Case Reports in Critical Care http://www.hindawi.com The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Mechanical Ventilation Weaning in Inclusion Body Myositis: Feasibility of Isokinetic Inspiratory Muscle Training as an Adjunct Therapy Thu, 24 Jul 2014 09:04:42 +0000 http://www.hindawi.com/journals/cricc/2014/902541/ Inclusion body myositis is a rare myopathy associated with a high rate of respiratory complications. This condition usually requires prolonged mechanical ventilation and prolonged intensive care stay. The unsuccessful weaning is mainly related to respiratory muscle weakness that does not promptly respond to immunosuppressive therapy. We are reporting a case of a patient in whom the use of an inspiratory muscle-training program which started after a two-week period of mechanical ventilation was associated with a successful weaning in one week and hospital discharge after 2 subsequent weeks. Leonardo Cordeiro de Souza, Josué Felipe Campos, Leandro Possidente Daher, Priscila Furtado da Silva, Alex Ventura, Pollyana Zamborlini do Prado, Daniele Brasil, Debora Mendonça, and Jocemir Ronaldo Lugon Copyright © 2014 Leonardo Cordeiro de Souza et al. All rights reserved. Acute Respiratory Distress Syndrome in Lemierre’s Syndrome Sun, 20 Jul 2014 06:34:19 +0000 http://www.hindawi.com/journals/cricc/2014/712946/ Lemierre’s syndrome is an infectious disease defined by the presence of septic thrombophlebitis with associated embolic phenomenon, most commonly to the lungs. Here we present two cases from a single institution of acute respiratory distress syndrome (ARDS) developing as a result of Lemierre’s syndrome in previously healthy young adult men. ARDS can occur as a consequence of pulmonary septic emboli and sepsis, both of which are well-described consequences of Lemierre’s syndrome. We describe important diagnostic and management considerations in the care of patients with hypoxemic respiratory failure and Lemierre’s syndrome. Essential components of management include prompt antibiotic therapy, lung-protective ventilation strategies, and supportive care. Paul N. Hein, Maida V. Soghikian, and Munveer S. Bhangoo Copyright © 2014 Paul N. Hein et al. All rights reserved. Failure of Ketamine Anesthesia in a Patient with Lamotrigine Overdose Wed, 09 Jul 2014 08:45:37 +0000 http://www.hindawi.com/journals/cricc/2014/916360/ Introduction. It is important to know which clinical situations prevent ketamine from working. Case Report. We present the case of the psychiatric inpatient who was admitted to our emergency department after ingesting a toxic dose of lamotrigine, unknown at that time. On admission, she was clearly in distress, displaying extreme agitation and violent ataxic movements. We opted to achieve sedation using intravenous ketamine boluses. Unexpectedly, after being injected with a total of 250 mg ketamine, our patient displayed no signs of dissociative anaesthesia. Discussion. There was no apparent reason for why ketamine failed, but an interaction between lamotrigine and ketamine was suspected. A literature search was performed. Very few articles describe interactions between lamotrigine and ketamine. Experimental studies, however, demonstrate how lamotrigine attenuates the neuropsychiatric effects of ketamine. Ketamine is classically described as an NMDA antagonist. Ketamine’s dissociative effects, however, are thought to be mediated by increased glutamate release via a pathway not dependent on NMDA receptors. Lamotrigine, on the other hand, is known to reduce cortical glutamate release. Conclusion. Lamotrigine reduces the glutamate release needed to mediate ketamine’s dissociative anaesthesia. This is important knowledge for anaesthesiologists in the emergency room where ketamine is often administered to unstable patients. Daniel Kornhall and Erik Waage Nielsen Copyright © 2014 Daniel Kornhall and Erik Waage Nielsen. All rights reserved. Myocardial Rupture following Carbon Monoxide Poisoning Wed, 09 Jul 2014 00:00:00 +0000 http://www.hindawi.com/journals/cricc/2014/281701/ We present the first case of severe cardiotoxicity of carbon monoxide leading to myocardial rupture and fatal outcome. 83-year-old woman was hospitalized 4 hours after the fire in her house with no respiratory or cardiac symptoms. After two days, she has suffered sudden collapse leading to cardiac arrest. Postmortem examination revealed intramural haemorrhage with myocardial rupture at the apex of the left ventricle. Minimal stenosis was noted in the proximal coronary arteries with no evidence of distal occlusion or any other long-standing heart disease. This case supports recommendations for targeted cardiovascular investigations in cases of CO poisoning. Gabija Dragelytė, Jūris Plenta, Sigitas Chmieliauskas, Algimantas Jasulaitis, Romas Raudys, Tomas Jovaiša, and Robertas Badaras Copyright © 2014 Gabija Dragelytė et al. All rights reserved. Zinc Phosphide Poisoning Mon, 30 Jun 2014 11:35:41 +0000 http://www.hindawi.com/journals/cricc/2014/589712/ Zinc phosphide has been used widely as a rodenticide. Upon ingestion, it gets converted to phosphine gas in the body, which is subsequently absorbed into the bloodstream through the stomach and the intestines and gets captured by the liver and the lungs. Phosphine gas produces various metabolic and nonmetabolic toxic effects. Clinical symptoms are circulatory collapse, hypotension, shock symptoms, myocarditis, pericarditis, acute pulmonary edema, and congestive heart failure. In this case presentation, we aim to present the intensive care process and treatment resistance of a patient who ingested zinc phosphide for suicide purposes. Erdal Doğan, Abdulmenap Güzel, Taner Çiftçi, İlker Aycan, Feyzi Çelik, Bedri Çetin, and Gönül Ölmez Kavak Copyright © 2014 Erdal Doğan et al. All rights reserved. Clinical and Imaging Resolution of Neonatal Hemochromatosis following Treatment Tue, 24 Jun 2014 09:13:37 +0000 http://www.hindawi.com/journals/cricc/2014/650916/ Neonatal hemochromatosis (NH) is an acute liver disease associated with both hepatic and extrahepatic iron deposition and is a leading cause of neonatal liver transplantation. The concept that NH is an alloimmune disease has led to the emergence of a new treatment approach utilizing exchange transfusion and intravenous immunoglobulin therapy. We present a two-day old neonate with progressive liver dysfunction who was diagnosed with NH. Magnetic resonance imaging confirmed tissue iron overload. Treatment with intravenous immunoglobulins and exchange transfusion led to rapid improvement in liver function. Follow-up physical examination at the age of 8 months showed normal development and near normal liver function. A repeat abdominal magnetic resonance scan at 8 months showed no signs of iron deposition in the liver, pancreas, or adrenal glands. The present report provides further support for the use of exchange transfusion and immunoglobulin therapy in NH and is the first to document resolution of typical iron deposition by magnetic resonance imaging. Ayelet Machtei, Gil Klinger, Rivka Shapiro, Osnat Konen, and Lea Sirota Copyright © 2014 Ayelet Machtei et al. All rights reserved. Opiate Withdrawal Complicated by Tetany and Cardiac Arrest Sun, 15 Jun 2014 09:26:10 +0000 http://www.hindawi.com/journals/cricc/2014/295401/ Patients with symptoms of opiate withdrawal, after the administration of opiate antagonist by paramedics, are a common presentation in the emergency department of hospitals. Though most of opiate withdrawal symptoms are benign, rarely they can become life threatening. This case highlights how a benign opiate withdrawal symptom of hyperventilation led to severe respiratory alkalosis that degenerated into tetany and cardiac arrest. Though this patient was successfully resuscitated, it is imperative that severe withdrawal symptoms are timely identified and immediate steps are taken to prevent catastrophes. An easier way to reverse the severe opiate withdrawal symptom would be with either low dose methadone or partial opiate agonists like buprenorphine. However, if severe acid-base disorder is identified, it would be safer to electively intubate these patients for better control of their respiratory and acid-base status. Irfanali R. Kugasia and Nehad Shabarek Copyright © 2014 Irfanali R. Kugasia and Nehad Shabarek. All rights reserved. Pulmonary Arterial Hypertension Secondary to Ethanol Sclerotherapy for Renal Artery Embolization Sun, 15 Jun 2014 00:00:00 +0000 http://www.hindawi.com/journals/cricc/2014/452452/ Pulmonary arterial hypertension (PAH) has been reported as a major complication to consider and promptly manage in the use of ethanol sclerotherapy. Most of the available data on the development of PAH is derived from the use of ethanol for embolization of arteriovenous malformation, but it has been rarely reported in its other fields of application. We describe a case of outpatient renal artery embolization using ethanol, in which respiratory failure develops secondary to PAH despite adhering to safe practice protocols. We highlight the importance of pulmonary arterial pressure monitoring and the treatment steps to follow in order to avoid irreversible fatal outcomes. Raya Saba, James Davis, Arvind Balavenkataraman, Aibek E. Mirrakhimov, Aram Barbaryan, Shyam Chalise, and Nkemakolam Iroegbu Copyright © 2014 Raya Saba et al. All rights reserved. Starvation Ketoacidosis: A Cause of Severe Anion Gap Metabolic Acidosis in Pregnancy Tue, 20 May 2014 12:41:38 +0000 http://www.hindawi.com/journals/cricc/2014/906283/ Pregnancy is a diabetogenic state characterized by relative insulin resistance, enhanced lipolysis, elevated free fatty acids and increased ketogenesis. In this setting, short period of starvation can precipitate ketoacidosis. This sequence of events is recognized as “accelerated starvation.” Metabolic acidosis during pregnancy may have adverse impact on fetal neural development including impaired intelligence and fetal demise. Short periods of starvation during pregnancy may present as severe anion gap metabolic acidosis (AGMA). We present a 41-year-old female in her 32nd week of pregnancy, admitted with severe AGMA with pH 7.16, anion gap 31, and bicarbonate of 5 mg/dL with normal lactate levels. She was intubated and accepted to medical intensive care unit. Urine and serum acetone were positive. Evaluation for all causes of AGMA was negative. The diagnosis of starvation ketoacidosis was established in absence of other causes of AGMA. Intravenous fluids, dextrose, thiamine, and folic acid were administered with resolution of acidosis, early extubation, and subsequent normal delivery of a healthy baby at full term. Rapid reversal of acidosis and favorable outcome are achieved with early administration of dextrose containing fluids. Nupur Sinha, Sindhaghatta Venkatram, and Gilda Diaz-Fuentes Copyright © 2014 Nupur Sinha et al. All rights reserved. The Abdomen in “Thoracoabdominal” Cannot Be Ignored: Abdominal Compartment Syndrome Complicating Extracorporeal Life Support Thu, 08 May 2014 14:38:46 +0000 http://www.hindawi.com/journals/cricc/2014/351340/ Extracorporeal life support (ECLS) is an incredible life-saving measure that is being used ever more frequently in the care of the critically ill. Management of these patients requires extreme vigilance on the part of the care providers in recognizing and addressing the complications and challenges that may arise. We present a case of overt abdominal compartment syndrome (ACS) in a previously well young male on ECLS with a history of trauma, submersion, hypothermia, and no intra-abdominal injuries. The patient developed ACS soon after ECLS was initiated which resulted in drastically compromised flow rates. Taking into account the patient’s critical status, an emergent laparotomy was performed in the intensive care unit which successfully resolved the ACS and restored ECLS flow. The patient had an unremarkable course following and was weaned off ECLS but unfortunately died from his original anoxic injury. This case highlights several salient points: first, care of patients on ECLS is challenging and multiple etiologies can affect our ability to manage these patients; second, intra-abdominal pressures should be monitored liberally in the critically ill, especially in patients on ECLS; third, protocols for emergent operative treatment outside of traditional operating rooms should be established and care providers should be prepared for these situations. Arthur J. Lee, Bryan J. Wells, Rosaleen Chun, Chad G. Ball, and Andrew. W. Kirkpatrick Copyright © 2014 Arthur J. Lee et al. All rights reserved. Left Main Coronary Artery Compression following Melody Pulmonary Valve Implantation: Use of Impella Support as Rescue Therapy and Perioperative Challenges with ECMO Tue, 18 Mar 2014 08:31:39 +0000 http://www.hindawi.com/journals/cricc/2014/959704/ The purpose of this case is to describe the complex perioperative management of a 30-year-old woman with congenital heart disease and multiple resternotomies presenting with pulmonary homograft dysfunction and evaluation for percutaneous pulmonary valve replacement. Transvenous, transcatheter Melody valve placement caused left main coronary artery occlusion and cardiogenic shock. An Impella ventricular assist device (VAD) provided rescue therapy during operating room transport for valve removal and pulmonary homograft replacement. ECMO support was required following surgery. Several days later during an attempted ECMO wean, her hemodynamics deteriorated abruptly. Transesophageal and epicardial echocardiography identified pulmonary graft obstruction, requiring homograft revision due to large thrombosis. This case illustrates a role for Impella VAD as bridge to definitive procedure after left coronary occlusion and describes management of complex perioperative ECMO support challenges. Erica D. Wittwer, Juan N. Pulido, Shane M. Gillespie, Frank Cetta Jr., and Joseph A. Dearani Copyright © 2014 Erica D. Wittwer et al. All rights reserved. Extreme Procalcitonin Elevation without Proven Bacterial Infection Related to Amphetamine Abuse Tue, 11 Mar 2014 13:11:37 +0000 http://www.hindawi.com/journals/cricc/2014/179313/ Systemic inflammatory response with rhabdomyolysis and consequent multiorgan failure is a known sequela of psychotropic drug abuse. However, in cases with uncertain past medical history the initial diagnosis can be challenging. Here we report the case of a 21-year-old male who was admitted to the intensive care unit with severe neurological impairment caused by amphetamine intoxication. First laboratory investigations revealed extremely high serum procalcitonin (PCT) levels reaching a maximum concentration of 1640 ng/mL on the second day of observation. Although PCT has high sensitivity and specificity in differentiating bacterial sepsis from nonbacterial inflammation, our case report shows for the first time that it can be extremely elevated following serious amphetamine intoxication without bacterial infection. András Lovas, Zsuzsanna Ágoston, Klára Késmárky, Péter Hankovszky, and Zsolt Molnár Copyright © 2014 András Lovas et al. All rights reserved. Black Coloured Urine following Organophosphorus Poisoning: Report of Two Cases Tue, 04 Mar 2014 13:42:25 +0000 http://www.hindawi.com/journals/cricc/2014/706021/ Organophosphorus poisoning is common in rural Asia. Clinical features result from overactivity of acetylcholine receptors. Blackish discoloration of urine is not a feature of organophosphorus poisoning. Only one case of black colored urine following quinalphos poisoning has been reported in literature. We report two cases of organophosphorus poisoning from two different compounds, following which patients passed black colored urine, in the absence of haemolysis or rhabdomyolysis. These cases indicate that blackish discoloration of urine in organophosphorus poisoning might not be as uncommon as it was believed to be. Besides, urinary excretion of metabolites might be an underlying mechanism, rather than hemolysis. Aneesh Basheer, Sudhagar Mookkappan, Vijay Shanmugham, Nagarajan Natarajan, and Kiran Kulirankal Copyright © 2014 Aneesh Basheer et al. All rights reserved. An Elusive Bullet in the Gastrointestinal Tract: A Rare Case of Bullet Embolism in the Gastrointestinal Tract and a Review of Relevant Literature Tue, 28 Jan 2014 07:52:29 +0000 http://www.hindawi.com/journals/cricc/2014/689539/ Bullet embolism within the gastrointestinal system is extremely rare. Such bullet injuries are infrequently covered in the general literature, but the surgeon should be aware of the phenomenon. Smaller caliber bullets are more common in civilian gunshot wound (GSW) events. These bullets are able to tumble through the gastrointestinal tract and cause perforation of the intestinal lumen which is small enough to be easily missed. Bullets retained in the abdominal cavity should not be dismissed as fixed and should be carefully monitored to ensure that they do not embolize within the bowel and cause occult lesions during their migration. We present a unique case wherein a bullet caused a minute perforation in the small bowel, before migrating to the distal colon, which resulted in late presentation of sepsis secondary to peritonitis. Saptarshi Biswas, Catherine Price, and Sunil Abrol Copyright © 2014 Saptarshi Biswas et al. All rights reserved. The Use of Hemodialysis in Refractory Hypercalcemia Secondary to Parathyroid Carcinoma Tue, 21 Jan 2014 07:45:53 +0000 http://www.hindawi.com/journals/cricc/2014/140906/ Parathyroid carcinoma is a rare cause of hypercalcemia. Hypercalcemic crisis is a medical emergency. Hemodialysis is rarely needed to treat hypercalcaemia. We report a case of refractory hypercalcaemia secondary to parathyroid carcinoma requiring haemodialysis. Huai Heng Loh and Nurain Mohd Noor Copyright © 2014 Huai Heng Loh and Nurain Mohd Noor. All rights reserved. Buried Bumper Syndrome Revisited: A Rare but Potentially Fatal Complication of PEG Tube Placement Thu, 16 Jan 2014 09:12:43 +0000 http://www.hindawi.com/journals/cricc/2014/634953/ Percutaneous endoscopic gastrostomy (PEG) has been used for providing enteral access to patients who require long-term enteral nutrition for years. Although generally considered safe, PEG tube placement can be associated with many immediate and delayed complications. Buried bumper syndrome (BBS) is one of the uncommon and late complications of percutaneous endoscopic gastrostomy (PEG) placement. It occurs when the internal bumper of the PEG tube erodes into the gastric wall and lodges itself between the gastric wall and skin. This can lead to a variety of additional complications such as wound infection, peritonitis, and necrotizing fasciitis. We present here a case of buried bumper syndrome which caused extensive necrosis of the anterior abdominal wall. Saptarshi Biswas, Sujana Dontukurthy, Mathew G. Rosenzweig, Ravi Kothuru, and Sunil Abrol Copyright © 2014 Saptarshi Biswas et al. All rights reserved. Pulmonary Edema in Myasthenic Crisis Thu, 26 Dec 2013 13:34:25 +0000 http://www.hindawi.com/journals/cricc/2013/863620/ We report a previously asymptomatic 50-year-old lady who came with myasthenic crisis as initial presentation of myasthenia gravis. She developed pulmonary edema following intravenous immunoglobulin administration and had ischemic changes in ECG and left ventricular dysfunction on echocardiography. She improved with diuretics, dobutamine, and fluid restriction alone. This is the first report in English-language medical literature describing the association between myasthenic crisis and likely takotsubo cardiomyopathy-related pulmonary edema following intravenous immunoglobulin administration. Uttara Swati Anand, Stalin Viswanathan, and Jayanthi Arulneyam Copyright © 2013 Uttara Swati Anand et al. All rights reserved. Air Embolism after Central Venous Catheter Removal: Fibrin Sheath as the Portal of Persistent Air Entry Mon, 07 Oct 2013 14:12:23 +0000 http://www.hindawi.com/journals/cricc/2013/403243/ Central venous catheterization is of common practice in intensive care units; despite representing an essential device in various clinical circumstances, it represents a source of complications, sometimes even fatal, related to its management. We report the removal of a central venous catheter (CVC) that had been wrongly positioned through left internal jugular vein. The vein presented complete thrombosis at vascular ultrasonography. An echocardiogram performed 24 hours after CVC removal showed the presence, apparently unjustified, of microbubbles in right chambers of the heart. A neck-thorax CT scan showed the presence of air bubbles within the left internal jugular vein, left innominate vein, and left subclavian vein. A vascular ultrasonography, focused on venous catheter insertion site, disclosed the presence of a vein-to-dermis fistula, as portal of air entry. Only after air occlusive dressing, we documented echographic disappearance of air bubbles within the right cardiac cavity. This report emphasizes possible air entry even many hours after CVC removal, making it mandatory to perform 24–72-hour air occlusive dressing or, when inadequate, to perform a purse string. Meggiolaro Marco, Erik Roman-Pognuz, Baritussio Anna, and Scatto Alessio Copyright © 2013 Meggiolaro Marco et al. All rights reserved. Reversible Right-Sided Heart Failure Secondary to Carcinoid Crisis Tue, 01 Oct 2013 14:29:57 +0000 http://www.hindawi.com/journals/cricc/2013/487801/ Carcinoid crisis is an infrequent and little-described complication of neuroendocrine tumors that can be life threatening. It may develop during induction of anesthesia, intraoperatively, during tumor manipulation and arterial embolization, or even spontaneously. The massive release of neuroendocrine substances can lead to potentially fatal complications. Somatostatin analogs inhibit the release of these substances and are the mainstay of treatment. The following case report describes a patient with reversible acute right-sided heart failure posterior to hepatic artery embolization. Mariana Soto Herrera, José A. Restrepo, Jesús H. Díaz, Andrés Ramos, Andrés Felipe Buitrago, and Mabel Gómez Mejía Copyright © 2013 Mariana Soto Herrera et al. All rights reserved. Extracorporeal Life Support in a Severe Blunt Chest Trauma with Cardiac Rupture Mon, 30 Sep 2013 15:07:30 +0000 http://www.hindawi.com/journals/cricc/2013/136542/ This report presents a case of severe blunt chest trauma secondary to a horse riding accident with resultant free-wall rupture of the left ventricle in association with severe lung contusion. We describe the initial surgical and medical management of the cardiac rupture which was associated with a massive haemoptysis due to severe lung trauma. Extra corporeal membrane oxygenation (ECMO) support was initiated and allowed both the acute heart and lung failure to recover. We discuss the successful use and pitfalls of ECMO techniques which are sparsely described in such severe combined cardiac and thoracic trauma. Launey Yoann, Flecher Erwan, Nesseler Nicolas, Malledant Yannick, and Seguin Philippe Copyright © 2013 Launey Yoann et al. All rights reserved. Volkman’s Contracture, Persistent Limb Ischaemia, and Amputation: A Complication of Brachial Artery Catheterisation for Haemodynamic Monitoring Using PiCCO Thu, 26 Sep 2013 17:06:07 +0000 http://www.hindawi.com/journals/cricc/2013/474358/ We report a case of a 64-year-old woman who was admitted to intensive care unit with multiorgan failure secondary to Plasmodium falciparum malaria. Haemodynamic monitoring using the transpulmonary thermodilution with pulse contour analysis system (PiCCO) was achieved via the left brachial artery. Two days later, a flexion deformity of the left hand was noted, and examination revealed left lower arm ischaemia. Removal of the catheter resulted in an immediate improvement of the contracture. However, distal pulses were still absent, and the arm remained ischaemic resulting in a below elbow amputation. This is the first documented case of a persistent limb ischaemia following the insertion of an arterial catheter for haemodynamic monitoring with PiCCO. We therefore highlight the need for regular assessment of limb perfusion after arterial catheterisation for haemodynamic monitoring with PiCCO. In addition, the brachial artery should be avoided, and femoral artery catheterisation is recommended. Veejay Bagga, Marion Palmer, Ramesh Sadasivan, and Govindan Raghuraman Copyright © 2013 Veejay Bagga et al. All rights reserved. Traumatic Mitral Valve and Pericardial Injury Tue, 10 Sep 2013 15:49:20 +0000 http://www.hindawi.com/journals/cricc/2013/385670/ Cardiac injury after blunt trauma is common but underreported. Common cardiac trauma after the blunt chest injury (BCI) is cardiac contusion; it is very rare to have cardiac valve injury. The mitral valve injury during chest trauma occurs when extreme pressure is applied at early systole during the isovolumic contraction between the closure of the mitral valve and the opening of the aortic valve. Traumatic mitral valve injury can involve valve leaflet, chordae tendineae, or papillary muscles. For the diagnosis of mitral valve injury, a high index of suspicion is required, as in polytrauma patients, other obvious severe injuries will divert the attention of the treating physician. Clinical picture of patients with mitral valve injury may vary from none to cardiogenic shock. The echocardiogram is the main diagnostic modality of mitral valve injuries. Patient’s clinical condition will dictate the timing and type of surgery or medical therapy. We report a case of mitral valve and pericardial injury in a polytrauma patient, successfully treated in our intensive care unit. Nissar Shaikh, Firdous Ummunissa, and Mohamed Abdel Sattar Copyright © 2013 Nissar Shaikh et al. All rights reserved. Very Late Bare Metal Stent Thrombosis Wed, 21 Aug 2013 09:51:25 +0000 http://www.hindawi.com/journals/cricc/2013/856095/ Very late stent thrombosis is a rare and not-well-understood complication after bare metal stent implantation. It usually presents as an ST elevation acute coronary syndrome and it is associated with high rates of morbidity and mortality. Pathophysiologic mechanisms are not well defined; nevertheless, recent studies have proposed a neoatherosclerotic process as the triggering mechanism. We present the case of a patient with bare metal very late stent thrombosis 12 years after implantation. Mariana Soto Herrera, José A. Restrepo, Andrés Felipe Buitrago, Mabel Gómez Mejía, and Jesús H. Díaz Copyright © 2013 Mariana Soto Herrera et al. All rights reserved. Shigella Bacteremia in a Patient with Visceral Leishmaniasis Mon, 19 Aug 2013 10:04:34 +0000 http://www.hindawi.com/journals/cricc/2013/920729/ Bacteremia due to Shigella is rare. A 26-year-old HIV-negative male presented with a persistent high-grade fever of two months duration to the Leishmaniasis Research and Treatment Center of University of Gondar Hospital. He was anorexic and had lost significant weight (from 76 to 57 kg in 4 months, BMI = 17.2 kg/m2). He also complained of headache, chills, and rigor. In the last one year, he was experiencing a few episodes of acute bloody diarrhea, the last episode being two months ago. Microscopy from splenic aspiration showed Leishman-Donovan bodies with parasite load of +3. The blood culture showed Shigella species, but the stool was culture negative. The isolate was sensitive to most tested antibiotic discs, sulfamethoxazole, ceftriaxone, gentamicin, tetracycline, and norfloxacilin, except ampicillin. Therefore, requesting blood culture for identifying unexpected type of organisms causing infections in patients with underlying diseases like visceral leishmaniasis should be encouraged. Mengistu Endris, Rezika Mohammed, Yegnasew Takele, Desalegn Woldeyohannes, Moges Tiruneh, and Ermias Diro Copyright © 2013 Mengistu Endris et al. All rights reserved. Ketamine Infusion Associated with Improved Neurology in a Patient with NMDA Receptor Encephalitis Mon, 19 Aug 2013 09:52:35 +0000 http://www.hindawi.com/journals/cricc/2013/383125/ A young lady was ventilated on intensive care for a prolonged period with NMDA receptor encephalitis. She had undergone steroid, immunoglobulin, and plasmapheresis with no evidence of recovery. Her main management issue was the control of severe orofacial and limb dyskinesia. Large doses of sedating agents had been used to control the dystonia but were ineffective, unless she was fully anaesthetised. The introduction of a ketamine infusion was associated with a dramatic improvement in her symptoms such that it was possible to remove her tracheostomy two days after commencement. She was discharged shortly after that and is making a good recovery. The successful use of ketamine has not previously been described in this context, and we hope this case report will provide some insight into the management of this rare but serious condition. Michael MacMahon, Morag R. Naysmith, Stephanie McCallion, and Jonathan Rhodes Copyright © 2013 Michael MacMahon et al. All rights reserved. The Rendu-Osler-Weber Disease Revealed by a Refractory Hypoxemia and Severe Cerebral Fat Embolism Thu, 01 Aug 2013 08:20:28 +0000 http://www.hindawi.com/journals/cricc/2013/434965/ The Rendu-Osler-Weber disease is a genetic disease which may lead to severe hemorrhage and less frequently to severe organ dysfunction. We report the case of a 22-year-old patient with no personal medical history who was involved in a motorcycle accident and exhibited severe complications related to large arteriovenous pulmonary shunts during his ICU stay. The patient developed an unexplained severe hypoxemia which was attributed to several arteriovenous shunts of the pulmonary vasculature by a contrast study during a transesophageal echocardiographic examination. The course was subsequently complicated by a prolonged coma associated with hemiplegia which was attributed to a massive paradoxical fat embolism in the setting of an untreated femoral fracture. In addition to hemorrhagic complications which may lead to intractable shock, arteriovenous malformations associated with the Rendu-Osler-Weber disease may involve the pulmonary vasculature and result in unexpected complications, such as hypoxemia or severe cerebral fat embolism in high-risk patients. Leonel Barreto, Jean-Bernard Amiel, Anthony Dugard, Nicolas Pichon, Marc Clavel, Bruno François, and Philippe Vignon Copyright © 2013 Leonel Barreto et al. All rights reserved. Urine Biochemistry in the Early Postoperative Period after Cardiac Surgery: Role in Acute Kidney Injury Monitoring Sun, 28 Jul 2013 13:27:51 +0000 http://www.hindawi.com/journals/cricc/2013/103450/ We have recently suggested that sequential urine electrolyte measurement in critically ill patients may be useful in monitoring kidney function. Cardiac surgery is one of the leading causes of acute kidney injury (AKI) in the intensive care unit (ICU). In this paper, we describe the sequential behavior of urine electrolytes in three patients in the early (first 60 hours) postoperative period after cardiac surgery according to AKI status: no AKI, transient AKI, and persistent AKI. We have found that the patient with no AKI had stable and high concentrations of sodium (NaU) and chloride (ClU) in sequential spot samples of urine. AKI development was characterized in the other two patients by decreases in NaU and ClU, which have started early after ICU admission. Transient AKI was marked by also transient and less severe decreases in NaU and ClU. Persistent AKI was marked by the less favorable clinical course with abrupt and prolonged declines in NaU and ClU values. These electrolytes in urine had a behavior like a “mirror image” in comparison with that of serum creatinine. We suggest that sequential urine electrolytes are useful in monitoring acute kidney injury development in the early postoperative period after cardiac surgery. Alexandre Toledo Maciel and Daniel Vitório Copyright © 2013 Alexandre Toledo Maciel and Daniel Vitório. All rights reserved. Ibuprofen-Induced Hypokalemia and Distal Renal Tubular Acidosis: A Patient’s Perceptions of Over-the-Counter Medications and Their Adverse Effects Thu, 25 Jul 2013 11:41:26 +0000 http://www.hindawi.com/journals/cricc/2013/875857/ We highlight a case of distal renal tubular acidosis secondary to ibuprofen and codeine use. Of particular interest in this case are the patient’s perception of over-the-counter (OTC) medication use, her own OTC use prior to admission, and her knowledge of adverse reactions or side effects of these medications prior to taking them. Mark D. Salter Copyright © 2013 Mark D. Salter. All rights reserved. Traumatic Page Kidney Induced Hypertension in Critical Care: Immediately Resolved or Long-Term Resistant Problem Wed, 17 Jul 2013 11:03:57 +0000 http://www.hindawi.com/journals/cricc/2013/201424/ Page kidney is a well-known phenomenon causing hypertension, due to compression of renal parenchyma by a subcapsular hematoma, of either traumatic or non-traumatic origin. The main therapeutic approach is based on surgical approach (nephrectomy or hematoma evacuation) and antihypertensive treatment. In this paper we present a post-traumatic case of Page Kidney in a Critical Care unit. We discuss different therapeutical opportunities to extremely elevated systemic blood pressure resistant to traditional drug therapy. E. Brotfain, L. Koyfman, A. Frenkel, A. Smolikov, A. Zlotnik, and M. Klein Copyright © 2013 E. Brotfain et al. All rights reserved. Prone Position Ventilation Used during a Transfer as a Bridge to Ecmo Therapy in Hantavirus-Induced Severe Cardiopulmonary Syndrome Mon, 15 Jul 2013 13:29:57 +0000 http://www.hindawi.com/journals/cricc/2013/415851/ Background. Transport of critically ill patients is a complex issue. We present a case using prone positioning as a bridge to extracorporeal membrane oxygenation (ECMO), performed by a critical retrieval team from a university hospital. Case Report. A 28-year-old male developed fever, progressive respiratory failure, and shock. He was admitted to ICU from a public hospital, and mechanical ventilation was begun, but clinical response was not adequate. ECMO was deemed necessary due to severe respiratory failure and severe shock. A critical retrieval team of our center was assembled to attempt transfer. Prone positioning was employed to stabilize and transfer the patient, after risk-benefit assessment. Once in our hospital, ECMO was useful to resolve shock and pulmonary edema secondary to Hantavirus cardiopulmonary syndrome. Finally, he was discharged with normal functioning. Conclusion. This case exemplifies the relevance of a retrieval team and bridge therapy. Prone positioning improves oxygenation and is safe to perform as transport if performed by a trained team as in this case. Preparation and organization is necessary to improve outcomes, using teams and organized networks. Catastrophic respiratory failure and shock should not be contraindications to transferring patients, but it must be done with an experienced team. R. Cornejo, D. Ugalde, O. Llanos, P. Bisbal, L. De la Barrera, C. Romero, R. Neira, Roberto González, and J. Gajardo Copyright © 2013 R. Cornejo et al. All rights reserved.