A case of anaphylactic shock due to an uncommon cause

In this new section of the Journal, we present a clinical case followed by the different steps taken by the medical team caring for this critically ill patient. A description of the events is true and accurate, and the diagnosis established in the order in which it is presented. A series of images depict the primary issues encountered by the authors. In addition, the authors include selected references to complement and enhance the educational value of this article.

Joseph Varon

A case of anaphylactic shock due to an uncommon cause


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Posttraumatic cerebral infarction caused by hemodynamic shearing stress following hemorrhagic shock

Background: Posttraumatic cerebral infarction (PTCI) is very rare and its pathogenesis is not well defined. In the case presented here, hemorrhagic shock was strongly suspected to be associated with the development of PTCI. Therefore, we hypothesized that a powerful shearing stress affected the pathogenesis of vulnerable endothelium causing damage and resulting in PTCI. By elucidating these mechanisms, it may be possible to predict the occurrence of PTCI.

Case: An 80-year-old woman was transferred to the emergency room after a traffic accident where her car collided against a wall. Upon admission, it was confirmed that she had a low Glasgow Coma Score (GCS); however, neither hemorrhage nor infarction appeared on initial brain computed tomography (CT) scans. Additionally, she had hemorrhagic shock (blood pressure 88/52 mmHg) causing hemothorax with multiple rib fractures, as well as fractures in the left humerus and thighbone. The patient did not seem to be able to move the left half of her body because of pain, and still had a low GCS 12 h after admission. Hence, diffusion-weighted magnetic resonance imaging (MRI) was performed and revealed acute cerebral infarction in the right temporal lobe, and MR angiography demonstrated moderate stenosis of the horizontal portion of the right middle cerebral artery.

Conclusions: To our knowledge, sudden hypotension following hemorrhagic shock produced a strong shear stress, which induced platelet aggregation and lead to the development of a cerebral infarction in our case.


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Red blood cell fragmentation in acute respiratory distress syndrome following Candida dubliniensis pneumonia

Background: The mechanisms underlying red blood cell fragmentation in intensive care patients remain controversial. Candida dubliniensis infection is very rarely reported in the world, and which has primarily been restricted to patients with a weak­ened immune system, and there is limited clinical information about the virulence of C. dubliniensis for hemolytic activity.

Case: A 79-year-old man, who had recovered from acute respiratory distress syndrome (ARDS), pre­sented with severe sepsis and was transferred to the emergency room. The ratio of arterial oxygen partial pressure to the fraction of inspired oxygenation (FiO2) (P/F ratio) in the arterial blood gas analysis was low (77%). Immediate treatment included in­tubation and antibiotic infusion. However, after 17 days, his general condition deteriorated suddenly, and red blood cell fragmentation was observed upon hematological examination. We treated him with an infusion of 4 units of packed red blood cells and 4000 units of haptoglobin. However, 3 days later, the patient died of multiple-organ failure and dissemi­nated intravascular coagulation. Throughout the treatment period, C. dubliniensis pneumonia was detected twice in the examination of his sputum.

Conclusion: To our knowledge, this is the first case report of red blood cell fragmentation in ARDS fol­lowing C. dubliniensis pneumonia in Japan.

Red blood cell fragmentation in acute respiratory distress syndrome following Candida dubliniensis pneumonia


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Obstructive and severe septic shock following a ruptured mature mediastinal teratoma

Most mature mediastinal teratomas are not symptomatic until they rupture, and the mechanisms underlying their rupture remain controversial. A 40-year-old woman was admitted to the emergency room with increasing respiratory distress 24 h before admission. Her clinical examination results indicated systemic inflammatory response syndrome with jugular venous distension and bilateral pitting edema on her lower extremity. Thoracic computed tomography confirmed a well-defined anterior mediastinal giant heterogenous mass (22 x 17 x 15 cm) with fluid content that had the same density of pleural effusion. In the culture examination of both sputum and pleural effusion, Streptococcus pneumonia was detected. Surgical findings showed that the tumor contained sebaceous material with some hair and teeth. No teratoma-pulmonary fistula was detected, but oozing through the thin and fragile microscopic hole on the tumor wall was observed. We describe a rare case of a patient with both obstructive and severe septic shock following a ruptured teratoma.

Obstructive and severe septic shock following a ruptured mature mediastinal teratoma


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Deep sedation contributes to high release of hypoxic pulmonary vasoconstriction in mechanically ventilated acute respiratory distress syndrome patients

Background: We report the cases of 2 patients with severe pneumonia who exhibited increased changes in hypoxic pulmonary vasoconstriction (HPV) during temporary increases in stroke volume and decreased stroke volume variation caused by in­creasing positive end-expiratory pressure (PEEP) under different sedation.

Cases: The first case was observed in a 79-year-old man with acute respiratory distress syndrome (ARDS) followed by pneumonia. The second case was observed in a 73-year-old woman on mechani­cal ventilation who suffered from ARDS following interstitial pneumonia.

The first patient was treated with 2 kinds of sedatives to improve oxygenation and protect the lungs. The second patient was treated with 3 kinds of sedatives. The first patient had a low P/F ratio (53.9/0.7=77) on mechanical ventilation. According to the recruit­ment maneuvers, an increasing PEEP leads to a slight temporary increase in stroke volume of about 2 mL. The patient died 3 days later due to multiple organ failure and disseminated intravascular co­agulation. The second patient had a low P/F ratio (38.5/0.7=55). As the PEEP increased, her stroke volume temporarily increased dramatically by about 8 mL. The patient recovered 56 days later.

Conclusions: HPV is an obstacle to oxygenation, prompting recruitment maneuvers for treating me­chanically ventilated ARDS patients; it is considered to be caused by physiological changes in the intracel­lular Ca2+ concentration in the pulmonary artery smooth muscle cells according to the sedation levels. The sedation level may contribute to decreased HPV in lung recruitment maneuvers.


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Gastromegaly as the cause of unexplained chest pain

A 61-year-old gentleman with past medical history of hypertension, hyperlipidemia, gastroesophageal reflux status post hiatal hernia repair in 1973, and recurrent diverticulitis was admitted to the intensive care unit (ICU) after undergoing elective laparoscopic recto-sigmoid hemicolectomy and colostomy formation. His immediate postoperative course was complicated by syncope while getting out of bed to ambulate. The patient regained consciousness within minutes and noted severe substernal chest pressure and dyspnea at rest. Physical examination revealed a blood pressure of 70/40 torr, heart rate 130/min and respiratory rate 28/min. Chest examination was unremarkable. Mild abdominal distension was noted without discomfort to palpation, and diffuse tympani on percussion. An emergent electrocardiogram was unremarkable. The patient received intravenous fluids and vasopressors. Laboratory testing revealed acute blood loss anemia with drop in baseline hemoglobin of four grams per deciliter. Following stabilization while awaiting blood transfusion, a chest X-ray was performed demonstrat­ing severe gastromegaly, which was then confirmed by abdominal X-ray (Figures 1 and 2). Subsequent abdominal and pelvic computed tomography (CT) with contrast to assess for obstruction, confirmed the pres­ence of gastromegaly without obstruction, and left lower quadrant hematoma without active bleeding (Figure 3). A nasogastric tube on continuous suction was inserted with subsequent resolution of the patient’s symptoms as well as the objective findings of hypotension, tachy­cardia, and tachypnea. A repeat radiograph revealed decompression of the patient’s stomach (Figure 4). Pressor support was weaned, and after completion of the patient’s blood transfusion, stopped. The patient had no further complications post-operatively and discharged home on post-operative day 2.

Gastromegaly as the cause of unexplained chest pain


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