CMV pneumonia in HIV-infected ventilated infants.

BACKGROUND: The contributing role of cytomegalovirus (CMV) in infants treated for Pneumocystis jiroveci pneumonia (PJP) is unknown. High dose steroids used in the treatment of PJP may further immunocompromise these infants contributing to the development of CMV pneumonia. AIM: The aim of this study was to determine the role of CMV pneumonia in infants being ventilated for suspected PJP. METHODS: In this prospective study HIV infected infants being treated with trimethoprim-sulfamethoxazole (TMP/SMX) and ventilated for suspected PJP were included if they had not responded to treatment. Open lung biopsy was performed if there was no improvement in ventilatory requirements. RESULTS: Twenty-five HIV positive infants with a mean age of 3.3 months were included. Lung biopsy was performed in 17 (68%) and post-mortem lung tissue was obtained in 8 (32%). After evaluation of the histology, immunohistochemistry, and viral cultures from lung tissue, the most likely causes of pneumonia were: CMV and PJP dual infection 36% (n = 9), CMV pneumonia 36% (n = 9), and PJP 24% (n = 6). The pp65 test for CMV antigen was falsely negative in 24%. The mean blood CD4 count was 287/microl. There was an association between the CD4 lymphocyte status and the final diagnosis, with the CMV and PJP group (CD4 110/microl) having the lowest CD4 status (P = 0.0128). Pediatric Intensive Care Unit (PICU) mortality was 72% (n = 18) and in hospital mortality 88%. CONCLUSION: Of the ventilated infants failing to respond to treatment, 72% had histologically confirmed CMV pneumonia, probably accounting for the high mortality in this cohort. The incidence of CMV disease in HIV infected infants being ventilated for severe pneumonia warrants that ganciclovir is used empirically until CMV disease is excluded. The role of lung biopsy in these circumstances needs to be researched.

The Pressure Flow Relationship of the Internal Mammary Artery after Offpump Anastomosis to the Left Anterior Descending Coronary Artery

Objective: To assess the pressure flow relationship of the internal mammary artery (IMA) in situ; after skeletonisation and after anastomosis to the left anterior descending (LAD) coronary artery; using either halothane; sevoflurane or propofol as an anaesthetic agent. Methods: 15 Pigs were used in total; five received halothane; five sevoflurane and five propofol as an anaesthetic agent. The flow in the internal mammary artery in each of the pigs; was measured at various arterial pressures. This was done with the IMA in situ; then after dissecting the artery off the chest wall using the skeletonisation technique and finally after offpump grafting to the left anterior descending coronary artery. Results: The pressure flow relationship of the internal mammary artery after skeletonisation was found to be linear (r=0.8650). The pressure flow correlation after grafting the skeletonised internal mammary artery to the left anterior descending coronary artery was found to be similarly linear (r=0.8766). In the sevoflurane subgroup; with the IMA still in situ; a degree of autoregulation was found to be present; but after skeletonisation this was subsequently lost (p=0.011). Conclusions: The pressure flow relationship in the internal mammary artery after skeletonising the vessel and after OPCAB anastomosis to the LAD was found to be linear. In the subgroup of pigs receiving sevoflurane; some degree of autoregulation was demonstrated in the in situ IMA. This remnant of autoregulation was lost after skeletonisation and after grafting of the vessel to the left anterior descending coronary artery

The outcome of infants younger than 6 months requiring ventilation for pneumonia caused by Mycobacterium tuberculosis.

INTRODUCTION: The outcome of young infants (<6 months) being ventilated for respiratory failure caused by Mycobacterium tuberculosis (MTB) has not been recorded. PATIENTS AND METHODS: A descriptive study of children <6 months admitted to the PICU from 1 February 1999 to 31 December 2005 with MTB causing respiratory failure. RESULTS: Seventeen infants were ventilated for respiratory failure caused by MTB: ten had ventilatory respiratory failure and seven had hypoxic failure. An index case was found in 47%. All chest radiographs (CXRs) were highly suggestive of tuberculosis. MTB was cultured in 15 cases. In the other two cases MTB was confirmed by histopathology. The median duration of ventilation was 6 days (range: 1-35 days) with a median PaO2/FiO2 of 85 and ventilatory index of 58. Transthoracic glandular enucleation was required to facilitate extubation in six babies. All the infants survived. At 6-month follow-up 35% had a normal CXR and all were asymptomatic. One child had CXR changes suggestive of bronchiectasis but was asymptomatic. CONCLUSION: The outcome of infants <6 months ventilated for respiratory failure caused by MTB is very good if TB is recognized timeously and appropriate management started. The diagnosis of TB in these infants can be made with a high index of suspicion and careful evaluation of the CXR.

Pasteurella multocida lung and liver abscess in an immune-competent child.

We report on a 20-month-old infant with a complicated lung and liver abscess caused by Pasteurella multocida after the child had been in close contact with a domestic cat. Surgical drainage confirmed lung and liver abscesses connected to each other, with involvement of the diaphragm.

Hydatid cyst fistula into the aorta presenting with massive hemoptysis. Case report and literature review.

Hydatid involvement of the aorta is extremely uncommon. We present a case where a hydatid cyst of the lung eroded into the thoracic aorta, causing massive hemoptysis. Successful repair was performed by resection (including left lower lobectomy) and graft interposition.

Myocardial abscess with contained rupture: successful repair.

Spontaneous rupture of the heart from myocardial abscess is a rare occurrence. Most cases of spontaneous cardiac rupture are due to myocardial infarction. We present a case of a contained rupture of the heart in a patient with staphylococcal septicemia. Although cultures from the pericardial space were negative the macroscopic and clinical picture was compatible with an abscess.

Pregnancy outcome in women with prosthetic heart valves.

The pregnancy outcome of 59 pregnancies in 38 women with prosthetic heart valves, managed at a tertiary referral centre from 1989-98 were reviewed. Ten women underwent valve replacement during pregnancy. The main outcome measures were major maternal complications and perinatal outcome. The maternal mortality rate for pregnancies following valve replacement surgery was 6.1%, with a 21% pregnancy loss before viability and a perinatal loss of 8%. Major morbidity in this group was as follows: haemorrhage 29.8%, cardiac failure 12.8%, thromboembolism 8.5%, infective endocarditis 6.4% and valve thrombosis 4.3%. No maternal mortality occurred among those who underwent valve replacement during pregnancy but their perinatal loss was 25%. We conclude that although maternal mortality and morbidity rates in women with prosthetic heart valves who became pregnant were high, the perinatal outcome was good except for women who underwent valve replacement during pregnancy who experienced a high perinatal loss rate.

Penetrating cardiac injuries--current evaluation and management of the stable patient.

Patients with penetrating cardiac injuries present in a stable or only mildly shocked condition--especially if the laceration has sealed off and the patient has been adequately resuscitated. A large proportion of patients presenting to our unit are in a reasonably stable condition after resuscitation, and rapid diagnosis may be difficult. We present our experience over a 5-year period (191 patients), with particular reference to the stable patient. All patients with penetrating precordial wounds should be assessed for a possible cardiac injury, especially if a period of hypotension has occurred. Clinical signs, central venous pressure, chest radiograph, pericardiocentesis and subxiphoid window are not always helpful in the diagnosis. Cardiac ultrasound is very useful (in the absence of haemothorax), and was performed in 103 of 191 patients, with 8 false-negatives and 3 false-positives. When an unstable patient presents with an obvious diagnosis use of cardiac ultrasound should be restricted. A subxiphoid window has diagnostic value where the cardiac ultrasound is inconclusive.

Surgical management of airway obstruction in primary tuberculosis in children.

BACKGROUND: The role of surgery in the management of airway obstruction from lymphobronchial tuberculosis is discussed in the present article. METHODS: Nine patients were operated on over a 4-year period and are currently presented. The age of the patients ranged between 5 and 28 months and 7 patients were male. Six patients required preoperative ventilation due to respiratory failure and all received standard posterolateral thoracotomies. Partial dissection and enucleation of bulky lymph nodes was performed in all but 1 patient. In that patient, the group of lymph nodes could be removed fully, including the sheath. RESULTS: All patients showed marked improvement and were weaned off the ventilator between 24 and 72 hours postoperatively. Long term follow-up was available in 7 patients and they are all doing well and are free of symptoms. CONCLUSIONS: Enucleation of mediastinal lymph nodes obstructing the airways in young patients with lymphobronchial tuberculosis is safe. It successfully relieves obstruction and is devoid of complication providing that incision, evacuation, and curettage of lymph nodes is performed avoiding overzealous dissection.

Current evaluation of cardiac stab wounds.

BACKGROUND: Patients with penetrating cardiac injuries may be stable or only mildly shocked, especially if the laceration has sealed off and the patient has been aggressively resuscitated. Clinical signs, chest roentgenograms, pericardiocentesis, and subxiphoid window are not always helpful in establishing the diagnosis. We reflect on the current evaluation based on 128 patients. METHODS: There were four groups of patients, ranging from lifeless (group I) to stable (group IV). Patients in groups I and II were prepared immediately for operation. Those in groups III and IV were often investigated further (chest roentgenogram and cardiac ultrasound). RESULTS: Mortality was 8%. Significant findings were a precordial stab, central venous pressure of more than 15 cm of water, one or more clinical signs of tamponade, and initial shock. Cardiac ultrasound was performed in 5 patients in group II (15%), 14 patients in group III (48%), and 37 patients in group IV (86%). There were no false positives, and 6 false negatives (11%). Thirty-one patients (24%) had clotted lacerations. There were no negative sternotomies. CONCLUSIONS: Efficient fluid resuscitation and rapid confirmation of diagnosis with cardiac ultrasound should decrease mortality. Stable patients with a precordial wound should undergo cardiac ultrasound or echocardiogram. Diagnosis may be reliably confirmed in these patients whose clinical signs often fluctuate (or rapidly deteriorate).

Intracardiac operation in seven pregnant women.

The outcome of open heart operations on pregnant women is not well documented. Between March 1985 and October 1988, 7 pregnant patients underwent valve replacement at Tygerberg Hospital. This included three redo operations and one double-valve replacement. The range of perfusion temperatures used during cardiopulmonary bypass was 28 degrees to 33 degrees C with aortic cross-clamp times of 53 to 121 minutes. One baby was stillborn, but the others were normally delivered at full term, and all the mothers survived. The stillborn baby was lost after the shortest procedure at the highest temperature during cardiopulmonary bypass.

Penetrating cardiac trauma: management strategy based on 129 surgical emergencies over 2 years.

Between 1986 and 1988, 129 patients with stab wounds to the heart were referred from the emergency room of our institution for a thoracic surgical procedure. Multiple entrance wounds of the heart were present in 12 patients, and through-and-through stab wounds were encountered in another 10. The overall hospital mortality rate was 8.5% (11/129), which includes a 54% mortality rate for the 13 patients undergoing emergency room thoracotomy. These patients were pulseless and unconscious either on arrival (n = 8) or soon thereafter (n = 5). Cardiopulmonary bypass was not used during the primary operation, although 7 patients underwent subsequent intracardiac repair with bypass without hospital mortality. Important aspects of our preoperative management strategy include: (1) aggressive transfusion to improve the central venous pressure/intrapericardial pressure gradient; (2) rapid drainage of the pleural and pericardial spaces to reduce intrapericardial pressure; (3) empirical partial correction of metabolic acidosis with sodium bicarbonate; and (4) emergency operation without unnecessary cardiac imaging. Patients suspected of having penetrating cardiac trauma and cardiac tamponade are best managed by aggressive primary intervention and immediate operation.

Cardiac echinococcosis: cyst removal in a beating heart.

A 17-year-old asymptomatic boy from a sheep farm had a systolic murmur on routine examination. The diagnosis of Echinococcus cyst in the right ventricular outflow tract was made by echocardiography. The cyst was removed with success with the patient on cardiopulmonary bypass with a beating heart.

Function of the liver and hepatic lipids of the lesser sand shark, Rhinobatos annulatus (Müller & Henle).

Seasonal variation recorded in the hepatosomatic index for sand sharks, Rhinobatos annulatus, was primarily due to accumulation of hepatic lipids. The contribution of liver lipids to the formation of egg yolk was estimated and found to be secondary to lipid reserves for metabolic functions. Maximum liver lipid content in mature sand sharks coincided with peak breeding activities. Hepatic lipids and their derivatives are an important fuel for muscle and thus needed for migration which occurred soon after parturition and mating. Liver colour was in synchrony with the variation in the total liver lipid content in both sexes of sand sharks.