RESUMO
BACKGROUND: The yellow fever (YF) vaccination is recommended by the WHO for people traveling or living in endemic areas at risk for yellow fever infections in Africa and South America. Although the live attenuated yellow fever vaccine is a safe and efficient vaccine, rare serious adverse events after vaccination have been reported. CASE PRESENTATION: We present the case of a 74-year-old male with multiorgan failure after yellow fever vaccination for a trip to Brazil. The patient required admission to the intensive care unit with a prolonged stay due to severe organ dysfunction. Five days after the YF vaccination, the patient experienced nausea, vomiting, diarrhea, and general illness. Three days later he sought medical attention and was transferred to the University Hospital Heidelberg with beginning multiorgan failure and severe septic shock, including hypotonia, tachypnea, thrombopenia, and acute renal failure the same day. Within one week after vaccination, antibodies against YF virus were already detectable and progressively increased over the next two weeks. Viral RNA was detected in serum on the day of admission, with a viral load of 1.0 × 105 copies/mL. The YF virus (YFV) RNA was also present in tracheal secretions for several weeks and could be detected in urine samples up to 20 weeks after vaccination, with a peak viral load of 1.3 × 106 copies/mL. After 20 weeks in the ICU with nine weeks of mechanical ventilation, the patient was transferred to another hospital for further recovery. CONCLUSIONS: The risk for severe adverse events due to the YF vaccination should be balanced against the risk of acquiring a severe YF infection, especially in elderly travelers.
RESUMO
AIMS: To investigate the prognostic implications of elevated high-sensitivity cardiac troponin T (hs-cTnT) values in presumably stable ambulatory coronary artery disease patients. METHODS AND RESULTS: We conducted a retrospective, single-centre pilot observational study in a low-risk population. All patients received routine measurement of hs-cTnT at index and follow-up visits. Endpoints were all-cause mortality and a composite of all-cause mortality, acute myocardial infarction, stroke and rehospitalization for acute coronary syndrome and heart failure. Nine hundred and sixty-five consecutive patients presenting to our outpatient clinic between June 2009 and June 2010 were screened; 693 patients with a stable clinical course, at least one hs-cTnT value and at least one follow-up visit qualified for analysis. Follow-up was 796 days. Five hundred and forty-seven patients (78.9%) had hs-cTnT values below and 146 patients (21.1%) had values above 14 ng/l, which was defined to categorize high and low levels as it was reported to be the 99th percentile of a reference population. We observed 13 deaths (all-cause mortality) including four cardiovascular deaths. Age, N terminal pro-brain natriuretic peptide levels and impaired renal function were independently associated with an elevated hs-cTnT in a multivariate analysis. Hs-cTnT values >14 ng/l were strongly associated with all-cause mortality (hazard ratio 12.9, 95% confidence interval (CI): 3.5-46.9, p=0.0001), the composite clinical endpoint (hazard ratio 2.35, 95% CI: 1.48-3.72, p=0.0003) and rehospitalization for heart failure (hazard ratio 3.36, 95% CI: 1.73-6.53, p=0.0004). Compared with the multivariable Framingham score hs-cTnT revealed a significantly better performance (area under the receiver operating characteristics curve (AUC) hs-cTnT: 0.882 vs. AUC Framingham score 0.639, p=0.0005). CONCLUSION: Elevated hs-cTnT levels provide excellent prognostic information regarding all-cause mortality and a combined clinical endpoint in presumably stable ambulatory coronary artery disease outpatients presenting for routine evaluation.
