Case Reports in Critical Care The latest articles from Hindawi © 2017 , Hindawi Limited . All rights reserved. Venovenous Extracorporeal Membrane Oxygenation as a Treatment for Obesity Hypoventilation Syndrome Thu, 23 Feb 2017 08:18:27 +0000 The mortality rate for respiratory failure resulting from obesity hypoventilation syndrome is high if it requires ventilator management. We describe a case of severe acute respiratory failure resulting from obesity hypoventilation syndrome (BMI, 60.2 kg/m2) successfully treated with venovenous extracorporeal membrane oxygenation (VV-ECMO). During ECMO management, a mucus plug was removed by bronchoscopy daily and 18 L of water was removed using diuretics, resulting in weight loss of 24 kg. The patient was weaned from ECMO on day 5, extubated on day 16, and discharged on day 21. The fundamental treatment for obesity hypoventilation syndrome in morbidly obese patients is weight loss. VV-ECMO can be used for respiratory support until weight loss has been achieved. Nao Umei and Shingo Ichiba Copyright © 2017 Nao Umei and Shingo Ichiba. All rights reserved. Spinal Cord Infarction in the Course of a Septic Shock: About One Case and Review of the Literature Mon, 20 Feb 2017 00:00:00 +0000 We report the case of a patient admitted to our intensive care unit in the course of a septic shock, secondary to cholangitis. After rapid hemodynamic stabilization, antibiotherapy, and endoscopic extraction of bile ducts stones, she appeared to have developed flaccid paraplegia. The suspected diagnosis of medullar ischemia was confirmed by typical MRI findings. This case stresses the potential pathogenic role of hypotension in medullar ischemia and the place of magnetic resonance imaging (MRI) as a reliable diagnostic tool. P. Henin, A. Molderez, V. Huberlant, and H. Trine Copyright © 2017 P. Henin et al. All rights reserved. Primitive Tumour of the Pulmonary Valve: Discussion of the Differential Diagnosis Sun, 19 Feb 2017 00:00:00 +0000 There is a paucity of information concerning cardiac tumours of the pulmonary valve due to their rarity at this location. We report a case of a 47-year-old patient suffering from haemoptysis, asthenia, and acute kidney injury (AKI). A transthoracic echocardiography (TTE) revealed a mass on the pulmonary valve. Further diagnostic investigation was completed until he exhibited worsening hemodynamic instability. This case emphasizes the lack of information regarding the management of a pulmonary valve tumour. A. Hannecart, D. Ndjekembo-Shango, F. Vallot, O. Simonet, and M. De Kock Copyright © 2017 A. Hannecart et al. All rights reserved. Malignant Catatonia Warrants Early Psychiatric-Critical Care Collaborative Management: Two Cases and Literature Review Mon, 30 Jan 2017 00:00:00 +0000 Malignant catatonia (MC) is a life-threatening manifestation which can occur in the setting of an underlying neuropsychiatric syndrome or general medical illness and shares clinical and pathophysiological features and medical comorbidities with the Neuroleptic Malignant Syndrome (NMS). The subsequent diagnosis and definitive therapy of MC are typically delayed, which increases morbidity and mortality. We present two cases of MC and review recent literature of MC and NMS, illustrating factors which delay diagnosis and management. When clinical features suggest MC or NMS, we propose early critical care consultation and stabilization with collaborative psychiatric management. Julia Park, Josh Tan, Sylvia Krzeminski, Maryam Hazeghazam, Meghana Bandlamuri, and Richard W. Carlson Copyright © 2017 Julia Park et al. All rights reserved. Recurrence of Postoperative Stress-Induced Cardiomyopathy Resulting from Status Epilepticus Sun, 22 Jan 2017 13:55:13 +0000 Introduction. Classically, stress-induced cardiomyopathy (SIC), also known as takotsubo cardiomyopathy, displays the pathognomonic feature of reversible left ventricular apical ballooning without coronary artery stenosis following stressful event(s). Temporary reduction in ejection fraction (EF) resolves spontaneously. Variants of SIC exhibiting mid-ventricular regional wall motion abnormalities have been identified. Recent case series present SIC as a finding in association with sudden unexplained death in epilepsy (SUDEP). This case presents a patient who develops recurrence of nonapical cardiomyopathy secondary to status epilepticus. Case Report. Involving a postoperative, postmenopausal woman having two distinct episodes of status epilepticus (SE) preceding two incidents of SIC. Preoperative transthoracic echocardiogram (TTE) confirms the patient’s baseline EF of 60% prior to the second event. Postoperatively, SE occurs, and the initial electrocardiogram exhibits T-wave inversions with subsequent elevation of troponin I. Postoperative TTE shows an EF of 30% with mid-ventricular wall akinesia restoring baseline EF rapidly. Conclusion. This case identifies the need to understand SIC and its diagnostic criteria, especially when cardiac catheterization is neither indicated nor available. Sudden cardiac death should be considered as a possible complication of refractory status epilepticus. The pathophysiology in SUDEP is currently unknown; yet a correlation between SUDEP and SIC is hypothesized to exist. Grant A. Miller, Yousef M. Ahmed, and Nicki S. Tarant Copyright © 2017 Grant A. Miller et al. All rights reserved. A Narrowing Diagnosis: A Rare Cause of Adult Croup and Literature Review Tue, 10 Jan 2017 12:55:21 +0000 Croup or laryngotracheitis is rare in adults. We present a case of an otherwise healthy young woman that presented in the winter with 3 days of increasing dyspnea, cough, and fever. She was hemodynamically stable but was found to have a barking cough, paradoxical abdominal breathing, and stridor. Chest radiograph revealed subglottic narrowing. Respiratory viral nucleic acid amplification testing was positive for respiratory syncytial virus. The patient was treated with nebulized epinephrine, dexamethasone, and a helium-oxygen mixture. Stridor resolved immediately after starting the helium-oxygen mixture. Within 72 hours, the patient made a complete clinical recovery without the need for escalation of care. Prehospital discharge chest radiograph demonstrated resolution of subglottic narrowing. Jayshil J. Patel, Emily Kitchin, and Kurt Pfeifer Copyright © 2017 Jayshil J. Patel et al. All rights reserved. Hemadsorption with Adult CytoSorb® in a Low Weight Pediatric Case Tue, 03 Jan 2017 11:39:54 +0000 Cytokine adsorber (CytoSorb) has been used successfully as adjunctive treatment for adult patients with elevated cytokine levels in the setting with severe sepsis and septic shock and to reduce blood myoglobin, unconjugated bilirubin, and conjugated bilirubin. In this article we present the case of a nine-month-old male infant who was admitted to the NICU due to sepsis after cardiac surgery, Fallot tetralogy, and multisystem organ failure (MSOF) including liver failure and renal failure which was successfully treated by a combination of continuous hemodiafiltration (HDF) and hemadsorption with CytoSorb. HDF was safe and effective from the first day for urea removal, but the patient’s bilirubin levels kept increasing gradually, culminating on the 9th day with a maximum value of 54 mg/dL of total bilirubin and 31.67 mg/dL of direct bilirubin when we performed hemadsorption with CytoSorb. Over the 49-hour period of hemadsorption, the total bilirubin value decreased from 54 to 14 mg/dL, and the patient’s general status improved considerably accompanied by a rapid drop of aminotransferases. Hemodynamic status has been improved as well and inotropes dropped rapidly. The patient’s ventilation settings improved during CytoSorb treatment permitting weaning the patient from mechanical ventilation after five days of hemadsorption. The patient was discharged home after 34 days of hospitalization, in a good general status. Catalin Gabriel Cirstoveanu, Ileana Barascu, and Samantha Mc Kenzie Stancu Copyright © 2017 Catalin Gabriel Cirstoveanu et al. All rights reserved. Beriberi Induced Cardiomyopathy Requiring Salvage Venoarterial Extracorporeal Membrane Oxygenation Mon, 05 Dec 2016 12:44:29 +0000 Beriberi refers to a constellation of symptoms caused primarily by thiamine (vitamin B1) deficiency. An acute and fulminant presentation of this rare condition has been described in the literature as “Shoshin” beriberi which is characterized by catastrophic cardiovascular collapse. Early recognition and treatment lead to dramatic improvements of symptoms. We present a case of thiamine deficiency-induced acute heart failure in a malnourished patient leading to cardiac arrest necessitating VA-ECMO (venoarterial extracorporeal membrane oxygenation) with improvement in heart function secondary to thiamine administration. Aditya Shah, Samir Patel, Sorabh Kothari, and Jennifer Denk Copyright © 2016 Aditya Shah et al. All rights reserved. Bent Metal in a Bone: A Rare Complication of an Emergent Procedure or a Deficiency in Skill Set? Sun, 27 Nov 2016 08:24:02 +0000 Intraosseous (IO) access is an important consideration in patients with difficult intravenous (IV) access in emergent situations. IO access in adults has become more popular due to the ease of placement and high success rates. The most common sites of access include the proximal tibia and the humeral head. The complications associated are rare but can be catastrophic: subsequent amputation of a limb has been described in the literature. We report a 25-year-old female presenting with diabetic ketoacidosis (DKA) in whom emergent IO access was complicated by needle bending inside the humerus. Conventional bedside removal was impossible and required surgical intervention in operating room. Mridula Krishnan, Katherine Lester, Amber Johnson, Kaye Bardeloza, Peter Edemekong, and Ilya Berim Copyright © 2016 Mridula Krishnan et al. All rights reserved. Intravenous Vitamin C Administered as Adjunctive Therapy for Recurrent Acute Respiratory Distress Syndrome Mon, 07 Nov 2016 09:39:28 +0000 This case report summarizes the first use of intravenous vitamin C employed as an adjunctive interventional agent in the therapy of recurrent acute respiratory distress syndrome (ARDS). The two episodes of ARDS occurred in a young female patient with Cronkhite-Canada syndrome, a rare, sporadically occurring, noninherited disorder that is characterized by extensive gastrointestinal polyposis and malabsorption. Prior to the episodes of sepsis, the patient was receiving nutrition via chronic hyperalimentation administered through a long-standing central venous catheter. The patient became recurrently septic with Gram positive cocci which led to two instances of ARDS. This report describes the broad-based general critical care of a septic patient with acute respiratory failure that includes fluid resuscitation, broad-spectrum antibiotics, and vasopressor support. Intravenous vitamin C infused at 50 mg per kilogram body weight every 6 hours for 96 hours was incorporated as an adjunctive agent in the care of this patient. Vitamin C when used as a parenteral agent in high doses acts “pleiotropically” to attenuate proinflammatory mediator expression, to improve alveolar fluid clearance, and to act as an antioxidant. Amit Bharara, Catherine Grossman, Daniel Grinnan, Aamer Syed, Bernard Fisher, Christine DeWilde, Ramesh Natarajan, and Alpha A. (Berry) Fowler Copyright © 2016 Amit Bharara et al. All rights reserved. Diffuse Alveolar Hemorrhage Associated with Edoxaban Therapy Mon, 31 Oct 2016 14:29:29 +0000 Introduction. The main adverse effect of anticoagulant therapy is bleeding, and major bleeding, including intracranial, gastrointestinal, and retroperitoneal bleeding, has been reported as an adverse effect of edoxaban, a direct oral anticoagulant (DOAC). Bleeding during systemic anticoagulation with edoxaban presents a therapeutic conundrum, because there is currently no safe or efficacious reversal agent to stop major bleeding. Case Report. A 51-year-old woman had multiple traumatic injuries, including lower limb fractures. On day 8, she developed deep venous thrombosis, and edoxaban was administered orally. On day 38, she developed fungemia, which was treated with an antifungal drug. On day 43, she presented with dyspnea. Chest computed tomography scan showed bilateral diffuse ground-glass opacities in the whole lung fields. The results of the subsequent workup (i.e., serum levels of the antineutrophil cytoplasmic antibody, antinuclear antibody, and antiglomerular basement membrane antibody) and microbiological study were unremarkable. Based on these findings, her condition was diagnosed as diffuse alveolar hemorrhage (DAH) associated with edoxaban therapy. The lung opacities disappeared spontaneously after edoxaban therapy was discontinued. Conclusion. DAH is a dangerous complication associated with edoxaban therapy. DOACs, including edoxaban, should be prescribed with caution, especially for patients in a critical condition. Kenichi Nitta, Hiroshi Imamura, Akihiro Yashio, Satoko Kashima, and Katsunori Mochizuki Copyright © 2016 Kenichi Nitta et al. All rights reserved. An Atypical Case of Myxedema Coma with Concomitant Nonconvulsive Seizure Sun, 30 Oct 2016 12:47:25 +0000 Hypothyroidism is a prevalent condition in the general population that is treatable with appropriately dosed thyroid hormone replacement medication. Infrequently, patients will present with myxedema coma, characterized by hypothermia, hypotension, bradycardia, and altered mental status in the setting of severe hypothyroidism. Myxedema coma has also been known to manifest in a number of unusual and dangerous forms. Here, we present the case of a woman we diagnosed with an uncharacteristic expression of myxedema coma and nonconvulsive seizure complicated by a right middle cerebral artery infarct. Pratik Patel, Mikhael Bekkerman, Cristina Varallo-Rodriguez, and Rajendra Rampersaud Copyright © 2016 Pratik Patel et al. All rights reserved. A Rare Clinical Course of Seronegative Pulmonary-Renal Syndrome Thu, 27 Oct 2016 09:37:06 +0000 Purpose. Pulmonary-renal syndrome (PRS) is characterized by diffuse alveolar hemorrhage and rapidly progressive glomerulonephritis mainly due to autoimmune etiologies. Seronegative PRS is a challenging entity to the clinician, since early diagnosis may be missed leading to delayed appropriate treatment. Materials and Methods. We present the clinical course of a 77-year-old patient who was admitted under the suspected diagnosis of pneumogenic sepsis and septic renal failure with fever, dyspnea, and elevated CRP levels. The diagnosis of pulmonary-renal syndrome was initially missed because of the absence of autoantibodies in all serological findings. Results. Despite delayed initiation of immunosuppressive therapy and a prolonged period of dialysis and extracorporeal membrane oxygenation the patient recovered well and was released to a rehabilitation center with nearly normalized creatinine levels. The diagnosis of PRS was established by renal biopsy. Conclusion. This case illustrates the important differential diagnosis of seronegative pulmonary-renal syndrome in patients with pulmonary and renal impairment. M. Fröhlich-Gildhoff, W. J. Jabs, C. Berhold, M. K. Kuhlmann, U. Ketterer, S. Kische, and H. Ince Copyright © 2016 M. Fröhlich-Gildhoff et al. All rights reserved. Ethylene Glycol Poisoning: An Unusual Cause of Altered Mental Status and the Lessons Learned from Management of the Disease in the Acute Setting Tue, 25 Oct 2016 05:57:04 +0000 Ethylene glycol is found in many household products and is a common toxic ingestion. Acute ingestions present with altered sensorium and an osmolal gap. The true toxicity of ethylene glycol is mediated by its metabolites, which are responsible for the increased anion gap metabolic acidosis, renal tubular damage, and crystalluria seen later in ingestions. Early intervention is key; however, diagnosis is often delayed, especially in elderly patients presenting with altered mental status. There are several laboratory tests which can be exploited for the diagnosis, quantification of ingestion, and monitoring of treatment, including the lactate and osmolal gaps. As methods of direct measurement of ethylene glycol are often not readily available, it is important to have a high degree of suspicion based on these indirect laboratory findings. Mainstay of treatment is bicarbonate, fomepizole or ethanol, and, often, hemodialysis. A validated equation can be used to estimate necessary duration of hemodialysis, and even if direct measurements of ethylene glycol are not available, monitoring for the closure of the anion, lactate, and osmolal gaps can guide treatment. We present the case of an elderly male with altered mental status, acute kidney injury, elevated anion gap metabolic acidosis, and profound lactate and osmolal gaps. R. Singh, E. Arain, A. Buth, J. Kado, A. Soubani, and N. Imran Copyright © 2016 R. Singh et al. All rights reserved. Plasma Exchange in the Management of Catastrophic Antiphospholipid Syndrome Wed, 19 Oct 2016 13:19:34 +0000 Objective. Report of a case of catastrophic antiphospholipid syndrome (CAPS) with multiple organ involvement leading to a life-threatening condition despite early combination corticosteroid and heparin therapy. Initiation of plasma exchange led to rapid improvement of the patient’s general condition. Design. Case report. Setting. University teaching hospital medical intensive care unit. Patient. Single case: 52-year-old man hospitalized for catastrophic antiphospholipid syndrome (CAPS) with cardiac, renal, and cutaneous involvement. Despite early methylprednisolone and heparin therapy, the patient’s condition progressively deteriorated, resulting in acute renal failure, right adrenal hemorrhage, and pulmonary involvement, leading to acute respiratory distress on day 6, requiring high-flow nasal cannula oxygen therapy with FiO2 of 1.0. Interventions. Plasma exchange was started on day 6. Endpoints and Main Results. A marked improvement of the patient’s general condition was observed after initiation of plasma exchange, with successful weaning of oxygen therapy and normalization of platelet count, troponin, and serum creatinine within four days. Conclusions. This case illustrates the efficacy of plasma exchange in CAPS and the difficulty for physicians to determine the optimal timing of plasma exchange. Dimitri Titeca-Beauport, Valery Salle, Loay Kontar, Julien Maizel, and Gabriel Choukroun Copyright © 2016 Dimitri Titeca-Beauport et al. All rights reserved. Meralgia Paresthetica after Prone Positioning Ventilation in the Intensive Care Unit Mon, 26 Sep 2016 12:46:46 +0000 Meralgia paresthetica (MP) is a mononeuropathy of the lateral femoral cutaneous nerve (LFCN) caused by external compression of the nerve during its course close to the anterior superior iliac spine. We present a case of a patient with acute respiratory distress induced by Legionella pneumonia who was admitted to the intensive care unit (ICU) for mechanical ventilation. In the ICU, the patient received one session of prone position ventilation for 8.5 consecutive hours. At evaluation six months later, the patient reported persistent bilateral numbness of the anterolateral thigh, which he complained had begun right after he woke up at the ICU. He was referred for further neurological and neurophysiological examination and was diagnosed with bilateral MP, a condition never previously described as a complication to mechanical ventilation in prone position in the ICU. Christian Svendsen Juhl, Martin Ballegaard, Morten H. Bestle, and Peer Tfelt-Hansen Copyright © 2016 Christian Svendsen Juhl et al. All rights reserved. Case Report of a Fatal Antifreeze Ingestion with a Record High Level and Impressive Renal Crystal Deposition Thu, 22 Sep 2016 06:02:34 +0000 Ethylene glycol, methanol, and diethylene glycol are readily available in many household and commercially available products. While these alcohols are relatively nontoxic themselves, their acidic metabolites are toxic and can result in significant morbidity and mortality. Herein we report a lethal case of massive ethylene glycol ingestion in a suicide with a record high level (1254 mg/dL) and images of the histologic examination of the kidneys revealing impressive calcium oxalate crystal deposition. Autopsy findings also showed evidence of mild cerebral edema. Heidi L. Erickson Copyright © 2016 Heidi L. Erickson. All rights reserved. Paliperidone Inducing Concomitantly Syndrome of Inappropriate Antidiuretic Hormone, Neuroleptic Malignant Syndrome, and Rhabdomyolysis Sun, 18 Sep 2016 10:54:50 +0000 Paliperidone, an active metabolite of risperidone, is a new atypical antipsychotic agent. Syndrome of inappropriate antidiuretic hormone (SIADH), neuroleptic malignant syndrome (NMS), and rhabdomyolysis are the uncommon side effects of psychotropic drugs. We report a case of 35-year-old male with schizoaffective disorder who was admitted for acute-on-chronic exacerbation of his psychotic disorder for which intramuscular paliperidone 234 mg injection was given. Two days later, the patient developed hyponatremic seizures secondary to SIADH which was treated with hypertonic saline. On the third day, he developed high grade fever and severe muscle rigidity with raised creatine phosphokinase (CPK) and liver enzymes levels. He was treated with dantrolene 100 mg, bromocriptine 2.5 mg, and lorazepam 2 mg. Our patient required management of the three rare conditions following treatment with paliperidone. This case highlights the need for health care providers to be aware of the rare, potentially life threatening but preventable hyponatremia, NMS, and rhabdomyolysis as a possible adverse effect of paliperidone. Jaspinder Kaur, Dileep Kumar, Mostafa Alfishawy, Ricardo Lopez, and Issac Sachmechi Copyright © 2016 Jaspinder Kaur et al. All rights reserved. Reversal of a Suspected Paradoxical Reaction to Zopiclone with Flumazenil Thu, 08 Sep 2016 17:37:36 +0000 We describe the care for an elderly woman who was admitted to the intensive care unit (ICU) to receive noninvasive ventilation for acute exacerbation of chronic obstructive pulmonary disease. After administration of the sleeping pill zopiclone, a nonbenzodiazepine receptor agonist (NBRA), the patient became agitated and was confused, a possible paradoxical reaction to benzodiazepines. These symptoms were immediately resolved after treatment with flumazenil, usually used to reverse the adverse effects of benzodiazepines or NBRAs and to reverse paradoxical reactions to benzodiazepines. This case indicates that zopiclone induced behavioral changes resembling a paradoxical reaction to benzodiazepines and these symptoms may be treated with flumazenil. Zarah Jordahn, Cheme Andersen, Anne Marie Roust Aaberg, and Frank Christian Pott Copyright © 2016 Zarah Jordahn et al. All rights reserved. Acute Liver and Renal Failure: A Rare Adverse Effect Exclusive to Intravenous form of Amiodarone Thu, 08 Sep 2016 11:12:07 +0000 Amiodarone is an antiarrhythmic drug which is highly effective against a wide spectrum of ventricular tachyarrhythmias making it irreplaceable in certain group of patients. We report an unusual case of acute liver and renal failure within 24 hours of initiation of intravenous (IV) amiodarone which resolved after stopping the medication. The mechanism of acute liver and renal toxicity is not clearly known but is believed to be secondary to amiodarone induced (relative) hypotension, idiosyncratic reaction to the drug, and toxicity of the vector that carries the medication, polysorbate-80. In this case review, we discuss the hyperacute drug toxicity caused by IV amiodarone being a distinctly different entity compared to the adverse effects shown by oral amiodarone and support the suggestion that oral amiodarone can be safely administered even in patients who manifest acute hepatitis with the IV form. Robin Paudel, Prerna Dogra, Saurav Suman, Saurav Acharya, and Jyoti Matta Copyright © 2016 Robin Paudel et al. All rights reserved. Compartment Syndrome as a Result of Systemic Capillary Leak Syndrome Mon, 05 Sep 2016 13:00:00 +0000 Objective. To describe a single case of Systemic Capillary Leak Syndrome (SCLS) with a rare complication of compartment syndrome. Patient. Our patient is a 57-year-old male, referred to our hospital due to polycythemia (hemoglobin (Hgb) of 220 g/L), hypotension, acute renal failure, and bilateral calf pain. Measurements and Main Results. The patient required bilateral forearm, thigh, and calf fasciotomies during his ICU stay and continuous renal replacement therapy was instituted following onset of acute renal failure and oliguria. Ongoing hemodynamic (Norepinephrine and Milrinone infusion) and respiratory (ventilator) support in the ICU was provided until resolution of intravascular fluid extravasation. Conclusions. SCLS is an extremely rare disorder characterized by unexplained episodic capillary hyperpermeability, which causes shift of volume and protein from the intravascular space to the interstitial space. Patients present with significant hypotension, hemoconcentration, hypovolemia, and oliguria. Severe edema results from leakage of fluid and proteins into tissue. The most important part of treatment is maintaining stable hemodynamics, ruling out other causes of shock and diligent monitoring for complications. Awareness of the clinical syndrome with the rare complication of compartment syndrome may help guide investigations and diagnoses of these critically ill patients. Kwadwo Kyeremanteng, Gianni D’Egidio, Cynthia Wan, Alan Baxter, and Hans Rosenberg Copyright © 2016 Kwadwo Kyeremanteng et al. All rights reserved. Pneumothorax Causing Pneumoperitoneum: Role of Surgical Intervention Tue, 30 Aug 2016 16:33:04 +0000 The most common cause of a pneumoperitoneum is a perforation of a hollow viscus and the treatment is an exploratory laparotomy; nevertheless, not all pneumoperitoneums are due to a perforation and not all of them need surgical intervention. We hereby present a case of pneumoperitoneum due to a diaphragmatic defect, which allowed air from a pneumothorax to escape through the diaphragmatic hernia into the abdominal cavity. Fernanda Duarte, Jessica Wentling, Humayun Anjum, Joseph Varon, and Salim Surani Copyright © 2016 Fernanda Duarte et al. All rights reserved. Hemodynamic Transesophageal Echocardiography-Guided Venous-Arterial Extracorporeal Membrane Oxygenation Support in a Case of Giant Cell Myocarditis Thu, 25 Aug 2016 09:50:40 +0000 Giant cell myocarditis (GCM) is a rare and commonly fatal form of fulminant myocarditis. During the acute phase, while immunosuppressive therapy is initiated, venoarterial extracorporeal membrane oxygenation (VA-ECMO) support is commonly used as a bridge to heart transplantation or recovery. Until recently, conventional transesophageal echocardiography and transthoracic echocardiography were the tools available for hemodynamic assessment of patients on this form of mechanical circulatory support. Nevertheless, both techniques have their limitations. We present a case of a 54-year-old man diagnosed with GCM requiring VA-ECMO support that was monitored under a novel miniaturized transesophageal echocardiography (hTEE) probe recently approved for 72 hours of continuous hemodynamic monitoring. Our case highlights the value of this novel, flexible, and disposable device for hemodynamic monitoring, accurate therapy guidance, and potential VA-ECMO weaning process of patients with this form of severe myocarditis. Juan G. Ripoll, Robert A. Ratzlaff, David M. Menke, Maria C. Olave, Joseph J. Maleszewski, and José L. Díaz-Gómez Copyright © 2016 Juan G. Ripoll et al. All rights reserved. Fatal Cerebral Air Embolism: A Case Series and Literature Review Sun, 21 Aug 2016 08:42:57 +0000 Cerebral air embolism (CAE) is an infrequently reported complication of routine medical procedures. We present two cases of CAE. The first patient was a 55-year-old male presenting with vomiting and loss of consciousness one day after his hemodialysis session. Physical exam was significant for hypotension and hypoxia with no focal neurologic deficits. Computed tomography (CT) scan of head showed gas in cerebral venous circulation. The patient did not undergo any procedures prior to presentation, and his last hemodialysis session was uneventful. Retrograde rise of venous air to the cerebral circulation was the likely mechanism for venous CAE. The second patient was a 46-year-old female presenting with fever, shortness of breath, and hematemesis. She was febrile, tachypneic, and tachycardic and required intubation and mechanical ventilation. An orogastric tube inserted drained 2500 mL of bright red blood. Flexible laryngoscopy and esophagogastroduodenoscopy were performed. She also underwent central venous catheter placement. CT scan of head performed the next day due to absent brain stem reflexes revealed intravascular air within cerebral arteries. A transthoracic echocardiogram with bubble study ruled out patent foramen ovale. The patient had a paradoxical CAE in the absence of a patent foramen ovale. Rashmi Mishra, Pavithra Reddy, and Misbahuddin Khaja Copyright © 2016 Rashmi Mishra et al. All rights reserved. Guide Wire Induced Cardiac Tamponade: The Soft J Tip Is Not So Benign Thu, 11 Aug 2016 10:54:43 +0000 Central venous catheter (CVC) insertion rarely causes cardiac tamponade due to perforation. Although it is a rare complication, it can be lethal if not identified early. We report a case of cardiac tamponade caused by internal jugular (IJ) central venous catheter (CVC) insertion using a soft J-tipped guide wire which is considered safe and rarely implicated with cardiac tamponade. A bedside transthoracic echocardiogram (TTE) revealed a pericardial effusion with tamponade. An emergent bedside pericardiocentesis was done revealing bloody fluid and resulted in clinical stabilization. Sankalp Dwivedi, Fayez Siddiqui, Milan Patel, and Shaun Cardozo Copyright © 2016 Sankalp Dwivedi et al. All rights reserved. Euglycemic Diabetic Ketoacidosis in a Patient with Cocaine Intoxication Mon, 08 Aug 2016 11:35:13 +0000 Diabetic ketoacidosis (DKA) is characterized by elevated anion gap metabolic acidosis, hyperglycemia, and elevated ketones in urine and blood. Hyperglycemia is a key component of DKA; however, a subset of DKA patients can present with near-normal blood glucose, an entity described as “euglycemic DKA.” This rare phenomenon is thought to be due to starvation and food restriction in insulin dependent diabetic patients. Cocaine abuse is considered a trigger for development of DKA. Cocaine also has anorexic effects. We describe an interesting case of euglycemic DKA in a middle-aged diabetic female presenting with elevated anion gap metabolic acidosis, with near-normal blood glucose, in the settings of noncompliance to insulin and cocaine abuse. We have postulated that cocaine abuse was implicated in the pathophysiology of euglycemic DKA in this case. This case highlights complex physiological interplay between type-1 diabetes, noncompliance to insulin, and cocaine abuse leading to DKA, with starvation physiology causing development of euglycemic DKA. Asma Abu-Abed Abdin, Muhammad Hamza, Muhammad S. Khan, and Awab Ahmed Copyright © 2016 Asma Abu-Abed Abdin et al. All rights reserved. Pentobarbital-Induced Myocardial Stunning in Status Epilepticus Requiring Extracorporeal Membrane Oxygenation: A Case Report and Literature Review Tue, 26 Jul 2016 13:38:43 +0000 Introduction. Mild hypotension is a well-recognized complication of intravenous pentobarbital; however fulminant cardiopulmonary failure has not been previously reported. Case Report. A 28-year-old woman developed pentobarbital-induced cardiopulmonary failure that was successfully treated with maximal medical management including arteriovenous extracorporeal membrane oxygenation. She made an excellent cardiopulmonary and neurological recovery. Discussion and Conclusion. Pentobarbital is underrecognized as a potential cause of myocardial stunning. The mechanism involves direct myocardial depression and inhibition of autonomic neuroanatomical structures including the medulla and hypothalamus. Early recognition and implementation of aggressive cardiopulmonary support are essential to optimize the likelihood of a favorable outcome. Tapan Kavi, Donna Molaie, Michael Nurok, Axel Rosengart, and Shouri Lahiri Copyright © 2016 Tapan Kavi et al. All rights reserved. A Rare Case of Persistent Lactic Acidosis in the ICU: Glycogenic Hepatopathy and Mauriac Syndrome Mon, 25 Jul 2016 09:59:22 +0000 Mauriac syndrome is a rare disorder that can present with the single feature of glycogenic hepatopathy in children and adults with poorly controlled diabetes mellitus. An often underrecognized finding of glycogenic hepatopathy is lactic acidosis and hyperlactatemia. Primary treatment of glycogenic hepatopathy is improved long-term blood glucose control. Resolution of symptoms and hepatomegaly will occur with improvement in hemoglobin A1C. We present here a case of a young adult female presenting to the intensive care unit with Mauriac syndrome. This case demonstrates exacerbation of lactic acidosis in a patient with glycogenic hepatopathy treated for diabetic ketoacidosis with high dose insulin and dextrose. Kirsten S. Deemer and George F. Alvarez Copyright © 2016 Kirsten S. Deemer and George F. Alvarez. All rights reserved. Iatrogenic Transient Complete Heart Block in a Preexisting LBBB Tue, 12 Jul 2016 12:04:42 +0000 Catheter induced cardiac arrhythmia is a well-known complication encountered during pulmonary artery or cardiac catheterization. Injury to the cardiac conducting system often involves the right bundle branch which in a patient with preexisting left bundle branch block can lead to fatal arrhythmia including asystole. Such a complication during central venous cannulation is rare as it usually does not enter the heart. The guide wire or the cannula itself can cause such an injury during central venous cannulation. The length of the guide wire, its rigidity, and lack of set guidelines for its insertion make it theoretically more prone to cause such an injury. We report a case of LBBB that went into transient complete heart block following guide wire insertion during a central venous cannulation procedure. Adil S. Wani, Adebayo Fasanya, Prachi Kalamkar, Christopher A. Bonnet, and Omer A. Bajwa Copyright © 2016 Adil S. Wani et al. All rights reserved. A Curious Case of Acute Respiratory Failure: Is It Antisynthetase Syndrome? Tue, 28 Jun 2016 15:27:22 +0000 Antisynthetase (AS) syndrome is a major subgroup of inflammatory myopathies seen in a minority of patients with dermatomyositis and polymyositis. Although it is usually associated with elevated creatine phosphokinase level, some patients may have amyopathic dermatomyositis (ADM) like presentation with predominant skin involvement. Interstitial lung disease (ILD) is the main pulmonary manifestation and may be severe thereby determining the prognosis. It may rarely present with a very aggressive course resulting in acute respiratory distress syndrome (ARDS). We report a case of a 43-year-old male who presented with nonresolving pneumonia who was eventually diagnosed to have ADM through a skin biopsy without any muscle weakness. ADM may be associated with rapidly progressive course of interstitial lung disease (ADM-ILD) which is associated with high mortality. Differentiation between ADM-ILD and AS syndrome may be difficult in the absence of positive serology and clinical presentation may help in clinching the diagnosis. Gurveen Malhotra, Nitya Ramreddy, Serafin Chua, Mira Iliescu, and Tanjeev Kaur Copyright © 2016 Gurveen Malhotra et al. All rights reserved.