Category Archives: Case Report

The Use of Inhaled Epoprostenol for Acute Respiratory Distress Syndrome Secondary due to COVID-19: A Case Series

Komal Imtiaz1, Wade Jodeh2, Dave Sudekum2, Bruno DiGiovine2, Jason Hecht2

1 University of Texas at Houston, Houston, TX, USA
2 St Joseph Mercy Ann Arbor. Ann Arbor, MI, USA

DOI: 10.2478/jccm-2021-0036

Introduction: Inhaled epoprostenol (iEpo) is a pulmonary vasodilator used to treat refractory respiratory failure, including that caused by Coronavirus 2019 (COVID-19) pneumonia.
Aim of Study: To describe the experience at three teaching hospitals using iEpo for severe respiratory failure due to COVID-19 and evaluate its efficacy in improving oxygenation.
Methods: Fifteen patients were included who received iEpo, had confirmed COVID-19 and had an arterial blood gas measurement in the 12 hours before and 24 hours after iEpo initiation.
Results: Eleven patients received prone ventilation before iEpo (73.3%), and six (40%) were paralyzed. The partial pressure of arterial oxygen to fraction of inspired oxygen (P/F ratio) improved from 95.7 mmHg to 118.9 mmHg (p=0.279) following iEpo initiation. In the nine patients with severe ARDS, the mean P/F ratio improved from 66.1 mmHg to 95.7 mmHg (p=0.317). Ultimately, four patients (26.7%) were extubated after an average of 9.9 days post-initiation.
Conclusions: The findings demonstrated a trend towards improvement in oxygenation in critically ill COVID-19 patients. Although limited by the small sample size, the results of this case series portend further investigation into the role of iEpo for severe respiratory failure associated with COVID-19.

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A Case of Self-salvation in a Determined Chloroquine Suicide Attempt

Sylvère Störmann, John Hoppe, Daniela Steinert, Matthias W. Angstwurm

Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Germany

DOI: 10.2478/jccm-2021-0036

This report concerns a young man who attempted suicide by ingesting a cocktail with a lethal dose of chloroquine phosphate and large amounts of diazepam. On presentation, the patient was drowsy, unresponsive and in cardiogenic shock with severely impaired left ventricular function. Active charcoal and vasopressors were administered, and despite his intoxication with diazepam, a high-dose diazepam treatment was initiated in the hospital. It is concluded that diazepam in the cocktail played a vital role in the survival of this patient. With a rise in numbers, every emergency and intensive care physician should be familiar with chloroquine poisoning.

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Hypercoagulopathy in Overweight and Obese COVID-19 Patients: A Single-Center Case Series

Azza Sarfraz1,2, Zouina Sarfraz1,3, Aman Siddiqui1,4, Ali Totonchian4, Syed Hashim Abbas Ali Bokhari5, Hafiza Hussain3, Muzna Sarfraz1, Gaurav Patel1, Muhammad Hassaan Amjad6, Sameer Saleem Tebha1, Ivan Cherrez-Ojeda7,8, Patrick Dreyer1, Harshad Amin1, Jack Michel1

1 Larkin Health System, South Miami, FL, USA
2 Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
3 Research and Publications, Fatima Jinnah Medical University, Lahore, Pakistan
4 Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
5 School of Medicine, The Aga Khan University, Karachi, Pakistan
6 Neurosurgery, Sir Ganga Ram Hospital, Lahore, Pakistan
7 Allergy and Pulmonology, Universidad de Especialidades Espíritu Santo, Ecuador
8 Respiralab Research Center, Guayaquil, Ecuador

DOI: 10.2478/jccm-2021-0032

A case series is presented of five overweight or obese patients with confirmed coronavirus disease 2019 (COVID-19) in South Miami, Florida, United States. A multitude of coagulation parameters was suggestive of a hypercoagulable state among the hospitalized COVID-19 patients. This article reports various manifestations of hypercoagulable states in overweight and obese patients, such as overt bleeding consistent with disseminated intravascular coagulation, venous thromboembolism, gastrointestinal bleeding as well as retroperitoneal hematoma. All of the required admission to the intensive care unit and subsequently patients died. The characteristics of COVID-19-associated coagulopathy are atypical and warrant a further understanding of the pathophysiology to improve clinical outcomes, specifically in overweight or obese patients.

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Severe Acute Motor Axonal Neuropathy Associated with Influenza-A (H1N1) Infection and Prolonged Respiratory Failure – A Case Report

Oana Mosora1, Laura Barcutean1,2, Rodica Balasa1,2, Raluca Fodor3, Smaranda Maier1,2, Zoltan Bajko1,2, Adina Stoian1,4, Anca Motataianu1,2

1 Neurology 1 Clinic, Emergency County Hospital Targu-Mures, Romania
2 Neurology Department, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
3 Anaesthesiology Department, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
4 Pathophysiology Department, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2021-0030

Acute Motor Axonal Neuropathy (AMAN) is an immune-mediated disorder of the peripheral nervous system, part of the spectrum of the Guillain-Barre syndrome (GBS). An infectious event most often triggers it reported a few weeks before the onset. The reported case is of a 56 years-old woman who developed acute motor axonal neuropathy three weeks after respiratory infection with influenza A virus subtype H1N1. Despite early treatment with plasmapheresis and intravenous immunoglobulins, the patient remained tetraplegic, mechanically ventilated for five months, with repetitive unsuccessful weaning trails. The probable cause was considered to be phrenic nerve palsy in the context of acute motor axonal neuropathy. This case highlights that acute motor axonal neuropathy is a severe and life-threatening form of Guillain-Barre syndrome associated with significant mortality and morbidity. Neurological and physical recovery strongly depend on the inter-professional effort in an intensive care unit and neurology professionals.

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Shock Due to an Obstructed Endotracheal Tube

Stefanie Foong Ling Chua, Chi Ho Chan, Suhitharan Thangavelautham

Singapore General Hospital, Singapore, Singapore

DOI: 10.2478/jccm-2021-0027

Endotracheal tube obstruction by a mucus plug causing a ball-valve effect is a rare but significant complication. The inability to pass a suction catheter through the endotracheal tube with high peak and plateau pressure differences are classical features of an endotracheal tube obstruction. A case is described of endotracheal tube obstruction from a mucus plug that compounded severe respiratory acidosis and hypotension in a patient who simultaneously had abdominal compartment syndrome. The mucus plug was not identified until a bronchoscopic assessment of the airway was performed. Due to the absence of classical signs, the delayed identification of the obstructing mucus plug exacerbated diagnostic confusion. It resulted in various treatments being trialed whilst the patient continued to deteriorate from the evasive offending culprit. We suggest that earlier and more routine use of bronchoscopy should be employed in an intensive care unit, especially as a definitive way to rule out endotracheal obstruction.

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Pneumocephalus Following an Accidental Dural Puncture, Treated Using Hyperbaric Oxygen Therapy. A Case Report

Flávio Marino1, André Ferreira Simões1, Ângela Simas1, João Gonçalves Pereira1,2,3

1 Intensive Care Unit Department, Hospital Vila Franca de Xira, Vila Franca de Xira, Lisboa, Portugal
2 Nova Medical School, Universidade Nova de Lisboa, Lisboa, Portugal
3 Grupo de Infeção e Sépsis, Porto, Portugal

DOI: 10.2478/jccm-2021-0017

Introduction: Neuraxial techniques, including epidural anaesthesia, are often used for perioperative pain control and are generally safe. However, both transient, mild and even severe, life-threatening neurologic complications can occur.
Case presentation: A seventy-eight-year-old man was admitted to the hospital for a radical nephrectomy plus transurethral resection due to kidney and bladder cancer. During the epidural exploration, an accidental dural puncture was noted. This was followed by the patient complaining of an intense headache. The epidural catheter was placed in a different location, and surgery was performed uneventfully. The patient presented with confusion, agitation, vertical nystagmus, vision loss, and paraparesis about two hours later. The epidural levobupivacaine and morphine infusion were stopped, followed by motor block resolution. A computerized head-tomography scan showed extra-axial multiple air spots involving the frontal and temporal lobes. Emergent hyperbaric oxygen therapy was commenced. After a single session, there was complete resolution of all symptoms and a marked reduction in the number and volume of the extra-axial air visible on the CT scan.
Conclusions: Although rare, pneumocephalus is a well-recognized complication of a dural puncture. Its rapid recognition in a patient with new-onset neurological symptoms and early treatment with hyperbaric oxygen therapy allows rapid clinical and imaging resolution and an improved prognosis.

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Postpartum Acute Basilar Artery Occlusion Secondary to Vertebral Artery Dissection. Case Report and Literature Review

Iulia-Adela Drăghici1, Lucian Marginean2, Rares-Cristian Filep2, Zoltan Bajko3,
Laura Barcutean3, Teodora Aldea1, Rodica Balasa3

1 1st Neurology Clinic, Emergency County Hospital Targu Mures, Romania
2 Department of Interventional Radiology, Emergency County Hospital Targu Mures, Romania
3 Department of Neurology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2021-0015

Female patients in the peripartum and postpartum periods have an increased risk of stroke than nonpregnant women. Cerebrovascular complications of pregnancy represent a significant cause of maternal mortality and morbidity and are potentially disabling. Acute basilar artery occlusion secondary to spontaneous vertebral artery dissection in the postpartum period is an infrequent entity and a major diagnostic and treatment challenge. In the present case, a 37-year-old female patient, eight weeks after caesarean delivery, presented with a history of sudden cervical pain, followed by headache and dizziness. Some hours later, she was found unconscious by her family and was transferred to the emergency department, where a neurological status assessment suggested vertebrobasilar stroke. The imagistic workup revealed right vertebral artery dissection and basilar artery occlusion without constituted ischemic lesions. The patient underwent endovascular intervention with dilation of the narrowed vertebral artery and stent retriever basilar artery thrombectomy, with a favourable clinical outcome. This report first presents the details of this case and the relevant literature data on postpartum arterial dissections and the subsequent ischemic complications and available treatment options.

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COVID -19 complicated by Acute Respiratory Distress Syndrome, Myocarditis, and Pulmonary Embolism. A case report

Rajai F. Bulbul, Jassim Al Suwaidi, Mohammed Al-Hijji, Hassan Al Tamimi, Ibrahim Fawzi

Hamad Medical Corporation, Doha, Qatar

DOI: 10.2478/jccm-2020-0041

A 49-year-old female Qatari woman, with no past medical history, presented at a hospital complaining of a history of cough and shortness of breath. The patient tested positive for severe acute respiratory syndrome (ARDS) and COVID-19. Subsequently, her course of treatment was complicated by severe acute respiratory distress syndrome, pulmonary embolism and severe myocarditis requiring treatment with venous-arterial extracorporeal membrane oxygenation as a bridge to complete recovery.

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Contrast Medium-Induced Encephalopathy after Coronary Angiography – Case Report

Sebastian Andone1, Rodica Balasa2, Laura Barcutean1, Zoltan Bajko2, Valentin Ion3, Anca Motataianu2, Adina Stoian4, Smaranda Maier2

1 Doctoral School, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
2 Department of Neurology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
3 Department of Analytical Chemistry and Drug Analysis, Faculty of Pharmacy, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
4 Department of Pathophysiology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2021-0010

Introduction: Contrast-induced encephalopathy represents a rare, reversible complication that appears after intravenous or intra-arterial exposure to contrast agents. There is no consensus in the literature regarding the mechanism of action. However, the theoretical mechanism is set around the disruption of the blood-brain barrier and the contrast agents’ chemical properties.
Case report: The case of a 70-year-old patient, known to have hypertension and type 2 diabetes mellitus is reported. The patient had undergone a diagnostic coronary angiography during which he received 100ml of Ioversol (Optiray 350™). Soon after the procedure, the patient began experiencing a throbbing headache, followed by intense behavioural changes and aggressive tendencies. He was transferred to the Neurology Clinic. The neurological examination was without focal neurological signs; however, the patient was very aggressive and uncooperative. The CT scan revealed a mild hyper-density in the frontal lobes. MRI scan revealed no pathological changes. Conservative treatment with diuretics and hydration was administered, and the patient experienced a complete resolution of symptoms in 72 hours.
Conclusion: Contrast-induced encephalopathy is a possible secondary complication to contrast agents and a diagnostic challenge, and it should not be overlooked, especially following procedures that use contrast agents.

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The Removal of a Fractured Guidewire During Mechanical Thrombectomy. A Case Report

Rares Cristian Filep1, Andrei Florin Bloj2, Lucian Marginean3

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

DOI: 10.2478/jccm-2021-0009

Recent randomized controlled trials have transformed the treatment of acute ischemic stroke. Mechanical or aspiration thrombectomy is the main treatment option for occlusions of large intracranial vessels. Despite its high technical success rate, endovascular thrombectomy can sometimes be complicated by anatomical peculiarities or device failures. The most frequent complications are related to vessel dissection or vessel perforation by devices while navigating intricate anatomy. Rarer still are technical device failures, like spontaneous stent-retriever detachment, which occurred with older generation retrievers. This case reports a rare device failure, which, to the best of our knowledge, has not been reported in the literature so far, namely a microwire fracture in the middle cerebral artery. This was successfully removed with an Eric stent-retriever. The potential causes and possible management strategies are discussed.

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