Background: Pulmonary tumor thrombosis can be a catastrophic manifestation of many solid tumors more so in gestational trophoblastic disease. Trophoblastic pulmonary embolism and subsequent pulmonary hypertension can lead to severe cor pulmonale. The role and utility of pulmonary vasodilators in this setting are not very well established since the etiology is considered tumor thrombosis. Most patients present with bleeding diathesis which precludes the use of anticoagulants. We suggest that the use of pulmonary vasodilators should be individualized as it can improve survival in select high-risk cases. Case description: A 35-year-old female with high-risk gestational trophoblastic neoplasm with lung metastasis presented with fever, dyspnea cough, and hemoptysis. She had a history of molar pregnancy which was evacuated under general anesthesia 6 months back. Transthoracic echocardiography showed acute cor pulmonale with severe pulmonary hypertension [pulmonary artery systolic pressure (PASP) 69 mm Hg] and the computed tomography pulmonary angiogram (CTPA) revealed a large tumor thrombus in the right pulmonary artery. She was started on sildenafil 10 mg bd for which she responded well with reduced PASP (45 mm Hg). She was discharged from the intensive care unit (ICU) on day 6. Conclusion and clinical significance: Trophoblastic pulmonary thrombosis causing pulmonary hypertension and acute right heart failure can be a life-threatening condition. In spite of the multifactorial etiology of thrombosis and microangiopathy, the use of pulmonary vasodilators can be lifesaving and their use should be individualized as this may benefit high-risk patients.

Aim and background: Internal jugular central venous catheter insertion is a common procedure in the intensive care unit. Complications and malpositioning are infrequent when performed under ultrasound guidance. We discuss the dilemma created by anatomical variation during central venous catheter placement. Case description: A 66-year-old woman underwent left internal jugular central line insertion under ultrasound guidance. Given the anatomical course of the vascular catheter as seen on the chest X-ray, blood gas analysis sampling through the same revealed venous values. High-resolution computed tomography of the chest showed the vascular catheter located in the left superior vena cava (LSVC). Conclusion: Intensivists need to be aware of vascular anomaly and anatomy associated with persistent LSVC to lessen the risk of complications associated with vascular cannulation. Clinical significance: Asymptomatic persistent LSVC can be detected during vascular procedures. Intensivists need to be aware of this asymptomatic anomaly as handling of the coronary sinus during procedures can lead to dysrhythmias and hemodynamic instability.

Aims and background: Non-Hodgkin's lymphoma (NHL) is a type of cancer that originates in the lymphatic system. Pregnancy complicates cancer management due to potential risks to both the mother and the fetus. The aim of this report is to understand the specific interplay between pregnancy, NHL, and metabolic pathways, particularly glycolysis, which is not well-documented in the existing literature. Case description: This case involved a pregnant patient with NHL who had elevated lactate levels and persistent low blood sugar, despite being treated for a respiratory infection. It should be a consideration for individuals with hematologic malignancies who exhibit both type-B lactic acidosis and hypoglycemia. Initiation of chemotherapy in our case led to improvement in the patient's type-B lactic acidosis over the course of a few days. The uniqueness of this case lies in the metabolic behavior of cancer cells during pregnancy, specifically the reliance on glycolysis despite oxygen availability. The combination of NHL, pregnancy, and aberrant metabolic pathways distinguishes this case from typical presentations. Conclusion: The cancer cells in the patient exhibited glycolysis even when oxygen was available, leading to high lactate levels. This is known as the Warburg effect. The Warburg effect introduces a rare and intricate clinical challenge that demands prompt identification and intervention. Clinical significance: Elevated lactate levels in lymphoma patients are not always indicative of a poor outcome. This observation should be validated through studies involving a large number of patients to establish its significance.

Aims and background: Severe community-acquired pneumoniae (CAP) complicated by myocarditis presents a significant clinical challenge, particularly with uncommon pathogens such as Streptococcus pneumoniae. This case emphasizes the complexity of managing a young adult with refractory hypoxemia, type 2 respiratory failure, metabolic acidosis, and shock, highlighting the need for a multidisciplinary approach. Case description: A 26-year-old male with severe CAP complicated by myocarditis initially received lung-protective mechanical ventilation and vasopressor support. Despite these measures, the patient's condition worsened. Cardiac evaluation showed elevated biomarkers and regional wall motion abnormalities, indicating myocarditis. Coronary angiography ruled out significant coronary artery disease. The diagnosis was refined to severe CAP with streptococcal myocarditis and type 2 respiratory failure. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) was initiated, supporting both cardiac and respiratory functions. Further investigation revealed left lower lobe consolidation and S. pneumoniae in bronchoalveolar lavage (BAL) polymerase chain reaction (PCR), prompting targeted antibiotic therapy. Steroid treatment, in line with severe pneumoniae guidelines, led to clinical improvement. Transition to venovenous ECMO (VV-ECMO) facilitated successful extubation and significant recovery. Conclusion: This case underscores the importance of a multidisciplinary approach, combining advanced ECMO support, targeted antibiotics, and adaptive treatment strategies to manage severe respiratory and cardiac complications in critically ill patients, particularly with rare etiologies like streptococcal myocarditis. Clinical significance: Advanced ECMO support, along with precise therapeutic interventions, is crucial for improving outcomes in severe CAP with concomitant myocarditis. This case demonstrates the effectiveness of such an approach in addressing both respiratory and cardiac failures, offering a framework for future similar cases.

Aim and background: Central lines are an integral part of resuscitation in a collapsing patient in the emergency department (ED). The common sites for insertion of central venous access are the internal jugular vein, femoral vein, and subclavian vein. The most frequently encountered complications in internal jugular access are pneumothorax, carotid artery puncture and cannulation, guidewire entrapment, and hematomas. Case description: We present a case of a 60-year-old female with arch of aorta cannulation leading to brachial artery thrombosis and limb ischemia. Conclusion: Arch of aorta cannulation and acute limb ischemia are vascular emergencies. Proper evaluation of landmarks, positioning of the patient, use of ultrasound-guided approach, correlation of arterial/venous blood gas analysis, proper anatomical acknowledgment on chest radiography and waveform analysis may prevent complications. Clinical significance: The complications associated with aortic cannulation increase the risk of stroke and arterial injury, which can further lead to complications such as hematoma formation, pseudoaneurysm, fistula, and even death. Manipulating the aorta during cannulation can cause a tear in its layers, leading to aortic dissection. We need to remember that accidental arterial puncture occurs in a small percentage of cases during jugular or subclavian approaches for central venous catheter (CVC) placement. While CVCs are essential for various medical purposes, proper technique, vigilance, and awareness of potential complications are crucial for patient safety.

Introduction: Melioidosis results from infection by Burkholderia pseudomallei. Clinical presentation ranges from asymptomatic infection to fulminant septicemia with septic shock. We describe a case where one patient with pneumonia and septic shock was found to have a disseminated abscesses there in the liver, spleen, and prostate. Case description: He was presented to the hospital emergency with septic shock and hypoxemic respiratory failure and transferred to the intensive care unit (ICU). Two sets of blood cultures sent at admission showed growth of nonlactose fermenting gram-negative rods. The organism was identified as B. pseudomallei by an automated VITEK2 Compact system. Computed tomography (CT) scan of the abdomen and pelvis revealed hepatomegaly with multiple abscesses, multiple splenic micro abscesses, prostatomegaly with multiple prostatic abscesses, and of thorax suggested multiple variable-sized nodules with subpleural consolidation. He received intravenous meropenem followed by ceftazidime for a total of 4 weeks. With clinical resolution, he was started on oral antibiotics trimethoprim-sulfamethoxazole and was discharged home to continue for 3 months. Discussion: Disseminated abscesses especially involving the liver and spleen are characteristics of melioidosis. Interestingly, in our case, a single patient had multifocal abscesses involving the liver, spleen, and prostate along with lung involvement. Conclusion: Melioidosis with disseminated abscess in a single patient especially of prostatic abscess as in our case has been rarely reported.

Aim and background: Capillary leak syndrome (CLS) following Russell's viper envenomation is a rare potentially fatal complication, even after administration of adequate antisnake venom. Case description: Here, we present the case of a 54-year-old male who presented with snakebite and subsequently developed CLS, characterized by conjunctival congestion, parotid swelling, hypoalbuminemia, and albuminuria. The patient experienced severe third-space fluid loss necessitating aggressive intravenous fluid resuscitation to maintain intravascular volume. Despite these efforts, renal hypoperfusion requiring dialysis and respiratory distress necessitating mechanical ventilation ensued. Through vigilant intensive care unit (ICU) monitoring and management, the patient eventually recovered without complications. Conclusion: This case underscores the importance of early identification of CLS and the need for close ICU monitoring, intensive ventilatory, and circulatory support. For guideline-directed and targeted therapy, future research of this lethal syndrome is imperative. Clinical significance: This article is to increase awareness regarding recognizing this rare fatal complication, overview of management, and emphasizing the importance of initiating early treatment that plays a significant role in recovery.

Aim and background: Drug-induced liver injury (DILI) is a complex clinical challenge due to its varied presentations and the broad spectrum of potential causative agents. Early recognition and timely intervention are critical to prevent life-threatening complications. This report discusses a case of DILI caused by fluconazole and metolazone, complicated by hepatic encephalopathy and acute kidney injury (AKI) and highlights successful management strategies. Case description: Here, we are discussing a case of a 64-year-old male with a history of type 2 diabetes, hypertension, dyslipidemia, and benign prostatic hypertrophy. He presented with fever, loose stools, and altered sensorium. He had jaundice, dehydration, and a Glasgow Coma Scale (GCS) of 13. Investigations showed direct hyperbilirubinemia and AKI. After ruling out viral and autoimmune causes, DILI was suspected, likely due to fluconazole and metolazone. The patient developed hepatic encephalopathy and worsening renal function. He was managed with drug withdrawal, N-acetylcysteine, hydrocortisone, and therapeutic plasma exchange. He showed significant improvement and was discharged in a fully recovered state. Conclusion: This case highlights the importance of early diagnosis and the role of therapeutic measures, including drug withdrawal and plasma exchange, in managing DILI with systemic complications. Clinical significance: This case underscores the importance of careful drug history assessment, the utility of Roussel Uclaf Causality Assessment Method (RUCAM) for causality evaluation, and the effectiveness of plasma exchange in treating severe DILI with complications like hepatic encephalopathy and AKI.

Aim and background: Achromobacter xylosoxidans is a rare opportunistic pathogen that can cause severe infections, particularly in immunocompromised patients. This case report describes a patient with A. xylosoxidans septicemia complicated by severe symptomatic bradycardia, hyperkalemia, and acute kidney injury (AKI) requiring dialysis. Case description: A 78-year-old female, a known case of hypertension, diabetes, and ischemic heart disease, presented with altered mental status and hypotension. She was found to have A. xylosoxidans septicemia, severe hyperkalemia, and symptomatic bradycardia requiring temporary pacing. Despite antibiotic treatment and management of electrolyte imbalances, the patient developed AKI requiring hemodialysis. Coronary angiography revealed critical triple-vessel disease, and the patient underwent successful coronary artery bypass grafting (CABG) surgery. Conclusion: This case highlights the potentially severe complications associated with A. xylosoxidans infections, including cardiac and renal dysfunction. Prompt recognition and aggressive management of these complications are crucial for patient survival. Clinical significance: This case emphasizes the importance of considering A. xylosoxidans as a potential cause of severe sepsis, especially in immunocompromised patients. Early diagnosis and appropriate antimicrobial therapy, along with management of associated complications such as cardiac and renal dysfunction, are essential for improving patient outcomes.

Aim and background: To study transient blindness caused by ondansetron, which is a very rare complication. Ondansetron is a selective 5-hydroxytryptamine receptor (5-HT-3) antagonist. It is a widely used antiemetic and has superior efficacy and safety compared with other antiemetics. However, transient blindness is a very rare complication of both oral and intravenous ondansetron. Case description: We present a case of a 76-year-old female with ondansetron-induced transient blindness. The cause of transient blindness was established after ruling out other causes with the help of neurological and ophthalmological examination and relevant investigations. Conclusion and clinical significance: Physicians should be aware of the potential for a rare complication of blindness due to ondansetron, which might confound with other causes of blindness in critical care and perioperatively.