Salmonella myocarditis in a young adult patient presenting with acute pulmonary edema, rhabdomyolysis, and multi-organ failure.

The mortality and morbidity of salmonella infections is seriously underestimated. Salmonella myocarditis is an unusual complication of salmonella sepsis in adults. Cases that do occur may be associated with high morbidity and mortality. We present a rare case of salmonella myocarditis with multi-organ failure in a previously healthy young adult man who was brought to the emergency room with fever, diarrhea, shortness of breath, and altered sensorium, discovered to have acute pulmonary edema and respiratory compromise for which he was assisted with mechanical ventilation for 8 days. Blood culture grew Salmonella typhi. Biochemically he exhibited myocardial, hepatic, and muscular enzymatic surge with renal failure, features of rhabdomyolysis, and disseminated intravascular coagulation. The patient showed a progressive improvement on treatment with ceftriaxone for 2 weeks in addition to decongestive therapy. He was discharged in good condition afterward.

Guillain-Barré syndrome associated with Salmonella paratyphi A.

A 31-year-old Nepali man was admitted to the intensive care unit with a 3-day history of fever associated with four-limb weakness, followed by difficulty in swallowing. The patient came from Nepal 20 days before admission. On examination the patient was conscious and appeared ill, with a temperature of 38.0 degrees C. His four limbs were weak (grades 2-3) and he was areflexic with mild facial weakness and absent gag reflex. Brain CT and MRI were normal. Cerebrospinal fluid analysis showed high protein. A neurophysiologic study showed data consistent with motor axonal polyradiculopathy. The patient was diagnosed with Guillain-Barré syndrome (GBS), and intravenous immunoglobulin (0.4 g/kg day for 5 days) was administered. On the third hospitalization day, the patient developed respiratory failure for which he was intubated and mechanically ventilated. On the same day, blood samples grew Salmonella paratyphi A (S. paratyphi A), which was sensitive to ceftriaxone. The patient was then diagnosed with GBS associated with S. paratyphi A, and treated with ceftriaxon (2 g administered intravenously, daily for 10 days). On the eleventh hospitalization day the patient was weaned from ventilator and extubated successfully. Subsequently, the patient improved, his fever subsided, and he regained muscle power satisfactorily.

Fulminant hepatic failure caused by Salmonella paratyphi A infection.

We report a case of fulminant hepatic failure associated with Salmonella paratyphi A infection, in a 29-year-old patient who was admitted to the intensive care unit (ICU) with fever of two days, headache and vomiting followed by behavioural changes and disorientation. On examination, the patient appeared acutely ill, agitated, confused, and deeply jaundiced. Temperature 38.5 degrees of C, pulse 92/min, blood pressure 130/89 mmHg. Both samples of blood grew S. paratyphi A, which was sensitive to ceftriaxone and ciprofloxacin. Ceftriaxon was administered with high-dose dexamethasone. Two weeks after treatment with ceftriaxon, the patient was discharged in satisfactory condition.

Rupture of spleen in a mechanically ventilated patient with falciparum malaria admitted with pulmonary edema.

Rupture of the spleen in malaria may constitute a diagnostic challenge to many clinicians particularly in non-endemic areas where experience with malaria is limited. Our aim is to increase the awareness among clinicians from non-endemic areas of serious malarial complications. We present a young American military man who was admitted to Hamad General Hospital and had 2 serious malarial complications, namely, acute pulmonary edema and rupture of the spleen. He was unusual compared with what was published previously in 4 main points: 1. The rupture of spleen occurred while the patient on mechanical ventilation and under the effect of sedation, which constituted a diagnostic challenge. 2. The 2 complications occurred in a patient with a low parasitemia. 3. The causative species for splenic rupture is Plasmodium falciparum, and 4. The first sample of peripheral blood smear for malarial parasite was negative. We treated him successfully and discharged home in a good condition.

Downbeat nystagmus following classical heat stroke.

Cerebellar syndrome following classical heat stroke is rare. We report a case of a 39-year-old man who presented with a cerebellar syndrome including downbeat nystagmus. MRI taken after 3 days of admission was normal. The downbeat nystagmus lasted for 6 days and than gradually disappeared. The ataxia and dysmetria improved gradually over 2 months. A brain CT scan performed 3 months later revealed no cerebellar atrophy. This case is unique as there were no predisposing factors (e.g. hypomagnesemia) and follow-up revealed complete reversibility of the ophthalmological abnormality. It reveals that the vestibulocerebellum is particularly vulnerable to thermal injury.

Antibiotic prescribing pattern in a medical intensive care unit in Qatar.

OBJECTIVES: The primary objectives were to evaluate the current usage of anti-microbial agents in the Medical Intensive Care Unit (MICU) of Hamad Medical Corporation (HMC) in Doha, State of Qatar and to correlate this with: a) the infectious disease pattern, b) the isolated microorganisms and their sensitivity pattern, and, importantly, c) the patient's clinical outcome. A secondary objective was to evaluate the influence of the use of steroid therapy on the development of fungal infections. METHODS: A prospective study covering a 2-month period from February through April 2004, including all patients admitted to the MICU for a minimum of 48 hours, and receiving a systemic antibiotic. RESULTS: From the 71 eligible patients admitted, 54 (76%) were treated for presumed or proven infections and received antibiotics, corresponding with 280 (89%) of the 313 patient days. Respiratory infections accounted for 57%. A total of 159 antibiotics (134 intravenously and 25 orally) were administered to the 54 patients during their stay in the MICU, corresponding with an average of almost 3 antibiotics per patient. Ceftriaxone was prescribed in 31 patients (57%) as initial therapy. Throughout the study period, a total of 385 microbiology samples for culturing were taken, corresponding with almost one sample per patient per day. Fifty-two percent of patients had a microbiologically proven infection (MPI): 18% with community-acquired pneumonia (CAP), 18% ventilated-acquired pneumonia (VAP), and 11% with hospital-acquired pneumonia (HAP). In the group of bacterial MPI, sensitivity pattern resulted in change in empirical antibiotic therapy in 12 of 23 patients (52%). In the group of patients with non-MPI, antibiotherapy was changed in 5 of the 26 patients (19%). Yeast infections developed in 13 of 30 (43%) patients receiving steroids (with 3 out of 9 patients (33%) receiving steroids for severe sepsis, and septic shock) compared to 5 of 24 (21%) patients receiving no steroids. CONCLUSION: This study highlights the urgent need for updated empiric and treatment guidelines as well as the monitoring of the antibiotic usage.

Organophosphate poisoning in pregnancy: a case report.

A 42-year-old pregnant woman (26 weeks of gestation, G(4)P(0+3)) presented at the emergency department with a two-hour history of dizziness, blurred vision and repeated vomiting. These symptoms started during the use of an undiluted insecticide liquid (diazinon 60 EC) while cleaning a small non-aired bathroom. After clinical and laboratory confirmation for organophosphate poisoning (plasma pseudocholinesterase levels 161 U/l), treatment with atropine and pralidoxime was started. She recovered within 7 days and delivered a healthy baby 12 weeks later (Apgar score 9 and 10) by elective cesarean section. The child showed no signs or symptoms of organophospate, atropine or pralidoxime exposure.