Fulminant methicillin-sensitive Staphylococcus aureus infection: from pinprick to multiorgan failure

2021 ◽  
Vol 14 (5) ◽  
pp. e239396
Author(s):  
Aunie Danyalian ◽  
Ivett Padron ◽  
Patricia Almeida ◽  
Mauricio Danckers
Keyword(s):  
Staphylococcus Aureus ◽  
Cardiopulmonary Arrest ◽  
Multiorgan Failure ◽  
Altered Mental Status ◽  
Spontaneous Circulation ◽  
Pericardial Fluid ◽  
Large Pericardial Effusion ◽  
Sterile Needle ◽  
Refractory Septic Shock ◽  
Initial Imaging

A woman in her 60s with diabetes presented to our institution with altered mental status. Preceding symptoms included headaches, nausea and vomiting. One month prior to presentation, she cut her left thumb and developed a pustule, which she occasionally manipulated with a non-sterile needle. On arrival, the patient was in shock, with a Glasgow Coma Scale of 3, requiring emergent intubation and intensive care unit admission. Her initial imaging studies revealed a large pericardial effusion and cerebral subcortical hypodensities. She suffered from a cardiopulmonary arrest with return of spontaneous circulation, with bedside echocardiogram revealing cardiac tamponade. She underwent emergent pericardiocentesis which revealed purulent drainage. Blood, pericardial fluid, cerebrospinal fluid, sputum and urine cultures returned positive for methicillin-sensitive Staphylococcus aureus. The hospital course was further complicated by refractory septic shock and fulminant multiorgan failure, ultimately leading to her demise.

Bone marrow necrosis and fat embolism syndrome: a near fatal complication in previously undiagnosed sickle beta + thalassaemia

2021 ◽  
Vol 14 (1) ◽  
pp. e238317
Author(s):  
Nibash Budhathoki ◽  
Sunita Timilsina ◽  
Bebu Ram ◽  
Douglas Marks
Keyword(s):  
Bone Marrow ◽  
Multiorgan Failure ◽  
Rare Condition ◽  
Altered Mental Status ◽  
Fat Embolism ◽  
Bone Marrow Necrosis ◽  
Embolism Syndrome ◽  
Hb S ◽  
High Index Of Suspicion ◽  
Specific Symptoms

Prevalence of haemoglobin sickle-β+ thalassaemia (Hb S/β+thal) is variable with geography ranging from 0.2% to 10% among sickle cell patients. Clinical presentation of Hb S/β+thal patients depends on HbA level, with milder disease often going undiagnosed. However, rarely these patients can present with a fulminant vaso-occlusive crisis (VOC). Given VOC can present with non-specific symptoms, the diagnosis and treatment is often delayed. Here, we present a patient who initially developed altered mental status, pancytopenia and multiorgan failure due a critical VOC resulting in bone marrow necrosis and fat embolism. Subsequent workup confirmed that our patient had Sickle-β+ thalassaemia, which had gone undiagnosed, despite subclinical evidence of haemolysis on routine lab work for years. Following diagnosis and initiation of RBC exchange, he improved significantly and was discharged home. High index of suspicion and bone marrow biopsy is vital for early diagnosis and management of this rare condition.

Loperamide Induced Recurrent Torsades de Pointes: A Case Report

2021 ◽  
pp. 089719002110048
Author(s):  
Gregory G. Jackson ◽  
Christine R. Lopez ◽  
Elizabeth S. Bermudez ◽  
Nina E. Hill ◽  
Dan M. Roden ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Torsades De Pointes ◽  
Altered Mental Status ◽  
Spontaneous Circulation ◽  
Prior History ◽  
Common Phenomenon ◽  
Medical Providers ◽  
Return Of Spontaneous Circulation ◽  
History Of ◽  
Overdrive Pacing

Purpose: A case of loperamide-induced recurrent torsades de pointes is reported to raise awareness of an increasingly common phenomenon that could be encountered by medical providers during the current opioid epidemic. Summary: A 40 year-old-man with a prior history of opioid abuse who presented to the emergency department after taking up to 100 tablets of loperamide 2 mg daily for 5 years to blunt opioid withdrawal symptoms and was subsequently admitted to the intensive care unit for altered mental status and hyperthermia. The patient had prolonged QTc and 2 episodes of torsades de pointes (TdP) that resulted in cardiac arrest with return of spontaneous circulation. He was managed with isoproterenol, overdrive pacing, and methylnatrexone with no other events of TdP or cardiac arrest. Conclusion: A 40-year-old male who developed torsades de pointes from loperamide overdose effectively treated with overdrive pacing, isoproterenol, and methylnatrexone.

Atrial Esophageal Fistula Secondary to Ablation for Atrial Fibrillation

2017 ◽  
Vol 12 (4) ◽  
pp. e3-e5 ◽  
Author(s):  
Lily K. Fatula ◽  
William D. Bolton ◽  
Allyson L. Hale ◽  
Barry R. Davis ◽  
James E. Stephenson ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Atrial Fibrillation ◽  
Mental Status ◽  
Cardiopulmonary Arrest ◽  
Altered Mental Status ◽  
Postoperative Recovery ◽  
Atrial Fibrillation Ablation ◽  
Esophageal Fistula ◽  
Chest Computed Tomography ◽  
Fistula Treatment

This article describes 2 patients who presented to our institution with left atrial esophageal fistula after atrial fibrillation ablation; it also compares our experience with other atrial esophageal fistula cases reported in the literature. We performed a retrospective review of 2 patients who presented to our hospital between July 2015 and September 2015 with atrial esophageal fistula. Patient A, a 57-year-old man, presented 31 days postablation with a fever and right-sided weakness. A chest computed tomography showed gas in the left atrium and esophagus; an echocardiogram confirmed the diagnosis of atrial esophageal fistula. The patient subsequently underwent a left thoracotomy. Postoperative recovery was poor and included significant coagulopathy, sepsis, cardiogenic shock, and multisystem organ failure. The patient died on postoperative day 28. Patient B, a 77-year-old man, presented 21 days post-atrial fibrillation ablation with left-arm weakness and altered mental status. An esophagram was performed and showed no evidence of an esophageal perforation. Because of positive cultures and worsening altered mental status, the patient underwent a head computed tomography, which showed pneumocephalus, leading to our suspicion of the atrial esophageal fistula. A follow-up chest computed tomography confirmed the atrial esophageal fistula. Treatment included an esophagectomy and repair of the atrium. Unfortunately, the atrial esophageal fistula closure dehisced, and the patient developed acute respiratory failure and cardiac tamponade, which led to cardiopulmonary arrest, and the patient died on postoperative day 10. Based on our experience, and the literature, we recommend that a chest computed tomography be immediately performed on patients presenting with the described symptoms after a recent atrial fibrillation ablation.

Abstract 308: Pupil Diameter Predicts the Outcome in Patients With Cardiopulmonary Arrest

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_2) ◽  
Author(s):  
Shunichi Imamura ◽  
Masaaki Miyata ◽  
Risa Kamata ◽  
Yutaro Nomoto ◽  
Issei Yoshimoto ◽  
...  
Keyword(s):  
Area Under Curve ◽  
Operating Characteristic ◽  
Pupil Diameter ◽  
Cardiopulmonary Arrest ◽  
Spontaneous Circulation ◽  
Optimal Management ◽  
Return Of Spontaneous Circulation ◽  
Significant Difference ◽  
The Mean ◽  
Age And Sex

Introduction: Early prediction of the outcome in patients with cardiopulmonary arrest (CPA) is important to select the optimal management. The pupil diameter is a simple neurological examination and it predicts the prognosis in patient with stroke. However, the clinical significance of pupil diameter in CPA has not been elucidated. Hypothesis: We hypothesized that pupil diameter would predict the prognosis of CPA patients. Methods: We retrospectively analyzed consecutive 45 patients with CPA and return of spontaneous circulation (ROSC) after cardiopulmonary resuscitation in our hospital. We analyzed age, sex, cause of CPA, time during CPA, pupil diameter at admission and death in hospital. Results: The mean of age was 67±20 years and male were 34 (76%). The median of CPA time was 33 min [25%, 75%; 22, 46] and pupil diameter was 4.8 mm [3.0, 6.0]. The 26 (58%) patients died in hospital after ROSC. There was no significant difference in age and sex between survival (n=19) and dead (n=26). The CPA time was significantly shorter in survival than that in dead (21 min [10, 39] vs 30 min [30, 52], p=0.005). Furthermore, pupil diameter was significantly smaller in survival compared with dead (3.0mm [2.5, 4.3] vs 5.0mm [4.4, 6.0]) (Figure). The receiver-operating characteristic (ROC) curve for survival after ROSC demonstrated that the area under curve was 0.73 and provided an optimal cut-off value at 4.0mm in pupil diameter with 75% sensitivity and 75% specificity. When CPA time was 28 minutes, the area under curve was 0.76, and sensitivity and specificity were 78% and 71%, respectively. Conclusion: As same as CPA time, pupil diameter is suggested to predict the outcome after ROSC in CPA patients.

scholarly journals Acute myopericarditis caused by Salmonella enterica serovar Enteritidis: a case report

2020 ◽  
Vol 4 (4) ◽  
pp. 1-5
Author(s):  
Omar Chehab ◽  
Emma McGuire ◽  
Robert L Serafino Wani ◽  
Roshan Weerackody
Keyword(s):  
Salmonella Enterica ◽  
Troponin T ◽  
Clinical Signs ◽  
Pericardial Fluid ◽  
Salmonella Enterica Serovar Enteritidis ◽  
Salmonella Spp ◽  
Large Pericardial Effusion ◽  
New Diagnosis ◽  
Diagnosed Diabetes ◽  
Newly Diagnosed Diabetes

Abstract Background Acute myopericarditis can be caused by a myriad of infectious and non-infectious aetiologies, however, it is often considered to be due to self-limiting viral infection. Salmonella spp. myopericarditis is rare and the few cases in the literature suggest significant associated morbidity and mortality. Case summary A 44-year-old man presented with fever, dyspnoea, and chest pain. He was found to have a large pericardial effusion with clinical signs of tamponade and sepsis. Therapeutic pericardiocentesis was performed and ceftriaxone and levofloxacin were administered. Fully sensitive Salmonella enterica serovar Enteritidis (S. Enteritidis) was isolated in his pericardial fluid and he made a full recovery after a 4-week course of ciprofloxacin. A new diagnosis of type 2 diabetes mellitus was made on admission. A follow-up cardiac magnetic resonance (CMR) scan was suggestive of myocarditis which was unexpected given a normal Troponin T level on presentation. Discussion We report a rare case of S. Enteritidis myopericarditis. Our case is notable as the patient was immunocompetent apart from newly diagnosed diabetes. This case highlights the value of CMR imaging in assessing for myocarditis and ventricular function.

scholarly journals A Case Report: Insulinoma in a Military Pilot Detected by 68Ga-Dotatate PET/CT

2020 ◽  
Vol 185 (9-10) ◽  
pp. e1887-e1890
Author(s):  
Lisa D Larose ◽  
Penny J Vroman ◽  
Sierra R Musick ◽  
Alexis A Beauvais
Keyword(s):  
Neuroendocrine Tumor ◽  
Air Force ◽  
Imaging Modality ◽  
Pancreatic Neuroendocrine Tumor ◽  
Altered Mental Status ◽  
Laparoscopic Distal Pancreatectomy ◽  
Nuclear Medicine Imaging ◽  
Pancreatic Lesion ◽  
Pet Ct ◽  
Initial Imaging

Abstract A 37-year-old active duty male Air Force instructor pilot, with no prior medical history, was found unresponsive at his home after awakening with symptoms of altered mental status when the Emergency Medical Service (EMS) was called. The patient was found to be hypoglycemic with a glucose of 37 mg/dL. The patient recovered after administration of a dextrose bolus. Further investigation revealed that over the last several years, the patient exhibited symptoms of lightheadedness and tremors if fasted greater than 3 hours. Further clinical workup strongly suggested the presence of a neuroendocrine tumor. Initial imaging studies to include a multiphasic dedicated pancreatic computed tomography (CT) scan did not demonstrate a pancreatic lesion. However, the utilization of an innovative new nuclear medicine imaging modality, a 68Ga-Dotatate PET/CT, clearly demonstrated a 19 × 16 mm lesion of the distal pancreatic tail, which guided surgical resection. He underwent a robotic-assisted laparoscopic distal pancreatectomy, pathologically characterized as an insulinoma. The patient’s symptoms immediately resolved with no recurrence over the next 6 months. The pilot was granted a waiver, returning him to his flying duties. The 68Ga-Dotatate PET/CT enabled the identification of an otherwise occult pancreatic neuroendocrine tumor ultimately leading to this patient’s definitive cure and the salvage of this military asset’s aviation career.

scholarly journals Pediatric Emergency Medicine Residency Experience: Requirements Versus Reality

2010 ◽  
Vol 2 (4) ◽  
pp. 571-576 ◽  
Author(s):  
Matthew R. Mittiga ◽  
Hamilton P. Schwartz ◽  
Srikant B. Iyer ◽  
Javier A. Gonzalez del Rey
Keyword(s):  
Emergency Medicine ◽  
Cardiopulmonary Arrest ◽  
High Volume ◽  
Altered Mental Status ◽  
Pediatric Emergency ◽  
Acute Illness ◽  
Illness Experience ◽  
Direct Patient Care ◽  
Pediatric Residents ◽  
Number Of Patients

Abstract Background An important expectation of pediatric education is assessing, resuscitating, and stabilizing ill or injured children. Objective To determine whether the Accreditation Council for Graduate Medical Education (ACGME) minimum time requirement for emergency and acute illness experience is adequate to achieve the educational objectives set forth for categorical pediatric residents. We hypothesized that despite residents working five 1-month block rotations in a high-volume (95 000 pediatric visits per year) pediatric emergency department (ED), the comprehensive experience outlined by the ACGME would not be satisfied through clinical exposure. Study Design This was a retrospective, descriptive study comparing actual resident experience to the standard defined by the ACGME. The emergency medicine experience of 35 categorical pediatric residents was tracked including number of patients evaluated during training and patient discharge diagnoses. The achievability of the ACGME requirement was determined by reporting the percentage of pediatric residents that cared for at least 1 patient from each of the ACGME-required disorder categories. Results A total of 11.4% of residents met the ACGME requirement for emergency and acute illness experience in the ED. The median number of patients evaluated by residents during training in the ED was 941. Disorder categories evaluated least frequently included shock, sepsis, diabetic ketoacidosis, coma/altered mental status, cardiopulmonary arrest, burns, and bowel obstruction. Conclusion Pediatric residents working in one of the busiest pediatric EDs in the country and working 1 month more than the ACGME-recommended minimum did not achieve the ACGME requirement for emergency and acute illness experience through direct patient care.

What enabled mother and twins to survive 18 minutes after maternal cardiopulmonary arrest?

2014 ◽  
Vol 3 (2) ◽  
Author(s):  
Ayumi Matsuoka ◽  
Masaaki Tanaka ◽  
Satoshi Dohi ◽  
Hiromasa Sasaki ◽  
Takumi Taniguchi ◽  
...  
Keyword(s):  
Coronary Artery ◽  
American Heart Association ◽  
American Heart ◽  
Cardiopulmonary Arrest ◽  
Heart Association ◽  
Spontaneous Circulation ◽  
Artery Dissection ◽  
Spontaneous Coronary Artery Dissection ◽  
Coronary Artery Dissection ◽  
Monochorionic Twins

AbstractA woman carrying monochorionic twins underwent sudden cardiopulmonary arrest at 31 weeks of gestation due to spontaneous coronary artery dissection in the hospital. The resuscitation techniques, with her uterus manually displaced to her left, were initiated immediately and maternal spontaneous circulation was resumed 18 min later. A cesarean section was performed 2 h after the revival and the patient was kept hypothermic for 24 h. Finally, full recovery of both mother and twins was achieved. As in this case, the resuscitation techniques for pregnant women recommended by the American Heart Association, and therapeutic hypothermia, might be effective and contribute much to the survival and recovery of patients.

scholarly journals Neuroleptic malignant syndrome as part of an akinetic crisis associated with sepsis in a patient with Lewy body disease

2019 ◽  
Vol 12 (2) ◽  
pp. bcr-2018-227216 ◽  
Author(s):  
Saki Manabe ◽  
Hidetaka Yanagi ◽  
Hideki Ozawa ◽  
Atsushi Takagi
Keyword(s):  
Neuroleptic Malignant Syndrome ◽  
Lewy Body ◽  
Cardiopulmonary Arrest ◽  
Lewy Body Disease ◽  
Kidney Injury ◽  
Spontaneous Circulation ◽  
Japanese Woman ◽  
Old Japanese ◽  
History Of ◽  
Tentative Diagnosis

A 65-year-old Japanese woman with Parkinson’s disease, later diagnosed with Lewy body disease, presented with a 2-day history of systemic tremors. She also had fever without rigidity or creatine kinase (CK) elevation. She was diagnosed with sepsis caused by pyelonephritis with acute kidney injury and parkinsonism exacerbation. Although antibiotic and fluid therapy improved her pyuria and renal function, her fever and tremors persisted. On the fourth day, her symptoms worsened and resulted in cardiopulmonary arrest; however, quick resuscitation allowed the return of spontaneous circulation. Simultaneously, hyperthermia, altered consciousness, extrapyramidal symptoms, dysautonomia and CK elevation were noted. Thus, dantrolene administration was initiated with a tentative diagnosis of neuroleptic malignant syndrome (NMS). This caused her fever to subside, and her symptoms gradually improved. It was difficult to distinguish between parkinsonism exacerbation associated with sepsis and NMS. Physicians should consider NMS early on, even if the patient does not fulfil the diagnostic criteria.

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