Multiple organ failure—a role for plasma exchange?

Two patients with multiple organ failure, septicaemia and a deteriorating clinical course were treated by plasma exchange in addition to standard supportive measures. Dramatic improvements were seen in cardio-respiratory (patient 1), neurological and renal parameters (patient 2) which were attributable to the exchanges. Plasma exchange might be of value as adjunctive therapy where overwhelming septicaemia occurs with multiple organ failure.     

An outbreak of Serratia marcescens septicaemia in neonatal intensive care unit in Gaza City, Palestine

We performed a case-control study of Serratia marcescens incidence in the neonatal intensive care unit of a governmental Gaza Strip hospital from January to December 2005. S. marcescens was detected in the blood of 159 confirmed nosocomial cases of septicaemia, 70 (44%) neonates died due to S. marcescens infection and 89 recovered. The main clinical symptoms were hypothermia 38%; jaundice 42%; Apgar score 4 at 1min in 29% of neonates; and Apgar score 5 at 5min in 5%. Risk factors significantly associated with S. marcescens infection were birthweight <1500g (OR: 1.7; P=0.026); <37 weeks gestational age (OR: 2.0; P=0.002); and use of mechanical ventilation (OR: 2.3; P=0.001). Agar diffusion susceptibility testing indicated that S. marcescens was generally susceptible to imipenem, followed by ciprofloxacin and ofloxacin. We identified potential risk factors associated with development of neonatal sepsis and highlight the importance of appropriate infection control measures to prevent serious infection.     

人心杆菌败血症1例

患者男,64岁,公务员。因左下腹疼痛伴肛门停止排便、排气1月余,在当地医院住院,腹部X线片显示肠梗阻,后腹痛缓解,予保守治疗后大便通畅,但出现左腰部疼痛。CT检查发现左输尿管中段狭窄合并左肾积水,行左输尿管镜检查并插双J管引流。2周后复查,肾积水减轻,遂于膀胱镜下拔除双J管。拔管后患者出现寒战、高热,体温高达39．9℃,无其他不适。予右美沙芬（美林）治疗后,体温降至正常,但过后仍持续发热。     

Abnormal bile duct epithelium accompanying septicaemia

Summary A 56-year-old female without previous hepatobiliary disease developed a severe obstructive cholestasis followingE. coli urinary tract infection with septicaemia. Liver biopsy showed cholangiolitis and a unique abnormality of almost all the interlobular bile ducts; the epithelium was irregular with polymorphic, angular, and hyperchromatic or pyknotic nuclei. Some ducts were ectatic, others narrowed due to protrusion of proliferating epithelium. In some areas the ducts were blurred or completely destroyed. Cholangitis or granulomas were, however, not present.Abnormal interlobular bile ducts have to our knowledge not previously been described in septicaemia. The lesion is morphologically distinguishable from other types of abnormal bile ducts. It is considered to be caused by endotoxaemia and seems to be reversible. The cholestasis may be due to endotoxic alteration of biliary secretion, bacterially induced inspissation of bile, and/or mechanical obstruction due to the bile duct lesions.     

Seltene Sepsisursache bei chronischem Dialysepatienten: Maltafieber (Febris undulans melitensis)

Summary A 45-years-old Greek patient developed septicaemia in his 10th year of hemodialysis treatment. Clinical investigation was directed first on bacterial infection of the arteriovenous shunt, on urosepsis or bronchopulmonary infection. Then, serologically (Widal's reaction and ELISA-test) and in different blood-cultures Brucella melitensis was detected as causative agent for Malta fever (Febris undulans). The focus of infection is suspected in unpasteurized sheep-milk cheese of mediterranean origine, wherein Brucella species can survive for months. The patient was treated effectively by a combination of amoxycilline and clavulanic acid.

---

Abkürzungen GOT Glutamat-Oxalat-Transpeptidase - GPT Glutamat-Pyruvat-Transpeptidase - gamma-GT -Glutamyl-Transpeptidase - ELISA enzyme-linked immunosorbent assay     

Diagnostic dilemma of sacral abscess presented with seizure and altered conscious level in a patient with spinal cord injury

Context: Infection and septicaemia may clinically presented with seizure and altered conscious level. In spinal cord injury (SCI) population, they are at risk of having pressure ulcer which can be complicated further with infection and septicaemia.

Findings: A 40-year-old man with complete T4 SCI and multiple clean and non-healing pressure ulcers at sacral and bilateral ischial tuberosity regions was initially admitted for negative pressure wound therapy (NPWT) dressing. He had an episode of seizure and subsequently had fluctuating altered conscious level before the diagnosis of deep-seated sacral abscess was made and managed. Prior investigations to rule out common possible sources of infections and management did not resolve the fluctuating event of altered consciousness.

Clinical relevance: We presented an unusual case presentation of septicemia in a patient with SCI with underlying chronic non-healing pressure ulcer. He presented with seizure and fluctuating altered conscious level. Even though a chronic non-healing ulcer appeared clinically clean, a high index of suspicion for deep seated abscess is warranted as one of the possible sources of infection, especially when treatment for other common sources of infections fails to result in clinical improvement.     

Characterization of an Enterococcus faecium small-colony variant isolated from blood culture

Small-colony variants (SCVs) of bacteria are slow-growing subpopulations which can cause latent or recurrent infections due to better intracellular survival compared to their wild-type counterparts. Atypical colony morphology and altered biochemical profile may lead to failure in identification of SCV strains. We here report for the first time the isolation of an Enterococcus faecium SCV phenotype. The case of a 65-year-old woman with acute myeloid leukaemia who developed symptoms of sepsis during induction chemotherapy is presented. E. faecium with normal and SCV phenotype was isolated from blood cultures. At the same time urine culture was positive with E. faecium suggesting that bacteraemia originated from the urinary tract. The SCV phenotype was characterized by atypical growth behaviour. Electron microscopic analyses revealed perturbation of the separation of daughter cells and the accumulation of cell wall material. Accordingly, the SCV variant showed a dysfunction or lack of spontaneous autolysis whereas the normal phenotype did not.In contrast to conventional identification systems based on biochemical characteristics, the E. faecium SCV was precisely identified by MALDI-TOF MS analysis implemented in our laboratory. Hence, the increasing use of MALDI-TOF MS analysis for the identification of bacteria might be an appropriate tool for the detection of SCV variants, the diagnosis of which is of importance for the clinical outcome and the antibiotic treatment.     

A dose-response study of phenylephrine in critically ill, septic surgical patients

Objective: To determine the response of haemodynamic and oxygen-transport parameters to phenylephrine in a dose-response fashion in septic non-hypotensive, vasodilated surgical intensive care unit (ICU) patients. Design: Prospective study. Setting: Surgical ICU of a tertiary care, university medical centre. Patients: Ten septic non-hypotensive, vasodilated surgical ICU patients. Interventions: Routine ICU monitoring, including pulmonary and radial artery catheters. Measurements: Haemodynamic and oxygen-transport measurements were taken at baseline and during therapy. Phenylephrine was infused intravenously for 3 h at progressively increasing doses of 0.5, 1.0, 2.0, 3.0, 4.0, and 8.0 μg · kg⁻¹ · min⁻¹ at 30-min intervals. Measurements were taken after each dose. Results: Mean arterial pressure (MAP) and systemic vascular resistance (SVRI) increased linearly with phenylephrine dose. Cardiac index and pulmonary artery occlusion pressures did not change. Statistically significant changes were observed in heart rate, MAP, stroke index, and systemic and pulmonary vascular resistance. Eight patients had a clinically significant increase (>15%) in oxygen consumption (VO₂I). Oxygen delivery (D₂OI) increased in only three patients. Serum lactate concentrations were unchanged or lower at the end of the study in all eight pateints, who displayed a 15% increase in VO₂I. Conclusions: Treatment with phenylephrine increased expected haemodynamic parameters in a linear fashion; however, clinical changes in VO₂I occurred at variable doses. Dose-response trials are needed to determine the optimal dose of phenylephrine. Further study is needed to evaluate the clinical effects of phenylephrine in septic patients. Received: 12 December 1995 / Accepted in revised form: 19 August 1996     

败血症的肝功能特点及其对败血症的诊断价值

目的：探讨肝功能对败血症诊断的价值。方法：选择2010年2月-2012年4月住本院重症医学科的脓毒症患者,动态监测入选患者的血培养及肝功能,根据按败血症诊断标准回顾性将患者分为败血症组和非败血症组,分析各肝功能指标在两组中的变化特点及对败血症的诊断意义。结果：败血症组肝功能早期常见γ-谷氨酰转肽酶（γ-GGT）、碱性磷酸酶（AIJP）、谷草转氨酶（AST）中1～3项升高。对比两组的第一次肝功能结果,败血症组的γ-GGT、ALP、AST显著高于非败血症组（P〈0．01）,其中γ-GGT升高对诊断败血症的诊断价值最高,以61．5μmmol／L为截断值,诊断败血症的灵敏度为87．5％,特异度为97．6％。21例1～GGT升高,γ-GGT阳性时间早于败血症血病原菌培养阳性时间3-9d。败血症组高胆红素血症发生率为33.3％,显著高于非败血症组（9．5％）。结论：γ-GGT升高可作为败血症的早期筛查指标,特定的肝功能变化特点可能作为败血症临床诊断的依据之一。