Case Reports in Critical Care http://www.hindawi.com The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Pancreaticopericardial Fistula: A Case Report and Literature Review Sun, 17 Apr 2016 12:38:21 +0000 http://www.hindawi.com/journals/cricc/2016/7169341/ Purpose. Pancreaticopericardial fistula (PPF) is an extremely rare complication of acute or chronic pancreatitis. This paper presents a rare case of PPF and provides systematic review of existing cases from 1970 to 2014. Methods. A PubMed search using key words was performed for all the cases of PPF from January 1970 to December 2014. Fourteen cases were included in the study. The cases were reviewed for demographic characteristics, diagnostic modalities, and treatment. Descriptive analysis of these variables was performed. Results. Median age was 43 years. 78% were known alcoholics and 73.3% had chronic pancreatitis. Dyspnea was present in 78%. Cardiac tamponade was present in 53%; 75% of patients had known chronic pancreatitis (RR = 0.74). Surgery was associated with best treatment outcomes and 50% of patients who underwent endoscopic treatment survived. Conclusion. PPF is a rare disease. This paper indicates that acute cardiac tamponade in patients with history of alcoholism and chronic pancreatitis could be a sign of an existing pancreaticopericardial fistula and early surgical intervention could be life-saving. Muhammad S. Khan, Najmi Shahbaz, Hassaan A. Zia, Muhammad Hamza, Henna Iqbal, and Ahmed Awab Copyright © 2016 Muhammad S. Khan et al. All rights reserved. Fatal Nonhepatic Hyperammonemia in ICU Setting: A Rare but Serious Complication following Bariatric Surgery Sun, 10 Apr 2016 09:28:37 +0000 http://www.hindawi.com/journals/cricc/2016/8531591/ Bariatric surgery is well established in reducing weight and improving the obesity-associated morbidity and mortality. Hyperammonemic encephalopathy following bariatric surgery is rare but highly fatal if not diagnosed in time and managed aggressively. Both macro- and micronutrients deficiencies play a role. A 42-year-old Hispanic female with a history of Roux-en-Y Gastric Bypass Procedure was brought to ED for progressive altered mental status. Physical exam was remarkable for drowsiness with Glasgow Coma Scale 11, ascites, and bilateral pedal edema. Labs showed elevated ammonia, low hemoglobin, low serum prealbumin, albumin, HDL, and positive toxicology. She remained obtunded despite the treatment with Narcan and flumazenil and the serum ammonia level fluctuated despite standard treatment with lactulose and rifaximin. Laboratory investigations helped to elucidate the etiology of the hyperammonemia most likely secondary to unmasking the functional deficiency of the urea cycle enzymes. Hyperammonemia in the context of normal liver function tests becomes diagnostically challenging for physicians. Severe hyperammonemia is highly fatal. Early diagnosis and aggressive treatment can alter the prognosis favorably. Gyanendra Acharya, Sunil Mehra, Ronakkumar Patel, Simona Frunza-Stefan, and Harmanjot Kaur Copyright © 2016 Gyanendra Acharya et al. All rights reserved. Severe Sepsis Associated with Lemierre’s Syndrome: A Rare but Life-Threatening Disease Tue, 05 Apr 2016 13:42:45 +0000 http://www.hindawi.com/journals/cricc/2016/1264283/ Background. The incidence of Lemierre’s syndrome has increased in the past decade. This posttonsillitis complication may be life threatening. Case Presentation. A 19-year-old patient was admitted to Surgical Intensive Care Unit of a French University Hospital for high fever, low blood pressure, and haemoptysis following a sore throat episode. Blood analysis revealed a thrombopenia, an acute renal failure, and an elevated lactate serum. Fusobacterium necrophorum was found in blood cultures. Computed tomography of the neck and lungs confirmed the diagnosis of Lemierre’s syndrome: pleural effusions, bilateral lung infiltrates, and an internal jugular vein thrombosis. Fluid administration and antibiotic treatment were quickly initiated. Patient left the unit four days after his admission without any organ dysfunction. Conclusion. Lemierre’s syndrome may lead to multiorgan dysfunction and should be rapidly identified. Audrey Tawa, Raphaëlle Larmet, Yannick Malledant, and Philippe Seguin Copyright © 2016 Audrey Tawa et al. All rights reserved. Severe Ketoacidosis Associated with Canagliflozin (Invokana): A Safety Concern Mon, 21 Mar 2016 14:26:33 +0000 http://www.hindawi.com/journals/cricc/2016/1656182/ Canagliflozin (Invokana) is a selective sodium glucose cotransporter-2 (SGLT-2) inhibitor that was first introduced in 2013 for the treatment of type 2 diabetes mellitus (DM). Though not FDA approved yet, its use in type 1 DM has been justified by the fact that its mechanism of action is independent of insulin secretion or action. However, some serious side effects, including severe anion gap metabolic acidosis and euglycemic diabetic ketoacidosis (DKA), have been reported. Prompt identification of the causal association and initiation of appropriate therapy should be instituted for this life threatening condition. Alehegn Gelaye, Abdallah Haidar, Christina Kassab, Syed Kazmi, and Prabhat Sinha Copyright © 2016 Alehegn Gelaye et al. All rights reserved. Retracted: Clinical Brain Death with False Positive Radionuclide Cerebral Perfusion Scans Tue, 15 Mar 2016 13:32:50 +0000 http://www.hindawi.com/journals/cricc/2016/2057806/ Case Reports in Critical Care Copyright © 2016 Case Reports in Critical Care. All rights reserved. Acute Warfarin Toxicity as Initial Manifestation of Metastatic Liver Disease Wed, 02 Mar 2016 07:09:15 +0000 http://www.hindawi.com/journals/cricc/2016/7389087/ Near complete infiltration of the liver secondary to metastasis from the head and neck cancer is a rare occurrence. The prognosis of liver failure associated with malignant infiltration is extremely poor; the survival time of patients is extremely low. We present a case of acute warfarin toxicity as initial manifestation of metastatic liver disease. Our patient is a 64-year-old woman presenting with epigastric pain and discomfort, found to have unrecordable International Normalized Ratio. She rapidly deteriorated with acute respiratory failure requiring mechanical ventilation, profound shock requiring high dose vasopressor infusion, severe coagulopathy, worsening liver enzymes with worsening of lactic acidosis and severe metabolic abnormalities, and refractory to aggressive supportive care and died in less than 48 hours. Autopsy revealed that >90% of the liver was replaced by tumor masses. Varalaxmi Bhavani Nannaka, Nihar Jani, Masooma Niazi, and Dmitry Lvovsky Copyright © 2016 Varalaxmi Bhavani Nannaka et al. All rights reserved. Adrenergic Inhibition with Dexmedetomidine to Treat Stress Cardiomyopathy during Alcohol Withdrawal: A Case Report and Literature Review Wed, 24 Feb 2016 10:00:24 +0000 http://www.hindawi.com/journals/cricc/2016/9693653/ Stress (Takotsubo) cardiomyopathy is a form of reversible left ventricular dysfunction with a heightened risk of ventricular arrhythmia thought to be caused by high circulating catecholamines. We report a case of stress cardiomyopathy that developed during severe alcohol withdrawal successfully treated with dexmedetomidine. The case involves a 53-year-old man with a significant history of alcohol abuse who presented to a teaching hospital with new-onset seizures. His symptoms of acute alcohol withdrawal were initially treated with benzodiazepines, but the patient later developed hypotension, and stress cardiomyopathy was suspected based on ECG and echocardiographic findings. Adjunctive treatment with the alpha-2-adrenergic agonist, dexmedetomidine, was initiated to curtail excessive sympathetic outflow of the withdrawal syndrome, thereby targeting the presumed pathophysiology of the cardiomyopathy. Significant clinical improvement was observed within one day of initiation of dexmedetomidine. These findings are consistent with other reports suggesting that sympathetic dysregulation during alcohol withdrawal produces ideal pathobiology for stress cardiomyopathy and leads to ventricular arrhythmogenicity. Stress cardiomyopathy should be recognized as a complication of alcohol withdrawal that significantly increases cardiac-related mortality. By helping to correct autonomic dysregulation of the withdrawal syndrome, dexmedetomidine may be useful in the treatment of stress-induced cardiomyopathy. Zachary M. Harris, Alvaro Alonso, and Thomas P. Kennedy Copyright © 2016 Zachary M. Harris et al. All rights reserved. Early Recognition of Foreign Body Aspiration as the Cause of Cardiac Arrest Tue, 23 Feb 2016 13:05:03 +0000 http://www.hindawi.com/journals/cricc/2016/1329234/ Foreign body aspiration (FBA) is uncommon in the adult population but can be a life-threatening condition. Clinical manifestations vary according to the degree of airway obstruction, and, in some cases, making the correct diagnosis requires a high level of clinical suspicion combined with a detailed history and exam. Sudden cardiac arrest after FBA may occur secondary to asphyxiation. We present a 48-year-old male with no history of cardiac disease brought to the emergency department after an out-of-hospital cardiac arrest (OHCA). The patient was resuscitated after 15 minutes of cardiac arrest. He was initially managed with therapeutic hypothermia (TH). Subsequent history suggested FBA as a possible etiology of the cardiac arrest, and fiberoptic bronchoscopy demonstrated a piece of meat and bone lodged in the left main stem bronchus. The foreign body was removed with the bronchoscope and the patient clinically improved with full neurological recovery. Therapeutic hypothermia following cardiac arrest due to asphyxia has been reported to have high mortality and poor neurological outcomes. This case highlights the importance of early identification of FBA causing cardiac arrest, and we report a positive neurological outcome for postresuscitation therapeutic hypothermia following cardiac arrest due to asphyxia. Muhammad Kashif, Hafiz Rizwan Talib Hashmi, and Misbahuddin Khaja Copyright © 2016 Muhammad Kashif et al. All rights reserved. A Rare but Reversible Cause of Hematemesis: “Downhill” Esophageal Varices Thu, 18 Feb 2016 12:46:49 +0000 http://www.hindawi.com/journals/cricc/2016/2370109/ “Downhill” varices are a rare cause of acute upper gastrointestinal bleeding and are generally due to obstruction of the superior vena cava (SVC). Often these cases of “downhill” varices are missed diagnoses as portal hypertension but fail to improve with medical treatment to reduce portal pressure. We report a similar case where recurrent variceal bleeding was initially diagnosed as portal hypertension but later found to have SVC thrombosis presenting with recurrent hematemesis. A 39-year-old female with history of end-stage renal disease presented with recurrent hematemesis. Esophagogastroduodenoscopy (EGD) revealed multiple varices. Banding and sclerotherapy were performed. Extensive evaluation did not show overt portal hypertension or cirrhosis. Due to ongoing bleeding requiring resuscitation, she underwent internal jugular (IJ) and SVC venogram in preparation for transjugular intrahepatic portosystemic shunt (TIPS), which demonstrated complete IJ and SVC occlusion. She underwent balloon angioplasty with stent placement across SVC occlusion with complete resolution of her varices and resolved hematemesis. “Downhill” varices are extremely rare, though previously well described. Frequently, patients are misdiagnosed with underlying liver disease. High index of suspicion and investigation of alternative causes of varices is prudent in those without underlying liver diseases. Prompt diagnosis and appropriate intervention can significantly improve morbidity and mortality. Lam-Phuong Nguyen, Narin Sriratanaviriyakul, and Christian Sandrock Copyright © 2016 Lam-Phuong Nguyen et al. All rights reserved. Wernicke’s Encephalopathy Complicating Hyperemesis during Pregnancy Tue, 16 Feb 2016 16:35:09 +0000 http://www.hindawi.com/journals/cricc/2016/8783932/ Wernicke’s encephalopathy is caused by severe thiamine deficiency; it is mostly observed in alcoholic patients. We report the case of a 28-year-old woman, at 17 weeks of gestational age, with severe hyperemesis gravidarum. She presented with disturbance of consciousness, nystagmus, ophthalmoplegia, and ataxia. The resonance magnetic imagery showed bilaterally symmetrical hyperintensities of thalamus and periaqueductal area. The case was managed with very large doses of thiamine. The diagnosis of Wernicke’s encephalopathy was confirmed later by a low thiamine serum level. The patient was discharged home on day 46 with mild ataxia and persistent nystagmus. Wernicke’s encephalopathy is a rare complication of hyperemesis gravidarum. It should be diagnosed as early as possible to prevent long-term neurological sequela or death. Thiamine supplementation in pregnant women with prolonged vomiting should be initiated, especially before parenteral dextrose infusion. Early thiamine replacement will reduce maternal morbidity and fetal loss rate. Mohamed Adnane Berdai, Smael Labib, and Mustapha Harandou Copyright © 2016 Mohamed Adnane Berdai et al. All rights reserved. Spurious Hyperchloremia and Negative Anion Gap in a Child with Refractory Epilepsy Thu, 11 Feb 2016 11:18:23 +0000 http://www.hindawi.com/journals/cricc/2016/7015463/ 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 http://www.hindawi.com/journals/cricc/2016/4708086/ 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 http://www.hindawi.com/journals/cricc/2016/9453286/ 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 http://www.hindawi.com/journals/cricc/2016/7078180/ 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 http://www.hindawi.com/journals/cricc/2016/8506357/ 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 http://www.hindawi.com/journals/cricc/2016/9852073/ 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 http://www.hindawi.com/journals/cricc/2015/542490/ 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 http://www.hindawi.com/journals/cricc/2015/624718/ 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 http://www.hindawi.com/journals/cricc/2015/265326/ 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 http://www.hindawi.com/journals/cricc/2015/908157/ 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 http://www.hindawi.com/journals/cricc/2015/953826/ 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 http://www.hindawi.com/journals/cricc/2015/362506/ 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 http://www.hindawi.com/journals/cricc/2015/143832/ 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 http://www.hindawi.com/journals/cricc/2015/509094/ 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 http://www.hindawi.com/journals/cricc/2015/793015/ 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 http://www.hindawi.com/journals/cricc/2015/164597/ 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 http://www.hindawi.com/journals/cricc/2015/690742/ 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 http://www.hindawi.com/journals/cricc/2015/513617/ 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 http://www.hindawi.com/journals/cricc/2015/536931/ 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 http://www.hindawi.com/journals/cricc/2015/295735/ 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.