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A 29-year-old woman with mixed connective tissue disease presented with signs of progressive pulmonary hypertension. After admission to the hospital her condition worsened rapidly and she developed a cardiac arrest resistant to cardiopulmonary resuscitation. Therefore, emergency extracorporeal assist was performed. No pulmonary embolism was found. Right heart catheterisation showed severe pulmonary hypertension, which was treated with nitric oxide ventilation. She was weaned from the extracorporeal assist with high doses of inotropic agents. Because of suspicion of exacerbation of her underlying disease, which led to pulmonary hypertension, immunosuppressive treatment was started with high doses of corticosteroids and plasma exchange. This resulted in slow recovery over the next four weeks. Control echocardiography showed complete normalisation of cardiac function without signs of pulmonary hypertension. Two months after admission she was discharged from the hospital in good condition.

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Protected specimen brushing (PSB), combined with quantitative culture, is now recognized as one of the reference methods for diagnosis of nosocomial pneumonia. However, no criteria exist with which to assess the quality of the PSB sample. We studied numbers of inflammatory cells and bronchial cells per microscopic field (magnification: x500, objective x50) in cytospin preparations of PSB samples. Results of cell count and quantitative culture in a first study period were compared with those in a second study period, following adaptation of the PSB technique and collection of samples from more peripheral sites. The cellular content of samples from patients and controls was investigated. We examined 86 samples from patients with suspected nosocomial pneumonia and 15 samples from uninfected controls. The number of samples with a high cellular content was considerably greater in the second study period. No positive cultures were obtained from samples containing < 10 cells per field. The numbers of cells in samples from uninfected controls were comparable to the numbers in samples from patients. Our results indicate that absence of cells probably represents inadequate sampling. Negative PSB cultures with cytospin preparations containing < 10 cells per microscopic field should therefore be considered with caution, and resampling considered.

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The value of direct examination of Giemsa and Gram stains of cytospin preparations of protected specimen brush samples was compared to that of quantitative culture. Sixty-one samples from patients suspected to have nosocomial pneumonia were analysed. Twenty-five samples were positive by quantitative culture, 21 of which contained microorganisms seen by direct examination. The presence of leucocytes was not specific for a positive culture, but in their absence, a positive culture was unlikely. The presence of intracellular organisms always correlated with a positive culture, but was not very sensitive.

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1. Changes in arterial oxygen tension after gastric lavage were investigated in a prospective study of 55 patients admitted for drug overdose. 2. A significantly greater decrease was observed in smokers compared to non-smokers. 3. A correlation was found between the tricyclic antidepressant serum level and the observed oxygen tension decrease. 4. The usefulness, as well as the safety of the lavage procedure, in managing tricyclic antidepressants overdoses is controversial.

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Pneumoperitoneum following cardiopulmonary resuscitation (CPR) results from a thoracic air leak (pneumothorax, pneumomediastinum) with escape of the air through diaphragmatic apertures (mostly foramen of Winslow) or primary perforation of the gastrointestinal tract (stomach or esophagus). We report three cases of pneumoperitoneum complicating CPR. As there was no clinical evidence of peritonitis, and the patients remained stable, a conservative approach was followed without surgical exploration. All patients recovered completely.

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A case is presented of a 26-year-old male with a 8-day history of fever and back pain, and limb weakness beginning 24 hours before admission. An abscess caused by a staphylococcus aureus was localised in the thoracic paravertebral region with penetration in the subarachnoidal space at T1. Myelography appeared to be superior to CAT-scan and NMRI of the cervico-thoracal region in supporting the diagnosis. Treatment by laminectomy of C7-T3 48 hours after admission did not lead to neurological improvement and an incomplete tetraplegia persisted. The importance and difficulty of early diagnosis is stressed.

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Evidence supports the hypothesis that plasma prostacyclin activity is deficient in hemolytic-uremic syndrome (HUS). We studied 2 adult patients with HUS. Plasma levels of 6-keto-PGF1 alpha, the stable metabolite of prostacyclin, were measured by radioimmunoassay. Both patients were found to have elevated 6-keto-PGF1 alpha levels. These findings are in contradiction with the prostacyclin deficiency hypothesis and with earlier reports of low or undetectable plasma levels of this metabolite. The patients were treated with IV prostacyclin after a single plasma exchange. The first patient, admitted with advanced renal failure, obtained a rapid remission but renal function did not recover; the second patient, admitted with a less pronounced degree of renal failure, reacted slowly to therapy but renal function partially recovered. We believe that, if any benefit is to be expected from prostacyclin therapy in HUS, it should be started early in the course of the disease.

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Several reports have described the association between diffuse intravascular coagulation (DIC) and arterial aneurysmal disease. We report a patient with extensive arterial aneurysmal disease who developed transient severe DIC during thrombosis of a popliteal aneurysm; following surgical removal of the thrombosed aneurysm, he was found to have chronic subclinical DIC. We believe thrombosis should be added to the complications of aneurysms which can cause DIC, next to dissection and rupture. The chronic DIC occurring after removal of the thrombosed aneurysm was characterized by an abnormal prothrombin time (PTT), low fibrinogen levels and elevated fibrin split products (FDP's); this pattern may be characteristic of the DIC complicating arterial aneurysms.

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Necrotizing fasciitis is a rapidly spreading infection of the subcutaneous tissue and fascia; diabetes mellitus appears to be the most frequent underlying disease. Early diagnosis and immediate aggressive surgical therapy are paramount to curtail morbidity and mortality, but diagnosis is often difficult and unnecessarily delayed. We describe a case of necrotizing fasciitis precipitating diabetic ketoacidotic coma where correct diagnosis was not made until the 14th hospital day. We stress the fact that physicians caring for critically ill patients should be keenly aware of the possibility of necrotizing fasciitis when tending diabetic patients with unexplained fever; failure to recognize the disease can have devastating results. Finally, we believe this to be the first reported case of diabetic ketoacidotic coma precipitated by necrotizing fasciitis.

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