Category Archives: Case Report

When a Stroke is not Just a Stroke: Escherichia coli Meningitis with Ventriculitis and Vasculitis: A Case Report

Barbara Ribeiro1, Peter Bishop1, Sima Jalili2

1 Intensive Care Unit, Colchester General Hospital, East Suffolk and North Essex NHS Foundation Trust, United Kingdom
2 Microbiology Department, Colchester General Hospital, East Suffolk and North Essex NHS Foundation Trust, United Kingdom

DOI: 10.2478/jccm-2020-0002

Introduction: Community-acquired Escherichia coli ventriculitis is considered a rare condition. Central nervous system (CNS) infection due to gram-negative bacilli is usually associated with previous neurosurgical interventions. The recent publication of cases of Escherichia coli meningitis and ventriculitis suggests its prevalence may be underestimated by the literature.
Case presentation: A case of community-acquired Escherichia coli CNS infection on a 58 year old patient presenting with altered consciousness but without neck stiffness, nor significant past medical history is reported. Imaging and lumbar puncture findings suggested a complex case of meningitis with associated ventriculitis and vasculitis. Escherichia coli was later identified in cultures. Subsequent multi-organ support in Intensive Care was required. The patient was treated with a prolonged course of intravenous antimicrobials guided by microbiology, resulting in some neurological recovery. The main challenges encountered in the management of the patient were the lack of clear recommendations on the duration of treatment and the potential development of multi-resistant organisms.
Conclusion: Bacterial central nervous system infections can have an atypical presentation, and an increasing number of cases of community-acquired ventriculitis have been reported. Early consideration should be given to use magnetic resonance imaging to help guide treatment. A long course of antibiotics is often required for these patients; however, the optimal duration for antimicrobial treatment is not well defined.

Keywords: , , , , , ,
Full text: PDF

Hyperammonemic Encephalopathy and Lipid Dysmetabolism in a Critically Ill Patient after A Short Course of Amiodarone

Maximilien Cappe1, Philippe Hantson1, Mina Komuta2, Marie-Françoise Vincent3, Pierre-François Laterre1, Ismaïl Ould-Nana1

¹ Department of Intensive Care, Cliniques St-Luc, Université catholique de Louvain, 1200 Brussels, Belgium
² Department of Pathology, Cliniques St-Luc, Université catholique de Louvain, 1200 Brussels, Belgium
³ Department of Clinical Chemistry, Cliniques St-Luc, Université catholique de Louvain, 1200 Brussels, Belgium

DOI: 10.2478/jccm-2019-0026

The case is reported of a 39-year-old severely obese woman who developed acute metabolic disorders after the administration of a short course of intravenous amiodarone. The main biological features were hypertriglyceridemia, hypoglycaemia, hyperlactatemia and hyperammonemia; all were reversible after amiodarone discontinuation. There was an associated rise in liver enzymes. However, the influence of co-factors on these metabolic disorders, such as acquired carnitine deficiency, severe obesity, a long-term course of pancreatitis, and abdominal infections, could not be excluded.

Keywords: , , ,
Full text: PDF

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.

Keywords: , , ,
Full text: PDF

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.

Keywords: , , , , ,
Full text: PDF

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.

Keywords: , , ,
Full text: PDF

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.

Keywords: , ,
Full text: PDF

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.

Keywords: , , ,
Full text: PDF

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.

Keywords: , , , ,
Full text: PDF

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.

Keywords: , , ,
Full text: PDF

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.

Keywords: ,
Full text: PDF