Patient: Female, 57-year-oldFinal Diagnosis: Emphysematous osteomyelitis and emphysematous pyelonephritisSymptoms: Diarhea • nausea • vomiting • weaknessMedication: —Clinical Procedure: Conservative therapySpecialty: Infectious DiseasesObjective:Rare diseaseBackground:Emphysematous osteomyelitis of the spine is characterized by intravertebral or intraosseous air. Emphysematous pyelonephritis (EP) is the infection of the renal parenchyma and perirenal tissues caused by gas forming microorganisms and thus is characterized by gas formation. Prompt diagnosis and initiation of necessary treatment is crucial, as both entities are associated with high mortality rates.Case Report:A 57-year-old female with uncontrolled hyperglycemia presented to the emergency department with history of sudden onset of weakness, nausea, vomiting and diarrhea for 3 days and with a fall on the same level the previous day. Laboratory examinations revealed leukocytosis, lymphopenia, thrombocytopenia, deteriorated renal function, and hyperglycemic hyperosmolar non-ketotic state. She was placed on aggressive intravenous hydration and insulin infusion pump. Due to the deterioration of her medical condition, she underwent abdominal and pelvic CT scanning that revealed emphysematous osteomyelitis of the spine and emphysematous pyelonephritis. Despite vigorous fluid resuscitation and systemic broad-spectrum antibiotic therapy, the patient’s condition deteriorated further and eventually led to death within 48 h.Conclusions:This case of fatal emphysematous osteomyelitis of the spine and EP serves as a significant reminder of those rare life-threatening entities, which affect patients with comorbidities, such as diabetes mellitus and other etiologies causing immunosuppression. The aim of the present case report is to highlight the importance and contribution of computed tomography in diagnosing these conditions and to emphasize the rare coexistence of these 2 emphysematous entities.
Background: Spontaneous intracranial hypotension (SIH) is a rare syndrome characterized by heterogeneity of presentation and prognosis, which can occasionally result in serious complications, such as the formation of subdural hematomas (SDHs). This case series aims to emphasize that SIH remains a diagnostic and therapeutic challenge; it can present with a broad clinical spectrum of symptoms, can lead to SDH and, if conservative treatment fails, an epidural blood patch (EBP) is a viable treatment option. Although the exact etiology of SIH is not known, it is believed to be due to cerebrospinal fluid (CSF) leak or a low CSF pressure. Case Series: Three patients (two males and one female) with ages ranging between 38 and 53 years old who presented with complaints of not only an orthostatic headache, but also a variety of symptoms of SIH, including the formation of two SDHs in one of them, were included in this series. These patients did not respond to conservative management and, subsequently, given the clinical and radiological evidence of SIH, were referred to the Anesthesiology Department for an EBP. Diagnostic workup was facilitated by imaging modalities, including magnetic resonance imaging (MRI) of the brain and spinal cord, prior to the EBP. All three patients were subjected to an EBP with an 18-gauge epidural needle. A total of between 30 and 43 mL of autologous blood was collected from the patients and was injected into the epidural space under strict aseptic conditions. Two lumbar (L1–L2, L2–L3) EBPs and one thoracic (T11–T12) EBP were performed on the three patients, respectively. All patients reported complete resolution of symptoms following the EBPs, while MRI improved substantially. Conclusions: This report describes three cases of SIH with CSF leak originating from the cervical, the thoracic and the lumbar level. The EBP restored CSF pressure and relieved the patients’ persistent symptoms. MRI helps in revealing indirect signs of a low volume of CSF, though it may not be possible to locate the actual site of the leak. In conclusion, EBP is a well-accepted and beneficial treatment modality for SIH when conventional measures fail.
avoid a specific type of anesthesia technique. We sought to determine if neuraxial anesthesia use during TKA/THA differed among those previously diagnosed with multiple sclerosis or myasthenia gravis in comparison to the population without the diseases. Methods This study is approved by Hospital for Special Surgery Institutional Review Board (IRB# 2016-436). We analyzed patients undergoing a TKA/THA procedure using the Premier Healthcare Database. We created individual multivariable logistic regression models to compare patients with multiple sclerosis or myasthenia gravis to the non-diagnosed population.Results We identified 2,184,193 patients undergoing a TKA/ THA procedure, with 7,559 having a preoperative diagnosis for multiple sclerosis and 3,176 for myasthenia gravis. Neuraxial use among patients with pre-existing multiple sclerosis was lower (OR: 0.62, p=<.0001) than the non-diagnosed population (Table 1). Neuraxial anesthesia use among patients with pre-existing myasthenia gravis was not significantly different than use among the non-diagnosed population (OR: 1.05, p=0.2359). Conclusions Neuraxial anesthesia use during a TKA/THA procedure among those with pre-existing multiple sclerosis was significantly lower than those without the disease while about the same as controls for myasthenia gravis, respectively. Although previous research indicates that there is no relationship between neuraxial use and the exacerbation of symptoms in those with multiple sclerosis, there is indication that anesthesiologists are more likely to use general anesthesia.
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