NEKARDIOGENI EDEM PLUĆA NAKON CARSKOG REZA

Acute dyspnea during and after pregnancy should bring a number of important conditions to the mind of a physician. Pulmonary embolism, amniotic fl uid embolism, pneumonia, aspiration and pulmonary edema must be considered. Although pulmonary edema is a very rare condition, the most common contributing factors include the administration of tocolytic agents, underlying cardiac disease, iatrogenic fluid overload and preeclampsia. We report on a case of noncardiogenic pulmonary edema in a 36-year-old woman a few hours after cesarean section. The acute event was probably due to iatrogenic fl uid overload combined with hemodynamic effects of oxytocin in interaction with hemodynamic changes at the end of pregnancy. The patient was successfully treated with diuretics and oxygen therapy, and after a few hours her chest radiograph and respiratory status were normal.Pojava akutne dispneje za vrijeme i nakon trudnoće treba pobuditi sumnju na nekoliko važnih diferencijalnih dijagnoza kao što su plućna tromboembolija, embolija amnionskom tekućinom, pneumonija, aspiracija i plućni edem. Plućni edem se javlja rijetko i obično je precipitiran tokolizom, već postojećom bolesti srca, volumnim preopterećenjem ili preeklampsijom. Opisujemo slučaj 36-godišnje bolesnice s nekardiogenim edemom pluća koji se manifestirao nekoliko sati nakon carskog reza kao rezultat volumnog opterećenja te istodobnog antidiuretskog djelovanja oksitocina i hemodinamskih promjena pred kraj trudnoće. Bolesnica je uspješno liječena diureticima i oksigenoterapijom. Nekoliko sati kasnije kontrolna slika srca i pluća i respiracijski status bili su normalni, a bolesnica nedugo zatim otpuštena iz bolnice

Primarni obostrani apsces bočnoslabinskog mišića u starijeg muškarca

Primary bilateral iliopsoas abscesses in the elderly are very rare in Europe. We report a case of an elderly male misdiagnosed with rheumatic low back pain. The delay in accurate diagnosis and therapy led to severe worsening of his general condition and septic shock. The diagnosis was established by multi-slice computed tomography (MSCT) and the patient was successfully treated by MSCT-guided percutaneous drainage of both psoas muscles. Septic shock and miscellaneous complications required continuous intensive care. The patient was discharged after 42 days of hospital treatment. Antibiotic therapy continued for the next six weeks until his complete recovery. Pain remains the most frequent and predominant symptom of spinal pathology regardless of the etiology. Immunocompromised patients or signs suggestive of bacterial infection require caution and a more comprehensive diagnostic work-up.Primarni, bilateralni apsces bočnoslabinskog mišića (m. iliopsoasa) u starijih osoba vrlo je rijedak u Europi. Prikazujemo slučaj starijeg muškarca u kojeg je postavljena pogrešna dijagnoza križobolje. Zakašnjenje u utvrđivanju bilateralnog apscesa iliopsoasa i primjeni odgovarajuće terapije uzrokovalo je pogoršanje općeg stanja i septički šok. Dijagnoza je potvrđena multi-slice kompjutoriziranom tomografijom (MSCT), a bolesnik je uspješno liječen postavljanjem drena pod kontrolom MSCT u oba psoasa. Septički šok i druge popratne komplikacije zahtijevale su kontiunirani nadzor u Jedinici intenzivne skrbi. Bolesnik je otpušten kući nakon 42 dana hospitalizacije. Antibiotska terapija nastavljena je još šest tjedana nakon otpusta do potpunog oporavka. Bol ostaje najčešći i dominantni simptom bilo kojeg patološkog procesa u području kralježnice. Imunokompromitirani bolesnici kao i bolesnici sa znacima koji upućuju na bakterijsku infekciju zahtijevaju posebnu pažnju i širu dijagnostičku obradu

Masivna plućna embolija nakon trombocitopenije izazvane heparinom

Immunomediated heparin-induced thrombocytopenia still presents a serious problem, especially when accompanied by thromboembolic complications. We report on a rare case of massive pulmonary embolism following perioperative prophylaxis with unfractionated and low-molecular-weight heparin. The lack of efficacious and safe heparin substitution only allowed for immediate heparin discontinuation and application of adjuvant therapy. A few days after heparin cessation the platelet count tended to return to normal, leading to the patient\u27s full recovery and discharge from the hospital. Heparin therapy requires careful examination of previous history of heparin use as well as close platelet monitoring for up to three weeks of therapy cessation.Imuna trombocitopenija izazvana heparinom još uvijek predstavlja ozbiljan problem, osobito ako je praćena tromboemboličnim komplikacijama. Ovdje prikazujemo rijedak slučaj masivne plućne embolije nastale nakon profilaktične primjene nefrakcioniranog i niskomolekularnog heparina. Manjak učinkovitog i sigurnog nadomjeska za heparin ostavio je samo mogućnost neposrednog ukidanja heparina i uvođenja pomoćne terapije. Nekoliko dana nakon prestanka liječenja heparinom broj trombocita počeo se je normalizirati, a nakon toga bolesnica se je potpuno oporavila i bila otpuštena iz bolnice. Liječenje heparinom zahtijeva brižno prikupljanje anamnestičnih podataka o ranijoj primjeni ovoga pripravka te pažljivo praćenje broja trombocita i do tri tjedna nakon prekida heparinske terapije

NEKARDIOGENI EDEM PLUĆA NAKON CARSKOG REZA

Acute dyspnea during and after pregnancy should bring a number of important conditions to the mind of a physician. Pulmonary embolism, amniotic fl uid embolism, pneumonia, aspiration and pulmonary edema must be considered. Although pulmonary edema is a very rare condition, the most common contributing factors include the administration of tocolytic agents, underlying cardiac disease, iatrogenic fluid overload and preeclampsia. We report on a case of noncardiogenic pulmonary edema in a 36-year-old woman a few hours after cesarean section. The acute event was probably due to iatrogenic fl uid overload combined with hemodynamic effects of oxytocin in interaction with hemodynamic changes at the end of pregnancy. The patient was successfully treated with diuretics and oxygen therapy, and after a few hours her chest radiograph and respiratory status were normal.Pojava akutne dispneje za vrijeme i nakon trudnoće treba pobuditi sumnju na nekoliko važnih diferencijalnih dijagnoza kao što su plućna tromboembolija, embolija amnionskom tekućinom, pneumonija, aspiracija i plućni edem. Plućni edem se javlja rijetko i obično je precipitiran tokolizom, već postojećom bolesti srca, volumnim preopterećenjem ili preeklampsijom. Opisujemo slučaj 36-godišnje bolesnice s nekardiogenim edemom pluća koji se manifestirao nekoliko sati nakon carskog reza kao rezultat volumnog opterećenja te istodobnog antidiuretskog djelovanja oksitocina i hemodinamskih promjena pred kraj trudnoće. Bolesnica je uspješno liječena diureticima i oksigenoterapijom. Nekoliko sati kasnije kontrolna slika srca i pluća i respiracijski status bili su normalni, a bolesnica nedugo zatim otpuštena iz bolnice

The Epidemiology and Diagnostic Approach to Acute Pulmonary Embolism in the University Hospital

The aim of this retrospective study was to evaluate the demographics and clinical characteristics of patients with pulmonary embolism treated in medical intensive care unit (ICU) at the University Hospital during a six-year period, and to assess the impact of several risk factors on patients’ survival. The study included 165 patients, mean age 69.3 ± 13.7 years, predominantly female (70.3%). Dominant symptom was dyspnea (97.0%), the most common sign tachypnea (69.6%). Pulmonary embolism was confirmed by high-probability ventilation/perfusion lung scan or multidetector computed tomography in 71.5% and was regarded as massive in 63 (38.2%), submassive in 23 (13.9%) and non massive in 79 patients (47.9%). Mean hospital stay was 5.7 ± 4.4 days for ICU, and 14.8 ± 9.1 days, overall. The ICU mortality was 26.7% and in-hospital mortality 30.9%. No statistical difference in mortality between male and female patients was observed (30.6% and 31.0%, respectively; p=0.965), but prolonged immobilization (p=0.002), recent operation (p=0.034) or malignancy (p=0.009) were shown to influence the outcome. Although a number of risk factors for developing pulmonary embolism have been identified and heparin prophylaxis along with early mobilization proposed to reduce the incidence, pulmonary embolism remains an important clinical problem with high mortality rate. The diagnostics should not wait and the therapy should start as soon as possible

LIJEČENJE TEŠKE DIJABETIČKE KETOACIDOZE U MLADE OSOBE

We present a case of severe diabetic ketoacidosis in a 19-year-old male with a history of poor compliance to insulin therapy. At arrival to our Emergency Department, the patient was comatose with extreme hyperglycemia, severe diabetic ketoacidosis, lactic acidosis and dehydration. The treatment consisted of intensive fl uid replacement and correction of all metabolic disturbances until complete recovery. In the vast majority of severe diabetic ketoacidosis cases, relatively fast and successful treatment result can be expected if intensive therapy is applied and if ketoacidosis is not triggered by a serious illness. Some essential contemporary guidelines and the importance of individual treatment approach are pointed out in the article. The role of high serum procalcitonin value in diabetic ketoacidosis is discussed.Prikazan je slučaj 19-godišnjeg bolesnika od dijabetesa koji nije redovito primjenjivao inzulin. Bolesnik je doveden na naš objedinjeni hitni prijam u komatoznom stanju, s ekstremnom hiperglikemijom, teškom dijabetičkom ketoacidozom, laktacidozom i dehidracijom. Liječen je intenzivnom nadoknadom volumena i korekcijom svih metaboličkih poremećaja do potpunog oporavka. U velikoj većini slučajeva teških dijabetičkih ketoacidoza može se očekivati relativno brza i uspješna korekcija ako se primijeni intenzivno liječenje i ako ketoacidoza nije potaknuta ozbiljnom bolesti. U članku su navedene neke bitne suvremene smjernice u liječenju i naglašena je važnost individualnog pristupa. Raspravljena je i uloga visoke serumske vrijednosti prokalcitonina u dijabetičkoj ketoacidozi

Obostrani endogeni endoftalmitis uzrokovan bakterijom pseudomonas aeruginosa u imunokompetentnog bolesnika s nozokomijalnom urosepsom nakon abdominalnog kirurškog zahvata

Endogenous endophthalmitis is a vision-threatening condition that results from hematogenous spread of infection to the eye, originating from a distant primary focus. It is considered as a rare entity that predominantly occurs in immune-compromised patients. We present a case of a critically ill immune-competent patient who underwent abdominal surgery later followed by nosocomial urosepsis complicated with bilateral Pseudomonas aeruginosa endogenous endophthalmitis that resulted in blindness. This case is clinically important because of the absence of predisposing factors for this kind of eye infection.Endogeni endoftalmitis je akutna komplikacija hematogenog rasapa infekcije iz udaljenog žarišta u oči, što u najvećem broju slučajeva rezultira sljepilom. Bolest je rijetka, a najčešće se javlja u imuno kompromitiranih bolesnika. Prikazujemo imuno kompetentnog bolesnika kod kojega se nakon hitne operacije inkarcerirane ingvinalne hernije razvila nozokomijalna urosepsa komplicirana obostranim endogenim endoftalmitisom uzrokovanim bakterijom Pseudomonas aeruginosa, koji je rezultirao sljepilom. Budući da se radi o bolesniku bez prethodno opisanih predisponirajućih čimbenika za razvoj ove teške bolesti, smatramo ovaj prikaz klinički važnim za rano prepoznavanje i što ranije agresivno liječenje ove teške bolesti

Diseased Teeth as a Focus - A Delusion or Reality?

U stomatološkoj praksi smanjen je interes da se infektivni fo kusi na zubima povezuju s poremećenim općim zdravstvenim stanjem i/ili reumatološkim tegobama. Zbog toga je u ovome radu prikazano dvoje bolesnika u kojih se temeljitom obradom došlo do zaključka da je streptokokna afekacija zubi bila uzrokom znatnih reumatskih poteškoća. Iznosi se podatak da od ukupne množine reumatoloških bolesnika 10% otpada na reaktivni artritis koji se može povezati s latentnim ili manifestnim infektivnim zarišitem u organizmu uključujući u njih bolesne zube. Nove spozanje govore u prilog činjenici da se atralgije i/ili artritisi pojavljuju kao imunološki odgovor samo u predisponiranih bolesnika, pri čemu je važno postojanje HLA B-27 antigena. Utvrđeno je da streptokoki skupine A i G mogu izazvati porast antistreptolizinskog titra (AST), a infekcija stafilokokima porast antistafilolizinskog titra (ASTA). Ako se isključe drugi fo kusi, takav imunološki odgovor organizma upućuje na mogućnost da postoji granulom zuba. U tome slučaju sanacija zuba može imati povoljan učinak.There is a decrease of interest in dental practice to relate dental infective foci to general condition disturbances and/or rheumatic difficulties. For that reason, we report on two patients, in whom careful medical treatment was followed by streptococcal land staphylococcal dental affection responsible for their rheumatic difficulties. The information is presented that 10% of all rheumatics have reactive arthritis which may be related to latent of manifest infective foci in the body, including diseased teeth. Some new concepts indicate that arthralgias and/or arthritis arise from immune response in predisposed patients only, the presence of HLA-B27 antigen being of considerable importance. It has been demonstrated that staphylococcal and group A and G streptococcal infection can increase the titer of antistaphylolysin (ASTA) and antistreptolysin (ASO) antibodies, respectively. It all other foci are excluded, such immune response indicates the possible presence of tooth root abscess. In this case, proper dental treatment may have a positive effect

Obostrani endogeni endoftalmitis uzrokovan bakterijom pseudomonas aeruginosa u imunokompetentnog bolesnika s nozokomijalnom urosepsom nakon abdominalnog kirurškog zahvata

Endogenous endophthalmitis is a vision-threatening condition that results from hematogenous spread of infection to the eye, originating from a distant primary focus. It is considered as a rare entity that predominantly occurs in immune-compromised patients. We present a case of a critically ill immune-competent patient who underwent abdominal surgery later followed by nosocomial urosepsis complicated with bilateral Pseudomonas aeruginosa endogenous endophthalmitis that resulted in blindness. This case is clinically important because of the absence of predisposing factors for this kind of eye infection.Endogeni endoftalmitis je akutna komplikacija hematogenog rasapa infekcije iz udaljenog žarišta u oči, što u najvećem broju slučajeva rezultira sljepilom. Bolest je rijetka, a najčešće se javlja u imuno kompromitiranih bolesnika. Prikazujemo imuno kompetentnog bolesnika kod kojega se nakon hitne operacije inkarcerirane ingvinalne hernije razvila nozokomijalna urosepsa komplicirana obostranim endogenim endoftalmitisom uzrokovanim bakterijom Pseudomonas aeruginosa, koji je rezultirao sljepilom. Budući da se radi o bolesniku bez prethodno opisanih predisponirajućih čimbenika za razvoj ove teške bolesti, smatramo ovaj prikaz klinički važnim za rano prepoznavanje i što ranije agresivno liječenje ove teške bolesti