Successful management of severe hypoglycemia induced by total parenteral nutrition in patients with hepatocellular injury: Three cases reports

BACKGROUND Glucose imbalance is common in total parenteral nutrition(TPN).Hypoglycemia seems to be less frequent than hyperglycemia,but it influences the clinical outcome to a greater extent.Therefore,it should be effectively prevented and treated.However,there is no relevant report on how to treat hypoglycemia caused by TPN in patients with liver cell injury.CASE SUMMARY We present three patients with liver cell injury who developed severe hypo-glycemia during or after TPN infusion.The causes of severe hypoglycemia and glucose-raising strategies were discussed.According to the physiological charac-teristics of the hepatocellular injury,the ratio of nutrition components prescribed in TPN was appropriately adjusted for the three cases.We simultaneously reduced the dose of insulin and fat emulsion,and increased the dose of glucose in TPN.The blood glucose level was restored to normal range and clinical symptoms were eliminated.CONCLUSION When hypoglycemia occurs during or after TPN in patients with hepatocellular injury,physicians need to simultaneously reduce insulin and fat emulsion,and increase glucose,and correct severe hypoglycemia in time to reduce its adverse consequences.

Diagnosis and management of severe pulmonary and extrapulmonary tuberculosis in critically ill patients:A mini review for clinicians

Among critically ill patients,severe pulmonary and extrapulmonary tuberculosis has high morbidity and mortality.Yet,it is a diagnostic challenge given its nonspecific clinical symptoms and signs in early stages of the disease.In addition,management of severe pulmonary and extrapulmonary tuberculosis is complicated given the high risk of drug-drug interactions,drug-disease interactions,and adverse drug reactions.To help clinicians acquire an up-to-date approach to severe tuberculosis,this paper will provide a narrative review of contemporary diagnosis and management of severe pulmonary and extrapulmonary tuberculosis in critically ill patients.

Accidental placement of venous return catheter in the superior vena cava during venovenous extracorporeal membrane oxygenation for severe pneumonia: A case report

BACKGROUND Venovenous extracorporeal membrane oxygenation(V-V ECMO)has become an important treatment for severe pneumonia,but there are various complications during the treatment.This article describes a case with severe pneumonia success-fully treated by V-V ECMO,but during treatment,the retrovenous catheter,which was supposed to be in the right internal vein,entered the superior vena cava directly in the mediastinum.The ECMO was safely withdrawn after multidiscip-linary consultation.Our experience with this case is expected to provide a reference for colleagues who will encounter similar situations.CASE SUMMARY A 64-year-old man had severe pulmonary infection and respiratory failure.He was admitted to our hospital and was given ventilation support(fraction of inspired oxygen 100%).The respiratory failure was not improved and he was treated by V-V ECMO,during which the venous return catheter,which was supposed to be in the right internal vein,entered the superior vena cava directly in the mediastinum.There was a risk of massive mediastinal bleeding if the catheter was removed directly when the ECMO was withdrawn.Finally,the patient underwent vena cava angiography+balloon attachment+ECMO with-drawal in the operating room(prepared for conversion to thoracotomy for vascular exploration and repair at any time during surgery)after multidiscip-linary consultation.ECMO was safely withdrawn,and the patient recovered and was discharged.CONCLUSION Patients may have different vascular conditions.Multidisciplinary cooperation can ensure patient safety.Our experience will provide a reference for similar cases.

Severe acute pancreatitis complicated with intra-abdominal infection secondary to trauma:A case report

BACKGROUND Pancreatic trauma(PT)is rare among traumatic injuries and has a low incidence,but it can still lead to severe infectious complications,resulting in a high mortality rate.Acute pancreatitis(AP)is a common complication after PT,and when combined with organ dysfunction and sepsis,it will result in a poorer prognosis.CASE SUMMARY We report a 25-year-old patient with multiple organ injuries,including the pancreas,due to abdominal trauma,who developed necrotising pancreatitis secondary to emergency caesarean section,combined with intra-abdominal infection(IAI).The patient underwent performed percutaneous drainage,pancreatic necrotic tissue debridement,and abdominal infection foci debridement on the patient.CONCLUSION We report a case of severe AP and IAI secondary to trauma.This patient was managed by a combination of conservative treatment such as antibiotic therapy and fluid support with surgery,and a better outcome was obtained.

Treatment of a patient with severe cerebral malaria during the COVID-19 pandemic in China:A case report

BACKGROUND On June 30,2021,China received certification from the World Health Organization for malaria elimination.However,this certification does not signify the absence of malaria within China.Due to the increasing frequency of international exchanges and collaborations,the threat of imported malaria persists in China.Consequently,the prevention and control of imported malaria have become a primary focus for our country to maintain its malaria elimination status.CASE SUMMARY Herein,we present a case report of a 53-year-old Chinese man who worked in Africa for nearly two years.He was diagnosed with malaria in the Democratic Republic of the Congo between November 19 and November 23,2022.After receiving effective treatment with oral antimalarial drugs,his condition improved,allowing him to return to China.He was later admitted to our hospital on January 12,2023,during the coronavirus disease 2019 pandemic in Huangshi,China.Through a thorough evaluation of the patient's symptoms,clinical signs,imaging and laboratory test results,and epidemiological data,he was rapidly diagnosed with severe cerebral malaria.The patient underwent successful treatment through a series of intensive care unit interventions.CONCLUSION The successful treatment of this imported case of severe cerebral malaria provides a valuable reference for managing patients with similar malaria infections and has significant clinical implications.

Critical respiratory failure due to pregnancy complicated by COVID-19 and bacterial coinfection:A case report

BACKGROUND In the past 3 years,the global pandemic of coronavirus disease 2019(COVID-19)has posed a great threat to human life and safety.Among the causes of death in COVID-19 patients,combined or secondary bacterial infection is an important factor.As a special group,pregnant women experience varying degrees of change in their immune status,cardiopulmonary function,and anatomical structure during pregnancy,which puts them at higher risk of contracting COVID-19.COVID-19 infection during pregnancy is associated with increased adverse events such as hospitalisation,admission to the intensive care unit,and mechanical ventilation.Therefore,pregnancy combined with coinfection of COVID-19 and bacteria often leads to critical respiratory failure,posing severe challenges in the diagnosis and treatment process.CASE SUMMARY We report a case of COVID-19 complicated with Staphylococcus aureus(S.aureus)coinfection in a pre-gnant woman at 34 wk of gestation.Her rapid progression of pulmonary lesions caused severe respiratory failure,and she received noninvasive ventilator-assisted respiratory treatment.Subsequently,we delivered a foetus via emergency caesarean section after accelerating the maturity of the foetal pulmonary system,and the respiratory condition of the puerperant woman significantly improved after the delivery of the foetus.Lavage fluid was taken under tracheoscopy to quickly search for pathogens by the metagenomic nextgeneration sequencing(mNGS),and both COVID-19 and S.aureus were detected.After targeted anti-infective treatment,the maternal condition gradually improved,and the patient was discharged from the hospital.CONCLUSION The coinfection of pregnancy with COVID-19 and bacteria often leads to critical respiratory failure,which is a great challenge in the process of diagnosis and treatment.It is crucial to choose the right time to deliver the foetus and to quickly find pathogens by mNGS.

Severe liver trauma with complex portal and common bile duct avulsion:A case report and review of the literature

BACKGROUND Given its size and location,the liver is the third most injured organ by abdominal trauma.Thanks to recent advances,it is unanimously accepted that the nonoperative management is the current mainstay of treatment for hemodynamically stable patients.However,those patients with hemodynamic instability that generally present with severe liver trauma associated with major vascular lesions will require surgical management.Moreover,an associated injury of the main bile ducts makes surgery compulsory even in the case of hemodynamic stability,thereby imposing therapeutic challenges in the tertiary referral hepato-biliopancreatic centers’setting.CASE SUMMARY We present the case of a 38-year-old male patient with The American Association for the Surgery of Trauma grade V liver injury and an associated right branch of portal vein and common bile duct avulsion,due to a crush polytrauma.The patient was referred to the nearest emergency hospital and because of the hemorrhagic shock,damage control surgery was performed by means of ligation of the right portal vein branch and right hepatic artery,and hemostatic packing.Afterwards,the patient was referred immediately to our tertiary hepato-bilio-pancreatic center.We performed depacking,a right hepatectomy and Roux-en-Y hepaticojejunostomy.On the 9th postoperative day,the patient developed a high output anastomotic bile leak that required a redo of the cholangiojejunostomy.The postoperative period was marked by a surgical incision site of incomplete evisceration that was managed non-operatively by negative wound pressure.The follow-up was optimal,with no complications at 55 mo.CONCLUSION In conclusion,the current case clearly supports that a favorable outcome in severe liver trauma with associated vascular and biliary injuries is achieved thru proper therapeutic management,conducted in a tertiary referral hepato-bilio-pancreatic center,where a stepwise and complex surgical approach is mandatory.

Pretreatment with a modified St.Thomas'solution in patients with severe upper limb injuries:Four case reports

BACKGROUND This study aims to describe the application of a modified St.Thomas'solution in patients with severe limb injuries.CASE SUMMARY Four patients who sustained a high-energy trauma and underwent complete upper limb amputation were pretreated with a modified St.Thomas'solution before upper limb replantation.After the perfusion solution stopped flowing from the blood vessel,the amputated upper limb amputation was replanted.The patients were instructed to perform functional rehabilitation training after the operation.All 4 patients were followed up for 5 years.All the severed upper limbs survived.Routine re-examination after the operation showed that the function of the affected limb was restored.All the patients were satisfied with the sensory and functional recovery of the affected limb.CONCLUSION The modified St.Thomas'solution can effectively improve the success rate of limb salvage surgery and the recovery of limb function in patients with a severe limb injury.

Short Term Outcome and Risk Factors for Mortality in Adults with Critical Severe Acute Respiratory Syndrome (SARS)

The independent risk factors to predict mortality of critical severe acute respiratory syndrome (SARS) were investigated. One hundred and two patients diagnosed with critical SARS were admitted to hospitals of Shanxi Province, from March 7, 2003 to June 4, 2003. The patients were prospectively studied after admission to access their short term outcomes and the risk factors associated with adverse outcomes, defined as death. All the demographic and clinical characteristics were studied and univariate and multivariate Logistic regression were employed to access the risk factors. The results showed that of the 102 cases, 23 patients died, with a crude mortality rate of 22.5 %. Multivariate Logistic regression revealed that age above 50 [odds ratio (OR) 1.10, 95 % confidence internal (CI) 1.03 to 1.16, P=0.004], lymphopenia at early stage (OR 14.62, 95 % CI 1.78 to 11.97, P=0.01) were independently associated with mortality. On the other side, psychotherapy (OR 0.01, 95 % CI 0.00 to 0.06, P<0.001) was independently associated with aliveness. It was concluded that critical SARS is a new disease entity that carries significant mortality and morbidity. Specific clinical and laboratory parameters predicting unfavorable and favorable outcomes have been identified.

Quality of Management of Severe Malaria Cases in Children under Five: A Case of Four Health Facilities in the Littoral Department in Benin

Background: Benin republic is a sub-Saharan African country endemic to malaria caused by Plasmodium falciparum. To reduce the death rate due to this scourge, it is essential to ensure quality care, especially for children under five years who are the most vulnerable. The main objective of this study is to assess the quality of severe malaria case management in patients under five years. Methods: Descriptive and analytical cross-sectional study was performed in health facilities in Cotonou city, the economic capital of Benin Republic. Study sample included 205 suspected cases of severe malaria among children aged under five years, in four health facilities. In each of hospitals, all children under five years with severe malaria presumption were enrolled in the study. Quality was assessed through five components: diagnosis, treatment, patient monitoring, counselling/advice, and patient’s follow-up. Based on the Benin Republic’s malaria case management standard protocol, the assessment criteria of each component were defined. Results: The sex ratio was 1.25 boys to a girl. The median of hospitalisation duration was 3 days with first quartile (Q1) = 2 and third quartile (Q3) = 5. Among 205 severe malaria cases included, 157 (76.59%) were not managed in accordance with the requirements of the national protocol of malaria case management. The different components of cases management are not all implemented during the care of patients. Conclusion: There is a need for training to health workers on implementation of severe malaria in children under 5 years protocol. Also, there is a need for investigation about factors associated with malaria protocol implementation.

Severe liver injury by heat stroke: analysis of 10 cases

Objective: To analyse the clinical features and prognosisof liver injury caused by heat stroke.Methods: The clinical data of 10 patients with severe liverinjury caused by heat stroke were analysed retrospective-ly.Results: In 4 patients the level of ALT was over 1000 U/L, in 3 patients ranged from 300 to 1000 U/L, and in 3patients 50-300 U/L. The level of TBIL in 2 patientswas over 400 μmol/L and in 5 varied from 20 to 75μmol/L. Two patients showed jaundice and petechia on

Predictors of severe and critical COVID-19:A systematic review

BACKGROUND Coronavirus disease 2019(COVID-19)has emerged as a public health crisis that was declared as a global pandemic by the World Health Organization.Although most cases have no or mild symptoms,around 10%of patients develop severe or critical illness that necessitates hospitalization and intensive care unit admission.AIM To assess the literature for the predictive factors that can identify patients having severe/critical COVID-19 disease.METHODS A Preferred Reporting Items for Systematic Reviews and Meta-Analysescompliant systematic search of the literature was conducted.Electronic databases including PubMed/MEDLINE,Scopus,and Cochrane Library were queried.The main outcome measures were the predictors of severe/critical COVID-19 and mortality.RESULTS Five studies including 583 patients of a median age of 50.5 years were reviewed.Patients were 346(59.4%)male and 237(40.6%)female.Of 583 hospitalized patients,242(41.5%)had critical illness.Acute respiratory distress disease occurred in 291 patients,accounting for 46.7%of total complications.Onehundred(17.1%)mortalities were recorded.The most commonly reported predictors of severe COVID-19 were older age,medical comorbidities,lymphopenia,elevated C-reactive protein,increased D-dimer,and increased neutrophil ratio.Findings on computed tomography(CT)scanning predictive of severe disease were bronchial wall thickening,CT score>7,linear opacities,consolidation,right upper lobe affection,and crazy paving pattern.CONCLUSION Several demographic,clinical,laboratory,and radiologic factors can help predict severe and critical COVID-19 along with the potential need for mechanical ventilation.Factors that were more commonly reported were older age,medical comorbidities,lymphopenia,increased neutrophil ratio,elevated C-reactive protein,and increased D-dimer.

Impact of disease severity on gastric residual volume in critical patients

AIM: To investigate whether illness severity has an impact on gastric residual volume (GRV) in medical critically ill patients. METHODS: Medical intensive care unit (ICU) patients requiring nasogastric feeding were enrolled. Sequential Organ Failure Assessment (SOFA) score was assessed immediately preceding the start of the study. Acute Physiology and Chronic Health Evaluation (APACHE) Ⅱ scores were recorded on the first, fourth, seventh, and fourteenth day of the study period. GRV was measured every 4 h during enteral feeding. The relationship be-tween mean daily GRV and SOFA scores and the correlation between mean daily GRV and mean APACHE Ⅱ score of all patients were evaluated and compared. RESULTS: Of the 61 patients, 43 patients were survivors and 18 patients were non-survivors. The mean daily GRV increased as SOFA scores increased (P < 0.001, analysis of variance). Mean APACHE Ⅱ scores of all patients correlated with mean daily GRV (P = 0.011, Pearson correlation) during the study period. Patients with decreasing GRV in the first 2 d had better survival than patients without decreasing GRV (P = 0.017, log rank test). CONCLUSION: GRV is higher in more severely ill medical ICU patients. Patients with decreasing GRV had lower ICU mortality than patients without decreasing GRV.

Diagnosis of erythropoietic protoporphyria with severe liver injury: A case report

BACKGROUND Porphyria is a rare disease with complex classification. Erythropoietic protoporphyria(EPP) is an autosomal recessively inherited disease, and most are caused by mutations in the FECH gene. EPP combined with liver injury is even rarer.CASE SUMMARY This paper reports a case of EPP which was admitted to the hospital with abnormal liver function and diagnosed by repeated questioning of medical history, screening of common causes of severe liver injury, and second generation sequencing of the whole exon genome. We also summarize the clinical characteristics of EPP with liver injury, and put forward some suggestions on EPP to provide a reference for the diagnosis of such rare disease.CONCLUSION A new mutation locus(c.32_35 dupCCCT) which may be related to the disease was found by detecting the FECH gene in the pedigree of this case.

Excellent response of severe aplastic anemia to treatment of gut inflammation: A case report and review of the literature

BACKGROUND Cumulative evidence suggests that the aberrant immune responses in acquired aplastic anemia(AA) are sustained by active chronic infections in genetically susceptible individuals. Recently, the constant source to trigger and sustain the pathophysiology has been proposed to come from the altered gut microbiota and chronic intestinal inflammation. In this case, our serendipitous finding provides convincing evidence that the persistently dysregulated autoimmunity may be generated, at least in a significant proposition of AA patients, by the altered gut microbiota and compromised intestinal epithelium.CASE SUMMARY A 30-year-old Chinese male patient with refractory severe AA experienced a 3-month-long febrile episode, and his fever was refractory to many kinds of injected broad-spectrum antibiotics. When presenting with abdominal cramps, he was prescribed oral mannitol and gentamycin to get rid of the gut infection. This treatment resulted in a quick resolution of the fever. Unanticipatedly, it also produced an excellent hematological response. He had undergone three episodes of recurrence within the one-year treatment, with each recurrence occurring 7-8 wk from the gastrointestinal inflammation eliminating preparations. However,subsequent treatments were able to produce subsequent remissions and consecutive treatments were successful in achieving durative hematological improvements, strongly indicating an etiological association between chronic gut inflammation and the development of AA. Interestingly, comorbid diseases superimposed on this patient(namely, psychiatric disorders, hypertension,insulin resistance, and renal dysfunction) were ameliorated together with the hematological improvements.CONCLUSION Chronic gut inflammation may be responsible for AA pathogenesis. The comorbidities and AA may share a common etiological association.

Therapeutic plasma exchange and continuous renal replacement therapy for severe hyperthyroidism and multi-organ failure:A case report

BACKGROUND Severe hyperthyroidism is a life-threatening exacerbation of thyrotoxicosis,characterized by high fever and multiorgan failure. The most common medical treatments are administration of antithyroid drugs and radioactive iodine, and thyroidectomy. In some patients, antithyroid therapy is limited due to serious adverse effects or failure to control disease progression. In some extreme cases,such as thyroid storm, conventional therapy alone does not yield effective and rapid improvement before the development of multiorgan failure.CASE SUMMARY This report describes a Chinese patient with severe hyperthyroidism accompanied by multiorgan failure, who was transferred to the medical intensive care unit of our hospital. The patient presented with palpitations, vomiting,diarrhea, and shortness of breath for a week. Laboratory tests showed elevation of thyroid hormones. Hepatic failure occurred with high aminotransferase levels and jaundice. Given her abnormal liver function and medication history, we could not exclude diagnosis of propylthiouracil-induced hepatic failure.Moreover, she also suffered from heart failure. Therapeutic plasma exchange(commonly known as TPE) and continuous renal replacement therapy(commonly known as CRRT) were used as life-saving therapy, which resulted in notable improvement of clinical symptoms and laboratory tests.CONCLUSION Combined TPE and CRRT are safe and effective for patients with hyperthyroidism and multiorgan failure.

Crohn’s-like acute severe colitis associated with Hermansky-Pudlak syndrome: A case report

BACKGROUND Hermansky-Pudlak syndrome(HPS)is a rare autosomal recessive disorder characterized by oculocutaneous albinism,platelet storage pool deficiency and systemic complications associated with ceroid deposition in the reticuloendothelial system.HPS types 1 and 4 are associated with Crohn’s disease(CD)-like gastrointestinal disorders,such as granulomatous enterocolitis or perianal disease.Cases of colitis can be particularly severe and,before the use of anti-tumor necrosis factor alpha(TNFα)therapy had become common,were reported as showing poor responsiveness to medical treatment.CASE SUMMARY We present the case of a 51-year-old albino woman who presented with acute severe colitis that led to the diagnosis of HPS.Histologic findings of biopsy samples showed chronic inflammation with deep ulcerations,and granulomas without caseous necrosis.Molecular genetic analysis confirmed HPS type 1,with a homozygous 27 base-pair deletion in exon 20 of the HPS1 gene.Once the patient’s bleeding diathesis was corrected by platelet transfusion,the granulomatous colitis responded dramatically to a medical treatment regimen that included corticosteroids,azathioprine and infliximab;this regimen is similar to that used in CD treatment.Although it remains unclear if the granulomatous enterocolitis in HPS is due to ceroid deposition or reflects the co-existence of CD and HPS,the fact that this case of HPS-related granulomatous colitis responded to the same therapeutic approach used in CD suggests that this type of colitis may result from HPS patients’genetic susceptibility to CD.CONCLUSION We report a case of severe colitis that led to the diagnosis of HPS,which was responsive to azathioprine and infliximab.

Anterior abdominal abscess-a rare manifestation of severe acute pancreatitis:A case report

BACKGROUND Severe acute pancreatitis(SAP)is a common critical disease of the digestive system.In addition to the clinical manifestations and biochemical changes of acute pancreatitis,SAP is also accompanied by organ failure lasting more than 48 h.SAP is characterized by focal or extensive pancreatic necrosis,hemorrhage and obvious inflammation around the pancreas.The peripancreatic fat space,fascia,mesentery and adjacent organs are often involved.The common local complications include acute peripancreatic fluid collection,acute necrotic collection,pancreatic pseudocyst,walled off necrosis and infected pancreatic necrosis.After reviewing the literature,we found that in very few cases,SAP patients have complications with anterior abdominal wall abscesses.CASE SUMMARY We report a 66-year-old Asian male with severe acute pancreatitis who presented with intermittent abdominal pain and an increasing abdominal mass.The abscess spread from the retroperitoneum to the anterior abdominal wall and the right groin.In the described case,drainage tubes were placed in the retroperitoneal and anterior abdominal wall by percutaneous puncture.After a series of symptomatic supportive therapies,the patient was discharged from the hospital with a retroperi-toneal drainage tube after the toleration of oral feeding and the improvement of nutritional status.CONCLUSION We believe that patients with SAP complicated with anterior abdominal abscess can be treated conservatively to avoid unnecessary exploration or operation.

Oxaliplatin-induced severe anaphylactic reactions in metastatic colorectal cancer: Case series analysis

AIM: To investigate oxaliplatin-induced severe anaphylactic reactions (SAR) in metastatic colorectal cancer in a retrospective case series analysis and to conduct a systemic literature review. METHODS: During a 6-year period from 2006 to 2011 at Kaohsiung Veterans General Hospital, a total of 412 patients exposed to oxaliplatin-related chemotherapy were retrospectively reviewed. Relevant Englishlanguage studies regarding life-threatening SAR following oxaliplatin were also reviewed in MEDLINE and PubMed search. RESULTS: Eight patients (1.9%, 8 of 412 cases) were identified. Seven patients were successful resuscitated without any sequelae and one patient expired. We changed the chemotherapy regimen in five patients and rechallenged oxaliplatin use in patient 3. Twenty-three relevant English-language studies with 66 patients were reported. Patients received a median of 10 cycles of oxaliplatin (range, 2 to 29). Most common symptoms were respiratory distress (60%), fever (55%), and hypotension (54%). Three fatal events were reported (4.5%). Eleven patients (16%) of the 66 cases were rechallenged by oxaliplatin. CONCLUSION: SAR must be considered in patients receiving oxaliplatin-related chemotherapy, especially in heavily pretreated patients. Further studies on the mechanism, predictors, preventive methods and management of oxaliplatin-related SAR are recommended.

Primary intratracheal schwannoma misdiagnosed as severe asthma in an adolescent:A case report

BACKGROUND Primary intratracheal schwannoma is an extremely rare type of benign airway tumor,especially in adolescents.The presenting symptoms are typically prolonged cough and wheezing that can be misdiagnosed as asthma in adolescent patients.CASE A 16-year-old adolescent girl admitted to a local hospital with symptoms of an irritating cough and wheezing was diagnosed with bronchial asthma and treated with budesonide and formoterol.Over the next year,the patient's wheezing and coughing symptoms gradually worsened and the antiasthma treatment was ineffective.One week prior to this admission,the patient developed dyspnea after catching a cold and was transferred to our hospital with a diagnosis of severe asthma.However,chest computed tomography and bronchoscopy showed a mass in the trachea.Primary intratracheal schwannoma was diagnosed by biopsy.Her symptoms were relieved by endoscopic resection by electrosurgical snaring combined with argon plasma coagulation.No relapse occurred during an 18 mo follow-up.CONCLUSION Primary intratracheal schwannoma should be considered in the differential diagnosis in adolescents with recurrent asthma-like attacks.