A fatal case of cerebral oedema and myocarditis associated with secondary dengue infection


Background: Secondary dengue infection (SDI), in the form of two sequential infections by different serotypes, will lead to severe dengue. Concomitant organ failure in particular cardiovascular (CVS) and central nervous system (CNS) carries further rise in the mortality rate.

Case report: We report a confirmed SDI in a 27-year-old man who presented with hypovolemic shock due to persistent vomiting and diarrhoea. He was stabilized after fluid resuscitation. However, he developed sudden onset of seizure and myocarditis with unstable haemodynamic thereafter. After stabilization, his gag and cough reflexes were absent with dilated pupils. Imaging of the brain showed extensive cerebral oedema with poor flow beyond the internal carotid arteries and its branches above circle of Willis. He remained comatose with subsequent complications of diabetes insipidus, secondary bacterial infection, and acute kidney injury. He passed away after 19 days of admission.

Discussion: There is a higher risk of severe dengue with SDI as it is associated with antibodydependent enhancement (ADE) mechanism. The pre-existing dengue antibodies enhance virus replication by activating memory T-cells causing surges in inflammatory cytokines. The increased capillary permeability with massive vascular leak most likely led to the extensive cerebral oedema in this patient. The concomitant cardiovascular failure also led to his irreversible outcome.

Conclusion: Severe cardiovascular and neurological manifestations can occur in SDI with resultant in the fatality. Therefore, early recognition of risk factors in the early phase of severe dengue is important to prevent the irreversible outcome.


Blood plasma plasmalogens and fatty acids in multiple organ dysfunction syndrome


Introduction: Changes in fatty acid composition as well as in a level of blood plasma plasmalogens in cases of various pathological conditions are evidences of lipid metabolism disorders and can indicate their reasons and degree. The objective of this study was to analyze fatty acids and plasmalogens of blood plasma in patients with multiple organ dysfunction syndrome (MODS).

Methods: Fatty acid ethyl esters and diethyl acetals of fatty aldehydes obtained during sample preparation were analyzed by capillary gasliquid chromatography.

Results: Marked changes in the plasma fatty acid composition and plasmalogen levels in pa tients with MODS were detected.

Conclusions: Based on the detected significant reduction in the plasmalogen levels of blood plasma, a conclusion was made about possible presence of peroxisome dysfunctions in patients with MODS. Peroxisome dysfunction may be one of the reasons of violation of detoxification processes, fatty acids oxidation disorder, prolongation and intensification of the inflammatory process, neurological disorders, and decreased blood antioxidant capacity. The assumption was made about an important role of fatty acids in disturbance of systemic hemodynamics, assessment of a degree of lipid metabolism disorders and activity of сatabolic response.


The effect of selective COX-2 inhibitor on blood glutamate in moderate traumatic brain injury


Head injury is the leading cause of death and disability in adolescence, children and the elderly. Post-traumatic brain damage is determined by combination of primary and secondary head injuries. Neuroinflammation is one mechanism of secondary brain injury. Selective cyclooxygenase (sCOX-2) inhibitors are drugs commonly used in treatment of postoperative pain but also possess an anti-inflammatory effect. The aim of this study is to determine the role of sCOX-2 inhibitors to inhibit the inflammatory processes in patients with head injury by measuring the glutamate levels.

This is a double blind randomized controlled study involving patients with moderate head injuries who underwent surgery at Dr. Hasan Sadikin Hospital Bandung since December 2013 until December 2015. After obtaining study approval from the Research Ethics Committees of School of Medicine Padjadjaran University/Dr. Hasan Sadikin Hospital, samples were clustered randomly into 5 groups: the control group, the COX2-group I (given sCOX-2 inhibitor once/day), the COX2-group II (given sCOX-2 inhibitor twice/day), the COX2-group III (given sCOX-2 inhibitor thrice/day), and the COX2-group IV (given sCOX-2 inhibitor four times/day), and each group consisted of 6 patients. All patients received standard therapy as recommended by Brain Trauma Foundation Guidelines 2007 as well as performed monitoring of blood pressure, pulse rate, respiratory rate, oxygen saturation, temperature and blood sugar during pre and postoperative stages. The data were analyzed using paired samples t-test and one-way Anova, which p<0.05 is considered as statistically significant.

Results showed that there was a significant reduction in glutamate level in COX2-group II with the p-value of 0.035. The study concluded that sCOX-2 inhibitor has a brain protective effect by lowering the levels of glutamate as neuroinflammatory biomarkers in patients with head injury.


Albumin level as a predictor of shock and recurrent shock in children with dengue hemorrhagic fever


Background: The severity of dengue hemorrhagic fever (DHF) can be seen from bleeding and plasma leakage manifestations. Albumin level is one of the markers of plasma leakage in dengue infection. Whether albumin can be used as a predictor of shock in DHF patients or of recurrent shock in dengue shock syndrome (DSS) patients still need to be further evaluated.

Objective: To determine serum albumin level as a predictor of shock in DHF and of recurrent shock in DSS.

Design: A cohort prospective study.

Setting: Department of Child Health, Prof. Dr. RD Kandou Hospital, Manado, Indonesia.

Patients and participants: Sixty-seven DHF patients and 58 DSS patients aged 1- to 14-yearold were enrolled in our study. Sampling was done with consecutive sampling method. The inclusion criteria were patients diagnosed with DHF/DSS based on World Health Organization (WHO) criteria (2011). The exclusion criteria were patients who received corticosteroids, blood transfusion, albumin infusion and patients with severe malnutrition. The dependent variables were shock and recurrent shock. The independent variable was serum albumin level. The relation between serum albumin level and shock or recurrent shock were analyzed using logistic regression test, power 0.80, α 0.05 and was significant if p<0.05. We used receiver operating characteristic (ROC) curve to determine prognostic factors. Data was analyzed using software SPSS v 21.0.

Results: There was significant correlation between albumin level and shock in DHF patients (p=0.0001, area under the curve (AUC) 0.865, cut-off 3.05, odds ratio (OR) 17.4, sensitivity 79%, specificity 81%), but there was no correlation between albumin level and recurrent shock in DSS patients.

Conclusions: Serum albumin level can be used as a predictor of shock in DHF patients but it cannot be used as predictor of recurrent shock in DSS patients.


Three years after the REDOXS study: What we have learned in the use of glutamine in ICU patients?


Critical illness has been associated with glutamine (Gln) plasma levels depletion and its supplementation is related with better outcomes. In 2013 the Reducing Deaths due to Oxidative Stress (REDOXS) study, showed that the supplementation of Gln to total parenteral nutrition was associated with higher mortality without conferring beneficial effects. These conclusions had a high impact in the clinical field: two of the main guidelines downgraded its recommendation. However, recent studies are answering questions regarding the safety use of this amino acid use and even suggesting new potential beneficial effects.

It is important to understand the main lessons learned of the REDOXS study related to the correct use of Gln intra venous and do not rule out its use for the intensive care unit patients. The scientific community is actively working in the field and we expect to have more evidence to guide the correct of this amino acid in parenteral nutrition.