Category Archives: Case Report

Cardiopulmonary Arrest Following a Single 25 mg Dose of Quetiapine: A Case Report

Pamela Chia1, Lim Chuan Poh2, John Ong3,4, Sharon Ong5,6

1 Division of Anaesthesiology and Perioperative Sciences, Singapore General Hospital, Singapore
2 Department of Pharmacy, Singapore General Hospital, Singapore
3 Department of Medicine, National University of Singapore, Singapore
4 Department of Engineering, University of Cambridge, Cambridge, United Kingdom
5 Department of Surgical Intensive Care, Singapore General Hospital, Singapore
6 Department of Surgical Intensive Care, Sengkang General Hospital, Singapore

DOI: 10.2478/jccm-2020-0035

Introduction: Quetiapine is commonly used in intensive care units (ICU) to treat delirium. Cardiopulmonary arrest caused by low dose quetiapine is unreported. Only two cases in the literature have reported acute respiratory failure after single doses of 50mg and 100mg respectively. We report a case of cardiopulmonary arrest in a patient after the administration of a single 25mg dose of quetiapine.
Case presentation: A 72-year-old Chinese female with multiple cardiovascular co-morbidities was admitted to the ICU intubated, following complications from an elective endovascular repair of an infrarenal abdominal aortic aneurysm. She was alert and extubated the following day. She subsequently showed signs of delirium and was administered a single 25mg dose of oral quetiapine. Seven hours after ingestion, she developed type 2 respiratory failure and eventually cardiopulmonary arrest. She was successfully resuscitated and other causes for cardiopulmonary arrest were excluded. Twenty-four hours following her cardiopulmonary arrest, her respiratory failure had completely reversed and she was extubated uneventfully.
Conclusion: This case report demonstrates that a single dose of oral quetiapine 25mg is sufficient to cause respiratory failure and cardiopulmonary arrest. Caution is advised when prescribing quetiapine in the elderly, especially in those with impaired drug clearance.

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The Prolonged Use of VV ECMO Support in COVID-19: A Case Report

Amelia Lucy Fitzgerald1, Hemal Hitesh Vachharajani1, Benjamin Paul Davidson1, Natalie Joanne Kruit1, Adam Trevor Eslick1,2

1 Westmead Hospital, Westmead, Sydney, New South Wales, Australia
2 Faculty of Medicine, University of Sydney, New South Wales, Australia

DOI: 10.2478/jccm-2020-0034

COVID-19 has resulted in unprecedented global health and economic challenges. The reported mortality in patients with COVID-19 requiring mechanical ventilation is high. VV ECMO may serve as a lifesaving rescue therapy for a minority of patients with COVID-19; however, its impact on overall survival of these patients is unknown. To date, few reports describe successful discharge from ECMO in COVID-19 after a prolonged ECMO run. The only Australian case of a COVID-19 patient, supported by prolonged VV ECMO in conjunction with prone ventilation, complicated by significant airway bleeding, and successfully decannulated after forty-two days, is described. VV ECMO is a resource-intense form of respiratory support. Providing complex therapies such as VV ECMO during a pandemic has its unique challenges. This case report provides a unique insight into the potential clinical sequelae of COVID-19, supported in an intensive care environment which was not resource-limited at the time, and adds to the evolving experience of prolonged VV ECMO support for ARDS with a goal to lung recovery.

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Rhabdomyolysis-Induced Acute Renal Injury in a Schizophrenic Patient

Mirela Tiglis1,2, Tudor Hurmuzache2, Cristina Bologa2, Tiberiu Paul Neagu1,2, Liliana Mirea1, Ioana Marina Grintescu1,2

1 “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
2 Emergency Clinical Hospital, Bucharest, Romania

DOI: 10.2478/jccm-2020-0032

Nowadays, schizophrenia is treated with atypical antipsychotics that can determine neuroleptic malignant syndrome or rhabdomyolysis appearance. In addition to trauma and muscular hypoxia, there are some drugs and toxins associated with rhabdomyolysis development, among which olanzapine. A case of severe rhabdomyolysis syndrome, with extremely high levels of serum creatine kinase (CK), followed by acute kidney failure, secondary to olanzapine overdose and prolonged immobilization is outlined. Continuous renal replacement therapy was performed, with a slow clearance of serum CK levels. Under supportive therapy, systemic alkalinisation with volume resuscitation and corticotherapy, patient’s general condition was improved, as well as his lower limb paresis. He followed frequent psychiatric evaluations and psychotherapies, before and after being transferred to a medical service. Rhabdomyolysis diagnosis is difficult in mild cases due to non-specific signs and symptoms, but it also has some typical manifestation, generically called “the rhabdomyolysis syndrome triad”. The treatment is usually supportive; renal replacement therapy is required in the presence of acute kidney injury unresponsive to aggressive volume resuscitation. The systemic myoglobin release is responsible for renal injury. Olanzapine muscle toxicity can lead to severe rhabdomyolysis syndrome complicated with acute kidney injury and multiple organ dysfunction syndrome. Rapid identification and aggressive therapeutic management are essential for improving patients’ outcome and prevent the occurrence of irreversible injuries.

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Bilateral Ocular Exophthalmia – A Case of Atypical Acute Myeloblastic Leukemia in a Child

Réka Toth1, Alina Grama2, Cristina Maki3, Mihaela Ioana Chinceșan2

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

DOI: 10.2478/jccm-2020-0031

Introduction: In acute myeloblastic leukaemia (AML) explosive proliferation and accumulation of immature myeloid cell clones take place, replacing the bone marrow, with the possibility of the formation of extramedullary tumour masses composed of myeloid cells. The onset of the disease less frequently consists of symptoms of extramedullary manifestation.
Case presentation: A Caucasian male child aged three years and 11 months was hospitalized for bilateral exophthalmos and otorrhea, due to an alteration in his general condition. Ocular ultrasound revealed an inhomogeneous thickening of the upper right muscles superior to the eyeball. A complete blood count showed severe anaemia, leucocytosis with neutropenia and thrombocytopenia. A peripheral blood smear evidenced myeloblasts. The result of the cytology of bone marrow confirmed the diagnosis of AML. Following blood product replacements and cytostatic treatment (AML-BFM 2004 HR protocol), the remission of exophthalmos and the correction of haematological parameters were favourable.
Conclusion: In a child with a sudden onset of exophthalmia and altered general condition, the diagnosis of acute leukaemia should be considered. The importance of performing a peripheral blood smear and bone marrow examination is emphasized so that diagnosis and initiation of treatment are not delayed.

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Role of Transesophageal Echocardiography in the Diagnosis of Multi-chamber Intracardiac Thrombosis During Liver Transplantation: A Case Series

Jocelyn Y. Wang, G. Burkhard Mackensen, Alexander Vitin, Kenneth Martay

University of Washington, Seattle, WA, USA

DOI: 10.2478/jccm-2020-0029

Intra-cardiac thrombosis is one of the most devastating complications during liver transplantation. In the majority of cases, ICT, followed by massive pulmonary embolism, is commonly occurring shortly after liver graft reperfusion, but it has been reported to occur at any stage of the surgery. We present a series of 3 cases of intra-cardiac thrombosis during orthotopic liver transplantation surgery, including a case of four-chamber intra-cardiac clot formation during the pre-anhepatic stage. This article represents a single-centre 14 year-long experience. Intra-operative TEE is the gold standard to diagnose intra-cardiac thrombosis, monitoring its size, location and dynamics, as well as myocardial performance and the effects of resuscitation efforts.

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Neuroleptic Malignant Syndrome or Catatonia? A Case Report

Sebastian Rodriguez1, Keith A. Dufendach2, Robert M. Weinreib3

1 University of California San Francisco, San Francisco, USA
2 University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, USA
3 University of Pennsylvania Health System, Perelman School of Medicine, University of Pennsylvania, USA

DOI: 10.2478/jccm-2020-0025

Introduction: A review of the literature has shown that there are many similarities in the presentation of neuroleptic malignant syndrome (NMS) and catatonia. Attempts to reconcile the differences have been made by suggesting that NMS and catatonia may represent different presentations of the same illness or that they lie within the same spectrum of a poorly understood clinical syndrome. The described case is of a patient who presented with NMS and catatonia which was difficult to diagnose, but which responded to treatment with intravenous diazepam.
Case presentation: The case concerns a 22-year-old male admitted for pulmonary hypertension to an intensive care unit (ICU). Three days following admission, he developed a high fever that did not respond to antibiotics. The patient then developed rigidity, nocturnal agitation, decreased responsiveness, and somnolence. Without the use of bromocriptine (Novartis, Basel, Switzerland) or dantrolene (Par Pharmaceuticals, Chestnut Ridge, USA) discontinuation of neuroleptics combined with intravenous diazepam (Pfizer, NY, USA) led to a very rapid response and marked improvement in the case.
Conclusions: Early recognition and management of NMS and MC in a complex, gravely ill patient, may be accomplished in the ICU despite obfuscation of traditional signs and symptoms of the NMS and MC syndrome. Such interventions can have life-saving effects on patients in danger of fatal autonomic instability.

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Hypoxic Respiratory Failure Further Complicated During Airway Exchange Catheter Placement

Osman Ali1, Avelino C. Verceles1,2, Matthew L. Barrett3, Christopher M. Franklin4, Imran Khan1, Negar Naderi5, Michael T. McCurdy2

1 University of Maryland Medical Center Midtown Campus, Baltimore, MD, USA
2 University of Maryland School of Medicine, Baltimore, MD, USA
3 Christiana Care Health System, Newark, DE, USA
4 Navicent Health, Macon, GA, USA
5 Inova Fairfax Medical Campus, Fairfax, VA, USA

DOI: 10.2478/jccm-2020-0023

Introduction: An airway exchange catheter is a hollow-lumen tube able to deliver oxygen and maintain access to a difficult endotracheal airway. This case report demonstrates an undocumented complication associated with an airway exchange catheter and jet ventilation, particularly in a patient with reduced airway diameter due to thick endotracheal secretions. Due to the frequent use of airway exchange catheters in the intensive care unit, this report highlights an adverse event of bilateral pneumothoraces that can be encountered by clinicians.
Case Presentation: This case report describes a 24-year-old female with severe adult respiratory distress syndrome and thick endotracheal secretions whose hospital course was complicated by bilateral pneumothoraces resulting from the use of an airway exchange catheter connected to jet ventilation. During the exchange, the catheter occluded the narrowed endotracheal tube to create a one-way valve that led to excessive lung inflation.
Conclusion: Airway exchange catheters used with jet ventilation in a patient with a narrowed endotracheal tube and reduced lung compliance have the potential risk of causing a pneumothorax. Clinicians should avoid temporary concomitant oxygenation via jet ventilation in patients with these findings and reserve the use of airway exchange catheters for difficult airways.

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Non-Cardiogenic Pulmonary Oedema Following the Use of Gadolinium-Based Contrast Medium: A Case Report

Chilan Nguyen1, Tho Pham2

1 St George Hospital, Kogarah, NSW, Australia
2 Alfred Health, VIC, Australia

DOI: 10.2478/jccm-2020-0019

Non-cardiogenic pulmonary oedema can be life threatening and requires prompt treatment. While gadolinium-based contrast is generally considered safe with a low risk of severe side effects, non-cardiogenic pulmonary oedema has become increasingly recognised as a rare, but possibly life-threatening complication. We present a case of a usually well, young 23-year-old female who developed non-cardiogenic pulmonary oedema with a moderate oxygenation impairment and no mucosal or cutaneous features of anaphylaxis following the administration of gadolinium-based contrast. She did not respond to treatment of anaphylaxis but made a rapid recovery following the commencement of positive pressure ventilation. Our case highlights the importance of recognising the rare complication of non-cardiogenic pulmonary oedema following gadolinium-based contrast administration in order to promptly implement the appropriate treatment.

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Catastrophic Caustic Ingestion: A Case Report

Kerri L Bouchard

University of Maryland Medical Center, Baltimore, USA

DOI: 10.2478/jccm-2020-0017

Introduction: The majority of oral ingestion of caustic material by adults is intentional, and the aftermath varies widely with potentially fatal results. Injuries range from superficial burns of facial and oropharyngeal structures to extensive necrosis of the gastrointestinal tract. Management focuses on the identification of the ingested substance and prompt treatment and supportive care of the multiple complications stemming from the ingestion. Complications following caustic ingestion include both immediate and long term.
Case presentation: A fifty-seven-year-old man presented following intentional ingestion of drain cleaner. The patient was intubated and underwent emergent esophagogastroduodenoscopy [EGD], which revealed extensive damage to his oesophagus and stomach. He survived his initial injury but had a prolonged hospital course and ultimately died after developing tracheoesophageal and bronchooesophageal fistulas which were too extensive for surgical repair.
Conclusion: The sequelae of caustic ingestion can be minor or severe, both immediate and delayed. Despite appropriate prompt management and supportive care, patients may die as a result of the initial injury or subsequent complications.

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An Intentional Aconite Overdose: A Case Report

Christopher Wood1, James Coulson2, John Thompson2, Stephen Bonner1

1 James Cook University Hospital, Middlesbrough, United Kingdom
2 National Poisons Information Service, United Kingdom

DOI: 10.2478/jccm-2020-0016

Background: Aconite is one of the most toxic known herbs, widely used for centuries as an essential Chinese medicine, but also for deliberate poisoning throughout history. Clinically indicated in herbal medicine for a range of ailments from headaches to muscle spasm, unfortunately, the narrow therapeutic window may lead to a range of toxic presentations. The mechanism of action of the pharmacologically active compounds in Aconite relate to the activation of voltage-gated sodium channels within a range of tissue including myocardial, neuronal and smooth muscle leading to persistent cellular activity.
Case presentation: We report on a rare case of a fifty-year-old male with intentional aconite overdose presenting with refractory cardiovascular instability from persistent life-threatening arrhythmias, respiratory failure, and seizure activity.
Conclusion: An overview of Aconite, its history, pharmacological effects, treatment of overdose and outcomes is presented.

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