Difficult intubation of a patient with progressive multifocal leukoencephalopathy and muscle spasticity: A case report

Progressive multifocal leukoencephalopathy (PML) is a demyelinating central nervous system disease characterized by neurological deficits, including cognitive impairment, altered mental status, and muscle spasticity. Preoperative evaluation and intraoperative airway management of the airway is difficult in patients with this disease. In this report, the authors describe a 62-year-old man with PML and spastic hemiparesis, who was scheduled for video-assisted thoracic bullectomy under general anesthesia. A preoperative airway evaluation, including Mallampati classification, could not be performed due to lack of patient cooperation. Additionally, the anesthesiologist did not perform diverse physical assessments of the airway or prepare an adequate airway management strategy. During induction of general anesthesia, difficulty with intubation was encountered because of limited mouth opening. This case emphasizes that anesthesiologists should have thorough knowledge of airway assessment and management strategies, and perform a comprehensive assessment to implement appropriate airway management in patients with this disease.

Anaphylaxis after rocuronium administration during induction of anesthesia

Anaphylaxis during anesthesia is rare, but often fatal. Rocuronium is a neuromuscular relaxant used for induction of anesthesia. We experienced a case of anaphylaxis after rocuronium administration during induction of anesthesia. A 64-year-old female patient was scheduled for bilateral radius fracture fixation. The history of patient showed no specific findings other than hypersensitivity to mackerel. She had no previous experience of anesthesia. Anesthesia was induced by intravenous injection of propofol 100 mg and continuous infusion was begun with remifentanil 0.25 µg/kg/min, followed by rocuronium 40 mg. Immediately after intravenous administration of rocuronium, the manual ventilation became difficult, and the patient developed erythema and severe hypotension. The patient was diagnosed with anaphylaxis based on clinical features and started treatment. First, we performed endotracheal intubation promptly. Then, immediate intravenous administration of epinephrine and fluid followed. Despite adequate treatment, hypotension was not corrected and intravenous epinephrine was administered. However, ventricular tachycardia occurred which was successfully treated with a defibrillator. Later, the patient uneventfully recovered in the intensive care unit. The patient was not tested for skin prick test, but rocuronium was the most likely cause of anaphylaxis at that time. The authors unexpectedly experienced drug-induced anaphylaxis, which is life-threatening to the patient. Clinicians should be aware of the diagnosis, treatment, and prevention as anaphylaxis can be hazardous to the patient.