Marko Kutleša

Acute Motor Axonal Neuropathy Associated with Pandemic H1N1 Influenza A Infection

BackgroundGuillain–Barre syndrome (GBS) is a well known entity that has many infectious agents reported as antecedent events. The spectrum of GBS includes acute inflammatory demyelinating polyneuropathy (AIDP), acute motor axonal neuropathy (AMAN), acute motor sensory axonal neuropathy (AMSAN), and some other variants like Miller-Fisher syndrome (MFS).MethodsPatient with AMAN variant of GBS after severe bilateral pneumonia and ARDS due to the novel pandemic H1N1 influenza A virus is presented.Results28-year-old white female was admitted to our Intensive Care Unit during the influenza pandemic because of severe ARDS due to bilateral pneumonia. The course of the disease was complicated with the new onset tetraplegia due to the AMAN variant of GBS. Treatment with plasma exchange was conducted and the patient had satisfactory recovery.ConclusionWe report a case of AMAN variant of GBS associated with proven H1N1 influenza A infection. This virus has not been reported previously as the agent of antecedent infection that induced this disorder. Risk factors for other causes of ICU neuromuscular weakness are usually present in the ICU patients and should not be the reason for reluctance in active quest for GBS. Once the diagnosis of GBS is established or suspected the treatment with plasma exchange or intravenous immune globulin is indicated.

Induced hypothermia in adult community-acquired bacterial meningitis – more than just a possibility?

We present the case series of adult community-acquired bacterial meningitis treated with hypothermia. The major criteria for therapeutic hypothermia (TH) was impaired carbon dioxide reactivity (CO(2)R) assessed by Transcranial Doppler (TCD). In patients without temporal acoustic window, minor criteria (optic nerve sheath diameter ≥ 6.0 mm plus GCS ≤ 8) were required. According to our, although limited experience, the use of mild hypothermia in selected patients with community-acquired bacterial meningitis accompanied with appropriate monitoring could be a promising treatment tool.

Therapeutic Hypothermia for Adult Viral Meningoencephalitis

BackgroundDespite the advances in critical care, severe viral meningoencephalitis continues to impose high rates of morbidity and mortality. Consequently, new treatment strategies are needed and we present therapeutic hypothermia (TH) as one of the possible efficacious treatment tools.MethodsWe present the case series in an adult intensive care unit of a tertiary care hospital. Eleven patients suffering from severe viral meningoencephalitis were treated with hypothermia. The major indication for TH was severely impaired consciousness associated with carbon dioxide reactivity loss assessed by Transcranial Doppler. Besides from the established treatment, all the patients underwent TH. Mild hypothermia (rectal temperature of 32–34°C) was maintained with continuous veno-venous hemofiltration.ResultsMedian Glasgow coma scale score in our patients at admission was 8 (3–10) and median Acute Physiology and Chronic Health Evaluation score was 24 (12–32). The overall mortality rate was 9% (1/11). Among survivors, the outcome was favorable in five patients [Glasgow Outcome Scale score (GOS) 4–5]. Remaining five patients had severe residual neurological deficit (GOS 3). Median GCS at discharge was 15 (8–15). With respect to disease severity, the outcome in presented patients was generally satisfactory.ConclusionsOur results suggest that use of mild hypothermia in selected adult patients with viral meningoencephalitis could be a promising treatment tool.

Influenza A 2009 H1N1 encephalitis in adults with viral RNA in cerebrospinal fluid

Abstract We present 3 cases of influenza A 2009 H1N1 encephalitis occurring in adults, corroborated by viral genome detection in cerebrospinal fluid (CSF) and evidence of meningeal inflammation on brain histopathology. This paper emphasizes the possibility of viral detection in CSF and stresses the lack of an effective treatment for neurological manifestations of influenza.

Prospective observational cohort study of cerebrovascular CO2 reactivity in patients with inflammatory CNS diseases

The purpose of this study was to evaluate the significance of cerebrovascular CO2 reactivity (CO2 R) in the course and outcome of inflammatory central nervous system (CNS) diseases. Sixty-eight patients with inflammatory CNS diseases and 30 healthy volunteers were included in this prospective observational cohort study. The observational period was between January 2005 and May 2009. The CO2 R was measured by transcranial Doppler (TCD) ultrasound using the breath-holding method. We compared patients with normal CO2 R (breath-holding index [BHIm] ≥ 1.18 = BHIN group) with patients who showed impaired CO2 R (BHIm < 1.18 = BHIR group). We also analyzed the association of impaired CO2 R with the etiology, severity, and outcome of disease. When compared to the BHIN group, the patients from the BHIR group were older, had a heavier consciousness disturbance, experienced more frequent respiratory failure, and, subsequently, had worse outcomes. There were no fatalities among the 28 patients in the BHIN group. The comparison of subjects with bacterial and non-bacterial meningitis revealed no significant differences. The unfavorable outcome of disease (Glasgow Outcome Scale [GOS] score 1–3) was significantly more common in subjects with impaired CO2 R (62.5% vs. 10.7%). Logistic regression analysis was performed in order to establish the prognostic value of BHIm. The outcome variable was unfavorable outcome (GOS 1–3), while the independent variables were age, Glasgow Coma Scale (GCS) score, and BHIm. The age and BHIm showed the strongest influence on disease outcome. A decrease of BHIm for each 0.1 unit increased the risk of unfavorable outcome by 17%. Our study emphasizes the importance of CO2 R assessment in patients with inflammatory CNS diseases.

Chronic fungal meningitis caused by Aureobasidium proteae

We present a case of chronic meningitis due to the mold Aureobasidium proteae. Clinical features, the disease course, as well as the diagnostic methods and optimal treatment options are discussed. This case confirms the neuroinvasiveness of A. proteae and introduces it as a new human pathogen.

Moraxella lacunata: A rare cause of infective endocarditis

We describe the first case of Moraxella lacunata definite native valve endocarditis in a patient with previously normal mitral valves. The disease was complicated with embolizations of the brain and spleen. After 6 weeks of antimicrobial treatment, valvular replacement was performed. The clinical course and diagnostic findings suggest that Moraxella lacunata possesses high aggressiveness leading to progressive valvular destruction and embolizations.

Therapeutic hypothermia for severe adult Herpes simplex virus encephalitis.

SummaryDespite antiviral treatment and advances in critical care, the Herpes simplex encephalitis (HSE) still has a poor outcome in a significant portion of patients. In severe cases of HSE, reduced carbon dioxide reactivity is usually present and these patients don’t respond to the usual treatment of brain edema and intracranial hypertension. We present case series of patients with severe form of HSE treated with therapeutic hypothermia (TH) and describe in detail the indications, methods, and the rationale for its use.In this case series, patients presented with severely impaired consciousness and very high predicted death rate as measured by Glasgow coma scale and Acute Physiology and Chronic Health Evaluation (APACHE II) score respectively. According to our findings, TH in carefully selected patients with HSE holds promise as an adjunctive to the antiviral treatment.ZusammenfassungTrotz antiviraler Therapie und Fortschritten in der Intensivbehandlung hat die Herpes simplex Encephalitis (HSE) noch immer bei vielen Patienten eine schlechte Prognose. Bei schweren Fällen von HSE besteht häufig eine herabgesetzte CO2 Reaktivität. Diese Patienten sprechen auch häufig nicht auf die übliche Therapie des Hirnödems und des erhöhten intracraniellen Drucks an.Wir stellen eine Fallserie von Patienten mit schwerer Verlaufsform einer HSE vor, die mit Hypothermie behandelt wurden. Die Indikation, Methodik und Überlegung zur Durchführung dieser Therapie werden im Detail beschrieben. Unsere Patienten präsentierten sich mit tiefer Bewusstlosigkeit und hatten entsprechend der Glasgow Koma Skala und der APACHE II Bewertung eine hohe Wahrscheinlichkeit, zu sterben. Nach unseren Ergebnissen ist die therapeutische Hypothermie in sorgsam ausgesuchten Patienten mit HSE als Zusatz zur antiviralen Therapie vielversprechend.

Antibiotic resistance among nosocomial isolates in a Croatian intensive care unit--results of a twelve-year focal surveillance of nosocomial infections.

Abstract Continuous 12-year (1990-2001) focal surveillance of the antibiotic resistance among the most common nosocomial pathogens (Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter sp. and Staphylococcus aureus) in 1325 Intensive Care Unit patients was performed. The surveillance period was divided in three 4-year time intervals (1990-1993, 1994-1997 and 1998-2001) and the prevalence of resistance was compared between intervals. Specimens included blood, urine and respiratory tract specimens. The incidence and trends of resistance to six antibiotics showed inconsistent results. Aminoglycoside resistance decreased among K. pneumoniae isolates (gentamicin 83%, 72.7% and 49.6%; amikacin 50.9%, 51.5% and 18.2%) and Acinetobacter sp. strains (amikacin 77%, 63.4% and 58.2%) but increased in P. aeruginosa (amikacin 27.5%, 63.3% and 44.1%). Overall, resistance to ceftazidime, ciprofloxacin, and imipenem increased but imipenem resistance is still low, particularly among Acinetobacter sp. Isolates (0, 2.1% and 1.5%). However, imipenem resistance increased among P. aeruginosa (10.2%, 31.6%, 22.1%). The prevalence of methicillin resistance was high but did not change during the surveillance period (82.3%, 78.3% and 82.2%). The present study suggests a complex picture of the development of antibiotic resistance in a single ICU. Significant changes occur over time but they are unpredictable and do not show identical tendencies for different species and antibiotics.

The importance of pathogens in sepsis: Staphylococcus aureus story

Abstract Different pathogens cause different outcomes for patients with sepsis. They influence intensive care unit (ICU) mortality, ICU length of stay (ICU LOS) and the need for mechanical ventilation (MV). We undertook a retrospective data-based analysis over a 6-y period. Seventy-eight patients with methicillin-sensitive Staphylococcus aureus (MSSA) and 74 patients with Escherichia coli (EC) sepsis were included in the study. ICU mortality for the MSSA group was 32 (41.0%) vs 26 (35.1%) for the EC group (p = 0.506; OR 1.28, 95% CI 0.67–2.48). There was no significant difference in ICU LOS (MSSA group: median 7.5, interquartile range (IQR) 4–14 days and EC: median 5, IQR 3–13.5 days; p = 0.214). Need for MV in the MSSA group was present in 45 (57.7%) patients vs 43 (58.1%) in the EC group. Univariate analysis did not show that MSSA was independently associated with ICU mortality (p = 0.506). Logistic regression analysis showed that after adjustment for APACHE II, the chance of ICU death doubled in the MSSA group (odds ratio 2.166; 95% confidence interval 1.004–4.858). The odds for ICU admission were 8 times higher in MSSA patients. MSSA sepsis should be considered as an independent factor for ICU mortality after adjustment for APACHE II.