Category Archives: Case Report

Toxic Megacolon – A Three Case Presentation

Irina Magdalena Dumitru1, Eugen Dumitru2, Sorin Rugina1,3, Liliana Ana Tuta2

1 Discipline of Infectious Diseases, Faculty of Medicine, Ovidius University of Constanta, Romania
2 Discipline of Internal Medicine, Faculty of Medicine, Ovidius University of Constanta, Romania
3 The Academy of Romanian Scientists

DOI: 10.1515/jccm-2017-0008

Introduction: Toxic megacolon is a life-threatening disease and is one of the most serious complications of Clostridium difficile infection (CDI), usually needing prompt surgical intervention. Early diagnosis and adequate medical treatment are mandatory.
Cases presentation: In the last two years, three Caucasian female patients have been diagnosed with toxic megacolon and treated in the Clinical Infectious Diseases Hospital, Constanta. All patients had been hospitalized for non-related conditions. The first patient was in chemotherapy for non-Hodgkin’s lymphoma, the second patient had undergone surgery for colon cancer, and the third patient had surgery for disc herniation. In all cases the toxin test (A+B) was positive and ribotype 027 was present. Abdominal CT examination, both native and after intravenous contrast, showed significant colon dilation, with marked thickening of the wall. Resolution of the condition did not occur using the standard treatment of metronidazole and oral vancomycin, therefore the therapy was altered in two cases using intracolonic administration of vancomycin and intravenous tigecycline.
Conclusions: In these three cases of CDI, the risk factors for severe evolution were: concurrent malignancy, renal failure, obesity, and immune deficiencies. Ribotype 027, a marker for a virulent strain of CD, was found in all three cases complicated by toxic megacolon. The intracolonic administration of vancomycin, and intravenous tigecycline was successful when prior standard therapy had failed, and surgery was avoided.

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Emergency Surgery in a Critically Ill Patient with Major Drug-Induced Bleeding and Severe Ischaemic Heart Failure

Dana Tomescu1,2, Mihai Popescu1,2

1 “Carol Davila” University of Medicine and Pharmacy, Department of Anaesthesia and Critical Care, Bucharest, Romania
2 Fundeni Clinical Institute, Department of Anaesthesia and Critical Care III, Bucharest, Romania

DOI: 10.1515/jccm-2017-0003

Introduction: Anticoagulant overdose frequently occurs in elderly populations especially in remote areas where medical services are scarce. When emergency surgery is required, such patients offer major anaesthetic challenges.
Case presentation: We describe the case of an elderly patient admitted to a surgical ward with acute abdominal pain, on dual anti-platelet therapy and acenocoumarol for a recent acute myocardial infarction treated percutaneously with two drug-eluting stents. Laboratory tests showed severe anticoagulant overdose with uncoagulable INR. The decision was made to use of both light transmission aggregometry [LTA] for platelet function testing and thromboelastography to aid in the management of perioperative haemostasis in order to prevent both severe bleeding and stent thrombosis. Surgery revealed haemoperitoneum, volvulus of the ileum and a venous mesenteric infarction. Intraoperative blood loss was minimal and no blood products were administered. Postoperative course was uneventful without either thrombotic or haemorrhagic complications and the patient was discharged from the Postanaesthesia Care Unit on postoperative day two.
Conclusion: The use of aggregometry and thrombography helped in both evaluation and management of haemostasis of a high-risk patient by goal-directed administration of pro-and anti- coagulants.

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Toxic Epidermal Necrolysis – A Case Report

Laura Stătescu1, Magda Constantin2, Horia Silviu Morariu3, Laura Gheucă Solovăstru1

1 Dermatology Department, University of Medicine and Pharmacy “Grigore T. Popa”, Iaşi, Romania
2 Dermatology Department, University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
3 Dermatology Department, University of Medicine and Pharmacy Târgu Mureş, România

DOI: 10.1515/jccm-2017-0002

Toxic epidermal necrolysis (TEN) is an acute, life-threatening muco-cutaneous disease, often induced by drugs. It is characterized by muco-cutaneous erythematous and purpuric lesions, flaccid blisters which erupt, causing large areas of denudation. The condition can involve the genitourinary, pulmonary and, gastrointestinal systems. Because of the associated high mortality rate early diagnosis and treatment are mandatory.
This article presents the case of a sixty-six years old male patient, known to have cirrhosis, chronic kidney failure, and diabetes mellitus. His current treatment included haemodialysis. He was hospitalized as an emergency to the Dermatology Department for erythemato-violaceous, purpuric patches and papules, with acral disposition, associated with rapidly spreading erosions of the oral, nasal and genital mucosa and the emergence of flaccid blisters which erupted quickly leaving large areas of denudation. Based on the clinical examination and laboratory investigations the patient was diagnosed with TEN, secondary to carbamazepine intake for encephalopathic phenomena. The continuous alteration in both kidney and liver function and electrolyte imbalance, required him to be transferred to the intensive care unit. Following pulse therapy with systemic corticosteroids, hydro-electrolytic re-equilibration, topical corticosteroid and antibiotics, there was a favourable resolution of TEN.
The case is of interest due to possible life-threatening cutaneous complications, including sepsis and significant fluid loss, in a patient with associated severe systemic pathology, highlighting the importance of early recognition of TEN, and the role of a multidisciplinary team in providing suitable treatment.

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A Fatal Case of Community Acquired Cupriavidus Pauculus Pneumonia

Emoke Almasy1, Janos Szederjesi1*, Paul Rad1, Anca Georgescu2

1 Discipline of Intensive Care, University of Medicine and Pharmacy Tîrgu Mureş, Romania
2 Discipline of Infectious Diseases, University of Medicine and Pharmacy Tîrgu Mureş, Romania

DOI: 10.1515/jccm-2016-0027

Introduction: Cupriavidus pauculus is a rarely isolated non-fermentative, aerobic bacillus, which occasionally causes severe human infections, especially in immunocompromised patients. Strains have been isolated from various clinical and environmental sources.
Case presentation: A 67-year-old man was admitted to the Intensive Care Unit with acute respiratory failure. The patient was diagnosed with bilateral pneumonia, pulmonary sepsis and underwent invasive mechanical ventilation. Examination revealed diminished bilateral vesicular breath sounds, fever, intense yellow tracheal secretions, a respiratory rate of 24/minute, a heart rate of 123/minute, and blood pressure of 75/55 mmHg. Vasoactive treatment was initiated. Investigations revealed elevated lactate and C-reactive protein levels. A chest X-ray showed bilateral infiltration. Parenteral ciprofloxacin and ceftriaxone were administered. Tracheal aspirate culture and blood culture showed bacterial growth of Cupriavidus pauculus. Colistin was added to the treatment. There was a poor clinical response despite repeated blood culture showing negative results. The diagnosis of multiple organ dysfunction syndrome (MODS) caused by C. pauculus was made. The patient died eleven days after admission.
Conclusions: Clinical improvement cannot always be expected in spite of targeted antibiotic therapy. This pathogen should be considered responsible for infections that usually develop in immunocompromised patients.

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Pneumoretroperitoneum after Attempted Epidural Anesthesia

Arkadi Isakov1*, Arnold Shtein2, Sholmo Kyzer1

1 Department of Surgery “B,” Wolfson Medical Center, Holon, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
2 Department of Anesthesiology, Wolfson Medical Center, Holon, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

DOI: 10.1515/jccm-2016-0029

Air may extend to the retroperitoneal space from retroperitoneal perforation of a hollow viscus, infection of the anterior pararenal space with gas-forming organisms and from pneumothorax or pneumomediastinum [1]. Rare pathologies, such as open reduction and internal fixation of femoral fractures and anaerobic abscess of the hip joint have also been described in relation to this complication [1,2]. A rare case of pneumoretroperitoneum caused by insufflation of air during an attempt to achieve epidural anesthesia is described.

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Staphylococcal Scalded Skin Syndrome in Child. A Case Report and a Review from Literature

Alina Grama1, Oana Cristina Mărginean1*, Lorena Elena Meliț1, Anca Meda Georgescu2

1 Pediatrics I Department, University of Medicine and Pharmacy Târgu-Mureș, Romania
2 Infectious Diseases Department, University of Medicine and Pharmacy Târgu-Mureș, Romania

DOI: 10.1515/jccm-2016-0028

Staphylococcal scalded skin syndrome (SSSS) is the medical term used to define a skin condition induced by the exfoliative toxins produced by Staphylococcus aureus. The disorder is also known as Ritter disease, bullous impetigo, neonatal pemphigus, or staphylococcal scarlet fever. The disease especially affects infants and small children, but has also been described in adults. Prompt therapy with proper antibiotics and supportive treatment has led to a decrease in the mortality rate.
The current case report describes the clinical progress of a patient with generalized erythema and fever, followed by the appearance of bullous lesions with tendency to rupture under the smallest pressure, and with extended areas of denudation.
The patient aged four years and six months was admitted to our clinic to establish the aetiology and treatment of a generalized bullous exanthema, followed by a skin denudation associated with fever and impaired general status.
Based on clinical and paraclinical examinations a diagnosis of Staphylococcal scalded skin syndrome was established which responded favourably to antibiotic treatment, hydro-electrolytic re-equilibration, and adequate local hygiene.
Staphylococcal infection can represent a problem of significant pathological importance sometimes requiring a multidisciplinary approach involving paediatricians, dermatologists, infectious diseases specialists, and plastic surgeons.

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Nosocomial Staphylococcal Toxic Shock. Case Report

Manuela Arbune1,2*, Loredana Tercu2

1 “Dunarea de Jos” University Galati, Romania
2 Hospital of Infectious Diseases “Sf. Cuvioasa Parascheva” Galaţi, Romania

DOI: 10.1515/jccm-2016-0020

Staphylococcal toxic shock syndrome (STSS) is a rare, potentially lethal infection, with a clinical picture of multiple organ dysfunction and shock. The etiology is Staphylococcus aureus exotoxin, while enterotoxins act as superantigens. Most cases are identified in women using a vaginal tampon.  A 51-year-old female, with a past medical history of biliary dyskinesia, presented in the emergency room complaining of sudden onset of abdominal pain, vomiting, headache, myalgia, and chills. The initial diagnosis was biliary colic and was treated parenterally with Amoxi-clavulanate and fluid replacement. Initially, progress was unsatisfactory. Four days after admission she developed a systemic inflammatory syndrome, diffuse rash, jaundice, oliguria, confusion, persistent hypotension and biological evidence of thrombocytopenia, nitrogen retention, and cholestasis. She was admitted to the intensive care unit. A gluteal phlegmon induced after intramuscular injections was identified and surgically treated. Blood bacteriological cultures were negative, though MRSA was isolated in phlegmon pus. A diagnosis of STSS was based on CDC criteria.
The risks of similar infections could be prevented by limiting intramuscular treatments and monitoring invasive procedures.

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Malignant Middle Cerebral Artery Infarction Secondary to Traumatic Bilateral Internal Carotid Artery Dissection. A Case Report

Zoltán Bajkó1, Rodica Bălaşa1, Anca Moţăţăianu1*, Laura Bărcuţean1, Adina Stoian2, Nicoleta Stirbu3, Smaranda Maier1

1 University of Medicine and Pharmacy Târgu Mureş, Department of Neurology
2 University of Medicine and Pharmacy Târgu Mureş, Department of Pathophysiology
3 Mediab Medical Center Târgu Mureş

DOI: 10.1515/jccm-2016-0021

Traumatic bilateral dissection of the carotid arteries is a rare condition with potentially life-threatening complications. The case of a 57-year-old male patient with acute onset left sided hemiparesis, twelve hours after a blunt head injury, caused by a horse kick, is reported. A cerebral CT scan revealed right middle cerebral artery (MCA) territory infarction. Based on Duplex ultrasound and Angio CT scan findings, a diagnosis of bilateral ICA dissection was established. Despite antithrombotic treatment, the patient presented with a progressive worsening of his neurological status. The control CT scan evidenced malignant right MCA territory infarction that required decompressive craniotomy. The patient was discharged with significant neurological deficits. Together with this case, the aetiologies, clinical manifestations, diagnostic and therapeutical options and outcome of carotid artery dissection are discussed.

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Complications of Sepsis in Infant. A Case Report

Lorena Elena Meliț1, Cristina Oana Mărginean2*, Anca Georgescu3, Carmen Duicu2

1 Pediatrics Clinic 1, County Clinical Emergency Hospital
2 University of Medicine and Pharmacy Tîrgu Mureș, Pediatrics Clinic 1
3 University of Medicine and Pharmacy Tîrgu Mureș, Infectious Diseases Clinic 1

DOI: 10.1515/jccm-2016-0012

Sepsis is a systemic inflammatory response (SIRS) characterized by two or more of the following: fever > 38.5 °C or <36 °C, tachycardia, medium respiratory frequency over two SD for age, increased number of leukocytes.
The following is a case of an eight months old, female infant, admitted in to the clinic for fever (39.7 C), with an onset five days before the admission, following trauma to the inferior lip and gum. Other than the trauma to the lip and gum, a clinical exam did not reveal any other pathological results. The laboratory tests showed leukocytosis, positive acute phase reactants (ESR 105 mm/h, PCR 85 mg/dl), with positive blood culture for Staphylococcus aureus MSSA. at 24 hours. Three days from admission, despite the administration of antibiotics (Vancomycin+Meronem), there was no remission of fever, and the infant developed a fluctuant collection above the knee joint. This was drained, and was of a serous macroscopic nature. A decision was made to perform a CT, which confirmed the diagnosis of septic arthritis. At two days after the intervention, the fever reappeared, therefore the antibiotic regime were altered (Oxacillin instead of Vancomycin), resulting in resolution of the fever. Sepsis in infant is a complex pathology, with non-specific symptoms and unpredictable evolution.

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The Pitfalls of Febrile Jaundice. A Case Report

Maria Obreja1*, Andra Teodor1,2, Daniela Leca1,2, Alexandr Ceasovschih3, Egidia Miftode1,2

1 “Sfânta Parascheva” Infectious Diseases Hospital Iași, România
2 “Grigore T. Popa”University of Medicine and Pharmacy, Iași,România
3 Department of Medicine, “Sfântul Spiridon” Emergency Clinical Hospital, Iași, România

DOI: 10.1515/jccm-2016-0013

Jaundice in sepsis is usually caused by cholestasis, and its onset can precede other manifestations of the infection. Inflammation-induced cholestasis is a common complication in patients with an extrahepatic infection or those with inflammatory processes. We describe the case of a 47 years old female who presented with low back pain and paravertebral muscular contracture. She subsequently developed a cholestatic syndrome with clinical manifestations such as jaundice, followed by fever and sepsis with multiple organ dysfunction. Initially labeled as biliary sepsis, the diagnosis was crucially reoriented as the blood cultures were positive for Streptococcus pyogenes and the magnetic resonance imaging (MRI) findings suggested spondylodiscitis as well as a paravertebral abscess.

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