Category Archives: Case Report

Acute Calculous Cholecystitis Associated with Leptospirosis: Which is the Emergency? A Case Report and Literature Review

Renata Moriczi, Mircea Gabriel Muresan, Radu Neagoe, Daniela Sala, Arpad Torok, Tivadar jr. Bara, Ioan Alexandru Balmos, Razvan Ion, Anca Meda Vasiesiu

George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2024-0033

Introduction: Leptospirosis is a bacterium with a worldwide distribution and belongs to the group of zoonoses that can affect both humans and animals. Most cases of leptospirosis present as a mild, anicteric infection. However, a small percentage of cases develop Weil’s disease, characterized by bleeding and elevated levels of bilirubin and liver enzymes. It can also cause inflammation of the gallbladder. Acute acalculous cholecystitis has been described as a manifestation of leptospirosis in a small percentage of cases; however, no association between leptospirosis and acute acalculous cholecystitis has been found in the literature.
Case presentation: In this report, we describe the case of a 66-year-old patient who presented to the emergency department with a clinical picture dominated by fever, an altered general condition, abdominal pain in the right hypochondrium, nausea, and repeated vomiting. Acute calculous cholecystitis was diagnosed based on clinical, laboratory, and imaging findings. During preoperative preparation, the patient exhibited signs of liver and renal failure with severe coagulation disorders. Obstructive jaundice was excluded after performing an abdominal ultrasound and computed tomography scan. The suspicion of leptospirosis was then raised, and appropriate treatment for the infection was initiated. The acute cholecystitis symptoms went into remission, and the patient had a favorable outcome. Surgery was postponed until the infection was treated entirely, and a re-evaluation of the patient’s condition was conducted six-week later.
Conclusions: The icterohemorrhagic form of leptospirosis, Weil’s disease, can mimic acute cholecystitis, including the form with gallstones. Therefore, to ensure an accurate diagnosis, leptospirosis should be suspected if the patient has risk factors. However, the order of treatments is not strictly established and will depend on the clinical picture and the patient’s prognosis.

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Uncommon Malposition of an Ultrasound-Guided Central Venous Catheter in the Renal Vein through the Superficial Femoral Vein: A Case Report

Ting-Chia Remus Young1,2, Kuang-Hua Cheng1,3, Kuan-Pen Yu1,4

1 Department of Critical Care Medicine, MacKay Memorial Hospital, Taipei, Taiwan
2 Department of Medicine, Mackay Medical College, New Taipei, Taiwan
3 Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taiwan
4 Department of Anesthesiology, MacKay Memorial Hospital, Taipei, Taiwan

DOI: 10.2478/jccm-2024-0026

Introduction: Malposition is a relatively rare complication associated with peripherally inserted central catheters (PICCs), particularly in cases of superficial femoral vein (SFV) catheterization. To the best of our knowledge, we are the first to report this rare case of SFV PICC malposition in the contralateral renal vein.
Case presentation: An 82-year-old woman underwent bedside cannulation of the SFV for PICC under ultrasound guidance. Subsequent radiographic examination revealed an unexpected misplacement, with the catheter tip positioned toward the contralateral renal vein. After pulling out the catheter on the basis of the X-ray result, it was observed that the catheter retained its function.
Conclusion: Although rare, tip misplacement should be considered in SFV PICC placement. Prompt correction of the tip position is crucial to prevent catheter malfunction and further catastrophic consequences. For critical patients receiving bedside SFV PICC insertion, postoperational X-ray is crucial for enhancing safety.

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Managing Multifactorial Deep Vein Thrombosis in an Adolescent: A Complex Case Report

Măriuca Mănescu 1, Alina Grama2, Andreea Ligia Dincă2, Mihaela Chinceșan2

1 Emergency County Hospital Targu-Mures, Targu Mures, Romania
2 George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2024-0024

Introduction: Although rarely diagnosed in the pediatric population, deep vein thrombosis (DVT) is experiencing a growing incidence, while continuously acquiring different nuances due to the widening range of risk factors and lifestyle changes in children and adolescents.
Case presentation: A 17-year-old female within four weeks after child delivery was admitted to our clinic due to a six-month history of pain in the left hypochondriac region. After a thorough evaluation, the presence of a benign splenic cyst was revealed, which was later surgically removed. Following the intervention, the patient developed secondary thrombocytosis and bloodstream infection which, together with pre-existing risk factors (obesity, compressive effect of a large cyst, the postpartum period, the presence of a central venous catheter, recent surgery, and post-operative mobilization difficulties) led to the occurrence of extensive DVT, despite anticoagulant prophylaxis and therapy with low-molecular-weight heparin.
Conclusions: DVT raises many challenges for the pediatrician, requiring a personalized approach. Although rare, pediatric patients with multiple concomitant high-risk factors should benefit from interdisciplinary care as DVT may not respond to standard therapy in such cases and rapidly become critical. Continual efforts to better understand and treat this condition will contribute to improved outcomes for pediatric patients affected by DVT.

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Cefiderocol and Intraventricular Colistin for Ventriculitis due to an Extensively Drug-Resistant Pseudomonas Aeruginosa

João Melo e Silva1, Diogo Oliveira2, João A. Louro3, Elisabete Monteiro4

1 Hospital de Vila Franca de Xira, Lisboa, Portugal
2 Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
3 Hospital Professor Doutor Fernando Fonseca EPE, Lisboa, Portugal
4 Centro Hospitalar Universitário de São João , Porto, Portugal

DOI: 10.2478/jccm-2024-0020

Rheumatoid arthritis, an inflammatory rheumatic disease predominantly affecting small limb joints, frequently compromises the cervical spine, resulting in spinal instability and the potential surgical necessity. This may result in severe complications, such as ventriculitis, often associated with a high mortality rate and multidrug-resistant organisms. A major challenge lies in achieving therapeutic antimicrobial concentrations in the central nervous system.
The authors present a case of a 65-year-old female, with cervical myelopathy due to severe rheumatoid arthritis. Following surgery, the patient developed ventriculitis caused by an extensively drug-resistant Pseudomonas Aeruginosa. Early diagnosis and prompt treatment played a crucial role in facilitating neurological and cognitive recovery.

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Posterior Reversible Encephalopathy Syndrome, not so Uncommon in Pediatric Patients with Renal Involvement: A Case Series

Ana-Maria Roxana Koller1, Alexandra Man1, Carmen Muntean2

1 Department of Pediatrics, County Emergency Clinical Hospital Targu Mures, Romania
2 George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2024-0004

Introduction: Posterior reversible encephalopathy syndrome (PRES) primarily shows neurological symptoms and is more frequent in males, often occurring in oncological patients. It can also be associated with renal conditions like post-streptococcal glomerulonephritis, a common cause of pediatric hypertension. Management involves blood pressure and seizure treatment. In some cases, it may lead to irreversible and severe complications. Early treatment is essential for prevention.
Presentation of case series: In the past six months, we have documented the cases of two patients, aged 15 and 10, both of whom presented with PRES and renal disease. These patients were admitted because of general malaise, headaches, nausea, vomiting, visual disturbances, and elevated blood pressure. Subsequently, both patients experienced epileptic episodes. Only the first patient required transfer to the Pediatric Intensive Care Unit (PICU). Cerebral magnetic resonance imaging (MRI) scans revealed distinct PRES lesions in both cases. Following comprehensive investigations, both cases were diagnosed with PRES in the context of acute post-streptococcal glomerulonephritis.
Conclusions: The patients showed improvement following the administration of antihypertensive and anticonvulsant medications, along with treatment for the underlying renal condition.

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Sudden Deterioration of a Young Patient During Elective Cesarean Section. Amniotic Fluid Embolism… or Else? – A Case Report

Ioana Roxana Codru1,2, Marian Valeriu Codru3, Bogdan Ioan Vintilă1,2, Ioana Gherman3, Dragoș Popescu1,3

1 Faculty of Medicine, Lucian Blaga University of Sibiu, Romania
2 Anesthesia and Intensive Care Clinic, Sibiu Emergency County Hospital, Romania
3 Obstetrics and Gynecology Clinic, Sibiu Emergency County Hospital, Romania

DOI: 10.2478/jccm-2024-0001

Sudden respiratory and circulatory collapse during or immediately after delivery, vaginal or surgical, can have many causes that can lead to poor maternal outcomes. A pregnancy-induced amniotic fluid embolism and anaphylaxis are two distinct medical conditions that appear similar clinically but have very different underlying mechanisms and treatment approaches. Amniotic fluid embolism is a rare but life-threatening obstetric emergency that leads to a systemic inflammatory response that can be easily confounded with an anaphylactic reaction. We report the case of a patient with no comorbidities or allergies before the current pregnancy that was proposed for delivery by C-Section under spinal anesthesia. After delivery of the placenta and administering the test dose of antibiotic, the patient developed sudden circulatory collapse, altered neurological status, and critical respiratory distress. At that point, the two presumed diagnoses were amniotic fluid embolism and anaphylaxis. Concurrently with the diagnostic pathway, supportive measures (intubation, mechanical ventilation, hemodynamic support) were taken. The clinical evolution was favorable, and after day three, the patient was discharged from the hospital. Our case highlights the significance of promptly distinguishing between anaphylaxis and amniotic fluid embolism to facilitate the timely management of the critical situation.

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Effectiveness of Minitracheostomy After Extubation in Patients with Pneumonia at High Risk of Reintubation: A Case Series

Akira Ouchi1, Yuji Takahashi2, Hidehiko Nakano2, Masaki Mochizuki2, Saiko Okamoto2, Hideaki Sakuramoto3, Kensuke Nakamura2

1 Ibaraki Christian University, Ibaraki, Japan
2 Hitachi General Hospital, Hitachi, Japan
3 Japanese Red Cross Kyushu International College of Nursing, Kyushu, Japan

DOI: 10.2478/jccm-2023-0029

Introduction: Minitracheostomy involves the percutaneous insertion of a 4-mm-diameter cricothyroidotomy tube for tracheal suctioning to facilitate the clearance of airway secretions. The advantage of using the minitracheostomy is in the clearance of secretions, however data on their usefulness for respiratory failure after extubation is limited.
Aim of the study: We aimed to assess the use of minitracheostomy for patients with challenging extubation caused by significant sputum.
Material and Methods: We conducted a retrospective analysis of consecutive case series. We analyzed the data of 31 patients with pneumonia. After minitracheostomy, the primary endpoints of reintubation within 72 hours and clinical effects, including mortality, length of intensive care unit (ICU), or hospital stay, were assessed. The successful extubation group included patients who did not require reintubation within 72 hours. Conversely, the reintubation group consisted of patients mandating reestablishment of intubation within 72 hours.
Results: Among those who underwent minitracheostomy after extubation, 22 (71%) underwent successful extubation and 9 underwent reintubation (reintubation rate: 29%). The in-hospital mortality rates after 30 days were 18.2% in the successful extubation group and 22.2% in the reintubation group. The ICU and hospital lengths of stay were 11 days (interquartile range: 8–14.3 days) and 23 days (interquartile range: 15.5–41 days), respectively, in the successful extubation group; they were 14 days (interquartile range: 11–18.5 days) and 30 days (interquartile range: 16–45.5 days), respectively, in the reintubation group.
Conclusions: The prophylactic use of minitracheostomy may be an option as a means of reducing reintubation in patients with pneumonia who are at very high risk of reintubation.Keywords: Airway extubation, weaning, ventilator weaning, respiration, tracheostomy, sputum, pneumonia
Keywords: airway extubation, ventilator weaning, tracheostomy, sputum, pneumonia

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COVID-19: A Possible Cause of Spontaneous Pneumoperitoneum

Patrícia Varela Ramos, Ana Maria Oliveira, Ângela Simas, Margarida Rocha Vera Cruz

Intensive Care Unit, Hospital de Vila Franca de Xira, Vila Franca de Xira, Portugal

DOI: 10.2478/jccm-2023-0018

Introduction: Pneumoperitoneum is the presence of air within the peritoneal cavity and is mostly caused by organ rupture. Spontaneous pneumoperitoneum accounts 5% to 15% of the cases and occurs in the absence of organ damage. The pulmonary origin of pneumoperitoneum is unusual, and probably associated with mechanical ventilation and alveolar leak. In patients with coronavirus disease 2019 (COVID-19) there are some reports of air leak, like pneumothorax, pneumomediastinum, pneumoperitoneum, and subcutaneous emphysema.
Case presentation: We present the case of a 70-year-old man with COVID-19 pneumonia admitted to the Intensive Care Unit (ICU). Since admission he was on Non-Invasive Ventilation (NIV), without improvement, needing Invasive Mechanical Ventilation (IMV) due to severe respiratory failure. Five days after IMV despite protective lung ventilation, massive spontaneous subcutaneous emphysema, pneumomediastinum and pneumoperitoneum were diagnosed. Besides initial conservative management 12 hours later, the patient developed abdominal compartment syndrome requiring percutaneous needle decompression.
Conclusions: Pneumoperitoneum can be considered a rare complication of COVID-19 pneumonia and its management, resulting not only from the viral pulmonary but also from secondary causes. Conservative management should be usually enough. However, in the presence of abdominal compartment syndrome prompt recognition and treatment are crucial and eventually lifesaving.

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Post-Operative Delirium Masking Acute Angle Closure Glaucoma

Zariel Jiaying Sim1, Xing Jieyin2, Thangavelautham Suhitharan2

1 Singhealth, Singapore, Singapore
2 Singapore General Hospital, Singapore, Singapore

DOI: 10.2478/jccm-2023-0016

Introduction: Acute angle closure glaucoma (AACG) is an ophthalmological emergency, and can lead to the devastating consequence of permanent vision loss if not detected and treated promptly. We present a case of an atypical presentation of unilateral AACG on post operative day (POD) 1, after a prolonged operation under general anaesthesia (GA).
Case presentation: A 65-year-old female underwent a 16 hour long operation for breast cancer and developed an altered mental status with a left fixed dilated pupil on POD 1. She was intubated to secure her airway in view of a depressed consciousness level and admitted to the intensive care unit. Initial blood investigations and brain imaging were unremarkable. On subsequent review by the ophthalmologist, a raised intraocular pressure was noted and she was diagnosed with acute angle closure glaucoma. She was promptly started on intravenous acetazolamide and pressure-lowering ophthalmic drops. Her intraocular pressure normalized in the next 24 hours with improvement in her mental status to baseline.
Conclusion: AACG needs to be consistently thought of as one of the top differentials in any post-operative patient with eye discomfort or abnormal ocular signs on examination. A referral to the ophthalmologist should be made promptly once AACG is suspected.

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Multiple Organ Dysfunction Secondary to Herpes Simplex Virus -1 Reactivation After Treatment With Dexamethasone and Sarilumab for Covid-19 Disease

Thomas Roe*, Sam Waddy, Nikitas Nikitas

University Hospitals Plymouth NHS Trust, Plymouth, Devon, United Kingdom

DOI: 10.2478/jccm-2023-0010

Introduction: The immunological response to the SARS-CoV-2 virus and the treatment of COVID-19 disease present a potential susceptibility to viral reactivation, particularly Herpes simplex virus-1 (HSV-1).
Case Presentation: A 49-year-old female presented to hospital with severe COVID-19 pneumonitis and was given sarilumab and dexamethasone. She was intubated and ventilated in the intensive care unit (ICU) and initially demonstrated biochemical and clinical evidence of improvement. This was followed by a severe acute deterioration in respiratory, renal, and cardiovascular function, accompanied by a vesicular rash on the face. Polymerase chain reaction confirmed HSV-1 reactivation and treatment with acyclovir was commenced. After 49 days in ICU the patient was successfully weaned from all organ support, and she made a satisfactory recovery.
Conclusions: HSV-1 reactivation is common in COVID-19 and likely contributes to poorer clinical outcomes. The mechanism causing susceptibility to viral reactivation is not clearly defined, however, the development of critical illness induced immunosuppression via dysfunction of interferon and interleukin pathways is a likely mechanism. This effect could be perpetuated with immunosuppressant medications, although further research is needed to characterise this phenomenon.

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