Acute ischemic stroke - an extrapulmonary COVID-19 presentation

Abstract

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that causes coronavirus disease 2019 (COVID-19) has emerged as a high contagious and deadly virus, with an endless capacity to surprise clinicians with new presentations and complications. Although COVID-19 typically presents as respiratory infection but it can present with thromboembolic event. Our hospital, one of the main territory care hospitals in Kuwait, experiencing sudden surge of stroke cases in last few weeks of COVID-19 pandemic. Stroke is a medical emergency which needs early recognition and management for better neurological outcome. In the COVID-19 pandemic, when seeing patients with neurological manifestations, clinicians should consider COVID-19 as a differential diagnosis and should take full protective measures until proven to be negative. Based on our experience, we want to highlight that COVID-19 patients can present with extrapulmonary manifestation like stroke. Emergency physicians, stroke team and intensivist should be wary of this fact. Triaging and COVID-19 screening is the key to minimize the virus spread and to ensure staff and other patients safety.


Authors: Beena Yousuf, Abdalaziz HRH Gh S. Alsarraf, Huda Alfoudri

Toxic shock syndrome related to the use of a menstrual cup in a pediatric patient

Abstract

Menstrual cups, made of hypoallergenic rubber or silicone, were first marketed in the 1930’s but have become increasingly popular. Menstrual cups may be less expensive, more environmentally friendly and potentially a safer alternative to tampons and menstrual pads, although the safety of these cups is unknown. We report a case of a 17.5-year-old female who developed probable toxic shock syndrome related to use of The DivaCup®. We suggest that women presenting with signs and symptoms of toxic shock syndrome be asked specifically about their use of a menstrual cup in addition to tampons, because it may be a risk factor and present requires prompt removal for source control.


Authors: Lucy B. Stanke, Elizabeth A. Farrington, Michael Stoiko

Cerebral pontine infarction after postpartum hemorrhagic shock

Abstract

Cerebral pontine infarction is a rare complication of hemorrhagic shock. We report an unconscious 30-year-old woman that was admitted with severe postpartum hemorrhage (PPH). The patient required two surgery to control the bleeding. Focal neurologic deficit was recognized after extubation. Computed tomography (CT) scan showed findings which were consistent with acute right-side pontine infarction. The patient’s symptoms improved with anti-thrombotic therapy and she was discharged on the thirteenth day of hospitalization. A routine stroke rehabilitation program was planned.


Authors: Faisal Muchtar, Syafri Kamsul Arif, Andi Husni Tanra, Hisbullah Amin, Arif Santoso, Mardiah Tahir

The use of COVID-19 IgM rapid test in the setting of negative RT-PCR to diagnose infection by SARS-CoV-2: A challenging case

Abstract

In December 2019, a novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) caused an outbreak of respiratory disease in Wuhan, China, that quickly spread to other countries causing a global pandemic. Although the reverse transcriptase polymerase chain reaction (RT-PCR) test for SARS-CoV-2 infection has become the standard method of diagnosis, this test has limitations that cause false negative results. The sudden onset, and spread of this virus, has created an urgency to find reliable screening and diagnostic tools to identify infected patients, prevent further transmission, and provide treatment for these patients. A rapid and accurate diagnostic tool, the COVID-19 combined IgG and IgM “Rapid” test can detect these antibodies against SARS-CoV-2 using a finger prick blood sample detecting infection in 15 minutes. We report the use of the COVID-19 IgM Rapid Test in the presence of high clinical suspicion, along with typical chest computed tomography findings suggestive of COVID-19 infection, in a patient who tested negative twice for the nasopharyngeal swab specimen RT-PCR test.


Authors: Elizabeth Gamboa, Melanie Duran, Alan Araiza, Daryelle Varon, Mariya Mohiuddin, Joseph C Gathe Jr, Joseph Varon

COVID-19-induced hepatic encephalopathy: A case report

Abstract

By the end of December 2019, a single stranded ribonucleic acid (RNA) virus, Coronavirus, was said to be responsible for an outbreak of respiratory infections of unknown origin in Wuhan, China. Globally, this virus has caused over 160,000 deaths and is expected to increase as the pandemic continues. The majority of patients with the coronavirus disease 2019 (COVID-19) infection present symptomatically with fever, shortness of breath, or cough; however, given that the Coronavirus targets the angiotensin converting enzyme 2 receptors (ACE2), it has been suspected that the virus also exhibits neuroinvasive effects. We present a case of a 32-year-old man with a one-week history of progressive shortness of breath, myalgias, arthralgias, fever peaks, who tested positive for COVID-19 and developed acute hepatic encephalopathy with altered mental status.


Authors: Elizabeth Gamboa, Diego Montelongo, Hussein Berjaoui, Daryelle S. Varon, Joseph C Gathe Jr, Joseph Varon

Multiple ventricular septal defects in an adult

Ventricular septal defect (VSD) is the second most commonly occurring congenital heart defect in adults. The incidence in adults is 10 %, as most defects usually close during early childhood. Mortality increases with age, and 75% at the age of 60. Symptoms and clinical presentation depend mainly on the size of the VSD. Patients with small VSDs usually remain asymptomatic. Larger VSDs can cause hemodynamic compromise, increased risk of infective endocarditis and reversal of shunt leading to Eisenmenger syndrome.


Authors: Kashmala Khan, Carlos Vargas, Salim R. Surani

Subarachnoid pneumorrhachis following blunt thoracic and spinal trauma

Abstract

Subarachnoid pneumorrhachis is an increasingly identified entity in the setting of trauma. We report a case of this finding incidentally and of a positive outcome with conservative management following multi-speciality opinion. Our case-series review identifies an increasing number of cases in the literature due to improvements in computerised tomography resolution and explores traumatic and non-traumatic precipitants, suspected mechanisms of introduction of air into the spinal canal and ventricular systems and support for non-interventional management in uncomplicated pneumorrhachis.


Authors: Ravi Mistry, Sarah Wongseelashote, Ross Freebairn

Case report: a fatal case of severe pancreatitis associated with rhabdomyolysis

Abstract

Background: Rhabdomyolysis is an uncommon presentation associated with severe acute pancreatitis (SAP). Patients usually present late and asymptomatic, thus it carries poorer clinical outcome and higher mortality rate.

Case report: We report a case of SAP in a 42-year-old man who presented with persistent epigastric pain, elevated serum amylase, and characteristics of acute pancreatitis on the contrast-enhanced computed tomography of the abdomen. Investigations revealed persistent hyperkalemia and severely elevated creatinine kinase in the presence of acute kidney injury, which led to the uncommon possibility of diagnosing severe rhabdomyolysis. He suffered complications of intra-abdominal hypertension, feeding intolerance, severe ARDS and multi-organ failure. He succumbed to death after a month despite aggressive intensive care therapies and support.

Discussion: The actual pathophysiology of rhabdomyolysis in SAP is complex. It is postulated that acute inflammation of pancreas causes ATP-dependent proton pump dysfunctions leading to skeletal muscle cells injury and therefore, rhabdomyolysis.

Conclusion: Coexistence of rhabdomyolysis with SAP have higher risk for fatality, therefore, its presence allows early triage, early aggressive resuscitation and intensive care management.


Authors: Saw Kian Cheah, Mohamed Izzad bin Isahak, Wan Rahiza Wan Mat, Shereen Suet Ping Tang, Rufinah Teo, Aliza Mohamad Yusof, Raha Abdul Rahman

McConnell’s sign is not specific for acute pulmonary embolism - A case report

Abstract

Since 1996, McConnell’s sign, defined as right free wall hypokinesia with apical sparing, described as one of the most specific echocardiographic finding for acute pulmonary embolism. It was incorporated in the standard teaching and text book as a tell-tale sign for the condition. This is a case report of a patient presented with chest pain and presyncope with markedly raised D-dimer and suspicious electrocardiogram finding. The bedside focused cardiac ultrasound revealed the classical McConnell’s sign. However, the computed tomography pulmonary angiogram for pulmonary embolism was negative. The patient was subsequently diagnosed as pulmonary hypertension secondary from chronic methamphetamine abuse. This case highlights that McConnell’s sign is not specific for acute pulmonary embolism. It is also important to stratify patient according to a validated clinical probability score for pulmonary embolism before initiating definitive acute treatment.


Authors: Mohamad Iqhbal Bin Kunji Mohamad, Mohd Fazrul Bin Moktar, Julina @Azimah Mohd Noor, Nur Abdul Karim, Izzat Bin Ismail, Abdul Halim Bin Sanib, Mohd Amin Mohd Mokhtar, Safreeda SF Salim

Surgical emphysema complicating inferior alveolar nerve cryoablation

We present a case of widespread surgical emphysema following cryoablation of the right inferior alveolar nerve in the setting of trigeminal neuralgia refractory to carbamazepine pharmacotherapy.


Authors: Ravi Mistry, Brigitte Hollander, Derek Goodison, Ross Freebairn

Fatal neck necrotizing fasciitis caused by hypermucoviscous Klebsiella pneumoniae

Abstract

Klebsiella pneumoniae is a gram-negative rod enterobacteria that is notorious for its role as carrier of extended spectrum beta-lactamase (ESBL) and its carbapenem resistant Enterobacteriaceae (CRE) species. However, hypermucoviscous Klebsiella pneumoniae is distinctly different from ESBL and CRE. We report a case of neck necrotizing fasciitis caused by hypermucoviscous Klebsiella pneumoniae in a 56-year-old male who presented to our emergency department (ED) with a swollen neck. His condition deteriorated rapidly requiring emergency intubation to secure his airway. Despite aggressive resuscitation and treatment with broad spectrum antibiotics and cytokine adsorption therapy, the patient succumbed to his disease. This report describes the clinical characteristics of hypermucoviscous Klebsiella pneumoniae and emphasizes the importance of early detection and subsequent aggressive source control interventions in necrotizing fascitiis caused by this particular bacteria.


Authors: U Wen Yeap

The successful treatment of severe aspiration pneumonitis with the combination of hydrocortisone, ascorbic acid and thiamine

Abstract

Aspiration pneumonitis is a neutrophil mediated inflammatory pneumonitis following the aspiration of regurgitated gastric contents. This syndrome occurs most commonly in patients with depressed levels of consciousness such as drug overdose, seizures, and during anesthesia. Aspiration pneumonitis is the most common cause of anesthesia-related deaths. Aspiration pneumonitis may be clinically silent or present as severe acute lung injury (ARDS) progressing to death. The treatment of acid aspiration pneumonitis is largely supportive. We present two cases of severe life threatening ARDS due to acid aspiration who were treated with the combination of hydrocortisone, ascorbic acid, and thiamine (HAT) and made a dramatic recovery. This treatment strategy should be considered in the management of patients with aspiration pneumonitis.


Authors: Margot M. Gurganus, Paul E. Marik, Joseph Varon

Secondary pyomyositis complicated by septic shock and sepsis-induced cardiomyopathy causing a massive erector spinae abscess in a patient after trigger point injection

Abstract

Trigger point injection is a common pain control method widely practiced around the world.

We report the case of a 53-year-old female who presented with lumbago and septic shock complicated with sepsis-induced cardiomyopathy three days after receiving a trigger point injection. She responded to sepsis treatment and empiric antibiotics but later required extensive drainage and debridement after a follow-up CT scan revealed a massive abscess above the fascia of erector spinae spanning from the level of the 1st thoracic spine to the 5th lumbar spine. With extensive surgical drainage and effective antimicrobial treatment, the patient recovered fully and was discharged without any sequelae.


Authors: Uwen Yeap, Yuto Makino, Kenji Sugimoto

Post-surgical right coronary artery injury secondary to tricuspid valve repair

Abstract

Injury to the right coronary artery (RCA) is a rare complication of tricuspid annuloplasty. We report a 64-year-old woman with history of valvular heart disease that was admitted for decompensated right heart failure. The patient underwent aortic valve replacement and tricuspid annuloplasty. Shortly after tricuspid annuloplasty the patient developed right ventricular (RV) infarction with hemodynamic compromise. The coronary angiogram shows subtotal occlusion at the mid segment of right coronary artery probably due to stitch of the tricuspid ring. The RCA has successfully been revascularized by percutaneous coronary angioplasty with bare metal stent, however the patient got into multi-organs failure syndrome and died at day 15 postoperatively.


Authors: Andrés Parisi, Ying Tung Sia

Late pacemaker perforation of the right ventricle. A case report and review of diagnosis and management

Abstract

Objectives: Pacemaker incidence and prevalence are on the rise over the last decade especially in the elderly population. Though complications are rare, most reported literature is about early pacemaker complication. Late complications are also reported, but mostly regarding malfunction or infections. Very few case reports and series report late cardiac perforations which could be catastrophic. We report a case of late cardiac perforation diagnosed and treated in our institution to raise the awareness of this very serious complication.

Case summary: A 65-year-old male who had a single chamber right ventricular pacemaker inserted two months earlier for sick sinus syndrome, presented to the hospital with complaint of shortness of breath. Chest X-ray (CXR) revealed new large left sided pleural effusions. Computed tomography (CT) scan of the chest suggested migration of the pacemaker lead with perforation of the right ventricle associated with hemothorax with no pericardial effusions. A bedside echo confirmed the perforation and showed minimal pericardial effusions with no cardiac tamponade. Clinically patient was hemodynamically stable. He underwent open surgical repair and placement of epicardial pacer leads.

Conclusions: Clinicians should be aware of the early and late complications of pacemaker insertions and how to diagnose and treat them appropriately to avoid unnecessary morbidity or mortality.


Authors: Vivian Shokry, Ehab Gamil Daoud