GBS in HIV

Q: Guillain-Barré syndrome(GBS) tends to occur in ΗІV infection during which phase? - select one

A) early

B) late

Answer: A

Although GBS can occur in any stage of НΙV infection, but it tends to occur in very early phase. It is thought to be due to acute HІV seroconversion and following immune reconstitution syndrome from the highly active antiretroviral therapy.

#neurology

#ID

Reference:

Piliero PJ, Fish DG, Preston S, et al. Guillain-Barré syndrome associated with immune reconstitution. Clin Infect Dis 2003; 36:e111.

Rasmussen's aneurysm

Q: What is Rasmussen's aneurysm?

Answer: Rasmussen's aneurysm is a pulmonary artery aneurysm adjacent to or within a tuberculous cavity. It may rupture and lead to fatal hemoptysis. Rasmussen's aneurysm is caused by weakening of the pulmonary artery wall from adjacent cavitary tuberculosis.

#pulmonary

#ID

References:

1. Chatterjee K, Colaco B, Colaco C, Hellman M, Meena N. Rasmussen's aneurysm: A forgotten scourge. Respir Med Case Rep. 2015 Aug 12;16:74-6. doi: 10.1016/j.rmcr.2015.08.003. PMID: 26744661; PMCID: PMC4681976.

2. Marak JR, Kumar T, Gara H, Dwivedi S. Rasmussen aneurysm: Case series of a rare complication of Pulmonary Tuberculosis. Respir Med Case Rep. 2023 Jul 20;45:101897. doi: 10.1016/j.rmcr.2023.101897. PMID: 37577119; PMCID: PMC10413191.

3. Fadul KY, Alsayed A, Abdalla E, Mohamed RS, Salman AM, Meer A, Fadul A. Rasmussen's Aneurysm in Active Pulmonary Tuberculosis: A Case Report. Cureus. 2024 Aug 29;16(8):e68148. doi: 10.7759/cureus.68148. PMID: 39347312; PMCID: PMC11438579.

Cryo-poor plasma

Q: 43 year old female is transferred to ICU with diagnosis of thrombocytopenic purpura (TTP). Looking at previous records, you found a similar episode 4 years ago. It is mentioned that patient didn't respond to regular plasma exchange and required cryo-poor plasma exchange. What is cryo-poor plasma? 

 Answer: Cryo-poor plasma or cryosupernatant refers to plasma from which cryoprecipitate has been removed. The resulting plasma has reduced Factor VIII, von Willebrand factor, Factor XIII, fibronectin, and fibrinogen levels. Cryo-poor plasma may treat relapsing TTP, for which regular plasma exchange is ineffective. 

The rationale for using cryo-poor plasma in these refractory patients is that no additional von Willebrand factor will be administered to these patients who already have too much von Willebrand factor activity due to the presence of extra-large multimers of vWf. Caution: It is not a component regularly stocked in the blood bank. Usually, it will require special preparation and advance notice.

 

#hematology 

 Reference: 

Marcela P. Mafra, Maria Meritxell Roca Mora, Amanda Godoi, Andres Valenzuela - Cryoprecipitate-Poor Plasma Instead of Fresh Frozen Plasma As Replacement Therapy in Thrombotic Thrombocytopenic Purpura: A Systematic Review and Meta-Analysis - Blood (2023) 142 (Supplement 1): 2629.- https://doi.org/10.1182/blood-2023-188500

Anaphylaxis after rectal exam

Case: 54 years old male is admitted to ICU with pneumonia. Patient is found to be moderately anemic. To be complete in evaluation and to rule out possible GI bleed, you asked resident to do rectal exam for guaiac stool. Resident performed rectal exam with latex-free gloves and surgilube (surgical lubricant). 10 minutes later patient coded with severe anaphylactic reaction. What could be a reason assuming no new medication administered?

Answer: Possible allergic reaction to Chlorhexidine

Surgilubes (surgical lubricants, aka KY Jelly) are usually considered innocuous compounds, but they contain chlorhexidine. Patients with severe allergies to chlorhexidine may react badly, particularly if it enters blood circulation after a rectal exam.

#allergy-immunology

#physical exam

References:

1. A Case of Anaphylaxis to Chlorhexidine during Digital Rectal Examination - J Korean Med Sci. 2008 June; 23(3): 526–528.

2. Anaphylaxis to the chlorhexidine component of Instillagel®: a case series - Advance Access published online on November 5, 2008, - British Journal of Anaesthesia

3. Chlorhexidine anaphylaxis in Auckland - Br. J. Anaesth., May 1, 2009; 102(5): 722 - 723.

4. Chlorhexidine anaphylaxis: case report and review of the literature - Contact Dermatitis. 2004 Mar;50(3):113-6

Hypotensive symptoms (ACE-I vs ARB)

Q: 58 years old noncompliant male is admitted to ICU with hypertensive crisis. He has improved after intravenous infusion of anti-hypertensive. Now ICU team is considering to switch over his IV anti-hypertensive to oral. Because of his previous history of congestive heart failure (CHF) and diabetes, ACE-Inhibitor (ACE-I) or angiotensin II receptor blockers (ARBs) are under consideration. Another factor to consider is autonomic dysfunction because of his diabetes. Which group of drugs are more prone to cause hypotensive symptoms? - select one

A) ACE-Is

B) ARBs

Answer: B

ARBs have an advantage over ACE-Is when it comes to cough and angioedema. But, hypotensive symptoms are more common with ARBs.

In patients who may have underlying autonomic dysfunction (like our patient in this question), it can be severe. It may require permanent discontinuation. This effect persists for a while after discontinuation (see reference #2). A desirable 'washout period' should be taken into consideration before exposing a patient to any such other risk (see reference #3)

#hemodynamic

#pharmacology

References:

1. ONTARGET Investigators, Yusuf S, Teo KK, et al. Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med 2008; 358:1547.

2. Lee JH, Kim YY, Heo HJ, Kim G, Oh C. Severe refractory hypotension during induction of general anesthesia in patient after 48 hours of azilsartan discontinuation: A case report. Medicine (Baltimore). 2023 Nov 24;102(47):e36126. doi: 10.1097/MD.0000000000036126. PMID: 38013296; PMCID: PMC10681524.

3. Hojo T, Shibuya M, Kimura Y, Otsuka Y, Fujisawa T. Refractory Hypotension During General Anesthesia Despite Withholding Telmisartan. Anesth Prog. 2020 Jun 1;67(2):86-89. doi: 10.2344/anpr-67-02-02. PMID: 32633774; PMCID: PMC7342806.

H2blockers and heart

Q; 42 years old male is admitted to ICU with Small Bowel Obstruction. Patient is made NPO. Also, famotidine is prescribed as an intravenous bid dose. During the administration of IV famotidine, the patient became hypotensive, and cardiac arrhythmia was noted on the monitor, which degenerated into cardiac arrest. H2-blockers (H2B) tend to cause? - select one

A) Sinus bradycardia

B) Sinus tachycardia

Answer: A

The use of anti-ulcer medications is common in the ICU. Although not common, rapid infusion of H2B may cause sinus bradycardia, hypotension, atrioventricular (AV) blocks, prolongation of the QT interval, and cardiac arrest. If possible, it is preferred to use the oral route as its bioavailability is not much affected by food, though first-pass metabolism may cause some decreased effects. Unfortunately, our patient in question can not have it. In such cases, slow administration is preferred. 

Risk factors for cardiac arrest are rapid intravenous infusion, high dose, renal or hepatic dysfunction(delays clearance), and underlying heart condition.

#pharmacology

#cardiology

References:

1. Hinrichsen H, Halabi A, Kirch W. Clinical aspects of cardiovascular effects of H2-receptor antagonists. Eur J Clin Invest 1995; 25 Suppl 1:47.

2. Lee KW, Kayser SR, Hongo RH, et al. Famotidine and long QT syndrome. Am J Cardiol 2004; 93:1325.

Vitamins, Pregnancy and Asthma

Q: 24 years old female is admitted to ICU with severe exacerbation of Asthma. While recovering, her spouse, who also has history of severe asthma, inquires about a news report that some vitamin intake by mother during pregnancy may reduce the risk of developing Asthma in the offspring. Which vitamin has been shown to reduce such risk in the early childhood of offspring? - select one

A) Vitain A

B) Vitamin B

C) Vitamin C

D) Vitamin D

E) Multi-Vitamin

Answer: D

There is a weak evidence of high-dose vitamin D intake (2000 to 4000 IU/day) by women during pregnancy - that reduces the risk of developing early life wheezing and allergic rhinitis, at least up to the age of 3-5 years in their children. This effect has been said to be more pronounced in northern climates (away from the equator). The effect is at least a 20% reduction. This effect is independent of other related factors such as maternal smoking status, maternal intake of vitamin E, zinc, and calcium, and vitamin D intake by the children. 

The proposed mechanism involves immunomodulation of multiple cell types, notably dendritic and T regulatory cells, and effects on in-utero lung development.

The high dose intake is in addition to the recommended dietary allowance (RDA) of 600 IU/day of vitamin D (the standard dose of prenatal vitamins). 

#ob-gyn

#vitamins

References:

1. Litonjua AA, Carey VJ, Laranjo N, et al. Effect of Prenatal Supplementation With Vitamin D on Asthma or Recurrent Wheezing in Offspring by Age 3 Years: The VDAART Randomized Clinical Trial. JAMA 2016; 315:362.

2. Erkkola M, Kaila M, Nwaru BI, et al. Maternal vitamin D intake during pregnancy is inversely associated with asthma and allergic rhinitis in 5-year-old children. Clin Exp Allergy 2009; 39:875.

3. Rothers J, Wright AL, Stern DA, et al. Cord blood 25-hydroxyvitamin D levels are associated with aeroallergen sensitization in children from Tucson, Arizona. J Allergy Clin Immunol 2011; 128:1093.

4. Litonjua AA. The role of vitamin D in the development, exacerbation, and severity of asthma and allergic diseases. In: Vitamin D and the lung: Mechanisms and disease associations, Litonjua AA (Ed), Humana Press, New York 2012.

5. Ramirez LG, Lee-Sarwar K, Kelly RS, et al. Association of Prenatal Maternal and Infant Vitamin D Supplementation with Offspring Asthma. Ann Am Thorac Soc 2024; 21:279.

BCIS

Q 28 years old motorbike rider, is taken to the Operating Room (OR) after motor vehicle trauma. The patient sustained multiple long bone fractures. Perioperatively, patient developed acute hypotension, severe hypoxia, cardiac arrhythmia and eventually went into cardiac arrest. Diagnosis of bone cement implantation syndrome (BCIS) is made. What is Bone cement implantation syndrome?

Answer:

BCIS is potentially a fatal complication during orthopedic surgeries, mostly associated with polymethylmethacrylate cement. The use of a long-stem femoral component is a significant risk factor. It is characterized by acute hypotension, hypoxia, neurologic symptoms, and cardiac arrhythmias. 

It is probably due to multiple mechanisms, including fat and marrow debris embolization, cement monomer toxicity, anaphylatoxin release, and prostaglandin release. 

Patients require aggressive volume resuscitation, oxygen, and usual care as in any shock situation.

#trauma

#orthopedics

#surgical critical care

References:

1. Saleh KJ, Kassim R, Yoon P, Vorlicky LN. Complications of total hip arthroplasty. Am J Orthop (Belle Mead NJ) 2002; 31:485.

2. Patterson BM, Healey JH, Cornell CN, Sharrock NE. Cardiac arrest during hip arthroplasty with a cemented long-stem component. A report of seven cases. J Bone Joint Surg Am 1991; 73:271.

3. Donaldson AJ, Thomson HE, Harper NJ, Kenny NW. Bone cement implantation syndrome. Br J Anaesth 2009; 102:12.

4. Mudgalkar N, Ramesh KV. Bone cement implantation syndrome: A rare catastrophe. Anesth Essays Res. 2011 Jul-Dec;5(2):240-2. doi: 10.4103/0259-1162.94796. PMID: 25885400; PMCID: PMC4173385.

AIP

Q: Which organ transplantation can be considered in extreme cases pf Acute Intermittent porphyria (AIP)? - select one

A) Pancreas

B) Liver

Answer: B

Interestingly, hepatic transplant is considered very effective in most cases of AIP where other therapies failed and were exhausted. It should be considered if patient does not have advanced motor neuropathy like quadriplegic patients.

Indications for liver transplant are frequent hospitalizations, unresponsiveness to hemin or givosiran, and poor quality of life. It should be highly considered in patients of AIP who develop primary liver cancer or have other acute hepatic porphyrias. 

It should be noted that traditionally used model for end-stage liver disease [MELD] score for liver transplantation does not apply to patients with AIP because they usually do not have advanced parenchymal liver damage even when neuropathic manifestations are severe. Patients with AIP and severe neuropathic symptoms who are being considered for liver transplant receive exception points for expedited waitlist priority. In the case of a living-related donor, the donor should be ruled out for AIP or latent AIP. Sibling donors may have asymptomatic AIP.

#hepatology

#transplantation

References:

1. Soonawalla ZF, Orug T, Badminton MN, et al. Liver transplantation as a cure for acute intermittent porphyria. Lancet 2004; 363:705.

2. Seth AK, Badminton MN, Mirza D, et al. Liver transplantation for porphyria: who, when, and how? Liver Transpl 2007; 13:1219.

3. Lissing M, Nowak G, Adam R, et al. Liver Transplantation for Acute Intermittent Porphyria. Liver Transpl 2021; 27:491.

EtCO2 and Epi

Q: During cardiac resuscitation, administration of epinephrine may cause erroneous ___________ in End-Tidal CO2 (EtCO2)? - select one

A) rise 

B) fall

Answer: B

The use of EtCO2 is on the rise in the ICU for various reasons. It is important to know the confounding factors.

EtCO2 may decrease rapidly moments after administration of epinephrine, although hemodynamics may show improvement. This effect is short-lived, though.

#resuscitation

#hemodynamics

Reference:

Sandroni C, De Santis P, D'Arrigo S. Capnography during cardiac arrest. Resuscitation 2018; 132:73.

TXA in UGIB

Q: Intravenous (IV) Tranexamic acid can be used as an effective adjuvant therapy in severe upper GI bleeding if it does not resolve appropriately with continuous Proton Pump Inhibitor (PPI) infusion.

A) true

B) False

Answer: B

Although Tranexamic acid is an effective antifibrinolytic agent, it failed to show any efficacy in patients with upper GI bleeds. It should not be used and has no major benefit.

Although there is weak evidence that it may decrease the risk of re-bleeding and the need for surgery, it has no significant effect on the number of blood transfusions or on mortality.

#GI

References:

1. Bennett C, Klingenberg SL, Langholz E, Gluud LL. Tranexamic acid for upper gastrointestinal bleeding. Cochrane Database Syst Rev 2014; :CD006640.

2. HALT-IT Trial Collaborators. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet 2020; 395:1927.

3. Burke E, Harkins P, Ahmed I. Is There a Role for Tranexamic Acid in Upper GI Bleeding? A Systematic Review and Meta-Analysis. Surg Res Pract. 2021 Jan 29;2021:8876991. doi: 10.1155/2021/8876991. PMID: 33564713; PMCID: PMC7864761.

FUO types

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Q: Which of the following is not a type of Fever of Unknown Origin (FUO)?

A) Classic FUO

B) Healthcare-associated FUO

C) Immunocompromised patients' FUO

D) Fictitious FUO

E) Travel-associated FUO

Answer: D

Multiple definitions of FUO have been proposed, but at its core, FUO is the fever in the absence of an identifiable cause despite reasonable evaluation for at least 3 weeks, above temperature >38.3°C. This definition describes classic FUO (choice A).

Healthcare-associated FUO

• ICU patient - Temperature >38.3°C (100.9°F) recorded several times in an ICU patient despite ≥3 days of investigations. The fever must not have been present or incubated upon admission.
• Non-ICU patient - Same definition as for ICU patients, except the patient is hospitalized but not critically ill.
• Post-operative patient—The same definition as for ICU patients applies, except fever is usually defined as ≥38.0°C (100.4°F).

FUO in immunocompromised patients

• Neutropenic patients - Temperature ≥38.3°C (100.9°F) or ≥38.0°C (100.4°F) sustained over one hour, recorded on several occasions over at least 3 days, despite appropriate antimicrobial therapy. Neutropenia is <500 neutrophils/microL or impending fall to that level within 48 hours.
• Patients with HIV and CD4 count <200 cells/microL - Despite appropriate evaluation, temperatures≥38.3°C (100.9°F) were recorded on several occasions for >3 weeks for outpatients or >3 days for inpatients.

Travel-associated FUO

A temperature>38.3°C (100.9°F) was recorded on several occasions for >3 weeks, despite 3 outpatient clinic evaluations, 1 week of intensive outpatient investigation, or 3 days of hospital-based evaluation, in a patient who traveled to another country, typically within the prior 12 months.

Although patients can have a fictitious fever, it is not a part of officially described types (at least yet) - Choice D

#ID

References:

1. Wright WF, Mulders-Manders CM, Auwaerter PG, et al. Fever of unknown origin (FUO) – A call for new research standards and updated clinical management. Am J Med 2022; 135:173.

Adapted from:

2. Wright W, Mackowiak P. Fever of unknown origin. In: Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 8th ed, Bennett J, Dolin R, Blaser M (Eds), Elsevier Saunders 2015. p. 721.

3. Haidar G, Singh N. Fever of Unknown Origin. N Engl J Med. 2022; 386:463.

4. Wright WF, Auwaerter PG. Fever and fever of unknown origin: Review, recent advances, and lingering dogma. Open Forum Infect Dis 2020; 7:ofaa132.

5. Durack DT, Street AC. Fever of unknown origin – reexamined and redefined. Curr Clin Top Infect Dis 1991; 11:35.

bupropion and brain

Q: 22 years old female is admitted to ICU with severe electrolyte imbalance due to underlying bulimia nervosa. After repletion, patient's electrolyte profile improved. Patient's bulimia nervosa seems related to her desire to lose weight. She read on internet that Bupropion helps in depression as well as it leads to weight loss. It may be a good idea to prescribe Bupropion.

A) True

B) False

Answer: B

Patients with bulimia nervosa or anorexia nervosa seem to have an extremely high risk of developing seizures from bupropion. In fact this drug is contraindicated in such patients.

Bupropion increases risk of seizures, especially with immediate-release formulations. This risk is dose-dependent and increases with higher dosage.

Although Bupropion does indeed help in weight reduction, it would not be prudent to use this drug solely for the purpose of weight reduction.

#pharmacology

#neurology

References:

1. Fava M, Rush AJ, Thase ME, et al. 15 years of clinical experience with bupropion HCl: from bupropion to bupropion SR to bupropion XL. Prim Care Companion J Clin Psychiatry 2005; 7:106.

2. Johnston JA, Lineberry CG, Ascher JA, Davidson J, Khayrallah MA, Feighner JP, Stark P. A 102-center prospective study of seizure in association with bupropion. J Clin Psychiatry. 1991 Nov;52(11):450-6. PMID: 1744061.

3. Serretti A, Mandelli L. Antidepressants and body weight: a comprehensive review and meta-analysis. J Clin Psychiatry 2010; 71:1259.

open vs lap choly

Q: Laparoscopic cholecystectomy is preferred over open cholecystectomy due to lower rate of overall serious complication rates?

A) True

B) False

Answer: B

Laparoscopic cholecystectomy, popularly known as "lap chole," is considered the "gold standard" for gallstones requiring surgical intervention due to various advantages, such as less postoperative pain, aesthetically appealing, shorter length of stay, and less disability off days from work. However, the overall serious complication rate in laparoscopic cholecystectomy is higher than in open cholecystectomy. 

It should be accepted that this inference on higher complications is biased for two reasons. First, open cholecystectomy is now reserved only for complicated and challenging cases, and less open cholecystectomies are performed nowadays. Second, if lap-choly requires conversion to open-choly in OR, it results in severe complications, with worst injuries to bile duct, hepatic artery, or portal vein - and all this goes under the banner of lap-chole!!

#surgical-critical-care

#hepatology

#procedures

References:

1. Khan MH, Howard TJ, Fogel EL, et al. Frequency of biliary complications after laparoscopic cholecystectomy detected by ERCP: experience at a large tertiary referral center. Gastrointest Endosc 2007; 65:247.

2. Hogan NM, Dorcaratto D, Hogan AM, et al. Iatrogenic common bile duct injuries: Increasing complexity in the laparoscopic era: A prospective cohort study. Int J Surg 2016; 33 Pt A:151.

3. Visser BC, Parks RW, Garden OJ. Open cholecystectomy in the laparoendoscopic era. Am J Surg 2008; 195:108.