Herpes simplex virus simultaneous encephalitis and liver failure in an immunocompetent adult: A case report


Herpes simplex virus (HSV) are challenging etiologic agents with a wide range of clinical manifestations. We present a case of a 34-year-old immunocompetent male who was brought to the Emergency Department (ED) with fever and prostration. In the first approach, blood tests revealed an acute hepatitis without an identified etiology. Besides the use of N-acetylcysteine, he became worst and evolved to acute liver failure and coma. HSV deoxyribonucleic acid (DNA) was identified in the cerebrospinal fluid (CSF) and blood. Although acyclovir was started on day 3, he developed cardiovascular shock with multiple organ failure and died on the 7th day of hospitalization. A high index of suspicion is needed, and early diagnosis should be promoted between clinicians.

Authors: Tiago Isidoro Duarte, Filipe Damião, Joana Ferrão, Tânia Sequeira, Filipe Sousa Cardoso, Nuno Germano

Upper airway obstruction due to bilateral laryngeal polyp: A challenge of treatment in rural area


A laryngeal polyp is a common benign lesion of phonotraumatic origins. However, a case of the laryngeal polyp with the upper airway obstruction is rare. The common symptoms include hoarseness or reduced vocal quality, and dyspnea could be present in severe cases. Depending on the anatomical location of the polyp, manipulation on the larynx could cause laryngospasm and life-threatening airway obstruction. In this case, the patient underwent a planned cesarean section under general anesthesia. However, her breathing rhythm did not return spontaneously after surgery and she was sent to the intensive care unit. Bilateral laryngeal polyps were discovered after the removal of an endotracheal tube. However, there was a delay in the removal of the polyps, where it was performed two months after the intensive care unit discharge. The histopathological results confirmed a diagnosis of bilateral angiomatous laryngeal polyps.

Authors: Hamsu Kadriyan, Elya Endriani, Fahrin Ramadhan Andiwijaya, Ida Lestari Harahap

Clinical profile and outcomes in adults with status epilepticus - A prospective observational study


Objectives: Status epilepticus (SE) is a common life-threatening medical emergency, and its neurological outcome requires prompt recognition and management. The present study aimed to determine the clinical profile and outcome of patients with status epilepticus.

Design: Prospective observational study.

Setting: The study was conducted in intensive care units under Emergency Medicine, General Medicine, Neuro Medicine, and Neurosurgery Departments of a tertiary care centre from March 2018 to September 2019.

Patients and participants: Forty-six status epilepticus patients attending intensive care units under Emergency Medicine, General Medicine, Neuro Medicine, and Neurosurgery Departments of a tertiary care centre were included and followed for 45 days.

Measurements and results: Baseline data on demographics, comorbidities, duration of each episode, number of episodes, treatment, brain imaging findings (computed tomography [CT] and magnetic resonance imaging [MRI]) and other comorbidities. The collected data was analyzed by analysis of variance (Anova) and independent t-test. P-value <0.05 was considered statistically significant. Out of 45 subjects included in the final analysis, 34 (75.6%) survived, and 11 (24.4%) had died during hospitalization. Mean±standard deviation of age was 43.1±1.02. Thirteen (71.1%) had diabetes mellitus as comorbidity. Twenty-four (53.3%) of them had >15 mins of seizure, 22 (48.9%) were in between 5 to 12 of Glasgow coma scale score. Among the study population, the probable etiology was head trauma 5 patients (11%), viral meningoencephalitis 7 patients (15.6%), acute cardiovascular system 9 patients (24.4%), and alcohol withdraw 14 patients (8.9%). Majority of them (18 patients [40%]) required third-line treatment, 33 patients (73.3%) required in hospital ventilator assistance, and 19 patients (42.2%) developed refractory status epilepticus (RSE). The duration of hospital stay was found to be significant for third-line treatment (21.9 days), mechanical ventilation (21.30 days), and RSE (23.8 days) with a p-value of 0.001.

Conclusion: The duration of hospital stay was significantly associated with the findings on brain MRI, the requirement of in-hospital ventilatory support, the treatment given, and the presence of RSE.

Authors: Aiswarya M. Nair, Priyadarshini Varadaraj, Sivaprakash Varadan, Vaasanthi Rajendran, Viswanathan Pandurangan, K. Madhavan, Anurag P.

Receptor-interacting protein kinase 3 has a good accuracy in predicting mortality of critically septic patients


Objective: Sepsis-related uncontrolled systemic inflammation may trigger necroptosis, which is correlated with receptor-interacting protein kinase 3 (RIPK3) level. A high level of RIPK3 is associated with organ dysfunction and thus, mortality. This study aimed to analyze the ability of RIPK3 level to predict mortality in septic patients.

Design: This was a prospective cohort study.

Setting: This study was conducted in intensive care unit from February until August 2019.

Patients and participants: This study included patients aged 18 years or more who met the Sepsis-3 definition. Baseline demographic data were measured.

Interventions: Blood was collected to measure RIPK3 at sepsis recognition. RIPK3 level was measured using enzyme-linked immunosorbent assay using Bio-Rad (Bio-Rad Laboratories, California, US). Hour-1 bundle resuscitation was performed on all participants. Participants were observed for 28 days for mortality. Data were analyzed using STATA program software.

Measurement and results: A total of 59 subjects were analyzed. The cutoff point of RIPK3 level was 0.51 ng/ml with 92.5% sensitivity and 89.5% specificity in predicting mortality. RIPK3 level has an excellent performance with area under the receiver operating characteristic (ROC) curve (AUC) value of 0.925.

Conclusions: RIPK3 level can be considered a useful tool to recognize high risk mortality among critically septic patients.

Authors: Mayang Indah Lestari, R. Sedono, Zulkifli, IA Liberty

Comparison of serum tumor necrosis factor, superoxide dismutase, and heat shock protein-70 levels during cardiopulmonary bypass and ischemia reperfusion injury after cardiopulmonary bypass in cardiac surgery


Objective: This study aims to determine the comparison between tumor necrosis factor (TNF)-a, superoxide dismutase (SOD), and heat shock protein (HSP)-70 levels during cardiopulmonary bypass (CPB) and ischemia reperfusion injury after cardiopulmonary bypass.

Design: This study was an analytical observational study with a cross sectional design.

Setting: This study was conducted at Dr. Soetomo General Hospital Surabaya. The period of study was from April 2020 to September 2020.

Patients and participants: Population of study was all adult patients who underwent on pump cardiac surgery. Study samples were patients who were included in inclusion criterion. Patients’ characteristics were presented as frequency and percentage.

Measurement and results: All interval data with normal distribution were analyzed using T-pair test. Statistical test using the Wilcoxon signed-ranks test (two-tailed) was performed to determine comparison of TNF-a, SOD, and HSP-70 levels during CPB and after CPB. There were 30 subjects who underwent adult cardiac surgeries including coronary artery bypass graft (CABG), valve, and double procedures. According to statistical test, there was a significant increase of TNF-a, SOD, and HSP-70 levels during cardiopulmonary bypass compared to after cardiopulmonary bypass with p-value <0.05. Pearson correlation test was performed to determine the correlation between elevated levels of TNF-a, SOD, HSP-70 during CPB impact. There was significant correlation between TNF-a and SOD (p<0.05), and also between SOD and HSP-70 (p<0.05).

Conclusion: Our study showed that CPB impact significantly contributes to the increase of TNF-a, SOD, and HSP-70 levels compared to after CPB in patient undergoing on pump cardiac surgeries.

Authors: Teuku Aswin Husain, Setiawan P, Yan Efrata Sembiring, Budiono

Sepsis-induced T-cell suppression in pediatric sepsis


Sepsis contributes to significant mortality and morbidity in children. Despite rigorous resuscitation effort, adequate antibiotics and advanced medical support, a significant proportion still face mortality due to multiple organ failure. Recent hypothesis suggests host’s immune response pathology in the form of compensatory anti-inflammatory response syndrome (CARS). This review aims to elucidate the pathophysiology of immune paralysis, both affecting innate and acquired immunity.

Authors: Antonius Hocky Pudjiadi