JournalTOCs

Case Reports in Critical Care
Number of Followers: 14

This is an Open Access Journal

Open Access journal
ISSN (Print) 2090-6420 - ISSN (Online) 2090-6439
Published by Hindawi

[340 journals]

Posterior Tracheal Wall Laceration Following Tracheostomy: A Progressive
Nightmare Under Long-Term Ventilation, Requiring Complex Repair With
vvECMO Support—A Case Report
- Abstract: Untreated tracheal membrane laceration (TML) may have life-threatening consequences. We present a case of untreated TML during or after tracheostomy. Air leakage along the cannula after tracheostomy was treated with raising cuff pressure up to > 100 mmHg and enlarging the tracheal lumen in the area of TML. Finally, small movements of the neck led to immediate blockade of the tubetip and repeated life-threatening asphyxia. Immobilization, anxiety states, addiction to sedatives, and several situations with hypercapnic coma led to ICU transferal to our tertiary thoracic center. Chronic TML was diagnosed with flexible bronchoscopy through the larynx and the tracheostomy. Operative repair under veno-venous extracorporeal membrane oxygenation (vvECMO) required tracheal transection at the lower border of the tracheostomy and detachment of both edges of the ruptured tracheal membrane from the anterior vertebral ligament and reconstruction with a running suture. With a 3/4 reanastomosis of the trachea, a new tracheostomy channel was created. Within the following 4 months, no further ventilation problems occurred. We conclude that untreated TML after tracheostomy may develop in a vicious circle with a permanent risk of death under long-term ventilation. Late repair can be complex even in experienced hands.
  PubDate: Wed, 28 May 2025 23:03:53 +000
Recognition of Transfusion-Related Acute Lung Injury in a Patient With
End-Stage Liver Disease and Sepsis
- Abstract: A man in his 40s with history of decompensated cirrhosis presented with acute leg pain. On presentation, he was febrile, tachycardic, and jaundiced. Laboratory findings included leukocytosis with bandemia, anemia, elevated creatinine, hyponatremia, lactic acidosis, hyperbilirubinemia, and elevated INR. His model for end-stage liver disease-sodium (MELD-Na) score was 32. Diagnostic paracentesis did not suggest spontaneous bacterial peritonitis, but blood cultures revealed Escherichia coli. He received intravenous fluids, broad-spectrum antibiotics, and packed RBC. He became acutely dyspneic, 1 h into the transfusion. Over the next 36 h, he developed worsening hypoxia with infiltrates on serial chest x-rays despite adequate diuresis. He required intubation for respiratory failure and his hospital course was complicated by hepatic encephalopathy. Ultimately, he was discharged on hospital Day 18 and was retrospectively diagnosed with transfusion-related acute lung injury (TRALI) Type II. This case focuses on management of TRALI in sepsis and highlights the elevated risk of transfusion-associated reactions in liver failure patients and its mortality and morbidity.
  PubDate: Sun, 18 May 2025 22:38:28 +000
Reversible Severe Acute Lactic Acidosis Caused by Thiamine Deficiency in
Intensive Care Unit
- Abstract: Lactic acidosis is a common cause of metabolic acidosis in hospitalized patients. It is typically caused by hypoperfusion and anaerobic metabolism and is often associated with sepsis. However, it can also result from impaired lactate metabolism, independent of hypoxemia. We report the case of a 50-year-old woman with severe lactic acidosis who was admitted to the intensive care unit. Lactic acidosis was initially attributed to an uncontrolled infection. However, brain magnetic resonance imaging revealed Wernicke’s encephalopathy due to thiamine deficiency. The administration of high-dose intravenous thiamine rapidly improved the mental status and normalized serum lactate levels. This case highlights the importance of identifying thiamine deficiency as a reversible cause of lactic acidosis in critically ill patients.
  PubDate: Thu, 08 May 2025 22:33:18 +000
Perioperative Anaphylaxis: A Systematic Approach to Evaluate High-Risk
Drug Allergy
- Abstract: Determining the etiology of perioperative anaphylaxis is a challenging task, as multiple medications are often administered simultaneously during anesthesia. This is compounded by the paucity of validated skin testing. While drug challenges are the definitive means of assessing for IgE-mediated drug allergy, they must be weighed with the risk of severe reaction. As such, multidisciplinary collaboration is warranted to ensure drug provocation testing is performed thoughtfully and safely. Here, we present a case of an 18-year-old male with juvenile kyphosis who underwent anesthesia prior to spinal fusion surgery. He was given intravenous fentanyl, propofol, dexamethasone, remifentanil, tranexamic acid, methadone, and cefazolin. Additionally, iodine, chlorhexidine, and tincture of benzoin were applied topically. Shortly after the start of anesthesia and prior to incision, he developed bronchospasm, hypoxia, hypotension, and pulseless electrical activity with a return of spontaneous circulation following cardiopulmonary resuscitation. A tryptase level drawn during the event was elevated at 23.7 μg/L (reference range: 0–11.4 μg/L). Months later, the patient underwent skin prick and intradermal testing in an allergy clinic, which was largely unrevealing for a culprit. Given the absence of validated predictive values for skin testing, drug provocation testing was performed with the patient admitted to the intensive care unit due to the high-risk nature of testing. Medications were selected for a challenge after multidisciplinary discussions with specialists in anesthesia and surgery based on the availability of alternative medications. Following negative drug provocation testing to intravenous dexamethasone, intravenous fentanyl, oral midazolam, intravenous methadone, and intravenous tranexamic acid, as well as topical challenges to chlorhexidine, iodine, and tincture of benzoin, the patient was instructed to continue to avoid cefazolin, propofol, and remifentanil and was able to subsequently undergo spinal fusion surgery safely. This case demonstrates a systematic approach for high-risk drug allergy testing that was facilitated by collaboration with allergy, intensive care, anesthesia, and surgery.
  PubDate: Mon, 07 Apr 2025 19:49:35 +000
A Rare Presentation of Patient With CIDP Found to Have Respiratory Failure
and Encephalopathy
- Abstract: Chronic inflammatory demyelinating polyneuropathy (CIDP) is a rare neuropathy that presents with progressive weakness, sensory disturbances, areflexia, and ataxia. Respiratory failure and encephalopathy are rare and atypical presentations in patients with CIDP. In this report, we discuss a rare presentation of respiratory failure that required intubation and encephalopathy in a patient presenting with clinical signs of typical CIDP supported by nerve conduction, neuroimaging, and cerebrospinal fluid studies. Treatment with plasma exchange and steroids led to minimal clinical improvement in this scenario. Prompt diagnosis and treatment is important, and further research is warranted to understand associations between CIDP and such rare features.
  PubDate: Mon, 07 Apr 2025 00:50:34 +000
Esophageal Achalasia: An Unusual Cause of Respiratory Distress
- Abstract: Esophageal achalasia is a rare condition affecting both men and women. It is a motility disorder of the esophagus resulting in the lack of relaxation of the lower sphincter, yielding to food stasis. While the condition typically presents with dysphagia and regurgitation, advanced stages may lead to severe complications including dyspnea and even acute respiratory distress. We herein report the case of a patient admitted to an intensive care unit following emergency prehospital management for acute respiratory failure and hemodynamic instability. The patient required invasive mechanical ventilation and vasopressor support due to tracheal compression and involvement of the cardiac, arterial, and venous structures. The diagnosis of esophageal achalasia was initially suspected. Based on CT, endoscopic esophageal decompression was performed, the situation dramatically improved, and diagnosis was subsequently confirmed by esophageal manometry.
  PubDate: Wed, 19 Feb 2025 03:04:43 +000
Acute Respiratory Distress Syndrome in Young Postrenal Transplant Patients
Receiving Basiliximab
- Abstract: Renal transplants have been increasing in number due to the rise in end-stage renal disease (ESRD) worldwide. Transplant is a good approach to management of renal disease, as it offers patients a better quality of life. However, complications such as acute graft rejection remain a concern in all transplant patients. Basiliximab is an antibody commonly used as part of acute rejection prevention in renal transplantation. This antibody has been demonstrated to have comparable efficacy as other agents currently used, with the added benefit of decreasing the amount of steroids required for adequate immunosuppression. The general side effect profile for basiliximab includes infection, gastrointestinal disturbance, hypertension, and hyperkalemia. Respiratory system-related effects include dyspnea and upper respiratory tract infections, most of which have been documented to be mild or moderate in severity. However, a search of the literature reveals that there are a few reported cases of severe respiratory side effects in patients receiving basiliximab after renal transplants. In this report, we discuss two separate cases of acute respiratory distress syndrome (ARDS) that occurred in two young male patients. Both patients were without any other comorbidities, who had recently undergone renal transplantation and received basiliximab as part of acute rejection prevention. Both cases have a similar timeline of symptom onset, and both patients quickly developed severe respiratory failure requiring extracorporeal membrane oxygenation (ECMO) for respiratory support. Analysis of possible causes of respiratory failure points to a common medication that was administered to both patients. This report adds to a growing number of cases that suggest basiliximab may play a role in the development of respiratory failure in young patients undergoing renal transplantation surgery.
  PubDate: Mon, 17 Feb 2025 09:03:20 +000
Wernicke Encephalopathy Related to Hyperemesis Gravidarum: A Retrospective
Study of 12 Cases
- Abstract: Conclusion: In HG, thiamin rapidly depletes which can lead to WE with adverse outcomes for the mother and fetus. Therefore, physicians must be vigilant in detecting early signs of WE to promptly provide a high dose of thiamin with targeted multimodal therapies as this could be lifesaving.
  PubDate: Sun, 02 Feb 2025 15:48:39 +000
Use of Hemoadsorption and Continuous Venovenous Hemodialysis With Enhanced
Middle Molecule Clearance in Drug-Induced Rhabdomyolysis
- Abstract: Drug-induced rhabdomyolysis has become increasingly prevalent due to the rising use of medications such as statins, antidepressants, and antipsychotics. These can lead to muscle cell destruction and the release of myoglobin, potentially causing kidney damage. Recent advancements include the use of CytoSorb hemoadsorption as a promising therapy to remove myoglobin and other potentially toxic substances from the bloodstream. A 47-year-old male with a complex medical history presented with weakness, pain, and dizziness. Lab results indicated severe rhabdomyolysis, most likely of medication-induced etiology. He developed acute kidney injury (AKI) and underwent continuous venovenous hemodialysis (CVVHD) combined with CytoSorb hemoadsorption. Despite initial stabilization, rhabdomyolysis parameters surged, necessitating the use of an additional high-flux filter with enhanced middle molecule clearance. CytoSorb therapy was administered for nine consecutive sessions, resulting in decreased creatine kinase (CK) and myoglobin levels. Due to persistent kidney injury, the patient required permanent dialysis and was transferred to a kidney disease center. This case highlights the complexity and severity of drug-induced rhabdomyolysis with hemoadsorption playing a pivotal role in reducing myoglobin levels and improving the patient’s condition. Combining hemoadsorption and filters with enhanced middle molecule clearance holds even more promise for improved myoglobin removal.
  PubDate: Mon, 20 Jan 2025 07:49:17 +000
A Case of Euglycemic Ketoacidosis Secondary to Continuous Renal
Replacement Therapy
- Abstract: Euglycemic ketoacidosis (EKA) has been reported as a rare but life-threatening complication of continuous renal replacement therapy (CRRT). EKA should be suspected in the setting of persistent high anion gap metabolic acidosis despite renal replacement therapy. Critically ill patients, especially those with diabetes mellitus, are at risk of EKA due to deficient caloric intake, the presence of excess counterregulatory stress hormones, and nutritional losses from CRRT. Even with the use of glucose-containing dialysates, EKA can be observed. Prompt treatment with insulin and glucose-containing infusions leads to rapid resolution of the condition. Early optimization of nutritional intake can prevent or mitigate EKA. This case report describes a patient who developed EKA while on CRRT for severe acute kidney injury from neuroleptic malignant syndrome.
  PubDate: Fri, 03 Jan 2025 13:43:06 +000
A Case Report of Angiotensin II Use in the Treatment of Refractory Shock
due to Amlodipine and Lisinopril Toxicity
- Abstract: Conclusion: Despite evidence of efficacy in refractory vasodilatory shock secondary to sepsis, there is a paucity of data on the use of angiotensin II as an adjunctive vasopressor in drug-induced shock. We report a case of successful use of angiotensin II in combined lisinopril and amlodipine overdose refractory to conventional vasopressor support. Combined overdose of ACEIs with calcium channel blockers (CCBs) has been shown to cause more significant hypotension and higher vasopressor requirements than overdose of CCBs alone. This may be due to the synergism between CCBs and ACEIs, where the normal homeostatic mechanism of the renin–angiotensin–aldosterone system (RAAS) activation in response to shock is now inhibited, leading to decreased compensatory vasoconstriction via angiotensin II and decreased endogenous catecholamine release. We hypothesize that angiotensin II may have been of particular benefit in this patient given the likelihood that reduced angiotensin II levels were contributing to his refractory shock.
  PubDate: Wed, 11 Dec 2024 10:38:31 +000
A Singular Case Analysis: Lamotrigine-Associated Stevens–Johnson
Syndrome
- Abstract: Stevens–Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) is an immune complex–mediated hypersensitivity reaction linked as an adverse side effect to many drugs. There have been case reports of similar incidences in Nepal related to various medications. Here, we present a case of a 29-year-old lady who developed a generalized erythematous rash over her body and erosion of the oral mucous membrane. Two weeks back she gave a history of initiation of lamotrigine, olanzapine, and sertraline. Given the strong association between SJS and lamotrigine, and the usual presentation being within the first 8 weeks of exposure to susceptible medications; she was diagnosed as SJS/TEN induced by lamotrigine. On April 1, 2024, she was admitted to the ICU at KIST MCTH. All the medicines were withheld, and she was managed with corticosteroids and antihistamines. She improved significantly within 7 days. Early identification of SJS, discontinuation of triggering medicines, and prompt initiation of supportive therapy improved the prognosis.
  PubDate: Tue, 26 Nov 2024 13:49:02 +000
Dynamic CRRT Prescription for Complicated Critically Ill Patient: A Case
Report
- Abstract: Continuous renal replacement therapies (CRRTs) and sequential extracorporeal blood purification (EBP) therapies can be used in patients with severe COVID-19 disease to support kidney failure and restore immune homeostasis. EBP prescription should be based on the patient’s clinical needs and frequently re-evaluated during the intensive care unit (ICU) stay. Personalization of treatment at the bedside plays a fundamental role for patient recovery. This aim can be simplified by using both clinical and molecular data collected from a patient-individualized web registry. In this case report, we describe how we apply a sequential approach to EBP therapies following the rapid evolution of a critically ill COVID-19 patient with acute kidney injury. We show patient strategies and outcomes using bedside data from a registry-based method for the routine use of EBP. We explain the choice of specific hemofilter prescription, also focusing on dose and anticoagulation strategies. We describe the difficulties, uncertainties, and mistakes made during EBP prescription. Furthermore, we discuss the causes and workable solutions that can be adopted by the ICU physician for a better EBP prescription, considering the current lack of well-recognized indications.
  PubDate: Wed, 20 Nov 2024 11:02:49 +000
Hemophagocytic Lymphohistiocytosis Presenting With ARDS in a Young Adult:
A Case Report
- Abstract: Fever is common in the ICU, with infectious causes accounting for only half of febrile episodes. This case examines a young male who developed high-grade fevers and pulmonary infiltrates unresponsive to broad-spectrum antibiotics. Examination revealed hepatosplenomegaly, hypertriglyceridemia, anemia, and thrombocytopenia, suggestive of hemophagocytic lymphohistiocytosis (HLH). Meeting 5 of 8 HLH criteria, high-dose steroids were administered, resulting in clinical improvement. HLH, with a high mortality risk, demands early recognition, complicated by nonspecific symptoms. This case highlights the rare manifestation of ARDS in HLH, adding diagnostic challenges in critical care settings.
  PubDate: Thu, 07 Nov 2024 12:18:08 +000
A Rare Case of Pulmonary Edema Secondary to Hydrochlorothiazide Use
- Abstract: Noncardiogenic pulmonary edema has been reported as a rare adverse reaction of hydrochlorothiazide. Symptoms can develop acutely after medication ingestion, and patients may present acutely ill. The mechanism by which hydrochlorothiazide causes pulmonary edema remains unknown and is considered idiosyncratic. Prompt supportive care and discontinuation of the medication is necessary to prevent and manage such a complication. This case report describes a patient who developed noncardiogenic pulmonary edema after taking a combination pill of hydrochlorothiazide-losartan.
  PubDate: Thu, 07 Nov 2024 10:02:57 +000
Sudden Onset of Coma and Fulminant Progression to Brain Death in a
48-Year-Old Male With Cerebral Malaria
- Abstract: Cerebral malaria is the most severe complication of Plasmodium falciparum infection. Left untreated, it is universally fatal. Coma is the clinical hallmark, emerging between the first and third days of fever. Adults typically present with mild cerebral edema, usually with a more favorable prognosis compared to the pediatric population. We present a case of a 48-year-old man with a recent travel to Angola who presented comatose on the second day of a febrile illness with clinical signs of cerebral herniation and diffuse cerebral edema and cerebellar tonsil ectopia on cranioencephalic computed tomography. He had a missed diagnosis on a first visit to the emergency department 2 days prior. The diagnosis of cerebral malaria was confirmed after the identification of the parasite in peripheral blood. He was admitted to an intensive care unit; however, progression to brain death was inevitable within a few hours. Malaria affects 5% of the world’s population. In Portugal, it has an incidence of 0.01 in every 1000 inhabitants, and all cases are imported. Despite its rarity in a nonendemic country, its severity alerts to the consideration of this syndrome in the etiologic workup of coma. The early recognition of the diagnosis is of major importance for the establishment of definitive treatment, as its timely administration has a crucial impact on the outcome.
  PubDate: Mon, 30 Sep 2024 06:05:40 +000
Utility of Point-of-Care Ultrasound During Prone Positioning
Cardiopulmonary Resuscitation
- Abstract: This report describes a 34-year-old male admitted to the medical intensive care unit (ICU) who sustained cardiac arrest while in prone positioning. Prone position CPR was initiated, and the utilization of point-of-care ultrasound (POCUS) during CPR was necessary to assess compression quality. Specifically, the popliteal was observed using POCUS to gauge the adequacy of compressions and subsequent perfusion during prone position CPR. This approach provides insight into assessing the effectiveness of chest compressions in a challenging prone position, potentially improving outcomes in similar cases. Further research and application of POCUS in this context may enhance the quality of CPR and patient care during cardiac arrest events in prone positioning.
  PubDate: Sat, 14 Sep 2024 14:48:18 +000
A Neglected Disease: Hidradenitis Suppurativa a Rare Cause of Amyloidosis
Complicated With Sepsis and Renal Failure: A Case Report
- Abstract: Conclusion: In the presence of amyloidosis with intervenient infections, the risk of chronic renal failure in HS cases can be kept in mind even if the patient is receiving TNF inhibitors.
  PubDate: Tue, 27 Aug 2024 09:35:13 +000
Tenecteplase Catheter-Directed Thrombolytic Therapy in Submassive
Pulmonary Embolism: A Case Report
- Abstract: Conclusion: CDT with tenecteplase was, for the first time, safely and effectively used in an intermediate high-risk PE patient. However, more studies are needed to confirm and establish these findings.
  PubDate: Wed, 21 Aug 2024 12:21:13 +000
Paroxysmal Sympathetic Hyperactivity Syndrome in the Setting of Fat Emboli
Syndrome Secondary to Polytrauma
- Abstract: Paroxysmal sympathetic hyperactivity (PSH) syndrome is a potentially life-threatening complication after traumatic brain injuries that results from a massive release of catecholamines in the brain. Fat embolism syndrome (FES) is a complication of long bone fractures that results in cerebral or pulmonary fat emboli. We describe PSH in the setting of cerebral FES in an adolescent female following polytrauma secondary to a motor vehicle collision to highlight the importance of rapid diagnosis and treatment of this rare complication.
  PubDate: Wed, 29 May 2024 09:20:00 +000
Bilateral Spontaneous Pneumothoraces in a Case of Tricuspid Valve
Endocarditis and Septic Emboli: A Rare Complication
- Abstract: Acute hypoxemic respiratory failure from infective endocarditis with septic emboli has been attributed to the vicious cycle of tissue damage and inflammatory cytokine response. Spontaneous pneumothorax is a rare complication and can be a late-onset presentation despite appropriate antibiotic therapy. We present a rare case of bilateral spontaneous pneumothoraces in a patient with tricuspid valve endocarditis and septic pulmonary emboli. We suspect that the profound inflammatory response from two different bacterial pathogens and the peripheral location of the septic thrombosis are the basis of the development of bilateral pneumothorax development in our patient.
  PubDate: Tue, 21 May 2024 10:05:00 +000
A Rare Case of a Good Neurological Outcome following Traumatic
Foix-Chavany-Marie Syndrome
- Abstract: Traumatic brain injury (TBI) can have profound acute and chronic effects, leading to permanent disabilities and diminished quality of life. Pseudobulbar palsy and its infrequent subtype, Foix-Chavany-Marie Syndrome (FCMS), represent rare complications of TBI, manifesting as deficits in craniofacial motor function and automatic-voluntary dissociation. We present a case of a 58-year-old male who developed FCMS following severe TBI from a cycling accident. Initial imaging revealed extensive brain injury with subsequent development of FCMS characterised by bilateral cranial nerve dysfunction, notably facio-pharyngo-glosso-masticatory diplegia with preserved automatic motor function. This case contributes to the limited literature on traumatic FCMS, highlighting its distinct clinical features and potential for favourable outcomes compared to nontraumatic cases. Early recognition and comprehensive management, including supportive therapy and addressing underlying conditions, are paramount for optimising patient outcomes.
  PubDate: Fri, 10 May 2024 05:50:01 +000
Simultaneous, Dual Continuous Venovenous Haemodiafiltration as Salvage
Therapy for Severe Sodium Valproate Intoxication
- Abstract: Sodium valproate overdose leads to CNS depression, cerebral oedema, and severe metabolic acidosis in cases of severe toxicity. Extracorporeal removal, specifically through intermittent haemodialysis, is recommended, though not always tolerated by or accessible to haemodynamically unstable patients in intensive care units. We present a case of a male in his mid-twenties presenting following a massive, intentional overdose of 13 g of sodium valproate over 7 hours, with an initial valproate blood concentration of 975 μg/ml (normal 50-100 μg/ml). He was hypoxic and severely acidotic on arrival and was given fluids and L-carnitine according to TOXBASE guidelines. This resulted in only marginal improvement to his acidosis. Once transferred to our intensive care unit, the patient was started on inotropic support followed by continuous venovenous hemofiltration (CVVHDF) at the maximum effluent rate of 60 ml/kg/hr. Due to his persisting metabolic acidosis and worsening hyperlacataemia, dual CVVHDF was started by adding another filter in series after 26 hours, increasing the maximum effluent rate to 96 ml/kg/hr. The patient remained on dual CVVHDF for 31 hours, during which his acidosis and lactate showed considerable improvement, and he was subsequently stepped down to single-filter CVVHDF for a further 20 hours until complete resolution of his acidosis. This case report recognises dual CVVHDF as a viable salvage therapy for severe sodium valproate overdose by facilitating the achievement of a higher effluent flow rate compared to what can be accomplished with single-filter CVVHDF.
  PubDate: Mon, 06 May 2024 12:20:00 +000
Torsades de Pointe Associated with Trazodone Consumption
- Abstract: Introduction. Trazodone is a serotonin receptor antagonist and reuptake inhibitor commonly used to treat major depression disorder (MDD), anxiety, and sleep disorders. It is considered safe for the heart due to minimal anticholinergic effects. Prolonged QT intervals can cause polymorphic ventricular tachycardia, known as torsades de pointe (TdP). We present a case of a 67-year-old female with a history of MDD who developed trazodone-induced TdP. Case Presentation. The patient was referred to a tertiary hospital with a ten-hour history of nausea and vomiting. Trazodone (50 mg daily) was started for her six days ago due to her past medical history of MDD. The initial electrocardiography (ECG) revealed a prolonged corrected QT interval ( ms) due to a long ST segment and generalized T wave inversion. A few moments after admission to the intensive care unit, she suddenly lost consciousness. ECG monitoring showed a TdP, which terminated immediately with the asynchronous defibrillation. A temporary pacemaker was implanted due to repeated arrhythmias and bradycardia. Arrhythmia did not recur for hours and days later. After four days of stopping trazodone, all abnormal ECG findings were resolved, and she was discharged with a normal ECG. She was followed up six months later; the ECG was normal, and she had no complaints. Conclusion. Trazodone may lead to QTc prolongation and TdP, potentially fatal even without risk factors for QTc prolongation. Close monitoring is essential to prevent adverse complications in trazodone users.
  PubDate: Sat, 20 Apr 2024 10:35:00 +000
Intragastric Botulinum Toxin Injection and Botulism: An Alarm for
Clinicians
- Abstract: Clostridium botulinum produces the most potent bacterial toxin, botulinum toxin A (BTXA), which has various therapeutic and cosmetic indications. Intragastric BTXA injection is a new obesity treatment method that was argued to be safe due to the inactivation of BTXA through the liver or metabolization within the gastric wall. However, a 36-year-old woman was admitted to the intensive care unit (ICU) due to developing botulism as a result of an intragastric injection of BTXA. The diplopia, headaches, ptosis, decreased muscle force, and respiratory distress two days after injection were her first chief complaints, and also, she experienced significant dysphagia, hoarse voice, thick tongue, constipation, hyposmia, and hypogeusia after two weeks. This case report highlights the necessity for physicians to have sufficient information about this method and consider possible life-threatening adverse effects including botulism.
  PubDate: Fri, 12 Apr 2024 06:05:00 +000
Sudden Cardiac Arrest in a Youth with Multiple Arrhythmic Substrates
- Abstract: Background. Mitral valve prolapse (MVP) is a common condition with an estimated prevalence of 1-3%, in which there is systolic displacement of a morphologically redundant mitral valve towards the left atrium. Mitral annular disjunction (MAD) is a separation of the MV attachment with the left ventricle, with hypermobility of the leaflets, and with systolic “curling” of the basal LV (left ventricle) myocardium. It is frequently associated with MVP and may confer an increased arrhythmic risk. Case Description. A 28-year-old male had ventricular fibrillation leading to out-of-hospital cardiac arrest, which was successfully resuscitated. His coronary arteries were unobstructed on invasive coronary angiography. Transthoracic echocardiogram (TTE) demonstrated MAD, confirmed by cardiac magnetic resonance (CMR) imaging and transoesophageal echocardiogram (TOE). The LV was severely dilated with reduced EF (ejection fraction), and the QTc interval was also prolonged. His father had died suddenly aged 50 years. Conclusions. This report describes the clinical dilemma of identifying and treating a patient with multiple potential causes of cardiac arrest. Despite being relatively common, the clinical significance of MAD is still uncertain and the extent to which it may be linked with complications such as ventricular arrhythmias and sudden cardiac death. MAD appears to confer an increased risk of ventricular arrhythmias, particularly when associated with MVP, particularly nonsustained VT.
  PubDate: Mon, 08 Apr 2024 10:20:00 +000
Extracorporeal Membrane Oxygenation in Acute Respiratory Failure due to
Hemorrhagic Alveolitis in a Patient with Acute Myeloblastic Leukemia
- Abstract: Introduction. Extracorporeal membrane oxygenation (ECMO) support for severe acute respiratory distress syndrome (ARDS) is nowadays widely used with notable results on the overall survival as reported in the ELSO registry near to 55% at 90 days. This is the reason why ECMO teams force the use of this extreme technique to several populations, even though there is still a lack of data about its use on hematological patients. Case Report. A 39-year-old woman without a history of previous diseases, but a new diagnosis of acute myeloblastic leukemia (AML) was admitted to intensive care unit (ICU) for worsening hypoxia and respiratory acidosis, presenting an ARDS with in spontaneous breathing treated with noninvasive ventilation via full-face mask. Meanwhile, chemotherapy was started leading to a severe bone marrow aplasia that was managed with multiple blood and platelet transfusions. These conditions did not allow physicians to start any invasive approaches. After 14 days, ARDS worsened whereas bone marrow recovered, making possible the beginning of an invasive mechanical ventilation, with low positive end-expiratory pressure and a low tidal volume. Moreover, an immediate extracorporeal CO2 removal (ECCO2R) therapy was added. Despite these efforts, no improvement was achieved, and that is why venovenous ECMO throughout femoral-jugular cannulation was applied. A full protective lung ventilation by ultralow tidal volumes was guaranteed. After 2 weeks of ECMO, a gradual weaning from ECMO support was started and completed after two days. No ECMO-related complications were registered. In the end, the patient started her weaning from the mechanical ventilation and reached 12 hours of spontaneous ventilation in oxygen therapy. Discussion. ECMO is used as a rescue therapy in patients affected by severe respiratory failure with life-threatening hypoxia and respiratory acidosis nonresponsive to other maneuvers. However, immunosuppression and coagulopathies of hematological malignancies are considered relative contraindications for ECMO, while long-lasting respiratory failure represents another relative contraindication to extracorporeal support. ECMO could be a valid option to improve the survival of hematological patients with severe ARDS and thrombocytopenia, and management could change case by case, even if high incidence of recurrency.
  PubDate: Mon, 18 Mar 2024 07:20:00 +000
A Case of Hepatotoxicity Induced by Therapeutic Ketamine Use for Sedation
- Abstract: Ketamine, initially developed as an anesthetic, has shown versatility in medical applications, including pain management, treatment-resistant depression, and sedation in the intensive care unit (ICU). While generally well-tolerated, long-term use at high doses raises concerns about potential toxicities, particularly in the liver. We present a case of a 27-year-old female with a complex medical history who received ketamine infusion for ICU sedation and experienced a sudden rise in liver function tests (LFTs), indicating possible ketamine-induced liver injury (KILI). The patient’s liver function normalized after ketamine discontinuation. KILI is infrequent with short-term ketamine use, but emerging case reports suggest it may be associated with chronic or intermittent exposure. The underlying mechanisms for KILI are not fully understood but may involve the accumulation of ketamine metabolites, causing direct toxic effects on the liver. As ketamine’s use expands, especially in critical care settings, clinicians should be vigilant for the potential development of KILI. Further research is needed to better understand its risk factors and mechanisms, as early detection and management of KILI are crucial to ensuring patient safety and optimizing ketamine’s therapeutic benefits.
  PubDate: Tue, 12 Mar 2024 11:05:01 +000
Transient Lactic Acidosis and Elevation of Transaminases after the
Introduction of Remdesivir in a Patient with Acute Kidney Injury
- Abstract: A 56-year-old woman was transferred to the intensive care unit (ICU) two days after an allogeneic stem cell transplantation (ASCT) when she presented acute respiratory distress due to the relapse of a SARS-CoV-2 infection. Following that, she received two intravenous doses of 100 mg remdesivir. Subsequently, the patient developed multiple instances of diarrhea, progressing to oliguria and acute kidney injury, necessitating continuous venovenous hemofiltration (CVVH). Despite the absence of signs of hypoxemia or cardiocirculatory failure requiring vasopressor intervention, a progressive lactic acidosis emerged. Two days after the onset of lactic acidosis, a significant rise in aminotransferases and lactate dehydrogenase occurred, in the absence of encephalopathy and coagulation disorders. Remdesivir therapy had been interrupted upon the initial signs of lactic acidosis. Despite an improvement in liver function tests and lactic acidosis, the patient’s condition deteriorated, ultimately leading to her demise on day 29 due to newly arising hematological complications.
  PubDate: Thu, 22 Feb 2024 08:50:00 +000

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