Disfunção hepática em pacientes de unidade de terapia intensiva médica prevê desfecho desfavorável / Hepatic dysfunction in medical intensive careunit patients predicts poor outcome

ABSTRACT Background: A large number of patients admitted to the medical intensive care unit (MICU) have abnormal liver function tests (LFT). This includes patients with critical illness with or without preexisting liver disease and patients with acute primary liver injury. There are very few studies which have investigated the spectrum of liver disease, clinical profile and outcome in patients admitted to the MICU. Objective To evaluate the occurrence, etiology, clinical profile, laboratory profile and outcome of hepatic dysfunction in patients admitted to the MICU. To evaluate the utility of model for end-stage liver disease (MELD) score on admission as a predictor of adverse short term outcome in patients with hepatic dysfunction admitted in MICU. Methods: It was a prospective observational study, conducted from December 2017 to December 2018 in a tertiary care hospital. Two hundred and two patients admitted to the MICU with LFTs as per the inclusion criteria were analyzed and their short-term outcome at 7 days was studied in relation to various parameters. Results: LFT abnormalities were present in 202/1126 (17.9%) of the patients admitted to MICU. Critical illness associated liver dysfunction was found in 172 (85.2%) patients, chronic liver disease in 11 (5.4%) patients and acute viral hepatitis in 19 (9.4%) patients. Most common symptom was fever (68.3%) followed by vomiting (48.0%). Among LFT abnormalities, elevated transaminases, raised international normalized ratio and high MELD score on admission correlated with poor short-term outcome. Requirement for inotropes and mechanical ventilation correlated with poor short-term outcome. Mortality did not differ significantly between patients with chronic liver disease, patients with acute viral hepatitis and patients with critical illness associated hepatic dysfunction. Hepatic dysfunction in MICU was associated with poor outcome and a high short-term mortality of 56.4% (114/202). Conclusion: Liver function abnormality is common in patients who are admitted to the MICU and its presence is an indicator of poor short-term outcome.

RESUMO Contexto: Um grande número de pacientes internados na unidade de terapia intensiva (UTI) tem testes de função hepática anormais (TFH). Isso inclui pacientes com doença crítica com ou sem doença hepática pré-existente e pacientes com lesão hepática primária aguda. Há poucos estudos que têm investigado o espectro da doença hepática, perfil clínico e desfecho em pacientes admitidos em UTI. Objetivo Avaliar a ocorrência, etiologia, perfil clínico, perfil laboratorial e desfecho de disfunção hepática em pacientes internados na UTI médica. Avaliar a utilidade do modelo para doença hepática em estágio terminal (MELD). Escore na admissão como preditor de desfecho adverso a curto prazo em pacientes com disfunção hepática admitida em UTI. Métodos: Foi realizado um estudo observacional prospectivo, de dezembro de 2017 a dezembro de 2018 em um hospital de atenção terciária. Foram analisados 202 pacientes internados na UTI com TFH conforme os critérios de inclusão e seu desfecho a curto prazo de 7 dias foi estudado em relação a diversos parâmetros. Resultados: Anormalidades dos testes estiveram presentes em 202/1126 (17,9%) dos pacientes internados na UTI. Doença crítica associada à disfunção hepática foi encontrada em 172 (85,2%) pacientes, doença hepática crônica em 11 (5,4%) pacientes e hepatite viral aguda em 19 (9,4%) pacientes. O sintoma mais comum foi a febre (68,3%), seguido de vômito (48,0%) casos. Entre as anormalidades do TFH, transaminases elevadas, INR e escore MELD elevados na admissão correlacionaram-se com desfecho ruim de curto prazo. Exigência de inotrópicos e ventilação mecânica correlacionaram-se com desfecho de curto prazo ruim. A mortalidade não diferiu significativamente entre pacientes com doença hepática crônica, pacientes com hepatite viral aguda e pacientes com doença crítica associada à disfunção hepática. A disfunção hepática em UTI esteve associada a um desfecho ruim e à uma alta mortalidade a curto prazo de 114/202 (56,4%). Conclusão: A anormalidade da função hepática é comum em pacientes que são admitidos nas unidades de tratamento intensivo e sua presença é um indicador de desfecho de curto prazo ruim.

Factors associated with the severity and complication of patients with malaria hospitalized between 2009 and 2013 in three municipalities of Colombia, case control study.

BACKGROUND: Malaria worldwide annual reported cases range between 250 and 500 million and nearly half a million deaths are reported every year. Colombia has a vast expanse of territory with environmental and social conditions conducive to malaria transmission, which is the reason why it has second place in Latin America for the number of cases of malaria. METHODS: This is a retrospective, paired, case-control study that compares patients with severe malaria and malaria patients without mention of complication. Medical records of patients with confirmed malaria diagnosis were reviewed. The objective of this study was to identify factors associated with complicated malaria in three municipalities of Colombia during the period 2009-2013. RESULTS: A total sample of 180 medical records was collected, 60 corresponding to cases and 120 to controls following a 1:2 ratio. From the total sample, 88.33 % (159) of subjects were originally from Tumaco, 7.78 %, most of the patients of the study (104) were diagnosed and treated in 2013. Among the laboratory findings, the platelet count was found to have statistically significant differences between cases and controls; this was also true for total bilirubin value and transaminases. The most prevalent severity finding was clinical jaundice, followed by elevated bilirubin (25 %) and elevated transaminases (44.4 %). Thrombocytopenia was found in 11/44 cases (20 %) and only five of 60 patients (8.3 %) presented severe anaemia. The multivariate analysis showed that a platelet count <100,000 and clinical jaundice not associated with organ failure, were the two variables associated with severe malaria in the patients described. CONCLUSIONS: Most of the cases studied, despite meeting criteria of severity, were shown not to be as morbid or severe as in other countries. Clinical jaundice and thrombocytopaenia are associated with severe malaria, and they can be used by general practitioners or primary care physicians to promptly identify patients who may have severe malaria.

Síndrome de hipersensibilidad a los anticonvulsivos: reporte de un caso / Anticonvulsant Hypersensitivity Syndrome: A Case Report

El síndrome de reacción cutánea con eosinofilia y síntomas sistémicos (DRESS) es una reacción idiosincrásica a medicamentos que se caracteriza por erupción cutánea, fiebre, linfadenopatía y disfunción de órganos internos. Se revisa el caso de una paciente con trastorno afectivo bipolar (TAB) que sufrió una respuesta inflamatoria sistémica asociada al uso de ácido valproico y, además, tuvo una importante reactivación de los síntomas al usar otros medicamentos cuyos mecanismos de acción farmacológicos son diferentes. El diagnóstico de DRESS es principalmente de exclusión, por lo que puede tardarse en detectarlo y terminar en una entidad potencialmente mortal.

DRESS syndrome (skin reaction with eosinophilia and systemic symptoms) is an idiosyncratic drug reaction characterized by rash, fever, lymphadenopathy, and internal organ dysfunction. This case report is on a patient with bipolar affective disorder who presented with a systemic inflammatory response associated with the use of valproic acid, and an important activation of symptoms when used with other drugs with a different pharmacological action mechanism. The diagnosis of DRESS syndrome is primarily by exclusion, and its detection may be difficult, which could potentially become fatal for the patient.

[Anticonvulsant Hypersensitivity Syndrome: A Case Report]. / Síndrome de hipersensibilidad a los anticonvulsivos: reporte de un caso.

DRESS syndrome (skin reaction with eosinophilia and systemic symptoms) is an idiosyncratic drug reaction characterized by rash, fever, lymphadenopathy, and internal organ dysfunction. This case report is on a patient with bipolar affective disorder who presented with a systemic inflammatory response associated with the use of valproic acid, and an important activation of symptoms when used with other drugs with a different pharmacological action mechanism. The diagnosis of DRESS syndrome is primarily by exclusion, and its detection may be difficult, which could potentially become fatal for the patient.

Clinical and hepatic evaluation in adult dengue patients: a prospective two-month cohort study / Avaliação das alterações clínicas e hepáticas em pacientes adultos com dengue: estudo prospectivo em um período de dois meses

INTRODUCTION: To analyze the liver dysfunction and evolution of signs and symptoms in adult dengue patients during a two-month follow-up period. METHODS: A prospective cohort study was conducted in Campos dos Goytacazes, Rio de Janeiro, Brazil, from January to July, 2008. The evolution of laboratory and clinical manifestations of 90 adult dengue patients was evaluated in five scheduled visits within a two-month follow-up period. Twenty controls were enrolled for the analysis of liver function. Patients with hepatitis B, hepatitis C, those known to be human immunodeficiency virus (HIV) seropositive and pregnant women were excluded from the study. RESULTS: At the end of the second month following diagnosis, we observed that symptoms persisted in 33.3% (30/90) of dengue patients. We also observed that, 57.7% (15/26) of the symptoms persisted at the end of the second month. The most persistent symptoms were arthralgia, fatigue, weakness, adynamia, anorexia, taste alteration, and hair loss. Prior dengue virus (DENV) infection did not predispose patients to a longer duration of symptoms. Among hepatic functions, transaminases had the most remarkable elevation and in some cases remained elevated up to the second month after the disease onset. Alanine aminotransferase (ALT) levels overcame aspartate aminotransferase (AST) during the convalescent period. Male patients were more severely affected than females. CONCLUSIONS: Dengue fever may present a wide number of symptoms and elevated liver transaminases at the end of the second month.

INTRODUÇÃO: Analisar prospectivamente a disfunção hepática e a evolução dos sinais e sintomas em pacientes adultos com dengue durante um período de dois meses. MÉTODOS: Realizamos um estudo prospectivo em Campos dos Goytacazes, Rio de Janeiro, Brasil, de janeiro a julho de 2008. Foi avaliada a evolução das manifestações clínicas e laboratoriais em 90 pacientes adultos com dengue, em um período de dois meses. Vinte controles foram arrolados para análise da função hepática. Em ambos os grupos foram realizadas coletas de dados e sangue nos primeiros cinco dias da doença, e aos 8, 15, 30 e 60 dias após o início da doença. Foram excluídos pacientes com hepatite B, hepatite C, gestantes e aqueles sabidamente soropositivos para HIV. RESULTADOS: No final do segundo mês do início da dengue, 33,3% (30/90) dos pacientes apresentaram persistência de pelo menos um sinal ou sintoma. Estavam presentes no final do segundo mês 57,7% (15/26) dos sinais ou sintomas. Os maiores percentuais de persistência foram: artralgia, adinamia, fraqueza, fadiga, anorexia, alteração do paladar e queda de cabelo. A infecção prévia pelo vírus da dengue (DENV) não predispôs a uma maior duração dos sintomas. Da função hepática, observamos alterações relevantes somente nos níveis das transaminases, que em alguns casos permaneceram elevados até o final do segundo mês. Os níveis de ALT ultrapassaram os de AST na convalescença. Homens apresentaram níveis mais elevados de transaminases quando comparados aos de mulheres. CONCLUSÕES: Dengue apresenta grande número de sintomas e transaminases elevadas no final do segundo mês de doença.

Compromiso hepático por Dengue en niños del Huila, Colombia / Dengue-related hepatic compromise in children from the Huila department of Colombia

Objetivo Determinar la frecuencia y severidad del compromiso hepático en niños con Dengue. Métodos Estudio descriptivo que incluyó a 108 niños menores de 13 años con diagnóstico de infección por virus de Dengue, confirmada por detección plasmática de NS1 e IgM dengue-específica, que consultaron al Hospital Universitario de Neiva, en el período de junio de 2009 a mayo de 2010.El grado de daño hepático fue evaluado por criterios clínicos y bioquímicos que incluyeron transaminasas y albúmina. El diagnóstico de infección con Leptospira o Hepatitis A fue realizado por detección de IgM plasmática específica medida en fase aguda y convaleciente. Resultados De los casos incluidos, 98 y 10 casos fueron clasificados como dengue con signos de alarma y Dengue grave, respectivamente. Dos de cada tres pacientes con Dengue presentaron signos de alarma y todos los pacientes con Dengue grave presentaron algún grado de compromiso hapático evidenciado clínica y bioquímicamente. Independientemente de la clasificación clínica, la hepatomegalia fue el signo clínico cardinal del compromiso hepático y se presentó en el 85 % del total de niños incluidos. De resaltar, 5 de los pacientes presentaron probable coinfección de dengue y leptospira, siendo la primera descripción en Colombia. En ninguno de los casos analizados se presentó enfermedad aguda por Hepatitis A. Conclusión El compromiso hepático es muy frecuente en la infección por virus Dengue. Enfermedades como la leptospirosis deben ser tenidas en cuenta no sólo en el diagnóstico diferencial del paciente pediátrico febril con compromiso hepático, sino como causa de coinfección en el niño con Dengue en el sur de Colombia.

Objective Dengue is the most important arthropod-borne viral disease in the world; it can be life-threatening because of liver involvement. Aim Determining liver involvement frequency and severity in dengue-infected children. Methods This was a descriptive case series study which involved studying 108 dengue-infected children aged less than 13 years old whose infection had been confirmed by the detection of dengue-specific IgM and NS1 in plasma. Clinical and biochemical parameters were used for evaluating liver involvement, including transaminases and albumin. Hepatitis A and leptospira infection were also evaluated by using ELISA to detect pathogen-specific IgM in plasma during acute and convalescence phases. The study was carried out at a teaching hospital in Neiva from June 2009 to May 2010. Results Ninety-eight of the aforementioned cases were clinically classified as dengue with warning signs (DWS) and 10 as severe dengue (SD). Two out of three DWS patients and all SD patients had some degree of liver involvement, shown clinically and biochemically. Regardless of the clinical classification, hepatomegaly was the main clinical sign of liver involvement and was present in 85% of all the children in the study. It is worth noting that 5 patients had probable dengue and leptospirosis co-infection, this being the first instance of this in Colombia. None of the cases analyzed here had acute hepatitis A. Conclusions Liver compromise should be considered in confirmed cases of dengue as shown in this series of children. Leptospirosis must be considered as differential diagnosis and also as causing co-infection in a febrile child.

Síndrome hepatorrenal: diagnóstico y tratamiento / Hepatorenal syndrome: diagnosis and treatment

El síndrome hepatorrenal es potencialmente reversible, se presenta en pacientes con cirrosis, ascitis, insuficiencia hepática aguda o hepatitis alcohólica y se caracteriza por deterioro de la función renal, alteraciones de la función cardiovascular e hiperactividad de sistemas como el nervioso simpático y el renina-angiotensina. Han sido innumerables las investigaciones realizadas sobre la coexistencia de la disfunción hepática y renal y su impacto en la morbilidad y mortalidad en las unidades de atención al paciente en estado crítico. El objetivo del presente artículo es proporcionar una revisión bibliográfica actualizada acerca del tema y facilitar la actuación médica ante los afectados con el mencionado síndrome.

The hepatorenal syndrome is potentially reversible, it is presented in patients with cirrhosis, ascites, acute hepatic failure or alcoholic hepatitis and it is characterized by deterioration of the renal function, changes of the cardiovascular function and hyperactivity of systems as the sympathetic nervous one and the renin-angiotensin system. The investigations carried out on the coexistence of the hepatic and renal disorders and their impact in the mobility and mortality in the institutions for critically ill patient have been countless. The objective of the present work is to provide an updated literature review about the topic and to facilitate the medical performance in those cases with the mentioned syndrome.

Ictericia y hepatopatía en el paciente con malaria / Jaundice and hepatopathy in patients with malaria

La ictericia es un hallazgo frecuente en el paciente con malaria. Según la Organización Mundial de la Salud, se considera un signo de peligro cuando se acompaña de aumento importante de las bilirrubinas y comúnmente se relaciona con disfunción hepática y lesión de otros sistemas. La lesión hepática en estos pacientes es frecuente, está asociada a otras complicaciones, y es reversible si se identifica y se trata a tiempo. Con este trabajo se pretende revisar el valor semiológico de la ictericia como indicador de malaria complicada, explicar su patogénesis y los mecanismos de daño hepático; además, hacer un enfoque del paciente con hepatopatía palúdica, diferenciando la disfunción hepática de la falla y la encefalopatía hepáticas.

Jaundice is a common finding in malaria patients. According to the World Health Organization, it is considered a sign of danger when accompanied by an important increase of bilirubin and it is frequently related to hepatic dysfunction and injury to other organs. Liver injury in these patients is common and it is associated with other complications. If it is identified and treated early, it is reversible. This paper reviews the semiological value of jaundice as an indicator of complicated malaria; it explains its pathogenesis and the mechanisms of liver damage. It also focuses on the patient with hepathopathy, distinguishing hepatic dysfunction, hepatic failure and hepatic encephalopathy.

Is hyperbilirubinaemia in appendicitis a better predictor of perforation than C-reactive protein? - a prospective study.

PURPOSE: To compare the performance for the prediction of perforated appendicitis of total bilirubin versus C-reactive protein (CRP), white blood cell count, the time period of symptoms' evolution, and systemic inflammatory response syndrome (SIRS). METHODS: Prospective observational study, applying receiver operating characteristics curve analysis to compare the sensitivity and specificity of the tested variables. RESULTS: The period of symptom's evolution was prolonged (105.2 ± 79.3 hours vs. 38.6 ± 17.5 hours), and CRP levels were higher in perforated appendicitis (176 ± 82.6 mg/l vs. 80 ± 76 mg/l). Most patients with perforated appendicitis had a SIRS score higher than 3 points. CRP (>76.7 mg/l), the time period of symptoms' evolution (>34.5 hours), and SIRS (3 points or more), were the best cutoff values to predict perforated appendicitis. CONCLUSIONS: Perforated appendicitis may be suspected based on CRP, SIRS and the time period of symptoms' evolution. We do not recommend the use of total bilirubin to predict perforation in appendicitis.