Unusual Case of Metformin-Associated Lactic Acidosis in Patient with Type 2 Diabetes Mellitus.

BACKGROUND Metformin is recommended as the first-line therapy for type 2 diabetes mellitus, according to the American Diabetes Association. It is considered a safe medication with minimal adverse effects, with the most common being gastrointestinal. Metformin-associated lactic acidosis (MALA) is a rare but life-threatening complication. MALA usually occurs in patients with kidney dysfunction. However, it can still occur with preserved kidney function with the ingestion of a large dose of metformin. CASE REPORT A 66-year-old man with a significant medical history of type 2 diabetes mellitus presented after an intentional ingestion of a high dose of metformin (3000 mg/day). He was admitted to our hospital with symptoms of fatigue, nausea, vomiting, abdominal pain, and watery diarrhea lasting for 3 days. His initial laboratory findings were remarkable, with a serum creatinine level of 819 µmol/L. Arterial blood gas revealed severe lactic acidosis, with a pH of 6.94, HCO3⁻- of 3 mEq/L, anion gap of 48 mmol/L, and lactate level of 15 mmol/L. Emergent continuous renal replacement therapy was done. Two days later, his condition improved considerably, and the lactic acidosis was resolved entirely. He was discharged on day 11 of hospitalization. CONCLUSIONS MALA is rare but life-threatening complication of treatment with metformin. MALA should be considered when there is evidence of metformin ingestion and renal insufficiency in patients with lactic acidosis. The curative treatment of MALA is based on hemodialysis, but the main remedy is prevention, which requires patient compliance with taking metformin as prescribed.

A Rare Case of Elizabethkingia meningoseptica Bacteremia After Liver Transplantation.

BACKGROUND Elizabethkingia meningoseptica is an emerging pathogen in hospital environments. Immunocompromised individuals have a high risk of infections caused by E. meningoseptica, especially after transplantation. E. meningoseptica is associated with prolonged hospital stays and high mortality. In addition, E. meningoseptica is commonly resistant to many antibiotics used for gram-negative bacterial infections. We introduce the first case of E. meningoseptica bacteremia in a recipient of a liver transplant in Vietnam. CASE REPORT A 55-year-old woman with end-stage liver disease due to biliary cirrhosis underwent living donor liver transplantation at the 108 Military Central Hospital. On day 3 after transplantation, the patient had an acute cellular rejection, and corticosteroid pulse therapy was used. On day 7 after transplantation, the patient had a fever and an increased white blood cell count and C-reactive protein level. Blood cultures were positive for E. meningoseptica. Intravenous levofloxacin was administered for 10 days. The patient showed an excellent treatment response to the antibiotic therapy and was discharged. CONCLUSIONS E. meningoseptica, a multidrug-resistant gram-negative bacteria, can be considered an emerging pathogen in the hospital environment, especially in patients receiving organ transplants. Early recognition helps physicians to improve patient outcomes.

Diagnostic Value of High-Sensitivity Troponin T for Subclinical Left Ventricular Systolic Dysfunction in Patients with Sepsis.

BACKGROUND: Left ventricular systolic dysfunction (LVSD) is common in sepsis. Speckle-tracking echocardiography (STE) is a useful emerging tool for evaluating the intrinsic left ventricular systolic function. High-sensitivity cardiac troponin T (hs-cTnT) is the most sensitive biomarker of myocardial injury. However, there are limited data regarding the association between hs-cTnT level and left ventricular systolic dysfunction based on STE in septic patients. We performed this prospective study to evaluate the diagnostic value of hs-cTnT level for subclinical left ventricular systolic dysfunction measured by STE in septic patients according to the sepsis-3 definition. METHODS: Patients with sepsis based on sepsis-3 definition admitted to the intensive care unit were prospectively performed STE and hs-cTnT level within 24 hours after the onset of sepsis. Baseline clinical and echocardiographic variables were collected. Left ventricular systolic dysfunction was defined as a global longitudinal strain of ≥-15%. RESULTS: During a 19-month period, 116 patients were enrolled in the study. The elevated hs-cTnT level was seen in 86.2% of septic patients, and 43.1% of patients had LVSD on STE. The median hs-cTnT level and the proportion of elevated hs-cTnT level (>14 ng/L) were significantly higher in patients with LVSD than in patients without LVSD. The area under the ROC curves of hs-cTnT to detect LVSD was 0.73 (P < 0.001). In the multivariate analysis, hs-cTnT (HR, 1.002; 95% CI, 1.000 to 1.004; P = 0.025) and septic shock (HR, 7.6; 95% CI, 2.25 to 25.76; P = 0.001) were independent predictors of LVSD. CONCLUSION: Our study indicated that the serum hs-cTnT level might be a useful biomarker for detecting LVSD in septic patients.

Prognostic Role of Left Ventricular Systolic Function Measured by Speckle Tracking Echocardiography in Septic Shock.

BACKGROUND: Left ventricular (LV) systolic dysfunction is common in septic shock. Global longitudinal strain (GLS) measured by speckle tracking echocardiography (STE) is a useful marker of intrinsic left ventricular systolic function. However, the association between left ventricular GLS and outcome in septic patients is not well understood. We performed this prospective study to investigate the prognostic value of LV systolic function utilizing speckle tracking echocardiography in patients with septic shock. METHODS: All the patients with septic shock based on sepsis-3 definition admitted to the intensive care unit were prospectively studied with STE within 24 hours after the onset of septic shock. Baseline clinical and echocardiographic variables were collected. The primary outcome was in-hospital mortality. RESULTS: During a 19-month period, 90 consecutive patients were enrolled in the study. The in-hospital mortality rate was 43.3%. Compared with survivors, nonsurvivors exhibited significantly less negative GLS (-13.1 ± 3.3% versus -15.8 ± 2.9%; p < 0.001), which reflected worse LV systolic function. The area under the ROC curves of GLS for the prediction of mortality was 0.76 (95% CI 0.67 to 0.87). Patients with GLS > -14.1% showed a significantly higher mortality rate (67.7% versus 15.6%; p < 0.0001; log-rank = 23.3; p < 0.0001). In the multivariate analysis, GLS (HR, 1.27; 95% CI 1.07 to 1.50, p = 0.005) and SOFA scores (HR, 1.27; 95% CI 1.08 to 1.50, p = 0.004) were independent predictors of in-hospital mortality. CONCLUSIONS: Our study indicated that LV systolic function measured by STE might be associated with mortality in patients with septic shock.

Subclinical Left Ventricular Systolic Dysfunction in Patients with Septic Shock Based on Sepsis-3 Definition: A Speckle-Tracking Echocardiography Study.

INTRODUCTION: Left ventricular dysfunction is quite common in septic shock. Speckle-tracking echocardiography (STE) is a novel, highly sensitive method for assessing left ventricular function, capable of detecting subclinical myocardial dysfunction, which is not identified with conventional echocardiography. We sought to evaluate subclinical left ventricular systolic function in patients with septic shock using speckle-tracking echocardiography. METHODS: From May 2017 to December 2018, patients aged ≥18 years admitted to the intensive care unit with the diagnosis of sepsis and septic shock based on the sepsis-3 definition were included. Patients with other causes of cardiac dysfunction were excluded. Transthoracic echocardiography was performed for all the patients within 24 hours of diagnosis. Left ventricular systolic function was assessed using conventional echocardiography and speckle-tracking echocardiography. RESULTS: Patients with septic shock (n = 90) (study group) and 37 matched patients with sepsis but no septic shock (control group) were included. Left ventricular ejection fraction (LVEF) by conventional echocardiography showed no significant difference between two groups (58.2 ± 9.9 vs. 58.6 ± 8.3, p=0.804). The global longitudinal strain (GLS) by STE was significantly reduced in patients with septic shock compared with that in the control (-14.6 ± 3.3 vs. -17.1 ± 3.3, p < 0.001). Based on the cutoff value of GLS ≥ -15% for the definition of subclinical left ventricular systolic dysfunction, this dysfunction was detected in 50 patients with septic shock (55.6%) and in 6 patients in the control group (16.2%) (p < 0.05). CONCLUSIONS: Speckle-tracking echocardiography can detect early subclinical left ventricular systolic dysfunction via the left ventricular global longitudinal strain compared with conventional echocardiographic parameters in patients with septic shock.