Acute osteomyelitis/septic pulmonary embolism associated with familial infections caused by PVL-positive ST6562 MRSA-IVa, a presumptive variant of USA300 clone.

Panton-Valentine leukocidin (PVL)-positive methicillin-resistant Staphylococcus aureus (MRSA) occasionally causes severe invasive infections. A 10-year-old immunocompetent boy in Hokkaido, the northern main island of Japan, was admitted with acute osteomyelitis of the right ilium, complicated by septic thrombophlebitis of the right common iliac vein and septic pulmonary embolism. As MRSA was isolated from blood and sputum samples of the patient, linezolid and vancomycin were initially used for treatment, and later clindamycin was added based on PCR-positive results for PVL genes. During his hospitalization, the patient was complicated by abscesses around the right ilium and septic arthritis of the right hip, which required surgical drainage. Prior to his admission, his youngest sister had developed a right breast abscess, and another sister and his mother developed contagious impetigo and hordeolum, respectively, during his hospitalization. These infections in the patient and his family members were caused by an identical PVL-positive MRSA strain belonging to ST6562, a single-locus variant of ST8. Due to the genetically close characteristics, this ST6562 MRSA was considered a genetic variant of the USA300 CA-MRSA clone (ST8-MRSA-IVa) predominating in the United States. The ST6562 MRSA-IVa is suggested to have occurred in Japan, associated with potential spread of the USA300 clone.

Comparison of the National Early Warning Scores and Rapid Emergency Medicine Scores with the APACHE II Scores as a Prediction of Mortality in Patients with Medical Emergency Team Activation: a Single-centre Retrospective Cohort Study.

INTRODUCTION: The medical emergency team enables the limitation of patients' progression to critical illness in the general ward. The early warning scoring system (EWS) is one of the criteria for medical emergency team activation; however, it is not a valid criterion to predict the prognosis of patients with MET activation. AIM: In this study, the National Early Warning Score (NEWS) and Rapid Emergency Medicine Score (REMS) was compared with that of the Acute Physiology and Chronic Health Evaluation II (APACHE II) score in predicting the prognosis of patients who had been treated a medical emergency team. MATERIAL AND METHODS: In this single-centre retrospective cohort study, patients treated by a medical emergency team between April 2013 and March 2019 and the 28-day prognosis of MET-activated patients were assessed using APACHE II, NEWS, and REMS. RESULTS: Of the 196 patients enrolled, 152 (77.5%) were men, and 44 (22.5%) were women. Their median age was 68 years (interquartile range: 57-76 years). The most common cause of medical emergency team activation was respiratory failure (43.4%). Univariate analysis showed that APACHE II score, NEWS, and REMS were associated with 28-day prognostic mortality. There was no significant difference in the area under the receiver operating characteristic curve of APACHE II (0.76), NEWS (0.67), and REMS (0.70); however, the sensitivity of NEWS (0.70) was superior to that of REMS (0.47). CONCLUSION: NEWS is a more sensitive screening tool like APACHE II than REMS for predicting the prognosis of patients with medical emergency team activation. However, because the accuracy of NEWS was not sufficient compared with that of APACHE II score, it is necessary to develop a screening tool with higher sensitivity and accuracy that can be easily calculated at the bedside in the general ward.

Using an ICU Diary to Communicate With Family Members of COVID-19 Patients in ICU: A Case Report.

Visitation restrictions for family members are problematic in intensive care management due to the COVID-19 pandemic. We analyzed the usefulness of an intensive care unit (ICU) diary about the experiences of family members of critical COVID-19 patients. Four family members of 2 COVID-19 patients participated in this report. Both patients were transferred to our ICU after 2 weeks of treatment at another ICU. An ICU diary was given to their family members post-transfer. The family members were interviewed before and after the patients' discharge; the recorded interviews were analyzed and categorized into several clusters using a text mining method. Five categories regarding their anxious feelings were classified before the use of the ICU diary, and 3 categories were based on their positive feelings after the use of the ICU diary. Intensive care unit diaries may be beneficial for disclosing patients' information when visitation restrictions are exercised due to the COVID-19 pandemic.

Successful diagnosis and treatment of pulmonary aspergillosis-related malignant catatonia using propofol and quetiapine: A case report.

INTRODUCTION: Malignant catatonia (MC) is a movement disorder syndrome characterized by immobility, rigidity, and consciousness disorders that develops in association with mental and physical diseases. It is often fatal due to hyperthermia, rhabdomyolysis, and acute kidney injury. Its clinical symptoms are similar to those of another disorder, neuroleptic malignant syndrome (NMS), and it is often difficult to distinguish between the 2 disorders. PATIENT CONCERNS: An Asian woman in her 60s with history of schizophrenia. She was admitted to our hospital because of symptoms such as fever, unconsciousness, and muscle rigidity. Blood tests showed kidney injury and high creatinine kinase levels. DIAGNOSES: At the time of admission, she had been diagnosed with NMS complicated by pulmonary aspergillosis and was undergoing treatment although there was no improvement. INTERVENTIONS: Subsequently, the administration of propofol, a gamma-aminobutyric acid A agonist, markedly improved the symptoms, and the diagnosis was corrected to MC. At the beginning of her hospitalization, she received dantrolene, bromocriptine, amantadine, and L-3,4-dihydroxyphenylalanine as treatment for NMS, but her symptoms did not improve. With propofol, which is used for sedation, her catatonic symptoms improved markedly. Quetiapine administration further improved the symptoms, and it eventually resolved completely. OUTCOMES: The patient's MC was in remission. Prolonged intensive care management resulted in a decline in activities of daily living, and she required rehabilitation at another hospital. CONCLUSION: This is the first report of MC with suspected involvement of pulmonary aspergillosis. MC differs from NMS, in that it is treated more effectively with gamma-aminobutyric acid A agonists. Although benzodiazepines are the first choice for the diagnosis and treatment of MC, they are ineffective for majority of patients with schizophrenia. However, even in such cases, propofol and quetiapine are effective, and they facilitate diagnosis and treatment.

Cardiac Failure Requiring Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) Management in a Refeeding Syndrome Patient with Diabetic Ketoacidosis: A Case Report.

BACKGROUND Refeeding syndrome is a complex metabolic disorder that develops following rapid nutritional administration after a long period of undernutrition. The onset mechanism involves intracellular transport of phosphorus, potassium, and water, in association with rapid glucose administration. The resulting hypophosphatemia is extremely dangerous and can cause severe heart failure and fatal arrhythmia. We successfully used extracorporeal cardiopulmonary support to manage a case of refeeding syndrome that occurred during the course of treatment of diabetic ketoacidosis. There are only a few reports of the use of cardiopulmonary support for the treatment of refeeding syndrome. CASE REPORT A 72-year-old man was admitted to the hospital for treatment of diabetic ketoacidosis. Despite receiving insulin and nutrition therapy, QT prolongation and ventricular fibrillation appeared on the electrocardiogram. Although coronary angiography was performed in consideration of the possibility of ischemic heart disease, no significant stenosis of the coronary arteries was identified. Due to persistent hypotension and recurrence of ventricular fibrillation, extracorporeal cardiopulmonary support was commenced in the ICU. His serum phosphorus level showed a marked decrease on his first day in the ICU, for which daily replacement therapy was administered during his ICU stay. No fatal arrhythmia developed thereafter. He was weaned off extracorporeal cardiopulmonary support on the fourth day of his ICU stay and was subsequently discharged from the hospital. CONCLUSIONS We suggest vigilant monitoring of electrolytes, including phosphate levels, in diabetic ketoacidosis patients, and active circulatory support, as required, in patients with refeeding syndrome.

Pathophysiologic Mechanisms of Hypothermia-Induced Pancreatic Injury in a Rat Model of Body Surface Cooling.

OBJECTIVE: The mechanisms underlying hypothermia-induced pancreatic injury are unclear. Thus, we investigated the pathophysiology of hypothermia-induced pancreatic injury. METHODS: We created a normal circulatory model with body surface cooling in rats. We divided the rats into control (36°C-38°C), mild hypothermia (33°C-35°C), moderate hypothermia (30°C-32°C), and severe hypothermia (27°C-29°C) (n = 5 per group) groups. Then, we induced circulatory failure with a cooling model using high-dose inhalation anesthesia and divided the rats into control (36°C-38°C) and severe hypothermia (27°C-29°C) (n = 5 per group) groups. Serum samples were collected before the introduction of hypothermia. Serum and pancreatic tissue were collected after maintaining the target body temperature for 1 hour. RESULTS: Hematoxylin and eosin staining of the pancreas revealed vacuoles and edema in the hypothermia group. Serum amylase (P = 0.056), lactic acid (P < 0.05), interleukin 1ß (P < 0.05), interleukin 6 (P < 0.05), and tumor necrosis factor α (P = 0.13) levels were suppressed by hypothermia. The circulatory failure model exhibited pancreatic injury. CONCLUSIONS: Hypothermia induced bilateral effects on the pancreas. Morphologically, hypothermia induced pancreatic injury based on characteristic pathology typified by vacuoles. Serologically, hypothermia induced protective effects on the pancreas by suppressing amylase and inflammatory cytokine levels.

Non-surgical treatment of tetanus infection associated with breast cancer skin ulcer: a case report and literature review.

BACKGROUND: Previous studies have reported poor prognosis in cases of tetanus that develops after bacteria enters via breast cancer-related skin ulcers that are not treated with surgical debridement. Herein, we review the literature concerning this presentation and report the first case of complete remission from tetanus without surgical debridement of the skin ulcer. CASE PRESENTATION: An Asian woman aged over 60 years had a history of skin ulcer caused by breast cancer. She was diagnosed with tetanus due to trismus and opisthotonus. Based on the suspicion that the skin ulcer was the portal of entry for tetanus bacteria, we considered several debridement and thoracic surgical options for tetanus treatment. However, debridement was not performed as the surgery was considered high risk and the patient did not consent to it. The patient received treatment with anti-tetanus globulin and metronidazole; sound insulation and shielding were also performed in a dark room. Subsequently, the patient's symptoms improved, and sound insulation and deep sedation management were completed on 19th day of hospitalization. With no symptom recurrence, the patient was discharged on Day 54. To date, over 3 years after treatment, no evidence of tetanus recurrence has been observed. The case was characterized by a lack of autonomic hyperactivity. The tetanus severity was likely representative of the low amount of toxin that the patient was exposed to. CONCLUSION: This case involved moderate severity tetanus originating from a chronic skin ulcer related to breast cancer. The patient survived without undergoing extensive debridement. No evidence of tetanus relapse was observed during the follow-up period, likely due to vaccination that might have restored the patient's active immunity. Debridement is not always necessary for tetanus complicated by breast cancer skin ulcers. Furthermore, appropriate toxoid vaccination is critical for preventing the onset and recurrence of tetanus in these patients.

Prognostic Significance of the Difference Between Mixed and Jugular Venous Oxygen Saturation After Severe Traumatic Brain Injury: A Post Hoc Analysis of the Brain Hypothermia Study.

BACKGROUND: In patients postcardiac arrest, it has been reported that the small value of the difference between mixed venous oxygen saturation (Svo2) and jugular venous oxygen saturation (Sjvo2) is associated with poor neurologic outcome. However, the importance of the difference between mixed venous oxygen saturation and jugular venous oxygen saturation (ΔSo2 [v - jv]) remains unknown in severe traumatic brain injury (TBI). The aim of this study was to examine whether ΔSo2 (v - jv) is associated with neurologic outcome and mortality in patients with severe TBI. METHODS: We conducted post hoc analyses of the Brain Hypothermia Study, a multicenter randomized controlled trial of mild therapeutic hypothermia for the treatment of severe TBI. The value of ΔSo2(v - jv) on day 1 and day 3 was compared between survivors (n = 65) and nonsurvivors (n = 25) or between patients with favorable (n = 47) and unfavorable (n = 43) neurologic outcomes. RESULTS: The reduction in ΔSo2 (v - jv) on day 3 was -2.0% (range, -6.9% to 6.5%) in the nonsurvivor group and 6.3% (range, -2.5% to 16.7%) in the survivor group. The difference was statistically significant (P = 0.03). The same tendencies were observed in the nonsurvivor group on day 1 and in the unfavorable neurologic outcome group on day 1 and day 3, but the difference was not significant. CONCLUSIONS: The reduction in ΔSo2(v - jv) on day 3 was associated with high mortality in patients with severe TBI.

Malignant hemispheric cerebral infarction associated with idiopathic systemic capillary leak syndrome.

Idiopathic systemic capillary leak syndrome (ISCLS) is a rare condition that is characterized by unexplained episodic capillary hyperpermeability due to a shift of fluid and protein from the intravascular to the interstitial space. This results in diffuse general swelling, fetal hypovolemic shock, hypoalbuminemia, and hemoconcentration. Although ISCLS rarely induces cerebral infarction, we experienced a patient who deteriorated and was comatose as a result of massive cerebral infarction associated with ISCLS. In this case, severe hypotensive shock, general edema, hemiparesis, and aphasia appeared after serious antecedent gastrointestinal symptoms. Progressive life-threatening ischemic cerebral edema required decompressive hemicraniectomy. The patient experienced another episode of severe hypotension and limb edema that resulted in multiple extremity compartment syndrome. Treatment entailed forearm and calf fasciotomies. Cerebral edema in the ischemic brain progresses rapidly in patients suffering from ISCLS. Strict control of fluid volume resuscitation and aggressive diuretic therapy may be needed during the post-leak phase of fluid remobilization.