Extrapulmonary involvement associated with Mycoplasma pneumoniae infection.

Mycoplasma pneumoniae infection usually presents with upper and lower respiratory tract infection. Extrapulmonary involvement is not uncommon, however. We report two cases of predominantly extrapulmonary manifestations of Mycoplasma pneumoniae infection without significant pulmonary involvement. Both cases were diagnosed by serology. These cases illustrate the diversity of clinical presentations of Mycoplasma pneumoniae infection. Clinicians should maintain a high index of suspicion.

Acquired factor V inhibitor in a patient receiving venous-venous extracorporeal membrane oxygenation for Legionella pneumonia.

We report a rare complication of factor V deficiency in a patient having Legionella pneumonia. This patient also had other complications like severe acute respiratory distress syndrome, acute kidney injury, and septic shock that required venous-venous extracorporeal membrane oxygenation support. This is the first reported case of acquired factor V deficiency in a patient receiving extracorporeal membrane oxygenation for Legionella pneumonia. With the combined use of intravenous immunoglobulin, rituximab and plasma exchange, we achieved rapid clearance of the factor V inhibitor within 1 week so as to allow safe decannulation of extracorporeal membrane oxygenation.

Hong Kong's experience on the use of extracorporeal membrane oxygenation for the treatment of influenza A (H1N1).

OBJECTIVE: To report Hong Kong's experience on the use of extracorporeal membrane oxygenation for the treatment of acute respiratory distress syndrome caused by influenza A (H1N1). DESIGN: Multi-centred, retrospective observational study. SETTING: Intensive care units in Hong Kong. PATIENTS: Recipients of extracorporeal membrane oxygenation for confirmed influenza A (H1N1) infection from 1 May 2009 to 28 February 2010. MAIN OUTCOME MEASURE: Hospital mortality. RESULTS: During the study period, 120 patients were mechanically ventilated in intensive care units, among whom seven received veno-venous extracorporeal membrane oxygenation. The median (interquartile range) age of the latter patients was 42 (39-50) years, four had various chronic illnesses and one had a body mass index of greater than 30 kg/m². The median (interquartile range) time from symptom onset to hospital admission was 5 (4-7) days. Corresponding values for the duration of extracorporeal membrane oxygenation, mechanical ventilation, intensive care unit stay, and hospital stay were 6 (6-10), 19 (11-25), 19 (18-30), and 31 (25-55) days, respectively. One patient died (hospital mortality, 14%) and six made full recoveries. All seven patients received oseltamivir; in addition three received intravenous zanamivir, four received convalescent plasma, and one received hyperimmune immunoglobulin. Nosocomial infection was the commonest complication. There was no life- or limb-threatening complication directly attributable to extracorporeal membrane oxygenation. CONCLUSION: In response to the pandemic of influenza A (H1N1), some intensive care units in Hong Kong were able to offer extracorporeal membrane oxygenation to selected cases. In this small series, patient outcomes were similar to those reported in other observational studies, indicating that intensive care units in Hong Kong are capable of successfully introducing this technology. However, the cost-effectiveness and optimal delivery of this strategy remain uncertain.

Prolonged myoclonus after a single bolus dose of propofol.

Propofol is a commonly used anaesthetic agent and is rarely associated with seizure-like phenomena. This case report presents a young woman with seizure-like phenomena lasting more than 4 weeks after a single dose of propofol. The underlying pathophysiology of this condition is poorly understood but a psychological component is possible in this case.

The first novel influenza A (H1N1) fatality despite antiviral treatment and extracorporeal membrane oxygenation in Hong Kong.

We report the first fatality caused by novel influenza A (H1N1) infection despite having the diagnosis confirmed and being given antiviral treatment after hospitalisation. This patient was also the first with influenza A (H1N1) to be supported with extracorporeal membrane oxygenation in Hong Kong. Although extracorporeal membrane oxygenation is an effective means of supporting patients with refractory hypoxaemia on high mechanical ventilatory support, it is labour-intensive and technically demanding. We also discuss the challenges faced when managing this case.

Spontaneous pneumomediastinum in patients with severe acute respiratory syndrome.

Spontaneous pneumomediastinum (SP) unrelated to assisted ventilation is a newly recognised complication of severe acute respiratory syndrome (SARS). The objective of the present study was to examine the incidence, risk factors and the outcomes of SP in a cohort of SARS victims from a community outbreak. Data were retrieved from a prospectively collected database of virologically confirmed SARS patients. One hundred and twelve cases were analysable, with 13 patients developing SP (11.6%) at a mean +/- SD of 19.6 +/- 4.6 days from symptom onset. Peak lactate dehydrogenase level was associated with the development of SP. SP was associated with increased intubation and a trend towards death. Drainage was required in five cases. For patients who survived, the SP and/or the associated pneumothoraces took a median of 28 days (interquartile range: 15-45 days) to resolve completely. In conclusion, spontaneous pneumomediastinum appeared to be a frequent complication of severe acute respiratory syndrome. Further research is needed to investigate its pathogenesis.

Tracheostomy in a patient with severe acute respiratory syndrome.

The coronavirus which causes severe acute respiratory syndrome (SARS) is a virulent and highly contagious organism. Of the 1755 SARS patients in Hong Kong, over 400 were healthcare workers. Meticulous attention to infection control and teamwork are essential to minimize cross-contamination and prevent staff from contracting the illness. These points are especially pertinent when anaesthetizing SARS patients for high-risk procedures such as tracheostomy. We describe the management of such a case.

Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study.

BACKGROUND: We investigated the temporal progression of the clinical, radiological, and virological changes in a community outbreak of severe acute respiratory syndrome (SARS). METHODS: We followed up 75 patients for 3 weeks managed with a standard treatment protocol of ribavirin and corticosteroids, and assessed the pattern of clinical disease, viral load, risk factors for poor clinical outcome, and the usefulness of virological diagnostic methods. FINDINGS: Fever and pneumonia initially improved but 64 (85%) patients developed recurrent fever after a mean of 8.9 (SD 3.1) days, 55 (73%) had watery diarrhoea after 7.5 (2.3) days, 60 (80%) had radiological worsening after 7.4 (2.2) days, and respiratory symptoms worsened in 34 (45%) after 8.6 (3.0) days. In 34 (45%) patients, improvement of initial pulmonary lesions was associated with appearance of new radiological lesions at other sites. Nine (12%) patients developed spontaneous pneumomediastinum and 15 (20%) developed acute respiratory distress syndrome (ARDS) in week 3. Quantitative reverse-transcriptase (RT) PCR of nasopharyngeal aspirates in 14 patients (four with ARDS) showed peak viral load at day 10, and at day 15 a load lower than at admission. Age and chronic hepatitis B virus infection treated with lamivudine were independent significant risk factors for progression to ARDS (p=0.001). SARS-associated coronavirus in faeces was seen on RT-PCR in 65 (97%) of 67 patients at day 14. The mean time to seroconversion was 20 days. INTERPRETATION: The consistent clinical progression, shifting radiological infiltrates, and an inverted V viral-load profile suggest that worsening in week 2 is unrelated to uncontrolled viral replication but may be related to immunopathological damage.