Category Archives: Case Report

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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Cerebellar Stroke in a COVID-19 Infected Patient. A Case Report

Khang Ning Loo1, You Jiang Tan2, Kaavya Narasimhalu2, Krishan Kumar Sharma3, Dorinda Chee Yee Chew4, Hei Man Wong5, Yvonne Fu Zi Chan5, Ken Cheah Hooi Lee6

1 Department of Internal Medicine, Singapore General Hospital, Singapore, Singapore
2 Department of Neurology, National Neuroscience Institute, Singapore General Hospital, Singapore, Singapore
3 Department of Neurosurgery, National Neuroscience Institute, Singapore General Hospital, Singapore, Singapore
4 Department of Diagnostic Radiology, Singapore General Hospital, Singapore, Singapore
5 Department of Infectious Disease, Singapore General Hospital, Singapore, Singapore
6 Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore

DOI: 10.2478/jccm-2021-0004

Background: Recent studies have reported that COVID-19 infected patients with stroke, who were often in the older age group, had a higher incidence of vascular risk factors, and more severe infection related respiratory symptoms. These observations provided little evidence to suggest that COVID-19 infection is a potential causative factor for stroke. This report describes a young patient with a cerebellar stroke secondary to COVID-19 infection.
Case presentation: A 45-year old male presented at a hospital, reporting a two-day history of headache, vertigo, persistent vomiting, and unsteady gait. Physical examination revealed gaze-evoked nystagmus on extraocular movement testing, left-sided dysmetria and dysdiadochokinesia. He was diagnosed with a left cerebellar stroke. An external ventricular drain was inserted, and sub-occipital craniectomy was performed to manage the effects of elevated intracranial pressure due to the extent of oedema secondary to the infarct. He also underwent screening for the COVID-19 infection, which was positive on SARS-COV-2 polymerase chain reaction testing of his endotracheal aspirate. Blood and cerebrospinal fluid samples were negative. After the surgery, the patient developed atrial fibrillation and had prolonged vomiting symptoms, but these resolved eventually with symptomatic treatment. He was started on aspirin and statin therapy, but anticoagulation was withheld due to bleeding concerns. The external ventricular drain was removed nine days after the surgery. He continued with active rehabilitation.
Conclusions: Young patients with COVID-19 infection may be more susceptible to stroke, even in the absence of risk factors. Standard treatment with aspirin and statins remains essential in the management of COVID-19 related stroke. Anticoagulation for secondary prevention in those with atrial fibrillation should not be routine and has to be carefully evaluated for its benefits compared to the potential harms of increased bleeding associated with COVID-19 infection.

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Resolution of Laryngeal Oedema in a Patient with Acquired C1-Inhibitor Deficiency. A Case Report

Noémi-Anna Bara1, Valentin Nadasan2

1 Hereditary Angioedema Expertise Centre, Sangeorgiu de Mures, Romania
2 George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2021-0003

Introduction: Laryngeal oedema caused by acquired angioedema due to C1-inhibitor deficiency (C1-INH-AAE) is a life-threatening condition. The swelling is bradykinin mediated and will not respond to the usual treatment with antihistamines, corticosteroids, or epinephrine. Instead, kallikrein-bradykinin-targeted therapies should be used promptly to prevent asphyxiation.
Case presentation: A 43 years old female presented at the Hereditary Angioedema Centre reporting a one-year history of peripheral, facial, and neck oedema. Treatment with antihistamines and corticosteroids had been ineffective. Laboratory results showed complement level deficiencies and monoclonal gammopathy characterised as immunoglobulin M. An abdominal ultrasound revealed splenomegaly. A bone marrow biopsy was normal. Based on these data, the diagnosis of C1-INH-AAE associated with monoclonal gammopathy of uncertain significance (MGUS) was made. As C1-INH-AAE can present with life-threatening, standard treatment-resistant laryngeal oedema, an emergency care treatment plan was proposed, and the patient was advised to present to the emergency department (ED) with this medical letter. Based on these recommendations, three laryngeal attacks were successfully treated in the ED with recombinant human C1-inhibitor (two attacks) and fresh frozen plasma (one attack). After these episodes, the patient was prescribed prophylactic treatment with antifibrinolytics. No further angioedema attacks were reported by the patient at the 18 months follow-up visit.
Conclusions: Because angioedema of the upper airways is a life-threatening condition, recognising the specific type of swelling by the emergency physician is critical in providing immediate and effective treatment to reduce the associated risk of asphyxiation. C1-INH-AAE being a rare disorder, patients should have available an emergency care treatment plan with recommendations of acute treatment possibilities.

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An Incident of a Massive Pulmonary
Embolism following Acute Aortic Dissection. A Case Report

Sofia Fernandes1, Mariana Rodrigues1, Catarina Barreiros1, Hugo Côrte-Real2, Ricardo Ferreira2, Ângelo Nobre2

1. Department of Anesthesiology, Centro Hospitalar Universitario Lisboa Norte EPE, Lisboa, Portugal
2. Department of Cardiothoracic Surgery, Centro Hospitalar Universitario Lisboa Norte EPE, Lisboa, Portugal

DOI: 10.2478/jccm-2021-0001

Acute aortic dissection and acute pulmonary embolism are two life-threatening emergencies. The presented case is of an 81-year-old man who has been diagnosed with an acute Stanford type A aortic dissection and referred to a tertiary hospital for surgical treatment. After a successful aortic repair and an overall favourable postoperative recovery, he was diagnosed with cervical and upper extremity deep vein thrombosis and was anticoagulated accordingly. He later presented with massive bilateral pulmonary embolism.

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Personalisation of Therapies in COVID-19 Associated Acute Respiratory Distress Syndrome, Using Electrical Impedance Tomography

Atsuko Shono1, Toru Kotani1, Inéz Frerichs2

1 Department of Intensive Care Medicine, Showa University School of Medicine, Shinagawa, Tokyo Japan
2 Department of Anesthesiology and Intensive Care Medicine, University Medical Center, Schleswig-Holstein, Campus Kiel, Germany

DOI: 10.2478/jccm-2020-0045

Introduction: Each patient suffering from severe coronavirus COVID-19-associated acute respiratory distress syndrome (ARDS), requiring mechanical ventilation, shows different lung mechanics and disease evolution. Therefore, lung protective strategies should be personalised for the individual patient.
Case presentation: A 64-year-old male patient was intubated ten days after the symptoms of COVID-19 infection presented. He was placed in the prone position for sixteen hours, resulting in a marked improvement in oxygenation. However, after being returned to the supine position, his SpO2 rapidly dropped from 98% to 91%, and electrical impedance tomography showed less ventilation at the dorsal region and a ventral shift of ventilation distribution. An incremental and decremental PEEP trial under electrical impedance tomography monitoring was carried out, confirming that the dependent lung regions were recruited with increased pressures and homogenous ventilation distribution could be provided with 14 cmH2O of PEEP. The optimal settings were reassessed next day after returning from the second session of the prone position. After four prone position-sessions in five days, oxygenation was stabilised and eventually the patient was discharged.
Conclusions: Patients with COVID-19 associated ARDS require individualised ventilation support depending on the stage of their disease. Daily PEEP trial monitored by electrical impedance tomography can provide important information to tailor the respiratory therapies.

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