Indian Journal of Critical Care Case Report

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Volume 3, Number 1, January-February 2024
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FROM THE EDITOR'S DESK

Subhash K Todi

From the Editor's Desk

[Year:2024] [Month:January-February] [Volume:3] [Number:1] [Pages:1] [Pages No:v - v]

   DOI: 10.5005/ijccr-3-1-v  |  Open Access | 

59

CLINICAL CASE DISCUSSION

Raghuram N Thiriveedhi, Ramesh Venkataraman, Sristi Patodia

Thrombocytopenia in the Critically Ill: An Animal with Several Heads

[Year:2024] [Month:January-February] [Volume:3] [Number:1] [Pages:5] [Pages No:1 - 5]

Keywords: Fever, Myalgia, Systemic hypertension, Thrombocytopenia

   DOI: 10.5005/jp-journals-11006-0089  |  Open Access |  How to cite  | 

Abstract

A 59-year-old male with a history of systemic hypertension and fever presented as an interesting patient with thrombocytopenia. While fever with thrombocytopenia is a common presentation, this patient's course in the hospital took multiple twists and turns, taking us through a tutorial in thrombocytopenia.

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CASE REPORT

Prakhar Sharma, Prakash Sivaramakrishnan, Mayank Mishra, Girish Sindhwani

Stridor and Paratracheal Mass: Primary Tracheal Tumor Presenting as an Isolated Paratracheal Lesion

[Year:2024] [Month:January-February] [Volume:3] [Number:1] [Pages:4] [Pages No:6 - 9]

Keywords: Case report, Primary tracheal tumor, Stridor, Tracheal tumors

   DOI: 10.5005/jp-journals-11006-0081  |  Open Access |  How to cite  | 

Abstract

A mid-40s nonsmoker man presented with acute symptoms of hoarseness of voice and stridor on expiration for the past 2 weeks. His general and systemic examination was unremarkable except for resting tachycardia and mild hypoxemia. Contrast-enhanced tomography of the chest (CECT) thorax revealed a right paratracheal mass lesion causing near-complete obstruction of the upper trachea, for which he underwent a rigid bronchoscopy procedure the next day with biopsy from the endoluminal mucosal infiltration of the trachea. Histopathology revealed non-small cell lung cancer (NSCLC) characteristics with p40 and p63 positivity on immunohistochemistry. Positron emission tomography-computed tomography (PET-CT) showed no metabolic activity in any other part of the body. The patient also underwent an upper gastrointestinal (GI) endoscopy, 70° nasal endoscopy, to rule out other primaries, which were normal. The patient was planned for definitive chemoradiotherapy along with a tracheal metallic stenting procedure. Postprocedure, the patient's symptoms improved, and he was discharged in good health and has been doing well in follow-up. This case demonstrates an extremely rare presentation of primary tracheal tumors (PTT) as a paratracheal mass with no metastases.

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CASE REPORT

Pritam A Shetty, Fathima T Basheer, Aineesh Vallurupalli, Manjunatha Hande, GK Adarsha, Prakyath Kotary, V Rajesh

Postpartum Atypical Hemolytic Uremic Syndrome—A Diagnostic Conundrum Requiring Meticulous Management: A Case Report

[Year:2024] [Month:January-February] [Volume:3] [Number:1] [Pages:4] [Pages No:10 - 13]

Keywords: Atypical hemolytic uremic syndrome, Case report, Complement dysfunction, Postpartum atypical hemolytic uremic syndrome, Thrombotic microangiopathy

   DOI: 10.5005/jp-journals-11006-0083  |  Open Access |  How to cite  | 

Abstract

Aim and background: Thrombotic microangiopathies (TMAs) are a range of conditions characterized by several key features, including microangiopathic hemolytic anemia (MAHA), thrombocytopenia, and the formation of microthrombi. This case report specifically examines one of the uncommon primary causes of TMA, namely atypical hemolytic uremic syndrome (aHUS). Case description: We present the scenario of a female in her late 20s, P1L1, who presented three days postdelivery with complaints of decreased urine output and fatigue. Her medical history comprised pregnancy-induced hypertension, primary postpartum hemorrhage (PPH), and two episodes of paroxysmal events accompanied by loss of consciousness, possibly indicative of tonic-clonic seizures. Blood investigations demonstrated features of intravascular hemolysis, thrombocytopenia, and significantly elevated levels of urea and creatinine. Further studies revealed low C3, normal C4, mildly reduced ADAMTS13, and slightly elevated ADAMTS inhibitor levels, which were insufficient to make a diagnosis of thrombotic thrombocytopenic purpura (TTP). Based on the above findings, the patient was diagnosed with aHUS and was started on repeated transfusions of packed red blood cells (PRBC) and fresh frozen plasma (FFP) along with intermediate hemodialysis and symptomatic measures. With an initial deterioration in condition requiring intubation on the second day, over the course of the week, she gradually improved and was discharged on day 21 of hospitalization. Conclusion: Early identification of aHUS is vital for cost-effective treatment. Advancements in complement studies can lead to quicker diagnosis, informed treatment decisions, and resource optimization. Clinical significance: This case report helps us derive, for example, one of the scenarios when an eye must be kept out for an uncommon diagnosis like aHUS.

128

CASE REPORT

K Krishna Chaitanya

A Rare Case of CMV-induced HLH in B-ALL

[Year:2024] [Month:January-February] [Volume:3] [Number:1] [Pages:4] [Pages No:14 - 17]

Keywords: Case report, Hemophagocytic lymphohistiocytosis, Septic shock, Steroid

   DOI: 10.5005/jp-journals-11006-0085  |  Open Access |  How to cite  | 

Abstract

Hemophagocytic lymphohistiocytosis (HLH) is a condition that demands a high index of suspicion and necessitates differentiation from sepsis as the treatment approaches for these two conditions diverge. Patients afflicted with hematological malignancies are susceptible to developing secondary HLH syndrome, which can arise either due to the malignancy itself or due to infections that emerge during chemotherapy. Prudent administration of chemotherapy regimens and the early identification of secondary HLH, whether attributed to malignancy or to infections, are pivotal in tailoring appropriate treatments and thereby mitigating mortality. This case involves a 50-year-old male diagnosed with B-cell acute lymphoblastic leukemia (B-ALL) and undergoing induction chemotherapy. The patient exhibited refractory shock without discernible sources of infection on routine cultures, along with normal procalcitonin levels. Additionally, acute liver failure and pancytopenia developed. Through diagnostic investigations, hemophagocytes were identified in bone marrow biopsy, and cytomegalovirus (CMV) viral load was detected in the blood, satisfying the Histiocyte Society's criteria for HLH. HLH often mimics sepsis, even though it can itself be triggered by an infection. Hence, it is imperative to accurately identify, differentiate, and treat both conditions appropriately.

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CASE REPORT

Ruchi Gupta, Sumit Ray

Methemoglobinemia in a Patient on Maintenance Hemodialysis: A Case Report

[Year:2024] [Month:January-February] [Volume:3] [Number:1] [Pages:3] [Pages No:18 - 20]

Keywords: Acquired methemoglobinemia, Amine filtration, Carbon filters, Case report, Dialysate filtration process, Filtration, Hemodialysis

   DOI: 10.5005/jp-journals-11006-0084  |  Open Access |  How to cite  | 

Abstract

In recent years, India has faced an increasing number of patients requiring dialysis with the insurgence of dedicated dialysis centers. Maintenance hemodialysis presents a unique but undermined potential source of exposure to patients whereby an individual is exposed to around 300–400 L of external water as dialysate fluid. The solutes in water used, along with disinfectants like chlorine, chloramines, amines, and nitrates if not filtered appropriately and used as dialysate may cause methemoglobinemia and other complications in patients undergoing dialysis. Acquired methemoglobinemia though a rare clinical condition, in its severest form, may lead to rapid clinical deterioration and death if not identified and managed in time. The oxidized form of iron in the methemoglobin impedes its binding to the oxygen molecule leading to a drop in oxygen-carrying capacity of the blood. The first step of management is to stop the inciting agent. In a chronic kidney disease (CKD), patient excretion of inciting agent may be impeded in case of renally excreted molecules leading to prolonged exposure and persisting methemoglobinemia. We report this rare case of severe methemoglobinemia in a patient with CKD on dialysis.

76

CASE REPORT

Archana Nair

Mackler's Triad to Suspect Boerhaave's Syndrome

[Year:2024] [Month:January-February] [Volume:3] [Number:1] [Pages:3] [Pages No:21 - 23]

Keywords: Boerhaave's syndrome, Case report, Esophageal rupture, Pneumomediastinum, Pneumothorax

   DOI: 10.5005/jp-journals-11006-0088  |  Open Access |  How to cite  | 

Abstract

Background: A case report of esophageal perforation presenting with the rare symptom triad of vomiting, chest pain, and subcutaneous emphysema (Mackler's triad) and its diagnostic evaluation and management. Case description: A 60-year-old patient presented to the emergency department (ED) with a history of two episodes of vomiting, followed by the development of chest pain, abdominal pain, and respiratory distress. On evaluation, the patient was tachypneic, tachycardic, and hypoxic. Subcutaneous emphysema was present in the neck and upper chest. As bedside ultrasound revealed bilateral pneumothorax, chest tubes were inserted on both sides, and the patient was intubated for severe respiratory distress. Computed tomography (CT) chest was suggestive of pneumomediastinum with bilateral pneumothorax. Based on the clinical and radiological evidence, a diagnosis of Boerhaave's syndrome (BS) was made, and the patient was taken up for upper gastrointestinal endoscopy followed by exploratory laparotomy. Patient had a 3 cm long esophageal perforation in left lateral wall of lower esophagus near gastroesophageal junction. Despite aggressive management, patient succumbed on the seventh postoperative day. Boerhaave's syndrome (BS) is a potentially lethal condition that poses a major diagnostic and therapeutic challenge for the emergency physician. Spontaneous esophageal perforation presenting with the classical Mackler's triad, that is, vomiting, chest pain, and subcutaneous emphysema is rare. A high index of suspicion is needed for prompt diagnosis, which, in turn, paves the way for early and appropriate management.

60

CASE REPORT

Shikha Sachan, Abhimanyu Kapoor, Sohan Lal Solanki

Severe Hypomagnesemia-induced Cerebellar Ataxia after Major Gastrointestinal Cancer Surgeries: A Report of Two Cases

[Year:2024] [Month:January-February] [Volume:3] [Number:1] [Pages:4] [Pages No:24 - 27]

Keywords: Case report, Cerebellar ataxia, Cerebellar edema, Cerebellar syndrome, Gastrointestinal oncosurgeries, Gut resection, Hypomagnesemia

   DOI: 10.5005/jp-journals-11006-0092  |  Open Access |  How to cite  | 

Abstract

Magnesium is a major intracellular ion and is vital for optimal body functions. Low serum magnesium levels can lead to many disorders, including severe neurological derangements. Postoperative patients of gastrointestinal (GI) cancer surgeries are vulnerable to severe magnesium deficiencies due to a variety of causative factors. A large proportion of hypomagnesemia-related disorders may go undetected or misdiagnosed, as magnesium level monitoring is not part of a routine electrolyte panel. We report two cases of distinct cerebellar syndromes due to cerebellar edema in postoperative patients of major GI oncosurgeries due to severe hypomagnesemia. Symptoms in both cases were reversed with prompt intravenous (IV) magnesium therapy. Our report suggests the importance of regular serum magnesium assessment in postoperative cases of major GI surgeries, including abdominal cancer surgeries.

52

CASE REPORT

Tushar Patel, Harjit Singh Mahay, Pankaj Kumar

Catatonia: Intensive Care Unit Perspectives

[Year:2024] [Month:January-February] [Volume:3] [Number:1] [Pages:2] [Pages No:28 - 29]

Keywords: Altered mental status, Benzodiazepines, Case report, Catatonia, Intensivist

   DOI: 10.5005/jp-journals-11006-0090  |  Open Access |  How to cite  | 

Abstract

Catatonia is a well-known psychiatric disorder. However, there is evolving evidence of it presenting in several medical and affective disorders. Familiarity with the diagnosis and presentation of catatonia in the intensive care unit (ICU) is often lacking among the intensivists. We hereby report a case of catatonia in a young patient with no history of psychiatric disorders in the past. He underwent a battery of tests to determine the cause of his altered mental status. He was treated with benzodiazepines following a lorazepam test when catatonia was suspected leading to an improvement in his condition. Awareness about catatonia among physicians and intensivists can lead to an early diagnosis and management of such cases.

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