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Multiple Organ Failure (multiple + organ_failure)
Selected AbstractsMultiple organ failure and severe bone marrow dysfunction in two 18 year-old Caucasian patients: Epstein,Barr virus and the haemophagocytic syndromeANAESTHESIA, Issue 11 2008P. A. Berry Summary Haemophagocytic lymphohistiocytosis secondary to viral infection is an unusual but well recognised cause of bone marrow dysfunction and multiple organ failure in young patients. Two 18 year-old patients were admitted to a tertiary liver unit with features of acute liver failure, cardio-respiratory collapse and pancytopenia. Serological tests and bone marrow examination with in-situ hybridisation revealed severe acquired haemophagocytic lymphohistiocytosis secondary to acute Epstein,Barr virus infection. Both patients died despite full supportive therapy; the first due to pulmonary haemorrhage, the second due to acute respiratory distress syndrome refractory to high frequency oscillatory ventilation. The clinical spectrum, diagnostic features and current evidence based recommendations for treatment of this condition are explored. The diagnosis of haemophagocytic lymphohistiocytosis should be considered in young patients with marked bone marrow dysfunction and multiple organ failure. Further research into appropriate therapy for patients with acute severe forms of the disease who require intensive organ support is required. [source] Causes of death among HIV-infected patients in the era of highly active antiretroviral therapy, Bordeaux, France, 1998,1999HIV MEDICINE, Issue 3 2002F Bonnet Objectives To describe the causes of death in HIV-infected patients in the era of highly active antiretroviral therapy (HAART). Method A retrospective survey conducted in Bordeaux, France. Medical records of all deaths that had occurred in 1998 and 1999 amongst patients followed within the Aquitaine cohort were reviewed by the same physician. Immediate and underlying causes of death were described, taking into account the morbidity at the time of death. Results Sixty-six deaths occurred in 1998, and 41 in 1999. Sixty-seven per cent of deceased patients were male. Median age at time of death was 43 years (range 25,71), median CD4 was 162 cells/µL (0,957); 28% of patients had a CD4 count > 200 cells/µL and 7% plasma viral load < 500 HIV-RNA copies/mL. Amongst morbidity present at the time of death, there were 23 bacterial infections, 16 non-Hodgkin's lymphomas, 16 cirrhoses, 15 non HIV-related malignancies, 13 central nervous system diseases and 10 myocardiopathies. The main immediate causes of death were: multiple organ failure (21%), coma (18%), septic shock (15%) and acute respiratory failure (14%). Underlying causes of death were AIDS-defining events (48%), non AIDS HIV-related infection (3%), hepatitis B- or C-associated cirrhosis (14%), non HIV-related malignancies (11%), cardiovascular events (10%), suicide and overdose (6%), treatment-related fatalities (4%), injury (2%) and unknown (2%). Patients dying from AIDS-related events were more often female, had a lower CD4 count, a higher level of HIV-RNA, a shorter history of HIV infection and were less often coinfected with hepatitis B and C viruses than those dying from other underlying causes. Conclusions AIDS-related events are no longer the major causes of death of HIV-infected patients in the era of HAART. This evolving mortality pattern justifies an adaptation of both the epidemiological surveillance and the clinical monitoring of HIV-infected patients. [source] Use of activated protein C has no avail in the early phase of acute pancreatitisHPB, Issue 6 2008Sinan Akay Abstract Objectives. Sepsis and acute pancreatitis have similar pathogenetic mechanisms that have been implicated in the progression of multiple organ failure. Drotrecogin alfa, an analogue of endogenous protein C, reduces mortality in clinical sepsis. Our objective was to evaluate the early therapeutic effects of activated protein C (APC) in a rat model of acute necrotizing pancreatitis. Subjects and method. Acute necrotizing pancreatitis was induced by intraductal injection of 5% Na taurocholate. Hourly bolus injections of saline or recombinant human APC (drotrecogin alfa) was commenced via femoral venous catheter four hours after the induction of acute pancreatitis. The experiment was terminated nine hours after pancratitis induction. Animals in group one (n=20) had a sham operation while animals in group two (n=20) received saline and animals in group three (n=20) received drotrecogin alfa boluses after acute pancreatitis induction. Pancreatic tissue for histopathologic scores and myeloperoxidase, glutathione reductase, glutathione peroxidase, and catalase activites were collected, and blood for serum amylase, urea, creatinine, and inleukin-6 measurements was withdrawn. Results. Serum amylase activity was significantly lower in the APC treated group than the untreated group (17,435±432 U/L vs. 27,426±118 U/L, respectively). While the serum interleukin-6 concentration in the APC untreated group was significantly lower than the treated group (970±323 pg/mL vs. 330±368 pg/mL, respectively). Conclusion. In the early phase of acute pancreatitis, drotrecogin alfa treatment did not result in a significant improvement in oxidative and inflammatory parameters or renal functions. [source] The role of the intestine in the pathophysiology and management of severe acute pancreatitisHPB, Issue 2 2003RS Flint Background The outcome of severe acute pancreatitis has scarcely improved in 10 years. Further impact will require new paradigms in pathophysiology and treatment. There is accumulating evidence to support the concept that the intestine has a key role in the pathophysiology of severe acute pancreatitis which goes beyond the notion of secondary pancreatic infection. Intestinal ischaemia and reperfusion and barrier failure are implicated in the development of multiple organ failure. Discussion Conventional management of severe acute pancreatitis has tended to ignore the intestine. More recent attempts to rectify this problem have included 1) resuscitation aimed at restoring intestinal blood flow through the use of appropriate fluids and splanchnic-sparing vasoconstrictors or inotropes; 2) enteral nutrition to help maintain the integrity of the intestinal barrier; 3) selective gut decontamination and prophylactic antibiotics to reduce bacterial translocation and secondary infection. Novel therapies are being developed to limit intestinal injury, and these include antioxidants and anti-cytokine agents. This paper focuses on the role of the intestine in the pathogenesis of severe acute pancreatitis and reviews the implications for management. [source] Early predictors of morbidity and mortality in trauma patients treated in the intensive care unitACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 8 2010O. BRATTSTRÖM Background: We investigated the incidence and severity of post-injury morbidity and mortality in intensive care unit (ICU)-treated trauma patients. We also identified risk factors in the early phase after injury that predicted the later development of complications. Methods: A prospective observational cohort study design was used. One hundred and sixty-four adult patients admitted to the ICU for more than 24 h were included during a 21-month period. The incidence and severity of morbidity such as multiple organ failure (MOF), acute lung injury (ALI), severe sepsis and 30-day post-injury mortality were calculated and risk factors were analyzed with uni- and multivariable logistic regression analysis. Results: The median age was 40 years, the injury severity score was 24, the new injury severity score was 29, the acute physiology and chronic health evaluation II score was 15, sequential organ failure assessment maximum was 7 and ICU length of stay was 3.1 days. The incidences of post-injury MOF were 40.2%, ALI 25.6%, severe sepsis 31.1% and 30-day mortality 10.4%. The independent risk factors differed to some extent between the outcome parameters. Age, severity of injury, significant head injury and massive transfusion were independent risk factors for several outcome parameters. Positive blood alcohol was only a predictor of MOF, whereas prolonged rescue time only predicted death. Unexpectedly, injury severity was not an independent risk factor for mortality. Conclusions: Although the incidence of morbidity was considerable, mortality was relatively low. Early post-injury risk factors that predicted later development of complications differed between morbidity and mortality. [source] Extranodal NK/T-cell lymphoma, nasal type, presenting after 5 years of remissionINTERNATIONAL JOURNAL OF DERMATOLOGY, Issue 3 2008Tomonobu Ito MD A 76-year-old woman with multiple edematous erythemas, erosions, and ulcers on the breast and abdomen was admitted to our hospital in June 2005. She had developed granulomatous bleeding lesions in the right nostril 6 years prior to her visit to our dermatology unit. She had been observed at the otorhinolaryngology department of our hospital, and a biopsy was taken from the nasal lesion. Computerized tomography and gallium scintigraphy (67Ga single-photon emission computed tomography) did not reveal any lesions corresponding to the diagnosis of malignant lymphoma. The histologic examination of the nasal specimen rendered a diagnosis of natural killer (NK)/T-cell lymphoma, nasal. Because imaging analysis indicated a small-sized tumor without metastases, oral prednisolone at 20 mg/day was administered for 1 month. The tumor decreased in size and disappeared after 19 months of low-dose steroid therapy. ,Five years after the initial treatment, the patient developed a fever of 38 °C with infiltrated erythemas and erosions on her breast. Erysipelas was initially suspected, but the antimicrobial agent did not show any effect and the multiple infiltrated erythemas and ulcers spread throughout her chest and abdomen (Fig. 1). The lymph nodes were not palpable. The right nasal cavity showed no granulomatous lesions or other signs of abnormality. The peripheral white blood cell count (3000/µL), red blood cell count (3.54 × 106/µL), and platelet count (112 × 103/µL) were reduced. Atypical lymphocytes were not observed. The serum lactic dehydrogenase (LDH; 1770 U/L; normal, 224,454 U/L), aspartate aminotransferase (AST; 140 U/L; normal, 10,30 U/L), and alanine aminotransferase (ALT; 57 U/L; normal, 3,29 U/L) levels were elevated. The soluble interleukin-2 (IL-2) receptor level was high (25,300 U/mL; normal, 167,497 U/mL). Epstein,Barr virus (EBV) serologic examination showed the immunoglobulin G (IgG) viral capsid antigen (VCA) at 1 : 320 and the EBV nuclear antigen (EBNA) at 1 : 40. IgM VCA and EBV early antigen-diffuse restricted antibody (EA) IgA and IgG were not detectable. Histologic findings from the left chest skin showed a distribution of atypical lymphocytes from the upper dermis to the subcutaneous tissue, and many foamy cells which had phagocytosed the hemocytes (Fig. 2a,b). Immunohistochemical analysis showed that the atypical lymphocytes were sCD3,, CD4,, CD8,, CD20,, CD56+, granzyme B+, and T-cell intracellular antigen (TIA-1) positive. Furthermore, EBV-encoded small RNAs (EBER), detected by in situ hybridization, exhibited a strong signal. The nasal lesions biopsied 6 years previously showed an identical staining pattern with the skin lesions immunohistochemically. Analysis of the T-cell receptor-, (TCR-,), TCR-,, and TCR-, gene did not reveal any clonal rearrangements, but the EBV gene was detected from the skin specimens by Southern blotting. Our patient's condition was diagnosed as a case of extranodal NK/T-cell lymphoma, nasal type, but the patient had concomitantly developed hemophagocytic syndrome (HPS). She was treated with a combination of steroid pulse therapy and chemotherapy (pirarubicin hydrochloride 30 mg/m2, cyclophosphamide 500 mg/m2, vincristine 1 mg/m2, prednisolone 30 mg/m2, etoposide 80 mg/m2). After the first session of chemotherapy, the lesions on the chest and abdomen diminished, but, 2 weeks later, the skin lesions recurred, and disseminated intravascular coagulation (DIC) induced by HPS supervened. The patient died as a result of multiple organ failure induced by HPS. Figure 1. Multiple infiltrated erythemas, erosions, and ulcers on the breast and abdomen Figure 2. Histologic findings of a skin biopsy specimen from the left chest (hematoxylin and eosin staining). (a) Dense infiltration of atypical lymphocytes from the upper dermis to the subcutaneous tissue (×40). (b) Many foamy cells had phagocytosed the hemocytes (×400) [source] Unusual presentation of necrotizing fasciitis in a patient who had achieved long-term remission after irradiation for testicular cancerINTERNATIONAL JOURNAL OF UROLOGY, Issue 3 2005TOMOAKI MIYAGAWA Abstract, We report a case of a 60-year-old man with necrotizing fasciitis complicated by streptococcal toxic shock syndrome. The patient had received high-dose chemotherapy and radiotherapy to the pelvis for relapsed seminoma 7 years previously. He had been in long-term remission. He was admitted to the Tsukuba University Hospital, Tsukuba-City, Ibaraki, Japan, with complaints of fever and localized erythema over the foreskin. The patient suffered from septic shock and multiple organ failure. Despite intensive care, he died 18 h after admission. Streptococcus pyogenes was isolated from both the wound and blood culture. To our knowledge, this is the first description of necrotizing fasciitis primarily affecting the penile skin. [source] Does Aortic Root Enlargement Impair the Outcome of Patients With Small Aortic Root?JOURNAL OF CARDIAC SURGERY, Issue 5 2006Hasan Ardal The aim of this study was to evaluate long-term results of the posterior root enlargement. Methods: Between 1985 and 2002, 124 patients underwent aortic valve replacement with a posterior root enlargement. The main indication was a small aortic valve orifice area to patient body surface area (indexed valve area < 0.85 cm2/m2). Fifty-four (44%) patients were male, and 70 (56%) were female with a mean age 39.1 ± 14.3 years. Indications for operation were severe calcified aortic valve stenosis (37.1%), severe aortic insufficiency (25.8%), or combination (37.1%). Seventy-five (60%) patients received double-valve replacement. A pericardial patch was used in 100 patients (80.6%) and a Dacron patch was used in 24 patients. Results: Operative mortality was 6.4% (8 patients). The causes of hospital mortality were low cardiac output syndrome (LCOS) (in 6 patients), cerebrovascular events (in 1 patient) and multiple organ failure (in 1 patient). Multivariate analysis demonstrated concomitant coronary revascularization to be a significant (p = 0.03) predictor for early mortality. There were six (5.4%) late deaths. Cox proportional hazards regression analysis demonstrated LCOS (p = 0.013) and infective endocarditis (p = 0.003) to be significant predictors for late mortality. Atrioventricular block required a permanent pacemaker was observed in 4 patients (3.2%). Conclusions: Posterior aortic root enlargement techniques can be easily applied without additional risks. Long-term survival and freedoms from valve-related complications are satisfactory. [source] Repair of Complete Atrioventricular Septal Defect with Tetralogy of Fallot:JOURNAL OF CARDIAC SURGERY, Issue 2 2004Literature Review, Our Experience Materials and Methods: Between January 1990 and January 2002, 17 consecutive children with CAVSD-TOF underwent complete correction. Nine patients (53%) underwent previous palliation. Mean age at repair was 2.9 ± 1.9 years. Mean gradient across the right ventricular outflow tract was 63 ± 16 mmHg. All children underwent closure of septal defect with a one-patch technique, employing autologous pericardial patch. Maximal tissue was preserved for LAVV reconstruction by making these incisions along the RV aspect of the ventricular septal crest. LAVV annuloplasty was performed in 10 (59%) patients. Six patients (35%) required a transannular patch. Results: Three (17.6%) hospital deaths occurred in this series. Causes of death included progressive heart failure in two patients and multiple organ failure in the other patient. Two patients required mediastinal exploration due to significant bleeding. Dysrhythmias were identified in 4 of 11 patients undergoing a right ventriculotomy versus none of the patients undergoing a transatrial transpulmonary approach (p = ns). The mean intensive care unit stay was 3.2 ± 2.4 days. Two patients required late reoperation due to severe LAVV regurgitation at 8.5 and 21 months, respectively, after the intracardiac complete repair. The mean follow-up time was 36 ± 34 months. All patients survived and are in NYHA functional class I or II. The LAVV regurgitation grade at follow-up was significantly lower than soon after operation, 1.1 ± 0.4 versus 1.7 ± 0.5 (p = 0.002). At follow-up, the mean gradient across the right ventricular outflow tract was 17 ± 6 mmHg, significantly lower than preoperatively (p < 0.001). Conclusions: Complete repair in patients with CAVSD-TOF seems to offer acceptable early and mid-term outcome in terms of mortality, morbidity, and reoperation rate. Palliation prior to complete repair may be reserved in specific cases presenting small pulmonary arteries or severely cyanotic neonates. The RVOT should be managed in the same fashion as for isolated TOF; however, a transatrial transpulmonary approach is our approach of choice. (J Card Surg 2004;19:175-183) [source] Mini-Maze Suffices as Adjunct to Mitral Valve Surgery in Patients with Preoperative Atrial FibrillationJOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 9 2000ANTON E. TUINENBURG M.D. Mini-Maze and Mitral Valve Surgery. Introduction: After mitral valve (MV) surgery, preoperative atrial fibrillation (AF) often recurs while cardioversion therapy generally fails. Additional Cox maze surgery improves postoperative arrhythmia outcome, but the extensive nature of such an approach limits general appliance. We investigated the clinical outcome of a simplified, less extensive Cox maze procedure ("mini-maze") as adjunct to MV surgery. Methods and Results: Thirteen patients with MV disease and preoperative AF were treated with combined surgery (group 1). Nine control patients without previous AF underwent isolated MV surgery (group 2). We retrospectively compared the results to findings in 23 patients with preoperative AF who had undergone isolated MV surgery (group 3). In group 1, mini-maze took an additional 46 minutes of perfusion time. One 75-year-old patient died of postoperative multiple organ failure. Seven patients showed spontaneously converting (within 2 months) postoperative AF. After 1 year, 82% were in sinus rhythm (SR). No sinus node dysfunction was observed. In group 2, all patients were in SR after 1 year. In group 3, only 53% were in SR after 1 year, despite serial cardioversion and antiarrhythmic drug therapy. Exercise tolerance and heart rate were comparable for groups 1 and 2. Left atrial function was present in all but one patient in group 1 and in all patients in group 2 (after MV reconstruction). Conclusion: Adding a relatively simple mini-maze to MV surgery improves arrhythmia outcome in patients with preoperative AF without introducing sinus node dysfunction or persistent absence of left atrial function. The results of this type of combined surgery are encouraging and deserve further attention. [source] Vasopressin decreases intestinal mucosal perfusion: a clinical study on cardiac surgery patients in vasodilatory shockACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 5 2009A. NYGREN Background: Low to moderate doses of vasopressin have been used in the treatment of cathecholamine-dependent vasodilatory shock in sepsis or after cardiac surgery. We evaluated the effects of vasopressin on jejunal mucosal perfusion, gastric-arterial pCO2 gradient and the global splanchnic oxygen demand/supply relationship in patients with vasodilatory shock after cardiac surgery. Methods: Eight mechanically ventilated patients, dependent on norepinephrine to maintain mean arterial pressure (MAP) ,60 mmHg because of septic/post-cardiotomy vasodilatory shock and multiple organ failure after cardiac surgery, were included. Vasopressin was sequentially infused at 1.2, 2.4 and 4.8 U/h for 30-min periods. Norepinephrine was simultaneously decreased to maintain MAP at 75 mmHg. At each infusion rate of vasopressin, data on systemic hemodynamics, jejunal mucosal perfusion, jejunal mucosal hematocrit and red blood cell velocity (laser Doppler flowmetry) as well as gastric-arterial pCO2 gradient (gastric tonometry) and splanchnic oxygen and lactate extraction (hepatic vein catheter) were obtained. Results: The cardiac index, stroke volume index and systemic oxygen delivery decreased and systemic vascular resistance and systemic oxygen extraction increased significantly, while the heart rate or global oxygen consumption did not change with increasing vasopressin dose. Jejunal mucosal perfusion decreased and the arterial-gastric-mucosal pCO2 gradient increased, while splanchnic oxygen or lactate extraction or mixed venous,hepatic venous oxygen saturation gradient were not affected by increasing infusion rates of vasopressin. Conclusions: Infusion of low to moderate doses of vasopressin in patients with norepinephrine-dependent vasodilatory shock after cardiac surgery induces an intestinal and gastric mucosal vasoconstriction. [source] Prognostic models in cirrhotics admitted to intensive care units better predict outcome when assessed at 48 h after admissionJOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, Issue 8pt1 2008Evangelos Cholongitas Abstract Background and Aim:, The accuracy of prognostic models in critically ill cirrhotics at admission to intensive care units (ICU) may be unreliable. Predictive accuracy could be improved by evaluating changes over time, but this has not been published. The aim of the present study was to assess the performance of prognostic models in cirrhotics at admission (baseline) and at 48 h to predict mortality in the ICU or within 6 weeks after discharge from the ICU. Methods:, One hundred and twenty-eight cirrhotics (77 males, mean age 49 ± 11.3 years) were consecutively admitted and alive 48 h after admission with 89% on mechanical ventilation, 76% on inotrope support, and 42% with renal failure. Prognostic models used were Child-Turcotte-Pugh (CTP), Model for End-stage Liver Disease (MELD), Acute Physiology and Chronic Health Evaluation (APACHE) II, Sequential Organ Failure Assessment (SOFA), failing organ systems (FOS) at baseline and at 48 h, ,score (difference between baseline and at 48 h) and the mean score (MN , score admission + 48 h/2) which were compared by area under the receiver operating characteristic curves (AUC). Results:, Mortality was 54.7% (n = 70) due to multiple organ failure in 55%. CTP, MELD, APACHE II, SOFA and FOS performed better at 48 h (AUC: 0.78, 0.86, 0.78, 0.88 and 0.85, respectively) than at baseline (AUC: 0.75, 0.78, 0.75, 0.81 and 0.79, respectively). The mean score had better discrimination than the baseline score; the ,score had poor predictive ability (AUC < 0.70). SOFA score (48 h: 0.88, mean: 0.88) and FOS (mean: 0.88) had the best accuracy, with a SOFA and MN-SOFA , 10 predicting mortality in 93% and 91%, respectively, and MN-FOS , 1.5 in 98%. Conclusions:, In cirrhotics, prognostic scores in the ICU at 48 h had better discrimination than baseline scores for short-term mortality. SOFA and FOS models had the best performance. [source] Analysis of clinical features of acute pancreatitis in Shandong Province, ChinaJOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, Issue 3 2007Yan Jing Gao Abstract Aim:, To investigate and obtain a more comprehensive view of the etiology and clinical features of acute pancreatitis in China. Method:, The study comprised 1471 patients in 10 cites of China who were admitted to hospitals for acute pancreatitis from January 1992 to December 2002. Data for each patient were collected on a standardized form. Results:, Of the 1471 patients (854 men, 617 women; mean age 43.3 years; range 13,82 years), 1280 had mild pancreatitis and 191 had the severe form. Cholelithiasis (20.2%), alcohol (17.3%) and diet-induced (12.4%) were the most frequent etiological factors, followed by biliary tract infections (5.6%), hyperlipidemia (2.3%) and other factors (5.1%). However, in about 36.1% of cases, the etiology of acute pancreatitis still remained unexplained. In coastal regions, cholelithiasis was the most frequent factor but alcohol ranked first in interior regions. In males, a small predominance of alcohol over cholelithiasis was seen (27.4%vs 14.3%) and there was a clear predominance of cholelithiasis over alcohol (28.4%vs 3.2%) in females. The differences in the frequency of cholelithiasis and alcohol between coastal regions and interior regions and males and females were statistically significant (P < 0.01). According to their frequency, complications of acute pancreatitis were pancreatic pseudocyst, pancreatic ascities and bacterial peritonitis, pulmonary infections, multiple organ failure, diabetes mellitus type 2 and shock. Conclusion:, Cholelithiasis, alcohol and diet-induced factors were the main etiological factors seen in China, whereas cholelithiasis alone predominated in females and alcohol ranked first in males. In about 36.1% of cases, the etiology of acute pancreatitis remained unknown. More attention should be paid to studying the etiologies of acute pancreatitis that remain unknown. [source] Closed lesser sac lavage in the management of pancreatic necrosisJOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, Issue 9 2004JAI DEV WIG Abstract Background and Aim:, Surgery for pancreatic necrosis complicating acute severe pancreatitis carries a high risk of morbidity and mortality. We evaluated the efficacy of necrosectomy and closed lesser sac lavage as a method of management of pancreatic necrosis. Methods:, Fifty-eight patients with pancreatic necrosis who underwent pancreatic necrosectomy consecutively in a tertiary care referral center were retrospectively analyzed. The technique of necrosectomy and postoperative lavage is described in detail. Details regarding the patient profile, disease severity, surgical details, postoperative morbidity, repeat interventions and the mortality are presented. Results:, Of the 58 patients, irrigation was able to be started in 48. Lavage was able to be continued until disease resolution or death in all but 10 patients. Post-operative locoregional complications were residual abscesses in 10, bleeding in eight, enteric fistulae in 12 and pancreatic fistulae in nine. Six patients needed postoperative percutaneous procedures, while 16 patients needed repeat surgery. Seventeen patients died (29%), all of whom had multiple organ failure involving more than two organs, while 11 developed sepsis. Conclusion:, Pancreatic necrosectomy and postoperative closed lesser sac lavage is an effective method of managing these patients, with acceptable morbidity, re-operation rates and mortality. [source] The inflammatory reflex , IntroductionJOURNAL OF INTERNAL MEDICINE, Issue 2 2005J. ANDERSSON Abstract. Sepsis is the third leading cause of death in the developed world. Despite recent advances in intensive care treatment and the discovery of antibiotics, sepsis remains associated with a high mortality rate. The pathogenesis of sepsis is characterized by an overwhelming systemic inflammatory response that is central to the development of lethal multiple organ failure. This volume of the Journal of Internal Medicine contains three reviews addressing novel aspects of a system we are only beginning to understand , the interactions between the immune and the nervous systems, the ,neuro-immune axis'. Tracey (Nature 2002; 420: 853) recently discovered that the nervous system, through the vagus nerve, can modulate circulating TNF- , levels induced by microbial invasion or tissue injury. This cholinergic anti-inflammatory pathway is mediated primarily by nicotinic acetylcholine receptors on tissue macrophages , the pathway leads to decreased production of proinflammatory cytokines. The author reports that treatment with the acetylcholine receptor agonist, nicotine, modulates this system and reduces mortality in ,established' sepsis. Watkins and Maier (J Intern Med 2005; 257: 139) illustrate that pathological pain (induced by inflammation) is not simply a strict neuronal phenomenon, but is a component of the immune response, and is modulated by peripheral immune cells and spinal cord glia cells. This may be of importance for future development of novel drugs for neuropathic pain as well as our understanding of increased risks for infections in anaesthetic skin areas. Blalock (J Immunol 1984; 132: 1067) elucidates the possibility that the immune system actually functions as the sixth sense, sensing microbes and microbial toxins that we cannot see, hear, taste, touch or smell. Activation of the sympathetic nervous system also has predominantly anti-inflammatory effects that are mediated through direct nerve to immune cell interaction or through the adrenal neuro-endocrine axis. [source] Pharmacological utility of melatonin in the treatment of septic shock: experimental and clinical evidenceJOURNAL OF PHARMACY AND PHARMACOLOGY: AN INTERNATI ONAL JOURNAL OF PHARMACEUTICAL SCIENCE, Issue 9 2006Germaine Escames Sepsis is a major cause of mortality in critically ill patients and develops as a result of the host response to infection. In recent years, important advances have been made in understanding the pathophysiology and treatment of sepsis. Mitochondria play a central role in the intracellular events associated with inflammation and septic shock. One of the current hypotheses for the molecular mechanisms of sepsis is that the enhanced nitric oxide (NO) production by mitochondrial nitric oxide synthase (mtNOS) leads to excessive peroxynitrite (ONOO,) production and protein nitration, impairing mitochondrial function. Despite the advances in understanding of its pathophysiology, therapy for septic shock remains largely symptomatic and supportive. Melatonin has well documented protective effects against the symptoms of severe sepsis/shock in both animals and in humans; its use for this condition significantly improves survival. Melatonin administration counteracts mtNOS induction and respiratory chain failure, restores cellular and mitochondrial redox status, and reduces proinflammatory cytokines. Melatonin clearly prevents multiple organ failure, circulatory failure, and mitochondrial damage in experimental sepsis, and reduces lipid peroxidation, indices of inflammation and mortality in septic human newborns. Considering these effects of melatonin and its virtual absence of toxicity, the use of melatonin (along with conventional therapy) to preserve mitochondrial bioenergetics as well as to limit inflammatory responses and oxidative damage should be seriously considered as a treatment option in both septic newborn and adult patients. This review summarizes the data that provides a rationale for using melatonin in septic shock patients. [source] Development of renal failure during the initial 24 h of intensive care unit stay correlates with hospital mortality in trauma patientsACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 7 2006T. Ala-Kokko Background:, Although multiple organ failure is the leading late cause of death, there is controversy about the impact of acute organ dysfunction and failure on trauma survival. Methods:, Consecutive adult trauma admissions between January 2000 and June 2003, excluding isolated head traumas and burns, were analysed for parameters of organ function during the first 24 h following intensive care unit (ICU) admission using the Sequential Organ Failure Assessment (SOFA) scoring system. A national prospectively collected ICU data registry was used for analysis, including data from 22 ICUs in university and central hospitals in Finland. Results:, The study population consisted of 1044 eligible trauma admissions; 32% of the cases were treated at university hospital level, the rest being secondary referral central hospital admissions. The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 15 (SD8), ICU mortality was 5.6% and a further 1.6% of patients died during their post-ICU hospital stay. Forty-five per cent of the patients were categorized as having multiple traumas. In univariate analysis, APACHE II , 25 [odds ratio (OR), 35; 95% confidence interval (CI), 18,66] and renal failure (OR, 29.5; 95% CI, 14,63) produced the highest ORs for ICU mortality. In the APACHE II-, sex- and age-adjusted logistic regression model, renal failure was a significant risk factor for both ICU and hospital mortality (OR, 11.8; 95% CI, 3.9,35.4; OR, 8.2; 95% CI, 2.9,23.2, respectively). Conclusion:, The development of renal failure during the initial 24 h of ICU stay remained an independent risk factor for mortality in trauma patients requiring intensive care treatment even after adjusting for the APACHE II score, age and sex. [source] Acute pancreatitis in dogsJOURNAL OF VETERINARY EMERGENCY AND CRITICAL CARE, Issue 4 2003Jennifer L. Holm DVM Abstract Objective: To summarize current information regarding severity assessment, diagnostic imaging, and treatment of human and canine acute pancreatitis (AP). Human-based studies: In humans, scoring systems, advanced imaging methods, and serum markers are used to assess the severity of disease, which allows for optimization of patient management. The extent of pancreatic necrosis and the presence of infected pancreatic necrosis are the most important factors determining the development of multiple organ failure (MOF) and subsequent mortality. Considerable research efforts have focused on the development of inexpensive, easy, and reliable laboratory markers to assess disease severity as early as possible in the course of the disease. The use of prophylactic antibiotics, enteral nutrition, and surgery have been shown to be beneficial in certain patient populations. Veterinary-based studies: The majority of what is currently known about naturally occurring canine AP has been derived from retrospective evaluations. The identification and development of inexpensive and reliable detection kits of key laboratory markers in dogs with AP could dramatically improve our ability to prognosticate and identify patient populations likely to benefit from treatment interventions. Treatment remains largely supportive and future studies evaluating the efficacy of surgery, nutritional support and other treatment modalities are warranted. Data sources: Current human and veterinary literature. Conclusions: Pancreatitis can lead to a life-threatening severe systemic inflammatory condition, resulting in MOF and death in both humans and dogs. Given the similarities in the pathophysiology of AP in both humans and dogs, novel concepts used to assess severity and treat people with AP may be applicable to dogs. [source] A case of suspected non-neurosurgical adult fatal propofol infusion syndromeACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 1 2006J. Eriksen A previously healthy woman (20 years old) was admitted to our hospital with several fractures after a car accident. She was sedated with propofol, etc. in doses ranging from 1.4 to 5.1 mg/kg/h for 88 h. She developed multiple organ failure with rhabdomyolysis and died. This case fulfils (except acidosis) the criteria of propofol,infusion syndrome (PRIS) in a young adult. [source] Living liver donor death related to complications of myelomaLIVER TRANSPLANTATION, Issue 3 2009Emmanuel Melloul We report a donor death after right hepatectomy for living donor transplantation due to an undiagnosed myeloma. The 47-year-old donor, who was the 147th case performed in our department, was in excellent health without any abnormalities in the preoperative investigations. Despite an uneventful right hepatectomy without transfusion, the patient developed a partial thrombus of the inferior vena cava with a right proximal pulmonary trunk embolism on postoperative day 6. Subsequently, he developed multiorgan dysfunction leading to a coagulopathy, respiratory distress, and renal failure requiring hemodialysis and mechanical ventilation. This clinical scenario led us to suspect a hematological disorder. Immune electrophoresis showed a monoclonal peak of immunoglobulin G (8.7 g/L), a myelogram revealed an abnormally high level of dystrophic plasmocytes (more than 7%), and biopsies of salivary glands confirmed the diagnosis of immunoglobulin G kappa myeloma. The patient progressively deteriorated because of simultaneous hemorrhagic and infectious pulmonary complications resulting in septic shock. Despite an adequate combination of antimicrobial therapy and pleural drainage, the donor died on postoperative day 57 from multiple organ failure. This unusual cause of donor death after right hepatectomy reinforces the need for an extensive preoperative assessment. We advocate the addition of urinary protein loss and electrophoresis to the standard donor assessment protocol. Liver Transpl 15:326,329, 2009. © 2009 AASLD. [source] Transmission of an undiagnosed sarcoma to recipients of kidney and liver grafts procured in a non-heart beating donorLIVER TRANSPLANTATION, Issue 6 2005Olivier Detry Transmission of an undiagnosed cancer with solid organ transplantation is a rare but dreadful event. In this paper the authors report the transmission of an undiagnosed sarcoma to recipients of kidney and liver grafts procured in a Maastricht category 3 non-heart beating donor. To the authors' knowledge this case is the first report of such a transmission with a liver graft procured in a non-heart beating donor. The cancer transferal was diagnosed 1 year after transplantation in the recipients of the liver and of one kidney. The liver recipient died from multiple organ failure after a failed attempt of tumor resection. The kidney recipient underwent immunosuppression withdrawal and transplantectomy. Non-heart beating donors should not be particularly at risk for undiagnosed cancer transmission if the procurement is performed according to the same rules of careful inspection of the abdominal and thoracic organs. After diagnosis of donor cancer transmission, kidney recipients should have the graft removed, and immunosuppression should be interrupted. The management of liver graft recipients is very difficult in this setting, and long-term survival was very rarely reported. (Liver Transpl 2005;11:696,699.) [source] Sickle liver disease,An unusual presentation in a compound heterozygote for HbS and a novel ,-thalassemia mutationAMERICAN JOURNAL OF HEMATOLOGY, Issue 9 2007Timothy J.S. Cross A 38-year-old Ghanaian man presented with a 6-month history of worsening pruritus, jaundice, and ascites. He was previously fit and well and rarely drank alcohol. Screening tests for chronic liver disease including viral, autoimmune, and other metabolic causes including iron overload were unremarkable. A liver biopsy performed at the referring hospital demonstrated intralobular cholestasis and cirrhosis. He was listed for liver transplantation but subsequently developed sepsis with multiple organ failure and died. The sickle solubility test was positive. Blood smear showed cells consistent with liver failure and no sickle cells. Hemoglobin electrophoresis revealed HbA2 2.8%, HbF 0.5%, and HbS greater than HbA (49.6% vs. 41.3%) in the absence of blood transfusion. Sequence analysis of the ,IVS2-844 C , A). A diagnosis of sickle hepatopathy causing decompensated cirrhosis was made. This case is unusual insomuch as this patient was asymptomatic for over 35 years and represents a novel presentation of sickle cell disease. Sickle cell disease should be considered in appropriate patients when unusual presentations of liver disease arise. Am. J. Hematol., 2007. © 2007 Wiley-Liss, Inc. [source] Multiple organ failure and severe bone marrow dysfunction in two 18 year-old Caucasian patients: Epstein,Barr virus and the haemophagocytic syndromeANAESTHESIA, Issue 11 2008P. A. Berry Summary Haemophagocytic lymphohistiocytosis secondary to viral infection is an unusual but well recognised cause of bone marrow dysfunction and multiple organ failure in young patients. Two 18 year-old patients were admitted to a tertiary liver unit with features of acute liver failure, cardio-respiratory collapse and pancytopenia. Serological tests and bone marrow examination with in-situ hybridisation revealed severe acquired haemophagocytic lymphohistiocytosis secondary to acute Epstein,Barr virus infection. Both patients died despite full supportive therapy; the first due to pulmonary haemorrhage, the second due to acute respiratory distress syndrome refractory to high frequency oscillatory ventilation. The clinical spectrum, diagnostic features and current evidence based recommendations for treatment of this condition are explored. The diagnosis of haemophagocytic lymphohistiocytosis should be considered in young patients with marked bone marrow dysfunction and multiple organ failure. Further research into appropriate therapy for patients with acute severe forms of the disease who require intensive organ support is required. [source] Evaluation of the Pneupac Ventipac portable ventilator in critically ill patientsANAESTHESIA, Issue 11 2001apparatus We assessed adequacy of ventilation in 20 critically ill patients with multiple organ failure using a Pneupac Ventipac portable ventilator and the effects on patients' haemodynamic stability. Baseline data were recorded over 15 min for a range of respiratory, haemodynamic and oxygen transport variables during ventilation with a standard intensive care ventilator (Engström Erica). Patients were then ventilated for 40 min using the portable ventilator. Finally, they were ventilated for a further 40 min using the standard intensive care ventilator. Heart rate, arterial and pulmonary artery pressures were recorded at 5-min intervals throughout the study period. Cardiac index and other haemodynamic data derived from a pulmonary artery catheter were recorded at 20-min intervals. Blood gas analysis was performed and oxygen transport data (oxygen delivery, oxygen consumption and physiological shunt) were calculated at the end of each of the three periods of ventilation. In general, no significant adverse effects of ventilation using the portable ventilator were observed for any of the variables studied. Arterial Po2 increased significantly during ventilation with the portable ventilator, reflecting the use of a higher inspired oxygen fraction during this part of the study. Oxygen consumption decreased significantly in one patient during ventilation by the portable ventilator although none of the other variables measured in this patient was altered. We conclude that ventilation of critically ill patients using the Pneupac Ventipac portable ventilator was safe, satisfactory and associated with minimal adverse effects on respiratory, haemodynamic and oxygen transport variables. [source] Epidemiology of post-injury multiple organ failure in an Australian trauma systemANZ JOURNAL OF SURGERY, Issue 6 2009David C. Dewar Abstract Background:, The epidemiology of post-injury multiple organ failure (MOF) is reported internationally to have gone through changes over the last 15 years. The purpose of this study is to describe the epidemiology of post-injury MOF in Australia. Methods:, A 12-month prospective epidemiological study was performed at the John Hunter Hospital (Level-1 Trauma Centre). Demographics, injury severity (ISS), physiological parameters, MOF status and outcome data were prospectively collected on all trauma patients who met inclusion criteria (ICU admission; ISS > 15; age > 18, head Abbreviated Injury Scale (AIS) <3 and survival >48 h). MOF was prospectively defined by the Denver MOF score greater than 3 points. Data are presented as % or Mean+/,SEM. Univariate statistical comparison was performed (Student t -test, X2 test), P < 0.05 was considered significant. Results:, Twenty-nine patients met inclusion criteria (Age 40+/,4, ISS 29+/,3, Male 62%), five patients developed MOF. The incidence of MOF among trauma patients admitted to ICU was 2% (5/204) and 17% (5/29) in the high-risk cohort. The maximum average MOF score was 6.3 +/,1, with the average duration of MOF 5+/,2 days. Two patients had respiratory and cardiac failure, two patients had failure of respiratory, cardiac and hepatic systems, while one patient had failure of respiratory, hepatic and renal systems. One MOF patient died, all non MOF patients survived. MOF patients had longer ICU stays (20+/,4 versus 7+/,0.8 P= 0.01), tended to be older (60+/,11 versus 35+/,4 p=0.07). None of the previously described independent predictors (ISS, base deficit, lactate, transfusions) were different when the MOF patients were compared with the non-MOF patients. Conclusion:, The incidence of MOF in Australia is consistent with the international data. In Australia MOF continues to cause significant late mortality and morbidity in trauma patients. MOF patients have longer ICU stay than high-risk non MOF patients, and use significant resources. Our preliminary data challenges the timeliness of the 10-year-old independent predictors of post-injury MOF. The epidemiology, the clinical presentation and the independent predictors of post-injury MOF require larger scale reassessment for the Australian context. [source] The role of bacteriolysis in the pathophysiology of inflammation, infection and post-infectious sequelaeAPMIS, Issue 11 2002Review article The literature dealing with the biochemical basis of bacteriolysis and its role in inflammation, infection and in post-infectious sequelae is reviewed and discussed. Bacteriolysis is an event that may occur when normal microbial multiplication is altered due to an uncontrolled activation of a series of autolytic cell-wall breaking enzymes (muramidases). While a low-level bacteriolysis sometimes occurs physiologically, due to "mistakes" in cell separation, a pronounced cell wall breakdown may occur following bacteriolysis induced either by beta-lactam antibiotics or by a large variety of bacteriolysis-inducing cationic peptides. These include spermine, spermidine, bactericidal peptides defensins, bacterial permeability increasing peptides from neutrophils, cationic proteins from eosinophils, lysozyme, myeloperoxidase, lactoferrin, the highly cationic proteinases elastase and cathepsins, PLA2, and certain synthetic polyamino acids. The cationic agents probably function by deregulating lipoteichoic acid (LTA) in Gram-positive bacteria and phospholipids in Gram-negative bacteria, the presumed regulators of the autolytic enzyme systems (muramidases). When bacteriolysis occurs in vivo, cell-wall- and -membrane-associated lipopolysaccharide (LPS (endotoxin)), lipoteichoic acid (LTA) and peptidoglycan (PPG), are released. These highly phlogistic agents can act on macrophages, either individually or in synergy, to induce the generation and release of reactive oxygen and nitrogen species, cytotoxic cytokines, hydrolases, proteinases, and also to activate the coagulation and complement cascades. All these agents and processes are involved in the pathophysiology of septic shock and multiple organ failure resulting from severe microbial infections. Bacteriolysis induced in in vitro models, either by polycations or by beta-lactams, could be effectively inhibited by sulfated polysaccharides, by D-amino acids as well as by certain anti-bacteriolytic antibiotics. However, within phagocytic cells in inflammatory sites, bacteriolysis tends to be strongly inhibited presumably due to the inactivation by oxidants and proteinases of the bacterial muramidases. This might results in a long persistence of non-biodegradable cell-wall components causing granulomatous inflammation. However, persistence of microbial cell walls in vivo may also boost innate immunity against infections and against tumor-cell proliferation. Therapeutic strategies to cope with the deleterious effects of bacteriolysis in vivo include combinations of autolysin inhibitors with combinations of certain anti-inflammatory agents. These might inhibit the synergistic tissue- and- organ-damaging "cross talks" which lead to septic shock and to additional post-infectious sequelae. [source] Better Correction of Metabolic Acidosis, Blood Pressure Control, and Phagocytosis with Bicarbonate Compared to Lactate Solution in Acute Peritoneal DialysisARTIFICIAL ORGANS, Issue 2 2001Visith Thongboonkerd Abstract: Lactate solution has been the standard dialysate fluid for a long time. However, it tends to convert back into lactic acid in poor tissue-perfusion states. The aim of this study was to evaluate the efficacy of magnesium (Mg)- and calcium (Ca)-free bicarbonate solution compared with lactate solution in acute peritoneal dialysis (PD). Renal failure patients who were indicated for dialysis and needed acute PD were classified as shock and nonshock groups, and then were randomized to receive either bicarbonate or lactate solution. Twenty patients were enrolled in this study (5 in each subgroup). In the shock group, there were more rapid improvements and significantly higher levels of blood pH (7.40 ± 0.04 versus 7.28 ± 0.05, p < 0.05), serum bicarbonate (23.30 ± 1.46 versus 18.37 ± 1.25 mmol/L, p < 0.05), systolic pressure (106.80 ± 3.68 versus 97.44 ± 3.94 mm Hg, p < 0.05), mean arterial pressure (80.72 ± 2.01 versus 73.28 ± 2.41 mm Hg, p < 0.05), percentages of phagocytosis of circulating leukocytes (65.85%± 2.22 versus 52.12%± 2.71, p < 0.05), and percentages of positive nitroblue tetrazolium (NBT) reduction test without and with stimulation (14.43 ± 1.93 versus 9.43 ± 2.12, p < 0.05 and 65.08 ± 6.80 versus 50.23 ± 4.21, p < 0.05, respectively) in the bicarbonate subgroup compared with the lactate subgroup. In the nonshock group, blood pH, serum bicarbonate, and phagocytosis assays in both subgroups were comparable. Lactic acidosis was more rapidly recovered and was significantly lower with bicarbonate solution for both shock and nonshock groups (3.63 ± 0.37 versus 5.21 ± 0.30 mmol/L, p < 0.05 and 2.92 ± 0.40 versus 3.44 ± 0.34 mmol/L, p < 0.05, respectively). Peritoneal urea and creatinine clearances in both subgroups were comparable for both shock and nonshock groups. There was no peritonitis observed during the study. Serum Mg and Ca levels in the bicarbonate subgroup were significantly lower, but no clinical and electrocardiographic abnormality were observed. We concluded that Mg- and Ca-free bicarbonate solution could be safely used and had better outcomes in correction of metabolic acidosis, blood pressure control, and nonspecific systemic host defense with comparable efficacy when compared to lactate solution. It should be the dialysate of choice for acute PD especially in the poor tissue-perfusion states such as shock, lactic acidosis, and multiple organ failure. [source] Strategy of Circulatory Support with Percutaneous Cardiopulmonary SupportARTIFICIAL ORGANS, Issue 8 2000Mitsumasa Hata Abstract: We evaluated the efficacy and problems of circulatory support with percutaneous cardiopulmonary support (PCPS) for severe cardiogenic shock and discussed our strategy of mechanical circulatory assist for severe cardiopulmonary failure. We also described the effects of an alternative way of PCPS as venoarterial (VA) bypass from the right atrium (RA) to the ascending aorta (Ao), which was used recently in 3 patients. Over the past 9 years, 30 patients (20 men and 10 women; mean age: 61 years) received perioperative PCPS at our institution. Indications of PCPS were cardiopulmonary bypass weaning in 13 patients, postoperative low output syndrome (LOS) in 14 patients, and preoperative cardiogenic shock in 3 patients. Approaches of the PCPS system were the femoral artery to the femoral vein (F-F) in 21 patients, the RA to the femoral artery (RA-FA) in 5 patients, the RA to the Ao (RA-Ao) in 3 patients, and the right and left atrium to the Ao in 1 patient. Seventeen (56.7%) patients were weaned from mechanical circulatory support (Group 1) and the remaining 13 patients were not (Group 2). In Group 1, PCPS running time was 33.1 ± 13.6 h, which was significantly shorter than that of Group 2 (70.6 ± 44.4 h). Left ventricular ejection fraction was improved from 34.8 ± 12.0% at the pump to 42.5 ± 4.6% after 24 h support in Group 1, which was significantly better than that of Group 2 (21.6 ± 3.5%). In particular, it was 48.6 ± 5.7% in the patients with RA-Ao, which was further improved. Two of 3 patients with RA-Ao were discharged. Thrombectomy was carried out for ischemic complication of the lower extremity in 5 patients with F-F and 1 patient with RA-FA. One patient with F-F needed amputation of the leg due to necrosis. Thirteen patients (43.3%) were discharged. Hospital mortality indicated 17 patients (56.7%). Fifteen patients died with multiple organ failure. In conclusion, our alternate strategy of assisted circulation for severe cardiac failure is as follows. In patients with postcardiotomy cardiogenic shock or LOS, PCPS should be applied first under intraaortic balloon pumping (IABP) assist for a maximum of 2 or 3 days. In older aged patients particularly, the RA-Ao approach of PCPS is superior to control flow rate easily, with less of the left ventricular afterload and ischemic complications of the lower extremity. If native cardiac function does not recover and longer support is necessary, several types of ventricular assist devices should be introduced, according to end-organ function and the expected support period. [source] Necrotizing haemorrhagic pneumonia proves fatal in an immunocompetent child due to Panton,Valentine Leucocidin, toxic shock syndrome toxins 1 and 2 and enterotoxin C-producing Staphylococcus aureusACTA PAEDIATRICA, Issue 7 2008Farah Mushtaq Abstract Panton,Valentine leucocidin (PVL) toxin-producing strains of Staphylococcus aureus (S. aureus) are associated with skin abscesses and furunculosis, with necrotizing pneumonia being a relatively rare problem. Here, we describe a fatal case of necrotizing pneumonia in a 14-year-old child who presented initially with sore throat and pyrexia. He deteriorated rapidly, developing hypotension, multiple organ failure and purpura fulminans. S. aureus was isolated from the tracheal aspirate, which was found to be positive for PVL, toxic shock syndrome toxins (TSST) 1 and 2 and staphylococcal enterotoxin C (SEC). It was postulated that purpura fulminans and toxic shock syndrome were a result of the abovementioned exotoxins. Conclusion: This case highlights the emergence of PVL-positive community-acquired S. aureus infection and association of purpura fulminans with superantigens. Practitioners should be aware of this illness in order to initiate appropriate treatment. [source] An autopsy case of late-onset Epstein,Barr virus associated post-transplant lymphoproliferative disorders 11 yr after kidney transplantationCLINICAL TRANSPLANTATION, Issue 2008Kumi Aita Abstract:, A 42-yr-old Japanese female presented with right cervical lymphadenopathy. She had been diagnosed with IgA glomerulonephritis at the age of 19 and had a one-yr history of hemodialysis after giving birth to her first child. At the age of 31, she had a living-related renal transplantation from her mother. On admission, she was diagnosed with diffuse large B-cell lymphoma (DLBL) by lymph node biopsy and was treated with Rituxymab plus CHOP (Rituximab/Cyclophosphamide/Doxorubicin/Vincristine/Prednisone). However, the therapy was not successful, and the patient had a rapidly deteriorating clinical course with elevated Epstein,Barr virus (EBV) loads in her peripheral blood. She died four months after the onset of lymphoma, because of disseminated intravascular coagulation and multiple organ failure. In kidney transplantation, the incidence of post-transplant lymphoproliferative disorders (PTLD) is between 0.4% and 2% and mostly occurs within a year after transplantation, in strong association with EBV infection. Late-onset PTLD, however, is more like standard lymphomas and is rarely induced by EBV. The present case was quite atypical of late-onset PTLD because the patient's high viral load was first detected 11 yr after transplantation and presented as a monomorphic B-cell lymphoma. [source] | |||||||||||||||||||||||||||||||