Atelectasis in the ICU: An unexpected finding

An 81 year-old male with a history positive for coronary artery disease, chronic hypertension and rheumatoid arthritis presented to the hospital complaining of diffuse chest pain. Chest x-ray on admission did not reveal lung masses, atelectasis, signs of infection or any other radiologic abnormality. Cardiac catheterization revealed multi-vessel disease. He underwent coronary artery bypass graft surgery on 5 vessels. On the first postoperative day the patient developed atelectasis of the entire right upper lobe. An emergency bronchoscopy revealed diffuse mucous plugs causing atelectasis of right upper lobe, which were suctioned until clear. In addition, an endobrochial polypoid glistening lesion accidentally found at the entrance of left lower lobe. (Figure) The biopsy of this lesion revealed large fragments of hyaline cartilage with fibromyxoid stromal changes consistent of an endobronchial hamartoma. These tumors are the most frequent benign tumors of the lung. Its endobronchial location is very rare. Lung hamartomas usually occur in a 0.3% of the general population, with a higher incidence during the sixth decade of life being the male gender more oftenly affected than females. Pulmonary hamartomas are usually benign, peripheral, well-circumscribed single lesions, in the lung parenchyma. Our patient had the hamartoma endoscopically resected and had no additional postoperative complications.


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Successful treatment of theophylline toxicity with continuous venovenous haemofiltration

Charcoal haemoperfusion remains the treatment of choice for severe theophylline toxicity. However, this technique may not be available in most hospitals. We described a case of 62-year-old man, who presented with severe theophylline toxicity (peak level 85 mg/L), which was treated successfully with high volume continuous venovenous haemofiltration (CVVH). We also review the literature concerning treatment of theophylline toxicity with haemofiltration.


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Persistent Vegetative State

A 39-year old gentleman with pancreatitis sustained cardiorespiratory arrest due to tension pneumothorax after a Swan-Ganz catheter placement. Despite recovering cardio-respiratory function, he did not regain consciousness. Three months later, he seemed awake, but did not answer questions, follow commands, blink to threat or exhibit purposeful movements. He had spastic quadraparesis, decerebrate posturing in response to noxious stimuli, sustained ankle clonus and bilateral Babinski sign. The electroencephalogram showed burst-suppression. MRI revealed cerebral atrophy with diffuse gray matter loss. Hyperintense signal involving remnants of the cerebral cortex (arrows) and basal ganglia (arrowheads) was also appreciated. Before falling ill, the patient casually manifested his wishes of not receiving life-sustaining therapies if he suffered irreversible brain injury. Medications and tube-feedings were discontinued.


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Legionnaire’s disease associated with acute respiratory distress syndrome and acute cerebral oedema

Objective: To report the original observation of a patient with legionella’s pneumopathy complicated with acute respiratory distress syndrome (ARDS) and a concomittant cerebral oedema occurred in the setting of positive end-expiratory pressure, reversible with the weaning of mechanical ventilation. Design and Setting: Case report, Intensive Care Unit, General Hospital. Patient: Young female patient with HIV infection Interventions: Diagnostic fiberoptic bronchoscopy, legionella urinary antigen, lumbar puncture, computed tomography and magnetic resonance imaging of the brain, mechanical ventilation, positive end-expiratory pressure, low tidal volume, permissive hypercapnia, prone position, systemic antibiotherapy. Results: Cerebrospinal fluid polymerase chain reaction was negative for both legionella and herpes virus or any other opportunistic infection. Chest radiographies showed the progressive resolution of ARDS with adapted antibiotherapy. The clinical improvement and total reversibility of cerebral oedema were observed in magnetic resonance imaging of the brain with concomitant weaning of positive end-expiratory pressure and mechanical ventilation. Conclusion: In ARDS, protective ventilatory strategy using low tidal volume ventilation, positive end-expiratory pressure and permissive hypercapnia are recommended to improve intrapulmonary shunt, arterial oxygenation and to decrease mortality, but the incidence of neurological complications as intracranial hypertension is probably underestimated. Further studies to evaluate the neurological impact (hemodynamic and anatomical consequences) of mechanical ventilation in ARDS are necessary.


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Images in critical care medicine. “Malignant bronchial tear: Emergency management”

A 73-year-old man with history of metastatic esophageal cancer and esophageal stent placement 4 months prior presentation presented after a syncopal episode related to severe cough. On arrival to the emergency department he was unresponsive, hypoxemic and acidotic. The patient was orotracheally intubated. Computed tomography of chest revealed extensive consolidation involving the right lung. Significant air leak with returning was noted post intubation with tidal volumes that were less than 50% of the initial volume. The endotracheal tube was replaced with defected cuff noted. The leak persisted and an emergency bronchoscopy revealed two large openings around secondary carina consistent with bronchial tears related to bronchoesophageal fistulization. These wall abnormalities appeared to enlarge with each delivered tidal volume. The air was escaping through the stomach and through the mouth. A flat film of the abdomen revealed large amounts of gas in stomach and bowel. The ET tube was pulled back and left main stem intubation was done under bronchoscopic guidance. The patient’s oxygen saturation improved and the leak resolved.


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Rescue therapy with high-frequency oscillatory ventilation in severe acute respiratory distress syndrome

There is emerging evidence on the effectiveness and safety of high-frequency oscillatory ventilation in patients with acute respiratory distress syndrome. We described two patients with severe acute respiratory distress syndrome in whom low tidal volume ventilation with conventional mechanical ventilator failed to achieve physiological improvement. The initiation of high-frequency oscillatory ventilation as rescue therapy in these patients resulted in remarkable improvement in oxygenation and hypercapnia.


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Five cases of murine typhus presented as acute respiratory distress

Murine typhus is a flea-borne, worldwide rickettsial disease caused by Rickettsia typhi. It is typically a mild illness, which clinical features include fever, rash, and headache, but sometimes it is fatal. Recently, we experienced 5 cases of ARDS associated with a Rickettsia typhi infection. These cases were not suspicious initially, but later they were proven by high titers of serum IgG antibodies (1:512 or higher) with the IFA method. All 5 patients had no rash. Three of them live in urban areas. Murine typhus would be one of the etiologies for ARDS of unknown causes, especially in an endemic region.


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Effect of Sivelestat Sodium Hydrate in Three Patients with Septic ARDS

We administered sivelestat sodium hydrate, a selective polymorphonuclear leukocyte elastase (PMNE) inhibitor, to three patients with septic ARDS. While causing a decrease in the serum PMNE and surfactant protein D levels, the neutroin phil elastase inhibitor improved the PaO2/FiO2 ratio in all the three patients, which allowed earlier weaning of these patients from artificial ventilation. These findings suggest that sivelestat may be effective in the treatment of septic ARDS.


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Tracheal Rupture: Airway Catastrophe Associated with Intubation

Disruption of the trachea following intubation is an uncommon but potentially fatal condition. The incidence is difficult to establish because many tracheal lacerations may be undetected clinically. Some patients present acutely with subcutaneous emphysema or may develop it only after several hours. Signs of tracheobronchial injury such as hemorgency rhage, cyanosis, air leak or compliance changes may be absent in some patients. Interdisciplinary treatment requires precise documentation of the extent of the injuries, using advanced imaging techniques and bronchoscopy. Early repair may be necessary to prevent acute tension pneumothorax, airway obstruction, and chronic tracheal stenosis.


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Assessment of Matrix Metalloproteinases-1 in Septic Acute

The extracellular matrix (ECM) does not simply maintain the form of tissues; it is a dynamic factor that plays a major role in cell function. Matrix metalloproteinases (MMPs) are the most important enzymes in ECM degradation, and their activity is controlled strictly by specific inhibitors, that is tissue inhibitors of metalloproteinase (TIMPs). We assessed the clinical course of changes in ECM-degrading enzymes TNF-a, IL-6, IL-8, and nitrite/nitrate (NOx) in the blood of two septic acute respiratory distress syndrome (ARDS) patients. Negative correlation was found between the PaO2/FIO2 ratio (P/F ratio) and MMP-1, but positive correlation was found between the P/F ratio and both the TIMP-1/MMP-1 ratio and MMP-1 • TIMP-1 complex level. TIMP-1 was consistently maintained at high levels. These results suggest that both MMP-1 and TIMP-1 may be involved in septic ARDS, and that the balance between MMP-1 and TIMP-1 is important.


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Thyroid Storm: A Forgotten Cause of Arrhythmias with Septic Feature

Hyperthyroidism is the condition resulting from the effect of excessive amounts of thyroid hormones on body tissues. A dramatic extreme expression of thyrotoxicosis known as thyroid strom occurs rarely but requires prompt recognition and intervention to avoid the 90 percent mortality of untreated disease. Characteristically the patient present with fever, rapid tachyarrhythmias and atrial fibrillation. High output congestive heart failure can result from the tachycardia and severe hypermetabolic state. Frequently the clinical picture is clouded by a secondary infection such as pneumonia, a viral infection, or infection of the upper respiratory tract. Because of its variable presentation and because thyroid storm is rare condition, the correct diagnosis may be missed. We report two interesting cases of thyroid storm. The first was a lady who presented with a supraventricular tachycardia and atrial fibrillation initially misdiagnosed as septicemia with arrhythmias. The second case was a man with longstanding undiagnosed hyperthyroidism who presented with threatening thyroid storm and atrial fibrillation associated with cardiomyopathy. Both patients were subsequently managed successfully at our hospital. We hope misdiagnosis and late treatment of the similar cases will be avoided in the future.


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Respiratory Distress in An Infant Induced By Respiratory Syncytial Virus Bronchiolitis Complicated By Bronchogenic Cyst

A 3-month-old infant developed respiratory distress as a result of respiratory syncytial virus bronchiolitis. The patient was first treated for initial symptoms which were gradually improving, but mechanical ventilation was required for seven days. Upon extubation, rapid respiratory distress ensued, requiring reintubation. Chest computed tomograph examination revealed a mediastinal mass, which was surgically removed and the patient was successfully weaned from mechanical ventilation. Histological diagnosis was bronchogenic cyst.


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Interleukin 11 and Stem Cell Factor Levels in Patients with Disseminated Intravascular Coagulation: A Report of Four Cases

Interleukin 11 (IL-11) and stem cell factor (SCF) stimulate platelet production. In this study, we examined serum IL-11 and SCF levels in 4 patients with disseminated intravascular coagulation (DIC) complicating massive trauma and infections. The serum concentrations of both IL-11 and SCF showed a marked increase coinciding with the development of DIC in these patients, regardless of the presence or absence of infections. Further studies are required to confirm whether the increase in levels of these two platelet- inducing cytokines with the onset of DIC reflects an enhancement of platelet production in order to maintain the biological system in balance, or simply an inflammatory biological response.


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Significantly Raised Brain Natriuretic Peptide in a Young Patient with Dengue Fever without Heart and Renal Failure

Objective: This is the fi rst case report of association of raised brain natriuretic peptide (BNP) in patients with dengue fever (DF). BNP is raised in patients with heart failure. It can also be elevated in renal failure and subarachnoid haemorrhage in the absence of heart failure. Raised BNP has never been described in patients with DF. Clinical features: We describe a young patient with DF who complained of sudden onset breathlessness on day 3 of admission. She was found to have right sided crepitations. Myocardial screen was done which was negative but BNP was 3555 pg/ml. Her SpO2 and arterial blood gas while breathing room air was normal. There was no elevated jugular venous pressure, pedal edema or laboratory evidence of heart failure. There was no renal impairment or systemic infl ammatory response syndrome. A transthoracic 2-dimensional echocardiography was normal. Treatment: Patient was treated with intravenous fl uids and oral clarithromycin for 5 days. Outcome: Patient was discharged on day 8 of admission. She was well but follow-up BNP was high but on downward trend. She refused any further invasive investigations for heart. Conclusions: BNP may be raised in patient with DF without heart failure. The exact pathogenesis of raised BNP in DF is unclear.


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Unilateral Diaphragmatic Pacing: An Innovative Solution for Unilateral Diaphragmatic Paralysis

Mechanical ventilation has always been a cornerstone of respiratory support for patients with respiratory muscle paralysis. In selected patients, diaphragm pacing (DP) through electrical stimulation of the phrenic nerves provides an alternative to mechanical ventilation with signifi cant advantages in life quality. We report an interesting case of unilateral diaphragmatic paralysis in which unilateral diaphragmatic pacing produced signifi cant improvement in quality of life.


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