Category Archives: Case Report

Acquired Tracheal Diverticulum as an Unexpected Cause of Endotracheal Tube Cuff Leak

René Agustin Flores-Franco*, Jesús Silva-Alcaraz

Departamento de Neumología y Medicina Interna, Hospital General Regional “Dr. Salvador Zubirán Anchondo”, Chihuahua, México

DOI: 10.1515/jccm-2015-0024

Introduction: Tracheal diverticulum has been associated with problems during endotracheal intubation but there are no reports concerning air leakage around an endotracheal tube (ETT).
Case report: The case of an elderly woman under mechanical ventilatory support because an exacerbation of chronic obstructive pulmonary disease (COPD) is reported. She presented with an inexplicably air leak around the endotracheal tube not attributed to structural defects. The intra-cuff pressure value was as high as 30 mmHg to prevent an air leakage. Bronchoscopy revealed a tracheal diverticulum at the site ofthe tube cuff that allowed air leakage around it. The problem was overcome by re-intubating the patient with a larger diameter tube and positioning its distal end above the diverticular opening.
Discussion: Endotracheal tube air leak is a frequently neglected problem. COPD and other inflammatory conditions are associated with changes in the elastic properties of the airways resulting in tracheomegaly or acquired tracheal diverticulum. Both entities have been linked to problems during intubation or ventilation of patients. However tracheal diverticulum has not been described previously as a cause of air leakage.
Conclusion: Acquired tracheal diverticulum should be recognized as a cause of air leakage in the intubated patient, especially if associated with a normal or elevated intracuff pressure.

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Neutrophil Viability as a Clinical Outcome Marker in Mechanically Ventilated Critically Ill Trauma Patients: A Case Series

Orsolya Benedek1, Mihaly Veres2, Minodora Dobreanu1

1 University of Medicine and Pharmacy of Tirgu Mures, Romania
2 County Clinical Emergency Hospital Tirgu Mures, Romania

DOI: 10.1515/jccm-2015-0019

Background: Trauma in its early stages leads to an acute inflammatory condition affecting all cellular lines. Neutrophil granulocytes make up the largest population of human white blood cells and are fundamental to the innate immune system. The objective of our pilot study was to evaluate neutrophil death and viability alterations in critically ill trauma patients in correlation with their clinical outcome.
Material and method: Critical ill trauma patients were enrolled in the study. In order to assess alterations in cellular death, blood samples were drawn using EDTA containing tubes and analyzed in the first twenty four hours after admission, then after forty eight and seventy two hours. Annexin V was used as a marker for apoptotic cells and propidium iodide for necrotic cells.
Results: The first two cases exhibited an increase in cellular viability by the second day as shown by a small increase in neutrophil apoptosis and a decrease in neutrophil necrosis. These patients progressed to a positive clinical outcome. The second two cases showed slight modifications in either physiological or pathological cellular death, and increasing levels of cellular necrosis. These patients progressed to a negative clinical outcome.
Conclusions: These cases suggest that neutrophil cell viability and death were associated with the patient’s clinical outcome.

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Acute Ischaemic Stroke Secondary to a Mobile Thrombus in the Common Carotid artery – Case Report

Zoltán Bajkó1,2, Smaranda Maier1,2, Silvia Rusu2, Anca Moțățăianu1,2

1 University of Medicine and Pharmacy Târgu Mureș, Department of Neurology, Gheorghe Marinescu street 38, 540139 Târgu Mureș, Romania
2 Mureș County Clinical Emergency Hospital Târgu Mureș, Neurology Clinic I, Gheorghe Marinescu street 50, 540136, Târgu Mureș, Romania

DOI: 10.1515/jccm-2015-0010

A mobile thrombus in the carotid arteries is a very rare ultrasonographic finding and is usually diagnosed after a neurological emergency, such as a transient ischemic attack or cerebral infarction. We present the case of a 54-year-old man with vascular risk factors (a heavy smoker, untreated hypertension) who was admitted to the emergency unit with right sided hemiparesis and aphasia. A cerebral CT scan showed a left middle cerebral artery territory infarction. The duplex ultrasound examination revealed mild atherosclerotic changes in the right common and internal carotid arteries, right-sided complete subclavian steal phenomenon and a complicated hypoechoic atherosclerotic plaque in the left common carotid artery with a large mobile thrombus.  Due to the high embolization risk, the patient was hospitalised and prescribed Aspirin together with low molecular weight Heparin. We recorded an improvement in the patient’s neurological status and the control duplex scan revealed disappearance of the thrombus. The presence of floating thrombus in a patient with clinical and imagistic evidence of stroke is a major therapheutic challenge for the neurologist. The treatment strategies are not standardized and must be individualized, however in our case parenteral anticoagulation proved to be successful.

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Intra-arterial Thrombolysis in Second Trimester of Pregnancy. A Case Report

Endre Pongrácz1, Szabolcs Farkas2, Miklós Dajka3, László Csiba2

1 Department of Neurology, Hetényi Géza Hospital,  H-5001 Szolnok, Tószegi street 21, Hungary
2 Department of Neurology, University of Debrecen, H-4012 Debrecen, Móricz Zsigmond street, no.22, Hungary
3 Department of Radiology, Avas Medical Centre LLC, H-5001 Szolnok, Tószegi street 21, Hungary

DOI: 10.1515/jccm-2015-0005

Here we present a successful intra-arterial thrombolysis performed in the second trimester of pregnancy (21 weeks). The intervention resulted in complete recanalization of the occluded right middle cerebral artery and favourable clinical and gestational outcome. Together with cases described in respective medical literature our report affirms that in pregnancy acute ischemic stroke could be treated effectively applying intra-arterial thrombolysis (using rt-PA). This therapy could provide opportunity to help in such desperate situations.

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Drug Closure of a Patent Ductus Arteriosus in an Extremely Low Birth Weight Premature Newborn. A Case Report

Elena Moldovan1, Manuela Cucerea1,2

1 University of Medicine and Pharmacy Tîrgu-Mureş, Romania, 38 Gheorghe Marinescu street, Tirgu Mures, 540139, Romania

2 Regional Center of Neonatal Intensive Care Unit UGON, 50 Gheorghe Marinescu street, Tirgu Mures, 540139, Romania

DOI: 10.1515/jccm-2015-0006

Introduction: Patent ductus arteriosus involves maintaining the permeability of the vascular ductus located between the pulmonary artery and the descending aorta, due to the failure of transition from foetal to adult type circulation. This malformation is characteristic to premature newborns with extremely low birth weight. The main pathophysiological factors identified in this pathology are immaturity of the smooth muscles, presence of vasodilator mediators and persistent hypoxaemia. Ductal-dependent cardiac malformations require drug therapy for keeping the permeability of the ductus arteriosus until the time of corrective surgery.
Case presentation: We present the case of an extremely low birth weight premature new-born, derived from twin pregnancy with suspected specific pathology, respectively feto-fetal transfusion syndrome, admitted to the Regional Centre of Neonatal Intensive Care Unit Tîrgu-Mureş.
Premature newborn with gestational age 31-32 weeks, extremely low birth weight, derived from twin pregnancy, with adequate prenatal follow up, was born by caesarean section for severe intrauterine growth restriction secondary to feto-fetal transfusion syndrome suspicion. The newborn developed respiratory distress syndrome by surfactant deficiency, intraventricular-haemorrhage grade I/II, and severe retinopathy. The detection of a systolic murmur in the second week of life, the diastolic theft revealed by trans-fontanellar ultrasound as well as lowered diastolic blood pressure values raised the suspicion of a patent ductus arteriosus and therefore specific treatment with ibuprofen, a cyclooxygenase inhibitor, was initiated. Progressive alteration of the newborn`s condition and the evidence of a coarctation of the aorta imposed the initiation of Prostaglandin E1 therapy and subsequent surgical correction.
Conclusions: Although beneficial, prophylactic or therapeutic closure of persistent ductus arteriosus may worsen the evolution of a newborn with a “silent” cardiac malformation and associated pathology.

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