Gas in Joints After Diving: Computed Tomography May Be Useful for Diagnosing Decompression Sickness.

A 26-y-old experienced scotoma scintillans after 59 min of scuba diving at a maximum depth of 26 m. After the patient smoked a cigarette, the scotoma scintillans ceased. However, he then developed a headache, general fatigue, and shoulder and elbow pain. He therefore called an ambulance. Based on the rules of the medical cooperative system for decompression sickness in Izu Peninsula, the fire department called a physician-staffed helicopter. After a physician checked the patient, his complaints remained aside from a low-grade fever. A portable ultrasound revealed bubbles in his inferior vena cava. Because of the risk of his being infected with COVID-19, he was transported to our hospital not by air evacuation but via ground ambulance staff while receiving a drip infusion of fluid and oxygen. After arriving at the hospital, his symptoms had almost subsided. Whole-body computed tomography revealed gas around the bladder, left hip, right knee, bilateral shoulder, joints, and right intramedullary humerus. The patient received high-concentration oxygen, infusion therapy, and observational admission. On the second day of admission, his symptoms had completely disappeared, and he was discharged. To our knowledge, this is the first report that computed tomography might be useful for detecting gas in multiple joints, suggesting the onset of decompression sickness after diving. This might be the first report of gas in an intramedullary space after diving as a potential cause of dysbaric osteonecrosis.

Suspected Virus-Inducing Severe Acute Respiratory Distress Syndrome Treated by Multimodal Therapy Including Extracorporeal Membrane Oxygenation and Immune Modulation Therapy.

A 44-year-old man who had been feeling general fatigue was found in an unconscious state on the same day. He had no remarkable medical history. On arrival at the hospital, his Glasgow Coma Scale was E1V2M3; he had tachycardia and hypertension, was afebrile, and in a severe hypoxic state. His PaO2/FiO2 (P/F) was under 100, even with tracheal intubation with 100% oxygen. Chest X-ray and CT revealed a bilateral ground-glass appearance with consolidation. Cardiac echo initially showed hyper-dynamic wall motion. The main results of a blood analysis suggested an acute inflammatory reaction, rhabdomyolysis, and pancreatitis. The microscopic findings of sputum and a rapid test for bacterial and viral infections were all negative. As he showed deterioration of P/F, venovenous extracorporeal membrane oxygenation (ECMO) was started. He also showed hypotension and therefore underwent vasopressor and steroid administration. Due to concerns of pneumonia, he received meropenem and azithromycin in addition to the infusion of γ-globulin and glycyrrhizin. The results of a COVID-19 test, culture of sputum, and collagen disease test were all negative. The serum virus neutralization assay as a serological test for Coxsackievirus B4 showed a four-fold increase in titer. The multimodal therapy mentioned above resulted in the improvement of his general condition, including acute respiratory distress syndrome (ARDS). In this report, we discuss the benefits of ECMO and immune modulation therapy in the treatment of severe ARDS.