Life-threatening Clinical Condition Research Articles

Not only Van Gogh: a case of BRASH syndrome with concomitant digoxin toxicity

BackgroundBradycardia, renal failure, atrioventricular (AV) node blocking, shock, and hyperkalemia syndrome is a potentially life-threatening clinical condition characterized by bradycardia, renal failure, atrioventricular (AV) node blocking, shock, and hyperkalemia. It constitutes a vicious circle in which the accumulation of pharmacologically active compounds and hyperkalemia lead to hemodynamic instability and heart failure.Case presentationA 66-year-old Caucasian female patient was admitted to the emergency department presenting with fatigue and bradycardia. Upon examination, the patient was found to be anuric and hypotensive. Laboratory investigations revealed metabolic acidosis and hyperkalemia. Clinical evaluation suggested signs of digoxin toxicity, with serum digoxin concentrations persistently elevated over several days. Despite the implementation of antikalemic measures, the patient’s condition remained refractory, necessitating renal dialysis and administration of digoxin immune fab.ConclusionBradycardia, renal failure, atrioventricular (AV) node blocking, shock, and hyperkalemia syndrome is a life-threatening condition that requires prompt management. It is important to also consider potential coexisting clinical manifestations indicative of intoxication from other pharmacological agents. Specifically, symptoms associated with the accumulation of drugs eliminated via the kidneys, such as digoxin. These manifestations may warrant targeted therapeutic measures.

Acute Abdominal Aortic Occlusion in a Paraplegic Patient: Case Report

Acute total occlusion of the abdominal aorta is a rare and life-threatening clinical condition. Thrombus is the most common etiology. Associated morbidity and mortality remain high, with high rates of limb loss, acute kidney injury, rhabdomyolysis, and death. Diagnosis is based on the physical examination at the time of presentation. Findings include absent pulses in the lower extremities, pale and cold skin, and neurological deficits. With this case, we aimed to remind that aortic total occlusion, a rare diagnosis, can also be present in patients who present to the emergency department with paraplegia.

Immunomodulating Phytochemicals: An Insight Into Their Potential Use in Cytokine Storm Situations.

Phytochemicals are compounds found in plants that possess a variety of bioactive properties, including antioxidant and immunomodulatory properties. Recent studies have highlighted the potential of phytochemicals in targeting specific signalling pathways involved in cytokine storm, a life-threatening clinical condition resulting from excessive immune cell activation and oversupply of proinflammatory cytokines. Several studies have documented the immunomodulatory effects of phytochemicals on immune function, including their ability to regulate essential cellular and molecular interactions of immune system cells. This makes them a promising alternative for cytokine storm management, especially when combined with existing chemotherapies. Furthermore, phytochemicals have been found to target multiple signalling pathways, including the TNF-α/NF-κB, IL-1/NF-κB, IFN-γ/JAK/STAT, and IL-6/JAK-STAT. These pathways play critical roles in the development and progression of cytokine storm, and targeting them with phytochemicals represents a promising strategy for controlling cytokine release and the subsequent inflammation. Studies have also investigated certain families of plant-related constituents and their potential immunomodulatory actions. In vivo and in vitro studies have reported the immunomodulatory effects of phytochemicals, which provide viable alternatives in the management of cytokine storm syndrome. The collective data from previous studies suggest that phytochemicals represent a potentially functional source of cytokine storm treatment and promote further exploration of these compounds as immunomodulatory agents for suppressing specific signalling cascade responses. Overall, the previous research findings support the use of phytochemicals as a complementary approach in managing cytokine storm and improving patient outcomes.

Developments and Trends of Nanotechnology Application in Sepsis: A Comprehensive Review Based on Knowledge Visualization Analysis.

Sepsis, a common life-threatening clinical condition, continues to have high morbidity and mortality rates, despite advancements in management. In response, significant research efforts have been directed toward developing effective strategies. Within this scope, nanotechnology has emerged as a particularly promising field, attracting significant interest for its potential to enhance disease diagnosis and treatment. While several reviews have highlighted the use of nanoparticles in sepsis, comprehensive studies that summarize and analyze the hotspots and research trends are lacking. To identify and further promote the development of nanotechnology in sepsis, a bibliometric analysis was conducted on the relevant literature, assessing research trends and hotspots in the application of nanomaterials for sepsis. Next, a comprehensive review of the subjectively recognized research hotspots in sepsis, including nanotechnology-enhanced biosensors and nanoscale imaging for sepsis diagnostics, and nanoplatforms designed for antimicrobial, immunomodulatory, and detoxification strategies in sepsis therapy, is elucidated, while the potential side effects and toxicity risks of these nanomaterials were discussed. Particular attention is given to biomimetic nanoparticles, which mimic the biological functions of source cells like erythrocytes, immune cells, and platelets to evade immune responses and effectively deliver therapeutic agents, demonstrating substantial translational potential. Finally, current challenges and future perspectives of nanotechnology applications in sepsis with a view to maximizing their great potential in the research of translational medicine are also discussed.

Venous-arterial extracorporeal membrane oxygenation for psittacosis pneumonia complicated with cardiogenic shock: case report and literature review

IntroductionDilated cardiomyopathy (DCM) is characterized by the enlargement of the left ventricle or biventricular, accompanied by myocardial systolic dysfunction. Chlamydia psittacosis (CP) is a zoonotic pathogen, which can cause severe pneumonia, respiratory failure, and acute organ dysfunction. The deterioration of DCM caused by CP infection is extremely rare, and few cases of successful management were reported.Case presentationWe reported a 67-year-old male patient with DCM and chronic heart failure. Who was admitted to ICU with severe pneumonia, acute hypoxemic respiratory failure, acute decompensated heart failure, arrhythmia, and cardiogenic shock. Mechanical ventilation (MV) and venous-arterial extracorporeal membrane oxygenation (VA-ECMO) were established for respiratory and circulatory support. Broncho alveolar lavage fluid(BALF)was collected for culture and metagenomics next-generation sequencing (mNGS) test. Repeated mNGS tests indicated the high possibility of CP pneumonia, thereafter, moxifloxacin and doxycycline were prescribed. After targeted antibiotics and organ support treatment, pneumonia, respiratory and circulatory failure were gradually resolved, patient was successfully weaned from MV and VA-ECMO. Finally, the patient was recovered and discharged alive.ConclusionsSevere respiratory and circulatory failure caused by CP infection in DCM patients is a rare life-threatening clinical condition. Early accurate diagnosis, targeted antibiotic therapy, coupled with extracorporeal life support posed positive impact on the patient’s disease course and outcome.

A Rare Case of Painless Destructive Thyroiditis Resulting in Thyroid Storm.

Thyroid storm is a life-threatening clinical condition that is usually triggered by untreated or interrupted treatment of Graves' disease, leading to the sudden onset of severe thyrotoxicosis, which requires an immediate diagnosis and treatment based on diagnostic criteria. Cases of thyroid storm caused by painless/painless subacute thyroiditis are very rare. We herein report an 85-year-old man with features of severe thyrotoxicosis caused by painless/painless subacute thyroiditis who had no uptake of 99mTcO4 and was negative for thyroid-stimulating hormone receptor antibodies. In thyroid storm patients in whom the findings are inconsistent with Graves' disease, careful follow-up and management are necessary, assuming the possibility of painless or painless subacute thyroiditis.

Thiostrepton-Nanomedicine, a TLR9 Inhibitor, Attenuates Sepsis-Induced Inflammation in Mice.

Sepsis is a life-threatening clinical condition caused by infection and transposition of pathogens and pathogen-associated molecular patterns (PAMPs) into the host bloodstream. During sepsis, activation of toll-like receptors (TLRs) on immune cells triggers the release of pro-inflammatory cytokines and overstimulates the production of vasodilatory mediators such as nitric oxide (NO). These vascular changes lead to widespread inflammation, tissue damage, multiple organ failure, and often death. New therapeutic options are urgently needed. To this end, thiostrepton (TST) has emerged as a candidate for sepsis treatment due to its action as an antibiotic and anti-inflammatory molecule (TLR7-9 inhibitor). Reports in the literature suggest that TLR9 inhibition substantially suppresses the excessive host inflammatory response and attenuates sepsis-induced mortality in the cecal ligation and puncture (CLP) murine model of sepsis. However, to the best of our knowledge, TST has never been directly tested as a therapeutic option for the management of sepsis, possibly due to its low water solubility and drug delivery issues. These facts prompted us to test the central hypothesis that TST encapsulated in phospholipid sterically stabilized micelles (TST-SSM) could be developed into a novel treatment for sepsis. Thus, using our published method of encapsulating the hydrophobic antibiotic TST-SSM, we evaluated the in vivo efficacy of TST-SSM nanomedicine in the murine model of polymicrobial sepsis. We found that TST-SSM increased the median survival of CLP-induced septic mice from 31 to 44 hr by reducing the bacterial burden in the blood and peritoneal lavage. Moreover, plasma levels of pro-inflammatory cytokines (interleukin 6 and tumor necrosis factor-alpha) and NO derivatives were also reduced, whereas renal and hepatic function biomarkers creatinine and aspartate transferase were significantly improved. In conclusion, we identified that TST-SSM nanomedicine has significant potential as a therapeutic agent for sepsis management, primarily due to its anti-inflammatory and antibiotic properties.

Mean Platelet Volume (MPV) and Plasma Lactate Level in the Diagnosis and Prognosis of Neonatal Bacteremia

Abstract Background Neonatal sepsis is a life-threatening clinical condition. It is associated with high morbidity and mortality if not treated properly. Blood culture remains the gold standard method diagnosis of sepsis, but it takes at least 24 hours for presumptive diagnosis. Owing to the fact that neonates are vulnerable and can deteriorate easily, rapid diagnosis and management is a must. Aim of the Work Determination of the role of mean platelet volume (MPV) and Blood Lactic acid (BLA) level in the diagnosis and prognosis of neonatal bacteremia. Materials and Methods Study included 108 clinically septic neonates aged 0-28 days, admitted to NICU in Ain Shams University Hospitals. All neonates were subjected to blood culture as gold standard method, complete blood picture (for MPV evaluation), CRP, and BLA, then they were equally divided into two groups bacteremic group, and non-bacteremic group. Results The current study showed that there was a significant difference between bacteremic and nonbacteremic group as regards MPV, CRP, and BLA with higher mean and median values among bacteremic group with P value 0.001, 0.003, and 0.021 respectively. High BLA level was found to be highly significant in non-survived neonates when compared to the survived ones with P value 0.001. Conclusion MPV and BLA tests are simple, rapid, and inexpensive methods to diagnose neonatal bacteremia. The available evidence confirms significantly higher MPV, and BLA in neonates with bacteremia compared to neonates with non-bacteremia causes of sepsis. Therefore, in clinical practice, MPV and BLA could be used as indicators for the early diagnosis of sepsis, while blood lactic acid could be used additionally as a predictor of mortality.

An Old Complication Welcomes Us In The Modern Era: Lingual hematoma during thrombolytic therapy

Lingual hematoma is a rare but potentially life-threatening clinical condition. Securing the airway and urgent treatment for underlying reasons are key management steps. We reported a case to illustrate the management of a lingual hematoma after rescue thrombolysis for a ST-segment elevation myocardial infarction (STEMI) patient.

Clinical outcomes and procedural characteristics of ventricular tachycardia ablation in patients with or without electrical storm

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Electrical storm (ES) is a life-threatening clinical condition characterized by the recurrence of three or more episodes of ventricular tachycardia (VT) and/or ventricular fibrillation within 24 hours, leading to ICD therapy. Catheter ablation of VT in patients with ES is a high-risk procedure but has been shown to reduce VT recurrence and the number of appropriate ICD therapies in patients with structural heart disease. Purpose Our study aimed to compare the characteristics and outcomes of VT ablation in patients with or without ES. Methods Our single-center study included a cohort of 39 consecutive patients (31 men, mean age=60.9±18.4 years) who underwent VT ablation between January 2020 and January 2022, 21 of them (53.8%) due to ES and 18 patients (46.2%) had an elective procedure. Clinical and procedural characteristics, VT recurrence, and mortality rates were compared between the two groups. Results Patients with ES were older than patients without ES (67.8 vs 54.2 years, p=0.004), they were mainly presented with ischaemic cardiomyopathy (85.7% vs 27.8%, p<0.0001), had a higher prevalence of congestive heart failure (90.5% vs 44.4%, p=0.001) and a more severe left ventricular dysfunction (LVEF: 30.8% vs 46.9%, p=0.002). During the procedure, in the ES group, all of the patients had left-sided ablation (transaortic: 80.9%, transseptal: 19.1%), while in patients without ES, 72.2% of the procedures were left-sided (p=0.04). In 8/39 patients (20.5%) endo-epicardial access was needed. The number of RF ablation points was significantly higher in the ES group (64.1 vs 36.1 points, p=0.01). Complications were detected only in the ES group: intraprocedural death occurred in one case due to an ES and consequently cardiogenic shock, and one patient had a dissection of the right femoral artery. There was no significant difference regarding procedure time, fluoroscopy time, and radiation exposure. The in-hospital 30-day mortality was 8/21 (28.6%) in patients with ES, while no patients died in the non-ES group. During longer clinical follow-up, there was no significant difference in the recurrence of VT episodes and mortality. Conclusion Patients presented with ES are a more vulnerable population with many comorbidities. Catheter ablation of VT in patients with ES is a more complex procedure with a higher complication rate and these patients have a higher risk of in-hospital mortality. Further studies are needed to determine the optimal timing of VT ablation in this patient population.

Usefulness of the Klotho protein, FGF-23 and GDF-15 in assessment of the new onset Acute Heart Failure

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): This work was supported by a grant from the Institute of Medical Sciences, University of Opole, Poland. Background Acute heart failure (AHF) is a life-threatening multifaceted clinical condition requiring intensive and expensive treatment. Earlier studies highlighted the difference in characteristics and prognosis of new onset AHF (NO- AHF) and acute decompensated heart failure (ADHF). Protein Klotho and FGF23 could be attractive tools in the evaluation of patients with AHF. GDF-15 is a recognized marker of the risk of death and complications, including bleeding in many cardiovascular diseases. Aim The aim of the study was to compare selected biomarkers (Protein Klotho, FGF-23, GDF-15) with clinical characteristics and 12-month outcomes of patients with NO-AHF and ADHF. Methods As part of the prospective Acute Heart Failure Registry (OP-AHF), data from 112 patients hospitalized in Intensive Cardiac Care Unit (ICCU) were collected from June 2019. Inclusion criteria were: hospitalization for AHF and the use of at least one of: intravenous diuretics, catecholamines or mechanical circulatory support. Blood samples were collected on admission, at discharge as well as at the 30-day. Patients were than follow-up for one year. Results Patients with NO-AHF constituted 46% of the study group (52 out of 112) and compared to patients with ADHF they were more often aged under 65 years (44% vs. 30%, p=0.12), better educated (25% vs. 8%, p=0.03), less frequently with diabetes (31% vs. 43%, p=0.17), hypertension (58% vs. 83%, p=0.03), and prior myocardial infarction (19% vs. 45%, p=0.004). In both groups there were more men (69% vs. 80%,p=0.19) and ischemic etiology of heart failure were more frequent (33% vs. 51%, p=0.42) in NO-AHF and ADHF, respectively. Left ventricular ejection fraction (LVEF) was insignificantly higher in patients with NO-AHF on admission (30% vs. 26%, p=0.6) and at discharge (35% vs. 30%, p=0.27).Only patient with NO-AHF improved LVEF at the 12- month follow–up (50% vs. 35%, p=0,003).It was no signifcant differences between median value of Klotho protein in both groups at admission, discharge and 30–day follow up visit. We observed significant reduction in FGF-23 and GDF-16 at tree time points (Table 1). 12-month mortality in patients with NO-AHF was insignificantly lower (17% vs. 28% in ADHF HR=1,7 (95% Cl=0.25-1.18)),also after correction for age, sex and ,LVEF- 20% vs. 25%, respectively, p=0.58; HR=1,26 (0.3-1.8). In the Cox multivariate model, the risk of death was presented as hazard ratio (HR) and was highest for GDF-15 in both groups (Table2). Conclusion Patients with the NO- AHF have different clinical profile than patients with acute decompensated heart failure with a tendency to lower 12-month mortality. There were no significant differences in the median value of Klotho protein in both groups. Reduction of the FGF-23 during hospitalization can serve as a marker of AHF compensation, thus FGF-23 could be a valuable tool for assessing response to treatment. GDF-15 seems to be the strongest predictor of death in both groups of AHF.

Clinical Review on the Management of Breast Cancer Visceral Crisis

Visceral crisis is a life-threatening clinical condition requiring urgent treatment and accounts for 10-15% of new advanced breast cancer diagnoses, mainly hormone receptor-positive/human epidermal growth factor 2 negative. As its clinical definition is an open topic with nebulous criteria and much room for subjective interpretation, it poses a challenge for daily clinical practice. International guidelines recommend combined chemotherapy as first-line treatment for patients with visceral crisis, but with modest results and a very poor prognosis. Visceral crisis has always been a common exclusion criterion in breast cancer trials, and the available evidence mainly comes from limited retrospective studies which are not sufficient to draw solid conclusions. The outstanding efficacy of innovative drugs, such as CDK4/6 inhibitors, questions the role of chemotherapy in this setting. In the lack of clinical reviews, we aim to critically discuss the management of visceral crisis, advocating future treatment perspectives for this challenging condition.

Evaluation of Therapeutic Effect of Resectoscopic Surgery on 90 Cases of Cesarean Scar Pregnancy

Cesarean scar pregnancy (CSP) is a rare but life-threatening clinical condition. In the absence of a unanimous agreement on the ideal treatment course, investigating less invasive techniques with minimal blood loss and iatrogenic damage to the female reproductive system holds interest. This study aims to evaluate the safety and efficacy of resectoscopic surgery in CSP. This single-arm interventional study was conducted on 90 patients with CSP at a tertiary university-based hospital from April 21, 2019 to January 2021. The primary endpoint was the comparison of 48-h postoperative β-hCG levels to preoperative values. The average gestational age at diagnosis time was 7.27 ± 2.06 weeks and the baseline myometrial thickness mean was 1.46 ± 0.56 mm. In nearly half of the cases, the baseline β-hCG was lower than 10,000 IU/ml. About 48 h after the study intervention, the β-hCG mean level decreased significantly (p-value = 0.009), 34,965.97 ± 104,670.23 to 6264.12 ± 8622.93 IU/ml. For all patients except two, at least a 30% decline in baseline β-hCG was reached and was more than 50% in most cases (n = 85). Although the Hb mean level decreased significantly (p-value < 0.001) after study intervention, 12.87 ± 1.63 to 11.27 ± 1.88 g/dL, this decline was not of clinical significance and was lower than 50% in all study patients, and was less than 10% in half of the cases. Despite the significant blood loss in patients undergoing surgery, the lack of short-term complications and rapid decline of serum β-hCG concentration presents resectoscopy as an alternative approach to other therapeutic interventions for CSP. Further research is warranted to confirm these results.

Endovascular aortic arch repair with chimney technique for pseudoaneurysm

BackgroundAortic pseudoaneurysm is a life-threatening clinical condition, and thoracic endovascular aortic repair (TEVAR) has been reported to have a relatively satisfactory effect in aortic pathologies. We summarized our single-centre experience using chimney TEVAR for aortic arch pseudoaneurysms with inadequate landing zones.MethodsA retrospective study was conducted from October 2015 to August 2020, 32 patients with aortic arch pseudoaneurysms underwent chimney TEVAR to exclude an aortic lesion and reconstruct the supra-aortic branches, including 3 innominate artery, 12 left common carotid arteries and 29 left subclavian arteries. Follow-up computed tomography was suggested before discharge; at 3, 6, 12 months and yearly thereafter.ResultsThe median age of 32 patients was 68.0 years (range, 28–81) with the mean max diameter of aneurysm of 47.9 ± 12.0 mm. Forty-four related supra-aortic branches were well preserved, and the technical success rate was 100%. The Type Ia endoleaks occurred in 3 (9%) patients. Two patients were lost to follow-up and 4 patients died during the follow-up period. The mean follow-up times was 46.5 ± 14.3 months. One patient died due to acute myocardial infarction just 10 days after chimney TEVAR and the other 3 patients passed away at 1.5 months, 20 months, and 31 months with non-aortic reasons. The 4.5-year survival estimate was 84.4%. The primary patency rate of the target supra-arch branch vessels was 97.7% (43/44), and no other aorta-related reinterventions and severe complications occurred.ConclusionFor aortic arch pseudoaneurysms with inadequate landing zones for TEVAR, the chimney technique seems to be feasible, with acceptable mid-term outcomes, and it could serve as an alternative minimally invasive approach to extend the landing zone. Slow flow type Ia endoleak could be treated conservatively after chimney TEVAR. Additional experience is needed, and the long-term durability of chimney TEVAR requires further follow-up.

Renal cell carcinoma with intracardiac tumor thrombus extension: Radical surgery yields 2 years of postoperative survival in a single-center study over a period of 30 years.

Renal cell carcinoma (RCC) with tumor thrombus extension into the right atrium (level IV) is a rare life-threatening clinical condition that can only be managed by means of a combined urological and cardiac surgical approach. The early and late outcomes of this radical treatment were analyzed in a large single-institution series over a period of 30 years. In 37 patients with RCC and intracardiac tumor thrombus extension, nephrectomy was performed followed by the extraction of the intracaval and intracardiac tumor thrombus under direct visual control during deep hypothermic circulatory arrest (DHCA). Recently, in 13 patients, selective aortic arch perfusion (SAAP) was instituted during DHCA. In all patients, precise removal of the tumor thrombus was accomplished in a bloodless field. The mean duration of isolated DHCA was 15 ± 6min, and 31.5 ± 10.2min in the case of DHCA + SAAP, at a mean hypothermia of 22.7 ± 4°C. In-hospital mortality was 7.9% (3 patients). In Kaplan-Meier analysis, the estimated median survival was 26.4 months whereas the 5-year cancer-related survival rate was 51%. Despite its complexity, this extensive procedure can be performed safely with a generally uneventful postoperative course. The use of cardiopulmonary bypass with DHCA, with the advantage of SAAP, allows for a safe, precise, and complete extirpation of intracaval and intracardiac tumor mass. Late outcomes after radical surgical treatment in patients with RCC and tumor thrombus reaching up in the right atrium in our series justify this extensive procedure.

Clinico-epidemiological profile and risk factors of hypertensive crisis among patients attended at a tertiary care hospital in Somalia

Hypertensive crisis (HC) is a life-threatening clinical condition in which an abrupt rise in arterial blood pressure can lead to acute damage to vital organs. The main objective of our study is to determine the epidemiological profile, clinical characteristics, and risk factors of hypertensive crisis patients in Somalia. This study was a prospective cross-sectional study conducted on HC patients attended at Mogadishu Somali Turkish Training and Research Hospital in Mogadishu, Somalia, from November 2020 to April 2021. A total of 6239 patients were screened during the study period. The prevalence of HC was 2.1% (128/6239). Of them, 76 (59.4%) were males. The mean (SD) age of the participants was 56.5 (± 16.9) years (range: 24–98 years). 54.7% (70/128) met the criteria for a hypertensive emergency, while 45.3% (58/128) met the criteria of hypertensive urgency. Most patients (55.5%) took a single antihypertensive medicine, with calcium channel blockers being the most frequently used (57.8%). Headache and palpitation were the most often reported symptoms upon admission (39.1% and 25%). The most often prescribed antihypertensive drugs for the initial therapy included Intravenous furosemide (35.2%), Sublingual captopril (25.8%), intravenous nitroglycerin (23.4%), and intravenous labetalol (20%). Among the forms or patterns of end-organ damage of HE, we most frequently observed acute heart failure (45.7%), acute pulmonary edema (29.9%), and acute renal injury (25.7%). Infrequent medical checkups, poor compliance with medications, poor compliance with exercise, positive family history of hypertension, and being male gender were significant predictors of HC, AOR = 20.312; p < 0.000, AOR = 7.021; p < 0.008, AOR = 6.158; p < 0.017, AOR = 3.545; p < 0.032, and AOR = 2.144; p = 0.001, respectively. In Somalia, the hypertensive crisis is common in this clinic population. Infrequent medical checkups, poor compliance with medications and exercise, positive family history of hypertension, and being male gender were significant predictors of HC.

Role of cerebrospinal fluid lactate in diagnosing meningitis in critically ill patients.

Meningitis is a life-threatening clinical condition associated with high mortality and morbidity. Early diagnosis and specific treatment may improve outcomes. Lack of specific clinical signs or tests make the diagnosis challenging. To assess the efficacy of cerebrospinal fluid (CSF) lactate in diagnosing meningitis in critically ill patients. A prospective, observational cohort study was carried out in a neuro-medical intensive care unit (ICU) over a 22 mo period. Adult patients, with suspected meningitis admitted in ICU, were serially recruited. Patients who refused consent, those with peripheral sensorineural deficit, or with any contraindication to lumber puncture were excluded. CSF cytology, bio-chemistry, lactates, culture and polymerase chain reaction based meningo-encephalitis panel were evaluated. Patients were divided in two groups based on clinical diagnosis of meningitis. The efficacy of CSF lactate in diagnosing meningitis was evaluated and compared with other tests. Seventy-one patients were included and 23 were diagnosed with meningitis. The mean values of CSF total leucocyte count (TLC), proteins and lactates were significantly higher in meningitis group. There was a significant correlation of CSF lactate levels with CSF cultures and meningo-encephalitis panel. CSF lactate (> 2.72 mmol/L) showed good accuracy in diagnosing meningitis with an area under the curve of 0.81 (95% confidence interval: 0.69-0.93), sensitivity of 82.6%, and specificity 72.9%. These values were comparable to those of CSF TLC and protein. Twelve patients with bacterial meningitis had significantly higher CSF lactate (8.9 ± 4.7 mmol/L) than those with non-bacterial meningitis (4.2 ± 3.8 mmol/L), P = 0.006. CSF lactate may be used to aid in our diagnosis of meningitis in ICU patients. CSF lactate (> 2.72 mmol/L) showed good accuracy, sensitivity, and specificity in diagnosing meningitis and may also help to differentiate between bacterial and non-bacterial meningitis.

A RARE CASE OF SERONEGATIVE PULMONARY RENAL SYNDROME

A RARE CASE OF SERONEGATIVE PULMONARY RENAL SYNDROME

451. CLINICAL PATTERNS AND TREATMENT OUTCOMES OF OESOPHAGEAL PERFORATION—A TEN-YEAR RETROSPECTIVE ANALYSIS FROM A TERTIARY CENTER IN SOUTH INDIA

Abstract Oesophageal perforation is a rare, often life-threatening clinical condition with reported mortality rates of 18 to 25%. Early diagnosis is often challenging with many patients presenting late and in shock. Management is even more challenging with a myriad of options but no standard options or criteria. We aim to review our ten-year experience of managing oesophageal perforation and propose an algorithmic approach for managing this condition. A retrospective review of patients diagnosed with oesophageal perforation from 2011 to 2020 was done. Oesophago-gastric anastomotic perforations and corrosive injuries were excluded. The data relevant for the study including Pittsburgh Severity Score (PSS) was collected from the hospital electronic medical records and strengthened using telephonic conversation. Thirty-six patients (M: F-26:10, mean age: 48 years) were included. In 21 (58%) patients, the perforation was localized to the thoracic oesophagus. The commonest cause of perforation was Iatrogenic (n = 22, 61%), followed by spontaneous (n = 9, 25%). A severe PSS score (≥7) was associated with increased risk of operative intervention (76%) and mortality (18%). Eighteen patients (50%) required operative interventions wherein a primary repair was performed in seven (39%) patients, sepsis drainage in eight (44%) patients, and a diversion in one (6%) patient. Overall, eleven (31%) patients required a re-intervention, and the overall in-hospital mortality was 8.3%. Early diagnosis and decision making using an algorithmic approach are critical in the management of oesophageal perforation. PSS score is a useful tool in assessing the severity of disease. A combined multidisciplinary approach involving therapeutic endoscopy, surgery, and critical care is essential. A minimally invasive surgical approach is a feasible option in selected group of patients.

Ventricular Tachycardia Electrical Storm

&#x0D; &#x0D; &#x0D; The term “electrical storm” (ES) indicates a life-threatening clinical condition characterized by the recurrence of hemodynamically unstable ventricular tachycardia (VT) and/or ventricular fibrillation (VF). We are presenting a case of ES in hemodynamically unstable VT treated at pre-hospital and hospital level.&#x0D; Seventy-one-year-old patient with a previous history of hypertension, insulin-dependent diabetes, congestive stroke and myocardial infarction, severe three-vessel coronary artery disease and myocardial revascularization, diabetic nephropathy, chronic kidney failure, and chronic ischemic cardiomyopathy, collapses at home. After examination and diagnostic procedures, the emergency medical physician (EMS) diagnoses hemodynamically unstable VT, which he treats with medication and gets the patient urgently transported to a hospital. In the next 24 h, during hospitalization, there are five more separate episodes of VT with pulse treated with DC shock and antiarrhythmics. On the twelfth day of hospitalization, an implantable cardioverter-defibrillator is implanted to prevent sudden cardiac death. On the seventeenth day, the patient is discharged from hospital in stable condition.&#x0D; The question arises of further best pharmacological and non-pharmacological therapy of ES in hemodynamically unstable VT. It is necessary to educate EMS physicians in the practical application of synchronized cardioversion at the prehospital level.&#x0D; &#x0D; &#x0D;