Seminars in respiratory and critical care medicine
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Diffuse alveolar hemorrhage (DAH) in primary and secondary vasculitis occurs when capillaritis is present. The diagnosis of DAH is considered in patients who develop progressive dyspnea with alveolar opacities on chest imaging (with density ranging from ground glass to consolidation) that cannot be explained otherwise. Hemoptysis, a valuable sign, is often absent. ⋯ DAH in systemic lupus erythematosus is either associated or not with capillaritis. Treatment of DAH should target the underlying disorder. In the primary vasculitides, corticosteroids and immunosuppressants, especially cyclophosphamide, are the mainstay of therapy, but plasma exchange, particularly in severe DAH, is the rule, although evidence of its effectiveness is awaited.
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Pulmonary vasculitides are a diverse group of limited and systemic disorders associated with inflammation of pulmonary vessels and parenchyma. These diseases often have distinctive clinical, serological, and histopathological features-extrapulmonary sites of involvement, circulating autoantibodies, predispositions for small or large vessels, and others. Some have characteristic inflammatory lesions; others are characterized by the absence of such lesions. ⋯ Other syndromes associated with DAH include Goodpasture syndrome, Henoch-Schönlein purpura, and systemic lupus erythematosus. Less commonly, DAH may be secondary to infection or drugs/toxins. Furthermore, in the absence of discernable systemic disease, DAH may be idiopathic-referred to as isolated pulmonary capillaritis (IPC) or idiopathic pulmonary hemosiderosis (IPH), depending on the presence of capillaritis.
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The incidence of invasive candidiasis in critically ill patients has increased over the past decade and is associated with considerable morbidity and mortality. CANDIDA is identified in up to 17% of ICU patients, with candidemia occurring in ∼1%. CANDIDA ALBICANS continues to account for approximately half of the invasive candidiasis cases, with non- ALBICANS CANDIDA species, such CANDIDA GLABRATA, increasing in frequency. ⋯ Systemic antifungal therapy is also being utilized in patients at increased risk for invasive candidiasis based on surrogate markers of infection such as colonization (preemptive therapy), or in patients with unresolving sepsis despite appropriate management (empirical therapy). Recent guidelines on the use of antifungal therapy have better identified patients who can be treated with azole derivatives and those who may benefit from echinocandins or polyenes. However, prospective trials are still needed to better identify appropriate therapy for patients at risk for, or with, confirmed invasive CANDIDA infections.
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Severe sepsis is one of the most common reasons for critically ill patients to be admitted to an intensive care unit (ICU) and has very high associated morbidity and mortality. The Surviving Sepsis Campaign was initiated with the hope that mortality might be reduced by standardizing care informed by data from an increasing number of clinical trials. Important methods for reducing mortality identified by recent studies include aggressive fluid resuscitation, early goal-directed therapy (EGDT), early administration of antibiotics, and the administration of activated protein C to eligible patients.