Factors associated with severity and mortality in patients with confirmed leptospirosis at a regional hospital in northern Taiwan

Background/purposeThe clinical, epidemiological, and laboratory factors associated with disease severity and mortality from confirmed leptospirosis patients in Taiwan are not well known. This retrospective study examined patients with suspected leptospirosis admitted to En-Chu-Kong Hospital, a regional teaching hospital in northern Taiwan.MethodsFrom January 2002 to July 2014, 733 suspected cases were reported to the National Reference Laboratory, 57 of which were identified as laboratory and clinical confirmed. We analyzed the clinical, epidemiological, and laboratory factors associated with disease severity and mortality in 57 cases.ResultsThe mean age was 59.1 ± 18.2 years, 74% were male, and 49% had occupational contact with soil. The major complications were pulmonary involvement (54%), shock (44%), ventilator support (32%), jaundice (32%), hemorrhage (30%), acute kidney injury (30%), meningitis (11%) and myocarditis (2%). Leptospira santarosai serova Shermani was present in 42 (74%) patients and 37 (58%) patients had severe leptospirosis. Sixteen (28%) patients had concomitant infections, including nine patients with bloodstream infection. The only independent predictor for severe leptospirosis was shock (OR 14.8, 95% CI 2.97–73.59). Eleven patients died (19%). Acute respiratory distress syndrome with severe pulmonary hemorrhage syndrome (6 patients) was present in 55% of the fatal cases. The factors independently related to mortality were prior steroid use (OR 20.2, 95% CI 1.9–217.5) and hemorrhage (OR 71.2, 95% CI 4.9 – >999.9).ConclusionThese results indicate that shock is a predictor of severe leptospirosis, and prior steroid use and hemorrhage are predictors of death from leptospirosis.     

The evaluation of sequential platelet counts has prognostic value for acute kidney injury patients requiring dialysis in the intensive care setting

OBJECTIVE:

To evaluate the prognostic value of platelet counts in acute kidney injury patients requiring renal replacement therapy.

METHODS:

This prospective cohort study was performed in three tertiary-care hospitals. Platelet counts were obtained upon admission to the intensive care unit and during the first week of renal replacement therapy on days 1, 3, 5 and 7. The outcome of interest was the hospital mortality rate. With the aim of minimizing individual variation, we analyzed the relative platelet counts on days 3, 5, 7 and at the point of the largest variation during the first week of renal replacement therapy. Logistic regression analysis was used to test the prognostic value of the platelet counts.

RESULTS:

The study included 274 patients. The hospital mortality rate was 62%. The survivors had significantly higher platelet counts upon admission to the intensive care unit compared to the non-survivors [175.5×10³/mm³ (108.5–259×10³/mm³) vs. 148×10³/mm³ (80−141×10³/mm³)] and during the first week of renal replacement therapy. The relative platelet count reductions were significantly associated with a higher hospital mortality rate compared with the platelet count increases (70% vs. 44% at the nadir, respectively). A relative platelet count reduction >60% was significantly associated with a worse outcome (mortality rate = 82.6%). Relative platelet count variations and the percentage of reduction were independent risk factors of hospital mortality during the first week of renal replacement therapy.

CONCLUSION:

Platelet counts upon admission to the intensive care unit and at the beginning of renal replacement therapy as well as sequential platelet count evaluation have prognostic value in acute kidney injury patients requiring renal replacement therapy.     

New clinical and ultrastructural aspects in leptospirosis icterohaemorrhagica (Weil's disease)

Summary Clinically, the coincidence of jaundice and acute renal failure with elevation of serum bilirubin, transaminases and fibrinogen, as well as thrombocytopenia and normal prothrombin time are characteristic for Morbus Weil. Liver biopsy, 13 days after onset of the disease, showed scattered foci of liver cell necrosis with surrounding leucocytic infiltration and mesenchymal proliferation as well as intrahepatic cholostasis. Kidney biopsy 17 days after the onset of the disease showed an acute interstitial inflammatory edema, and electronmicroscopically, a glomerulonephrosis with a loose, finely granular thickening of the lamina rara interna. The latter lesion is not completely restituted after 4 1/2 months. Glomerular and intertubular endothelial cells show severe reparatory-proliferative alterations after 2 1/2 weeks. The glomerulonephrosis as well as the interstitial edema are considered as consequence of the direct lesion of endothelial cells by leptospirae, the anuria is considered as consequence of the interstitial edema as well as of the circulatory collapse.

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Zusammenfassung Klinisch ist das Zusammentreffen von Ikterus und akuter Niereninsuffizienz mit Erhöhung von Serumbilirubin, Transaminasen und Fibrinogen, sowie Thrombocytopenie und normaler Prothrombinzeit charakteristisch für Morbus Weil. Die Leberbiopsie am 13. Tag zeigt spärliche Herde mit Leberzellnekrose, umgeben von Leukocyteninfilatration und mesenchymaler Proliferation, daneben intrahepatische Cholostase. Die Nierenbiopsie am 17. Tag ergibt ein akutes interstitielles entzündliches Ödem und elektronenmikroskopisch eine Glomerulonephrose mit lockerer, feingranulärer Verdickung der Lamina rara interna. Letztere Veränderung ist nach 4 1/2 Monaten noch nicht völlig restituiert. Glomeruläres und intertubuläres Endothel lassen nach 2 1/2 Wochen schwere, reparatorisch-proliferative Veränderungen erkennen. Die Glomerulonephrose und das interstitielle Ödem werden als eine Folge der direkten Endothelläsion durch die Leptospiren, die Anurie als Folge des interstitiellen Ödems und des Kreislaufkollapses aufgefaßt.

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Supported by the Swiss National Foundation for Medical Research.     

A case of severe acute kidney injury by near-drowning

Acute kidney injury (AKI) secondary to near-drowning is rarely described and poorly understood. Only few cases of severe isolated AKI resulting from near-drowning exist in the literature. We report a case of near-drowning who developed to isolated AKI due to acute tubular necrosis (ATN) requiring dialysis. A 21-yr-old man who recovered from near-drowning in freshwater 3 days earlier was admitted to our hospital with anuria and elevated level of serum creatinine. He needed five sessions of hemodialysis and then renal function recovered spontaneously. Renal biopsy confirmed ATN. We review the existing literature on near-drowning-induced AKI and discuss the possible pathogenesis.     

Nutritional parameters are associated with mortality in acute kidney injury

OBJECTIVE:

The objective of this study was to perform a nutritional assessment of acute kidney injury patients and to identify the relationship between nutritional markers and outcomes.

METHOD:

This was a prospective and observational study. Patients who were hospitalized at the Hospital of Botucatu School of Medicine were evaluated between January 2009 and December 2011. We evaluated a total of 133 patients with a clinical diagnosis of acute kidney injury and a clinical presentation suggestive of acute tubular necrosis. We explored the associations between clinical, laboratory and nutritional markers and in-hospital mortality. Multivariable logistic regression was used to adjust for confounding and selection bias.

RESULTS:

Non-survivor patients were older (67±14 vs. 59±16 years) and exhibited a higher prevalence of sepsis (57.1 vs. 21.4%) and higher Acute Tubular Necrosis-Individual Severity Scores (0.60±0.22 vs. 0.41±0.21) than did survivor patients. Based on the multivariable analysis, laboratorial parameters such as blood urea nitrogen and C-reactive protein were associated with a higher risk of death (OR: 1.013, p = 0.0052; OR: 1.050, p = 0.01, respectively), and nutritional parameters such as low calorie intake, higher levels of edema, lower resistance based on bioelectrical impedance analysis and a more negative nitrogen balance were significantly associated with a higher risk of death (OR: 0.950, p = 0.01; OR: 1.138, p = 0.03; OR: 0.995, p = 0.03; OR: 0.934, p = 0.04, respectively).

CONCLUSIONS:

In acute kidney injury patients, a nutritional assessment seems to identify nutritional markers that are associated with outcome. In this study, a low caloric intake, higher C-reactive protein levels, the presence of edema, a lower resistance measured during a bioelectrical impedance analysis and a lower nitrogen balance were significantly associated with risk of death in acute kidney injury patients.     

Prognostic factors associated with severe leptospirosis

Leptospirosis is an anthropozoonosis caused by Leptospira interrogans. It occurs worldwide and is endemic in French Polynesia. Leptospirosis is associated with a large variety of clinical symptoms. Most infections caused by leptospires are either sub-clinical or of very mild severity, but 5-10% of infections result in multiple organ damage, including kidney, liver and lung lesions. Among 71 patients hospitalised in Papeete for severe leptospirosis during a period of 2 years, the main risk-factors for a severe outcome were hypotension, oliguria and an abnormal chest auscultation at the first physical examination. Survival depends on rapid diagnosis and early appropriate management. Well-defined criteria may help physicians to improve the timely treatment of high-risk patients.     

Weil's disease (leptospirosis) manifesting as fulminant hepatic failure: Report of an autopsy case

We report an autopsy case of a 60-year-old man with Weil's disease who died of fulminant hepatic failure. Ante-mortem blood culture yielded the growth of Leptospira interrogans (serovar icterohaemorrhagiae). At autopsy, the liver weighed 1210 g and showed a typical appearance of “acute yellow liver atrophy”. Zone 3 (centrilobular region) showed submassive necrosis of hepatocytes accompanied by marked hemorrhage. Hepatocytes in zones 1 and 2 were well preserved, and the leptospira antigen was immunohistochemically demonstrated in several hepatocytes. Dissociation of liver cell plates was not observed. An immunohistochemical study demonstrated that CD31-positive, sinusoidal endothelial cells had almost completely disappeared in zone 3. This finding suggested that severe and selective damage to endothelial cells in zone 3 was the main cause of the submassive hepatocellular necrosis, which led to fulminant hepatic failure in the present case.     

发热伴血小板减少综合征布尼亚病毒细胞嗜性研究

目的 了解发热伴血小板减少综合征布尼亚病毒（SFTSV）细胞嗜性,加强对SFTSV传播与致病机制的理解.方法 通过不同感染复数（multiplicity of infection）的SFTSV感染Vero等10种不同组织来源的细胞株,采用双抗体夹心ELISA法和间接免疫荧光实验（IFA）检测不同时间点的细胞培养上清和细胞内病毒抗原表达水平,绘制病毒动态生长曲线,并观察记录细胞病变（cytopathic effect,CPE）情况,确定SFTSV细胞嗜性.结果 Vero、HEK 293、COS-7、CHO、HepG2、Hela、THP-1和MRC-5等不同组织来源的细胞均可感染SFTSV,并产生明显细胞病变,但病毒在不同细胞中的复制水平差异显著,其中Vero细胞对SFTSV较易感,病毒可增殖至10S0TCID50/ml以上;Raji细胞、Jurkat细胞不能感染SFTSV.结论 SFTSV具有广嗜性,可以感染肝、肺、肾、子宫和卵巢等多器官以及免疫系统等来源的细胞系,但不能感染T和B淋巴细胞源细胞系,为SFTSV相关基础研究提供重要线索.     

The role of funduscopy in severe thrombocytopenia: A prospective study

PurposePlatelet transfusions for patients suffering from severe thrombocytopenia are regulated by clinical bleedings and platelet counts. The aim of this study was to assess the prevalence of retinal hemorrhage in patients with hematologic and oncologic malignancies and severe thrombocytopenia, and to determine the benefit of systematic funduscopic examination in this setting.Materials and methodsHospitalized patients with hematologic and oncologic malignancies having a platelet count less than 25,000 per μL underwent indirect ophthalmoscopy. The prevalence of retinal hemorrhage and its correlation with different patients’ characteristics were determined. The decision to transfuse platelets or not following bedside indirect ophthalmoscopy was left at the discretion of the treating physician.ResultsA total of 34 severe thrombocytopenic patients were included in the study. The prevalence of retinal hemorrhage was detected in 10 patients (29.4%). No significant correlation was found between the occurrence of retinal hemorrhage and age, platelet count or thrombocytopenia etiology (P > 0.05). No significant difference was found concerning the rate of transfusion between those with and without retinal hemorrhage.ConclusionAccording to our statistical results, retinal hemorrhage is a frequent finding in severely thrombocytopenic patients. Early detection may lead to an increase in the platelet transfusion threshold from to 30,000 per μL offering additional protection against spontaneous bleedings. Funduscopy is a safe and easy exam to perform systematically in patients with severe thrombocytopenia.     

Acute Kidney Injury after Using Contrast during Cardiac Catheterization in Children with Heart Disease

Acute kidney injury (AKI) is closely associated with the mortality of hospitalized patients and long-term development of chronic kidney disease, especially in children. The purpose of our study was to assess the evidence of contrast-induced AKI after cardiac catheterization in children with heart disease and evaluate the clinical usefulness of candidate biomarkers in AKI. A total of 26 children undergoing cardiac catheterization due to various heart diseases were selected and urine and blood samples were taken at 0 hr, 6 hr, 24 hr, and 48 hr after cardiac catheterization. Until 48 hr after cardiac catheterization, there was no significant increase in serum creatinine level in all patients. Unlike urine kidney injury molecule-1, IL-18 and neutrophil gelatinase-associated lipocalin, urine liver-type fatty acid-binding protein (L-FABP) level showed biphasic pattern and the significant difference in the levels of urine L-FABP between 24 and 48 hr. We suggest that urine L-FABP can be one of the useful biomarkers to detect subclinical AKI developed by the contrast before cardiac surgery.

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舟山海岛严重发热伴血小板减少综合征血常规及凝血功能分析

目的 探讨舟山海岛地区严重发热伴血小板减少综合征（severe fever with thrombocytopenia syndrome,SFTS）患者临床血常规及凝血功能特征.方法 采用血细胞分析仪及全自动凝血仪分别检测2011年5月至2013年10月舟山医院收治的27例SFTS患者治疗前及治疗10 d后血常规、凝血功能.x2检验、t检验或相关性分析血常规、凝血功能检测值的变化.结果 SFTS患者治疗前白细胞、中性粒细胞、淋巴细胞、血小板均明显低于正常体检者,差异有统计学意义（P＜0.05）;SFTS治疗痊愈者血小板明显高于死亡者,差异有统计学意义（P＜0.05）.SFTS患者治疗前PT、APTT、TT均较正常体检者长,FIB较正常体检者低,差异有统计学意义（P＜0.05）.Pearson相关性分析结果显示治疗前SFTS患者APTT与血小板数量有明显负相关性（P＜0.05）,治疗10 d后SFTS患者PT、APTT、TT与血小板数量亦有明显负相关性（P＜0.05）.结论 密切关注血常规及凝血功能状态对诊断及监测SFTS患者疾病进展情况具有非常显著的临床意义,并且特别需关注血小板及APTT的动态变化.     

Hemophagocytic syndrome in a patient with acute tubulointerstitial nephritis secondary to hepatitis A virus infection

Hepatitis A virus (HAV) infection is generally a self-limited disease, but the infection in adults can be serious, to be often complicated by acute kidney injury (AKI) and rarely by virus-associated hemophagocytic syndrome (VAHS). Our patient, a 48-yr-old man, was diagnosed with HAV infection complicated by dialysis-dependent AKI. His kidney biopsy showed acute tubulointerstitial nephritis with massive infiltration of activated macrophages and T cells, and he progressively demonstrated features of VAHS. With hemodialysis and steroid treatment, he was successfully recovered.     

A case of exercise-induced acute renal failure with G774A mutation in SCL22A12 causing renal hypouricemia

Acute renal failure with severe loin pain which develops after anaerobic exercise is rare. One of predisposing factors of exercise-induced acute renal failure is renal hypouricemia. Idiopathic renal hypouricemia is a genetic disorder characterized by hypouricemia with abnormally high renal tubular uric acid excretion. The mutation in SCL22A12 gene which encodes renal uric acid transporter, URAT1, is the known major cause of this disorder. We here described a 25-yr-old man showing idiopathic renal hypouricemia with G774A mutation in SCL22A12 who presented exercise-induced acute renal failure. There have been a few reports of mutational analysis in Korean idiopathic renal hypouricemia without acute renal failure. This is the first report of genetically diagnosed idiopathic renal hypouricemia with exercise-induced acute renal failure in Korea.     

早期血清ALB水平检测用于急性心肌梗死患者急性肾损伤预测的临床价值

目的 分析早期检测血清白蛋白（albumin,ALB）对急性心肌梗死患者急性肾损伤的预测价值。方法 纳入急性心肌梗死患者100例,其中有急性肾损伤患者48例,无急性肾损伤患者48例,探讨早期血清ALB对急性心肌梗死患者发生急性肾损伤的预测价值。结果 两组患者在性别、年龄和体质量指数上无统计学差异（P＞0.05）;有急性肾损伤患者的心率、收缩压、舒张压、尿量、白细胞、血糖、血肌酐水平更高,行冠状动脉支架治疗概率、左室射血分数、红细胞比容、ALB水平更低（P＜0.05）;多因素Logistic回归分析显示,肾损伤的危险因素包括ALB、白细胞计数和血肌酐（P＜0.05）;经校正混杂因素后,低ALB血症为肾损伤的危险因素(P＜0.05)。结论 早期检测血清ALB水平,可对急性心肌梗死患者发生急性肾损伤的风险进行预测。     

发热伴血小板减少综合征病毒热稳定性和灭活条件初步研究

目的 阐明新发危害严重的发热伴血小板减少综合征病毒的稳定性和理化灭活条件.方法 评估细胞培养制备的SFTS病毒在不同温度下的热稳定性,对紫外线、酸性环境、常用消毒剂、有机溶剂敏感性.处理后病毒感染Vero细胞,用间接免疫荧光法确定病毒复制,并采用基于病毒核蛋白的双抗体夹心ELISA方法滴定病毒与无相应处理的对照组,比较分析各种理化条件对病毒感染性的影响.结果 SFTS病毒在37℃能够存活较短时间,感染性下降较快,在4℃能保持相对稳定,1周内感染性无明显下降.对热敏感,60℃30 min能够完全灭活病毒.对紫外线敏感,185 μW/cm2紫外线照射30 min可灭活病毒.对乙醚、氯仿等有机溶剂,β-丙内酯、甲醛和常用有机氯消毒剂敏感,在合适的浓度下可在较短时间内有效灭活病毒,400 mg/L的有效氯灭活病毒需室温放置10 min以上,在pH3.0条件对病毒活力有损害,但不能完全灭活病毒.结论 研究结果初步客观的评价了SFTSV热稳定性和灭活条件,为科学研究和疾病控制中样本采集、病毒灭活、安全防护等工作提供了科学依据.     

Factors associated with severe disease in hospitalized adults with pandemic (H1N1) 2009 in Spain

The risk factors for complications in patients with influenza A (H1N1)v virus infection have not been fully elucidated. We performed an observational analysis of a prospective cohort of hospitalized adults with confirmed pandemic influenza A (H1N1)v virus infection at 13 hospitals in Spain, between June 12 and November 10, 2009, to identify factors associated with severe disease. Severe disease was defined as the composite outcome of intensive‐care unit (ICU) admission or in‐hospital mortality. During the study period, 585 adult patients (median age 40 years) required hospitalization because of pandemic (H1N1) 2009. At least one comorbid condition was present in 318 (54.4%) patients. Pneumonia was diagnosed in 234 (43.2%) patients and bacterial co‐infection in 45 (7.6%). Severe disease occurred in 75 (12.8%) patients, of whom 71 required ICU admission and 13 (2.2%) died. Independent factors for severe disease were age <50 years (OR, 2.39; 95% CI, 1.05–5.47), chronic comorbid conditions (OR, 2.93; 95% CI, 1.41–6.09), morbid obesity (OR, 6.7; 95% CI, 2.25–20.19), concomitant and secondary bacterial co‐infection (OR, 2.78; 95% CI, 1.11–7) and early oseltamivir therapy (OR, 0.32; 95% CI 0.16–0.63). In conclusion, although adults hospitalized for pandemic (H1N1) 2009 suffer from significant morbidity, mortality is lower than that reported in the earliest studies. Younger age, chronic comorbid conditions, morbid obesity and bacterial co‐infection are independent risk factors for severe disease, whereas early oseltamivir therapy is a protective factor.     

Megalocytic Interstitial Nephritis Following Acute Pyelonephritis with Escherichia coli Bacteremia: A Case Report

Megalocytic interstitial nephritis is a rare form of kidney disease caused by chronic inflammation. We report a case of megalocytic interstitial nephritis occurring in a 45-yrold woman who presented with oliguric acute kidney injury and acute pyelonephritis accompanied by Escherichia coli bacteremia. Her renal function was not recovered despite adequate duration of susceptible antibiotic treatment, accompanied by negative conversion of bacteremia and bacteriuria. Kidney biopsy revealed an infiltration of numerous histiocytes without Michaelis-Gutmann bodies. The patient''s renal function was markedly improved after short-term treatment with high-dose steroid.

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Pathophysiological mechanism of lung injury in patients with leptospirosis

AIMS: Acute lung injury (ALI) is a serious clinical problem. We investigated the pathogenetic mechanisms of ALI caused by leptospirosis. METHODS: The study included five cases of leptospirosis. We monitored the arterial pressure (AP) and heart rate (HR) and analysed the AP and HR variabilities for assessment of autonomic functions. Histopathological changes in the lung, brain, kidney, and liver were examined. In addition, we identified the expression of inducible nitric oxide synthase (iNOS) using immunohistochemical stain. RESULTS: Five patients associated with leptospirosis died of ALI. Before death, severe hypotension and bradycardia occurred. Spectral analysis of AP and HR variabilities indicated decreased sympathetic drive with increased parasympathetic activity. Pathological examinations revealed alveolar haemorrhage and necrotic lesions in various organs. Immunohistochemical stain disclosed iNOS activity in multiple organs. Biochemical determinations indicated hypoxia, hyperglycaemia, increased nitrite/nitrate, methyl guanidine and other factors. CONCLUSIONS: These changes suggest that leptospirosis causes severe hypotension and bradycardia accompanied by autonomic dysfunction. Finally, multiple organ failure and damage ensued. The pathogenesis of lung and organ injury may involve iNOS and NO production.     

沙棘汁对环磷酰胺所致大鼠血小板减少的影响

目的:观察沙棘汁(JFH)对血小板功能、质量的影响。方法:Wistar大鼠48只,随机分成空白对照组、造模组、益血生胶囊(YSJN)组、沙棘汁组。采用环磷酰胺30mg/kg每日腹腔注射(连续3d)复制成血小板减少模型,然后分组进行治疗。持续11d。于造模后第2、4、6和8d进行血小板计数,并同时检测血小板平均体积(MPV)、血小板体积变异系数(PDW),第8d心脏取血检测血小板内3’,5’一环-磷酸腺苷(cAMP)、3’,5’一环-磷酸鸟苷(cGMP)及血小板聚集功能等。结果:沙棘汁可抑制凝血时间的缩短,使血小板数量增高,加强血小板聚集功能,同时降低血小板内cGMP含量。结论:沙棘汁具有促进血小板功能、改善血小板质量、防止血小板下降和促进血小板数量恢复的功效。