Successful closure of a bronchopleural fistula by intrapleural administration of fibrin sealant: a case report with review of literature.

CONTEXT: There are no established guidelines for the proper treatment of patients with bronchopleural fistulas (BPFs). Apart from attempts to close the fistula, emphasis of treatment and management is placed on preventive measures, early administration of antibiotics, drainage of the empyema and aggressive nutritional and rehabilitative support. CASE REPORT: A 53-year-old male presented with nausea, vomiting, and dry cough with eventual respiratory failure. He was found to have an empyema of the left hemithorax which was managed with thoracostomy drainage and antibiotics. However, he had persistent air leak through the chest tube due to a BPF. Bronchoscopy failed to localize the involved segment. Application of fibrin glue through the chest tube succeeded in completely sealing the leak. CONCLUSION: To our knowledge, this is the first case report in which fibrin glue was successfully used intrapleurally to close a BPF related to an empyema.

Neuroleptic malignant syndrome associated with haloperidol use in critical care setting: should haloperidol still be considered the drug of choice for the management of delirium in the critical care setting?

A 48-year-old man was brought to the emergency department because of intoxication. The patient was in respiratory distress, subsequently intubated for airway protection. On hospital day 5, he was diagnosed with delirium. Haloperidol was initiated at 5 mg intravenous every 6 h and titrated up to a dose of 60 mg /day over 5 days. On hospital day 18, his temperature peaked to 107.1°F. Other symptoms included mental status change, muscular rigidity and autonomic dysfunction. Neuroleptic malignant syndrome (NMS) associated with haloperidol was suspected. No other causes for these symptoms were present. Concurrent medications were reviewed and ruled out for possible drug-induced fever. Haloperidol was discontinued and dantrolene and bromocriptine was initiated. The temperature decreased to 102.2°F within 3 h and other symptoms resolved overtime. The temporal relationship between the patient's fever decline with the discontinuation of haloperidol, and improvement with dantrolene and bromocriptine, the diagnosis was believed to be haloperidol-induced NMS.

Hepatic hydrothorax without any evidence of ascites.

Hepatic hydrothorax usually presents in association with ascites, but there are rare cases when it does not. This case helps to support the differential of hepatic hydrothorax in patients who have a history of liver cirrhosis, portal hypertension, and recurrent pleural effusions without ascites. We hope to support the conclusion that a patient with recurrent pleural effusions, without ascites, does not exclude gastrointestinal involvement in its etiology.