Case Reports in Critical Care The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . 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. Liver Trauma in the Kitchen: Preparing Whipped Cream with a Siphon Is Not without Risk Sun, 07 Jun 2015 08:19:09 +0000 We report the case of a 36-year-old woman suffering from liver injury caused by the malfunction of a whipped cream siphon. When this patient handled the whipped cream siphon, the screwed metallic upper part of the siphon was suddenly dissociated from its base and came violently striking her right hypochondrium. At first, the severity of injury was underestimated. Subsequently, due to the persistence of pain experienced by the patient, an abdominal CT scan was performed. It highlighted a severe liver injury with rupture of a branch of the hepatic artery. The evolution was favorable after completion of an embolization and a secondary capsular rupture. Jeremy Bourenne, Béatrice Eon, Fouad Bouzana, Dominique Lambert, Estelle Jean, Pierre Michelet, and Marc Gainnier Copyright © 2015 Jeremy Bourenne et al. All rights reserved. Diagnostic Challenge in a Patient with Severe Anion Gap Metabolic Acidosis Sun, 31 May 2015 14:05:27 +0000 The approach to the patient with acute renal failure and elevated anion and osmolal gap is difficult. Differential diagnoses include toxic alcohol ingestion, diabetic or starvation ketoacidosis, or 5-oxoproline acidosis. We present a 76-year-old female with type 2 diabetes mellitus, who was found at home in a confused state. Laboratory analysis revealed serum pH 6.84, bicarbonate 5.8 mmol/L, pCO2 29 mmHg, anion gap 22.2 mmol/L, osmolal gap 17.4 mOsm/kg, elevated beta-hydroxybutyrate (4.2 mmol/L), random blood sugar 213 mg/dL, creatinine 2.1 mg/dL, and potassium 7.5 mmol/L with no electrocardiogram (EKG) changes. Fomepizole and hemodialysis were initiated for presumed ethylene glycol or methanol ingestion. Drug screens returned negative for ethylene glycol, alcohols, and acetaminophen, but there were elevated urine levels of acetone (11 mg/dL). The acetaminophen level was negative, and 5-oxoproline was not analyzed. After 5 days in the intensive care unit (ICU), her mental status improved with supportive care. She was discharged to a nursing facility. Though a diagnosis was not established, our patient’s presentation was likely due to starvation ketosis combined with chronic acetaminophen ingestion. Acetone ingestion is less likely. Overall, our case illustrates the importance of systematically approaching an elevated osmolal and anion gap metabolic acidosis. Eugene M. Tan, Ejaaz Kalimullah, M. Rizwan Sohail, and Kannan Ramar Copyright © 2015 Eugene M. Tan et al. All rights reserved. Pulmonary Hemorrhage Secondary to Disseminated Strongyloidiasis in a Patient with Systemic Lupus Erythematosus Tue, 26 May 2015 10:11:19 +0000 Introduction. Pulmonary hemorrhage secondary to disseminated strongyloidiasis is an unusual, well-recognized entity in immunocompromised patients with autoimmune disease, which is associated with the hyperinfection syndrome, sepsis, and a high mortality rate. Case Presentation. We present a case of a 44-year-old Mexican woman with systemic lupus erythematosus and acute bacterial meningitis who developed pulmonary hemorrhage with acute respiratory failure requiring mechanical ventilation, treated with broad spectrum systemic antibiotics and high dose methylprednisolone, who subsequently developed a characteristic purpuric skin eruption and septic shock and died two days later of refractory hypoxemia caused by massive pulmonary bleeding. The postmortem examination reports filariform larvae of S. stercolaris in lung, skin, and other organs. Conclusion. This case highlights the importance of considering disseminated strongyloidiasis in the differential diagnosis of diffuse alveolar hemorrhage in systemic lupus erythematosus, and screening for S. stercolaris infection before initiation of immunosuppressive therapy should be considered, especially in endemic areas. Disseminated strongyloidiasis has a high mortality rate, explained in part by absence of clinical suspicion. Erika P. Plata-Menchaca, V. M. De la Puente-Diaz de Leon, Adriana G. Peña-Romero, and Eduardo Rivero-Sigarroa Copyright © 2015 Erika P. Plata-Menchaca et al. All rights reserved. Gas-Forming Pyogenic Liver Abscess with Septic Shock Sun, 24 May 2015 14:23:12 +0000 The pyogenic liver abscess caused by Clostridium perfringens (C. perfringens) is a rare but rapidly fatal infection. The main virulence factor of this pathogen is its α-toxin (lecithinase), which decomposes the phospholipid in cell membranes leading to cell lysis. Once the bacteria are in blood stream, massive intravascular hemolysis occurs. This can present as anemia on admission with evidence of hemolysis as indicated by low serum haptoglobin, high serum lactate dehydrogenase (LDH), elevated indirect bilirubin, and spherocytosis. The clinical course of C. perfringens septicemia is marked by rapidly deteriorating course with a mortality rate ranging from 70 to 100%. The very rapid clinical course makes it difficult to diagnose on time, and most cases are diagnosed at autopsy. Therefore it is important to consider C. perfringens infection in any severely ill patient with fever and evidence of hemolysis. We present a case of seventy-seven-year-old male with septic shock secondary to pyogenic liver abscess with a brief review of existing literature on C. perfringens. Muhammad S. Khan, Muhammad K. Ishaq, and Kellie R. Jones Copyright © 2015 Muhammad S. Khan et al. All rights reserved. Anaphylactoid Reaction from IV Contrast Dye Causing Ischemic Colitis with Portal Venous Gas Thu, 23 Apr 2015 06:51:56 +0000 Portal venous gas is a radiographic finding with numerous causes. The most common etiologies include bowel ischemia or other intra-abdominal catastrophes. The finding of portal venous gas carries a high mortality rate. We report the first case of portal venous gas associated with anaphylactoid reaction to intravenous contrast dye in a middle-aged woman. This was likely secondary to anaphylactoid-induced ischemic colitis. This patient was managed conservatively and had a good outcome. Adeleke Adesina, Adam Colombo, and Rebecca Jeanmonod Copyright © 2015 Adeleke Adesina et al. All rights reserved. Always Consider the Possibility of Opioid Induced Respiratory Depression in Patients Presenting with Hypercapnic Respiratory Failure Who Fail to Improve as Expected with Appropriate Therapy Sun, 29 Mar 2015 12:31:25 +0000 Hypercapnic respiratory failure is a frequently encountered medical emergency. Two common causes are acute exacerbations of chronic obstructive pulmonary disease (COPD) and as a side effect of opioids. The two causes may coexist leading to diagnostic confusion and consequent delay in optimal management. We report a case of what was initially thought to be an exacerbation of COPD. The patient failed to improve with treatment as expected which led to the empirical administration of naloxone resulting in a dramatic reversal of her respiratory failure. The patient was subsequently discovered to be taking regular dihydrocodeine for chronic back pain. Martin Steynor and Andrew MacDuff Copyright © 2015 Martin Steynor and Andrew MacDuff. All rights reserved. Recurrent Febrile Neutropenia and Thrombocytopenia in a Chronic Cocaine User: A Case of Levamisole Induced Complications Sun, 22 Mar 2015 10:43:36 +0000 Cocaine is used by approximately 1.5 million Americans each month and up to 69% of the cocaine seized contains levamisole. The real incidence of cocaine-levamisole induced neutropenia is unclear but probably underestimated. Associated complications include fever, thrombocytopenia, skin-vasculitis disorders, and rarely kidney injury. We present a young male, with chronic active cocaine use presenting with recurrent episodes of febrile neutropenia and thrombocytopenia. He underwent extensive work-up and was treated with many antibiotics and we suspect that his neutropenia and thrombocytopenia were caused by recurrent cocaine-levamisole use. Eduardo Martinez, Raza Alvi, Sindhaghatta Venkatram, and Gilda Diaz-Fuentes Copyright © 2015 Eduardo Martinez et al. All rights reserved. Nitric Oxide-Sensitive Pulmonary Hypertension in Congenital Rubella Syndrome Mon, 16 Feb 2015 13:02:43 +0000 Persistent pulmonary hypertension is a very rare presentation of congenital virus infection. We discuss the case of complete congenital rubella syndrome presenting at echocardiography with pulmonary hypertension that worsened after ductus ligation. Cardiac catheterization showed a normal pulmonary valve and vascular tree but a  mmHg. The infant promptly responded to inhaled nitric oxide while on mechanical ventilation and was later shifted to oral sildenafil. It is not clear whether our observation may be due to direct viral damage to the endothelium or to the rubella virus increasing the vascular tone via a metabolic derangement. Francesco Raimondi, Fiorella Migliaro, Elisa Di Pietro, Francesco Borgia, Antonio Rapacciuolo, and Letizia Capasso Copyright © 2015 Francesco Raimondi et al. All rights reserved. Staphylococcal Toxic Shock Syndrome Caused by Tampon Use Mon, 26 Jan 2015 07:37:14 +0000 The authors report a case of near-fatal sepsis with multiorgan failure resulting from a Staphylococcal tampon-associated toxic shock syndrome, requiring a lengthy critical care admission. Successful treatment of this condition focuses on early identification, source control, and administration of antimicrobial agents. Intravenous immunoglobulin therapy used early may prevent widespread tissue necrosis. Cian McDermott and Michael Sheridan Copyright © 2015 Cian McDermott and Michael Sheridan. All rights reserved.