Stellate ganglion block & ventricular arrhythmias.

An electrical or ventricular storm is a life-threatening condition that must be treated as soon as possible. Here we have successfully saved a 32-year-old male patient with ventricular storm by going beyond the conventional treatment of ACLS. The ultrasound-guided stellate ganglion block terminates sympathetic over discharge thus terminates electrical storm. The emergency physicians need to be aware of the right timing, indication & ultrasound-guided nerve block technique as it is time a sensitive & final rescue technique to save the patient. Lack of expertise can lead to treatment failure or delay which can lead to poor resuscitation outcomes.

Detection of red cell alloantibody prior to overflow phenomenon in a case of warm AIHA secondary to Chronic Lymphocytic Leukemia and Myasthenia Gravis: A case report.

INTRODUCTION: Defects in the lymphoid system have been linked to immune dysregulation, which might explain why lymphoid neoplasms and immunological disorders tend to occur concurrently. Chronic Lymphocytic Leukemia (CLL), characterised by the accumulation of dysfunctional lymphocytes, is associated with autoimmune cytopenias such as autoimmune haemolytic anaemia (AIHA). Detection of underlying alloantibody in warm AIHA, is challenging for any transfusion medicine specialist. This report highlights the significance of overflow phenomenon in detection of alloantibody in a case of warm AIHA secondary to CLL and myasthenia gravis. CASE REPORT: A 56-year-old male with a history of myasthenia gravis and thymoma progressed to B-cell CLL presented with severe anaemia and thrombocytopenia leading to multiple red blood cell (RBC) transfusions in the last two months. Clinical profile and laboratory workup suggested features of AIHA, and subsequent immunohaematological workup hinted towards an impending overflow phenomenon due to differential reactivity pattern observed between serum and eluate with antibody screen/identification panel. The eluate was pan-reactive with an antibody screen/ identification panel, while the serum showed a discrete anti-C alloantibody pattern. A compatible and antigen-negative RBC unit was successfully transfused, followed by medical management. DISCUSSION: The overflow phenomenon in AIHA depends on antibody titre and its affinity for RBC antigens. In the index case, the impending 'overflow or spillover' of autoantibodies into the patient's serum allowed us to detect underlying alloantibody without performing allogeneic adsorption and transfuse antigen-negative and crossmatch compatible PRBC unit. CONCLUSION: This case emphasises the significance of understanding the overflow phenomenon in AIHA as it can guide a transfusion medicine specialist in the early detection and identification of underlying alloantibodies, which is crucial for appropriate transfusion management in AIHA. However, early presentation and timely workup, along with a high level of suspicion, is crucial to identify this phenomenon.

Study Protocol: IMPETUS: Implementing a Uniform Stroke Care Pathway in Medical Colleges of India: IMPETUS Stroke.

Introduction: In India, a national program for stroke (national programme for the control of cardiovascular diseases, diabetes, cancer, and stroke) and stroke management guidelines exist. Its successful implementation would need an organized system of stroke care in practice. However, many challenges exist including lack of awareness, prehospital notification systems, stroke ready hospitals, infrastructural weaknesses, and rehabilitation. We present here a protocol to investigate the feasibility and fidelity of implementing a uniform stroke care pathway in medical colleges of India. Methods and Analysis: This is a multicentric, prospective, multiphase, mixed-method, quasi-experimental implementation study intended to examine the changes in a select set of stroke care-related indicators over time within the sites exposed to the same implementation strategy. We shall conduct process evaluation of the implementation process as well as evaluate the effect of the implementation strategy using the interrupted time series design. During implementation phase, education and training about standard stroke care pathway will be provided to all stakeholders of implementing sites. Patient-level outcomes in the form of modified Rankin Scale score will be collected for all consecutive patients throughout the study. Process evaluation outcomes will be collected and reported in the form of various stroke care indicators. We will report level and trend changes in various indicators during the three study phases. Discussion: Acute stroke requires timely detection, management, and secondary prevention. Implementation of the uniform stroke care pathway is a unique opportunity to promote the requirements of homogenous stroke care in medical colleges of India.

Acute Myocardial Infarction in Hemophilia A with HIV and Hyperhomocysteinemia- a rare case report.

BACKGROUND: Patients with hemophilia have a hypocoagulable state and less chances of thrombus formation. Therefore, expected to have a lower cardiovascular mortality than the general population. The lower cardiovascular mortality can be explained by less chances of thrombus formation due to hypocoagulability. CASE PRESENTATION: Here we present a case of a 42-year-old male patient presented with severe chest pain radiating to back for 4 days. ECG was suggestive of recent acute anteroseptal myocardial infarction. There was a history of receiving intravenous recombinant factor VIII, 1 hour prior to the onset of chest pain for knee joint swelling. The occurrence of acute coronary syndromes in patients with hemophilia A is uncommon and rarely reported. CONCLUSION: Here we report a patient of severe hemophilia A who developed acute myocardial infarction after administration of recombinant factor VIII.

Empyema necessitans with osteomyelitis of fifth rib due to Nocardia farcinica: a case report.

BACKGROUND: Empyema necessitans is a rare pulmonary condition described as the presence of pus in the pleural cavity with insidious extension into the surrounding soft tissue. The common microbial aetiology of empyema necessitans is tuberculosis. Nocardiosis a cause of empyema necessitans is rarely described in the literature. We herein present a case of an 80-year-old male with empyema necessitans with osteomyelitis of rib caused by Nocardia farcinica. CASE PRESENTATION: An 80-year-old male presented with complaints of soft swelling on the left lower posterior chest wall associated with dry cough and breathlessness on exertion. Computed Tomography (CT) thorax demonstrated empyema necessitans with features of left fifth rib osteomyelitis. Radiological guided aspiration of the chest wall collection revealed Nocardia species and surgical drainage of abscess was performed. Matrix-assisted laser desorption/ionization time-of-flight-mass spectrometry (MALDI-TOF-MS) identified the isolate as Nocardia farcinica. He was treated with three-drug regimen: Trimethoprim-sulfamethoxazole, amikacin and ceftriaxone for 2 weeks. After showing improvement patient was discharged and advised to take oral Trimethoprim-sulfamethoxazole for the next 6 months with periodic follow-up. CONCLUSIONS: As our case demonstrates, the possibility of invasive Nocardiosis should not be overlooked even in immunocompetent patients. Clinicians should aware of this rare entity while treating patients with empyema necessitans.

Celiac disease with Budd-Chiari syndrome: A rare association.

Budd-Chiari syndrome is characterized by hepatic venous outflow tract obstruction. We describe an 18-year-old female of known celiac disease presented with progressive abdomen distention and shortness of breath for the last 1 month. Computed tomography of abdomen revealed hepatic vein obstruction. The patient was diagnosed with Budd-Chiari syndrome. Coagulation profile showed an increased homocysteine level. Serum folate level was also decreased. The patient was put on oral anticoagulant with a gluten-free diet. After 4 weeks, the patient showed significant improvement with decreased ascites. The association of Budd-Chiari syndrome with Celiac disease has not yet been fully understood. There have been few reports that described this rare association. Budd-Chiari syndrome should be considered as an important differential in a patient with unexplained ascites and celiac disease.

Acute Brucellosis Presenting as an Autoimmune Hemolytic Anemia.

Brucellosis is one of the most widespread zoonosis in the world. Hematological complications in brucellosis usually present as mild anemia, leukopenia, or pancytopenia. Autoimmune hemolytic anemia in brucellosis is rarely reported. Here, we report an 18-year-old female presented to us with progressive fatigue, jaundice, and fever. Hematological investigations revealed hemolytic anemia. Direct Coombs test was positive. Further evaluation showed positive serology and culture for Brucella. The patient was diagnosed with brucellosis with autoimmune hemolytic anemia. She was put on rifampicin and doxycycline along with corticosteroids. After 6 weeks, the patient was symptomatically improved with complete remission of hemolytic anemia. The possibility of brucellosis should be considered as a differential diagnosis of autoimmune hemolytic anemia, especially those living in the endemic areas.