Acute respiratory failure as a manifestation of an arachnoid cyst

Arachnoid cysts are the most common congenital cystic lesions in the brain occurring in the middle fossa, suprasellar region and occasionally in the posterior fossa. Conventionally all cysts are considered as benign and symptoms are attributed to expansion of cysts causing compression of adjacent neurological structures, bleeds within the cyst or due to the development of acute hydrocephalus. We are reporting this case of a 15-year-old female patient with non-progressive weakness in the limbs since the age of seven years who presented with acute onset syncopal attacks and respiratory failure. She was intubated and ventilated. An magnetic resonance imaging scan showed large posterior fossa cyst extending up to mid second cervical vertebra causing compression of the medulla and pons, with mild hydrocephalus. After a failed attempt to wean her from the ventilator a cysto peritoneal shunt surgery was performed following which she was weaned from the ventilator successfully. Weakness in the upper and lower limbs, which had increased in the preceding month, also improved following the surgery

Case Report - Sudden unexpected death in an undiagnosed sickle disease

We present a rare case of unexpected sudden death in a young woman with undiagnosed sickle disease. The provocative factors for the terminal events were excessive exercise in the form of trekking, urinary infection, and emotional stress .the sudden cardiovascular collapse could have resulted from acute pulmonary hypertension resulting from severe hemolysis or acute chest syndrome

Variability of serum phenytoin levels in critically ill head injured patients in intensive care unit

Patients with large variations in phenytoin levels despite standard doses may prove to become difficult clinical problems. Our study of 34 head injury patients whose serum phenytoin levels were measured on day one and day five following intravenous loading and maintenance dose of phenytoin, showed 38.24% patients, to have therapeutic phenytoin levels on day one, while 20% were in toxic range. On day five, 23% patients were in toxic and 29.41% were in therapeutic range. Only 21% patients remained in the therapeutic range during the monitoring period. This study shows that there is a wide variability of phenytoin levels in the ICU patients with a difference of more than 100% between the highest and lowest phenytoin level in individual cases (in four patients the difference exceeded 500%) raising concern about the safety of the drug. Hence it is recommended that intensive care unit patients receiving phenytoin therapy should have periodic serum phenytoin obtained even in absence of seizures or classic signs phenytoin toxicity

Rate of Change of Rapid Shallow Breathing Index and Extubation Outcome in Mechanically Ventilated Patients

Background. Rapid shallow breathing index (RSBI) has been widely used as a predictor of extubation outcome in mechanically ventilated patients. We hypothesize that the rate of change of RSBI between the beginning and end of a 120-minute spontaneous breathing trial (SBT) could be a better predictor of extubation outcome than a single RSBI measured at the end of SBT in mechanically ventilated patients. Methodology. In this prospective observational study, we enrolled 193 patients who met the inclusion criteria, of whom 33 patients were unable to tolerate a 120-minute SBT and were excluded from the study. The study population consisted of 160 patients, categorized into three subgroups: patients with normal lung (no reported history of respiratory diseases), patients with airway disease, and patients with parenchymal disease who completed 120 minutes of SBT on low levels of pressure support ventilation. RSBI was obtained from the ventilator display at the 5th and the 120th minutes of SBT. The rate of change of RSBI (RSBI 5–120) was calculated as (RSBI 2-RSBI 1)/RSBI 1 × 100. Receiver-operating characteristic (ROC) curves were plotted for RSBI 5–120 and RSBI 120 in all patients and among the three subgroups (normal group, airway group, and parenchymal group) to compare the superiority of their best thresholds in predicting extubation failure. Results. The RSBI 5–120 threshold for extubation failure in the entire patient group was 23% with an overall accuracy of 88% (AUC = 0.933, sensitivity = 91%, and specificity = 86%) and the threshold of RSBI 120 for extubation failure in the entire patient group was 70 breaths/min/L with an overall accuracy of 82% (AUC = 0.899, sensitivity = 85%, and specificity = 81%). In patients in the normal lung group, the threshold of RSBI 5–120 was 22%, with an overall accuracy of 89% (AUC = 0.892, sensitivity = 87.5%, and specificity = 90%), and the RSBI 120 threshold was 70 breaths/min/L, with an overall accuracy of 89% (AUC = 0.956, sensitivity = 88%, and specificity = 90%). The RSBI 5–120 threshold in patients with airway disease was 25% with an accuracy of 86% (AUC = 0.892, sensitivity = 85%, and specificity = 86%) and the threshold of RSBI 120 was 73 breaths/min/L with an accuracy of 83% (AUC = 0.874, sensitivity = 85%, and specificity = 82%). In patients in the parenchymal disease group, the threshold of RSBI 5–120 was 24%, with an accuracy of 90% (AUC = 0.966, sensitivity = 92%, and specificity = 89%) and RSBI 120 threshold was 71 breaths/min/L, which was 88% accurate (AUC = 0.893, sensitivity = 85%, and specificity = 89%). Conclusion. The rate of change of RSBI between the 5th and 120th minutes was moderately more accurate than the single value of RSBI measured at the 120th minute in predicting extubation outcome

Rapid shallow breathing index

Predicting successful liberation of patients from mechanical ventilation has been a focus of interest to clinicians practicing in intensive care. Various weaning indices have been investigated to identify an optimal weaning window. Among them, the rapid shallow breathing index (RSBI) has gained wide use due to its simple technique and avoidance of calculation of complex pulmonary mechanics. Since its first description, several modifications have been suggested, such as the serial measurements and the rate of change of RSBI, to further improve its predictive value. The objective of this paper is to review the utility of RSBI in predicting weaning success. In addition, the use of RSBI in specific patient populations and the reported modifications of RSBI technique that attempt to improve the utility of RSBI are also reviewed

Immunogenicity of a recombinant malaria vaccine candidate, domain I + II of AMA-1 ectodomain, from Indian P. falciparum alleles

Among the few vaccine candidates under development, apical membrane antigen (AMA-1) of Plasmodium falciparum is one of the most promising erythrocyte stage malaria vaccine candidates under consideration. The overall structure of AMA-1 appears to be conserved as compared to other surface proteins, but there are numerous amino acid substitutions identified among different P. falciparum isolates. Antisera raised against recombinant AMA-1 or naturally acquired human antibodies were strongly inhibitory only towards homologous parasites. In an attempt to examine the strain specificity of antibodies elicited to AMA-1, we have cloned, expressed and purified two allelic variants of domain I+II of AMA-1 ectodomain from Indian P. falciparum isolates in bacteria. One of these is a new haplotype not reported so far and varies in 18 aa positions from the geographically diverse forms 3D7 and 15 from FVO. Refolded proteins were recognized by a conformation specific monoclonal antibody 4G2.dc1 and hyper immune sera. Immunization of mice and rabbits with the purified proteins using CFA/IFA adjuvant generated high titer polyclonal antibodies. Both the alleles induced high levels of IgG1, IgG2a and IgG2b and a low level of IgG3 in mice. Lymphocyte proliferation assays using splenocytes from immunized mice showed significant proliferative responses and cytokines interleukin-2 (IL-2), IL-4, IL-10 and IFN-γ presence in the culture supernatants. The anti-AMA-1 rabbit antibodies obtained with both the proteins were active in an in vitro parasite growth invasion/inhibition assay. These results suggest that recombinant AMA-1 domain I+II formulated with CFA/IFA adjuvant elicited cellular and humoral responses and is capable of inducing high titer invasion inhibitory antibodies supporting further development of this vaccine candidate

Original Article - Cerebral venous thrombosis: An experience with anticoagulation with low molecular weight heparin

Cerebral venous sinus thrombosis [CVST] is often an infrequent cause of neurological dysfunction resulting in admissions in Intensive care units [ICU]. Because of its myriad presentation it may be under diagnosed. Unfractionated Heparin [UFH] has been advocated in treatment but needs frequent monitoring. We studied the clinical profile of patients of cerebral venous sinus thrombosis, use of low molecular weight heparin [LMWH] with emphasis on safety in 64 patients of CVST

Severe lung injury following inhalation of nitric acid fumes

Objective: We present a rare case of survival following inhalation of nitric acid fumes and its decomposition products, which resulted in severe pulmonary edema and Acute Respiratory Distress Syndrome (ARDS). Successful outcome followed ventilatory support and use of steroids. Design: Case report. Setting: Tertiary-level medical intensive care unit. Patient: A single case of inhalation of nitric oxide fumes. Intervention: Ventilatory support and addition of steroids. Measurement and main results: Improvement and discharge. Conclusion: Inhalation of nitric acid fumes and its decomposition gases such as nitrogen dioxide results in delayed onset of severe pulmonary edema deteriorating into ARDS. Intensive respiratory management, ventilatory support, and steroids can help in survival

Expression, purification and characterization of allelic variants of MSP-1<SUB>42</SUB> from Indian Plasmodium falciparum isolates

The C-terminal 19 and 42 kDa fragments of Plasmodium falciparum merozoite surface protein 1 (MSP-1) have shown to be protective in animals against lethal parasite challenge. The MSP-1<SUB>19</SUB> being highly conserved may lack sufficient number of T-cell epitopes in order to elicit a broader response in genetically diverse populations. The inclusion of additional epitopes from the N-terminal MSP-1<SUB>42</SUB> has shown to enhance the protective efficacy of MSP-1<SUB>19</SUB> vaccine. In an attempt to examine the strain specific immunogenicity to MSP-1, we have cloned and expressed three diverse allelic variants of MSP-1<SUB>42</SUB> from Indian P. falciparum isolates in bacteria. Among three alleles, one was extremely rare and not been found before. These purified and refolded recombinant products were recognized by conformation specific monoclonal antibodies and hyper-immune sera. Immunization of mice and rabbits with the purified proteins generated high titer biologically active polyclonal antibodies supporting further development of this vaccine candidate antigen

Case Report - Hypersensitivity and dose related side effects of phenytoin mimicking critical illness

OBJECTIVE: To describe phenytoin-induced rare hypersensitivity and dose related reactions, emphasizing the importance of early omission of drug to achieve clinical improvement. DESIGN: Case series and review of literature. SETTING: Tertiary level medical intensive care unit. PATIENTS: Three cases, two of whom had hypersensitivity reactions and the third had drug-induced dyskinesia. INTERVENTION: Omission of phenytoin and corticosteroid therapy in two cases. RESULTS: Improvement and discharge. CONCLUSION: A high index of suspicion of drug-induced complications is necessary especially when multiple drugs are being administered to critically ill patients