Low-dose heparin for sepsis-associated disseminated intravascular coagulation and septic shock

Abstract

Background: Sepsis and septic shock are severe clinical problems with high mortality rates, characterized by a systemic inflammation with substantial procoagulant elements and activating some clotting factors. Those are possible to develop the disseminated intravascular coagulation (DIC). Heparin is a well-known anticoagulant, which also provides anti-inflammatory properties. Nevertheless, the efficacy of heparin was limited by the potential risk of bleeding in critically ill patients. In this case report, we would like to explain the therapeutic effects of low-dose heparin on sepsis-associated DIC and septic shock.

Case report: We report a case of a 60-year-old male with sepsis-associated DIC and septic shock caused by pneumonia. The patient had decreased consciousness for 10 hours before hospitalization. Standard intensive care and intravenous low-dose heparin (250 IU/h) were performed in the Intensive Care Unit (ICU). On day 12 of ICU admission, the patient's condition was fully conscious and clinically stable. Therefore, the patient discharged from ICU with no bleeding manifestation and no sequelae.

Conclusion: Low-dose heparin successful treats patient with sepsis-associated DIC and septic shock.


Authors: Arie Zainul Fatoni, Suwarman, Hori Hariyanto, Oloan E. Tampubolon, Wiwi Jaya

A case of severe respiratory distress in a patient with chronic myeloid leukemia receiving dasatinib

Abstract

Introduction: Dasatinib is a multi-kinase inhibitor used primarily in the treatment of chronic myeloid leukemia (CML). The major reported side effects are pleural effusion, pulmonary hypertension, and severe infection. The most common infection among these patients is pneumonia. Here, we present a case of severe respiratory failure in a patient with CML who was taking dasatinib.

Case presentation: A 75-year-old male with CML, hypertension, hyperlipidemia presented to the emergency department with progressively worsening shortness of breath and hemoptysis for one week. The patient’s CML had been well controlled with dasatinib since his diagnosis two years ago, and the most recent BCR-ABL1 assay was undetectable. Computed tomography (CT) of the chest revealed diffuse ground glass opacity with superimposed interlobular septal thickening and intralobular lines (“crazy-paving pattern”) and a moderate-sized right pleural effusion. Therapeutic thoracentesis yielded 1.8 l of lymphocyte predominant, exudative pleural effusion. Pneumocystis jirovecii polymerase chain reaction (PCR) of induced sputum was positive, which was consistent with the CT finding of “crazy-paving pattern.” Dasatinib was held for the possibility of drug induced pneumonitis and pleural effusion, and the patient was successfully treated with trimethoprim-sulfamethoxazole for his pneumocystis jirovecii pneumonia (PCP).

Conclusion: Our case suggests that a common tyrosine kinase inhibitor, dasatinib, cannot only act as an effective antileukemic agent, but also can cause several adverse effects including pleural effusion and immunosuppression. Physicians should consider opportunistic infections in their differential when patients on dasatinib present with respiratory insufficiency.


Authors: Natsumi T. Hamahata, Sophie Rodrigues Pereira, Ehab G. Daoud

Resuscitation incoherence after cardiac arrest due to acute intraoperative pulmonary emboli related acute right heart failure: A case report

Abstract

Resuscitation incoherence is a mismatch between macrocirculation, microcirculation, and cellular parameters after resuscitation. We report a 34-year-old obese male patient, suffering from end-stage renal disease or chronic kidney disease (CKD), underwent routine hemodialysis three times a week and hypercoagulability state with rivaroxaban therapy. He had a cardiac arrest during kidney transplant surgery. Acute right heart failure causing cardiac arrest was presumably caused by acute intraoperative pulmonary embolism. Hemodynamic and resuscitation incoherence occurred and proper treatment was needed. At the time of cardiac arrest, hemodynamic coherence was lost and resuscitation was performed to restore this loss by correcting the possible causes of cardiac arrest. Although the return of spontaneous circulation (ROSC) was successfully achieved, a type 1 resuscitation incoherence occurred where the macrocirculation was optimal but cellular parameters were disturbed by cell hypoxia, characterized by high levels of lactate. Type 2 resuscitation incoherence was also found in this patient until the end of treatment in the intensive care unit (ICU). Cellular parameters such as lactate levels and the venoarterial carbon dioxide tension difference to arteriovenous oxygen content difference ratio (P[v-a]CO2)/(C[a-v]O2) continued to improve during ICU treatment, but cell hypoxia might occur since the central venous pressure (CVP) value as a macrocirculation parameter was likely to increase, presumed to be caused by incomplete resolved acute pulmonary embolism related chronic thromboembolic pulmonary hypertension.


Authors: Ade Susanti, Mayang Indah Lestari, Dita Aditianingsih

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