Chian Min Loo

Severe adenovirus pneumonia requiring extracorporeal membrane oxygenation support – Serotype 7 revisited

INTRODUCTION Adenovirus causing severe fatal pneumonia has been well described in infants, children, and patients with immunocompromised function, but reports in previously healthy adults are rare. We report 3 cases of severe adenovirus pneumonia in whom conventional mechanical ventilation failed and required extracorporeal membrane oxygenation support. METHODS Retrospective case records review of 3 patients admitted to the medical intensive care unit, Singapore General Hospital, a tertiary care university-affiliated hospital, with severe adenovirus pneumonia requiring extracorporeal membrane oxygenation support from February to March 2013. RESULTS All 3 patients were previously healthy immunocompetent adults from the community with negative HIV serology. Duration prior to development of respiratory failure requiring intubation and invasive mechanical ventilation was 2, 8 and 3 days. Veno-venous extracorporeal membrane oxygenation (ECMO) support as rescue ventilation was instituted in all 3 patients after 2, 16, and 5 days of conventional mechanical ventilator support. Duration on ECMO support was 16, 22, and 9 days and mechanical ventilation was 18, 62, and 19 days respectively. Length of stay in intensive care unit was 18, 68, and 21 days, and length of stay in hospital was 20, 70, and 31 days respectively. Two of the 3 patients died. CONCLUSION The mainstay of treatment for patients with severe adenovirus pneumonia is still supportive, with the use of antivirals not apparently effective. Whilst ECMO support for rescue ventilation may be considered, the outcomes do not appear as promising as other viral pneumonias, mirroring that previously described in the paediatric population.

Factors associated with mortality among patients with active pulmonary tuberculosis requiring intensive care.

INTRODUCTION The aim of this study was to identify patient characteristics and risk factors associated with in-hospital mortality of patients with pulmonary tuberculosis (PTB) requiring intensive care unit (ICU) management. METHODS A retrospective chart review was conducted of all patients with active PTB admitted to the ICU at Singapore General Hospital, Singapore, between January 2005 and December 2010. RESULTS There were 2,155 patients with active PTB diagnosed, of whom 83 (3.9%) patients were admitted to the ICU, but eight were excluded because their admission to the ICU was unrelated to PTB. The most common comorbidities were diabetes mellitus (n = 23, 30.7%) and immunocompromised host (n = 25, 33.3%). A few (n = 4, 5.3%) of the patients had HIV coinfection. A majority (n = 67, 89.3%) of patients required mechanical ventilation and the mean duration of mechanical ventilation was 8.05 ± 14.43 days. Mean duration of ICU stay and hospital stay were 10.23 ± 15.8 days and 33.7 ± 50.7 days, respectively. In-hospital mortality was 62.7% (n = 47), and 36 of these patients died while in the ICU (ICU mortality, 48.0%). Univariate analysis identified ischaemic heart disease, low albumin, Acute Physiology and Chronic Health Evaluation score, disseminated intravascular coagulation, shock and multiorgan failure as significantly associated with mortality. Multivariate analysis showed that low albumin on the day of ICU admission was the only significant independent predictor of death (p = 0.033). CONCLUSION In-hospital mortality from active PTB requiring ICU admission was 62.7%, and low albumin was an independent predictor of mortality in this study.

A suspicious clot

A 72-year-old man presented with right-sided pleuritic chest pain, chronic cough and weight loss. Chest x ray revealed a moderate sized pleural effusion. Chest CT showed thromboembolism of the right main pulmonary artery, and pleural effusion with compression atelactasis of the right lower lobe of the lung (fig 1). As the thrombus appeared suspicious, being unilateral, central and occupying the entire lumen of the pulmonary artery without abnormality in the contralateral lung, magnetic resonance arteriography was performed which showed heterogeneous enhancement (fig 2). Positron …

Role of bronchoprovocation tests in identifying exercise-induced bronchoconstriction in a non-athletic population: a pilot study

BACKGROUND Studies on diagnostic tests for exercise-induced bronchoconstriction (EIB) have centered around the asthmatic and elite athletic population. Traditionally, the exercise challenge test (ET) was recommended to assess EIB. We aimed to compare the performance of surrogate testing, mainly the hypertonic saline (HS) test, and methacholine challenge test (MCT) versus ET in identifying EIB among non-athletic subjects. METHODS We prospectively recruited subjects who did not have confirmed active asthma, but who reported exercise-induced dyspnoea. The participants underwent HS and ET on separate days within two weeks. MCT performed within one year were obtained retrospectively from medical records. The sensitivity, specificity, and accuracy of each diagnostic test were calculated using ET as the gold standard. RESULTS We recruited 27 participants (mean age 20.6±2.5 years; 92.6% male). Five (18.5%) had a history of self-reported asthma prior to recruitment. Eleven participants (40.7%) had a positive ET test. The sensitivity, specificity and accuracy of HS in diagnosing EIB was 90.9%, 62.5% and 74.1%; while that of MCT was 88.9%, 83.3% and 85.7% respectively. Six subjects were positive to HS but had negative ET test. CONCLUSIONS Both HS and MCT were found to be suitable alternatives to ET in screening for EIB in the non-athletic population in this pilot study. Further large scale studies are required to confirm this finding. These tests have the potential to replace ET for the diagnosis of EIB in centres without ET equipment or facilities.