http://www.hindawi.com The latest articles from Hindawi Publishing Corporation © 2013 , Hindawi Publishing Corporation . All rights reserved. Tue, 23 Apr 2013 14:31:44 +0000 http://www.hindawi.com/crim/cc/2013/832306/ This paper describes the case of a 75-year-old female who presented with significant hemoptysis over a 7–10 day period. She had a history of a left lower lobectomy 10 years prior for a “lung abscess.” She subsequently had multiple episodes of cough, fevers, and possible pneumonia treated with multiple courses of Amoxicillin and Amoxicillin/Clavulanate. Review of her chest CT upon presentation to the hospital showed a large necrotic lingular infiltrate, which had been progressively increasing in size over at least one year. Bronchoscopy showed a yellowish, soft round body in the superior lingular subsegment. Endobronchial and transbronchial biopsies showed actinomyces species. This is a very interesting case of indolent actinomycosis which we suspect had a very slow progressive course secondary to the multiple courses of antibiotics that the patient was treated with. Mary S. Baker and Khalil Diab Copyright © 2013 Mary S. Baker and Khalil Diab. All rights reserved. Mon, 22 Apr 2013 11:34:09 +0000 http://www.hindawi.com/crim/cc/2013/948234/ We report a case of a 32-week-gestation male who presented initially with symptoms suggestive of an interrupted aortic arch. The absence of a VSD prompted further investigations, including a CT angiogram, which revealed that he had an extensive thrombus in his aorta. He underwent a successful aortic thrombectomy with arch repair on cardiopulmonary bypass support. In view of the extensive thrombus, the patient was referred to the haematology team. There was no family history of prothrombotic tendencies. Richard Neal, Katharina Mattishent, and Fiona Reynolds Copyright © 2013 Richard Neal et al. All rights reserved. Mon, 15 Apr 2013 12:20:48 +0000 http://www.hindawi.com/crim/cc/2013/416168/ We present a case of a valvular mass diagnosed by emergency department bedside ultrasonography in a young patient with syncope. Bedside ultrasound has become a valuable tool in the evaluation of patients with syncope in the emergency department. This patient was believed to have a fibroelastoma on ultrasound that was confirmed by magnetic resonance and ultimately by postsurgical pathological evaluation. The indications and findings of using ultrasonography as part of the workup of syncope in the emergency department are discussed. Giuliano De Portu, L. Connor Nickels, Eike Flach, and Latha Ganti Stead Copyright © 2013 Giuliano De Portu et al. All rights reserved. Tue, 02 Apr 2013 18:25:45 +0000 http://www.hindawi.com/crim/cc/2013/154143/ Background. The use of transdermal fentanyl systems has increased over recent years, especially in patients with chronic pain. Large misuse potential and fatal outcomes have been described. Case Presentation. A 58-year-old patient presenting with clinical signs of opioid poisoning (hypoventilation, bradycardia, hypotension, and miosis) was admitted to our ICU. The first body check revealed a 75 mcg per hour fentanyl patch at the patient's right scapula. Some months ago, patient's aunt died after suffering from an oncological disease. During breaking up of her household, the patches were saved by the patient. Not knowing the risk of this drug, he mistook it as a heat plaster. Investigations. Laboratory test showed an impaired renal function and metabolic acidosis. Urine drug test was negative at admittance and 12 h later. CCT scan presented a global hypoxic brain disease. Treatment and Outcome. The patient was discharged 30 days after admittance in a hemodynamic stable condition but a vegetative state and transferred to a rehabilitation center. Learning Points. With the ongoing increase in fentanyl patch prescriptions for therapeutic reasons, it is likely that misuse cases will become more relevant. Conventional urine drug screening tests are not able to exclude the diagnosis fentanyl intoxication. History taking should include family member's drug prescriptions. Ingo Voigt Copyright © 2013 Ingo Voigt. All rights reserved. Wed, 20 Feb 2013 11:16:08 +0000 http://www.hindawi.com/crim/cc/2013/714945/ Introduction. The results of the recent DECRA study suggest that although craniectomy decreases ICP and ICU length of stay, it is also associated with worst outcomes. Our experience, illustrated by these two striking cases, supports that early decompressive craniectomy may significantly improve the outcome in selected patients. Case Reports. The first patient, a 20-year-old man who suffered severe brain contusion and subarachnoid haemorrhage after a fall downstairs, with refractory ICP of 35 mmHg, despite maximal medical therapy, eventually underwent decompressive craniectomy. After 18 days in intensive care, he was discharged for rehabilitation. The second patient, a 23-year-old man was found at the scene of a road accident with a GCS of 3 and fixed, dilated pupils who underwent extensive unilateral decompressive craniectomy for refractory intracranial hypertension. After three weeks of cooling, paralysis, and neuroprotection, he eventually left ICU for rehabilitation. Outcomes. Four months after leaving ICU, the first patient abseiled 40 m down the main building of St. Mary’s Hospital to raise money for the Trauma Unit. He has returned to part-time work. The second patient, was decannulated less than a month later and made a full cognitive recovery. A year later, with a titanium skull prosthesis, he is back to part-time work and to playing football. Conclusions. Despite the conclusions of the DECRA study, our experience of the use of early decompressive craniectomy has been associated with outstanding outcomes. We are currently actively recruiting patients into the RESCUEicp trial and have high hopes that it will clarify the role of the decompressive craniectomy in traumatic brain injury and whether it effectively improves outcomes. E. García Vicente, V. Garnelo Rey, M. Manikon, S. Ashworth, and M. H. Wilson Copyright © 2013 E. García Vicente et al. All rights reserved. Thu, 14 Feb 2013 09:24:56 +0000 http://www.hindawi.com/crim/cc/2013/123134/ Granulomatosis with Polyangiitis (GPA) is a rare systemic anti neutrophil cytoplasmic antibody (ANCA-) associated granulomatous vasculitis of the small and medium sized blood vessels. Diffuse alveolar hemorrhage (DAH) is a rare life-threatening complication of GPA. In our patient, cyclophosphamide was held secondary to complications of acute kidney injury, hematuria, and concern for a possible hemorrhagic cystitis. However, during the workup for hematuria the patient acutely developed respiratory failure and was found to have DAH. The patient was initially supported with mechanical ventilation volume control mode, steroids, and plasma exchange. With no improvement of oxygenation, the mode of ventilation was changed to airway pressure release ventilation (APRV) and the patient was started on rituximab. The patient clinically improved over the next few days, was able to be extubated, and was transferred out of the intensive care unit. Braden Powers, Aditya Uppalapati, Sindhura Gogineni, and Zafar Akram Jamkhana Copyright © 2013 Braden Powers et al. All rights reserved. Tue, 12 Feb 2013 15:44:14 +0000 http://www.hindawi.com/crim/cc/2013/493216/ Objective. To report an unusual cause of coma in an adult. Design. Case report. Setting. University teaching hospital. Patient. A previously healthy 53-year-old man initially presented with altered mental status and progressed to coma. He was found to be substantially hyperammonemic and did not improve with lactulose therapy and continuous venovenous hemodialysis. Results. Biochemical testing revealed previously undiagnosed ornithine transcarbamylase deficiency, and the patient responded to arginine, sodium phenylacetate, and sodium benzoate. Conclusion. Even in adult patients with no known history, inborn errors of metabolism must be considered in the differential diagnosis of unexplained coma. Defects of the urea cycle can present with an unprovoked hyperammonemic coma. Daniel L. Roberts, David A. Galbreath, Bhavesh M. Patel, Timothy J. Ingall, Amer Khatib, and Daniel J. Johnson Copyright © 2013 Daniel L. Roberts et al. All rights reserved. Tue, 12 Feb 2013 09:04:04 +0000 http://www.hindawi.com/crim/cc/2013/507169/ Although uncommon during pregnancy, cirrhosis results in multiple medical complications impacting both mother and fetus. Previous reports suggest liver dysfunction in pregnancy causes accumulation of neurotoxins within the maternal compartment that increases neonatal morbidity through placental transfer. We present a case of a 36-year-old G2P1 female with history of biliary cirrhosis presenting at 32-weeks' gestation with hepatic congestion progressing to hepatic encephalopathy prompting delivery. Umbilical cord sampling and postnatal infant testing demonstrated elevated ammonia levels which resolved by 12 hours of life without intervention. At discharge, the infant did not demonstrate evidence of neurologic deficit. We conclude that acute maternal hepatic encephalopathy and hyperammonemia due to chronic liver disease do not portend adverse neonatal outcomes, notably encephalopathy. Deana J. Hussamy, David B. Nelson, and Stephan A. Shivvers Copyright © 2013 Deana J. Hussamy et al. All rights reserved. Mon, 28 Jan 2013 11:04:56 +0000 http://www.hindawi.com/crim/cc/2013/414856/ Hyoscine N-butyl bromide, also known as scopolamine, is a type of antimuscarinic agent. This drug is associated with numerous common side effects, including abdominal fullness, constipation, urinary retention, blurred vision, skin flushing, tachycardia, decreased sweating, and salivation. The most unfavorable side effect is hemodynamic instability. In the present case, hypotension and acute myocardial infarction developed after intravenous hyoscine injection as a premedication therapy for colonoscopy. It was difficult to differentiate the cause-effect relationship between myocardial infarction and hypotension. Because both conditions were present under drug effects, we considered 2 possible diagnoses. One was coronary spasm with cardiogenic shock, and the other was myocardial ischemic sequela due to shock status. The latter diagnosis was confirmed after a series of examinations. Guan-Liang Chen and Wen-Hsiu Hsu Copyright © 2013 Guan-Liang Chen and Wen-Hsiu Hsu. All rights reserved. Tue, 22 Jan 2013 08:51:35 +0000 http://www.hindawi.com/crim/cc/2013/180401/ Staphylococcus lugdunensis is a common skin flora not typically associated with infection. There are, however, several cases reported in the literature of Staphylococcus lugdunensis as a causative bacterium of various infections. This paper reports an additional case of pacemaker associated endocarditis with Staphylococcus lugdunensis as the causative bacterium. Michael Ward and Kevin M. Boehm Copyright © 2013 Michael Ward and Kevin M. Boehm. All rights reserved. Thu, 17 Jan 2013 15:13:12 +0000 http://www.hindawi.com/crim/cc/2013/627972/ Basilar artery fenestration is an uncommon congenital variant that has been associated with aneurysms and posterior circulation infarcts in the adult literature. Little is known about the functional consequences of basilar artery fenestration, if any, in childhood. We present a case of a previously healthy 12-year-old boy who presented with diplopia, tinnitus, and ataxia who had subtle findings on diffusion-weighted magnetic resonance imaging consistent with posterior circulation territory infarction. Computed tomography angiography and magnetic resonance angiography revealed an area of signal abnormality in the basilar artery, which was confirmed on conventional angiography to be a type 2 basilar artery fenestration, without thrombus or aneurysm. The patient recovered from his neurologic deficits over two days and was placed on prophylactic aspirin therapy without recurrence of symptoms. This rare anatomic variant of the posterior circulation is important for physicians to recognize and may have associated neurologic consequences during childhood worthy of further investigation. J. J. Gold and J. R. Crawford Copyright © 2013 J. J. Gold and J. R. Crawford. All rights reserved. Tue, 08 Jan 2013 09:48:29 +0000 http://www.hindawi.com/crim/cc/2013/327250/ Alveolar capillary dysplasia with misalignment of pulmonary veins (ACD/MPV) is a rare, fatal, developmental lung disorder, which usually presents as persistent pulmonary hypertension of the newborn (PPHN) unresponsive to treatment. The authors present their own experience with three cases admitted during the last 15 years. Joana Miranda, Gustavo Rocha, Henrique Soares, Ana Vilan, Otília Brandão, and Hercília Guimarães Copyright © 2013 Joana Miranda et al. All rights reserved. Sun, 30 Dec 2012 13:34:01 +0000 http://www.hindawi.com/crim/cc/2012/147614/ We report a case of successful conservative management of acute traumatic rupture of the azygous vein. A 48-year-old male was involved in a motor vehicle collision. Primary survey revealed acute right intrathoracic haemorrhage. He remained haemodynamically stable with rapid infusion of warmed crystalloid solution and blood. Computed tomographic imaging showed a contained haematoma of the azygous vein. The patient was managed conservatively in the intensive care. Azygous vein laceration resulting from blunt thoracic trauma is a rare condition that carries a universally poor prognosis unless the appropriate treatment is instituted. Clinical features include acute hypovolaemic shock, widened mediastinum on chest radiograph, and a right-sided haemothorax. Haemodynamic collapse necessitates immediate resuscitative thoracotomy. Interest in this injury stems from the severity of the clinical condition, difficulty in diagnosis, the onset of a rapidly deteriorating clinical course all of which can be promptly reversed by timely and appropriate treatment. Although it is a rare cause of intramediastinal haemorrhage, it is proposed that a ruptured azygous vein should be considered in every trauma case causing a right-sided haemothorax or widened mediastinum. All cases described in the literature to date involved operative management. We present a case of successful conservative management of this condition. Cian McDermott, Gabrielle O'Connor, Eilish McGovern, and Geraldine McMahon Copyright © 2012 Cian McDermott et al. All rights reserved. Sun, 23 Dec 2012 14:42:48 +0000 http://www.hindawi.com/crim/cc/2012/652146/ Paraquat (1,1′-dimethyl-4,4′-dipyridylium) is a broad spectrum liquid herbicide associated with both accidental and intentional ingestion, leading to severe and often fatal toxicity. Despite widespread availability, reports of herbicide poisoning from India are not common. Diagnosis is often difficult in the absence of proper history, nonspecific clinical features, and lack of diagnostic tests. We report two cases of fatal paraquat poisoning from a tertiary care hospital, Kota, Rajasthan, India. Surendra Khosya and Sunil Gothwal Copyright © 2012 Surendra Khosya and Sunil Gothwal. All rights reserved. Thu, 20 Dec 2012 11:13:15 +0000 http://www.hindawi.com/crim/cc/2012/178260/ Disseminated intravascular coagulation (DIC), as a cause of acute coronary stent thrombosis, has not yet been reported to our knowledge. We report a case of 64-year-old male, who presented with non-ST-segment elevation myocardial infarction (NSTEMI). Coronary angiography revealed right coronary artery (RCA) stenosis and a drug eluting stent was deployed. Fifteen hours following the intervention, the patient developed an inferior wall ST elevation myocardial infarction. Repeat cardiac catheterization showed an acute in-stent thrombosis. Following thrombectomy, another stent was placed. The patient noted to have an acute drop in platelet count following the second intervention. Two hours following repeat intervention, the patient again developed chest pain and EKG showed recurrent ST-segment elevations in leads II, III, and aVF. Prior to repeat cardiac catheterization, the patient became unresponsive and developed cardiogenic shock. The patient was resuscitated and intubated, and repeat catheterization showed complete stent thrombosis. Intracoronary tissue plasminogen activator (tPA) was given. The platelet count further dropped. Additional studies confirmed the diagnosis of DIC. No further cardiac catheterization was done at this point. The patient then later had a cardiac arrest and unfortunately cardiopulmonary resuscitation could not revive him. Amongst the etiologies of acute stent thrombosis, DIC was deemed a possible cause. Syed Amer, Ali Shafiq, Waqas Qureshi, Mohammed Muqeetadnan, and Syed Hassan Copyright © 2012 Syed Amer et al. All rights reserved. Mon, 17 Dec 2012 08:34:29 +0000 http://www.hindawi.com/crim/cc/2012/467810/ Rupture of the free wall of the left ventricle occurs in approximately 4% of patients with infarcts and accounts for approximately 20% of the total mortality of patients with myocardial infractions. Relatively few cases are diagnosed before death. Several distinct clinical forms of ventricular free wall rupture have been identified. Sudden rupture with massive hemorrhage into the pericardium is the most common form; in a third of the cases, the course is subacute with slow and sometimes repetitive hemorrhage into the pericardial cavity. Left ventricular pseudoaneurysms generally occur as a consequence of left ventricular free wall rupture covered by a portion of pericardium, in contrast to a true aneurysm, which is formed of myocardial tissue. Here, we report a case of contained left ventricular free wall rupture following myocardial infarction. Arthur Shiyovich and Lior Nesher Copyright © 2012 Arthur Shiyovich and Lior Nesher. All rights reserved. Sun, 16 Dec 2012 15:31:25 +0000 http://www.hindawi.com/crim/cc/2012/262815/ We report a case of a 59-year-old woman who presented with worsening dyspnea which rapidly progressed to severe heart failure. Coronary arteries showed no obstruction. Supportive measures stabilized the patient’s hemodynamics. Initially intravenous solumedrol was given, but when the patient’s condition continued to deteriorate, intravenous immunoglobulin (IVIG) was added to the treatment regimen and her condition improved. Studies show no benefit to using immunosuppressive agents in viral myocarditis, but benefits have been demonstrated in other etiologies. Patients presenting with acute fulminant myocarditis with unknown etiology that continue to deteriorate with aggressive heart failure treatment may benefit from steroids and IVIG. Michael Barrie, Lucas McKnight, and Pallavi Solanki Copyright © 2012 Michael Barrie et al. All rights reserved. Sat, 08 Dec 2012 11:51:19 +0000 http://www.hindawi.com/crim/cc/2012/659415/ Purpose. To describe the successful use of dexmedetomidine as the primary procedural sedative for a percutaneous tracheotomy procedure and to systematically present the supporting literature. Materials and Methods. A Case report of our experience and systematic literature search. PubMed, Embase, and Google Scholar were searched without restriction using the key words dexmedetomidine, percutaneous tracheotomy, and tracheotomy procedure. All relevant published references were retrieved irrespective of their methodological quality. Results. In total, only 3 relevant references were found. These include one small placebo controlled randomized trial and 2 case reports. The randomized, placebo controlled trial enrolled patients already sedated on midazolam and included 64 total patients. The 2 other case reports both described the use of dexmedetomidine as the primary procedural sedative. All of the cases reported the successful completion of the percutaneous tracheotomy without any major complication, but none reported the subjective patient experience. Conclusion. Based on the available published literature and our experience, we suggest that dexmedetomidine be considered for use as the primary procedural sedative for percutaneous tracheotomy procedure. Dexmedetomidine’s ability to provide adequate sedation and amnesia, without blunting the respiratory drive and protective reflexes of the patient, may make it an optimal agent in specific cases. Jerrold L. Perrott, Michelle T. Co, Steven C. Reynolds, and Derek J. R. Gunning Copyright © 2012 Jerrold L. Perrott et al. All rights reserved. Tue, 20 Nov 2012 09:19:16 +0000 http://www.hindawi.com/crim/cc/2012/924328/ Objective. The case of a patient who developed a fatal post-exertional heat stroke is reported. Case Report. A 20-year-old man with a history of morbid obesity, hypertension, and schizophrenia was admitted to our intensive care unit because of multiorgan failure due to severe heat stroke. He had been working under the sun. Treatment included aggressive body cooling but, in spite of the best supportive care, the patient succumbed in a few hours. We concluded that the adverse event was possibly associated with his obesity and the use of antipsychotics. Histological evaluation revealed lesions consistent with severe hyperthermia and shock. Conclusions. Heat stroke is an uncommon clinical entity characterized by systemic heat and loss of the body's normal mechanisms for dealing with heat stress, such as sweating and temperature control. When heat stroke is diagnosed early and supportive care begins promptly the prognosis is optimal but it becomes a life-threatening disease when treatment is delayed. Lack of physical acclimatization and the use of certain medications that interfere with salt and water balance can impair thermoregulation under conditions of high environmental temperature. Health professionals must be adequately prepared to prevent, recognise, and treat them urgently. María Jesús Gómez Ramos, Francisco Miguel González Valverde, Carmen Sánchez Álvarez, Lisa Ortin Katnich, and Francisco Pastor Quirante Copyright © 2012 María Jesús Gómez Ramos et al. All rights reserved. Sun, 11 Nov 2012 11:40:07 +0000 http://www.hindawi.com/crim/cc/2012/760407/ Spontaneous eye opening associated with burst suppression electroencephalogram has been reported in adults following postanoxic injury. Previous reports have correlated the onset of epileptiform bursts with the eye opening and attribute it to a brainstem-release phenomenon associated with poor prognosis. The author presents a case of a 12-year-old boy with burst suppression electroencephalogram following severe anoxic injury where the eye opening occurred at the conclusion of the bursts that has never been previously reported. These electroencephalographic findings are important for intensive care physicians to recognize and may provide further insight into the pathophysiological mechanism of this rare phenomenon. John R. Crawford Copyright © 2012 John R. Crawford. All rights reserved. Mon, 05 Nov 2012 16:18:56 +0000 http://www.hindawi.com/crim/cc/2012/342819/ Pheochromocytoma is a rare catecholamine-secreting tumor derived from chromaffin cells. The diagnosis is usually suggested by classic history in a symptomatic patient, presence of a strong family history in a patient, or discovery of an incidental mass on imaging in an asymptomatic patient. Traumatic hemorrhage into an occult pheochromocytoma presenting as hypovolemic shock is a rare presentation of pheochromocytoma. We report a case of a 48-year-old female, who presented in hypovolemic shock due to unilateral adrenal hemorrhage secondary to a fall from horse. Computed tomographic imaging revealed that the source of the hypovolemic shock was hemorrhagic right adrenal mass with active extravasation. The patient underwent emergent selective arterial embolization of right superior adrenal artery and a small adrenal branch from the right renal artery to control the hemorrhage. The patient subsequently progressed to sepsis and MODS, needing multiple surgical procedures and a protracted recovery in the ICU. In the ICU, the patient suffered from rapid cyclic fluctuation of her systolic blood pressure and was subsequently diagnosed with pheochromocytoma secondary to traumatic hemorrhage. We discuss this rare case along with the presentation and diagnostic workup of this critically ill patient with a previously undiagnosed pheochromocytoma. Arpit Amin, Saptarshi Biswas, and Francis Baccay Copyright © 2012 Arpit Amin et al. All rights reserved. Wed, 24 Oct 2012 10:19:41 +0000 http://www.hindawi.com/crim/cc/2012/312458/ Occasionally, malaria may present with unusual signs and symptoms. We report a case of an uncommon presentation of Plasmodium falciparum infection in a 59-year-old Ethiopian immigrant, which initially presented with hyperglycaemia and multiple organ dysfunction syndrome (MODS). Reports of unusual presentations of malaria are few and cases of severe malaria with hyperglycaemia are rarely described. As hyperglycaemia is associated to most severe malaria and high mortality, our aim is to catch the attention of the physicians on this entity. Leonardo Chianura, Isabella Corinna Errante, Giovanna Travi, Roberto Rossotti, and Massimo Puoti Copyright © 2012 Leonardo Chianura et al. All rights reserved. Sun, 21 Oct 2012 09:05:18 +0000 http://www.hindawi.com/crim/cc/2012/189705/ Ovarian hyperstimulation syndrome (OHSS) is a potentially life-threatening complication, usually iatrogenic after ovulation induction. OHSS is a very rare event in spontaneously conceived pregnancies. Only few cases have been reported in literature to the best of our knowledge. We report a very rare case of spontaneous critical OHSS (according to classification of severity of OHSS as mentioned in Greentop guidelines no. 5, 2006) associated with triplet pregnancy in a 26-year-old woman suffering from severe abdominal pain, distension, and dyspnea. Our case highlights the importance of a strong suspicion for OHSS when a clinical presentation could not be explained by common medical conditions. Nisha Rani Agrawal, Garima Gupta, Kusum Verma, and Neeraj Varyani Copyright © 2012 Nisha Rani Agrawal et al. All rights reserved. Thu, 11 Oct 2012 11:58:01 +0000 http://www.hindawi.com/crim/cc/2012/821565/ Odontoid fractures are typically associated with low rates of acute neurologic deficit and morbidity/mortality in nonelderly patients. In the patient in this case, traumatic injury triggered by a syncopal event led to a combined C1-C2 fracture and a fatal spinal cord injury with apnea, quadriplegia, and cardiovascular instability. We briefly review the anatomical basis for the pathophysiology of cardiac dysfunction following high-cervical spine injury and present an example of a worst-case scenario. Christian A. Bowers, Gregory F. Jost, and Andrew T. Dailey Copyright © 2012 Christian A. Bowers et al. All rights reserved. Tue, 09 Oct 2012 13:02:27 +0000 http://www.hindawi.com/crim/cc/2012/782507/ Lagocephalus sceleratus, or better known as the pufferfish, or fugu, is widespread in Asia and Indo-Pacific regions. It is a poisonous fish containing tetrodotoxin (TTX) which is a potent neurotoxin. In the Far East, fugu is considered a delicate dish, especially in Japan where it is prepared by experts. Nevertheless, poisoning from Lagocephalus sceleratus is not a rare event. Recent data from Japan indicate an incidence of 45 patients per year and a mortality rate of 11%. Mediterranean sea is not the natural habitat of Lagocephalus sceleratus. However, by now multiple reports have established a firm presence of Lagocephalus sceleratus in Mediterranean region as well. This phenomenon is explained by migration of pufferfish across the Suez Channel (lessepsian migration) (Eisenman et al., 2008, Bentur et al., 2008). With lessepsian migration came the first reports of TTX poisoning in the Mediterranean region. We report a patient with a particularly severe and life-threatening TTX poisoning caused by consumption of Lagocephalus sceleratus and treated by cholinesterase inhibitor to a complete and uneventful recovery. Julia Kheifets, Boris Rozhavsky, Zehava Girsh Solomonovich, Rodman Marianna, and Arie Soroksky Copyright © 2012 Julia Kheifets et al. All rights reserved. Tue, 18 Sep 2012 09:43:35 +0000 http://www.hindawi.com/crim/cc/2012/141505/ Nurofen Plus is a common analgesic containing ibuprofen and codeine. We present a case of a 38-year-old lady who developed renal tubular acidosis with severe hypokalaemia, after chronic abuse of Nurofen Plus tablets. She presented with confusion and profound biochemical abnormalities requiring critical care admission for electrolyte replacement. Ibuprofen causes renal tubular acidosis due to its effects on carbonic anhydrase activity. M. J. Blackstock and A. Lee Copyright © 2012 M. J. Blackstock and A. Lee. All rights reserved. Sun, 16 Sep 2012 11:11:55 +0000 http://www.hindawi.com/crim/cc/2012/359360/ Herpes simplex virus type 1 (HSV-1) infections cause typical dermal and mucosal lesions in children and adults. Also complications to the peripheral and central nervous system, pneumonia or hepatitis are well known. However, dissemination to viscera in adults is rare and predominantly observed in immunocompromised patients. Here we describe the case of a 70-year-old male admitted with macrohematuria and signs of acute infection and finally deceasing in a septic shock with multi organ failure 17 days after admission to intensive care unit. No bacterial or fungal infection could be detected during his stay, but only two days before death the patient showed signs of rectal, orolabial and genital herpes infection. The presence of HSV-1 was detected in swabs taken from the lesions, oropharyngeal fluid as well as in plasma. Post-mortem polymerase chain reaction analyses confirmed a disseminated infection with HSV-1 involving various organs and tissues but excluding the central nervous system. Autopsy revealed a predominantly retroperitoneal diffuse large B-cell lymphoma as the suspected origin of immunosuppression underlying herpes simplex dissemination. Michael Glas, Sigrun Smola, Thorsten Pfuhl, Juliane Pokorny, Rainer M. Bohle, Arno Bücker, Jörn Kamradt, and Thomas Volk Copyright © 2012 Michael Glas et al. All rights reserved. Tue, 31 Jul 2012 12:01:59 +0000 http://www.hindawi.com/crim/cc/2012/459296/ A 31-year-old male was transferred to our hospital with severe heart failure due to viral myocarditis. He progressed to multiorgan failure requiring intubation and maximal doses of multiple vasopressors. Circulatory support was provided with an Impella device as a bridge to an extracorporeal membrane oxygenation (ECMO) system. On full mechanical cardiovascular support, the patient's hemodynamic status improved and ECMO and Impella were explanted after 48 hours. Three days later, he was extubated and continued on to a full recovery. There are no specific therapies for fulminant myocarditis but first-line treatment is supportive care. ECMO is commonly used in patients with severe heart failure. In severe systolic dysfunction, left ventricular decompression is required to reduce myocardial wall stress, decrease myocardial oxygen requirements, and enhance the chances of recovery. The Impella, an active support system, is less invasive than classical decompressive techniques and is associated with lower requirements for blood products with fewer thromboembolic complications. This is the only case reported of the contemporary use of Impella and ECMO as a bridge to full recovery in an adult with myocarditis. It also presents a novel use of the Impella device in decompressing the left ventricle of an adult patient on ECMO. Sachin Narain, Gian Paparcuri, Thomas M. Fuhrman, Richard B. Silverman, and William T. Peruzzi Copyright © 2012 Sachin Narain et al. All rights reserved. Tue, 10 Jul 2012 15:24:12 +0000 http://www.hindawi.com/crim/cc/2012/295867/ Background. Acute hepatic failure (AHF) is uncommon as a leading symptom in patients with exertional heat stroke (EHS). Which stage to perform the liver transplantation for severe hepatic failure in EHS is still obscure at clinical setting. The conservative management has been reported to be successful in treating heat-stroke-associated AHF even in the presence of accepted criteria for emergency liver transplantation. Case Presentation. Here, we reported a 35-year-old male who presented with very high transaminases, hyperbilirubinemia, significant prolongation of the prothrombin time, and coma. No other causes for AHF could be identified but physical exhaustion and hyperthermia. Although the current patient fulfilled London criteria for emergency liver transplantation, he spontaneously recovered under conservative treatment including intravenous fluids, cooling, diuretics as mannitol, and hepatocyte growth-promoting factors. Conclusions. Meticulous supportive management could be justified in some selected cases of AHF due to EHS. Qi Jin, Erzhen Chen, Jie Jiang, and Yiming Lu Copyright © 2012 Qi Jin et al. All rights reserved. Thu, 07 Jun 2012 08:44:24 +0000 http://www.hindawi.com/crim/cc/2012/585879/ Serum troponin is a useful laboratory study for the diagnosis of acute myocardial infarction. However, elevations can also be seen in a variety of other diseases processes. Falsely positive troponin values caused by interference with current troponin assays have been reported. We report a unique case that demonstrates the fluctuation of falsely elevated troponin correlating with hemoglobin, serving as a marker of heterophile antibody levels. A 74-year-old gentleman presented to our Emergency Department with a several-day history of increasing shortness of breath associated with a new-onset chest pain and a troponin I level of 77.28 ng/mL. Throughout his stay, fluctuations in measured troponin levels correlated strongly with fluctuations in hemoglobin levels. Several investigations confirmed false elevated troponin levels secondary to heterophile antibody interference. We conclude that hemoglobin trending in our patient represented a surrogate measure of his heterophile antibody titers with time and that fluctuations in these levels correlated with respective fluctuations in the falsely elevated troponin levels. Sam Ghali, Keith Lewis, Viviane Kazan, Neezam Altorok, Jamil Taji, Mohammad Taleb, Kiranmayee Lanka, and Ragheb Assaly Copyright © 2012 Sam Ghali et al. All rights reserved.