Case Reports in Critical Care The latest articles from Hindawi © 2017 , Hindawi Limited . All rights reserved. Severe Rhabdomyolysis due to Presumed Drug Interactions between Atorvastatin with Amlodipine and Ticagrelor Thu, 25 May 2017 00:00:00 +0000 Atorvastatin and ticagrelor combination is a widely accepted therapy for secondary prevention of ischaemic heart disease. However, rhabdomyolysis is a well-known rare side effect of statins which should be considered when treatments are combined with cytochrome P450 3A4 enzyme inhibitors. We report a case of atorvastatin and ticagrelor associated severe rhabdomyolysis that progressed to multiorgan failure requiring renal replacement therapy, inotropes, intubation, and mechanical ventilation. Despite withdrawal of the precipitating cause and the supportive measures including renal replacement therapy, creatinine kinase increased due to ongoing rhabdomyolysis rapidly progressing to upper and lower limbs weakness. A muscle biopsy was performed to exclude myositis which confirmed extensive myonecrosis, consistent with statin associated rhabdomyolysis. After a prolonged ventilatory course in the intensive care unit, patient’s condition improved with recovery from renal and liver dysfunction. The patient slowly regained her upper and lower limb function; she was successfully weaned off the ventilator and was discharged for rehabilitation. To our knowledge, this is a second case of statin associated rhabdomyolysis due to interaction between atorvastatin and ticagrelor. However, our case differed in that the patient was also on amlodipine, which is considered to be a weak cytochrome P450 3A4 inhibitor and may have further potentiated myotoxicity. Iouri Banakh, Kavi Haji, Ross Kung, Sachin Gupta, and Ravindranath Tiruvoipati Copyright © 2017 Iouri Banakh et al. All rights reserved. Refractory Lactic Acidosis in Small Cell Carcinoma of the Lung Tue, 23 May 2017 07:33:55 +0000 Background. Elevated lactate levels in critically ill patients are most often thought to be indicative of relative tissue hypoxia or type A lactic acidosis. Shock, severe anemia, and thromboembolic events can all cause elevated lactate due to tissue hypoperfusion, as well as the mitochondrial dysfunction thought to occur in sepsis and other critically ill states. Malignancy can also lead to elevation in lactate, a phenomenon described as type B lactic acidosis, which is much less commonly encountered in the critically ill. Case Presentation. We present the case of a 73-year-old Caucasian woman with type 2 diabetes and hypertension who presented with abdominal pain, nausea, vomiting, nonbloody diarrhea, and weight loss over five weeks and was found to have unexplained refractory lactic acidosis despite fluids and antibiotics. She was later diagnosed with small cell carcinoma of the lung. Conclusions. In this case report, we describe a critically ill patient whose elevated lactate was incorrectly attributed to her acute illness, when in truth it was an indicator of an underlying, as yet undiagnosed, malignancy. We believe this case is instructive to the critical care clinician as a reminder of the importance of considering malignancy on the differential diagnosis of a patient presenting with elevated lactate out of proportion to their critical illness. Daniel J. Oh, Ellen Dinerman, Andrew H. Matthews, Abraham W. Aron, and Katherine M. Berg Copyright © 2017 Daniel J. Oh et al. All rights reserved. Successful Use of Extracorporeal Membrane Oxygenation for the Treatment of Cardiogenic Shock due to Scorpion Envenomation Thu, 27 Apr 2017 06:57:24 +0000 Introduction. The occurrence of a cardiogenic shock is a rare presentation after scorpion envenomation. The treatment includes classically the use of inotropes and specific vasodilators. Case Presentation. We report a case of an 11-year-old boy presenting with cardiogenic shock and pulmonary edema after a scorpion sting. Despite adequate management at the emergency department and intensive care unit, the patient’s hemodynamic status worsened rapidly, justifying his transfer to our department for ventricular mechanical assistance by venoarterial extracorporeal membrane oxygenation. The following outcomes were favorable and the boy was discharged home on day 29 without aftereffects. Conclusion. This is the first report of successful use of extracorporeal membrane oxygenation for the treatment of cardiogenic shock after scorpion envenomation. Amine Tarmiz, Imene Mgarrech, Chokri Kortas, and Sofiane Jerbi Copyright © 2017 Amine Tarmiz et al. All rights reserved. Disseminated Necrotizing Leukoencephalopathy Complicating Septic Shock in an Immunocompetent Patient Mon, 24 Apr 2017 00:00:00 +0000 Disseminated necrotizing leukoencephalopathy (DNL) is characterized by multiple microscopic foci of white matter necrosis. DNL was initially thought to be exclusively associated with immunosuppression conditions but it has been recently described in immunocompetent patients in septic shock. A 90-year-old immunocompetent woman with no previous neurological impairment presented with septic shock and drowsiness that responded well to therapy with clinical improvement and a full neurological recovery. Unexpectedly deterioration with progression to coma occurred. Investigation excluded other causes and Magnetic Resonance Imaging (MRI) was consistent with the diagnosis of DNL showing bilateral multifocal white matter lesions with a nonvascular pattern with restricted diffusion. Neurological impairment persisted with progression to death. DNL is an unexpected diagnosis in an immunocompetent patient. We compared the present case to those found in the literature of DNL complicating septic shock and discuss the antemortem diagnosis based on MRI findings. Pedro Gaspar-da-Costa, Sofia Reimão, Sandra Braz, João Meneses Santos, and Rui M. M. Victorino Copyright © 2017 Pedro Gaspar-da-Costa et al. All rights reserved. Optic Nerve Sheath Diameter as a Bedside Assessment for Elevated Intracranial Pressure Wed, 05 Apr 2017 09:48:02 +0000 A previously fit and healthy 26-year-old lady with no significant medical history presented with a two-month history of headaches. The headaches were prolonged, generalised, and unusually severe for the patient. Examination revealed papilloedema. The patient’s optic nerve sheath diameter was measured 3 mm posterior to the globe and found to be 7.5 mm. The patient subsequently had computed tomography scan of her brain that showed an optic nerve sheath diameter of 7.56 mm as measured 3 mm posterior to the globe. After an obstructive lesion was ruled out on the computed tomography scan, a lumbar puncture was then performed and cerebrospinal fluid was drained. An ultrasound of the optic nerve sheath diameter was repeated showing a reduced diameter of 5.6 mm. The patient was admitted to the neurology unit and ultimately diagnosed with idiopathic intracranial hypertension. This case report highlights the potential of rapidly identifying elevated intracranial pressure using a noninvasive method. Peter Williams Copyright © 2017 Peter Williams. All rights reserved. DKA-Induced Takotsubo Cardiomyopathy in Patient with Known HOCM Mon, 03 Apr 2017 06:11:33 +0000 The first published case of Diabetic Ketoacidosis-induced Takotsubo cardiomyopathy was in 2009. Our patient is the 1st reported case of Diabetic Ketoacidosis- (DKA-) induced Takotsubo cardiomyopathy (TC) in a patient with known hypertrophic cardiomyopathy (HOCM) in the United States. In the literature, there are only two examples linking DKA to TC; however, this report focuses on the biochemical and physiological causes of TC in a patient with known HOCM and new-onset DKA. TC in previously diagnosed HOCM poses particular complications. With the above patient’s baseline outflow tract obstruction due to septal hypertrophy, the acute reduction in EF due to TC resulted in transient drop in brain perfusion and, therefore, syncope. Ayla Gordon, Gina LaCapra, and Roberto Roberti Copyright © 2017 Ayla Gordon et al. All rights reserved. Hypercapnea and Acidemia despite Hyperventilation following Endotracheal Intubation in a Case of Unknown Severe Salicylate Poisoning Wed, 29 Mar 2017 07:36:52 +0000 Salicylates are common substances for deliberate self-harm. Acute salicylate toxicity is classically associated with an initial respiratory alkalosis, followed by an anion gap metabolic acidosis. The respiratory alkalosis is achieved through hyperventilation, driven by direct stimulation on the respiratory centers in the medulla and considered as a compensatory mechanism to avoid acidemia. However, in later stages of severe salicylate toxicity, patients become increasingly obtunded, with subsequent loss of airway reflexes, and therefore intubation may be necessary. Mechanical ventilation has been recommended against in acute salicylate poisoning, as it is believed to take away the compensatory hyperpnea and tachypnea. Despite the intuitive physiological basis for this recommendation, there is a paucity of evidence to support it. We describe a case of a 59-year-old male presenting with decreased level of consciousness and no known history of ingestion. He was intubated and experienced profound hypercarbia and acidemia despite mechanical ventilation with high minute ventilation and tidal volumes. This case illustrates the deleterious effects of intubation in severe salicylate toxicity. Shannon M. Fernando, Valérie Charbonneau, and Hans Rosenberg Copyright © 2017 Shannon M. Fernando et al. All rights reserved. Iatrogenic Right-Sided Pneumothorax Presenting as ST-Segment Elevation: A Rare Case Report and Review of Literature Sun, 26 Mar 2017 07:09:59 +0000 Pneumothorax is a well-recognized complication of central venous line insertion (CVL). Rarely, pneumothorax can lead to electrocardiogram (ECG) findings mimicking ST-segment elevation myocardial infarction. We present a 63-year-old man with iatrogenic right-sided pneumothorax who developed ST-segment elevation on a 12-lead ECG suggestive of myocardial infarction. The ECG findings completely resolved after needle decompression and chest tube placement. This case points up this rare electrocardiographic finding with discussion of possible mechanisms and differential diagnosis. Bashar Alzghoul, Ayoub Innabi, Anusha Shanbhag, Kshitij Chatterjee, Farah Amer, and Nikihil Meena Copyright © 2017 Bashar Alzghoul et al. All rights reserved. Increased Intracranial Pressure during Hemodialysis in a Patient with Anoxic Brain Injury Mon, 20 Mar 2017 00:00:00 +0000 Dialysis disequilibrium syndrome (DDS) is a serious neurological complication of hemodialysis, and patients with acute brain injury are at increased risk. We report a case of DDS leading to intracranial hypertension in a patient with anoxic brain injury and discuss the subsequent dialysis strategy. A 13-year-old girl was admitted after prolonged resuscitation from cardiac arrest. Computed tomography (CT) revealed an inferior vena cava aneurysm and multiple pulmonary emboli as the likely cause. An intracranial pressure (ICP) monitor was inserted, and, on day 3, continuous renal replacement therapy (CRRT) was initiated due to acute kidney injury, during which the patient developed severe intracranial hypertension. CT of the brain showed diffuse cerebral edema. CRRT was discontinued, sedation was increased, and hypertonic saline was administered, upon which ICP normalized. Due to persistent hyperkalemia and overhydration, ultrafiltration and intermittent hemodialysis were performed separately on day 4 with a small dialyzer, low blood and dialysate flow, and high dialysate sodium content. During subsequent treatments, isolated ultrafiltration was well tolerated, whereas hemodialysis was associated with increased ICP necessitating frequent pauses or early cessation of dialysis. In patients at risk of DDS, hemodialysis should be performed with utmost care and continuous monitoring of ICP should be considered. Anton Lund, Mette B. Damholt, Ditte G. Strange, Jesper Kelsen, Hasse Møller-Sørensen, and Kirsten Møller Copyright © 2017 Anton Lund et al. All rights reserved. The Use of Coupled Plasma Filtration Adsorption in Traumatic Rhabdomyolysis Sun, 19 Mar 2017 06:58:21 +0000 Severe musculoskeletal injuries induce the release of sarcoplasmic elements such as muscle enzymes, potassium, and myoglobin in the systemic circulation. The circulating myoglobin damages the glomerulus and renal tubules. Conventional haemodialysis is not able to remove myoglobin, due to its high molecular weight (17,8 kilodaltons [kDa]). We treated four traumatic rhabdomyolysis patients with Coupled Plasma Filtration Adsorption (CPFA) in order to remove myoglobin followed by 14 hours of Continuous Veno-Venous Hemofiltration (CVVH). During the treatment, all patients showed clinical improvement with a decrease in muscular (creatine kinase [CK] and myoglobin) and renal (creatinine and potassium) damage indices. One patient, in spite of full renal recovery, died of cerebral haemorrhage on the 26th day of hospital stay. Mario Pezzi, Silvia Renda, Anna Maria Giglio, Anna Maria Scozzafava, Simona Paola Tiburzi, Patrizia Casella, Fabrizio Iannelli, and Mario Verre Copyright © 2017 Mario Pezzi et al. All rights reserved. Nuclear Imaging to Detect Diaphragmatic Perforation as a Rare Complication of Microwave Ablation Tue, 14 Mar 2017 00:00:00 +0000 Acquired diaphragmatic perforation leading to massive hepatic hydrothorax and respiratory failure is a rare complication of microwave ablation (MWA) of hepatocellular carcinoma (HCC). Imaging modalities to detect pleuroperitoneal communication remain poorly described. We report a nuclear imaging technique used to efficiently diagnose and locate diaphragmatic defects. A 57-year-old male with cirrhosis and HCC presented with respiratory distress after undergoing MWA of a HCC lesion. He was admitted to the intensive care unit for noninvasive positive pressure ventilator support. Chest radiography revealed a new large right pleural effusion. Large-volume thoracentesis was consistent with hepatic hydrothorax. The fluid reaccumulated within 24 hours; therefore an acquired diaphragmatic perforation induced by the ablation procedure was suspected. To investigate, Technetium-labeled albumin was injected into the peritoneal cavity. The tracer accumulated in the right hemi thorax almost immediately. The patient then underwent transjugular intrahepatic portosystemic shunting in efforts to relieve portal hypertension and decrease ascites volume. Unfortunately, the patient deteriorated and expired after few days. Although diaphragmatic defects develop in cirrhotic patients, such small fenestrations do not normally lead to rapid development of life-threatening pleural effusion. MWA procedures can cause large diaphragmatic defects. Immediate detection of this complication is essential for initiating early intervention. Stephanie Cull, Gebran Khneizer, Abhishek Krishna, Razi Muzaffar, Sameer Gadani, and Zafar Jamkhana Copyright © 2017 Stephanie Cull et al. All rights reserved. Acute Gastric Volvulus and Atrial Fibrillation with RVR: A Coincidence or Association Wed, 08 Mar 2017 09:09:14 +0000 Gastric volvulus is a rare and life-threatening condition that involves the abnormal rotation of the stomach around its axis by more than 180°. The association between acute gastric volvulus and atrial fibrillation with rapid ventricular response is rare with only few cases that have been reported. Our patient was an 86-year-old female who presented with upper abdominal pain, distension, nausea, and shortness of breath. Clinical and laboratory workup revealed acute gastric volvulus with diaphragmatic hernia. On presentation, she was also in atrial fibrillation with rapid ventricular response. She was successfully treated by laparotomy with reduction of the gastric volvulus and repair of the diaphragmatic hernia, with significant improvement. Omar Nadhem, Omar Salh, and Faisal Khasawneh Copyright © 2017 Omar Nadhem et al. All rights reserved. Bronchopleural Fistula Resolution with Endobronchial Valve Placement and Liberation from Mechanical Ventilation in Acute Respiratory Distress Syndrome: A Case Series Tue, 07 Mar 2017 00:00:00 +0000 Patients who have acute respiratory distress syndrome (ARDS) with persistent air leaks have worse outcomes. Endobronchial valves (EBV) are frequently deployed after pulmonary resection in noncritically ill patients to reduce and eliminate bronchopleural fistulas (BPFs) with persistent air leak (PAL). Information regarding EBV placement in mechanically ventilated patients with ARDS and high volume persistent air leaks is rare and limited to case reports. We describe three cases where EBV placement facilitated endotracheal extubation in patients with severe respiratory failure on prolonged mechanical ventilation with BPFs. In each case, EBV placement led to immediate resolution of PAL. We believe endobronchial valve placement is a safe method treating persistent air leak with severe respiratory failure and may reduce days on mechanical ventilation. Haris Kalatoudis, Meena Nikhil, Fuad Zeid, and Yousef Shweihat Copyright © 2017 Haris Kalatoudis et al. All rights reserved. Abnormal Breathing Patterns Predict Extubation Failure in Neurocritically Ill Patients Tue, 28 Feb 2017 00:00:00 +0000 In neurologically injured patients, predictors for extubation success are not well defined. Abnormal breathing patterns may result from the underlying neurological injury. We present three patients with abnormal breathing patterns highlighting failure of successful extubation as a result of these neurologically driven breathing patterns. Recognizing abnormal breathing patterns may be predictive of extubation failure and thus need to be considered as part of extubation readiness. Pragya Punj, Premkumar Nattanmai, Pravin George, and Christopher R. Newey Copyright © 2017 Pragya Punj et al. All rights reserved. Effective and Safe Use of Glucocorticosteroids for Rescue of Late ARDS Sun, 26 Feb 2017 06:27:32 +0000 We describe a case of severe refractory hypoxemia requiring prolonged extra corporeal membrane oxygenation (ECMO) support in a case of postpartum acute respiratory distress syndrome (ARDS). The clinical course was marked by persistently poor lung compliance and several complications of ECMO, that is, significant hemolysis, hemothorax, and intracranial bleeding. We report marked improvement of lung mechanics and respiratory function, leading to accelerated separation from ECMO, following rescue administration of low dose methylprednisolone 24 days after the onset of ARDS. Corticosteroid treatment was safe and well tolerated. In contrast with the conclusions of the 2006 ARDS Network trial, our report establishes a case in support of the use of low dose methylprednisolone as a safe and effective rescue treatment option in selected subsets of patients with nonresolving ARDS. Paolo Diana, Dustin T. Money, Michael G. Gelvin, and Nadia Lunardi Copyright © 2017 Paolo Diana et al. 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.