Etiology and Outcomes of ARDS in a Rural-Urban Fringe Hospital of South India

Objectives. Etiology and outcomes of acute lung injury in tropical countries may be different from those of western nations. We describe the etiology and outcomes of illnesses causing acute lung injury in a rural populace. Study Design. A prospective observational study. Setting. Medical ICU of a teaching hospital in a rural-urban fringe location. Patients. Patients ≥13 years, admitted between December 2011 and May 2013, satisfying AECC criteria for ALI/ARDS. Results. Study had 61 patients; 46 had acute lung injury at admission. Scrub typhus was the commonest cause (7/61) and tropical infections contributed to 26% of total cases. Increasing ARDS severity was associated with older age, higher FiO 2 and APACHE/SOFA scores, and longer duration of ventilation. Nonsurvivors were generally older, had shorter duration of illness, a nontropical infection, and higher total WBC counts, required longer duration of ventilation, and had other organ dysfunction and higher mean APACHE scores. The mortality rate of ARDS was 36.6% (22/61) in our study. Conclusion. Tropical infections form a major etiological component of acute lung injury in a developing country like India. Etiology and outcomes of ARDS may vary depending upon the geographic location and seasonal illnesses

Fatal Fulminant Hepatic Failure in a Diabetic with Primary Dengue

We report a 49-year-old diabetic with dengue hemorrhagic fever who developed fulminant hepatitis, severe coagulopathy, shock, and refractory metabolic acidosis and died on the eighth day of illness. This is the only second report of an adult with fatal fulminant hepatic failure due to dengue, and the first case arising from a primary dengue infection

Emphysematous Cystitis and Bladder Rupture

We describe a 32-year-old lady who was admitted with a urinary tract infection following vacuum-assisted delivery. She was diagnosed with Enterococcus faecium related emphysematous cystitis, bladder gangrene and rupture necessitating emergency laparotomy and partial cystectomy. She had a repeat laparotomy nine days later due to continuing bladder necrosis on cystoscopy. The patient stayed in hospital for over two months due to complications including hospital acquired Klebsiella pneumonia, adult respiratory distress syndrome and malnutrition. Discharge occurred one week after an ileal conduit and ileostomy were performed

Telemediations

Postprin

Unusual Complications of Quinalphos Poisoning

This 40-year-old man was treated for suicidal quinalphos 25%EC consumption. He developed intermediate syndrome with normal response to repetitive nerve stimulation, pancreatitis with high enzyme elevations, and normal computed tomography and excreted black, brown, and orange urine sequentially over the first nine days of hospitalization. The last complication has not been previously reported with any organophosphate compound. He finally succumbed to complication of ventilator associated pneumonia related septic shock and ventricular tachycardia

Quantum of fluids in hospitalised patients with dengue and warning signs- a pilot cross-sectional study

Background: Dengue is an endemic arboviral illness in Asia with significant morbidity and mortality. The World Health Organization (WHO) in 2009 revised the category of dengue severity into Classes A, B, and C based on the presence or absence of warning signs. The quantum of oral and intravenous fluids(IVF) in hospitalised patients with Group B(warning signs) have not been studied so far. Oral fluids in hospitalised patients and monitoring of their administration with help of patients’ relatives have not been assessed. Methods: Consecutive patients with dengue fever and warning signs were studied for 48 hours after hospitalisation. Vital signs, anthropometry, biochemical and haematological investigations, electrocardiogram were studied. Patients were asked to consume between four and five litres of fluids. Maintenance and bolus IVF were administered depending upon the presence of compensated or hypotensive shock. Intake and urinary output were monitored by the patient’s attendant. Total fluids(oral and intravenous) were divided by each anthropometric measurement-height, weight, body mass index(BMI) and body surface area(BSA). Significance of compensated and hypotensive shock, thrombocytopenia and 20% change in haematocrit, bleeding episodes and the need for transfusions, and organ impairment were considered in relation to total amount of fluids received daily. Findings: Forty-one patients were studied. All had warning signs at admission, and 37 continued to have them on Day1. Serositis and/or organ involvement-hepatitis, acute kidney injury, myositis, or cardiac dysfunction were observed in 15, and bleeding manifestations were seen in seven. Patients with obesity and hypotensive shock received significantly more fluids on Day1; taller patients and those with tachycardia, higher haematocrit and elevated creatine kinase correspondingly received more on Day2. Serositis, hepatitis, severe thrombocytopenia, bleeding, and compensated shock did not have any correlation with anthropometry-related fluid calculation. Hypotensive shock had significant correlations with fluids/BSA and fluids/weight, while laboratory parameters correlated best with fluids/BMI. Interpretation: Most adults hospitalised with dengue fever and warning signs during an epidemic seem to require >100mL/kg/day of fluids during their stay. Also, advising a similar amount of fluids at home during dengue epidemics may further reduce the need for admissions as shown in some studies. In resource-poor settings, participation of patients and their relatives in the bedside management of fluid administration may go a long way in preventing morbidity and mortality in dengue fever. Adults with dengue probably need a better anthropometric measurement to decide the quantum of fluids

Henoch-Schonlein purpura presenting sequentially as nodular rash, erythema nodosum, and palpable purpura

We describe a 26-year-old woman who presented with a nodular rash on the elbows following an insect bite. Two days later, she developed erythema nodosum. Both these lesions were treated symptomatically. One week later, she had purpura, abdominal pain, hematuria, and arthralgias, following which steroids were administered. Her investigations revealed only microscopic hematuria that disappeared with therapy. This pattern of sequential appearance of rash and a nodular morphology are both unique features not previously reported

Pneumomediastinum and Bilateral Pneumothorax Following near Drowning in Shallow Water

We report pneumomediastinum, bilateral pneumothorax and acute respiratory distress syndrome in a victim of near drowning who was intoxicated and did not have thoracic or neck trauma. Chest radiograph revealed the above findings, later confirmed by computed tomography. He was in shock and also had gastrointestinal (GI) bleeding and renal dysfunction. With adequate resuscitative measures including fluids, blood transfusions, intercostal tube drainage and mechanical ventilation he made a complete recovery. Good prognostic indicators in near drowning patients include higher Glasgow Coma Scale, short submersion time and quick resuscitative measures even in the presence of serious cardiorespiratory or hemodynamic compromise