Category Archives: Case Report

Serratia marcescens Sepsis in a Child with Deep Venous Thrombosis – A Case Report

Iulia Armean1, Carmen Duicu2, Cornel Aldea3, Lorena Melit1

1 Pediatric Clinic No 1, County Emergency Clinical Hospital, Tirgu Mures, Romania
2 1st Department of Pediatrics, University of Medicine and Pharmacy of Tirgu Mureș, Romania
3 2nd Pediatric Clinic, Clinical Emergency Hospital for Children, Cluj-Napoca, Romania

DOI: 10.2478/jccm-2018-0004

Introduction: Venous thromboembolism is a rare condition in paediatrics that included both deep venous thrombosis and pulmonary embolism. Serratia marcescens is a gram-negative bacterium that belongs to the Enterobacteriaceae family and tends to affect immunocompromised hosts.
Case report: We report the case of an 11-year-old boy, admitted in the Pediatric Clinic I from Emergency County Hospital Tîrgu Mureș, Romania with intense pain, swelling, cyanosis and claudication of the left foot. His personal history revealed a recent appendectomy. A close family was reported to have had a deep venous thrombosis. The laboratory tests, performed on the day of admission, revealed increased inflammatory biomarkers and D-dimer. Coagulation tests gave a low activated partial thromboplastin time (APTT). Doppler venous ultrasound and CT-exam established a diagnosis of deep venous thrombosis. Anticoagulant therapy was initiated, but on the tenth day of admission, the patient developed signs and symptoms of sepsis, and the blood culture revealed Serratia marcescens. After antibiotic and anticoagulant therapy, the patient progressed favourably. The patient was a carrier of the heterozygous form of Factor V Leiden.
Conclusions: The association between deep venous thrombosis and Serratia marcescens sepsis can compromise a condition in pediatric patients.

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Stroke Secondary to Traumatic Carotid Artery Injury – A Case Report

Zoltán Bajkó1, 2, Smaranda Maier1, 2, Anca Moțățăianu1, 2, Rodica Bălașa1, 2, Smaranda Vasiu2, Adina Stoian2, 3, Sebastian Andone2

1 Department of Neurology, University of Medicine and Pharmacy Târgu Mureș, Romania
2 Mureș County Clinical Emergency Hospital, Târgu Mureș, Romania
3 Department of Pathophysiology, University of Medicine and Pharmacy Târgu Mureș, Romania

DOI: 10.2478/jccm-2018-0003

Introduction: Lesions of the carotid and vertebral arteries secondary to direct trauma, called blunt cerebrovascular injuries (BCVI) are relatively rare and are markedly different from spontaneous dissections. Ischaemic stroke is a significant complication, with high morbidity and mortality rates. The basis of a diagnosis relies on appropriate, high sensitivity imaging screening.
Case report: We present the case of a 31 years old male patient with polytraumatism secondary to a motor vehicle accident, who was admitted to an orthopaedic clinic for multiple lower extremity fractures. His fractures were treated surgically. He developed in the 3rd day after the admission left sided hemiparesis secondary to ischaemic stroke. The diagnosis of traumatic carotid artery injury (TCAI) was based on duplex ultrasound and angio CT scans. The outcome was favourable despite the severe carotid lesions presenting with occlusion secondary to dissection.
Conclusions: In the majority of BCVI cases there is a variable latent period between the time of injury and the development of stroke. The management of cases is challenging because in the majority of cases there are multiple associated injuries. Although antithrombotics are widely used in the treatment, there is no consensus regarding the type of agent, the optimal dose or treatment duration.

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Severe Austrian Syndrome in an Immunocompromised Adult Patient – A Case Report

Ioana Raluca Chirteș1, Dragos Florea2, Carmen Chiriac1,3, Oana Maria Mărginean1, Cristina Mănășturean3, Alexander A Vitin4, Anca Meda Georgescu1,3

1 University of Medicine and Pharmacy of Tirgu Mures, Romania
2 National Institute of Infectious Diseases ”Prof. Dr Matei Bals”, Laboratory of Molecular Biology, Bucharest, Romania
3 Mures County Hospital, Infectious Diseases Clinic I, Tirgu Mures, Romania
4 Department of Anesthesiology & Pain, Medicine University of Washington Medical Center, Seattle WA, USA

DOI: 10.1515/jccm-2017-0025

Background: Known also as Osler’s triad, Austrian syndrome is a complex pathology which consists of pneumonia, meningitis and endocarditis, all caused by the haematogenous dissemination of Streptococcus pneumoniae. The multivalvular lesions are responsible for a severe and potential lethal outcome.
Case report: The case of a 51-year-old female patient, with a past medical history of splenectomy, is presented. She developed bronchopneumonia, acute meningitis and infective endocarditis as a result of Streptococcus pneumoniae infection and subsequently developed multiple organ dysfunction syndromes which led to a fatal outcome. Bacteriological tests did not reveal the etiological agent. The histopathological examination showed a severe multivalvular endocarditis, while a PCR based molecular analysis from formalin fixed valvular tissue identified Streptococcus pneumoniae as the etiologic agent.
Conclusions: The presented case shows a rare syndrome with a high risk of morbidity and mortality. Following the broad-spectrum treatment and intensive therapeutic support, the patient made unfavourable progress which raised differential diagnosis problems. In this case, the post-mortem diagnosis demonstrated multiple valvular lesions occurred as a result of endocarditis.

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Neutropenia and T-Wave Inversion as Toxin-Mediated Complications of a Streptococcal Infection

Cristina Popescu1,2, Anca Leuştean1,2, Alina Elena Orfanu1,2, Codruţa Georgiana Carp2, Victoria Aramă1,2

1 “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
2 ”Prof. Dr. Matei Balş” National Institute for Infectious Diseases, Bucharest, Romania

DOI: 10.1515/jccm-2017-0030

Introduction: Streptococcal infection can be responsible for multiple complications, such as toxic, septic or allergic disorders. Toxin-mediated complications (TMC) can appear during the acute phase of disease and can involve any organ, causing carditis, arthritis, nephritis, hepatitis etc.
Case presentation: The case of a young woman without a history of recurrent streptococcal tonsillitis, admitted to “Matei Balş” National Institute for Infectious Diseases, Bucharest, Romania, presenting with fever, sore throat and exudative tonsillitis, is detailed. The initial test for Streptococcus pyogenes was negative. The patient had leukopenia with severe neutropenia, high values of inflammatory biomarkers and electrocardiographic (ECG) changes with inverted T waves in leads V1-4 and flattened T waves in V5-6. There were no other cardiac signs or symptoms. The patient received cefuroxime for two days. On admission, the patient was prescribed Penicillin G and dexamethasone which resulted in a rapid recovery. The leucocytes count returned to normal as did the ECG abnormalities. At the time of discharge, the antistreptolysin O titre was high.
Conclusions: The case highlights the toxin-mediated complications (TMC) of streptococcal infection which occur from the outset of the disease.

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Lethal Subarachnoid and Intracerebral Haemorrhage Associated with Temporal Arteritis. A Case Report

Réka Gál1, Rodica Bălaşa2, Zoltán Bajkó2, Smaranda Maier2, Iunius Simu3, Adrian Bălaşa4

1 Mureş County Clinical Emergency Hospital Târgu Mureş, Neurology Clinic II, Târgu Mureş, România
2 University of Medicine and Pharmacy Târgu Mureş, Department of Neurology, Târgu Mureş, România
3 University of Medicine and Pharmacy Târgu Mureş, Department of Radiology, Târgu Mureş, România
4 University of Medicine and Pharmacy Târgu Mureş, Department of Neurosurgery, Târgu Mureş, România

DOI: 10.1515/jccm-2017-0028

Giant cell arteritis is a systemic inflammatory vasculitis, typically involving the superficial temporal arteries, but with possible ischemic and hemorrhagic cerebrovascular complications.
The case is reported of a patient with a clinical picture of giant cell arteritis, who had multiple occupational exposures to various infectious agents.
His initial favourable progress was followed by an atypical outcome. Despite immunosuppressive treatment, he developed fatal subarachnoid and intracerebral haemorrhages, possibly due to rupture of a microaneurysm of the posterior cerebral artery.

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Cytoreduction with Hyperthermic Intraperitoneal Chemotherapy and Renal Insufficiency Related to Diabetes Mellitus: An Anesthetic Challenge

Adrian Bartos1, Caius Breazu2,3, Dana Bartos2,3, Lidia Ciobanu3,4, Calin Mitre2,3

1 Department of Surgery, Regional Institute of Gastroenterology and Hepatology “Prof. Dr. Octavian Fodor”, Cluj-Napoca, Romania
2 Department of Anesthesiology and Intensive Care Medicine, Regional Institute of Gastroenterology and Hepatology “Prof. Dr. Octavian Fodor”, Cluj-Napoca, Romania
3 University of Medicine and Pharmacy „Iuliu Hatieganu”, Cluj-Napoca, Romania
4 Department of Gastroenterology, Regional Institute of Gastroenterology and Hepatology, “Prof. Dr. Octavian Fodor”, Cluj-Napoca, Romania

DOI: 10.1515/jccm-2017-0027

Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) improves the prognosis in selected patients with peritoneal surface malignancies but it is an extensive procedure predisposing to major complications. Among them, renal toxicity was reported. Severe renal insufficiency is considered a contraindication for this complex procedure. We present a patient with diabetic nephropathy with renal insufficiency KDOQI 3 and peritoneal metastasis from sigmoid adenocarcinoma with a good clinical outcome after CRS with HIPEC, highlighting the anesthetic precautions considered for this particular clinical case.

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The Use of Continuous Ketamine for Analgesia and Sedation in Critically Ill Patients with Opioid Abuse: A Case Series

Cierra N. Treu1,2, Christine M. Groth1, Jignesh H. Patel1

1 University of Rochester Medical Center, Rochester, NY, USA
2 SBH Health System, Bronx, New York, USA

DOI: 10.1515/jccm-2017-0026

Managing pain and agitation in patients with opioid abuse is becoming more common in intensive care units. Tolerance to commonly used agents is often observed, leading to inadequate pain control and increased agitation. Ketamine’s unique mechanism of action and opioid-sparing effects make it an ideal agent for patients with suboptimal response to opioid therapy.
This report describes our experience using continuous ketamine infusions for analgesia and sedation in four mechanically ventilated patients with histories of opioid abuse that had suboptimal response to standard therapy. Ketamine was successful in improving analgesia and sedation in three patients while reducing the need for other analgesics and sedatives with minimal adverse effects.
Continuous ketamine infusions may be useful to facilitate mechanical ventilation in patients with histories of opioid abuse with minimal toxicity. More information is needed on the optimal dose and titration parameters.

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Repeated Bronchoscopy – Treatment of Severe Respiratory Failure in a Fire Victim

Ovidiu Rusalim Petris1, Cristina Bologa2, Victorita Sorodoc2, Catalina Lionte2

1 Nursing Department, 2nd Internal Medicine Clinic, “Sf. Spiridon” Clinical County Emergency Hospital, “Gr. T. Popa” University of Medicine, Iasi, Romania
2 Internal Medicine Department, 2nd Internal Medicine Clinic, “Sf. Spiridon” Clinical County Emergency Hospital, “Gr. T. Popa” University of Medicine, Iasi, Romania

DOI: 10.1515/jccm-2017-0024

A case of respiratory failure in a domestic fire victim presenting with 1-3-degree skin burns on 10% of the total body surface, is reported. Forty-eight hours after admission to hospital, the patient developed severe respiratory failure that did not respond to mechanical ventilation. Severe obstruction of the airway had resulted from secretions and deposits of soot-forming bronchial casts. The patient required repeated bronchoscopies to separate and remove the bronchial secretions and soot deposits. An emergency bronchial endoscopic exam was crucial in the patient’s survival and management. The patient was discharged from the hospital after twenty-four days.

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Lung Abscess Remains a Life-Threatening Condition in Pediatrics – A Case Report

Ioana Raluca Chirteș1, Cristina Oana Mărginean2,4, Horea Gozar3,4, Anca Meda Georgescu1,4, Lorena Elena Meliț2,4

1 Infectious Diseases Clinic 1 Tg. Mureș, Romania
2 Paediatrics Clinic 1 Tg. Mureș, Romania
3 Paediatric Surgery and Orthopedics Clinic Tg. Mureș, Romania
4 University of Medicine and Pharmacy Tg. Mureș, Romania

DOI: 10.1515/jccm-2017-0023

Pulmonary abscess or lung abscess is a lung infection which destroys the lung parenchyma leading to cavitations and central necrosis in localised areas formed by thick-walled purulent material. It can be primary or secondary. Lung abscesses can occur at any age, but it seems that paediatric pulmonary abscess morbidity is lower than in adults. We present the case of a one year and 5-month-old male child admitted to our clinic for fever, loss of appetite and an overall altered general status. Laboratory tests revealed elevated inflammatory biomarkers, leukocytosis with neutrophilia, anaemia, thrombocytosis, low serum iron concentration and increased lactate dehydrogenase level. Despite wide-spectrum antibiotic therapy, the patient’s progress remained poor after seven days of treatment and a CT scan established the diagnosis of a large lung abscess. Despite changing the antibiotic therapy, surgical intervention was eventually needed. There was a slow but steady improvement and eventually, the patient was discharged after approximately five weeks.

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Reoccurrence of Bleeding of a Chronic Subdural Haematoma Following a Fall

Rafael García Carretero

Internal Medicine Department, Mostoles University Hospital, Rio Jucar, 28935, Mostoles (Madrid), Spain

DOI: 10.1515/jccm-2017-0020

The case of a 60-year-old patient who presented with an acute-on-chronic subdural haematoma is reported. Chronic haematoma usually remains asymptomatic, and this is considered to be an unusual course of events. Trivial or minor injury may cause the cortical bridge veins and fragile vessels in the former haematoma to rupture with concomitant reoccurrence of bleeding. Old age, repeated traumatic brain injuries, brain atrophy, antiplatelet agents and oral anticoagulants such as warfarin are considered to be the underlying conditions to cause the reoccurrence of bleeding. However, our patient did not have any of those conditions.

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