COVID-19-Induced Fatal Thrombotic Thrombocytopenic Purpura in a Healthy Young Patient: A Case ReportRead the full article
Case Reports in Critical Care publishes case reports and case series in all areas of critical care medicine, including anesthesiology, perioperative and critical care medicine, and postoperative critical care management and recovery.
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Peripartum Cardiomyopathy-Induced Cardiogenic Shock Causing Hypoxic-Ischemic Encephalopathy in a COVID-19 Patient
Background. Cardiogenic shock complicating peripartum cardiomyopathy (PPCM) is a rare but lethal syndrome. The etiology of PPCM is not fully elucidated and is probably multifactorial, and viral infection might play some role. It has been documented that the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) directly invades the cardiomyocytes and most commonly damages this vital organ via complex systemic devastating mechanisms. Case presentation. A 28-year-old pregnant female was admitted to a COVID-19 field hospital due to a SARS-CoV-2 infection. She gave birth by spontaneous vaginal delivery at 34 gestational weeks. Six hours after the delivery, she presented signs of hemodynamic collapse and became comatosed, requiring a transfer to the COVID-19 intensive care center. The brain magnetic resonance imaging excluded thromboembolism, intracerebral hemorrhage, and central nervous system infection and revealed a hypoxic-ischemic encephalopathy. Bedside echocardiography documented a dilated left ventricle and severely reduced left ventricular systolic function with an ejection fraction of 24%. The management was aimed at a cardiogenic shock secondary to peripartum cardiomyopathy. The clinical course was favorable: the hemodynamics stabilized, the cognitive function fully recovered, and the patient was extubated on the second day of admission to the intensive care unit. The patient was discharged from the hospital ten days after admission. Neurological and cardiovascular checkups six months after discharge showed full recovery. Conclusion. Peripartum cardiomyopathy-induced cardiogenic shock with severe neurological consequences in COVID-19 patients was rare but did exist. A systemic approach and vigorous efforts to pinpoint the accurate diagnosis played important roles in the prompt and appropriate management.
Unique Complications of MIS-C and Its Treatment: Encephalopathy in a Child with MIS-C Who Developed Life-Threatening Gastrointestinal Hemorrhage
In this case report, we describe a previously healthy eleven-year-old male diagnosed with multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease 2019. The patient presented with shock and neurologic symptoms including altered mental status and dysarthria. Brain magnetic resonance imaging, obtained to rule out thromboembolic injury, demonstrated cytotoxic edema of the corpus callosum, an imaging finding similar in nature to several previous reports of MRI abnormalities in children with MIS-C. Following administration of intravenous immunoglobulin and pulse-dose steroids, the patient convalesced and was discharged home. Medications prescribed upon discharge included a steroid taper, daily aspirin, and proton pump inhibitor. Four days later, he was readmitted with shock and life-threatening gastrointestinal (GI) hemorrhage. After extensive evaluation of potential bleeding sources, angiography revealed active bleeding from two arterial vessels supplying the duodenum. The patient demonstrated no further signs of bleeding following successful coil embolization of the two vessels. We hypothesize that the vasculitic nature of MIS-C combined with anti-inflammatory and antithrombotic therapy placed him at risk of GI hemorrhage. This case highlights unique radiologic features of MIS-C as well as potential complications of treatment.
Hopeful News for Physicians Who Involved in the Treatment of Critical Aluminum Phosphide (Rice Pill) Poisoning Patients
Introduction. Aluminum phosphide (rice tablet) was first introduced as a pesticide in India. Rice tablets are commonly used in Iran due to their high efficacy against rodents and insects, low cost, and availability. Aluminum phosphide is a lethal poison without antidote and causes cardiocirculatory collapse and has negative inotropic cardiac effect. Human and animal studies showed that high dose insulin had positive cardiac inotropic effects. GIK (glucose, insulin, and potassium) assists heart uptake of carbohydrates that are the major fuel substrate of the myocard muscle under stressed conditions and leading to correction of acidosis, increased myocardial contractility, and peripheral vascular resistance. Case Presentation. In this manuscript, a young woman with aluminum phosphide poisoning was described to have presented with hypotension, hypoxemia, and severe metabolic acidosis. In contrast to our previous experiences that approximately all rice tablet poisoning patients with shock were dead despite full conservative treatment, this patient miraculously was saved with high dose intravenous regular insulin infusion and was discharged from the hospital with good condition and without any complications. Conclusion. Rice tablet poisoning has high fatality rate, and to date, no antidote is available. GIK is suggested as a potential life saving treatment for critical rice tablet poisoning patients with symptoms and signs of shock.
Use of Point-of-Care Ultrasound for Early Identification of Acute Aortic Root Dissection
Point-of-care ultrasound (POCUS) is becoming a frequently utilized imaging tool in the emergency department (ED) as it can aid in early diagnosis of many pathologies. This is a case report of a 55-year-old male who presented to the emergency department by ambulance for sudden onset chest pain followed by a syncopal episode. Point-of-care echocardiogram revealed a large pericardial effusion with a significantly dilated aortic root, concerning for aortic dissection. Patient was emergently taken for a computed tomography (CT) scan, which was only remarkable for an ascending thoracic aortic aneurysm but failed to show an aortic dissection flap. On repeat POCUS, a dissection intimal flap, large pericardial effusion with tamponade physiology, and aortic regurgitation were identified and later confirmed on transesophageal echocardiogram. This case report details a rare pathology that was correctly identified on initial POCUS before it was seen on CT scan.
Symmetrical Peripheral Gangrene: Report of Three Cases
Symmetrical peripheral gangrene (SPG) is a rare clinical syndrome characterized by an acute onset of ischemic damage in two or more extremities without obstruction or vasculitis of supplying vessels. Body parts commonly affected include toes, hands, scrotum, and earlobes, increasing the risk of limb amputation and impairing the quality of life. The vascular injury mechanism is disseminated intravascular coagulation. SPG may manifest unpredictably in conditions associated with septic shock, low output states, vasospastic conditions, myeloproliferative disorders, or hyperviscosity syndrome. A review on the topic is presented based on a 3-case series of SPG that required amputation of fingers and toes after the administration of vasopressors in a septic shock context.
Severe Bradycardia Leading to Hemodynamic Instability Associated with Remdesivir Use in a Patient with COVID-19 Pneumonia
Remdesivir (RDV) is an approved treatment for hospitalized patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. There is limited literature on the cardiac adverse effects of RDV. We report a case of a patient who developed hemodynamically unstable bradycardia after the initiation of RDV that resolved after discontinuing RDV.