RESUMEN
BACKGROUND: At the turn of the century, only 300 cases of warfarin-induced skin necrosis (WISN) had been reported. WISN is a rare but potentially fatal complication of warfarin therapy. There are no published reports of WISN occurring in patients with HIV-1 infection or tuberculosis (TB). METHODS: We retrospectively reviewed cases of WISN presenting from April 2005 to July 2008 at a referral hospital in Cape Town, South Africa. RESULTS: Six cases of WISN occurred in 973 patients receiving warfarin therapy for venous thrombosis (0.62%, 95% CI 0.25 - 1.37%). All 6 cases occurred in HIV-1-infected women (median age 30 years, range 27 - 42) with microbiologically confirmed TB and venous thrombosis. All were profoundly immunosuppressed (median CD4+ count at TB diagnosis 49 cells/microl, interquartile range 23 - 170). Of the 3 patients receiving combination antiretroviral therapy, 2 had TB-IRIS (immune reconstitution inflammatory syndrome). The median interval from initiation of antituberculosis treatment to venous thrombosis was 37 days (range 0 - 150). The median duration of parallel heparin and warfarin therapy was 2 days (range 1 - 6). WISN manifested 6 days (range 4 - 8) after initiation of warfarin therapy. The international normalised ratio (INR) at WISN onset was supra-therapeutic, median 6.2 (range 3.8 - 6.6). Sites of WISN included breasts, buttocks and thighs. Four of 6 WISN sites were secondarily infected with drug-resistant nosocomial bacteria (methicillin-resistant Staphylococcus aureus (MRSA), Acinetobacter, extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella pneumoniae) 17 - 37 days after WISN onset. In 4 patients, the median interval from WISN onset to death was 43 days (range 25 - 45). One of the 2 patients who survived underwent bilateral mastectomies and extensive skin grafting at a specialist centre. CONCLUSION: This is one of the largest case series of WISN. We report a novel clinical entity: WISN in HIV-1 infected patients with TB and venous thrombosis. The occurrence of 6 WISN cases in a 40-month period may be attributed to (i) hypercoagulability, secondary to HIV-1 and TB: (ii) short concurrent heparin and warfarin therapy; and (iii) high loading doses of warfarin. Active prevention and appropriate management of WISN are likely to improve the dire morbidity and mortality of this unusual condition.
Asunto(s)
Anticoagulantes/efectos adversos , Infecciones por VIH/epidemiología , Piel/patología , Tuberculosis/epidemiología , Trombosis de la Vena/epidemiología , Warfarina/efectos adversos , Adulto , Comorbilidad , Femenino , Humanos , Necrosis/inducido químicamente , Estudios Retrospectivos , Piel/efectos de los fármacos , Tuberculosis Pulmonar/epidemiologíaRESUMEN
SETTING: Paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is an important complication in human immunodeficiency virus type I (HIV-1) infected tuberculosis (TB) patients who start combination antiretroviral treatment (ART). Neurological manifestations occur in more than 10% of TB-IRIS cases. Apart from a few case reports, the radiological features of neurological TB-IRIS have not been described. OBJECTIVE: To describe the neuroradiological findings of patients with paradoxical neurological TB-IRIS. DESIGN: Computed tomography (CT; n = 13) and magnetic resonance imaging (n = 3) findings of 16 patients were reviewed. RESULTS: IRIS manifestations included meningitis (n = 4), intracranial space occupying lesions (SOLs, presumed tuberculomas; n = 5), meningitis and SOLs (n = 5), radiculomyelitis (n = 1) and spondylitis (n = 1). In patients with tuberculoma IRIS, we observed a high prevalence of 1) low density lesions on non-contrast-enhanced CT (all lesions), 2) multiple lesions (in 5/10 patients) and 3) perilesional oedema (17/22 lesions). In patients with meningitis, meningeal enhancement (n = 2) and hydrocephalus (n = 1) were infrequently observed. CONCLUSION: This is the first substantial series to describe the radiological features of paradoxical neurological TB-IRIS. Compared to published radiological findings of tuberculomas in HIV-1-infected patients (not receiving ART), an increased inflammatory response is suggested in tuberculoma IRIS. However, this was not observed in patients with TB meningitis IRIS.
Asunto(s)
Terapia Antirretroviral Altamente Activa/efectos adversos , Infecciones por VIH/complicaciones , Síndrome Inflamatorio de Reconstitución Inmune/diagnóstico por imagen , Tuberculosis/complicaciones , Adulto , Femenino , Infecciones por VIH/tratamiento farmacológico , Humanos , Síndrome Inflamatorio de Reconstitución Inmune/inducido químicamente , Síndrome Inflamatorio de Reconstitución Inmune/fisiopatología , Imagen por Resonancia Magnética , Masculino , Estudios Retrospectivos , Método Simple Ciego , Tomografía Computarizada por Rayos X , Tuberculoma/complicaciones , Tuberculosis Meníngea/complicaciones , Adulto JovenRESUMEN
BACKGROUND AND OBJECTIVES: Diabetes affects approximately 1 million South Africans. Hospital admissions, the largest single item of diabetes expenditure, are often precipitated by hyperglycaemic emergencies. A recent survey of a 200- bed hospital, serving approximately 1.3 million Cape Town residents, showed that hyperglycaemic emergencies comprised 25.6% of high-care unit admissions. A study was undertaken to determine the reasons for, and financial cost of, these admissions. METHODS: All hyperglycaemic admissions during a 2-month period (1 September - 31 October 2005) were surveyed prospectively. Admissions were classified using the American Diabetes Association classification of hyperglycaemic emergencies. Demographic data, and the reason for, duration of and primary outcome of admission, were recorded. The following costs per admission were calculated using publicsector pricing: (i) total costs; (ii) patient-specific costs; (iii) nonpatient- specific costs; and (iv) capital costs. RESULTS: Sepsis (36%), non-compliance with therapy (32%) and a new diagnosis of diabetes (11%) were the predominant reasons for admission of 53 hyperglycaemic emergency cases. Mean duration of hospital stay was 4 days, with an in-hospital mortality of 7.5%. Mean cost per admission was R5 309. Clinical staff (25.8%), capital (25.6%) and overhead (34%) costs comprised 85.4% of expenditure. DISCUSSION AND RECOMMENDATIONS: Hyperglycaemic admissions, costing more than R5 300 per patient, represent a health burden that has remained unchanged over the past 20 years. Urgently required primary care preventive strategies include early diagnosis of diabetes, timely identification and treatment of precipitating causes, specifically sepsis, and education to improve compliance.