[COVID-19 and herpesvirus encephalitis]. / COVID-19 y encefalitis por herpesvirus.

INTRODUCTION: The SARS-CoV-2 virus, which causes COVID-19, could give rise to damage the nervous system. Many studies have been conducted on this topic, but few have focused specifically on encephalitis. The effect of SARS-CoV-2 on the clinical expression of other neurotropic viruses, such as Herpesviridae, is unknown. CASE REPORTS: We describe the cases of two young men (39 and 18 years old) in whom SARS-CoV-2 had been detected -reverse transcription polymerase chain reaction (RT-PCR)-, and with a clinical diagnosis and cerebrospinal fluid (CSF) analysis consistent with encephalitis. The first patient had a positive PCR for varicella zoster virus in CSF, while the second had a positive PCR for herpes simplex virus types 1 and 2. The first patient, who was recently diagnosed with human immunodeficiency virus, presented with fever, headache, vomiting, cough, inappropriate behaviour and epileptic seizures; the second was seen to have fever, headache, myalgia and exanthema. Both offered the same laboratory findings (lymphopenia and high interleukin 6). CSF showed pleocytosis with a predominance of monomorphonuclear cells, hyperproteinorrachia and normal glycorrhachia. A cranial CT scan showed only mild diffuse cerebral oedema in the first case. Both cases were treated with corticosteroids, antibiotics and acyclovir. The second progressed favourably, while the first did not. CONCLUSIONS: Little is known about co-infection of SARS-CoV-2 with neurotropic viruses, such as Herpesviridae, and we have only limited evidence of direct neurological involvement of SARS-CoV-2, due to the technical difficulty of detecting it in the nervous system, thus making it important to take co-infection into account in order to be able to establish an early diagnosis and treatment to improve prognosis.

TITLE: COVID-19 y encefalitis por herpesvirus.Introducción. El virus SARS-CoV-2, causante de la COVID-19, podría generar lesiones en el sistema nervioso. Son múltiples los estudios relacionados con esto, pero escasos en cuanto a la encefalitis en particular. A su vez, se desconoce el efecto del SARS-CoV-2 sobre la expresión clínica de otros virus neurótropos, como los Herpesviridae. Casos clínicos. Se describen dos casos de varones jóvenes, de 39 y 18 años, con detección de SARS-CoV-2 ­reacción en cadena de la polimerasa con transcripción inversa (RT-PCR)­, con diagnóstico clínico y análisis del líquido cefalorraquídeo (LCR) compatibles con encefalitis. En el primer paciente se obtuvo una PCR positiva para el virus de la varicela zóster en el LCR, mientras que, en el segundo, para el virus del herpes simple de los tipos 1 y 2. El primer paciente, con diagnóstico reciente positivo para el virus de la inmunodeficiencia humana, presentó fiebre, cefalea, vómitos, tos, conductas inapropiadas y crisis epiléptica; y el segundo, fiebre, cefalea, mialgias y exantema. Ambos compartieron hallazgos en la analítica (linfopenia e interleucina 6 elevada). En el LCR se observó pleocitosis con predominio de monomorfonucleares, hiperproteinorraquia y glucorraquia normal. La tomografía computarizada de cráneo sólo evidenció un edema cerebral difuso leve en el primer caso. En ambos casos se realizó un tratamiento con corticoides, antibióticos y aciclovir. En el segundo, la evolución fue favorable, mientras que en el primero, no. Conclusiones. Poco se conoce sobre la coinfección del SARS-CoV-2 con virus neurótropos, como los Herpesviridae, lo que se suma a la escasa evidencia de la afectación neurológica directa del SARS-CoV-2, debido a la dificultad técnica para su detección en el sistema nervioso, por lo que es importante considerar la coinfección para realizar un diagnóstico y un tratamiento precoces que mejoren el pronóstico.

COVID-19 y encefalitis por herpesvirus / COVID-19 and herpesvirus encephalitis

Introducción: El virus SARS-CoV-2, causante de la COVID-19, podría generar lesiones en el sistema nervioso. Son múltiples los estudios relacionados con esto, pero escasos en cuanto a la encefalitis en particular. A su vez, se desconoce el efecto del SARS-CoV-2 sobre la expresión clínica de otros virus neurótropos, como los Herpesviridae. Casos clínicos: Se describen dos casos de varones jóvenes, de 39 y 18 años, con detección de SARS-CoV-2 –reacción en cadena de la polimerasa con transcripción inversa (RT-PCR)–, con diagnóstico clínico y análisis del líquido cefalorraquídeo (LCR) compatibles con encefalitis. En el primer paciente se obtuvo una PCR positiva para el virus de la varicela zóster en el LCR, mientras que, en el segundo, para el virus del herpes simple de los tipos 1 y 2. El primer paciente, con diagnóstico reciente positivo para el virus de la inmunodeficiencia humana, presentó fiebre, cefalea, vómitos, tos, conductas inapropiadas y crisis epiléptica; y el segundo, fiebre, cefalea, mialgias y exantema. Ambos compartieron hallazgos en la analítica (linfopenia e interleucina 6 elevada). En el LCR se observó pleocitosis con predominio de monomorfonucleares, hiperproteinorraquia y glucorraquia normal. La tomografía computarizada de cráneo sólo evidenció un edema cerebral difuso leve en el primer caso. En ambos casos se realizó un tratamiento con corticoides, antibióticos y aciclovir. En el segundo, la evolución fue favorable, mientras que en el primero, no. Conclusiones: Poco se conoce sobre la coinfección del SARS-CoV-2 con virus neurótropos, como los Herpesviridae, lo que se suma a la escasa evidencia de la afectación neurológica directa del SARS-CoV-2, debido a la dificultad técnica para su detección en el sistema nervioso, por lo que es importante considerar la coinfección para realizar un diagnóstico y un tratamiento precoces que mejoren el pronóstico.(AU)

Introduction: The SARS-CoV-2 virus, which causes COVID-19, could give rise to damage the nervous system. Many studies have been conducted on this topic, but few have focused specifically on encephalitis. The effect of SARS-CoV-2 on the clinical expression of other neurotropic viruses, such as Herpesviridae, is unknown. Case reports: We describe the cases of two young men (39 and 18 years old) in whom SARS-CoV-2 had been detected–reverse transcription polymerase chain reaction (RT-PCR)–, and with a clinical diagnosis and cerebrospinal fluid (CSF) analysis consistent with encephalitis. The first patient had a positive PCR for varicella zoster virus in CSF, while the second had a positive PCR for herpes simplex virus types 1 and 2. The first patient, who was recently diagnosed with human immunodeficiency virus, presented with fever, headache, vomiting, cough, inappropriate behaviour and epileptic seizures; the second was seen to have fever, headache, myalgia and exanthema. Both offered the same laboratory findings (lymphopenia and high interleukin 6). CSF showed pleocytosis with a predominance of monomorphonuclear cells, hyperproteinorrachia and normal glycorrhachia. A cranial CT scan showed only mild diffuse cerebral oedema in the first case. Both cases were treated with corticosteroids, antibiotics and acyclovir. The second progressed favourably, while the first did not. Conclusions: Little is known about co-infection of SARS-CoV-2 with neurotropic viruses, such as Herpesviridae, and we have only limited evidence of direct neurological involvement of SARS-CoV-2, due to the technical difficulty of detecting it in the nervous system, thus making it important to take co-infection into account in order to be able to establish an early diagnosis and treatment to improve prognosis.(AU)

[APACHE II and SAPS II as predictors of brain death development in neurocritical care patients]. / APACHE II y SAPS II como predictores de evolucion a muerte encefalica en pacientes neurocriticos.

AIM: To assess the prognostic value of APACHE II and SAPS II scales to predict brain death evolution of neurocritical care patients. PATIENTS AND METHODS: Retrospective observational study performed in a tertiary hospital. Include 508 patients over 16 years old, hospitalized in ICU for at least 24 hours. The variables of interest were: demographic data, risk factors, APACHE II, SAPS II and outcome. RESULTS: Median age: 41 years old (IR: 25-57). Males: 76.2%. Most frequent reason for admission: trauma (55.3%). Medians: Glasgow Coma Scale (GCS), 10 points; APACHE II, 13 points; SAPS II, 31 points; and ICU stay, 5 days. Mortality in the ICU was 28.5% (n = 145) of whom 44 (8.7%) evolved to brain death. Univariate logistic regression analysis showed that GCS, APACHE II and SAPS II scores, as well as ICU stay days behaved as predictors of brain death evolution. However, the multivariate analysis performed including APACHE II and SAPS II scores showed that only APACHE II maintained statistical significance, despite the good discrimination of both scores. CONCLUSION: Transplant coordinators might use the APACHE II score as a tool to detect patients at risk of progression to brain death, minimizing the loss of potential donors.

TITLE: APACHE II y SAPS II como predictores de evolucion a muerte encefalica en pacientes neurocriticos.Objetivo. Evaluar si las escalas pronosticas APACHE II (Acute Physiology and Chronic Health Evaluation II) y SAPS II (Simplified Acute Physiology Score II) son capaces de predecir la evolucion a muerte encefalica en pacientes neurocriticos. Pacientes y metodos. Estudio retrospectivo, observacional, realizado en un hospital de tercer nivel. Se incluyo a 508 pacientes mayores de 16 años, ingresados con patologia neurocritica aguda, con estancia en la unidad de cuidados intensivos de al menos 24 horas. Las variables de interes fueron: datos demograficos, factores de riesgo, APACHE II, SAPS II y resultado pronostico. Resultados. Mediana de edad: 41 años (rango intercuartilico: 25-57). Varones: 76,2%. Motivo de ingreso mas frecuente: traumatismo (55,3%). Medianas: escala de coma de Glasgow (GCS), 10 puntos; APACHE II, 13 puntos; SAPS II, 31 puntos; y estancia en cuidados intensivos, cinco dias. La mortalidad en la unidad de cuidados intensivos fue de 145 (28,5%). De ellos, 44 (8,7%) evolucionaron a muerte encefalica. El analisis de regresion logistica univariante mostro que la GCS, las escalas APACHE II y SAPS II, y los dias de estancia en la unidad de cuidados intensivos se comportaron como variables predictoras de evolucion a muerte encefalica. Sin embargo, en el analisis multivariante realizado con APACHE II y SAPS II, se evidencio que solo APACHE II mantiene significacion estadistica, a pesar de la buena discriminacion de ambas escalas. Conclusion. Los coordinadores de trasplantes podrian usar la escala APACHE II como una herramienta para detectar pacientes con riesgo de evolucion a muerte encefalica, minimizando la perdida de potenciales donantes.

Desempeño de los puntajes APACHE II y SAPS II para calcular la razón de mortalidad estandarizada en una Unidad de Cuidados Intensivos polivalente de la Argentina / Performance of the scores APACHE II and SAPS II for calculate the mortality ratio standardized in a Unit Intensive care polyvalent of Argentina

Objetivo: Estudiar el desempeño del Acute Physiology and Chronic Health Evaluation II (APACHE II) y el Simplified Acute Physiologic Score (SAPS II) para calcular la razón de mortalidad estandarizada en nuestra Unidad de Cuidados Intensivos. Diseño: Estudio retrospectivo y de observación entre enero de 2007 y diciembre de 2013. Ámbito: Unidad de Cuidados Intensivos polivalente. Pacientes: De ambos sexos, >18 años, internados, como mínimo, 24 horas. Intervenciones: Ninguna. Variables de interés: APACHE II, SAPS II, mortalidad, razón de mortalidad estandarizada. Resultados: Se analizaron 2641 pacientes que reunieron los datos requeridos. Edad promedio: 50.14 (± 16.95) años, varones: 67%, promedio de internación: 6.79 (± 9.14) días, mortalidad: 23,82%. Mortalidad promedio estimada por APACHE II 21,8% (± 21,4) y por SAPS II 27,4% (± 29,1) (p = 0,000). La razón de mortalidad estandarizada para la población estudiada con APACHE II fue de 1,09 (IC95%: 1,01-1,18) y con SAPS II fue de 0,87 (IC95%: 0,80-0,93). El puntaje APACHE II tuvo una adecuada calibración, pero no así el SAPS II (test de Hosmer-Lemeshow: p = 0,4042 y p = 0,0024, respectivamente). La discriminación de los puntajes APACHE II y SAPS II fue buena (ABC = 0,830 ± 0,010; p <0,001; IC95% 0,811-0,849 y ABC = 0,836 ± 0,001; p <0,001; IC95% 0,818-0,854, respectivamente).Conclusiones: El puntaje APACHE II tuvo una discriminación y una calibración buenas, y el SAPS II tuvo buena discriminación y mala calibración. Por lo tanto, en nuestra Unidad, sería razonable emplear el puntaje APACHE II para calcular la razón de mortalidad estandarizada (AU)

Objective: To study the performance of APACHE II and SAPS II for the estimation of the standardized mortality ratio (SMR) in our Unit. Design: Retrospective observational study performed from January 2007 to December 2013. Setting: An Intensive Care Unit in a tertiary hospital. Patients: Both sexes, >18 years old, hospitalized for at least 24 hours. Interventions: None. Variables of interest: APACHE II, SAPS II, mortality, standardized mortality ratio. Results: Data from 2,641 patients who gathered the required information, were analyzed. The average age was 50.14 (± 16.95) years, 67% were male, the average time of hospitalization was 6.79 (± 9.14) days and mortality was 23.82%. The average mortality was 21.8% estimated with APACHE II score, and 27.4% with SAPS II (p 0.000). The standardized mortality ratio for the studied population using APACHE II was 1.09 (95%CI: 1.01-1.18), and 0.87 (95%CI: 0.80-0.93) with SAPS II. APACHE II had adequate calibration but this not occurred with SAPS II (Hosmer-Lemeshow test: p=0.4042 and p=0.0024, respectively). Discrimination of APACHE II and SAPS II scores was good (AUC: 0.830 ± 0.010, p <0.001, 95%CI 0.811-0.849, and AUC: 0.836 ± 0.001, p <0.001, 95%CI 0.818-0.854, respectively). Conclusions: We conclude that APACHE II score had good discrimination and calibration, while SAPS II score had good discrimination and bad calibration. Therefore, in our Intensive Care Unit it would be reasonable to use the APACHE II score to calculate the standardized mortality ratio.(AU)

[Usefulness of procalcitonin upon admission to intensive care in the diagnosis and prognosis of sepsis]. / Valor de la procalcitonina al ingreso en terapia intensiva para el diagnóstico y el pronóstico de la sepsis.

OBJECTIVE: To assess the usefulness of procalcitonin (PCT) upon admission to the Intensive Care Unit (ICU) in the diagnosis and prognosis of sepsis DESIGN: A 12-month prospective observational cohort study was carried out SETTING: An 11-bed polyvalent ICU Belonging to a University hospital PATIENTS: Fifty patients with systemic inflammatory response syndrome (SIRS) were included. The mean age of the patients was 51.66 years, and 68% of them were males VARIABLES OF INTEREST: Upon admission, the concentration of PCT and C-reactive protein (CRP) was assessed. At discharge, the final diagnosis and outcome were reviewed RESULTS: Thirty-six patients had sepsis. Mean PCT ± SD was higher in sepsis than in non-infectious SIRS (19.3 ± 4.9 vs. 0.65 ± 0.2) ng/ml) (P=.001). PCT had greater discriminating power than CRP (AUC 0.932 vs. 0.827). The cut-off value of PCT for the diagnosis of sepsis was 0.92 ng/dl, with a sensitivity of 80.56%, specificity 85.71%, positive predictive value 93.55% and negative predictive value 63.16%, LR+ 5.64 and LR- 0.23. Mortality was higher in patients with sepsis (52.78% vs. 21.43%) (P=.039). Mean PCT ± SD upon admission among survivors and deceased patients with sepsis was 18.7 ± 6.7 and 19.5 ± 7.5 ng/ml, respectively (P=.934). CONCLUSIONS: PCT upon admission to the ICU is useful for the diagnosis of sepsis, and is more effective than PCR in this respect. However, it is of no help in estimating the short-term prognosis.

Exhaled breath condensate pH in mechanically ventilated patients.

OBJECTIVES: In this prospective clinical trial we aimed to answer if spontaneous exhaled breath condensate (EBC) in the trap of the expiratory arm of the ventilator could replace EBC collected by coolant chamber standardized with Argon as an inert gas. Second, if EBC pH could predict ventilator associated pneumonia (VAP) and mortality. PATIENTS: We included 34 critically ill patients (males = 26), aged = 54.85 ± 19.86 (mean ± SD) yrs, that required mechanical ventilation due to non-pulmonary direct cause (APACHE II score = 23.58 ± 14.7; PaO(2)/FiO(2) = 240.00 ± 98.29). SETTING: ICU with 9 beds from a regional teaching hospital. INTERVENTION AND RESULTS: The patients were followed up until development of VAP, successful weaning or death. There were significant differences between mean EBC pH from the 4 procedures with the exception of spontaneous EBC de-aerated with Argon (n = 79; 6.74 ± 0.28) and coolant chamber deaerated with Argon (n = 79; 6.70 ± 0.36; p = NS by Tukey's Multiple Comparison Test). However, none of the procedures were extrapolated between each other according to Bland & Altman method. The mean EBC pH from the trap without Argon was 6.50 ± 0.28. From the total of 34 patients, 22 survived and were discharged and 12 patients died in the ICU. CONCLUSION: Spontaneous EBC pH could not be extrapolated to EBC pH from coolant chamber and it did not change in subjects who dead, neither subject with VAP in comparison with baseline data. The lack of other biomarker in EBC and the lack of a control group determinate the need for further studies in this setting.

La infección como factor pronóstico en terapia intensiva / Infection as a factor prognosis in intensive therapy

Objetivo. Estudiar la relación de la patología infecciosa como motivo de ingreso a Terapia Intensiva (UTI) y la evolución a corto plazo. Diseño. Retrospectivo y observacional. Procedimiento. Se revisaron los datos de los pacientes internados entre el 01/ 01/1996 y el 31 /12/2006. Para el análisis se crearon 6 grupos de gravedad según el escore APACHE II de ingreso. La influencia de la patología de ingreso, sexo y días de internación fue determinada con regresión logística múltiple. En cada grupo de APACHE II se analizó el riesgo de muerte de los pacientes que ingresaron por patología infecciosa. Resultados. Se analizaron 5.263 pacientes. Edad media 55,08 años (r 11-98); sexo masculino 63%; días de estadía en UTI 4,05 días (±5,44); APACHE II 11,3 (±8,27); mortalidad 22,4%; patología de ingreso: cardiovascular 31,50%, infecciosa 14,48%, neurológica 9,86%, respiratoria 8,09%, digestiva 7,30%, medio interno 3,55% y otras 25,22%. La patología infecciosa fue el único factor que fue significativo en su relación a mortalidad todos los grupos de APACHE II. Cuando se analizaron en forma conjunta todos los pacientes y se incorporó al modelo de regresión logística el valor de APACHE II, resultaron significativos: patología cardiovascular, digestiva, infecciosa, neurológica, respiratoria y APACHE II, siendo la patología infecciosa la de mayor peso estadístico. Conclusión. Nuestro estudio sugiere que la patología infecciosa es un factor de riesgo independiente de mortalidad. Por lo tanto los pacientes infectados deberían ser considerados de alto riesgo, lo que puede determinar un nivel e intensidad de atención diferencial con la finalidad de disminuir las cifras de morbimortalidad.(AU)

Infections as Prognosis Factor in Critical Care Units Objective. To study the prevalence of infectious diseases as a cause of critical care unit admission and its short-term evolution. Design. Retrospective and observational study. Procedure. The patients admitted between January, 1st, 1,996 and December, 31st, 2,006 was reviewed. For the purpose of the analysis, there were 6 groups created according to the APACHE II score, to stratify severity at intensive-care unit admission. The influence of the illness at admission, gender and days at intensive care unit was determined through multiple logistic regression. In each APACHE II group, the mortality in patients admitted for infectious diseases were analyzed. Results. 5,263 patients were analyzed. Average age: 55.08 years (r 11-98); male gender: 63 %; length of stay at intensive care unit: 4.05 days (±5.44); APACHE II 11.3 (±8.27); mortality: 22.4%; causes of admission: cardiovascular disease: 31.50%, infectious disease: 14.48%, neurological disease: 9.86%, respiratory disease: 8.09%, digestive disease: 7.30%, disorders of fluids and electrolytes 3.55% and others: 25.22%. The only significant factor among all APACHE II groups was the infectious diseases. When all patients were analyzed as a whole and the results were included in logistic regression model from APACHE II, the most significant diseases were: cardiovascular, digestive, infectious, neurological, respiratory and APACHE II. The infectious diseases had the highest statistical weight. Conclusion. Our study suggests that infectious disease is an independent mortality factor. Thus, to reduce mortality and reduce hospital costs, patients with infectious diseases should be considered high-risk patients.(AU)

[Acridine orange staining method in the diagnosis of catheter-related bloodstream infections]. / Naranja de acridina para el diagnósticode bacteriemias relacionadas con catéteres.

OBJECTIVE: To study if the utility of acridine orange (AO) staining method on blood extracted through intravenous device (ID) is a reliable method to diagnose catheter-related bloodstream infection (CRB). DESIGN: Prospective and observational study. PATIENTS: Patients with central ID and clinical data consistent with CRB who gave their consent to participate. Patients having another infection site were excluded. INTERVENTION: At the moment of the clinical suspicion of CRB and before removing the ID, blood samples were extracted from peripheral veins and through the ID to be analyzed by AO staining. After extracting the samples, the catheter was removed and sent for microbiological analysis with Liñares et al and Maki et al techniques. CRS was defined as development of the same microorganism in the tip of the catheter (endoluminal surface with > or = 10 (3) UFC/ml and/or extraluminal surface > or = 15 UFC/ml) and in the peripheral blood. VARIABLES OF INTEREST: Sensitivity, specificity, negative and positive and negative predictive values and positive likelihood ratios (LR) were calculated for the diagnosis of CRB. RESULTS: A total of 121 patients were studied and 4 were diagnosed with CRB: 2 infected with Staphylococcus aureus, 1 with Pseudomonas aeruginosa and 1 with Candida albicans. AO sensitivity was 87.5%, specificity 92.7% and the negative predictive value was 99.5%. Positive likelihood ratio was 12.04 and negative LR 0.13. CONCLUSIONS: Although the number of events does not allow for the estimation of the efficacy of AO to diagnose CRB, its high negative predictive value would make it possible to rule out this infectious complication with some degree of safety.