Management of purulent pericarditis.

A 50 year old man was admitted to ICU due to purulent pericarditis, purulent inflammation of the soft tissue of the neck, purulent mediastinitis and pneumonia. Subxyphoid periocardiotomy followed by the insertion of a drain into the pericardial space was performed. Four other drains were also inserted to drain purulent fluid from the neck (two drains) and mediastinum (two drains). During the surgical procedure, 700 ml of purulent pericardial fluid from the pericardial sac and 200 ml of purulent fluid from the mediastinum were drained. Antibiotic therapy was started upon admission to the hospital. Streptococcus species, Acinetobacter baumani and Enterococcus casseliflavus were cultured. Antibiotic therapy was adjusted to the results of the antibiogram. Despite revised antibiotic therapy, daily drainage from the pericardium--during several days after surgery--was around 200 ml. Due to the huge purulent pericardial drainage streptokinase, delivered directly into pericardial space, was given. The clinical effect of intrapericardial streptokinase administration was excellent. After 17 days drainage of purulent pericardial fluid was not observed. No clinical signs and symptoms of constrictive pericarditis developed. Repeated echocardiography examinations showed no signs of constrictive pericarditis and no pericardial fluid. The patient was discharged in good general condition.

[Echocardiography improves the chance of conclusive results in spiral computed tomography of suspected pulmonary embolism]. / Echokardiografia okresla szanse diagnostycznego wyniku spiralnej tomografii komputerowej w podejrzeniu zatorowosci plucnej.

While highly specific for detecting thromboembolism in proximal pulmonary arteries, spiral computed tomography (spiral CT) cannot reliably exclude pulmonary embolism. Therefore "negative" spiral CT in patients with high clinical probability of acute pulmonary embolism should be considered as non-conclusive. The goal of our study was to check whether echo/Doppler could stratify patients with suspected pulmonary embolism according to the chance of obtaining a conclusive spiral CT result. Echo/Doppler recordings of 51 patients (27 F, mean aged 50 +/- 19) admitted to ICU with high probability of acute pulmonary embolism were compared with the results of spiral CT of pulmonary artery. Pulmonary embolism was revealed by spiral CT in 36 pts. who at echocardiography were found to have shorter acceleration time (AcT 86 +/- 27 vs 117 +/- 7 ms, p < 0.00001) and right ventricle enlargement (PK 30 +/- 5 vs 25 +/- 2 mm p < 0.0001). The velocity of tricuspid regurgitation (TVPG) could not be measured in 19 patients. Among patients with long AcT (> or = 120 ms) or without right ventricle enlargement 8 of 14 and 14 of 28 patients, respectively had no intrapulmonary clots at spiral CT. Echo/Doppler helps in preselection of patients in whom confirmation of PE with spiral CT is highly probable. In patients without indirect echocardiographic sings of pulmonary embolism, despite high clinical probability the chance of a conclusive spiral CT is 40-50%. This should be kept in mind when selecting the most effective diagnostic strategy in individual cases.

[Thrombectomy in a patient with a mobile clot in the inferior vena cava--case report]. / Trombektomia u pacjenta z balotujaca skrzeplina w zyle glównej dolnej--opis przypadku.

Switching from heparin to acenocoumarol was complicated by severe retroperitoneal bleeding in a 50-years old patient with massive pulmonary embolism and deep venous thrombosis. The haematomas were evacuated by surgical procedure. Planned insertion of a vena cava filter was abandoned because of a mobile clot in inferior vena cava (IVC) reaching above renal veins as evidenced by spiral computed tomography (SCT). Patient was transferred to the Surgical Department of Medical Academy in Warsaw where thrombectomy was performed. In spite of mechanical and pharmacological methods of venous thrombosis prophylactic, thrombectomy was complicated by massive proximal deep venous thrombosis of right leg and distal part of IVC. Patient was successfully treated with UFH i.v. followed by low molecular weight heparins. No bleeding complications were observed. Screening for thrombophilia and cancer were negative. This case report is an example of difficulties in clinical management in a patient who has both life-threatening thromboembolic disease and bleeding.

[Noninvasive intermittent positive pressure ventilation in treatment of chronic respiratory disease exacerbation]. / Nieinwazyjne wspomaganie wentylacji w leczeniu zaostrzen przewleklej niewydolnosci oddychania.

Noninvasive intermittent positive pressure ventilation (NIPPV) via nasal mask became a routine method of treatment of severe exacerbations of chronic respiratory failure. The aim of the study was to apply NIPPV in patients with COPD admitted to hospital due to exacerbation of the disease who on standard treatment developed progressing respiratory acidosis (pH < 7.30). Fourteen COPD patients were treated with NIPPV. Arterial blood gases at the beginning of treatment were: PaO2 41 +/- 9 mmHg, PaCO2 = 87 +/- 17 mmHg, pH = 7.30 +/- 0.05. In 10 patients NIPPV applied quasi continuously resulted in clinical improvement and an amelioration of arterial blood gases. PaO2 rose from 41 +/- 9 mmHg to 56 +/- 12 mmHg, PaCO2 fell from 85 +/- 17 to 57 +/- 9 mmHg and pH rose from 7.30 +/- 0.05 to 7.41 +/- 0.04. In 4 patients NIPPV did not prevent further progression of respiratory acidosis. They were intubated and mechanically ventilated. Three patients survived and were discharged home. One patient died from septic shock. We conclude that NIPPV is an effective method to treat respiratory acidosis developing during exacerbation of severe COPD.

[The evaluation of carcinoembryonic antigen determination in the pericardial fluid in the diagnosis of the cause of pericarditis]. / Ocena przydatnosci oznaczania antygenu rakowoplodowego w plynie osierdziowym w rozpoznawaniu przyczyn zapalenia osierdzia.

Pericardial fluid CEA level was measured with radioimmunoassay in 19 patients with large pericardial effusion of unknown origin. In 11 patients malignancy was diagnosed. In all of these patients pericardial fluid CEA levels were above 7 ng/ml (mean value 52.6 +/- 42.6 ng/ml). In 8 patients the etiology of pericarditis was non-malignant. In all of them pericardial fluid CEA levels were below 7 ng/ml (mean value 2.2 +/- 1.6 ng/ml). In 9 patients with malignant pericarditis serum CEA levels were also determined: they were found to be lower than pericardial fluid CEA values in 6 patients. It was concluded that pericardial fluid CEA elevation is a reliable criteria of neoplastic pericardial involvement.

Neuron-specific enolase in non-neoplastic lung diseases, a marker of hypoxemia?

Neuron-specific enolase (NSE) is a glycolytic enzyme localized within neuronal and neuroendocrine tissues. Serum NSE is widely used as a marker of neuroendocrine tumors. Moderate serum NSE elevation has been reported in some patients with benign lung diseases. We decided to investigate whether the elevation of serum NSE in non-neoplastic lung diseases is connected with hypoxemia and to what extent the recovery of sufficient ventilation with a respirator may influence NSE concentrations. Serum NSE was estimated by means of radioimmunoassay in 83 patients with various non-neoplastic lung diseases. Serum NSE exceeding 12.5 micrograms/L was significantly more frequent in patients with marked hypoxemia (PaO2 < 6.67 kPa; p = 0.03) than in others. The median NSE value in the group of patients without respiratory failure (Ro) was 7.2 micrograms/L (10% > 12.5 micrograms/L), in the group of patients with respiratory failure not requiring mechanical ventilation (Rf) it was 8.5 micrograms/L (24% > 12.5 micrograms/L), and in the group of patients with respiratory failure requiring mechanical ventilation (Rfv) 13.1 micrograms/L (60% > 12.5 micrograms/L). The differences between the Rfv group and the other two groups (Rf and Ro) were significant (P = 0.049 and p = 0.0004, respectively). During successful mechanical ventilation elevated serum NSE decreased to values below the cutoff in 8/10 patients. We conclude that serum NSE elevation is a frequent event in patients with terminal hypoxemia in the course of benign lung diseases. Normalization of serum NSE is observed in the majority of patients during the first week of mechanical ventilation.

The role of carcinoembryonic antigen (CEA) and neuron-specific enolase (NSE) evaluation in pericardial fluid for the recognition of malignant pericarditis.

This study was designed to assess the value of tumor marker evaluation in pericardial fluid for the recognition of malignant pericarditis. Thirty-six patients with signs and symptoms of large pericardial effusion entered the study. Pericardiocentesis with pericardial fluid drainage was performed in all of them. CEA and NSE levels were evaluated in the pericardial fluid and compared to pericardial fluid cytology. The median CEA value in malignant effusions was 80 ng/ml (range 0-305 ng/ml) and in non-malignant ones 1.26 ng/ml (range 0.2-18.4 ng/ml), p < 0.01. The sensitivity of CEA elevation above 5 ng/ml for the recognition of malignant pericarditis was 73% and the specificity was 90%. Pericardial fluid cytology was positive in 22 of 26 patients with malignant pericarditis (85%). CEA exceeding 5 ng/ml or positive cytology were seen in 96% of the patients with malignant pericarditis. The median NSE value in malignant pericardial effusions was 41.8 micrograms/l (range 2-172 micrograms/l) and in non-malignant ones 5.85 micrograms/l (range 1-83.9 micrograms/l), p < 0.3. For the differential diagnosis of large pericardial effusions we would recommend simultaneous cytologic examination of pericardial fluid and CEA assessment. NSE measurement in hemorrhagic pericardial fluid is of limited value.

New approaches to the management and treatment of malignant pericardial effusion.

The purpose of this study was the evaluation of the effectiveness of intrapericardial administration of tetracycline, 5-fluorouracil and cisplatin in patients with recurrent malignant pericardial effusion. In 33 cases with malignant pericardial effusion 46 pericardiocenteses under two-dimensional echo-cardiography were performed. No complications were observed after this procedure. Pericardiocentesis was followed by catheterization of the pericardial space for a mean period of 15 days (range 1-64). In 4 cases bacterial pericarditis was observed during catheterization. The mean volume of the pericardial fluid was 2.41 (range 0.4-13 l). In cases with bloody pericardial fluid the PO2, PCO2 and pH of the fluid were estimated and the results compared with the values for venous blood obtained from the upper limbs. Highly statistically significant differences were documented. Twenty cases of malignant pericardial effusion were treated with direct pericardial administration of cisplatin, 3 with 5-fluorouracil and 2 with tetracycline. Good results (no fluid reaccumulation) were observed only after cisplatin therapy. We conclude that pericardiocentesis performed under two-dimensional echo cardiography, followed by pericardial catheterization and direct pericardial treatment with cisplatin are the methods of choice in cases with malignant pericardial effusion. In cases with bloody pericardial fluid PO2, PCO2 and pH analysis can be useful to differentiate the source of the bloody fluid (blood or bloody fluid).

[Still's disease as an example of fever of unknown origin: diagnostic and therapeutic difficulties]. / Choroba Stilla przyczyna goraczki niejasnego pochodzenia: trudnosci diagnostyczno-róznicowe i lecznicze.

A case of systemic form of juvenile chronic arthritis (Still's disease) is presented. Difficulties in confirmation of diagnosis are described. After nonsteroidal-antiinflammatory drugs and cytostatics administration very good therapeutical effect was achieved.

[Kartagener syndrome and hemangiomatous proliferation of lung capillaries: case report and literature review]. / Zespól kartagenera i naczyniakowatosc kapilarów plucnych: opis przypadku i przeglad pismiennictwa.

The authors present a case of Kartagener syndrome complicated by pulmonary hypertension accompanied by the lung capillaries haemangiomatous proliferation (post mortem diagnosis). Review of a literature (23 published cases) of the haemangiomatous proliferation of lung capillaries emphasizes clinico-pathological aspects and differential diagnosis. A rarity of Kartagener syndrome is another interesting point of a published case.

[Clinically silent pulmonary embolism in patients with proximal deep venous thrombosis]. / Klinicznie bezobjawowy zator tetnicy plucnej u chorych z zakrzepica odcinka proksymalnego zyl glebokich konczyn dolnych.

In 18 patients with proximal deep venous thrombosis (PDVT) confirmed by phlebography, no symptoms and signs of pulmonary embolism (PE) were observed. All patients were treated with nadroparin. During first 6 days of treatment in all patients perfusion lung scans were performed. 8 patients (44.4%) of all group developed lung scans positive for PE (silent PE). Period of successful treatment of PDVT was 10 days. No evidence of recurrent PE were observed during the period of treatment. We conclude that: 1. Frequency of silent PE in patients with PDVT is very high-lack of symptoms and signs of PE does not exclude the presence of PE in this group of patients. 2. In all patients with PDVT perfusion lung scan should be performed even in cases with no symptoms and signs of PE. 3. Low molecular weight heparins administered subcutaneously are effective in treatment either silent PE or PDVT.

[Low doses of rtPA administered as a bolus in treatment of clinically acute massive pulmonary embolism]. / Male dawki rtPA podawane w bolusach w leczeniu klinicznie masywnego zatoru tetnicy plucnej.

12 patients (7 male and 5 female) with confirmed pulmonary embolism (PE) with: angiography-5 cases, conventional contrast-enhanced CT-2 cases, echocardiography-2 cases, autopsy-3 cases were diagnosed as clinically acute PE. Criteria of clinically acute PE were: cardiac arrest-1 case-2 cases, shock-1 case, acute cor pulmonale-9 cases and acute cor pulmonale with shock. All patients were treated with heparin, administered with therapeutic prolongation of aPTT. Clinically acute PE (if possible confirmed with angiography, TC and/or echocardiography) was treated with rtPA administered in 10 minutes lasting bolus in doses 0.6-0.8 mg per kg of body weight (50 mg of rtPA during 10 minutes administered into peripheral veins). In 9 patients with pulmonary hypertension, significant decrease of tricuspidal gradient (measured echocardiographically during several hours after administration of rtPA) was documented. Improvement in PaO2, SaO2 and decrease of heart rate and respiratory rate were also achieved. No serious bleeding complications were observed after mentioned treatment. Control investigations (conventional contrast-enhanced CT and spiral CT) performed several days after rtPA administration revealed thrombus in pulmonary artery. We conclude: I rtPA administered in bolus simultaneously with heparin significantly decreased pulmonaryhypertension; rtPA administered simultaneously with heparin is safe method of treatment of PE; hemodynamic improvement after administration of rtPA is not univocal with full fibrynolitic effect.

[Pericardial syndrome in the course of pulmonary embolism in personal material]. / Zespól osierdziowy w przebiegu zatoru tetnicy plucnej w materiale wlasnym.

UNLABELLED: Dressler-like syndrome has been described in about 3-4% of patients after pulmonary embolism (PE). Out of 207 patients admitted to our hospital in whom the clinical diagnosis of PE was confirmed by scintigraphy, spiral computer tomography and angiography, in 19 patients (9.2%) pericardial fluid was detected and pericardial syndrome (PS) after PE was diagnosed. Other causes of pericarditis were excluded. Mean value of pericardial fluid in echocardiographic examination-behind left ventricular posterior wall was 3.84 mm (range 2-10 mm). No clinical or echocardiographic symptoms of cardiac tamponade were observed. In 6 patients PS complicated clinically massive PE, in 3 patients-non-massive PE, in 10 patients recurrent PE. In 6 patients fibrinolytic and in 13 patients heparin therapy was instituted. In 3 cases corticosteroids were given. No increase of pericardial fluid during fibrinolytic or heparin therapy was observed. CONCLUSIONS: 1. PS after PE is more frequent, than it was estimated previously 2. During therapy of PE the echocardiographic monitoring of the amount of pericardial fluid is mandatory 3. The clinician considering in similar situations the risk-benefit ratio of fibrinolytics and anticoagulants should not abstain from the use of these drugs in the presence of PS after PE, in cases with high probability of cardiac tamponade-pericardial catheter should be used.

[The value of measuring adenosine deaminase activity in pericardial effusion fluid for diagnosing the etiology of pericardial effusion]. / Wartosc oznaczania aktywnosci deaminazy adenozyny w plynie osierdziowym w diagnostyce etiologii wysieku osierdziowego.

The diagnosis of tuberculous pericarditis is difficult. The cultures of the pericardial fluid for M.tuberculosis are often negative. The determination of ADA activity in pleural fluid in TB patients /PTS/ is very useful. It seemed reasonable to measure ADA activity in pericardial effusion. ADA activity in pericardial fluid of 40PTS/19 women and 21 men/with large pericardial effusion of different etiologies who were treated in our institute in years 1988-1995 was investigated. The median age was 44 years. In each case the pericardiocentesis was performed. PTS were grouped as follows: group I-4 PTS with strongly suspected TB pericarditis, group II-32 PTS with malignancy and group III-4 PTS with miscellaneous diseases. In group I the mean ADA activity was 24U/I(3-60), in group II 18U/I (3-60) and in group III 18U/I (0-37) (with a cutoff value for ADA activity of 40U/I). It was definitive bacteriologic diagnosis of TB pericarditis in PTS of group I. Our observation does not confirm the earlier data about the high ADA activity in clinically suspected TB pericarditis without bacteriologic diagnosis. The value of ADA determination in pericardial fluid is its high specificity (97%) in excluding of TB etiology of pericardial effusion.

[Evaluation of intrapericardial cisplatin administration in cases of recurrent malignant pericardial effusion and cardiac tamponade]. / Ocena skutecznosci leczniczej wewnatrzosierdziowego zastosowania cysplatyny w przypadkach nawracajacych wysieków nowotworowych i tamponady serca.

30 consecutive patients with large malignant pericardial effusion (MPE) entered this prospective study. After pericardiocentesis and insertion of a polyurethane catheter, pericardial fluid was drained. Malignant etiology of pericardial fluid was confirmed by cytological examination. After confirmation of MPE cisplatin (10 mg in 20 ml normal saline) was instilled over 5 minutes during 5 consecutive days directly into pericardial space. If fluid reaccumulation occurred the courses were repeated every 3 weeks. Treatment was considered successful if the patient with malignant effusion survived 30 days without recurrence of symptoms of large pericardial effusion and other interventions directed to the pericardium were required. Positive effect of intrapericardial treatment with cisplatin was achieved in 18 cases (60%). Mean period of response was 3, 7 months (+/-6). Cisplatin administered directly into pericardial space is effective and safe method of treatment of recurrent MPE. Sclerosis of the pericardial space is rare complication connected with CP. Positive effect of CP can depend on improvement of lymphatic drainage from heart. CP seems to be method of choice in intal intrapericardial treatment in patients with malignant cardiac tamponade and recurrent MPE in course of lung cancer.

[Massive pulmonary artery embolism complicated by acute pulmonary heart disease]. / Masywny zator tetnicy plucnej powiklany ostrym sercem plucnym.

43-year old woman, with considerable overweight had been admitted to Intensive Medical Care Unit with suspicion of pulmonary embolism (PE). The patient had the limb immobilized in gypsum for last several weeks. This episode was tangled with recurrent thrombosis of deep veins in the left limb, treated with heparin and oral anticoagulants irregularly without sufficient control. Taking into consideration the data of anamnesis, clinical picture and the results of ECG, chest X-ray, gasometric and echocardiographic examination we got much closer to the recognition of PE. Our suspicion of PE was confirmed by the result of pulmonary angiography. Indications for thrombolytic treatment (r-tPA) had been established. During the following hours considerable improvement of general state was observed. The therapy was continued with constant drip infusion of heparin. No prolongation of therapeutic PTT was observed. The deficit of AT III was diagnosed. In this situation the patient was given AT III to obtain normalization of its level and therapeutic extension of PTT. Therefore there were settled indications for the operation of uterus with myoma changes. As the rich thrombolytic material in the leg's vein was found the patient was implanted LGM Filter, with excellent prophylactic effect (no PE in perioperative period). The clinical course of our case enabled to present most of diagnostic, therapeutic and preventive methods applied in venous thromboembolism.

[Weaning from mechanical ventilation in patients with exacerbations of chronic respiratory insufficiency--personal experience]. / Odzwyczajanie od sztucznej wentylacji chorych z zaostrzeniem przewleklej niewydolnosci oddechowej--doswiadczenia wlasne.

Nineteen patients with exacerbation of chronic respiratory insufficiency treated with mechanical ventilation were included in the study. The mean weaning time from the respirator was 15.9 days (+/- 12.1), ranging from 2 to 49 days. Success was met in 9 patients using inspiratory pressure support (IPS), in 2 synchronized intermittent mandatory ventilation (SIMV), in 8 the simplest model (stepwise prolongation of spontaneous ventilation during continuous mechanical ventilation--CMV/SV). All options were used in the same patients throughout the weaning procedure. The use of IPS led to a successful weaning in those patients in whom other options (CMV/SV, SIMV) were not fortunate. The application of IPS was begun at 40 cm H2O, gradually decreasing the support pressure. The duration of spontaneous breathing in all weaning options was not only depended on gasometric values, continuous SaO2 monitoring, but mainly on the patients' subjective sense of fatigue. The impression of exhaustion preceded the changes of gasometric parameters and fall of SaO2. The basis of effective weaning is proper selection of respirator parameters, providing almost identical gasometric values if individual patient's to those prior exacerbation of chronic respiratory insufficiency. The duration of weaning negatively correlated (0.25) with FEV1 values.

[Outcome of patients with clinically acute massive pulmonary embolism]. / Losy chorych z klinicznie ostrym masywnym zatorem tetnicy plucnej.

Acute massive pulmonary embolism (AMPE) is an event that places the recipient at an unusually high risk of sudden death. Among 183 patients with thromboembolic disease, AMPE has been diagnosed clinically in 58 cases (32%). Diagnostic criteria: cardiac arrest (24 cases--41%), shock (12--21%) acute cor pulmonale (ACP 15--26%) and ACP with shock (7 cases--12%). There were 33 women and 25 men aged 22-88 years in this group. In 25 patients heparin (H), in 7 streptokinase (S), in 1 tPA, in 7 S after H have been used, 26 patients (45%) survived, 32 (55%) died: there were 20 sudden deaths. Advanced underlying cardiopulmonary diseases or/and recurrent pulmonary embolism seem to be the most important predictors of fatal outcome of AMPE.

[Lung neoplasms with pericardial metastasis, complicated by venous thromboembolism: case report]. / Rak pluca z przerzutami do osierdzia, powiklany choroba zakrzepowo-zatorowa: opis przypadku.

Among the risk factors of venous thromboembolism malignant neoplasms play a very important role. 43-years old man with adenocarcinoma of the lung, neoplasmatic cardiac tamponade and recurrent deep venous thrombosis has been presented. The pitfalls in diagnosis and particularly in treatment of venous thromboembolism in cancer-patients have been discussed.