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Circulating plasma IL-6 levels are high during protracted critical illness, and are partially responsible for the relative adrenal insufficiency found in a subset of severely ill patients.

Furthermore, the bowel was silent and abdominal compartment syndrome with a measured pressure of 25 cmH 2 O (on 8th day), developed. CT of the abdomen, on 8th day, revealed multiple peritoneal and extraperitoneal fluid collections with infectious extension to the retroperitoneum. Surgical drainage was performed; the abdomen remained open. A slow progressive recovery was followed. Closure of the abdominal walls was performed on 25th day. The patient remained in the ICU for 39 days. Serum antistreptolycin O (ASO) titer was 580 IU/ml on the 6th day (normal range, 0-180 IU/ml), rising to 2,750 IU/ml on the 21st day. Although erythema and edema of the posterior pharynx were present and the tonsils were enlarged upon admission to the ICU, swabs cultures obtained from the throat grew only commensals.He was discharged home on the 50th day on oral penicillin ( Fig. 1A). Usual laboratory findings were all in normal values. An extensive search for immunodeficiency (including assays of immunoglobulins and IgG subclasses, serum complement levels, and white cell burst) and HIV were negative. Three months later the fever and weakness reoccurred. A new abdominal CT revealed a prevesical abscess and a large abscess in the right lower abdominal quadrant. In addition, diffuse obscurity of the retroperitoneum in combination with thickening of the obturator internus muscle, possibly indicating infectious extenPrimary peritonitis caused by group A streptococci (GAS) is quite unexpected in previously healthy adults without underlying disease [1, 2,3]. Moreover, primary peritonitis due to a combination of GAS and E. coli has not been previously reported in the literature.A 40-year-old, previous healthy man, presented to an outboard clinic with 2-day history of fever 39°C, ephidrosis, and a sore throat; only antifebrile medication was prescribed. Five days later, he was admitted to a regional hospital with clinical and laboratory findings of acute peritonitis. The patient underwent urgent laparotomy. Diffuse peritonitis with a large amount of fine intra-peritoneal cloudy fluid was found; no bowel perforation was established. Broad-spectrum antibiotics (Metronidazole, netilmicin, piperacillin/tazobactam) were initiated. Two days later, the patient was led to the operating room for second time, as his condition was still unstable, requiring noradrenaline; again, no focus of infection or intestine perforation could be identified. The patient continued to deteriorate due to severe sepsis, and finally was intubated on the 4th day after the first operation, and transferred to the ICU.Upon admission to the ICU, a soft-tissue inflammation with extensive skin erythema, edema, and tenderness -with no sharply demarcated margins from the surrounding uninvolved tissue -extending to the right abdominal wall and the right thigh was evident. Although necrotizing fasciitis was considered [4], undermining of the skin was not demonstrated. Meanwhile, GAS (sensitive to penicillin) and E. coli were cultured in all peritoneal pus samples, obtained at the time...

Objective. We evaluated whether routine ultrasound examination may illustrate gallbladder abnormalities, including acute acalculous cholecystitis (AAC) in the intensive care unit (ICU). Patients and Methods. Ultrasound monitoring of the GB was performed by two blinded radiologists in mechanically ventilated patients irrespective of clinical and laboratory findings. We evaluated major (gallbladder wall thickening and edema, sonographic Murphy's sign, pericholecystic fluid) and minor (gallbladder distention and sludge) ultrasound criteria. Measurements and Results. We included 53 patients (42 males; mean age 57.6 ± 2.8 years; APACHE II score 21.3 ± 0.9; mean ICU stay 35.9 ± 4.8 days). Twenty-five patients (47.2%) exhibited at least one abnormal imaging finding, while only six out of them had hepatic dysfunction. No correlation existed between liver biochemistry and ultrasound results in the total population. Three male patients (5.7%), on the grounds of unexplained sepsis, were diagnosed with AAC as incited by ultrasound, and surgical intervention was lifesaving. Patients who exhibited ≥2 ultrasound findings (30.2%) were managed successfully under the guidance of evolving ultrasound, clinical, and laboratory findings. Conclusions. Ultrasound gallbladder monitoring guided lifesaving surgical treatment in 3 cases of AAC; however, its routine application is questionable and still entails high levels of clinical suspicion.

Background. Prolonged immobilization, nutritional and vitamin D deficiency, and specific drug administration may lead to significant bone resorption. Methods and Patients. We prospectively evaluated critically ill patients admitted to the ICU for at least 10 days. Demographics, APACHE II, SOFA scores, length of stay (LOS), and drug administration were recorded. Blood collections were performed at baseline and on a weekly basis for five consecutive weeks. Serum levels of PINP, β-CTx, iPTH, and 25(OH)vitamin D were measured at each time-point. Results. We enrolled 28 patients of mean age 67.4 ± 2.3 years, mean APACHE II 22.2 ± 0.9, SOFA 10.1 ± 0.6, and LOS 31.6 ± 5.7 days. Nineteen patients were receiving low molecular weight heparin, 17 nor-epinephrine and low dose hydrocortisone, 18 transfusions, and 3 phenytoin. 25(OH)vitamin D serum levels were very low in all patients at all time-points; iPTH serum levels were increased at baseline tending to normalize on 5th week; β-CTx serum levels were significantly increased compared to baseline on 2nd week (peak values), whereas PINP levels were increased significantly after the 4th week. Conclusions. Our data show that critically ill patients had a pattern of hypovitaminosis D, increased iPTH, hypocalcaemia, and BTMs compatible with altered bone metabolism.

A 43-year-old psychiatric patient was transferred in coma and hypercapnic respiratory failure at the emergency department. He was intubated for airway protection and transferred to the Intensive Care Unit (ICU). Abdominal X-ray revealed a radiopaque mass; a pharmacobezoar was suspected and confirmed by gastroscopy; one large in the stomach fundus and a smaller one in the pylorus. Gastric lavage through the gastroscope and administration of gastro-kinetic drugs and laxatives were able to dilute the bezoars. Tablets retrieved from the stomach identified as methadone and toxicological tests of the gastric fluid confirmed the presence of methadone as the only organic chemical compound. The patient was extubated on the 7th day and released from the ICU on the 10th day under psychiatric consultation having normal vital signs. Methadone gastric bezoar may lead to persistent intoxication, respiratory failure, and coma requiring ICU care. Diagnosis may be difficult and a high index of suspicion is needed.

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