Fulminant Cases Research Articles

Fulminant antiphospholipid antibody syndrome complicated by Aspergillus tracheobronchitis

Aspergillus fumigatus is a filamentous mold that causes infections in patients who are inmmunocompromised. We report a case of Aspergillus tracheobronchitis in fulminant systemic lupus erythematosus case. Diagnosis with more invasive diagnostic procedures & aggressive antifungal therapy is indicated at early stage.

Comparison of the Clinical Presentation, Treatment, and Outcome of Fulminant and Acute Myocarditis in Children

Myocarditis (MC) is an important cause of cardiac dysfunction in children. Fulminant MC is sometimes fatal, and sequelae may develop during follow-up. We conducted a nationwide survey to determine the clinico-epidemiological features of MC in Japanese children and adolescents. Survey questionnaires were mailed to 627 hospitals, which were asked if they had treated MC patients aged between 1 month and 17 years during the period from January 1997 through December 2002. Responses were collected until December 2005, and data were collected and analyzed until January 2008. A total of 169 patients were reported: 64 fulminant cases, 89 acute cases, and 8 chronic cases. Incidence was 43.5 cases/year and 0.26 cases/100,000. Pathogens were identified in 37 patients; coxsackie virus accounted for 60%. Major cardiovascular manifestations at onset were congestive heart failure, refractory arrhythmia, and syncope in 70, 37, and 17 patients, respectively. Intravenous immunoglobulin was administered to 73 patients. Mechanical support seemed to be effective and life-saving. Among the 169 patients, 123 survived. Cardiovascular sequelae were reported in 49 patients. The survival rate for children with fulminant MC was disappointing. Overall, two-thirds of survivors had no sequelae. Mechanical support may reduce the mortality and the risk of clinical worsening.

Development and evaluation of an ovine antibody-based platform for treatment of Clostridium difficile infection.

Treatment of Clostridium difficile is a major problem as a hospital-associated infection which can cause severe, recurrent diarrhea. The currently available antibiotics are not effective in all cases and alternative treatments are required. In the present study, an ovine antibody-based platform for passive immunotherapy of C. difficile infection is described. Antibodies with high toxin-neutralizing titers were generated against C. difficile toxins A and B and were shown to neutralize three sequence variants of these toxins (toxinotypes) which are prevalent in human C. difficile infection. Passive immunization of hamsters with a mixture of toxin A and B antibodies protected them from a challenge with C. difficile spores in a dose-dependent manner. Antibodies to both toxins A and B were required for protection. The administration of toxin A and B antibodies up to 24 h postchallenge was found to reduce significantly the onset of C. difficile infection compared to nonimmunized controls. Protection from infection was also demonstrated with key disease isolates (ribotypes 027 and 078), which are members of the hypervirulent C. difficile clade. The ribotype 027 and 078 strains also have the capacity to produce an active binary toxin and these data suggest that neutralization of this toxin is unnecessary for the management of infection induced by these strains. In summary, the data suggest that ovine toxin A and B antibodies may be effective in the treatment of C. difficile infection; their potential use for the management of severe, fulminant cases is discussed.

Isolation of Sochi Virus From a Fatal Case of Hantavirus Disease With Fulminant Clinical Course

Sochi virus, a novel genetic variant of Dobrava-Belgrade virus, was isolated in cell culture from a fulminant lethal case of hantavirus disease presenting with shock and combined kidney and lung failure. Sochi virus is transmitted to humans from host reservoir Apodemus ponticus and must be considered a life-threatening emerging agent.

Transjugular Liver Biopsy in Acute Hepatitis: The Importance of Histology Assessment

Purpose: Acute hepatitis of unknown etiology (including possible drug related hepatitis and in some cases of acute liver failure) as been an indication for liver biopsy and when evolving with significant coagulation disorders (prolonged prothrombin or low platelets) the transvenous approach is recommended for its safety and diagnostic yield. Methods: From a series of 1200 consecutive procedures in 18 years, we have analyzed the importance of the assessment of liver histology for the management of acute liver disease patients. The first 350 procedures were performed with TJ Henriksen aspiration needle and Quick-Core® (Tru-Cut type for the following 850 cases). We considered for this analyses only patients without previous known chronic liver disease (such as alcoholic cirrhosis with superimposed alcoholic hepatitis). Patients were referred for confirmation of a suspected diagnosis except in 49 fulminant hepatic failure cases were transjugular liver biopsy (TLB) was requested to assess the percentage of hepatocellular necrosis and reticular collapse, in order to promote or disregard OLT. Results: In all 138 cases (78 females, 60 males; mean age 43 years (13-77 years old)) histology was available and adequate to confirm a diagnosis. Beyond fulminant cases (49), drug induced liver disease accounted for 27 patients, hematological disorders in 23, autoimmune hepatitis in 13, acute wilson in 8, acute fatty liver of pregnancy in 8, sepsis in 7 and acute viral hepatitis (A, C and CMV) with immune bizarre features in 3. Complication directly related to the procedure were 5 (4 cervical hematomas, because of venous oozing and 1 transient auricular arrythmia). Conclusion: TLB had a significant role in allowing a thorough diagnosis in cases of acute hepatitis evolving with coagulation disorders. Drug induced liver disease, autoimmune hepatitis, along with referrals from Hematology and Obstetric department accounted for the majority of cases.

Clinicopathological considerations in acute disseminated encephalomyelitis (ADEM): a fulminant case with favorable outcome

We report the clinical course and pathological features of a 52-year-old woman with fulminant acute disseminated encephalomyelitis (ADEM). She presented with subacute tetraparesis, which developed over 2 days, and progressive loss of consciousness. CCT showed pronounced bihemispherical and periventricular edema. Multifocal glioma was suspected, and the patient was referred for brain biopsy to the neurosurgery department at our hospital. On admission, the patient presented with progressive tetraparesis and aphasia. Subsequently, she developed epileptic seizures. Cranial magnetic resonance imaging (MRI) revealed confluent bihemispherical and periventricular white matter edema (Fig. 1a) with abnormal patchy gadolinium enhancement, compatible with progressive multifocal leukoencephalopathy (PML), multifocal brain tumor or ADEM. Cerebrospinal fluid (CSF) analysis revealed mild pleocytosis (11 cells/ll) with increased protein levels, and normal glucose and lactate levels. No intrathecal IgG and IgM synthesis or oligoclonal bands (OCB) were observed in CSF. Antiviral and antibiotic treatment was initiated. Stereotactic brain biopsy from right frontal periventricular white matter (Fig. 1b) was performed 5 days after disease onset. Histopathology ruled out malignant brain tumor but showed acute perivascular inflammation.

Hepatitis A Infection in Recent International Adoptees and Their Contacts in Minnesota, 2007–2009

The goal of this study was to describe hepatitis A-infected adoptees and the risk of transmission to their contacts. This was a retrospective review of adoptee-associated cases of hepatitis A and hepatitis A-infected adoptees identified in Minnesota from 2007 through 2009. From 2007 through 2009 in Minnesota, 10 cases of hepatitis A, including 1 fulminant case, were associated with international adoptees. Eight cases were direct contacts of a hepatitis A-infected adoptee, and 2 other cases secondary contacts of an adoptee. During the same period, hepatitis A infection was identified in 21 recently arrived foreign-born adoptees; all were younger than 60 months of age, and only 6 were symptomatic. Clinicians should be aware that transmission of hepatitis A may occur among both direct and secondary contacts of young children recently adopted from hepatitis A-endemic areas and that infected young children may be asymptomatic. Household members and other close contacts of international adoptees should be counseled about hepatitis A prevention, including vaccination. In addition, screening for hepatitis A should be considered for recently arrived adoptees from endemic areas.

Overwhelming postsplenectomy infection due to Mycoplasma pneumoniaein an asplenic cirrhotic patient: Case report

BackgroundMycoplasma pneumoniae infection is usually self-limited, but some fulminant cases are fatal, even when occurring in previously healthy individuals. It can also be the cause of overwhelming postsplenectomy infection (OPSI).Case presentationWe report a case of OPSI in a 41-year-old woman with hypersplenism associated with hepatitis B cirrhosis. We detected a significant Mycoplasma pneumoniae agglutination titer, but no evidence of infection with Chlamydia pneumoniae, Legionnella spp., or any other bacterial or fungal pathogens. She eventually died despite aggressive therapy.ConclusionsM. pneumoniae could be an underestimated cause of OPSI, and should be suspected in fulminant infectious cases in asplenic patients.

Immunological and molecular epidemiological characteristics of acute and fulminant viral hepatitis A.

BackgroundHepatitis A virus is an infection of liver; it is hyperendemic in vast areas of the world including India. In most cases it causes an acute self limited illness but rarely fulminant. There is growing concern about change in pattern from asymptomatic childhood infection to an increased incidence of symptomatic disease in the adult population.ObjectiveIn-depth analysis of immunological, viral quantification and genotype of acute and fulminant hepatitis A virus.MethodsSerum samples obtained from 1009 cases of suspected acute viral hepatitis was employed for different biochemical and serological examination. RNA was extracted from blood serum, reverse transcribed into cDNA and amplified using nested PCR for viral quantification, sequencing and genotyping. Immunological cell count from freshly collected whole blood was carried out by fluorescence activated cell sorter.ResultsFulminant hepatitis A was mostly detected with other hepatic viruses. CD8+ T cells count increases in fulminant hepatitis to a significantly high level (P = 0.005) compared to normal healthy control. The immunological helper/suppressor (CD4+/CD8+) ratio of fulminant hepatitis was significantly lower compared to acute cases. The serologically positive patients were confirmed by RT-PCR and total of 72 (69.2%) were quantified and sequenced. The average quantitative viral load of fulminant cases was significantly higher (P < 0.05). There was similar genotypic distribution in both acute and fulminant category, with predominance of genotype IIIA (70%) compared to IA (30%).ConclusionsImmunological factors in combination with viral load defines the severity of the fulminant hepatitis A. Phylogenetic analysis of acute and fulminant hepatitis A confirmed genotypes IIIA as predominant against IA with no preference of disease severity.

¿Cómo manejar al paciente con artritis reumatoide y serología virus de hepatitis B, hepatitis C, virus de la inmunodeficiencia humana?

Chronic viral infections in rheumatic patients are a diagnostic and therapeutic challenge. Some of the disease-modifying antirheumatic drugs (DMARD) commonly used in rheumatoid arthritis, such as methotrexate and leflunomide, are hepatotoxic. With biological therapy, which is now widely used in patients refractory to these and other DMARD, some cases of reactivation of hepatitis B, even fulminant cases, have been reported, especially when employing TNF antagonists and rituximab, so their use must be carefully assessed and usually accompanied by antiviral therapy. However, there have not been reports of reactivation of hepatitis C after immunosuppressive therapy. In patients with HIV infection, administration of immunosuppressive therapy carries a high risk of opportunistic infections, although the new highly active antiviral therapy allows the use of some drugs in selected cases.

392 SPECIFIC HBSAG GENETIC-DETERMINANTS ARE ASSOCIATED WITH OCCULT HBV-INFECTION IN VIVO AND HBSAG-DETECTION

Background and Aim: Measuring serum HBVDNA levels after diagnosing acute hepatitis B is not a routine procedure. Its kinetics, however, could have a significant prognostic importance for the future development of the infection. The aim of our study is to detrmine whether HBVDNA levels could have prognostic value as far as the outcome of the infection is concerned: self-limited disease, fulminant or self-limited infection Material and methods: Our study included a dynamic examination of HBVDNA in 45 patients with acute HBV infection with different outcome – recovery, protrached course and fulminant hepatitis as two forms that differ from the self-limited HBV infection. HBVDNA was measured on the 1, 2, 7, 30, 60, 90, 180 day after admission to the hospital using Taq Man HBVDNA Real-time PCR. Results: HBVDNA was found in all patients. In fulminant cases relatively high levels of HBVDNA were found from the very beginning (above 10,000,000 IU/ml) and they were HBeAg(−). In patients who recovered and became HBsAg(−) replication reached maximal levels in the beginning of the symptomatic phase. With the recovery form the symptoms it fell and its disappearance marked the fall of the ALT levels and negativation of the HBsAg. The fall of HBVDNA on the 7 day from the admission to the hospital and the following disappearance in the range of the 60 day proved to be predictive for the self-limited course. In patients with protrached hepatitis HBVDNA proved to be with relatively higher levels drom the beginning (p < 0.016, F = 6.196) especially in the HBeAg(+) cases. These levels persisted at the time of 90 and 180 day with following chronification. Conclusion: The follow-up of the replication showed, that in the majority of cases the elimination of the virus becomes in the first 2 months. The persistence of the viremia on the 60 day necessitates its further examination due to the risk of chronification. High risk for protrached course is observed in the anicteric HBeAg(+) cases with relatively high replication (above 100,000,000 IU/ml).

Virological and clinical characteristics on reactivation of occult hepatitis B in patients with hematological malignancy

The virological characteristics of hepatitis B virus (HBV) implicated in the reactivation of occult hepatitis B in patients who have received hematopoietic stem-cell transplantation or chemotherapy for the hematological malignancy are not well defined. Twenty-eight HBsAg-negative patients who received hematopoietic stem-cell transplantation and 138 HBsAg-negative patients treated for malignant lymphoma with chemotherapy including rituximab were enrolled. Three of the 28 patients (10.7%) received hematopoietic stem-cell transplantation and one of the 138 (0.72%) patients treated for malignant lymphoma with chemotherapy developed de novo HBV hepatitis. Anti-HBc was detected in four and anti-HBs in two patients. Genotype Bj was detected in two and C in two of they all possessed wild-type sequences in the core promoter region. A precore stop mutation (A1896) was detected in a patient with genotype Bj who developed fulminant hepatic failure. HBV DNA was detected in pretreatment HBsAg-negative samples in two of four patients, and the HBV genome sequence identified from sera before chemotherapy and at the time of de novo HBV hepatitis showed 100% homology. In an in vitro replication model, genotype Bj with the A1896 clone obtained from a fulminant case had a replication level much higher than clones obtained from de novo hepatitis B patients with genotype Bj or C with G1896. In conclusion, this is the first report demonstrating de novo hepatitis B from the reactivation of occult HBV infection confirmed by molecular evolutional analysis. The fulminant outcome of HBV reactivation can be associated with genotype Bj exhibiting high replication due to the A1896 mutation.

How does one manage patients with rheumatoid arthritis and positive serology to hepatitis B, hepatitis C, human immunodeficiency virus?

Chronic viral infections in rheumatic patients are a diagnostic and therapeutic challenge. Some of the disease-modifying antirheumatic drugs (DMARD) commonly used in rheumatoid arthritis, such as methotrexate and leflunomide, are hepatotoxic. With biological therapy, which is now widely used in patients refractory to these and other DMARD, some cases of reactivation of hepatitis B, even fulminant cases, have been reported, especially when employing TNF antagonists and rituximab, so their use must be carefully assessed and usually accompanied by antiviral therapy. However, there have not been reports of reactivation of hepatitis C after immunosuppressive therapy. In patients with HIV infection, administration of immunosuppressive therapy carries a high risk of opportunistic infections, although the new highly active antiviral therapy allows the use of some drugs in selected cases.

Fulminant necrotizing fasciitis following the use of herbal concoction: a case report

IntroductionNecrotizing fasciitis is a rare and life-threatening rapidly progressive soft tissue infection. A fulminant case could involve muscle and bone. Necrotizing fasciitis after corticosteroid therapy and intramuscular injection of non-steroidal anti-inflammatory drugs has been reported. We present a case of fulminant necrotizing fasciitis occurring in a patient who used a herbal concoction to treat a chronic leg ulcer.Case presentationA 20-year-old Ibo woman from Nigeria presented with a three-year history of recurrent chronic ulcer of the right leg. She started applying a herbal concoction to dress the wound two weeks prior to presentation. This resulted in rapidly progressive soft tissue necrosis that spread from the soft tissue to the bone, despite aggressive emergency debridement. As a result she underwent above-knee amputation.ConclusionThe herbal concoction used is toxic, and can initiate and exacerbate necrotizing fasciitis. Its use for wound dressing should be discouraged.

Pneumatosis intestinalis after liver transplantation

To evaluate clinical features and CT findings of pneumatois intestinalis in recipients following liver transplantation and to determine whether certain clinical and CT findings enable differentiation of indolent pneumatois intestinalis from fulminant cases. This retrospective study was approved by our institutional review board, with informed consent waived. Among 2080 liver transplantation recipients at our institution between January 1998 and April 2008, 22 (1%) presented with pneumatois intestinalis on postoperative follow-up. Patients were divided into recovery and mortality groups, and then clinical features and CT findings were compared between two groups. Although indolent pneumatois intestinalis more frequently presented incidentally (61%) after 2 weeks of surgery (89%) than fulminant pneumatois intestinalis (0, 50%), there were no statistically significant differences (P=.14, .09). Right colon was affected in the recovery group without exception (n=18,100%), and all four patients (100%) in mortality group showed small bowel involvement (P<.05). Caliber changes of superior mesenteric artery and vein in mortality group were significantly greater (49.6%, 67.0%) than those in recovery group (101.7%, 99.0%) (P<.05, respectively). Pneumatois intestinalis in mortality group more commonly accompanied portomesenteric air-embolism, visceral infarction, hemorrhagic ascites, and small bowel ileus than indolent counterpart (P<.05, respectively). Typical indolent pneumatois intestinalis is found incidentally later than 2 weeks of liver transplantation surgery, but there is some overlap between indolent and fulminant pneumatois intestinalis in terms of onset and mode of presentation. Among CT findings, grave signs are small bowel involvement, caliber changes in mesenteric vessels, portomesenteric air-embolism, visceral infarction, hemorrhagic ascites, and small bowel ileus.

NEONATAL FULMINANT TYPE 2 INFANTILE HEPATIC HEMANGIOENDOTHELIOMA INVOLVING SKIN, VISCERA AND SOFT TISSUE

We present the fulminant case of a neonate whose symptoms, lesions, imaging, and laboratory tests perfectly simulated a neonatal neuroblastoma and the definitive diagnosis was finally given by necropsy as follows: Infantile hepatic hemangioendothelioma type 2 with extrahepatic extension affecting skin, lung, intestine, suprarenal, and soft tissue.

Phylogenetic analysis and subtyping of acute and fulminant strains of hepatitis E virus isolates of North India with reference to disease severity

Hepatitis E is endemic to the Indian subcontinent, with a seroprevalence of 4-20%, and more than 25% of acute viral hepatitis is due to HEV. The northern parts of India have been experiencing outbreaks and sporadic cases of HEV since 1955. In a total of sixteen HEV sequences, ten acute viral hepatitis and 6 fulminant hepatic failure cases were analysed. Subtypes 1a and 1c of HEV are prevalent in North India, with the subtype-1c showing a trend towards fulminancy.

Pulmonary melioidosis in febrile neutropenia: the rare and deadly duet

We present the first two fulminant cases of pulmonary melioidosis in febrile neutropenic patients with acute and varied presentations seen in our institution and their fatal outcome. A high index of suspicion coupled with microbiological confirmation can facilitate the administration of the appropriate therapy in cases of melioidosis that differ from other bacterial infections in terms of presentation and the response to antimicrobials.

High-resolution Computed Tomography Findings in Hantavirus Pulmonary Syndrome

The hantavirus pulmonary syndrome (HPS) is an acute, rapidly progressive disease transmitted by rodent excreta, with endothelial damage playing a central role in the pathophysiology. It usually affects rural workers. The lung itself is the target organ and reflects all the patterns of endothelial involvement of this disease. The radiologic findings of HPS are vast and range from a mild interstitial involvement to total obliteration of the airspaces with or without pleural effusion. There are no specific findings on high-resolution computed tomography in HPS; nevertheless, findings of thickening of interlobular septa, ground-glass opacities, and occasionally small ill-defined nodular opacities have been described. The authors report a fulminant case of HPS and discuss its varied high-resolution computed tomography findings. To our knowledge, the "crazy-paving" pattern has not been seen previously in such cases.

A fulminant case of acute respiratory distress syndrome associated with Mycoplasma pneumoniae infection

Acute respiratory distress syndrome (ARDS) caused by mycoplasmas is very rare. This report describes a severe case of atypical pneumonia due to M. pneumoniae in a formerly healthy young woman who developed high grade fever and cough leading to severe disseminated lung disease and finally to fatal ARDS. This case came into picture when killer atypical pneumonia, namely, SARS (severe acute respiratory syndrome), spread very fast from South-Asian countries to the rest of the world. Moreover, the clinical presentation and radiologic features of SARS bear resemblance to the syndrome of atypical pneumonia, which lead us to investigate this case into detail. We suggest that M. pneumoniae infections should be included in the differential diagnosis of pathogens causing ARDS, establishing an early diagnosis may have important therapeutic implications.