New insights into the mechanisms involved in B-type natriuretic peptide elevation and its prognostic value in septic patients.

INTRODUCTION: Elevated plasma B-type natriuretic peptide (BNP) levels in patients with critical sepsis (severe sepsis and septic shock) may indicate septic cardiomyopathy. However, multiple heterogeneous conditions may also be involved in increased BNP level. In addition, the prognostic value of BNP in sepsis remains debatable. In this study, we sought to discover potential independent determinants of BNP elevation in critical sepsis. The prognostic value of BNP was also evaluated. METHODS: In this observational study, we enrolled mechanically ventilated, critically septic patients requiring hemodynamic monitoring through a pulmonary artery catheter. All clinical, laboratory and survival data were prospectively collected. Plasma BNP concentrations were measured daily for five consecutive days. Septic cardiomyopathy was assessed on day 1 on the basis of left and right ventricular ejection fractions (EF) derived from echocardiography and thermodilution, respectively. Mortality was recorded at day 28. RESULTS: A total of 42 patients with severe sepsis (N = 12) and septic shock (N = 30) were ultimately enrolled. Daily BNP levels were significantly elevated in septic shock patients compared with those with severe sepsis (P ≤0.002). Critical illness severity (assessed by Acute Physiology and Chronic Health Evaluation II and maximum Sequential Organ Failure Assessment scores), and peak noradrenaline dose on day 1 were independent determinants of BNP elevation (P <0.05). Biventricular EFs were inversely correlated with longitudinal BNP measurements (P <0.05), but not independently. Pulmonary capillary wedge pressures (PCWP) and volume expansion showed no correlation with BNP. In septic shock, increased central venous pressure (CVP) and CVP/PCWP ratio were independently associated with early BNP values (P <0.05). CONCLUSIONS: The severity of critical illness, rather than septic cardiomyopathy, is probably the major determinant of BNP elevation in patients with critical sepsis. Daily BNP values are of limited prognostic value in predicting 28-day mortality; however, fast BNP decline over time and a decrease in BNP <500 pg/ml may imply a favorable outcome.

Cytokine levels in the sera of patients with idiopathic pulmonary fibrosis.

BACKGROUND: Idiopathic pulmonary fibrosis (IPF) is a fibroproliferative disorder. Cytokines contribute an important but yet undefined role to its pathogenesis. OBJECTIVES: The present study aims to compare serum levels of cytokines involved in Th-1 and Th-2 immunity, such as interleukins (IL) IL-2, IL-4, IL-8, IL-10, interferon-gamma (IFN-gamma) and IL-12 (p40) in patients with IPF and healthy volunteers. Twenty patients with IPF and 40 healthy controls (HC) participated. METHODS: Cytokines were assessed by enzyme-linked immunoabsorbent assay (ELISA). RESULTS: Median values of serum IL-2, IL-8, IL-10, IL-12 (p40) were higher in the IPF than the control group: IPF group: 1.05 U/ml, 12.55, 10.13, 44.17 pg/ml; control group: 0.05 U/ml, 6.91, 0.75, 4.51 pg/ml, respectively (P<0.05). IFN-gamma serum levels were lower in the IPF (0.19 pg/ml) than in the control group (0.49 pg/ml). IL-4 values did not differ in a statistically significant way among the groups: 8.40 pg/ml in the IPF group, and 7.46 pg/ml in the control group (P>0.05). IL-4 positively correlated to fast expiratory volume in 1s (FEV1%) and forced vital capacity (FVC%), while IL-8 negatively correlated to the respective values (P<0.005). CONCLUSIONS: IL-2, IL-8, IL-10 and IL-12 (p40) were found to be elevated in the sera of patients with IPF. IFN-gamma was found to be decreased in the sera of patients with IPF.

ICAM-1, ICAM-2 and ICAM-3 in the sera of patients with idiopathic pulmonary fibrosis.

In order to test the serum levels of ICAM-1, ICAM-2 and ICAM-3 in patients with idiopathic pulmonary fibrosis (IPF), twenty patients with IPF and eleven with secondary interstitial fibrosis (SIF), as well as forty healthy volunteers (HV) were studied. Serum intracellular adhesion molecules (ICAM) 1, 2 and 3 were assessed by ELISA. Functional respiratory tests, which included spirometry and lung diffusing capacity were simultaneously performed. Median values of serum ICAM-1 and ICAM-2 were higher in the patients' than in the healthy volunteers' (HV) group: IPF group: 946.60 ng/ml and 400.14 ng/ml; SIF group: 901.58 ng/ml and 378.27 ng/ml; HV group: 308.40 ng/ml and 217.55 ng/ml, respectively (p<0.05). ICAM-3 serum levels were equal between the three groups. ICAM-2 negatively correlated to DLCO values. (p<0.005). It can be concluded that ICAM 1 and 2 are elevated in the sera of patients with pulmonary fibrosis. ICAM-2 might be associated with a more impaired clinical status.

Septic shock due to visceral leishmaniasis, probably transmitted from blood transfusion.

A case of visceral leishmaniasis (VL) in a 77-year-old woman, with renal failure on haemodialysis, admitted in the intensive care unit (ICU) with vascular instability requiring vassopressor treatment, is presented. Initially, no co-infection could be detected. The patient initially responded well when liposomal amphotericin B was administered, after bone marrow demonstrated multiple intra-cellular Leishmania amastigotes and extra-cellular promastigotes. However, the patient died from uncontrolled septic shock from a secondary bacterial infection, the tenth day of admission. To our knowledge, vascular instability has not been reported in VL. Moreover, non-vector transmission was also suspected in this case. The patient had undergone cholecystectomy three months earlier, during which two blood units had been transfused; IgG anti-Leishmania antibodies at a high titer were detected in one of the two healthy blood donors, later.

Atypical presentation of varicella-zoster virus encephalitis in an immunocompetent adult.

BACKGROUND: Varicella-zoster virus encephalitis is uncommon, but not rare, in immunocompetent adults. Typically, patients develop stroke with hemiplegia caused by large vessel vasculopathy days to weeks after herpes zoster ophthalmicus. METHOD: A previously healthy 66-year-old man developed obtundation deteriorating to coma within 24 hours. He had lymphocytic meningitis and multiple bilateral edematous and hemorrhagic lesions predominantly in the white matter, and intraventricular and subarachnoid hemorrhage. Treatment with acyclovir and dexamethasone was readily administered. The diagnosis of varicella-zoster virus encephalitis was confirmed by polymerase chain reaction analysis of the cerebrospinal fluid. No zosteriform rash preceded or followed encephalitis. Two years later, the patient is in good health, and no relapse or sign of immunosuppression has been reported. CONCLUSION: This is a case of varicella-zoster virus encephalitis in an immunocompetent patient presenting without typical rash and with clinicoradiologic features of multifocal encephalitis, which characterize immunosuppression.