scholarly journals Klebsiella brain abscess in an immunocompetent patient: a case report

2021 ◽  
Vol 15 (1) ◽  
Author(s):  
Clay Wu ◽  
Semi Han ◽  
Ahmet Baydur ◽  
Brett Lindgren
Keyword(s):  
Computed Tomography ◽  
Klebsiella Pneumoniae ◽  
Brain Abscess ◽  
Mental Status ◽  
Klebsiella Oxytoca ◽  
Brain Magnetic Resonance Imaging ◽  
Altered Mental Status ◽  
Immunocompetent Patient ◽  
Normal Limits ◽  
Brain Abscesses

Abstract Background Klebsiella pneumoniae brain abscesses are a rare entity and typically present in immunocompromised patients. We present a case of an overall healthy patient who developed a Klebsiella pneumoniae brain abscess in the absence of liver pathology. Case presentation A 46-year-old Vietnamese man with past medical history significant for hypertension presented to the hospital with acute on chronic worsening of altered mental status, personality changes, and gait dysfunction. Initial vitals revealed temperature of 37.1 °C, heart rate 87 beats/minute, blood pressure 150/87 mmHg, respiratory rate 18/minute, and oxygen saturation 99% on room air. Physical exam was notable for altered mental status, Glasgow Coma Scale (GCS) score of 14, and right lower facial droop. Cardiopulmonary exam was within normal limits. Head computed tomography (CT) showed a left frontotemporal mass, with subsequent brain magnetic resonance imaging (MRI) revealing a ring-enhancing lesion concerning for a brain abscess. The abscess was urgently drained; however, there was intraoperative spillage into the ventricles. Intraoperative cultures grew Klebsiella pneumoniae, and the patient was maintained on appropriate antibiotics. He developed worsening mental status, septic shock, and cerebral edema requiring decompressive left hemicraniectomy. Computed tomography of the abdomen and pelvis revealed no hepatic lesions. The patient did not improve, and the family elected for comfort measures. Conclusion High mortality is associated with Klebsiella pneumoniae (as opposed to Klebsiella oxytoca) brain abscesses, especially in the setting of intraventricular spread. This case illustrates the need for early detection, and an aggressive medical and surgical treatment approach is required for a potential favorable outcome.

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.

An Early Case of Fat Embolism Syndrome Occurring Following Polytrauma

2020 ◽  
pp. 000313482094364 ◽  
Author(s):  
Janelle-Cheri A. Millen ◽  
Carrie Watson ◽  
John M. Cain ◽  
Joshua Hagan ◽  
Winston T. Richards ◽  
...  
Keyword(s):  
Intracranial Hypertension ◽  
Mental Status ◽  
Brain Magnetic Resonance Imaging ◽  
Altered Mental Status ◽  
Fat Embolism ◽  
Long Bone ◽  
Status Change ◽  
Fat Embolism Syndrome ◽  
Embolism Syndrome ◽  
Maximal Medical Therapy

Fat embolism syndrome (FES) is a clinical entity occurring due to the presence of fat particles in the microcirculation, typically manifesting 12-72 hours after long bone trauma with respiratory distress, altered mental status, and petechial rash. Our case is that of a 17-year-old girl who suffered multiple orthopedic injuries without intracranial trauma after being a pedestrian struck by a vehicle. Despite presenting with a normal Glasgow Coma Score (GCS), within 4 hours of presentation, she was noted to have an acute mental status change to a GCS 7 with a normal computed tomography brain. Magnetic resonance imaging of the brain was suggestive of FES which, in this patient, had a rapidly progressing course with the development of severe cerebral edema and intracranial hypertension refractory to maximal medical therapy. Our patient required bilateral craniectomies for intracranial decompression and progressed over a 2-month hospital course to have subsequent cranioplasty and functional neurologic improvement. FES requires a high index of clinical suspicion in the presence of long bone fracture with unexplained altered mental status. The clinical course can be rapidly progressing with the development of intracranial hypertension which may benefit from surgical decompression with optimistic prognosis.

Altered Mental Status During the COVID-19 Pandemic

2021 ◽  
pp. 254-256
Author(s):  
Sara Mariotto ◽  
Silvia Bozzetti ◽  
Maria Elena De Rui ◽  
Fulvia Mazzaferri ◽  
Andrew McKeon ◽  
...  
Keyword(s):  
Magnetic Resonance Imaging ◽  
Cerebrospinal Fluid ◽  
Magnetic Resonance ◽  
Mental Status ◽  
Central Nervous System Infection ◽  
Brain Magnetic Resonance Imaging ◽  
Altered Mental Status ◽  
High Dose ◽  
Resonance Imaging ◽  
Vein Thrombosis

In March 2020, a 68-year-old man with a history of pulmonary thromboembolism sought care at the emergency department for fever, cough, headache, and confusion. Because of severe respiratory failure, orotracheal intubation was required, and the patient was admitted to the intensive care unit, where bilateral deep vein thrombosis and hematemesis occurred. After 2 weeks, owing to respiratory improvement, the patient was weaned from ventilator support and sedation. However, persistent fluctuations in confusion, anxiety, agitation, and cognitive-motor slowing were noted. One week later, he was referred to the infectious diseases unit, where altered mental status persisted in the absence of fever, seizures, or episodes of impaired consciousness. Chest radiography showed small, bilateral, ground-glass opacities. Brain magnetic resonance imaging showed bilateral involvement of mesial temporal lobes and hippocampus on fluid-attenuated inversion recovery sequences, in the absence of contrast enhancement or restricted diffusion. Nasopharyngeal samples were positive for SARS-CoV-2 on reverse transcriptase–polymerase chain reaction testing. Cerebrospinal fluid examination showed a slight increase in protein concentration, 1 white blood cell/µL, and no evidence of central nervous system infection. In particular, SARS-CoV-2 RNA was not detected. The patient was diagnosed with postinfectious inflammatory (limbic) encephalitis in the course of SARS-CoV-2 infection. The patient was treated with lopinavir/ritonavir and hydroxychloroquine. His recent thromboembolism prevented the administration of intravenous immunoglobulins, and high-dose corticosteroids were not administered because of the recent episode of hematemesis. Improvement in cognitive symptoms was noted 6 weeks after onset. At the time of this writing, May 2020, a few cases of encephalitis after COVID-19 had already been described. These have generally been characterized by fever, cognitive dysfunction, epileptic seizures, coma, and cerebrospinal fluid inflammatory findings. It appears that a common magnetic resonance imaging appearance in these patients is that of diffuse inflammatory encephalitis.

scholarly journals Operative Hysteroscopy Intravascular Absorption Syndrome Causing Hyponatremia with Associated Cerebral and Pulmonary Edema

2019 ◽  
Vol 3 (3) ◽  
pp. 252-255 ◽  
Author(s):  
Marco Elegante ◽  
Joseph Hamera ◽  
Jane Xiao ◽  
David Berger
Keyword(s):  
Computed Tomography ◽  
Emergency Department ◽  
Pulmonary Edema ◽  
Mental Status ◽  
Cerebral Edema ◽  
Altered Mental Status ◽  
Supplemental Oxygen ◽  
Hysteroscopic Myomectomy ◽  
Operative Hysteroscopy ◽  
Intravenous Saline

Operative hysteroscopy intravascular absorption syndrome is an iatrogenic syndrome caused by absorption of hypo-osmolar distension medium during hysteroscopy, which can lead to rapid hyponatremia with resulting cerebral and pulmonary edema. We present a case of a 47-year-old female who underwent hysteroscopic myomectomy at an outpatient ambulatory surgical center who was brought to the emergency department with dyspnea, hypoxia, and altered mental status. Workup showed hyponatremia with cerebral edema on computed tomography of the head and pulmonary edema on chest radiograph. The patient improved after resuscitation with intravenous saline and supplemental oxygen, and she was discharged home the next day.

scholarly journals Listeria Monocytogenes Brain Abscess in Crohn’s Disease Treated with Adalimumab

2017 ◽  
Vol 11 (3) ◽  
pp. 675-679 ◽  
Author(s):  
Amporn Atsawarungruangkit ◽  
Fernando Dominguez ◽  
Gustavo Borda ◽  
Nikolaos Mavrogiorgos
Keyword(s):  
Central Nervous System ◽  
Nervous System ◽  
Crohn’S Disease ◽  
Listeria Monocytogenes ◽  
Crohn's Disease ◽  
Brain Abscess ◽  
Mental Status ◽  
Altered Mental Status ◽  
Tnf Alpha ◽  
Gram Positive

Listeria monocytogenes is a gram-positive bacterium that causes listeriosis. Brain abscess is a very uncommon manifestation of listeriosis and has not been reported to be associated with adalimumab (humira), one of the approved medications for treating Crohn’s disease. A 45-year-old female with Crohn’s disease presented with sudden onset of fever, headache, nausea, vomiting, and altered mental status for 1 day. She was on prednisone and 6-mercaptopurine. She had started taking adalimumab 17 days prior to admission. She had signs of toxicity, confusion, and nuchal rigidity, but showed neither central nervous system deficits nor focal deficits. The laboratory results revealed Gram-positive coccobacillus, positive blood and cerebrospinal fluid culture for Listeria monocytogenes, and a 5 × 5 mm ring-enhancing lesion of brain abscess on MRI. After holding off 6-mercaptopurine and adalimumab, her mental status improved on the next day. Finally, she was discharged on day 7 of hospitalization with ampicillin 2 g intravenously every 4 h for a total of 2 weeks. Two weeks later, the follow-up MRI showed a 2-mm area of residual enhancement in the left temporal lobe at the site of the previous brain abscess. Adalimumab, as a tumor necrosis factor (TNF)-alpha inhibitor, carries a risk of triggering opportunistic infection, such as listeriosis. With an altered mental status or neurological signs in patients receiving TNF-alpha antagonizing agent, physicians should suspect bacterial infection in the central nervous system and promptly initiate treatment for brain abscess if needed.

scholarly journals Is Spontaneous Hypoglycemia a Feature of XLID Type Nascimento?

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A389-A390
Author(s):  
Amin A L Mardini ◽  
Ishita Singh
Keyword(s):  
Intellectual Disability ◽  
Amino Acid ◽  
Mental Status ◽  
Genetic Disorder ◽  
Altered Mental Status ◽  
Acth Stimulation ◽  
Normal Limits ◽  
First Case ◽  
Additional Imaging ◽  
History Of

Abstract Introduction: X-linked intellectual disability (XLID) type Nascimento is a rare, under-diagnosed genetic disorder caused by intragenic mutations in the UBE2A gene. The syndrome was first described in 2006 by Nascimento et el. It is characterized by intellectual disability, dysmorphic facial features, skin anomalies, hypotonia, impaired speech, and seizures. To date, there is no literature to suggest that it affects glucose homeostasis. Case: A 63-year-old male with a history of XLID (mutation in UBE2A pL112P variant), seizures, dementia, stage II CKD, polycystic kidneys, and hyperkalemia presented to the emergency department with altered mental status and blood glucose (BG) of 22 mg/dL. Mental status improved after correction of hypoglycemia. He had multiple admissions for hypoglycemia, however, no history of diabetes mellitus, or use of hypoglycemia inducing medications. Home medications included Patiromer for hyperkalemia. Family history was remarkable for XLID type Nascimento in his brother and sister’s son. Imaging and laboratory studies conducted on prior admissions were inconclusive. Abdominal CT scan showed a 6mm cyst in the head of the pancreas, but no mass. A 72-hour fast after holding dextrose infusion did not yield a clear biochemical differential. BG 51 mg/dL, Insulin <0.5 (3.0–25 mU/L), C-peptide 0.6 (1.1–4.4 ng/mL), pro-insulin 3.2 (0.0–10.0 pmol/L), β-hydroxybutyrate 0.2 (<0.6 mmol/L). BG increased to greater than 25 mg/dL with 1 mg IV glucagon. Insulin antibody was negative (<5 uU/ml). IGF-1, IGF-2 were low at 17 (49–188 ng/mL) and 142 (333-967ng/mL) respectively. Thyroid function and ACTH stimulation test were within normal limits. Aldosterone <0.1(0.0–30 ng/dL), renin 0.195 (0.167–5.38 ng/mL/hr). Urine metabolic screen, urine amino acid screen, plasma amino acid screen and white cell lysosomal enzymes were normal for the nephew and not performed in our patient. The patient’s family requested not pursuing a repeat 72-hour fast, additional imaging or invasive procedures. Dexamethasone 0.5mg orally at bedtime was started which improved blood sugars and patient was discharged. He presented 2 weeks later with recurrent hypoglycemia. Dexamethasone was titrated to 1.5 mg with no improvement. Diazoxide 3mg/kg/day was subsequently started while dexamethasone was tapered and discontinued. Hypoglycemia did not recur. Conclusion: This is the first case report describing spontaneous hypoglycemia in an individual with XLID type Nascimento. Our patient also had hyporeninemic hypoaldosteronism which raises the question of endocrine abnormalities as a manifestation of XLID type Nascimento and if hypoglycemia is an inborn error of metabolism in this patient.

scholarly journals Is this Withdrawal or Intoxication? Case Report Regarding Complications of Unregulated Use of Tianeptine, Etizolam, and Phenibut in the USA

CNS Spectrums ◽  
2021 ◽  
Vol 26 (2) ◽  
pp. 169-169
Author(s):  
Sadia B. Ghani ◽  
Eric Taylor ◽  
Siddesh Gopalakrishnan
Keyword(s):  
Substance Use ◽  
Mental Status ◽  
Altered Mental Status ◽  
Easy Access ◽  
The Internet ◽  
Normal Limits ◽  
Concurrent Use ◽  
The Usa ◽  
History Of ◽  
Benzodiazepine Withdrawal

AbstractBackgroundThe internet allows easy access for the sales of psychoactive agents that are not regulated by the FDA. Some of those agents are used to help manage anxiety, depression and sleep, such as tianeptine, etizolam, and phenibut. These medications have the potential for abuse and potentially leading to altered mental status when intoxicated or withdrawing. This presents a challenge to clinicians who may not be aware of availability of such substances. Available literature has discussed the use of above substances individually, but how do you treat if there is use of more than one substance with different mechanisms of actions? Here we present a case of an adult male who has used all three agents simultaneously, leading to a hospital admission.Case HistoryA 32-year-old male presented to the emergency department (ED) for altered mental status (AMS). He has a documented history of anxiety but was never treated with prescription medications. No history of substance use was documented. He was self-medicating with concurrent use of tianeptine (atypical antidepressant with mu agonist properties,) phenibut (GABA mimetic) and etizolam (a benzodiazepine-like agent). During his stay, he was agitated and delirious with reports of visual hallucinations. Neuroimaging and lab studies were within normal limits, EEG showed no seizure activity. Over the course of his hospital stay, he was started on Depakote for agitation, a Valium taper for suspected benzodiazepine withdrawal and prevention of seizures, Seroquel for delirium, and baclofen for suspected GABAergic withdrawal symptoms. The patient’s AMS improved and he was discharged on hospital day 10.ConclusionsThis case illustrates the difficulty managing poly-substance use/abuse and stresses the importance for physicians to screen for psychoactive agents purchased over the internet or over the counter to improve treatment outcomes. Continued discussions with patients regarding risks/benefits of use of such substances would be beneficial and help increase awareness.

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