Case Reports in Critical Care最新文献

Accumulating evidence suggests that a patient subgroup with severe COVID-19 develops a cytokine release syndrome leading to capillary leakage and organ injury. Recent publications addressing therapy of cytokine storms recommended new extracorporeal therapies such as hemoadsorption. This case report describes a 59-year-old SARS-CoV-2-positive patient with severe ARDS. Due to severe hyperinflammation with concomitant hemodynamic instability and progressive renal failure, combination of continuous renal replacement and CytoSorb® hemoadsorption therapy was initiated. Treatment resulted immediately in a control of the hyperinflammatory response. Simultaneously, lung function continued to improve accompanied by profound hemodynamic stabilization. We report the successful utilization of CytoSorb® hemoadsorption in the treatment of a patient with SARS-CoV-2-induced cytokine storm syndrome.

Streptococcus equi subsp. zooepidemicus (S. equi subsp. zooepidemicus), which carries the Lancefield group C antigen, is an uncommon human pathogen. It is considered an opportunistic commensal of the equine upper respiratory tract and causes invasive infections in immunocompromised hosts, following close contact to infected horses. Meningitis caused by S. equi subsp. zooepidemicus is a rare infectious disease with high rates of complications. We present the case of a 56-year-old female with acutely altered mental status following three days of fever and vomiting. For several months, she was taking care of horses. The most relevant preexisting illnesses were chronic hepatitis C infection and traumatic paraplegia due to spinal cord injury 30 years ago. Laboratory evaluation on admission revealed leukocytosis, hyponatremia, and elevated C-reactive protein. Cerebral CT scan showed diffuse cerebral edema. Whereas cerebrospinal fluid real-time PCR assay for common pathogens was negative, cultures showed S. equi subsp. zooepidemicus. She recovered fully after intravenous administration of ceftriaxone for four weeks. This is one of only few reported cases of S. equi subsp. zooepidemicus meningitis and the first case in chronic hepatitis C infection. Our case supports the necessity for extended microbiological examination especially in immunocompromised patients if PCR examination for common pathogens is negative.

Systemic capillary leak syndrome (SCLS) is a rare disorder manifesting as shock, hemoconcentration, and hypoalbuminemia, which may be either idiopathic or secondary to an underlying disease process. We report a case of an adult with COVID-19 infection associated with new onset SCLS. Our case joins only two other cases of new SCLS associated with COVID-19 infection reported in the literature. The clinical and laboratory findings in this case are distinct from findings seen in COVID-19 cytokine storm syndrome. Whether our therapeutic approach was efficacious is unknown. Further research into causes and therapies for these syndromes is urgently indicated.

Ethylene glycol is commonly used in antifreeze, and ingestion of even a small amount can result in acute kidney injury, severe metabolic acidosis, and neurological injury. When cases are recognized early, treatment involves administration of alcohol dehydrogenase inhibitors to prevent conversion to toxic metabolites of glycolate, glyoxolate, and oxalate. In later presentations with more severe renal injury, hemodialysis may be required for clearance of toxic metabolites and supportive care for renal failure. We present the first reported case of severe ethylene glycol intoxication requiring support of extracorporeal membrane oxygenation (ECMO) due to refractory cardiopulmonary collapse.

Pericardial tamponade results in multiple organ dysfunction and can lead to cardiac arrest. Cardiopulmonary resuscitation (CPR), a life-saving measure performed on patients in cardiac arrest, can lead to thoracic organ damage. However, CPR rarely acts as a therapeutic treatment for pericardial tamponade. Our case describes a patient admitted with pericardial tamponade in whom CPR provided therapeutic treatment with pericardial rupture and resolution of the tamponade.

Because of its characteristic features of autoinfection, the parasitic nematode Strongyloides stercoralis can infect patients for years. An acceleration of its autoinfective cycle can be triggered by human T-lymphotropic virus-1 (HTLV-1) infection, mainly by the deviation of the protective Th2- to Th1-type immune response and can lead to severe disease by dissemination of Strongyloides stercoralis larvae carrying intestinal bacteria to multiple organs. Meningitis caused by enteric Gram-negative bacteria is a potentially fatal complication of disseminated strongyloidiasis. Herein, we present the case of a Strongyloides-HTLV-1 coinfected patient, admitted for E. coli meningitis. One day after initiation of ivermectin, the patient developed significant S. stercoralis dissemination, complicated by multiorgan failure syndrome, and died from neurological failure. While the initial clinical scenario of our case has already been well described in the literature, its course after antihelminthic treatment initiation remains unclear and needs to be discussed.

The opioid epidemic continues to have devastating consequences for children and families across the United States with rising prevalence of opioid use and abuse. Given the ease of access to these medications, accidental ingestion and overdose by children are becoming increasingly more common. The recognition of opioid-induced neurotoxicity and the associated life-threatening complication of acute cerebellar cytotoxic edema are crucial, as are the high morbidity and mortality without timely intervention. We discuss an infant with acute cytotoxic cerebellar edema following mucosal exposure to a transdermal fentanyl patch.

COVID-19 has been declared a pandemic since March 2020 and it has been responsible for millions of deaths worldwide. The SARS-CoV-2 causes a spectrum of diseases mainly affecting the respiratory system. It can also complicate other systems causing thromboembolic phenomena and myocardial ischaemia. An entity of hypoxia has been described in these patients which show no clinical signs and symptoms of respiratory distress despite being extremely hypoxic. This is called silent or happy hypoxia. The exact mechanism for this is not known. We report 4 cases which had similar presentations of silent hypoxia but had different course of illness and different outcomes. All 4 patients did not show any signs of respiratory distress, but had oxygen saturation less than 82%. 3 of them needed intensive care unit support for oxygen therapy and subsequently needed noninvasive ventilation. Only one required invasive ventilation. The fourth patient did not require intensive care support. The patient who required invasive ventilation succumbed due to severe COVID pneumonia whereas the other 3 patients were discharged from the hospital. Silent hypoxemia can go undetected in COVID-19 patients particularly in the time of a pandemic. This case series highlights the importance of meticulous clinical examination including oxygen saturation measurements in suspected or confirmed patients with COVID-19. The course of illness can be different in different populations, and this needs further clinical evidence.

Background: We report two pediatric cases of anticholinergic toxidrome, including the youngest reported to date, in which standard therapeutic strategies were either contraindicated or ineffective, while treatment with dexmedetomidine was rapidly efficacious with no adverse effects. Moreover, with the recent shortage of physostigmine, we highlight an alternative treatment in this clinical setting. Case Summaries. In case 1, a two-year-old had an overdose presenting with an anticholinergic toxidrome. However, his hypopnea precluded the use of benzodiazepines due to the high likelihood of intubation. In case 2, a 14-year-old had a polypharmacy overdose inducing agitated delirium that was refractory to high-dose benzodiazepines. Due to the unknown ingestion, physostigmine was avoided. In both cases, dexmedetomidine helped the patient remain calm and metabolize the ingestions.

Conclusion: Our experience suggests that dexmedetomidine may be a useful adjunct in anticholinergic presentations in the setting of polypharmacy, when standard therapy is proven ineffective, contraindicated, or unavailable.

Background. Novel coronavirus-19 disease (COVID-19) is associated with significant cardiovascular morbidity and mortality. However, there have been very few reports on complete heart block (CHB) associated with COVID-19. This case series describes clinical characteristics, potential mechanisms, and short-term outcomes of critically ill COVID-19 patients complicated by CHB. Case Summary. We present three cases of new-onset CHB in critically ill COVID-19 patients. Patient 1 is a 41-year-old male with well-documented history of Familial Mediterranean Fever (FMF) who required mechanical ventilator support for acute hypoxic respiratory failure from severe COVID-19 pneumonia. He developed new-onset CHB without a hemodynamic derangement but subsequently had acute coronary syndrome complicated by cardiogenic shock. Patient 2 is a 77-year-old male with no past medical history who required intubation for severe COVID-19 pneumonia acute hypoxic respiratory failure. He developed CHB with sinus pause requiring temporary pacing but subsequently developed multiorgan failure. Patient 3 is 36-year-old lady 38 + 2 weeks pregnant, gravida 2 para 1 with no other medical history, who had an emergency Lower Section Caesarean Section (LSCS) as she required intubation for acute hypoxic respiratory failure. She exhibited new-onset CHB without hemodynamic compromise. The CHB resolved spontaneously after 24 hours. Discussion. COVID-19-associated CHB is a very rare clinical manifestation. The potential mechanisms for CHB in patients with COVID-19 include myocardial inflammation or direct viral infiltration as well as other causes such as metabolic derangements or use of sedatives. Patients diagnosed with COVID-19 should be monitored closely for the development of bradyarrhythmia and hemodynamic instability.