Piperacillin-Induced Immune Hemolysis Presenting with Tachycardia and Cardiac Arrest

A 20-year-old nonverbal patient with profound developmental disabilities was treated with intravenous piperacillin-tazobactam for respiratory infection. After 8 days, he became afebrile with normal pulmonary status, but his pulse remained inexplicably rapid (114/minute). Investigations revealed severe normochromic normocytic hemolytic anemia (hemoglobin: 40 g/L, reticulocytes: 9.4%, nucleated erythrocytes: 5%). While being hospitalized, patient experienced sudden cardiac arrest from which he was successfully resuscitated. He had no blood loss or intrinsic heart disease to explain the acute anemia or cardiac arrest. He had uneventfully received piperacillin-tazobactam on 7 occasions during the preceding 5 years for >50 days. Patient was treated with intravenous crystalloids, methylprednisolone and transfusion of 3 units of packed erythrocytes. Piperacillin-tazobactam was discontinued. A direct antiglobulin test was positive for immunoglobulin G and complement. Antibody to piperacillin was detected in patient's serum by the “immune-complex” method confirming “piperacillin-induced immune hemolytic anemia (PIHA)”. On discharge (day 15), patient's hemoglobin improved to 115 g/L (baseline: 131 g/L). Vigilant clinical and hematological monitoring for anemia is indicated in piperacillin-treated patients, particularly in those unable to verbalize their discomfort. Repeated piperacillin exposure may sensitize and predispose patients to PIHA

Scombrotoxinism: Protracted Illness following Misdiagnosis in the Emergency Department

Background. Scombrotoxinism is an acute toxin-induced illness caused primarily by bacterial synthesis of histamine in decomposed fish. Case Report. Immediately after taking 2-3 bites of cooked salmon, a clerical worker developed oral burning, urticaria, and asthma. In the emergency department, she was diagnosed with “allergies”; scombrotoxinism was never considered. She then developed wide-ranging symptoms (e.g., chronic fatigue, asthma, anxiety, multiple chemical sensitivity, and paresthesiae) and saw many specialists (in pulmonology, otorhinolaryngology, allergy, toxicology, neurology, psychology, and immunology). During the next 500+ days, she had extensive testing (allergy screens, brain MRI, electroencephalogram, electromyogram, nerve conduction velocity, heavy metal screen, and blood chemistry) with essentially normal results. She filed a workers’ compensation claim since this injury occurred following a business meal. She was evaluated by a Qualified Medical Evaluator (GL) on day 504, who diagnosed scombrotoxinism. Comment. Scombrotoxinism should be considered in all patients presenting to the emergency department with “oral burning” or allergy symptoms following “fish consumption.” Initial attention to such history would have led to a correct diagnosis and averted this patient’s extended illness. Specialist referrals and tests should be ordered only if clinically indicated and not for diagnostic fishing expedition. Meticulous history is crucial in resolving clinical dilemmas

Case Report Necrotizing Fasciitis: Diagnostic Challenges in a Mute Bedridden Patient with Atypical Laboratory Parameters

A 27-year-old mute bedridden patient required parenteral corticosteroids and antibiotics, and hospitalization for an acute respiratory illness. After 2 days, staff noted a ∼0.3 cm blister on the patient's right heel. Within 19 hours, blistering increased and the foot became partly gangrenous. The patient developed high fever (40.3 • C), and leukocytosis (count: 13 × 10 9 /L; was 6.5 × 10 9 /L ten days earlier). Necrotizing fasciitis (NF) was diagnosed and treated with emergency leg amputation. Histopathology revealed necrosis of fascia, muscle, subcutaneous tissue, and skin. In bedridden patients, corticosteroids may particularly facilitate serious infections, and initial NF blistering may be mistaken for pressure ulcers. Vigilant and frequent whole body monitoring is necessary for all patients incapable of verbalizing their symptoms

Necrotizing Fasciitis: Diagnostic Challenges in a Mute Bedridden Patient with Atypical Laboratory Parameters

A 27-year-old mute bedridden patient required parenteral corticosteroids and antibiotics, and hospitalization for an acute respiratory illness. After 2 days, staff noted a ~0.3 cm blister on the patient’s right heel. Within 19 hours, blistering increased and the foot became partly gangrenous. The patient developed high fever (40.3°C), and leukocytosis (count: 13×109/L; was 6.5×109/L ten days earlier). Necrotizing fasciitis (NF) was diagnosed and treated with emergency leg amputation. Histopathology revealed necrosis of fascia, muscle, subcutaneous tissue, and skin. In bedridden patients, corticosteroids may particularly facilitate serious infections, and initial NF blistering may be mistaken for pressure ulcers. Vigilant and frequent whole body monitoring is necessary for all patients incapable of verbalizing their symptoms