ABSTRACT
BACKGROUND: Shock is among the most common conditions that clinicians face in intensive care unit (ICU), of which hypovolemic shock is encountered most frequently; some patients instead suffer from neurogenic, cardiogenic, or infectious forms of shock. However, there are additional types of shock from unusual causes that are often undiagnosed. Here, we report the case of a patient who was initially misdiagnosed with hypovolemic shock, but exhibited persistent hypotension because of continuous fluid replacement and vasoactive drug administration, and was eventually diagnosed with hypopituitarism with crisis. CASE SUMMARY: A 73-year-old Chinese man was admitted to the neurosurgery department following injury caused by a heavy object with symptoms of anemia and high fever. He was transferred to the ICU on the fourth day after hospitalization because of hypotension and unconsciousness. Blood analysis indicated that the patient was suffering from anemia and thrombocytopenia. Ultrasonography showed that there was no apparent abnormality in the cardiac structure but there was mild tricuspid regurgitation. Computed tomography revealed that there were signs of hemorrhage at the right basal ganglia; accordingly, hypovolemic shock, possibly septic shock, was initially considered. Even after routine treatment for shock, the hypotension remained severe. The patient was again thoroughly examined to investigate the underlying cause. The antishock therapy was supplemented with corticosteroids to counter potential hypopituitarism. The patient made a full recovery, and the blood pressure returned to normal. CONCLUSION: A case of pituitary adenoma with multiple injuries was identified. Because of hypopituitarism, functionality of the corresponding endocrine system was restricted, with the most pronounced manifestation being unstable blood circulation requiring hormone replacement therapy. Such cases are relatively rare but may occur if multiple injuries are sustained. The present case represents a reference for the clinical treatment of patients with multiple injuries.
ABSTRACT
Coxsackievirus A4 (CVA4) is one of the most prevalent pathogens associated with hand, foot and mouth disease (HFMD), an acute febrile illness in children, and is also associated with acute localized exanthema, myocarditis, hepatitis and pancreatitis. Despite this, limited CVA4 genome sequences are currently available. Herein, complete genome sequences from CVA4 strains (n = 21), isolated from patients with HFMD in Shandong province, China between 2014 and 2016, were determined and phylogenetically characterized. Phylogenetic analysis of the VP1 gene from a larger CVA4 collection (n = 175) showed that CVA4 has evolved into four separable genotypes: A, B, C, and D; and genotype D could be further classified in to two sub-genotypes: D1 and D2. Each of the 21 newly described genomes derived from isolates that segregated with sub-genotype D2. The CVA4 genomes displayed significant intra-genotypic genetic diversity with frequent synonymous substitutions occurring at the third codon positions, particularly within the P2 region. However, VP1 was relatively stable and therefore represents a potential target for molecular diagnostics assays and also for the rational design of vaccine epitopes. The substitution rate of VP1 was estimated to be 5.12 × 10-3 substitutions/site/year, indicative of ongoing CVA4 evolution. Mutations at amino acid residue 169 in VP1 gene may be responsible for differing virulence of CVA4 strains. Bayesian skyline plot analysis showed that the population size of CVA4 has experienced several dynamic fluctuations since 1948. In summary, we describe the phylogenetic and molecular characterization of 21 complete genomes from CVA4 isolates which greatly enriches the known genomic diversity of CVA4 and underscores the need for further surveillance of CVA4 in China.