<% vol = 16 number = 1 nextlink = 47 prevlink = 38 titolo = "CASE REPORT: SEVERE BURN COMPLICATED BY THE ACUTE RESPIRATORY DISTRESS SYNDROME AND DISSEMINATED CANDIDIASIS" volromano = "XVI" data_pubblicazione = "March 2003" header titolo %>

Koulermou G., Yiallouros C.

Clinic for Plastic Surgery, Microsurgery and Burns, Makarios Hospital III, Nicosia, Cyprus

SUMMARY. This report describes the successful treatment of a severely burned female patient suffering from the acute respiratory distress syndrome and disseminated candidiasis. The various phases are presented, as well as the antibiotic therapy administered. Careful treatment prevented the occurrence of the frequently dangerous complications in such cases.

We report a case of severe burns complicated by the acute respiratory distress syndrome (ARDS) and disseminated candidiasis.
The patient was a 54-yr-old female who sustained a fire burn involving 72% total body surface area. The chart in Fig. 1 shows the affected areas, a large percentage of which (30%) was full-thickness. There was no evidence of inhalation injury and the patient had no other pathological condition.

<% immagine "Fig. 1","gr0000016.jpg","Burns chart",230 %> <% riquadro "54-yr-old female 72% TBSA burn
Fire burn without evidence 30% full-thickness
of inhalation injury 42% deep partial-thickness" %>

Resuscitation was started immediately, using as a guide the Parkland formula and Ringer’s lactate, with the early addition of plasma and colloid solutions (18 h post-burn).
On day 2 post-burn, the patient developed severe dyspnoea, tachypnoea, and hyperpyrexia (39.5 °C).The white blood cell count was 18,900. The chest x-ray was clear but the blood gases showed severe hypoxaemia.
The patient was placed in a special ventilator delivering positive end expiratory pressure (PEEP). On day 4 post-burn, as was expected, the chest x-ray showed clear evidence of bilateral pulmonary infiltration typical of ARDS. The blood gases improved (Figs. 2a,b).

<% immagine "Fig. 2a","gr0000017.jpg","",230 %>

<% immagine "Fig. 2b","gr0000018.jpg","Second and fourth post-burn days.",230 %>

<% riquadro "Dysponea-tachypnoea Hyperpyrexia (39.5 °C) WBC 19000" %>

On day 8 post-burn, there was resolution of the x-ray finding, together with a slight further improvement in the blood gases (Fig. 3).

<% immagine "Fig. 3","gr0000019.jpg","Eight post-burn day.",230 %> <% riquadro "Corticosteroids Fluid restriction Intensive physiotherapy
Oxygen mask with positive PEEP" %>

ARDS can be defined as a specific form of acute lung injury in which structured changes and functional abnormalities lead first to proteinaceous alveolar oedema and then to altered respiratory system mechanics and hypoxaemia.
The conditions associated with ARDS are shock, infection, trauma (burns), aspiration, and multiple blood transfusions.
The pathogenesis of ARDS follows three stages: first is the exudative phase (days 1-3), then the proliferative phase (days 3-7), and finally, after one week, the fibrotic stage.
Diagnostic criteria, on the basis of the American-European Consensus Conference on ARDS, are:
- identifiable cause of associated condition
- dyspnoea
- hypoxaemia (PaO2/F1O2 < 200)
Treatment of ARDS includes the following measures:
- mechanical ventilation using especially PEEP
- fluid restriction - diuresis
- exogenous surfactant
- intensive physiotherapy
- Corticosteroids are no longer universally used.
Complications include:
- pulmonary problems
- stress-related ulcers
- multiple organ system failure, which is the main cause of death after ARDS
The patient received consecutively the following antibiotic treatment: day 2, imipenem; day 6, medronidale and gentamicin; day 22, piperacillin/tazobactrim. All the antibiotics were chosen after twice-weekly screening of the patient with cultures (wound, respiratory secretions, and urine). The patient received broad-spectrum antibiotics for 40 days.
The patient was taken twice to the operating room for escharectomy and skin grafting.
On day 24 post-burn, the patient developed positive blood culture for Candida al. These cultures were positive for 24 days. We started amphotericin B, which we later switched to fluconazole because of liver dysfunction. We also performed ultra-sound on the liver, kidney, and spleen, as well as ocular fundus examination in order to rule out dissemination of Candida to these organs (Figs. 4a,b).

<% immagine "Fig. 4a","gr0000020.jpg","",230 %>

<% immagine "Fig. 4b","gr0000021.jpg","Clinical tests.",230 %>

<% riquadro "Positive culture for Candida: 24th post-burn day
Positive culture consecutively for 24 days
Treatment: Amphotericine B, Fluconazole for forty-one days
Check up U/S liver-spleen
U/S kidney
Ocular fundus examination" %>

The expense of treatment against Candida infection is enormous - the cost of fluconazole approaches 7,000 Cyprus pounds.
Certain groups of patients are at high risk for the development of candidiasis: neutropenic patients, organ transplant recipients, post-surgical patients, and burn victims using central intravenous catheters, as well as patients receiving broad-spectrum antibodies.
The Candida organism forms clusters of inflammatory cells and then micro-abscesses that spread to various organs (heart, lung, liver, spleen, kidney, eye).
The diagnosis is based on which organ is involved: skin lesions, endophthalmitis, hepatomegaly, splenomegaly, mental status alterations, cardiac and urinary tract manifestations.
Laboratory diagnosis is confirmed by multiple blood cultures, which are frequently negative, and pre-mortem diagnosis thus remains a clinical diagnosis.
The principles of treatment of candidiasis include:
- discontinuation of systemic antibiotic therapy
- removal of intravenous and urinary catheters
- amphotericin B or fluconazole
Mortality in both ARDS and disseminated candidiasis is very high, approaching 50% of cases. That is why our patient is so happy (Figs. 5,6).

<% immagine "Fig. 5","gr0000022.gif","Patient's progress.",230 %>

<% immagine "Fig. 6","gr0000023.jpg","Smiling patient after successful treatment.",230 %>

RESUME. Les Auteurs décrivent le traitement réussi d’une patiente sévèrement brûlée atteinte du syndrome de détresse respiratoire aiguë et de candidose disséminée. Ils présentent les diverses phases, comme aussi la thérapie antibiotique administrée. Le traitement soigné a prévenu la manifestation des complications dangereuses qui peuvent se vérifier dans ce type de cas.

<% riquadro "This paper was received on 20 October 2002.

Address correspondence to: Prof. G. Koulermou, Clinic for Plastic Surgery, Microsurgery and Burns, Makarios Hospital III, Nicosia, Cyprus." %>
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