Multi-organ involvement caused by Scedosporium apiospermum infection after near drowning: a case report and literature review.

BACKGROUND: Scedosporium apiospermum (S. apiospermum) is a rare fungal pathogen that causes disseminated infections. It rarely affects immunocompetent individuals and has a poor prognosis. CASE PRESENTATION: A 37-year-old woman presented with multiple lesions in the lungs, brain, and eyes, shortly after near drowning in a car accident. The primary symptoms were chest tightness, limb weakness, headache, and poor vision in the left eye. S. apiospermum infection was confirmed by metagenomic next-generation sequencing (mNGS) of intracranial abscess drainage fluid, although intracranial metastases were initially considered. After systemic treatment with voriconazole, her symptoms improved significantly; however, she lost vision in her left eye due to delayed diagnosis. CONCLUSION: While S. apiospermum infection is rare, it should be considered even in immunocompetent patients. Prompt diagnosis and treatment are essential. Voriconazole may be an effective treatment option.

A systematic review and disability-adjusted life years of Scedosporium/Lomentospora infection in patients after near-drowning.

Scedosporium/Lomentospora species exist as saprophytic moulds that can potentially lead to serious infections in patients who have experienced near-drowning incidents. Scedosporium species are distributed across different regions of the world while Lomentospora prolificans has quite a restricted geographic distribution. We aimed to systematically review scedosporiosis cases after near-drowning, their clinical manifestations, underlying diseases, treatments, outcomes and its impact through disability-adjusted life years (DALYs). Five available sources were searched from 1 January 2007, to 20 April 2022. Thirty-eight studies, including 41 patients, were evaluated. Mean age was 33.6 ± 18.6 years (range 1-68), and 28 were male (68.3%). Central nervous system (CNS) dissemination predominated (36/41; 87.8%), presenting mainly as multiple brain abscesses (26/41; 63.4%), followed by lung involvement (22/41; 56.4%). Scedosporium apiospermum species complex was the most causative agent (38/41; 92.7%). Overall mortality was 51.2%. Half of the patients (18/37) were cured after receiving proper treatment, and in most cases, voriconazole alone or in combination with surgery or other antifungals caused survival. The mean survival time was 123 ± 27 days. Mean DALYs in 1980-2022 were 46.110 ± 3.318 (39.607-52.612). Time to diagnosis was estimated to be 120 days, and there was no association between time to diagnosis and outcome. Voriconazole is a potentially effective therapy, and combination of surgery and antifungal treatment may lead to more favourable outcome. Advances in early diagnosis and appropriate antifungal therapy may have contributed to reducing its mortality.

Perforating Calcinosis Cutis as a Complication of Intraosseous Fluid Infusion in the Setting of a Near-Drowning Event.

Iatrogenic calcinosis cutis represents a subset of calcinosis cutis resulting secondary to treatments or procedures. We present the first report of calcinosis cutis resulting from the intraosseous infusion and one of a few cases with associated transepidermal elimination. A previously healthy 2-year-old female presented with a new-onset unilateral shin rash 1 week following hospitalization for a near-drowning event. A dermatologic exam revealed multiple small, tender, firm, chalky-white papules with surrounding erythema, in addition to two erythematous macules superior and medial to the papular lesions, corresponding to prior intraosseous access sites. The rash persisted despite trials of topical mupirocin and acyclovir cream, prompting a referral to a dermatologist. An excisional biopsy was performed, revealing circumscribed dermal deposits of acellular basophilic material connected to the overlying epidermis through an invaginated keratin plug. A von Kossa silver stain highlighted the deposits, confirming the diagnosis of perforating calcinosis cutis. The lesions did not recur following the excisional biopsy. Iatrogenic calcinosis cutis may be seen as a complication of the infusion of calcium-containing fluids via intraosseous access, in addition to the more commonly observed peripheral intravenous access. Awareness of this disorder is important in order to distinguish it from an infectious mimic and guide the selection of therapy.

Participation of autophagy in acute lung injury induced by seawater.

Seawater drowning can lead to acute lung injury (ALI). However, the molecular and cellular mechanisms underlying this phenomenon remain elusive. The overall aim of this study is to clarify the role of autophagy in seawater-induced ALI, by which we can further understand the molecular mechanism and develop new methods for prevention and treatment of seawater-induced ALI. In this study, electron microscopy, western blot analysis, and RT-PCR were used to detect autophagy in lung tissues. Moreover, arterial blood gas analysis, lung weight coefficient, TNF-α, IL-8 in bronchoalveolar fluid (BALF), histopathology were used to detect the lung injury of seawater exposure. An inhibitor of autophagy (3-Methyladenine, 3-MA) was injected intraperitoneally before seawater exposure to further explore the role of autophagy in ALI. Electron microscopy revealed increasing autophagosomes in alveolar epithelial cell in seawater group compared with the control. The transcription and expression levels (mRNA and protein levels) of the LC3 II significantly increased in lung tissue of seawater group compared with those in control group. Furthermore, the alterations of autophage were basically consistent with the changes in arterial blood gas, lung weight coefficient, TNF-α, IL-8 in BALF and morphologic findings. In addition, inhibition of autophagy by 3-MA partly ameliorated seawater-induced ALI, as indicated by reduced lung weight coefficient and TNF-α in BALF, as well as increased PaO2. In conclusion, seawater aspiration triggered autophagy, and autophagy may be a scathing factor responsible for ALI induced by seawater.

Extracorporeal membrane oxygenation can provide cardiopulmonary support during bronchoscopic clearance of airways after sand aspiration.

BACKGROUND: Sand aspiration occurs in situations of cave-in burial and near-drowning. Sand in the tracheobronchial airways adheres to the mucosa and can cause tracheal and bronchial obstruction, which can be life-threatening even with intensive management. In previous case reports of airway obstruction caused by sand aspiration, fiber optic or rigid bronchoscopy has been effective in removing loose sand, but removal of sand particles lodged in smaller airways has proven challenging and time-consuming. CASE REPORT: In this case report of sand aspiration with acute pulmonary failure, the use of extracorporeal membrane oxygenation for respiratory support allowed more effective removal of sand particles by rigid bronchoscopy and lavage with less patient compromise. CONCLUSION: Our case of sand aspiration is unique in that the patient presents with complex medical problems (mixed respiratory and metabolic acidosis), hypothermia, hypoxemia, and neoplastic conditions. The fact that she survived the sand aspiration and a long inter-hospital transport time (90 min) with inadequate ventilation and oxygenation without apparent ill effects suggests that the measures we took to resuscitate her and extract the sand from her airways were reasonable and appropriate.

A case of severe acute kidney injury by near-drowning.

Acute kidney injury (AKI) secondary to near-drowning is rarely described and poorly understood. Only few cases of severe isolated AKI resulting from near-drowning exist in the literature. We report a case of near-drowning who developed to isolated AKI due to acute tubular necrosis (ATN) requiring dialysis. A 21-yr-old man who recovered from near-drowning in freshwater 3 days earlier was admitted to our hospital with anuria and elevated level of serum creatinine. He needed five sessions of hemodialysis and then renal function recovered spontaneously. Renal biopsy confirmed ATN. We review the existing literature on near-drowning-induced AKI and discuss the possible pathogenesis.

Fulminant cryptosporidiosis after near-drowning: a human Cryptosporidium parvum strain implicated in invasive gastrointestinal adenocarcinoma and cholangiocarcinoma in an experimental model.

In the present work, we report the characterization of a Cryptosporidium parvum strain isolated from a patient who nearly drowned in the Deule River (Lille, France) after being discharged from the hospital where he had undergone allogeneic stem cell transplantation. After being rescued and readmitted to the hospital, he developed fulminant cryptosporidiosis. The strain isolated from the patient's stools was identified as C. parvum II2A15G2R1 (subtype linked to zoonotic exposure) and inoculated into SCID mice. In this host, this virulent C. parvum isolate induced not only severe infection but also invasive gastrointestinal and biliary adenocarcinoma. The observation of adenocarcinomas that progressed through all layers of the digestive tract to the subserosa and spread via blood vessels confirmed the invasive nature of the neoplastic process. These results indicate for the first time that a human-derived C. parvum isolate is able to induce digestive cancer. This study is of special interest considering the exposure of a large number of humans and animals to this waterborne protozoan, which is highly tumorigenic when inoculated in a rodent model.

Therapeutic bronchoscopy in a child with sand aspiration and respiratory failure from near drowning--case report and literature review.

Foreign matter aspiration occurs relatively commonly in drowning and near-drowning events. In most cases, stomach contents are aspirated. Sand aspiration rarely occurs and there are no reported cases in children with near drowning. Limited data are available on clinical presentation and management of sand aspiration with accidental burial. We report a 3-year-old boy who nearly drowned while swimming in brackish waters and was found face down in sand. Sand aspiration was suspected when the child continued to have persistent wheezing and high ventilatory requirement despite intensive bronchodilator and corticosteroids therapy with an inability to wean after 4 days post-near-drowning event. Radiology was non-specific in the absence of sand bronchogram. Presence of sand in the airways was confirmed when a bronchoscopy was undertaken and sand seen in the bronchoalveolar lavage fluid. Sequential lung washing followed by exogenous surfactant administration (3 ml/kg) was undertaken and lead to significant improvement such that within 12 hr post-therapeutic lavage, his ventilatory requirements reduced substantially. The child was extubated 4 days post-lavage and on review 2 months post-event, was clinically well with airway resistance within normal predicted values measured on forced oscillatory spirometry (IOS).

Casi ahogamiento en pediatría: epidemiología y factores pronósticos / Near drowning in a pediatric population: epidemiology and prognosis

Introducción. El ahogamiento por sumersión es un cuadro con alta morbimortalidad; es la tercera causa accidental de muerte en la población infantil. El objetivo fue analizar y describir factores de riesgo, pronóstico y supervivencia de las víctimas por casi ahogamiento, admitidas en un hospital universitario de alta complejidad. Población, material y métodos. Estudio retrospectivo, observacional, analítico. Se estudiaron los pacientes admitidos en una Unidad de Cuidados Intensivos Pediátricos, entre junio del año 2000 y enero de 2008. Se analizaron múltiples variables. Resultados. Ingresaron 30 pacientes, cuya mediana de edad fue 25 meses (intervalo: 11-144 meses), predominio masculino. El 41,3 por ciento de los episodios ocurrieron en verano, 60 por ciento de los niños estaba bajo supervisión de los padres. El tiempo medio de sumersión fue > 10 minutos en el 3,4 por ciento, tuvieron apnea al ingreso 26 por ciento y el Puntaje de Glasgow fue < 5 en 19,99 por ciento. El ácido láctico fue mayor a 3 mmol/l en 10 pacientes. Se asociaron con mal pronóstico, quienes al ingreso tuvieron glucemia ≥ 300 mg por ciento (OR: 3,325), apnea (OR: 2,752), bradicardia (OR: 4,74), Glasgow < 5 (OR: 3,550) y tiempo de sumersión > a 10 minutos (OR: 5,12). Murieron 2/30 pacientes. Conclusión. En nuestra población, la presencia de apneas, bradicardia, glucemia ≥ 300 mg por ciento, Puntaje de Glasgow < 5 y sumersión mayor a 10minutos, se asociaron a mal pronóstico. La elevación de ácido láctico > 6 mmol/l al ingreso y a las 24 h fue marcador de lesión grave.

[Vegetable oil-induced acute respiratory distress syndrome (ARDS) in near drowning: evaluation based on extravascular lung water index].

Lipoid pneumonia usually presents after chronic recurrent ingestion of oily substances or accidental aspiration during "fire-eating" demonstrations. Massive exposure by near drowning extremely rare and potentially fatal. We present here a case of survival after total immersion in oil in her workplace. A 66-year-old woman who nearly drowned in a vat of vegetable oil was admitted as an emergency case with severe hypoxia after rescue. Chest computed tomography (CT) findings showed bilateral ground-glass opacity, consolidation, and the case fulfilled the criteria for acute respiratory distress syndrome (ARDS). Bronchoscopy and bronchoalveolar lavage performed on admission indicated oil droplets and marked neutrophilia (67%), which made us diagnose ARDS induced by lipoid pneumonia. We commenced treatment with pulsed steroids and strictly managed fluid balance under mechanical ventilation. Despite immediate improvement in oxygenation, the value of extravascular lung water index (EVLWI) measured by the PiCCO system consistently remained over 30 ml/Kg through her clinical course. We concluded that lipoid pneumonia is characterized by prolonged elevatation of pulmonary vascular permeability.

Scedosporium apiospermum brain abscess treated with surgery and voriconazole. Case report.

Scedosporium apiospermum is a fungus found in the soil and in contaminated water. Common cutaneous manifestations include Madura foot, a painless swelling on the sole of the foot. Invasive infection is usually associated with immunosuppression. The authors present a 16-month-old immunocompetent boy who had a near-drowning event. Following this, he was severely disabled with spastic quadriparesis. Early computerized tomography scans revealed diffuse hypoxic injury. Magnetic resonance images obtained 3 months after the initial event demonstrated multiple ring-enhancing lesions in the brain. Aspiration of the lesion was performed. Scedosporium apiospermum, the asexual form of Pseudallescheria boydii, was cultured. Conventional antifungal agents were commenced, with minimal effect. The child was subsequently treated with a new antifungal agent, voriconazole, a broad-spectrum triazole antifungal agent with good penetration into the cerebrospinal fluid. The patient improved, with a good radiological outcome and a moderate clinical outcome. The authors review the use of voriconazole for central nervous system infections and review the literature on S. apiospermum associated with near drowning.

Percutaneous tracheotomy in children.

We present three cases of the Fantoni percutaneous translaryngeal tracheostomy (TLT) performed under direct rigid bronchoscopy. The surgeries were performed in the near-drowned 5-year-old boy, and 15-year-old lupus erythematosus girl with a permanent brain damage resulted from a cardiac arrest, 11-year-old cardiac girl with postintubation laryngeal stenosis. In the first two cases, the procedure went uneventful; in one case the tube was accidentally pulled out during the rotation phase and surgical tracheostomy was performed. We describe the TLT procedure in details, calling special attention at the fact that the TLT is especially suitable for children below 10 years of age and is associated with very few complications.

Pulmonary Pseudallescheria boydii infection with cutaneous zygomycosis after near drowning.

Pseudallescheria boydii is a ubiquitously occurring fungus. While rarely causing opportunistic infection in humans, it is the most common cause of fungal pneumonia in cases of near drowning, and is associated with high mortality. P. boydii typically causes cutaneous mycetomas but may invade the lungs or brain. P. boydii infections are difficult to treat due to amphotericin B resistance and frequent need for surgical resection. Zygomycetous infections, often referred to as "mucormycoses," usually occur in immunocompromised hosts, trauma or burn victims. Like P. boydii, these organisms are found on decaying vegetation and in soil. Zygomycetous infections generally require debridement and prolonged amphotericin B. We report a case of P. boydii pneumonia with a simultaneous brain lesion and cutaneous mucormycosis in a near drowning patient. The pneumonia responded to treatment with voriconazole and the brain lesion resolved without surgery. The cutaneous mucormycosis responded to surgery and amphotericin B. This is the first documented case of simultaneous invasive P. boydii and cutaneous mucormycosis successfully treated with dual systemic antifungal therapy and resection.

Central nervous system Aspergillus fumigatus infection after near drowning.

AIMS: To report the case of a 26 year old white man, who developed chronic meningitis and intracerebral granulomata 15 days after an episode of near drowning in a swamp. METHODS: Aspergillus fumigatus was isolated from cerebrospinal fluid cultures. RESULTS: The patient died 70 days after the symptoms were first noticed, and seven days after a subarachnoid haemorrhage. Aspergillus has never been reported before as a cause of intracranial infection after near drowning. CONCLUSIONS: Physicians must be aware of this possibility when confronted with such a situation, because there are now effective therapeutic options for systemic aspergillosis.

Infection of the CNS by Scedosporium apiospermum after near drowning. Report of a fatal case and analysis of its confounding factors.

This report describes a fatal case of central nervous system pseudallescheriasis. A 32 year old white man presented with headache and meningismus 15 days after nearly drowning in a swine sewage reservoir. Computerised tomography and magnetic resonance imaging of the head revealed multiple brain granulomata, which vanished when steroid and broad spectrum antimicrobial and antifungal agents, in addition to dexamethasone, were started. Cerebrospinal fluid analysis disclosed a neutrophilic meningitis. Treatment with antibiotics and amphotericin B, together with fluconazole and later itraconazole, was ineffective. Miconazole was added through an Ommaya reservoir, but was insufficient to halt the infection. Pseudallescheria boydii was finally isolated and identified in cerebrospinal fluid cultures, a few days before death, three and a half months after the symptoms began. Diagnosis was delayed because of a reduction in the lesions after partial treatment, which prevented a stereotactic biopsy. Physicians should be aware of this condition, and provide prompt stereotactic biopsy. Confirmed cases should perhaps be treated with voriconazole, probably the most effective, currently available treatment for this agent.

Heterotopic ossification in childhood and adolescence.

Heterotopic ossification, or myositis ossificans, denotes true bone in an abnormal place. The pathogenic mechanism is still unclear. A total of 643 patients (mean age, 9.1 years) admitted for neuropediatric rehabilitation were analyzed retrospectively with respect to the existence of neurogenic heterotopic ossification. The purpose of this study was to obtain information about incidence, etiology, clinical aspect, and consequences for diagnosis and therapy of this condition in childhood and adolescence. Heterotopic ossification was diagnosed in 32 patients (mean age, 14.8 years) with average time of onset of 4 months after traumatic brain injury, near drowning, strangulation, cerebral hemorrhage, hydrocephalus, or spinal cord injury. The sex ratio was not significant. In contrast to what has been found in adult studies, serum alkaline phosphatase was not elevated during heterotopic ossification formation. A persistent vegetative state for longer than 30 days proved to be a significant risk factor for heterotopic ossification. The incidence of neurogenic heterotopic ossification in children seems to be lower than in adults. A genetic predisposition to heterotopic ossification is suspected but not proven. As a prophylactic regimen against heterotopic ossification we use salicylates for those patients in a coma or persistent vegetative state with warm and painful swelling of a joint and consider continuous intrathecal baclofen infusion and botulinum toxin injection for those patients with severe spasticity. We prefer to wait at least 1 year after trauma before excision of heterotopic ossification.