Fatal necrotizing myositis from fulminant Streptococcus dysgalactiae subspecies equisimilis (SDSE) infection: A case report of autopsy images.

Over the past few decades, Streptococcus dysgalactiae subspecies equisimilis (SDSE) have been considered as weak pathogenicity compared with S. pyogenes (GAS). Some recent reports argue that SDSE may bring severe soft tissue infection as same as GAS. No reports have been tried to reveal the clinical characteristics and autopsy images of fulminant SDSE infection. In this case report, we aimed to present a case of fatal necrotizing myositis from fulminant SDSE infection at iliopsoas, including autopsy appearance.

Prognostic significance of acute pain preceding out-of-hospital cardiac arrest.

BACKGROUND: Sudden loss of consciousness (LOC) and chest pain are common manifestations of out-of-hospital cardiac arrest (OHCA). History of acute pain may be helpful in estimating aetiology and prognosis of OHCA victims. The objective of this study was to evaluate the relationship between acute pain at various locations preceding collapse and outcome. METHODS: Clinical data of 250 witnessed, non-traumatic OHCA victims were reviewed, and the incidence of pain based on anatomical distribution was documented. The focus was on identifying the difference between those collapsing with LOC alone and those collapsing with chest pain (CP). Clinical variables predictive of survival were identified using a logistic regression model. RESULTS: Among the 250 victims, 55.2% collapsed with LOC alone. The incidence of acute pain was: 28.0% for CP, 3.2% for headache, 2.8% for abdominal pain and 2.4% for back pain. The overall 6-month survival rate was 7.2%. The LOC group had a significantly higher return of spontaneous circulation (ROSC) rate compared with the CP group (48.6% vs 31.4%, p<0.05). The rate was elevated in the LOC group; however, only when the initial rhythm was non-shockable. There was no significant intergroup difference in the survival rate. Initial shockable rhythm positively and history of cardiovascular diseases negatively predicted survival. None of the victims in the headache, abdominal pain or back pain groups survived. CONCLUSION: The LOC group's seemingly higher ROSC rate may be due to its aetiological heterogeneity. Complaint of a headache, abdominal pain or back pain in OHCA victims carries a poor prognosis.

Cardiac arrest due to food asphyxiation in adults: resuscitation profiles and outcomes.

AIM: Food asphyxiation is uncommon but unignorable cause of sudden death in the elderly. Several autopsy studies, which identified those at particular risk, have been conducted on the subject. Resuscitation profiles and outcomes of food asphyxiation victims presenting with out-of-hospital cardiac arrest (OHCA) to the emergency department, however, have rarely been reported. METHODS: Data on adults (> or = 20 years) presenting with OHCA after witnessed food asphyxiation were retrieved from an institutional database. Clinical variables were evaluated to identify their demographic characteristics. Their outcomes, represented by return of spontaneous circulation (ROSC) and survival rate, were also investigated. RESULTS: Sixty-nine food asphyxiation victims presenting with OHCA were identified during the 4-year period. Food asphyxiation occurred most frequently in the age group of 71-80 years, followed by that of 81-90 years. The majority of victims had medical conditions that adversely affected mastication/swallowing, such as dementia. Bystander cardiopulmonary resuscitation (CPR) was performed only in 26%, although bystanders often attempted to clear the airway without performing CPR. Despite the high ROSC rate of 78%, only 7% survived to discharge. Asphyxiation-ROSC interval might play a crucial role in determining the outcomes: the interval was < or = 10 min in all survivors, while it was longer than 10 min in all non-survivors. CONCLUSION: Because of their advanced age and debilitating general condition, it may be difficult to substantially improve the outcomes of food asphyxiation victims. Effort should be directed to prevent food asphyxiation, and public education to perform standard CPR for food asphyxiation victims including the Heimlich manoeuvre is warranted.

Early CT signs in out-of-hospital cardiac arrest survivors: Temporal profile and prognostic significance.

AIM: Although computed tomography (CT) signs of ischaemia, including loss of boundary (LOB) between grey matter and white matter and cortical sulcal effacement, in cardiac arrest (CA) survivors are known, their temporal profile and prognostic significance remains unclear; their clarification is necessary. METHODS: Brain CT scans were obtained immediately after resuscitation in 75 non-traumatic CA survivors in a prospective fashion. They were divided into two groups according to the CA-return of spontaneous circulation (ROSC) interval: < or =20 min vs. >20 min. The incidence of the CT signs and predictability of these signs for outcome, assessed 6 months after CA, was evaluated and compared. RESULTS: The incidence of the positive LOB sign was 24% in the < or =20-min group and 83% in the >20-min group, and the difference was statistically significant (p<0.001). The interval of 20 min seemed to be the time window for the LOB development. The incidence of the positive sulcal effacement sign was 0% in the < or =20 min group and 34% in the >20-min group, and the difference was statistically significant (p=0.004). A positive LOB sign was predictive of unfavourable outcome with an 81% sensitivity and 92% specificity. A positive sulcal effacement sign was predictive of unfavourable outcome with a 32% sensitivity and 100% specificity. CONCLUSION: A time window may exist for ischaemic CT signs in CA survivors. The LOB sign may develop when the CA-ROSC interval exceeds 20 min, whereas the sulcal effacement sign may develop later. However, their temporal profile and outcome predictability should be verified by multicentre studies.

Headache, cardiac arrest, and intracranial hemorrhage.

Headache is one of the most common manifestations of non-traumatic intracranial hemorrhage, which is an uncommon, but not rare, cause of cardiac arrest in adults. History of a sudden headache preceding collapse may be a helpful clue to estimate the cause of out-of-hospital cardiac arrest (OHCA). Medical records of witnessed OHCA patients were reviewed to identify those who complained of a sudden headache preceding collapse, and the incidence of intracranial hemorrhage among them as well as their clinical characteristics was investigated retrospectively. During the 12-month period, 124 patients who sustained a witnessed OHCA were treated. Among them, 74 (60%) collapsed without any pain complaint, and only 6 (5%) complained of a sudden headache preceding collapse. All of the six patients were resuscitated: four had a severe subarachnoid hemorrhage (SAH), while the other two had a massive cerebellar hemorrhage. By contrast, 39 of the 74 patients who collapsed without any pain were resuscitated. Among them, another six patients were found to harbor an SAH. Thus, a total of 12 among the 124 witnessed OHCA (10%) sustained a fatal intracranial hemorrhage. While OHCA patients who collapse complaining of a sudden headache are uncommonly seen in the emergency room, they have a high likelihood of harboring a severe intracranial hemorrhage. It should also be reminded that approximately half of patients whose cardiac arrest is due to an intracranial hemorrhage may collapse without complaining of a headache. The prognosis of those with cerebral origin of OHCA is invariably poor, although they may relatively easily be resuscitated temporarily. Focus needs to be directed to avoid sudden death from a potentially treatable cerebral lesion, and public education to promote the awareness for the symptoms of potentially lethal hemorrhagic stroke is warranted.

Subarachnoid haemorrhage as a cause of out-of-hospital cardiac arrest: a prospective computed tomography study.

AIM: Aneurysmal subarachnoid haemorrhage (SAH) is a relatively common cause of out-of-hospital cardiac arrest (OHCA). Early identification of SAH-induced OHCA with the use of brain computed tomography (CT) scan obtained immediately after resuscitation may help emergency physicians make therapeutic decision as quickly as they can. METHODS: During the 4-year observation period, brain CT scan was obtained prospectively in 142 witnessed non-traumatic OHCA survivors who remained haemodynamically stable after resuscitation. Demographics and clinical characteristics of SAH-induced OHCA survivors were compared with those with "negative" CT finding. RESULTS: Brain CT scan was feasible with an average door-to-CT time of 40.0 min. SAH was found in 16.2% of the 142 OHCA survivors. Compared with 116 survivors who were negative for SAH, SAH-induced OHCA survivors were significantly more likely to be female, to have experienced a sudden headache, and trended to have achieved return of spontaneous circulation (ROSC) prior to arrival in the emergency department less frequently. Ventricular fibrillation (VF) was significantly less likely to be seen in SAH-induced than SAH-negative OHCA (OR, 0.06; 95% CI, 0.01-0.46). Similarly, Cardiac Trop-T assay was significantly less likely to be positive in SAH-induced OHCA (OR, 0.08; 95% CI, 0.01-0.61). CONCLUSION: Aneurysmal SAH causes OHCA more frequently than had been believed. Immediate brain CT scan may particularly be useful in excluding SAH-induced OHCA from thrombolytic trial enrollment, for whom the use of thrombolytics is contraindicated. The low VF incidence suggests that VF by itself may not be a common cause of SAH-induced OHCA.

Megacolon in an adult case of hypoganglionosis, a pseudo-Hirschsprung's disease: an autopsy study.

We report an autopsied 20-year-old man case of intestinal necrosis associated with megacolon from hypoganglionosis, a pseudo-Hirschsprung's disease. The patient had suffered from severe constipation since two years of age, and presented abdominal distention from age ten. Autopsy revealed marked dilatation and necrosis of the entire large intestine. Although ganglion cells in the intestinal plexus were found throughout the large intestine, their number was reduced to 12-20% of that in the normal control. In pseudo-Hirschsprung's disease, there are occasional cases where an acute abdomen first presents itself in adulthood after running its course as chronic constipation.

Risk stratification of adult pneumonia in a tertiary emergency center in Japan.

OBJECTIVE: To determine whether the guidelines for community-acquired pneumonia published by the Infectious Disease Society of America (IDSA) and the Japanese Respiratory Society (JRS) are applicable to stratifying the mortality risk of patients visiting a tertiary emergency center in Japan. METHODS: Patients were categorized into three risk groups (low, intermediate and high) based on the IDSA guidelines and three severity groups (mild, moderate and severe) using the JRS guidelines. The mortality rates among each set of groups were then compared using 30-day follow-up data. PATIENTS: Ninety-seven consecutive patients with pneumonia who visited the emergency room and were admitted to our hospital were retrospectively identified. RESULTS: Based on the IDSA guidelines, the patients were categorized into a high, intermediate, or low-risk group (38.1%, 51.5% and 10.3%, respectively). Cumulative mortality rates were 18.9% for the high-risk group and 4.0% for the moderate-risk group (p=0.02); no deaths occurred in the low-risk group. Based on the JRS guidelines, the patients were also classified into a severe, moderate, or the mild-severity group (69.1%, 25.8% and 5.2%, respectively). The mortality rate was 13.4% in the severe group, whereas no deaths occurred in the moderate or mild-severity groups. CONCLUSION: The IDSA and JRS guidelines allow short-term mortality risks to be recognized at a tertiary emergency center in Japan.