Indian Journal of Critical Care Case Report

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2023 | September-October | Volume 2 | Issue 5

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FROM THE EDITOR'S DESK

From the Editor's Desk

[Year:2023] [Month:September-October] [Volume:2] [Number:5] [Pages:1] [Pages No:v - v]

   DOI: 10.5005/ijccr-2-5-v  |  Open Access | 

181

Clinicopathological Correlation

Rashmi Joshi, Aravind Sekar, Aman Sharma, Sreedhara B Chaluvashetty, Mini P Singh, Amanjit Bal, Ritambhra Nada

Double Trouble: Coronavirus Disease 2019 with Lupus Flare

[Year:2023] [Month:September-October] [Volume:2] [Number:5] [Pages:7] [Pages No:117 - 123]

Keywords: Autopsy, Coronavirus disease 2019, Diffuse alveolar damage, Diffuse alveolar hemorrhage, Systemic lupus erythematosus

   DOI: 10.5005/jp-journals-11006-0078  |  Open Access |  How to cite  | 

Abstract

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused the coronavirus disease (COVID-19) pandemic, with over 65 million deaths worldwide. Clinical manifestations of COVID-19 varied from asymptomatic to severe acute respiratory distress syndrome. The exact incidence of COVID-19 in lupus patients is not known. However, studies have shown that lupus patients might be more prone to SARS-CoV-2 infection and may have severe clinical manifestations due to aberrant baseline inflammation and dysregulated immune responses. Further, the immunosuppressive treatment that lupus patients receive also compromises their immunity and paves the way for infection. We intend to present the complete clinical and autopsy findings of a 28-year-old female who presented with lupus flares involving major organs and acquired COVID-19 infection during treatment. Subsequently, there was worsening respiratory failure, and she finally succumbed to death despite all supportive measures.

197

CASE REPORT

Sangam Yadav, Vidhi Jain, Mahima Khatri, Tejashree Nare

Candida pelliculosa Infection in Adults Admitted in Intensive Care Unit of Tertiary Care Center: Should We Treat or Not?

[Year:2023] [Month:September-October] [Volume:2] [Number:5] [Pages:4] [Pages No:124 - 127]

Keywords: Candida pelliculosa, Case report, Echinocandins, Outbreak, Intensive care unit

   DOI: 10.5005/jp-journals-11006-0070  |  Open Access |  How to cite  | 

Abstract

Introduction: Candida pelliculosa (C. pelliculosa) infection has been reported as an agent of healthcare-associated candidemia in the neonatal intensive care unit (ICU) but is less commonly reported in critically ill adults. Case description: We reported two cases in our adult ICU who were found to have this uncommon infection. The first patient was a 25-year-old female with preeclampsia who underwent emergency lower segment cesarean section (LSCS) for abruption placentae and showed signs of sepsis. On examining her blood cultures, we could isolate C. pelliculosa and start her on anti-fungal treatment, to which she responded appropriately. The second case was of a 57-year-old male with pituitary apoplexy on steroid therapy whose surveillance blood culture was also flagged for C. pelliculosa. However, he was not started on any treatment. We try to discuss the difference in approach to treatment in both cases, though they flagged for the same organism. Conclusion: These cases further emphasize the necessity of source control, as C. pelliculosa infection has been linked to outbreaks.

196

CASE REPORT

Ujjawal Shriwastav, Arnab Choudhury, Sahil Kumar, Jithesh Gangadharan, Mukesh Bairwa, Dhiri R Pradhan

Stroke of Misfortune: Unpacking the Association between Cannabis and Young Stroke

[Year:2023] [Month:September-October] [Volume:2] [Number:5] [Pages:4] [Pages No:128 - 131]

Keywords: Arterial thrombosis, Case report, Posterior circulation, Tetrahydrocannabinol, Young stroke

   DOI: 10.5005/jp-journals-11006-0072  |  Open Access |  How to cite  | 

Abstract

This case study presents a rare case of a 21-year-old male with a posterior circulation stroke solely due to cannabis use disorder. The patient presented with a sudden onset of vomiting and headache, which progressed to include neurological deficits such as facial palsy and limb weakness. Imaging revealed acute nonhemorrhagic infarcts in the pons, medulla, and cerebellar hemispheres and thrombosis in the right vertebral and partial eccentric thrombosis of the basilar artery. The patient tested positive for tetrahydrocannabinol (THC), the active ingredient in cannabis. While stroke is more common in older adults, the incidence of stroke in young adults has increased by several folds in recent decades. Stroke in the young poses unique diagnostic challenges as risk factors vary and are different compared to those in the classical older population. Illicit substance abuse is one of the important risk factors in young stroke. This case highlights the importance of recognizing cannabis use disorder as a risk factor for stroke in young adults and the need for further research into the link between cannabis use disorder and stroke.

231

CASE REPORT

Nithya Panangadan, Ramanan Rajagopal, Mohanaselvi Sivaraman

Neuromelioidosis Presenting as Cerebral Venous Thrombosis Requiring Emergency Decompressive Craniectomy and Prolonged Neurointensive Care

[Year:2023] [Month:September-October] [Volume:2] [Number:5] [Pages:3] [Pages No:132 - 134]

Keywords: Burkholderia pseudomallei, Case report, Diagnosis, Neuromelioidosis

   DOI: 10.5005/jp-journals-11006-0071  |  Open Access |  How to cite  | 

Abstract

Cerebral sinus venous thrombosis (CSVT) is a rare form of venous thromboembolism. CSVT represents almost 0.5–3% of all types of strokes, affecting predominantly younger people. Neuromelioidosis presenting as CSVT is a rare entity and requires a high index of suspicion, combined neurological, neurosurgical, neurointensive care, and infectious disease (ID) inputs along with appropriate and prompt antibiotic cover for improved outcomes. The role of decompressive craniectomy, antibiotic therapy, and duration have been discussed in brief. A rare case of neuromelioidosis presenting as CSVT requiring emergency decompressive craniectomy and prolonged neurointensive care with rehabilitative therapy has been discussed.

194

CASE REPORT

Upendrakumar S Kapse, Kapil G Zirpe, Shrirang N Bamne, Sushma K Gurav, Lomesh Bhirud, Avinash Nanivadekar, Abhijit M Deshmukh, Prasad B Suryawanshi, Prajakta P Wankhede

Posterior Reversible Encephalopathy Syndrome in Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Case Report

[Year:2023] [Month:September-October] [Volume:2] [Number:5] [Pages:4] [Pages No:135 - 138]

Keywords: Case report, Chronic obstructive pulmonary disease, Posterior reversible encephalopathy syndrome, Seizure, Steroids

   DOI: 10.5005/jp-journals-11006-0074  |  Open Access |  How to cite  | 

Abstract

Background: Presentation of seizures in patients with chronic obstructive pulmonary disease (COPD) is an infrequent finding. Posterior reversible encephalopathy is a rare and potentially treatable entity in such scenarios. Case description: We present a case of a 61-year-old female, with a diagnosed case of COPD for 5 years, on regular treatment. She was admitted to the intensive care unit (ICU) with a history of fever, vomiting, and an increased level of drowsiness. She had shown good improvement with the initial management of acute infective exacerbation of COPD. After 96 hours of admission, she had status epilepticus. Magnetic resonance imaging (MRI) findings and clinical features solved the mystery of status epilepticus and altered sensorium. Presentation of posterior reversible encephalopathy syndrome (PRES) in acute exacerbation of COPD is a rare condition but should be kept in mind as one of the important differential diagnoses for those presenting with seizures with or without encephalopathy, even in the absence of accelerated hypertension. Neuroimaging is essential for the exclusion of other possible conditions. PRES is treatable and reversible with or without full recovery. Conclusion: Seizures in patients with COPD can be caused by PRES, which is a potentially reversible condition. A conclusive diagnosis can be established by relevant neuroimaging. Clinical significance: The PRES is a potential cause of seizures in patients with COPD.

178

CASE REPORT

Priyanka Singh, Amit S Vasan, Manu Chopra, Robin Choudhary, Nitin B Ahuja, Kunal Kumar

En Bloc Extraction of Mucus Plug from Bronchus Using a Cryoprobe in a Postoperative Patient: A Case Report

[Year:2023] [Month:September-October] [Volume:2] [Number:5] [Pages:3] [Pages No:139 - 141]

Keywords: Case report, Cryoprobe, Lung collapse, Mucus plug

   DOI: 10.5005/jp-journals-11006-0073  |  Open Access |  How to cite  | 

Abstract

Introduction: Postoperative pulmonary complications are a common cause of patient deterioration in both medical and surgical intensive care unit (ICUs). Sudden pulmonary collapse is a sentinel event in postoperative settings and can lead to respiratory compromise if not managed aggressively. It commonly occurs due to blood clots or mucus plugging of airways. In ICU settings, copious secretions, poor cough reflex, and poor respiratory efforts due to pain may all lead to the accumulation of mucus in the respiratory tract. Management of these plugs requires hydration, bronchodilation, mucolytic agents, and physiotherapy. Complete collapse leads to opacification of hemithorax, which may sometimes be confused with pleural effusion. Hence, all residents and ICU staff must be sensitized to avoid the inadvertent putting of a needle in such cases solely on the basis of a chest radiograph. Frequently, lung collapse warrants bronchoscopic intervention. Case description: Here, we report a case of sudden lung collapse in a young postoperative patient who had a sudden lung collapse and oxygenation impairment. Also, the mucus plug did not get extracted with routine bronchoscopy, and a cryoprobe was used. The extracted mucus plug en masse was a cast of bronchial tree. Conclusion: We wish to highlight the need for awareness of complications of endobronchial obstruction in ICUs and the use of cryoprobes in such scenarios.

230

CASE REPORT

Lokesh Kadam, Ritu Singh, Anup Gohatre

Double Trouble of Liver in Pregnancy: A Boon in Disguise!

[Year:2023] [Month:September-October] [Volume:2] [Number:5] [Pages:3] [Pages No:142 - 144]

Keywords: Acute liver failure, Case report, Cholestasis intrahepatic, Pregnancy

   DOI: 10.5005/jp-journals-11006-0076  |  Open Access |  How to cite  | 

Abstract

Liver diseases unique to pregnancy are categorized based on the stage of pregnancy they occur. In the intensive care unit (ICU), common liver disorders encountered include intrahepatic cholestasis of pregnancy (ICP), acute fatty liver of pregnancy (AFLP), and hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome. ICP is the most prevalent liver disorder during pregnancy and generally has a good prognosis after delivery. AFLP, on the other hand, is a potentially life-threatening condition that typically manifests in the second to third trimester of pregnancy. In this particular case, unique instance of AFLP and ICP overlap, with both the mother and fetus surviving. The patient initially presented with acute liver failure even after the delivery of the fetus, leading to a working diagnosis of AFLP based on clinical signs, symptoms, and laboratory reports. Subsequently, the patient developed multiorgan dysfunction syndrome (MODS) and required invasive ventilator support, renal replacement therapy, and measures to reduce intracranial pressure. Fortunately, the patient recovered from MODS; however, her liver function tests remained elevated. A liver biopsy was performed, revealing microvesicular fatty accumulation in hepatocytes and bile plugs in biliary ducts, confirming the diagnosis of AFLP with ICP. While the pathophysiology and clinical presentations of these conditions differ, there can be some overlapping and masked symptoms, particularly in critically ill patients. Although rare, there have been a few documented cases of simultaneous occurrence of ICP and AFLP in critically ill patients.

208

CASE REPORT

Rupak Banerjee, Paramita Basu, Samyogita Choudhary, Chandrashish Chakravarty

Noncirrhotic Multifactorial Hyperammonemia: Unmasking an Adult-onset Partial Urea Cycle Disorder

[Year:2023] [Month:September-October] [Volume:2] [Number:5] [Pages:3] [Pages No:145 - 147]

Keywords: Case report, Cerebral edema, Continuous renal replacement therapy, Noncirrhotic hyperammonemic encephalopathy, Status epilepticus, Urea cycle disorder

   DOI: 10.5005/jp-journals-11006-0075  |  Open Access |  How to cite  | 

Abstract

Aim and background: Urea cycle disorder (UCD) is a metabolic disturbance and can be a harbinger of life-threatening hyperammonemic encephalopathy. We report a case of adult-onset partial urea cycle defect precipitated by septic shock and status epilepticus and its successful treatment with continuous renal replacement therapy, adaptive nutrition, nitrogen scavengers, and gut decontamination. Case description: A 37-year-old woman with known seizure disorder presented with status epilepticus, urosepsis, and septic shock due to Enterococcus faecalis infection. Her two other sisters died from an unknown neuropsychiatric illness in early childhood. She was initially treated with invasive mechanical ventilation, vasopressor support, intravenous antibiotics, and antiepileptic drugs. After stabilization of hemodynamics and control of visible seizures, her mental status was not improving despite the sedation hold. Further workup revealed high ammonia, respiratory alkalosis, triphasic waveform on the electroencephalogram, normal liver function and sonologic evidence of cerebral edema. Urinary analysis for amino acids and organic acids was noncontributory. A partial defect in the urea cycle was suspected and she was successfully treated with continuous renal replacement therapy and other available adjunctive treatments to a favorable outcome. Conclusion: In patients who present with noncirrhotic hyperammonemic encephalopathy and have had one or multiple stressors, a diagnosis of UCD should be suspected to optimize early management and improve prognosis.

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