Acute generalised exanthematous pustulosis (AGEP) is a rare cutaneous eruption, most often caused by commonly used antibiotics. It is characterised by an acute onset of non-follicular sterile pustular rash and erythema within hours or days of drug exposure and usually resolves spontaneously within 1–2 weeks once the drug is discontinued. Haemodynamic involvement in the form of shock is rare. Here, we present a severe case of AGEP, manifesting with systemic involvement and haemodynamic instability resulting in shock with multiorgan dysfunction. The associated drugs were erythromycin and fluconazole with a possible combined effect of these two drugs that resulted in systemic involvement. Our patient improved markedly, both haemodynamically and dermatologically, after discontinuation of the drugs and with systemic steroid therapy.
Patient was readmitted to the hospital and treated with cefepime and metronidazole. Positive physical findings were the presence of a high pitched decrescendo diastolic murmur and widened pulse pressure. Transesophageal echocardiogram showed mobile echogenic lobulated mass of the non-coronary cusp of aortic valve with resultant severe aortic insufficiency. The patient received an aortic valve replacement. He was discharged with 6 weeks of intravenous ceftriaxone. CK endocarditis is rare in immunocompetent adults. Our literature search yielded only four prior case reports. Based on our patient's urinary symptoms at presentation along with evidence of pyuria and bacteriuria, this patient's principle infection was likely genitourinary in nature. In conclusion, it is important for clinician's to closely monitor patients with CK bacteremia. If patients have underlying valvular disease, the development of vegetation can be rapid and can be fatal if left undetected.Learning Objectives: Background: Antifibrinolytic agents are widely used to overcome acute episodes of bleedings in traumatic hyperfibrinolysis, where rotational thrombelastometry can provide a rapid diagnostic and therapeutic guidance. However, the therapeutic role of antifibrinolytics as well as the diagnostic value of thrombelastometric analysis remains undefined in non-traumatic fibrinolytic bleedings. Methods: We report a 68 year old woman whose initial presentation were clinically striking facial hemorrhages after syncope. Rotational thrombelastometric analysis was used for diagnosis of hyperfibrinolysis and to demonstrate the in vitro effects of tranexamic acid prior to its in vivo use. Results: ROTEM® demonstrated a complete absence of clotting, and tranexamic acid improved clotting both in vitro and in vivo revealing pronounced hyperfibrinolysis. Initial platelet counts were 66x109/L, fibrinogen levels <50 mg/dL, D-dimer 100 μg/mL and prothrombin time 72% resulting in an overt ISTH-DIC score of 5. Additionally, the activated partial thromboplastin time was non-measurable (>180s) on admission, and paralleled the course of D-dimer levels during the hospitalization period (rs=0.86; p<0.001). Computed tomography revealed colorectal cancer (adenocarcinoma G2 in histological analysis), metastasis in inguinal lymph nodes as well as a large intra-cardiac thrombus of 7 cm diameter, which was the likely cause of hyperfibrinolytic disseminated intravascular coagulation. Conclusion: These data demonstrate hyperfibrinolytic DIC associated with a large cardiac thrombus, diagnostic and therapeutic guidance by thrombelastometry and the capacity of tranexamic acid to restore clotting in non-traumatic hyperfibrinolysis. APTT could be a marker of the severity of hypofibrinogenemia in hyperfibrinolytic type of DIC.
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