Group A Streptococcus Pneumonia in a Previously Healthy Individual: Is It Still a Thing?

Group A streptococcus (GAS) is known to cause many different kinds of infections, including invasive pneumonia in rare cases. When it is the causative agent, it is associated with a more severe disease course, but it can often be adequately treated if caught early enough. We hereby present the case of a 32-year-old male with no past medical history who presented with fever, hemoptysis, and tachycardia. Laboratory results showed leukocytosis, hyponatremia, mild transaminitis, and elevated creatine kinase. Initial imaging findings and clinical presentation were concerning for tuberculosis (TB) vs. community-acquired pneumonia (CAP), as it yielded a consolidation in the right upper lobe. The patient had no obvious risk factor except for imprisonment two years prior to symptoms onset. Empirical antibiotics and steroids were started. Quantiferon and acid-fast bacteria (AFB) were negative, but sputum and blood cultures were positive for Streptococcus pyogenes, ruling out TB. Antibiotic therapy was narrowed down. The patient responded well to therapy, with subsequent resolution of symptoms. The current body of knowledge regarding respiratory infections caused by GAS is limited by multiple factors, including its relative rarity and the diversity of how it can present, especially in a developed country. Its mimicry characteristics of other clinical entities, such as TB, can be deceiving, which can delay appropriate treatment if it occurs in settings where the diagnostic tools are not readily available. By sharing more cases and atypical presentations of this disease, the clinical presentations of this pathogen can be more fully understood, and it can be more rapidly identified and treated.

Low Risk Meets High Stakes: Unraveling the Mystery of Low D-dimer Pulmonary Embolism.

Pulmonary embolisms (PEs) are potentially life-threatening emergencies that carry significant morbidity and mortality. Advances in treatment options and the safety of existing procedures have effectively reduced the long-term and short-term effects of the condition. Therefore, it is important to make an early diagnosis so that treatment options can be thoroughly explored. The D-dimer is an important tool in the early diagnosis of PEs. It is especially useful in ruling out the diagnosis in patients with a low to moderate suspicion of the disease. We present a case of a 22-year-old male who presented with exertional dyspnea, congestion, and rhinorrhea for one day and was noted to have persistent hypoxia and tachycardia. The influenza test was positive, and he was started on oseltamivir. Due to persistent hypoxia, a CT pulmonary angiogram was ordered and revealed filling defects in the left lower lobe segmental vessels suggestive of PE, as well as multifocal multilobar bilateral ground-glass opacities. He was initially treated with a heparin drip and subsequently switched to eliquis. After a significant improvement in his hypoxia, he was discharged home for outpatient follow-up, including a hypercoagulable workup. This case demonstrates that despite the usefulness of the D-dimer as a diagnostic tool for PEs, it cannot solely or fully replace the full gamut of screening tools used to determine the risk of PE. Although rare, false-negative scores do occur; therefore, the tool should always be used in conjunction with other scoring systems, physician gestalt, and within the specific clinical context.

Superior Mesenteric Artery Dissection After Lumbar Puncture.

We hereby present a case of iatrogenic dissection of the superior mesenteric artery dissection in a 63-year-old female undergoing a lumbar puncture (LP). She presented with severe diffused abdominal pain accompanied by lower back pain, nausea and vomiting a few hours after undergoing an LP due to ongoing headaches. Abdominal CT showed evidence of hemoperitoneum. She was then transferred to another facility and while in route received one unit of packed red blood cellsdue to drop in hemoglobin levels from 15 to 11 gm/dl. Physicians should consider the possibility of arterial variations and the level at which spinal tap is performed during interventions. Acute abdominal pain is a significant, common complaint that should be appropriately investigated.

Effectiveness of Hyperbaric Oxygenation Versus Normobaric Oxygenation Therapy in Carbon Monoxide Poisoning: A Systematic Review.

Carbon monoxide (CO) is a gas product of combustion, considered highly poisonous. Prolonged CO exposure is responsible for more than half of fatal poisonings and is also one of the leading causes of poisoning in Western countries. We aimed to compare the effectiveness of therapy with hyperbaric oxygen (HBO) versus normobaric oxygen (NBO) in the setting of carbon monoxide poisoning (COP). We independently searched the National Library of Medicine's Medline (PubMed™), ScienceDirect™, and Scielo™ for any relevant studies published from 1989 to 2017, using the following keywords: hyperbaric therapy, hyperbaric oxygenation, normobaric therapy, carbon monoxide poisoning, carboxyhemoglobin, Haldane effect. We analyzed the studies that suggested the effectiveness of HBO or NBO. Also, we searched for studies related to COP; including history, epidemiology (risk factors, incidence, demographics), pathophysiology, clinical manifestations, diagnosis, and treatment. Sixty-eight articles were found, sixteen of which dealt with either HBO or NBO or both. Twelve suggested HBO as the treatment of choice in COP; four studies indicated that NBO was an adequate treatment due to its cost-effectiveness and availability in the emergency department (ED). HBO has been shown in several studies to be effective in moderate to high-risk COP situations, being the therapy of choice to avoid sequelae, especially neurologically. NBO can be considered as a reasonable alternative due to its cost-effectiveness. The availability and understanding of different therapeutic interventions are critical in the management of patients with COP in ED and the Critical Care unit.

Sequential Targeted Temperature Management: Case Report and Literature Review.

We present the case of a 59-year-old gentleman with a history of nonmetastatic tonsillar malignancy and radiation chondronecrosis, who underwent targeted temperature management (TTM) in a sequential manner. The first time the patient underwent therapeutic cooling occurred after he developed a respiratory arrest followed by a cardiac arrest and prolonged hypoxemia after a diagnostic laryngoscopy. The patient was kept at 32°C for 24 hours, and 48 hours after rewarming woke up neurologically intact. However, six hours post-extubation, he suffered upper airway obstruction, followed by a prolonged cardiac arrest. Return of spontaneous circulation on this second episode was achieved after 45 minutes of resuscitation maneuvers. The patient was cooled again and kept at 32°C for 48 hours. Five days later, the patient recovered, with an intact neurologically function. This case stands out the importance of sequential TTM after repeat cardiac arrests with a return of spontaneous circulation (ROSC), demonstrating this process as a neuroprotective way of treatment.

Role of vitamin C in diabetic ketoacidosis: Is it ready for prime time?

Diabetic ketoacidosis (DKA) is life-threatening acute metabolic complication of diabetes mellitus (DM) that is characterized by acidosis, ketosis, and hyperglycemia, currently affecting mostly patients under 30 years of age with diabetes mellitus type 1. In both, DM and DKA, a pro-inflammatory state exists. This clinical entity occurs as a result of hyperglycemia-induced disturbances, resulting in an increased oxidative metabolism. For the latter reason, the use of vitamin C seems promising in DKA due to its antioxidant role in reducing the superoxide radicals that are consequence of the oxidative stress. This can decrease the pro-inflammatory state and avoids complications. Vitamin C, or also known as ascorbic acid, has been widely used in several illnesses, such as common cold, tissue healing, fertility, atherosclerosis, cancer prevention, immunity restoration, neuro-degenerative disease and also has been suggested to decrease the risk of DM, and this reason is giving place to believe that vitamin C can have an important role in treating diabetic complications such as DKA. In order to counteract these oxidative disturbances in DKA patients, we analyzed the current data regarding vitamin C and evaluate its role in any type treatment of this complication in the near future.

Clinical features of Guillain-Barré Syndrome in a tertiary-level hospital in Mexico / Síndrome de Guillain-Barré en el Hospital de Especialidades del Centro Médico Nacional Siglo XXI

Background: Guillain-Barré Syndrome (GBS) is an acute polyneuropathy characterized by symmetrical weakness of the limbs with hyporeflexia or areflexia with a maximum progression within four weeks and can impair respiratory function and implies disability at a long. The aim of this paper was to describe the clinical, epidemiological and neurophysiological features of patients with GBS at the Hospital de Especialidades del Centro Medico Nacional Siglo XXI (HECMNSXXI) Methods: An observational, retrospective cross-sectional study, data were collected form clinical records of adults with GBS hospitalized in HECMNSXXI from March 2012 to March 2016. The recorded variables were demographics, previous infection, clinical presentation, disability scores, prognosis scores and neurophysiological subtypes. Results: Clinical records of 94 patients were analysed with a mean age of 53 years, 61% male, with previous infection in 80%. Albumin cytologic dissociation was present in 50%. Medical Research Council (MRC) sum scores mean was 32, the SGB disability score at admittance with a mean of 3.63. The axonal subtype was in 68%, and demyelinating in 29%, not conclusive in 3%. Conclusions: In this study the demographic and clinical features are similar to other previous reports, we documented a greater proportion of axonal subtype, which are related with important disability and worse prognosis.

Introducción: El síndrome de Guillain-Barré (SGB) es una polirradiculoneuropatía aguda caracterizada por debilidad simétrica progresiva de las extremidades con hipo o arreflexia, que progresa en un máximo de 4 semanas y que puede llevar a la falla respiratoria y a discapacidad a largo plazo. El objetivo de este trabajo fue describir las características clínicas, epidemiológicas y neurofisiológicas de pacientes con SGB del Hospital de Especialidades del Centro Médico Nacional Siglo XXI (HECMNSXXI). Métodos: Se realizó un estudio observacional de tipo transversal retrolectivo. Se obtuvieron datos de expedientes clínicos de adultos con diagnóstico de SGB hospitalizados en el HECMNSXXI en el periodo de marzo de 2012 a marzo de 2016. Se registraron variables demográficas, clínicas y neurofisiológicas. Resultados: Se incluyeron 94 pacientes con un promedio de edad de 53 años, en su mayoría hombres, con infección previa en 80%. La fuerza muscular medida con la escala del Medical Research Council (MRC) fue en promedio de 32, la escala de discapacidad del SGB (Hughes) al ingreso tuvo un promedio de 3.63. La variedad axonal se encontró en 68%, la desmielinizante en 29% y en 3% no concluyente. Conclusiones: Se documentan en esta muestra características demográficas y clínicas similares a lo reportado en la literatura, así como la mayor proporción de variedades axonales, las cuales tienen mayor severidad en la presentación clínica así como mal pronóstico.