Clinical and bacteriological profile and outcome of sepsis in dermatology ward in tertiary care center in New Delhi.

Background: There is paucity of data regarding the clinical and bacteriological profile of sepsis in dermatology in-patients. Aims: To study the frequency, etiology, and outcome of sepsis dermatology in-patients. Methods: The study was conducted in a 30-bedded dermatology ward of a tertiary care center. Sepsis was defined by presence of ≥2 SIRS (systemic inflammatory response syndrome) criteria along with evidence of infection (clinically obvious/culture proven infection of skin or internal organs). Patients were also assessed for known (common) risk factors of sepsis. In suspected sepsis patients, at least two samples of blood cultures by venepuncture were taken. Pus, skin swab, urine, and sputum samples were also collected for culture as needed with avoidance of contamination. Results: Among 860 admitted patients studied from November 2004 to July 2006, 103 (12%) fulfilled SIRS criteria. Of these, 63 had nonsepsis causes of SIRS positivity, while 40 (4.65%) had sepsis. Majority of the sepsis patient had vesicobullous diseases (42.5%), erythroderma (25%), toxic epidermal necrolysis (TEN) (22.5%). Severe sepsis developed in 17 (42.5%) patients, while 15 (37.5%) died. Methicillin-resistant Staphylococcus aureus (MRSA) was the commonest organism isolated (99; 25.9%) in all culture specimens followed by Acinetobacter spp. (52; 13.6%), Pseudomonas spp. (40; 10.5%), Methicillin-sensitive S. aureus (MSSA: 33; 8.7%), and Klebsiella spp. (22; 5.8%). Various risk factors affecting mortality and sensitivity patterns for various isolates were also analyzed. Conclusion: Sepsis occurred in 40 (4.65%) inpatients in dermatology ward. The frequency of sepsis was highest in TEN (90%), followed by drug-induced maculopapular rash (20.0%), erythroderma (17.5%), and vesicobullous diseases (8.5%). MRSA, acinetobacter, pseudomonas, MSSA, and Klebsiella were important etiological agents involved in sepsis in dermatology in-patients.

Lipoid pneumonia: An uncommon entity.

Lipoid pneumonia is a rare form of pneumonia caused by inhalation or aspiration of fat-containing substances like petroleum jelly, mineral oils, certain laxatives, etc. It usually presents as an insidious onset, chronic respiratory illness simulating interstitial lung diseases. Rarely, it may present as an acute respiratory illness, especially when the exposure to fatty substance(s) is massive. Radiological findings are diverse and can mimic many other diseases including carcinoma, acute or chronic pneumonia, ARDS, or a localized granuloma. Pathologically it is a chronic foreign body reaction characterized by lipid-laden macrophages. Diagnosis of this disease is often missed as it is usually not considered in the differential diagnoses of community-acquired pneumonia; it requires a high degree of suspicion. In suspected cases, diagnosis may be confirmed by demonstrating the presence of lipid-laden macrophages in sputum, bronchoalveolar lavage fluid, or fine needle aspiration cytology/biopsy from the lung lesion. Treatment of this illness is poorly defined and constitutes supportive therapy, repeated bronchoalveolar lavage, and corticosteroids.

Use of non-invasive ventilation in a pregnant woman with acute respiratory distress syndrome due to pneumonia.

Utility of non-invasive ventilation (NIV) in patients with acute respiratory distress syndrome (ARDS) is not proven. We report a case of a 28-year-old primigravida female with ARDS due to community-acquired severe pneumonia in whom non-invasive ventilation was instituted in an attempt to improve oxygenation and avoid intubation. This lead to an improvement in arterial oxygenation and reduction in respiratory rate of the patient and gradual disappearance of fetal distress.

Management of severe sepsis: role of "bundles".

Sepsis is the leading cause of hospital admissions, morbidity and mortality. Treating sepsis is expensive resulting in consumption of major health care resources. With development of newer and potent antimicrobial agents, moratlity due to sepsis has reduced markedly, but remains unacceptably high. Recently, various strategies like fluid therapy, low dose corticosteroids, tight glycaemic control, recombinant human activated protein C [(rhAPC), drotrecogin alfa] and lung protective ventilation have shown favourable results. Further, it is thought that combination of these strategies in the form of "bundles" can further improve the outcome. Concerted utilisation of the "sepsis bundles" is likely to improve outcome of this serious disorder.

Hemorrhagic pseudocyst of the adrenal gland causing acute abdominal pain.

Acute abdominal pain is a common clinical entity with varied etiology. Hemorrhagic pseudocysts of the adrenal gland are rare lesions that might be considered in the differential diagnosis of acute abdominal pain. Herein, we report a case of young married female presenting with acute pain abdomen and fever, who was diagnosed to have hemorrhagic pseudocyst of the adrenal gland.

Mediastinal pseudocysts in chronic pancreatitis with spontaneous resolution.

A 39 year old male, chronic alcoholic for 12 years, presented with recurrent abdominal pain for last 3 years. He was admitted in our hospital with history of breathlessness, chest pain and abdominal pain for last 20 days. On investigation he had raised total leukocyte count with elevated serum amylase and lipase. Chest radiograph showed mediastinal widening and ultrasound of abdomen revealed chronic pancreatitis with peripancreatic pseudocysts. CT scan revealed extensive phlegmonous collections with cyst formation in the mediastinum which extended from the level of thoracic inlet to below the level of the diaphragm. There were in addition multiple pancreatic and lesser sac pseudocysts. Patient was stable and was hence closely observed on conservative treatment with complete abstinence from alcohol. We performed no surgical, endoscopic or radiological interventions. A repeat CT performed after 14 weeks showed almost complete resolution of the mediastinal pseudocyst. Overall adequate conservative management and timely imaging follow-up before planning any intervention helped us to see that there can be spontaneous resolution of mediastinal pseudocysts.

Tuberculosis and pregnancy.

As tuberculosis (TB) is prevalent all over the world and affects all ages, its management during pregnancy and lactation is of special importance. It affects the health of both mother and the infants. There are many constraints in the diagnosis of TB in pregnancy including hazards of radiography. Treatment of tuberculosis requires a careful selection of drugs and avoiding agents, which are unsafe during pregnancy. Untreated TB cases risk to both mother and infant. Most of the antituberculosis drugs are secreted in breast milk but the concentrations are sub-therapeutic. INH prophylaxis is a serious consideration for infants born to mothers with active pulmonary TB. Congenital TB, although rare, is a definite entity and needs to be recognized.

Neuromuscular weakness in critically ill.

Neuromuscular weakness in critically ill has been increasingly reported in the recent years. Occasionally it may lead to difficulty in weaning the patients from mechanical ventilation, which is difficult to diagnose clinically. Though in well-planned studies the incidence has been reported to be high, the diagnosis is often missed due to the presence of various confounding factors in the form of drug effects, underlying disorder and coexisting abnormalities of the central nervous system. A high index of suspicion with detailed neurological and electrophysiological examination is required for an early and accurate diagnosis. A wide spectrum of disorders and drugs can be responsible for the critical illness neuromuscular abnormality. The most frequent and defined disorders include; critical illness polyneuropathy (CIP) which is characterized by a sensorimotor reversible polyneuropathy presenting as distal symmetrical weakness with loss of deep tendon reflexes. Acute myopathy is another important disorder in this group which usually presents with quadriplegia often related to steroid use. Persistent blockade of neuromuscular junction is also defined in critically ill patients. It is, therefore, important to understand these disorders and their implications in the management of these patients. Some of the conditions require prolonged neuro-rehabilitation. The various acquired disorders leading to neuromuscular abnormalities in critical care, and their diagnosis and management are discussed.

Critical illness polyneuropathy: how often do we diagnose it?

Neuromuscular weakness in critically ill patients is a diagnostic challenge. Critical illness polyneuropathy, an important cause of failure to wean from assisted ventilation is often missed due to lack of suspicion and initiative to undertake regular bedside neurological and electrophysiological examinations in critically ill patients. We report two cases who developed motor weakness while receiving mechanical ventilation in whom axonal neuropathy was diagnosed on electrophysiological studies, establishing a diagnosis of critical illness polyneuropathy. Both patients had evidence of sepsis and multiorgan failure. One case could be successfully weaned off and weakness improved while other succumbed to the underlying illness.

Thoracoscopic excision of mediastinal bronchogenic cyst: a case report and review of literature.

Thoracoscopic resection of mediastinal cysts results in less postoperative pain, shorter hospital stay and better cosmetic outcome when compared to the standard thoracotomy. We report successful thoracoscopic resection of a mediastinal cyst in a 17-year-old male who presented with right-sided chest pain.

Wegener's granulomatosis: an isolated lung mass responding to antituberculosis therapy and atypical course.

We describe an unusual case of Wegener's granulomatosis (WG), in a middle aged, non-smoking female who presented with a lung mass with constitutional symptoms. FNABC from mass revealed a single ill-defined granuloma without necrosis. There was a definite clinical and radiological response to anti-tuberculosis treatment. She was later found to have another mass lesion in nasopharynx. ANCA was negative initially but became positive once disease flare up occurred. Multisystem involvement with clinical features of vasculitis were seen during the flare up and resulted in a fatal outcome. Unusual features and literature on this entity is discussed.

Pulmonary hyalinizing granuloma presenting with dysphagia.

We describe a middle aged, non-smoking female who presented with dysphagia and underwent repeated endoscopies and oesophageal dilatation for a period of six months without any response. On imaging she was found to be having a lobulated mass with a radiological differential diagnosis of malignancy, lymphoma or a rare inflammatory lesion. After an inconclusive CT guided biopsy the patient underwent thoracoscopy on which an unresectable mass was found. The biopsy from the mass revealed pulmonary hyalinizing granuloma (PHG). To best of our knowledge this is the first case of PHG presenting as dysphagia reported in the English Literature. Literature on this rare entity is reviewed.

Primary pulmonary lymphoma presenting as lung mass.

The commonest cause of lung mass in an elderly patient is bronchogenic carcinoma. We are reporting an unusual case of lung mass that was diagnosed following exploratory thoracotomy and pneumonectomy. Sputum examination, bronchoscopy and percutaneous fine needle aspiration cytology were inconclusive. On histopathology, a diagnosis of non-Hodgkin's lymphoma (NHL) was made. There was no involvement of any other site on detailed work up. The patient was advised chemotherapy.

Pulmonary functions in patients with epidemic dropsy.

Pulmonary functions were performed in thirteen patients with epidemic dropsy. The epidemic occurred in Delhi in 1998 during which 102 patients with epidemic dropsy reported to our medical unit. Other investigations included chest radiograph, ECG, liver and renal function tests. There was a restrictive ventilatory defect with diminution of diffusion capacity for carbon monoxide in these patients. Echocardiogram was done in seven of these patients and was normal. The cause of breathlessness and restrictive ventilatory defect is likely to be non-cardiogenic pulmonary oedema.

Pulmonary mucormycosis in a diabetic renal transplant patient.

A 50-year-old male, diabetic, post transplant patient had recurrent pneumonia. The first episode responded well to antibiotics, while on the second occasion he had a necrotising pneumonia, which developed into a thick-walled cavity. Despite antibiotics, his condition rapidly deteriorated precluding bronchoscopy or percutaneous biopsy. Post-mortem lung biopsy revealed typical hyphae of mucormycosis.

Non-invasive ventilation: current status.

Mechanical ventilation is being increasingly used in many disciplines by specialists who manage critically ill patients. Non-invasive ventilation (NIV) refers to the method of providing assisted ventilation without endotracheal intubation. This technique requires a positive-pressure ventilator, connected by a tubing to an interface device that directs intermittent positive pressure through the upper airway and actively assists ventilation. The use of NIV is increasing for patients with acute and chronic respiratory failure, because of its convenience, lower cost and minimal complications. The greatest advantage of NIV is that endotracheal intubation is not required. Although it is an extremely useful technique, it cannot be used in all patients and correct patient selection is important. It has been extensively used in patients with chronic obstructive pulmonary disease with acute or acute-on-chronic respiratory failure. It has also been found to be useful in acute respiratory distress syndrome, acute cardiogenic pulmonary oedema and acute severe asthma. All patients with respiratory failure need to be considered for NIV if they fulfil the requisite criteria. Patients who are unable to protect the upper airway, those with severe life-threatening hypoxaemia, or major associated organ dysfunction are unlikely to benefit from this technique. Despite these limitations, NIV can be useful in many conditions that lead to respiratory failure. NIV is a relatively new technique and has not found a place in all intensive care units. It is expected that this modality will be used more frequently in the near future.

Air travel and supplemental oxygen therapy in patients with cardiopulmonary diseases.

Air travel has become more popular in modern society and increasing number of patients with cardiopulmonary diseases are travelling by air. Although it represents a safe form of transportation, it leads to significant stress to an individual and its certain inherent risks may cause or promote hypoxia in patients with cardiopulmonary diseases. Clinicians will have to deal with situations where they will be asked to assess the fitness to travel and need for supplemental oxygen during flight. Once in a while the clinician may be required to help a co-passenger in distress during air travel. Predicting requirement of supplemental oxygen during commercial air flight requires knowledge of physiology of commercial air flight and available prediction equations. With modern pressurized aircrafts most of the patients with cardiopulmonary diseases would be able travel by air safely.