Unusual exanthema combined with cerebral vasculitis in pneumococcal meningitis: a case report

<p>Abstract</p> <p>Introduction</p> <p>Bacterial meningitis is a complex, rapidly progressive disease in which neurological injury is caused in part by the causative organism and in part by the host's own inflammatory responses.</p> <p>Case presentation</p> <p>We present the case of a two-year-old Greek girl with pneumococcal meningitis and an atypical curvilinear-like skin eruption, chronologically associated with cerebral vasculitis. A diffusion-weighted MRI scan showed lesions with restricted diffusion, reflecting local areas of immunologically mediated necrotizing vasculitis.</p> <p>Conclusions</p> <p>Atypical presentations of bacterial meningitis may occur, and they can be accompanied by serious unexpected complications.</p

Longitudinal changes of bioenergy, metabolism and immune response in acute phase of severe sepsis

Background: Cell stress induced by severe sepsis (SS) or systemic inflammatory response syndrome (SIRS) presents with acute inflammatory, hormonal, immune and metabolic derangements. Their relation with mitochondrial dysfunction has not been adequately studied.Objectives: The purpose of the study was to evaluate the longitudinal changes of inflammatory-hormonal response, innate-immunity, bioenergetics and metabolism in critically ill patients, adults and children with severe sepsis and to compare them with patients groups with SIRS and healthy groups (H), adults and children.Materials / Methods: We studied 68 children (SS / 18, SIRS / 23, H / 27) and 79 adults (SS / 23, SIRS / 23, H / 33) on 1, 3 and 5 day of hospitalization. Body Mass Index (BMI) z-scores and disease severity scores (PeLOD, APACHE, TISS, SOFA) were calculated. Cardiac contractility (EF, SF), troponin (Tn) and lactate were measured, as well as energy consumption (EE) with Gas Module E-COVX, ATP in white blood cells with luciferase luminescent assay, glutamine and NO2 / NO3 levels with high-pressure liquid chromatography (HPLC), lipid peroxidation products (TBARS) by colorimetric assay, resistin, serum antiponectin and extracellular Heat Shock Proteins (HSP) HSP90α, serum HSP72, adiponectin and resistin by ELISA.Intracellular Heat Shock Proteins (HSP72, HSP90α) expressions by flow cytometry.Results: Longitudinal both in adults (ICU) and children (PICU), resistin, dexponcepin, extracellular HPS72 and 90a values showed a sustained pattern of stimulation throughout the acute 5-day phase. In this period, VO2, VCO2, EE showed a hypometabolic pattern similar in children and adults.The increased expression of NO3, NO2, TBARS and adiponectin in sepsis showed a diffuse pattern relating to their age-related expression per age group. Mitochondrial bioenergy was longitudinal reduced in adults and children who did not survive compared to survivors, and was accompanied by significantly reduced metabolism and hypometabolic patterns on days 3 and 5 (p <0.05). Surviving patients had a significant variation in baseline BVR, lactate, EU, VO2, VCO2 and metabolic profile compared to patients who died, who showed inability to recover hypometabolism or antioxidant status on day 5.Conclusion: SS is characterized from longitudinally stronger intracellular repression of ATP, HPS72, HSP90α, metabolism (EE, albumin, glutamine) and extracellular induction of inflammatory hormones (resistin) and innate immunity proteins signaling acute stress danger (HSP72) compared to SIRS. A pattern of early longitudinal induction of metabolic-hormones and eHSP72/HSP90α, repression of bioenergetics and innate immunity, hypo-metabolism, and amino-acid kinetics changes discriminate sepsis from SIRS; malnutrition, hypometabolism, and persistently increased resistin and adiponectin are associated with poor outcome.KEY WORDS: sepsis, SIRS, bioenergy, HSP, resistin, metabolism, calorimetry; amino acids; nitric oxide; heat shock proteins; ATP; resistin; adiponectin; sepsis; traumaΕισαγωγή: Το κυτταρικό στρες από σοβαρή σήψη (severe sepsis, SS) ή σύνδρομο συστηματικής φλεγμονώδους απάντησης (Systemic inflammatory response syndrome, SIRS) εκδηλώνεται με οξείες φλεγμονώδεις, ορμονικές, ανοσολογικές και μεταβολικές διαταραχές. Η συσχέτισή τους με πιθανή δυσλειτουργία μιτοχονδρίων δεν έχει επαρκώς μελετηθεί. Σκοπός: Σκοπός της μελέτης ήταν η εκτίμηση των διαχρονικών μεταβολών φλεγμονώδους-ορμονικής αντίδρασης, ενδογενούς-ανοσίας, βιοενέργειας και μεταβολισμού σε ασθενείς, ενήλικες και παιδιά, με σοβαρή σήψη (SS) και η σύγκριση με αντίστοιχες ομάδες ασθενών με SIRS και υγιών (H), ενηλίκων και παιδιών.Υλικά/Μέθοδοι: Μελετήθηκαν 68 παιδιά (SS/18, SIRS/23, H/27) και 79 ενήλικες (SS/23, SIRS/23, H/33) διαχρονικά, την 1, 3η και 5η ημέρα νοσηλείας. Υπολογίστηκαν ο δείκτης μάζας σώματος (Body mass index (BMI) z-scores) και τα scores βαρύτητας νόσου (PeLOD, APACHE, TISS, SOFA). Μετρήθηκαν η καρδιακή συσταλτικότητα (EF, SF), η τροπονίνη (Tn), το γαλακτικό οξύ, η κατανάλωση ενέργειας (Energy expenditure, EE) με Gas Module E-COVX, το ATP στα λευκά αιμοσφαίρια με δοκιμασία λουσιφεράσης (luciferase luminescent assay), τα επίπεδα γλουταμίνης και NO2/NO3 με υγρή χρωματογραφία υψηλής πίεσης (HPLC), τα προϊόντα υπεροξείδωσης λιπιδίων (TBARS) με χρωματομετρική δοκιμασία, η ρεζιστίνη, η αντιπονεκτίνη ορού και οι εξωκυττάριες Heat Shock Proteins (HSP) με την ποσοτική ανοσοενζυμική μέθοδο ELISA (sandwich enzyme-linked immunosorbent assay), και οι ενδοκυττάριες HSP72, HSP90α με κυτταρομετρία ροής (flow cytometry). Αποτελέσματα: Διαχρονικά τόσο σε ενήλικες (ICU) όσο και σε παιδιά (PICU) οι τιμές ρεζιστίνης, αντιπονεκτίνης, εξωκυττάριας HPS72 και 90α παρουσιάζαν σταθερό πρότυπο διέγερσης σε όλη την οξεία φάση των 5 ημέρων. Στη χρονική αυτή περίοδο, οι παράμετροι μεταβολισμού VO2, VCO2, EE παρουσίασαν σταθερό υπομεταβολικό προφίλ, ίδιο σε ενήλικες και παιδιά. Η αυξημένη έκφραση των NO3, NO2, TBARS και αντιπονεκτίνης στη σήψη παρουσίασαν μια πιο ασταθή εικόνα όσον αφορά τη διαχρονική τους έκφραση ανά ηλικιακή ομάδα.Η βιοενέργεια των μιτοχονδρίων ήταν διαχρονικά μειωμένη σε ενήλικες κα παιδιά που δεν επιβίωσαν σε σχέση με εκείνους που επιβίωσαν, και συνοδεύονταν από σημαντικά μειωμένο μεταβολισμό και υπομεταβολικά πρότυπα την 3η και 5η ημέρα (p<0.05). Οι ασθενείς που επιβίωσαν παρουσίαζαν σημαντική διαφοροποίηση των αρχικών τιμών BVR, γαλακτικού, ΕΕ, VO2, VCO2 και μεταβολικού προφιλ σε σύγκριση με ασθενείς που πέθαναν, οι οποίοι έδειξαν αδυναμία ανάκαμψης του υπομεταβολισμού ή της αντιοξειδωτικής κατάστασης την 5η ημέρα. Συμπέρασμα: Η SS χαρακτηρίζεται διαχρονικά, από ισχυρότερη ενδοκυττάρια καταστολή μεταβολισμού, μείωση κατανάλωσης ενέργειας, μείωση των ATP, HPS72, HSP90α, αλβουμίνης, γλουταμίνης και εξωκυττάρια αύξηση φλεγμονωδών ορμονών, ρεζιστίνης και αντιπονεκτίνης και πρωτεϊνών έμφυτης ανοσίας (HSP72). Μια πρώιμη κατάσταση υπομεταβολισμού, με καταστολή βιοενέργειας και ενδογενούς ανοσίας, η οποία και παραμένει διαχρονικά μαζί με συνεχιζόμενη κατάσταση φλεγμονής, με διαχρονικά αυξημένες μεταβολικές ορμόνες και πρωτείνες eHSP72/HSP90α, φαίνεται να ξεχωρίζει τη σήψη από το SIRS, και συνδέεται με αυξημένο κίνδυνο θανάτου.Λέξεις κλειδιά: σήψη, SIRS, βιοενέργεια, HSP, μιτοχόνδρια, μεταβολισμός, θερμιδομετρία, αμινοξέα, οξείδιο του αζώτου, ATP, ρεζιστίνη, αντιπονεκτίνη, τραύμ

The sweet lung: Chewing gummi bear aspiration

Inhalation of foreign bodies, a leading cause of accidental death, is most common in preschool children. In this article we report our experience with a 5-year-old Greek girl who presented with a 24-hour history of sore throat, chest pain, and shortness of breath. Emergency bronchoscopy was performed and multiple small chewing gummi bear (HARIBO) particles impacted in the orifices of the right main bronchus and right lobar and segmentalinic bronchi were successfully removed and aspirated. Aspiration of gummi bears, which is for the first time reported, may cause a silent choking episode leading to life-threatening bronchi obstruction at multiple sites, even in children older than 4 years

Severe and Atypical Presentation of Takotsubo Cardiomyopathy in a Pediatric Patient after a Serious Crash Injury—Case Report and Literature Review

Takotsubo cardiomyopathy is an uncommon clinical entity in children, resulting in severe but sometimes reversible systolic dysfunction of the left ventricle. This condition is triggered by multiple emotional or physical stressors, while neurogenic stress cardiomyopathy after brain injuries has become increasingly recognized in children over the past few years. We report the case of an 11-year-old child with an atypical clinical presentation after a serious car crash accident. An initial computed tomography scan revealed an acute epidural hematoma, which was immediately treated by an emergency craniotomy. During the patient’s following pediatric intensive care unit hospitalization, severe hemodynamic instability was observed, leading to gradually higher doses of vasopressors for circulatory support. On echocardiography, the patient had signs of severe cardiac contractility compromise, with characteristic pattern of regional wall motion abnormalities of the left ventricle, which, in combination with seriously elevated cardiac enzymes, electrocardiographic (ECG) abnormalities and continuous thermodilution hemodynamic monitoring (PICCO) findings, led to intensification of inotropic support and to the diagnosis of takotsubo cardiomyopathy. Despite supportive measures, the patient developed multiorgan failure and succumbed to their serious illness. For this atypical case, extracorporeal membrane oxygenation (ECMO) was addressed as an option for the seriously failing heart, but due to the extremely high risk of intracranial bleeding, it could not be used for this patient’s treatment. In conclusion, Takotsubo cardiomyopathy should be suspected in pediatric cases of cardiac dysfunction after serious injuries or stress conditions

Heat Shock Protein 72 Expressing Stress in Sepsis: Unbridgeable Gap between Animal and Human Studies—A Hypothetical “Comparative” Study

Heat shock protein 72 (Hsp72) exhibits a protective role during times of increased risk of pathogenic challenge and/or tissue damage. The aim of the study was to ascertain Hsp72 protective effect differences between animal and human studies in sepsis using a hypothetical “comparative study” model. Forty-one in vivo (56.1%), in vitro (17.1%), or combined (26.8%) animal and 14 in vivo (2) or in vitro (12) human Hsp72 studies (P<0.0001) were enrolled in the analysis. Of the 14 human studies, 50% showed a protective Hsp72 effect compared to 95.8% protection shown in septic animal studies (P<0.0001). Only human studies reported Hsp72-associated mortality (21.4%) or infection (7.1%) or reported results (14.3%) to be nonprotective (P<0.001). In animal models, any Hsp72 induction method tried increased intracellular Hsp72 (100%), compared to 57.1% of human studies (P<0.02), reduced proinflammatory cytokines (28/29), and enhanced survival (18/18). Animal studies show a clear Hsp72 protective effect in sepsis. Human studies are inconclusive, showing either protection or a possible relation to mortality and infections. This might be due to the fact that using evermore purified target cell populations in animal models, a lot of clinical information regarding the net response that occurs in sepsis is missing

Oxidant/Antioxidant Status Is Impaired in Sepsis and Is Related to Anti-Apoptotic, Inflammatory, and Innate Immunity Alterations

Oxidative stress is considered pivotal in the pathophysiology of sepsis. Oxidants modulate heat shock proteins (Hsp), interleukins (IL), and cell death pathways, including apoptosis. This multicenter prospective observational study was designed to ascertain whether an oxidant/antioxidant imbalance is an independent sepsis discriminator and mortality predictor in intensive care unit (ICU) patients with sepsis (n = 145), compared to non-infectious critically ill patients (n = 112) and healthy individuals (n = 89). Serum total oxidative status (TOS) and total antioxidant capacity (TAC) were measured by photometric testing. IL-6, -8, -10, -27, Hsp72/90 (ELISA), and selected antioxidant biomolecules (Ζn, glutathione) were correlated with apoptotic mediators (caspase-3, capsase-9) and the central anti-apoptotic survivin protein (ELISA, real-time PCR). A wide scattering of TOS, TAC, and TOS/TAC in all three groups was demonstrated. Septic patients had an elevated TOS/TAC, compared to non-infectious critically ill patients and healthy individuals (p = 0.001). TOS/TAC was associated with severity scores, procalcitonin, IL-6, -10, -27, IFN-γ, Hsp72, Hsp90, survivin protein, and survivin isoforms -2B, -ΔΕx3, -WT (p p TOS/TAC (0.96 (95% CI = 0.93–0.99)) was higher than AUCTAC (z = 20, p TOS (z = 3.1, p = 0.002) in distinguishing sepsis. TOS/TAC, TOS, survivin isoforms -WT and -2B, Hsp90, IL-6, survivin protein, and repressed TAC were strong predictors of mortality (p < 0.01). Oxidant/antioxidant status is impaired in septic compared to critically ill patients with trauma or surgery and is related to anti-apoptotic, inflammatory, and innate immunity alterations. The unpredicted TOS/TAC imbalance might be related to undefined phenotypes in patients and healthy individuals

Oxidant/Antioxidant Status Is Impaired in Sepsis and Is Related to Anti-Apoptotic, Inflammatory, and Innate Immunity Alterations

Oxidative stress is considered pivotal in the pathophysiology of sepsis. Oxidants modulate heat shock proteins (Hsp), interleukins (IL), and cell death pathways, including apoptosis. This multicenter prospective observational study was designed to ascertain whether an oxidant/antioxidant imbalance is an independent sepsis discriminator and mortality predictor in intensive care unit (ICU) patients with sepsis (n = 145), compared to non-infectious critically ill patients (n = 112) and healthy individuals (n = 89). Serum total oxidative status (TOS) and total antioxidant capacity (TAC) were measured by photometric testing. IL-6, -8, -10, -27, Hsp72/90 (ELISA), and selected antioxidant biomolecules (Zeta n, glutathione) were correlated with apoptotic mediators (caspase-3, capsase-9) and the central anti-apoptotic survivin protein (ELISA, real-time PCR). A wide scattering of TOS, TAC, and TOS/TAC in all three groups was demonstrated. Septic patients had an elevated TOS/TAC, compared to non-infectious critically ill patients and healthy individuals (p = 0.001). TOS/TAC was associated with severity scores, procalcitonin, IL-6, -10, -27, IFN-gamma, Hsp72, Hsp90, survivin protein, and survivin isoforms -2B, -Delta Epsilon x3, -WT (p &lt; 0.001). In a propensity probability (age-sex-adjusted) logistic regression model, only sepsis was independently associated with TOS/TAC (Exp(B) 25.4, p &lt; 0.001). The AUC(TOS/TAC) (0.96 (95% CI = 0.93-0.99)) was higher than AUC(TAC) (z = 20, p &lt; 0.001) or AUC(TOS) (z = 3.1, p = 0.002) in distinguishing sepsis. TOS/TAC, TOS, survivin isoforms -WT and -2B, Hsp90, IL-6, survivin protein, and repressed TAC were strong predictors of mortality (p &lt; 0.01). Oxidant/antioxidant status is impaired in septic compared to critically ill patients with trauma or surgery and is related to anti-apoptotic, inflammatory, and innate immunity alterations. The unpredicted TOS/TAC imbalance might be related to undefined phenotypes in patients and healthy individuals