RESUMEN
INTRODUCTION: Intrapleural fibrinolytic enzyme therapy is a potentially surgery-sparing treatment for poorly resolving parapneumonic effusion and empyema. It is safe in the majority of patients, however the most significant risk associated with this treatment is severe bleeding secondary to pleural hemorrhage. Contraindications for intrapleural enzyme therapy are not widely agreed upon and little is known about how to treat this difficult and potentially lethal hemorrhagic complication. CASE PRESENTATION: An independent 82-year-old Caucasian man presented to hospital with an empyema complicating community-acquired pneumonia and coincidental pulmonary embolus. He was initially commenced on intravenous antibiotics, pleural drainage and anticoagulation, however failed to improve significantly and was commenced on intrapleural fibrinolytic enzyme therapy. Shortly after, he suffered severe pleural hemorrhage that was uncontrollable despite emergency thoracotomy and washout. Subsequent hemostasis was achieved after re-exploration and application of topical fibrin-thrombin sealant spray. The patient survived and was discharged home. CONCLUSIONS: Intrapleural enzyme therapy can be effective in loculated parapneumonic effusion and empyema, but massive pleural hemorrhage can complicate its use. Pleural hemorrhage appears to be associated with anticoagulation or coagulopathy, and can be difficult to manage. This case adds to the body of data on bleeding complications following intrapleural enzyme therapy, and to the best of our knowledge is the first report of fibrin-thrombin sealant use in this setting.
Asunto(s)
Empiema Pleural/etiología , Terapia Enzimática/efectos adversos , Pleurodesia/métodos , Neumonía/fisiopatología , Terapia Trombolítica/métodos , Anciano de 80 o más Años , Empiema Pleural/diagnóstico , Empiema Pleural/terapia , Adhesivo de Tejido de Fibrina , Humanos , Masculino , Derrame Pleural/tratamiento farmacológico , Neumonía/complicaciones , Resultado del TratamientoRESUMEN
Asparaginase Erwinia chrysanthemi (Erwinaze®) is approved in the USA for use in patients with acute lymphoblastic leukemia (ALL) who have developed hypersensitivity to Escherichia coli-derived asparaginase. The approved regimen of intramuscular Erwinaze® was associated with sustained, clinically meaningful asparaginase activity in patients with ALL who had to discontinue treatment with pegaspargase (a pegylated formulation of E. coli asparaginase) because of hypersensitivity. Another study revealed that development of E. coli-derived asparaginase allergy and a switch to Erwinaze® maintained event-free survival in pediatric patients with newly diagnosed ALL. In a multicenter, compassionate-use trial, Erwinaze® was generally well tolerated, with the most commonly occurring adverse events including hypersensitivity, pancreatitis, fever, hyperglycemia, and increased transaminase levels. Subclinical hypersensitivity may result in the inactivation of asparaginase and affect treatment outcome; monitoring of serum asparaginase levels may be used to identify subclinical hypersensitivity.
Asunto(s)
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Asparaginasa/uso terapéutico , Proteínas Bacterianas/uso terapéutico , Drogas en Investigación/uso terapéutico , Terapia Enzimática , Erwinia/enzimología , Leucemia-Linfoma Linfoblástico de Células Precursoras/tratamiento farmacológico , Antineoplásicos/administración & dosificación , Antineoplásicos/efectos adversos , Antineoplásicos/metabolismo , Antineoplásicos/uso terapéutico , Protocolos de Quimioterapia Combinada Antineoplásica/administración & dosificación , Protocolos de Quimioterapia Combinada Antineoplásica/efectos adversos , Asparaginasa/administración & dosificación , Asparaginasa/efectos adversos , Asparaginasa/metabolismo , Asparagina/sangre , Asparagina/metabolismo , Proteínas Bacterianas/administración & dosificación , Proteínas Bacterianas/efectos adversos , Proteínas Bacterianas/metabolismo , Hipersensibilidad a las Drogas/etiología , Monitoreo de Drogas , Drogas en Investigación/administración & dosificación , Drogas en Investigación/efectos adversos , Drogas en Investigación/metabolismo , Terapia Enzimática/efectos adversos , Proteínas de Escherichia coli/efectos adversos , Humanos , Inyecciones Intramusculares , Polietilenglicoles/efectos adversos , Guías de Práctica Clínica como Asunto , Leucemia-Linfoma Linfoblástico de Células Precursoras/sangre , Leucemia-Linfoma Linfoblástico de Células Precursoras/metabolismo , Estados UnidosRESUMEN
The aim of this study was to elucidate effects of systemic enzymotherapy on the clinical course of infectious endocarditis and the frequency of thromboembolic complications in drug addicts compared with controls. Another objective was to develop an optimal regime of enzymotherapy depending on the severity of the disease. Inclusion of wobenzyme in the combined treatment of infectious endocarditis permitted to accelerate the achievement of clinical improvement, normalize blood rheologic characteristics, reduce severity of intoxication and systemic inflammation, decrease the frequency of septic thromboembolia of the pulmonary artery.