[A woman with an abdominal swelling after coughing]. / Een vrouw met een zwelling in de buik na een hoestbui.

We present the case of a 79-year old woman with acute abdominal swelling and pain after coughing. She was in hemorrhagic shock and received blood transfusion after which hemodynamic stabilization occured. This case illustrates that a rectus sheath hematoma can be the (uncommon) cause of acute abdominal pain and shock.

[Crystal meth - a new kid on the block]. / Crystal meth ­ een nieuwkomer.

In this article we describe epidemiological, pharmacological and clinical aspects of abuse of metamphetamines, also known as crystal meth. These aspects are illustrated by two cases of methamphetamine abuse and the complications associated with it. Metamphetamine abuse is often associated with sexual activity, a combination known as 'chemsex'. A chronic addiction to chemsex can have devastating effects on the user's social, psychological, and physical wellbeing. We describe a patient suffering from recurrent relapses in his addiction to chemsex. Acute crystal meth intoxications can result in very serious complications. We describe a patient suffering from severe neurological complications and rhabdomyolysis.

[A women with burning pain in her arms after a fall]. / Een vrouw met brandende pijn in de armen na een val.

BACKGROUND: The central cord syndrome is an incomplete spinal cord injury that can develop after a minor trauma to the cervical spinal column. CASE DESCRIPTION: A 73-year-old woman presented at our Emergency Department with pyelonephritis accompanied by weakness and a burning feeling in her arms and legs after a fall on her head. The weakness and pain did not improve during her hospital admission. On consultation with a neurologist, the patient was diagnosed with central cord syndrome. As the neurological loss of function did not resolve spontaneously, the patient underwent laminectomy and spondylodesis. Postoperatively her symptoms improved. After 22 days in hospital, the patient was discharged to a rehabilitation clinic. CONCLUSION: In older patients with pre-existing degenerative cervical spinal stenosis, central cord stenosis resulting from minor trauma can cause severe and invalidating symptoms. The early tracing and treatment of patients with this syndrome is essential in order to increase the chance of neurological and functional recovery.

Autonomic nervous system activity and the risk of nosocomial infection in critically ill patients with brain injury.

PURPOSE: Nosocomial infection contributes to adverse outcome after brain injury. This study investigates whether autonomic nervous system activity is associated with a decreased host immune response in patients following stroke or traumatic brain injury (TBI). METHODS: A prospective study was performed in adult patients with TBI or stroke who were admitted to the Intensive Care Unit of our tertiary university hospital between 2013 and 2016. Heart rate variability (HRV) was recorded daily and assessed for autonomic nervous system activity. Outcomes were nosocomial infections and immunosuppression, which was assessed ex vivo using whole blood stimulations with plasma of patients with infections, matched non-infected patients and healthy controls. RESULTS: Out of 64 brain injured patients, 23 (36%) developed an infection during their hospital stay. The ability of brain injured patients to generate a host response to the bacterial endotoxin lipopolysaccharides (LPS) was diminished compared to healthy controls (p < 0.001). Patients who developed an infection yielded significantly lower TNF-α values (86 vs 192 pg/mL, p = 0.030) and a trend towards higher IL-10 values (122 vs 84 pg/mL, p = 0.071) following ex vivo whole blood stimulations when compared to patients not developing an infection. This decreased host immune response was associated with altered admission HRV values. Brain injured patients who developed an infection showed increased normalized high-frequency power compared to patients not developing an infection (0.54 vs 0.36, p = 0.033), whereas normalized low-frequency power was lower in infected patients (0.46 vs 0.64, p = 0.033). CONCLUSION: Brain injured patients developing a nosocomial infection show parasympathetic predominance in the acute phase following brain injury, reflected by alterations in HRV, which parallels a decreased ability to generate an immune response to stimulation with LPS.