Chief Complaint Of Fever Research Articles

Bacteremia caused by Desulfovibrio desulfuricans with the intestinal tract as the portal of entry: two case reports and a literature review

BackgroundDesulfovibrio desulfuricans (D. desulfuricans), a commensal anaerobic gram-negative rod endemic to the soil environment and human gastrointestinal tract, rarely causes bloodstream infections. We report two rare cases of bacteremia caused by D. desulfuricans in which the intestinal tract was the portal of entry. In addition, we summarize findings on D. desulfuricans.Case presentationCase 1: A 51-year-old man presented to the emergency department with the chief complaints of fever and right lower abdominal pain. He was admitted to the hospital with ascending colonic diverticulitis and received empirical antibacterial therapy with piperacillin/tazobactam. Blood culture revealed D. desulfuricans. The patient was discharged after 2 weeks of antimicrobial therapy. Case 2: A 95-year-old woman presented to our hospital with a chief complaint of fever. Owing to an elevated inflammatory response and pyuria, the patient was diagnosed with pyelonephritis and treated with ceftriaxone. Klebsiella pneumoniae was detected in her urine culture, while D. desulfuricans was detected in her blood culture. The patient was then treated with ampicillin/sulbactam for 14 days. The fecal occult blood test result was positive, suggesting a colonic mucosal lesion, such as a malignant tumor, may have been the portal of entry for D. desulfuricans bacteremia. Previous literature reviews indicate that D. desulfuricans bacteremia often results from liver or renal abscesses, intestinal lesions, among others, serving as the portal of entry. Although no specific underlying disease has been reported, it is more common in the older population. We encountered two cases of D. desulfuricans bacteremia and combined them with 15 cases from previous studies to explore the characteristics of the disease. The proportion of patients aged \\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\:\\ge\\:$$\\end{document}60 years was 73.7%; overall, 73.7% had gastrointestinal complications, and 63.2% had abdominal symptoms at the time of presentation.ConclusionsWe encountered two rare cases of D. desulfurican bacteremia. This type of bacteremia is more common in elderly people over 60 years of age and is often associated with hepatobiliary and gastrointestinal diseases.

Diagnosis dan Tata Laksana <i>Thyroid Storm</i> yang Dipicu oleh Perikarditis Akut

Thyroid storm is a life-threatening condition that requires prompt diagnosis and emergency treatment. This condition manifests as multiple organ decompensation characterized by loss of consciousness, high fever, heart failure, diarrhea,and jaundice. We report a case of a 51-year-old man with a chief complaint of fever that has been felt since the night before admission. Body temperature was up to 38°C and started while he was resting. Patient also reported dry, intense cough, since five days ago, accompanied with shortness of breath when lying down. The patient also felt palpitations sincethe previous night and still felt until the morning of admission, and did not improve with rest. The patient was diagnosed by observation of suspension shock due to cardiogenic shock, suspect Graves’ disease (thyroid storm), ADHF profileB et causa suspect CAD, AF RVR, type 2 DM, myofascial pain syndrome with differential diagnosis: headache related toinfection, hyponatremia chronic asymptomatic hypoosmolar hypervolemic et causa suspect dilution, hypoalbuminemia etcausa suspect chronic inflammation, and upper respiratory tract infection. Thyroid storm cases require a multidisciplinaryapproach in terms of diagnosis and therapy. In this case, the patient is referred to the internal medicine, cardiac, andneurology departments.

Evaluation of non-malignant neutropenia in children at tertiary care hospital of South Gujarat

: Neutropenia is defined as absolute neutrophil count <1500cells/mm. This condition is observed in different situations - from a variant of the normal to life-threatening acquired and congenital diseases. Diseases like Tuberculosis, malaria, pertussis, typhoid, dengue, HIV, etc. can cause neutropenia. Mild cases are usually asymptomatic. But severe cases are extremely susceptible to infections, mainly viral infections like CMV, EBV, HIV, etc. Clinical manifestations, like complications, depend on the severity of neutropenia. The clinical manifestations of isolated neutropenia are diverse, including the frequency of infectious episodes. A thorough infectious history of neutropenic patients is the initial step of the evaluation. : To enlist the causes and clinical features, to document various treatment modalities, and to assess the outcome of children with non-malignant neutropenia. : Hospital based prospective cross-sectional study was conducted for 20 months among 42 patients at Department of Pediatrics of tertiary care Hospital. Study was conducted from February 2021 to August 2022. : Total 20 were males and 22 were females. Among the study participants, 36 were >2 years of age and 6 were <2 years of age had nonmalignant neutropenia. Among the study participants, 40 were from urban area and 2 were from rural area. More number of patients had come with chief complaint of fever. : The current population of children in India is close to 1.41 billion and 10.2% of it suffering from neutropenia makes it an important health problem that needs to be thoroughly evaluated.

Late Presentation of Coarctation of the Aorta in an 11-Year-Old Male Child: A Case Study

Introduction: Coarctation of the aorta is a condition characterized by a narrowed segment of the aorta due to thickening of the artery wall. This case study highlights the late diagnosis of coarctation of the aorta in an 11-year-old male child who presented with symptoms initially suggestive of a respiratory infection. Case study: An 11-year-old male presented to the outpatient department with chief complaints of fever, cough, and poor appetite. He developed two episodes of epistaxis and hypertension with soft systolic murmur. Echocardiography showed severe coarctation of the aorta. Discussion: Coarctation of the aorta is a relatively common congenital heart defect that can remain asymptomatic until later in childhood or adulthood. It is the seventh most common type of CHD. The delay in the diagnosis of coarctation of the aorta underscores the challenges of recognizing cardiac anomalies in pediatric patients presenting with nonspecific complaints. Conclusion: Healthcare providers must remain vigilant and thorough in their assessment to prevent late diagnoses and associated complications in pediatric patients.

Kluyvera ascorbata: An Emerging Pathogen and Rare Cause of Urinary Tract Infection in Immunocompetent Patients at a Tertiary Care Center in North India

Kluyvera spp. is a Gram-negative bacillus and was discovered by Kluyver and van Niel, included in the family Enterobacteriaceae. We report two cases of urinary tract infection due to Kluyvera ascorbata. The first case was a 61-year-old male, who was admitted to the nephrology department of the hospital with chief complaints of fever with chills from 1 week, abdominal pain, and difficulty in passing urine. The second case was a 29-year-old female, who presented to the medicine department of the hospital with a 4-day history of fever with associated chills and rigor, abdominal pain, chills, and weakness. These patients were treated with nitrofurantoin given orally for 7 days they recovered completely. This case series highlights the role of K. ascorbata, and in general of Kluyvera species, as an unusual but potentially dangerous pathogen, the need for prompt identification to determine potential pathogenicity in the immunocompetent as well as in the immunocompromised host, and to assess the efficacy of antibiotics such as carbapenems and nitrofurantoin.

Risk of serious bacterial infections in pediatric patients with hyperpyrexia.

Hyperpyrexia has been associated with a greater prevalence of bacterial infections in the pediatric population, which prior to routine childhood vaccinations, has led to invasive testing and empiric antibiotic use for urinary tract infections, bacterial pneumonia, bacteremia, and bacterial meningitis. Since the implementation of routine childhood vaccinations, the prevalence of serious bacterial infections (SBIs) has declined. This study aims to determine if there is an association between hyperpyrexia and serious bacterial infections in well-appearing febrile pediatric patients presenting to the emergency department (ED). This is a cross-sectional study conducted between January 1, 2019, and December 31, 2019, at a single urban tertiary care pediatric ED. Patients were included if they were between 61 days and ≤18 years old presenting with a chief complaint of fever. Patients were excluded if they received antibiotics within 3 days of presentation, underwent surgical procedures within 2weeks of presentation, had an ED visit for febrile illness within 2weeks of study visit, were transferred from another institution, or were ill appearing. Prevalence of SBI was described and compared by presence of hyperpyrexia, age group, chronic medical condition, gender, and vaccination status. Logistic regression was used to analyze the association between SBIs and hyperpyrexia. Of the 3862 charts reviewed, 2565 patients were included. The prevalence of SBI was 5.6%. A total of 413 patients presented with hyperpyrexia. Of the patients with hyperpyrexia, 31 (7.5%) had a serious bacterial infection. Hyperpyrexia was not significantly associated with SBIs in our logistic regression models (adjusted Odds Ratio 1.40, 95% confidence interval 0.92-2.12). Serious bacterial infections were uncommon in our population. There is no statistically significant association between hyperpyrexia and SBIs in well-appearing pediatric patients presenting to the ED with fever. The lack of a statistically significant association between hyperpyrexia and SBIs argues that clinicians should be cautious using hyperpyrexia as an independent risk factor for SBIs. More research is needed to identify independent and grouped SBI risk factors in well-appearing pediatric patients presenting to the ED.

Chronic kidney disease on the background of bardet–biedl syndrome: a case report and review of literature

Introduction: Bardet–Biedl syndrome (BBS) is a rare autosomal recessive multisystem disorder characterized by retinal dystrophy, obesity, postaxial polydactyly, renal dysfunction, learning difficulties, and hypogonadism. In this case report, the authors present the clinical course and management of a patient with BBS who developed chronic kidney disease (CKD). Case presentation: An 18-year-old male presented to the emergency department with chief complaints of fever, cough, vomiting, and decreased urine output for 7 days. Parents complained that the child had a delay in development compared to other children of the same age group. On examination, the patient had tachypnea, periorbital and pedal edema, expiratory wheeze with bilateral basal crackles, polydactyly, central obesity, microtestes, and delayed developmental milestones. Ultrasonography revealed bilateral small kidneys with increased cortical echotexture and loss of corticomedullary differentiation. Based on clinical features, the patient was diagnosed with CKD in the background of BBS. Hemodialysis was initiated after the diagnosis. Discussion: The management of CKD in the background of BBS poses unique challenges due to the complex multisystem involvement of this genetic disorder. There should be early reorganization and management of this condition so that the patient can have a better quality of life. Moreover, in developing countries like Nepal, genetic testing and diagnosis should be made easily accessible for better patient outcome. Conclusion: Multidisciplinary approach involving nephrologists, ophthalmologists, endocrinologists, and geneticists is important to optimize the treatment and long-term management of Badet Biedel patients.

Impact of the Early COVID-19 Pandemic on Emergency Department Visits of Adult Cancer Patients With Fever or Respiratory Symptoms: A Korean Nationwide Population-Based Study, 2016-2020.

We performed a nationwide analysis to evaluate the impact of the early coronavirus disease 2019 (COVID-19) pandemic on emergency department (ED) visits by adult cancer patients having COVID-like symptoms. We analyzed the National Emergency Department Information System (NEDIS) data on ED visits by adult cancer patients who presented with chief complaints of fever or respiratory symptoms (FRS) indicative of COVID-19, from 2016 to 2020. An interrupted time series analysis with a quasi-Poisson regression model was performed, adjusting for seasonality and time, to evaluate whether underlying trends for monthly ED visits and the in-hospital mortality rate (%) per month changed with the pandemic among these patients. We also estimated the adjusted odds ratio (aOR) of in-hospital deaths among cancer patients using multivariable logistic regression analysis. ED visits by cancer patients with FRS decreased during the COVID-19 pandemic (relative risk [RR] with 95% confidence interval [CI]: slope change, 0.99 [0.98-1.00] and step change, 0.84 [0.76-0.92]). However, the in-hospital mortality rate (%) for these patients was increased (slope change, 1.14 [1.04-1.25] and step change, 0.99 [0.98-1.01]). Factors such as urgent triage status, ambulance use, and treatment in hospitals with fewer than 300 staffed beds significantly contributed to increased aOR of in-hospital deaths during the COVID-19 pandemic compared to the pre-pandemic period. Further studies are needed to highlight the importance of ED service preparation in planning and managing resources for cancer patients during future pandemics.

Pre-operative management of a patient with tubo-ovarian abscess and diabetic ketoacidosis

Background: Diabetic ketoacidosis (DKA) is a serious consequence of uncontrolled diabetes, especially in patients complicated by certain infections. Patients with DKA often require surgery; however, at the same time are more vulnerable to unintended postoperative complications. Therefore, proper pre-operative management in these patients is prominent. This study aimed to summarize pre-operative management of a patient with DKA and tubo-ovarian abscess. Case Presentation: A 45-year-old female was referred to Dr. Soetomo Hospital Surabaya with a chief complaint of fever, right abdominal pain, and white vaginal discharge. The patient had a history of uncontrolled DM since 2014. Ultrasonography examination revealed the presence of a hyperechoic mass in the uterine fundus (size: 6,39 x 7,36 cm). Initial laboratory examination indicated leukocytosis, hyperglycemia, hyponatremia, proteinuria, and ketoacidosis condition. The patient was diagnosed with DKA, type 2 diabetes mellitus (T2DM), tubo-ovarian abscess. Before undergoing surgery to remove the abscess, the patient received fluid therapy (NaCl 0,9%); insulin therapy (rapid-acting insulin 2x4 IU intravenous (IV), bicarbonate 100 mEq in 400 mL normal saline/24 hours IV, and rapid-acting insulin pump 1 IU/hour); diet therapy, and antibiotic therapy (ampicillin 1 gr every 6 hours IV, gentamycin 240 mg every 24 hours IV, and metronidazole 500 mg every 8 hours IV). Regular examination was performed, which included the evaluation of random blood glucose (RBG) every 3 hours, serum electrolytes every 24 hours, repeat blood gas analysis every 24 hours, blood culture, and vaginal swabs. Conclusion: Euglycemia is the main goal of perioperative treatment in order to enhance postoperative results. Careful blood glucose management should be performed before surgery to decrease patients' morbidity and mortality. It must also be highlighted that regular patient monitoring through clinical and laboratory markers is essential to treat DKA successfully.

Acute cholecystitis with sepsis due to Edwardsiella tarda: a case report

BackgroundEdwardsiella tarda (E. tarda) is a Gram-negative facultative anaerobe belonging to Enterobacteriales and is commonly isolated from fishes and reptiles. Infection due to E. tarda is uncommon among humans, with a reported human retention rate of 0.001%. It can cause sepsis in the elderly or those with pre-existing conditions such as liver failure, autoimmune disease, or malignancy. E. tarda is susceptible to many antibiotics; however, a high mortality rate (approximately 40%) has been reported with sepsis.Case presentationA 65-year-old woman presented to our hospital with a chief complaint of fever and abdominal pain for 2 days. Her blood tests showed elevated inflammatory markers, and contrast-enhanced computed tomography showed distention and wall thickening of the gallbladder and inflammation of peri-gallbladder fat. Subsequently, a diagnosis of cholecystitis with systemic inflammatory response syndrome was made. Laparoscopic cholecystectomy was performed after starting antimicrobial therapy. Blood culture of samples obtained on admission were positive for E. tarda, which was also detected in bile juice culture. Therefore, she was diagnosed with bacteremia caused by E. tarda, and postoperative antimicrobial therapy was continued. The patient improved, and there were no complications.ConclusionsWe experienced an extremely rare case of acute cholecystitis caused by E. tarda. Only a few cases of acute cholecystitis due to E. tarda have been reported. Furthermore, similar to this case, no previous study has reported the detection of E. tarda in both blood and bile cultures in acute cholecystitis cases. In addition to appropriate surgical intervention, continuous administration of antibiotics based on culture results resulted in a favorable outcome.

The Most Common Cause of Fever in International Travelers Visiting Kasih Ibu Hospital Denpasar for the 2019-2020 Period

Background: Fever is one of the most common symptoms that international travelers complain of due to various causes. Fever is associated with mild to severe illnesses, such as Coronavirus Disease 19, typhoid fever, dengue fever, malaria, chikungunya, or gastrointestinal infection. Purpose: This study aimed to determine the most common cause of fever in international travelers visiting Kasih Ibu Hospital Denpasar from 2019 to 2020. Methods: This cross-sectional study using medical records of international travelers with chief complaints of fever uses purposive sampling. Result: The age of the subject was dominated by the adult age group in 2019 (77.3%) and 2020 (77.1%), with more females in 2019 (50.8%) while more males in 2020 (57.8%), 2019 the most common cause of fever was dengue infection (50.8%) while in 2020 the most common cause of fever was COVID-19 (53.5%). Conclusion: Dengue was the most common cause of fever in 2019, and COVID-19 was the most common cause of fever in 2020.

Successful treatment of nonocclusive mesenteric ischemia in a reconstructed jejunum after esophagectomy and remnant gastric tube resection: a case report

BackgroundNonocclusive mesenteric ischemia (NOMI), an ischemic bowel disease without a disruption of the mesenteric blood flow or strangulation of the mesentery or intestine, may cause a lethal clinical course. We report a very rare case of jejunal necrosis caused by NOMI in the pedicled mesentery of the reconstructed jejunum after remnant gastric tube resection for heterochronous gastric tube cancer after esophagectomy.Case presentationAn 80-year-old man visited our department with chief complaints of fever and appetite loss after 4 months from gastric tube resection and digestive reconstruction with pedicled jejunum. Contrast-enhanced computed tomography (CT) revealed impaired blood flow without torsion of the mesentery, severe wall thickness, and micro-penetration in the reconstructed jejunum and combined pyothorax in the right thoracic cavity. Esophagogastroduodenoscopy demonstrated extensive mucosal necrosis confined to the jejunum, which was elevated in the thoracic cavity. The jejunal necrosis due to NOMI occurring in the reconstructed jejunum was suspected, and lifesaving small bowel resection with right thoracotomy was considered necessary. However, radical operation with right thoracotomy was considered to be excessively invasive and not valid due to the patient’s poor physical status, advanced age, and presence of left adrenal metastasis from the remnant gastric cancer. Therefore, we selected the conservative treatment with fasting, transnasal drainage, and administration of antibiotics due to the patient’s intention. CT-guided right thoracic drainage for the intrathoracic abscess was needed 10 days after starting treatment and the inflammatory response rapidly improved. Follow-up CT and esophagogastroduodenoscopy revealed the improvement in the ischemic changes in jejunal mucosa without perforation. Intake was initiated at 20 days after symptom onset, and the patient was discharged at 40 hospital days without any complications and sequelae.ConclusionsTo the best of our knowledge, this is the first case of NOMI occurring in the reconstructed jejunum after remnant gastric tube resection that was successfully treated with a conservative treatment. For NOMI, it is important to make appropriate diagnosis based on imaging findings and perform proper assessment of the patient’s condition. Conservative treatments may be also useful depending on the patient’s condition.

Concurrent occurrence of acute pancreatitis and intracerebral hemorrhage as presenting manifestations in lupus: a case report.

The authors hereby present the case of an 18-year-old female with chief complaints of fever, abdominal pain, headache, vomiting, and loss of vision. She was diagnosed with acute pancreatitis (AP) and intracerebral hemorrhage (ICH) with an etiology linked to SLE. SLICC criterion was used to diagnosed SLE while ATLANTA criteria for AP and neuro-radiological findings for ICH. Emergency temporo- parietal-occipital-osteoplastic craniotomy was done for ICH as well as started with immunosuppressive therapy for SLE. On the 18th day of admission, she was discharge with maintenance medications for SLE. While the vision took over a month to come to a premorbid state, she was clinically improved within 2 weeks of admission. Clinical manifestation of SLE vary greatly. AP and intracranial bleeding are few of the rare presentation of SLE. Acute presentation of both conditions in an otherwise healthy individual in the initial course of disease left the clinician with a wide array of differentials. Literature shows very little evidence of co-occurrence of ICH and pancreatitis as an initial manifestation in SLE patients. The exclusive diagnosis of these potentially fatal condition is made holistically with clinical, biochemical, and radiological parameters. SLE may present with atypical, life-threatening initial manifestations. Early diagnosis and timely intervention in therapy can lead to successful management. The treating physician must consider, SLE when a straightforward diagnosis is associated with inexplicable multiple concomitant abnormalities, especially in young women.

A Case Report On Sepsis With Brain Stem Encephalitis In A Patient With Quadriplegia

Introduction : Every year, 1 in 10,000 people develop encephalitis, which frequently has grave neurologic repercussions. Identifying the cause and establishing the prognosis are difficult aspects of managing encephalitis patients. Presentation of case : A 20-year- Female came to a rural tertiary care hospital with the chief complaint of Fever, abnormal jerky movements of limbs and body, vomiting, and loose stools last 3 days. The patient was apparently alright 3 days ago when she developed a fever that was insidious in onset and progressive in nature not associated with chills or rigors, remitting with antipyretic medication. She also experienced abnormal jerky movements of all four limbs along with stiffness, associated with jaw lock, tongue bite, and frothing from the mouth, there was post ictal drowsiness along with it, with no involuntary bowels or bladder evacuation. History of loose stools 2 episodes, watery in nature, non-blood or mucus stained. She also complained of 2 episodes of vomiting which was projectile in nature and associated with nausea containing food particles and water. The patient had a history of 70 days PNC and delivered normally vaginally full-term delivery, without any complications. Management : Patient was intubated and was taken on a mechanical ventilator on volume control mode. Started treatment Inj meropenem 500mg iv for 7 days, INJ clindamycin 600mg iv for 5 days, injection vancomycin 500mg iv for 3 days, injection linezolid 600mg iv for 5 days, injection acyclovir 500mg iv for 14 days, injection doxy 100mg iv bd for days, injection ciprofloxacin 400mg iv for 7 days, injection colistin for 14 days, injection MPs 250mg IV od for days, injection Emset 4mg iv /sos, injection lomoh 0.6ml/od for 31 days, injection mannitol 150mg iv for 14 days, injection pan 40mg iv for 7 days, injection Emset 4mg iv for 5 days, injection levipil 500mg iv for 5 days. oral suctioning 2 hourly, physiotherapy. The patient’s general condition was stable. Conclusion : BE is a disease that advances quickly and has incapacitating effects. Significant gains were visible after receiving extensive supportive and rehabilitative therapy.

Salmonella meningitis with hydrocephalus as complication in children: A case series

Background: Bacterial meningitis by salmonella serotype is a rare infection among neonates and young children. The treatment of salmonella meningitis requires bactericidal agents that are capable of penetrating into cerebrospinal fluid (CSF). Acute complications of bacterial meningitis mainly include hydrocephalus, subdural collection, cerebral infarction, ventriculitis, empyema, intracranial abscess and cranial nerve palsy. Two Cases Presentation: First case, 1 months-old boy brought to the general hospital with chief complaint of fever. Patient had decreased of consciousness and bulging of anterior fontanella. Analysis of cerebrospinal fluid (CSF) showed Pandy test (+4) and None test (+4), high protein 369 mg/dl (mononuclear 44%, polymorphonuclear 56%), liquor glucose 2 mg/dl, CSF culture and blood culture resulted salmonella. Electrolyte and blood sugar was normal, complete blood count showed leukocytes 13.96x 103/µL and mild normochromic normocytic anemia. Head CT scan revealed communicating hydrocephalus. Second case, 6 months-old boy brought to general hospital with seizure as chief complaint. Cerebrospinal fluid (CSF) analysis showed Pandy test (+4) and None test (+4), high protein 569 mg/dL, liquor glucose 26 mg/dL, CSF culture and blood culture results found salmonella sp. Head CT scan revealed subdural hygroma at frontoparietal. Patient was treated by 3rd generation of cephalosporins (ceftriaxone) for 4 weeks. Patient discharge from hospital. Summary: Management of salmonella meningitis include administration of empiric antibiotic, supportive treatment and management of complication. High dose of antibiotic is given empirically without waiting for the results of culture. Learning Points: Clinical manifestations and outcome of meningitis salmonella

Impact of the COVID-19 pandemic on medical-seeking behavior in older adults by comparing the presenting complaints of the emergency department visits

BackgroundThe outbreak of the coronavirus disease 2019 (COVID-19) has caused a catastrophic event worldwide. Since then, people’s way of living has changed in terms of personal behavior, social interaction, and medical-seeking behavior, including change of the emergency department (ED) visiting patterns. The objective of this study was to analyze the impact of the COVID-19 pandemic on the ED visiting patterns of the older people to explore its variable expression with the intention of ameliorating an effective and suitable response to public health emergencies.MethodsThis was a retrospective study conducted in three hospitals of the Cathay Health System in Taiwan. Patients aged ≥ 65 years who presented to the ED between January 21, 2020, and April 30, 2020 (pandemic stage), and between January 21, 2019, and April 30, 2019 (pre-pandemic stage) were enrolled in the study. Basic demographics, including visit characteristics, disposition, and chief complaints of the patients visiting the ED between these two periods of time, were compared and analyzed.ResultsA total of 16,655 older people were included in this study. A 20.91% reduction in ED older adult patient visits was noted during the pandemic period. During the pandemic, there was a decrease in ambulance use among elderly patients visiting the ED, with the proportion decreasing from 16.90 to 16.58%. Chief complaints of fever, upper respiratory infections, psychological and social problems increased, with incidence risk ratios (IRRs) of 1.12, 1.23, 1.25, and 5.2, respectively. Meanwhile, the incidence of both non-life-threatening and life-threatening complaints decreased, with IRRs of 0.72 and 0.83, respectively.ConclusionHealth education regarding life-threatening symptom signs among older adult patients and avocation of the proper timing to seek medical attention via ambulance were crucial issues during the pandemic.

En bloc resection of gastrobronchial fistula associated with mesh infection

Abstract A 50-year-old woman presented with chief complaints of fever and cough. She had a poorly controlled left lung abscess and a history of congenital left diaphragmatic hernia treated 9 years prior with composite mesh. Computed tomography showed suspected fistula formation between the left lower lung lobe and stomach, and the tract was visualized in a contrast study from an upper gastrointestinal endoscope. We suspected a gastrobronchial fistula associated with mesh infection and performed en bloc resection of the mesh and inflamed organ tissue, comprising resection of the left lower lung lobe and left diaphragm, partial gastrectomy, and splenectomy. The diaphragm was reconstructed using the latissimus dorsi and rectus abdominis muscles. To our knowledge, this is the first report describing this treatment strategy for gastrobronchial fistula associated with mesh infection. The patient's postoperative course was favourable.

A case of acute cholecystitis with abnormally high CA19-9

BackgroundCA19-9 is strongly expressed in malignant tumors of the digestive system and is widely used as a marker for gastrointestinal cancer. In this report, we describe a case of acute cholecystitis in which CA19-9 was markedly elevated.Case presentationA 53-year-old man was admitted to our hospital with a diagnosis of acute cholecystitis after being referred to our hospital with a chief complaint of fever and right hypochondrial pain. CA19-9 was abnormally high at 17,539.1 U/ml. Although the possibility of malignancy was considered, there was no obvious malignant lesion on imaging; the patient was diagnosed with cholecystitis, and laparoscopic cholecystectomy was performed the day after admission. The surgical specimen showed no malignant findings either grossly or in the final pathological examination. There were no complications in the patient’s postoperative course, and he was discharged from the hospital on the third postoperative day. CA19-9 level quickly returned to within normal range after surgery.ConclusionsIn acute cholecystitis, CA19-9 levels exceeding 10,000 U/ml are very rare. We report a case of acute cholecystitis without malignant findings despite a high CA19-9 level.

Impact on Emergency Department Interventions After Implementing a Guideline Based on the Pediatric Emergency Care Applied Research Network Prediction Rule for Identifying Low-Risk Febrile Infants 29 to 60 Days Old.

The Pediatric Emergency Care Applied Research Network (PECARN) prediction rule identifies febrile infants at low risk for serious bacterial infection (SBI). However, its impact on avoidable interventions in the emergency department remains unknown. To study the impact on lumbar puncture (LP) performance, empiric antibiotic use, and admissions after implementing a febrile infant clinical practice guideline for infants aged 29 to 60 days based on the PECARN prediction rule in the pediatric emergency department. This single center preintervention to postintervention study included infants 29 to 60 days old who presented with a chief complaint of fever from November 2018 to November 2021 and were assessed for SBI via blood culture and either urinalysis or urine culture. A new clinical practice guideline based on the PECARN prediction rule was implemented on December 2019. Lumbar puncture attempts, antibiotic administration, and admissions were compared preimplementation and postimplementation and in subgroups of low- and high-risk patients. Of 1597 (PRE: 785, POST: 812) infants presenting with fever, 1032 (PRE: 500, POST: 532) met inclusion criteria. Adoption of guideline recommendations (measured as procalcitonin order rate) was 89.7% in eligible infants postimplementation. Overall, there was a significant decrease in LPs (PRE: 30.6%, POST: 22.6%, P < 0.05) and no significant change in antibiotics or admissions. Among low-risk infants, there was a significant reduction in LPs (PRE: 17.2%, POST: 4.4%, P < 0.05) and antibiotics (PRE: 14.5%, POST: 4.1%; P < 0.05). There was no change in missed SBI (PRE: 3, POST: 2, P = 0.65). No cases of missed meningitis preimplementation or postimplementation were observed. After implementation of a guideline based on the PECARN prediction rule, we observed a reduction of LPs and antibiotics in low-risk infants. Overall, a decrease in LPs was observed, whereas antibiotic use and admissions remained unchanged.

Dengue Fever Presenting as Ischaemic Stroke: A Case Report

Several neurological manifestations are common in dengue fever. They are encephalitis, encephalopathy, Guillain Barre Syndrome (GBS), Intracranial haemorrhage, but, ischemic stroke is a rare complication. This is a case report of ischaemic stroke in a patient with dengue fever. A 39-year-old female patient presented to the emergency department with the chief complaints of fever, retro orbital pain since four days, and one episode of seizure on the day of presentation. Examination revealed left homonymous hemianopia. Diagnosis of dengue was made based on Immunoglobulin M (IgM) Enzyme-Linked Immunosorbent Assay (ELISA) positive for dengue. Magnetic Resonance Imaging (MRI) brain showed acute infarcts in right temporal, right occipital and right hippocampal region. Severity of hemianopia decreased as the days progressed and platelet count gradually improved to normal limits within five days. Adequate fluid management was given and the patient was discharged once stable. Anti-platelets were started after two weeks during the follow-up. Examination during follow-up showed decrease in hemianopia to just mild blurring of vision on left gaze. Ischemic stroke is even rarer entity and clinicians should be made aware of these complications.