Pulmonary melioidosis in a patient with diabetes mellitus

A 32-year-old male diabetic developed an acute episode of progressive pulmonary melioidosis while employed in Vietnam. Ketosis and undue glycosuria frequently noted in diabetics with other acute infections were not recognized in this patient. The patient's response to combined and long-term antimicrobials was excellent. This approach to therapy is recommended in acute cases and refractory cases of chronic disease.     

Improved patient survival after cardiac arrest using a cardiopulmonary support system

A portable cardiopulmonary bypass system that can be rapidly deployed in a nonsurgical setting using nursing staff was used in 38 patients with cardiovascular collapse refractory to ACLS protocol. Percutaneous or cutdown cannulation sites were: femoral vein-femoral artery (n = 18), right internal jugular vein-femoral artery (n = 2), right atrium-ascending aorta (n = 12), or a combination approach (n = 4). Two patients could not be cannulated. Patient diagnoses were pulmonary emboli (n = 3), failed coronary angioplasty (n = 7), myocardial infarction with cardiogenic shock (n = 5), trauma (n = 7), aortic stenosis (n = 2), postcardiotomy deterioration (n = 10), deterioration after cardiac transplantation (n = 2), cardiomyopathy with shock (n = 1), and ruptured ascending aortic dissection (n = 1). Ninety-five percent of patients (36 of 38) were successfully resuscitated to a stable rhythm. Eight diagnostic procedures (coronary angiography, n = 4; pulmonary angiography, n = 3; and aortography, n = 1) were performed while patients were on cardiopulmonary support. Early deaths resulted from massive hemorrhage (n = 8), inability to cannulate (n = 2), and irreversible myocardial injury (n = 10). Sixty-six percent (24 of 36) of patients successfully cannulated underwent conversion to standard cardiopulmonary bypass with attendant operative procedure or placement of ventricular assist device or total artificial heart. Fifty percent (18 of 36) of patients cannulated were successfully weaned from cardiopulmonary support, and 17% (6/36) are long-term survivors.(ABSTRACT TRUNCATED AT 250 WORDS)     

MPO-ANCA-associated pulmonary-renal vasculitis in a patient with diabetes mellitus

Diabetes mellitus is one of the major causes of chronic renal failure. Typical findings of diabetic nephropathy are early hyperfiltration followed by microalbuminuria and overt proteinuria, resulting in a progressive decrease in glomerular filtration rate. Rapidly progressive glomerulonephritis has rarely been reported in patients with diabetes mellitus. Here, we describe a patient with MPO-ANCA-associated vasculitis, presenting with pulmonary-renal syndrome. Immunosuppressive treatment, including pulse methyl-prednisolone and cyclophosphamide, was administered and the disease was resolved.     

Emphysematous pyelonephritis and renal amoebiasis in a patient with diabetes mellitus

Emphysematous pyelonephritis is an uncommon and life-threatening infection of the kidney that is characterized by gas formation within or around the kidney and is associated with diabetes mellitus and urinary tract infection. Amoebiasis is a protozoal infection caused by Entamoeba histolytica. In its invasive forms, the disease is characterized by visceral abscess formations. We present a case of concomitant emphysematous pyelonephritis and renal amoebiasis in a 42-year-old female with uncontrolled diabetes mellitus. The patient did not respond well to initial supportive treatment and antibiotherapy. Therefore, nephrectomy was performed. She did extremely well after the operation and was discharged with antidiabetics and antibiotics.     

Unresponsive asystolic cardiac arrest responding to external cardiac pacing in a patient with phaeochromocytoma

An anaesthetised 48-year-old woman became haemodynamically unstable following biopsy of a thoracic mass suggesting a diagnosis of a thoracic phaeochromocytoma. Surgery was postponed to allow confirmatory investigations and pre-operative adrenoceptor blockade with phenoxybenzamine and labetalol. Nine days later, following resection of her phaeochromocytoma, she suffered an intra-operative asystolic cardiac arrest which was unresponsive to standard resuscitation protocols and required external cardiac pacing. We discuss the issues involved and suggest that the competitive alpha(1) adrenoceptor antagonist doxazosin may be preferable to the covalently bound mixed alpha adrenoceptor antagonist phenoxybenzamine in the pre-operative preparation of patients with phaeochromocytoma.     

Glomerular mesangial fibrillary deposits in a patient with diabetes mellitus

Various systemic or primary glomerular diseases can result in deposition of fibrillary material in the glomerular tuft and may cause an important diagnostic challenge for the pathologists. Biopsy findings of a patient with type 2 diabetes is presented here in which striking fibrillary structures were identified in the mesangium by ultrastructural examination. The distinction between diabetic fibrillosis and fibrillary glomerulonephritis accompanying diabetic nephropathy is discussed in the setting of a literature review.     

Complete recovery of consciousness in a patient with decorticate rigidity following cardiac arrest after thoracic epidural injection

A 46-yr-old man with dysaesthesia (burning sensation) followingherpes zoster in the left upper chest region was treated witha single thoracic (T2/T3) epidural injection (1.0% lidocaine3 ml+0.125% bupivacaine 3 ml) as an outpatient. Twentyminutes after the injection, a nurse noticed the patient tobe unconscious with dilated pupils, apnoea and cardiac arrest.Following immediate cardiopulmonary resuscitation, the patientwas treated with an i.v. infusion of thiamylal sodium 2–4 mg kg^–1 h^–1and his lungs were mechanically ventilated. When the patientdeveloped a characteristic decorticate posture, mild hypothermia(oesophageal temperature, 33–34°C) was induced. Onthe 17th day of this treatment, after rewarming (35.5°C)and discontinuation of the barbiturate, the patient respondedto command. Weaning from the ventilator was successful on the18th day. About 4 months after the incident, the patientwas discharged with no apparent mental or motor disturbances.We suggest that mild hypothermia with barbiturate therapy mayhave contributed to the successful outcome in this case. BrJ Anaesth 2000; 85: 632–4 ^* Corresponding author     

Preoperative preparation of patient with diabetes mellitus

The goal of this article is to present the importance of diabetes mellitus as comorbidity in patients submitting to different surgical procedures. The results of numerous studies that have been presented here showed worst surgical outcome in patients with bad diabetes control. This review considers the elements for preoperative evaluation and preparation of these patients (former therapy, longterm metabolic control, micro and macrovascular complications etc). According to existing data, the goals for preoperative preparation and the regimes for their achievement have been defined. Also, the regimes for blood glucose controle during intraoperative and postoperative period have been evaluated in this article.