Pneumomediastinum caused by occult paraquat poisoning: Case report.

RATIONALE: Paraquat is a widely applied contact herbicide that is highly poisonous. About 20% of patients with paraquat poisoning develop pneumomediastinum as a complication with a mortality rate of almost 100%. PATIENT CONCERNS: A 15-year-old boy presented with a 1-month history of retrosternal chest pain with no obvious cause. High-resolution computed tomography showed pneumomediastinum. DIAGNOSES: After all likely causes of pneumomediastinum were eliminated, the diagnosis of occult paraquat poisoning was made when serum paraquat concentration was revealed at 467.40 ng/mL, despite the patient's denial of ingestion or contact. INTERVENTIONS: Hemoperfusion, intravenous glucocorticoid, and ulinastatin was administered for 3 days with other routine treatment against paraquat poisoning. The serum paraquat concentration decreased to zero. OUTCOMES: Despite the general high mortality and poor prognosis of paraquat poisoning, the patient recovered and was completely asymptomatic at his 3-month follow-up. LESSONS: Paraquat poisoning should be suspected as a differential diagnosis when patients present with pneumomediastinum without recognizable cause.

Clinically amyopathic dermatomyositis with rapidly progressive interstitial pneumonia: The relation between the disease activity and the serum interleukin-6 level.

A 67-year-old woman exhibited chilblain-like erythema on the bilateral auricles, erythema with hyperkeratosis on the sides of fingers and the bilateral elbows, and erythema on the extensor/flexor sides of the finger joints and the iliac regions. Fine crackles were audible on the dorsal side of the bilateral lower lung regions. We diagnosed clinically amyopathic dermatomyositis accompanied by rapidly progressive interstitial pneumonia. While we initiated immunosuppressive therapy, the respiratory failure showed no responses. We performed endotoxin adsorption therapy using polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP). After the first PMX-DHP session, the respiratory condition was slightly improved but it soon deteriorated. At the second PMX-DHP session, subcutaneous and mediastinal emphysema was noted. The patient died, showing no improvement in the respiratory condition. We measured the levels of serum interleukin (IL)-6, tumor necrosis factor (TNF)-α and IL-10 before and after PMX-DHP and compared them with previously reported levels. The levels of TNF-α and IL-10 showed no or slight changes, but those of IL-6 at the beginning of the treatment were higher compared with previous reports. After the first PMX-DHP, the IL-6 level decreased with slight improvement in respiratory condition. However, after the second PMX-DHP, it increased markedly with exacerbation of the respiratory failure. The serum IL-6 level is considered to be effective for the evaluation of the disease activity and prognosis under the treatment by PMX-DHP.

Bone marrow mesenchymal stromal cells to treat tissue damage in allogeneic stem cell transplant recipients: correlation of biological markers with clinical responses.

Bone marrow mesenchymal stromal cells (BMSCs) have been used to treat acute graft-versus-host disease (GVHD) and other complications following allogeneic hematopoietic stem cell transplantation (SCT). We conducted a phase I trial using third party, early passage BMSCs for patients with steroid-refractory GVHD, tissue injury, or marrow failure following SCT to investigate safety and efficacy. To identify mechanisms of BMSC immunomodulation and tissue repair, patients were serially monitored for plasma GVHD biomarkers, cytokines, and lymphocyte phenotype. Ten subjects were infused a fixed dose of 2 × 10(6) BMSCs/kg intravenously weekly for three doses. There was no treatment-related toxicity (primary endpoint). Eight subjects were evaluable for response at 4 weeks after the last infusion. Five of the seven patients with steroid-refractory acute GVHD achieved a complete response, two of two patients with tissue injury (pneumomediastinum/pneumothorax) achieved resolution but there was no response in two subjects with delayed marrow failure. Rapid reductions in inflammatory cytokines were observed. Clinical responses correlated with a fall in biomarkers (Reg 3α, CK18, and Elafin) relevant for the site of GVHD or tissue injury. The GVHD complete responders survived significantly longer and had higher baseline absolute lymphocyte and central memory CD4 and CD8 counts. Cytokine changes also segregated with survival. These results confirm that BMSCs are associated with rapid clinical and biomarker responses in GVHD and tissue injury. However, BMSCs were ineffective in patients with prolonged GVHD with lower lymphocyte counts, which suggest that effective GVHD control by BMSCs requires a relatively intact immune system.

Bilateral spontaneous pneumothoraces, pneumopericardium, pneumomediastinum, and subcutaneous emphysema: a rare presentation of paraquat intoxication.

Pneumothorax, subcutaneous emphysema, and pneumomediastinum occur frequently in critically ill patients in association with blunt or penetrating injuries or other conditions while performing Valsalva-like maneuvers. We present the case of a patient with bilateral pneumothoraces, pneumomediastinum, pneumopericardium, and subcutaneous emphysema after acute paraquat intoxication.

Reduced platelet counts in neonatal respiratory distress syndrome.

Platelet counts were studied in preterm infants with the respiratory distress syndrome (RDS), excluding patients with significant perinatal and postnatal hypoxia. Counts fell to a nadir on day 4 (p less than 0.000). Exploratory analysis indicated that severity of RDS (levels of FiO2 and mean airway pressure), airleak syndrome, grade of intraventricular hemorrhage (IVH) and low platelet count on day 1 were correlated with low platelet count on days 4 and 5. Further analysis by stepwise removal of each variable demonstrated statistically that FiO2 exerted a unique influence on the change in platelet count between day 1 and days 4/5 (p less than 0.002). It is concluded that the severity of RDS is strongly associated with the fall in platelet count in the first few postnatal days. The effect of IVH on platelet count may be secondary to the effect of the RDS.

Malignant pneumomediastinum: successful tube mediastinostomy in the neonate.

Five critically ill neonates underwent tube mediastinostomy in the neonatal intensive care nursery for tension pneumomediastinum. All of the neonates showed immediate clinical improvement, with a decrease in peak airway pressure and elevation of arterial oxygen pressure levels. There were no complications directly attributable to the procedure. We believe that pneumomediastinum in association with severe hypoxia, metabolic acidosis, and high ventilation pressures indicates clinically significant tension in the mediastinum. This results in a decrease in systemic blood pressure and pulmonary venous return that is not amenable to conservative management. Needle aspiration is inadequate because of the dynamic nature of the air leak. Tube decompression of the mediastinum is the treatment of choice in these circumstances.