The emerging syndrome of envenoming by the New Guinea small-eyed snake Micropechis ikaheka

The New Guinea small-eyed or Ikaheka snake, <it>Micropechis ikaheka</it>, which occurs throughout New Guinea and some adjacent islands, is feared by the indigenes. The first proven human fatality was in the 1950s and this species has since been implicated in many other cases of severe and fatal envenoming. Reliable attribution of envenoming to this species in victims unable to capture or kill the snake recently became possible by the use of enzyme immunoassay. Eleven cases of proven envenoming by <it>M. ikaheka</it>, with two fatalities, were identified in Papua New Guinea and Irian Jaya. Five patients showed no clinical signs of envenoming by other Australasian elapids: mild local swelling, local lymphadenopathy, neurotoxicity, general myalgia, spontaneous systemic bleeding, incoagulable blood and passage of dark urine (haemoglobinuria or myoglobinuria). Two patients developed hypotension and two died of respiratory paralysis 19 and 38 h after being bitten. <it>In vitro</it> studies indicate that the venom is rich in phospholipase A2, is indirectly haemolytic, anticoagulant and inhibits platelets, but is not procoagulant or fibrinolytic. It shows predominantly post-synaptic neurotoxic and myotoxic activity. Anecdotally, Commonwealth Serum Laboratories' (CSL) death adder antivenom has proved ineffective whereas CSL polyvalent antivenom may be beneficial. Anticholinesterase drugs might prove effective in improving neuromuscular transmission and should be tested in patients with neurotoxic envenoming.      

Predictors of outcome in Cryptococcus neoformans var. gattii meningitis

In Papua New Guinea, <it>Cryptococcus neoformans</it> var. <it>gattii</it> meningitis has a high fatality rate even in immunocompetent patients. Our retrospective study attempted to identify marker of poor prognosis. Of 88 immunocompetent patients, 30 (34.1%) died, usually soon after admission, and mortality was higher in men (<it>p</it> = 0.025) and older patients (<it>p</it> = 0.039). Death was associated with altered consciousness (<it>p</it>&lt;0.001), a history of convulsions prior to treatment (<it>p</it> = 0.002) and a maximum systolic blood pressure of &gt;150 mmHg (<it>p</it> = 0.017). These data suggest that death results from raised intracranial pressure and subsequent tentorial herniation. However, CSF opening pressure measured on admission was raised in 29/36 (81%) patients and did not predict outcome. In survivors, relapse was uncommon and was not predicted by discharge serum cryptococcal antigen titres, which were frequently raised on completion of therapy in asymptomatic patients. Mortality may be reduced if efforts are made to lower intracranial pressure in those patients who present with markers of poor prognosis.      

Autoantibodies against bactericidal/permeability-increasing protein in patients with cystic fibrosis

Cystic fibrosis (CF), a genetic disorder, is characterized by chronic pulmonary infection/inflammation which leads to respiratory failure. The presence of anti-neutrophil cytoplasmic autoantibodies (ANCA) has previously been observed in the sera of patients with CF. In view of the known relationship of ANCA with primary vasculitis and of their putative pathogenetic role in these disorders, we studied the presence, specificity and isotype of ANCA and their clinical associations in 66 adult CF patients. None of the 66 CF samples had autoantibodies to the major ANCA antigens, proteinase 3 or myeloperoxidase. However, 60/66 (91%) CF samples contained IgG and 55/66 (83%) IgA, autoantibodies to bactericidal/permeability increasing protein (BPI), a recently characterized ANCA specificity. All the IgA anti-BPI-positive samples were also IgG anti-BPI-positive. The autoantibody specificity was confirmed by inhibition assay and immunoblotting of CF sera against a neutrophil granule preparation. Furthermore, in this cross-sectional study, anti-BPI levels were inversely correlated with the observed reductions in FEV1 and FVC (IgA anti-BPI and FEV1: r = 0.508, <it>p</it> &lt; 0.0001), and both IgG and IgA anti-BPI levels were higher in CF patients with secondary vasculitis (<it>n</it> = 6) than in those without (<it>p</it> &lt; 0.05). ANCA with specificity for BPI were present in the majority of CF sera in this study and autoimmune processes may be associated with the development of pulmonary injury in CF.      

Liver involvement in murine typhus

Liver involvement was retrospectively evaluated in 137 patients with murine typhus. Fifteen (10.9%) were jaundiced. One patient had been subjected to cholecystectomy after misdiagnosis of acute cholecystitis. Serum aminotransferase levels were abnormal in 48/52 measurements, and there were elevations of &gt;5-fold in 14 patients. Liver biopsies and/or necropsies from four jaundiced patients showed portal tract and sinusoidal infiltrates, cloudy swelling/and necrosis of the hepatocytes and occasional pseudogranuloma formation. There were striking mitoses even in the early stage, suggesting rapid hepatocellular regeneration. Haemolytic diseases (G7PD deficiency or haemoglobinopathies), alcoholism, and a second infection probably also contributed to the pathogenesis of jaundice in murine typhus. This rickettsiosis should be included among differential diagnoses of acute hepatitis in patients exposed to areas endemic for <it>Rickettsia typhi</it>.      

Early surgery in infective endocarditis

Optimal timing of surgical intervention in infective endocarditis is important in reducing mortality. We prospectively studied 126 consecutive episodes of infective endocarditis treated in one institution over 5 years, with special emphasis on long-term results and on the effects on outcome of surgical interventions. Twenty-six patients (21%) underwent acute surgery on median treatment day 14. Mortality during treatment was 8% for patients undergoing acute surgery vs. 11% for those not undergoing surgery, and the adjusted 5-year survival rate of acute surgically treated patients was 91%, compared with 69% for the medically treated patients. Using univariate analysis, excess mortality during 5 years follow-up was associated with new cardiac decompensation at entry (<it>p</it> &lt; 0.01), age (<it>p</it> &lt; 0.01), no acute surgery (<it>p</it> &lt 0.05) and mitral valve involvement (<it>p</it> &lt; 0.05). Multivariate analysis showed new cardiac decompensation at entry to be an independent predictor of cardiac death at 5 years follow-up (relative risk 2.39, CI 1.05-5.45), while no surgery during active disease implied a relative risk of 3.45, though not statistically significant. Patients undergoing surgery very early (&les; 10 days of treatment) did not have a poorer outcome. Acute valve replacement, as compared with medical therapy only, might be important to increase both short-term and long-term survival in infective endocarditis.      

Genetic analysis of thermolabile methylenetetrahydrofolate reductase as a risk factor for myocardial infarction

Hyperhomocyst(e)inemia is associated with an increased risk of coronary artery disease and myocardial infarction. Both genetic and environmental factors influence the plasma level of homocysteine. One of the metabolic pathways for homocysteine involves the enzyme methylenetetrahydrofolate reductase (MTHFR), which regulates the conversion of homocysteine to methionine. A thermolabile variant of MTHFR is associated with reduced enzyme activity and increased plasma homocysteine levels. Recently, the cause of this variant of MTHFR has been identified as a single base change altering an alanine to a valine residue in the protein. Using a PCR-based assay to distinguish the normal and thermolabile variants of MTHFR in this study, we investigated whether the thermolabile variant is a genetic risk factor for myocardial infarction. In a study of 532 subjects (310 myocardial infarction patients and 222 population-based controls), we found no difference in either MTHFR genotype distribution (<it>p</it> = 0.57) or allele frequencies (<it>p</it> = 0.68) between cases and controls. The allele frequencies of the thermolabile variant were 0.34 and 0.35 in cases and controls, respectively. The age- and sex-stratified odds ratio for risk of myocardial infarction associated with homozygosity for the thermolabile variant was 0.85 (95% CI 0.50-1.50, <it>p</it> = 0.57) and that with carriage of the thermolabile allele was 1.06 (95% CI 0.73-1.52, <it>p</it> = 0.76). The odds ratio remained non-significant when restricted to young subjects (&lt;60 years) or males, and were not influenced by several other risk factors for myocardial infarction considered either singly or in combination. Interestingly, in both cases and controls, there was a trend toward a higher prevalence of hypertension in subjects carrying the normal allele, although as this is a <it>post-hoc</it> finding it needs to be interpreted with caution. The thermolabile variant of MTHFR is not a major risk factor for myocardial infarction and is unlikely to explain a significant proportion of the reported association of hyperhomocyst(e)inemia with coronary artery disease.      

The clinical course and management of thoracic empyema

We report a prospective multi-centre study of the clinical course and hospital management of thoracic empyema in 119 patients (mean age 54.8). The commonest presenting symptom was malaise (75%), 55% were febrile; 31% were previously well with no predisposing condition. Initial treatments were antibiotics alone (5), needle aspirations (46), intercostal tube drainage (61), rib resection (3) and decortication (4). Overall, intercostal drainage was used in 77 patients (16 failed aspirations), surgical rib resection in 24 (1 failed aspirations, 20 failed drainage), and surgical decortication in 28 (6 failed aspirations, 17 failed drainage). Only 4 patients received intrapleural fibrinolytic agents. Aspiration and drainage were likely to fail if the empyema was &gt;40% of the hemithorax. Median time from treatment start to discharge was: aspirations, 26 days; drainage, 23 days; resection 11 days; decortication, 12 days. Overall 21 patients died (12 with empyema as the major cause); two had been surgically treated. Mortality correlated with age, diabetes, heart failure, and low serum albumin at admission. Infecting organisms, identified in 109 patients (92%) included anaerobes (37), <it>Str. melleri</it> (36), and <it>Str. pneumoniae</it> (28). Six months after discharge, all but six survivors had regained their previous health.      

CD4 and total lymphocyte counts as predictors of HIV disease progression

CD4+ T-lymphocyte (CD4) counts are a standard laboratory marker of disease progression in HIV infection, but expense precludes their use in large parts of the world. Total lymphocyte counts (TLC), in contrast, are widely available. We compared CD4 and TLC counts as predictors of developing AIDS or death in 831 HIV-positive out-patients (582 males and 249 females with both homosexual (males, n=316) and heterosexual (n=515) transmission patterns. The first CD4 count &lt;200/&mgr;l and first TLC &lt;1250/&mgr;l predicted similar (p=0.52) survival, irrespective of clinical stage. For each clinical stage, a significant difference in progression to AIDS and mortality was predicted by TLC above or below 1250/&mgr;l (p &lt;0.03). Survival and progression to AIDS occurred at similar rates in patients with a TLC &lt;1250/&mgr;l or a CD4 count &lt;200/&mgr;l (p &gt;0.1), and patients with a TLC &gt;1250/&mgr;l or a CD4 count &gt;200/&mgr;l (p &gt;0.5). A TLC &gt;1250/&mgr;l preceded the development of <it>Pneumocystis carinii</it> pneumonia or cerebral toxoplasmosis in 76% of patients. In this longitudinal study, TLC and CD4 counts were equal predictors of disease progression. A TLC &lt;1250/&mgr;l could be considered an indication for commencing cotrimoxazole prophylaxis.      

The systemic inflammatory response syndrome as a predictor of bacteraemia and outcome from sepsis

Criteria defining the <it>systemic inflammatory response syndrome</it> (SIRS) were used to assess prospectively 270 clinical episodes in which blood cultures were taken from patients in general medicine. SIRS, severe sepsis and septic shock occurred in 149 (55%), 13 (5%) and 9 (3%) episodes, respectively. However, evidence of organ hypoperfusion indicating severe sepsis was recorded as sought in only 26% of episodes of SIRS. Crude mortality at 28 days increased sequentially as more SIRS criteria were met, rising from 12% in non-SIRS blood culture episodes, to 36% when all four criteria were met. Mortality from severe sepsis and septic shock was 38% and 56%, respectively. In 61/64 (95%) episodes of clinically important bacteraemia, patients fulfilled SIRS criteria when the blood culture was taken. However, the positive predictive value of SIRS for predicting bacteraemia was only 7%. Patients who did not fulfill SIRS criteria when blood cultures were taken were at low risk of bacteraemia and comprised 45% (121/270) of the study population. Three patients in this low-risk group had bacteraemia. Mortality in bacteraemic patients with severe sepsis or septic shock who were initially treated with ineffective antibiotics for up to 48 h was 80%, compared to 42% in those always treated appropriately.      

Treating paracetamol overdose by charcoal haemoperfusion and long-hours high-flux dialysis

After serious paracetamol overdose, charcoal haemoperfusion was used to remove paracetamol from the circulation, aiming to reduce the severity of subsequent hepatic damage. Daily long-hours high-flux dialysis was given to patients with grade III-IV hepatic encephalopathy, and also to those at risk of developing encephalopathy. We reviewed patients treated in this manner who had not received N-acetylcysteine within the first 15 h after overdose. From January 1983 to January 1993, 73 patients with serious paracetamol overdose were seen, of whom 51 received charcoal haemoperfusion and/or high-flux dialysis. Patients who were admitted within the first 42 h after overdose and who received haemoperfusion and/or dialysis had significantly lower peak levels of prothrombin time, bilirubin and creatinine than those who were admitted after 42 h. Mortality was also lower amongst patients admitted before 42 h, at 2/18 (11%) vs. 15/33 (45%), <it>p</it> &lt; 0.05.      

The spectrum of meningitis in a population with high prevalence of HIV disease

We studied the spectrum of meningitis and impact of HIV infection retrospectively (8 months) and prospectively (5 months) in 284 adult patients with meningitis hospitalized in Soweto, South Africa. Tuberculous meningitis (TBM) was the most common cause of meningitis (25.4%) followed by acute bacterial meningitis (ABM; 22.5%), acute viral meningitis (14.1%) and cryptococcal meningitis (13%). The in-hospital mortality was &gt;40% in TBM, ABM, cryptococcal meningitis, the neurosurgery and the parameningeal/parenchymal groups. At least 37.3% of all patients were HIV-seropositive (only 67% of patients were tested). In at least 27% of the study group the meningitis was an AIDS-defining illness (TBM, cryptococcal meningitis). Only 56.2% of patients with ABM has positive cultures (CSF or blood), of which <it>Streptococcus pneumoniae</it> was by far the most frequently found organism (35.8%). The spectrum of meningitis in HIV-affected communities in Africa can be expected to change towards a predominance of TBM and cryptococcal meningitis.      

Muscle Shear Wave Elastography in Inclusion Body Myositis: Feasibility,Reliability and Relationships with Muscle Impairments

Degenerative muscle changes may be associated with changes in muscle mechanical properties. Shear wave elastography (SWE) allows direct quantification of muscle shear modulus (MSM). The aim of this study was to evaluate the feasibility and reliability of SWE in the severely disordered muscle as observed in inclusion body myositis. To explore the clinical relevance of SWE, potential relationships between MSM values and level muscle impairments (weakness and ultrasound-derived muscle thickness and echo intensity) were investigated. SWE was performed in the biceps brachii at 100°, 90°, 70° and 10° elbow flexion in 34 patients with inclusion body myositis. MSM was assessed before and after five passive stretch-shortening cycles at 4°/s from 70° to 10° elbow angle and after three maximal voluntary contractions to evaluate potential effects of muscle pre-conditioning. Intra-class correlation coefficients and standard errors of measurements were >0.83 and <1.74?kPa and >0.64 and <1.89?kPa for within- and between-day values, respectively. No significant effect of passive loading–unloading and maximal voluntary contractions was found (all p values? >0.18). MSM correlated to predicted muscle strength (all Spearman correlation coefficients (ρ)?>?0.36; all p values?<?0.05). A significant correlation was found between muscle echo intensity and muscle shear modulus at 70° only (ρ?=?0.38, p?<0.05). No correlation was found between muscle thickness and MSM (all ρ values?>?0.23 and all p values?>?0.25, respectively). Within- and between-day reliability of muscle SWE was satisfactory and moderate, respectively. SWE shows promise for assessing changes in mechanical properties of the severely disordered muscle. Further investigations are required to clarify these findings and to refine their clinical value.     

Fibrodysplasia (myositis) ossificans progressiva: clinicopathological features and natural history

Patients with fibrodysplasia (myositis) ossificans progressiva (FOP) (<it>n</it> = 28) were studied for up to 24 years. All had characteristic short big toes potentially recognizable at birth; there were radiographic changes in the toes, thumbs, cervical spine and metaphyses of the long bones, including exostoses. Ossification in the large skeletal muscles began from birth to 16 years (mean age 4.6 years) initially in 25 patients in the neck and upper spinal muscles, and later around the hips, major joints and jaw. The rate and extent of disability was unrelated to the time of onset. There was no evidence that any form of treatment produced consistent benefit. Despite the unique combination of skeletal abnormalities and ectopic ossification, the first diagnosis in patients with FOP was often wrong and usually delayed after ectopic ossification began (mean 2.7 years, range 0-14). Except where presentation was unusual, such as progressive stiffness, this delay was mainly due to failure to recognize the significance of the abnormal toes. The most frequent erroneous histological diagnoses were soft tissue sarcoma or fibromatosis. This series emphasizes the usually incorrect initial diagnosis, the misinterpretation of the histology, the unpredictable prognosis and the failure of current treatment. Despite its extreme rarity, there is a need for wider knowledge of this condition both to avoid clinical errors and to stimulate research.      

Evolución de la fuerza muscular en paciente críticos con ventilación mecánica invasiva

ObjectiveTo assess the evolution of muscle strength in critically ill patients with mechanical ventilation (MV) from withdrawal of sedatives to hospital discharge.Material and methodA cohort study was conducted in two intensive care units in the Hospital Universitari de Bellvitge from November 2011 to March 2012. Inclusion criteria: Consecutive patients with MV > 72 h. Dependent outcome: Muscle strength measured with the Medical Research Council (MRC) scale beginning on the first day the patient was able to answer 3 out of 5 simple orders (day 1), every week, at ICU discharge and at hospital discharge or at day 60 Independent outcomes: factors associated with muscle strength loss, ventilator-free days, ICU length of stay and hospital length of stay. The patients were distributed into two groups (MRC< 48, MRC ≥ 48) after the first measurement.ResultsThirty-four patients were assessed. Independent outcomes associated with muscle strength weakness were: days with cardiovascular SOFA >2 (P<.001) and days with costicosteroids (P<.001). Initial MRC in MRC<48 group was 38 (27-43), and 52 (50-54) in MRC ≥ 48. The largest muscle strength gain was obtained the first week (31% versus 52%). A MRC < 48 value was associated with more MV days (P<.007) and a longer ICU stay. (P<.003).ConclusionThe greatest muscle strength gain after withdrawing of the sedatives was achieved in the first week. Muscle strength loss was associated with a cardiovascular SOFA > 2 and costicosteroids. Patients with a MRC < 48 required more days with MV and a longer ICU stay.     

平衡功能训练对慢重症康复期患者下肢平衡及运动功能的作用研究

目的：探讨平衡功能训练对(Chronically Critical Ill,CCI)康复期患者下肢平衡及运动功能的临床改善作用。方法 将2014年1月~2015年12月在我院重症监护室住院治疗的CCI患者随机分为对照组和观察组,采用常规康复治疗方案对对照组进行干预,在常规干预的基础上结合平衡功能训练对观察组进行干预,比较两组在干预前及干预第3、6、9、12天的博格平衡功能(Berg balance scale,BBS)、起身行走能力(Timed get up and go test,TUGT)、最大步行速度(Maximum walking speed,MWS)及下肢步行功能(Functional ambulation category scale,FAC)。结果 观察组在干预第3、6、9、12天的BBS、TUGT、及MWS均明显优于对照组,差异具有统计学意义(P＜0.05),重复测量方差分析显示,上述指标在不同时间的组内效应、时间效应和交互效应均具有统计学意义(P＜0.001);两组在干预第3及6天的FAC分级差异具有统计学意义(P＜0.001)。结论 通过实施平衡功能训练有利于促进慢重症康复期患者的平衡及步行功能的恢复,缩短临床康复进程。     

ICU床旁重症超声对呼吸机相关性肺炎早期诊断和动态评估价值探讨

目的 探讨床旁重症超声对ICU呼吸机相关性肺炎(VAP)早期诊断和动态评估的价值。方法 对56例临床疑诊为呼吸机相关性肺炎的患者同时行肺超声(LUS)和胸部 CT 及实验室检查,以临床最终确诊为标准,分析LUS对VAP的早诊断价值。运用ROC分析患者在治疗第1、3、7、10天肺部超声评分、白细胞计数(WBC)、降钙素原(PCT)、超敏 C 反应蛋白(hs- CRP)、临床肺部感染评分(CPIS)结果。结果 与临床随访诊断标准比较,床旁LUS诊断VAP的灵敏度和特异度分别为：93%、76.9%。胸部CT诊断VAP的灵敏度和特异度为分别为：95.3%、84.6%,卡方检验LUS与CT诊断VAP的灵敏度与特异度差异均无统计学意义(p＞0.05)。随访第1、3、7、10d,VAP患者肺部超声评分及WBC、PCT、hs-CRP感染指标、CPIS评分均随治疗时间的延长而下降,床旁LUS高评分值与炎性指标升高具有一致性但下降速率慢。ROC分析显示第1、3、7、10d,LUS评分曲线下面积(AUC)分别为：0.918、0.920、0.900和0.900(均p＜0.05),且与CPIS具有较好一致性;其中第1d床旁LUS评分95%CI(0.823～0.998)和第3dCPIS的95%CI(0.806～1)为最佳。结论 肺超声诊断呼吸机相关性肺炎准确率高,能动态实时观察病灶变化,是一种无创的、重复性好的、可靠的检查手段,对于ICU呼吸机相关性肺炎的早期诊断和动态评估具有临床应用价值。     

Effect of convalescent plasma therapy on mortality in moderate-to-severely Ill COVID-19 patients

IntroductionThe role of plasma therapy in the management of the COVID-19, pandemic has been speculated. However, in view of the varied response regarding its effectiveness from various multicenter studies, there is a need to conduct more single center population-specific studies. We, thus, aimed to assess the role of convalescent plasma therapy in COVID-19 patient management in a single -center.MethodsThis retrospective study was conducted using records of all COVID-19 patients who received plasma therapy over a period of 6 months in a dedicated COVID-19 hospital in Delhi. Information pertaining to transfusion, disease severity, associated comorbidities, the treatment given and patient outcome were recorded. Data was analyzed using SPSSv23.ResultsOf the141 patients who received plasma therapy, 62% were discharged after treatment. Mortality was found to be significantly higher in patients > 60 years of age (p < 0.001), those with severe COVID-19 infection (p < 0.05) and pre-existing renal disease (p < 0.05). The admission-transfusion interval was significantly correlated to mortality and was a sensitive parameter for predicting outcome at cut off value of < 5 days (p < 0.001). There was no significant association of mortality with patient blood group, plasma antibody levels or donor hemoglobin levels.ConclusionsWe report improvement and recovery in a large number of patients who received convalescent plasma within the first 5 days of hospitalization with moderate to severe disease. Further research to compare dosage and administration protocols to delineate role of CCP in survival of COVID-19 patients is needed before it isprematurely shelved.     

Changes in muscle tissue oxygenation during stagnant ischemia in septic patients

Objective To determine changes in the rate of thenar muscles tissue deoxygenation during stagnant ischemia in patients with severe sepsis and septic shock.Design and setting Prospective observational study in the medical ICU of a general hospital.Patients and participants Consecutive patients admitted to ICU with septic shock (n=6), severe sepsis (n=6), localized infection (n=3), and healthy volunteers (n=15).Interventions Upper limb ischemia was induced by rapid automatic pneumatic cuff inflation around upper arm.Measurements and results Thenar muscle tissue oxygen saturation (StO₂) was measured continuously by near-infrared spectroscopy before and during upper limb ischemia. StO₂ before intervention was comparable in patients with septic shock, severe sepsis, or localized infection and healthy volunteers (89 [65, 92]% vs. 82 [72, 91]% vs. 87 [85, 92]% vs. 83 [79, 93]%, respectively; p>0.1). The rate of StO₂ decrease during stagnant ischemia after initial hemodynamic stabilization was slower in septic shock patients than in those with severe sepsis or localized infection and in controls (–7.0 [–3.6, –11.0] %/min vs. –10.4 [–7.8, –13.3] %/min vs. –19.5 [–12.3, –23.3] vs. –37.4 [–27.3, –56.2] %/min, respectively; p=0.041). At ICU discharge the rate of StO₂ decrease did not differ between the septic shock, severe sepsis, and localized infection groups (–17.0 [–9.3, –28.9] %/min vs. –19.9 [–13.3, –23.6] %/min vs. –23.1 [–20.7, –26.2] %/min, respectively), but remained slower than in controls (p<0.01). The rate of StO₂ decrease was correlated with Sequential Organ Failure Assessment (SOFA) score (r=0.739, p<0.001).Conclusions After hemodynamic stabilization thenar muscle tissue oxygen saturation during stagnant ischemia decreases slower in septic shock patients than in patients with severe sepsis or localized infection and in healthy volunteers. During ICU stay and improvement of sepsis the muscle tissue deoxygenation rate increases in survivors of both septic shock and severe sepsis and was correlated with SOFA score.     

Giardiasis as a cause of hypokalemic myopathy in congenital immunodeficiency

Hypokalemic myopathy may occur in several infections. We report a case of severe and transient myopathy secondary to hypokalemia induced by chronic intenstinal infection withGiardia lamblia in a patient with common variable hypogammaglobulinemia. Hypokalemic myopathy is documented by serum enzymes, electromyography (reduction in the number of voluntarily activated motor unit action potentials and an increase in polyphasic motor unit action potentials, and pathological changes (hematoxylin-eosin, ATPase staining). The case reported involves hypokalemic myopathy induced by giardiasis in a patient with primary immunodeficiency; the histopathological changes observed in a skin/muscle biopsy from this patient are described for the first time.     

Acute Renal Failure Due to Leptospirosis: Clinical Features and Outcome in Six Cases

Six cases of severe leptospiral infection with renal failureare described. Five of the six patients had acute oliguric renalfailure requiring dialysis. Renal function recovered over threeweeks and by two months all patients had plasma creatinine levels< 200 µmol/litre. The initial diagnosis of leptospirosisdepended on clinical and epidemiological features because serologicalconfirmation was not possible during the first week of the illness.All the patients had either high risk occupations or a historyof exposure to external sources of infection. All had fever,myalgia, jaundice and muscle tenderness. Although biirubin levelswere high (> 350 µmol/litre in five) the elevationsof aspartate transaminase and alkaline phosphatase levels, andprolonga tions of prothrombin times were relatively slight.Thrombocytopenia occurred in five of the six cases. Leptospiracomplement fixation tests were weakly positive or negative onadmission in five cases but rose to significant levels subsequently.Penicillin treathient resulted in Jarisch-Herxheimer reactionsin three cases. The important complications were: upper gastro-intestinalhaemorrhage (five cases), thrombocytopenia <30000 platelets/mm³(four cases), atrial fibrilla tion (three cases), drowsinesswith asterixis (four cases). All six patients were seriouslyill and required intensive supportive therapy. All survived.