Sindrome Hemolitico Uremico Jueves 26 Enero 2023.pptx

1. SLIDESMANIA.COM SLIDESMANIA.COM Hemolytic Uremic Syndrome Dr. Carlota Cabrer R1 Gastroenterología CEDIMAT

2. SLIDESMANIA.COM SLIDESMANIA.COM ● Renal impairment ● Microangiopathic hemolytic anemia ● Thrombocytopenia. Hemolytic-uremic syndrome (HUS) Consists of a triad of CHAPTER 37 Gastrointestinal and Hepatic Manifestations of Systemic Diseases 5. PART IV Topics Involving Multiple Organs. Sleisenger_and_Fordtran's_Gastrointestinal_and_Liver_Disease_11th.pdf.

3. SLIDESMANIA.COM SLIDESMANIA.COM Typical HUS • Diarrhea-positive • STEC • Shigella Atypical HUS • Diarrhea-negative • Primary causes • Complement genes mutations

4. SLIDESMANIA.COM SLIDESMANIA.COM - Shiga toxin-producing E. coli 0157:H7 - Nonenteric infections (especially Streptococcus pneumoniae) - Malignancies, pregnancy, transplantation, anticancer molecules, immunosuppressive agents, and antiplatelet agents. Triggers of HUS include : CHAPTER 37 Gastrointestinal and Hepatic Manifestations of Systemic Diseases 5. PART IV Topics Involving Multiple Organs. Sleisenger_and_Fordtran's_Gastrointestinal_and_Liver_Disease_11th.pdf.

5. SLIDESMANIA.COM SLIDESMANIA.COM CHAPTER 110 Infectious Enteritis and Proctocolitis. PART X Small and Large Intestine. Sleisenger_and_Fordtran's_Gastrointestinal_and_Liver_Disease_11th.pdf. Shiga toxin 2 is more potent and much more frequently associated with severe human disease (bloody diarrhea and HUS risk) than Shiga toxin. STEC that do not contain a gene encoding Shiga toxin 2 rarely, if ever, cause HUS.

6. SLIDESMANIA.COM SLIDESMANIA.COM ● It was named the enterohemorrhagic E. coli. ● In 2017, FoodNet suggested STEC infections increased by 28% compared with 2014 to 2016. ● In Latin America, E. coli 0157:H7 remains the predominant strain (>70 percent). ● The incidence of STEC-HUS in Latin America remains ten times higher than in other continents. In 1982, a new outbreak of acute hemorrhagic colitis emerged in Michigan and Ohio https://www.uptodate.com/contents/treatment-and-prognosis-of-shiga-toxin-producing-escherichia-coli-stec-hemolytic-uremic-syndrome-hus-ichildren

7. SLIDESMANIA.COM SLIDESMANIA.COM ● Transmission -> fecal-oral route. ● Children are predominantly involved. ● Incubation period of 3 days ○ Abdominal cramps, nausea, vomiting, fever or chills, and diarrhea that becomes hemorrhagic in 70% of cases. ● The median duration of diarrhea is 3 to 8 days, Shiga toxin-producing E. coli (STEC) 0157:H7 Infection CHAPTER 37 Gastrointestinal and Hepatic Manifestations of Systemic Diseases 5. PART IV Topics Involving Multiple Organs. Sleisenger_and_Fordtran's_Gastrointestinal_and_Liver_Disease_11th.pdf.

8. SLIDESMANIA.COM SLIDESMANIA.COM Typical clinical course of Escherichia coli O157:H7 infections Risk factors for HUS: - Age less than 5 years - Attendance at a large day care center - Presence of bloody diarrhea - High WBC count. https://www.uptodate.com/contents/treatment-and-prognosis-of-shiga-toxin-producing-escherichia-coli-stec-hemolytic-uremic-syndrome-hus-ichildren

9. SLIDESMANIA.COM SLIDESMANIA.COM ● Transport of Shiga toxins to the submucosa, with binding to endothelial cells. ○ Microvascular damage ○ Platelet aggregation ○ Microvascular fibrin thrombi ○ Clinical and histologic picture that resembles ischemic colitis. ● Shiga toxins bind to PMNs and circulate to other organs such as the kidneys, causing direct damage to kidney epithelial cells (podocytes and tubular cells), kidney mesangial cells, and vascular endothelial cells. Physiopathology CHAPTER 110 Infectious Enteritis and Proctocolitis. PART X Small and Large Intestine. Sleisenger_and_Fordtran's_Gastrointestinal_and_Liver_Disease_11th.pdf.

10. SLIDESMANIA.COM SLIDESMANIA.COM Approach to patients with suspected or confirmed Shiga toxin-producing Escherichia coli infection

11. SLIDESMANIA.COM SLIDESMANIA.COM

13. SLIDESMANIA.COM SLIDESMANIA.COM https://www.uptodate.com/contents/treatment-and-prognosis-of-shiga-toxin-producing-escherichia-coli-stec-hemolytic-uremic-syndrome-hus-ichildren

14. SLIDESMANIA.COM SLIDESMANIA.COM ● Peripheral blood smear with a large number of schistocytes and helmet cells. ● Elevation of the serum indirect bilirubin concentration. ● Reduction in the serum haptoglobin concentration. ● Elevation of the serum lactate dehydrogenase (LDH) levels. Diagnosis (HUS) https://www.uptodate.com/contents/treatment-and-prognosis-of-shiga-toxin-producing-escherichia-coli-stec-hemolytic-uremic-syndrome-hus-ichildren

15. SLIDESMANIA.COM SLIDESMANIA.COM ● CDC recommends a combination of culture for O157 STEC and a nonculture Stx assay. ● Because most isolates of E. coli O157:H7 do not ferment sorbitol, screening for this pathogen usually is done with sorbitol-MacConkey agar. ● Shiga toxin protein assay. ● DNA testing for Shiga toxin genes may be done using polymerase chain reaction (PCR) to amplify Shiga toxin genes (STX1 and STX2). Diagnosis (STEC) Thrombotic microangiopathies (TMAs) with acute kidney injury (AKI) in adults: CM-TMA and ST-HUS. Uptodate. https://www.uptodate.com/contents/thrombotic-microangiopathies-tmas-with-acute- kidney-injury-aki-in-adults-cm-tma-and-st-hus?search=sindrome%20hemolitico%20uremico%20en%20adultoss&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2

16. SLIDESMANIA.COM SLIDESMANIA.COM CT-patterns of mural enhancement in patients with bowel wall thickening. https://radiologyassistant.nl/abdomen/bowel/bowel-wall-thickening-ct-pattern#type-3-water-target-sign-infectious-colitis

17. SLIDESMANIA.COM SLIDESMANIA.COM Abdominal CT Water target Sign https://radiologyassistant.nl/abdomen/bowel/bowel- wall-thickening-ct-pattern#type-3-water-target-sign- infectious-colitis

18. SLIDESMANIA.COM SLIDESMANIA.COM Treatment ● The risk of HUS is increased by antimicrobial therapy. ● The use of ST-HUS implies that recovery will occur spontaneously. ● Supportive cares involve hydration and transfusion for severe anemia. ● Renal replacement therapy is frequently required in the acute phase and chronic kidney disease may result in some. ● Transfusion of platelets when a patient with a platelet count of <50,000/microL requires an invasive procedure or has clinically important bleeding. https://www.uptodate.com/contents/treatment-and-prognosis-of-shiga-toxin-producing-escherichia-coli-stec-hemolytic-uremic-syndrome-hus-ichildren

19. SLIDESMANIA.COM SLIDESMANIA.COM The subjects who received antibiotics were also more likely to develop HUS (24% vs 8%) Exposures to antibiotics within the first week of illness also tripled the risk of developing HUS (aOR 3.62; 95% CI, 1.23–10.6; P = .02; Table 4). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3493180/ Exposure to trimethoprim-sulfamethoxazole or metronidazole was each statistically significantly associated with HUS. Wong CS, Mooney JC, Brandt JR, Staples AO, Jelacic S, Boster DR, Watkins SL, Tarr PI. Risk factors for the hemolytic uremic syndrome in children infected with Escherichia coli O157:H7: a multivariable analysis. Clin Infect Dis. 2012 Jul;55(1):33-41. doi: 10.1093/cid/cis299.

20. SLIDESMANIA.COM SLIDESMANIA.COM May 2019 May 2019

21. SLIDESMANIA.COM SLIDESMANIA.COM ●Anemia ●Thrombocytopenia ●Fluid and electrolyte disturbances ●Acute kidney injury (AKI) ●Hypertension ●Neurologic dysfunction ●Other organ involvement including colon, heart, pancreas, and lung. https://www.uptodate.com/contents/treatment-and-prognosis-of-shiga-toxin-producing-escherichia-coli-stec-hemolytic-uremic-syndrome-hus-ichildren

22. SLIDESMANIA.COM SLIDESMANIA.COM Complications ● HUS or thrombotic thrombocytopenic purpura. ● Pancreatitis, hemoperitoneum, colonic perforation, or strictures.

23. SLIDESMANIA.COM SLIDESMANIA.COM Preventive measures. ● Cooking of ground beef, avoiding unpasteurized fruit juices, and hand hygiene if contact with farm animals occurs (e.g., state or county fairs). https://www.uptodate.com/contents/shiga-toxin-producing-escherichia-coli-microbiology-pathogenesis-epidemiology-and-prevention?sectionName=Transmission&search=sindrome%20hemolitico%20uremico%20en%20adultoss

24. SLIDESMANIA.COM SLIDESMANIA.COM Clinical Case Masculine 73 y/o Past Medical History: hypothyroidism, rectal abscess and rectocutaneous fistula treated (02/2019). Chief Complaint: Nausea, vomiting and diarrhea >10 episodes/ day. Abdominal pain. Started 3 days ago.

25. SLIDESMANIA.COM SLIDESMANIA.COM ● HEENT: normocephalic and atraumatic without tenderness, visible or palpable masses, depressions, or scarring. Hair is of normal texture and evenly distributed. Conjunctivae are clear without exudates or hemorrhage. Sclera is non-icteric. No signs of nystagmus. Eyelids are normal in appearance without swelling or lesions. External ear and ear canal are non-tender and without swelling. Nares are patent bilaterally. Oral mucosa appears dehydrated. Tongue normal in appearance without lesions and with good symmetrical movement. No buccal nodules or lesions are noted. The pharynx is normal in appearance without tonsillar swelling or exudates. The neck is supple without adenopathy. Trachea is midline. Carotid pulse 2+ bilaterally without bruit. No JVD. ● Cardiac: The external chest is normal in appearance without lifts, heaves, or thrills. PMI is not visible and is palpated in the 5th intercostal space at the midclavicular line. Heart rate and rhythm are normal. No murmurs, gallops, or rubs are auscultated. S1 and S2 are heard and are of normal intensity. ● Respiratory: The chest wall is symmetric and without deformity. No signs of trauma. Chest wall is non-tender. No signs of respiratory distress. Lung sounds are clear in all lobes bilaterally without rales, ronchi, or wheezes. Resonance is normal upon percussion of all lung fields. VITAL SIGNS BP 120/80mmHg Pulse 90 bpm RR 16 O2: 99% T 37.1C

26. SLIDESMANIA.COM SLIDESMANIA.COM ● Abdominal: Abdomen is soft, symmetric, presence of distention and tenderness to palpation in hypogastric and left lumbar region. There are no visible lesions or scars. The aorta is midline without bruit or visible pulsation. Umbilicus is midline without herniation. Bowel sounds are present and normoactive in all four quadrants. No masses, hepatomegaly, or splenomegaly are noted. ● Genital/Rectal: Normal rectal sphincter tone. No external masses or lesions. Stool is watery and with presence of red blood striae. Genitalia: normal. ● Extremities: Upper and lower extremities are atraumatic in appearance without tenderness or deformity. No swelling or erythema. Full range of motion is noted to all joints. Muscle strength is 5/5 bilaterally. Tendon function is normal. Capillary refill is less than 3 seconds in all extremities. Pulses palpable. Steady gait noted. ● Neurological: The patient is awake, alert and oriented to person, place, and time with normal speech. Motor function is normal with muscle strength 5/5 bilaterally to upper and lower extremities. Sensation is intact bilaterally. Reflexes 2+ bilaterally. Cranial nerves are intact. Cerebellar function is intact. Memory is normal and thought process is intact. No gait abnormalities are appreciated.

28. SLIDESMANIA.COM SLIDESMANIA.COM ADMISSION

29. SLIDESMANIA.COM SLIDESMANIA.COM ABDOMINAL AND PELVIC CT Importante edema de toda la mucosa del colon, con múltiples dilataciones diverticulares, en relación a Colitis extensa. Datos de Colelitiasis Crónica. Aortoesclerosis.`

31. SLIDESMANIA.COM SLIDESMANIA.COM ● Mantener hidratación intensiva EV ● Dieta Cero ● Suspender Antibioterapia. ● Sustituir Ondansetron por Dramidon. ● Suspender Propinoxato-Lisina. Paracetamol SOS ● Paromomicina 500mg c/8hr vo ● Enterogermina 1 vial c/12hhr vo ● Analíticas control. ● Rx Torax y Abdomen en AM.

34. SLIDESMANIA.COM SLIDESMANIA.COM CONTROLES…

36. SLIDESMANIA.COM SLIDESMANIA.COM DE ALTA CON INSTRUCCIONES

37. SLIDESMANIA.COM SLIDESMANIA.COM CONTROLES AMBULATORIOS

38. SLIDESMANIA.COM SLIDESMANIA.COM - GEA SECUNDARIA A INFECCION POR ENTAMOEBA HYSTGOLITICA Y E. DIPAR RESUELTA - COLITIS INFECCIOSA EXTENSA SECUNDARIA A E. COLI – STEC RESUELTA - AKIN PB PRERENAL VS SECUNDARIO A MICROANGIOPATIA TROMBOTICA POR SHU INCIPIENTE RESUELTO.

39. SLIDESMANIA.COM SLIDESMANIA.COM Gracias!

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