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Monday, 2 December 2013

Thyroid disease: Euthyroid sick syndrome as a result of Sepsis - Diseases associated to Sepsis

Euthyroid sick syndrome
Euthyroid sick syndrome is defined as a condition of  low T3 low T4 syndrome. According ot the study by the Mayo Clinic, in  other word this is the abnormalities of thyroid hormone concentrations seen commonly in a wide variety of nonthyroidal illnesses, resulting in low triiodothyronine, total thyroxine, and thyroid stimulating hormone concentrations(a). Decreased triiodothyronine (T3) levels are most common. Patients with more severe or prolonged illness also have decreased thyroxine (T4) levels. Serum reverse T3 (rT3) is increased. Patients are clinically euthyroid and do not have elevated thyroid-stimulating hormone (TSH) levels(b). Causes of euthyroid sick syndrome include a number of acute and chronic conditions, including pneumonia, fasting, starvation, sepsis, trauma, cardiopulmonary bypass, malignancy, stress, heart failure, hypothermia, myocardial infarction, chronic renal failure, cirrhosis, and diabetic ketoacidosis and inflammatory bowel disease(c). Others, in the study of classified SES into 3 subgroups according to the different alterations seen in the values of T3, T4, FT3, FT4, TSH, rT3 and TBG suggested that in SES type I the diseases seen, in order of frequency, were: obstructive chronic bronchopneumopathy with acute respiratory failure, diabetic ketoacidosis, neoplasms, ischemic heart disease, cardiac failure, chronic renal failure, liver diseases, acute cerebral vasculopathies, sepsis and collagenopathies. The disease seen in the 2 cases of SES type II was obstructive chronic bronchopneumopathy with acute respiratory failure. In SES type III the diseases seen were, in order of frequency: diabetic ketoacidosis, lung diseases, ischemic heart disease, cardiac failure, peripheral arteriopathies, acute cerebral vasculopathies, neoplasms, liver diseases, acute renal failure(d).

Euthyroid sick syndrome as a result of Sepsis  
 Sepsis is defined as a condition caused by chemicals released into the bloodstream to fight the infection trigger inflammation throughout the body as a result of severe infection(a)(b). according to the study by the University of Utah, sepsis is the commonest cause of admission to medical ICUs across the world. Mortality from sepsis continues to be high. Besides shock and multi-organ dysfunction occurring following the intense inflammatory reaction to sepsis, complications arising from sepsis-related immunoparalysis contribute to the morbidity and mortality from sepsis(c).
Diseases associated to Sepsis
1. Staphylococcal infections
Preterm infants are especially susceptible to late-onset sepsis that is often due to Gram-positive bacterial infections resulting in substantial morbidity and mortality(24).

2. Elevated central venous pressure 
Elevated central venous pressure is associated with impairment of microcirculatory blood flow in sepsis(25).

3. Neonatal cellulitis
there is a report of a case of late onset neonatal invasive group A streptococcal disease characterized with rapidly progressing cellulitis and development of sepsis(26). 

4. Methicillin-resistant Staphylococcus aureus
There is a report of  the spectrum of community-acquired S. aureus infections and  to compare the patients infected with methicillin-susceptible or methicillin-resistant strains among patients aged <20 years. Overall, 90 cases of community-acquired S. aureus were detected in an 11-year period(27).  

5. Bladder infection 
Bladder bacteria is common but unique cause for sepsis(28).

6. Urinary tract infection
In the study to evaluate the effectiveness of Lactobacillus GG supplementation in reducing the incidence of urinary tract infections (UTIs), bacterial sepsis and necrotizing enterocolitis (NEC) in preterm infants, found that seven days of Lactobacillus GG supplementation starting with the first feed is not effective in reducing the incidence of UTIs, NEC and sepsis in preterm infants. Further studies are required to confirm our results in lower birthweight populations(29).

7. Venous thromboembolism (VTE) (deep venous thrombosis and pulmonary embolus)
According to the study b ythe UC Davis School of Medicine, there was increased risk of AbVTE early (<90 days; hazard ratio [HR] 5.4 [confidence interval (CI), 2.3-12.5]), but not late (≥90 days; HR 1.5 [CI, 0.9-2.6]) after splenectomy. There was increased risk of VTE both early (HR 5.2 [CI, 3.2-8.5]) and late (HR 2.7 [CI, 1.9-3.8]) after splenectomy. The cumulative incidence of sepsis was 11.1% among the ITP patients who underwent splenectomy and 10.1% among the patients who did not. Splenectomy was associated with a higher adjusted risk of sepsis, both early (HR 3.3 [CI, 2.4-4.6]) and late (HR 1.6 or 3.1, depending on comorbidities). ITP patients post splenectomy are at increased risk for AbVTE, VTE, and sepsis(30).

8.  Hydroureteronephrosis
 Hydroureteronephrosis without vesicoureteral reflux or lower-urinary-tract obstruction is uncommon in infants. There has been considerable interest in and controversy over the cause and management of this entity. We have cared for three neonates with severe hydroureteronephrosis after acute urinary tract infections, who were treated without operation, according to Pais VM, and Retik AB(31).

9. Osteomyelitis
Sepsis and osteomyelitis about the ankle joint present a challenging clinical problem. Osteomyelitis usually follows open fracture of the distal tibia, often with a pilon fracture component. Treatment of subsequent osteomyelitis and sepsis, including the authors' experiences, is discussed. Septic ankle arthritis can occur hematogenously. In some patients, the optimal treatment for concomitant osteomyelitis and sepsis is a below knee amputation(32). 

10. Necrotizing fasciitis
There is a report of a case of necrotizing fasciitis and sepsis caused by Aeromonas hydrophila after crush injury of the lower extremity(33).

11. Phlebitis
There is a report of a case of Septic pulmonary emboli secondary to internal jugular vein phlebitis (postanginal sepsis) caused by Eikenella corrodens(34).

12. Lymphedema
There is a report of a patient with congenital penoscrotal lymphedema complicated by cellulitis, lymphangitis, and severe sepsis associated with a streptococcal infection. This case represents the importance of obtaining a detailed clinical history and physical findings(35).

13. Vancomycin-Resistant Enterococci (VRE)
The prevalence of the VRE that caused bacteraemia increased from 2003 to 2010. This increase might be attributed to the clonal spread of VREfm belonging to ST18 and ST414. The all-cause 14 day mortality rate was lower in patients with bacteraemia due to VREfm isolates that belonged to ST414(36).
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Sources
(a) http://en.wikipedia.org/wiki/Sepsis
(b) http://www.mayoclinic.com/health/sepsis/DS01004 
(c) http://www.ncbi.nlm.nih.gov/pubmed/24082613
(24) http://www.ncbi.nlm.nih.gov/pubmed/23935651 
(25) http://www.ncbi.nlm.nih.gov/pubmed/23919272 
(26) http://www.ncbi.nlm.nih.gov/pubmed/20807361 
(27) http://www.ncbi.nlm.nih.gov/pubmed/24055391 
(28) http://www.ncbi.nlm.nih.gov/pubmed/5564785 
(29) http://www.ncbi.nlm.nih.gov/pubmed/12169832 
(30) http://www.ncbi.nlm.nih.gov/pubmed/23637127 
(31) http://www.ncbi.nlm.nih.gov/pubmed/1089891 
(32) http://www.ncbi.nlm.nih.gov/pubmed/11232476 
(33) http://www.ncbi.nlm.nih.gov/pubmed/18687029 
(34) http://www.ncbi.nlm.nih.gov/pubmed/6383158 
(35) http://www.ncbi.nlm.nih.gov/pubmed/11138888 
(36) http://www.ncbi.nlm.nih.gov/pubmed/22618861