RESUMEN
Pediatric septic shock is associated with severe hypovolemia, and children frequently respond well to aggressive volume resuscitation. In recent years, improved outcome has been reported when aggressive volume resuscitation and goal-directed therapies were applied to children with septic shock. We report a case of severe meningococcal septic shock in a child aged 16 months where aggressive volume resuscitation and anticoagulation therapy were applied.
Asunto(s)
Anticoagulantes/uso terapéutico , Antitrombinas/uso terapéutico , Fibrinolíticos/uso terapéutico , Fluidoterapia , Meningitis Meningocócica/terapia , Choque Séptico/terapia , Reanimación Cardiopulmonar , Coagulación Intravascular Diseminada/tratamiento farmacológico , Coagulación Intravascular Diseminada/etiología , Femenino , Humanos , Lactante , Meningitis Meningocócica/líquido cefalorraquídeo , Meningitis Meningocócica/microbiología , Proteína C/uso terapéutico , Choque Séptico/líquido cefalorraquídeo , Choque Séptico/microbiología , Resultado del TratamientoRESUMEN
We have examined the in vitro stimulatory effects of lipopolysaccharide (LPS)-containing samples (meningococcal shock plasma, n = 10; non-shock plasma, n = 10; cerebrospinal fluid (CSF), n = 7) before and after immunodepletion of interleukin (IL)-10 in a monocyte target assay. We also studied the stimulatory effects of plasma collected from 3 patients with lethal septicemia caused by Streptococcus pneumoniae without detectable LPS but with 100-fold increased levels of heat-shock protein 70 (HSP70). HSP70 may, like LPS, activate monocytes via the Toll-like receptor 4 (TLR4). The samples were analyzed for LPS, tumor necrosis factor (TNF)-alpha, IL-10 and HSP70; applied on human monocytes (purity > 95%) before and after IL-10 immunodepletion, in the absence or presence of CD14 blocking mAb (60bca) or the lipid A antagonist, Rhodobacter sphaeroides diphosphoryl lipid A (RsDPLA) which blocks TLR4. Monocyte activation was measured by increased TNF-alpha secretion and tissue factor (TF) up-regulation by monocyte procoagulant activity (PCA). There was a positive correlation between patient plasma LPS levels (n = 10) and increases in TNF-alpha secretion by the monocytes after immunodepletion of IL-10 (r = 0.82). Pretreatment of the monocytes with mAbCD14 or RsDPLA reduced TNF-alpha secretion to median 5% and 12%, respectively, of the levels before the receptor complex was blocked. The median levels of HSP70 were 543 ng/ml (range, 468-962 ng/ml) in pneumococcal shock plasma, 81.5 ng/ml (range, 41-331 ng/ml) in meningococcal shock plasma and 24 ng/ml (range, < 0.8-41 ng/ml) in meningococcal non-shock plasma. Pneumococcal septic shock plasmas with significantly higher levels of HSP70 (P < 0.05) did not induce TNF-alpha secretion in the monocytes. The results strongly suggest that LPS in meningococcal shock plasma is the major activator of monocytes whereas HSP70 (in plasma concentrations up to 963 ng/ml) does not activate monocytes in this assay.
Asunto(s)
Interleucina-10 , Receptores de Lipopolisacáridos/metabolismo , Lipopolisacáridos/sangre , Glicoproteínas de Membrana/metabolismo , Monocitos/metabolismo , Receptores de Superficie Celular/metabolismo , Choque Séptico , Adolescente , Adulto , Anticuerpos Bloqueadores/farmacología , Niño , Preescolar , Proteínas HSP70 de Choque Térmico/sangre , Proteínas HSP70 de Choque Térmico/farmacología , Humanos , Lactante , Interleucina-10/sangre , Interleucina-10/deficiencia , Lipopolisacáridos/toxicidad , Activación de Macrófagos/efectos de los fármacos , Activación de Macrófagos/fisiología , Glicoproteínas de Membrana/antagonistas & inhibidores , Infecciones Meningocócicas/sangre , Infecciones Meningocócicas/fisiopatología , Persona de Mediana Edad , Monocitos/efectos de los fármacos , Neisseria meningitidis/química , Neisseria meningitidis/patogenicidad , Polisacáridos Bacterianos , Receptores de Superficie Celular/antagonistas & inhibidores , Sepsis/sangre , Sepsis/fisiopatología , Choque Séptico/sangre , Choque Séptico/líquido cefalorraquídeo , Receptor Toll-Like 4 , Receptores Toll-Like , Factor de Necrosis Tumoral alfa/metabolismoRESUMEN
Plasma level of adrenomedullin (AM), a potent vasodilator peptide, is increased in patients with sepsis. AM was also found to be present in cerebrospinal fluid (CSF) of humans, and intracerebroventricular injection of AM resulted in elevated systemic blood pressure in rats. In the present study, we measured AM levels in CSF and plasma of 7 patients with septic shock who had severe hypotension, and compared with those of 10 control patients receiving primary transurethral resection of bladder tumor. CSF samples were obtained through the procedure of lumbar puncture and AM levels were measured by radioimmunoassay. AM concentration in CSF of the septic patients was increased to a level 35 times higher than that of control group (35 +/- 21 vs. 0.9 +/-0 .3 pmol/L, mean +/- S .D., p < 0.01). Similarly, plasma AM concentration was increased by 27 times compared with control group (176 +/- 71 vs. 6.5+/-1.8 pmol/L, p < 0.01). Despite the similar increase in CSF and plasma AM, no significant correlation was found between the AM concentrations in the CSF and plasma (r = 0.01 P = 0.95). Taken together with the central actions of AM, these findings suggest that AM of the central nervous system may be involved in pathophysiology of sepsis of humans.
Asunto(s)
Adrenomedulina/líquido cefalorraquídeo , Choque Séptico/líquido cefalorraquídeo , Adolescente , Adrenomedulina/sangre , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Casos y Controles , Femenino , Humanos , Masculino , Persona de Mediana Edad , Choque Séptico/sangreRESUMEN
Embora rara, e interessante e ainda pouco explicavel a associaçäo entre infecçäo neonatal estreptococica e o desenvolvimento tardio de hernia diafragmatica direta. Descrevem-se dois recém-nascidos pré-termo com sepse precoce (um deles pelo Streptococcus B) e o reconhecimento tardio de hernia diafragmatica no nono e no vigésimo quinto dia de vida. Em ambos, apos estabilizaçäo do quadro infeccioso, houve piora clínica e radiológica, com derrame pleural e atelectasia. O diagnóstico foi realizado através de radiografias seriadas, ultra-sonografia e tomografia computadorizada de torax e abdome. A suspeita diagnóstica de hernia diafragmatica direita deve ser aventada em todo recém-nascido com sepse pelo Streptococcus B em que, após melhora clinica inicial, ocorrer piora da insuficiência respiratória, aparecimento de derrame pleural, atelectasia ou opacificaçäo completa do hemitorax direito
Asunto(s)
Humanos , Recién Nacido , Femenino , Adulto , Choque Séptico/complicaciones , Hernia Diafragmática/cirugía , Infecciones Estreptocócicas/diagnóstico , Líquido Cefalorraquídeo/microbiología , Choque Séptico/líquido cefalorraquídeo , Choque Séptico/sangre , Drenaje , Hernia Diafragmática/diagnóstico , Infecciones Bacterianas/etiología , Derrame Pleural , Streptococcus agalactiae/aislamiento & purificación , Tomografía Computarizada por Rayos XRESUMEN
Inflammation may play an important role in the evolution of damage after traumatic brain injury (TBI). IL-6 and IL-10 are markers of inflammation that are pro- and anti-inflammatory in nature, respectively. They have been used as an index of the degree of inflammation in diseases including sepsis and meningitis. We hypothesized that both IL-6 and IL-10 would be increased in the cerebrospinal fluid (CSF) of children after TBI. We measured ventricular CSF concentrations of these metabolites (ELISA) each of the first 3 days after TBI in 15 children. CSF IL-6 was increased on day 1 (p < 0.05 vs days 2 or 3). CSF IL-10 was similarly increased on day 1 (p < 0.05). CSF IL-6 after TBI is similar to serum IL-6 levels previously reported in children with septic shock. In contrast, the CSF IL-10 response was markedly attenuated following TBI compared to sepsis. These data suggest a unique balance between pro- and anti-inflammatory cytokines in brain after TBI.
Asunto(s)
Lesiones Encefálicas/líquido cefalorraquídeo , Ventrículos Cerebrales/metabolismo , Inflamación/líquido cefalorraquídeo , Interleucina-10/líquido cefalorraquídeo , Interleucina-6/líquido cefalorraquídeo , Choque Séptico/líquido cefalorraquídeo , Niño , Preescolar , Humanos , LactanteRESUMEN
A previously healthy 8-year-old girl presented with flu-like symptoms, developed toxic shock-like syndrome, and died within 48 hours. At autopsy she was found to have purulent meningitis. The group A beta-hemolytic streptococcus isolated from her CSF was a member of clone ET 2. This strain produced a variant form of streptococcal pyrogenic exotoxin A (SPEA 2) that has recently been associated with widespread toxic shock-like syndrome.
Asunto(s)
Meningitis Bacterianas/microbiología , Choque Séptico/microbiología , Infecciones Estreptocócicas , Streptococcus pyogenes , Encéfalo/microbiología , Encéfalo/patología , Niño , Resultado Fatal , Femenino , Humanos , Meningitis Bacterianas/líquido cefalorraquídeo , Meningitis Bacterianas/patología , Choque Séptico/líquido cefalorraquídeo , Infecciones Estreptocócicas/líquido cefalorraquídeo , Infecciones Estreptocócicas/patologíaRESUMEN
Toxic shock syndrome (TSS) is a well-defined clinical syndrome attributed to certain exotoxins produced by Staphylococcus aureus. The acute episode is often characterized by a toxic encephalopathy, possibly caused by direct neurotoxicity of these exotoxins, although this mechanism has never been proven. We describe a patient who developed TSS, meningitis and cauda equina syndrome simultaneously several days after lumbar laminectomy. A space-occupying lesion was excluded. Enterotoxin C-producing S. aureus was cultured from the surgical wound and the cerebrospinal fluid (CSF). The patient recovered from TSS but remained partially paralyzed. Presumably the cauda equina syndrome was caused by neurotoxic effects of the intrathecally produced S. aureus exotoxins. This case provides evidence for the neurotoxic effects of TSS-associated S. aureus exotoxins.
Asunto(s)
Cauda Equina , Laminectomía/efectos adversos , Vértebras Lumbares , Meningitis/etiología , Síndromes de Compresión Nerviosa/etiología , Choque Séptico/etiología , Espondilolistesis/cirugía , Espondilólisis/cirugía , Infecciones Estafilocócicas/etiología , Staphylococcus aureus , Adulto , Electromiografía , Femenino , Floxacilina/uso terapéutico , Humanos , Meningitis/líquido cefalorraquídeo , Meningitis/microbiología , Meningitis/terapia , Síndromes de Compresión Nerviosa/diagnóstico , Choque Séptico/líquido cefalorraquídeo , Choque Séptico/microbiología , Choque Séptico/terapia , Infecciones Estafilocócicas/líquido cefalorraquídeo , Infecciones Estafilocócicas/microbiología , Infecciones Estafilocócicas/terapia , Vancomicina/uso terapéuticoRESUMEN
To evaluate the role of interleukin (IL)-8 in meningococcal disease, a solid-phase double-ligand ELISA was used to quantitate IL-8 in sera and cerebrospinal fluid (CSF) from patients with meningococcal meningitis, bacteremia, or both with or without septic shock. IL-8 was demonstrated in sera from 28 of 62 patients; levels were significantly higher in patients with septic shock without meningitis (median, 36.1 ng/mL) than in patients with other manifestations (median, < 0.02 ng/mL), and 4 of 5 patients who died had high levels. IL-8 was detected in all 27 CSF samples. Serum IL-8 levels correlated highly significantly with those of IL-6 (r = .83) and tumor necrosis factor (TNF; r = .64), while the correlations between corresponding CSF levels were less pronounced (r = .43 and r = .38, respectively) but still significant. Serum IL-8 levels were highest in patients with a symptom history < 12 h. The elimination rate of IL-8 from serum varied and was similar to that of IL-6 and TNF. IL-8 appears to participate in the complex cytokine network during the initial phase of systemic meningococcal infections.
Asunto(s)
Interleucina-8/sangre , Infecciones Meningocócicas/etiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Bacteriemia/sangre , Bacteriemia/líquido cefalorraquídeo , Bacteriemia/etiología , Niño , Preescolar , Femenino , Humanos , Interleucina-1/análisis , Interleucina-6/análisis , Interleucina-8/líquido cefalorraquídeo , Cinética , Recuento de Leucocitos , Masculino , Meningitis Meningocócica/sangre , Meningitis Meningocócica/líquido cefalorraquídeo , Meningitis Meningocócica/etiología , Infecciones Meningocócicas/sangre , Infecciones Meningocócicas/líquido cefalorraquídeo , Persona de Mediana Edad , Neutrófilos , Choque Séptico/sangre , Choque Séptico/líquido cefalorraquídeo , Choque Séptico/etiología , Factor de Necrosis Tumoral alfa/análisisRESUMEN
An ovine surgical model for peptide investigations is presented. Techniques for exteriorization of the carotid artery, catheterization of the sagittal sinus, hypophysectomy via a transnasopharyngeal approach, and ventricular and cisternal cannulation in the sheep are employed within the model. Several experimental applications in neurosurgical research are presented.
Asunto(s)
Modelos Biológicos , Proteínas del Tejido Nervioso/sangre , Neurocirugia/métodos , Anestesia , Animales , Arterias Carótidas/cirugía , Cateterismo/métodos , Catéteres de Permanencia , Ventrículos Cerebrales/irrigación sanguínea , Cisterna Magna/irrigación sanguínea , Craneotomía/métodos , Duramadre/irrigación sanguínea , Femenino , Hipofisectomía/métodos , Masculino , Proteínas del Tejido Nervioso/líquido cefalorraquídeo , Perfusión , Ovinos , Choque Séptico/sangre , Choque Séptico/líquido cefalorraquídeoRESUMEN
Cerebrospinal fluid (CSF) electrolytes, lactate, pyruvate, total proteins, and osmolality, together with arterial plasma electrolytes, total proteins, osmolarity, and systemic arterial blood pressure were monitored during 2 mg/kg and 5 mg/kg E coli endotoxin shock in spontaneously breathing dogs. During four hours of shock, Na+, K+ osmolarity, and total proteins did not change in either plasma or CSF. CSF lactate and lactate/pyruvate ratio were significantly elevated, whereas pyruvate was decreased throughout the four hours of shock. Systemic arterial blood pressure was below control during the entire shock period. Saline control experiments yielded no significant changes in all parameters monitored. These data show that during four hours of shock the brain has shifted form aerobic to anaerobic metabolism the degree of which is not sufficient to cause any detectable changes in membrane permeability or alterations in Na+/K+ active processes.
Asunto(s)
Choque Séptico/líquido cefalorraquídeo , Animales , Presión Sanguínea , Perros , Endotoxinas , Escherichia coli , Femenino , Lactatos/líquido cefalorraquídeo , Masculino , Potasio/líquido cefalorraquídeo , Piruvatos/líquido cefalorraquídeo , Choque Séptico/etiología , Choque Séptico/fisiopatología , Sodio/líquido cefalorraquídeoRESUMEN
Eighty four cases of meningococcal infections are reviewed. Fifty seven cases presented themselfs as meningococcal meningitis, twelve cases as sepsis with moderate hypotension and 15 cases were sepsis with septic shock. A brief course of the disease, shock, echymosis, absence of meningeal signs, leucopenia and intravascular coagulation were findings more frequent in the group of patients with hiperacute sepsis, whereas other signs as fever, headaches, vomiting and petechiae were present with equal frequency in the three groups. N. meningitis was isolated in 73% of the cases. Shock (18.85%) and intravascular coagulation (12%) were the complications more frequently found, followed by convulsions (4.81%), arthritis (4.81%), skin necrosis (4.81%), subdural efusion (3.57%), cerebral palsy (3.40%), thrombophlebitis (1.20%), recurrence (1.20%), inapropiate antidiuretic hormone secretion (1.20%) and subaracnoideal hemorrage (1.20%). The overall mortality was 10.70% and 60% of the patients which initially presented with shock and intravascular coagulation died. Autopsy findings included wide spred hemorragic lesions and intravascular thrombi in skin, mucous membranes and viscera. Adrenal hemorrhage was present in five of the six cases studied.