Candida parapsilosis meningitis associated with shunt infection in an adult male.

Candida parapsilosis is a very rare cause of meningitis. Though several cases have now been reported in neonates and children, only one has been described in an adult. We report on a 55-year-old male that was admitted due to altered mental status. He had recent sinus drainage and polypectomy, craniotomy with drainage of brain abscess, and ventriculo-peritoneal shunt placement. On admission, imaging studies showed no evidence of shunt dysfunction but did reveal extensive white matter decreased attenuation. Microscopic examination of the first 10 daily cerebrospinal fluid (CSF) cultures revealed yeast. Flucytosine and liposomal amphotericin B were started and externalization of shunt was performed on day 3. On day 8, CSF culture from admission grew C. parapsilosis; fluconazole was added. On day 10, daily CSF still showed yeast and cultures consistently grew C. parapsilosis. Shunt was removed and bilateral ventriculostomy drains were inserted. CSF after procedure as well as at follow-up examinations throughout his 3-month hospitalization were negative for yeast. Extended treatment with flucytosine and fluconazole was initiated. At 8-month follow-up, successful treatment of C. parapsilosis infection without recurrence was confirmed. This case underscores the need for suspicion of C. parapsilosis as a cause of meningitis after invasive surgeries in adults.

Unique case of thrombotic thrombocytopenic purpura and diabetes insipidus.

Thrombotic thrombocytopenic purpura (TTP) is a rare and often fatal disorder characterized by thrombocytopenia, microangiopathic hemolytic anemia, mental status changes, and renal dysfunction. Central diabetes insipidus (CDI) is a rare disease due to anatomic lesions of the hypothalamicpituitary system associated with various underlying diseases, or trauma. We present an unusual case of TTP and CDI in a 47 year-old African American female who was admitted to our hospital with crampy abdominal pain and nausea. The patient had tachycardia, fever and hypotension. The patient subsequently became confused, developed seizures, and her renal function deteriorated. Bone marrow analysis showed adequate megakaryocytes while a peripheral smear revealed severe thrombocytopenia, polychromasia and schistocytes. The diagnosis of thrombotic thrombocytopenic purpura (TTP) was made and plasmapharesis initiated. Over the next few days, the patient developed severe polyuria with a rise in serum sodium. Central diabetes insipidus was diagnosed and DDAVP (desmopressin acetate, 1-deamino-8-D-arginine vasopressin) was given. However, DDAVP was stopped several times due to worsening thrombocytopenia. Renal function worsened and the patient expired. A review of the literature revealed only one case of report of TTP and central diabetes insipidus. Our case was the only one reporting the use of DDAVP in such a setting.

Prolonged requirement for ventilatory support in a patient with Eskalith overdose.

Lithium (Eskalith) is commonly used in the treatment of depressive and bipolar affective disorders, in a population at relatively high risk for overdose. Lithium may help correct a chemical imbalance in the brain; however, it has a comparatively narrow therapeutic index. Thus, lithium intoxication is a frequent complication of chronic lithium therapy. The central nervous system (CNS) is the major organ system affected, although the renal, gastrointestinal (GI), endocrine, and cardiovascular (CV) systems also may be involved. Here we present a forty-two-year-old Caucasian female with altered mental status, inability to eat, speak or walk properly, with shaking and vomiting for three days. Past medical history was significant for hepatitis C and bipolar disorder. Vital signs were within normal limits. Physical exam revealed a patient with aphasia, tremor, and an expressionless face, able to make eye contact and move all four extremities. However, she was unable to follow commands and she expressed rigidity of extremities, mild tachycardia, and stupor. Severely elevated serum lithium levels were found. A diagnosis of severe lithium toxicity was made and the patient was admitted to the telemetry unit. Intravenous hydration with normal saline was initiated as the patient had normal kidney function, and urinary output was monitored. All psychotropic medications were held except for a benzodiazepine. In the meantime the patient developed acute respiratory distress, was intubated on clinical grounds and was transferred to the intensive care unit. Acute cardiogenic pulmonary edema and other causes of respiratory distress were ruled out; diagnosis of Adult Respiratory Distress Syndrome (ARDS) was made. After two months of mechanical ventilation, the patient was stabilized. Mental status, vital signs, and all laboratory parameters including thyroid function tests, normalized. The patient was transferred to a rehabilitation center. This is a rare case of ARDS associated with lithium intoxication.

Meeting the challenge of bioterrorism: lessons learned from West Nile virus and anthrax.

Hospital emergency departments (EDs) and ambulatory clinics may be the first to recognize illness related to a bioterrorist event. Every health-care institution must develop a weapons-of-mass- destruction (WMD) preparedness plan as part of its all-hazards disaster planning. As part of an all-hazards disaster plan, WMD preparedness should use the incident-command model to insure the required chain of command for effectively coordinating activities between hospital departments and external agencies. Preparedness for bioterrorism poses unique challenges. In the event of a biological attack, the hospital infection control staff and administration must already have in place the means to communicate with local and state public health agencies, the Centers for Disease Control and Prevention (CDC), local law-enforcement agencies, and the Federal Bureau of Investigation (FBI). Local and regional planners must consider how to coordinate the responses of emergency medical services (EMS), police, and fire departments with healthcare providers and the news media. Most hospitals are ill equipped to deal with a catastrophic event caused by WMD. The burden of responding to such events will fall initially on ED physicians and staff members. The severity of such an incident might be mitigated with careful planning, training and education. The responses of one hospital network to the outbreak of West Nile virus and, more recently, to the threat of anthrax, are presented as guides for bioterrorism preparedness.