ABSTRACT
BACKGROUND: Methemoglobinemia (MetHb) is a rare and potentially severe dyshemoglobinemia that can be induced by exposure to oxidizing agents, decreasing the functional capacity of the hemoglobin molecule to transport and release oxygen into the tissues. MetHb can originate from gases with oxidizing capacity generated by internal combustion engines, although since the universalization of catalyst converters in automobiles, a tiny proportion of MetHb poisoning is due to exposure to engine gases and fumes. Within this group, only two cases due to suicidal motivations have been reported in the last 30 years. CASE PRESENTATION: Here, we expose the case of a patient with MetHb levels of 25.2% (normal 0-1.5%) who with suicidal motivations had attached and locked a hose to the exhaust pipe of her vehicle with electrical tape, becoming exposed to a sustained concentration of the vehicle's exhaust. Upon her arrival at the emergency department, the presence of generalized greyish cyanosis with alterations of the sensorium, dissociation between saturation measured by arterial blood gas analysis and pulse oximetry (98% vs. 85%), no response to high-flow oxygen therapy, and an excellent response to intravenous methylene blue treatment were highlighted. CONCLUSIONS: This report illustrates an original case of acute toxic acquired MetHb due to inhalation of oxidizing substances originating from the bad ignition of an internal combustion engine. When evaluating a patient with suspected gas intoxication, we usually consider poisoning by the most common toxins, such as carbon monoxide or cyanide. In this context, we propose an algorithm to assist in the suspicion of this entity in patients with cyanosis in the emergency department. MetHb poisoning should be suspected, and urgent co-oximetry should be requested when there is no congruence between cyanosis intensity and oxygen saturation measured by pulse oximetry, if there is discordance between the results of oxygen saturation measured by arterial blood gas and pulse oximeter, and if there is no response to oxygen treatment. This algorithm could be useful to not delay diagnosis, improve prognosis, and limit potential sequelae.
ABSTRACT
The purpose of the study was to analyze the relationship between the high-sensitivity troponin T levels in patients with confirmed influenza virus infection and its severity determined by mortality during the care process. In addition, a high-sensitivity troponin T cut-off value was sought to allow us to a safe discharge from the emergency department. An analytical retrospective observational study was designed in which high-sensitivity troponin T is determined as an exposure factor, patients are followed until the resolution of the clinical picture, and the frequency of mortality is analyzed. We included patients ≥ 16 years old with confirmed influenza virus infection and determination of high-sensitivity troponin T. One hundred twenty-eight patients were included (96.9% survivors, 3.1% deceased). Mean and median blood levels of high-sensitivity troponin T of survivors were 26.2 ± 58.3 ng/L and 14.5 ng/L (IQR 16 ng/L), respectively, and were statistically different when compared with those of the deceased patients, 120.5 ± 170.1 ng/L and 40.5 ng/L (IQR 266.5 ng/L), respectively, p = 0.012. The Youden index using mortality as the reference method was 0.76, and the cut-off value associated with this index was 24 ng/L (sensitivity 100%, specificity 76%, NPV 100%, PPV 4%) with AUC of 88,8% (95% CI: 79.8−92.2%), p < 0.001. We conclude that high-sensitivity troponin T levels in confirmed virus influenza infection are a good predictor of mortality in our population, and this predictor is useful for safely discharging patients from the emergency department.
ABSTRACT
CASE DESCRIPTION: Case of lipemia retinalis secondary to hyperchylomicronemia in a 40-year-old man with a history of total body irradiation and immunosuppressive treatment that was attended in this hospital due to decreased visual acuity and abdominal pain. CLINICAL FINDINGS: Hyperchylomicronemia caused the development of acute pancreatitis and lipemia retinalis. The latter is an infrequent ocular manifestation that reflects excessive triglyceride blood levels in the organism (>2,000 mg/dL). Lipemia retinalis is characterized by the accumulation of chylomicrons in the retinal vessels, which gives them a white and creamy appearance in direct retinal ophthalmoscopy. The initial clinical suspicion of hyperchylomicronemia was based on the visualization of the supernatant in the analytical tube. TREATMENT AND RESULT: In the absence of definitive biochemical results, and owing to the need for special processing of the sample, lipid-lowering treatment and serum therapy were established after ophthalmological confirmation of lipemia retinalis, with subsequent full recovery of visual acuity. CLINICAL RELEVANCE: Given the initial difficulty to determine the accurate triglyceride levels in this kind of patient, early visualization of milky-colored retinal vessels on a salmon-colored eye fundus can help develop an early clinical suspicion of severe hyperchylomicronemia and contribute to limit the severity of complications.
Subject(s)
Hyperlipidemias , Hypertriglyceridemia , Pancreatitis , Retinal Diseases , Acute Disease , Adult , Humans , Male , Retinal Diseases/diagnosis , Retinal Diseases/etiologyABSTRACT
Abstract Case description: Case of lipemia retinalis secondary to hyperchylomicronemia in a 40-year-old man with a history of total body irradiation and immunosuppressive treatment that was attended in this hospital due to decreased visual acuity and abdominal pain. Clinical findings: Hyperchylomicronemia caused the development of acute pancreatitis and lipemia retinalis. The latter is an infrequent ocular manifestation that reflects excessive triglyceride blood levels in the organism (>2,000 mg/dL). Lipemia retinalis is characterized by the accumulation of chylomicrons in the retinal vessels, which gives them a white and creamy appearance in direct retinal ophthalmoscopy. The initial clinical suspicion of hyperchylomicronemia was based on the visualization of the supernatant in the analytical tube. Treatment and result: In the absence of definitive biochemical results, and owing to the need for special processing of the sample, lipid-lowering treatment and serum therapy were established after ophthalmological confirmation of lipemia retinalis, with subsequent full recovery of visual acuity. Clinical relevance: Given the initial difficulty to determine the accurate triglyceride levels in this kind of patient, early visualization of milky-colored retinal vessels on a salmon-colored eye fundus can help develop an early clinical suspicion of severe hyperchylomicronemia and contribute to limit the severity of complications.
Resumen Descripción del caso: Caso de lipemia retinalis secundaria a hiperquilomicronemia en varón de 40 años con antecedentes de irradiación corporal total y medicación inmunosupresora que acude al hospital por disminución de agudeza visual y dolor abdominal. Hallazgos clínicos: La hiperquilomicronemia contribuyó al desarrollo de pancreatitis aguda y lipemia retinalis. Esta última es una manifestación ocular infrecuente que refleja unos parámetros excesivos de triglicéridos en el organismo (>2,000 mg/dL). La Lipemia Retinalis consiste en la acumulación de quilomicrones en los vasos retinianos lo que les confiere un aspecto blanco y cremoso en la oftalmoscopia retiniana directa. La sospecha clínica inicial de hiperquilomicronemia se produjo por la visualización de sobrenadante en el tubo analítico. Tratamiento y resultado: Sin tener resultados definitivos bioquímicos, por necesidad de procesamiento especial de la muestra, se instauró tratamiento hipolipemiante y sueroterapia tras la confirmación oftalmológica de Lipemia Retinalis con recuperación total de la agudeza visual. Relevancia clínica: Dada la dificultad inicial para determinar las cifras reales de triglicéridos en este tipo de pacientes, la visualización precoz de vasos retinianos de color lechoso sobre lecho de color asalmonado en el fondo de ojo puede ser de ayuda para elaborar una sospecha clínica temprana de hiperquilomicronemia severa que contribuya a limitar la gravedad de las complicaciones.
Subject(s)
Adult , Humans , Male , Pancreatitis , Retinal Diseases , Hypertriglyceridemia , Hyperlipidemias , Retinal Diseases/diagnosis , Retinal Diseases/etiology , Acute DiseaseABSTRACT
No disponible
Subject(s)
Humans , Influenza, Human/diagnosis , Influenza, Human/epidemiology , Biomarkers , Prognosis , Influenza in Birds/diagnosis , Pneumonia/complications , Pneumonia/diagnosis , Chromatography, Affinity , Prospective StudiesSubject(s)
Influenza, Human , Natriuretic Peptide, Brain , Adrenomedullin , Biomarkers , Emergency Service, Hospital , Humans , Peptide Fragments , PrognosisABSTRACT
No disponible
Subject(s)
Humans , Natriuretic Peptide, Brain/analysis , Pneumonia/mortality , Sepsis/mortality , Shock, Septic/prevention & control , Risk Factors , Prospective StudiesSubject(s)
Influenza, Human , Seasons , Delivery of Health Care , Emergency Service, Hospital , Humans , IncidenceSubject(s)
Pneumonia , Sepsis , Hospitalization , Humans , Natriuretic Peptide, Brain , Peptide FragmentsABSTRACT
No disponible
