critical care medicine cases

1. Case :-1
A curious case of drug complication
1 Copyright 2016 Society of Critical Care Medicine

2. FIRST admission
• A 18 yrs old male patient admitted on 28/4/21 with c/o fever since 15 days
• severe neutropenia since ten days[ tc remain below 1000]
• abdominal pain.
• A out side widal positive and working diagnosis of leukemia with PUO
• Patient already treated outside in multiple hospital for the same, bone marrow done shows agranulocytosis
with occasional blast ,blood c/s twice negative count still persistently on lower side patient treated with Gcsf
and folinic acid
• Pateint remain haemodynamically stable so kept in isolation room in general ward with doxycycline
linezolid AKT4 and metrogyl continued in view of thickend colon wall colitis( could be intestinalTB
/brucellosis)
• While getting In depth history he had taken dapsone since last 4 month for the skin diseases from local
physician.

3. Various differentials kept
• All other investigations done nothing significant except colitis picture in ct abdomen.and
some disseminated patches in the lung on lower segment.
• Pt count not improved for five days and total of 7 days of the receiving Gcsf
• Endoscopy done on 5th day of admission found to have multiple ulcers in ascending colon
classical of the amoebiasis biopsy done shows nonspecific inflammation.
• Pt was already on metrogyl since total 15 days ,so started on tinidazole.
• Second d/d severe amoebiasis leading to bone marrow suppression{ not known and biopsy
from the colon not confirmatory)
• Third primary haematological issues (haematological references inconclusive)

4. Patient improved !!!!!
• Pt count surprisingly started rising without any new intervension and making the case of
dapsone inuced agranulocytosis.
• Unfortunatly patient took DAMA in view of financial crisis at the tc of 2900 they not ready
to wait till the abdominal pain subside.

5. • After 2 day he give call that feeling better and taken some food. But at the same day call
from her mother is that he started having bloody diarrhea asked her to bring the patient to
hospital
•Second admission
• Pt reached to the hospital in arrest situation at 4 pm 9 th May with severe bleeding per rectum
immediately intubated and cpr given with volume replacement pt had ROSC after 20 minutes
and shifted to the icu

6. Miracle do happen!!!!
Patient HB was 3 gm% and so replaced 4 pcv to achieve haemodynamic stability.
Colonoscopy planned for the next day in vew of active bleeding and neurostatus unknown.
Patient become better within 8-10 hrs and bleeding stopped and become conscious on
ventilator
Colonoscopy done shows extensive ulceration in ascending colon upto the transverse colon
adrenaline injection done and option discussed for the surgical hemicolectomy {not preferred
emblosiation as there is already a disease present in colon}
Bleeding some how stopped patient required HD because of ischemic injury but started urine
within next 24hrs and patient extubated after 72 hrs of mechanical ventilation.

7. Second episode of circulatory collapse
• Patient relative not ready for radical surgery at this juncture as patient started to settled
down plus financial crisis is also one of the reason for conservative management.
• Patient started improving in general ward and taking oral food, passing stool but has
abdominal pain.
• After 10 days of the stability and generalised improvement with decreasing creatinine pt had
sudden episode of rebleeding and pt collapse again while shifting in to the icu from the
ward
• And required intubation and mechanical ventilation.

8. Finally surgery
• Now explained to the relative about the need of
the urgent laparotomy and hemicolectomy
• They were ready for the same and urgent
laparotomy done with hemicolectomy and
diversion ileostomy done
Patient improved and gradually weans of from the
ventilator
Had still wound gaping present.
Histopathology of the specimen shows pyogenic
gangrenous necrosis, nodes nonspecific
Patient discharge with ileostomy and normal wbc
,creatinine.

9. Third admission
• Abdominal pain with fever???? No but now phobia
• But non specific and discharged within one day.
•Fourth admission
• Ileostomy closure done un- eventfully patient discharge after 4 days of stay in august.

10. Diagnosis
dapsone induced agranulocytosis leading to flare up of the colitis.

11. Discussion
• Positives
• Good end result
• Successful recovery without neurological
damage.
• Despite of multiple insult could prevent
organ injury.

12. Dengue fever
with twist

13. • A 29 years old patient having c/o generalized weakness, fever since 4-5 days.
• Patient was primarily treated at private hospital where DENGUE NS1 POSITIVE.
• Then patient develop MELENA and HEMATURIA . So, patient shifted to KD hospital for
further management. On nov 2
• On arrival patient was conscious, oriented and hemodynamically stable. SPO2:99% on
RA.
• Patient was admitted in ICU.
• His CBC reads HB 15 wbc 4500 platelet 8000
• In view of thrombocytopenia 4 units PRC was transfused.
• USG abdomen showed grade 1 fatty liver. Diffuse edematous wall thickening of gall
bladder, mild ascites, mild bilateral pleural effusion.
• X-ray chest showed right pleural effusion.
• INJ.CEFTRIAXONE 1GM (BD), INJ.DOXYCYCLINE 100MG (BD) started.
Along with multivitamin in view of the severe thrombocytopenia
• NOV 3 HB 17TC 6900 PLATELET 10000 AGAIN platelets transfused
• On Nov 4 Hb-16.1,TC-16000, PC-16000 (MANUAL 20000) so patient shifted to ward in
hemodynamically stable condition. SPO2:98% on RA

14. • On Nov 5 patient was hemodynamically stable. pulse rate 70/MIN SPO2:98%.
• Cbc 13.8 tc 9300 platelets 22000
• On Nov 6 Patient conscious , oriented P:50/MIN., RR:22/MIN. But oxygen
saturation SPO2:78% on RA. So, patient shifted to ICU with O2 support
• Chest x-ray done showed moderate right sided pleural effusion.
• 2d echo done shows good lvef not much significant.
• In ICU patient maintaining SPO2:88-90% with 8-10lit/min of O2.
• Scrub typhus which was sent earlier came negative.
• USG chest done showed bilateral pleural effusion moderate on right side and mild on left
side.
• Cbc 12.7 tc 22000 platelet 35000
• So steroid stopped and antibiotic upgraded
• INJ.CEFOPARAZONE + SULBACTUM 3GM

15. • On Nov 7 oxygen requirement increases, patient put on 10lit/min O2 with NRBM.
• Maintaining SPO2:89% and have sinus bradycardia. Even with bipap support
• 2D ECHO repeated in view of bradycardia which showed all cardiac chamber normal
in size, good LV systolic function , LVEF:55%, no RWMA at rest.
• NT PRO BNP:931.
• INR:1.48, INJ.VIT K 30MG stat and the 10mg OD started for 3days.
• Blood and urine culture done which was negative.
• CVP line inserted in RIGHT IJV under all aseptic precautions under LA.
• LFT sent on 6 NOV shows billirubin 6.9 sgpt 2122 sgot 6579
• Cross reference to Dr. Kartik Desai {gastro reference}done in view of altered LFT and as
per his advise USG ABDOMEN done which showed grade 1 fatty liver changes, diffuse
edematous gall bladder wall thickening , mild ascites, moderate right side pleural
effusion.
• INJ.N-acetylcysteine started in hepatic failure dose.

16. • On NOV 8 patient maintaining SPO2:88-90% with 10lit/min O2.
• Review done by Dr. Kartik Desai advised for repeat LFT.
• Triglyceride :306.9
• S. ceruloplasmin: normal.
• Leptospira IgM: Negative.
• Pleural fluid tapping done from right side under all aseptic precautions around 400ml
fluid tapped.
• Pleural fluid Routine micro done showed normal.
• INJ.HUMAN ALBUMIN started for 3 days.

17. So far lab reports
DATE NOV 3 NOV 6
TOTAL BILIRUBIN 1.80 6.944
DIRECT BILIRUBIN 0.946 3.488
INDIRECT BILIRUBIN 0.854 3.456
ALKALINE PHOSPHATE
SGPT 163 2122
SGOT 501 6579
AMYLASE
LIPASE
DATE HB TC PLATELETS MANUAL
PLATELETS
PLATELETS
TRANSFUSED
OCT 31 13.6 12600 188000
NOV 2 15.0 4500 8000 4 UNITS
NOV 3 17 6900 10000 15000 4 UNITS
NOV 4 16.1 4900 16000 20000
NOV 5 13.8 9300 22000 30000
NOV 6 12.7 22100 35000 40000
NOV 7 11.5 39800 51000 60000
NOV 8 10.6 28800 68000

18. • On NOV 9 1 unit PCV transfused in view of HB:7.9.
• Retic count :0.5 (normal)
• LDH:6477(high) suggestive of hemolysis.
• O2 requirement decreased with SPO2:88-90% with 6-8lit/min O2.
• Simultaneous ABGA done showed PH:7.49, PCO2:31.6, PO2:99.
• So, methemoglobin level
• Cause ?

19. • On Nov 10 patient is hemodynamically stable, maintaining SPO2:90-92% with 4-5lit/min
O2.
• 1 unit PCV transfused in view of HB:7.3.
• G6PD :1.05( normal 73.8)(cause of hemolysis).
• Methemoglobin :2.2 (normal <1% in adults).
• On Nov 11 patient hemodynamically stable. Maintaining SPO2:98% on RA.
• 2 unit PCV transfused in view of HB:7.4.
• Patient shifted to ward.
• On Nov 12 blood report done showed HB:8.5.
• ON Nov 13 patient discharged with stable hemodynamics.

20. DATE HB TC PLATELETS MANUAL PLATELETS PLATELETS TRANSFUSED
OCT 31 13.6 12600 188000
NOV 2 15.0 4500 8000 4 UNITS
NOV 3 17 6900 10000 15000 4 UNITS
NOV 4 16.1 4900 16000 20000
NOV 5 13.8 9300 22000 30000
NOV 6 12.7 22100 35000 40000
NOV 7 11.5 39800 51000 60000
NOV 8 10.6 28800 68000
NOV 9 7.9 24700 76000
NOV 10 7.3 23600 87000
NOV 11 7.4 17600 69000
NOV 12 8.5 12500 65000
NOV 13 7.5 8900 63000

21. DATE NOV 3 NOV 6 NOV 8 NOV 9 NOV 10 NOV 11 NOV 13
TOTAL BILIRUBIN 1.80 6.944 7.50 7.56
DIRECT BILIRUBIN 0.946 3.488 1.68 1.44
INDIRECT BILIRUBIN 0.854 3.456 5.81 6.122
ALKALINE PHOSPHATE
SGPT 163 2122 1268 561 213
SGOT 501 6579 2765 1096 133
AMYLASE 644
LIPASE 1358 2795 1161 219.3

22. WAS IT dengue pancreatitis ?
• Evidence suggests that haemolysis can also falsly elevate the lipase level
• Usg abdomen done not shows pancreatitic swelling
• It started rising after haemolysis started
• And abdominal pain was there but not severe

24. THE CULPRIT
• ITWASVITCOFOL CWAS MOST PROBABLE CAUSE
• Or dengue( itself )induced haemolysis