Air embolism is the entry of gas into vascular structures. It is a rare life-threatening complication of several medical procedures, in particular lung biopsy and central catheter insertion. The prevalence is 0.06%, but may be underestimated. It can have an asymptomatic course. Symptomatic air embolism can be accompanied by respiratory insufficiency and myocardial or cerebral infarction. We present a 78-year-old woman with acute hypotension and unconsciousness after lung biopsy. A CT scan showed air embolism in both the pulmonary and systemic circulation, followed by myocardial infarction and stroke. She was admitted to the intensive care unit for stabilisation and hyperbaric oxygen therapy. The patient improved, but a hemi-paralysis remained. Recognising air embolism is important to prevent further embolisation and to start treatment. Treatment is mostly supportive. In severe cases, 100% oxygen is supplied to expel air, thereby limiting permanent injury. In case of neurological and cardiac complications, hyperbaric oxygen is indicated.
Meigs syndrome is a rare clinical entity of benign origin in which a triad of ovarian tumour (usually ovarian fibroma or fibroid-like tumour), hydrothorax and ascites co-exist and raise suspicion of malignancy. Here, we report the case of a 60-year-old female presenting with a suspicion of ovarian cancer with pleural fluid and ascites, although eventually found to be of benign origin and curated after resection of the tumour. By presenting the case, we emphasise the importance of meticulously evaluating the diffierential diagnosis in patients with suspected advanced cancer in the absence of pathological confirmation. Moreover, we raise awareness for the complexity of evaluating which patient categories could benefit from intensive care treatment. In this specific case, with the absence of a pathological diagnosis, the option of benign cause is important to consider, even when possible malignancy interacts with a patient's wishes for treatment.
A 72-year-old patient was admitted to the intensive care unit with respiratory failure due to rapidly progressive interstitial lung disease (ILD). All cultures and PCRs focused on ILD were negative and a paraneoplastic phenomenon was deemed unlikely after screening for malignancy. Inflammatory myositis was suspected as the patient also presented fever, progressive pitting oedema and arthritis in both hands and feet. A myositis blot revealed high titres of anti- Jo-1 antibodies: the patient was diagnosed with antisynthetase syndrome and was treated with high-dose corticosteroids, cyclophosphamide and intravenous immunoglobulins with a gradual full recovery. Antisynthetase syndrome should be considered in patients with idiopathic or rapidly progressive ILD.
A 48-year-old male presented to our emergency department after a suicide attempt using the helium method. This increasingly popular method of inhaling helium rapidly causes asphyxia and death. When the supply of helium is interrupted, it may result in post-anoxic encephalopathy, as demonstrated in this case.
In this article we present two cases of Capnocytophaga canimorsus (C. canimorsus)-related sepsis presenting with different clinical symptoms. C. canimorsus is a commensal bacterium in the gingival flora of dogs and cats but can cause severe illness in humans after transmission through bites or licks. Risk factors include a reported dog or cat bite, alcoholism, immune deficiency, advanced age, splenectomy or hyposplenism. We discuss the role of hyposplenism in this disease. Treatment of C. canimorsus sepsis is with antibiotics and in the case of multi-organ failure supportive.
In this paper we describe how the data infrastructure of an existing national quality registry was adapted to meet public health, research and capacity needs for information on COVID-19 hospitalisations in the Netherlands.
In this case report, we describe an 85-year-old female patient who presented with a rare but important problem of anticoagulant rebound complicating dabigatran use. Despite multiple attempts to correct the bleeding, it continued and the coagulation times remained prolonged. Important risk factors for high dabigatran concentrations and prolonged coagulation are renal insufficiency, drug-drug interactions and older age. Treatment of dabigatran-related bleeding with idarucizumab may be complicated by a rebound effect presenting as the reappearance of dabigatran after an initial response. The risk of anticoagulation rebound is higher with higher initial dabigatran levels and is associated with the severity of renal insufficiency. The rebound is best monitored by the diluted thrombin time and may be treated with repeated doses of idarucizumab. In case of persisting bleeding and high dabigatran levels, renal replacement therapy is an acceptable therapeutic option.
Encephalopathy is a severe and underestimated neurological complication of COVID-19 infection, with a high prevalence in COVID-19 patients in intensive care. We present a case of a 68-year-old male with severe COVID-19 encephalopathy and prolonged lowered consciousness, without showing any brain imaging abnormalities. There are multiple mechanisms of cause, such as inflammatory, hypoxic-metabolic and sepsisrelated factors, and residual sedation, which were treated as described without effect on the encephalopathy. Interestingly, our patient showed no abnormalities on brain imaging and the encephalopathy only disappeared a full month after respiratory recovery. Encephalopathy considerably prolonged his ICU stay and after discharge from the medical rehabilitation clinic, he still showed mild neurological impairment. The late neurological recovery suggests that the severity of encephalopathy may not only be related to the severity of the COVID-19 pneumonia and there might be an inflammatory neurological response, without showing brain imaging abnormalities.
In the last two years we have experienced the effects of the COVID-19 pandemic in our lives and hospitals. Pandemics are part of the history of humanity and we can be certain that in the future new pandemics will appear. In fact, due to the growth in the human population, increased travel and global warming, it is to be expected that new pandemic pathogens will arise more frequently than before. Additionally, decreased barriers between animals and humans will give rise to spillover events, which will result in the introduction of new zoonotic pathogens in humans. In each of the parts of this series we will, in a short format, highlight a potential pandemic pathogen and describe its characteristics, history and potential for global pandemics. This part of the series focusses on MERS-CoV infection which, up until now, has been fairly contained in a small part of the world but definitely has traits that make it a pathogen to watch. As in previous parts of this series, we will highlight its clinical picture and explain why it should not be underestimated.
Ruptured abdominal aortic aneurysm is a life-threatening condition that occurs mainly in the elderly patient. The decision whether or not to operate on an elderly patient with a ruptured aneurysm is complicated and should include an evaluation of frailty. Three cases of octogenarians who presented with a ruptured abdominal aneurysm and had varying premorbid degrees of frailty are described, including the decision whether or not to operate on these patients, and their clinical course. A ruptured abdominal aneurysm in the over-80s remains a condition with high mortality and morbidity. However, an acceptable quality of life can be achieved with surgical intervention for selected patients. Currently, there is a lack of specific preoperative tools for prognostication in the elderly patient. Assessment of frailty can contribute to the decision whether surgery will be worthwhile. In addition, the ethics surrounding decisions in the acutely and critically ill elderly patients are discussed.
In the last two years we have experienced the effects of the COVID-19 pandemic in our lives and hospitals. Pandemics are part of the history of humanity and we can be certain that in the future new pandemics will appear. In fact, due to the growth in the human population, increased travel and global warming, it is to be expected that new pandemic pathogens will arise more frequently than before. Additionally, decreased barriers between animals and humans which will give rise to spillover events which will result in the introduction of new zoonotic pathogens in humans. In each of the parts of this series we will, in a short format, highlight a potential pandemic pathogen and describe its characteristics, history and potential for global pandemics. This part of the series is devoted to the Zika virus (ZIKV). We describe the history of ZIKV, the clinical picture and finally, we conclude with a discussion about the pandemic risk of ZIKV infection.
