Aim: To study a rare presentation of acute leukoencephalopathy with acute chest syndrome and pulmonary infarction all at once in a patient of sickle cell disease (SCD). Background: Acute leukoencephalopathy with acute chest syndrome is a very rare complication in a patient with SCD. Both complications occur due to vaso-occlusive crisis. Acute chest syndrome presents with fever, cough, shortness of breath, and pulmonary thromboembolism as a likely etiology. Acute leukoencephalopathy usually presents as posterior reversible leukoencephalopathy (PRES) characterized by headache, seizure, encephalopathy, visual symptoms, and focal neurological deficits. Magnetic resonance imaging (MRI) findings usually reveal edematous changes in the occipital and parietal lobes. Case description: Hereby, we present a case of acute leukoencephalopathy with acute chest syndrome with pulmonary infarct (due to pulmonary thromboembolism) in a case of SCD with the help of clinical, laboratory, and radiological correlation. In this case, an MRI brain showed involvement of the frontal lobe, thalamus, and cerebellum, which is an extremely rare presentation. The patient was given antibiotics, bilevel-positive airway pressure (BiPAP) support, and steroids, as a result of which the patient showed significant clinical improvement. Conclusion and clinical significance: In this case, we concluded that leukoencephalopathy can involve atypical areas with acute chest syndrome, which is very rare in the adult population and is a matter of clinical significance for future research.

Introduction: The increasing burden associated with drug-resistant bacteria is a global concern, and this issue has been highlighted across the world in the political arena through the Global Action Plan on antimicrobial resistance (AMR). Antimicrobial agents play a pivotal role and can be groundbreaking if chosen and administered correctly. Case description: Here, we describe a patient diagnosed with bacterial infection with an atypical susceptibility pattern. Conclusion: Imipenem-susceptible meropenem-resistant Klebsiella pneumoniae (ISMRK) is an unusual strain with varying acquired susceptibility. Comprehensive workup, knowledge, and appropriate treatment have been shown to lead to better outcome.

Aim and background: With a better understanding of the various causes of cardiac arrest (CA) and the development of novel technologies and devices, conventional cardiopulmonary resuscitation (CPR) has undergone several modifications for improved outcomes. Case description: We hereby present a case of a 57-year-old diabetic lady who suffered refractory CA, which was successfully managed with extracorporeal cardiopulmonary resuscitation (e-CPR). The patient was on venoarterial extracorporeal membrane oxygenation for 5 days and was discharged home without any neurological morbidity on day 10 of admission. Conclusion: Indian extracorporeal membrane oxygenation (ECMO) centers are also getting equipped to promptly manage refractory CA cases with extracorporeal technologies. Clinical significance: This is the first case to be reported from Eastern India of successful e-CPR for in-hospital CA.

Aim and background: This case report aims to highlight the atypical presentation of ANCA-associated vasculitis, where the patient experienced simultaneous occurrences of diffuse alveolar hemorrhage (DAH) and ileal perforation. ANCA-associated vasculitis is an autoimmune disorder that can lead to inflammation and damage of small blood vessels, resulting in various clinical manifestations. DAH is a common and severe pulmonary complication, while ileal perforation is a rare and life-threatening gastrointestinal complication. Case description: A 35-year-old male patient was admitted to the ICU with fever, dyspnea, and hemoptysis. He was diagnosed with MPO-positive ANCA vasculitis based on laboratory findings, and diagnostic tests. The patient's condition rapidly deteriorated, requiring invasive ventilatory support. He was treated with a combination of cyclophosphamide, rituximab, and high-dose corticosteroids. During treatment, he developed abdominal pain, dyspnea, and hypotension, and was found to have a small bowel perforation on imaging. The patient underwent emergency exploratory laparotomy, and the perforation was surgically repaired. Conclusion: This case highlights the atypical and severe manifestations of ANCA-associated vasculitis, with the occurrence of DAH and ileal perforation. The management of such complex cases requires a multidisciplinary approach, with prompt and aggressive treatment of the vasculitis and management of the complications. Clinical significance: This case emphasizes the importance of clinicians being aware of the potential for rare and atypical manifestations of ANCA-associated vasculitis. Early recognition and prompt intervention are crucial to improve patient outcomes. The case also need for further research to better understand the pathophysiological mechanisms and establish optimal treatment protocols for these rare complications.

Aim and background: Commonly found in glues, paints, varnishes and industrial solvents, toluene is a widely abused drug due to its acute neurologic effects including euphoria and subsequent depression. However, its abuse is also associated with dangerous electrolyte and metabolic abnormalities, rhabdomyolysis, acute kidney injury (AKI) and cardiac abnormalities. Case description: A young lady, chronic inhalational abuser of toluene, presented to our hospital with acute intoxication secondary to ingestion of whitener solution in an unconscious state. She was found to have severe acidemia and hypokalemia, progressing to acute kidney injury (AKI). The patient was admitted in ICU for mechanical ventilation, and correction of electrolyte and metabolic abnormalities. Thereafter, she made a complete recovery and was successfully discharged. Conclusion: The hallmark of toluene intoxication is a normal anion gap hyperchloremic metabolic acidosis with severe hypokalemia or distal renal tubular acidosis (RTA) type 1. Patients may also develop AKI, rhabdomyolysis and cardiac abnormalities (arrhythmias and ST-T segment changes due to severe hypokalemia), but rarely respiratory depression. Management involves adequate resuscitation, intensive care admission and aggressive correction of acid base and electrolyte abnormalities, as there is no specific antidote. Clinical significance: Early recognition and management of clinical features and complications like AKI and arrythmias is of utmost importance in patients with toluene intoxication.

Aim and background: Tropical infections have a high prevalence in India. Mostly, coinfection with more than one tropical infection makes the diagnosis difficult and increases mortality and morbidity. To increase more awareness regarding tropical infections which can turn into life threatening situations and the need for aggressive management for that. Case description: We present a case of a 51-year-old lady admitted with vomiting and diarrhea, which rapidly progressed into sepsis and multiorgan dysfunction. Blood investigations showed coinfection with hepatitis E, scrub typhus, and dengue. She was treated aggressively with all conservative and interventional measures. Conclusion: Despite our best efforts, she had a persistent high-grade fever, severe anemia, thrombocytopenia, and markedly increased liver enzymes with raised D-dimer, fibrinogen, and ferritin, leading to secondary hemophagocytic lymphohistiocytosis (HLH) syndrome. She succumbed to the illness ultimately. Clinical significance: triple coinfection of dengue, hepatitis E, and scrub typhus, which, to our knowledge, has not been previously reported in the literature, making it an exceptionally rare presentation.

Aim and background: Spinal epidural abscess (SEA) is the collection of pus mostly affecting the epidural space of the spine. Tubercular and fungal etiologies are more commonly accountable for SEA in developing countries and in immunocompromised populations. Case description: The patient presented to us with complaints of fever, bilateral lower limb weakness, and urinary retention of 2 weeks’ duration. After contrast-enhanced magnetic resonance imaging (CEMRI) revealed a posterior epidural collection in the dorsal spine, he was empirically started on antibiotics, antitubercular drugs, and steroids. Following an urgent neurosurgical consultation, he underwent a two-level dorsal (D6-D7) laminectomy with evacuation. The drained pus sample revealed Candida albicans growth, which was sensitive to fluconazole. He was started on intravenous (IV) fluconazole followed by echinocandins. Amphotericin, which remains the drug of choice for invasive Candida of the nervous system, could not be initiated in our patient despite the identification of the species, in view of rapidly progressive renal failure. Unfortunately, despite all measures, his condition continued to deteriorate, and he finally succumbed to acute renal failure and sepsis. Conclusion: Spinal epidural abscess is a rare but potentially fatal disease that is often missed or misdiagnosed. Appropriate and timely treatment can help reduce the rate of mortality and morbidity from this fulminant disease. Clinical significance: Fungal SEA is a rare entity and often goes undiagnosed, leading to its mismanagement and subsequent high morbidity and mortality.

Aim and background: Acquired Methemoglobinemia, is one of the least common differential diagnoses while evaluating a cyanotic and hypoxemic patient. Typically results from toxin exposure, leading to significant morbidity and mortality if not promptly diagnosed and treated. Case description: A 38-year-old woman presented with altered consciousness, and respiratory distress, 13 hours after ingesting emamectin benzoate. She exhibited refractory hypoxemia, cyanosis with a “saturation gap”, and a co-oximetric methemoglobin level of 33%. Treatment included methylene blue infusion, Vitamin C, and N-acetylcysteine. Her mentation and oxygen saturation improved gradually, and she was discharged on the sixth day. Conclusion: Methemoglobinemia following pesticide ingestion is rare but fatal. Physicians should consider it in cases of refractory hypoxemia and a “saturation gap”. Treatment with antidotes is crucial and continued monitoring is essential to detect and manage potential relapse. Clinical significance: This is the first case report of methemoglobinemia followed by emamectin benzoate poisoning.

Aim and background: Glufosinate-ammonium (GLA), a herbicide commonly used in Andhra Pradesh, becomes toxic upon accidental consumption in undiluted form, affecting multiple organ systems. There is no specific antidote, only symptomatic treatment available for this type of poisoning. Conventional treatment methods may not always yield satisfactory outcomes due to varied toxicokinetics. This case report highlights the significance of promptly initiating resin hemoperfusion to effectively clear the lipophilic glufosinate compounds in an intensive care setting. Case description: A 50-year-old male presented to our hospital after ingesting approximately 250 mL of 13.5% GLA compound. He exhibited altered sensorium and seizures, which were attributed to hyperammonemia. After stabilizing airway, breathing, and circulation (ABC), he underwent two cycles of resin-based hemoperfusion lasting 3.6 hours each, resulting in a gradual reduction in ammonium levels and an improvement in sensorium. Eventually, he was weaned off and extubated successfully from mechanical ventilation and discharged without any neurological deficits. Conclusion: This approach yielded several positive outcomes like reduction of hyperammonemia, improvement of neurological manifestations, shortened intensive care unit (ICU) stay, facilitated early weaning from mechanical ventilation. Clinical significance: The early recognition of neurological symptoms and the timely implementation of hemoperfusion, were instrumental in achieving positive outcomes.