Review article: Environmental heatstroke and long-term clinical neurological outcomes: A literature review of case reports and case series 2000–2016

Global temperatures are rising; extreme environmental heat can result in adverse health effects including heatstroke. Acute effects of heat are well recognised, but there is less understanding of potential long-term adverse outcomes. Our aim was to review recent medical literature for clinical cases of environmental heatstroke with a focus on neurological outcome. Structured search strategies were designed to retrieve publications of heatstroke case reports using Ovid Medline and Embase (2000–2016). One thousand and forty-nine abstracts were identified, and after application of exclusion criteria 71 articles deemed relevant. Ninety cases were identified from 71 articles. 100% presented with acute neurological symptoms; 87.8% presented with non-neurological symptoms. 44.4% patients recovered fully, 23.3% died, 23.3% suffered convalescent or long-term neurological sequelae, and in 8.9% no long-term follow up was available. 57.1% of the patients who died or had a neurological deficit had no documented co-morbidity. Patterns of neurological deficits included 66.7% patients with motor dysfunction, 9.5% cognitive impairment, 19% both motor and cognitive impairment and 4.7% other. In total 71.4% of the impaired patients had long-term cerebellar dysfunction. Adverse long-term neurological outcomes were common in surviving patients presenting with environmental heatstroke. Permanent neurological deficits were present in 34.4% of survivors where outcome was known; many were young, healthy individuals. Cerebellar injury was common suggesting cerebellar structures are vulnerable to heat. These findings highlight that people of all ages and pre-morbid states are at risk of severe heat-related illness. In the face of climate change, effective interventions for heat-related illness, including both treatment and prevention are necessary.     

Emergency department initiation of cardiopulmonary bypass: a case report and review of the literature

Background

Out-of-hospital cardiac arrest carries a dismal prognosis. Percutaneous extracorporeal membrane oxygenation (ECMO) has been used with success for in-hospital arrests, and some literature suggests improvement in long-term survival for out-of-hospital arrests as well.

Objectives

This case highlights the use of ECMO in the emergency department.

Case Report

We report a case in which emergency physician-initiated ECMO was used as a bridge to definitive care in an out-of- hospital cardiac arrest in the United States.

Conclusions

ECMO is a novel adjunct for patients in cardiac arrest in whom the usual advanced life support techniques have failed.     

Müllerian adenosarcoma of the ovary: case report and review of the literature

Müllerian adenosarcoma is a rare neoplasm that can arise in both uterine and extrauterine locations. This report describes the ultrasound and magnetic resonance imaging findings of one case of ovarian adenosarcoma and reviews the literature as to the previously described imaging findings. Adenosarcoma should be considered in patients with a predominantly solid pelvic mass on imaging, particularly in those with a history of endometriosis or findings compatible with endometriosis on ultrasound or magnetic resonance imaging. A very low resistive index on ultrasound may also be suggestive of this diagnosis.     

Aortic dissection and turner’s syndrome: case report and review of the literature

Cardiovascular abnormalities are frequently encountered in patients with Turner’s syndrome. These include coarctation of the aorta, aortic root dilatation, bicuspid aortic valve, atrial and ventricular septal defects. Aortic dissection is a rare but devastating complication of Turner’s syndrome that usually occurs in adulthood. We report a case of Turner’s syndrome with coarctation of the aorta and chronic aortic dissection, and review the relevant literature. There have been 21 prior reported cases of aortic dissection in patients with Turner’s syndrome. Possible etiologic factors contributing to the occurrence of aortic dissection in this syndrome are protean. They include the presence of cystic medial necrosis, coarctation of the aorta, bicuspid aortic valve, aortic root dilatation, and hypertension, although cases of aortic dissection and Turner’s syndrome have been described in patients without any risk factors. As our knowledge of the natural history of congenital heart defects and risk factors for aortic dissection in Turner’s syndrome is limited, periodic cardiac evaluation of these patients may be warranted. Early recognition and treatment of this potentially lethal complication of Turner’s syndrome is essential.     

Rhodococcus equi pulmonary–central nervous system syndrome: brain abscess in a patient on high-dose steroids—a case report and review of the literature

Rhodococcus equi has emerged as an opportunistic pathogen usually causing necrotizing pneumonia in immunosuppressed patients but has been found increasingly in extrapulmonary sites. We report the 1st case of R. equi brain abscess in a patient receiving corticosteroid monotherapy and review the literature for risk factors and sites of infection.     

Cardiac effects of “mad honey”: a case series

Background. Grayanotoxins (GTX), also known as andromedotoxins, are produced by plants of the Ericacae family. This toxin is responsible for “mad honey” intoxication, which can present with fatal cardiac bradyarrhythmias and circulatory collapse. GTXs lead to cardiac toxicity because they increase sodium channel permeability and activate the vagus nerve. Objective. We evaluated 42 patients (33 males) prospectively who had been hospitalized with diagnosis of “mad honey” intoxication in a state hospital setting. Methods and results. The median age of patients was 48.5 years and all patients were admitted with complaints of nausea, vomiting, dizziness, fainting, and sweating. Five of the patients had syncope before admission. On admission, the mean systolic blood pressure was 73.1 ± 12.7 mmHg, the mean diastolic blood pressure was 52.1 ± 11.3mmHg, mean heart rate was 38 ± 7 bpm. On initial electrocardiograms, 18 patients had sinus bradycardia, 15 patients had complete atrioventricular block, and 9 patients had nodal rhythm. All patients were monitored in a coronary care unit and treated sympomatically with atropine, intravenous fluids, and dopamine. None of the patients needed temporary pacing and all were discharged without complications. Conclusion. “Mad honey,” which is produced widely in northern parts of Turkey can be toxic. This intoxication should be considered in patients admitted to emergency department with bradycardia and hypotension especially in regions where this honey is produced.     

Management of maternal Amanita phalloïdes poisoning during the first trimester of pregnancy: a case report and review of the literature

BACKGROUND: Amanita phallo?des poisoning produces acute liver failure and often death. Maternal poisonings are rare, and medical decisions of abortion or liver transplantation in this critical situation frequently are based on laboratory data. We report here the case of a 22-year-old-woman in the 11th week of pregnancy, who ingested mushrooms. CASE REPORT: The patient's clinical symptoms (e.g., vomiting and diarrhea) and blood chemistry data (persistent increases of aspartate aminotransferase and alanine aminotransferase and severe decreases in prothrombin, factor V, factor II, factor VII, and factor X) indicated poisoning of medium severity. The management consisted of intravenous hydration, and administration of silymarine and N-acetylcysteine. No fetal damage was observed, and birth and development of the infant (now 2 years of age) proceeded without incident. CONCLUSION: Abortion is not necessarily indicated in maternal poisoning by A. phallo?des, even in the first trimester of pregnancy.     

Transient increase of CA 19–9 serum concentrations in a liver transplant recipient with cystic fibrosis and hepatic abscess: a case report and brief literature review

CA 19–9 (carbohydrate antigen 19–9) is a tumor marker widely used for surveillance of patients with pancreatic cancer. However, even high levels of CA 19–9 may not necessarily be cancer-associated thereby complicating the diagnosis. This case report highlights a transient increase of CA 19–9 in a triple transplanted patient with cystic fibrosis and continuous immunosuppression for 20 years who was under antibiotics. This case emphasizes the need for a balanced interpretation of biological results, especially in cases where many confounding factors are present such as diabetes, chronic renal failure, cystic fibrosis and infections. This case also provides an opportunity to formulate a number of recommendations for the interpretation of tumor marker results in order to avoid long and costly further investigations.     

Physicians’ knowledge,perceptions and behaviour towards antibiotic prescribing: a systematic review of the literature

Background: Knowledge, perceptions and prescribing behaviour are key to antibiotic prescribing. The aim of this paper is to systematically review this. Method: An extensive literature search from 1990 to 2014. Results: Nineteen articles were included; eight in ambulatory care, seven in hospital settings and four in both, across all countries. Physicians still have inadequate knowledge and misconceptions about antibiotic prescribing. Moreover, some physicians, although aware that antibiotics are of limited benefit in some conditions, still prescribed them. Several factors influenced prescribing, including patients’ expectations, severity and duration of infections, uncertainty over diagnosis, potentially losing patients and influence of pharmaceutical companies. Pocket-sized guidelines seen as an important source of information for physicians. Conclusion: Inadequate knowledge of prescribing is prevalent among physicians. However, many physicians were interested in improving their antibiotic prescribing. Multifaceted interventions targeting all key stakeholders, including patients, are needed to improve future antibiotic prescribing.     

Sarcomatoid carcinoma of the pancreas — a rare tumor with an uncommon presentation and course: A case report and review of literature

BACKGROUNDSarcomatoid carcinoma of the pancreas (SCP) is a rare type of pancreatic neoplasm, and only a few cases have been described in the literature. Histologically, it is composed mostly of atypical spindle cells with apparent sarcomatous features.CASE SUMMARYThis is a report of a 61-year-old Chilean woman who underwent medical investigation for acute abdominal pain. Computed tomography identified a solid tumor in the tail of the pancreas with features suspicious of malignancy. En-bloc distal pancreatectomy and splenectomy were performed to excise the tumor. Histopathology and immunohistochemistry were confirmatory of sarcomatoid carcinoma with lymphovascular invasion. After surgery, the patient did not receive chemotherapy. Previous studies indicate a poor prognosis for this type of malignancy. However, our patient has survived for 35 mo with no recurrence to date.CONCLUSIONThe case presented herein is a patient with an SCP with a rare presentation and long-term survival after surgery despite not receiving adjuvant chemotherapy.     

Giant schwannoma of the cauda equina without neurological deficits – case report and review of the literature

Schwannomas and ependymomas are the most frequent tumours of the filum terminale. Giant schwannomas, however, are very rare in this location with less than 30 cases reported in the literature, most of them presenting with preoperative neurological deficits. We present the case of a giant schwannoma in a 75-year-old lady extending from the level of lower D12 to upper L3 vertebra with low-back pain as the only symptom. Microsurgical removal of the tumour was accomplished via an L1-L2 laminotomy without permanent neurological deficits. Giant schwannoma of the cauda equina is a rare tumour with variable symptoms. Early diagnosis is crucial to obtain good postoperative results. Total removal without additional neurological deficits can be achieved by appropriate microsurgical techniques.     

Small-cell neuroendocrine carcinoma of the rectum — a rare tumor type with poor prognosis: A case report and review of literature

BACKGROUNDSmall-cell neuroendocrine carcinoma (SNEC) of the rectum is a rare tumor associated with poor prognosis.CASE SUMMARYWe report a case of a 77-year-old male who came into our hospital because of blood with his stool. An endoscopy revealed a cauliflower-like neoplasm in his rectum. Imaging examination showed that the lesion in the upper rectum was likely rectal cancer, and there was no evidence of metastasis. The patient was treated with surgery. Pathological examination confirmed SNEC of the rectum and an R0 resection was achieved. However, 1 mo after the operation, the patient developed intestinal and ureteral obstructions due to peritoneal metastases. Finally, the patient died from renal failure.CONCLUSIONSNEC of the rectum is a high-grade carcinoma with an aggressive phenotype, and surgery should be cautiously considered.     

Contrast-enhanced multiphasic CT and MRI of primary hepatic pregnancy: a case report and literature review

Primary hepatic pregnancy is extremely rare and difficult to diagnose radiologically. We present a 32-year-old woman with primary hepatic pregnancy diagnosed by using multi-modality imaging techniques, including ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI), which highlights diagnostic challenges. These techniques can define tissue planes in detail and identify embryo implantation into the hepatic parenchyma, thereby allowing accurate preoperative diagnosis and preoperative planning by the surgical team. To the best of our knowledge, this study is the first in the English literature to report a case of primary hepatic pregnancy, in which diffusion-weighted and contrast-enhanced multiphasic MRI were utilized for diagnosis and evaluation.