Introduction: Infective endocarditis is an emerging disease in ICU settings with high morbidity and in hospital mortality of up to 20%. Staphylococci and Streptococci are the most common organism causing the disease. Diagnosis and management of Infective endocarditis is challenging because of the pre-existing illness and complex nature of the disease at presentation to ICU. Case description: We present, a rare case of double valve infective endocarditis in a 48-year-old diabetic patient with Burkholderia cepacia infection who presented as febrile illness with cardio-respiratory failure. This organism is gaining importance with the increasing rate of nosocomial infections. In view of virulent multi-drug resistant organism, large vegetations, cardiogenic shock and dual valve involvement, patient underwent surgical intervention along with prolonged course of appropriate antibiotic therapy. Discussion: Burkholderia cepacia infections are rare and are usually nosocomial, multi-drug resistant and commonly causing infections only in the immunocompromised hosts, patients with granulomatous disease and hospitalized patients. Management includes correct identification with high index of suspicion, appropriate antibiotic with early surgical intervention, especially in the setting of a complicated Infective endocarditis, as seen in our case. Conclusion: A multidisciplinary team approach with antibiotics and appropriate timing of surgery helps to reduce morbidity, mortality and improves clinical outcomes.

Ochrobactrum anthropi (O. anthropi) are environmental organisms and are emerging opportunistic pathogens of low virulence in humans. O. anthropi is resistant to several broad-spectrum antimicrobial agents. It is resistant to several β lactam agents, which are commonly used to treat gram-negative infections. We report a case of meningitis due to O. anthropi in a patient diagnosed with phyllodes tumor of the breast in a cancer hospital.

Highlights Pyrexia of unknown origin is among the topic of concern in intensive care unit. Some rare isolates like Myroides species affect the immunocompromised host and have intrinsic resistance to various existing class of antimicrobial agents. Patient with prolonged ICU stay, receiving broad spectrum antibiotics, steroids with compromised nutrition and other comorbidities like anemia in this case make them susceptible for opportunistic infections. In this era, when antimicrobial resistance has reached alarming levels day by day all over the world, these organisms require early identification and prompt treatment to reduce the morbidities, length of ICU stay, and financial burden. Myroides spp. are an emerging multidrug resistant organism. This case report elucidates urinary tract infection in a postpartum patient admitted in ICU with fever and acuter onset areflexic flaccid quadriparesis.

Introduction: Patients admitted to intensive care units (ICU) often have multiple co-morbidities and are on several drugs. These medications may have drug interactions that may complicate the disease course of the patient. Case description: Here, we describe a patient with chronic kidney disease on atrioventricular (AV) nodal-blocking drugs who developed refractory bradycardia and shock, managed with emergency dialysis. Conclusions: A new clinical entity of bradycardia, renal failure, AV nodal blocking drugs, shock, and hyperkalemia (BRASH) syndrome has been described in which patients with underlying renal dysfunction may develop bradycardia, hyperkalemia, and shock when prescribed AV nodal blocking agents. Bradycardia and shock may be life-threatening and refractory to standard therapy. Hence, physicians should be aware of the underlying pathophysiology and therapeutic measures required to manage BRASH syndrome in order to improve patient outcomes.

Background and clinical case: Acute kidney injury (AKI) with anuria is a common occurrence in intensive care unit (ICU) patients and is also among the common reason for ICU admission in the postoperative period with multiple etiologies. Iatrogenic tying of the ureter during surgery while resection is rare but a significant cause of unexplained anuria during hysterectomy. Delayed diagnosis results in more severe clinical sequelae and unfavorable legal outcomes. Isolated anuria with stable hemodynamics and acceptable arterial blood gas (ABG) parameters should raise suspicion of iatrogenic anuria. This article aims to outline the clinical course and management of a syndromic patient with multiple challenges who presented with anuria, later the cause of which was found to be iatrogenic tying of the ureter during surgery. The diagnosis of this rare occurrence warrants vigilance, early detection, and prompt management. Conclusion: A multidisciplinary team approach and early use of available imaging modalities like ultrasonography (USG), digital subtraction angiography (DSA), and retrograde pyelogram (RPG) help in the identification and management, thus reducing morbidity and mortality.

Case description: A 39-year-old woman, gestation twice and one birth, that is, one live delivery and one abortion after an unplanned pregnancy (G2P1L1A1) in her 35th week of gestation presented with an episode of seizure followed by unconsciousness. Course of treatment: After securing her airway, her pregnancy was terminated, and she was treated with anti-seizure medications. She then progressed to refractory status epilepticus (RSE). Eclampsia and primary brain infections were ruled out. Magnetic resonance imaging (MRI) of the brain showed hyperintensities in the bilateral hippocampus and medial temporal lobes. With electroencephalogram (EEG) guidance, seizures were controlled with intravenous (IV) anesthetic agents, in addition to seven antiepileptic medications. After ruling out infective etiology, pulse dose steroid therapy and plasma exchange were initiated. However, her autoimmune encephalitis workup turned up to be negative. On further evaluation, her antinuclear antibodies (ANA) and extractable nuclear antigen (ENA) profiles were positive for ANA, anti-Sjögren's-syndrome-related antigen A autoantibodies (anti-Ro) 52, anti-Ro/SSA, and anti-La/SSB. A diagnosis of primary neuro Sjögren's syndrome was made. In view of persistent seizures despite high dose steroid and plasma exchange therapy, IV cyclophosphamide was initiated. Subsequently, the IV anesthetic agents were weaned off. On weaning of IV anesthetics, she was conscious and oriented and then weaned off ventilation gradually. She was then discharged with oral steroids and oral antiepileptics. Conclusion: RSE can be a rare initial presentation of primary Sjögren's syndrome.

Introduction: In recent studies, veno-venous extracorporeal membrane oxygenation (VV ECMO) has been used to salvage blunt thoracic trauma patients with severe acute respiratory distress syndrome (ARDS), by providing required oxygenation in precarious scenarios. No such cases were found to be reported from Indian hospitals, and hence, we submit the following case. Case: A 30-year-old gentleman suffered blunt thoracic trauma. He presented with left side flail chest, with extensive bilateral contusions, and bilateral hemopneumothorax with extensive surgical emphysema. Initially, the patient was managed on invasive mechanical ventilation as per ARDS net protocol. However, the patient's oxygenation did not improve and he was required to be put on VV ECMO as per extracorporeal life support indications. Thereafter, he was weaned from VV ECMO on day 5 and later on, from mechanical ventilation. He was discharged from the hospital on day 30. Conclusion: Veno-venous extracorporeal membrane oxygenation (VV ECMO) is safe to use in severe ARDS patients who are not responding to oxygenation on mechanical ventilation.

Platypnea-orthodeoxia syndrome (POS) is a sparingly documented symptom in the spectrum of the coronavirus disease 2019 (COVID-19) manifestations, which can manifest with a variety of symptoms, ranging from a minor flu-like sickness to lethal severe acute respiratory distress syndrome (ARDS). In two cases with severe COVID-19 pneumonia that we saw POS in, both patients stated that their POS symptoms had resolved on follow-up after 4 weeks of conservative treatment. The pathophysiology of POS may be explained by gravitational redistribution of pulmonary blood flow, which results in enhanced basal arteriovenous shunting and upper zone dead space ventilation in some cases with severe COVID-19 disease due to their predominant involvement of basal parts of lung parenchyma.

The cause of pleuropericardial effusion can be varied and includes many differential diagnoses. One of the very rare causes of pleuropericardial effusion can be hypothyroidism. The clinical findings of hypothyroidism are generally subtly leading to delay in diagnosis. We present a case of a middle-aged patient who presented at our tertiary care center with massive pleuropericardial effusion due to hypothyroidism which was managed conservatively. Hypothyroidism can present as pleuropericardial effusion and the treating physician should keep that differential while evaluating and treating such cases.