Usefulness of extracorporeal membrane oxygenation in status asthmaticus with severe tracheal stenosis.

Extracorporeal membrane oxygenation, traditionally used to treat refractory hypoxemic respiratory failure due to acute respiratory distress syndrome, is being used to treat other etiologies of severe respiratory failure refractory to conventional mechanical ventilation. We present a 30-year-old woman with concomitant life-threatening airway obstruction due to severe tracheal stenosis and status asthmaticus treated effectively with veno-venous extracorporeal membrane oxygenation.

Iron pill pneumonitis with reactive lymph nodes.

Iron pill pneumonitis can result from accidental aspiration. It usually presents as a triad of airway inflammation, aspiration, and hemosiderin deposition. We report a case of an elderly woman with chronic cough, infiltrates, and lymphadenopathy on imaging alongside nonnecrotizing granulomas on biopsy diagnosed with iron pill pneumonitis.

Pleural-based granular cell tumor.

Granular cell tumors are rare tumors of Schwann cell origin that arise from tissues of neural crest and mesenchymal origin. We report the clinical, radiographic, and pathological features of a pleural-based granular cell tumor in a 60-year-old African American man.

DRESS Syndrome Following Metformin Administration: A Case Report and Review of the Literature.

The drug rash with eosinophilia and systemic symptoms syndrome also known as DRESS syndrome refers to an idiosyncratic drug reaction commonly characterized by rashes, fever, lymphadenopathy, and internal organ involvement. We report a case of this syndrome in a 40-year-old man presenting with a rash, generalized pruritus, lymphadenopathy, and eosinophilia after metformin treatment. To the best of our knowledge, this is the first report linking metformin to the DRESS syndrome. The patient improved remarkably with drug withdrawal. A high index of clinical suspicion is emphasized to facilitate prompt diagnosis of medication related adverse effect and its discontinuation. In this article, we review the recent literature on DRESS syndrome.

Tricyclic antidepressant overdose treated with adjunctive lipid rescue and plasmapheresis.

Tricyclic antidepressant poisoning remains a major cause of morbidity and mortality, particularly in the setting of suicidal attempts. The current standard of care for treatment is the administration of sodium bicarbonate infusion. Adjunctive lipid emulsion therapy and plasmapheresis have received attention recently. We report an 18-year-old patient who was successfully managed with lipid emulsion and plasmapheresis as adjuncts to sodium bicarbonate treatment and review some of the recent literature.

Pneumomediastinum, pneumorrhachis, and subcutaneous emphysema in Pneumocystis jiroveci pneumonia in AIDS.

Pneumomediastinum, the presence of free air within the mediastinal cavity, is sometimes accompanied by subcutaneous emphysema and pneumorrhachis (air within the spinal canal). We report the case of a 28-year-old man with previously undiagnosed HIV who was diagnosed with extensive pneumomediastinum, pneumorrhachis, and subcutaneous emphysema secondary to Pneumocystis jiroveci pneumonia after presenting with chest pain, dyspnea, and central cyanosis. Surgical consultation was requested, but a conservative approach of observation proved sufficient as the free air was resorbed into the surrounding tissues.

Adjuvant corticosteroids for reducing death in neonatal bacterial meningitis.

BACKGROUND: Bacterial meningitis remains a significant cause of neonatal and childhood morbidity and mortality in many countries of the world, particularly in developing countries. In some instances, children recover but remain impaired as a result of neurological sequelae such as hearing loss, developmental delay and cognitive impairment. OBJECTIVES: To assess the effectiveness and safety of adjunctive corticosteroids in reducing death and neurological sequelae in neonates with bacterial meningitis. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 7), MEDLINE via PubMed (1966 to July 2015), African Index Medicus (up to January 2015), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (up to July 2015), EMBASE (up to July 2015) and the metaRegister of Controlled Trials (mRCT) for ongoing trials. SELECTION CRITERIA: All randomised controlled trials (RCTs) or quasi-RCTs of adjunctive corticosteroids for treatment of neonates with bacterial meningitis. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed and extracted data on methods, participants, interventions and outcomes (all-cause death until hospital discharge, presence of sensorineural deafness at one year and presence of neurological deficits or developmental delay at two years, adverse events). Risk ratio (RR), risk difference (RD) and number needed to treat for an additional beneficial outcome (NNTB) or number needed to treat for an additional harmful outcome (NNTH) were calculated when appropriate. We assessed quality using the Cochrane risk of bias assessment tool and the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) system. MAIN RESULTS: We found two trials with 132 participants that met our inclusion criteria. One of the included trials was a quasi-randomised trial.Adjunctive corticosteroids reduced the risk of death (typical RR 0.46, 95% confidence interval (CI) 0.24 to 0.88; typical RD -0.19, 95% CI -0.33 to -0.04; NNTB = 6; two studies, 132 participants, very low-quality evidence) but did not have a significant effect on the number of infants with sensorineural deafness at two years (RR 1.80, 95% CI 0.18 to 18.21; RD 0.04, 95% CI -0.12 to 0.21; one study, 38 participants, low-quality evidence). In one trial, dexamethasone reduced the likelihood of hearing loss at four to 10 weeks post discharge (RR 0.41, 95% CI 0.17 to 0.98; RD -0.25, 95% CI -0.48 to -0.01; one study, 59 participants, low-quality evidence). Data reported on the other outcomes of interest were insufficient. AUTHORS' CONCLUSIONS: Very low-quality data from two randomised controlled trials suggest that some reduction in death and hearing loss may result from use of adjunctive steroids alongside standard antibiotic therapy for treatment of patients with neonatal meningitis. Benefit is not yet seen with regards to reduction in neurological sequelae. Researchers who wish to clarify these findings must conduct more robustly designed trials with greater numbers of participants, evaluating more relevant outcomes and providing adequate follow-up.

Microscopic polyangiitis causing diffuse alveolar hemorrhage and rapidly progressive glomerulonephritis.

Diffuse alveolar hemorrhage complicating small vessel vasculitis is a life-threatening emergency and should be considered in the differential diagnosis of patients who develop rapidly progressive dyspnea with alveolar opacities on chest imaging. In these patients, the coexistence of pulmonary and renal involvement suggests a multisystem disease. We present a case of a man who presented to our hospital with diffuse alveolar hemorrhage, severe anemia, and rapidly progressive glomerulonephritis.

Noncirrhotic hyperammonemia causing relapsing altered mental status.

Hyperammonemia is a recognized cause of encephalopathy. However, it is commonly seen in patients with liver disease. The clinical entity of noncirrhotic hyperammonemia is now being increasingly recognized. We report a man who presented to our hospital with relapsing altered mental status later diagnosed as noncirrhotic hyperammonemia.

Antimicrobials for treating symptomatic non-typhoidal Salmonella infection.

BACKGROUND: Non-typhoidal Salmonella (NTS) commonly causes diarrhoea, and is usually self-limiting, although sometimes people become ill with sepsis and dehydration. Routine antibiotic use for this infection could result in persistent colonization and the spread of resistant bacterial strains. OBJECTIVES: To assess the efficacy and safety of giving antibiotics to people with NTS diarrhoea. SEARCH METHODS: We searched the Cochrane Infectious Diseases Group trials register (up to August 2012), the Cochrane Controlled Trials Register (CENTRAL) published in The Cochrane Library (up to Issue 8 2012); and MEDLINE, African Index Medicus, CINAHL, EMBASE, LILACS, and the Science Citation Index, all up to 6 August 2012. We also searched the metaRegister of Controlled Trials (mRCT) for both completed and on going trials and reference lists of relevant articles. SELECTION CRITERIA: Randomized controlled trials (RCTs) comparing any antibiotic treatment for diarrhoea caused by NTS species with placebo or no antibiotic treatment. We selected trials that included people of all ages who were symptomatic for NTS infection. Examples of symptoms included fever, abdominal pain, vomiting and diarrhoea. We excluded trials where the outcomes were not reported separately for the NTS subgroup of patients. Two review authors independently applied eligibility criteria prior to study inclusion. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data on pre-specified outcomes and independently assessed the risk of bias of included studies. The primary outcome was the presence of diarrhoea between two to four days after treatment. The quality of evidence was assessed using the GRADE methods. MAIN RESULTS: Twelve trials involving 767 participants were included. No differences were detected between the antibiotic and placebo/no treatment arms for people with diarrhoea at two to four days after treatment (risk ratio (RR) 1.75, 95% confidence interval (CI) 0.42 to 7.21; one trial, 46 participants; very low quality evidence). No difference was detected for the presence of diarrhoea at five to seven days after treatment (RR 0.83, 95% CI 0.62 to 1.12; two trials, 192 participants; very low quality evidence), clinical failure (RR 0.88, 95% CI 0.62 to 1.25; seven trials, 440 participants; very low quality evidence). The mean difference for diarrhoea was 0 days (95% CI -0.54 to 0.54; 202 participants, four studies; low quality evidence);for fever was 0.27 days (95% CI -0.11 to 0.65; 107 participants, two studies; very low quality evidence); and for duration of illness was 0 days (95% CI -0.68 to 0.68; 116 participants, two studies; very low quality evidence). Quinolone antibiotic treatment resulted in a significantly higher number of negative stool cultures for NTS during the first week of treatment (microbiological failure: RR 0.33, 95% CI 0.20 to 0.56; 166 participants, four trials).Antibiotic treatment meant passage of the same Salmonella serovar one month after treatment was almost twice as likely (RR 1.96, 95% CI 1.29 to 2.98; 112 participants, three trials), which was statistically significant. Non-severe adverse drug reactions were more common among the patients who received antibiotic treatment. AUTHORS' CONCLUSIONS: There is no evidence of benefit for antibiotics in NTS diarrhoea in otherwise healthy people. We are uncertain of the effects in very young people, very old people, and in people with severe and extraintestinal disease. A slightly higher number of adverse events were noted in people who received antibiotic treatment for NTS.

Antipyretic measures for treating fever in malaria.

BACKGROUND: Fever is common in malaria, and drugs and sponging are widely used for symptomatic relief. Some researchers have suggested that fever reduction may prolong malaria illness. OBJECTIVES: We aimed to assess whether treatments to reduce fever in malaria influence the course of the illness. SEARCH METHODS: We searched the Cochrane Infectious Diseases Group Trial Register (June 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 6, 2012), MEDLINE (1966 to June 2012); EMBASE (1980 to June 2012) and LILACS (June 2012). We contacted researchers and organisations working in the field to enable us identify other unpublished or ongoing trials. SELECTION CRITERIA: Randomized controlled trials of fever reduction measures in adults or children with confirmed malaria. DATA COLLECTION AND ANALYSIS: Inclusion criteria were independently applied by two authors. We extracted data from trials that met our pre-specified criteria using a standard data extraction form. Mean differences with 95% confidence intervals (CI) were calculated for continuous data. GRADE was used to evaluate and summarize the quality of the evidence. MAIN RESULTS: Ten randomized controlled trials with 990 participants including both adults and children met our inclusion criteria. All were small scale trials with methodological limitations and were conducted in a variety of patients. Some trials detected an impact of antipyretic drugs on fever clearance time, while others did not. Regarding parasite clearance,no clear influence of anti-pyresis was demonstrated (six trials, 423 participants, very low quality of evidence). No difference in the number or severity of adverse events between antipyretic drugs and control was detected. AUTHORS' CONCLUSIONS: We do not know whether antipyretics alter parasite clearance time. Whether further trials are worthwhile to investigate this or not would require a judgement of whether this was an important question to resolve using interventional trials.

Supplementary vitamin E, selenium, cysteine and riboflavin for preventing kwashiorkor in preschool children in developing countries.

BACKGROUND: Protein Energy Malnutrition is an important cause of child morbidity and mortality in middle- and low-income countries. It has been suggested that excessive free radical activity may be responsible for the clinical manifestation of kwashiorkor. Antioxidants may be able to curb excessive free radical activity and prevent the development of kwashiorkor in susceptible children. OBJECTIVES: To evaluate the benefits of supplementation of vitamin E, selenium, cysteine and riboflavin (alone or in combination) in preventing kwashiorkor. SEARCH STRATEGY: We conducted searches of CENTRAL 2009 (The Cochrane Library 2009 Issue 2), MEDLINE 1966 to 2009, EMBASE 1980 to 2009, CINAHL 1982 to 2009, LILACS 1982 to 2009, Meta register of Controlled trials, Open Sigle, African Index Medicus. SELECTION CRITERIA: Randomised controlled trials (RCTs) and quasi-RCTs evaluating vitamin E, selenium, cysteine and riboflavin alone or in combination in healthy pre-school children in middle- and low-income countries. DATA COLLECTION AND ANALYSIS: Two authors extracted and independently analysed data. MAIN RESULTS: One cluster-RCT including 2372 children met our inclusion criteria. Children were randomised, based on household, either to a supplement containing all four micronutrients or to placebo. No statistically significant difference in the incidence of kwashiorkor between the intervention and control groups could be demonstrated at 20 weeks (RR 1.70; 95% CI 0.98 to 2.42). Nor could any statistically significant difference in all-cause mortality be demonstrated (RR 0.75; 95% CI 0.17 to 3.36). AUTHORS' CONCLUSIONS: Based on the one available trial, we could draw no firm conclusion for the effectiveness of supplementary antioxidant micronutrients for the prevention of kwashiorkor in pre-school children.