Case Reports in Critical Care The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . 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. Not All Acute Abdomen Cases in Early Pregnancy Are Ectopic; Expect the Unexpected: Renal Angiomyolipoma Causing Massive Retroperitoneal Haemorrhage Sun, 26 Jun 2016 09:37:01 +0000 Retroperitoneal haemorrhage (or retroperitoneal haematoma) refers to an accumulation of blood found in the retroperitoneal space. It is a rare clinical entity with variable aetiology including anticoagulation, ruptured aortic aneurysm, acute pancreatitis, malignancy, and bleeding from renal aneurysm. Diagnosis of retroperitoneal bleed is sometimes missed or delayed as presentation is often nonspecific. Multislice CT and arteriography are important for diagnosis. There is no consensus about the best management plan for patients with retroperitoneal haematoma. Stable patients can be managed with fluid resuscitation, correction of coagulopathy if any, and blood transfusion. Endovascular options involving selective intra-arterial embolisation or stent-grafts are clearly getting more and more popularity. Open repair is usually reserved for cases when there is failure of conservative or endovascular measures to control the bleeding or expertise is unavailable and in cases where the patient is unstable. Mortality of patients with retroperitoneal haematoma remains high if appropriate and timely measures are not taken. Haemorrhage from a benign renal tumour is a rarer entity which is described in this case report which emphasizes that physicians should have a wide index of suspicion when dealing with patients presenting with significant groin, flank, abdominal, or back pain, or haemodynamic instability of unclear cause. Our patient presented with features of acute abdomen and, being pregnant, was thought of having a ruptured ectopic pregnancy. Muhammad Asim Rana, Ahmed F. Mady, Nagesh Jakaraddi, Shahzad A. Mumtaz, Habib Ahmad, and Kamal Naser Copyright © 2016 Muhammad Asim Rana et al. All rights reserved. Use of Continuous Renal Replacement Therapy for Removal of Dabigatran in a Patient in Need of Emergent Surgery Thu, 26 May 2016 07:05:35 +0000 Purpose. To report the ability to remove serum dabigatran using continuous renal replacement therapy (CRRT) in a patient with life-threatening bleeding. Summary. A 77-year-old female with history of atrial fibrillation who takes dabigatran for stroke prevention presented with abdominal pain. Patient was found to have bleeding and possible mesenteric ischemia and was taken to the operating room and had continued bleeding postoperatively. CRRT was initiated for the removal of any remaining dabigatran, with serum dabigatran levels collected to evaluate removal of dabigatran with CRRT. This patient had an increased dabigatran level prior to intervention, which decreased to an undetectable level after use of CRRT. Greater than 80% of the drug was removed due to 4 hours of CRRT and residual kidney function. Reversal of dabigatran is an area of current research with recent FDA approval of idarucizumab for use. Conclusion. Bleeding may occur as a result of the use of dabigatran and change in patient’s clinical condition. Use of CRRT may be an option in removing serum dabigatran in the case of a life-threatening bleed. Sara E. Parli, Melissa L. Thompson Bastin, and Daniel A. Lewis Copyright © 2016 Sara E. Parli et al. All rights reserved. Left Lung Torsion: Complication of Lobar Resection for an Early Stage Lung Adenocarcinoma Tue, 17 May 2016 13:00:42 +0000 Lobar torsion is a fatal but fortunately rare occurrence following lung resection. Early clinical signs and radiographic features may be nonspecific resulting in diagnostic delay. A high index of suspicion is vital for early diagnosis and intervention to avoid further parenchymal necrosis and deadly gangrene. We report a case of left lower lobe torsion in a 76-year-old female following elective upper lobectomy for underlying lung adenocarcinoma. Diagnosis was made following highly suggestive radiographic findings prompting bronchoscopy and revision thoracotomy. An emergency detorsion failed to restore lung viability and was followed by completion pneumonectomy. The patient recovered and was discharged on the seventh postoperative day. Wissam Mansour, Elias Moussaly, Ali Abou Yassine, John Nabagiez, and Rabih Maroun Copyright © 2016 Wissam Mansour et al. All rights reserved. Pancreaticopericardial Fistula: A Case Report and Literature Review Sun, 17 Apr 2016 12:38:21 +0000 Purpose. Pancreaticopericardial fistula (PPF) is an extremely rare complication of acute or chronic pancreatitis. This paper presents a rare case of PPF and provides systematic review of existing cases from 1970 to 2014. Methods. A PubMed search using key words was performed for all the cases of PPF from January 1970 to December 2014. Fourteen cases were included in the study. The cases were reviewed for demographic characteristics, diagnostic modalities, and treatment. Descriptive analysis of these variables was performed. Results. Median age was 43 years. 78% were known alcoholics and 73.3% had chronic pancreatitis. Dyspnea was present in 78%. Cardiac tamponade was present in 53%; 75% of patients had known chronic pancreatitis (RR = 0.74). Surgery was associated with best treatment outcomes and 50% of patients who underwent endoscopic treatment survived. Conclusion. PPF is a rare disease. This paper indicates that acute cardiac tamponade in patients with history of alcoholism and chronic pancreatitis could be a sign of an existing pancreaticopericardial fistula and early surgical intervention could be life-saving. Muhammad S. Khan, Najmi Shahbaz, Hassaan A. Zia, Muhammad Hamza, Henna Iqbal, and Ahmed Awab Copyright © 2016 Muhammad S. Khan et al. All rights reserved. Fatal Nonhepatic Hyperammonemia in ICU Setting: A Rare but Serious Complication following Bariatric Surgery Sun, 10 Apr 2016 09:28:37 +0000 Bariatric surgery is well established in reducing weight and improving the obesity-associated morbidity and mortality. Hyperammonemic encephalopathy following bariatric surgery is rare but highly fatal if not diagnosed in time and managed aggressively. Both macro- and micronutrients deficiencies play a role. A 42-year-old Hispanic female with a history of Roux-en-Y Gastric Bypass Procedure was brought to ED for progressive altered mental status. Physical exam was remarkable for drowsiness with Glasgow Coma Scale 11, ascites, and bilateral pedal edema. Labs showed elevated ammonia, low hemoglobin, low serum prealbumin, albumin, HDL, and positive toxicology. She remained obtunded despite the treatment with Narcan and flumazenil and the serum ammonia level fluctuated despite standard treatment with lactulose and rifaximin. Laboratory investigations helped to elucidate the etiology of the hyperammonemia most likely secondary to unmasking the functional deficiency of the urea cycle enzymes. Hyperammonemia in the context of normal liver function tests becomes diagnostically challenging for physicians. Severe hyperammonemia is highly fatal. Early diagnosis and aggressive treatment can alter the prognosis favorably. Gyanendra Acharya, Sunil Mehra, Ronakkumar Patel, Simona Frunza-Stefan, and Harmanjot Kaur Copyright © 2016 Gyanendra Acharya et al. All rights reserved. Severe Sepsis Associated with Lemierre’s Syndrome: A Rare but Life-Threatening Disease Tue, 05 Apr 2016 13:42:45 +0000 Background. The incidence of Lemierre’s syndrome has increased in the past decade. This posttonsillitis complication may be life threatening. Case Presentation. A 19-year-old patient was admitted to Surgical Intensive Care Unit of a French University Hospital for high fever, low blood pressure, and haemoptysis following a sore throat episode. Blood analysis revealed a thrombopenia, an acute renal failure, and an elevated lactate serum. Fusobacterium necrophorum was found in blood cultures. Computed tomography of the neck and lungs confirmed the diagnosis of Lemierre’s syndrome: pleural effusions, bilateral lung infiltrates, and an internal jugular vein thrombosis. Fluid administration and antibiotic treatment were quickly initiated. Patient left the unit four days after his admission without any organ dysfunction. Conclusion. Lemierre’s syndrome may lead to multiorgan dysfunction and should be rapidly identified. Audrey Tawa, Raphaëlle Larmet, Yannick Malledant, and Philippe Seguin Copyright © 2016 Audrey Tawa et al. All rights reserved. Severe Ketoacidosis Associated with Canagliflozin (Invokana): A Safety Concern Mon, 21 Mar 2016 14:26:33 +0000 Canagliflozin (Invokana) is a selective sodium glucose cotransporter-2 (SGLT-2) inhibitor that was first introduced in 2013 for the treatment of type 2 diabetes mellitus (DM). Though not FDA approved yet, its use in type 1 DM has been justified by the fact that its mechanism of action is independent of insulin secretion or action. However, some serious side effects, including severe anion gap metabolic acidosis and euglycemic diabetic ketoacidosis (DKA), have been reported. Prompt identification of the causal association and initiation of appropriate therapy should be instituted for this life threatening condition. Alehegn Gelaye, Abdallah Haidar, Christina Kassab, Syed Kazmi, and Prabhat Sinha Copyright © 2016 Alehegn Gelaye et al. All rights reserved. Retracted: Clinical Brain Death with False Positive Radionuclide Cerebral Perfusion Scans Tue, 15 Mar 2016 13:32:50 +0000 Case Reports in Critical Care Copyright © 2016 Case Reports in Critical Care. All rights reserved. Acute Warfarin Toxicity as Initial Manifestation of Metastatic Liver Disease Wed, 02 Mar 2016 07:09:15 +0000 Near complete infiltration of the liver secondary to metastasis from the head and neck cancer is a rare occurrence. The prognosis of liver failure associated with malignant infiltration is extremely poor; the survival time of patients is extremely low. We present a case of acute warfarin toxicity as initial manifestation of metastatic liver disease. Our patient is a 64-year-old woman presenting with epigastric pain and discomfort, found to have unrecordable International Normalized Ratio. She rapidly deteriorated with acute respiratory failure requiring mechanical ventilation, profound shock requiring high dose vasopressor infusion, severe coagulopathy, worsening liver enzymes with worsening of lactic acidosis and severe metabolic abnormalities, and refractory to aggressive supportive care and died in less than 48 hours. Autopsy revealed that >90% of the liver was replaced by tumor masses. Varalaxmi Bhavani Nannaka, Nihar Jani, Masooma Niazi, and Dmitry Lvovsky Copyright © 2016 Varalaxmi Bhavani Nannaka et al. All rights reserved. Adrenergic Inhibition with Dexmedetomidine to Treat Stress Cardiomyopathy during Alcohol Withdrawal: A Case Report and Literature Review Wed, 24 Feb 2016 10:00:24 +0000 Stress (Takotsubo) cardiomyopathy is a form of reversible left ventricular dysfunction with a heightened risk of ventricular arrhythmia thought to be caused by high circulating catecholamines. We report a case of stress cardiomyopathy that developed during severe alcohol withdrawal successfully treated with dexmedetomidine. The case involves a 53-year-old man with a significant history of alcohol abuse who presented to a teaching hospital with new-onset seizures. His symptoms of acute alcohol withdrawal were initially treated with benzodiazepines, but the patient later developed hypotension, and stress cardiomyopathy was suspected based on ECG and echocardiographic findings. Adjunctive treatment with the alpha-2-adrenergic agonist, dexmedetomidine, was initiated to curtail excessive sympathetic outflow of the withdrawal syndrome, thereby targeting the presumed pathophysiology of the cardiomyopathy. Significant clinical improvement was observed within one day of initiation of dexmedetomidine. These findings are consistent with other reports suggesting that sympathetic dysregulation during alcohol withdrawal produces ideal pathobiology for stress cardiomyopathy and leads to ventricular arrhythmogenicity. Stress cardiomyopathy should be recognized as a complication of alcohol withdrawal that significantly increases cardiac-related mortality. By helping to correct autonomic dysregulation of the withdrawal syndrome, dexmedetomidine may be useful in the treatment of stress-induced cardiomyopathy. Zachary M. Harris, Alvaro Alonso, and Thomas P. Kennedy Copyright © 2016 Zachary M. Harris et al. All rights reserved. Early Recognition of Foreign Body Aspiration as the Cause of Cardiac Arrest Tue, 23 Feb 2016 13:05:03 +0000 Foreign body aspiration (FBA) is uncommon in the adult population but can be a life-threatening condition. Clinical manifestations vary according to the degree of airway obstruction, and, in some cases, making the correct diagnosis requires a high level of clinical suspicion combined with a detailed history and exam. Sudden cardiac arrest after FBA may occur secondary to asphyxiation. We present a 48-year-old male with no history of cardiac disease brought to the emergency department after an out-of-hospital cardiac arrest (OHCA). The patient was resuscitated after 15 minutes of cardiac arrest. He was initially managed with therapeutic hypothermia (TH). Subsequent history suggested FBA as a possible etiology of the cardiac arrest, and fiberoptic bronchoscopy demonstrated a piece of meat and bone lodged in the left main stem bronchus. The foreign body was removed with the bronchoscope and the patient clinically improved with full neurological recovery. Therapeutic hypothermia following cardiac arrest due to asphyxia has been reported to have high mortality and poor neurological outcomes. This case highlights the importance of early identification of FBA causing cardiac arrest, and we report a positive neurological outcome for postresuscitation therapeutic hypothermia following cardiac arrest due to asphyxia. Muhammad Kashif, Hafiz Rizwan Talib Hashmi, and Misbahuddin Khaja Copyright © 2016 Muhammad Kashif et al. All rights reserved. A Rare but Reversible Cause of Hematemesis: “Downhill” Esophageal Varices Thu, 18 Feb 2016 12:46:49 +0000 “Downhill” varices are a rare cause of acute upper gastrointestinal bleeding and are generally due to obstruction of the superior vena cava (SVC). Often these cases of “downhill” varices are missed diagnoses as portal hypertension but fail to improve with medical treatment to reduce portal pressure. We report a similar case where recurrent variceal bleeding was initially diagnosed as portal hypertension but later found to have SVC thrombosis presenting with recurrent hematemesis. A 39-year-old female with history of end-stage renal disease presented with recurrent hematemesis. Esophagogastroduodenoscopy (EGD) revealed multiple varices. Banding and sclerotherapy were performed. Extensive evaluation did not show overt portal hypertension or cirrhosis. Due to ongoing bleeding requiring resuscitation, she underwent internal jugular (IJ) and SVC venogram in preparation for transjugular intrahepatic portosystemic shunt (TIPS), which demonstrated complete IJ and SVC occlusion. She underwent balloon angioplasty with stent placement across SVC occlusion with complete resolution of her varices and resolved hematemesis. “Downhill” varices are extremely rare, though previously well described. Frequently, patients are misdiagnosed with underlying liver disease. High index of suspicion and investigation of alternative causes of varices is prudent in those without underlying liver diseases. Prompt diagnosis and appropriate intervention can significantly improve morbidity and mortality. Lam-Phuong Nguyen, Narin Sriratanaviriyakul, and Christian Sandrock Copyright © 2016 Lam-Phuong Nguyen et al. All rights reserved. Wernicke’s Encephalopathy Complicating Hyperemesis during Pregnancy Tue, 16 Feb 2016 16:35:09 +0000 Wernicke’s encephalopathy is caused by severe thiamine deficiency; it is mostly observed in alcoholic patients. We report the case of a 28-year-old woman, at 17 weeks of gestational age, with severe hyperemesis gravidarum. She presented with disturbance of consciousness, nystagmus, ophthalmoplegia, and ataxia. The resonance magnetic imagery showed bilaterally symmetrical hyperintensities of thalamus and periaqueductal area. The case was managed with very large doses of thiamine. The diagnosis of Wernicke’s encephalopathy was confirmed later by a low thiamine serum level. The patient was discharged home on day 46 with mild ataxia and persistent nystagmus. Wernicke’s encephalopathy is a rare complication of hyperemesis gravidarum. It should be diagnosed as early as possible to prevent long-term neurological sequela or death. Thiamine supplementation in pregnant women with prolonged vomiting should be initiated, especially before parenteral dextrose infusion. Early thiamine replacement will reduce maternal morbidity and fetal loss rate. Mohamed Adnane Berdai, Smael Labib, and Mustapha Harandou Copyright © 2016 Mohamed Adnane Berdai et al. All rights reserved. Spurious Hyperchloremia and Negative Anion Gap in a Child with Refractory Epilepsy Thu, 11 Feb 2016 11:18:23 +0000 We report a case with spurious hyperchloremia with negative anion gap in a child who was taking potassium bromide for refractory epilepsy. Blood chemistry showed a high chloride level (171 mEq/L) and a negative anion gap (−52 mEq/L). Plasma chloride concentration is measured by an ion-selective electrode method; however the presence of other anions like bromide and iodides can interfere with chloride level and largely overestimates the chloride concentration. Thus hyperchloremia with a negative anion gap is a clue to the diagnosis of halides like bromide and iodide ingestion. Madhuradhar Chegondi and Balagangadhar R. Totapally Copyright © 2016 Madhuradhar Chegondi and Balagangadhar R. Totapally. All rights reserved.