October 2014 Critical Care Case of the Month: A Skin Rash in the ICU

Robert A. Raschke, MD

Banner Good Samaritan Medical Center

Phoenix, AZ

History of Present Illness

A 28 year old man was admitted to an outside hospital with an ethylene glycol overdose in an apparent suicide attempt. At that time the patient was delirious and vomiting. He had a severe metabolic acidosis and a creatinine of 2.1 mg/dL. He was intubated, a nasogastric tube was placed, and he was transferred to the toxicology service.

PMH, FH, SH

There was no significant past medical history. Family history was noncontributory. He was a nonsmoker who recently had a fight with his girlfriend prompting the suicide attempt.

Physical Examination

Vital signs were stable and he was sedated and nasally intubated receiving mechanical ventilation. There were no other significant findings on physical examination

Which of the following can be used for ethylene glycol poisoning? (Click on the correct answer to proceed to the next of 5 panels)

1. Ethanol
2. Fomezipole
3. Hemodialysis
4. Pyridoxine
5. All of the above

Reference as: Raschke RA. October 2014 critical care case of the month: a skin rash in the ICU. Southwest J Crit Care Med. 2014;9(4):208-13. doi: http://dx.doi.org/10.13175/swjpcc110-14 PDF

Ultrasound for Critical Care Physicians: A Tempting Dilemma

Issam Marzouk MD

Lana Melendres MD

Michel Boivin MD

Division of Pulmonary, Critical Care and Sleep

Department of Medicine

University of New Mexico School of Medicine

MSC 10-5550

Albuquerque, NM 87131 USA

A 46 year old woman presented with progressive severe hypoxemia and a chronic appearing pulmonary embolus on chest CT angiogram to the intensive care unit. The patient was hemodynamically stable, but had an oxygen saturation of 86% on a high-flow 100% oxygen mask. The patient had been previously investigated for interstitial lung disease over the past 2 year, this was felt to be due to non-specific interstitial pneumonitis. Her echocardiogram findings are as presented below (Figures 1 and 2).

Figure 1. Parasternal long axis view. Upper panel: static image. Lower panel: video.

 

Figure 2. Apical four chamber view. Upper panel: static image. Lower panel: video

The patient had refractory hypoxemia despite trials of high flow oxygen and non-invasive positive pressure ventilation. She had mild symptoms at rest but experienced severe activity intolerance secondary to exertional dyspnea. Vitals including blood pressure remained stable and normal during admission and the patient had a pulsus paradoxus measurement of < 10 mmHg. She had previously had an echocardiogram 6 months before that revealed significant pulmonary hypertension.

What would be the most appropriate next step regarding management of her echocardiogram findings? (click on the correct answer to move to the next panel)

1. Diagnostic pericardiocentesis
2. Urgent therapeutic pericardiocentesis
3. Avoid pericardiocentesis at this time
4. Urgent thrombolysis with tissue plasminogen activator

Reference as: Marzouk I, Melendres L, Boivin M. Ultrasound for critical care physicians: a tempting dilemma. Southwest J Pulm Crit Care. 2014;9(3):193-6. doi: http://dx.doi.org/10.13175/swjpcc128-14 PDF

September 2014 Critical Care Case of the Month: Bad Case of Colic

Sherry Andrews MD

Eyad Almasri MD

Pulmonary and Critical Care

UCSF Fresno

Fresno, CA

History of Present Illness:

A 70 year old man with a past medical history of chronic kidney disease, bipolar disorder, benign prostatic hypertrophy, hypertension and diabetes presented to the emergency department with constipation associated with bloating for 15 days. He denies flatus. He tried over the counter laxatives (polyethylene glycol) with no relief. He has no recent history of colonoscopy or recent antibiotic use. He denies chills, diarrhea, dysuria, fever, hematochezia, hematuria, melena, nausea or vomiting. In the emergency department, he is tachypneic with a grossly distended abdomen.

Past Medical History:

• Diabetes
• Hypertension
• Chronic kidney disease
• Bipolar disorder
• Benign prostatic hypertrophy
• Hyperlipidemia

Past Surgical History:

• Cholecystectomy 2012

Medications:

• Aspirin 81 mg daily
• Furosemide 20 mg daily
• Quetiapine 300 daily
• Doxazosin- 4 mg daily
• Clonazepam 1 mg – twice daily as needed
• Simvastatin 20 mg – daily
• Pioglitazone 15 mg daily

Social History:

He is a retired farm laborer and worked in a cannery. He is married and has two adult children.

He was a former smoker and quit in 2010 He denies any alcohol or illicit drug use

Physical Exam:

• Vital signs – Temperature 37.2 °C, heart rate 84 beats/min, respiratory rate 18-24 breaths/min, blood pressure 121/83 mmHg, SpO2 94 % on 4 L NC 
• General – Average build, well-nourished, in mild distress
• HEENT – Unremarkable
• Neck - Supple, no jugular venous distention
• Chest – Decreased breath sounds right base more than left base
• Heart - Regular rate, normal S1/S2, no murmur
• Abdomen – hypoactive bowel sounds, soft, distended, non-tender to palpation but diffusely tympanic.
• Neurological - Appropriately moves all 4 extremities, CN II-XII grossly intact
• Extremities - No edema
• Skin - No rash or palpable nodules

Laboratory:

• CBC: WBC 6.4 X 10³ /μL, hemoglobin 15.3 g/dL, hematocrit 45%, Platelets 121,000 /μL.
• Chemistries: Na⁺ 141 mmol/L, K⁺ 4.5 mmol /L, Cl^- 105 mmol /L, CO₂ 25 mmol /L, blood urea nitrogen (BUN) 24 mg/dL, creatinine 1.2 mg/dL, glucose 95 mg/dL, calcium 9.9 mg/dL, albumin 4.2 g/dL, liver function tests within normal limits. hemoglobin A1C 5.1%. lactic acid 1.8 mmol/L
•  Coagulation: Prothrombin time (PT) 16.6 sec, international normalized ratio (INR) 1.3

Radiography:

A CT scan abdomen and pelvis was done and a representative coronal view is shown in Figure 1.

Panel 1. Coronal cut of computed Tomography (CT) of the abdomen and pelvis on admission.

Which of the following are characteristics of acute colonic pseudo-obstruction (Ogilvie’s syndrome)? (Click on the correct answer to proceed to the next panel)

1. Antibiotics and abnormal bacterial overgrowth are implicated in the pathogenesis
2. Immediate surgical decompression is required
3. It is a complication of inflammatory bowel disease
4. It occurs in the absence of an anatomic lesion that obstructs the flow of intestinal contents

Reference as: Andrews S, Almasri E. September 2014 critical care case of the month: bad case of colic. Southwest J Pulm Crit Care. 2014;9(3):151-9. doi: http://dx.doi.org/10.13175/swjpcc094-14 PDF 

Life Threatening Zygomyces Infection of the Gastrointestinal Tract

Mohanad Al-Qaisi, MD¹

Charles Stauffer, MD¹

Gerges Makar, MD¹

Tim Kuberski, MD²

¹Department of Medicine, Maricopa Medical Center, Phoenix, Arizona

²Department of Medicine, Infectious Diseases, Maricopa Medical Center, Phoenix, Arizona

Abstract

A 25 year old diabetic woman was admitted into the Intensive Care Unit because of ketoacidosis, hypotension and upper gastrointestinal bleeding. Emergency endoscopic biopsy of the upper gastrointestinal tract demonstrated invasive, non-septate fungal hyphae suggestive of either a Zygomyces or Basidiobolus. Amphotericin B was not used because of its ineffectiveness against Basidiobolus and her renal failure. In addition, first generation antifungal azoles were not used because of their ineffectiveness against Zygomyces. The patient responded to medical therapy and the broad-spectrum azole antifungal posaconazole which has activity against both Basidiobolus and Zygomyces. The patient recovered from her critical illness and on follow up was without residual problems.

Introduction

Zygomyces are a group of fungi which include Mucor, Rhizopus and Absidia, the more common pathologic fungi in the order of Mucorales. As a group, these fungi are characterized by having non-septate hyphae and cause aggressive angioinvasion in certain immunosuppressed settings like ketoacidosis (1). We present a patient who presented with a life-threatening septic syndrome, ketoacidosis and gastrointestinal bleeding due to an infection by an unknown non-septate hyphal fungus, eventually identified as Rhizopus species. On presentation the patient was critically ill and admitted to the Intensive Care Unit. Her early course was complicated by a therapeutic antifungal dilemma which could influence her survival.

Case Report

A 25 years old woman with diabetes was admitted to the Intensive Care Unit with septic syndrome and diabetic ketoacidosis. She was hypotensive, blood pressure was 75/42 mmHg, heart rate 147/min, temperature 38.7 C. Pertinent blood testing revealed the following; glucose 623 mg/dl, creatinine 2.15 mg/dl, bicarbonate 13.6 mmol/L, lactic acid 6.8 mmol/L, WBC 9200/ μL, hemoglobin 7.4 gm/ dl. She was treated aggressively with intubation, mechanical ventilation, vasopressors and continuous renal replacement therapy (CRRT). Her diabetes was treated conventionally. Her course was complicated by a drop in hemoglobin from 11.4 to 7.0 gm/ dl despite transfusions. Her stool was found to be hemoccult positive.

Upper endoscopy showed multiple ulcers involving the gastric body extending onto the cardia which was covered with coffee ground exudate. Biopsies were obtained and showed a "fungus" with non-septate hyphae on preliminary histopathology and amphotericin B was initiated empirically. She continued to experience significant hematemesis and hypotension requiring multiple transfusions (4 units). The amphotericin B was discontinued because of progressive azotemia. Upon review of the pathology from the stomach biopsy, the possibility was raised that she might have either a Basidiobolus or Zygomyces infection (Figure 1).

Figure 1 illustrates the difference in appearance of non-septate hyphae between fungi in tissue in vivo and on culture in vitro. (A) Fungal culture (in vitro) showing the non­ septate hyphae. (B) GMS stain of the stomach tissue from the patient (in vivo) showing fungus fragments having broad, irregular, non-septate hyphae, arrow. The hyphae morphology becomes distorted with angioinvasion and tissue necrosis.

The patient was started empirically on oral posaconazole 400 mg twice daily which theoretically would be effective for both fungi. Within a few days the ketoacidosis resolved, the gastrointestinal bleeding stopped and she was discharged a few days later. After her discharge a Rhizopus species was cultured and identified as the causative agent.

Discussion

The therapeutic dilemma in the treatment of this patient was related to the inability to differentiate between two potential fungal pathogens, Zygomyces or Basidiobolus on the basis of only tissue pathology. Under ideal circumstances the histopathology might differentiate the two, however trying to distinguish between the two can be difficult because both have non-septate hyphae, are morphologically similar, and can involve the stomach. Based on morphology the differentiation between Basidiobolus and Rhizopus is subtle. For Basidiobolus the hyphal elements typically show "sparse" septation while Rhizopus hyphal elements show "infrequent" septation. There was an added problem in that confirmatory cultures can take weeks before a specific identification can be made. Zygomyces infections tend to be rapidly destructive, but are rare to involve the gastrointestinal tract (1). In contrast, Basidiobolus rananum is endemic to Arizona and generally known to primarily cause gastrointestinal infections (2). That organism however, usually causes an indolent process and is less likely to be fatal. However, there is a case report of angioinvasive disease with basidiobolomycosis reminiscent of mucormycosis in diabetics (3). Epidemiological studies on Basidiobolus suggest that the common risks for this infection include living in Arizona, having diabetes and use of medications that suppress stomach acids (2).

A high index of suspicion in our patient with some of these risk factors made Basidiobolus a consideration. Importantly, the antifungal treatment of Basidiobolus is different than for the Zygomyces (i.e., Rhizopus). Basidiobolus is known to be resistant to amphotericin B and the preferred treatment is itraconazole (2).

Our patient initially received a few doses of amphotericin B empirically because of the report of a non-septate "fungus" on biopsy. Amphotericin B is the drug of choice for Zygomyces, but not for Basidiobolus (4). Notably itraconazole is not effective for the Zygomyces. The treatment decision was made to use posaconazole because of its broad spectrum antifungal activity that would have activity against both Zygomyces and Basidiobolus. In addition, there is a report of posaconazole being used successfully to treat gastrointestinal basidiobolomycosis (5). Of the Zygomyces, Rhizopus is the most common cause of human infections, more than Mucor. Certainly correcting the ketoacidosis and gastrointestinal bleeding contributed to her improvement, but the mortality rate in diabetic patients with Zygomyces involving the gastrointestinal tract is about 85% (6). The patient appeared to be effectively treated based on the therapeutic antifungal decision while the patient was critically ill. She was seen in follow up several weeks later without any obvious residual effects. Her response to posaconazole suggests it would be an effective consideration in places like Arizona where Basidiobolus and Zygomyces could be in the differential.

References

1. Chayakulkeeree M, Ghannoum MA, Perfect JR. Zygomycosis: the re-emerging fungal infection. Eur J Clin Microbiol Infect Dis. 2006;25(4):215-29. [CrossRef] [PubMed]
2. Vikram HR, Smilack JD, Leighton JA, Crowell MD, De Petris G.. Emergence of gastrointestinal basidiobolomycosis in the united states, with a review of worldwide cases. Clin Infect Dis. 2012;54(12):1685-91. [CrossRef] [PubMed]
3. Bigliazzi C, Poletti V, Dell'Amore D, Saragoni L, Colby TV. Disseminated basidiobolomycosis in an immunocompetent woman. J Clin Microbiol. 2004;42(3):1367-9. [CrossRef] [PubMed]
4. Guarro J, Aguilar C, Pujol I. In-vitro antifungal susceptibilities of Basidiobolus and Conidiobolus spp. strains. J Antimicrob Chemother. 1999;44(4):557-60. [CrossRef] [PubMed]
5. Rose RR, Lindsby MD, Hurst SF, Paddock CD, Damodaran T, Bennett J. Gastrointestinal basidiobolomycosis treated with posaconazole. Med Mycol Case Rep. 2012;2:11-4. [CrossRef] [PubMed]
6. Roden MM, Zaoutis TE, Buchanon WL, Knudsen TA, Sarkisova TA, Schaufele RL, Sein M, Sein T, Chiou CC, Chu JH, Kontoyiannis DP, Walsh JT. Epidemiology and outcome of zygomycosis: a review of 929 reported cases. Clin Infect Dis. 2005;41(5):634-53. [CrossRef] [PubMed]

Reference as: Al-Qaisi M, Stauffer C, Makar G, Kuberski T. Life threatening zygomyces infection of the gastrointestinal tract. Southwest J Pulm Crit Care. 2014;9(2):133-6. doi: http://dx.doi.org/10.13175/swjpcc090-14 PDF 

Ultrasound For Critical Care Physicians: Where Did the Bubbles Go?

A 35-year-old woman with factor V Leiden deficiency on chronic anticoagulation therapy and a history of multiple deep vein thrombosis, pulmonary embolism and transient ischemic attacks presented for an evaluation of dyspnea. An echocardiogram with agitated saline contrast (bubble study) was performed (Figure 1).

Figure 1. Apical 4 chamber video taken from bubble study.

What is the best explanation for the findings in the video?

1. Intra-atrial right to left shunting
2. Normal bubble study
3. Pulmonary arterial-venous malformation
4. Ventricular septal defect

Reference as: Natt B, Snyder L, Lax D. Ultrasound for critical care physicians: where did the bubbles go? Southwest J Pulm Crit Care. 2014;9(2):91-3. doi: http://dx.doi.org/10.13175/swjpcc100-14 PDF