RESUMEN
OBJECTIVE: To determine the involvement of coagulation in bleeding and poor outcome in patients with severe leptospirosis. METHODS: In a prospective study, parameters of the coagulation system were measured on admission and during follow-up in 52 consecutive patients with severe leptospirosis. RESULTS: All patients showed coagulation disorders, such as prolonged prothrombin time (PT) and activated partial thromboplastin time, marked procoagulant activity [thrombin-antithrombin (TAT) complexes, prothrombin fragment 1+2, D-dimer], reduced levels of anticoagulant markers (protein C, antithrombin) and increased (anti-) fibrinolytic activity [plasmin-antiplasmin (PAP) complexes, plasminogen activator inhibitor-1]. These disorders were more pronounced in patients who died eventually. PT prolongation was associated with mortality (OR 1.4, 95% CI: 1.0-1.8, P = 0.04). Bleeding occurred in 31 subjects (60%). Of these, 24 had mild bleeding and seven had severe haemorrhages. Thrombocytopenia (platelets =100 x 10(9)/l) was significantly associated with clinical bleeding (OR 4.6, 95% CI: 1.3-16). A subanalysis of patients with and without severe bleeding revealed a more pronounced imbalance of the coagulation system in patients with severe bleeding, as reflected by a significant association with PT (OR 1.4, 95% CI: 1.0-1.8, P = 0.05) and the TAT/PAP ratio (OR 1.3, 95% CI: 1.0-1.6, P = 0.05), which is an indicator of the balance between coagulation and fibrinolysis. Overt disseminated intravascular coagulation (DIC) was found in 10 (22%) of the 46 patients for whom the score could be calculated. There was no significant association between DIC scores, bleeding diathesis or poor outcome. CONCLUSION: The coagulation system was strongly activated in patients with leptospirosis. This was more pronounced in the deceased and in patients with severe bleeding than in than the survivors and in those without severe bleeding.
Asunto(s)
Trastornos de la Coagulación Sanguínea/parasitología , Leptospirosis/complicaciones , Adulto , Coagulación Sanguínea , Pruebas de Coagulación Sanguínea/métodos , Coagulación Intravascular Diseminada/parasitología , Métodos Epidemiológicos , Femenino , Fibrinólisis , Humanos , Leptospirosis/sangre , Leptospirosis/diagnóstico , Masculino , Persona de Mediana Edad , Tiempo de Tromboplastina Parcial , Pronóstico , Tiempo de ProtrombinaRESUMEN
Cerebral toxoplasmosis is a potentially fatal infection most commonly seen in immunocompromised patients. We present a patient on long-term immunosuppressive therapy after kidney transplantation and a recent history of oligometastatic rectal cancer, with cerebral lesions as a result of toxoplasmosis. Heightened awareness of the occurrence of opportunistic infections in patients with cancer who are taking immunosuppressive drugs is needed among clinicians.
Asunto(s)
Infecciones Oportunistas , Neoplasias del Recto , Toxoplasmosis Cerebral , Encéfalo , Humanos , Huésped InmunocomprometidoRESUMEN
Cytomegalovirus (CMV) infections are often asymptomatic, but symptoms can range from a mononucleosis-like syndrome to a severe, disseminated infection in immunocompromised patients. We present two cases of immunocompetent patients with acute CMV infection directly followed by portal vein thrombosis in one and pulmonary embolism in the other patient. Thromboembolism may be a severe complication of acute CMV infection, with possible therapeutic implications.
Asunto(s)
Infecciones por Citomegalovirus/complicaciones , Vena Porta , Embolia Pulmonar/virología , Trombosis/virología , Anciano , Anticoagulantes/uso terapéutico , Femenino , Humanos , Masculino , Persona de Mediana Edad , Embolia Pulmonar/diagnóstico por imagen , Embolia Pulmonar/tratamiento farmacológico , Trombosis/diagnóstico por imagen , Trombosis/tratamiento farmacológicoRESUMEN
Leptospirosis is a zoonosis of worldwide distribution, spread by the urine of infected animals. It is a major public health problem, especially in developing countries, where circumstances for transmission are most favourable. The clinical picture varies from mild disease to a severe illness with haemostatic derangements and multiorgan failure eventually leading to death. Although the haemorrhagic complications of severe disease are serious, the pathophysiology is scarcely elucidated. The complex mechanisms involved in inflammation-induced coagulation activation are extensively studied in various infectious diseases, i.e. Gram-negative sepsis. Tissue factor-mediated coagulation activation, impairment of anticoagulant and fibrinolytic pathways in close concert with the cytokine network are thought to be important. But for human leptospirosis, data are limited. Because of the growing interest in this field, the impact of leptospirosis, and the availability of new therapeutic strategies, we reviewed the evidence regarding the role of coagulation in leptospirosis and provide suggestions for future research.
Asunto(s)
Trastornos de la Coagulación Sanguínea/complicaciones , Leptospirosis/complicaciones , Coagulación Sanguínea/fisiología , Trastornos de la Coagulación Sanguínea/inmunología , Trastornos de la Coagulación Sanguínea/fisiopatología , Citocinas/inmunología , Células Endoteliales/inmunología , Células Endoteliales/parasitología , Células Endoteliales/fisiología , Fibrinólisis/fisiología , Trastornos Hemorrágicos/complicaciones , Trastornos Hemorrágicos/inmunología , Trastornos Hemorrágicos/fisiopatología , Hemostasis/fisiología , Humanos , Leptospirosis/inmunología , Leptospirosis/fisiopatología , Modelos BiológicosRESUMEN
Leptospirosis, although ubiquitous and potentially lethal, is often not diagnosed. The seroprevalence of anti-Leptospira antibodies and the utility of two rapid tests for the serodiagnosis of the disease were studied in Binh Thuan, an area in southern Vietnam with favourable conditions for Leptospira. In an initial survey, blood samples from 44 patients with undifferentiated fever and 83 healthy subjects were each examined for anti- Leptospira antibodies using three tests: an ELISA; a latex card-agglutination test (Dri Dot); and a lateral-flow assay (LeptoTek Lateral Flow). In the ELISA, samples from 35% of the healthy subjects and 40% of the febrile patients were found to have titres of anti- Leptospira IgM of at least 1:80. Only one of the 13 patients checked again, in ELISA, 3 weeks later, showed the marked increase in IgM titre that is indicative of acute leptospirosis. In the initial survey, although the positive results of the lateral-flow assay, applied to whole blood and serum, showed a good agreement with those of the ELISA (kappa = 0.743), the results of the lateral-flow assay were often indeterminate. The card-agglutination test was more specific. The overall agreement between the results of the rapid tests and those of the ELISA was generally poor. When the samples classified as 'indeterminate' in the lateral-flow assay were considered positive, the maximum kappa-value for this assay applied to whole blood was only 0.512. In conclusion, it appears that high seroprevalences of anti- Leptospira IgM and low incidences of acute leptospirosis limit the diagnostic value of the rapid tests that were investigated. The lateral-flow assay is not specific enough. The card-agglutination test is possibly better but, because of the low incidence, its sensitivity could not be evaluated adequately in the present study.