Fulminant Organ Failure Research Articles

Tickle Me ECMO…Differences and Outcomes Unearthed for Kids Requiring Extracorporeal Membrane Oxygenation in Severe Acute Respiratory Syndrome Coronavirus 2-Associated Disease.

Tickle Me ECMO…Differences and Outcomes Unearthed for Kids Requiring Extracorporeal Membrane Oxygenation in Severe Acute Respiratory Syndrome Coronavirus 2-Associated Disease.

Fulminant Herpes Pneumonia Postaortic Surgery with Known Ankylosing Spondylitis.

Herpes simplex virus (HSV) pneumonitis is rare after cardiac surgery. A 36-year-old gentleman with ankylosing spondylitis underwent emergency surgery for a complex aortic aneurysmal disease. Preoperative treatment of aortitis with antitumor necrosis factor and steroid medication and surgical stress including cardiopulmonary bypass potentially created an immunosuppressive state and reactivation of undiagnosed HSV. Rapid HSV pneumonia ensued, culminating in fulminant organ failure and mortality. HSV pneumonia should be considered postoperatively in patients with severe respiratory distress, especially if immunocompromised.

S2572 Post-Liver Transplantation Lymphoproliferative Disorder Presenting as Biliary Stricture

INTRODUCTION: A 63 year-old man with non-alcoholic steatohepatitis (NASH) cirrhosis who underwent orthotopic liver transplant (OLT) presented 1 year later with obstructive jaundice due to a biliary stricture. Further investigation revealed encasement of the bile duct by a tumor, later determined to be post-transplant lymphoproliferative disorder (PTLD). PTLD represents a rare cause of post-OLT biliary stricture. CASE DESCRIPTION/METHODS: Post-transplant course was complicated by Grade 2 acute rejection, necessitating high-intensity immunosuppression. He later developed laboratory derangements, intermittent fevers, weight loss, and sweating episodes which were ascribed to active cytomegalovirus (CMV) and Epstein-Barr Virus (EBV) viremia. One year post-transplantation, an acute elevation in total bilirubin prompted an MRCP which revealed a soft tissue mass arising from segment VIII of the liver, extending into the porta hepatis and encasing the common bile duct at the surgical anastomosis. Biopsy showed diffuse large B cell lymphoma, later classified as stage IV disease with diffuse lymph node and bony metastasis. His tacrolimus was discontinued and systemic chemotherapy with R-CHOP was initiated. DISCUSSION: PTLD includes a heterogenous group of lymphoproliferative disorders that occur after solid organ or allogenic hematopoietic stem-cell transplantation, generally in the setting of EBV. PTLD may occur in up to 5.5% of adults following liver transplant. The clinical presentation of PTLD is heterogenous, and may range from incidental findings to fulminant organ failure. Treatment for PTLD consists of reduction of immunotherapy and systemic chemotherapy regimens, such as R-CHOP. Biliary complications after OLT are reported in up to 40% of cases, and usually involve biliary strictures. Biliary strictures are classified as anastomotic or non-anastomotic and are usually secondary to vascular or surgical complications. Post-OLT biliary stricture resulting from PTLD is quite rare. This case demonstrates the difficulties of prevention and diagnosis of PTLD-related biliary stricture. The presence of acute rejection necessitated high-intensity immunosuppression, which predisposed the patient to both CMV and EBV. These active viral infections were used to explain persistent “B symptoms” and abnormal laboratory findings that may have actually been the direct result of PTLD. This case illustrates the need to consider PLTD-related biliary stricture in any post-OLT transplant patient presenting with obstructive jaundice.Figure 1.: This demonstrates an isointense mass on T2-weighted imaging, which involves hepatic segment 8 and extends towards the porta hepatis with resultant stricture of the post-transplant biliary anastomosis and subsequent intrahepatic biliary dilatation.Figure 2.: On diffusion weighted imaging, the mass demonstrates marked diffusion restriction, with corresponding low signal on ADC.Figure 3.: 18F-FDG PET demonstrates intense FDG uptake within the mass, with multifocal hypermetabolic metastatic disease involving several lymph node groups as well as multiple osseous structures.

Legalon® SIL: The Antidote of Choice in Patients with Acute Hepatotoxicity from Amatoxin Poisoning

More than 90% of all fatal mushroom poisonings worldwide are due to amatoxin containing species that grow abundantly in Europe, South Asia, and the Indian subcontinent. Many cases have also been reported in North America. Initial symptoms of abdominal cramps, vomiting, and a severe cholera-like diarrhea generally do not manifest until at least six to eight hours following ingestion and can be followed by renal and hepatic failure. Outcomes range from complete recovery to fulminant organ failure and death which can sometimes be averted by liver transplant. There are no controlled clinical studies available due to ethical reasons, but uncontrolled trials and case reports describe successful treatment with intravenous silibinin (Legalon® SIL). In nearly 1,500 documented cases, the overall mortality in patients treated with Legalon® SIL is less than 10% in comparison to more than 20% when using penicillin or a combination of silibinin and penicillin. Silibinin, a proven antioxidative and anti-inflammatory acting flavonolignan isolated from milk thistle extracts, has been shown to interact with specific hepatic transport proteins blocking cellular amatoxin re-uptake and thus interrupting enterohepatic circulation of the toxin. The addition of intravenous silibinin to aggressive intravenous fluid management serves to arrest and allow reversal of the manifestation of fulminant hepatic failure, even in severely poisoned patients. These findings together with the available clinical experience justify the use of silibinin as Legalon® SIL in Amanita poisoning cases.