolism in sepsis. Patients with sepsis have reduced plasma phospholipid concentrations of gamma-linolenic acid (GLA, 18:3 ω-6), dihomo-GLA (20:3 ω-6), arachidonic acid (AA, 20:4 ω-6), alpha-linolenic acid (ALA, 8:3 ω-3), and eicosapentaenoic acid (EPA, 20:5 ω-3) that are generated from dietary essential fatty acids {EFAs: cis-linoleic acid (LA) and α-linolenic acid (ALA)}. EFAs form the precursors to both pro-inflammatory and anti-inflammatory eicosanoids. Lipoxin A4 (LXA4), an anti-inflammatory eicosanoid derived from AA, enhances blood and peritoneal neutrophil phagocytic action, improves survival and promotes a more complete resolution of inflammation in sepsis. Prostaglandin E1 (PGE1), derived from DGLA, has actions like LXA4 and augments LXA4 generation. Vitamin C enhances the formation of PGE1 that may account for its beneficial action in sepsis and other conditions. EFAs metabolism is interfered with by corticosteroids and pro-inflammatory interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α). EFAs need several co-factors including but not limited to vitamins B1, B6, and B12 for their optimum metabolism. Hence, it is proposed that co-administration of EFAs along with vitamins C, B1, B6, and B12 with or without corticosteroids may be of significant benefit in sepsis and septic shock.
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Corticoesteroides , Ácido Ascórbico , Ácidos Grasos Esenciales , Sepsis , Humanos , Corticoesteroides/uso terapéutico , Ácido Ascórbico/uso terapéutico , Ácido Ascórbico/sangre , Ácido Ascórbico/administración & dosificación , Ácidos Grasos Esenciales/metabolismo , Ácidos Grasos Esenciales/sangre , Ácidos Grasos Esenciales/uso terapéutico , Sepsis/tratamiento farmacológico , Sepsis/sangreRESUMEN
OBJECTIVE: The aim of this study is to evaluate the diagnostic utility of coagulation parameters-prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen (FIB), D-Dimer (D-D), prothrombin time activity (PTA), and international normalized ratio (INR) -in combination with inflammatory markers, including procalcitonin (PCT), C-reactive protein (CRP), interleukin-6 (IL-6), systemic inflammation index (SII), and lymphocyte-C-reactive protein ratio (LCR), for stratifying sepsis severity. METHODS: This retrospective study included 123 patients diagnosed with sepsis and confirmed by positive blood cultures between October 2020 and October 2024. A control group comprising 50 healthy individuals undergoing routine physical examinations was also included. Clinical data were collected and analyzed using SPSS 25.0. The sensitivity, specificity, receiver operating characteristic (ROC) curves, and area under the curve (AUC) values of each indicator were calculated to evaluate their diagnostic value. RESULTS: No statistically significant differences were observed in baseline demographic or clinical characteristics between the sepsis and control groups (p > 0.05). Significant differences were identified between the groups in PT, APTT, D-D, PTA, INR, and CRP values (p < 0.05).The correlation coefficients between different grades of sepsis (shock and non-shock) and PT, APTT,DD,INR,PTA,LCR, CRP were r = 0.328,r = 0.254,r = 0.272,r = 0.347,r = -0.331,r = -0.179,r = 0.200, respectively. P < 0.05 is statistically significant,It is suggested that the classification is positively correlated with PT,APTT,DD,INR and CRP. PTA and LCR are negatively correlated, but the correlation in hierarchical diagnosis is low. Compared with sepsis group, the area under the curve (AUC) of coagulation index and inflammatory index in septic shock group was calculated. The area under the curve of PT in coagulation index was 0.695, the sensitivity was 53.2 %, and the specificity was 82.9 %. The area under the APTT curve was 0.651, the sensitivity was 66.0 %, and the specificity was 64.5 %. The area under the DD curve was 0.662, the sensitivity was 76.6 %, and the specificity was 57.9 %. Among the inflammatory indicators, the area under the CRP curve was 0.619, with a sensitivity of 63.8 % and a specificity of 63.2 %. ROC analysis revealed that the AUC of LCR in the septic shock group was 0.604, with a sensitivity of 66.0 % and specificity of 57.9 %. Combined detection of PT, LCR, and DD yielded an AUC of 0.8705, with a sensitivity of 74.5 % and specificity of 68.8 %. CONCLUSION: Combined detection of coagulation markers such as PT with inflammatory markers including LCR, and DD may enhance the diagnostic accuracy for stratifying sepsis severity and identifying progression to septic shock.
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Coagulación Sanguínea , Inflamación , Sepsis , Humanos , Sepsis/diagnóstico , Sepsis/sangre , Estudios Retrospectivos , Biomarcadores/sangre , Masculino , Femenino , Persona de Mediana Edad , Inflamación/diagnóstico , Inflamación/sangre , Anciano , Adulto , Proteína C-Reactiva/análisis , Curva ROC , Polipéptido alfa Relacionado con Calcitonina/sangreRESUMEN
OBJECTIVES: To describe the epidemiology of methylene blue (MB) use in septic shock and explore the association between MB dose and hospital outcomes. DESIGN: Retrospective cohort study. SETTING: United States. PATIENTS: Eight hundred fifty-nine thousand eight hundred sixty-eight adult (≥ 18 yr) patients from 1100 centers with a diagnosis of septic shock (sepsis with vasopressor administration), discharged from Premier Healthcare Database hospitals in the United States from 2008 to 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We included patients who received MB at any point during hospitalization (to describe utilization), then separately focused on those who received MB within the first 3 hospital days (to examine association of dose with outcomes). The primary outcome was hospital mortality. We used mixed-effects multivariable regression models to evaluate the MB use and the association between MB dose (modeled as a five-knot restricted cubic spline) and outcomes. Among patients with septic shock, 4082 patients (0.5%) from 663 hospitals received at least one dose of MB. Patients receiving MB tended to be younger and received major surgery. Hospitals in which MB was administered were larger urban teaching hospitals. After multivariable adjustment, use of MB was lower in 2016-2020 than in 2008. Of 2507 patients (61.4%) who received MB within the first 3 days of hospitalization, 375 (15.0%) died in hospital. Our spline analysis suggests a nonlinear association between MB dosing and outcomes among patients receiving MB early in their hospitalization. CONCLUSIONS: Use of MB in septic shock is rare in the United States, but with substantial inter-hospital variability and decreased use over time through 2020. Randomized evidence is required to evaluate the efficacy and safety of MB.
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Azul de Metileno , Choque Séptico , Humanos , Choque Séptico/tratamiento farmacológico , Choque Séptico/mortalidad , Azul de Metileno/uso terapéutico , Azul de Metileno/administración & dosificación , Estudios Retrospectivos , Masculino , Femenino , Persona de Mediana Edad , Mortalidad Hospitalaria , Anciano , Estados Unidos/epidemiología , Vasoconstrictores/uso terapéutico , AdultoRESUMEN
A colopleural fistula represents a rare pathological communication between the colon and the pleural cavity, typically resulting from trauma, malignancy, or inflammatory bowel disease. One of the exceedingly rare complications of a fistula is fecopneumothorax, characterized by the presence of gas and fecal matter in the pleural space, which can lead to fatal sepsis if not diagnosed promptly. We report an instance of a traumatic colopleural fistula in a 49-year-old male who suffered multiple gunshot wounds to the chest. Despite emergent surgical intervention and intensive critical care management, the patient developed a fecohemopneumothorax and ultimately died from septic shock. This case emphasizes the necessity for early radiologic evaluation for enterothoracic fistulas in trauma patients exhibiting persistent sepsis and abnormal thoracic drainage.
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Introduction and importance: Gastrointestinal perforation is a very common surgical emergency with significant mortality and morbidity, which needs urgent intervention. Foreign body-related perforations are very rare, accounting for less than 1% of cases. However, Colonic perforation by Eel fish is an extremely rare phenomenon; only three cases have been reported in the existing literature. Here, we report a rare case of traumatic colonic perforation with septic shock by a rectally inserted Eel fish. Case Presentation: A 25-year-old male presented to the emergency department with a 4-day history of abdominal pain, accompanied by high-grade fever and a loss of consciousness lasting 1 day. Initial workups suggested the case might be a case of intestinal perforation with septic shock. However, in the abdominal X-ray, there was a bizarre radiopaque shadow in the right iliac fossa. Emergency exploratory laparotomy was done, and a large perforation was found at the rectosigmoid junction. Multiple pieces of fish bone were found in the peritoneal cavity. A putrefied Eel fish was found in the peritoneal cavity, approximately 25 cm in length. Clinical Discussion: After thorough peritoneal toileting, a Hartmann-like procedure, where the distal end was closed and secured with a silk suture and the proximal exteriorized for fecal diversion, was done, and the patient was shifted to the intensive care unit. However, despite the best medical care, the patient expired on the third postoperative day. Conclusion: Live animals causing rectal perforation have rarely been documented in the literature. Unusual healthcare beliefs, inadvertent sexual conduct, or criminal aggressiveness may be involved. However, the cause may remain a mystery. Rapid diagnosis with proper history, aided by imaging, with urgent surgical intervention, may increase patient survival. Therefore, emergency care physicians should also be conscious of the rare and unusual causes of intestinal perforation to reach the diagnosis promptly.
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Pheochromocytomas are rare neuroendocrine tumors that can cause life-threatening cardiovascular complications due to excessive catecholamine secretion. We report an unusual case in which acute gastroenteritis served as the trigger for a severe pheochromocytoma crisis. A 64-year-old woman with a history of an undiagnosed left adrenal mass presented with a two-day history of nausea, vomiting, and diarrhea. She rapidly deteriorated into septic shock, requiring vasopressor support and hydrocortisone. Subsequently, she developed an acute myocardial infarction and heart failure. During hospitalization, she exhibited dramatic blood pressure fluctuations (60-220/40-110 mmHg), with paroxysmal hypertensive crises accompanied by the classic triad of palpitations, headache, and profuse sweating. Laboratory studies revealed markedly elevated plasma and urinary catecholamine levels. Abdominal computed tomography (CT) confirmed a 3.3 cm left adrenal mass, leading to the diagnosis of pheochromocytoma. This case underscores that common infections, such as acute gastroenteritis, can act as potent stressors to precipitate a pheochromocytoma crisis, resulting in a complex and life-threatening presentation including septic shock, cardiogenic shock, and acute myocardial infarction. Early recognition of this potential trigger and the underlying tumor is critical for guiding appropriate management and preventing catastrophic outcomes. Physicians should maintain a high index of suspicion for pheochromocytoma in patients with unexplained hemodynamic instability, even in the setting of a common infectious illness.
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Background: Vasopressin and its derivatives, as second-line vasoactive agents, are increasingly being applied in the treatment of septic shock, but their effects on major organs, particularly the renal system, remain inadequately evaluated. Methods: A systematic search was conducted based on 4 online databases Embase, PubMed, ScienceDirect, and Scopus, for studies published up to April 2025 that compared the renal function outcomes between vasopressin versus norepinephrine. All the studies enrolled adult patients with septic shock. Both short-term outcomes (urine output, serum creatinine levels) and long-term outcomes (acute kidney injury (AKI) rate, renal failure (RF), days free of RF, and renal replacement therapy (RRT)-use rate) were assessed. Results: A total of 13 studies met the inclusion criteria, comprising 10 RCTs and 3 retrospective cohort studies, with a total of 2,024 septic shock patients (aged 46.76-68 years) engaged. Meta-analysis showed no significant differences between the vasopressin and norepinephrine groups in the incidence of AKI (Risk Ratio (RR) = 1.07, 95% CI [0.86, 1.33], P = 0.53), days free of RF (MD = 1.52, 95% CI [-2.21, 5.25], P = 0.43), incidence of RF (RR = 1.01, 95% CI [0.85, 1.19], P = 0.94), or urine output (MD = -161.93 mL, 95% CI [-690.31, 366.45], P = 0.55). However, vasopressin was associated with a significantly lower serum creatinine level (MD = -0.15 mg/dL, 95% CI [-0.29, -0.02], P = 0.028) and a reduced RRT utilization rate (RR = 0.76, 95% CI [0.62, 0.93], P < 0.01) compared to norepinephrine. Conclusion: Vasopressin demonstrates potential renal protective effects in the management of septic shock, as evidenced by a significant reduction in serum creatinine levels and a decreased need for renal replacement therapy compared with norepinephrine. However, the evidence supporting its benefit in reducing the incidence of AKI and RF, or prolonging the days free of RF remains of low quality.
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Septic shock remains a leading cause of preventable childhood death, yet contemporary populationlevel data on early and postdischarge outcomes in low and middleincome settings are scarce. We analyzed nationwide trends and risk factors for inhospital and longterm mortality among Thai children with septic shock. This was a retrospective national study encompassing 18,697 children aged 1 month to under 18 years old hospitalized with septic shock in Thailand from January 2015 to December 2022. In-hospital mortality occurred in 5,375 children (28.7%). Acute respiratory failure was the strongest factor associated with in-hospital death (aOR 15.51, 95% CI 13.24-18.16; p < 0.001). Additionally, neoplasm was the most potent co-morbidity associated with mortality (aOR 2.43, 95% CI 2.12-2.78; p < 0.001). Of 13,322 hospital survivors, 2,155 (16.2%) died during followup. Postdischarge mortality was highest in preschool children and was also associated with neoplasms (aHR 4.56, 95% CI 4.05-5.13; p < 0.001). Nationwide data show that more than one in four Thai children with septic shock die in hospital, and one in eight additional deaths occur after discharge. Respiratory failure and malignant disease markedly heighten risk. Timely, guideline-concordant resuscitation, proactive management of high-risk comorbidities, and structured post-ICU follow-up are urgent priorities to improve both early and long-term survival.
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Choque Séptico , Humanos , Tailandia/epidemiología , Choque Séptico/mortalidad , Choque Séptico/epidemiología , Preescolar , Masculino , Femenino , Lactante , Niño , Adolescente , Estudios Retrospectivos , Alta del Paciente , Mortalidad Hospitalaria/tendencias , Factores de Riesgo , Recién Nacido , Insuficiencia Respiratoria/mortalidad , Análisis de Supervivencia , Pueblos del Sudeste AsiáticoRESUMEN
We report a rare case of rapid tumor ingrowth causing complete occlusion of an uncovered self-expandable metal stent (SEMS) within two months of placement in a 65-year-old female patient with pancreatic head adenocarcinoma. The patient developed septic shock secondary to ascending cholangitis, requiring intensive care unit admission. Endoscopic retrograde cholangiopancreatography revealed complete stent occlusion due to tumor ingrowth. Successful salvage was achieved through coaxial placement of a covered SEMS through the occluded stent, with resolution of sepsis and restoration of biliary drainage. This case highlights the aggressive nature of pancreatic adenocarcinoma and the importance of vigilant monitoring for early stent failure, particularly in patients awaiting chemotherapy, where treatment delays can significantly impact survival outcomes.
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BACKGROUND: Hypervirulent Klebsiella pneumoniae (HvKp) causes severe invasive infections, but the lack of a standardized definition complicates surveillance. The emergence of carbapenem-resistant HvKp (CR-HvKp) poses a "dual-risk" threat whose impact is poorly quantified. This meta-analysis aimed to determine pooled proportions of severe outcomes stratified by diagnostic criteria and quantify the mortality risk associated with CR-HvKp. METHODS: Following PRISMA guidelines, we systematically searched five databases for studies published up to July 2025 reporting clinical outcomes of HvKp infection. A random-effects model was used to calculate pooled proportions of liver abscess, metastatic spread, septic shock, microbiological failure and mortality, with subgroup analyses by HvKp definition (phenotypic, molecular, combined, or clinical). Odds ratios (OR) for mortality in CR-HvKp versus carbapenem-susceptible (CS)-HvKp were pooled. RESULTS: From 4413 records, 79 studies involving 4240 patients were included. The pooled proportion of liver abscess was 24% (95% CI 17-32%) and metastatic spread was 22% (95% CI 12-32%), both significantly influenced by the diagnostic criteria used (p < 0.0001). Pooled mortality for HvKp was 21% (95% CI 15-27%). In stark contrast, pooled mortality for CR-HvKp was 57% (95% CI 35-78%). The frequency of microbiological failure among HvKp infected patients was reported to be 39%. A meta-analysis of six studies revealed CR-HvKp infection was associated with over 12-fold higher odds of death compared to CS-HvKp infection. CONCLUSION: HvKp continues to cause severe invasive infections, though outcome estimates vary due to inconsistent definitions. Mortality increases markedly when carbapenem resistance co-exists with virulence, indicating that poor outcomes are driven by both pathogenic and resistance mechanisms. Standardized diagnostic criteria and expanded genomic surveillance are essential to improve epidemiological comparability and guide early detection and containment of high-risk HvKp strains.
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Background: High-intensity focused ultrasound (HIFU) ablation is widely regarded as a safe and minimally invasive technique for treating uterine fibroids. However, severe complications such as uterine rupture and septic shock remain exceedingly rare. Case presentation: We report a case of a 42-year-old woman who developed uterine rupture complicated by septic shock one month after undergoing HIFU ablation for uterine fibroids. Conclusions: Although HIFU ablation for uterine fibroids is widely considered a safe and minimally invasive procedure, clinicians should recognize the potential for severe complications, including uterine rupture and septic shock.
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Neutropenic patients with acute myeloid leukemia (AML) are at high risk for severe, multidrug-resistant infections. Sepsis due to carbapenem-resistant Pseudomonas aeruginosa (CRPA) in this population often leads to septic shock and acute respiratory distress syndrome (ARDS), with historically poor outcomes. CytoSorb™ hemoadsorption has been proposed as an adjunctive therapy for refractory septic shock, but evidence in hematologic malignancies remains limited. This report describes a 29-year-old male with newly diagnosed AML complicated by neutropenic fever, bacteremia due to CRPA, and subsequent hospital-acquired pneumonia progressing to ARDS. Despite multiple antibiotic regimens and aggressive intensive care management, including mechanical ventilation, prone positioning, and continuous renal replacement therapy (CRRT), the patient developed refractory septic shock with persistent lactic acidosis and elevated inflammatory markers. Early adjunctive CytoSorb hemoadsorption was initiated, guided by maximal CytoScore criteria, as part of a comprehensive supportive strategy. Following CytoSorb therapy, the patient demonstrated transient hemodynamic and biochemical improvement; however, profound neutropenia and multi-organ failure persisted. Microbiological clearance of CRPA was not achieved; given confirmed colistin susceptibility and unknown carbapenemase mechanism, a salvage combination of colistin plus ceftazidime-avibactam was employed. Transient hemodynamic improvement was observed after CytoSorb initiation; however, cytokine assays were not performed, and microbiological clearance was not achieved, precluding any mechanistic attribution to CytoSorb. This case highlights the complexity of managing CRPA sepsis and ARDS in neutropenic AML patients, and the challenges in attributing observed clinical improvement to CytoSorb therapy in the context of multiple simultaneous interventions. The absence of cytokine assays (e.g., IL-6, TNF-α) precludes any mechanistic attribution of observed changes to cytokine adsorption, and interpretation should remain descriptive rather than causal. Observed transient changes occurred amid simultaneous interventions (broad-spectrum antibiotics, CRRT, prone ventilation, corticosteroids, and filgrastim), precluding attribution to any single therapy, including CytoSorb. Given the fatal outcome and persistent CRPA positivity, the clinical impact of this observation is limited, and the generalizability of a single-case report is restricted. Cautious interpretation is warranted, and CytoSorb may be considered as part of a comprehensive care bundle rather than as a standalone solution. Alternative tetracycline-based combinations were reviewed but not adopted under our center's salvage protocol for this XDR presentation. Future studies are warranted to clarify its clinical benefit and optimal timing in this population.
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BACKGROUND: Sepsis remains a leading cause of global mortality, with culture-negative cases posing major challenges to diagnosis and risk stratification. This study explores the utility of commonly used biomarkers in predicting sepsis-induced mortality and evaluates the performance of age-stratified binary logistic regression model. METHODS: A prospective observational study was conducted over one year, including 960 patients with suspected sepsis. Clinical parameters including procalcitonin (PCT), C-reactive protein (CRP), Total Leucocyte count (TLC), blood culture & other relevant variables related to sepsis were recorded. Binary logistic regression models were developed separately for each age group (new-born/infants, adults, older adults) to predict the sepsis-induced mortality. RESULTS: A statistically significant logistic regression model was achieved only in the new-born/infant group. CRP levels ≥100 mg/L emerged as a strong and independent predictor of mortality (AUC = 0.80, p = 0.02). Although serum creatinine demonstrated a significant association in univariate analysis, it did not retain significance in the multivariate model. PCT levels and blood culture positivity were not significant predictors of mortality in any age group. In adults and older adults, model performance was poor, showing a strong class imbalance and limited sensitivity. CONCLUSIONS: The strong predictive value of CRP in the new-born/infant group serves as a revalidation of its clinical utility in sepsis, particularly in the context of the poor performance of other commonly used biomarkers such as PCT and TLC. The results also highlight the importance of age-specific modelling and reinforce the need for a multi-marker approach in sepsis diagnostics.
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Proteína C-Reactiva , Creatinina , Sepsis , Humanos , Sepsis/mortalidad , Sepsis/sangre , Sepsis/diagnóstico , Masculino , Femenino , Persona de Mediana Edad , Creatinina/sangre , Anciano , Proteína C-Reactiva/metabolismo , Proteína C-Reactiva/análisis , Biomarcadores/sangre , Estudios Prospectivos , Adulto , Factores de Edad , Valor Predictivo de las Pruebas , Polipéptido alfa Relacionado con Calcitonina/sangre , Lactante , Anciano de 80 o más Años , Modelos Logísticos , Recuento de Leucocitos , Adulto JovenRESUMEN
Septic shock, a life-threatening intensive care unit condition characterized by persistent hypotension and organ dysfunction despite fluid resuscitation, is a leading cause of intensive care unit mortality. Vasoactive drugs are central to hemodynamic support in septic shock but their benefit-potential adverse event trade-off remains controversial; existing studies link high-dose vasopressors to increased mortality, though the association with 28-day mortality is unclear due to limitations like small sample sizes or single-center designs. This retrospective cohort study, based on the Medical Information Mart for Intensive Care-IV database (V3.1), included 2961 adult patients with septic shock who received vasoactive drugs and had hyperlactatemia between 2008 and 2022. The association between total vasoactive drug exposure and mortality was investigated using quartile grouping, Kaplan-Meier (K-M) survival analysis, restricted cubic spline regression, and subgroup analysis. Multivariable Cox proportional hazards models with incremental adjustments for demographics, comorbidities and laboratory markers were applied to evaluate hazard ratios. The overall in-hospital 28-day mortality rate was 31.37%. Mortality significantly increased across quartiles of vasoactive drug exposure, rising from 15.26% to 43.67% (χ²â =â 152.73, Pâ <â .001). Multivariable Cox models demonstrated consistently elevated mortality risks with higher exposure quartiles, showing significant dose-response trends. Restricted cubic spline analysis showed a nonlinear association between vasoactive drug exposure and 28-day mortality, with a threshold of 470.98 units: below it, lower exposure raised risk; above it, higher exposure reduced risk. Subgroup analyses found this association was more pronounced in males, patientsâ ≤â 60 years old, those without cirrhosis, chronic kidney disease, cancer, and those with comorbid heart failure. The exposure dose of vasoactive drugs in patients with septic shock exhibits a non-linear association with 28-day mortality, with significant heterogeneity in risk characteristics across different dose ranges.
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Mortalidad Hospitalaria , Choque Séptico , Vasoconstrictores , Humanos , Choque Séptico/mortalidad , Choque Séptico/tratamiento farmacológico , Estudios Retrospectivos , Masculino , Femenino , Vasoconstrictores/efectos adversos , Vasoconstrictores/uso terapéutico , Vasoconstrictores/administración & dosificación , Persona de Mediana Edad , Anciano , Unidades de Cuidados Intensivos/estadística & datos numéricos , Bases de Datos Factuales , Modelos de Riesgos Proporcionales , Estimación de Kaplan-MeierRESUMEN
INTRODUCTION: Majority of patients admitted to intensive care units (ICUs) succumb to sepsis and its complications. However, currently available predictors fail to reliably gauge the severity of organ damage. There is a pressing need to identify biomarkers that can accurately forecast outcomes. Interleukin-6 (IL-6) has emerged as a potential biomarker, with some studies suggesting its utility as an early predictor of multi-organ failure in sepsis. This study evaluated the role of IL-6 in predicting mortality in an Indian ICU setting. METHODOLOGY: This prospective observational study included adult patients diagnosed with sepsis and a quick SOFA score ≥ 2. IL-6 levels, SOFA scores, and other clinical parameters were measured within 24 hours of admission. Univariate and multivariate analyses identified factors associated with mortality. RESULTS: The overall ICU mortality rate was 39%. Multivariate analyses indicated that IL-6 levels, total SOFA scores, and number of antibiotics used were independently associated with mortality. The IL-6 levels showed strong positive correlations with the total SOFA score (r = 0.77, p < 0.001) and individual organ dysfunction scores; particularly in cardiovascular (r = 0.61, p < 0.001), renal (r = 0.64, p < 0.001), and central nervous system (r = 0.6, p < 0.001). CONCLUSIONS: IL-6 levels, in combination with SOFA scores, provide a robust predictor of mortality in sepsis patients. The strong correlation between IL-6 levels and organ dysfunction scores suggests its potential as a biomarker for sepsis severity and progression.