Hypertriglyceridemia in Critically Ill Patients With SARS-CoV-2 Infection.

BACKGROUND: Patients with SARS-CoV-2 infection could develop severe disease requiring critical care admission. Case reports indicated high incidence of hypertriglyceridemia (HTG) in critically ill patients infected with SARS-CoV-2, which might be related to the drugs. OBJECTIVE: We sought to determine the risk factors associated with HTG in this population and to investigate the relationship between HTG and lipase. METHODS: A retrospective observational study was conducted at our hospital between March 1 and June 30, 2020. Patients were included if they were ≥18 years old, admitted to the intensive care unit (ICU), tested positive for SARS-CoV-2, and had triglycerides (TG) checked during their hospital stay. RESULTS: Of the 111 critically ill patients, 103 patients were included. Males comprised 88.3% of the sample. The median TG at baseline was 197.4 (IQR: 139.8-283) mg/dL. The lipase median level at baseline was 23.00 (IQR: 0.00-69.50) IU/L. The results of the mixed-effects logistic regression analysis indicated that patient-level variables, favipiravir use, blood glucose level, and propofol use were significantly associated with HTG. There was no relationship between lipase and TG levels over time. Furthermore, TG concentrations over time showed a similar trend to inflammatory markers. CONCLUSION AND RELEVANCE: The incidence of clinically significant HTG was high and was associated with propofol and favipiravir use. HTG might reflect the high inflammatory state in these patients. Clinicians should look at the full picture before changing therapies based only on HTG. Our findings need to be replicated in a larger prospective study.

Passive leg raising-induced changes in pulse pressure variation to assess fluid responsiveness in mechanically ventilated patients: a multicentre prospective observational study.

BACKGROUND: Passive leg raising-induced changes in cardiac index can be used to predict fluid responsiveness. We investigated whether passive leg raising-induced changes in pulse pressure variation (ΔPPVPLR) can also predict fluid responsiveness in mechanically ventilated patients. METHODS: In this multicentre prospective observational study, we included 270 critically ill patients on mechanical ventilation in whom volume expansion was indicated because of acute circulatory failure. We did not include patients with cardiac arrythmias. Cardiac index and PPV were measured before/during a passive leg raising test and before/after volume expansion. A volume expansion-induced increase in cardiac index of >15% defined fluid responsiveness. To investigate whether ΔPPVPLR can predict fluid responsiveness, we determined areas under the receiver operating characteristic curves (AUROCs) and grey zones for relative and absolute ΔPPVPLR. RESULTS: Of the 270 patients, 238 (88%) were on controlled mechanical ventilation with no spontaneous breathing activity and 32 (12%) were on pressure support ventilation. The median tidal volume was 7.1 (inter-quartile range [IQR], 6.6-7.6) ml kg-1 ideal body weight. One hundred sixty-four patients (61%) were fluid responders. Relative and absolute ΔPPVPLR predicted fluid responsiveness with an AUROC of 0.92 (95% confidence interval [95% CI], 0.88-0.95; P<0.001) each. The grey zone for relative and absolute ΔPPVPLR included 4.8% and 22.6% of patients, respectively. These results were not affected by ventilatory mode and baseline characteristics (type of shock, centre, vasoactive treatment). CONCLUSIONS: Passive leg raising-induced changes in pulse pressure variation accurately predict fluid responsiveness with a small grey zone in critically ill patients on mechanical ventilation. CLINICAL TRIAL REGISTRATION: NCT03225378.

Venous Tropism in Renal Cell Carcinoma: A Rare Imaging Presentation.

Renal cell carcinoma (RCC) is one of the most prevalent malignancies in adults. Accurate staging and assessment of tumor extent are critical for effective management. RCC often demonstrates a tendency for venous invasion, commonly extending into the renal vein and inferior vena cava. However, RCC extending into the gonadal veins is an uncommon manifestation. In this report, we present the imaging features of a 62-year-old woman presented with left flank pain. The ultrasound examination revealed a large hyperechoic mass in the left renal fossa, replacing almost the entire left kidney with the contiguous extension of the tumor into the left renal vein and ovarian vein. Color Doppler showed the presence of flow within the thrombus, confirming the presence of a malignant thrombus. Contrast-enhanced CT examination revealed a large heterogeneously enhancing mass in the left kidney with the contiguous extension of tumor thrombus in the left renal vein, IVC, and into the left ovarian vein. This report highlights how imaging techniques can be instrumental in detecting and characterizing rare but significant tumor extensions, which can have crucial prognostic implications for overall patient management.

Infantile fetiform abdominal mass: Teratoma or fetus in fetu? A case report with insights into radiological diagnosis and surgical management.

Fetus-in-fetu (FIF) is a rare congenital anomaly in which a malformed parasitic twin develops within the body of a live fetus or child. Abdominal teratoma, a type of germ cell tumor, can be a great imaging mimicker of FIF and vice-versa, as they both can present as a heterogeneous mass with calcifications and a fat component. Radiological differentiation of these 2 entities should be made because of the difference in surgical planning and treatment options. Features such as visualization of distinct bony vertebral elements and encysted cystic components are the specific features of Fetus in fetu [1]. In contrast, the presence of elevated serum markers can help diagnose teratoma. Here, we report a case of a 5-month-old girl presented with progressive distension of the upper abdomen for the last 2 months, noticed by her mother. Her initial imaging with abdominal X-ray and ultrasonography showed the presence of a large heterogenous solid-cystic mass in the upper abdomen with large elongated calcifications. A provisional diagnosis of teratoma vs FIF was considered. CECT abdomen showed clear identification of osseous structures of the axial and appendicular skeleton within a fat density mass, along with an encapsulated cystic component, strongly suggestive of FIF. Her serum tumor markers were within normal limits. The final diagnosis of FIF was confirmed on Laparotomy and postoperative specimens.

Pathophysiology, mechanisms, and managements of tissue hypoxia.

Oxygen is needed to generate aerobic adenosine triphosphate and energy that is required to support vital cellular functions. Oxygen delivery (DO2) to the tissues is determined by convective and diffusive processes. The ability of the body to adjust oxygen extraction (ERO2) in response to changes in DO2 is crucial to maintain constant tissue oxygen consumption (VO2). The capability to increase ERO2 is the result of the regulation of the circulation and the effects of the simultaneous activation of both central and local factors. The endothelium plays a crucial role in matching tissue oxygen supply to demand in situations of acute drop in tissue oxygenation. Tissue oxygenation is adequate when tissue oxygen demand is met. When DO2 is severely compromised, a critical DO2 value is reached below which VO2 falls and becomes dependent on DO2, resulting in tissue hypoxia. The different mechanisms of tissue hypoxia are circulatory, anaemic, and hypoxic, characterised by a diminished DO2 but preserved capacity of increasing ERO2. Cytopathic hypoxia is another mechanism of tissue hypoxia that is due to impairment in mitochondrial respiration that can be observed in septic conditions with normal overall DO2. Sepsis induces microcirculatory alterations with decreased functional capillary density, increased number of stopped-flow capillaries, and marked heterogeneity between the areas with large intercapillary distance, resulting in impairment of the tissue to extract oxygen and to satisfy the increased tissue oxygen demand, leading to the development of tissue hypoxia. Different therapeutic approaches exist to increase DO2 and improve microcirculation, such as fluid therapy, transfusion, vasopressors, inotropes, and vasodilators. However, the effects of these agents on microcirculation are quite variable.

Tocilizumab and COVID-19: Timing of Administration and Efficacy.

Elevated concentrations of interleukin-6 have been demonstrated to be an important key factor in COVID-19 host immune impairment. It represents an important prognostic factor of harm associated with COVID-19 infection by stimulating a vigorous proinflammatory response, leading to the so-called "cytokine storm". Therefore, immunomodulatory interventions targeting interleukin-6 receptor antagonism have been investigated as potential treatments to counterbalance the host immune dysregulation and to support the advantageous effects of corticosteroids. Tocilizumab is a recombinant humanized monoclonal antibody that has gained much interest during the COVID-19 pandemic as an interleukin-6 receptor antagonist. Various early observational studies have reported beneficial effects of tocilizumab. Moreover, consequent randomized controlled trials have subsequently shown significant positive results about tocilizumab efficacy and safety, focusing on outcomes like mortality, risk of intensive care unit admission, and the need for mechanical ventilation, while others presented conflicting findings. In this review, we first described the pathophysiology of COVID-19 infection while highlighting the role of interleukin-6. Furthermore, we also discussed the non-conclusive evidence about tocilizumab to be used as the standard of care therapy for all patients with COVID-19 pneumonia, as well as its beneficial effects in selected patients.

Patient-Ventilator Dyssynchrony in Critically Ill Patients.

Patient-ventilator dyssynchrony is a mismatch between the patient's respiratory efforts and mechanical ventilator delivery. Dyssynchrony can occur at any phase throughout the respiratory cycle. There are different types of dyssynchrony with different mechanisms and different potential management: trigger dyssynchrony (ineffective efforts, autotriggering, and double triggering); flow dyssynchrony, which happens during the inspiratory phase; and cycling dyssynchrony (premature cycling and delayed cycling). Dyssynchrony has been associated with patient outcomes. Thus, it is important to recognize and address these dyssynchronies at the bedside. Patient-ventilator dyssynchrony can be detected by carefully scrutinizing the airway pressure-time and flow-time waveforms displayed on the ventilator screens along with assessing the patient's comfort. Clinicians need to know how to depict these dyssynchronies at the bedside. This review aims to define the different types of dyssynchrony and then discuss the evidence for their relationship with patient outcomes and address their potential management.

Use of Bedside Ultrasound to Assess Muscle Changes in the Critically Ill Surgical Patient.

BACKGROUND: Critical illness causes hypercatabolism, loss of lean body mass (LBM), and poor outcomes. Evaluating LBM in the critically ill is challenging, and it is uncertain whether nutrition support (NS) impacts LBM. This study measured quadriceps muscle layer thickness (QMLT) by bedside ultrasound (US) to estimate LBM changes in surgical intensive care unit (SICU) patients and healthy controls (HCs). METHODS: Trained RDNs measured QMLT via US at the midpoint and one-third distance between the superior margin of the patella and the anterior superior iliac spine. QMLT measurements were taken upon enrollment and repeated 1-2 times over 10 days. RESULTS: Fifty-two SICU patients and 15 HCs were enrolled. Average SICU percent QMLT loss per day at the midpoint and one-third landmarks was 3.2 ± 3.8 (P < 0.001) and 2.9 ± 5.7 (P = 0.001); and QMLT loss was higher between the second and third measurements (4.0 ± 8.0, P = 0.005 and 4.3 ± 9.8, P = 0.017 at the midpoint and one-third landmarks) compared with that at the first and second measurements (1.7 ± 9.2, P = 0.20 & 1.7 ± 9.4, P = 0.22). Changes were not associated with NS received. No significant QMLT change was found in HCs. CONCLUSIONS: SICU patients significantly lost QMLT over 10 days, with greater losses occurring after 5 days. These results support RDNs performing USs to detect QMLT changes and suggest this technique could be valuable to evaluate LBM changes in critically ill patients.

Effects of Methylprednisolone on Ventilator-Free Days in Mechanically Ventilated Patients with Acute Respiratory Distress Syndrome and COVID-19: A Retrospective Study.

Objectives: There are limited data regarding the efficacy of methylprednisolone in patients with acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19) requiring invasive mechanical ventilation. We aimed to determine whether methylprednisolone is associated with increases in the number of ventilator-free days (VFDs) among these patients. Design: Retrospective single-center study. Setting: Intensive care unit. Patients: All patients with ARDS due to confirmed SARS-CoV-2 infection and requiring invasive mechanical ventilation between 1 March and 29 May 2020 were included. Interventions: None. Measurements and Main Results: The primary outcome was ventilator-free days (VFDs) for the first 28 days. Defined as being alive and free from mechanical ventilation. The primary outcome was analyzed with competing-risks regression based on Fine and Gray's proportional sub hazards model. Death before day 28 was considered to be the competing event. A total of 77 patients met the inclusion criteria. Thirty-two patients (41.6%) received methylprednisolone. The median dose was 1 mg·kg-1 (IQR: 1-1.3 mg·kg-1) and median duration for 5 days (IQR: 5-7 days). Patients who received methylprednisolone had a mean 18.8 VFDs (95% CI, 16.6-20.9) during the first 28 days vs. 14.2 VFDs (95% CI, 12.6-16.7) in patients who did not receive methylprednisolone (difference, 4.61, 95% CI, 1.10-8.12, p = 0.001). In the multivariable competing-risks regression analysis and after adjusting for potential confounders (ventilator settings, prone position, organ failure support, severity of the disease, tocilizumab, and inflammatory markers), methylprednisolone was independently associated with a higher number of VFDs (subhazards ratio: 0.10, 95% CI: 0.02-0.45, p = 0.003). Hospital mortality did not differ between the two groups (31.2% vs. 28.9%, p = 0.82). Hospital length of stay was significantly shorter in the methylprednisolone group (24 days [IQR: 15-41 days] vs. 37 days [IQR: 23-52 days], p = 0.046). The incidence of positive blood cultures was higher in patients who received methylprednisolone (37.5% vs. 17.8%, p = 0.052). However, 81% of patients who received methylprednisolone also received tocilizumab. The number of days with hyperglycemia was similar in the two groups. Conclusions: Methylprednisolone was independently associated with increased VFDs and shortened hospital length of stay. The combination of methylprednisolone and tocilizumab was associated with a higher rate of positive blood cultures. Further trials are needed to evaluate the benefits and safety of methylprednisolone in moderate or severe COVID-19 ARDS.

Severe Acute Kidney Injury in Critically Ill Patients with COVID-19 Admitted to ICU: Incidence, Risk Factors, and Outcomes.

BACKGROUND: Critically ill patients with COVID-19 are prone to develop severe acute kidney injury (AKI), defined as KDIGO (Kidney Disease Improving Global Outcomes) stages 2 or 3. However, data are limited in these patients. We aimed to report the incidence, risk factors, and prognostic impact of severe AKI in critically ill patients with COVID-19 admitted to the intensive care unit (ICU) for acute respiratory failure. METHODS: A retrospective monocenter study including adult patients with laboratory-confirmed severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection admitted to the ICU for acute respiratory failure. The primary outcome was to identify the incidence and risk factors associated with severe AKI (KDIGO stages 2 or 3). RESULTS: Overall, 110 COVID-19 patients were admitted. Among them, 77 (70%) required invasive mechanical ventilation (IMV), 66 (60%) received vasopressor support, and 9 (8.2%) needed extracorporeal membrane oxygenation (ECMO). Severe AKI occurred in 50 patients (45.4%). In multivariable logistic regression analysis, severe AKI was independently associated with age (odds ratio (OR) = 1.08 (95% CI (confidence interval): 1.03-1.14), p = 0.003), IMV (OR = 33.44 (95% CI: 2.20-507.77), p = 0.011), creatinine level on admission (OR = 1.04 (95% CI: 1.008-1.065), p = 0.012), and ECMO (OR = 11.42 (95% CI: 1.95-66.70), p = 0.007). Inflammatory (interleukin-6, C-reactive protein, and ferritin) or thrombotic (D-dimer and fibrinogen) markers were not associated with severe AKI after adjustment for potential confounders. Severe AKI was independently associated with hospital mortality (OR = 29.73 (95% CI: 4.10-215.77), p = 0.001) and longer hospital length of stay (subhazard ratio = 0.26 (95% CI: 0.14-0.51), p < 0.001). At the time of hospital discharge, 74.1% of patients with severe AKI who were discharged alive from the hospital recovered normal or baseline renal function. CONCLUSION: Severe AKI was common in critically ill patients with COVID-19 and was not associated with inflammatory or thrombotic markers. Severe AKI was an independent risk factor of hospital mortality and hospital length of stay, and it should be rapidly recognized during SARS-CoV-2 infection.

Convalescent Plasma Efficacy in Life-Threatening COVID-19 Patients Admitted to the ICU: A Retrospective Cohort Study.

(1) Background: There are limited data regarding the efficacy of convalescent plasma (CP) in critically ill patients admitted to the intensive care unit (ICU) due to coronavirus disease 2019 (COVID-19). We aimed to determine whether CP is associated with better clinical outcome among these patients. (2) Methods: A retrospective single-center study including adult patients with laboratory-confirmed SARS-CoV-2 infection admitted to the ICU for acute respiratory failure. The primary outcome was time to clinical improvement, within 28 days, defined as patient discharged alive or reduction of 2 points on a 6-point disease severity scale. (3) Results: Overall, 110 COVID-19 patients were admitted. Thirty-two patients (29%) received CP; among them, 62.5% received at least one CP with high neutralizing antibody titers (≥1:160). Clinical improvement occurred within 28 days in 14 patients (43.7%) of the CP group vs. 48 patients (61.5%) in the non-CP group (hazard ratio (HR): 0.75 (95% CI: 0.41-1.37), p = 0.35). After adjusting for potential confounding factors, CP was not independently associated with time to clinical improvement (HR: 0.53 (95% CI: 0.23-1.22), p = 0.14). Additionally, the average treatment effects of CP, calculated using the inverse probability weights (IPW), was not associated with the primary outcome (-0.14 days (95% CI: -3.19-2.91 days), p = 0.93). Hospital mortality did not differ between CP and non-CP groups (31.2% vs. 19.2%, p = 0.17, respectively). Comparing CP with high neutralizing antibody titers to the other group yielded the same findings. (4) Conclusions: In this study of life-threatening COVID-19 patients, CP was not associated with time to clinical improvement within 28 days, or hospital mortality.

Mechanism of continence after repair of posterior urethral disruption: evidence of rhabdosphincter activity.

PURPOSE: Controversy exists regarding continence mechanisms in patients who undergo posterior urethral reconstruction after pelvic fracture. Some evidence suggests that continence after posterior urethroplasty is maintained by the bladder neck or proximal urethral mechanism without a functioning distal mechanism. We studied distal urethral sphincter activity in patients who have undergone posterior urethroplasty for pelvic fracture. MATERIALS AND METHODS: A total of 12 patients who had undergone surgical repair of urethral disruption involving the prostatomembranous region underwent videourodynamics with urethral pressure profiles at rest, and during stress and hold maneuvers. Bladder pressure and urethral pressure, including proximal and distal urethral sphincter activity and pressure, were assessed in each patient. RESULTS: All 12 patients had daytime continence of urine postoperatively with a followup after anastomotic urethroplasty of 12 to 242 months (mean 76). Average maximum urethral pressure was 71 cm H2O. Average maximum urethral closure pressure was 61 cm H2O. The average urethral pressure seen during a brief hold maneuver was 111 cm H2O. Average functional sphincteric length was 2.5 cm. Six of the 12 patients had clear evidence of distal urethral sphincter function, as demonstrated by the profile. CONCLUSIONS: Continence after anastomotic urethroplasty for posttraumatic urethral strictures is maintained primarily by the proximal bladder neck. However, there is a significant contribution of the rhabdosphincter in many patients.

Telemedicine/Virtual ICU: Where Are We and Where Are We Going?

Intensive care unit telemedicine (tele-ICU) is technology enabled care delivered from off-site locations that was developed to address the increasing complexity of patients and insufficient supply of intensivists. Although tele-ICU deployment is increasing, it continues to cover only a small proportion of ICU patients. This is primarily due to expense, with first-year costs exceeding $50,000 per bed. Meta-analyses of outcomes indicate survival benefits and quality improvements, albeit with significant heterogeneity. Depending on the context, a wide range of estimated incremental cost-effectiveness ratios reflects variable effects on cost and outcomes, such as mortality or length of stay. Tele-ICUs may fit within a hybrid model of care to complement high-intensity ICU staff coverage. However, more research is required to foster consensus and determine best practices. This review summarizes data on tele-ICU structure, operations, outcomes, and costs. Evidence was extracted from meta-analyses, with secondary data from Cleveland Clinic's tele-ICU experience.

Acute kidney injury in postoperative shock: is hyperoncotic albumin administration an unrecognized resuscitation risk factor?

BACKGROUND: The use of hyperoncotic albumin (HA) for shock resuscitation is controversial given concerns about its cost, effectiveness, and potential for nephrotoxicity. We evaluated the association between early exposure to hyperoncotic albumin (within the first 48 h of onset of shock) and acute organ dysfunction in post-surgical patients with shock. METHODS: This retrospective, cohort study included 11,512 perioperative patients with shock from 2009 to 2012. Shock was defined as requirement for vasopressors to maintain adequate mean arterial pressure and/or elevated lactate (> 2.2 mmol/L). Subsets of 3600 were selected after propensity score and exact matching on demographics, comorbidities, and treatment variables (> 30). There was a preponderance of cardiac surgery patients. Proportional odds logistic regression, multivariable logistic regression or Cox proportional hazard regression models measured association between hyperoncotic albumin and acute kidney injury (AKI), hepatic injury, ICU days, and mortality. RESULTS: Hyperoncotic albumin-exposed patients showed greater risk of acute kidney injury compared to controls (OR 1.10, 95% CI 1.04, 1.17. P = 0.002), after adjusting for imbalanced co-variables. Within matched patients, 20.3%, 2.9%, and 4.4% of HA patients experienced KDIGO stages 1-3 AKI, versus 19.6%, 2.5%, and 3.0% of controls. There was no difference in hepatic injury (OR 1.16; 98.3% CI 0.85, 1.58); ICU days, (HR 1.05; 98.3% CI 1.00, 1.11); or mortality, (OR 0.88; 98.3% CI 0.64, 1.20). CONCLUSIONS: Early exposure to hyperoncotic albumin in postoperative shock appeared to be associated with acute kidney injury. There did not appear to be any association with hepatic injury, mortality, or ICU days. The clinical and economic implications of this finding warrant further investigation.

Short-Term Impact of Concussion in the NHL: An Analysis of Player Longevity, Performance, and Financial Loss.

Many studies have focused on the long-term impact of concussions in professional sports, but few have investigated short-term effects. This study examines concussion effects on individual players in the National Hockey League (NHL) by assessing career length, performance, and salary. Contracts, transactions, injury reports, and performance statistics from 2008-17 were obtained from the official NHL online publication. Players who sustained a concussion were compared with the 2008-17 non-concussed player pool. Career length was analyzed using Kaplan-Meier survival curves and stratification of player age, experience, and longevity. Player performance and salary changes were evaluated between the years before versus after concussion. Performance and salary changes were compared against non-concussed NHL athletes before/after their career midpoints. Of the 2194 eligible NHL players in the 9-year period, 309 sustained 399 concussions resulting in injury protocol. The probability of playing a full NHL season post-concussion was significantly decreased compared with the non-concussed pool (p < 0.05), specifically 65.0% versus 81.2% at 1 year into a player's career, 49.8% versus 67.4% at 2 years, and 14.6% versus 43.7% at 5 years. Performance was reduced at all non-goalie positions post-concussion (p < 0.05). Players scored 2.5 points/year less following a concussion. The total annualized financial impact from salary reductions after 1 concussion was $57.0 million, with a decrease of $292,000 per year in contract value per athlete. This retrospective study demonstrates that NHL concussions resulting in injury protocol activation lead to shorter career lengths, earnings reductions, and decreased performance when compared with non-concussed controls.

A teenager presents with fulminant hepatic failure and acute hemolytic anemia.

A teenager was admitted to an outside hospital ED following an episode of melena. He had been complaining of intermittent abdominal pain, nausea, malaise, and easy fatigability for 2 months, with significant worsening of symptoms 2 weeks prior to this episode. He had no significant medical, surgical, or family history. On presentation at the outside ED, he was found to be profoundly icteric and encephalopathic. Initial laboratories suggested anemia, acute kidney injury, and acute liver failure, leading to a presumptive diagnosis of acute fulminant liver failure necessitating transfer to our institution.

Infections and urinary stone disease.

The relationship between urinary infections and stone formation has been recognized since antiquity and it has been over a century since bacterial degradation of urea was postulated to cause struvite stones. Specific therapy for urease-producing bacteria, such as urease-inhibitors and antibiotics, has allowed for treatment for this subset of urinary stones. Future directions for research include development of novel urease-inhibitors and chemicals to enhance the protective glycosaminoglycan layer. An improved understanding of the pathogenesis of calcium-based stones has led to the discovery of potential roles for nanobacteria and Oxalobacter formingenes. Methods of altering intestinal regulation of oxalate by reintroduction of lactic acid bacteria may significantly impact the treatment of calcium oxalate stones. The use of catheters, both urethral and ureteral, is common in the urinary tract and is associated with significant morbidity, primarily from associated infections. Catheters to prevent bacterial colonization and formation of biofilms have been created using various coatings, including ciprofloxacin, hydrogel, and silver. Use of these types of catheters may minimize infections and encrustation inherent with their placement in the urinary tract.

Visceral leishmaniasis in immunosuppressed Caucasian patient.

A 64-year-old man was admitted with fever, weight loss, fatigue and night sweats. He was known to have rheumatoid arthritis and had been taking methotrexate for 1 year. He had worked in Saudi Arabia until 1994 and had been living in Spain for 6 months every year. Clinical examination showed an enlarged spleen. Routine investigations showed pancytopaenia. Serial blood cultures were negative. CT scan confirmed splenomegaly and was otherwise unremarkable. Bone marrow biopsy revealed Leishmania amastigote consistent with a diagnosis of visceral leishmaniasis. After discussing with the hospital for tropical diseases (HTD), he was started on liposomal amphotericin B. Following two infusions of amphotericin B, he started improving as his fever, night sweats and weakness had settled. He was then discharged and followed up in HTD clinic 4 weeks later where he was found to be consistently improving.