A case of recurrent systemic capillary leak syndrome triggered by influenza A infection associated with cardiogenic shock supported by veno-arterial extracorporeal membrane oxygenation

Systemic capillary leak syndrome (SCLS) is a rare and under-recognized disease which is potentially fatal. We report a case of SCLS triggered by influenza A infection associated with fulminant cardiogenic shock, successfully supported by veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Strong clinical suspicion with appropriate supportive treatment can be life-saving for patients with SCLS.

Diagnosing capillary leak in critically ill patients: development of an innovative scoring instrument for non-invasive detection

Background The concomitant occurrence of the symptoms intravascular hypovolemia, peripheral edema and hemodynamic instability is typically named Capillary Leak Syndrome (CLS) and often occurs in surgical critical ill patients. However, neither a unitary definition nor standardized diagnostic criteria exist so far. We aimed to investigate common characteristics of this phenomenon with a subsequent scoring system, determining whether CLS contributes to mortality. Methods We conducted this single-center, observational, multidisciplinary, prospective trial in two separately run surgical ICUs of a tertiary academic medical center. 200 surgical patients admitted to the ICU and 30 healthy volunteers were included. Patients were clinically diagnosed as CLS or No-CLS group (each N = 100) according to the grade of edema, intravascular hypovolemia, hemodynamic instability, and positive fluid balance by two independent attending physicians with > 10 years of experience in ICU. We performed daily measurements with non-invasive body impedance electrical analysis, ultrasound and analysis of serum biomarkers to generate objective diagnostic criteria. Receiver operating characteristics were used, while we developed machine learning models to increase diagnostic specifications for our scoring model. Results The 30-day mortility was increased among CLS patients (12 vs. 1%, P = 0.002), while showing higher SOFA-scores. Extracellular water was increased in patients with CLS with higher echogenicity of subcutaneous tissue [29(24–31) vs. 19(16–21), P < 0.001]. Biomarkers showed characteristic alterations, especially with an increased angiopoietin-2 concentration in CLS [9.9(6.2–17.3) vs. 3.7(2.6–5.6)ng/mL, P < 0.001]. We developed a score using seven parameters (echogenicity, SOFA-score, angiopoietin-2, syndecan-1, ICAM-1, lactate and interleukin-6). A Random Forest prediction model boosted its diagnostic characteristics (AUC 0.963, P < 0.001), while a two-parameter decision tree model showed good specifications (AUC 0.865). Conclusions Diagnosis of CLS in critically ill patients is feasible by objective, non-invasive parameters using the CLS-Score. A simplified two-parameter diagnostic approach can enhance clinical utility. CLS contributes to mortality and should, therefore, classified as an independent entity. Trial Registration: German Clinical Trials Registry (DRKS No. 00012713), Date of registration 10/05/2017, www.drks.de Graphical Abstract

Clinical Nursing during CD4-Specific CAR T Cells Treatment for One Mycosis Fungoides Patient Improves Generalized Skin Lesion

Objective: To summarize the clinical nursing approach to CART treatment in one mycosis fungoides patient with generalized skin lesions, and to provide experience for reference in clinical nursing for such patients undergoing CART treatment. Method: Case Presentation: The patient, female, aged 43 years, was pathologically diagnosed to mycosis fungoides. Clinical state was tumor stage, as well TNMB stage was T4N3M0B1. The patient was admitted to the hospital with diffuse crimson papules, nodules, tumor, associated with brown, black pigmentation, complained of pruritus. The tumor surface ulcerated and oozing fluid at the surface of the head, bilateral cheeks, bilateral axillae, abdomen, right groin appeared infiltrated with flower like growth, the large of which was about 6x7 cm, and microorganism culture of secretory showed acinetobacter baumannii and corynebacterium striatum. Human derived CD4-CART treatment was given after chemotherapy pretreatment. The patient occurred severe granulocytic deficiency, fever, skin infection, gastrointestinal bleeding, respiratory failure, cardiac insufficiency, secondary hemophagocytic syndrome. Nursing strategy: 1. Strengthen basic care and application of sterile laminar flow beds. 2. Closely monitor physical signs, and discover early high fever, hypotension, low blood oxygen and other CRS reactions. 3. Special professional person conducted sterile dressing change to avoid cross infection; Perform weekly microorganism culture of secretory and adjust antibiotics symptomatically; Mechanical debridement and the use of debridement glue are given to the wound accompanied by yellow excoriation, black scab; Prevention of infection using fusidic acid cream, silver pyrimidine sulfate dressings, and hydrophilic silver containing dressings; Lesional wounds are covered with a lipidic hydrogel foam dressing to achieve wet healing. 4. Reinforce nutritional support and psychological care. Result: After the fusion of CAR T cells, the patient developed grade 4 cytokine release syndrome (CRS), grade 0 ICANS. Fever appeared on the day 0 of fusion, the body temperature was up to 40.1℃. The fever sustained 16 days. No septic shock occurred; Hypoxemia was noted on day 4 after fusion to a minimum of 69% with invasive ventilator assisted breathing and life support given; On day 4 after fusion, the capillary leak syndrome occurred, and the systemic tumor and skin lesion were swollen compared with before, resulting in marked wound redness and oozing fluid. After active treatment, careful nursing with aseptic dressing change, the patient successfully passed through the CRS reaction period, and the lesional skin wound was completely repaired after 3 months. Conclusions: T cells are absent after CD4-CAR T cell therapy, and patients present with a state of immunodeficiency that predisposes to opportunistic infections. Severe patients with mycosis fungoides associated with systemic skin lesions treated with CART are prone to severe cytokine release syndrome, which can manifest as hyperthermia, severe agranulocytosis, thrombocytopenia, and capillary leak syndrome, and may easily lead to more precancerous wounds. At this time, close observation of the changes in the life condition, active control of the CRS response, while supplemented with sterile debridement replacement, systemic symptomatic use of antibiotics, can reduce the incidence of infection, improve the safety of treatment, and ultimately promote the repair of tumor skin lesions wounds. Disclosures No relevant conflicts of interest to declare.