Hyperthyroidism With Non-chylous Ascites: A Case Report.

Ascites is the accumulation of fluid in the abdominal cavity and is commonly attributed to various etiologies, including portal hypertension and peritoneal diseases. Hyperthyroidism is rarely associated with ascites, which is typically chylous and accompanied by high central venous pressure. We present a unique case of a 57-year-old woman with untreated hyperthyroidism who manifested non-chylous ascites without evidence of high venous pressure. Initially presenting with left lower leg pain, the patient presented with leg edema, abdominal distention, and diarrhea. A range of diagnostic tests ruled out common etiologies of ascites, such as liver cirrhosis, renal impairment, heart failure, infection, and malignancy. Ascites was characterized by low triglyceride levels, while no evidence of high venous pressure was found. Notably, the patient showed decreased levels of rapid turnover proteins, suggesting hypercatabolism and insufficient protein synthesis due to hyperthyroidism. Upon the initiation of antithyroid therapy, the patient's symptoms markedly improved. In conclusion, this report highlights a rare manifestation of hyperthyroidism that resulted in non-chylous ascites without high venous pressure. This underscores the need to include hyperthyroidism in the differential diagnosis of unexplained ascites, particularly in cases in which classical hyperthyroid symptoms are absent.

Retrospective observational study of changes in serum cytokines and adiponectin with continuous plasma exchange with dialysis therapy for severe COVID-19.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) is associated with a marked increase in the inflammatory cytokines, IL-6 and IL-18. Blood purification therapy aimed at controlling cytokines is one treatment option; however, evidence of its effectiveness is needed. Plasma exchange with dialysis (PED) is a blood purification method involving selective plasma exchange with dialysate flowing through the outer hollow fiber of the plasma separator. In this retrospective study, we investigated the efficacy of continuous PED (cPED) over 48 h in five patients with severe COVID-19. METHODS: We assessed changes in IL-6 and IL-18, as well as adiponectin (APN). RESULTS: There were no significant differences in changes in IL-6 and IL-18, but there was a marked improvement in cases with abnormally high IL-6 and IL-18 levels at baseline. APN, which inhibits inflammatory cytokines, was significantly elevated post-cPED. CONCLUSION: Our results suggest that cPED therapy is an effective treatment for COVID-19.

Severe acute respiratory distress syndrome caused by Otsujito.

Background: Kampo prescriptions can cause drug-induced lung injury (DLI) and acute respiratory distress syndrome (ARDS). However, severe respiratory failure induced by Otsujito (OJT) is extremely rare. High-dose steroid pulse therapy is generally given to patients with severe DLI. Case Presentation: A 63-year-old man with respiratory distress was admitted to our hospital. The patient was diagnosed with severe ARDS caused by OJT, which had been prescribed 4 weeks prior to admission. Thus, OJT was discontinued, and intensive care for ARDS, including ventilation and prone positioning, was implemented. His respiratory condition rapidly improved after treatment with an initial methylprednisolone dose (1.5 mg/kg/day). He was extubated on day 4 and discharged on day 16. The steroid dose was gradually reduced and discontinued by day 116. Conclusion: A severe case of ARDS caused by OJT was successfully treated with low-dose steroids and specialized intensive care.

Chest Pain Diagnosed as Acute Leukemia: Focus on Coagulation Abnormalities Rather Than White Blood Cell Count.

Chest pain is an important symptom for emergency physicians. It is one of the most common causes for admission in emergency departments. Acute leukemia (AL) rarely causes chest symptoms due to ostalgia, and it is difficult to diagnose leukemia as the cause of chest pain. An 83-year-old woman with no history of trauma presented to the emergency department with a one-day history of severe chest pain. There were no abnormalities on electrocardiography, echocardiography, specific biomarkers for cardiac injury, or contrast computed tomography of the chest and pelvis. The white blood cell count was normal, but the patient had prominent thrombocytopenia with platelets of 68,000/µL, prothrombin time-international normalized ratio (PT-INR) of 1.2, activated partial thromboplastin time (APTT) of 25.3 s, and D-dimer of 73.55 µg/mL. Due to the holiday, blast cells could not be measured on the same day. The next day's examination revealed blast cells in the peripheral blood. The patient was admitted to the hematology department and discharged three months later. This case suggests the need to consider AL in chest pain associated with coagulation abnormalities and thrombocytopenia, regardless of the white blood cell count.

Severe Drug-Induced Liver Injury From Over-the-Counter Medication.

Drug-induced liver injury (DILI) is difficult to diagnose as it presents with a wide variety of clinical manifestations and there is no established specific biomarker. However, clinicians require expertise in diagnosing DILI as it can lead to critical illness, is relatively common, and can be caused by a variety of drugs, herbal medicines, and supplements. A 67-year-old male was admitted to the hospital with a fever, jaundice, and fatigue. Abdominal ultrasonography, computed tomography, and magnetic resonance cholangiopancreatography revealed no morphological abnormalities in the hepatobiliary system. On the third day of hospitalization, the liver damage and acute kidney injury progressed, and the patient was transferred to our intensive care unit. To further investigate the cause of multiple organ damage, the patient underwent repeated history taking and additional laboratory testing. In addition to the common causes of hepatic and renal damage, we also tested for rickettsiosis and leptospirosis, as the patient reported partaking regularly in outdoor leisure activities. On day seven of hospitalization, the patient recalled taking over-the-counter herbal flu medications approximately five days prior to admission; therefore, we suspected DILI and performed a drug-induced lymphocyte stimulation test (DLST). The DLST was positive for one drug. As other causes had been ruled out, the patient was diagnosed with severe DILI. The clinical course of the patient was observed with the patient's laboratory data and fever improving spontaneously. This case taught us several important lessons for the investigation of liver injury. Firstly, even with over-the-counter drugs, liver injury can be severe. Secondly, while the DLST is available for investigating DILI, false positives, especially for medicinal herbs, should be noted, and it is necessary to adequately rule out other diseases. Finally, when the cause of liver injury is unclear, patient history taking should be repeated carefully.

Baclofen Withdrawal With Reversible Posterior Leukoencephalopathy Syndrome: Bacterial Meningitis Mimicker.

BACKGROUND: The intrathecal baclofen (ITB) pump is an effective treatment for patients with spasticity unresponsive to oral medication. CASE REPORT: A 31-year-old woman with spinal cord injury sequelae was admitted to the emergency department due to sudden headache and excessive confusion. The patient was on ITB for lower limb spasticity. On presentation, her vital signs revealed blood pressure of 171/106 mm Hg, heart rate of 141 beats/min, and temperature of 39.0°C. Antibiotics were promptly administered intravenously for suspicion of bacterial meningitis. Based on magnetic resonance imaging and cerebrospinal fluid findings, as well as clinical signs such as marked lower limb spasticity, the final diagnosis was determined to be baclofen withdrawal syndrome complicated by reversible posterior leukoencephalopathy syndrome (RPLS). Improved consciousness was quickly achieved on blood pressure control. Resolution of spasticity was achieved after intravenous midazolam and intrathecal baclofen via lumbar puncture. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Baclofen withdrawal syndrome is the leading differential diagnosis for impaired consciousness and fever among patients using ITB pumps. Moreover, baclofen withdrawal syndrome mimics a wide variety of conditions, including sepsis. This unique case was complicated by intrathecal baclofen withdrawal syndrome coexisting with RPLS, thus presenting more similarly to bacterial meningitis than the usual baclofen withdrawal, due to marked headache, altered consciousness, and generalized convulsive symptoms. In addition to general withdrawal management, commencement of antihypertensive therapy for RPLS may have an immediate effect on the improvement of impaired consciousness.

Daijokito Administration in Critically Ill Patients Increasing the Stool Volume: A Retrospective Observational Study.

Introduction: Daijokito, a traditional Japanese herbal medicine (Kampo), has been used to treat abdominal distention of the middle yang stage pattern. The use of Daijokito has not been thoroughly investigated in critical care. To investigate a new Kampo approach to defecation control in critically ill patients, our study aimed to assess the effects of Daijokito on fecal management. Methods: We analyzed 30 consecutive patients treated with Daijokito in the intensive care unit (ICU) between March 2017 and February 2021. The eligibility criteria were patients who were newly prescribed Daijokito in the ICU during the study period. Exclusion criteria were patients who were started on other laxatives within one day of beginning Daijokito. The study's primary outcome was defecation volume three days before and three days after starting Daijokito. We recorded the most dominant stool quality within three days after the start of Daijokito. Results: Twenty-one patients were included in the analysis. The median age was 69.0 years, and the median sequential organ failure assessment score on admission to the ICU was 6.0. Major diseases included trauma, pancreatitis, and burns. Administration of Daijokito resulted in defecation in 17 of twenty-one patients (81.0%). Comparison of defecation volume between 3 days before Daijokito administration and three days, including the day of Daijokito administration, showed that defecation volume increased significantly after Daijokito administration, with a median of 0 to 360 g (p < 0.001). At the three-day follow-up, six of 17 (35.3%) patients defecated on the day of Daijokito administration, and nine (52.9%) defecated on the day after administration. One patient was judged to have excessive defecation, and Daijokito administration was discontinued. Stool quality was normal in one (5.9%) of the 17 patients, soft-formed in two (11.8%), loose-unformed in 11 (64.7%), and liquid in three (17.6%). Discussion: Daijokito administration in critically ill patients caused defecation in 81% of the patients and significantly increased stool volume. The novelty of this study is that it sheds light on the Kampo treatment of defecation control in critically ill patients. In addition to the present report, further studies are warranted to quantify the therapeutic efficacy and safety of Daijokito.

Severe pleural effusion associated with nilotinib for chronic myeloid leukaemia: cross-intolerance with tyrosine kinase inhibitors.

Nilotinib is used as standard treatment in managing chronic myeloid leukaemia (CML). A 23-year-old man with CML and on nilotinib was admitted to the intensive care unit due to respiratory failure. Three years prior, he developed pleural effusion from dasatinib therapy thus, his CML regimen was changed to nilotinib. Although the pleural effusion had once improved, the chest imaging revealed left-dominant bilateral pleural effusion. Endotracheal intubation and left thoracic drainage were performed. Nilotinib treatment was discontinued, and approximately 60 hours later, nilotinib concentrations of 927 and 2092 ng/mL were determined in his blood and pleural effusion, respectively. Severe pleural effusion may be induced in patients administering nilotinib, and nilotinib concentrations in blood and pleural effusion can be elevated in patients with nilotinib-related pleural effusion. Cross-occurrence of pleural effusions needs to be monitored precisely, especially in patients who are switched to other tyrosine kinase inhibitors after dasatinib treatment.

Continuous plasma exchange with dialysis for thrombotic microangiopathy in intensive care unit: Retrospective observational study.

Continuous plasma exchange with dialysis is a novel method of blood purification and is a modification of the plasma exchange. Technically, this process suggests a reduction in adverse events, cost-effectiveness, and compatibility with hemodynamic instability. The therapeutic effect of plasma exchange on thrombotic microangiopathies has been established. We present three clinical cases in the intensive care unit that illustrate continuous plasma exchange with dialysis as a flexible blood purification therapy for critically ill patients; a radical treatment, thrombotic microangiopathies; supportive therapy, multiple organ failure; and fluid balance regulator. The retrospective analysis of 13 continuous plasma exchange with dialysis sessions showed that the platelet count increased significantly (p = 0.0096) after its administration. The total protein, albumin, fibrinogen, or calcium did not decrease significantly after continuous plasma exchange with dialysis, suggesting therapeutic efficacy and fewer adverse events. A prospective study on thrombotic microangiopathies for continuous plasma exchange with dialysis is currently underway.

Continuous Plasma Exchange With Dialysis for Severe Sepsis: Case Series of a Novel Blood Purification Method.

Sepsis is associated with life-threatening organ dysfunction. Drastic treatment methods such as antimicrobials and surgical control have been used to manage sepsis. However, there are currently no other sepsis-specific treatments capable of improving mortality rates. Plasma exchange (PE) for the removal of toxic substances and the replacement of consumed bioprotective proteins has been advocated as a potential treatment for sepsis. Although the evidence for the efficacy of PE for sepsis is quite limited, in a recent finding, sepsis patients treated with PE showed improvement in fluid balance and organ damage. Continuous PE with dialysis (cPED), which is a modified version of PE, is a novel blood purification method. cPED is a combination of selective PE and hemodialysis and operates slowly in a simple circuit that can potentially provide powerful supportive care for patients with multiple organ failure. In this report, we present two cases of treatment with cPED in patients with severe sepsis and organ damage. Both patients were discharged alive without any adverse events from cPED. cPED improved fluid balance as well as laboratory parameters that had reflected multiple organ failure. This suggests a possible reduction in side effects such as leakage of bio-essential proteins and citric acid reactions to large doses of fresh frozen plasma. The clinical course of these two patients may be useful for setting outcomes in future clinical studies regarding the effectiveness of cPED for severe sepsis.

Association Between the Simplest Clinical Factors and Emergency Department Dispositions: A Retrospective Observational Study.

The emergency department (ED) is a complex and busy environment that requires rapid decision making. We assessed the relationship between disposition from the ED and information that can be obtained at a glance in the ED. The presentation of the implications of commonplace information could assist healthcare providers in ensuring smooth and safe ED care. Thus, we aimed to quantitatively assess how readily obtainable findings, such as age, sex, and vital signs, are involved in the disposition of adult patients transferred to the ED. This retrospective observational study was conducted in the ED of a regional university hospital containing approximately 600 beds. Of the 685 patients included in the analysis, 351 patients were admitted to the hospital (including 12 deaths in the ED) and 334 patients were discharged from the ED. A multiple logistic regression model that included age, sex, systolic blood pressure, heart rate, respiration rate, temperature, and SpO2 as variables identified independent associations between age (p=0.003), sex (p<0.001), systolic blood pressure (p=0.023), heart rate (p<0.001), and respiratory rate (p=0.028) and admission from the ED. The receiver operating characteristic curves drawn from the multiple logistic regression model comprising these five variables had an area under the curve (AUC) of 0.701 (95% confidence interval: 0.657-0.744, p<0.001). Examination of sensitivity, specificity, and likelihood ratios (LRs) for these five variables for clinical utility showed a slightly higher sensitivity for age ≥50 years (0.849) and respiratory rate ≥18 bpm (0.769); higher specificity for systolic blood pressure ≤100 mmHg (0.938), pulse rate ≥100 bpm (0.834), and respiratory rate ≥26 bpm (0.887); higher positive LR for systolic blood pressure ≤100 mmHg (2.039) and pulse rate ≥110 bpm (2.729); and slightly lower negative LR for age ≥50 years (0.656), male sex (0.647), respiratory rate ≥20 bpm (0.669). These results are meaningful as they quantify the intuition of a skilled clinician, which can help in clinical decision making, reduce errors, and promote clinical education. Our study provides a basis for explaining to novice healthcare providers that the careful observation of ED patients, even in the absence of special laboratory tests, can help them to make judgments regarding the disposition of the patients from the ED. In conclusion, age, sex, systolic blood pressure, heart rate, and respiratory rate were independently associated with a disposition from the ED. A multivariate model including these five variables showed the moderate-quality potential to predict admission from the ED. The sensitivity, specificity, and LR of systolic blood pressure, heart rate, and respiratory rate showed the characteristics of each vital sign. These provide healthcare providers in the ED an immediate clue regarding the patient's illness.

A case of cardiac arrest due to a ruptured renal artery pseudoaneurysm, a complication of renal biopsy.

Renal artery pseudoaneurysms (RAPs) are a rare complication of percutaneous kidney biopsies that generally present as hematuria and back pain and are treated with angioembolization. A 60-year-old man was admitted to our emergency department for sudden left back pain. He was taking an oral anticoagulant for atrial fibrillation. He had undergone an ultrasound-guided percutaneous renal biopsy 26 days prior. We diagnosed him with hemorrhagic shock from the renal artery. Although he received a massive rapid blood transfusion, he went into cardiac arrest. Resuscitative endovascular balloon occlusion of the aorta (REBOA) was performed and, within 10 min, the patient achieved return of spontaneous circulation and regained consciousness. Subsequently, angioembolization was successfully performed for a 12.5 mm × 5.9 mm pseudoaneurysm in the left renal inferior pole close to the site of the renal biopsy. A total of 1680 mL of red blood cells and fresh frozen plasma were administered respectively until hemostasis was completed. He was then treated with continuous hemodialysis in the intensive care unit (ICU) for 6 days. He stayed in the ICU for 9 days and was moved to the general ward with full neurological recovery and a sufficiently stable condition to be able to walk. In conclusion, clinicians should be aware of the possibility of severe hemorrhagic shock due to RAPs after renal biopsy. Moreover, even if the patient goes into cardiac arrest, there is a possibility of full recovery if REBOA is performed and angioembolization is completed.

A Case of Fatal Asthma: Rapid Transition to Cardiac Arrest and Rapid Recovery of Respiratory Status.

The global mortality of bronchial asthma continues to decrease, with a reported 57% decline in age-standardized mortality rates between 1993 and 2006.Asthma may rarely be encountered as a cause of cardiac arrest on arrival in the emergency department these days, especially in high-income countries. Rapid worsening of symptoms and rapid improvement in respiratory status after initiation of treatment have been noted as a hallmark of cardiac arrest due to asthma. A 62-year-old male was admitted to our emergency department after dyspnea and dry coughing attack lasting approximately 15 minutes and resulted in cardiopulmonary arrest. His arterial blood gas analysis showed mixed acidosis with pH 7.00, partial pressure of oxygen (PaO2) 184, partial pressure of carbon dioxide (PaCO2) 90 mmHg, HCO3 - 22.2, lactate 104 mg/dL. He returned to spontaneous circulation after about 30 minutes of cardiopulmonary arrest. The very slight wheeze on expiration was heard in the left lung and his chest x-ray showed increasing permeability of the lung, which suggested air trapping. Based on his history of asthma, the background of medication discontinuation, and physical findings, the diagnosis of cardiac arrest due to an asthma attack was made. Two hours after admission, PaCO2 normalized and his respiratory condition stabilized rapidly. However, epileptic seizures due to hypoxic encephalopathy were prolonged. Although he was then managed in the intensive care unit, he was diagnosed with irreversible brain damage due to hypoxic encephalopathy and shifted to palliative care. Asthmatic cardiac arrest is now rare, but still important. And it may be difficult to identify asthma as a cause of cardiac arrest if the respiratory status improves rapidly. Therefore, keeping in mind the presence of asthma cases of rapid deterioration to cardiopulmonary arrest and case of rapid treatment response may lead to a correct diagnosis.

Severe Sepsis Caused by Bacteria That Entered via the Intestinal Tract: A Case of Crohn's Disease in a Child.

Typical causes of infection in Crohn's disease (CD) patients include intra-abdominal abscess, microperforation of the intestine, and fistula formation. Use of immunosuppressive drugs and abdominal surgery are often associated with CD sepsis. In this case, an 11-year-old boy who did not receive any concomitant treatment was admitted for evaluation owing to weight loss. On the 22nd day of hospitalization, he suddenly experienced a septic shock and was admitted to the intensive care unit (ICU). Enterobacter cloacae was detected in the blood culture. No findings as to the source of the intra-abdominal infection were present. The patient was treated with antibiotics, ventilator management, circulatory management with massive intravenous fluids and vasoactive agents, and blood purification therapy. Suspecting the presence of CD based on weight loss and a history of perianal abscess two years prior, a lower gastrointestinal endoscopy was performed. The results revealed a longitudinal ulcer with skip lesions. His general condition was stabilized, and he was extubated on the seventh day in the ICU. He subsequently began treatment for CD in the general pediatric ward. In conclusion, when a sepsis on account of the intra-abdominal infection is suspected, but the infection focus is not evident and the immunosuppressive background is unclear, CD should be considered. Doing so will ensure that sepsis and CD are treated appropriately.