Background: Nosocomial meningitis is a medical emergency that requires early diagnosis, prompt initiation of therapy, and frequent admission to the intensive care unit (ICU). Methods: A retrospective study was conducted in adult patients diagnosed with nosocomial meningitis who required admission to the ICU between April 2010 and March 2020. Meningitis/ventriculitis and intracranial infection were defined according to Centers for Disease Control and Prevention guidelines.Results: An incidence of 0.75% of nosocomial meningitis was observed among 70 patients. The mean patient age was 59 years and 34% were ≥65 years. Twenty-two percent of patients were in an immunocompromised state. A clear predisposing factor for nosocomial meningitis (traumatic brain injury, basal skull fracture, brain hemorrhage, central nervous system [CNS] invasive procedure or device) was present in 93% of patients. Fever was the most frequent clinical feature. A microbiological agent was identified in 30% of cases, of which 27% were bacteria, with a predominance of Gram-negative over Gram-positive. Complications developed in 47% of cases, 24% of patients were discharged with a Glasgow coma scale <14, and 37% died. There were no clear clinical predictors of complications. Advanced age (≥65 years old) and the presence of complications were associated with higher hospital mortality. Conclusions: Nosocomial meningitis in critical care has a low incidence rate but high mortality and morbidity. In critical care patients with CNS-related risk factors, a high level of suspicion for meningitis is warranted, but diagnosis can be hindered by several confounding factors.
When stroke patients present with respiratory failure, the first thought that clinicians have is that it is probably related to aspiration pneumonia. However, other causes should be considered, such as intracardiac or intrapulmonary shunts, that could present with paradoxical embolism. Paradoxical embolism is a rare entity defined by the occurrence of a venous thrombotic event associated with a systemic arterial embolism. Frequently, paradoxical embolism presents with platypnoea-orthodeoxia syndrome. Platypnoea-orthodeoxia syndrome is uncommon and is characterized by dyspnoea and hypoxaemia induced by orthostatic position, where symptoms and oxygenation are relieved by recumbency. The authors report a case of a patient who presented with an ischaemic stroke and progression to platypnoea-orthodeoxia syndrome with documentation of simultaneous pulmonary embolism and pulmonary arteriovenous malformations.
We report the case of a 61-year-old man admitted to our emergency department with fever. At admission, he was hypotensive and tachycardic. In the initial investigation, elevation of inflammatory parameters, acute kidney injury (Kidney Disease Improving Global Outcomes (KDIGO) 3), hyperbilirubinemia, and hepatic cytocholestasis were evident. Empirical antibiotic therapy was started, after sepsis was assumed without an identifiable cause. His condition took an unfavorable clinical course, with respiratory failure, hepatosplenomegaly, pancytopenia, hyperferritinemia and hypofibrinogenemia. Microbial culture studies and a general immunological study were negative and lymphoproliferative disease was therefore excluded. Bone marrow aspirate revealed hemophagocytosis without granulomas. A diagnosis of hemophagocytic lymphohistiocytosis was assumed and pulse methylprednisolone therapy initiated. As this resulted in only a transient improvement, immunoglobulin and rituximab were initiated as a second-line therapy. The patient sadly had an unfavorable outcome despite all measures undertaken. In the postmortem study, Mycobacterium tuberculosis complex was isolated in the bone marrow aspirate, which led to the postmortem diagnosis of disseminated tuberculosis and angioinvasive pulmonary aspergillosis. The clinical presentation of disseminated tuberculosis is non-specific and hemophagocytic lymphohistiocytosis is one of its rare presentations. The mortality rate of hemophagocytic lymphohistiocytosis is high and increases with delayed diagnosis of the underlying condition and respective treatment.
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