Refractory status epilepticus in a pediatric patient: Exploring the association with thyroid dysfunction.

Hashimoto's thyroiditis is an autoimmune thyroid disease characterized by lymphocytic infiltration and thyroid-specific autoantibodies. Hashimoto's encephalopathy, a rare entity associated with these antibodies, presents as a relapsing encephalopathy with neuropsychiatric manifestations and seizures. A 15-year-old girl, initially healthy, experienced a tonic-clonic seizure. Despite unremarkable initial assessments, she returned with generalized convulsive status epilepticus. Hashimoto's thyroiditis was suggested by elevated thyroid-stimulating hormone levels, low thyroxine levels, and high anti-thyroid antibodies, and was confirmed by ultrasound. Steroids were not used initially due to seizure cessation with anesthesia. Post-treatment with levothyroxine and antiepileptics, she was seizure-free at follow-up and eventually maintained solely on levothyroxine. Hashimoto's encephalopathy, characterized by diverse symptoms, often necessitates corticosteroids, immunoglobulins, and plasmapheresis, as traditional anti-seizure medications fail. Further research into its etiology and pathophysiology is essential. Consider Hashimoto's encephalopathy in unexplained seizures, especially with ineffective standard treatments. Pediatric diagnostic criteria need to be revisited.

A retrospective study of the predictors of mortality among patients in intensive care units at North West-Bank hospitals in Palestine.

OBJECTIVES: The intensive care unit (ICU) mortality rate remains high, especially in developing countries, regardless of the advances in critical management. There is a lack of studies about mortality causes in hospitals and particularly ICUs in Palestine.This study evaluated the demographic and clinical characteristics of critically ill patients and determined the predictors of mortality among patients in the ICU. METHODS: A retrospective study assessed all patients who stayed in the ICU for more than 24 h from January 2017 to January 2019. Data were collected from the patient's files. Patient characteristics (background, clinical variables, and comorbidities) were recorded. RESULTS: The study included 227 eligible ICU patients. The cases' mean age was 55.5 (SD ± 18.2) years. The overall ICU mortality rate was 31.7%. The following factors were associated with high adjusted mortality odds: admission from inside the hospital (adjusted odds ratio (aOR), 2.1, 95% CI: 1.1-3.9, p < 0.05), creatinine level ≥2 mg/dl on admission (aOR, 2.7, 95% CI: 1.3-5.8, p < 0.01), hematology malignancy patients (aOR, 3.4, 95% CI: 1.6-6.7, p = 0.001), immune-compromised (aOR, 2.5, 95% CI: 1.3-4.7, p < 0.01), septic shock (aOR, 27.1, 95% CI: 7.9-88.3, p < 0.001), hospital-acquired infections (aOR: 13.4, 95% CI: 4.1-57.1, p < 0.001), and patients with multiple-source infection (aOR: 16.3, 95% CI: 6.4-57.1, p < 0.001). Also, high SOFA and APACHE scores predicted morality (p < 0.001). CONCLUSION: The mortality rate among ICU patients was high. It was higher among those admitted from the hospital wards, septic shock, hospital-acquired infection, multiple infection sources, and multi-drug resistance infections. Thus, strategies should be developed to enhance the ICU environment and provide sufficient resources to minimize the effects of these predictors.

Focal necrosis of the falciform ligament as a rare cause of abdominal pain: A case report.

The falciform ligament, a peritoneal fold that anatomically separates the right and left lobes of the liver, may infrequently be a cause of patients' complaints. In very rare instances, fatty appendages of the falciform ligament may undergo torsion, resulting in fat infarction. Despite its rarity, falciform ligament pathologies often mimic common abdominal issues, leading to misdiagnosis. Herein, we report a case of inflammation and necrosis of the falciform ligament in a 72-year-old female. The patient presented with abdominal pain, a positive Murphy's sign, and elevated inflammatory markers. Imaging, including a computed tomography (CT) scan, was pivotal in confirming the diagnosis of falciform ligament necrosis. Contrary to the proposed surgical approach (resection of the falciform ligament) in some reported cases, conservative management (including analgesia, hydration, and antibiotics) proved successful in this case. This report emphasizes the importance of considering falciform ligament torsion in upper abdominal pain differential diagnoses and highlights the key role of imaging for accurate diagnosis.

Sheehan's syndrome unveiled after decades without a diagnosis: A case report.

Sheehan's syndrome is defined as a postpartum infarction of the pituitary gland following hypovolemic shock due to obstetric hemorrhage. Sheehan's syndrome's symptoms are often subtle, and hence it is often overlooked. In this report, we discuss a case of an 82-year-old woman who developed severe postpartum hemorrhage after her last childbirth at the age of 37, which required multiple blood transfusions. Since then, she had progressively developed malaise and lastly presented with a new onset of confusion. Basic laboratory tests detected poorly controlled hypothyroidism and severe hyponatremia, which are well-known late-presenting conditions of Sheehan's syndrome. Escaping the diagnosis for more than four decades is extremely rare and beyond what is reported previously. Despite being a rare cause of hyponatremia in the elderly, physicians should maintain a high index of suspicion and are required to look for a readily treatable and preventable cause of hyponatremia (after excluding the common causes), which may alleviate the suffering of these patients.

Case report: Pancytopenia as a rare presentation of Sheehan's syndrome.

Sheehan's syndrome is a postpartum hypopituitarism state caused by necrosis of the pituitary gland. It is usually the result of severe hypotension or shock caused by massive hemorrhage during or after delivery. Sheehan's syndrome symptoms are often subtle and hence it is diagnosed late. Herein, we report a case of a 41-year-old woman who developed severe postpartum hemorrhage after childbirth that required a total abdominal hysterectomy to control bleeding at the age of 36 years. Since then, she has progressively developed symptoms of headache, general fatigue, and malaise, and finally presented with pancytopenia for investigations. Anemia is a well-known hematological association with Sheehan's syndrome while pancytopenia is rarely reported. However, complete recovery of pancytopenia was observed after the treatment. Pancytopenia (due to bone marrow failure to produce cells) is a serious finding in clinical practice that causes significant stress as it may point to a diagnosis of malignancy (mainly leukemia) and other serious disorders. Despite being a rare cause, a high index of suspicion is required from the physicians in women with pancytopenia, in order to look for a possible treatable cause of pancytopenia (like Sheehan's syndrome), if the common causes were excluded.

Scleromyxedema in a 21 year old female patient with acute lymphoblastic leukemia: a case report.

BACKGROUND: Scleromyxedema is a rare, para-neoplastic, chronic, progressive condition of the Lichen myxedematosus (LM) family. The clinical picture consists of generalized confluent papular eruptions with possible systemic manifestations, which may be fatal as it still constitutes a therapeutic dilemma. Histologically, it is characterized by dermal mucin deposition, fibroblast proliferation with fibrosis, with monoclonal gammopathy in the absence of thyroid disease. Some atypical forms of the disease were reported in the literature, but none were reported in acute leukemia. CASE PRESENTATION: Herein, we report a case of a 21 years old female patient, known case of acute lymphoblastic leukemia (ALL), who developed numerous hyper-pigmented erythematous papules and plaques, mainly over her thighs, lower abdomen, and sub-mammary flexures. Histopathology of skin lesions confirmed the diagnosis of atypical scleromyxedema. Her symptoms significantly improved with the use of high dose intravenous immunoglobulin (IVIG). CONCLUSIONS: Despite that scleromyxedema is associated with many hematologic disorders, it is very rarely associated with acute lymphoblastic leukemia, and a high index of suspicion is needed for diagnosis. IVIG remains a reasonable management of such a disabling disease.

Epidemiology of Sepsis Syndrome among Intensive Care Unit Patients at a Tertiary University Hospital in Palestine in 2019.

BACKGROUND: Sepsis syndrome is an emerging healthcare problem, especially in critically ill patients, regardless whether it's community- or hospital-acquired sepsis. This study evaluates the characteristics of these patients, in addition to the type, source, and outcome of sepsis and septic shock, in a university tertiary hospital in Palestine. It also studies the most common organisms encountered in these patients. MATERIALS AND METHODS: This is retrospective observational chart review study of all adult admissions to the intensive care unit over a period of 2 years. The presence of sepsis and septic shock was assessed and documented based on the Third International Consensus Definitions (Sepsis-3). Data regarding demographics, severity, comorbidities, source of infection, microbiology, length of stay, and outcomes (dead/alive at discharge from ICU) were recorded. RESULTS: A total number of 174 patients were included. The mean age was 57.4 years, with cardiovascular diseases and diabetes being the leading comorbidities encountered in them. Respiratory infections were the most common site of sepsis, found in around 71% of patients, followed by urinary tract infections. More than 70% of cases were due to hospital-acquired infections (HAIs). Acinetobacter species were the most common gram-negative organisms encountered, while Enterococcus was the most common gram-positive organisms. Around 54% of patients had multidrug-resistant organisms. The average length of stay in the ICU was 8 days. The average mortality rate was 39.7%, which is higher among septic shock patients. CONCLUSION: Both sepsis and septic shock carry high morbidity and mortality rates, and they are very frequent among critically ill patients. Special care and developing management bundles are crucial in controlling and preventing this threat. HOW TO CITE THIS ARTICLE: Rabee HA, Tanbour R, Nazzal Z, Hamshari Y, Habash Y, Anaya A, et al. Epidemiology of Sepsis Syndrome among Intensive Care Unit Patients at a Tertiary University Hospital in Palestine in 2019. Indian J Crit Care Med 2020;24(7):551-556.