Successful Treatment of Pseudomembranous Colitis with Fecal Microbiota Transplantation - A Case Study on A Patient Rescued by Extracorporeal Cardiopulmonary Resuscitation After Cardiac Arrest.

BACKGROUND Pseudomembranous colitis (PMC) is an opportunistic, nosocomial infection caused by Clostridium difficile. CASE REPORT Here we described a patient who developed PMC during her recovery from cardiac arrest. A 16-year-old female high school student experienced sudden cardiac arrest. Spontaneous circulation was not returned by standard cardiopulmonary resuscitation. After her admission to the emergency unit, her cardiac function and neurologic function were finally resumed by extracorporeal cardiopulmonary resuscitation (ECPR); however, after 14 days, her recovery was complicated with excessive diarrhea and shock. Colonoscopy confirmed the diagnosis of PMC. Metronidazole and vancomycin were immediately administered; however, the treatment did not result in any improvement. Fecal microbiota transplantation was then performed, and after 4 transplantations, her diarrhea was significantly ameliorated. After hospital stay for 135 days, the patient was finally discharged with grade II brain function. She later recovered self-care ability in follow-up. CONCLUSIONS The patient suffered from a long-term gastrointestinal ischemia-hypoxia resulting from cardiac arrest. The use of broad-spectrum antibiotics in the later treatment led to refractory PMC, which was successfully managed by multiple fecal microbiota transplantation.

Medical evacuation from abroad of critically ill patients: A case report and ethical issues.

RATIONALE: Patients repatriated from foreign hospitals are sources of extensively drug-resistant (XDR) bacteria outbreaks. Thus, an individual benefit potential for the patient opposes a collective ecological risk potential. These ethical issues have not been well studied. PATIENT CONCERNS: We report the case of a 74-year-old patient repatriated from Mauritius to the French island of Reunion who presented mesenteric infarction evolving over several days, and who suffered a cardiac arrest before transfer. DIAGNOSES: In Reunion Island, a CT-scan revealed a multisegmental enlarged parietal enlargement associated with free peritoneal effusion and a suboccluded aspect of the superior mesenteric artery. INTERVENTIONS: Surgical exploration showed a severe mesenteric infarction with peritonitis, and a resection of 120cm of the small intestine was conducted. This patient was infected with a vanA glycopeptide-resistant Enterococcus faecium and a carbapenem-resistant Klebsiella pneumoniae which produced carbapenemases NDM-1 and OXA-181, which required specific care and could have led to a local epidemic. OUTCOMES: The patient died after 9 days after being admitted to the ICU. LESSONS: Repatriation of critically ill patients from abroad should be considered according to ethical criteria, evaluating, if possible, the expected benefits, and ecological risks incurred. Limiting unnecessary transfers could be an effective measure to limit the spread of XDR bacteria.

Lemierre's syndrome and 2016 American College of Physician guidelines for pharyngitis: no to empiric coverage for bacterial pharyngitis. While no role for routine Fusobacterium PCR, keep suspicion for this pathogen.

An 18-year-old woman presented to clinic with acute pharyngitis with 4/4 Centor criteria. Rapid streptococcal antigen test was negative. The patient, who was allergic to penicillin, was prescribed azithromycin. Ultimately, after 5 days and without any corticosteroids, she presented to the emergency department with 10/10 chest pain and was admitted to the intensive care unit. CT showed nodular lung disease and blood cultures on admission grew Fusobacterium, likely Fusobacterium nucleatum. She sustained two cardiac arrests, three tube thoracostomies, acute kidney injury requiring dialysis and ventilatory failure requiring tracheostomy. After 16 days in hospital and 18 days in long-term acute care, the patient was discharged home. It is unclear how much of this could have been prevented by prescribing an antimicrobial that had activity against Fusobacterium When severe pharyngitis occurs, Fusobacterium needs to be considered as an underlying cause. In vitro macrolides have marginal activity against most anaerobes, such as this pathogen, and should be avoided.

Sepsis-associated in-hospital cardiac arrest: Epidemiology, pathophysiology, and potential therapies.

Sepsis-associated cardiac arrest is a relatively common occurrence with especially poor outcomes. Of the greater than 200,000 in-hospital cardiac arrests that occur in the United States annually, between 30,000 and 60,000 occur in patients with underlying sepsis. These patients are less likely to survive than cardiac arrest victims without sepsis. In this review, we discuss the epidemiology of sepsis-associated in-hospital cardiac arrest in adults and children, the relevant physiology responsible for its pathogenesis and poor outcomes, and potential therapeutic interventions based on this pathophysiology. We postulate that persistence of sepsis pathophysiology during and after cardiac arrest is responsible for these poor outcomes. This includes derangements of vascular tone and intravascular volume status; myocardial dysfunction; hypoxemia, acidemia, and other metabolic derangements; and pulmonary hypertension. Potential interventions that specifically target this pathophysiology before, during, and after cardiac arrest may augment standard cardiopulmonary resuscitation and post-resuscitation care for patients with sepsis and septic shock.

Is it safe to leave an ECMO circuit primed?

Extracorporeal membrane oxygenation (ECMO) is a means of life support for failing patients who require extreme life-saving measures due to failure of their heart, lungs or both organs. In a patient suffering cardiac arrest, the faster circulation via cardiopulmonary resuscitation (CPR) can be instituted the better the outcome is. If an ECMO circuit needs to be built and primed it may add significant minutes to the response time. The purpose of this study is to test for any growth in primed ECMO circuits at given time intervals to prove the safety of leaving an ECMO circuit primed. This, in turn, may lead to decreased response time, with an arrest and the placement of the arresting patient on ECMO. Five ECMO circuits were set up, primed and sampled for bacterial growth at 0, 24, 48 and 72 hours and then at one-week intervals, with an end point of four weeks. No bacterial growth was found at any point during the sampling process.

Severe septic shock and cardiac arrest in a patient with Vibrio metschnikovii: a case report.

INTRODUCTION: Vibrio metschnikovii is a very rare species and can be fatal to patients with massive comorbidity. Until now only eight other cases have been reported. CASE PRESENTATION: This case report describes a 78-year-old Danish man who presented with fever, hypotension and unconsciousness and he developed cardiac arrest. Vibrio metschnikovii was identified in all his blood samples and effective antibiotics were initiated. CONCLUSIONS: The human sources are believed to include shrimps, birds, water, sewage and seafood. We report the first case of Vibrio metschnikovii from a Nordic country and the report shows that even though isolation of Vibrio metschnikovii from human clinical samples is very rare, it still infects humans and may be fatal, despite sufficient treatment.

[Cardiac arrest during serve Pneumocystis jiroveci infection in an immune-compromised patient after splenectomy]. / Zatrzymanie krazenia w przebiegu pneumocystozowego zapalenia pluc u chorego z usunieta sledziona.

BACKGROUND: Pneumocystis jiroveci (old name Pneumocystis carini) can cause severe pneumonia in immune-compromised patients, most commonly those who are HIV infected. CASE REPORT: A 68-yr-old man, who eight years earlier had undergone trauma related splenectomy, was admitted to ITU after a cardiac arrest due to septic shock caused by unknown pathogen. He had been treated for three weeks with various antibiotics without improvement. On the second day after resuscitation, high concentration of lgM anti-Pneumocystis jivecii antibodies was found, and high-dose trimetoprim therapy was started and continued for two weeks, Further treatment was complicated by ventilator-associated pneumonia (Acinetobacter baumannii); the patient eventually recovered without any neurological sequelae, and was transferred to a low-dependency area after 4 weeks in ITU. CONCLUSION: We conclude that Pneumocystis jiroveci infection should be suspected as a cause of severe pneumonia in splenectomised patients.

Extracorporeal life support for treatment of children with enterovirus 71 infection-related cardiopulmonary failure.

PURPOSE: Enterovirus 71 (EV71) infection leading to cardiopulmonary failure (CPF) is rare, but usually fatal. In such cases, intensive cardiorespiratory support is essential for survival. In this study, we report our experience in the treatment of EV71-related CPF with extracorporeal life support (ECLS). METHODS: This was a retrospective study of a total of 13 children, aged 16 +/- 10 months, with EV71-related hemodynamically unstable CPF, which was refractory to conventional treatments, who were rescued by transsternal ECLS from 2000 to 2008. The clinical manifestations and outcomes of the 13 children (present cohort) were compared with those of 10 children (past cohort) who had EV71-related CPF without ECLS between 1998 and 2000. RESULTS: Among these 13 patients, 10 were successfully weaned off ECLS and survived. The myocardial recovery time was 71 +/- 28 (median, 69) h, and the ECLS duration was 93 +/- 33 (median, 93) h. Six surviving patients had a good neurological outcome at hospital discharge. All surviving patients had some neurological sequelae but showed improvement at follow-up, including dysphagia in nine, central hypoventilation in seven, limb weakness in six and seizure in three. The present cohort had better neurological outcomes (46 vs. 0%, P = 0.005) and a higher survival rate (77 vs. 30%, P = 0.024) than the past cohort, respectively. CONCLUSIONS: Patients with EV71-related CPF supported by ECLS had a higher survival rate and fewer neurological sequelae than those who only received conventional treatments. ECLS is an effective alternative method for treatment of children with refractory EV71-related CPF.

Clostridium septicum aortitis causing aortic dissection in a 22-year-old man.

Clostridium septicum infection is a rare cause of aortic dissection, and the mortality rate for the condition is high. Only 26 cases of C. septicum aortitis have been reported; all of those patients were elderly, and 20 of them had an associated colonic neoplasm. Herein, we present the case of a 22-year-old man whose C. septicum aortitis resulted in aortic dissection that involved the entire length of the aorta. Upon autopsy, no neoplasm or other predisposing condition was identified in this patient. To the best of our knowledge, this is the 1st report of C. septicum aortitis, fatal or otherwise, in a young individual.

Fatal acute purulent pericarditis in a patient with renal transplant: a case report.

OBJECTIVES: Acute purulent pericarditis is a lifethreatening disease, although it is becoming uncommon in the era of antibiotics. MATERIALS AND METHODS: We present a case of fatal acute massive purulent pericarditis in a kidney transplant recipient. RESULTS: A 46-year-old woman had an unrelated commercial renal transplant in 2003. She had a history of diabetes mellitus and hepatitis C infection. Kaposi sarcoma developed in the posttransplant period. Her last admission was prompted by the development of acute rejection confirmed by transplant biopsy, and she was treated with intravenous methylprednisolone. Three days before her death, thrombophlebitis of the right forearm was noted. We postulate that this could have been the source of the fulminant purulent pericarditis, as the organism in the pericardial fluid was Staphylococcus aureus, a common pathogen in thrombophlebitis. She was initially resuscitated after cardiac arrest but died shortly after. CONCLUSIONS: Severe purulent pericarditis in the immunocompromised patient can occur abruptly. The source of infection may show minimal signs and symptoms. Thrombophlebitis and other apparently minor infections should not be overlooked in such patients.

[Out-of-hospital cardiac arrest in children with bacterial tracheitis]. / Laryngotrachéites bactériennes révélées par un arrêt cardiaque en préhospitalier.

UNLABELLED: Bacterial tracheitis is a severe cause of acute infectious upper-airway obstruction. Its characteristics include thick purulent secretions with or without plaques or pseudomembrane formation. Fatal complications are infrequent if an appropriate treatment is conducted. CASE REPORT: We report on 2 cases of bacterial tracheitis revealed by out-of-hospital cardiac arrest. At presentation in winter, both children first had the symptoms of viral croup. However, no response to the appropriate therapy for this disease was observed. A cardiac arrest occurred on the second day. Bronchoscopy allowed diagnosis. Findings on initial examination were erythema, edema and purulent secretions. Bacterial cultures of tracheal secretions were positive with Staphylococcus aureus. Serology with influenza A virus was also positive. Despite antibiotics and mechanical ventilation, both children died in the pediatric intensive care unit, consecutively to irreversible ischemic brain injury. CONCLUSION: Bacterial tracheitis remains a life-threatening upper-airway infection. Prompt recognition and accurate diagnosis could lead to decreased mortality. It is essential to reassess any croup whose outcome is not rapidly favourable. Such patients should be monitored in a pediatric intensive care unit.

Predictors of unfavorable outcomes in enterovirus 71-related cardiopulmonary failure in children.

BACKGROUND: Enterovirus 71 (EV71) can sometimes cause fatal or disabling diseases in children; therefore EV71-infected children with cardiopulmonary failure were investigated at Chang Gung Children's Hospital to discover the prognostic predictors. METHODS: We investigated 27 EV71-infected children with cardiopulmonary failure from May 2000 to September 2001 and analyzed their clinical data to find predictors associated with unfavorable outcomes of deaths or ventilator dependence. RESULTS: Of the 27 patients, 8 (30%) died and 10 (37%) were ventilator-dependent. Troponin I levels correlated most strongly with fatality, with 5 of the 6 children with troponin I levels >40 ng/ml dying (P = 0.001). Other factors correlated with fatality were cerebrospinal fluid white blood cell count > or =100/microL (P = 0.002) and initial systolic pressure < or =100 mm Hg (P = 0.05). Of the 19 survivors, 10 (53%) were left with central hypoventilation, dysphagia and/or limb weakness plus atrophy. The factors associated with ventilator dependence included higher inotrope equivalent (P < 0.001), duration of hypotension > or =40 hours, initial blood systolic pressure < or =100 mm Hg, positive EV71 isolation and age > or =12 months. CONCLUSIONS: Poor prognostic factors were related to cardiovascular and neurologic damage; therefore physicians may consider advanced cardiovascular support for EV71-infected children with cardiopulmonary failure.