Hendrik E. Demey

Herpes simplex virus in the respiratory tract of critical care patients: a prospective study

BACKGROUND Herpes simplex virus (HSV) is occasionally detected in the lower respiratory tract of patients in intensive care, but its clinical importance in such situations remains unclear. We did a prospective cohort study to define the prevalence, origin, risk factors, and clinical relevance of HSV in the respiratory tract of patients undergoing critical care. METHODS We tested 764 patients admitted to intensive care for the presence of HSV in the respiratory tract, and assessed statistical relations between this virus and clinical variables. FINDINGS HSV was detected by oropharyngeal swab in the upper respiratory tract of 169 (22%) of 764 patients, within 10 days of admission for 150 (89%) of these individuals. The virus was isolated in 58 (16%) of 361 patients whose lower respiratory tract was sampled. The presence of HSV in the throat was a risk factor for development of HSV infections in the lower respiratory tract (p<0.001). HSV was isolated most frequently in patients with severe disease. HSV in the throat was associated with acute respiratory distress syndrome (p<0.001) and with increased length of stay in intensive care (p<0.001). INTERPRETATION Our data suggest that HSV reactivation or infection of the upper respiratory tract is frequent among patients in intensive care, and is a risk factor for development of lower respiratory tract infection with this virus, possibly by means of aspiration.

Propylene glycol-induced side effects during intravenous nitroglycerin therapy

Propylene glycol, an alcohol frequently used as a solvent in medical preparations, is considered non-toxic. We found that this solvent, used in a commercially available IV nitroglycerin solution, may cause hyperosmolality, hemolysis and lactic acidosis. The influence of kidney function as the main determinant in causing accumulation of this solvent and consequently hyperosmolality is emphasized. A review of the literature dealing with propylene glycol is given. The possible mechanisms of neurological disturbances occurring during IV nitroglycerin therapy are discussed.

Unusual D‐Lactic Acid Acidosis from Propylene Glycol Metabolism in Overdose

Objective: To report a case of D‐lactic acid acidosis owing to massive oral ingestion of propylene glycol. Case Report: A 72‐year old man with known congestive failure was admitted to the ICU with encephalopathy. Twelve hours prior to admission he had erroneously ingested a large amount of propylene glycol (PG). The laboratory revealed high anion gap (anion gap = 27 meq/l) acidosis (arterial pH = 7.16) and an increased osmolal gap. Toxicological analysis revealed a low serum propylene glycol level. Biochemical analysis indicated that very high amounts of D‐lactic acid (up to 110 mmol/l), but not of the usual type of L‐lactic acid, were responsible for the metabolic acidosis. Hemodialysis was initiated and associated with a decline of both the acidosis and D‐lactic acid levels. The patient regained conciousness. Conclusion: Ingestion of massive doses of propylene glycol, previously not reported as a cause of D‐lactic acidosis, should be added to the differential diagnosis of this rare condition.

Exchange blood transfusion in severe falciparum malaria: retrospective evaluation of 61 patients treated with, compared to 63 patients treated without, exchange transfusion.

The rationale for exchange blood transfusion (ET) in severe falciparum malaria is threefold: reduction of parasitaemia, reduction of presumptive ‘toxic’ factors, and improvement of the rheological quality of the blood. We evaluated the records of 61 patients treated with ET to describe the present status of malaria treatment in Germany, Austria and Switzerland and to assess the efficacy of ET. Clinical data of 61 patients treated with ET were compared to data of 63 patients treated in 2 hospitals where ETs were generally not performed. We found that exchange transfusion is applied according to the clinician’s subjective impression rather than strict guidelines. Logistic regression analysis adjusting for the differences in clinical parameters between patients treated with or without ET did not identify treatment as a prognostic indicator (odds ratio for relative risk of death with ET: 1.3; 95% CI: 0.4–4.9). Exchange transfusion did not significantly improve the unfavourable prognosis in cases of severe falciparum malaria. However, failure to reach statistical significance may be due to the retrospective design of the study and therefore non‐systematic approach.

Meningoencephalitis caused by **Streptococcus pneumoniae**: a diagnostic and therapeutic challenge. Diagnosis with diffusion-weighted MRI leading to treatment with corticosteroids

Streptococcus pneumoniae is a common cause of bacterial meningitis but only rarely causes other infections such as brain abscess, encephalitis, encephalomyelitis or meningoencephalitis. We report on three adult patients with meningoencephalitis caused by S. pneumoniae. In all three, CT and MRI revealed widespread brain lesions, suggesting extensive parenchymal injury. Diffusion-weighted MRI showed lesions with restricted diffusion, reflecting local areas of ischaemia with cytotoxic oedema secondary to an immunologically mediated necrotising vasculitis and thrombosis. High levels of markers of neuronal, glial and myelin damage were found in the cerebrospinal fluid. According to the literature, brain parenchyma lesions in adults with pneumococcal meningoencephalitis are often associated with death or severe neurological deficit. Our patients were treated with pulse doses of glucocorticoids: this resulted in dramatic clinical improvement and an excellent final neurological recovery.

Prehospital thrombolytic treatment of acute myocardial infarction with anisoylated plasminogen streptokinase activator complex.

In cooperation with a group of general practitioners (GP), we investigated the possible risk and benefit of prehospital initiation of thrombolytic therapy in acute myocardial infarction (AMI) with anisoylated plasminogen streptokinase activator complex (APSAC) at the patients home. During a 14-month period, 58 patients with suspected AMI were evaluated by their GP using a protocol with strict inclusion and exclusion criteria. The GP alerted a special mobile intervention team which administered APSAC at home in 13 of the 19 patients. Coronary reperfusion was achieved in ten of these 13 patients. Apart from short and easily treated episodes of bradycardia and/or hypotension after the injection of the thrombolytic drug in four of 13 patients, no major adverse events were noted in the early treatment period. The estimated time gain by treating the patient at home instead of starting the treatment in the coronary care unit was 46 +/- 14 min. Therefore, at-home initiation of thrombolytic treatment seems feasible, fast, and safe.

Selective ambulatory management of imported falciparum malaria: a 5-year prospective study

The ambulatory management of imported Plasmodium falciparum malaria is controversial because criteria for safe selection of patients are imprecise. The aim of the present study was to investigate the evolution and outcome of patients diagnosed with Plasmodium falciparum malaria at a Belgian referral institute in order to assess the safety of the institute’s current selective ambulatory management protocol. From 2000 to 2005, all patients diagnosed with P. falciparum infection at the Institute of Tropical Medicine and the University Hospital of Antwerp were enrolled prospectively. Ambulatory treatment was offered to nonvomiting patients if they exhibited none of the 2000 World Health Organization criteria of severity and had parasitemia below 1% at the initial assessment. The treatment of choice was quinine (plus doxycycline or clindamycin) for inpatients and atovaquone-proguanil for outpatients. P. falciparum malaria was diagnosed in 387 patients, of whom 246 (64%) were Western travelers or expatriates and 117 (30%) were already on antimalarial therapy. At diagnosis, 60 (15%) patients had severe malaria. Vital organ dysfunction was initially seen in 34 and developed later in five others. Five patients died. Of the 327 patients initially assessed as having uncomplicated malaria, 113 (35%) were admitted immediately; of these, 4 developed parasitemia ≥5% at a later stage but without any clinical consequence. None of the 214 individuals initially treated as outpatients experienced any malaria-related complications, including 10 who were admitted later. Vital organ dysfunction was observed in only 2 of the 214 patients with initial parasitemia <1% who had not taken antimalarial agents (both patients had impaired consciousness at presentation). Ambulatory treatment is safe in treatment-naive malaria patients with parasitemia <1% who do not vomit and who do not exhibit any criteria of severe malaria.

Acute poisoning with amphetamines (MDEA) and heroin: antagonistic effects between the two drugs

A case of oral ingestion of large doses of both the amphetamine-derivative 3,4-methylene dioxyethamphetamine (MDEA) and heroin is reported. Despite high serum levels of both drugs, the patient did not present with the classic signs and symptoms normally seen during intoxication with these drugs. The patient recovered after symptomatic treatment. The possibility that opposite pharmacological properties of the two drugs prevented the patients death is discussed.

A cluster of airport malaria in Belgium in 1995

In Europe 64 cases of airport malaria have been registered between 1969 and 1996, most of them in France, Switzerland and Belgium. In the summer of 1995 six cases of airport malaria occurred at the International airport of Brussels, Belgium. Of the six patients three were airport employees, three were occasional visitors. One patient died, the diagnosis was made by PCR amplification and DNA sequencing after exhumation. Two different species of Plasmodium were detected, and infections occurred on at least two different floors of the airport. An inquiry revealed that the cabin of airplanes is correctly sprayed, according to WHO recommendations, but that the inside of the hand luggage, the cargo hold, the animal compartment, the wheel bays and container flights remain possible shelters for infected mosquitoes. In a case of fever of unknown origin, airport malaria should be considered in the differential diagnosis, especially during hot summers, and when thrombocytopenia is present. Additional antimosquito measures should be generalised, encompassing highly exposed personnel, container content and handling buildings, animal cages, wheel bays, and the boundary between the sorting and the reception of luggage.

Mastitis and Toxic Shock Syndrome

Toxic shock syndrome (TSS) secondary to mastitis or breast abscess is only seldom described. We report a case of definite TSS due to postpartum staphylococcal mastitis which evolved over a period of 3 weeks to a breast abscess, recurring after 2 months. Only the episode of acute mastitis was complicated with TSS, while Staph. aureus could be isolated during the period of mastitis from milk and during drainage of the second breast abscess.