Spontaneous Escherichia Coli Meningitis in an Adult

Escherichia coli meningitis has been reported rarely in adult patients. Moreover, it is very rare in an adult patient without diabetes mellitus or neurosurgical shunts. Even with treatment, it carries a high mortality ranging from 27% to 90%, and mortality without treatment is 100% [1-3].
We describe a rare case of an adult patient, without known predisposing factors such as diabetes mellitus or neurosurgical shunts, who presented with E. coli meningitis.


Authors:

Gastric Strongyloides with Ulceration and Klebsiella pneumonia Bacteraemia

Strongyloides infection is usually confi ned to small intestine in gastrointestinal tract. Gastric mucosal Strongyloides with ulceration is extremely uncommon. We describe a patient who presented with gastrointestinal bleeding with gastric Strongyloides diagnosed by biopsy from the base of the gastric ulcer. Patient was treated with ivermectin 9 mg once a day for 2 days. The hospital stay was complicated by severe Klebsiella pneumoniae bacteraemia which needed treatment with meropenem for 2 weeks. Patient was discharged after 40 days of hospital stay.


Authors:

Abdominal Compartment Syndrome: Case Report

Abdominal compartment syndrome (ACS) was originally described in trauma patients but is now known to occur in critically ill patients with a myriad of acute illnesses. Recent epidemiological studies have characterized the prevalence of intraabdominal hypertension (defi ned as an intraabdominal pressure [IAP] measured at the urinary bladder ¡Ý12 mmHg) between 2% and 33% [1,2] and the prevalence of ACS (defi ned as an IAP ¡Ý20 mmHg and associated organ system dysfunction) between 1% and 15%. These prevalences are similar to those quoted for sepsis and septic shock in trauma patients. Multiple studies have shown that massive fl uid resuscitation is the most common risk factor for ACS. The rise in intraabdominal pressure causes worsening of the capillary leak as a consequence of their primary illness, further decreasing vital organ perfusion and resulting in multiple organ dysfunction syndrome (MODS). Management includes hemodynamic support and abdominal decompression. Because of its protean manifestations, a high index of suspicion and frequent monitoring of the IAP in high-risk patients are the best preventive measures. Our case report shows the clinical features of a patient with ACS. The diagnosis was made early in the clinical source, yet appropriate management was deferred because of the uncertainty management in this critically ill patient.


Authors:

Perforated Pre-pyloric Ulcer Presenting with ST elevation on EKG

A 66 year-old female with long-standing history of rheumatoid arthritis on chronic steroid therapy, presented for routine kyphoplasty for a compression fracture of L1 and L2. Pre-operative electrocardiogram (EKG) revealed a normal sinus rhythm and no abnormalities. Her intra-operative course was complicated by severe hypotension. A post operative EKG revealed ST elevation in inferior and lateral leads with ST changes. She underwent a left heart catheterization that revealed normal coronary arteries and an ejection fraction of 70%. Because of concomitant abdominal discomfort, a computed tomography of abdomen was obtained and revealed a perforated viscus.


Authors:

Changing Medical ICU Environment and the Impact on Nosocomial Infection

Nosocomial infections (NIs) are one of the most common complications that occur in ICU patients and confer an increased relative risk of 3.5 for mortality. These types of infections may affect from 5 to 35% of patients who are admitted to ICU’s. Guidelines for Environmental Infection Control in Health-Care Facilities by the CDC, and the Healthcare Infection Control Practices Advisory Committee [HICPAC] guidelines have become standard. These recommendations have been tested in clinical trials of routine infection control surveillance. Also, a revised policy for antimicrobial therapy has proved a reduction in ICU acquired infections and mortality. An extensive review of the principles of infection control in the ICU has been published elsewhere.


Authors:

Massive Pericardial Effusion as a Presentation of Hypothyroidism

A 46 year-old Hispanic female with no past medical history, and no history of trauma presented to the hospital with complaints of shortness of breath worsening gradually over past two months. The patient’s physical examination was remarkable for diminished heart sounds at auscultation. A complete blood count chemistry was within normal limit. Collagen vascular profi le was negative. A chest x-ray revealed enlarged cardiac shilloute suggestive of pericardial effusion. A computed tomography (CT) scan of chest showed massive pericardial effusion. A 2D-echocardiogram confi rmed the massive pericardial effusion without any evidence of right ventricular collapse. Pericardiocentesis was performed draining 2800 ml of straw-colored fl uid. Cultures and cytology of the pericardial fl uid were negative. Additional blood workup revealed an elevated thyroid stimulating hormone level. The patient was started on thyroid replacement therapy and had an uneventful recovery.


Authors:

Hyperthyroidism Presenting as Acute Muscular Weakness

A 25 year-old Hispanic gentleman without any significant past medical history, presented to the emergency department with a 3 hour history of sudden onset shortness of breath and acute progressive quadriparesis. He specifically denied any recent viral infection, recent travel or illicit drug use. He worked as a "chef" in a local restaurant. On initial physical examination, the patient was a slender male in moderate-to-severe respiratory distress. Blood pressure was 160/90 mmHg, heart rate 150 bpm, respiratory rate 32/minute, temperature 38.5 oC and oxygen saturation by pulse oximetry of 98%. Bilateral exophthalmos was noted and homogenous enlargement of thyroid gland palpated without tenderness. Lung examination was unremarkable despite his respiratory distress. Heart sounds were normal and no murmurs were heard. Muscle strength in the lower extremities was 0/5, and upper extremities were 2/5. Sensory system examination and deep tendon reflexes appeared within normal limits. After administration of oxygen and the initiation of an intravenous line, an electrocardiogram was obtained revealing a second degree heart block, right bundle branch block and U waves. Initial laboratory data revealed severe hypokalemia with potassium level of 1.3 mmol/L and a phosphorous of 0.7mg/dL Thyroid stimulating hormone (TSH) level was <0.01 uIU, and T4 level was 23.8 ug/dl (normal: 4.5- 12.0). A subsequent electrocardiogram revealed no further U waves few hours after potassium supplementation. The patient was started on propylthiouracil (PTU) 100mg every eight hours, propranolol 40 mg three times per day for a confirmed diagnosis of thyrotoxicosis, and was discharged home 2 days later for out patient follow up. Hypokalemic periodic paralysis may be associated with hyperthyroidism (thyrotoxicosis-periodic paralysis), especially among Asian men. The nature of relationship between hyperthyroidism and periodic paralysis is not well established, but a mutation in a potassium channel gene (R83H-KCNE3) has been identified in one man with both disorders.


Authors:

Undetected Atrial Myxoma Presenting as Severe Dyspnea

Myxomas are the most common type of primary cardiac tumors, comprising 30-50% of the total in most pathological series. The incidence of atrial myxomas ranges between 0.5 and 1 per million of population/year.


Authors:

Percutaneous Common Carotid Artery Access for Stenting of a Critical Left Internal Carotid Artery Stenosis in a Nonagenarian: A

Purpose. To describe the successful endovascular treatment using direct carotid artery access in a high risk elderly patient with symptomatic internal carotid artery stenosis. Case Report. A 98 year-old man who was independent and lived alone was admitted to our hospital for symptoms of progressive weakness, associated with disorientation and difficulty with speech. Duplex carotid ultrasound was performed which revealed a totally occluded right internal carotid artery and high grade stenosis of the left internal carotid artery. Because of his advanced age he was deemed to be at high surgical risk for a standard endarterectomy, thus he was referred for carotid artery stenting.Using the femoral artery approach, multiple guiding catheters and sheaths were advanced to the left common carotid artery. Adequate support for intervention could not be obtained. The procedure was aborted and the patient was referred for carotid endarterectomy. However, due to his advanced age, he felt that surgery was too high risk thus he chose an alternative attempt to endovascular carotid stenting.Therefore, he was brought back to the catheterization laboratory two days later for direct carotid access. Carotid artery stenting was accomplished with a 6F sheath, a cerebral protection device and a Nitinol stent all percutaneously via the left common carotid artery. The patient was discharged the following day without complications. At 3-month follow-up, the patient is functional and independent without recurrence of symptoms. Conclusion. Direct carotid access can be successfully accomplished in patients if the femoral artery approach is anatomically prohibitive. In those of advanced age or other high risks for surgery, direct carotid access can be considered an option for revascularization.


Authors:

Multiple Shotgun Pellet Embolization to the Pulmonary Artery

Pellet embolization to the pulmonary artery from a shotgun injury is a rare event. Our current experience with this entity is described. We reviewed the literature of Bullet Embolization with emphasis on management. We believe that shotgun pellet pulmonary artery embolism should be regarded as a separate entity from bullet embolism. The mechanism of injury and its sequelae, leading to complication is very much subtle compared to bullet embolism per se. After entry into the venous system, smaller sized pellets can easily lodge into the distal segments of pulmonary artery but tend to have less deleterious effect as compared to bigger sized bullet. We therefore recommend non-surgical management of pellet pulmonary embolism with clinical follow up to determine emergence of complications.


Authors:

Hypothyroidism Induced Cardiac Tamponade in Intensive Care Unit—A Rare Presentation

Hypothyroidism is common disease with multisystem involvement. Pericardial tamponade secondary to hypothyroidism is extremely rare. In current paper we describe a case of middle age Hispanic man presenting with pericardial tamponade due to severe hypothyroidism, and discuss the relevant literature.


Authors:

A Case of Strongyloides Stercoralis Hyperinfection Syndrome

It is known that Strongyloides stercoralis can induce intestinal strongyloidiasis, hyperinfection syndrome or disseminated strongyloidiasis. Paralytic ileus and associated bacterial infections may be seen as complications of hyperinfection syndrome or disseminated disease. This report discusses a case of hyperinfection syndrome in a patient who was receiving chronic immunosuppressive treatment for rheumatoid arthritis. In spite of treatment for hyperinfection syndrome with oral albendazole and rectal ivermectin, the patient’s condition worsened and he died of progressive respiratory failure. The limitations of treatment for hyperinfection syndrome will briefly be discussed.


Authors:

Opening Up to Lung Recruitment. Pulmonary Contusion and Derecruitment - The Role of Inflammation

Purpose of review: It was recently reported that a lung protective ventilation strategy resulted in no fatalities in 17 patients with ARDS secondary to lung contusion. Although the efficacy of a lung protective ventilation strategy to reduce mortality in ARDS patients has been demonstrated, the underlying mechanisms for this reduction remain unclear. Recent findings: ARDS is characterized by an inflammatory state of the lung that can be aggravated by mechanical ventilation. Especially mechanical ventilation allowing cyclic opening and closing of unstable alveoli, enhances cytokine release and can even result in loss of compartmentalization. Disbalance in the cytokine response can promote bacterial colonization and result in multiorgan failure. Recent clinical trials and experimental studies have demonstrated that recruitment of collapsed alveoli and stabilization of alveoli using sufficient levels of PEEP can reduce inflammation, bacterial colonization and the number of failing organs, thereby decreasing mortality. Summary: Lung protective ventilation strategies minimizing this cyclic opening and closing by recruiting collapsed alveoli and subsequent stabilization with adequate levels of PEEP offer the clinician a tool to improve patient outcome in ARDS. This benefit is partly mediated by maintaining a ‘natural’ balance in the cytokine response. Future studies should explore this strategy in a randomized prospective study.


Authors:

Demyelinating disease of the brain presenting as ring enhancing lesions in a critically ill patient

A 26-year-old Latin-American woman with a history of alcohol and cocaine abuse was brought to the emergency department with the complaint of fever, altered mental status and weakness of 3-day duration. Her initial vital signs included a blood pressure of 80/40 torr, heart rate 140/min, respiratory rate 32/min, SaO2 96% on room air, temperature 41oC. Aggressive fluid resuscitation was started, blood cultures obtained, and empiric antibiotics started. A lumbar puncture revealed six white blood cells per field with normal glucose levels. An emergent magnetic resonance imaging (MRI) of the brain revealed multiple ring enhancing lesions seen as areas of increased signal on T2 flair and diffusion sequences. These lesions were seen almost exclusively in the deep white matter (Figures). Based on these images toxoplasmosis was considered as the cause of the patient’s altered mental status. Serum toxoplasma titers were abnormal. The patient’s condition deteriorated evolving into status epilepticus requiring airway management and assisted mechanical ventilation. An open brain biopsy was performed and cultures were negative for bacterial, fungal, tuberculosis or toxoplasmosis. Microscopic pathological analysis revealed findings consistent with an acute demyelinating disease. The presence of multiple white matter lesions on MRI favors demyelinating disease but ring-enhancing lesion makes it an unusual presentation of demyelinating diseases of the brain.


Authors: