Patient: Male, 48Final Diagnosis: Pituitary apoplexy complicated by cerebral infarctionSymptoms: Disturbed conscious level • loss of visionMedication: —Clinical Procedure: —Specialty: RadiologyObjective:Unusual clinical courseBackground:Pituitary macroadenoma is a common benign tumor that usually presents with visual field defects or hormonal abnormalities. Cerebral infarction can be a complication of a large pituitary adenoma. We report a rare case of bilateral anterior cerebral arteries infarcts by a large pituitary macroadenoma with apoplexy.Case Report:A 48-year-old male patient presented with altered conscious level and sudden loss of vision for one-day duration. Magnetic resonance imaging of the brain showed a large seller and suprasellar hemorrhagic mass of pituitary origin, with associated bilateral areas of diffusion restriction in the frontal parasagittal regions, consistent with infarctions. Magnetic resonance angiography showed elevation and compression of A1 segment of both anterior cerebral arteries by the hemorrhagic pituitary macroadenoma. The patient underwent trans-sphenoidal resection of the pituitary adenoma, but unfortunately, ischemia was irreversible. Computed tomography (CT) done post-operatively showed hypodensity in the frontal and parietal parasagittal areas, which was also persistent in the follow up CT scans. The patient’s neurological function remained poor, with GCS of 8/15, in vegetative state.Conclusions:Vascular complications of the pituitary apoplexy, although uncommon, can be very severe and life threatening. Early detection of vascular compromise caused by hemorrhagic pituitary macroadenoma can prevent delay in intervention. Clinicians should also consider pituitary adenoma as a possible cause of stroke.

C. difficile colitis can cause intra-abdominal hypertension (IAH) and ACS. Rapid diagnosis, early aggressive supportive care, metronidazole and prokinetics are necessary to lower the morbidity and mortality of C. difficile colitis associated with IAH and ACS.

Epidural analgesia or anesthesia is a common procedure for pain relief, especially in obstetrics. Pneumorrhachis and pneumothorax are rare complications of epidural analgesia. They are considered asymptomatic entities but have recently caused increased morbidity and mortality. As the use of epidural analgesia and anesthesia increased significantly in the last decade, clinicians must be aware of this entity. This is a case report of pneumorrhachis causing pneumothorax and pneumomediastinum leading to respiratory distress. Case: A 26-year-old obese primigravida at 37 weeks’ gestation and with failure of progression of labor underwent lower segment cesarean section under epidural anesthesia. The procedure including the delivery of fetus was uneventful. In the post-anesthesia care unit, the patient became tachypneic, and her oxygen saturation was low despite supplemented oxygen by face mask and adequate analgesia. She was afebrile and was admitted to the surgical intensive care unit (SICU) for further management. In the SICU, incentive spirometry was initiated, and analgesia with intravenous fentanyl was given. Her echocardiogram was normal. Computer tomographic examination ruled out pulmonary embolism but showed pneumorrhachis with extension into the mediastinum and right apical pneumothorax. She was hemodynamically stable. In the next two days, her tachypnea settled, and the oxygen saturation improved to normal. On the third day, she was transferred to the ward and discharged home from there. She was followed up in the outpatient clinic after one and four weeks and was doing well, and her repeat imaging studies were normal. Conclusion: Epidural analgesia can lead to pneumorrhachis and can cause pneumothorax leading to respiratory distress.

Background: Immunomodulatory property of intravenous immunoglobulin (IVIG) has been used to counteract severe systemic inflammation in coronavirus disease 2019 (COVID-19). However, its use in acute respiratory distress syndrome (ARDS) due to COVID-19 pneumonia is not well established.Methods: In this retrospective study, we analyzed electronic health records of COVID-19 patients admitted to intensive care units (ICUs) at Hazm Mebaireek General Hospital, Qatar, between March 7, 2020, and September 9, 2020. Patients receiving invasive mechanical ventilation for moderate-to-severe ARDS were divided into two groups based on whether they received IVIG therapy. The primary outcome was all-cause ICU mortality. Secondary outcomes studied were ventilator-free days and ICU-free days at day-28 and incidence of acute kidney injury (AKI). Propensity score matching was used to adjust for confounders, and the primary outcome was compared using competing-risks survival analysis.Results: Among 590 patients included in the study, 400 received routine care, and 190 received IVIG therapy in addition to routine care. One hundred eighteen pairs were created after propensity score matching with no statistically significant differences between the groups. Overall ICU mortality in the study population was 27.1%, and in the matched cohort, it was 25.8%. Mortality was higher among IVIG-treated patients (36.4% vs. 15.3%; sHR 3.5; 95% CI 1.98- 6.19; P<0.001). Ventilator-free days and ICU-free days at day-28 were lower (P<0.001 for both), and the incidence of AKI was significantly higher (85.6% vs. 67.8%; P=0.001) in the IVIG group.Conclusion: IVIG therapy in mechanically ventilated patients with COVID-19 related moderate-to-severe ARDS was associated with higher ICU mortality. A randomized controlled study is required to confirm this observation further.

Background: Immunomodulatory property of intravenous immunoglobulin (IVIG) has been used to counteract severe systemic inflammation in coronavirus disease 2019 (COVID-19). However, its use in acute respiratory distress syndrome (ARDS) due to COVID-19 pneumonia is not well established.Methods: In this retrospective study, we analyzed electronic health records of COVID-19 patients admitted to intensive care units (ICUs) at Hazm Mebaireek General Hospital, Qatar, between March 7, 2020, and September 9, 2020. Patients receiving invasive mechanical ventilation for moderate-to-severe ARDS were divided into two groups based on whether they received IVIG therapy. The primary outcome was all-cause ICU mortality. Secondary outcomes studied were ventilator-free days and ICU-free days at day-28 and incidence of acute kidney injury (AKI). Propensity score matching was used to adjust for confounders, and the primary outcome was compared using competing-risks survival analysis.Results: Among 590 patients included in the study, 400 received routine care, and 190 received IVIG therapy in addition to routine care. One hundred eighteen pairs were created after propensity score matching with no statistically significant differences between the groups. Overall ICU mortality in the study population was 27.1%, and in the matched cohort, it was 25.8%. Mortality was higher among IVIG-treated patients (36.4% vs. 15.3%; sHR 3.5; 95% CI 1.98- 6.19; P<0.001). Ventilator-free days and ICU-free days at day-28 were lower (P<0.001 for both), and the incidence of AKI was significantly higher (85.6% vs. 67.8%; P=0.001) in the IVIG group.Conclusion: IVIG therapy in mechanically ventilated patients with COVID-19 related moderate-to-severe ARDS was associated with higher ICU mortality. A randomized controlled study is required to confirm this observation further.

Background & Aim: Since The emergence of the COVID-19, patients with cancer have been among the most vulnerable patients, as this infection can be severe and mostly requires intensive care therapy. Literature discussing the risk factors and the outcome of these patients in intensive care units (ICU) is accumulating. Our study aims to search for the incidence of COVID-19 infection in cancer patients and analyses their associated comorbidities, possible risk factor for infections, and their outcomes. Methods: Patients with active cancer under treatment and those recently diagnosed with cancer and had confirmed COVID-19 infection requiring ICU admission were included in our study over 8 months, from March to October 2022. Patient demographic data, comorbidities, ICU stay, duration of hospital stay, oxygenation/ventilatory requirements, treatment, secondary bacterial infection, and outcome were collected from the COVID-19 patients' registry in the ICU. Data were entered into the SPSS program version 23, and results were considered statistically significant at p ≤ 0.05. Results: A total of 24 patients with cancer and COVID-19 infection required intensive care therapy. The most common type of malignancy in those patients was solid organ tumor (13 vs. 11 patients), and most of the study sample were males (20/ 83.3%). Seventy-five percent (18 patients) required intubation and invasive ventilation. Twenty-nine percent (7 patients) had secondary bacterial pneumonia and bacteremia. In addition, 70% had septic shock and required vasopressors. Acute kidney injury (AKI) due to rhabdomyolysis (P<0.001), secondary bacterial infection (P<0.006), bacteremia and pneumonia (P<0.02), invasive ventilation (P<0.02) and requiring muscle relaxant (P<0.02), the requirement for High flow nasal cannula and prone position (P<0.03 and 0.01) respectively, shock (P<0.004) were significantly associated with increased mortality. Patients with cancer and COVID-19 had higher severity scores (P<0.003), longer ventilation duration (P<0.002), and ICU stay (P<0.002). Overall mortality was 45%.8, there was no significant difference in mortality rate between patients with solid organ tumors and hematological malignancy with COVID-19 infection requiring intensive care therapy (P<0.68). Conclusion: Cancer patients requiring ICU were more prone to develop AKI, rhabdomyolysis, secondary infection, requiring ventilation and prone position, and septic shock. These patients had a significantly high mortality rate and were severely ill, requiring prolonged ventilation and ICU stays.

Laparoscopic surgery is the standard of care for various abdominal pathologies due to apparent advantages. Nevertheless, the initial steps of the Veress needle or trocar are inserted blindly in laparoscopic surgeries, which may cause major vascular, bowel, or urinary tract injuries. We report two cases of vascular laparoscopic entry injuries.

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