Case presentation: A 58-year-old gentleman presented to A&E with low back pain for a few days and lower limb weakness for 24 hours. His background history was not medically significant. On examination, GCS 14/15, lower limbs power 2/5, and palpable urinary bladder. DRE revealed poor anal tone. MRI spine showed epidural abscess at L3-L4 & L5-S1 level and urgent decompressive spinal surgery was performed. IV antibiotics were started and the patient was admitted to the general HDU for vasopressor support. Since the operation, he developed cold, pale, swollen right leg, with no palpable peripheral arteries. A CT aortogram showed occlusion of the right popliteal artery. Right popliteal artery exploration with anterior and posterior tibial embolectomy and fasciotomies were done. As the patient was slow to wake up post-surgery, he was transferred to ICU. MRI brain showed no pathology. Transthoracic echocardiogram revealed no vegetation. As clinical suspicion of infective endocarditis was high, transoesophageal echocardiogram and real-time 3D analysis was done which showed a large highly mobile echogenic mass attached to the left atrial surface of the anterior mitral leaflet (A1 and A2) causing moderate MR. Urgent surgical mitral valve repair and removal of a 2 cm vegetation were performed. Both the blood culture and the culture of the vegetation tissue confirmed the growth of Staphylococcus aureus (MSSA). After 8 weeks of hospital stay, the patient was discharged home. Discussion: The objective of this case presentation is to reemphasize that infective endocarditis is not a single organ disease and can present to different specialities. Transthoracic echocardiography has reduced sensitivity in the critical care setting. So, there should be a relatively low threshold for transoesophageal echocardiography. Although the mortality rate of infective endocarditis is relatively high in ICU patients, multidisciplinary team management may result in favourable outcomes.
With an estimated incidence of 0.02 to 3.23%1, neuroleptic malignant syndrome (NMS) is a rare idiosyncratic reaction to antipsychotic drugs; having a relatively high fatality rate of about 10%2. Here, we are reporting, a 38 years old female schizoaffective patient, presented with fever, muscle rigidity and altered sensorium who had started tablet risperidone(an atypical antipsychotic drug) 11 days prior to hospital admission. After initial sepsis work up and neuroimaging, infective causes and acute cerebrovascular incidents were ruled out and a presumptive diagnosis of NMS was made. Immediate discontinuation of suspected causative agent, along with the provision of supportive care leads to complete resolution of all the symptoms in our patient.Bangladesh Crit Care J September 2018; 6(2): 108-110
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