High-dose cefepime as an alternative treatment for infections caused by TEM-24 ESBL-producing Enterobacter aerogenes in severely-ill patients.

This study evaluated retrospectively the efficacy of treatment with cefepime vs. a carbapenem, in combination with amikacin or ciprofloxacin, for seriously-ill patients infected with ESBL-producing Enterobacter aerogenes who were admitted to an intensive care unit. Forty-four episodes of infection were investigated in 43 patients: 21 treated with cefepime; 23 with a carbapenem. The two treatment groups did not differ statistically in terms of age, APACHE II scores, and infection sites, but the average duration of antibiotic exposure was significantly shorter in the cefepime group (8.5 days vs. 11.4 days; p 0.04). Clinical improvement was seen in 62% of patients receiving cefepime vs. 70% of patients receiving a carbapenem (p 0.59). Bacteriological eradication was achieved in 14% of patients receiving cefepime vs. 22% of patients receiving a carbapenem (p 0.76). The 30-day mortality rates related to infection were 33% in the cefepime group and 26% in the carbapenem group (p 0.44). Thus, outcome parameters did not differ significantly between the two groups. Nevertheless, a statistically significant increase in failure to eradicate ESBL-producing E. aerogenes was observed as the MICs of cefepime rose (p 0.017). Pulsed-field gel electrophoresis revealed three distinct clones, but one predominant clone harbouring the bla(TEM-24) gene was associated with most (42/44) of the episodes of infection. It was concluded that cefepime may be an alternative agent for therapy of severe infections caused by TEM-24 ESBL-producing E. aerogenes, although further studies are required to confirm these observations.

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.

Peptide conjugated chitosan foam as a novel approach for capture-purification and rapid detection of hapten--example of ochratoxin A.

A novel bioassay for the detection and monitoring of Ochratoxin A (OTA), a natural carcinogenic mycotoxin produced by Aspergillus and Penicillium fungi, has been developed and applied for the screening of red wine. Here we report the immobilization and orientation of NOF4, a synthetic peptide, onto 3-D porous chitosan supports using a N-terminal histidine tag to allow binding to M(++) ions that were previously adsorbed onto the high surface area biopolymer. Three divalent cations (M(++)=Zn(++), Co(++), Ni(++)) were evaluated and were found to adsorb via a Langmuir model and to have binding capacities in the order Zn(++)>Co(++)>Ni(++). Following Zn(++) saturation and washing, C-terminus vs. the N-terminus His-tagged NOF4 was evaluated. At 1000 µg L(-1) OTA the N-terminus immobilization was more efficient (2.5 times) in the capture of OTA. HRP labeled OTA was added to the antigen solutions (standards or samples) and together competitively incubated on biospecific chitosan foam. The chemiluminescence substrate luminol was then added and after 5 min of enzymatic reaction, light emission signals (λmax=425 nm) were analyzed. Calibration curves of %B/B0 vs. OTA concentration in PBS showed that half-inhibition occurred at 1.17 µg L(-1), allowing a range of discrimination of 0.25 and 25 µg L(-1). In red wine, the minimum concentration of OTA that the system can detect was 0.5 µg L(-1) and could detect up to 5 µg L(-1). Assay validation was performed against immunoaffinity column (IAC) tandem reversed-phase high pressure liquid chromatography with fluorescence detection (HPLC-FLD) and provided quite good agreement. The association of chitosan foam and specific peptide represents a new approach with potential for both purification-concentration and detection of small molecules. In the future this assay will be implemented in a solid-sate bioelectronic format.

Early diagnosis of cerebral fat embolism syndrome by diffusion-weighted MRI (starfield pattern).

BACKGROUND: Cerebral fat embolism syndrome is a rare, but potentially lethal, complication of long bone fractures. Neurological symptoms are variable, and the clinical diagnosis is difficult. The purpose of this case study is to demonstrate the value of diffusion-weighted MRI of the brain for early diagnosis of fat embolism syndrome. Case Description- A non-head-injured 18-year-old woman suffered acute mental status changes 21 hours after an uncomplicated fracture of the left tibia. MRI of the brain was performed 48 hours after injury. T2-weighted images showed multiple nonconfluent areas of high signal intensity, which, on the diffusion-weighted scans, were revealed as bright spots on a dark background ("starfield" pattern). We suggest that this indicates areas of restricted diffusion that are due to cytotoxic edema, resulting from multiple microemboli. CONCLUSIONS: High-intensity lesions in the brain on diffusion-weighted images may serve as an early-appearing and more sensitive indicator of the diagnosis of fat embolism in the clinical context of long bone injury without head trauma.

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)

Acute poisoning with amphetamines (MDEA) and heroin: antagonistic effects between the two drugs.

A case of oral ingestion of large doses of both the amphetamine-derivative 3,4-methylene dioxyethamphetamine (MDEA) and heroin is reported. Despite high serum levels of both drugs, the patient did not present with the classic signs and symptoms normally seen during intoxication with these drugs. The patient recovered after symptomatic treatment. The possibility that opposite pharmacological properties of the two drugs prevented the patients death is discussed.

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.

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.

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.

Combined type B aortic dissection and fusiform abdominal aortic aneurysm. Case reports.

Two patients are described with a combined type B aortic dissection and a fusiform abdominal aortic aneurysm, the dissection not involving the aneurysm. In a seventy-year-old man a type B aortic dissection and a large abdominal aneurysm were found. An infrarenal aortic bifurcation graft was inserted. He died fifteen months later of cardiogenic shock. In a sixty-six-year-old man diagnosis of a primary aortoduodenal fistula was made together with a limited type B dissection. A straight aortic interposition graft was inserted. He died eleven months later of the complications of a secondary aortoduodenal fistula. Although combination of aortic dissection and abdominal aneurysm is a rare occurrence, conservative management of the aortic dissection and interposition graft for the abdominal aneurysm was successful as initial treatment in these 2 patients.

Massive dobutamine overdose in a cardiovascular compromised patient.

A case of dobutamine overdose is presented. Due to a prescription mistake a patient with recent myocardial necrosis and acute arterial occlusion received up to 70 mcg/kg/min of dobutamine IV. This resulted in arterial hypotension, diminished vascular resistance, oliguria and signs of cutaneous and mucosal hyperemia. Interruption of the dobutamine infusion and substitution with dopamine normalised all abnormalities. The differences between the hemodynamic profiles of dobutamine and dopamine are discussed.

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.

A series of five adult cases of respiratory syncytial virus-related acute respiratory distress syndrome.

Respiratory syncytial virus is a common cause of respiratory tract disease in children, predominantly presenting with mild symptoms. We present five cases of respiratory syncytial virus infection of the lower respiratory tract in immunocompromised adults suffering from severe respiratory insufficiency leading to bilateral pneumonia and fulfilling the criteria for acute respiratory distress syndrome. Respiratory syncytial virus was cultured as the only pathogen in the bronchoalveolar lavage fluid in four of these patients. Despite various therapeutic interventions, only one patient survived. Respiratory syncytial virus was implicated as a direct cause of respiratory failure. Respiratory syncytial virus may be an underestimated cause of severe respiratory failure and acute respiratory distress syndrome in the immunocompromised adult admitted to the intensive care unit.

Selective ambulatory management of imported falciparum malaria: a 5-year prospective study.

The ambulatory management of imported Plasmodium falciparum malaria is controversial because criteria for safe selection of patients are imprecise. The aim of the present study was to investigate the evolution and outcome of patients diagnosed with Plasmodium falciparum malaria at a Belgian referral institute in order to assess the safety of the institute's current selective ambulatory management protocol. From 2000 to 2005, all patients diagnosed with P. falciparum infection at the Institute of Tropical Medicine and the University Hospital of Antwerp were enrolled prospectively. Ambulatory treatment was offered to nonvomiting patients if they exhibited none of the 2000 World Health Organization criteria of severity and had parasitemia below 1% at the initial assessment. The treatment of choice was quinine (plus doxycycline or clindamycin) for inpatients and atovaquone-proguanil for outpatients. P. falciparum malaria was diagnosed in 387 patients, of whom 246 (64%) were Western travelers or expatriates and 117 (30%) were already on antimalarial therapy. At diagnosis, 60 (15%) patients had severe malaria. Vital organ dysfunction was initially seen in 34 and developed later in five others. Five patients died. Of the 327 patients initially assessed as having uncomplicated malaria, 113 (35%) were admitted immediately; of these, 4 developed parasitemia >/=5% at a later stage but without any clinical consequence. None of the 214 individuals initially treated as outpatients experienced any malaria-related complications, including 10 who were admitted later. Vital organ dysfunction was observed in only 2 of the 214 patients with initial parasitemia <1% who had not taken antimalarial agents (both patients had impaired consciousness at presentation). Ambulatory treatment is safe in treatment-naive malaria patients with parasitemia <1% who do not vomit and who do not exhibit any criteria of severe malaria.

Hypoprothrombinemia due to cefamandole.

Two patients are described with severe coagulation disturbances, in one instance leading to extensive skin bleeding, secondary to the use of cefamandole. This cefalosporin antibiotic carries the same N-methylthiotetrazole side chain as moxalactam. Pathogenetic mechanisms leading to hypoprothrombinemia, its prevention and treatment are discussed.

The Paceport catheter: a new pacemaker system introduced through a Swan-Ganz catheter.

We describe a new stainless steel, teflon-coated 2.4 F pacemaker wire with a flexible tip that can be introduced through an extra lumen of a specially designed 7.5 F Swan-Ganz catheter. The extra lumen opens at 19 cm from the tip of the catheter; this opening can be positioned in the right ventricular cavity. The pacemaker wire can be introduced at the time of insertion of the Swan-Ganz catheter or later when the need for ventricular pacing arises. The Paceport catheter was tested in 23 patients. Satisfactory ventricular pacing was achieved in 19 patients at thresholds between 0.5 and 4.0 mA (median 2.0 mA). The threshold increased by 1 mA during long-term pacing (8-24 hr). Attempts to use the pacemaker were abandoned when short runs of ventricular tachycardia developed upon introduction, while an exceptionally high threshold was observed in another patient. The Paceport system is recommended for patients who require hemodynamic monitoring and urgent ventricular pacing.