[Year:2024] [Month:November-December] [Volume:3] [Number:6] [Pages:1] [Pages No:v - v]
An Unusual Cause of Seizures Leading to Sudden Death: Clinicopathological Correlation
[Year:2024] [Month:November-December] [Volume:3] [Number:6] [Pages:7] [Pages No:147 - 153]
Keywords: Acute heart failure, Bleeding, Cardiac arrest, Cardiac seizures, Case report, Chronic thromboembolism, Coagulopathy, Pulmonary embolism, Streptokinase, Thrombolysis
DOI: 10.5005/jp-journals-11006-0143 | Open Access | How to cite |
Abstract
Introduction: Sudden cardiac arrest is an emergency that claims millions of lives annually. The causes can be extremely varied. A thorough history, clinical examination, including effective bedside investigations like point-of-care ultrasound (POCUS), two-dimensional (2D) echo, and urgent neuroimaging, if indicated, are indispensable in diagnosis. Brief case summary: In this report, we describe the case of a 40-year-old male who presented with complaints of sudden loss of consciousness, followed by recurrent seizures. He was found to be in cardiac arrest and was successfully revived by cardiopulmonary resuscitation (CPR). Bedside evaluation using POCUS suggested right ventricular dysfunction and deep vein thrombosis (DVT) of the left popliteal vein. Clinical suspicion of pulmonary thromboembolism (PTE) was confirmed on computed tomography (CT) pulmonary angiography. The presence of stroke or cerebral venous thrombosis was ruled out. He was diagnosed with and managed for PTE that caused right heart failure and cardiac arrest. A pathological autopsy was conducted, which confirmed the presence of PTE and demonstrated evidence of acute as well as chronic thromboembolism in multiple arteries and veins. Occult malignancy was ruled out. The etiology of chronic thrombotic conditions remained elusive. Discussion: Seizures as the presenting feature of PTE have been infrequently reported. The proposed mechanism involves sudden cerebral hypoperfusion due to cardiac failure. The presence of multiple arterial and venous thromboembolisms points toward a systemic prothrombotic state. During the discussion, several potential causes were explored, including coronavirus disease (COVID), vaccination status, alcohol intake, chronic liver disease, and drug abuse, each supported by relevant findings from the case.
[Year:2024] [Month:November-December] [Volume:3] [Number:6] [Pages:3] [Pages No:154 - 156]
Keywords: Hemophagocytic lymphohistiocytosis, Hemophagocytic lymphohistiocytosis, Intensive care unit, Intravenous immunoglobulin, Sepsis
DOI: 10.5005/jp-journals-11006-0133 | Open Access | How to cite |
Abstract
Aim and background: Hemophagocytic lymphohistiocytosis (HLH) presents a challenge due to its catastrophic nature of uncontrolled immune activation and nonspecific symptoms, complicating diagnosis. Despite its association with poor outcomes, guidelines recommend multimodal approaches including intravenous immunoglobulin (IVIG). In this case series, we highlight the role of IVIG in improving outcomes. Case description: We illustrate the clinical courses of four patients with secondary HLH. All cases fulfilled diagnostic criteria for HLH, exhibiting fever, elevated ferritin levels, cell lineage abnormalities, and hemophagocytosis on bone marrow biopsy. All four patients required high doses of vasopressors. IVIG (2 gm/kg over 3 days) was initiated at various stages of treatment alongside dexamethasone 10 mg/m2/day. Two patients who received early IVIG demonstrated improvements in cell lineage and hemodynamics, while the other two, receiving IVIG relatively late due to delayed manifestations or diagnoses, succumbed to their illness. Conclusion: Diagnosing HLH is challenging due to its nonspecific features, and the presence of sepsis and septic shock in intensive care settings further complicates diagnosis. We recommend early evaluation of patients with a high suspicion of HLH, with prompt bone marrow biopsy. We observed clinical and laboratory improvements following initiation of IVIG therapy (2 gm/kg over 3 days) alongside dexamethasone. Clinical significance: This case series emphasizes the importance of early HLH diagnosis and the initiation of a short course of IVIG (2 gm/kg over 3 days) as the preferred initial treatment, along with dexamethasone, rather than as a salvage therapy.
[Year:2024] [Month:November-December] [Volume:3] [Number:6] [Pages:2] [Pages No:157 - 158]
Keywords: Case report, Fat embolism syndrome, Patent foramen ovale, Transesophageal echocardiography
DOI: 10.5005/jp-journals-11006-0134 | Open Access | How to cite |
Abstract
Aim and background: Fat embolism occurs when bony or soft tissue trauma causes fat to enter the circulation, or in atraumatic disorders where circulating fat particles coalesce abnormally within the circulation. The fat particles deposit in the pulmonary and systemic circulations, although only 1–2% develop a clinical disorder with respiratory, cerebral, and dermal manifestations known as fat embolism syndrome (FES). Management of FES requires early immobilization of fractures and symptomatic management of respiratory, cardiovascular, and neurological abnormalities. Case description: Here, we discuss a 32-year-old male with Marfanoid-like features who presented with an alleged history of a road traffic accident and was diagnosed with both a bone fracture in the right leg and a comminuted intertrochanteric fracture in the left hip. The patient underwent proximal femur nail antirotation 2 (PFNA2) fixation of the left hip and postoperatively developed decreased response, desaturation, and low urine output. Conclusion: This case discusses the increased chances of neurological symptoms in individuals with congenital heart abnormalities, such as a patent foramen ovale, and the need for further cardiac evaluation, including imaging such as transesophageal echocardiography.
[Year:2024] [Month:November-December] [Volume:3] [Number:6] [Pages:2] [Pages No:159 - 160]
Keywords: Case report, Critically ill, Erythrocytapheresis, Methylene blue, Methemoglobinemia
DOI: 10.5005/jp-journals-11006-0135 | Open Access | How to cite |
Abstract
Aim and background: Acquired methemoglobinemia is a disorder of altered hemoglobin which leads to impaired oxygen delivery to tissues. It can occur after exposure to certain oxidizing agents. Acquired methemoglobinemia is diagnosed by using pulse oximetry and arterial blood gas analysis with co-oximetry. Most of the cases respond to methylene blue therapy. Case description: Here, we present a case of 21-year-old male patient presented to emergency department with alleged history of consumption of unknown quantity of biopesticide and developed severe refractory methemoglobinemia which did not respond to methylene blue, but was successfully treated with therapeutic erythrocytapheresis. Conclusion: Based on our case, therapeutic erythrocytapheresis is a potentially effective and safe treatment for critically ill patients with acquired refractory methemoglobinemia. Further research is required to evaluate the efficacy and safety of this modality. Clinical significance: Methemoglobinemia not improving with methylene blue therapy can be seen in some patients. Erythrocytapheresis can be used for therapy in such cases.
Coronary Air Embolism During Lung Biopsy: A Rare but Insidious Problem
[Year:2024] [Month:November-December] [Volume:3] [Number:6] [Pages:4] [Pages No:161 - 164]
Keywords: Air embolism, Cerebellar infarction, Coronary thrombosis
DOI: 10.5005/jp-journals-11006-0140 | Open Access | How to cite |
Abstract
Aim and background: To study an unusual presentation of coronary air embolism causing non-ST elevation myocardial infarction that occurred during a lung nodule biopsy procedure. Coronary air embolism can be a dreaded complication that may occasionally occur during cardiac catheterization, cardiac surgeries, and other cardiac procedures but is not so common during noncardiac procedures. The sequelae of this complication can range from being clinically insignificant to catastrophic coronary and/or cerebral air embolism. Case description: A 58-year-old male diagnosed with left-sided parotid carcinoma with suspected lung metastasis underwent a biopsy of lung lesion under local anesthesia. At the end of the procedure, the patient developed hemoptysis with unconsciousness. A cardiac code was activated, and the patient was immediately resuscitated. The patient developed a large pneumothorax with alveolar bleeding along with significant coronary air embolism. An electrocardiogram showed inferior wall myocardial ischemia. The patient was medically managed and made an uneventful recovery. Conclusion and clinical significance: The case highlights the unusual but catastrophic effects of coronary air embolism. It also shows that early recognition and timely treatment can improve outcomes.
[Year:2024] [Month:November-December] [Volume:3] [Number:6] [Pages:4] [Pages No:165 - 168]
Keywords: Case report, Coma, Hyperammonemia, Postpartum, Urea cycle disease
DOI: 10.5005/jp-journals-11006-0142 | Open Access | How to cite |
Abstract
Aim and background: Urea cycle disorders (UCDs) are rare genetic metabolic conditions resulting from deficiencies in urea cycle enzymes, which lead to hyperammonemia. In cases of partial enzyme deficiencies, symptoms may not emerge until adulthood, often triggered by stress, illness, or pregnancy. Pregnancy exacerbates these challenges, as the peri-partum catabolic state can precipitate hyperammonemic crises. This report describes a case of isolated hyperammonemia in a postpartum patient due to urea cycle enzyme deficiency. Case description: A 24-year-old primigravida presented with disorientation and somnolence on the fourth postoperative day after a cesarean section. Her history revealed decreased mentation and vision since childhood. Laboratory tests were normal except for elevated serum ammonia levels (698 µmol/L), which increased to 898 µmol/L despite treatment with lactulose and rifaximin. The diagnosis of urea cycle enzyme deficiency was confirmed by raised levels of urinary orotic acid after allopurinol administration. Hemodialysis was performed, which helped reduce ammonia levels to 38.9 µmol/L. The patient was discharged with citrulline and a protein-restricted diet. Conclusion: This case underscores the importance of considering UCDs in postpartum patients with unexplained coma. The interplay of increased metabolic demands and the disruption of ammonia detoxification due to intrauterine demise or delivery can trigger hyperammonemia. Early diagnosis and prompt treatment, including hemodialysis, are crucial for improving outcomes. Clinical significance: A high index of suspicion for UCDs is essential in postpartum patients presenting with altered sensorium. Frequent serum ammonia level monitoring and timely intervention can prevent severe complications and improve survival rates in these life-threatening conditions.
Aortic Dissection Masquerading as a Stroke
[Year:2024] [Month:November-December] [Volume:3] [Number:6] [Pages:3] [Pages No:169 - 171]
Keywords: Acute ischemic stroke, Aortic dissection, Case report, Ischemic infarct, Thrombolysis
DOI: 10.5005/jp-journals-11006-0126 | Open Access | How to cite |
Abstract
Aim and background: Aortic dissection is a life-threatening condition, it is a recognised cause of acute ischemic stroke. Aortic dissection is a contraindication to thrombolysis with recombinant tissue plasminogen activator (rt-PA). Consequently, the exclusion of aortic dissection is imperative before initiating anticoagulants or thrombolysis. Case description: We present a case of a 58-year-old female presented to the hospital with complaints of decreased responsiveness and giddiness at home. She was put on mechanical ventilator due to low GCS (Glasgow coma scale). Initial CT was normal, she was shifted to the ICU for further management. Later the same day of admission, she was noted to have right sided paucity of movement, MRI done showed acute infarcts in bilateral posterior and left anterior watershed zones suspicious of hemorrhagic transformation, flair intensity mismatch was not seen. Her ECHO showed septal hypokinesia and aortic regurgitation and a flap like structure, aortic dissection which was later confirmed by carotid Doppler and CT aortogram: showed Stanford A type of aortic dissection. The same day, she underwent ascending aorta and hemiarch replacement. Eventually discharged on day 17th of admission with minimal neurological deficit. Conclusion: Thrombolysis stands as a cornerstone in the management of acute ischemic stroke; however, the oversight of concurrent aortic dissection could gravely escalate both mortality and morbidity. Clinical significance: In the case presented, a vigilant clinical evaluation, complemented by prompt imaging and bedside echocardiography, was pivotal in the post hoc diagnosis of aortic dissection. This timely intervention was instrumental in steering an early therapeutic course, culminating in a positive patient prognosis.
[Year:2024] [Month:November-December] [Volume:3] [Number:6] [Pages:4] [Pages No:172 - 175]
Keywords: Case report, Gastric perforation, Mucormycosis, Splenic infarction
DOI: 10.5005/jp-journals-11006-0138 | Open Access | How to cite |
Abstract
Aim and background: Mucormycosis is a rare and often fatal opportunistic illness that is more common in immunocompromised patients. Involvement of the gastrointestinal tract is uncommon, accounting for only 7% of all reported cases. Here, we present an unusual manifestation with gastric perforation and splenic infarction due to a splenic artery mycotic thrombus, along with a literature review. Case description: A 40-year-old female with poorly controlled diabetes mellitus presented with acute decompensated heart failure and diabetic ketoacidosis. During her course, she had a significant hemoglobin drop and was diagnosed with multiple necrotic gastric ulcerations with subsequent gastric perforation and splenic infarction. We searched the PubMed and Embase databases with the terms: (splenic infarction) AND (gastric perforation) AND (mucormycosis) till May 2024. To date, six cases have been reported of combined gastric and splenic involvement by mucormycosis. Most of the patients had an underlying immunosuppressive state. Despite combined medical and surgical treatment modalities, only 17% survived the illness. The most common presentation was necrotic ulceration. Conclusion: Due to the disease's rarity, the precise diagnosis of gastric mucormycosis may be delayed. Diligent clinical insight is required for the early diagnosis and management of the disease, especially in immunocompromised patients. Radiological imaging modalities, such as computed tomography (CT) scans or magnetic resonance imaging of the abdomen, generally demonstrate non-specific findings. Additional testing involving endoscopic or surgical biopsies of the lesions is necessary for rapid diagnosis. Clinical significance: The early diagnosis and timely initiation of antifungal therapy can be beneficial in halting the fulminant course of gastrointestinal mucormycosis.