Acute necrotizing pancreatitis associated with Covid-19: A case report


Coronavirus infection is commonly associated with pulmonary manifestations. Extra pulmonary manifestations including gastrointestinal involvement is also well established recently in COVID positive patients. However, pancreatic involvement due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is an unusual presentation and therefore much more attention has to be given to the pancreatic injury caused by SARS-CoV-2 infection. There is different pathophysiology behind the pancreatic dysfunction associated with SARS-CoV-2 infection. It can either be the systematic inflammatory immune response causing tissue damage or direct invasion of pancreatic cells. The virus enters the host cells or tissues via its spike protein that binds to the angiotensin-converting enzyme 2 (ACE2) present in the pancreatic islets cells, which in turn leads to pancreatic injury and dysfunction. It can also occur as an adverse effect of medications like ritonavir-lopinavir that is a therapeutic option for COVID-19 patients. Here, we report a case of a patient with COVID-19-induced acute pancreatitis where medical history and further investigations eliminated all the other expected causes of pancreatitis. He came with complaints of hiccups for two weeks and abdominal pain. He tested positive for COVID-19 and was managed with antibiotics like meropenem. Laboratory investigations as well as computed tomography abdomen paved way for the detection of pancreatic involvement. Pancreatic injury and COVID-19 infection were resolved during the course in hospital and the patient was discharged on medications including zinc, vitamin C supplementation, and also with ciprofloxacin.

Authors: Ameya B., Mahima A., Anju G., Nirmal KP, Uma Devi P., Rajesh G., Priya Nair, Dipu TS, Merlin Moni, Shine S.

Calciphylaxis: A case report and literature review


Necrotising fasciitis is an extremely life-threatening condition, which mainly develop from the necrosis of the subcutaneous fascia and adjacent tissue. It can be caused recurrently from moderate to severe systemic toxicity and be fatal due to lack of medical or surgical treatment. Any absence of particular clinical features can easily result in the under diagnosis such as cellulites or abscess.

The infection can be caused by one or more micro-organisms, both aerobic and anaerobic. Calciphylaxis or calcific uremic arteriolopathy (CUA) is a rare limb threatening condition commonly seen in renal disease patients. It is commonly caused by the accumulation of calcium deposits in the subcutaneous tissue and in the small arteries. Hence, we report a case of 50-year-old female with necrotising fasciitis who was diagnosed with a very rare condition of calciphylaxis.

Authors: Aishwarya Rajeev, Roshni PR

Role of vasopressin in hyponatremic dehydration


Excessive correction of hyponatremia frequently occurs in the management of hyponatremic dehydration. This is more common in infants when correction of dehydration rapidly covers the hyponatremia faster than desired. This is the case of a 2½-month-old male infant with hyponatremic dehydration, which was overcorrected during the initial phase of treatment and was later managed by subcutaneous vasopressin. Vasopressin has got a dual role in the management of hyponatremic dehydration as it helps in dehydration correction as well as slow correction of sodium.

Authors: Anna Kurian, Sruthi G., Sajith Kesavan, Roshni PR

Herpes simplex virus simultaneous encephalitis and liver failure in an immunocompetent adult: A case report


Herpes simplex virus (HSV) are challenging etiologic agents with a wide range of clinical manifestations. We present a case of a 34-year-old immunocompetent male who was brought to the Emergency Department (ED) with fever and prostration. In the first approach, blood tests revealed an acute hepatitis without an identified etiology. Besides the use of N-acetylcysteine, he became worst and evolved to acute liver failure and coma. HSV deoxyribonucleic acid (DNA) was identified in the cerebrospinal fluid (CSF) and blood. Although acyclovir was started on day 3, he developed cardiovascular shock with multiple organ failure and died on the 7th day of hospitalization. A high index of suspicion is needed, and early diagnosis should be promoted between clinicians.

Authors: Tiago Isidoro Duarte, Filipe Damião, Joana Ferrão, Tânia Sequeira, Filipe Sousa Cardoso, Nuno Germano

Upper airway obstruction due to bilateral laryngeal polyp: A challenge of treatment in rural area


A laryngeal polyp is a common benign lesion of phonotraumatic origins. However, a case of the laryngeal polyp with the upper airway obstruction is rare. The common symptoms include hoarseness or reduced vocal quality, and dyspnea could be present in severe cases. Depending on the anatomical location of the polyp, manipulation on the larynx could cause laryngospasm and life-threatening airway obstruction. In this case, the patient underwent a planned cesarean section under general anesthesia. However, her breathing rhythm did not return spontaneously after surgery and she was sent to the intensive care unit. Bilateral laryngeal polyps were discovered after the removal of an endotracheal tube. However, there was a delay in the removal of the polyps, where it was performed two months after the intensive care unit discharge. The histopathological results confirmed a diagnosis of bilateral angiomatous laryngeal polyps.

Authors: Hamsu Kadriyan, Elya Endriani, Fahrin Ramadhan Andiwijaya, Ida Lestari Harahap

What is low cardiac output syndrome? A report of two cases


Background: One of the diagnostic criteria of low cardiac output syndrome (LOS) is a cardiac index of less than 1.8 l/min/m2. However, recognition of this syndrome differs among intensivists as to whether or not LOS is synonymous with cardiogenic shock.

Case reports: Here, we present two cases of heart failure who were initially treated with diuretics and subsequently fell into a state of low cardiac output. We treated the patient with low blood pressure with inotropes and the patient with high blood pressure with a vasodilator according to their hemodynamics. We observed that cardiac power was the most significant hemodynamic change in response to these treatments. In this paper, we discuss the definition of LOS and show several criteria for determining LOS.

Conclusions: Broadly, there are several conditions of determining LOS. Even with those conditions, we should still be aware of the pathophysiology of each patient with heart failure. We propose that the definition of LOS should be a state of low cardiac output with corresponding symptoms, even if their blood pressure is high.

Authors: Yuichi Baba, Toru Kubo, Yuri Ochi, Tatsuya Noguchi, Naohito Yamasaki, Hiroaki Kitaoka

Outcomes in severe SARS-CoV-2 patients with liberal oxygenation and steroid therapy - a single centre experience

Real-world reports on outcomes of SARS-CoV-2 infection using higher oxygenation targets along with steroid therapy are lacking. We conducted a retrospective study of patients requiring oxygen support following targets of oxygenation >95% along with steroid therapy. Group 1 with oxygenation through a nasal cannula or Hudson mask, Group 2 oxygenation with venturi system, and Group 3 with high flow nasal oxygen, 35-50 litres; non-invasive ventilation; mechanical ventilation delivering. One hundred and eighteen patients (Group 1 74 patients, Group 2 15 patients, and Group 3 29 patients) were studied. The mean age was 55.7 years and most were male (n=77). One hundred and fourteen received dexamethasone or methylprednisolone. Most (88.3%) had at least one pre-existing chronic medical illness. Overall mortality was 22.8% (n=27). Group 3 had the highest mortality (75.9%) followed by Group 2 (26.7%) and Group 1 (1.35%). Our observation raises the query if a higher target of oxygenation for non-mechanical ventilated patients coupled with steroid therapy is beneficial.

Authors: Priyadarshini Varadaraj, Sowmya Gopalan, Aiswarya M. Nair, Lakshmi Marappa, Vaasanthi Rajendran, Viswanathan Pandurangan, Sudha Madhavan, Rajkumar Mani, Emmanuel Bhaskar

Restrictive fluid and fluid removal approach in diabetic ketoacidosis with septic AKI: A case report


Diabetic ketoacidosis is a life-threatening complication that requires a rapid restoration of intravascular volume usually with aggressive administration of intravenous fluid with 0.9% sodium chloride as recommended by the American Diabetes Association. We report a 50-year-old obese female patient with a history of diabetes mellitus (DM) since 20 years ago and routinely using insulin. She experienced dyspnea and presumably was caused by diabetic ketoacidosis. The patient was given fluid resuscitation with normal saline, but the dyspnea did not resolve and the work of breathing increased further, so the patient was intubated and admitted to the intensive care unit. Aggressive fluid resuscitation carries potential adverse effects such as hyperchloremic metabolic acidosis, interstitial multi-organ edema, and increased incidence of acute kidney injury. The first day of ICU treatment, positive cumulative fluid balance occurred and fluid removal was indicated. Fluid removal using diuretic or ultrafiltration is a part of the treatment of organ congestion and fluid overload after the initial phase of shock resuscitation to achieve negative fluid balance. This case showed that restricted fluid and fluid removal improve the patient outcome, especially in diabetic ketoacidosis and septic AKI patients.

Authors: Elvia AS, Mayang Indah Lestari, Yohannes WH George

Brain stem infarction as a complication of probable meningitis/encephalitis associated with COVID-19: A case report from Lombok, West Nusa Tenggara

AbstractCoronavirus disease 2019 (COVID-19), firstly discovered in Wuhan, China, has spread globally and was declared by the World Health Organization (WHO) as a pandemic since March 11, 2020. By June 13, 2020, the number of Covid cases in Indonesiawas 37420 with 2091 mortality cases. Lombok is situated in the province of West Nusa Tenggara, currently the number of Covid-19 cases 937. We report a case of probable meningitis/encephalitis associated with COVID-19 with symptoms of fever, headache, and cough. The patient was brought to the Emergency Room with decreased of consciousness, seizures, and neck rigidity. The thoracic examination and head computed tomography (CT) scan revealed pneumonia and brain stem infarction, respectively. Nasopharyngeal swab examination was performed and identified the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ribonucleic acid (RNA) leading to meningitis due to COVID-19.

Authors: Ilsa Hunaifi, Karina Anindita, Elya Endriani, Sri Kartika Sari, Ririn Setyawati, Indah Widya Astuti, Sandra Yuliana Andini Putri, Zainul Muttaqin

A case report: Does amynophilline have opportunity in COVID-19 management?

AbstractThe novel coronavirus disease 2019 (COVID-19) is caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2), which causes severe acute respiratory distress syndrome (ARDS). ARDS causes the patient to have difficulty breathing, the appearance of pneumonia from chest radiological images, and from the examination results by pulse oximetry, the picture of oxygenation is poor. Most clinical complaints require mechanical ventilation and treatment in the intensive care unit (ICU). We made several attempts to increase oxygenation and ventilation from a pharmacological and non-pharmacological perspective. From pharmacology, given drugs that help from an immunological aspect, reduce preload, help cardiac contractility, and anti-virus. In this case report, we report aminophylline administration as a therapeutic modality in critically ill patients' handling due to COVID-19.

Authors: Anna Surgean Veterini, Lucky Andriyanto, Hamzah

Dabigatran-induced hemopericardium with tamponade


Background: Rapidly changing the pharmacokinetics and pharmacodynamics in critically ill patients with acute kidney injury leads to patients having a high risk of bleeding despite the early cessation of direct oral anticoagulant (DOAC). Bleeding complications can occur at a rare hidden site, the hemopericardium; this type of complication requires point-of-care ultrasound examinations (POCUS) for early detection and the performance of ultrasound-guided drainage as a lifesaving procedure.

Case presentation: An 84-year-old woman with atrial fibrillation who was taking 110 mg bid dabigatran and who presented with obstructive sleep apnea and deteriorated renal function as well as type 2 respiratory failure. The patient was compliant with the dosage of dabigatran (110 mg twice daily), and the last dose was taken a few hours prior to being transferred to the critical care unit. Within 24 hours, the patient was notably lethargic and oliguric. Laboratory examination demonstrated a deterioration in renal function. Serial transthoracic echocardiography demonstrated new mild pericardial effusion that progressively increased for the next 4 hours with signs of early cardiac tamponade. Idarucizumab was administered. The patient underwent successful echocardiography guided pericardiocentesis without complications. A 500 ml of grossly hemorrhagic fluid was removed. The patient recovered to baseline status over the course of one week, with laboratory and clinical resolution of multiorgan failure and no echocardiographic evidence of hemopericardium.

Conclusion: Life-threatening hidden hemorrhagic complications warrant caution in patients receiving DOAC. Our case highlights both a rare bleeding complication of dabigatran, and the effectiveness of idarucizumab, the approved reversal agent. Clinicians should closely monitor patient renal function in the setting of critical care area. Urgent POCUS detected the complication early, and ultrasound guided pericardiocentesis was followed by improved hemodynamic.

Authors: Zouheir Ibrahim Bitar, Ossama Sajeh Maadarani, Mahmoud Jaber Mohsen, Tamer Mohamed Zaalouk

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


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


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


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


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