Case Reports in Critical Care The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Spurious Hyperchloremia and Negative Anion Gap in a Child with Refractory Epilepsy Thu, 11 Feb 2016 11:18:23 +0000 We report a case with spurious hyperchloremia with negative anion gap in a child who was taking potassium bromide for refractory epilepsy. Blood chemistry showed a high chloride level (171 mEq/L) and a negative anion gap (−52 mEq/L). Plasma chloride concentration is measured by an ion-selective electrode method; however the presence of other anions like bromide and iodides can interfere with chloride level and largely overestimates the chloride concentration. Thus hyperchloremia with a negative anion gap is a clue to the diagnosis of halides like bromide and iodide ingestion. Madhuradhar Chegondi and Balagangadhar R. Totapally Copyright © 2016 Madhuradhar Chegondi and Balagangadhar R. Totapally. All rights reserved. A Case of Waterhouse-Friderichsen Syndrome Resulting from an Invasive Pneumococcal Infection in a Patient with a Hypoplastic Spleen Thu, 28 Jan 2016 13:06:41 +0000 A 50-year-old male was brought to our emergency department by ambulance with complaints of pain and numbness in both legs. At arrival, purple spots were evident on his neck and face. Examination of the vital sign indicated septic shock. Laboratory data and blood gas analysis revealed disseminated intravascular coagulation, multiple organ failure, and metabolic acidosis. Peripheral blood smears revealed Howell-Jolly bodies, indicating decreased splenic function. A rapid urinary pneumococcal antigen test was also found to be positive. After admission to the intensive care unit, extensive treatment, including polymyxin-B direct hemoperfusion and administration of methylprednisolone and broad spectrum antibiotics was immediately initiated. Despite of our efforts to save his life, the patient died six hours after the arrival. The following day, blood cultures revealed the presence of Streptococcus pneumoniae. An autopsy revealed a hypoplastic spleen and a bilateral adrenal hemorrhage, indicating acute adrenal insufficiency caused by sepsis. Finally, the patient was diagnosed with Waterhouse-Friderichsen syndrome. Although severe infection may be seen in the splenectomized patients, it should be noted that patients with a hypoplastic spleen may have acute severe infections. We, therefore, report a case of Waterhouse-Friderichsen syndrome resulting from an invasive pneumococcal infection in a patient with a hypoplastic spleen. Kazumasa Emori, Nobuhiro Takeuchi, and Junichi Soneda Copyright © 2016 Kazumasa Emori et al. All rights reserved. DRESS Syndrome in the ICU: When a Patient Is Treated with Multiple Drugs Sun, 24 Jan 2016 13:57:38 +0000 The Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome is life-threatening. It associates a skin condition with hematological and visceral disorders. The DRESS syndrome diagnosis in the intensive care unit (ICU) is difficult as clinical features are nonspecific. Furthermore, the need to treat patients with multiple drugs usually prevents the identification of the causative drug. We report the case of a patient who developed two bouts of DRESS caused by piperacillin-tazobactam, the first being complicated with a distributive shock. Cases of DRESS occurring inside ICU are seldom reported. However, any intensivist may encounter this situation during his career and should be aware of its diagnostic and management specific aspects. Florent Moriceau, Johanne Prothet, Benjamin J. Blaise, Benoit Ben Said, Mathieu Page, Charles-Eric Ber, Jullien Crozon, and Thomas Rimmelé Copyright © 2016 Florent Moriceau et al. All rights reserved. Beta Lactamase Producing Clostridium perfringens Bacteremia in an Elderly Man with Acute Pancreatitis Sun, 24 Jan 2016 08:41:46 +0000 Clostridium perfringens bacteremia is associated with adverse outcomes. Known risk factors include chronic kidney disease, malignancy, diabetes mellitus, and gastrointestinal disease. We present a 74-year-old man admitted with confusion, vomiting, and abdominal pain. Exam revealed tachycardia, hypotension, lethargy, distended abdomen, and cold extremities. He required intubation and aggressive resuscitation for septic shock. Laboratory data showed leukocytosis, metabolic acidosis, acute kidney injury, and elevated lipase. CT scan of abdomen revealed acute pancreatitis and small bowel ileus. He was started on vancomycin and piperacillin-tazobactam. Initial blood cultures were positive for C. perfringens on day five. Metronidazole and clindamycin were added to the regimen. Repeat CT (day 7) revealed pancreatic necrosis. The patient developed profound circulatory shock requiring multiple vasopressors, renal failure requiring dialysis, and bacteremia with vancomycin-resistant enterococci. Hemodynamic instability precluded surgical intervention and he succumbed to multiorgan failure. Interestingly, our isolate was beta lactamase producing. We review the epidemiology, risk factors, presentation, and management of C. perfringens bacteremia. This case indicates a need for high clinical suspicion for clostridial sepsis and that extended spectrum beta lactam antibiotic coverage may be inadequate and should be supplemented with use of clindamycin or metronidazole if culture is positive, until sensitivities are known. Rashmi Mishra, Nupur Sinha, and Richard Duncalf Copyright © 2016 Rashmi Mishra et al. All rights reserved. Identification Bracelet Precipitated Acute Compartment Syndrome during Intravenous Infusion in an Obtunded Patient Tue, 19 Jan 2016 16:21:26 +0000 Acute compartment syndrome is a serious condition requiring immediate medical care. A lack of urgent medical treatment can result in serious complications such as loss of function and even amputation. While the pathophysiology of acute compartment syndrome is well understood, numerous potential causes are still being discovered. A rare cause of acute compartment syndrome is IV infiltration. We present a case of acute compartment syndrome resulting from intravenous infusion due to proximal placement of a patient identification bracelet. We conclude that both routine evaluation for IV infiltration and proximal placement of IV lines are essential for prevention of acute compartment syndrome. Wahib Zafar, Benjamin Chaucer, Suleyman Felek, Edward L. Arsura, and Jay Nfonoyim Copyright © 2016 Wahib Zafar et al. All rights reserved. Cytokine Reduction in the Setting of an ARDS-Associated Inflammatory Response with Multiple Organ Failure Sun, 17 Jan 2016 13:52:27 +0000 A 45-year-old male was admitted to our hospital with a small bowel obstruction due to torsion and was immediately scheduled for surgical intervention. At anesthesia induction, the patient aspirated and subsequently developed a severe SIRS with ARDS and multiple organ failure requiring the use of ECMO, CRRT, antibiotics, and low dose steroids. Due to a rapid deterioration in clinical status and a concurrent surge in inflammatory biomarkers, an extracorporeal cytokine adsorber (CytoSorb) was added to the CRRT blood circuit. The combined treatment resulted in a rapid and significant reduction in the levels of circulating inflammatory mediators. This decrease was paralleled by marked clinical stabilization of the patient including a significant improvement in hemodynamic stability and a reduced need for norepinephrine and improved respiratory function as measured by PaO2/FIO2, ventilator parameters, lung mechanics, and indirect measures of capillary leak syndrome. The patient could be discharged to a respiratory weaning unit where successful respiratory weaning could be achieved later on. We attribute the clinical improvement to the rapid control of the hyperinflammatory response and the reduction of inflammatory mediators using a combination of CytoSorb and these other therapies. CytoSorb treatment was safe and well tolerated, with no device-related adverse effects observed. Karl Träger, Christian Schütz, Günther Fischer, Janpeter Schröder, Christian Skrabal, Andreas Liebold, and Helmut Reinelt Copyright © 2016 Karl Träger et al. All rights reserved. The Wide and Unpredictable Scope of Synthetic Cannabinoids Toxicity Mon, 14 Dec 2015 12:51:46 +0000 Drug use and abuse continue to be a large public health concern worldwide. Over the past decade, novel or atypical drugs have emerged and become increasingly popular. In the recent past, compounds similar to tetrahydrocannabinoid (THC), the active ingredient of marijuana, have been synthetically produced and offered commercially as legal substances. Since the initial communications of their abuse in 2008, few case reports have been published illustrating the misuse of these substances with signs and symptoms of intoxication. Even though synthetic cannabinoids have been restricted, they are still readily available across USA and their use has been dramatically increasing, with a concomitant increment in reports to poison control centers and emergency department (ED) visits. We describe a case of acute hypoxemic/hypercapnic respiratory failure as a consequence of acute congestive heart failure (CHF) developed from myocardial stunning resulting from a non-ST-segment elevation myocardial infarction (MI) following the consumption of synthetic cannabinoids. Jose Orsini, Christa Blaak, Eric Tam, Salil Rajayer, Joaquin Morante, Angela Yeh, and Ashvin Butala Copyright © 2015 Jose Orsini et al. All rights reserved. Myasthenic Crisis in an Elderly Patient with Positive Antibodies against Acetylcholine and Anti-MuSK, Successfully Treated with Noninvasive Mechanical Ventilation Thu, 10 Dec 2015 08:45:37 +0000 Myasthenia gravis is an autoimmune disease characterized by muscle weakness. Subjects with antibodies against acetylcholine usually have greater ocular symptoms, lower bulbar weakness, and fewer respiratory complications, compared to individuals with anti-MuSK antibodies. The presence of positivity to both types of antibodies in the same patient is uncommon, and the clinical behavior of these individuals is uncertain. A myasthenic crisis is characterized by respiratory and bulbar muscle weakness, causing acute respiratory failure which requires mechanical ventilatory support. We present the case of a 73-year-old man with a medical history of myasthenia gravis and positive antibody titers against acetylcholine and anti-MuSK, who sought for medical assessment because of respiratory tract infection symptoms, dysphagia, and generalized weakness. Initially, no respiratory distress was found. After 24 hours the patient showed respiratory deterioration and neurological impairment. Endotracheal intubation was rejected, so ventilatory support with noninvasive ventilation was started. The patient was supported by intense respiratory therapy, and infusion of immunoglobulin was initiated. The individual responded favorably, improving his general condition. Weaning from noninvasive mechanical ventilation was possible after six days. Our case illustrates that noninvasive ventilation, properly supported by intense respiratory therapy, can be a great option to avoid intubation in the myasthenic patient. José A. Fernández, Antonio Fernández-Valiñas, Daniel Hernández, Joel Orozco, and Antonio Lugo Copyright © 2015 José A. Fernández et al. All rights reserved. Ventricular Tachycardia from a Central Line Fracture Fragment Embolus: A Rare Complication of a Commonly Used Procedure—A Case Report and Review of the Relevant Literature Thu, 03 Dec 2015 13:55:45 +0000 A 22-year-old male admitted with multiple gunshot wounds (GSW) had central line placed initially for hemodynamic monitoring and later for long term antibiotics and total parenteral nutrition (TPN). On postoperative day 4 he presented with bouts of nonsustained ventricular tachycardia; the cause was unknown initially and later attributed to a catheter fragment accidentally severed and lodged in the right heart. Percutaneous retrieval technique was used to successfully extract the catheter fragment and complete recovery was achieved. Saptarshi Biswas and Patrick McNerney Copyright © 2015 Saptarshi Biswas and Patrick McNerney. All rights reserved. Venovenous Extracorporeal Membrane Oxygenation for Negative Pressure Pulmonary Hemorrhage in an Elderly Patient Wed, 18 Nov 2015 07:37:09 +0000 The patient in this case report was an 88-year-old male. Acute upper airway obstruction by food led to transient cardiac arrest, and negative pressure pulmonary hemorrhage (NPPH) occurred 1 hour after the foreign body obstruction. Using venovenous extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome resulting from NPPH, his respiratory state was recovered and hemoptysis stopped. NPPH is a life-threatening disease, the rapid recognition of which is required to initiate appropriate therapy. Although active hemorrhage might be a contraindication for ECMO, our experience showed this to be an effective treatment option. Moreover, our experience suggests that the application of ECMO to elderly patients should be considered on a case-by-case basis. Kenichiro Ishida, Mitsuhiro Noborio, Nobutaka Iwasa, Taku Sogabe, Yohei Ieki, Yuki Saoyama, Kyosuke Takahashi, Yumiko Shimahara, and Daikai Sadamitsu Copyright © 2015 Kenichiro Ishida et al. All rights reserved. Meningococcemia Presenting as a Myocardial Infarction Wed, 11 Nov 2015 13:05:24 +0000 Neisseria meningitidis is an encapsulated gram negative diplococcus that colonizes the nasopharynx and is transmitted by aerosol or secretions with the majority of cases occurring in infants and adolescents. Meningococcemia carries a high mortality which is in part due to myocarditis. Early recognition and prompt use of antibiotics improve morbidity and mortality. We report a 55-year-old male presenting to the emergency department with chest pain, shortness of breath, and electrocardiogram changes suggestive of ST elevation MI who developed cardiogenic shock and multisystem organ failure from N. meningitidis. We present this case to highlight the unique presentation of meningococcemia, the association with myocardial dysfunction, and the importance of early recognition and prompt use of antibiotics. Daniel Lachant and David Trawick Copyright © 2015 Daniel Lachant and David Trawick. All rights reserved. Cardiac and Pulmonary Ultrasound for Diagnosing TRALI Wed, 28 Oct 2015 09:31:19 +0000 Unexpected acute respiratory failure after anesthesia is a diagnostic challenge: residual neuromuscular blockade, bronchial hyperresponsiveness, laryngospasm, atelectasis, aspiration pneumonitis, and other more uncommon causes should be taken into account at diagnosis. Lung ultrasound and echocardiography are diagnostic tools that would provide the differential diagnosis. We report a suspected case of a transfusion related acute lung injury (TRALI) following administration of platelets. The usefulness of lung and cardiac ultrasound is discussed to facilitate the challenging diagnosis of the acute early postoperative respiratory failure. J. I. Alonso-Fernández, J. R. Prieto-Recio, C. García-Bernardo, I. García-Saiz, J. Rico-Feijoo, and C. Aldecoa Copyright © 2015 J. I. Alonso-Fernández et al. All rights reserved. Ciprofloxacin-Induced Thrombotic Thrombocytopenic Purpura: A Case of Successful Treatment and Review of the Literature Mon, 26 Oct 2015 14:25:20 +0000 A 49-year-old African American woman was admitted to our hospital with abdominal pain, nausea, vomiting, lethargy, and confusion. She was receiving ciprofloxacin for a urinary-tract infection prior to admission. Laboratory examination revealed anemia, thrombocytopenia, elevated lactate dehydrogenase, and serum creatinine. Peripheral smear showed numerous schistocytes, and the patient was diagnosed with thrombotic thrombocytopenic purpura (TTP). Ciprofloxacin was identified as the offending agent. The patient received treatment with steroids and plasmapheresis, which led to rapid clinical recovery. This is the first case to our knowledge of successfully treated ciprofloxacin-induced TTP; previously reported cases had fulminant outcomes. Quinolones are an important part of the antibiotic armamentarium, and this case can raise awareness of the association between quinolones and TTP. A high index of suspicion for detection and early and aggressive management are vitally important for a successful outcome. Hafiz Rizwan Talib Hashmi, Gilda Diaz-Fuentes, Preeti Jadhav, and Misbahuddin Khaja Copyright © 2015 Hafiz Rizwan Talib Hashmi et al. All rights reserved. Boerhaave Syndrome, Pneumothorax, and Chylothorax in a Critically Ill Patient with Tuberous Sclerosis Complex Thu, 15 Oct 2015 06:30:10 +0000 Tuberous sclerosis complex (TSC) is an autosomal dominant, variably expressed multisystem disease. The predominant pulmonary features of TSC are identical to those of lymphangioleiomyomatosis (LAM). Pneumothorax, multifocal micronodular pneumocyte hyperplasia, and chylothorax are rare complications of TSC. We report a young male with pneumothorax, lung nodules, and chylous effusion who developed empyema thoracis after esophageal rupture. Hospital course was complicated by respiratory failure. Family opted to transfer to hospice care. Chylothorax is a rare complication of TSC with few scattered reports mostly in female patients. Patients with TSC are usually managed by multispecialists and it is important to be aware of the rare pulmonary manifestations of this disease. A male patient with TSC having lung nodules presenting with chylothorax and empyema thoracis from Boerhaave syndrome makes our case unique. Mohsin Ijaz, Arsalan Rafiq, Sindhaghatta Venkatram, and Gilda Diaz-Fuentes Copyright © 2015 Mohsin Ijaz et al. All rights reserved. Delirium Accompanied by Cholinergic Deficiency and Organ Failure in a 73-Year-Old Critically Ill Patient: Physostigmine as a Therapeutic Option Tue, 13 Oct 2015 11:15:40 +0000 Delirium is a common problem in ICU patients, resulting in prolonged ICU stay and increased mortality. A cholinergic deficiency in the central nervous system is supposed to be a relevant pathophysiologic process in delirium. Acetylcholine is a major transmitter of the parasympathetic nervous system influencing several organs (e.g., heart and kidneys) and the inflammatory response too. This perception might explain that delirium is not an individual symptom, but rather a part of a symptom complex with various disorders of the whole organism. The cholinergic deficiency could not be quantified up to now. Using the possibility of bedside determination of the acetylcholinesterase activity (AChE activity), we assumed to objectify the cholinergic homeostasis within minutes. As reported here, the postoperative delirium was accompanied by a massive hemodynamic and renal deterioration of unclear genesis. We identified the altered AChE activity as a plausible pathophysiological mechanism. The pharmacological intervention with the indirect parasympathomimetic physostigmine led to a quick and lasting improvement of the patient’s cognitive, hemodynamic, and renal status. In summary, severe delirium is not always an attendant phenomenon of critical illness. It might be causal for multiple organ deterioration if it is based on cholinergic deficiency and has to be treated at his pathophysiological roots whenever possible. Benedikt Zujalovic and Eberhard Barth Copyright © 2015 Benedikt Zujalovic and Eberhard Barth. All rights reserved. Early Angiographic Resolution of Cerebral Vasospasm with High Dose Intravenous Milrinone Therapy Thu, 17 Sep 2015 13:50:18 +0000 Background. Treatment of symptomatic delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH) is difficult. Recent studies suggest intravenous (IV) high dose milrinone as a potential therapy. The timing to angiographic response with this is unclear. Methods. We reviewed the chart of one patient admitted for SAH who developed symptomatic DCI and was treated with high dose IV milrinone. Results. A 66-year-old female was admitted with a Hunt and Hess clinical grade 4, World Federation of Neurological Surgeons (WFNS) clinical grade 4, and SAH secondary to a left anterior choroidal artery aneurysm which was clipped. After bleed day 6, the patient developed symptomatic DCI. We planned for angioplasty of the proximal segments. We administered high dose IV milrinone bolus followed by continuous infusion which led to clinical improvement prior to angiography. The angiogram performed 1.5 hours after milrinone administration displayed resolution of the CT angiogram and MRI based cerebral vasospasm such that further intra-arterial therapy was aborted. She completed 6 days of continuous IV milrinone therapy, was transferred to the ward, and subsequently rehabilitated. Conclusions. High dose IV milrinone therapy for symptomatic DCI after SAH can lead to rapid neurological improvement with dramatic early angiographic improvement of cerebral vasospasm. F. A. Zeiler and J. Silvaggio Copyright © 2015 F. A. Zeiler and J. Silvaggio. All rights reserved. Tension Pneumothorax and Subcutaneous Emphysema Complicating Insertion of Nasogastric Tube Thu, 10 Sep 2015 12:56:46 +0000 Nasogastric tube has a key role in the management of substantial number of hospitalized patients particularly the critically ill. In spite of the apparent simple insertion technique, nasogastric tube placement has its serious perhaps fatal complications which need to be carefully assessed. Pulmonary misplacement and associated complications are commonplace during nasogastric tube procedure. We present a case of tension pneumothorax and massive surgical emphysema in critically ill ventilated patient due to inadvertent nasogastric tube insertion and also discussed the risk factors, complication list, and arrays of techniques for safer tube placement. Narjis AL Saif, Adel Hammodi, M. Ali Al-Azem, and Rasheed Al-Hubail Copyright © 2015 Narjis AL Saif et al. All rights reserved. Mediastinal Packing for Intractable Coagulopathy in Acute Aortic Dissection (Types 1 and 2 DeBakey): A Life-Saving Technique—Report of Experiences Mon, 07 Sep 2015 11:34:16 +0000 Nonsurgical bleeding after complex thoracic aortic procedures (such as aortic dissection and aortic aneurysm) is a great challenge for cardiac surgeons because of severe coagulopathy, exsanguinous bleeding, and inevitable death. Temporary mediastinal packing (with sponge) in such cases is the only life-saving technique with good result in most cases. Herein, we presented three cases with acute aortic dissection with intractable bleeding that was successfully managed with mediastinal packing. Aliasghar Moeinipour, Mehdi Fathi, Alireza Sepehri Shamloo, Shahram Amini, Hamid Hoseinikhah, and Akram Kianinejad Copyright © 2015 Aliasghar Moeinipour et al. All rights reserved. Takotsubo Cardiomyopathy in the Setting of Tension Pneumothorax Sun, 23 Aug 2015 12:10:14 +0000 Background. Takotsubo cardiomyopathy is defined as a transient left ventricular dysfunction, usually accompanied by electrocardiographic changes. The literature documents only two other cases of Takotsubo cardiomyopathy in the latter setting. Methods. A 78-year-old female presented to the ED with severe shortness of breath, hypertension, and tachycardia. On physical exam, heart sounds (S1 and S2) were regular and wheezing was noticed bilaterally. We found laboratory results with a WBC of 20.0 (103/μL), troponin of 16.52 ng/mL, CK-mb of 70.6%, and BNP of 177 pg/mL. The patient was intubated for acute hypoxemic respiratory failure. A chest X-ray revealed a large left-sided tension pneumothorax. Initial echocardiogram showed apical ballooning with a LVEF of 10–15%. A cardiac angiography revealed normal coronary arteries with no coronary disease. After supportive treatment, the patient’s condition improved with a subsequent echocardiogram showing a LVEF of 60%. Conclusion. The patient was found to have Takotsubo cardiomyopathy in the setting of a tension pneumothorax. The exact mechanisms of ventricular dysfunction have not been clarified. However, multivessel coronary spasm or catecholamine cardiotoxicity has been suggested to have a causative role. We suggest that, in our patient, left ventricular dysfunction was induced by the latter mechanism related to the stress associated with acute pneumothorax. Michael Gale, Pablo Loarte, Brooks Mirrer, Thierry Mallet, Louis Salciccioli, Alison Petrie, and Ronny Cohen Copyright © 2015 Michael Gale et al. All rights reserved. Disseminated Histoplasmosis and Secondary Hemophagocytic Syndrome in a Non-HIV Patient Mon, 10 Aug 2015 12:01:43 +0000 Histoplasma duboisii, a variant of Histoplasma capsulatum that causes “African histoplasmosis,” can be resistant to itraconazole, requiring intravenous amphotericin B treatment. Rarely, these patients do not respond to intravenous antifungal therapy, and in such cases, patients may progress to develop secondary hemophagocytic lymphohistiocytosis (HLH). We present a case of a 34-year-old male patient with sickle cell disease who presented with a 5-month history of an enlarging painless axillary mass, persistent low grade fevers, night sweats, weight loss, and anorexia. An excisional biopsy of the right axillary lymph node revealed yeast and granulomas consistent with histoplasma infection. He was started on oral itraconazole. After 4 weeks of therapy, laboratory evaluation revealed worsening anemia, thrombocytopenia, and transaminitis. Due to failure of oral therapy, he was admitted for intravenous amphotericin B treatment. During his hospital course anemia, thrombocytopenia, and transaminitis all worsened. A bone marrow biopsy was done that was consistent with HLH. His clinical status continued to deteriorate, developing multiorgan failure and disseminated intravascular coagulation. He unfortunately had a cardiorespiratory arrest after eight days of admission and passed away. Muhammad Kashif, Hassan Tariq, Mohsin Ijaz, and Jose Gomez-Marquez Copyright © 2015 Muhammad Kashif et al. All rights reserved. From Eye Drops to ICU, a Case Report of Three Side Effects of Ophthalmic Timolol Maleate in the Same Patient Thu, 06 Aug 2015 11:30:09 +0000 Timolol Maleate (also called Timolol) is a nonselective beta-adrenergic blocker and a class II antiarrhythmic drug, which is used to treat intraocular hypertension. It has been reported to cause systemic side effects especially in elderly patients with other comorbidities. These side effects are due to systemic absorption of the drug and it is known that Timolol is measurable in the serum following ophthalmic use. Chances of life threatening side effects increase if these are coprescribed with other cardiodepressant drugs like calcium channel or systemic beta blockers. We report a case where an elderly patient was admitted with three side effects of Timolol and his condition required ICU admission with mechanical ventilation and temporary transvenous pacing. The case emphasizes the need of raising awareness among physicians of such medications about the potential side effects and drug interactions. A close liaison among patient’s physicians is suggested. Muhammad Asim Rana, Ahmed Fouad Mady, Basheer Abdel Rehman, Abdulrahman Alharthy, Basim Huwait, Asim Riaz, and Waleed Tharwat Aletreby Copyright © 2015 Muhammad Asim Rana et al. All rights reserved. Combined Negative- and Positive-Pressure Ventilation for the Treatment of ARDS Tue, 28 Jul 2015 08:27:41 +0000 Objective. Tracheal intubation and positive-pressure ventilation as the current standard of care for the adult respiratory distress syndrome (ARDS) seem to have reached their limit in terms of a further relevant reduction of the still very high mortality. Case Presentation. A 75-year-old male patient developed ARDS after abscess drainage with deteriorating oxygenation, despite positive end-expiratory pressure (PEEP) values above 15 cm H2O. We applied external negative-pressure ventilation with a chamber respirator using −33 cm H2O at inspiration and −15 cm H2O at expiration, combined with conventional pressure support using a PEEP of about 8 cm H2O and a pressure support of 4–12 cm H2O. Alveolar infiltrates disappeared rapidly and PaO2/FiO2 values surpassed 300 mmHg after the first application and 500 mmHg after the second. Negative-pressure ventilation was used for 6–18 hours/day over five days. Now, 13 years later, the patient is still alive and has a good quality of life. Conclusion. Using this or similar concepts, not only in intubated patients but also as a noninvasive approach in patients with ARDS, offers new options that may genuinely differ from the present therapeutic approaches and may, therefore, have the potential to decrease the present high mortality from ARDS. Konstantinos Raymondos, Jörg Ahrens, and Ulrich Molitoris Copyright © 2015 Konstantinos Raymondos et al. All rights reserved. Traumatic Cervical Spondyloptosis in a Neurologically Stable Patient: A Therapeutic Challenge Thu, 16 Jul 2015 05:54:00 +0000 This is a case report of a neurologically intact patient following posttraumatic cervical spondyloptosis. We discuss the disease, management protocol and some surgical nuances to prevent any damage to the cord during different stages of its treatment. Sunil Munakomi, Binod Bhattarai, and Iype Cherian Copyright © 2015 Sunil Munakomi et al. All rights reserved. Rare Strain of Vibrio cholerae Septicemia in a Patient with Multiple Myeloma Wed, 15 Jul 2015 09:10:58 +0000 Introduction. Non-O1/non-O139 is a rare strain of Vibrio cholera that has been documented to cause significant morbidity and mortality in the immunosuppressed population. Case Presentation. A patient with multiple myeloma develops non-O1/non-O139 Vibrio cholera septicemia, leading to multiorgan failure and ultimately death. Discussion. An exceedingly rare strain of Vibrio cholera, non-O1/non-O139, may be an important factor of morbidity and mortality in certain immunosuppressed populations, such as patients with multiple myeloma and malignancies. Conclusion. Bacteremia involving generally noninvasive microbes, such as non-O1/non-O139 Vibrio cholerae, can have significant deleterious effects in the immunosuppressed patients as shown by this case report. Physicians need to be more diligent when treating these patients. Deepu Daniel and Sunil Kumar Copyright © 2015 Deepu Daniel and Sunil Kumar. All rights reserved. Flucytosine Pharmacokinetics in a Critically Ill Patient Receiving Continuous Renal Replacement Therapy Sun, 12 Jul 2015 10:25:03 +0000 Purpose. A case report evaluating flucytosine dosing in a critically ill patient receiving continuous renal replacement therapy. Summary. This case report outlines an 81-year-old male who was receiving continuous venovenous hemofiltration (CVVH) for acute renal failure and was being treated with flucytosine for the treatment of disseminated Cryptococcus neoformans infection. Due to patient specific factors, flucytosine was empirically dose adjusted approximately 50% lower than intermittent hemodialysis (iHD) recommendations and approximately 33% lower than CRRT recommendations. Peak and trough levels were obtained, which were supratherapeutic, and pharmacokinetic parameters were calculated. The patient experienced thrombocytopenia, likely due to elevated flucytosine levels, and flucytosine was ultimately discontinued. Conclusion. Despite conservative flucytosine dosing for a patient receiving CVVH, peak and trough serum flucytosine levels were supratherapeutic (120 μg/mL at 2 hours and 81 μg/mL at 11.5 hours), which increased drug-related adverse effects. The results indicate that this conservative dosing regimen utilizing the patient’s actual body weight was too aggressive. This case report provides insight into flucytosine dosing in CVVH, a topic that has not been investigated previously. Further pharmacokinetic studies of flucytosine dosing in critically ill patients receiving CVVH are needed in order to optimize pharmacokinetic and pharmacodynamic parameters while avoiding toxic flucytosine exposure. Megan E. Kunka, Elizabeth A. Cady, Heejung C. Woo, and Melissa L. Thompson Bastin Copyright © 2015 Megan E. Kunka et al. All rights reserved. Normalization of Activated Partial Thromboplastin Time Correlates with Low Levels of Dabigatran in a Patient with Severe Sepsis Mon, 29 Jun 2015 06:12:47 +0000 The oral anticoagulant dabigatran etexilate can be a challenge when patients need acute surgery. Sepsis and acute renal failure exacerbate the anticoagulant effect. There is no specific reversal agent for dabigatran etexilate, but it can be removed by hemodialysis. We present a case where a patient treated with dabigatran etexilate was admitted to intensive care unit with severe sepsis and acute renal failure and in need of bilateral lower limp amputation due to ischemia. The patient had severe coagulopathy and was treated with continuous venovenous hemofiltration in attempt to remove dabigatran etexilate before surgery. Rikke Ebenhard Højland, Stine Borch Thorup, and Bodil Steen Rasmussen Copyright © 2015 Rikke Ebenhard Højland et al. All rights reserved. Spontaneous Dissection of the Renal Artery in Vascular Ehlers-Danlos Syndrome Mon, 15 Jun 2015 12:45:42 +0000 Ehlers-Danlos syndrome (EDS) is a rare heterogeneous group of connective tissue disorders. The vascular type (vEDS) is an autosomal dominant disorder caused by heterozygous mutations in the COL3A1 gene predisposing to premature arterial, intestinal, or uterine rupture. We report a case of a 38-year-old woman with a recent diagnosis of vEDS admitted in the Emergency Department with a suspicion of a pyelonephritis that evolved to a cardiopulmonary arrest. A fatal retroperitoneal hematoma related with a haemorrhagic dissection of the right renal artery was found after emergency surgery. This case highlights the need to be aware of the particular characteristics of vEDS, such as a severe vascular complication that can lead to a fatal outcome. Filipa Pereira, Teresa Cardoso, and Paula Sá Copyright © 2015 Filipa Pereira et al. All rights reserved. Severe Dextran-Induced Anaphylactic Shock during Induction of Hypertension-Hypervolemia-Hemodilution Therapy following Subarachnoid Hemorrhage Thu, 11 Jun 2015 05:59:20 +0000 Dextran is a colloid effective for volume expansion; however, a possible side effect of its use is anaphylaxis. Dextran-induced anaphylactoid reaction (DIAR) is a rare but severe complication, with a small dose of dextran solution sufficient to induce anaphylaxis. An 86-year-old female who underwent clipping for a ruptured cerebral aneurysm was admitted to the intensive care unit. Prophylactic hypertension-hypervolemia-hemodilution therapy was induced for cerebral vasospasm following a subarachnoid hemorrhage. The patient went into severe shock after administration of dextran for volume expansion, and dextran administration was immediately discontinued. The volume administered at that time was only 0.8 mL at the most. After fluid resuscitation with a crystalloid solution, circulatory status began to recover. However, cerebral vasospasm occurred and the patient’s neurological condition deteriorated. Five weeks after the shock, she was diagnosed with hypersensitivity to dextran by a skin test. When severe hypotension occurs after dextran administration, appropriate treatments for shock should be performed immediately with discontinuation of dextran solution. Although colloid administration is recommended in some guidelines and researches, it is necessary to consider concerning the indication for volume expansion as well as the risk of colloid administration. Tohru Shiratori, Atsushi Sato, Masao Fukuzawa, Naoko Kondo, and Shogo Tanno Copyright © 2015 Tohru Shiratori et al. All rights reserved. Severe Uncompensated Metabolic Alkalosis due to Plasma Exchange in a Patient with Pulmonary-Renal Syndrome: A Clinician’s Challenge Mon, 08 Jun 2015 12:46:53 +0000 Metabolic alkalosis secondary to citrate toxicity from plasma exchange is very uncommon in patients with normal renal function. In patients with advanced renal disease this can be a fatal event. We describe a case of middle-aged woman with Goodpasture’s syndrome treated with plasma exchange who developed severe metabolic alkalosis. High citrate load in plasma exchange fluid is the underlying etiology. Citrate metabolism generates bicarbonate and once its level exceeds the excretory capacity of kidneys, the severe metabolic alkalosis ensues. Our patient presented with generalized weakness, fever, and oliguria and developed rapidly progressive renal failure. Patient had positive serology for antineutrophilic cytoplasmic antibodies myeloperoxidase (ANCA-MPO) and anti-glomerular basement membrane antibodies (anti-GBM). Renal biopsy showed diffuse necrotizing and crescentic glomerulonephritis with linear glomerular basement membrane staining. Patient did not respond to intravenous steroids. Plasma exchange was started with fresh frozen plasma but patient developed severe metabolic alkalosis. This metabolic alkalosis normalized with cessation of plasma exchange and initiation of low bicarbonate hemodialysis. ANCA-MPO and anti-GBM antibodies levels normalized within 2 weeks and remained undetectable at 3 months. Patient still required maintenance hemodialysis. Mohsin Ijaz, Naeem Abbas, and Dmitry Lvovsky Copyright © 2015 Mohsin Ijaz et al. All rights reserved. Clinical Brain Death with False Positive Radionuclide Cerebral Perfusion Scans Mon, 08 Jun 2015 07:53:18 +0000 Practice guidelines from the American Academy of Neurology for the determination of brain death in adults define brain death as “the irreversible loss of function of the brain, including the brainstem.” Neurological determination of brain death is primarily based on clinical examination; if clinical criteria are met, a definitive confirmatory test is indicated. The apnea test remains the gold standard for confirmation. In patients with factors that confound the clinical determination or when apnea tests cannot safely be performed, an ancillary test is required to confirm brain death. Confirmatory ancillary tests for brain death include (a) tests of electrical activity (electroencephalography (EEG) and somatosensory evoked potentials) and (b) radiologic examinations of blood flow (contrast angiography, transcranial Doppler ultrasound (TCD), and radionuclide methods). Of these, however, radionuclide studies are used most commonly. Here we present data from two patients with a false positive Radionuclide Cerebral Perfusion Scan (RCPS). Sindhaghatta Venkatram, Sara Bughio, and Gilda Diaz-Fuentes Copyright © 2015 Sindhaghatta Venkatram et al. All rights reserved.