Journal of medical cases最新文献

Babesiosis is a potentially life-threatening tick-borne parasitic infection. Severe disease in splenectomized individuals may require exchange transfusion. A 58-year-old male with a history of splenectomy presented with 2 weeks of subjective fever, weakness, and abdominal pain. He denied any rashes, tick bites, or recent travel. He had a motor vehicle accident a few years ago and had undergone an emergency splenectomy. On examination, the patient was febrile (39.3 °C), tachycardic (106/min), and jaundiced. Labs revealed anemia and thrombocytopenia. Computed tomography (CT) abdomen revealed asplenia. As it was summer, there was concern for a tick-borne illness. A peripheral smear showed schistocytes, and labs revealed hyperbilirubinemia, high lactate dehydrogenase (LDH), low haptoglobin, and reticulocytosis (13%), consistent with hemolysis. Testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), Ehrlichia, Borrelia, Anaplasma, and viral hepatitis was negative. Antibody testing for Babesia microti was positive. A blood parasite smear confirmed Babesia microti with a parasitemia of 9.5%. The patient received intravenous azithromycin and atovaquone for severe babesiosis. On day 2 of hospitalization, parasitemia increased to 14.7%. Hemoglobin and platelets dropped further on day 3. His parasite load remained consistently above 10% despite medical treatment. A decision was made for a red blood cell (RBC) exchange transfusion for severe disease, which was performed on the fourth day of hospitalization. Clinical improvement was seen after one session of exchange RBC transfusion. Hemoglobin remained stable, and thrombocytopenia improved 1 day after RBC exchange transfusion. Parasitemia dropped to 1.2% after 4 days of exchange transfusion, and azithromycin was switched to oral. He received 9 days of inpatient azithromycin and atovaquone. He was discharged with a plan to continue the oral antimicrobials for 3 more weeks. Asplenia and parasitemia > 10% are associated with severe babesiosis. Asplenia, in particular, is associated with severe infection, hospitalization, and prolonged duration of therapy. Exchange transfusion in severe babesiosis can be lifesaving.

Pheochromocytoma-induced Takotsubo cardiomyopathy is a rare but life-threatening condition, caused by excessive plasma catecholamine levels, resulting in acute myocardial dysfunction. Clinical presentation includes a rapid development of heart failure due to regional wall motion abnormalities (most commonly affecting all mid to apical left ventricle (LV) wall segments) causing the "octopus-trap-like" LV shape. A 45-year-old female patient presented with acute cardiogenic shock of non-ischemic etiology. Her past medical history included a similar episode, which was followed by full recovery, but at this admission she required hemodynamic support with venoarterial extracorporeal membrane oxygenation. The systolic function was restored, and further investigation revealed high 24-h urine metanephrine levels and a mass of the left adrenal gland, leading to the diagnosis of pheochromocytoma. After treatment with firstly alpha-blockers and then beta-blockers, the pheochromocytoma was surgically removed.

Trisomy 18 is the second most common autosomal trisomy aside from trisomy 21. Anesthesiologists were unlikely to manage such patients in the past, specifically those surviving later into childhood due to the 90% mortality rate within the first year of life and the lack of procedural options that were available. However, a paucity of literature regarding the anesthetic management of such patients exists. Trisomy 18 patients present a unique anesthetic challenge, given the presence of associated dysmorphic facial features and the involvement of multiple organ systems, leading to difficult airway and hemodynamic disturbances. In this case report, we present the anesthetic management of a 9-year-old patient with trisomy 18 undergoing a multilevel spinal fusion. Despite significant intraoperative hemorrhage, the patient was able to tolerate the procedure without complications, likely owing to the meticulous preoperative preparation and the patient's survival later into childhood. This case contributes to a small subset of literature which suggests that patients with trisomy 18 who survive later into childhood have an improved ability to tolerate general anesthesia.

This case report describes a novel therapy for patients with severe autism spectrum disorder (ASD) that is worth further investigation. A 19-year-old male adolescent with ASD, who was not responding to standard treatment received fecal microbiota transplant (FMT) using donor material from his typically developing female sibling. The patient's ASD symptoms were assessed by assessors who were blind to the patient's past ASD symptomatology. Assessors used the Childhood Autism Rating Scale (CARS), an observation-based rating scale to assess developmental delay in children with autism (range of CARS scores is 15 - 60; a score > 28 is indicative of autism; higher score is positively correlated with degree of severity), at baseline and again at six timepoints post-FMT. The patient experienced marked improvements in microbiome diversity and composition over the year and a half period that followed the FMT procedure. Additionally, the patient who was previously nonverbal said his first two words and experienced a reduction in aggression 1-month post-FMT. To the authors' knowledge, this is the first report to demonstrate the use of familial FMT in an adolescent patient with ASD. Given that ASD symptom improvements post-FMT tend to occur in younger patients, the authors hypothesize that the use of a familial donor may be an important factor that contributed to the improved outcomes experienced by this older child.

This study presents a case of norepinephrine and dobutamine-induced dynamic left ventricular outflow tract obstruction (LVOTO) caused by systolic anterior motion (SAM) in a patient experiencing acute anterior myocardial infarction (MI). In a 76-year-old patient presenting with acute MI, intensive use of norepinephrine and dobutamine may lead to the development of dynamic LVOTO and SAM. The presence of hypotension and a new cardiac murmur may suggest a mechanical complication such as acute mitral regurgitation (MR) or ventricular septal rupture (VSR). The assessment of the left ventricular outflow tract (LVOT) using echocardiography plays a critical role in the diagnosis of SAM and its associated MR and dynamic LVOTO. The patient's condition was stabilized through the cessation of inotropes and the implementation of aggressive fluid resuscitation, resulting in improved hemodynamics. In conclusion, prompt identification of the underlying pathophysiological mechanisms is imperative for effectively managing this condition and preventing hemodynamic exacerbation.