Critical Care Commons^™

A True Bloody Emergency: An Unusual Case Of Thrombotic Thrombocytopenic Purpura, Joshua M. Ninan

Research Symposium

Background: Thrombotic thrombocytopenic purpura (TTP) is a primary thrombotic microangiopathy that is classically characterized by thrombocytopenia and microangiopathic hemolytic anemia (MAHA). Although rare with an annual incidence of 3.7 cases per one million adults, it is considered a true hematological emergency due to its fatality rate of almost 100% if appropriate treatment is not initiated immediately. This makes it vitally important to identify and treat patients with TTP, a task that becomes unusually challenging in the absence of the disorder’s other characteristically diagnostic clinical features such as mucosal bleeding, fever, or presence of schistocytes.

Case Presentation: A 30-year-old gentleman with …

New Onset Positive Autoantibodies Following Covid-19 Infection, David Hernandez, Adnaan Sheikh, Shakira Laing, Mariana Adieb, Omar Siddiqui, Rohail Baig, Annabel Antonini, James Vienneau, Camden Burns

Advances in Clinical Medical Research and Healthcare Delivery

The World Health Organization (WHO) declared the novel coronavirus (COVID-19) outbreak a global pandemic on March 11, 2020. Since the original outbreak in December 2019, over 100 million people have been confirmed to have been infected by COVID-19 and over two million people have died. The presentation seen in patients may vary widely based on multiple factors. Fever has been reported in up to 99% of patients, while other common symptoms seen are dyspnea, fatigue, anosmia, and myalgia. Around 80% of COVID-19 patients present with a mild respiratory illness that can be managed at home, while around 15% need basic …

A Rare Case Of Takotsubo Cardiomyopathy In An Elderly Lady During Hospital Stay, Himabindu Kolli, Ashika A. Chacko, Pooja Maknoor, Nazish Khan, Timothy Heath

Research Colloquium

Introduction: Takotsubo Cardiomyopathy (TTC) is an acute, reversible form of left ventricular systolic dysfunction, most often triggered by a sudden physical, or less commonly emotional event. Here, we describe a patient who developed Takotsubo Cardiomyopathy during her hospital stay.

Case Description: 74-year-old Hispanic lady, a nursing home resident presented to the ED with altered mental status. She was admitted for septic shock due to UTI. Echocardiogram demonstrated normal systolic function, with 60-65% LV ejection fraction. After initiation of antibiotic therapy, she showed clinical improvement with resolution of shock.

On day 8 of hospitalization, patient became emotionally upset and her clinical …

Covid-19 As A Second Hit For Anti-Phospholipid Syndrome, Himabindu Kolli, Pooja Maknoor, Celin Rajan, Nevin Varghese

Research Colloquium

Background: Anti-phospholipid syndrome (APS) is an autoimmune disorder characterized by venous and arterial thrombosis, usually in setting of underlying autoimmune disorders. Here, we present a case of anti-phospholipid syndrome post covid infection.

Case Presentation: 41-year-old lady presented to the ER with complaints of left sided facial droop for 3-day duration. On further evaluation, she was found to have subacute ischemic stroke and was managed with anticoagulation and supportive treatment. Past medical history is significant for a recent diagnosis of Covid infection and for subsequent development of lower extremity deep vein thrombosis (DVT). She was started on anticoagulation with rivaroxaban for …

Tenofovir Induced Hypokalaemia - A Case Report, Ankisha Gupta, Kiran P. K, Rajendra Prasad S

Digital Journal of Clinical Medicine

Tenofovir, an important medication for HIV/AIDS, carries the risk of hypokalemia in patients receiving treatment. Factors such as dietary deficits, vomiting, or diarrhea further increase this risk. Tenofovir acts as a mitochondrial toxin by inhibiting the DNA polymerase gamma enzyme, crucial for mitochondrial DNA replication. Consequently, ATP generation is depleted through the aerobic pathway, leading to dysfunction in the proximal tubule. This dysfunction manifests as renal acidosis type 2, which involves reduced bicarbonate excretion by the proximal tubule, resulting in renal bicarbonate wasting and decreased serum bicarbonate levels. Consequently, the lumen of the distal nephron becomes negatively charged, leading to …

Characterization Of Antibiotic Susceptibility Profiles Of Extensively- And Pan-Drug Resistant Acinetobacter Baumannii Clinical Isolates, Rachel Carr, Justin Halim, Rebecca Fliorent, Henry Fraimow, Dejan Nikolic, Valerie Carabetta

Rowan-Virtua Research Day

Acinetobacter baumannii is an opportunistic pathogen common in intensive care units (ICUs), particularly among immunocompromised individuals. Nosocomial A. baumannii infections have become increasingly problematic in recent years, as these bacteria rapidly acquire antibiotic resistance, leading to the emergence of multidrug, extensively drug and pan drug-resistant (MDR, XDR, and PDR, respectively) isolates. Recently, Cooper University Hospital (CUH) experienced a large increase in highly drug-resistant A. baumannii infections, which had a mortality rate of 60%. Oftentimes, physicians had to turn to combinations of drugs with no experimental verification or historically shelved antibiotics, such as the polymyxins, in a desperate attempt to save …

Death Due To Drug Reaction With Eosinophilia And Systemic Symptoms (Dress) Syndrome: A Case Report, Samantha P. Sternad, Jane Pangburn, Chad Johnston, David Rowe

HCA Healthcare Journal of Medicine

Background

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a life-threatening, multi-organ adverse drug reaction with an incidence of 1 in 1000 to 1 in 10 000 highrisk drug exposures.

Case Presentation

An elderly female presented to the hospital with progressive weakness and a diffuse erythematous macular rash covering most of her body that started 3 days prior. Over the next 3 days, the patient quickly deteriorated, developing disorientation with acute onset left-sided weakness, leukocytosis, thrombocytopenia, eosinophilia, liver and kidney failure, and hypoxia. Clinical and histological changes supported the diagnosis of DRESS syndrome caused by intravenous (IV) ampicillin …

Impact Of Risk Factors On The Evolution Of Severe Acute Pancreatitis, Andra Maria Trotea, Raluca Grigorescu, Dragos Serban, Radu Palade, Simona Balasescu, Cristian Mihai Branescu, Daniel Radu, Corneliu Tudor, Tiberiu Alexandru Trotea

Journal of Mind and Medical Sciences

Introduction. Severe acute pancreatitis (SAP) is an acute inflammatory condition of the pancreas with increasing incidence and mortality rates in recent years. The aim of this study was to evaluate the impact of age, comorbidities, and different scoring systems on the complications and outcomes of SAP. Materials and Methods. A retrospective study was conducted on 161 patients diagnosed and treated for SAP at the Bucharest University Hospital in the intensive care unit (ICU), in the period 2014-2021. The impact of risk factors for the development of SAP, occurrence of complications (respiratory, cardiac, etc.), length of hospital stays and mortality was …

Recurrent Cyanotic Spells In An Octogenarian, Chin Tong Kwok, Chun Kit Wong

Journal of the Hong Kong College of Cardiology

We report rare case of an octogenarian who, after years of diagnostic delay, was found to have a patent foramen ovale, and due to an ascending aortic aneurysm that anatomically facilitated right-to-left shunt, presenting with life-threatening cyanotic attacks. The characteristic orthodeoxia-platypnea syndrome and high alveolar arterial gradient hint to the diagnosis. She was eventually treated successfully with urgent percutaneous PFO closure. Routine ordering of a transthoracic echocardiogram, without agitated saline injection under provocation maneuvers, may not be sufficient to rule out shunts.

Lungs Of A Chronic Smoker: The Case Of Heroin Induced Emphysema In A 35-Year-Old Male, Neil Gerts, George Ishak, Ian Joel, Jasprit Takher

Far West Division Research Day 2023

No abstract provided.

Modified Early Warning Scoring (Mews) Versus Epic Deterioration Index (Edi): Battle Royale For Which Has The Best Patient Outcomes In The Inpatient Setting, Dirk A. Church

DNP Projects

Abstract

Background: The increased workload bedside nurses face today requires new tools to assist with the identification of deteriorating patients during hospitalization. The Modified Early Warning Score (MEWS) tool has formed the background of early warning tools. Newer, more complex tools, like Epic’s Deterioration Index (EDI), have been developed to identify patient deterioration earlier. There is lack of evidence in the literature comparing different early warning tools, implementation, and patient outcomes.

Objective: The purpose of the study was to examine models for EWS notification for RRT and patient outcomes between the use of the MEWS and EDI in an adult, …

Improving Use Of A Standardized Medical Icu Order Set, Ernesto Munoz-Pena, Sesha Sai Kanakamedala, Ramzy Daoud, Suhail Saad-Omer, Aarushi Varshney, Tristan Tanner, Alexander Kong, Joshua Shultz, Ashwini Komarla

North Florida Division Research Day 2023

No abstract provided.

Where’S Adam? Successful Treatment Of Covid-19 Vaccine-Related Refractory Thrombotic Thrombocytopenic Purpura, Christopher Fontela, Alfredo Toll, Jose Fernandez, Gabriel Barciela-Perez, Jorge Diaz, Greisy Curbelo-Sesin, Ilde Manuel Lee, Jose Gascon

East Florida Research Day 2023

A 54-year-old man with a medical history notable for hypertension and type 2 diabetes mellitus presented with altered mental status. Initial assessment revealed altered consciousness, aphasia, and diffuse generalized petechiae. Having recently migrated from Colombia, he had received four doses of the Pfizer COVID-19 vaccine, with the last dose administered one month prior to presentation. Laboratory results indicated severe thrombocytopenia (platelet count: 3), microangiopathic hemolytic anemia, acute myocardial, liver, and kidney injury, prompting a presumptive diagnosis of thrombotic thrombocytopenic purpura (TTP). Confirmation was achieved through an ADAMTS13 level of less than 2 percent. Despite initiating high-dose solumedrol and emergent plasmapheresis, …

Atraumatic Splenic Rupture: An Unaccustomed Complication Of H. Parainfluenzae Endocarditis, Daniel P. High, Jose M. Acosta-Rullan, Danay Herrera, Mauricio Danckers

East Florida Research Day 2023

No abstract available.

Cannabis Consumption And The Emergence Of Giant Lung Bullae: A Case Report And Clinical Analysis, Rafael Miret, Jose Rodriguez Castro, Armando Cabrera, Mauricio Danckers, Raiko Diaz, Nikhil Bhardwaj

East Florida Research Day 2023

Please see supplemental content for full abstract with figures and references.

Introduction: Vanishing Lung Syndrome (VLS), also known as idiopathic giant bullous emphysema, is a rare pulmonary condition characterized by the development of large, thin-walled bullae within the lung parenchyma. While the exact etiology of VLS remains unclear, there is growing interest in exploring a potential association between VLS and cannabis use. This case report aims to contribute to the existing body of knowledge by presenting a case of VLS in a patient with a history of chronic cannabis consumption in prior years.

Clinical Presentation: A 44-year-old former smoker male …

Statins: Masked Anti-Epileptic Warriors, Govinda Khatri, Priya Kotak, Ayush Kumar, Mohammad Mehedi Hasan

Medical College Documents

No abstract provided.

A Case Of Adult Multisystem Inflammatory Syndrome Following Covid-19 Vaccine, Meghan Brown, Nika Zorko Garbajs, Simon Zec, Hisham Mushtaq, Anwar Khedr, Abbas Bashir Jama, Ibtisam Rauf, Mikael Mir, Aishwarya Reddy Korsapati, Shikha Jain, Thoyaja Koritala, Ramesh Adhikari, Amos Lal, Ognjen Gajic, Juan Pablo Domecq, Sarah Goksoy, Brian Bartlett, Amit Sharma, Nitesh Kumar Jain, Syed Anjum Khan

Journal of Community Hospital Internal Medicine Perspectives

Multisystem inflammatory syndrome is a life-threatening condition associated with elevated inflammatory markers and multiple organ injury. A diagnosis of exclusion, it has been reported after severe acute respiratory syndrome coronavirus 2 infection (SARS-CoV-2) in children and adults; recently it has been described in some post-COVID-19 vaccinated individuals. The prognosis with supportive care and immunomodulatory therapy is good, although some individuals may require treatment in the intensive care unit (ICU). Here we report a case of a 58-year-old man who developed multi-organ failure after receiving the second dose of the Moderna mRNA-1273 COVID-19 vaccine. He required critical organ support in the …

Impact Of Serum Igg Levels Against Sars-Cov-2 On Clinical Outcomes For Hopitalized Covid Patient, Bipin Ghimire, Bijaya Thapa, Nishant Aggarwal, Luai Madanat, Melinda Sager, Daniel O'Connor, Alexandra Halalau

Conference Presentation Abstracts

BACKGROUND: The SAR-CoV-2 pandemic continues to negatively impact the healthcare system globally with over 800,000 deaths in the United States and millions more worldwide. The cases are rising despite availability of vaccines. For most immunocompetent patients these vaccines will generate a humoral response and also a memory T-cell response. Few if any studies have reported data that measure anti-spike IgG titers and also correlate those titers with clinical outcomes in the instance of breakthrough infection.

METHODS: We conducted a pilot prospective observational clinical study enrolling 30 immunocompetent patients who were admitted with a positive SARS-CoV-2 PCR. Leftover blood from admission …

From Head To Hilum: Angiosarcoma With Pulmonary Metastasis, Tanaz Salimnia, Lauren A. Abplanalp, Raashi Chawla, K Hughes, R Ghandchi, Matthew Weatherhead, Sanjay Dogra

Conference Presentation Abstracts

With an estimated five-year survival of less than 40 percent, angiosarcomas are rare and often misdiagnosed fataltumors originating from blood or lymphatic vessels with a predilection for the head and neck. They account for 1percent of all soft tissue sarcomas and are often mistaken for benign mimickers leading to the late-stage diagnosiswhen the body is already riddled with metastatic disease with the lung being the most common site of metastases.This case illustrates the myriad of pulmonary complications associated with this uncommon but fatal vasoformativemalignancy. The patient is a 73-year-old male diagnosed with angiosarcoma of the right scalp status post excision,reconstruction, …

Identifying Novel Subphenotypes In Covid-19 Using Protein Biomarkers, A Spicer, P A. Verhoef, C Lopez-Espina, A Bhargava, L Schmalz, M Sims, A V. Palagiri, K V. Iyer, M J. Crisp, A Halalau, N Maddens, A Espinosa

Conference Presentation Abstracts

RATIONALE: COVID-19 is widely heterogeneous in presentation, even across patients with similar demographics and medical history. Identification of subphenotypes based on host immune responses that are biologically discrete and predict outcomes may enable personalized COVID-19 therapies. Accordingly, using a composite of electronic health record (EHR) data and 36 research biomarkers, we sought to compare COVID-19 immune responses across patients of varying disease severity, identify subphenotypes within hospitalized COVID-19 patients, and test for heterogeneity of treatment effect (HTE) to intravenous corticosteroids across these subphenotypes. METHODS: In this multicenter retrospective analysis of prospectively collected data, patients presenting to three medical centers from …

Performance In Mortality Prediction Of Saps 3 And Mpm-Iii Scores Among Adult Patients Admitted To The Icu Of A Private Tertiary Referral Hospital In Tanzania: A Retrospective Cohort Study, Nadeem Kassam, Eric Aghan, Samina Somji, Omar Aziz, James Orwa, Salim R. Surani

Internal Medicine, East Africa

Background: Illness predictive scoring systems are significant and meaningful adjuncts of patient management in the Intensive Care Unit (ICU). They assist in predicting patient outcomes, improve clinical decision making and provide insight into the effectiveness of care and management of patients while optimizing the use of hospital resources. We evaluated mortality predictive performance of Simplified Acute Physiology Score (SAPS 3) and Mortality Probability Models (MPM0-III) and compared their performance in predicting outcome as well as identifying disease pattern and factors associated with increased mortality.

Methods: This was a retrospective cohort study of adult patients admitted to the ICU of the …

Conference Proceedings: Select Abstracts Presented At 2021 Advocate Aurora Health Scientific Day

Journal of Patient-Centered Research and Reviews

Abstracts published within this supplement were presented at the 47th annual Advocate Aurora Health Scientific Day, held virtually on May 26, 2021. This research symposium provides a forum for disseminating results from studies conducted by faculty, fellows, residents, and other allied health professionals associated with Midwest-based health system Advocate Aurora Health, which publishes the Journal of Patient-Centered Research and Reviews.

A Randomized Controlled Trial To Determine Whether Beta-Hydroxy-Beta-Methylbutyrate And/Or Eicosapentaenoic Acid Improves Diaphragm And Quadriceps Strength In Critically Ill Mechanically Ventilated Patients, Gerald S. Supinski, Paul F. Netzel, Philip M. Westgate, Elizabeth A. Schroder, Lin Wang, Leigh Ann Callahan

Internal Medicine Faculty Publications

BACKGROUND: Intensive care unit acquired weakness is a serious problem, contributing to respiratory failure and reductions in ambulation. Currently, there is no pharmacological therapy for this condition. Studies indicate, however, that both beta-hydroxy-beta-methylbutyrate (HMB) and eicosapentaenoic acid (EPA) increase muscle function in patients with cancer and in older adults. The purpose of this study was to determine whether HMB and/or EPA administration would increase diaphragm and quadriceps strength in mechanically ventilated patients.

METHODS: Studies were performed on 83 mechanically ventilated patients who were recruited from the Medical Intensive Care Units at the University of Kentucky. Diaphragm strength was assessed as …

Knowledge And Attitude Towards Identification And Management Of Sepsis Among Resident Physicians In A Tertiary Care Teaching Hospital In Pakistan, Ainan Arshad, Abdul Aziz, Ahmed Ayaz, Syed Maaz Salahuddin, Bushra Jamil

Section of Internal Medicine

This study was conducted to determine the compliance and knowledge of sepsis guidelines among resident physicians in a tertiary care hospital of a developing country. A self-structured validated questionnaire was prepared to evaluate compliance and knowledge of the Surviving Sepsis Campaign (SSC) guidelines. A total of 76 resident physicians completed the questionnaire; out of these, 51 (67%) were from Internal Medicine department and 25 (33%) were from Emergency Medicine department of the Aga Khan University Hospital, Karachi. A total of 71 (93%) participants claimed to be aware of the SSC guidelines but only 20 (26%) considered themselves very knowledgeable on …

Methamphetamine Associated Cardiomyopathy In Pregnancy: The Distinctions And The Implications, Ashan Hatharasinghe, Hossein Akhondi

HCA Healthcare Journal of Medicine

Introduction

Methamphetamine associated cardiomyopathy (MAC) and peripartum cardiomyopathy (PPCM) are both rare obstetric conditions. Literature regarding methamphetamine associated cardiomyopathy in the obstetric population is limited, and it can be difficult to make the distinction between the two given the similarities in clinical presentation. However similar, there are significant distinctions in the pathophysiology of these two that can help clinicians with the management process.

Clinical Findings and Outcomes

This case involves a 35-year-old Hispanic G6P5005 at 37 weeks gestation presenting with acute respiratory failure secondary to acute decompensated heart failure with reduced ejection fraction and superimposed preeclampsia leading to urgent cesarean …

Subcutaneous Emphysema And Pneumomediastinum In Patients With Covid-19 Disease; Case Series From A Tertiary Care Hospital In Pakistan, Sher Sethi, Amber Sabeen Ahmed, Sadaf Hanif, Masooma Aqeel, Ali Bin Sarwar Zubairi

Section of Internal Medicine

Since December 2019, the clinical symptoms of coronavirus disease 2019 (COVID-19) and its complications are evolving. As the number of COVID patients requiring positive pressure ventilation is increasing, so is the incidence of subcutaneous emphysema (SE). We report 10 patients of COVID-19, with SE and pneumomediastinum. The mean age of the patients was 59 ± 8 years (range, 23-75). Majority of them were men (80%), and common symptoms were dyspnoea (100%), fever (80%) and cough (80%). None of them had any underlying lung disorder. All patients had acute respiratory distress syndrome on admission, with a median PaO2/FiO2 ratio of 122.5. …

A Retrospective Review Of Outcomes In Intensive Care Unit Patients Infected With Sars-Cov2 In Correlation To Admission Acute Physiologic Assessment And Chronic Health Evaluation Ii Scores, Pratishtha Singh, Kayle M. Warren, Hannah Adler, Andrew Mangano, Jilian Sansbury, Richard Duff

South Atlantic Division Research Day 2021

No abstract provided.

Management Of Refractory Ventricular Fibrillation With Double Sequential Defibrillation, Kaitlyn A. Brown

Capstone Showcase

Patients experiencing cardiac arrest are treated according to ACLS protocols, however current protocols lack recommendations for the treatment of refractory Ventricular Fibrillation which persists after more than 3 cycles of CPR and defibrillation. One potential intervention for these cases that is being researched is the use of simultaneous or sequential activation of two defibrillators. This literature review analyzed the results of several studies to determine if double sequential defibrillation (DSD) is a viable treatment to achieve return of spontaneous circulation (ROSC) and improved patient survival. The results of the studies were mixed with some showing positive outcomes, and others showing …

Risk Factors For Intensive Care Unit Admission And Mortality In Hospitalized Covid-19 Patients, Ahmed Ayaz, Ainan Arshad, Hajra Malik, Haris Ali, Erfan Hussain, Bushra Jamil

Medical College Documents

Background: This study investigated the clinical features and outcome of hospitalized coronavirus disease 2019 (COVID-19) patients admitted to our quaternary care hospital.
Methods: In this retrospective cohort study, we included all adult patients with COVID-19 infection admitted to a quaternary care hospital in Pakistan from March 1 to April 15, 2020. The extracted variables included demographics, comorbidities, presenting symptoms, laboratory tests and radiological findings during admission. Outcome measures included in-hospital mortality and length of stay.
Results: Sixty-six COVID-19 patients were hospitalized during the study period. Sixty-one percent were male and 39% female; mean age was 50.6±19.1 years. Fever and cough …

When Myocardial Infarction Is Choosing Young Victims, Cristina Nedelcu, Mihaela Ionescu, Paris Ionescu, Vitalie Morosanu, Gabriel Smarandache, Dumitru Cristinel Badiu, Florentina Gherghiceanu, Vlad Denis Constantin, Emanuele Maria Merlo, Daniel Niţă

Journal of Mind and Medical Sciences

We present the case of a 31-year-old patient, without cardiovascular risk factors, without significant pathological or family history of cardiovascular disease, who was diagnosed with severe coronary artery disease, left main bifurcation localization, which required surgical coronary revascularization. The angiographic and intraoperative aspect excluded the most common causes of non-atherosclerotic causes of coronary lesions. Vasculitis was another possible etiology but was also excluded based on the normal clinical examination, negative inflammation markers, lack of diffuse vascular impairment, TPHA and negative VDRL. Prolonged mental stress can lead to accelerated progression of atherosclerosis by inducing endothelial dysfunction, our patient describing a “burnout …