Background:Duchenne muscular dystrophy (DMD) is an X-linked recessive genetic disorder characterized by the absence of dystrophin, leading to progressive muscle degeneration and generalized weakness. It primarily affects males in early childhood and progresses to loss of ambulation and cardiac and respiratory complications. Case Report:This case report describes a 26-year-old male with terminal-stage DMD who was admitted to the surgical intensive care unit (SICU) in a critically ill state with multiple-organ failure. He was ventilator-dependent via tracheostomy, hypotensive, anemic, and required cardiovascular support. He also had multiple pressure ulcers, including a Stage IV ulcer with associated edema, acute renal failure managed with continuous renal replacement therapy (CRRT), and sepsis due to mixed bacterial and fungal infections. Broad-spectrum antimicrobial therapy and intensive wound care were provided. This case highlights that advanced-stage DMD is a severe multisystem condition requiring intensive, specialized, and multidisciplinary care. Conclusion:This case underscores the critical importance of a multidisciplinary approach in managing complex patient conditions, emphasizing the prevention of secondary complications such as pressure ulcers and pulmonary infections. Adherence to evidence-based guidelines, coupled with psychosocial and ethical considerations related to quality of life, remains essential. Establishing standardized care protocols, enhancing healthcare team training on the specific needs of these patients, and promoting home-based and palliative care services are strongly recommended to ensure comprehensive, coordinated, and patient-centered management.
Background:Aortoenteric fistulas (AEFs) are an uncommon but often life-threatening cause of gastrointestinal (GI) hemorrhage in patients with a history of abdominal aortic aneurysm (AAA) repair. Dieulafoy lesions are a rare cause of GI bleeding, which can have significant morbidity if not identified promptly. Case Report:In this case, we describe a 65-year-old male with a history of AAA repair, complicated by graft infection, who was admitted for GI bleeding. An initial esophagogastroduodenoscopy (EGD) revealed a Dieulafoy lesion in the gastric fundus, which was treated with endoscopic clips. The patient was discharged after clinical improvement. Two weeks later, he returned with recurrent bleeding and hemodynamic instability. Repeat EGD showed no active bleeding but revealed persistent blood in the stomach and duodenum. Subsequent imaging raised concern for AEF; ultimately, emergent surgical exploration confirmed the diagnosis, revealing graft dehiscence and communication into the duodenum. Conclusion:This case highlights the diagnostic challenge of GI bleeding in patients with a history of AAA repair. AEFs may present with "herald bleeds" that mimic other causes of GI bleeding such as Dieulafoy lesions, delaying definitive diagnosis and treatment. Subtle radiologic findings, such as perigraft air, induration, or loss of normal aortic fat planes, should prompt urgent surgical evaluation, particularly in patients with a history of aortic instrumentation, infected grafts, or recurrent bleeding despite endoscopic therapy. High clinical suspicion, early CT angiography, and timely surgical consultation are critical to improving outcomes in these patients.
Pulmonary toxoplasmosis is a rare but potentially life-threatening manifestation of Toxoplasma gondii infection in immunocompetent individuals. Clinical presentation is often nonspecific and may mimic viral or atypical pneumonia, leading to delayed diagnosis. We report the case of a previously healthy 32-year-old man who presented with a mononucleosis-like syndrome complicated by rapidly progressive hypoxemic respiratory failure requiring invasive mechanical ventilation. Initial evaluation revealed marked systemic inflammation, cytopenias, hyperferritinemia, and mixed-pattern hepatitis. Chest computed tomography demonstrated bilateral consolidations, ground-glass opacities, pleural effusions, and interstitial changes. Extensive microbiological and immunological investigations were initially unrevealing. Polymerase chain reaction (PCR) testing for T. gondii was positive in blood despite negative IgG serology and isolated IgM positivity, raising concern for potentially misleading serological findings. The diagnosis of pulmonary toxoplasmosis was subsequently confirmed by PCR detection of T. gondii DNA in bronchoalveolar lavage fluid. Targeted treatment with trimethoprim-sulfamethoxazole led to rapid clinical and biochemical improvement, allowing successful extubation after 6 days of mechanical ventilation and complete radiological resolution prior to discharge. This case highlights the diagnostic challenges of pulmonary toxoplasmosis in immunocompetent hosts and underscores the importance of molecular testing in critically ill patients with severe pneumonia and ambiguous serological findings.
Multiple acyl-coenzyme A dehydrogenase deficiency (MADD) is a rare inherited disorder that disrupts fatty acid metabolism. We report a case of a patient who presented with confusion, undifferentiated shock, and rapidly worsening lactic acidosis and hyperammonemia, unexplained in severity by primary liver dysfunction. Metabolic investigations suggested the probable cause was late-onset MADD, likely triggered by pneumonia and exacerbated by early administration of fatty acid-containing sedatives. Early recognition of MADD and other metabolic disorders, whether inherited or acquired, is crucial for timely diagnosis and management. Unexplained hyperammonemia and other metabolic abnormalities should prompt clinicians to consider these rare conditions.
Background:Acute abdominal pain accompanied by severe metabolic acidosis during pregnancy is frequently attributed to pregnancy-related conditions. Hypertriglyceridemia-induced acute pancreatitis (HTG-AP) complicated by diabetic ketoacidosis (DKA) is rare in pregnancy and may be overlooked because of overlapping clinical and laboratory features. Case Presentation:We report a critically ill pregnant woman in the late second trimester who presented with abdominal pain and vomiting. Initial evaluation revealed severe metabolic acidosis and marked hypertriglyceridemia, and the patient was ultimately diagnosed with HTG-AP complicated by DKA. During the disease course, with confirmed intrauterine fetal demise (IUFD), management goals transitioned to maternal-centered critical care. However, the patient also exhibited profound metabolic derangement, intra-abdominal hypertension, and systemic stress responses, rendering immediate pregnancy termination associated with a high perioperative risk. The patient was admitted to the intensive care unit (ICU) and received continuous renal replacement therapy (CRRT) to correct refractory metabolic acidosis, followed by therapeutic plasma exchange to rapidly reduce triglyceride burden. These interventions stabilized the internal milieu and served as a bridging strategy for definitive critical care decision-making. After multidisciplinary evaluation, cesarean delivery was performed once maternal metabolic status had sufficiently stabilized. The patient's condition gradually improved, and she was discharged in good recovery. Conclusions:This case highlights the diagnostic pitfalls of HTG-AP complicated by DKA during pregnancy and underscores the importance of individualized decision-making regarding the timing of pregnancy termination in the setting of IUFD. Multidisciplinary collaboration and the appropriate use of extracorporeal organ support may play a crucial role in optimizing maternal outcomes in such complex critical care scenarios.
Introduction:Neonatal sepsis is a systemic infection in newborn infants within the first month of life. It is a serious condition with a higher rate of mortality, thus it requires prompt recognition and treatment. Invasive candidiasis (IC) is a substantial source of morbidity and mortality in the neonatal intensive care unit (NICU) and the third most frequent cause of late-onset sepsis in very-low-birth-weight (VLBW) newborns. For the IC, the major etiological agent is Candida albicans, but other nonalbicans Candida (NAC) species can also invade the bloodstream and spread the infection. In a recent scenario, the outbreak of Wickerhamomyces anomalous (formerly C. pelliculosa) fungemia in a NICU presents a significant challenge in healthcare settings. This case report series presents six cases of W. anomalous sepsis in neonates admitted to our NICU. Case report:The study investigated the clinical and treatment profile of six cases of fungemia originating from the NICU. The objective was to assess the therapy outcome. An automated system (VITEK 2) was used for rapid biochemical identification of Candida species, which revealed W. anomalous growth. Furthermore, the susceptibility of these isolates to antifungal drugs was evaluated using VITEK 2 automated antifungal susceptibility testing (AFST) system. In this case report, we presented six cases of term neonates who were admitted due to respiratory distress. The neonate received numerous antibiotic courses as well as nutrients from a parenteral source due to severe enteral nutrition intolerance. Notably, the four patients did not undergo any invasive procedures; they received only mechanical ventilation support. Subsequently, one patient (Case 6) underwent surgery, and another (Case 5) remained on a ventilator. Neither of the patients who underwent invasive procedures survived. Further, all the W. anomalous isolated from NICU cases were susceptible to fluconazole, voriconazole, and amphotericin B. Conclusion:Our case serves as a reminder to maintain a higher level of suspicion for fungal infections in preterm and term infants in the NICU. Antifungal prophylaxis may be considered for these patients if one or more risk factors are present. Additionally, it is important to note that NAC species can occasionally be the causative agent. Therefore, we should always bear in mind the possibility of these fungal pathogens as infectious agents in neonates with risk factors.
Background:Early mobilisation (EM) in the intensive care unit (ICU) is associated with a reduced incidence of intensive care unit-acquired weakness, shorter hospital length of stay and improved functional outcomes. However, most of the available evidence derives from patient populations at low risk of safety-related adverse events. This limits the generalisability of its benefits to more complex clinical scenarios, such as the concurrent administration of blood products, continuous parenteral nutrition, antiarrhythmic infusions or multiple haemodynamic pharmacological support. Consequently, evidence regarding the safety of EM in these contexts remains scarce. This case series is aimed at describing the safety of EM under unusual and high-risk clinical conditions, an area that remains underexplored in the international literature. Case Presentation:We describe six critically ill patients presenting with conditions traditionally considered high risk for EM. Two patients were receiving active transfusion of blood products: a 70-year-old woman under invasive mechanical ventilation and a 69-year-old man with upper gastrointestinal bleeding and moderate anaemia; both performed active exercises during red blood cell transfusion. Two additional patients were receiving continuous enteral nutrition: a 42-year-old man requiring invasive mechanical ventilation and a 76-year-old woman; both undertook active exercises during nutritional administration. The fifth case involved a 65-year-old woman with atrial flutter treated with an amiodarone infusion. The sixth case was a 65-year-old woman with cardiomyopathy and suspected sepsis, requiring triple haemodynamic pharmacological support with noradrenaline, vasopressin and dobutamine. Exercise prescription was individualised according to intensity, type and duration, based on the dosing determined by the attending physiotherapist. All interventions were conducted under continuous monitoring. No adverse events or complications related to EM or invasive devices were observed. Conclusions:EM can be safely implemented in critically ill patients, even under conditions traditionally considered high risk, provided that strict criteria for clinical stability and continuous monitoring are applied. These findings provide relevant preliminary evidence supporting the feasibility of active rehabilitation in the ICU and open new avenues for research aimed at defining specific safety criteria for EM in high-risk populations.
Although beta-lactam antibiotics are widely used in intensive care, rare but potentially fatal anaphylactic reactions can occur due to cross-reactions between penicillins and cephalosporins. We report the case of a 68-year-old man who suffered perioperative cardiac arrest following the administration of cefuroxime. During the postoperative period, the patient received ampicillin/sulbactam without any signs of hypersensitivity. Following a switch to piperacillin/tazobactam prior to a procedure, the patient suddenly developed cardiovascular arrest and died. The autopsy revealed no macroscopic cause of death, but immunohistochemistry showed mast cell degranulation ("starry sky pattern") in the tissue, suggesting anaphylaxis. We present the clinical and histopathological findings of a case with severe allergic reactions to both cefuroxime and piperacillin/tazobactam, as a result of either cross-reaction or isolated sensitization to both antibiotics. This case report highlights the potential risks of cross-reactivity between beta-lactam antibiotics and the importance of autopsy in ambiguous cases. Clinicians should be aware of cross-reactivity or cosensitization to multiple beta-lactams in patients with a beta-lactam allergy and consider non-beta-lactam alternatives in high-risk cases.
Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are cornerstones in the treatment of Type 2 diabetes (T2D), but their use is associated with diabetic ketoacidosis (DKA), a potentially life-threatening complication in the critical care setting. We present two cases of male patients with T2D who developed SGLT2i-associated ketoacidosis under different stressors: the first following coronary artery bypass graft (CABG) surgery and the second after the addition of semaglutide to his therapeutic regimen. Both patients presented with high anion gap metabolic acidosis, ketonuria, and plasma glucose levels < 200 mg/dL. Management required intravenous insulin protocols and glucose supplementation to reverse ketosis. This report emphasizes the need for preoperative suspension protocols and close monitoring of changes in combination therapy to avoid diagnostic delays in the intensive care unit.
Cobalamin C (Cbl-C) disease, the most common inborn error of cobalamin metabolism caused by biallelic pathogenic MMACHC variants, leads to multisystem involvement from methylmalonic acid and homocysteine accumulation. When diagnosed early, it is treatable. Rapid genome sequencing (GS) is becoming increasingly accessible and enables timely diagnosis and prompt treatment. We report a neonate who had severely decreased prenatal and postnatal biventricular function requiring inotropic support. Given the critically ill condition and unclear etiology, rapid GS was obtained and revealed homozygous pathogenic MMACHC variants, confirming a diagnosis of Cbl-C disease. This prompted the early initiation of treatment with high-dose hydroxocobalamin, betaine, levocarnitine, and folic acid. His cardiac function gradually improved, and he was discharged at 28 days of life. Critical care providers should suspect treatable inherited metabolic disorders in patients with unexplained presentations and recognize rapid GS as a powerful tool for early identification and treatment in critically ill patients.
Introduction:Diabetic ketoacidosis is associated with cerebral edema, which, although rare, is associated with an increased mortality rate. Case Report:In this case report, we discuss the use of a hypertonic saline solution in a 42-year-old male with wild-type gliosarcoma who presented with hyperglycemia to avoid cerebral edema.
Digoxin, a cardiac glycoside historically used for rate control in atrial arrhythmias and symptom relief in chronic heart failure, possesses a narrow therapeutic index and is highly susceptible to pharmacokinetic and pharmacodynamic disruption in critically ill patients. Its use in acute decompensated heart failure and cardiogenic shock is therefore controversial. We present the case of a 75-year-old woman with chronic heart failure with reduced ejection fraction who developed progressive bradycardia and cardiogenic shock after treatment with digoxin and amiodarone for 2:1 atrial flutter. Her hospital course was complicated by acute kidney injury, severe hyperkalemia, ischemic hepatitis, and persistent bradycardia following electrical cardioversion. Serum digoxin levels were supratherapeutic early in the intensive care unit course and subsequently normalized, though bradyarrhythmias persisted. The patient's presentation and clinical trajectory were consistent with BRASH (bradycardia, renal failure, AV-nodal blockade, shock, and hyperkalemia) syndrome , with amiodarone-digoxin interaction and systemic hypoperfusion likely amplifying myocardial digoxin sensitivity. She improved with supportive therapy, correction of metabolic derangements, withdrawal of AV-nodal-blocking agents, and cardioversion, without administration of digoxin-specific antibody fragments. This case highlights the importance of early recognition of BRASH physiology, cautious use of AV-nodal blockers in low-output states, and prioritization of underlying physiologic correction over reliance on serum drug levels alone in critically ill patients.
Rationale:The study is aimed at exploring the complex clinical scenario of a patient with systemic lupus erythematosus who developed a rare coinfection with Listeria monocytogenes and Mycobacterium tuberculosis. The rationale is to highlight the diagnostic and therapeutic challenges in managing such a case, particularly in the context of immunosuppression and the need for effective antimicrobial therapy. This case underscores the importance of advanced diagnostic techniques like metagenomic next-generation sequencing in identifying coinfections and the critical balance required in treating both infections while managing the underlying autoimmune condition. Patient Concerns:This case report presents a 58-year-old female patient who initially manifested thrombocytopenia and was diagnosed with SLE in an external hospital. After treatment, her condition did not improve. On the contrary, she developed a fever and a headache, and her disturbance of consciousness gradually worsened. The patient was admitted to our hospital with a suspected diagnosis of lupus encephalopathy and central nervous system infection. Diagnoses:MRI plain scan showed linear enhancement shadows in the right temporal pole and bilateral cerebellar hemisphere regions on the fluid-attenuated inversion recovery three-dimensional volumetric fluid-attenuated inversion recovery contrast-enhanced scan. Subsequently, NGS of the cerebrospinal fluid detected L. monocytogenes and M. tuberculosis, suggesting a possible mixed infectious meningitis caused by these two pathogens. Interventions:The patient underwent a comprehensive treatment regimen including antiListeria and antituberculosis therapies. Unfortunately, this was followed by the development of liver failure and various other complications. In response, we administered interventions such as blood purification and liver support measures. Furthermore, we organized a multidisciplinary consultation to address the complex medical needs of the patient. Outcomes:Despite aggressive medical interventions, the patient's condition deteriorated. She developed multiorgan failure, which significantly impacted her prognosis. The patient's family elected to withdraw life-sustaining treatment, and the patient passed away within 24 h after discharge. Lessons:This case underscores the importance of early and accurate diagnosis, particularly for immunocompromised patients with complex clinical presentations. Identifying mixed infections is crucial, and it also poses a significant challenge in selecting appropriate antimicrobial agents and conducting relevant tests.
Bupropion is a synthetic cathinone that acts as a norepinephrine and dopamine reuptake inhibitor and is an atypical antidepressant commonly prescribed for major depressive disorder and smoking cessation. Although generally well tolerated at therapeutic doses, bupropion overdose can lead to severe toxicity, primarily characterized by seizures and cardiac arrhythmias. Management of severe intoxications remains mainly supportive, with no specific antidote available. Intravenous lipid emulsion (ILE) therapy has emerged as a potential treatment for poisoning with highly lipophilic drugs. Initially found to reverse local anesthetic toxicity, ILE is hypothesized to work via multiple mechanisms, including a “lipid shuttle” effect and direct stabilization of highly excitable membranes in the brain and heart. However, its precise role in nonanesthetic drug intoxications remains incompletely understood. We report a case of a massive, intentional bupropion overdose (24,000 mg) in a patient with no coingestion of other toxic substances aside from alcohol. The patient developed refractory seizures and severe ventricular arrhythmias, which were successfully reversed after ILE administration. Serial blood measurements of bupropion and its metabolites were performed before and after ILE administration, supporting both lipid sequestration of the drug and direct cardioprotective effects. A preprint of this study is available online (Della Casa et al. 2026).
Importance:Klebsiella pneumoniae invasive liver abscess syndrome (ILAS) is an emerging disease characterized by liver abscess without biliary disease, often with multiorgan metastatic infection. It can cause severe critical illness with significant morbidity and disability. There remains limited literature and understanding of this syndrome in the United States. Objectives:This article aims to describe the clinical characteristics of hospitalized and critically ill patients with ILAS and providing management considerations for critical care clinicians. Main Outcomes and Measures:Adult patients admitted to Scripps Health from Janurary 1, 2018 to April 1, 2024 were reviewed. Inclusion criteria required radiographic evidence of a liver abscess and cultures (blood or abscess) positive for K. pneumoniae. Data collected included demographics, symptoms and signs, laboratory and radiologic data, metastatic infection characteristics, treatment, mortality, and morbidity. Patient cases were described, and a narrative review describing clinical, therapeutic, and prognostic characteristics was conducted. Results:Six patients had ILAS. Mean age was 54.8 years, no immunosuppression (defined as underlying malignancy, drug-induced, or chronic infection), 83% had diabetes, 50% were male, and 50% were of Asian ethnicity. Liver abscesses were multilocular (50%), and all had percutaneous catheter drainage. Fifty percent of patients developed distant metastatic infections: emphysematous cystitis, pulmonary septic emboli, complicated parapneumonic pleural effusions, meningitis, ventriculitis, cerebral septic emboli, and endophthalmitis. These patients were younger, male, and had a higher rate of intensive care unit (ICU) admission and mechanical ventilation. Two patients required ICU admission with septic shock, diabetic ketoacidosis, respiratory failure, severe thrombocytopenia, and altered mental status. K. pneumoniae isolates were pansensitive except to ampicillin. There was no in-hospital mortality. The patient with meningitis and ventriculitis had full neurological recovery, and the patient with endophthalmitis had very poor residual visual acuity. Conclusions and Relevance:ILAS is an emerging disease that can cause severe critical illness with multiorgan involvement. Early identification of the disease and metastatic infection is essential to provide appropriate treatment. Additionally, ILAS patients require screening for endophthalmitis.
Background:Air embolism is a rare but potentially fatal complication associated with central venous catheter (CVC) use even several days after placement. Although often asymptomatic, large or rapidly introduced volumes of air can result in severe neurologic and cardiovascular compromise. Case Presentation:We report a case of fatal cerebral air embolism in a male stroke patient in his early 60s with a history of diabetes, nephropathy, and peritoneal dialysis. Following ischemic stroke, a CVC was inserted for hemodialysis. Seventeen days after stroke onset, the patient was found unconscious, with seizures and signs of acute neurologic deterioration. The hemodialysis catheter was discovered unplugged and unclamped, suggesting accidental or intentional self-manipulation. Imaging confirmed a massive air embolism in both arterial and venous cerebral circulations. Despite immediate intervention, the patient remained unconscious and died 5 days later. Autopsy confirmed the diagnosis and excluded cardiac or pulmonary shunts. Conclusion:This case highlights the fatal potential of air embolism following CVC mishandling. Prevention requires meticulous catheter management, staff training, and informing patients about risks.
Background:Intraosseous access is commonly used for vascular access in emergent settings. It is generally thought to be well tolerated with minimal complications. We report the first case of clinically significant macroscopic pulmonary fat embolism secondary to intraosseous access. Case Presentation:A 67-year-old woman developed profound hypotension and severe biventricular dysfunction shortly after intraosseous access and resuscitation. She required emergent venoarterial extracorporeal membrane oxygenation and Impella for cardiopulmonary support. Computed tomography revealed a new macroscopic pulmonary fat embolism compared with prior imaging 1 day prior. Aspiration thrombectomy was successfully performed with significant improvement in hemodynamics. Unfortunately, she suffered an anoxic brain injury during resuscitation and was ultimately transitioned to comfort care. Conclusions:Although intraosseous access is often considered a safe procedure, this case highlights the need for awareness of this rare but serious and potentially lethal complication. Treatment of pulmonary fat embolism is often supportive; however, aspiration thrombectomy has a potential therapeutic role in macroscopic cases.
Heat stroke is a life-threatening emergency characterized by severe hyperthermia and acute central nervous system (CNS) dysfunction. We describe a 72-year-old man who was found unresponsive in his vehicle on a day with ambient temperatures exceeding 90°F. On arrival, his core temperature was 105.8°F, and Glasgow Coma Scale (GCS) score was 5. Despite prompt initiation of active cooling and supportive care with normalization of body temperature, the patient developed persistent and fluctuating encephalopathy. Extensive metabolic, infectious, and toxicologic evaluations were unrevealing. Thyroid-stimulating hormone was normal, arterial blood gases showed no acid-base derangements, ammonia and liver function tests were within normal limits, and urine toxicology was negative. Electroencephalography demonstrated diffuse cerebral slowing without epileptiform activity. Brain MRI performed approximately 1 week after admission under anesthesia, including diffusion-weighted imaging, showed no acute abnormalities, revealing only mild age-related atrophy and chronic small-vessel ischemic changes. The patient's neurologic function failed to recover over a prolonged hospitalization, and he ultimately died following transition to comfort-focused care on hospital Day 27. This case highlights that severe and persistent encephalopathy may occur in the setting of probable heat stroke despite unrevealing conventional neuroimaging and underscores the diagnostic uncertainty and limitations of MRI in evaluating heat-related neurologic injury.
Pyomyositis is an uncommon bacterial infection of the skeletal muscle, traditionally associated with tropical regions and immunocompromised hosts. We present a case of a 44-year-old immunocompetent female in Northern California who developed pyomyositis involving the vastus medialis, rectus femoris, and vastus lateralis. A drainable abscess was not initially demonstrated on computed tomography (CT) imaging, and diagnosis was delayed by findings of deep vein thrombosis (DVT) with septic pulmonary emboli in the setting of septic shock due to methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia. Two possible pathogenetic mechanisms were considered: either a provoked DVT from immobilization following recent lower extremity surgery served as a nidus for bacterial seeding, or alternatively, a superficial thigh abscess triggered a hypercoagulable state leading to DVT formation and subsequent bacterial seeding. In either scenario, muscle strain from impaired mobility rendered the tissues vulnerable to abscess formation. The patient required multiple surgical debridements and prolonged intravenous antibiotic therapy for successful treatment. This case reveals atypical pathogenetic mechanisms for pyomyositis and highlights the necessity for physicians to remain vigilant for this disease process that has demonstrated an increasing incidence rate in the United States, even in immunocompetent hosts and in temperate climates.
Septic shock is associated with high mortality worldwide despite adequate treatment. Various blood purification techniques have been available on the market for several years, aiming to remove circulating inflammatory mediators and to attenuate life-threatening cytokine storms. In this case report, we describe the successful reduction of a cytokine storm in a patient with severe refractory septic shock and the onset of rhabdomyolysis-induced renal failure through the use of extracorporeal blood purification.
