Effectiveness of Delayed Intrapleural Alteplase Instillation for Infected Residual Traumatic Hemothorax. Case Report.

In thoracic trauma, many cases may present with hemothorax, and, of those, a portion can complicate in empyema. These cases can reveal themselves to be of difficult management, particularly in peripheral hospitals with complicated access to thoracic surgery. Intrapleural fibrinolytic instillation can be of use and has been widely reported, mostly in the case of empyema. In the literature, the use of fibrinolytics in hemothorax mostly pertained to the older fibrinolytics, such as streptokinase and urokinase. Recent studies describe the use of alteplase in these patients but mostly in the first days after the trauma, when it becomes clear that the first chest tube is not being effective. We report a case of residual traumatic hemothorax that could not be evacuated after multiple chest tubes placements and was finally cleared after instillation of alteplase late in the course of the disease.

Acute Inflammation and Metabolism.

Inflammation is an adaptive process to the noxious stimuli that the human body is constantly exposed to. From the local inflammatory response to a full-blown systemic inflammation, a wide complex sequence of events occurs. Persistent immunosuppression and catabolism may ensue, until multiple organ failure finally sets in. And since clinically useful and specific biomarkers are lacking, diagnosis may come late. A thorough understanding of these events (how they begin, how they evolve, and how to modulate them) is imperative, but as yet poorly studied. This review aims to consolidate current knowledge of these events so that the management of these patients is not only evidence-based, but also built on an understanding of the inner workings of the human body in health and in disease.

From the Pharynx to the Abdomen: A Case of Primary Peritonitis.

Primary peritonitis usually occurs in patients with comorbidities previously diagnosed with ascites. However, a primary peritoneal infection in previously healthy patients may also ensue. There has been an increase in reported cases of primary peritonitis due to Streptococcus pyogenes affecting mostly women. It usually presents as a severe acute abdominal pain, which prompts surgical exploration. Although infected ascitic fluid is seen, there is no rupture. In this article, we present a case of primary peritonitis due to Streptococcus pyogenes which rapidly evolved to septic shock and acute respiratory distress syndrome. The abdominal and pelvic computed tomography at admission showed no ascitic fluid. However, a few hours later, during surgical exploration, purulent ascitic fluid was seen throughout the abdominal cavity. It is important to be aware of this rapid accumulation of ascitic fluid, even without visceral perforation, as peritoneal lavage may be warranted to contain the infection.

A peritonite primária geralmente ocorre em doentes com co-morbilidades previamente diagnosticados com ascite. Pode também ocorrer num doente previamente saudável. Recentemente, tem havido um número crescente de relatos de peritonite primária por Streptococcus pyogenes, com maior incidência nas mulheres. Nestes casos, geralmente ocorre dor abdominal aguda e intensa, que motiva intervenção cirúrgica urgente, constatando-se posteriormente não haver ruptura de víscera oca, embora haja líquido ascítico purulento. Neste artigo, descrevemos um caso de peritonite primária por Streptococcus pyogenes, que evoluiu rapidamente para choque séptico e síndrome de dificuldade respiratória aguda. Embora a tomografia computorizada inicial não tenha revelado líquido ascítico, algumas horas após, durante o ato cirúrgico, observou-se líquido ascítico purulento em grande quantidade. Esta rápida acumulação de líquido purulento na cavidade abdominal, mesmo sem perfuração de víscera oca, deverá ser rapidamente reconhecida, sendo que a lavagem peritoneal poderá vir a ser uma opção para conter o foco de infeção.