Patients with large variations in phenytoin levels despite standard doses may prove to become difficult clinical problems. Our study of 34 head injury patients whose serum phenytoin levels were measured on day one and day five following intravenous loading and maintenance dose of phenytoin, showed 38.24% patients, to have therapeutic phenytoin levels on day one, while 20% were in toxic range. On day five, 23% patients were in toxic and 29.41% were in therapeutic range. Only 21% patients remained in the therapeutic range during the monitoring period. This study shows that there is a wide variability of phenytoin levels in the ICU patients with a difference of more than 100% between the highest and lowest phenytoin level in individual cases (in four patients the difference exceeded 500%) raising concern about the safety of the drug. Hence it is recommended that intensive care unit patients receiving phenytoin therapy should have periodic serum phenytoin obtained even in absence of seizures or classic signs phenytoin toxicity.
Pseudomonas aeruginosa is usually considered a relatively rare pathogen of pyogenic liver abscess in healthy children. A 3-year-old girl presented with fever, abdominal pain, and vomiting. Ultrasonography of the abdomen showed multiple liver abscesses. During her stay in hospital, she developed portal vein thrombosis, hepatic encephalopathy, and multiorgan dysfunction. Her blood culture and pus culture grew pseudomonas aeruginosa. She was started on intravenous antibiotics and supportive treatment. Ultrasound guided aspiration was done and a pigtail catheter was inserted. However, she did not respond to the treatment and died on the 14th day of admission. The immune work up of the patient was normal. Through this case, we wish to highlight this unusual case of community-acquired pseudomonas aeruginosa liver abscess in a previously healthy child. Clinicians should be aware of this association for early diagnosis and timely management.
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