Management of ventricular dysrhythmia secondary to trazodone overdose.

Torsades de pointes (TdP), a life-threatening ventricular dysrhythmia, was recorded in a 30-year-old woman who had taken a deliberate overdose of trazodone. The patient was successfully defibrillated to normal sinus rhythm and given intravenous magnesium sulfate according to Advanced Cardiovascular Life Support guidelines. The patient was discharged and experienced no further complications.

Hemorrhagic bullae represent an ominous sign for cirrhotic patients.

Hemorrhagic bullae are a clinical manifestation of many underlying diseases, especially soft-tissue infection. The aim of this study was to evaluate the characteristics and prognosis of cirrhotic patients with hemorrhagic bullae. Fifteen patients with liver cirrhosis and hemorrhagic bullae had been admitted to Chang Gung Memorial Hospital, Kaohsiung, from January to December 2003. Their clinical courses were retrospectively reviewed in detail and all of the collected data were analyzed. This study puts emphasis on the clinical presentation and outcome of these cases. The mean age of patients was 55.0 +/- 12.1 years, and 12 patients were male. Prostration and unusual extremity pain were the two leading reasons to visit our Emergency Department. The hemorrhagic bullae were located on the upper or lower extremities and in one patient, on the whole body. In this series all hemorrhagic bullae were infection-related. Although aggressive treatment was started immediately upon arrival, 14 patients died of overwhelming sepsis and 12 patients died within 48 h from the emergence of hemorrhagic bullae. Hemorrhagic bullae in cirrhotic patients usually imply a fatal infection and Gram-negative bacteria are the most common pathogen. Appropriate antimicrobial therapy and early surgical intervention are necessary to achieve survival in these patients.

Status epilepticus induced by star fruit intoxication in patients with chronic renal disease.

Star fruit has been reported as containing neurotoxins that often cause severe neurological complications in patients with chronic renal disease. We report two patients with chronic renal failure at a pre-dialyzed stage who developed refractory status epilepticus after ingestion of star fruit. In addition, we review 51 cases in the literature. Among 53 patients, 16 patients presented with epileptic seizures (30%). The mortality rate was as high as 75% in patients with seizures. On the other hand, in patients without seizures, the mortality rate was only 0.03%. There is a poor correlation with the degree of underlying renal function and mortality due to intoxication. We propose that epileptic seizure is significantly associated with poor prognosis, and that status epilepticus is an unpredictable and potentially fatal complication in star fruit intoxication. We advise consultant neurologists that star fruit intoxication must be considered when patients with chronic renal disease present with seizures or other unexplained neurological or psychiatric symptoms. Since no effective treatment has been established, star fruit consumption should be avoided in patients with chronic renal disease, especially in the elderly.

Massive pulmonary embolism in a young patient on clozapine therapy.

Clozapine-associated induction of venous thromboembolism has potentially catastrophic consequences. We report a case of sudden death caused by bilateral main pulmonary trunk thrombosis in a 31-year-old man receiving clozapine therapy. The patient presented with general weakness and exertional dyspnea. Bilateral main pulmonary trunk thrombosis was clearly demonstrated by helical chest computed tomography.

Case reports of leptospirosis in southern Taiwan.

Leptospirosis, a zoonotic disease with worldwide distribution, is often overlooked in Taiwan. Clinicians at our medical center in southern Taiwan became alert to the potential for leptospirosis after the first documented case of severe leptospirosis--Weil's syndrome was diagnosed at our emergency department in early September 2000. Four additional cases of leptospirosis were subsequently diagnosed within a 2-month period. All of the patients were hospitalized, and presented with high fever, severe myalgia, jaundice, and acute renal failure. Two of these patients who rapidly received doxycycline therapy survived, while the remaining three patients who received delayed penicillin therapy died. These cases suggest that the incidence of leptospirosis may have been underestimated in Taiwan, and underscore the urgent need for increased clinician awareness of this infectious disease.

Risk factors for the outcome of cirrhotic patients with soft tissue infections.

GOAL: The aims of this study were to identify risk factors that influence outcomes of cirrhotic patients with soft tissue infections and to describe specific management for such patients. BACKGROUND: Soft tissue infections account for 11% of infections overall in cirrhotic patients and the severe form of necrotizing infection carries a high mortality rate. It is essential that clinicians make an early diagnosis and start appropriate treatment to improve outcomes of cirrhotic patients with soft tissue infections. METHODS: Cirrhotic patients who had been admitted to our hospital with the diagnosis of soft tissue infection from June 1, 2003 to June 1, 2005 were included in this retrospective study. Clinical manifestations, laboratory data, and microbiologic results were recorded and compared between survivor and nonsurvivor groups. RESULTS: There was a total of 118 episodes of admission for soft tissue infection with 26 episodes resulting in mortality and 92 in survival. The following clinical parameters showed significant differences between the 2 groups: Child-Pugh grade C, pain, altered consciousness, emergence of hemorrhagic bullae, and local injury. The following laboratory data showed significant differences between the 2 groups: appearance of band form, serum creatinine, serum albumin below 2.5 g/dL, serum bilirubin above 3 mg/dL, and prothrombin time prolongation greater than 5 seconds. Gram-negative bacterial infection was predominant in the nonsurvivor group and was statistically significant. Multivariate analysis showed that the emergence of hemorrhagic bullae and Child-Pugh grade C were independent predictive factors for outcome. CONCLUSIONS: When treating soft tissue infection in cirrhotic patients, especially in those with Child-Pugh C liver function or emergence of hemorrhagic bullae, it is essential to start surgical evaluation and specific broad-spectrum antibiotics early to reduce the high mortality associated with this disease.

The use of Charlson comorbidity index for patients revisiting the emergency department within 72 hours.

BACKGROUND: To validate the use of the Charlson Comorbidity Index (CCI) for predicting admission of patients revisiting the Emergency Department (ED) within 72 hours. METHODS: Non-trauma patients aged above 17 years old who revisited an urban ED within 72 hours during January of 2004 were included in this retrospective observational study. Demographic data, diagnosis, CCI, in-hospital mortality rate and length of hospital stay were reviewed, and comparisons were made between the patients who were admitted or discharged on their return visits. RESULTS: Of the 168 enrolled patients, 60 were admitted to a ward and 108 were discharged. Revisiting patients with high CCIs (> or = 2) had a higher admission rate (67.3% vs. 22.7%; p < 0.001) and an increased adjusted odds ratio of admission (odds ratio (OR) 2.06; 95% confidence interval (CI) 1.14-3.75) than low CCI patients. Admitted revisiting patients with high CCIs had poorer prognoses, longer hospital stays (11.79 +/- 8.92 days vs. 6.78 +/- 5.17 days; p < 0.05) and a higher in-hospital mortality rate (15.2% vs. 3.7%; p = 0.209). CONCLUSION: CCI was well correlated with the admission possibility of patients revisiting the ED within 72 hours. More clinical management and discharge strategies should target those revisiting patients who have more comorbidities.

Fatal aeromonas hydrophila infection of soft tissue after endoscopic injection sclerotherapy for gastric variceal bleeding.

Aeromonas hydrophila, an anaerobic gram-negative bacillus, can cause severe infections in immune-compromised patients. We present a 45-year-old cirrhotic man who suffered from hematemesis and received emergency endoscopic injection sclerotherapy (EIS) for gastric variceal bleeding. Twenty-one hours after EIS, painful swelling of the bilateral lower extremities and fever occurred. Severe soft-tissue infections with emergence of hemorrhagic bullae over the bilateral lower extremities followed. Even under aggressive treatment, the patient died of overwhelming sepsis 42 hours after EIS. Cultures of the blood and serosanguineous fluid from the hemorrhagic bullae revealed Aeromonas hydrophila. To the best of our knowledge, this is the first case of fatal Aeromonas hydrophila infection after emergancy EIS for gastric variceal bleeding reported in the English literature. It is worth emphasizing that physicians should consider Aeromonas hydrophila infection in cirrhotic patients who develop soft-tissue infections after variceal bleeding whether emergency EIS has been performed or not.