Indian Journal of Critical Care Case Report

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2022 | September-October | Volume 1 | Issue 2

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From the Editor's Desk

[Year:2022] [Month:September-October] [Volume:1] [Number:2] [Pages:1] [Pages No:00 - 00]

   DOI: 10.5005/ijccr-1-2-v  |  Open Access |  How to cite  | 



Pankaj Suresh Ghormade, Kavyesh Sahu, Swapnil Prabhakar Akhade

Right Ventricle Myocardial Infarction due to Coronary Thrombosis in a Patient after Sustaining Electric Injury

[Year:2022] [Month:September-October] [Volume:1] [Number:2] [Pages:4] [Pages No:31 - 34]

Keywords: Coronary thrombosis autopsy, Electric injury, Myocardial infarction, Right ventricle

   DOI: 10.5005/jp-journals-11006-0012  |  Open Access |  How to cite  | 


Involvement of the heart is common in electric shock when the current follows a particular path. Electrical injuries affect the cardiovascular system in nearly 1/3rd of the patient, and myocardial infarction (MI) is a potential, although rare, consequence of electric shock. Deaths after an electric shock are immediate due to cardiac arrhythmias or brainstem dysfunction. However, anticipating cardiac events in the survivor patient is a challenging task. We have described a case of a 32-year-old female who sustained accidental electric shock due to contact with the live wire. The patient was revived on initial cardiopulmonary resuscitation (CPR). She survived for 30 hours after initiating treatment, and her electrocardiogram (ECG) revealed sinus tachycardia. She had an electric entry burn injury over the left thenar eminence and left thumb. Thrombotic occlusion or right coronary with transmural infarction of the anterolateral wall of the right ventricle was a prominent finding in the autopsy.



Biswajit Nayak

Trichosporon asahii Bloodstream Infection in an Immunocompetent Patient: A Rare Entity

[Year:2022] [Month:September-October] [Volume:1] [Number:2] [Pages:2] [Pages No:35 - 36]

Keywords: Bloodstream infection, Immunosuppressed, Trichosporon asahii

   DOI: 10.5005/jp-journals-11006-0013  |  Open Access |  How to cite  | 


Infection with non-Candida species like Trichosporon is an emerging cause of fungal infection. It often causes fatal, life-threatening infections in immunosuppressed patients. They may have a varied presentation depending on the patient's immune status, ranging from self-limiting cutaneous manifestation to pneumonia, meningitis, and disseminated bloodstream infection. They cause infection in neutropenic and critically ill patients on broad-spectrum antibiotics with invasive medical devices. Herein we are reporting a rare Trichosporon asahii bloodstream infection in a non-neutropenic critically ill patient.



Bhavinkumar Patel, Karan Shah, Yogesh Bhargava

A Rare Case Report of Pneumonia with Bloodstream Infection by Kocuria kristinae

[Year:2022] [Month:September-October] [Volume:1] [Number:2] [Pages:3] [Pages No:37 - 39]

Keywords: Acute respiratory distress syndrome, Cytokine removal therapy, Cytokine storm, Kocuria kristinae, Septic shock, Subcutaneous emphysema

   DOI: 10.5005/jp-journals-11006-0014  |  Open Access |  How to cite  | 


We are presenting a rare case of pneumonia with acute respiratory distress syndrome (ARDS), septic shock, and cytokine storm by Kocuria kristinae. K. kristinae is usually a commensal, but it can be a pathogenic organism as well. We started teicoplanin as per the culture sensitivity report and continued for 10 days. We did ARDSnet protocol ventilation along with cytokine removal therapy as interleukin 6 (IL-6) level was very high (>5000) during and after cytokine removal therapy, oxygen, and vasopressors requirement reduced dramatically. The patient also developed subcutaneous emphysema, so the peep was reduced, which resolved conservatively. Over the period of time patient improved, was extubated, and discharged.



Ashwini M Suryawanshi, Dilip R Karnad, Ravindra M Ghawat, Aniruddha V More, Preetam Kalaskar

Central Pontine Myelinolysis without Rapid Changes in Sodium Level: Possible Association with Malnutrition, Hypophosphatemia and Hypokalemia

[Year:2022] [Month:September-October] [Volume:1] [Number:2] [Pages:2] [Pages No:40 - 41]

Keywords: Central pontine myelinolysis, Hyponatremia, Hypophosphatemia, Malnutrition

   DOI: 10.5005/jp-journals-11006-0015  |  Open Access |  How to cite  | 


Central pontine myelinolysis (CPM) is a rare demyelinating condition most commonly associated with a rapid rise in plasma osmolality, especially during the correction of chronic hyponatremia. The clinical consequences can vary from mild motor weakness to devastating locked-in syndrome (LIS). The condition has also been described in association with other conditions like alcoholism, an acquired immunodeficiency syndrome (AIDS), hepatic failure1 hypernatremia, hypophosphatemia,2,3 liver transplantation, and carbamate poisoning.4 We report a case of a 76-year-old female with carcinoma rectum with acute gastroenteritis, sepsis, and acute kidney injury who developed CPM, not related to rapid correction of hyponatremia, during recovery from the acute illness. Highlights: Central pontine myelinolysis (CPM), which is part of the osmotic demyelination syndrome (ODS), usually results from the rapid increase in plasma osmolality during the correction of chronic hyponatremia. The clinical consequences vary from mild motor weakness to devastating LIS. ODS has also been described in association with alcoholism, malnutrition, diabetes mellitus (DM), liver transplantation, and electrolyte abnormalities like hypernatremia, hypophosphatemia, and hypokalemia. A 76-year-old female with rectal adenocarcinoma was admitted with anorexia, prolonged diarrhea due to Clostridium difficile infection, malnutrition, and sepsis. She had hypophosphatemia, hypocalcemia, and hypoalbuminemia on admission and persistent hypokalemia due to profuse diarrhea. She developed CPM with no evidence of rapid correction of sodium. We postulate that CPM may have been a consequence of malnutrition, hypophosphatemia, and hypokalemia.



Kinjal K Purohit, Harda H Shah, Harsh J Panchal, Pranjal Modi, Bharat Tiwari

Refractory Hypoxemia with Hepatopulmonary Syndrome following Liver Transplant: Is there a Role of Trendelenburg Position? A Case Report

[Year:2022] [Month:September-October] [Volume:1] [Number:2] [Pages:4] [Pages No:42 - 45]

Keywords: Hepatopulmonary syndrome, Hypoxemia, Liver transplantation, Mechanical ventilation, Trendelenburg positioning, Ventilation perfusion mismatch

   DOI: 10.5005/jp-journals-11006-0016  |  Open Access |  How to cite  | 


We report a case of a 50-year-old man who underwent liver transplantation for severe hepatopulmonary syndrome. Preoperatively, patient had orthodeoxia and platypnea leading to severe hypoxemia, requiring home oxygen therapy. Postoperatively, Trendelenburg position was given for the management of refractory hypoxemia. The outcome was measured by oxygen saturation using pulse oximetry and partial pressure of oxygen in ABGA. Post-transplant hypoxia for HPS can be managed in multiple ways but out of all of them, positioning is a simple maneuver without any severe complications that may correct the pathophysiologic abnormalities seen in HPS by gravitationally shifting blood away from the lung bases to improve oxygenation.



Promita Barua, Chandrashish Chakravarty, Soumya Bhattacharya, Lawni Goswami

Spontaneous Splenic Rupture in Chronic Myelomonocytic Leukemia Post G-CSF Administration

[Year:2022] [Month:September-October] [Volume:1] [Number:2] [Pages:2] [Pages No:46 - 47]

Keywords: Acute abdomen, Chronic myelomonocytic leukemia, Granulocyte colony-stimulating factor, Hemoperitoneum, Shock, Splenic injury, Spontaneous splenic rupture

   DOI: 10.5005/jp-journals-11006-0017  |  Open Access |  How to cite  | 


Highlights Splenic rupture is a potentially life-threatening condition, often associated with trauma. Spontaneous splenic rupture (SSR) is very rare and is usually reported as secondary to some pathological conditions like infection (malaria, infectious mononucleosis), pancreatitis, sarcoidosis, or hematological malignancy. In this case report, we present an unusual presentation of SSR in a case of chronic myelomonocytic leukemia (CMML) who received granulocyte colony-stimulating factor (G-CSF) 10 days before presentation. Splenic rupture is one of the main causes of acute abdomen and should be considered in CMML or lymphoma. The history of G-CSF use is significant as it may cause SSR.



Sarita S Chammanam, Ramakrishna M Iyengar, Balachandra Sulleri Raju

A Case Report on Delayed Presentation and Diagnosis of Mild Hemophilia A

[Year:2022] [Month:September-October] [Volume:1] [Number:2] [Pages:2] [Pages No:48 - 49]

Keywords: Delayed diagnosis, Hemophilia A, Mild form

   DOI: 10.5005/jp-journals-11006-0018  |  Open Access |  How to cite  | 


Background: Hemophilia A is a genetic bleeding disorder due to clotting factor VIII deficiency. A delay in diagnosis can result in an increase in morbidity and mortality. The natural history of milder forms of the disease is poorly understood. Therefore, the aim of this study was to enable early detection and management of patients with undiagnosed mild hemophilia A with recurrent episodes of bleeding only after major trauma or surgery. Method: To identify the etiology, we tested the serum D-dimer, serum ionized calcium, coagulation profile, mixing study, Lupus anticoagulant activity, anticardiolipin antibody panel, Von Willebrand workup, and platelet aggregation study. Result: The coagulation profile done showed persistent isolated prolongation of aPTT, followed by a mixing study which favored factor deficiency. This was then confirmed with a Factor Assay which reported Factor VIII deficiency. The patient was then supplemented with Factor VIII, after which he had no further episodes of bleeding and improved clinically.



Lakshmi Vas, Varsha Suryavanshi, Jhanvi Vora Hemani

Reversal of Quadriplegia with Ultrasound-guided Dry Needling of Muscles Affected by Critical Illness Polyneuromyopathy/Neuropathy

[Year:2022] [Month:September-October] [Volume:1] [Number:2] [Pages:5] [Pages No:50 - 54]

Keywords: Critical illness myopathy, Critical illness neuropathy, Critical illness polyneuromyopathy, Quadriparesis, Quadriplegia, Ultrasound-guided dry needling

   DOI: 10.5005/jp-journals-11006-0019  |  Open Access |  How to cite  | 


Case report: A 70-year-old developed critical illness polyneuropathy/critical illness polyneuromyopathy (CIP/CIPNM) quadriparesis with bilateral foot drop after a prolonged intensive care unit (ICU) stay. Systematic ultrasound-guided dry needling (USGDN) of axial and limb muscles reversed the low-grade co-contraction of agonist/antagonists of extremities surmised to cause CIP/CIPNM paresis to restore reciprocal inhibition essential for normal movements. Disability of Arm, Shoulder, and Hand (DASH) score improved from 96 to 15, allowing daily activity resumption within 2 weeks and independent walking at 8 weeks with a walker for right foot drop. Sonography documented the reversal of structural disruption of muscle with USGDN. Conclusion: CIP/CIPNM reversal with USGDN suggests low-grade co-contraction as a probable cause of paresis in this patient.



Rajasekar Ramadurai, Santhosh Arulprakasam, Srinivasan Swaminathan

Organophosphorus or Imidacloprid Poisoning? A Clinical Conundrum

[Year:2022] [Month:September-October] [Volume:1] [Number:2] [Pages:3] [Pages No:55 - 57]

Keywords: Atropine, Imidacloprid poisoning, Organophosphate, Poisoning

   DOI: 10.5005/jp-journals-11006-0020  |  Open Access |  How to cite  | 


Introduction: Organophosphorus compounds (OPC) account for a major proportion of poisoning in India, with a high mortality rate. Neonicotinoid compounds like imidacloprid are considered to be safer for humans; however, poisoning of these compounds is a rising trend, and the knowledge regarding the management is sparse. Hereby we report the management of a case of imidacloprid poisoning, which initially presented with OPC-like symptoms. Case description: A 19-year-old male presented with a history of suicidal consumption of unknown insecticide and with complaints of vomiting, abdominal pain, and drowsiness. Owing to the presumptive diagnosis of OPC poisoning, atropine and pralidoxime were given in a rural health center and referred to our institute. On presentation, his vitals were stable. With no signs of OPC poisoning noted, on further probing, the bystanders had revealed a container of imidacloprid, and hence the diagnosis was made. Since there is no specific antidote, he was managed conservatively. On the next day, he developed breathlessness, altered sensorium with neck flop, and hence intubated in view of impending respiratory failure. He was evaluated for systemic manifestations of imidacloprid. He was continuously agitated, previously attributed to atropine delirium but now suspected due to neurological manifestation of the poisoning. Also, he has ongoing rhabdomyolysis; hence renal protective measures were done. Eventually, the systemic manifestations subsided, and the patient improved and was weaned off ventilatory support after a week. He was hence discharged after psychiatric consultation and follow-up. Discussion: OPC poisoning is the most common cause of poisoning in India; newer neonicotinoid compounds like imidacloprid have been used. Occasionally, the presence of OPC along with neonicotinoids in commercially available formulations leads to the manifestations of both compounds and hamper the clinical presentation of the other compound leading to misjudgment and hence uncertainty in treatment. The use of antidotes like atropine and pralidoxime will alleviate the muscarinic symptoms. But oximes aggravate the nicotinic effects in the absence of OPC. Since we faced a similar clinical scenario, there was a clinical conundrum. Vigilant monitoring for multi-organ involvement is necessary in such cases. Conclusion: Timely diagnosis, monitoring for clinical effects and complications, and adequate supportive measures and interventions form the core of the management of imidacloprid poisoning.



Wasim Shabbir Shaikh, Zeyad Faroor Alrais, Ghaya Alrais

Pyopericardium Complicated by Cardiac Tamponade: A Near-fatal Presentation

[Year:2022] [Month:September-October] [Volume:1] [Number:2] [Pages:3] [Pages No:58 - 60]

Keywords: Cardiac tamponade, Pericardiocentesis, Pyopericardium

   DOI: 10.5005/jp-journals-11006-0021  |  Open Access |  How to cite  | 


Pericardial effusion is the presence of an abnormal amount of fluid/or an abnormal character to fluid in pericardial space. It is commonly seen as part of multisystem infections, malignancy, renal failure, or autoimmune diseases. When fluid in pericardial effusion is pus, it is called pyopericardium or purulent pericarditis. It is one of the dreaded manifestations of bacterial pericarditis. It can be idiopathic/primary without any underlying cause or secondary to infection elsewhere in the body. Pericardial effusion due to pyopericardium may present with cardiac tamponade with life-threatening hemodynamic compromise. Pyopericardium, if not treated in time, may have a 100% mortality. We hereby report a successfully treated case of primary pyopericardium presented with sepsis and cardiac tamponade with multi-organ failure in an immunocompetent host. To the best of our knowledge, there are no previous case reports from our region on acute pyopericardium with tamponade. A 39-year-old man was brought to the emergency department with complaints of breathlessness and fatigue. Screening echocardiography suggested pericardial effusion with cardiac tamponade. We performed emergency pericardiocentesis with drainage of 500 mL of frank pus from the pericardial space. Culture grew Streptococcus mitis, confirming the diagnosis of acute purulent pericarditis. The patient received intravenous antibiotics and other supportive intensive care. He was later discharged from the intensive care unit (ICU) to the medical ward for further continuation of care. Multidisciplinary team management is of paramount importance for the proper diagnosis and treatment of this disease. The case is highlighted because of its unusual causative organism and near-fatal outcome, especially with late diagnosis and management.


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