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Query: UMLS:C0012739 (disseminated intravascular coagulation)
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Urea Cycle Disorders (UCD) is an inborn error of urea synthesis in which ammonium and other nitrogenous precursors of urea accumulate leading to episodic coma and a high mortality rate. Therapy with peritoneal dialysis, essential amino acids or their nitrogen-free analogues has increased survival. The authors report 5 cases of urea cycle disorders, all of whom developed and were rescued from hyperammonemic coma. However, the eventual outcome was quite variable. Argininosuccinate lyase deficiency (ALD) Case 1. A 2 month old male infant, a product of a consanguineous marriage (Suphanburi province); developed poor feeding on day 7, lethargy, convulsion, hepatomegaly and respiratory alkalosis leading to respiratory failure and coma. Hyperammonemia, elevation of glutamic acid and argininosuccinic acid and its anhydrides confirmed the diagnosis of ALD. He is now 9 years old and severely retarded. Case 2. A male infant with history of lethargy, poor feeding on day 3, treated as sepsis and required respiratory support for 6 days; subsequently readmitted at age 2 weeks with vomitting, lethargy, seizure activity and hyperammonemia, and was treated by a local pediatrician in Songkhla province. There was a history of parental consanguinity and he was referred to Siriraj Hospital on day 64 with severe essential amino acid deficiency and acrodermatitis enteropathica with markedly elevated plasma citrulline level. In spite of aggressive treatment; the patient developed sepsis and he expired on day 78. Ornithine transcarbamylase deficiency (OTC) Case 3. An eleven-month-old male infant, the product of a non-consanguineous marriage, developed neonatal onset of hyperammonemia on day 5 after poor feeding, lethargy, hypothermia, seizure, apnea and coma. He was rescued from neonatal hyperammonemic coma on day 9 after aggressive treatment, but expired at eleven months of age after overwhelming sepsis. Case 4. A male infant, sibling of case 3 was referred to Siriraj Hospital on day 8 with hyperammonemia and coma. In spite of intensive genetic counseling given after the birth of their first child with OTC, the couple chose to have another baby without informing any physician. The baby developed vomiting and lethargy on day 2; subsequently hyperammonemia was noted. In spite of aggressive treatment given; hepatic dysfunction, renal failure and disseminated intravascular coagulation defects occurred on day 15. He expired on day 18 after parental permission for discontinuation of all treatment. Argininosuccinate synthetase deficiency (ASS) or Citrullinemia. Case 5. A seven week old female infant, the product of a consanguineous marriage and of Pakistani ethnic origin; developed intermittent vomiting from day 6. Initial diagnoses included ruminations, sepsis and pyloric stenosis for which she was operated on (day 30); however, vomiting continued; subsequently seizures, hyperammonemic coma developed and she was rescued from hyperammonemic coma within 30 hours. Significant elevations of citrulline and L-glutamine were demonstrated. She was discharged in excellent condition to her home in Dubai, the United Arab Emirates.
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PMID:Urea cycle disorders in Thai infants: a report of 5 cases. 1240 52

During the recent decade an increasing number of inquiries concerning cases of overdoses exhibiting typical signs of the serotonin syndrome have been recorded at the Swedish Poisons Information Centre. Four of these cases are presented together with a review of the literature. All patients had overdosed moclobemide and in one case this was the only drug taken. The other patients had ingested moclobemide together with citalopram (2 cases) and clomipramine (1 case). Moreover, other serotoninergic pharmaceuticals as sertraline and sumatriptan were simultaneously ingested in one case and buspirone in another. Three of the cases had hyperthermia, > 40 degrees C and the same number showed pronounced muscle rigidity, coma and mydriasis. Other severe signs and symptoms upon admission included positive Babinski and trismus in two cases each and seizures in one. All patients received mechanical ventilation. Two were treated with dantrolene sodium and one of them was given cyproheptadine as well. One patient received cyproheptadine treatment alone and another prolonged muscle relaxation. Three patients had a typical short clinical course, whereas one patient developed rhabdomyolysis, DIC and arrhythmias. All patients fully recovered.
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PMID:[Serotonin syndrome--several cases of this often overlooked diagnosis]. 1255 8

Sheehan's syndrome occurs as a result of ischemic pituitary necrosis due to severe postpartum hemorrhage. It may be rarely seen without massive bleeding or after normal delivery. Improvement in obstetric care and availability of rapid blood transfusion coincided with a remarkable reduction in the frequency of Sheehan's syndrome particularly in western society. But it has recently been reported more often from well-developed countries. It is one of the most common causes of hypopituitarism in underdeveloped or developing countries. Enlargement of pituitary gland, small sella size, disseminated intravascular coagulation and autoimmunity have been suggested to play a role in the pathogenesis of Sheehan's syndrome in women who suffer from severe postpartum hemorrhage. The patients may seek medical advice because of various presentations ranging from non-specific symptoms to coma and the clinical manifestation may change from one patient to another. Failure of postpartum lactation and failure to resume menses after delivery are the most common presenting symptoms. Although a small percentage of patients with Sheehan's syndrome may cause abrupt onset severe hypopituitarism immediately after delivery, most patients have a mild disease and go undiagnosed and untreated for a long time. It may result in partial or panhypopituitarism and GH is one of the hormones lost earliest. The great majority of the patients has empty sella on CT or MRI. Lymphocytic hypophysitis should be kept in mind in differential diagnosis. In this review, the old and recent data regarding Sheehan's syndrome are presented.
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PMID:Sheehan's syndrome. 1523 29

The case of fatal course of rotaviral gastroenteritis at eight months old boy has been described. Two days history of frequent watery stools in home care, hyperosmolar dehydration grading to hypovolemic shock, cardiopulmonary resuscitation in regional hospital, transported comatose with vital functions support. In spite of temporary stabilization of the patient, there was retrogression to multiorgan failure (ischemic myocardial infliction, circulatory failure, ARDS, renal failure, DIC, enteritis, post ischemic hepatopathy). Four day later patient exits. Rotaviruses have been proved from stools specimen post mortem.
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PMID:[Lethal course of rotavirus gastroenteritis - a case history.]. 1592 23

Heat exhaustion and heatstroke are part of a continuum of heat-related illness. Both are common and preventable conditions affecting diverse patients. Recent research has identified a cascade of inflammatory pathologic events that begins with mild heat exhaustion and, if uninterrupted, can lead eventually to multiorgan failure and death. Heat exhaustion is characterized by nonspecific symptoms such as malaise, headache, and nausea. Treatment involves monitoring the patient in a cool, shady environment and ensuring adequate hydration. Untreated heat exhaustion can progress to heatstroke, a much more serious illness involving central nervous system dysfunction such as delirium and coma. Other systemic effects, including rhabdomyolysis, hepatic failure, arrhythmias, disseminated intravascular coagulation, and even death, are not uncommon. Prompt recognition and immediate cooling through evaporation or full-body ice-water immersion are crucial. Physicians also must monitor electrolyte abnormalities, be alert to signs of renal or hepatic failure, and replace fluids in patients with heatstroke. Most experts believe that physicians and public health officials should focus greater attention on prevention. Programs involving identification of vulnerable individuals, dissemination of information about dangerous heat waves, and use of heat shelters may help prevent heat-related illness. These preventive measures, when paired with astute recognition of the early signs of heat-related illness, can allow physicians in the ambulatory setting to avert much of the morbidity and mortality associated with heat exhaustion and heatstroke.
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PMID:Management of heatstroke and heat exhaustion. 1595 43

Jaundice is not an unusual accompaniment of malaria. It can occur due to intravascular hemolysis, disseminated intravascular coagulation, and, rarely, 'malarial hepatitis'. Although the primary schizogony of the malarial parasite always leads to the rupture of the infected hepatocyte, alteration of the hepatic functions is uncommonly recorded due to this event. Histologically, the hepatitis or the actual inflammation in the liver has never been demonstrated. Nonetheless, the term 'malarial hepatitis' (MH) has been used in the literature to describe the occurrence of hepatocellular jaundice in patients with Plasmodium falciparum infection. The authors' own data and review of the literature indicate that it is not an uncommon entity. In endemic areas, jaundice is seen in approximately 2.5% of patients with falciparum malaria. It also appears to be a heterogeneous syndrome and one can recognize two clinical subsets. In one group there was an acute, virulent presentation with coma, renal failure and in some cases even hemorrhagic manifestations. It is only in this setting that jaundice signified a 'severe' disease as noted by the World Health Organization action program. This presentation is often confused with acute viral hepatitis and acute hepatic failure in non-endemic areas, but can be clinically differentiated.
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PMID:Jaundice in malaria. 1610 16

A 23-year-old comatose man was presented in the emergency room. He had been working inside a building under construction on a hot summer's day. His core body temperature was 42.1 degrees C and he was diagnosed with heat stroke. Urgent cooling procedures, including applying cold vapor to the patient's skin, a gastric lavage with cold water and an intravenous cold saline infusion, were not completely successful and his body temperature remained above 40 degrees C. Because his high temperature was refractory to conventional cooling procedures and we suspected that acute renal failure (ARF) by rhabdomyolysis would develop, we applied hemodialysis (HD) using cold dialysate (initially 30 degrees C and later 35 degrees C), followed by continuous hemodiafiltration (CHDF) with cold dialysate (35 degrees C) at a high flow rate of 18,000 mL per hour. The patient's body temperature fell below 38.0 degrees C within 3 h and was kept below 38.0 degrees C. Continuous hemodiafiltration was continued for one week. During the first week, the patient suffered from multiple organ failure (MOF) involving renal failure, as well as the failure of heart, liver, lung, and central nervous systems. Disseminated intravascular coagulation also developed. However, by virtue of cold CHDF, he almost recovered 3 weeks after the onset, except for remaining mild liver and renal dysfunction. In severe heat stroke, cold HD and high flow, cold CHDF should be a therapeutic choice for cooling and treatment of MOF. Considering mild liver and renal dysfunction still remained, this case suggested these procedures should be initiated at the very beginning of the treatment of severe heat stroke.
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PMID:Heat stroke with multiple organ failure treated with cold hemodialysis and cold continuous hemodiafiltration: a case report. 1620 19

Reactions after bee or wasp sting are similar to anaphylaxis. Symptoms such as weakness, fatigue, vomiting, diarrhea, urticaria, and hypotension may occur. Serious toxic reactions usually occur after numerous stings. Massive bee envenomations can result in immediate onset of shock, hemolysis, rhabdomyolysis, disseminated intravascular coagulation (DIC), coma, and renal failure. In milder cases, patients may only have isolated prolonged activated partial thromboplastin time (aPTT) and normal prothrombin time (PT), clinically without a tendency to bleed. As a rule, they recover spontaneously without any complication. We report three cases of wasp stings; they all manifested prolongation of aPTT and finally recovered completely. Isolated prolongation of aPTT in cases of wasp stings may be related to an extract from the venom inhibiting the coagulation pathway.
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PMID:Isolated prolongation of activated partial thromboplastin time following wasp sting. 1623 65

Bromvalerylurea is one of the non-barbiturates products and has been used as analgesics and hypnotics in Japan. A 20-year-old woman was admitted to our hospital for loss of consciousness. She had a 6-month history of transient delirium and drunken gait. Physical examination revealed erythema less than thumb's head size at her face, shoulder and thigh. Neurologically, she had a state of coma and low muscle tonus. EEG showed the pattern of burst-suppression. The level of her serum chloride was not elevated. The erythema made us check up her state of acute bromvalerylurea intoxication. High blood concentration of bromvalerylurea led to diagnosis of the bromvalerylurea intoxication. The maximum value of her serum bromvalerylurea concentration was 107 microg/ml on the second hospital day, while the concentration in cerebrospinal fluid were also increased and remained for several days. She was treated with respiration control and drip infusions. She gradually improved and recovered to be alert. She was complicated severe liver dysfunction and disseminated intravascular coagulation resulting from bromvalerylurea intoxication, also treated with intensive care and gradually recovered. We should take notice to bromvalerylurea, easily available over the counter, as one of the drugs which may cause severe loss of consciousness or coma, and general complications. And if the bromvalerylurea intoxication is prospective, we should consider whether the option of gastric irrigation is available regardless of the elapsed time.
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PMID:[A case of acute bromvalerylurea intoxication: clinical course and alteration in serum bromvalerylurea concentration]. 1668 Dec 62

Ninety-nine patients with meningcoccal disease were admitted to the medical department of King Fahd Hospital, Medina during the Haj season of 1407H. (August 1987G). Neisseria meningitidis group A (Clone III-I) was responsible for this outbreak. This bacteria was brought into the Kingdom of Saudi Arabia by the pilgrims from South Asia who were carriers of the disease. Middle age and elderly seemed to be vulnerable to meningococcal disease. The majority of the patients presented with fever, headache, vomiting, skin rash, and signs of meningeal irritation. Diabetics afflicted with meningococcal disease fared badly; of 13 diabetics in the study, eight died. The mortality rate in our patients was 12.1%, a figure comparing favorably with other studies. The factors which influenced mortality included age above 50, shock, coma, renal failure, DIC, upper gastrointestinal bleeding, female sex and other associated diseases. The outbreak was successfully controlled by mass vaccination with polyvalent vaccine of the pilgrims and local population along with chemoprophylaxis with rifampicin.
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PMID:Meningococcal disease: Clinical profile of 99 patients. 1759 Jun 68


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