Abstract: The rapidly expanding cases of the coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have exposed vulnerable populations, including pregnant women to an unprecedented public health crisis. Recent data show that pregnancy in COVID-19 patients is associated with increased hospitalization, admission of the intensive care unit, and intubation. However, very few resources exist to guide the multidisciplinary team in managing critically ill pregnant women with COVID-19. We report our experience with managing a morbidly obese pregnant woman at 36 weeks’ gestation with history of asthma and malignancy who presented with persistent respiratory symptoms at an outside hospital after being tested positive for SARS-CoV-2 polymerase chain reaction (PCR). Early in the course of the hospitalization, patient received remdesivir, convalescent plasma, bronchodilator, systemic steroids, and IV heparin for COVID-19 and concomitant asthma exacerbation and pulmonary embolism. Due to increasing oxygen requirements, she was eventually intubated and transferred to our institution for higher level of care. Respiratory acidosis, severe hypoxemia, and vent asynchrony were managed with vent setting adjustment and paralytics. After 12 hours from spontaneous rupture of her membranes and with stabilization of maternal status, patient underwent a term cesarean delivery for nonreassuring fetal heart tracing. The neonate was discharged on the 2nd day of life, while the patient was extubated on the 6th postpartum day and was discharged to acute inpatient rehabilitation facility on the 19th hospital day. This report highlights the disease progression of COVID-19 in a pregnant woman, the clinical challenges in the critical care aspect of patient management, and the proposed multidisciplinary strategies utilizing an algorithmic approach to optimize maternal and neonatal outcomes. PubDate: Fri, 16 Oct 2020 05:35:00 +000
Abstract: Thrombocytopenia is a rare and sometimes life-threatening complication of Vancomycin. A 52-year-old male patient with acute kidney injury was treated with Vancomycin for ventilator-associated pneumonia. Three days later, his platelets decreased from to over a 36-hour period. The patient developed significant intrapulmonary bleeding leading to profound hypoxemia. Workup was negative for thrombotic thrombocytopenic purpura, disseminated intravascular coagulopathy, atypical hemolytic uremic syndrome, heparin-induced thrombocytopenia, and autoimmune diseases. All recently started medications were discontinued, and the patient was started empirically on methylprednisolone and intravenous immunoglobulin. The patient’s platelets increased, and his airway bleeding stopped within 48 hours; his platelet count returned to normal by 18 days. Vancomycin-dependent anti-platelet antibodies were identified in the patient’s serum by flow cytometry. Thrombocytopenia is an underrecognized complication of Vancomycin that can lead to life-threating bleeding. Stopping Vancomycin may be sufficient to reverse the thrombocytopenia in patients with normal renal function, but more aggressive measures such as steroids, IVIG, and dialysis may be required to stop bleeding and reverse thrombocytopenia in patients with underlying kidney injury who cannot effectively excrete Vancomycin. PubDate: Wed, 30 Sep 2020 13:20:01 +000
Abstract: Background. Acidemia has been long thought to lead to hemodynamic compromise. While some literature to date challenges this idea, there is no consensus on this topic. Case Summary. To our knowledge, this is the most severe case of hypercapnia and acidosis due to carbon dioxide (CO2) insufflation during laparoscopy reported in the literature. Remarkably, this patient remained hemodynamically normal despite having a blood pH below 6.81. This prompts a wider discussion about the effects of blood pH on human physiology. Most patients who present acidotic are critically ill and have confounding underlying metabolic or respiratory pathophysiology driving their illness. In this case, the patient experienced no respiratory insult leading to an increase in blood CO2 but rather had CO2 iatrogenically introduced into the circulatory system, effectively detaching the deleterious effects of CO2 from the respiratory pathologies that so often cause its accumulation. Conclusion. This raises the question, in patients with severe acidosis and hemodynamic compromise, is acidosis a symptom of the underlying process, or is the acidosis itself causing harm' PubDate: Mon, 28 Sep 2020 17:20:01 +000
Abstract: We present this case of a young woman with SARS-CoV-2 viral infection resulting in coronavirus 2019 (COVID-19) lung disease complicated by a complex hydropneumothorax, recurrent pneumothorax, and pneumatoceles. A 33-year-old woman presented to the hospital with a one-week history of cough, shortness of breath, and myalgia, with no other significant past medical history. She tested positive for COVID-19 and subsequently, her respiratory function rapidly deteriorated, necessitating endotracheal intubation and mechanical ventilation. She had severe hypoxic respiratory failure requiring a protracted period on the mechanical ventilator with different ventilation strategies and multiple cycles of prone positioning. During her proning, after two weeks on the intensive care unit, she developed tension pneumothorax that required bilateral intercostal chest drains (ICD) to stabilise her. After 24 days, she had a percutaneous tracheostomy and began her respiratory wean; however, this was limited due to the ongoing infection. Thorax CT demonstrated a left-sided pneumothorax, with bilateral pneumatoceles and a sizeable, complex hydropneumothorax. Despite the insertion of ICDs, the hydropneumothorax persisted over months and initially progressed in size on serial scans needing multiple ICDs. She was too ill for surgical interventions initially, opting for conservative management. After 60 days, she successfully underwent a video-assisted thoracoscopic surgery (VATS) for a washout and placement of further ICDs. She was successfully decannulated after 109 days on the intensive care unit and was discharged to a rehabilitation unit after 116 days of being an inpatient, with her last thorax CT showing some residual pneumatoceles but significant improvement. Late changes may mean patients recovering from the COVID-19 infection are at increased risk of pneumothoracies. Clinicians need to be alert to this, especially as bullous rupture may not present as a classical pneumothorax. PubDate: Sat, 19 Sep 2020 07:35:00 +000
Abstract: Lazarus phenomenon refers to autoresuscitation of a patient declared dead after cessation of cardiopulmonary resuscitation (CPR). The Lazarus phenomenon is rarely encountered and pathophysiology is not very well understood, but physicians need to be aware of this phenomenon. It is prudent that a physician leading a CPR effort waits for some time and monitors the patient further using blood pressure and electrocardiogram before confirming that a patient is actually dead. PubDate: Fri, 18 Sep 2020 16:35:00 +000
Abstract: Coronavirus 2019 disease (COVID-19) is a viral illness caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It emerged in Wuhan, China, in December 2019 and has caused a widespread global pandemic. The symptoms of COVID-19 can vary from mild upper respiratory symptoms to severe pneumonia with hypoxemic respiratory failure. Multiple studies and reports have reported a hypercoagulable state associated with this disease, and various recommendations have emerged to guide the use of anticoagulants for prophylaxis. We are reporting a case of symptomatic acute splenic thrombosis causing splenic infarction in a patient suffering from a severe case of COVID-19 and despite the use of an intermediate dose of low-molecular-weight heparin (LMWH). The patient was treated with full-dose anticoagulation and was eventually discharged home on a direct oral anticoagulant. PubDate: Fri, 04 Sep 2020 14:05:01 +000
Abstract: Coagulopathy has proven to be a common complication of the novel coronavirus SARS-CoV-2, with evidence of elevated D-dimers and fibrin degradation products associated with an increased incidence of thromboembolism. Despite emerging evidence describing the coagulopathy and its clinical relevance in COVID-19, fewer studies have addressed the potential role of empiric therapeutic anticoagulation in this setting. We report the case of a patient admitted to our intensive care unit (ICU) with severe acute respiratory distress syndrome (ARDS) secondary to COVID-19 whose clinical trajectory improved dramatically after initiation of a therapeutic dose of LMWH. The patient showed progressive elevation of fibrinogen and D-dimers despite a prophylactic dose of LMWH during her ICU stay. This was met with a moderate increase of troponin T-hs, an escalating need for vasopressors, and a progressive decrease in her P/F ratio despite preserved lung static compliance. Her platelet count was normal and had an elevated fibrinogen during the first week of ICU stay. The ECG was normal, and a bedside transthoracic echocardiogram showed no evidence of pulmonary embolism and a preserved EF with no regional wall motion abnormalities (RMWA). The chest X-ray was not dissimilar to previous exams, and the ABG showed hypoxia with normal pCO2 values. The decision was made to commence empiric therapeutic enoxaparin. The patient did not experience bleeding complications, and her clinical trajectory appeared to change dramatically. She was successfully extubated three days later and proceeded to clinical recovery and eventual discharge from the ICU. The available evidence shows that there is undoubtedly coagulopathy associated with COVID-19 with various subsequent forms of clinical manifestation described in the literature. Evidence also shows the benefits of heparin as an anticoagulant. From the discussion of this case report, however, it can be concluded that despite the plausible theoretical rationale, studies pertaining to the role of empiric therapeutic anticoagulation in this setting fall short of providing compelling evidence. Subsequently the role of empiric therapeutic anticoagulation in COVID-19 remains unclear with a pressing call for further research. PubDate: Thu, 27 Aug 2020 12:50:01 +000
Abstract: Elevated cardiac enzymes are often seen in the setting of sepsis. The mechanism involves hypoperfusion and possible compromise to myocardial tissue. Electrocardiogram (ECG) changes in the setting of septic shock are less common and can vary widely. Rarely, ST-segment elevations can occur. This case describes a 54-year-old female who presented with septic shock secondary to pyelonephritis and Escherichia coli bacteremia. The patient was admitted to the intensive care unit on norepinephrine and required mechanical ventilation. A significant rise in troponin I (peak 19.8 ng/mL) was seen and ECG showed ST-segment elevations in leads I and aVL with reciprocal ST depressions in leads II, III, and aVF. The patient was taken urgently for left cardiac catheterization, which showed no evidence of obstructive coronary artery disease. When distinguishing between septic shock and cardiogenic shock, insertion of a pulmonary artery catheter may help with diagnosis and treatment of cardiogenic shock. Catheter hemodynamic monitoring can also confirm the diagnosis. In our patient’s case, hemodynamic monitoring was initiated and was not consistent with cardiogenic shock. ST-segment elevations in the high lateral leads and elevated cardiac markers were likely due to severe transmural ischemia secondary to increased oxygen demand. The patient was continued on intravenous antibiotics for treatment of her septic shock. She was extubated and weaned off of norepinephrine within 48 hours. Repeat ECG performed after resolution of the infection showed normal sinus rhythm with no ST-segment changes. Cardiac dysfunction in the setting of septic shock is well described in medical literature; however, the mechanisms of dysfunction are not explicitly understood. Transient hypoperfusion, coronary vasospasm, and localized endothelial damage are possible components. It is important to think of varying etiologies, other than acute coronary syndrome when approaching patients in septic shock with acute ST-segment changes and elevated cardiac markers. PubDate: Tue, 18 Aug 2020 15:50:00 +000
Abstract: A 68-year-old male with a witnessed out-of-hospital cardiac arrest while jogging who was managed with extracorporeal cardiopulmonary resuscitation (ECPR) is presented. The patient was found to be in refractory ventricular fibrillation by emergency medical service personnel and underwent advanced cardiac life support (ACLS) protocol with placement of an automated chest compression device. He was emergently transported to the cardiac catheterization laboratory. Due to refractory ventricular fibrillation, he was placed on venoarterial extracorporeal membranous oxygenation (VA-ECMO). Coronary angiography at that time showed nonobstructive coronary artery disease. Management with VA-ECMO and other supportive measures were continued for 5 days, after which a cardiac magnetic resonance imaging was performed with findings consistent with acute myocarditis. His condition substantially improved, and he was discharged from the hospital with good neurologic and functional status. Fulminant myocarditis is often fatal, but aggressive supportive measures with novel ECPR protocols may result in recovery, as it happened in this case. PubDate: Fri, 07 Aug 2020 13:05:00 +000
Abstract: Background. SARS-CoV-2 is a newly emerged virus that has spread rapidly, exhibiting tremendous morbidity and mortality. Some potential pharmaceutical targets have been identified but are still lacking proper validation. Case Presentation. We describe the case of a young, immunosuppressed and critically ill patient with previous Influenza B infection, requiring extracorporeal membrane oxygenation, which was then followed, in the succeeding months, by SARS-CoV-2 infection complicated by severe adult respiratory distress syndrome. Her clinical course exhibited complications, including pulmonary embolism, acute kidney injury, pneumothorax, pneumomediastinum, multiple cardiac arrests, and eventually death. Conclusion. Coinfection with other respiratory pathogens and opportunistic infections are possible. PubDate: Fri, 31 Jul 2020 07:05:01 +000
Abstract: Paraneoplastic diarrhea is a commonly described complication of gastrointestinal tract or endocrine malignancies. It is an extremely rare complication of lung adenocarcinoma, with only one previously reported case in the literature. A 46-year-old female with newly diagnosed stage IVb lung adenocarcinoma presented to our intensive care unit in hypovolemic shock with symptoms suggestive of diabetes insipidus (DI) as well as profuse large volume watery diarrhea. Exhaustive serological and microbiological workup revealed the diarrhea to be paraneoplasitc in nature. This case represents the second known case of paraneoplastic diarrhea secondary to lung adenocarcinoma. Clinicians should be aware of this rare phenomenon. PubDate: Sat, 25 Jul 2020 07:05:00 +000
Abstract: Acute respiratory distress syndrome (ARDS) is a disorder that involves the activation of alveolar macrophages triggering the innate immune system. The parenchymal lung injury seen in ARDS is a result of many proinflammatory elevations including interleukin-6. There remains no effective standard of care of ARDS, and current treatments at this time currently do not target the immunological mechanisms or pathways involved. Treatments involving this pathway should be further investigated as targeted treatment. We discuss a case of a patient with multiple myeloma who was hospitalized with drug-induced ARDS who had a rapid response to an anti-interleukin-6 monoclonal antibody. PubDate: Wed, 22 Jul 2020 14:35:00 +000
Abstract: We describe a young male patient chronically on a ventilator secondary to decreased mobility from amyotrophic lateral sclerosis (ALS). He had both a tracheostomy for breathing and percutaneous endoscopic gastrostomy (PEG) for feeding. Using 24-hour urinary creatinine excretion data, we calculated an estimate of skeletal muscle (SM) mass. SM mass was indexed to height and weight to obtain the SM index. The SM index is used as a determinant to define sarcopenia. From the data, we found that this patient had the smallest SM index ever recorded at 2.2 kg/m2, consistent with extremely advanced sarcopenia. As a comparison, “severe” sarcopenia in a male is defined as a kg/m2. This method can be used in ICU patients to evaluate for sarcopenia which is a predictive marker for mortality. PubDate: Sat, 11 Jul 2020 13:50:00 +000
Abstract: Diabetic ketoacidosis is a leading cause of morbidity and mortality in diabetic patients, and its diagnosis should be timely and accurate. SGLT2 inhibitors are a new class of antidiabetic medications that increase the renal excretion of glucose. It is thought that increased urinary excretion of glucose will mask hyperglycemia during DKA. This can lead to a delayed diagnosis of DKA and worsen outcomes. In this report, we detail a case of euglycemic DKA in a patient who presented to the Emergency Department meeting criteria for septic shock. PubDate: Wed, 01 Jul 2020 13:50:00 +000
Abstract: Acute fatty liver of pregnancy (AFLP) is a rare disorder that typically presents in the third trimester. We report a case of a 21-year-old woman with a history of intrauterine fetal demise at 19 weeks’ gestation who developed fulminant liver failure 1 week after the fetal demise. She was diagnosed with AFLP as per the Swansea criteria. An orthotopic liver transplant was attempted but was unsuccessful. AFLP usually presents between the 30th to 38th weeks of gestation. However, it can occur in the postpartum period after only 19 weeks of gestation as highlighted in our case. PubDate: Tue, 16 Jun 2020 08:50:07 +000
Abstract: We report a case of attempted suicide by Cerbera odollam seed ingestion by a transgender patient who was successfully treated at our hospital. While the C. odollam plant has multiple practical and ornamental functions, its seeds have traditionally been utilized for suicidal and homicidal purposes in many parts of the world. Physicians should be aware of the presentation, diagnosis, and treatment of C. odollam ingestion given the current ease of availability of these seeds in the United States and the increased reports of suicide attempts. PubDate: Mon, 15 Jun 2020 15:20:00 +000
Abstract: Drowning is an acute respiratory failure as a result from immersion or submersion of the airways in a liquid medium (predominantly water). Inhalation of water causes severe lung damage due to the destruction of pulmonary surfactant, resulting in decreased lung elasticity, alveolar collapse, alteration of ventilation-perfusion ratio, intrapulmonary blood shunting, hypoxia, acute lung injury, and Acute Respiratory Distress Syndrome (ARDS). Poractant alfa (Curosurf®), a natural surfactant effective in the treatment of newborn respiratory distress, has been used in various forms of ARDS, but in drowning syndromes, experience is still poor. We describe a series of nine clinical cases of drowning, six adults and three children, treated in our Intensive Care Unit (ICU) with endobronchial administration of poractant alfa. After 24 and 48 hours of administration in all cases, there was an improvement in arterial blood gas analysis (ABG) parameters and imaging. All patients were discharged without clinical consequences. PubDate: Sat, 06 Jun 2020 04:35:00 +000
Abstract: Objective. This case describes symptomatic pulmonary cement embolism as a rare postvertebroplasty complication and highlights its critical yet ill-defined management. Background. Pulmonary cement embolism (PCE) is a feared complication of vertebroplasty in the treatment of vertebral fractures. While the majority of PCEs are asymptomatic, symptomatic PCEs often present with chest pain, tachycardia, signs of severe respiratory distress, and death. Computer tomography angiogram (CTA) allows visualization of cement within the pulmonary vasculature. Despite the well-established risk of PCE, clinical management is unclear with limited research on treatment options. Reported treatments include anticoagulation, embolectomy, CPR, and supportive care and observation. Report. We report the case of a 75-year-old woman who experienced shortness of breath, tachypnea, tachycardia, hypertension, and hypoxemia five days following a corrective surgery for a compression fracture of L3 with pedicle screw fixation, fusion of L2 through L4, and L2 vertebral body cement augmentation with polymethyl methacrylate. Results. Breath sounds were diminished bilaterally with respiratory alkalosis and hypoxemia evident on arterial blood gas. CTA revealed intravasated cement throughout the right lung, including the pulmonary artery and upper and middle lobar arteries. The proposed mechanism is embolization of cement particles from the lumbar veins, which also showed intravasation. Due to the inorganic nature of the occluding material, the use of a thrombolytic agent was ruled against. Treatment included bronchodilators, 3 L of oxygen via nasal cannula, and prophylactic antibiotics, pulmonary toilet, and incentive spirometry. Symptomatic management was continued until she was discharged from the hospital in a stable condition. Conclusions. Postvertebroplasty pulmonary cement embolisms can be managed conservatively, without the use of anticoagulant or thrombolytic agents. This case illustrates a variation of care for this rare presentation and adds to the sparse literature on the management of PCEs. PubDate: Fri, 05 Jun 2020 07:05:01 +000
Abstract: Acute respiratory distress syndrome, characterized by the Berlin criteria, is associated with a high mortality rate. Its treatment includes addressing the underlying etiology, general supportive measures, and achievement of effective oxygenation. New key data indicates that in a subset of patients, noninvasive ventilation techniques can be a therapeutic and equivalent alternative to traditional invasive ventilation. We present a rare case of ARDS triggered by nasal bupropion inhalation and effectively treated with noninvasive positive pressure ventilation resulting in complete resolution. PubDate: Thu, 28 May 2020 17:20:01 +000
Abstract: Background. Naegleria Fowleri is a single-cell, thermophilic amphizoid amoeba, and a rare known causative agent for primary amoebic meningoencephalitis with >97% mortality rate. The amoeba resides in freshwater lakes and ponds but can also survive in inadequately chlorinated pools and recreational waters. The mode of infection includes activities such as diving or jumping into freshwater or submerging the head under the water. Although most commonly seen in the southern United States, it is essential to keep this clinical suspicion in mind regardless of geography, as presenting symptoms can be very similar to classic bacterial meningitis. Case Summary. We report the first-ever case in the state of New Jersey of a 29-year-old male presented after a visit to a recreational water park in Texas five days before his presentation with altered mental status. In ICU, his ICP remained refractory to multiple therapies, including antibiotics and antivirals, external ventriculostomy drain, hypertonic saline, pentobarbital-induced coma, and bilateral hemicraniectomies. The CSF analysis revealed trophozoites indicating a protozoan infection, which we diagnosed in the neurocritical unit, and the patient was then immediately started with treatment that included amphotericin B, rifampin, azithromycin, and fluconazole. This suspicion was promptly confirmed by the Center for Disease Control (CDC). Unfortunately, despite all the aggressive intervention by the multidisciplinary team, the patient did not survive. Conclusion. As per the CDC, only four people out of 143 known infected individuals in the United States from 1962 to 2017 have survived. Symptoms start with a median of 5 days after exposure to contaminated water. Given the rarity of this case and its very high mortality rate, it is crucial to diagnose primary amoebic meningoencephalitis accurately as its presentation can mimic bacterial meningitis. It is vital to obtain a careful and thorough history, as it can aid in prompt diagnosis and treatment. PubDate: Thu, 28 May 2020 17:20:01 +000
Abstract: Invasive aspergillosis represents a clinical picture frequently associated with host’s immunosuppression which usually involves a high morbidity and mortality. In general, the most frequent fungal entry is the lungs with secondary hematogenous dissemination, but there are other hypotheses like a gastrointestinal portal of entry. There are some rare publications of cases with invasive aspergillosis in immunocompetent patients. We present the case of an immunocompetent patient without any risk factors except for age, ICU stay, and surgical intervention, who developed a septic shock by invasive gastrointestinal aspergillosis as primary infection. Due to the unusualness of the case, despite all the measures taken, the results were obtained postmortem. We want to emphasize the need not to underestimate the possibility for an invasive aspergillosis in an immunocompetent patient. Not only pulmonary but also gastrointestinal aspergillosis should be taken into account in the differential diagnosis to avoid a delay of treatment. PubDate: Tue, 26 May 2020 06:20:00 +000
Abstract: We report an intensive care patient who was given excessive amounts of antithrombin concentrate in response to spuriously low antithrombin activity measurements and was then treated with plasmapheresis (therapeutic plasma exchange or TPE) to remove the excess. PubDate: Fri, 08 May 2020 19:20:00 +000
Abstract: A two-year-old female presented with acutely altered mental status following eight days of fever and rash. She had been camping at an Indiana campground 11 days prior to the onset of illness and was evaluated twice for her fever and rash prior to admission. Laboratory evaluation on admission revealed thrombocytopenia, hyponatremia, and elevated transaminases. The patient developed diffuse cerebral edema, and despite intensive care, the edema led to brain death from Rocky Mountain spotted fever (RMSF). We present this case to highlight the importance of considering RMSF and other tick-borne illnesses in a child with prolonged fever and rash in a nonendemic area and also the difficulty of diagnosis in early stages of disease. A detailed travel history, evaluation of key laboratory findings (white blood count, platelet count, and transaminases), and close follow-up if rash and fevers persist may help to improve detection of RMSF. If a tick-borne illness such as RMSF is suspected, empiric doxycycline therapy should be started immediately, as lab confirmation may take several days and mortality increases greatly after five days of symptoms. PubDate: Mon, 04 May 2020 15:50:00 +000
Abstract: Cerebral edema is a devastating complication of DKA which is extremely rare in adults but is the leading cause of diabetes-related death in the pediatric population. Newly diagnosed diabetes, younger age, first episode of DKA, severity of DKA at presentation, and administration of bicarbonate are predictive of cerebral edema in DKA. We present a case of a young adult with DKA as the presenting symptom of diabetes, whose clinical course was complicated by renal failure, refractory shock, and cerebral edema. This case addresses the controversy surrounding bicarbonate therapy in DKA and its possible role in the development of a rare fatal complication of DKA. PubDate: Thu, 30 Apr 2020 06:50:00 +000
Abstract: Pancreatitis causes a systemic inflammatory response that can lead to acute respiratory distress syndrome (ARDS). We present a case of severe ARDS complicated by a pulmonary embolism (PE) in a 39-year-old female that developed rapidly progressive pancreatitis secondary to hypertriglyceridemia. PubDate: Tue, 28 Apr 2020 07:35:01 +000
Abstract: Coccidioidomycosis is a predominantly pulmonary disease caused by species of Coccidioides, a fungus endemic to the American Southwest. Most cases involve exclusively pulmonary manifestations while less than one percent present with disseminated infection, usually with meningeal or skin involvement. In this case, a patient with a history of odynophagia, sore throat, productive cough, weight loss, and abnormalities on chest radiograph presented with sepsis and diabetic ketoacidosis. During admission, the patient underwent bronchoscopy with resulting tissue and bronchoalveolar lavage samples positive for Coccidioides immitis, later supported by confirmatory serum studies. This case illustrates a rare presentation of vocal fold involvement without direct invasion from a continuous site and highlights the importance of a high index of suspicion for disseminated coccidioidomycosis with prompt antifungal treatment in order to avoid the very high morbidity and mortality in such cases. PubDate: Mon, 20 Apr 2020 07:05:00 +000
Abstract: A 56-year-old male was admitted to the emergency department for acute pulmonary edema and septic shock, yet no clear source of infection was noted upon physical examination. Due to his unstable condition, bedside ultrasound was performed. A heterogeneous mass in the liver was noted; hence, a tentative diagnosis of liver abscess was made. The abscess was confirmed by abdominal magnetic resonance imaging. Drainage of the abscess was attempted and guided by early ultrasound. This case highlights that point-of-care ultrasound, when performed by an ultrasound-capable critical care physician, can significantly decrease the time to diagnosis for septic patients. PubDate: Mon, 06 Apr 2020 07:50:01 +000
Abstract: Acute pancreatitis (AP) is a real clinical challenge. Acute pancreatitis remains a common cause of emergency department consultations and a major cause for hospitalization. Gallstones and drinking a lot of alcohol are the most frequent causes of AP. Moreover, AP can be induced by diabetic ketoacidosis (DKA) complicated by hypertriglyceridemia. We report 4 cases of DKA with hypertriglyceridemia complicated by AP in previously undiagnosed diabetes patients. All of our patients presented to the emergency ward with abdominal pain. Their physical exam showed epigastric tenderness. An abdominal CT scan was performed for each patient, showing an AP grade E. Laboratory samples showed high serum glucose levels. They had metabolic acidosis with elevated anion gap. They had high lipasemia and amylasemia. Their lipid panel was disturbed with a high level of cholesterol (from 12.8 mmol/l to 33 mmol/l) and triglyceridemia (from 53 to 133 mmol/l). Our patients were admitted into our ICU where they received fluid resuscitation and intravenous insulin, and their triglycerides rates decreased gradually. Two patients recovered to a good health state, and the two others developed septic shock, requiring the use of large-spectrum antibiotics, and acute kidney injury (AKI) with refractory metabolic acidosis, requiring hemodialysis. Despite the intensive treatment, they developed an unrecoverable multiorgan failure. Through our case series, we aim to highlight the importance of making an early diagnosis, which can be difficult in some situations due to overlapping signs; however, it is crucial for a good recovery. A good understanding of the pathway of hypoinsulinemic states causing hypertriglyceridemia then AP is important because it is the key to best management. PubDate: Sat, 04 Apr 2020 13:35:01 +000
Abstract: Introduction. Isolated jejunal perforation from blunt abdominal trauma is an extremely rare intra-abdominal injury that poses a huge diagnostic challenge. Delay in diagnosis and initiation of treatment often leads to significant morbidity and mortality. Diagnosis particularly in resource-poor settings may be extremely challenging and often relies on a high index of suspicion. This is due to lack of adequate diagnostic facilities and human resource to deal with the condition with resulting high occurrence of adverse outcomes. Case Presentation. We report a case of isolated jejunal perforation with associated mesentery injury in a young college student who sustained a kick to his abdomen while playing soccer. This is an unusual presentation since most reported cases often resulted from motor vehicular accidents, bicycle handlebar, and fall from a height. We emphasized the role of critical level of suspicion with a good history and physical examination as the major source of diagnosis since diagnostic procedures, such as abdominal ultrasonography and computed tomography, are largely unavailable in most resource-constraint settings. Early surgical intervention following diagnosis leads to good recovery and reduced mortality. Conclusion. Sufficient vigilance and suspicions of small bowel perforation should always be considered after blunt trauma even when symptoms and physical findings are minimal and when diagnostic capacity is limited. PubDate: Thu, 26 Mar 2020 13:05:03 +000
Abstract: Background. Pembrolizumab is a checkpoint inhibitor that targets the programmed cell death-1 receptor (PD-1) and has shown to be effective against several malignancies, including lung cancer. However, life-threatening immune-related adverse events can result from these immunotherapy treatments. Case presentation. A 62-year-old man with HIV, metastatic adenocarcinoma of the lung, and no previous history of diabetes presented to the emergency department with new-onset nausea, vomiting, and generalized weakness. Glucose was 1191 mg/dl, hemoglobin A1c 11%, and potassium 6.9 mEq/L. He had metabolic acidosis with a lactate of 6.6 mmol/L and anion gap of 38 mEq/L, and ketones were detected on the urinalysis. Severe diabetic ketoacidosis was diagnosed, and the patient was admitted to the intensive care unit. Additional investigations showed low C-peptide and negative anti-glutamic acid decarboxylase antibody, anti-insulin antibody, and anti-islet-antigen 2Ab antibody. After ruling out other possible etiologies, pembrolizumab was considered to be the cause of the diabetes and ketoacidosis. Conclusions. Life-threatening adverse drug events associated with checkpoint inhibitors such as pembrolizumab are on the rise. We recommend to closely follow and monitor patients receiving these immunotherapies. This strategy could lead to early detection and prevention, as well as reduction of more serious life-threatening complications requiring intensive care. PubDate: Wed, 25 Mar 2020 15:35:00 +000
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