Abstract: The authors describe the case of a patient treated with several cycles of chemotherapy due to an advanced stage non-Hodgkin lymphoma. One daafter the last cycle, he was admitted to our Intensive Care Unit with a septic shock-like clinical picture which didn’t respond to the aggressive treatment and the patient died a few hours later. The autoptical findings cast some doubts on the diagnosis, and demonstrated the presence of other factors imitating its symptoms. In this article, the mimickers of septic shock are reviewed and discussed, as some of them require an aggressive immunosuppression instead of the recommended treatment for septic shock. PubDate: Tue, 10 Sep 2019 10:05:02 +000
Abstract: Introduction. Acute symptomatic seizures are frequent in the critically ill patient and can be difficult to treat. The novel anticonvulsant perampanel may be effective in the treatment of status epilepticus considering its mechanism of action of being an AMPA antagonist. We present four cases of super refractory status epilepticus treated with high dose perampanel. Method. Case report. Cases. Four patients were treated with perampanel for their refractory status epilepticus. One patient had new onset refractory status epilepticus of unknown etiology. Three other patients had status epilepticus as a result of their cardiac arrest. Two of the cardiac arrest patients had myoclonus. In all patients, the additional of perampanel resulted in a reduction of seizure burden without affecting hemodynamics or hepatic or renal function. Conclusion. Perampanel may be effective in the treatment of super-refractory status epilepticus of varying etiologies. A larger, prospective study is needed to further assess this therapy. PubDate: Mon, 02 Sep 2019 00:05:17 +000
Abstract: We describe the prognostic implication and aggressive clinical course of lymphoma-related lactic acidosis in a rare HIV-related lymphoma. Patient was diagnosed with plasmablastic lymphoma and developed severe lactic acidosis, and was treated on the medical floor and in the medical intensive care unit. Her lactic acidosis was considered to be type B, secondary to her underlying lymphoma since she never had an infectious source, hypovolemic state, or low/high cardiac-output state. The mechanism of the lymphoma-related lactic acidosis is from altered cellular metabolism, thought to aid in lymphoma proliferation, rather than tissue hypoperfusion. It is a rare complication of aggressive lymphomas and signifies a poor prognosis. Patients having this complication should be considered for close monitoring and management in an intensive care unit until definitive treatment (i.e., chemotherapy) can be implemented. PubDate: Tue, 20 Aug 2019 00:05:04 +000
Abstract: Diabetic ketoacidosis (DKA) in pregnancy is associated with high fetal mortality rates. A small percentage of DKA occurs in the absence of high glucose levels seen in traditional DKA. Prompt recognition and management is crucial. We report a case of a 30-year-old pregnant woman with type 1 diabetes mellitus admitted with euglycemic DKA (blood glucose PubDate: Tue, 20 Aug 2019 00:05:03 +000
Abstract: Cresol is a phenol derivative used as a disinfectant that may cause gastrointestinal corrosive injury, central nervous system, cardiovascular disturbances, renal, and hepatic injury following intoxication. We present a case of a female patient who was admitted to the emergency department after ingesting an unknown amount of cresol; she was admitted with tachypnea, shortness of breath with low oxygen level in the blood. She did not develop hepatic or renal dysfunction. The gastrointestinal endoscopy was performed and showed esophagus and gastric erosins only. The patient was sedated and ventilated for 7 days. After receiving supportive intensive care, the patient recovered and was sent for psychiatric evaluation. Cresol intoxication can be fatal, and cause a respiratory failure with an acute respiratory distress syndrome (ARDS), hepatic, and renal injury. This shows the importance of intensive care in the management of cresol poisoning. PubDate: Tue, 20 Aug 2019 00:05:02 +000
Abstract: A 39-year-old African-American female presented to the emergency department with a seven-day history of right upper quadrant abdominal pain accompanied by nausea, vomiting, and diarrhea. She was noted to be alert and following commands, but tachypneic with Kussmaul respirations; and initial laboratory testing supported a diagnosis of diabetic ketoacidosis (DKA) and hypokalemia. To avoid hypokalemia-induced arrhythmias, insulin administration was withheld until a serum potassium (K) level of 3.3 mEq/L could be achieved. Efforts to increase the patient’s potassium level via intravenous repletion were ineffectual; hence, an attempt was made at more aggressive potassium repletion via hemodialysis using a 4 mEq/L K dialysate bath. The patient was started on Aldactone and continuous veno-venous hemodialysis (CVVH) with ongoing low-dose insulin infusion. This regimen was continued over 24 h resulting in normalization of the patient’s potassium levels, resolution of acidosis, and improvement in mental status. Upon resolution of her acidemia, the patient was transitioned from insulin infusion to treatment with a subcutaneous insulin aspart and insulin detemir, and did not experience further hypokalemia. Considering our success, we propose CVVH as a tool for potassium repletion when aggressive intravenous (IV) repletion has failed. PubDate: Wed, 14 Aug 2019 07:55:05 +000
Abstract: We present a case of serious antidepressant discontinuation syndrome (ADDS) in a 72- year-old woman in the intensive care unit (ICU). Although this syndrome may be mild under ambulatory conditions, ICU patients can experience serious neurocognitive symptoms that are difficult to differentiate from delirium. We report delayed recognition of the ADDS in a patient in the ICU who was initially diagnosed with severe hyperactive delirium. Subsequent to hiatal hernia surgery, the patient was admitted to the ICU for aspiration and was intubated. Due to increasing agitation the patient received high doses of dexmedetomidine, fentanyl, midazolam, and propofol. The patient was treated with high doses of a serotonin norepinephrine reuptake inhibitor (SNRI) antidepressant, duloxetine, for 2 years. However, the antidepressant was not effectively administered postsurgically due to gastroparesis. The signs and symptoms of ADDS can occur cryptogenically if they are partially masked by sedating agents. Due to concern for the discontinuation syndrome and the inability to administer duloxetine via a nasogastric tube, another SNRI, venlafaxine, was administered. Venlafaxine administration allowed unexpectedly prompt dose reduction and then total discontinuation of all sedating agents, allowing liberation from mechanical ventilation and ICU discharge. This case illustrates the importance of avoiding antidepressant discontinuation in the ICU. PubDate: Sun, 04 Aug 2019 12:05:02 +000
Abstract: Kounis syndrome is associated with mast cell activation resulting in acute coronary syndrome secondary to an allergic insult. Various drugs such as antibiotics, analgesics, and environmental exposures such as bee, wasp sting, and poison ivy are known to induce Kounis syndrome. A 68-year-old man admitted with a cobra bite on both hands to emergency care unit and sustained cardiorespiratory arrest. Electrocardiogram, taken 6 hours after the cardiac arrest, showed ST elevations in leads V2 to V5 suggestive of anterior ST elevation myocardial Infarction (STEMI). Serum Troponin was 10 ng/ml (control= PubDate: Sun, 04 Aug 2019 10:05:04 +000
Abstract: L. adecarboxylata is a Gram-negative rod previously named Escherichia adecarboxylata, isolated as normal flora in the gut of animals including human stool. Most reported cases refer to immunocompromised patients with polymicrobial infections and water environments. Here we present a case of 51-year-old immunocompetent female presented with nausea, vomiting, malaise, and subjective fever for few days. On examination, she was drowsy but arousable and oriented to person, place, time, and situation. Her abdomen was tender globally and more tender in the epigastric area. Vitals showed a temperature of 37°C, pulse of 110 beats/min, blood pressure of 75/50 mmHg, and oxygen saturation of 91% on room air. An HIV panel and hepatitis panel were negative. Liver and gallbladder ultrasound was performed, revealing multiple nonmobile stones with shadowing noted within the gallbladder sac, a thickened gallbladder wall, and a moderate amount of pericholecystic fluid. Broad spectrum antibiotics, crystalloid fluids, and vasopressors were initiated. A few hours after admission she developed respiratory failure for which she underwent endotracheal intubation. An ultrasound guided gallbladder drain was performed. Culture of the biliary fluid yielded pure growth of pan-sensitive L. adecarboxylata; antibiotics were narrowed accordingly. The patient was on the maximum doses of vasopressin, norepinephrine, and epinephrine with a blood pressure of 75/45 and a mean arterial pressure of 51. She passed away on the fourth day of admission. PubDate: Sun, 04 Aug 2019 10:05:03 +000
Abstract: We report a case of septic shock treated with PMX-DHP that was complicated with Lemierre syndrome caused by Fusobacterium necrophorum. The patient was a 31-year-old man who was initially diagnosed with influenza. He received treatment; however, because his symptoms gradually worsened, he was transported to our hospital 10 days following his diagnosis. His initial examination revealed symptoms of respiratory distress and an altered level of consciousness. Based on laboratory and imaging results, it became clear that he suffered from septic shock of unknown etiology, disseminated intravascular coagulation, and acute renal and respiratory failure. We initiated treatment with vasopressors, an antibacterial agent, immunoglobulins as well as an appropriate ventilator management; however, his unstable circulatory condition continued. As soon as PMX-DHP was initiated, 2 days following admission to the ICU, his circulatory instability normalized. F. necrophorum was ultimately detected after a culture examination, and contrast-enhanced computed tomography revealed a jugular vein thrombus, which led to the diagnosis of Lemierre syndrome. The patient’s condition gradually improved, and he was discharged from the ICU after 19 days. PubDate: Tue, 30 Jul 2019 08:05:14 +000
Abstract: Hypotonic hyponatremia is a common electrolyte disorder defined by a blood serum sodium value of less than 136 meq/L. A challenge in managing hyponatremia is accurately determining the etiology for the free water excess as management can markedly differ. Accurate diagnosis of the etiology of hypotonic hyponatremia requires precision in the determination of extracellular volume status. Determination of volume status has traditionally relied on physical examination, imaging modalities, and clinical gestalt, all of which are inaccurate. Portal vein pulsatility is an easy to perform bedside ultrasound imaging study which can be used as a marker for hypervolemia and venous congestion. We present 2 cases of hypervolemic hyponatremia in which portal vein pulsatility was used in the diagnosis and management and as a marker for efficacy of treatment. PubDate: Mon, 15 Jul 2019 08:05:05 +000
Abstract: We present here the case of a 55-year-old male who presented to the emergency department with severe abdominal pain and respiratory distress secondary to mesenteric ischemia. His critical illness on preexisting chronic kidney disease, previously undiagnosed alcoholic cirrhosis, and congestive heart failure led to a rare yet fatal consequence of refractory hypoglycemia. Critical illness associated hypoglycemia generally occurs as a result of high metabolic consumption with relative insulin excess and insufficient nutritional intake that is seen frequently in critically ill patients. This, along with reduced hepatic and renal gluconeogenesis seen in preexisting liver and renal disease, can cumulate to life-threatening hypoglycemia and is seen as a poor prognostic factor in the ICU setting. PubDate: Wed, 22 May 2019 09:05:02 +000
Abstract: We describe an acute complication to a tracheostomy cannula in the form of a dislocated cannula after a surgical tracheostomy in a 65-year-old male patient. The case illustrates the development of progressing subcutaneous emphysema resulting in a cannot intubate, cannot oxygenate (CICO) situation and the airway management of the patient with respiratory distress. Early recognition and situational awareness are essential in the management of patients with acute airway complications. Consequently, deliberate practice and continuing professional development should be encouraged so that we can best manage acute situations when they occur. PubDate: Mon, 13 May 2019 08:05:02 +000
Abstract: Fluoroquinolones are commonly prescribed antimicrobials that have been implicated in alterations of glucose metabolism. We report a case of refractory fluoroquinolone-induced hypoglycemia in a patient with type-2 diabetes mellitus on glipizide that was successfully treated with octreotide. A patient was admitted with hypoglycemia after having been initiated on levofloxacin therapy. Despite treating the hypoglycemia supportively with multiple boluses of 25 g of dextrose, a continuous dextrose infusion, and glucagon, the patient experienced repeated episodes of rebound hypoglycemia. The persistent hypoglycemia was eventually reversed with the administration of subcutaneous octreotide. Clinicians should be cognizant of this adverse effect of fluoroquinolones, as well as predisposing risk factors, and consider octreotide as an adjunctive therapy for refractory hypoglycemia cases. PubDate: Thu, 09 May 2019 13:05:01 +000
Abstract: Tricuspid papillary muscle rupture after blunt chest trauma is an infrequent injury that often remains undiagnosed until patients become symptomatic months to years after the trauma occurred. It is imperative to diagnose patients early with this condition in order to optimize chances of successful recovery and avoidance of sequelae of long-term tricuspid regurgitation such as atrial fibrillation and right heart failure. Here we describe a case of a 58-year-old man involved in a motocross accident suffering amongst other injuries extensive bilateral rib fractures, hemopneumothoraces, and asymptomatic anterior tricuspid papillary muscle rupture. In addition, a review of the literature and an approach for the workup of trauma patients at risk for blunt cardiac injury are provided. PubDate: Thu, 09 May 2019 09:05:00 +000
Abstract: Electrocardiogram (ECG) changes suggestive of cardiac ischemia are frequently demonstrated in patients with ischemic stroke and subarachnoid hemorrhage. However, little is known of such changes particularly acute ST segment myocardial infarction (STEMI) in patients with intracerebral hemorrhage (ICH), especially after neurosurgery. We present a patient with intraparenchymal hemorrhage due to cerebral arteriovenous malformation (AVM) who exhibited acute STEMI after neurosurgery. Serial cardiac biomarkers and echocardiograms were performed which did not reveal any evidence of acute myocardial infarction. The patient was managed conservatively from cardiac stand point with no employment of anticoagulants, antiplatelet therapy, fibrinolytic agents, or angioplasty and recovered well with minimal neurological deficit. This case highlights that diffuse cardiac ischemic signs on the ECG can occur in the setting of an ICH after neurosurgery, potentially posing a difficult diagnostic and management conundrum. PubDate: Mon, 22 Apr 2019 00:05:07 +000
Abstract: Background. Streptococcal toxic shock syndrome (STSS) is a rapidly progressive infection, with potentially rapid patient deterioration in a very short period. We experienced a rare case of STSS during anticancer chemotherapy, and we continuously measured presepsin (P-SEP) and evaluated its usefulness. Case Presentation. A 60-year-old woman with pulmonary metastasis from cervical cancer began anticancer chemotherapy. A fever of >40°C and right lower leg swelling developed on day 3. Symptoms worsened despite cefmetazole treatment (1.0 g/day). Blood culture was performed without suspecting STSS. On day 5, symptoms worsened and acute disseminated intravascular coagulation (DIC) and sequential organ failure assessment (SOFA) scores increased. C-reactive protein (CRP) increased from 28.8 mg/dl to 35.5 mg/dl and P-SEP also increased from 1,635 to 2,350 pg/mL. STSS was suspected due to the rapid progression of brown discoloration of the entire right lower leg. Ceftriaxone 2 g/day and clindamycin 1,200 mg/day were begun. On the evening of day 5, blood culture revealed rapidly progressive group A streptococci. After that, symptoms improved rapidly with treatment, and SOFA and DIC scores also decreased. While CRP remained at about 0.5 mg/dl, P-SEP remained slightly elevated at about 400 pg/mL. A residual infection focus was suspected. Contrast-enhanced computed tomography (CT) revealed a capsule-enclosed abscess in the right lower leg soleus muscle on day 32. Debridement was performed and antibiotics were continued until P-SEP was 88 pg/mL. CT confirmed the disappearance of the abscess. Conclusion. Prompt diagnosis by blood culture and a sufficiently early, appropriate change in antibiotic therapy led to successful recovery from STSS during anticancer chemotherapy without lower limb amputation. P-SEP was useful in assessment of the residual infection focus and suspending treatments. PubDate: Tue, 16 Apr 2019 13:05:09 +000
Abstract: Large pyogenic liver abscess is a rare and difficult to treat entity in pediatric patients. Percutaneous drainage rather than open surgical drainage has become more common in recent years, even for large abscesses. Percutaneous drainage can be complicated by catheter obstruction. We present the case of a 16-year-old male presenting with abdominal pain, fever, and chills. He was diagnosed with a 9-centimeter liver abscess. A CT-guided percutaneous drainage was placed. The catheter initially drained well, but then became occluded. Tissue plasminogen activator was instilled into the catheter every 6 hours for a total of five doses, resulting in increased drainage and improved clinical state of the patient. To our knowledge, this is the first reported use of tissue plasminogen activator in pyogenic liver abscess in the pediatric population. PubDate: Sun, 14 Apr 2019 13:05:04 +000
Abstract: Introduction. Inhaled nitric oxide (iNO) is a selective pulmonary vasodilator with limited indications in adults. We present a patient with hypoxemia and right ventricular dysfunction due to submassive acute pulmonary emboli where iNO was used as a bridge to thrombolysis. Case. A 29-year-old male was admitted to the intensive care unit (ICU) for alcohol intoxication complicated with aspiration pneumonia and acute respiratory failure requiring mechanical ventilation. His medical history included morbid obesity (BMI 43) and alcohol dependence syndrome. Nine days after admission, he developed severe acute hypoxia and tachycardia with arterial oxygen tension (PaO2) of 52 mmHg requiring a positive end-expiratory pressure (PEEP) of 14 cmH2O and fraction of inspired oxygen (FiO2) of 1. Chest computed tomography (CT) revealed a large embolus in the right main pulmonary artery and transthoracic echocardiogram (TTE) reported new right ventricular dilatation with decreased right ventricular function. Due to the severe hypoxemia, he was started on iNO via the breathing circuit of the ventilator at a concentration of 20 parts per million (ppm) with steady improvement in oxygenation after 1 hour with a PaO2 of 81 mmHg on the same ventilator setting. The patient was given thrombolysis with alteplase and the iNO was slowly tapered off during the subsequent four days with concomitant successful tapering of PEEP to 8 cmH2O and FiO2 of 0.45. Conclusion. Inhaled NO has been used to improve ventilation-perfusion matching and also to reduce pulmonary vascular resistance (PVR). Its effects on PVR may be useful in the setting of acute pulmonary emboli where vascular obstruction and vasoconstriction contribute to increased pulmonary arterial pressure and PVR which can present as acute right heart failure. We suggest that iNO, if available, could be considered in those patients with acute pulmonary emboli associated with significant hypoxemia as an adjunctive therapy or bridge to thrombolysis or thrombectomy. PubDate: Thu, 28 Mar 2019 09:05:05 +000
Abstract: Chylous effusions are a well-known complication from a variety of etiologies including trauma, malignancies, and anatomic defects, with the most common location being in the pleural space. A pericardial chylous effusion (chylopericardium) is uncommon, and a chylopericardium with concomitant bilateral chylous pleural effusions (chylothoraces) has only been reported in less than a handful of case reports. Our patient presented with bilateral chylothoraces and a chylopericardium with tamponade physiology secondary to Hodgkin’s Lymphoma. In this article, we discuss our treatment of this patient with the somatostatin analogue octreotide, as well as the standard of care dietary fat restriction, in order to control these effusions until the patient’s chemotherapy took effect. PubDate: Mon, 25 Mar 2019 09:05:00 +000
Abstract: Systemic heparinisation is required for extracorporeal membrane oxygenation therapy, to prevent clotting of circuit and formation of thrombus in patient. Activated clotting time (ACT) or activated partial thromboplastin time (aPTT) has been the mainstay of monitoring of heparin dose. Thromboelastogram (TEG) is increasingly being used again in recent years with the advancement in technology. Its clinical usefulness in the monitoring of anticoagulation of ECMO therapy is demonstrated in the case presented. Our patient suffered from severe hemoptysis due to active microscopic polyangiitis and respiratory failure. Heparin infusion was given at the initiation of ECMO support without further aggravation of hemoptysis. Dose of heparin was adjusted successfully with the integration of the clotting profile and TEG results. PubDate: Mon, 25 Mar 2019 08:05:02 +000
Abstract: Gastric emphysema is a relatively rare clinical entity caused by injury to the gastric mucosa. A 62-year-old Japanese male with a history of heavy alcohol consumption and smoking was admitted to the emergency intensive care unit due to severe hypercapnic respiratory acidosis. His body mass index was only 12.6. Ten days after initiation of enteral feeding, he complained of abdominal pain. Computed tomography revealed intraluminal air in the distended gastric wall. Esophagogastroduodenoscopy showed diffuse edema, redness, and erosion throughout the stomach. Based on the findings of narrow angle and short distance of the aorta-superior mesenteric artery, the patient was diagnosed with gastric emphysema associated with superior mesenteric artery syndrome. He was successfully managed nonoperatively with treatments including intravenous antibiotics, gastric decompression, and bowel rest. Physicians should be aware of this unusual condition in such critically ill patients complaining of abdominal pain and needing close monitoring and observation to exclude gastric necrosis or perforation. PubDate: Mon, 18 Mar 2019 09:05:00 +000
Abstract: Objective. To describe the case of a patient who developed a serotonin syndrome due to a 3,4-methylenedioxymethamphetamine ingestion with electrical storm and refractory cardiac arrest. Design. Case report. Study Selection. ICU of a university hospital. Patient. A 22-year-old man transferred to the emergency room with hyperthermia, tremors, and mydriasis presented a cardiac arrest due to ventricular fibrillation. Interventions. We implemented extra-corporeal life support combined with vasoactive drugs. Later, he also benefited from renal replacement therapy and mechanical ventilation. Measurements and Main Results. We were able to rapidly regulate our patient’s temperature and we weaned all hemodynamic support in the first week of hospitalisation. Conclusion. Extracorporeal life support has several advantages as part of the management of hemodynamic instability induced by serotonin syndrome. PubDate: Thu, 07 Mar 2019 07:05:04 +000
Abstract: Case Presentation. This clinical case presents the history of a woman hospitalized for acute respiratory distress syndrome (ARDS). A 62-year-old woman, with regular physical activity and no history of respiratory disease or smoking, was hospitalized for moderate ARDS with bilateral pneumonitis. Fourteen days later, she was discharged from the intensive care unit and received respiratory physical therapy. One month later, she experienced exertional dyspnea. A regression of alveolar condensation with persistent sequelae at the pulmonary bases was noted. Three months later, the patient continued daily physical activity with satisfactory tolerance. A reduction in alveolar-capillary transfer, inappropriate hyperventilation upon exercise, and impairment of gas exchanges at maximal effort, suggestive of pulmonary shunt, were demonstrated. At the 6-month evaluation, the patient displayed exertional dyspnea with residual bilateral basal consolidations. Six months later, the dyspnea had ceased. The persistence of bilateral basal interstitial syndrome associated with bronchial dilatation and pleural-based consolidations was noted, as well as a stable impaired alveolar-capillary diffusing capacity. Discussion. Upon discharge from intensive care, pulmonary follow-up should be proposed to ARDS survivors. Moreover, pulmonary function testing at rest and exercise is advised as soon as possible to evaluate the respiratory sequelae. This will help to limit the severity of complications through adapted exercise rehabilitation and then regular physical activity. PubDate: Wed, 06 Mar 2019 08:05:02 +000
Abstract: Background and Importance. Cerebral fat embolism (CFE) occurs mainly after long-bone fractures. Often reducing to minor neurological disorders as confusion, it can sometimes cause more severe consequences such as coma or even death. While CFE has been described for several years, there is no consensual treatment. Clinical Presentation. We report the case of a 15-year-old girl with a severe cerebral fat embolism secondary to a longboard fall with a femur fracture. She developed in less than 4 hours a coma. On day 4, she lost her brainstem reflexes with a clinical condition close to brain death, with a very high intracranial pressure (ICP) value above 75 mmgH at worst. She was treated as having a trauma brain injury based on ICP control with a decompressive hemicraniectomy. She recovered in some weeks, allowing discharge to a post ICU rehabilitation center, one month after admission. Conclusion. We report a severe case of cerebral fat embolism with good outcome. It was managed as a trauma brain injury. We emphasize the neurological management based on ICP and discuss the position of hemicraniectomy. PubDate: Thu, 28 Feb 2019 09:05:05 +000
Abstract: Methemoglobinemia is a rare complication in clinical practice. It is most commonly seen in patients undergoing endoscopic procedures, including EGDs, laryngoscopies, bronchoscopies, and nasogastric tube insertions. This is thought to be a disease seen almost exclusively in patients with genetic predispositions to develop it; the increasing use of topical anesthetics during procedures has made methemoglobinemia a disease entity that every clinical provider should be able to recognize and treat. Clinically, patients become cyanotic with mild oxygen derangements on pulse oximetry, in the range of 84 to 90%. Paradoxically, these patients demonstrate normal to supranormal oxygen levels in the blood on blood gas analysis. We report a case of 34-year-old female postoperative Roux-en-Y gastric bypass patient who developed hypoxia and cyanosis after a routine EGD procedure to relieve a food impaction. Differentials of aspiration and pulmonary embolism were plausible; stat blood gas analysis clinched the diagnosis and managed with intravenous methylene blue. PubDate: Sun, 24 Feb 2019 07:05:00 +000
Abstract: Cytomegalovirus (CMV) can cause severe disease including colitis, pneumonitis, and less commonly encephalitis, in profoundly immunocompromised individuals. CNS imaging findings are nonspecific and diagnosis is made by identifying CMV in cerebral spinal fluid through PCR testing or cell culture. Early initiation of antiviral therapy is key with an overall poor outcome. Here we present a patient with newly diagnosed AIDS and pneumocystis jiroveci pneumonia who was febrile and remained encephalopathic for the first 6 weeks of his admission despite treatment and extensive work up for encephalopathy. Ultimately, he was diagnosed with CMV encephalitis and radiculitis and failed to improve significantly. This case is important because of multiple points (1) the uncommon presentation of CMV encephalitis/radiculitis occurring over 1 month into a hospitalization; (2) in the era of highly active antiretroviral therapy (HAART) severe complications of AIDS are rarely seen by newer generations of physicians and are not typically thought of; (3) the difficulties in evaluating altered mental status and weakness in an intubated patient receiving sedation. In immunosuppressed patients on mechanical ventilation, early evaluation with LP should be considered when altered mental status and fever of unclear etiology are present. PubDate: Mon, 18 Feb 2019 07:05:00 +000
Abstract: Background. We describe a case of secondary Hemophagocytic Lymphohistiocytosis (HLH) from autoimmune hepatitis mimicking severe sepsis in a man admitted to the intensive care unit. Case Presentation. A 34-year-old Pakistani male with a prior history of biopsy-proven autoimmune hepatitis presented to a regional hospital with severe fever, cytopenias, hyperferritinemia, hypertriglyceridemia, splenomegaly, and a bone marrow biopsy showing hemophagocytosis. After ruling out mimicking conditions, a diagnosis of HLH was made using the HLH-2004 diagnostic criteria. He was treated with dexamethasone and etoposide, without bone marrow transplantation (BMT) due to poor functional status. At one-year after follow-up, he had returned to his baseline functional status without recurrence. Conclusion. We describe a rare case of secondary HLH in the setting of autoimmune hepatitis. Broadly, this case report educates clinicians to consider this potentially missed diagnosis. This case also informs clinicians that treatment of secondary HLH with BMT may not be necessary for the management of secondary HLH due to autoimmune hepatitis. Finally, it provides a detailed description of the natural history of a single patient with secondary HLH due to autoimmune hepatitis. PubDate: Mon, 04 Feb 2019 08:05:01 +000
Abstract: Introduction. Isolated Clostridium difficile small bowel enteritis is a rare condition with significant morbidity and mortality. Presentation of Case. An 83-year-old female with refractory ulcerative colitis underwent a total proctocolectomy and end ileostomy. Her postoperative course was complicated with return to the operating room for repair of an incarcerated port site hernia. Subsequently, she developed septic shock and multiorgan failure requiring intubation and mechanical ventilation, renal replacement therapy, and high dose vasopressors. Diagnostic workup revealed diffuse small bowel wall thickening on computed tomography scan as well as positive nucleic acid amplification test for C. difficile toxin B gene. Despite treatment with antibiotics and maximum attempts at resuscitation, the patient expired. Discussion. C. difficile infection most commonly affects the colon but rarely can involve the small bowel. The pathogenesis of C. difficile enteritis is unclear but is believed to mirror that of colitis. Surgical patients are susceptible for C. difficile infection, as they tend to be relatively immunosuppressed in the postoperative period. Radiologic findings of enteritis may mimic those of colitis and this includes small bowel dilation and thickening. Treatment for this condition has not been well established but it is approached similar to colitis. Conclusion. Despite an increase in the number of case reports of C. difficile enteritis, it continues to be a rare but potentially fatal infection. Clinicians should maintain a high index of suspicion especially in patients with inflammatory bowel disease who undergo colon resections. PubDate: Sun, 03 Feb 2019 09:05:02 +000
Abstract: We present a case of repeated cardiac arrests derived from dynamic hyperinflation in a patient with severe tracheobronchomalacia. Mechanical ventilation led to auto-PEEP with hemodynamic impairment and pulseless electric activity. Adjusted ventilation settings, deep sedation, and muscle paralysis followed by acute stenting of the affected collapsing airways restored ventilation and prevented recurrent circulatory collapse. We briefly review the pathophysiology and treatment options in patients with dynamic hyperinflation. PubDate: Tue, 29 Jan 2019 09:05:00 +000
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