Category Archives: JCCM 2017, Vol. 3, Issue 4
Neutropenia and T-Wave Inversion as Toxin-Mediated Complications of a Streptococcal Infection
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.
Let’s Talk About Sepsis
The current definition of sepsis is based on comparatively contemporary knowledge. However, the disease process is not fully understood and treatment still profoundly challenging. Definitions and guidelines have changed over the recent years, and clinicians are always interested to know what the new and current thoughts on the subject are.
Many papers have been published in the medical press, reporting on definitions, scores, models, cytokines, therapies, new trends, statistics, campaigns, including a sepsis anniversary day-which is not celebrating but fighting against sepsis. Together they signify the enormous interest in the subject.
The American College of Chest Physicians and the Society of Critical Care Medicine met in 1992 and gave the first definition of sepsis and associated organ failure . Eleven years later, American intensivists met European intensivists to evaluate if there was a need for a new definition of sepsis . [More]
Lethal Subarachnoid and Intracerebral Haemorrhage Associated with Temporal Arteritis. A Case Report
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.
Clinical Features and Outcomes of Fusobacterium Species Infections in a Ten-Year Follow-up
Objective. Although uncommon, Fusobacterium infections have a wide clinical spectrum, ranging from local pharyngeal infections to septic shock. Our aim was to characterize and analyze the clinical features and outcomes in patients with Fusobacterium infections, and determine which variables were able to predict a poor outcome.
Methods. We conducted a retrospective, hospital-based study using the computerized records of a second-level Spanish general hospital, serving a population of 155,000 inhabitants. The cohort was enrolled among patients cared for at the hospital between 2007 and 2016. Demographic, clinical data, microbiological characterization and outcomes at discharge, were analyzed.
Results. We collected data for all 26 patients over a 10-year period (annual incidence of 1.78 per 100,000), with an incidence of bacteremia of 0.53 cases per 100,000 population per year. F. nucleatum and F. necrophorum were the most frequent isolations (53.8% and 38.5%, respectively). F. necrophorum was found to be associated with a younger population. Although we found no deaths attributable to Fusobacterium, 15 patients (57%) were found to have severe infections due to this pathogen, and 7 patients (26.9%) were admitted to the Intensive Care Unit (ICU). The only identifiable risk factor for a severe infection (sepsis, septic shock or ICU admission) was the presence of bacteremia.
Conclusions. Fusobacterium infections are uncommon. F. necrophorum tends to cause infection in younger individuals, while F. nucleatum has a preference for older patients. The clinical spectrum is wide, ranging from local, non-severe infections, such as sinusitis or pharyngitis, to abscess formation and life-threatening infections.
Cytoreduction with Hyperthermic Intraperitoneal Chemotherapy and Renal Insufficiency Related to Diabetes Mellitus: An Anesthetic Challenge
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.
The Use of Continuous Ketamine for Analgesia and Sedation in Critically Ill Patients with Opioid Abuse: A Case Series
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.
Repeated Bronchoscopy – Treatment of Severe Respiratory Failure in a Fire Victim
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.