Case report. Setting. Pediatric intensive care unit (PICU), university hospital. Patients. A 13-year-old patient presenting with prolonged oligoanuric
kidney failure and unexplained
primary hypothyroidism three weeks after severe abdominal
sepsis with multiple organ dysfunction and major
rhabdomyolysis due to bilateral lower leg
compartment syndrome, necessitating moderate size fasciotomies, disinfected daily with
PVP-I. Interventions. Interruption of
PVP-I exposure and initiation of
thyroid hormone substitution. Measurements and Main Results.
Hypothyroidism was revealed during diagnostic work-up for persistent
hypertriglyceridemia.
Thyroxine (T4) (4.0 mg/L) and tri-iodothyronine (T3) (64 ng/L) were moderately low, yet
thyroid stimulating hormone (TSH) (16.8 mIU/L) was fourfold the maximal normal range value. This pattern, atypical for prolonged
critical illness-related
hypothyroidism, prompted interruption of
PVP-I exposure and initiation of
thyroid hormone substitution. Urinary production and
creatinine clearance recovered during the following days, and one week later,
intermittent renal replacement therapy could be terminated, suggesting that
PVP-I toxicity and/or
hypothyroidism may have contributed to the persistent
renal failure three weeks after resolved
septic shock and
rhabdomyolysis. Elevated serum and urinary anion gap normalized simultaneously, but this evolution of rather nonspecific indices could be multifactorial.
CONCLUSION:
PVP-I is a commonly used broad-spectrum
antimicrobial agent for prevention and treatment of
wound infections. Toxic complications due to
PVP-I absorption, after disinfection of extended thermal
injuries larger than 20% of the body surface, have been described. In
critically ill children, however, toxic effects of
PVP-I may occur due to repeated disinfection of less extended
wounds. Proposed screening strategies include: monitoring of the volumes of
PVP-I applied daily; of the thyroid function, the serum, and/or urinary anion gap and the urinary
iodide concentrations. These strategies, however, remain to be validated. This case report should be a wake-up call for daily integration of
wound management in the clinical evaluation of
critically ill patients.