Category Archives: Case Report

Accidental Modopar© Poisoning in a Two-Year-Old Child. A Case Report

Adnane Lahlou, Saïd Benlamkaddem, Mohamed Adnane Berdai, Mustapha Harandou

Obstetric and Pediatric Intensive Care Unit, Hassan II Academic Hospital, Fez, Morocco

 

DOI: 10.2478/jccm-2019-0024

Levodopa is a dopamine precursor and a mainstay treatment in the management of Parkinson’s disease. Its side effects induce dyskinesia, nausea, vomiting, and orthostatic hypotension. Acute levodopa acute poisoning is uncommon, with only a few reported cases in the medical literature. Treatment of poisoning by levodopa is mainly supportive. The case of a child admitted to a hospital for acute levodopa poisoning is presented in this report.

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SIRS Triggered by Acute Right Ventricular Function, Mimicked Septic Shock

Yingke He1, John Ong2, Thuan Tong Tan3, Brian K. P. Goh4, Sharon G. K. Ong5

1 Division of Anaesthesiology, Singapore General Hospital, Singapore
2 Department of Engineering, Materials Engineering and Material-Tissue Interactions Group, University of Cambridge, United Kingdom
3 Department of Infectious Diseases, Singapore General Hospital, Singapore
4 Department of Hepato-pancreato-biliary and Transplant Surgery, Singapore General Hospital, Singapore
5 Department of Surgical Intensive Care, Singapore General Hospital, Singapore

DOI: 10.2478/jccm-2019-0022

Background: The systemic inflammatory response syndrome (SIRS) is a complex immune response which can be precipitated by non-infectious aetiologies such as trauma, burns or pancreatitis. Addressing the underlying cause is crucial because it can be associated with increased mortality. Although the current literature associates chronic heart failure with SIRS, acute right ventricular dysfunction has not previously been reported to trigger SIRS. This case report describes the presentation of acute right ventricular dysfunction that triggered SIRS and mimicked septic shock.
Case presentation: A 70-year-old male presented to the Intensive Care Unit (ICU) with elevated inflammatory markers and refractory hypotension after a robotic-assisted laparoscopic radical choledochectomy with pancreaticoduodenectomy. Septic shock was misdiagnosed, and he was later found to have a pulmonary embolus. Thrombectomy and antimicrobials had no significant effect on lowering the elevated inflammatory markers or improving the persistent hypotension. Through Point of Care Ultrasound (POCUS), right ventricular dysfunction was diagnosed. Treatment with intravenous milrinone improved blood pressure, normalised inflammatory markers and led to a prompt discharge from the ICU.
Conclusion: Acute right ventricular dysfunction can trigger SIRS, which may mimic septic shock and delay appropriate treatment.

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Transient Diabetes Insipidus Following Organophosphorus Poisoning

Niraj Kumar Keyal, Amid Bhujel

Department of Critical Care Medicine, B & C Medical College and Teaching Hospital and Research Center, Birtamode, Nepal

DOI: 10.2478/jccm-2019-0023

Introduction: Organophosphorus poisoning is the most common poison used for suicidal attempt in Nepal. Diabetes insipidus is unusual and rare in this poisoning. This is the second case report of Diabetes insipidus developing in organophosphorus poisoning. Management of diabetes insipidus includes desmopressin and adequate fluid management.
Case presentation: A 34-year-old female patient accompanied by her father presented at the Emergency department with an alleged history of ingestion of unknown amount of chlorpyrifos, cypermethrin and quinalphos. On admission, she had a Glasgow Coma Scale (GCS) of 7/15. Her blood pressure was 110/60 mm Hg, pulse 54/min, respiratory rate 45/min and saturation 35% on room air, pinpoint pupil reactive to light and bilateral crepitations. She was immediately resuscitated with two litres of normal saline and intubated with a 7 mm endotracheal tube. Atropinisation was done, and pralidoxime was started. She developed a urine output of 250-350 ml per hour with rising sodium and serum osmolality. The urine examination showed low sodium and urine specific gravity. A diagnosis of diabetes insipidus was made. There was no immediate improvement in her GCS. She was managed with 5% dextrose and subcutaneous desmopressin and was transferred out of the intensive care unit on the sixth day and was discharged from hospital on the fifteenth day.
Conclusion: Diabetes insipidus is a rare transient complication in organophosphorus poisoning that requires careful observation and early management with desmopressin and adequate fluid balance to improve patient outcome.

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Fatal Hypocalcaemia Due to Hungry Bone Syndrome with Secondary Refractory HyperParathyroidism after Parathyroidectomy: A Case Report

Corina Pop Radu1,2, Valentin Daniealopol3, Ario Santini2,4, Ruxandra Darie3, Daniela Tatiana Sala2, 3

1 Endocrinology Department, Mures County Emergency Hospital, Targu Mures, Romania
2 University of Medicine, Pharmacy, Science and Technology of Targu Mures, Romania
3 2nd Surgery Department, Mures County Emergency Hospital, Targu Mures, Romania
4 Hon Fellow, University of Edinburgh, United Kingdom

DOI: 10.2478/jccm-2019-0021

Introduction: Hungry bone syndrome (HBS) refers to the rapid, profound, and prolonged hypocalcaemia associated with hypophosphatemia and hypomagnesaemia, and is exacerbated by suppressed parathyroid hormone (PTH) levels, which follows parathyroidectomy in patients with severe primary hyperparathyroidism (PHPT) and preoperative high bone turnover. [1]
Case report: This report concerns a dialysed patient who underwent surgical treatment for secondary refractory hyperparathyroidism. Haemodialysis was carried out pre-operatively, and subsequently, a total parathyroidectomy with auto-transplantation of parathyroid tissue in the sternocleidomastoid muscle (SCM) was performed. Rapid and progressive hypocalcaemia symptoms developed during the second day postoperatively. Acute cardiac symptoms with tachyarrhythmia, haemodynamic instability and finally asystole occurred, which required cardiopulmonary resuscitation (CPR). The ionic calcium level was 2.2 mg/dL being consistent with a diagnosis of HBS. A second cardiac arrest unresponsive to CPR followed an initial period of normal sinus rhythm. Death ensued shortly after. Before death, the ionic calcium was 3.1 mg/dL.
Conclusion: HBS, after parathyroidectomy in patients with secondary hyperparathyroidism (SHPT), may be severe, prolonged and sometimes fatal. Generally, HBS symptomatology is that of a mild hypocalcaemia. It can, however, include heart rhythm disturbances with haemodynamic alterations requiring intensive care measurements and even cardiopulmonary resuscitation. A close clinical and laboratory post-parathyroidectomy monitoring of dialysed patients is of the utmost importance.

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Diagnostic Difficulties in a Severely Ill HIV Patient with Multiple Superinfections – A Case Report

Cristina Mănășturean1, Cristiana Oprea2, Dan Oțelea3, Anca Meda Georgescu1,4

1 Infectious Diseases Clinic I, Mures County Hospital , Târgu Mureș, Romania
2 Victor Babeș Clinical Hospital of Infectious and Tropical Diseases, Bucharest, Romania
3 Molecular Diagnostics Laboratory, National Institute for Infectious Diseases, Bucharest, Romania
4 University of Medicine, Pharmacy, Science and Technology of Târgu-Mureș, Romania

DOI: 10.2478/jccm-2019-0020

Introduction: As chronic HIV infection is prone to co-infections more than any other infectious condition, many severely immune-depressed patients require advanced diagnostic investigations and complex treatment.
Case report: The case of a 30-year-old severely immune-depressed patient with AIDS, who developed neurological impairment and was diagnosed with encephalitis is presented. Multiple diagnostic approaches had to be used in order to identify the etiologic agents responsible for the clinical, immunological and biological evolution. Despite using advanced laboratory investigations and complex treatment, the patient developed multiple organ dysfunction syndromes that led to a fatal outcome.
Conclusions: Establishing etiologic relations and treatment priorities in patients with severe immunodeficiency and co-infections can prove difficult, underlining the need of rapid syndromic testing.

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The Management of a Thirteen Weeks Pregnant Woman Rendered Brain-Dead Following a Ruptured Aneurysm

Iwona Pikto-Pietkiewicz, Antoni Okniński, Rafał Wójtowicz, Marlena Wójtowicz

Central Clinical Hospital of the MSWiA. Clinical Department of Intensive Care and Anaesthesiology. Warsaw, Poland

DOI: 10.2478/jccm-2019-0015

Introduction: The current lack of clear guidelines on how to manage cases of brain-dead pregnant patients makes this topic controversial and extremely difficult to deal with for both medical and ethical reasons. This report deals with such a situation.
Case presentation: A twenty-seven years old woman, thirteen weeks pregnant, with a ruptured brain aneurysm was admitted to an Intensive Care Unit. She presented with loss of all brain functions, but somatic support was sustained to enable the delivery of her baby.
Conclusion: The case report gives a detailed account of the management of the mother before the successful delivery of her baby. It indicates the need for ongoing contributions to the debate on this delicate subject area to establish guidelines on how to manage brain-dead pregnant patients.

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Locked-In Syndrome Following Cervical Manipulation by a Chiropractor: A Case Report

Guillaume Giordano Orsini1, Giorgios-Emmanouil Metaxas2, Vincent Legros3

1 Emergency Department, University Hospital of Reims, Reims, France
2 Radiology Department, University Hospital of Reims, Reims, France
3 Intensive Care Unit, University Hospital of Reims, Reims, France

DOI: 10.2478/jccm-2019-0014

Introduction: Vertebrobasilar occlusion poses difficult diagnostic issues and even when properly diagnosed has a poor prognosis. Newer studies highlight a better outcome when thrombectomy was carried out between six and twenty-four hours after an initial diagnosis of stroke. This paper reports a case where a patient suffered a vertebrobasilar stroke secondary to a traumatic bilateral vertebral arteries dissection was treated with late thrombectomy.
Case presentation: A 34-year-old woman was manipulated on the cervical spinal column by a chiropractor. Following three weeks of cervical pain, she presented with severe aphasia and quadriplegia (NIHSS = 28). An MRI scan indicated ischemia of the vertebrobasilar system. Thirty-one hours after the onset of these symptoms, a thrombectomy was performed. After one month, the patient could move her head and the proximal part of her limbs but remained confined to bed (NIHSS = 13).
Conclusion: The current case illustrates the benefit of late mechanical thrombectomy for a posterior cerebral circulation infarct. Although there was a delay in treatment, partial recovery ensued.

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Cervical Spine Spondylitis with an Epidural Abscess in a Patient with Brucellosis: A Case Report

Mohammad Reza Hasanjani Roushan1, Soheil Ebrahimpour1, Zeinab Mohseni Afshar2, Arefeh Babazadeh1

1 Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, I.R. Iran
2 Department of Infectious Diseases, Kermanshah University of Medical Sciences, Kermanshah, Iran

DOI: 10.2478/jccm-2019-0013

Introduction: Human brucellosis, the most prevalent zoonotic disease worldwide, is a systemic infection which can involve several organs. Among musculoskeletal complaints, spondylitis is the most frequent complication of brucellosis and primarily affects the lumbar and thoracic vertebrae. The involvement of the cervical spine is infrequent.
Case report: This case report concerns an unusual case of cervical spine spondylitis with an epidural abscess due to Brucella in a 43-year-old man. The diagnosis was based on the patient being domiciled in an endemic region, his symptoms and his occupation. Clinical outcomes improved following antimicrobial therapy of rifampin, doxycycline, and gentamycin, and were confirmed radiologically.
Conclusion: Early diagnosis and treatment are crucial for these patients. The timely commencement of medical treatment can help prevent surgery.

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Pyruvate Dehydrogenase Complex Deficiency: An Unusual Cause of Recurrent Lactic Acidosis in a Paediatric Critical Care Unit

Neha Gupta, Chrystal Rutledge

Department of Pediatrics, Division of Pediatric Critical Care, University of Alabama at Birmingham, Birmingham, AL, USA

DOI: 10.2478/jccm-2019-0012

Pyruvate dehydrogenase complex deficiency (PDCD) is a rare neurodegenerative disorder associated with abnormal mitochondrial metabolism. Structural brain abnormalities are common in PDCD. A case of a patient with PDCD with an unusual presentation is described. A 20-month-old boy with hypotonia and developmental delay, presented with hypoxia and respiratory distress due to bronchiolitis. During hospitalisation, he was prescribed PediaSure® feeds. Two days after starting these feeds, he developed respiratory arrest requiring intubation. His blood gas before arrest revealed lactate of 8.9 mmol/L despite normal haemodynamics. After stabilisation and a period of compulsory fasting, subsequent feeding with PediaSure® resulted in the recurrence of lactic acidosis. A metabolic workup revealed an elevated serum pyruvate level. Brain MRI was normal. Skeletal muscle biopsy confirmed PDCD. The most common cause of PDCD is a mutation in the X-linked PDHA1 gene. The severity of PDCD can range from neonatal death to more delayed onset of symptoms as in our index case. Normal brain MRI is reported in only 2% of patients with PDCD. There is no effective treatment for PDCD. In patients with proximal muscle weakness and feeding intolerance with glucose-containing feeds, the presence of lactic acidosis should raise the suspicion of PDCD irrespective of the patient’s age and normal MRI.

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Increased Susceptibility to Postoperative PCA Morphine-Induced Respiratory Depression in a Patient with an Undiagnosed Traumatic Porencephalic Cyst – A Case Report

Cristina Petrișor1,2, Sebastian Trancă1,2, Andreea Cordoș2,3, Vasile Bințințan2,3

1 Anesthesia and Intensive Care II Department, “Iuliu Hațieganu” University of Medicine and Pharmacy Cluj-Napoca, Romania
2 Clinical Emergency County Hospital Cluj-Napoca, Romania
3 Surgery Department I, “Iuliu Hațieganu” University of Medicine and Pharmacy Cluj-Napoca, Romania

DOI: 10.2478/jccm-2019-0011

Introduction: Patient-controlled analgesia with morphine is routinely used for postoperative pain management. Due to the safety profiles of the technique, which are patient/disease related or technique/equipment related, severe respiratory depression requiring opioid antagonists or airway management are uncommon.
Case presentation: The case of a patient with right colon carcinoma who was operated on for hemicolectomy under general anaesthesia and who presented with apnoea, after postoperatively receiving an initial bolus of 1mg of morphine. A large post-traumatic porencephalic cyst of the left brain hemisphere, previously undiagnosed, was found on the computed tomography scan. We excluded human errors, technique and equipment factors, and the patient did not have any other predisposing conditions like sleep apnoea, obesity, recent head injury or concurrent use of other sedatives. Previously the patient had been entirely asymptomatic, and her increased susceptibility to respiratory depression was the only clinical manifestation of porencephaly.
Conclusion: Adult acquired porencephaly is seldom reported in the literature, clinical manifestations depending on the location and size of the cyst. In the present reported case, increased susceptibility to low-dose opioids might be associated with the structural and functional reorganisation of the brain after head trauma with the occurrence of the porencephalic cyst of the brain.

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