Treatment of a patient with severe lactic acidosis and multiple organ failure due to mitochondrial myopathy:A case report

BACKGROUND Mitochondrial myopathy is a rare genetic disease with maternal inheritance that may involve multiple organ systems.Due to the lack of typical characteristics,its clinical diagnosis is difficult,and it is often misdiagnosed or even missed.CASE SUMMARY The patient was a young college student.When he presented at the hospital,he had severe lactic acidosis,respiratory failure,and shock with multiple organ dysfunction syndrome(MODS).He was treated by mechanical ventilation,venoarterial extracorporeal membrane oxygenation,and other organ support.However,his condition continued to worsen.After a thorough and detailed medical and family history was taken,a mitochondrial crisis was suspected.A muscle biopsy was taken.Further genetic testing confirmed a mitochondrial gene mutation(TRNL13243A>G).The final diagnosis of mitochondrial myopathy was made.Although there is no known specific treatment,intravenous methylprednisone and intravenous immunoglobulin were started.The patient’s shock eventually improved.The further course was complicated by severe infection in multiple sites,severe muscle weakness,and recurrent MODS.After 2 mo of multidisciplinary management and intensive rehabilitation,the patient could walk with assistance 4 mo after admission and walk independently 6 mo after admission.CONCLUSION More attention should be paid to mitochondrial myopathy to avoid missed diagnosis and misdiagnosis.

Combined human growth hormone and lactulose for prevention and treatment of multiple organ dysfunction in patients with severe chronic hepatitis B

AIM: To evaluate the efficiency and safety of combined recombinant human growth hormone (rhGH) and lactulose for treatment and/or prevention of multiple organ dysfunction in patients with chronic severe hepatitis B. METHODS: Forty-eight inpatients with chronic severe hepatitis B were randomly divided into rhGH group (n = 28)and control group (n = 20). In rhGH group, 4-4.5 IU of rhGH was injected intramuscularly once daily for 2-4 wk,and 100 mL of enema containing 30 mL of lactulose, 2 g of metronidazole and 0.9% saline was administered every 2 d for 2-4 wk. Their symptoms and complications were noted. Liver and kidney functions were analyzed by an Olympus analyzer. Serum GH, IGF-1, IGFBP1 and IGFBP3 were measured by ELISA.RESULTS: Clinical symptoms of 90% of these patients in rhGH group were obviously improved. The total effectiveness in rhGH group was better than that in control group (75% vs40%, P＜0.05). After 2- and 4-wk treatment of rhGH respectively, serum albumin (26.1±4.1 vs 30.2±5.3,31.9±5.1 g/L), prealbumin (79.6±28.0 vs 106.6±54.4,108.4±55.0 g/L), cholesterol (76.3±16.7 vs 85.6±32.3,96.1±38.7 mg/dL), and IGFBP1 (56.8±47.2 vs 89.7±50.3ng/mL after 2 wk) were significantly increased compared to control group (P＜0.05). However, serum GH was decreased. The increase of serum IGF1 and IGFBP3 after rhGH treatment was also observed.CONCLUSION: rhGH in combination with lactulose may be beneficial to the prevention and treatment of multiple organ dysfunction in patients with chronic severe hepatitis.

Morphological changes in interstitial cells of Cajal in the deep muscular plexus and enteric motor neurons of the intestine in rats with multiple organ dysfunction syndrome

BACKGROUND：Gastrointestinal motility dysfunction in multiple organ dysfunction syndrome （MODS） has been reported to be related to damage to interstitial cells of Cajal （ICC）. In the entedc nervous system, ICC and smooth muscle cells are connected in a network to form a special functional unit. Many gastrointestinal motility dysfunction diseases are associated with damage to this network.OBJECTIVE：To investigate the morphological changes of intestinal ICC, and to explore the mechanisms underlying gastrointestinal motility dysfunction in rats with MODS.DESIGN, TIME AND SE＇I-FING：The randomized, controlled, experiment was performed at the Central Laboratory of the First Affiliated Hospital of Dalian Medical University of China between June 2007 and March 2009.MATERIALS：Escherichia coli （E. colistrain O127 H6） and bovine serum albumin were purchased from Sigma, USA.METHODS：A total of 40 Wistar rats were equally and randomly divided into MODS group and control group. Suspension of E. coil strain O127 H6 containing BaSO4 and saline were sterilely injected into the abdominal cavity of rats in the MODS and control groups, respectively.MAIN OUTCOME MEASURES：Immunohistochemical double-staining and confocal laser scanning microscopy were used to observe the morphological changes in intestinal cholinergic nerves and ICC in the deep muscular plexus network. Electron microscopy was employed to evaluate the ultrastructural features of ICC in the deep muscular plexus of rats with MODS.RESULTS：Compared with the control group, the distributions and densities of cholinergic/nitrergic newes and ICC in the deep muscular plexus were significantly decreased in the MODS group （P 〈 0.01）. The enteric nerve-ICC network were disrupted.CONCLUSION：There is ultrastructural injury in the ICC in the deep muscular plexus and enteric nerves of the intestine in rats with MODS, which may be associated with the dysmotility of the gastrointestinal tract in MODS.

Clinical Effects of Intensive Insulin Therapy Treating Traumatic Shock Combined with Multiple Organ Dysfunction Syndrome

The therapeutic effects of intensive insulin therapy in treatment of traumatic shock combined with multiple organ dysfunction syndrome （MODS） were investigated. A total of 114 patients with traumatic shock combined with MODS were randomly divided into two groups： control group （n=56） treated with conventional therapy, and intensive insulin therapy group （n=58） treated with conventional therapy plus continuous insulin pumping to control the blood glucose level at range of 4.4-6.1 mmol/L. White blood cells （WBC） counts, prothrombin time （PT）, serum creatinine （SCr）, alanine aminotransferase （ALT）, serum albumin and PaO2 were measured before and at the day 1, 3, 5, 7 and 14 after treatment. The incidence of gastrointestinal dysfunction, the incidence of MODS, hospital stay and the mortality were also observed and compared. After intensive insulin therapy, the WBC counts, SCr, ALT and PT were significantly reduced （P0.05）, but the level of serum albumin was significantly increased （P0.05） at the day 3, 5, 7 and 14. In the meantime, the PaO2 was significantly elevated at the day 3, 5 and 7 （P0.01） after intensive insulin therapy. The incidence of gastrointestinal dysfunction, the incidence of MODS, the length of hospital stay and the mortality were markedly decreased （P0.01）. The results suggest early treatment with intensive insulin therapy is effective for traumatic shock combined with MODS and can decrease the length of hospital stay and the mortality.

Mild hypothermia in improving multiple organ dysfunction after cardiac arrest

BACKGROUND： Resuscitation after cardiac arrest （CA） with a whole-body ischemia–reperfusion injury causes brain injury and multiple organ dysfunction （MODS）. This study aimed to determine whether mild systemic hypothermia could decrease multiple organ dysfunctions after resuscitation from cardiac arrest.METHODS： The patients who had been resuscitated after cardiac arrest were reviewed. During the resuscitation they had been assigned to undergo therapeutic hypothermia （target temperature, 32°C to 34°C, measured in the rectum） over a period of 24 to 36 hours or to receive standard treatment with normothermia. Markers of different organ injury were evaluated for the ？ rst 72 hours after recovery of spontaneous circulation （ROSC）.RESULTS： At 72 hours after ROSC, 23 patients in the hypothermia group for whom data were available had favorable neurologic, myocardial, hepatic and pulmonic outcomes as compared with 26 patients in the normothermia group. The values of renal function were not signi？ cantly different between the two groups. However, blood coagulation function was badly injured in the hypothermia group.CONCLUSION： In the patients who have been successfully resuscitated after cardiac arrest, therapeutic mild hypothermia can alleviate dysfunction after resuscitation from cardiac arrest.

Prolonged intestinal mucosal acidosis is associated with multiple organ failure in human acute pancreatitis: Gastric tonometry revisited

AIM： To evaluate whether multiple determinations of intramucosal pH （pHi） in acute pancreatitis （AP） patients could provide additional information of the disease severity during early hospitalization. METHODS： Twenty-one patients suffering from acute pancreatitis were monitored by gastric tonometry in the first 72 h after hospital admission. RESULTS： In the survivor group （n = 15） the initially low phi values returned to normal level （pHi ≥ 7.32） within 48 h （median pHi： d 1： 7.21; d 2： 7.32; d 3： 7.33）. In contrast, pHi values in the non-survivor group n = 6） were persistently either below or in the low normal range （median pHi 7.12; 7.12; 7.07 respectively）, but pHi differences between the two groups reached significance only after 24 h （P 〈 0.01）. Mucosal acidosis detected at any time during the monitored period was associated with the emergence of single or multiple organ dysfunction （P 〈 0.01）. CONCLUSION： Prolonged gastric mucosal acidosis was associated with remote organ dysfunction and failure in Acute Pancreatitis, however, correlation with the fatal outcome became significant only 24 h after admission. Due to its non-invasive nature gastric tonometry may supplement the pro-inflammatory markers to achieve a multi-faceted monitoring of the disease.

Application of bedside continuous blood purification in patients with multiple organ dysfunction syndromes

BACKGROUND:The complications of systemic inflammatory response syndrome(SIRS)include acute lung injury,acute kidney injury,shock,and multiple organ dysfunction syndrome(MODS).In recent years,how to clear inflammatory mediators has become a hot topic in critical care medicine.Researchers hypothesize that continuous blood purification(CBP) can effectively eliminate a variety of inflammatory mediators which participate in the occurrence of MODS and adjust the immune imbalance.This study aimed to observe the effects of CBP in MODS patients.METHODS:In this retrospective clinical study,a total of 38 MODS patients,18 males and 20 females,were enrolled.After conventional therapy,all the patients received CBP.Biochemistry,blood gas analysis,oxygenation index,mean arterial blood pressure(MAP),acute physiology and chronic health evaluation(APACHE) II scores were monitored.RESULTS:After CBP,the vital signs of patients were rapidly stable,and electrolyte disorders and acid-base imbalance were corrected.Renal function,blood gas,oxygenation index were all improved.MAP was increased,and APACHE II score was significantly decreased.All patients had good tolerance,stable hemodynamics,and no obvious adverse reaction on CBP compared with pre-CBP.CONCLUSION:CBP can effectively clean toxins,correct electrolyte acid-base balance,and improve systemic inflammatory response syndrome and the organ function of MODS patients.

Blood hemoperfusion with resin adsorption combined continuous veno-venous hemofiltration for patients with multiple organ dysfunction syndrome

BACKGROUND:Blood hemoperfusion with resin adsorption can clean larger molecules that exceed the molecular weight cutoff of combined continuous veno-venous hemofiltration(CWH).Hence blood hemoperfusion with resin adsorption combined CWH(HP+CWH) has higher ability of mediator clearance,and can improve clinical outcomes in theory.This study aimed to investigate the effect of blood hemoperfusion with resin adsorption combined continuous veno-venous hemofiltration(HP+CWH) on plasm cytokines like TNF-α,IL-1β,IL-6,cellular immunity and prognosis in patients with multiple organ dysfunction syndrome(MODS).METHODS:This was a prospective,randomized clinical trial.A total of 30 patients who had been diagnosed with MODS were enrolled in this study.Patients were randomly allocated to routine treatment+HP+CWH group(treatment group) and routine treatment+only CWH group(control group).In the treatment group,patients received blood hemoperfusion with resin adsorption for 2hours,and then received CWH for 10 hours every day.In the control group,patients received CWH for 12 hours only every day.The patients in the two groups received blood purification therapy for three days.The plasma of patients in the treatment group was obtained at 0,2,12,24,26,36,48,50,60 hours,5th day,7th day and 10 th day,respectively.The plasma of patients in the control group was obtained at 0,12,24,36,48,60 hours,5th day,7th day and 10 th day,respectively.APACHE Ⅱscore,T-lymphocytes subpopulations,blood lactate acid concentration,heart rate,breathing rate,and oxygenation index were observed.RESULTS:Plasma cytokines like TNF-α,IL-1β,IL-6 decreased markedly after HP(P<0.01);T-lymphocytes subpopulations CD3+,CD4+,CD8+,CD4+/CD8+ increased after HP+CWH or only CWH.The plasma concentrations of TNF-α,IL-1β and IL-6 in the two groups were not markedly different at 12,36,and 50 hours.But on the 5th day,the plasma concentrations of TNF-α,IL-1β and IL-6 in the treatment group were lower than those in the control group(P<0.05).On the 28 th day,5patients died in the treatment group,and 6 patients in the control group.CONCLUSIONS:Both HP+CWH and CWH can clean plasma cytokines like TNF-α,IL-1β,and IL-6,and improve cellular immunity and clinical symptoms and signs of patients.Compared with only CWH,the plasma concentrations of TNF-α,IL-1β and IL-6 were lower on the 5th day,and patients have an increased survival rate on the 28 day in the HP+CWH group.

Multiple organ dysfunction and rhabdomyolysis associated with moonwort poisoning: Report of four cases

BACKGROUND Moonwort is a widely used Chinese herbal medicine. It has various pharmacological effects, such as relieving cough and preventing asthma. To date,multiple organ dysfunction and rhabdomyolysis caused by moonwort poisoning have not been reported.CASE SUMMARY Here we report four cases of moonwort poisoning that presented with multiple organ dysfunction and rhabdomyolysis accompanied by vomiting, fatigue, and muscle aches. One patient was an adult male, two were adult females, and one was a boy, with an age range of 7–64 years. The adults were treated with hemoperfusion and symptomatic therapies, while the child was treated with plasma exchange and symptomatic therapies. All four patients recovered.CONCLUSION Blood purification combined with symptomatic treatment may be an effective method for managing multiple organ dysfunction and rhabdomyolysis caused by acute moonwort poisoning.

Multiple-Organ Extracorporeal Support Therapies in Critically Ill Patients

The critically ill patient is capable of presenting a multiple organ dysfunction syndrome (MODS) caused by different diseases, which can be infectious (sepsis, septic shock) as well as non-infectious (pancreatitis, large surgeries, traumatic injuries, burn patients and brain injuries), this syndrome is characterized by global hemodynamic and organ perfusion alterations accompanied by an uncontrolled and marked inflammatory response unresponsive to pharmacological treatment due to which extracorporeal organ support can be a viable option. Acute renal lesion can occur in up to 60% of patients receiving intensive care, and close to 10% - 20% require renal replacement therapy (RRT) globally this can be provided as peritoneal dialysis (PD) or intermittent hemodialysis (IHD), continuous renal replacement therapy (CRRT), hybrid therapies known as sustained slow efficiency dialysis (SLED), which combines the benefits IHD and CRRT, slow continuous ultrafiltration (SCUF). Extracorporeal membrane oxygenation (ECMO) and extracorporeal elimination of CO2, have been used more frequently lately, these are temporal artificial support used for respiratory and/or cardiac insufficiency that is refractory to conventional treatment. Acute liver failure in adults has a mortality rate close to 50% furthermore one-third of patients hospitalized for cirrhosis are likely to progress to acute liver failure which will drastically increase its mortality. Based on concepts of albumin dialysis, one of its most known is the following: Molecular Adsorbent Recirculating System (MARS), Fractionated Plasma Separation and Absorption—FPSA (Prometheus®) and also, hemoperfusion with different cartridges used in different extracorporeal therapies, used in liver failure, rhabdomyolysis, cytokine release syndrome and more in the context of the pandemic covid19. The objective of this review is to know the different extracorporeal therapies and the therapeutic utility in critical patients.

Association of low non-invasive near-infrared spectroscopic measurements during initial trauma resuscitation with future development of multiple organ dysfunction

BACKGROUND: Near-infrared spectroscopy(NIRS) non-invasively monitors muscle tissue oxygen saturation(St O2). It may provide a continuous noninvasive measurement to identify occult hypoperfusion, guide resuscitation, and predict the development of multiple organ dysfunction(MOD) after severe trauma. We evaluated the correlation between initial St O2 and the development of MOD in multi-trauma patients.METHODS: Patients presenting to our urban, academic, Level I Trauma Center/Emergency Department and meeting standardized trauma-team activation criteria were enrolled in this prospective trial. NIRS monitoring was initiated immediately on arrival with collection of St O2 at the thenar eminence and continued up to 24 hours for those admitted to the Trauma Intensive Care Unit(TICU). Standardized resuscitation laboratory measures and clinical evaluation tools were collected. The primary outcome was the association between initial St O2 and the development of MOD within the f irst 24 hours based on a MOD score of 6 or greater. Descriptive statistical analyses were performed; numeric means, multivariate regression and rank sum comparisons were utilized. Clinicians were blinded from the StO 2 values.RESULTS: Over a 14 month period, 78 patients were enrolled. Mean age was 40.9 years(SD 18.2), 84.4% were male, 76.9% had a blunt trauma mechanism and mean injury severity score(ISS) was 18.5(SD 12.9). Of the 78 patients, 26(33.3%) developed MOD within the first 24 hours. The MOD patients had mean initial St O2 values of 53.3(SD 10.3), signifi cantly lower than those of nonMOD patients 61.1(SD 10.0); P=0.002. The mean ISS among MOD patients was 29.9(SD 11.5), significantly higher than that of non-MODS patients, 12.1(SD 9.1)(P<0.0001). The mean shock index(SI) among MOD patients was 0.92(SD 0.28), also signifi cantly higher than that of non-MODS patients, 0.73(SD 0.19)(P=0.0007). Lactate values were not signifi cantly different between groups.CONCLUSION: Non-invasive, continuous St O2 near-infrared spectroscopy values during initial trauma resuscitation correlate with the later development of multiple organ dysfunction in this patient population.

A Case Report of Scrub Typhus: Secondary Acute Arrest of Hemopoiesis with Multiple Organ Dysfunction Syndromes

Scrub typhus is a zoonotic disease caused by Orientia tsutsugamushi (O. tsutsugamushi) in which humans are accidental hosts. Acute arrest of hemopoiesis (AAH) always manifests in pancytopenia and with supportive treatment or inducement removal, the AAH patients would show significant improvement in blood routine for about a week. As a rapidly progressive and potentially life-threatening organ function disorder syndrome, multiple organ dysfunction syndrome (MODS) is often induced by many factors including infection, illness and injury. We received a rare case of scrub typhus rapidly presenting with AAH and MODS 2 weeks ago. The clinical data of a 32-year-old female with O. tsutsugamushi-induced AAH and MODS was summarized retrospectively and analyzed with a literature review. In this case, we selected tigecycline and moxifloxacin as treatment regimens for scrub typhus. When the potential infection was controlled, her pancytopenia and hepatic function rapidly improved in a few days.

Successful treatment of severe burn patients with multiple organ dysfunction syndrome:A case report

Multiple organ dysfunction syndrome is the presence of altered organ function of two or more organ systems in acute ill patients with severe trauma,burn,shock and infection.In this case,the patient with burn area amounted to 95%and the third-degree burn was up to 90%.He underwent gastrointestinal tract,blood clotting,lung,brain,heart,liver dysfunction,and cardiac arrest for 30 minutes during the courses of treatment,and was discharged from the hospital after 108 days on the basis of comprehensive treatment and repeated skin grafting.

Vascular endothelium,a promising target for effectively treating fulminant diquat intoxication?

Following the withdrawal of paraquat,diquat(DQ)has emerged as the predominant herbicide.When people come into contact with or ingest DQ,may lead to poisoning and potentially fatal outcomes.Reports suggest that the mortality of DQ poisoning can be as high as 50%.DQ poisoning can be categorized as mild,moderate to severe or fulminant.In cases of fulminant poisoning,victims often succumb to multiple organ failure within 48 h.This presents a significant challenge in the clinical management.Scholars have discovered that oxidative stress,inflammatory injury,and cell apoptosis play crucial roles in the DQ poisoning.However,the underlying connection of the extensive organ damage remains unknown.The abnormal function and activity of endothelial cells(EC)should play a crucial role in tissue damage caused by DQ due to rich microcirculation and high sensitivity to perfusion in the vulnerable organs.However,reports on DQ-induced EC injury is rare.We made a preliminary discovery-the presence of severe vascular endothelial damage in the kidneys and lungs affected by DQ.Therefore,we hypothesize that DQ poisoning may be attributed to EC damage,ultimately resulting in multiple organ failure.

Impact of interleukin 6 levels on acute lung injury risk and disease severity in critically ill sepsis patients

BACKGROUND Sepsis is a life-threatening condition characterized by a dysregulation of the host response to infection that can lead to acute lung injury(ALI)and multiple organ dysfunction syndrome(MODS).Interleukin 6(IL-6)is a pro-inflammatory cytokine that plays a crucial role in the pathogenesis of sepsis and its complications.AIM To investigate the relationship among plasma IL-6 levels,risk of ALI,and disease severity in critically ill patients with sepsis.METHODS This prospective and observational study was conducted in the intensive care unit of a tertiary care hospital between January 2021 and December 2022.A total of 83 septic patients were enrolled.Plasma IL-6 levels were measured upon admission using an enzyme-linked immunosorbent assay.The development of ALI and MODS was monitored during hospitalization.Disease severity was evaluated by Acute Physiology and Chronic Health Evaluation II(APACHE II)and Sequential Organ Failure Assessment(SOFA)scores.RESULTS Among the 83 patients with sepsis,38(45.8%)developed ALI and 29(34.9%)developed MODS.Plasma IL-6 levels were significantly higher in patients who developed ALI than in those without ALI(median:125.6 pg/mL vs 48.3 pg/mL;P<0.001).Similarly,patients with MODS had higher IL-6 levels than those without MODS(median:142.9 pg/mL vs 58.7 pg/mL;P<0.001).Plasma IL-6 levels were strongly and positively correlated with APACHE II(r=0.72;P<0.001)and SOFA scores(r=0.68;P<0.001).CONCLUSIONElevated plasma IL-6 levels in critically ill patients with sepsis were associated with an increased risk of ALI andMODS.Higher IL-6 levels were correlated with greater disease severity,as reflected by higher APACHE II andSOFA scores.These findings suggest that IL-6 may serve as a biomarker for predicting the development of ALI anddisease severity in patients with sepsis.

Exertional heat stroke with pronounced presentation of microangiopathic hemolytic anemia:A case report

BACKGROUND Exertional heat stroke(EHS)is a critical condition arising from prolonged physical exertion in high temperatures that typically presents with normal hemoglobin levels.However,atypical presentations can also occur,leading to significant complications such as hemolytic anemia and organ dysfunction.CASE SUMMARY This case report describes a male patient who experienced moderate-to-severe anemia that was difficult to correct,with a confirmed diagnosis of microangiopathic hemolytic anemia accompanying multiple organ dysfunction syndrome,indicative of critical EHS.Despite intensive resuscitation efforts,the patient’s condition deteriorated,necessitating admission to the intensive care unit for advanced management.CONCLUSION This case highlights the importance of recognizing atypical presentations of EHS,particularly that with significant hemolytic anemia and concurrent organ failure.Clinicians should maintain a high level of suspicion for these complications in patients displaying symptoms of heat-related illness,especially when caused by strenuous activity,as early diagnosis and intervention are crucial to improve patient outcomes.

Epidemiology and clinico-laboratory manifestations of scrub typhus in Hadoti region of Rajasthan,India:A cross-sectional study

Objective:To study epidemiology,clinical manifestations,and laboratory parameters of scrub typhus in Hadoti region of Rajasthan,India.Methods:A cross-sectional study was conducted on 50 patients with scrub typhus between August 2022 and November 2022.Scrub typhus was diagnosed by ELISA IgM scrub typhus antibody.The data about demography,vital parameters,and lab investigations were collected and analyzed.Results:Ninety-two percent of the patients were from a rural background(92%),86% were farmers and the majority were females.Most patients were 40-60 years old.The major complaints were fever(100%),myalgia(100%),headache(82%),and body swelling(80%).Major complications were pneumonia(68%),multiple organ dysfunction syndrome(62%),hepatitis(44%),and acute kidney injury(42%).Triglyceride levels were>200 mg/dL in 80% of patients,albumin<3.5 g/dL in 98% and eschar mark was present in 24%of patients.Conclusions:Scrub typhus is a serious acute febrile illness that can lead to multi-organ dysfunction and is associated with significant mortality.Increasing awareness regarding disease in endemic regions,early screening of patients,and treatment as early as possible could help prevent the patient from severe life-threatening complications.

Acute diffuse peritonitis secondary to a seminal vesicle abscess:A case report

BACKGROUND Seminal vesicle abscess(SVA)is the manifestation of a relatively rare urinary system infection.In response to urinary system inflammation,an abscess forms in special locations.However,acute diffuse peritonitis(ADP)induced by SVA is unusual.CASE SUMMARY We report a case of a left SVA in a male patient complicated with pelvic abscess,ADP,multiple organ dysfunction syndrome,infectious shock,bacteremia,and acute appendiceal extraserous suppurative inflammation as a result of a long-term indwelling urinary catheter.The patient received a course of morinidazole+cefminol antibiotics but showed no obvious relief,so the perineal SVA underwent puncture drainage and abdominal abscess drainage+appendectomy was performed.The operations were successful.After the operation,anti-infection,anti-shock,and nutritional support treatments were continued and various laboratory indicators were regularly reviewed.The patient was discharged from the hospital after recovery.This disease is a challenge for the clinician because of the unusual spreading path of the abscess.Moreover,appropriate intervention and adequate drainage of abdominal and pelvic lesions are necessary,especially when the primary focus cannot be determined.CONCLUSION The etiology of ADP varies,but acute peritonitis secondary to SVA is very rare.In this patient,the left SVA not only affected the adjacent prostate and bladder but also spread retrogradely through the vas deferens,forming a pelvic abscess in the loose tissues of the extraperitoneal fascia layer.Inflammation involving the peritoneal layer led to ascites and pus accumulation in the abdominal cavity,and appendix involvement led to extraserous suppurative inflammation.In clinical practice,surgeons need to consider the results of various laboratory tests and imaging examinations to make comprehensive judgments involving the diagnosis and treatment plan.

Mutating Escherichia coli caused multiple organ dysfunction syndrome

Pathogenic Escherichia coli is of great concern in the clinical setting.But few reports have demonstrated the variation in disease course.We present a severe case of multiple organ dysfunction syndrome caused by E.coli infection.Pathogens isolated from blood and urine samples harboured many virulence factors.Whole‐genome sequencing and conventional analyses showed that the isolates experienced beneficial variations,both genetically and phenotypically,during the disease course.These findings showed that E.coli can cause sys-temic symptoms and informed us of the importance of assessing the reasons for such variations in pathogens occurring in vivo.

Delayed ethyl pyruvate therapy attenuates experimental severe acute pancreatitis via reduced serum high mobility group box 1 levels in rats

AIM： To investigate the effect of delayed ethyl pyruvate （EP） delivery on distant organ injury, survival time and serum high mobility group box 1 （HMGB1） levels in rats with experimental severe acute pancreatitis （SAP）. METHODS： A SAP model was induced by retrograde injection of artificial bile into the pancreatic ducts of rats. Animals were divided randomly into three groups （n = 32 in each group）： sham group, SAP group and delayed EP treatment group. The rats in the delayed EP treatment group received EP （30 mg/kg） at 12 h, 18 h and 30 h after induction of SAP. Animals were sacrificed, and samples were obtained at 24 h and 48 h after induction of SAP. Serum HMGB1, aspartate arninotransferase （AST）, alanine arninotransferase （ALT）, blood urea nitrogen （BUN）, and creatinine （Cr） levels were measured. Lung wet-to-dry-weight （W/D） ratios and histological scores were calculated to evaluate lung injury. Additional experiments were performed between SAP and delayed EP treatment groups to study the influence of EP on survival times of SAP rats. RESULTS： Delayed EP treatment significantly reduced serum HMGB1 levels, and protected against liver, renal and lung injury with reduced lung W/D ratios （8.22 ±0.42 vs 9.76 ± 0.45, P 〈 0.01）, pulmonary histological scores （7.1 ± 0.7 vs 8.4 ± 1.1, P 〈 0.01）, serum AST （667 ± 103 vs 1 368 ± 271, P 〈 0.01）, ALT （446 ± 91 vs 653 ± 98, P 〈 0.01） and Cr （1.2 ± 0.3 vs 1.8 ± 0.3, P 〈 0.01） levels. SAP rats had a median survival time of 44 h. Delayed EP treatment significantly prolonged median survival time to 72 h （P 〈 0.01）. CONCLUSION： Delayed EP therapy protects against distant organ injury and prolongs survival time via reduced serum HMGBllevels in rats with experimental SAP. EP may potentially serve as an effective new therapeutic option against the inflammatory response and multiple organ dysfunction syndrome （MODS） in SAP patients.