Journal of Acute Care

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Volume 1, Number 2, May-August 2022
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EDITORIAL

BK Rao

Echocardiography in Intensive Care Unit: We Need a Certification Program

[Year:2022] [Month:May-August] [Volume:1] [Number:2] [Pages:2] [Pages No:49 - 50]

   DOI: 10.5005/jp-journals-10089-0027  |  Open Access |  How to cite  | 

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Original Article

Kedar Bangal, Sriram Korukonda, C Reddy Sampath K, Raghu Bheemiah

Balanced Salt Solution in Type-2 Diabetes Mellitus undergoing Off-pump Coronary Artery Bypass Grafting: Ringer Lactate vs Plasmalyte®

[Year:2022] [Month:May-August] [Volume:1] [Number:2] [Pages:5] [Pages No:51 - 55]

Keywords: Blood sugar, Electrolyte balance, Insulin, Potassium, Renal dysfunction, Systemic inflammatory response syndrome, Tracheotomy

   DOI: 10.5005/jp-journals-10089-0020  |  Open Access |  How to cite  | 

Abstract

Background: Coronary artery bypass grafting (CABG) is a surgical option for patients with significant coronary artery disease (CAD) who are not suitable candidates for percutaneous interventions. Cardiopulmonary bypass (CPB) with cardiac arrest (on-pump) provides a surgical field free of motion and blood, allowing safe anastomosis construction. Off-pump CABG (OPCABG) avoids serious complications associated with CPB such as stroke, renal dysfunction, and systemic inflammatory response syndrome. Intravenous fluids are administered to maintain the circulation blood volume and cardiac output during surgical manipulation of the heart during OPCABG. This study was performed to compare the effects of Ringer's lactate (RL) and Plasmalyte® (PL) on the acid base status and electrolyte balance in patients suffering from type-2 diabetes mellitus (T2-DM) undergoing elective OPCABG surgery. Methods: After obtaining ethical approval and informed consent, this study was performed on patients with type-2 DM undergoing elective OPCABG. Patients undergoing CABG on CPB, concomitant procedures, emergency, renal dysfunction, conversion to CPB were excluded. OPCABG was performed as per the standard institutional protocol. Intraoperative management of DM was done using recommended guidelines namely maintenance of blood sugar between 140 and 180 mg% and insulin infusion titrated to achieve the blood glucose in the desired range. Serum potassium was maintained between 4 and 5 mmol/L. Arterial blood gases and lactate levels were determined at two hourly intervals throughout the perioperative period. Comparison of serum lactate levels, base deficit levels, potassium levels, and pH values was done by paired t-test. Outcome measures included low-output state, renal dysfunction, bleeding, tracheotomy, ICU stay, hospital stay, and mortality. Results: There were 50 patients in the group with 25 in each group. None of the patients was converted to on-pump and complete data were available to all patients. At 12th postoperative hour, lactate was significantly lower (p < 0.014) and serum potassium levels were significantly higher (p < 0.018) in PL group. When compared to the PL group, the base excess levels were significantly higher (p < 0.035) in ringer lactate group at 24th postoperative hour. Excepting for this, there were no significant differences in any of the measured parameters, outcomes, length of ICU stay, and hospital stay in the two groups. Conclusion: In well-controlled patients of type-2 DM with precise perioperative monitoring and management of blood glucose and serum potassium, there were no significant differences in outcomes between RL and PL in diabetic patients undergoing OPCABG.

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Original Article

Marutheesh Mallappa, Suman S Reddy, Sarika Kunwar, Pradeep Rangappa, Ipe Jacob, Karthik Rao

Outcome of Septic Shock Patients treated with Vitamin C and Thiamine: A Prospective Cohort Study

[Year:2022] [Month:May-August] [Volume:1] [Number:2] [Pages:5] [Pages No:56 - 60]

Keywords: Ascorbic acid, Ascorbic acid and thiamine protocol, Hydrocortisone, Mortality, Sepsis, Septic shock, Vitamin C

   DOI: 10.5005/jp-journals-10089-0031  |  Open Access |  How to cite  | 

Abstract

Background: Although there has been great progress in the field of medicine, mortality associated with the age-old problem of sepsis still remains high. One of the newer modalities to treat sepsis is the hydrocortisone, ascorbic acid (AA), and thiamine (HAT) therapy, using HAT, which is proposed to reduce organ failure and mortality by restoring dysregulated host immune response and mitochondrial function as well as neutralizing reactive oxygen species (ROS). Studies evaluating the treatment of severe sepsis, burns, and trauma with vitamin C administration have shown inconsistent results. Several studies have also shown the detrimental effect of a positive fluid balance on patients with sepsis, including an increased risk of mortality. This study aims to evaluate the effect of vitamin C with thiamine on improving the outcome of septic shock. Materials and methods: This prospective cohort study was conducted at a tertiary care intensive care unit (ICU) and enrolled adult septic shock patients admitted over a 6-month period between April and September 2018. They formed an intervention group that received intravenous (IV) vitamin C 1.5 gm every 6 hours and thiamine 200 mg every 12 hours in addition to antibiotics. This was compared with a retrospective cohort of patients admitted between July to December 2017, which received only antibiotics. Both vitamin C and thiamine were initiated within 6 hours of admission and given for a period of 4 days. Hydrocortisone, as an infusion of 200 mg over 24 hours, was used in all patients on vasopressor support. The primary outcome evaluated was ICU mortality and secondary outcomes, ICU length of stay (LOS), hospital LOS, mechanical ventilation-free days (MVFDs), vasopressor-free days (VFDs), and cumulative fluid balance after 4 days. Results: A total of 30 patients fulfilled the inclusion criteria and formed the intervention group. This was compared with a retrospective group which was equally matched in their baseline characteristics and acute physiology and chronic health evaluation (APACHE) II scores (20 vs 21), as well as antibiotics, are given. ICU mortality was 19% in the intervention group and 34.1% in the retrospective group (p = 0.115). ICU LOS was higher in the intervention group (5 vs 4 days, p = 0.014). There was no difference in the other secondary outcome parameters, namely, hospital LOS (10 vs 8 days, p = 0.141), MVFDs (5 vs 6, p = 0.493), VFDs (4 vs 6, p = 0.415), and cumulative fluid balance (+583 mL vs +450 mL, p = 0.209). Conclusion: Intravenous (IV) administration of vitamin C and thiamine may not be beneficial in improving the outcome in patients with septic shock.

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REVIEW ARTICLE

Harish M Maheshwarappa, Shreedhar S Joshi, Robert James Premkumar, Shivangi Mishra, Shiva Prasad

Hemoadsorption (CytoSorb®) in Management of Cytokine Storm and Implication in COVID-19 Pandemic

[Year:2022] [Month:May-August] [Volume:1] [Number:2] [Pages:7] [Pages No:61 - 67]

Keywords: Blood filtration, Coronavirus disease 2019, Cytokine storm, CytoSorb®, Hemoadsorption

   DOI: 10.5005/jp-journals-10089-0019  |  Open Access |  How to cite  | 

Abstract

Introduction: Sepsis-related deaths contribute up to 20% of all global deaths, with the highest-burden from sub-Saharan Africa and Southeast Asia. Cytokines are the mediators of organ dysfunction in systemic inflammatory response syndrome (SIRS) across varied etiologies, including sepsis. The imbalance of pro-and anti-inflammatory cytokines continues to be the crux of the pathophysiology of organ dysfunction in septic shock. Therapies to treat cytokines either by antagonizing them or filtering them out of the body are evolving. Hemoadsorption is a process of filtering out cytokines and other metabolites involved in SIRS by surface adsorption. Materials and methods: We searched for terms–Hemoadsorption, CytoSorb, in PubMed and Google Scholar. We enrolled manuscripts with patients at Indian Centers for review. We extend our review of cytokine storm in COVID-19 and the utility of CytoSorb as an adjuvant in the management of septic shock in COVID-19. Conclusion: Severe acute respiratory syndrome coronavirus -2 (SARS-CoV-2) infection causing COVID-19 (Coronavirus disease - 2019) pandemic has affirmed cytokine storm as the principal pathology causing morbidity and mortality. Management strategies are mostly supportive since specific antiviral therapy is still in the incipient stage. Cytokine adsorption is being used across most Western countries in COVID-19 septic shock. COVID-19 with cytokine storm as its main pathology is a suitable substrate for the use of CytoSorb. COVID-19 patients with elevated cytokine levels can be offered CytoSorb® hemoadsorption along with other supportive therapies.

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VIEWPOINT

Natesh R Prabu

Oxygen Targets in Critically Ill Patients: Let's be Cautiously Liberal

[Year:2022] [Month:May-August] [Volume:1] [Number:2] [Pages:3] [Pages No:68 - 70]

Keywords: Critically ill patients, Hyperoxia, Hypoxemia, Oxygen targets

   DOI: 10.5005/jp-journals-10089-0026  |  Open Access |  How to cite  | 

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VIEWPOINT

Syed Nabeel Muzaffar, Shaik Arif Pasha, Neeraj Guttikonda

Conservative Oxygen Therapy is the Way Forward in Critical Illness

[Year:2022] [Month:May-August] [Volume:1] [Number:2] [Pages:3] [Pages No:71 - 73]

Keywords: Conservative oxygen therapy, Critical illness, Oxygen therapy

   DOI: 10.5005/jp-journals-10089-0030  |  Open Access |  How to cite  | 

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COMMENTARY

Shaik A Pasha

Oxygen Targets in Critical Illness: Commentary on the Pro–Con Debate

[Year:2022] [Month:May-August] [Volume:1] [Number:2] [Pages:2] [Pages No:74 - 75]

Keywords: Hypoxia, Hyperoxia, Mitochondrial hibernation

   DOI: 10.5005/jp-journals-10089-0035  |  Open Access |  How to cite  | 

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CASE REPORT

Pooja Natarajan, Priya Jain, Noel MP Samy, Varun Shetty

Implications for Anesthesia in Takayasu's Arteritis for Bentall Surgery

[Year:2022] [Month:May-August] [Volume:1] [Number:2] [Pages:4] [Pages No:76 - 79]

Keywords: Anesthesia implication, Aorta occlusion, Bentall surgery, Takayasu arteritis

   DOI: 10.5005/jp-journals-10089-0021  |  Open Access |  How to cite  | 

Abstract

Takayasu's arteritis (TA) is a rare chronic granulomatous inflammatory disease of the aorta, commonly affecting young females. Cardiovascular manifestations of TA include a carotid bruit, blood pressure (BP) differences in arms and claudication of extremities. Anesthesia in TA necessitates precise monitoring of BP. Preservation of end-organ perfusion, especially in cardiac surgery on cardiopulmonary bypass (CPB), is one of the most challenging aspects of anesthesia in TA undergoing aortic surgery. We report a case of a young lady of TA who presented with ascending aortic aneurysm, occlusion of branches of the aorta with severe aortic regurgitation (AR), who underwent Bentall surgery successfully. We also describe the anesthesia implications in this case to demonstrate the challenges of monitoring pulseless disease, maintenance of hemodynamics, and perfusion, which is essential for preventing permanent tissue damage in a tissue-flow compromised state.

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CASE REPORT

Sudhakar Almad, Raghavendra Deshpande, Pradeep Rangappa, Karthik Rao, Veeresh M Annigeri

Abdominal Cocoon: A Rare Case of Intestinal Obstruction

[Year:2022] [Month:May-August] [Volume:1] [Number:2] [Pages:3] [Pages No:80 - 82]

Keywords: Abdominal cocoon, Encapsulating peritoneal sclerosis, Intestinal obstruction

   DOI: 10.5005/jp-journals-10089-0022  |  Open Access |  How to cite  | 

Abstract

Abdominal cocoon [encapsulating peritoneal sclerosis (EPS)] is a rare cause of intestinal obstruction characterized by the formation of a fibrocollagenous peritoneal membrane that encases abdominal viscera, mainly small intestinal loops. It is believed to be a result of a chronic intra-abdominal fibro-inflammatory process that results in the formation of marbled, thickened leathery cocoon-like fibroconnective tissue sheets that cover, fix, and ultimately constrict the gut compromising its motility. EPS can be primary (idiopathic) or secondary to several other causes like long-term peritoneal dialysis, postrenal transplantation, abdominal tuberculosis (TB), peritoneal shunts, etc. The etiology of the primary EPS is unknown, and diagnosis is mostly made after exploratory laparotomy and histopathological analysis of the sac. Surgical exploration with resection of thick membranes and associated adhesions is the mainstay of the treatment. The condition has a good postoperative outcome, provided it is diagnosed and managed early. We herein report an unusual case of a 43-year-old patient who developed intestinal obstruction-like symptoms with vomiting and abdominal pain. Computed tomography (CT) scan revealed typical findings of the abdominal cocoon which was later confirmed at surgery. To our best knowledge, only a few such cases have been reported so far.

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CASE REPORT

Mahesha Padyana, AK Ajith Kumar, Sarath Kumar

Boerhaave's Syndrome: A Case of Delayed Presentation with Fatal Outcome

[Year:2022] [Month:May-August] [Volume:1] [Number:2] [Pages:3] [Pages No:83 - 85]

Keywords: Boerhaave's syndrome, Computed tomography, Esophageal rupture, Thoracotomy

   DOI: 10.5005/jp-journals-10089-0023  |  Open Access |  How to cite  | 

Abstract

Spontaneous esophageal rupture due to an abrupt rise in intraluminal pressure combined with negative intrathoracic pressure (e.g., vomiting) is also known as Boerhaave's syndrome. This case study presents an overview of the syndrome, including morbidity, mortality, and treatment. A 45-year-old patient reported to the emergency department with retrosternal pain after forceful vomiting, which occurred 2 days earlier. Computed tomography (CT) showed a left-sided esophageal rupture along with pneumomediastinum and subcutaneous emphysema. Emergency thoracolaparotomy has been done, and esophageal perforation has been sealed. However, the patient's clinical condition deteriorated on the 5th postoperative day and he finally succumbed to sepsis and multiorgan failure.

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CASE REPORT

Sanjana Anand, R Rajavardhan, Rajesh Mohan Shetty, KR Anoop

Spontaneous Tumor Lysis Syndrome in an Undiagnosed Solid Organ Malignancy: Adenocarcinoma of the Colon

[Year:2022] [Month:May-August] [Volume:1] [Number:2] [Pages:3] [Pages No:86 - 88]

Keywords: Adenocarcinoma colon, Critical care, Oncological emergency, Solid organ malignancy, Spontaneous tumor lysis syndrome, STLS, TLS, TLS in solid organ malignancy, Tumor lysis syndrome

   DOI: 10.5005/jp-journals-10089-0029  |  Open Access |  How to cite  | 

Abstract

Spontaneous tumor lysis syndrome (TLS) is a rare life-threatening condition resulting from the lysis of a large number of tumor cells. It is more commonly seen in hematological malignancies than in solid tumors. We would like to bring to light the unique case of a 77-year-old gentleman with spontaneous TLS and undiagnosed adenocarcinoma of the colon. He initially presented with spontaneous TLS and was later diagnosed to have metastatic adenocarcinoma of the colon. Given its scarce occurrence and vague clinical presentation, there are very high chances of missing the diagnosis. Early recognition and prompt intervention would significantly reduce morbidity and mortality.

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Medical Philately

Pradeep Rangappa

Pioneers of Organ and Tissue Transplantation

[Year:2022] [Month:May-August] [Volume:1] [Number:2] [Pages:3] [Pages No:89 - 91]

Keywords: Arm transplant, Heart transplant, History, Kidney transplant, Organ transplant, Philately

   DOI: 10.5005/jp-journals-10089-0032  |  Open Access |  How to cite  | 

Abstract

The first written transplant account is attributed to Ebers Papyrus (Fig. 1,), written circa 1550 BC mentioning skin grafting for treating burns. Roman Catholic accounts report the 3rd-century saints Damian and Cosmas as replacing the gangrenous leg of the Roman Deacon Justinian with the leg of a recently deceased Ethiopian (Fig. 2). Most accounts have the saints performing the transplant in the 4th century AD, decades after their death; some accounts have them only instructing living surgeons who performed the procedure. The more likely accounts of early transplant deal with skin transplantation. The first reasonable account is of the Indian surgeon Sushrutha in the 2nd century BC, who used autografted skin transplantation in nose reconstruction rhinoplasty. The success or failure of these procedures is not well-documented.

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Educational Forum

Muralidhar Kanchi, Arjun Alva, Rajesh Shetty, AK Ajith Kumar, Pradeep Rangappa

Echocardiography in Intensive Care Unit: Do We Need a Certification Program?

[Year:2022] [Month:May-August] [Volume:1] [Number:2] [Pages:10] [Pages No:92 - 101]

Keywords: Acute care medicine, Bedside monitoring, Critical care unit, Critically ill patients, Echocardiography, Emergency medicine, Intensive care unit, Ultrasound machine

   DOI: 10.5005/jp-journals-10089-0033  |  Open Access |  How to cite  | 

Abstract

Echocardiography is an important diagnostic tool used in cardiological settings. However, over the last four decades, the use of echocardiography has extended to operating rooms, critical care units, emergency medicine, and acute care medicine. As a bedside monitoring, echocardiography has been an important tool in the critical care setting.

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Video CME

Vimal Bhardwaj

Femoral Venous Doppler: A Marker of Venous Congestion

[Year:2022] [Month:May-August] [Volume:1] [Number:2] [Pages:2] [Pages No:102 - 103]

Keywords: Femoral venous Doppler, Inferior vena cava, Venous congestion

   DOI: 10.5005/jp-journals-10089-0034  |  Open Access |  How to cite  | 

Abstract

This video depicts the femoral venous Doppler (FVD) and inferior vena cava (IVC) relationship. IVC visualization has emerged as a popular technique to depict venous congestion and decide on deresuscitation/fluid administration. There are several scenarios wherein IVC visualization might be challenging for that is. Obesity, postabdominal, and cardiac surgeries, in addition to IVC visualization, are marred with imaging controversies surrounding the long and short axes with diaphragmatic movement causing false values of measurement.1 Considering the caveats surrounding IVC measurement and taking into consideration the anatomical, physiological continuum relationship between the right femoral vein and IVC. FVD might provide a reliable window into the dimension of IVC. Normal FVD is predominantly antegrade flow, nonpulsatile in nature, with a respiratory variation.2 The same has been shown in the video wherein IVC is <2 cm with respiratory variation, corresponding FVD shows predominant antegrade flow, nonpulsatile in nature, and abolishing waveform during inspiration which depicts a noncongested state.

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MEDICAL EDUCATION/CME

Muralidhar Kanchi, CC Vinil Kumar, Viju Wilben, Arjun Alva, Vimal Bharadwaj, Ratan Guptha, TS Srinath, Poonam Malhotra, Saravana Kumar, Alexander Thomas

Feasibility of Hybrid Training for Basic and Advanced Cardiac Life Support during COVID-19 Pandemic

[Year:2022] [Month:May-August] [Volume:1] [Number:2] [Pages:6] [Pages No:104 - 109]

Keywords: Cardiac life support, Cardiopulmonary resuscitation, Hybrid training, Lifesaving skills, Online training, Resuscitation, Training during pandemic

   DOI: 10.5005/jp-journals-10089-0025  |  Open Access |  How to cite  | 

Abstract

Background: The coronavirus disease of 2019 (COVID-19) pandemic in the years 2020 and 2021 disrupted the professional life of healthcare providers in the most unprecedented manner. Notwithstanding this, COVID-19 substantially diminished the platform for the dissemination of knowledge and skills due to restrictions and limited training opportunities. The need for recruitment of healthcare providers to meet the growing demands owing to the pandemic has caused a huge gap in demand and delivery of quality care, especially in basic and advanced cardiac life support skills (BLS/ACLS). In the wake of the pandemic, education, training, seminars, and even medical conferences have found a novel approach to sharing knowledge by utilizing e-learning modules. Technological advancement and studies have proved that e-learning is non-inferior to face-to-face education. However, it would be illogical to conduct certain types of training, such as cardiac life support, fully through online modules since this sort of training demands a considerable amount of time in hands-on sessions. We aimed to investigate the feasibility and effectiveness of training and imparting skills in BLS/ACLS using a combination of online and offline “hybrid technique” education and thereby minimizing exposure to a potentially infectious environment. Materials and methods: The schedule of the hybrid National Cardiac Life Support (NCLS) was structured as a 2-day training program, the 1st day as an “online” virtual learning module and the 2nd day as “on-site” for hands-on training. All the didactic sessions of NCLS were dealt with online on day 1 using PowerPoint presentations through the Teams Microsoft platform, teaching materials, and ingeniously framed training videos as per standard guidelines. This day 1 session lasted for a total of 5 hours, which was interactive with the active participation of the participants. Day 2 consisted of on-site “hands-on” training with manikins with the best possible COVID-19 precautions. Instructors monitored one-one skill impartment with correct techniques of high-quality cardiopulmonary resuscitation (CPR). The duration of training on day 2 was 7 hours, followed by an assessment. The assessment consisted of two sessions, namely, theory and skill assessments for BLS and ACLS. During the assessment, all the necessary COVID-19 precautions were taken into consideration. To complete the NCLS program successfully, candidates must score a minimum of 80% in the assessment, failing which, the candidates are subjected to remediation or reappearing for the test. Upon successful completion of the training, the candidates are certified in NCLS with a validity of 2 years. Results: A total of 11 hybrid NCLS training programs were conducted over a period of 18 months with a total of 276 trainees. The overall rating of the hybrid NCLS based on the analysis of feedback, was good/outstanding by 97% of attendees, which was similar to the feedback obtained from the traditional pre-COVID-19 standard NCLS program. To perform meaningful statistical analysis, 11 standard NCLS programs were chosen in a random manner (computer generated), and these programs were compared to 11 hybrid NCLS programs. The pre-COVID-19 standard NCLS classroom training trained 3,078 healthcare providers through 127 courses from its inception (October 2016) till the onset of the COVID-19 pandemic, whereas 276 candidates were trained through 11 hybrid NCLS programs. Conclusion: A standard and structured cardiac arrest resuscitation training program which is tailor-made to the Indian scenario by incorporating evidence obtained from universal/local research shall undoubtedly uplift the quality of resuscitation during the pandemic. Most importantly, training with precautions against infection is a paramount consideration during a pandemic. If online learning technology can play a role here, it is incumbent upon all of us to explore its full potential.

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PICTORIAL ESSAY

Sudhakar Almad, Pradeep Rangappa, Ipe Jacob, Karthik Rao

Pyoderma Gangrenosum in an Immunosuppressed Patient

[Year:2022] [Month:May-August] [Volume:1] [Number:2] [Pages:2] [Pages No:110 - 111]

Keywords: Azathioprine, Inflammatory exudate, Immunosuppression, Neutrophil dysfunction, Pyoderma gangrenosum

   DOI: 10.5005/jp-journals-10089-0018  |  Open Access |  How to cite  | 

Abstract

Pyoderma gangrenosum (PG) is a rare, cutaneous, and ulcerative disorder that occurs as a result of neutrophil dysfunction and is generally seen in patients with underlying systemic diseases. PG is mainly treated by corticosteroids and immunosuppressive agents. We present this case as a rare case of rapidly progressive PG in a lady with sarcoidosis that occurred despite being on immunosuppression with azathioprine.

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TRAINEE CORNER

Sarath Kumar, Shiv Kumar, Darshan U Siddappa

Acute Viral Encephalitis in Adults

[Year:2022] [Month:May-August] [Volume:1] [Number:2] [Pages:6] [Pages No:112 - 117]

Keywords: Encephalitis, Herpes simplex virus, Magnetic resonance imaging

   DOI: 10.5005/jp-journals-10089-0024  |  Open Access |  How to cite  | 

Abstract

Encephalitis is a syndrome characterized by altered mental status along with acute fever, seizures, and neurological deficits. The syndrome has many causes, the most commonly identified causes are neurotropic viruses. Herpes simplex virus (HSV) encephalitis is a potentially life-threatening condition which can be diagnosed with a combination of history, examination, magnetic resonance imaging (MRI) brain, and lumbar puncture. We report a case of a young immunocompetent adult presented with fever, altered mentation, and seizure. We are reporting classical findings of HSV encephalitis in an MRI brain study. We also described a few common viral encephalitis encountered in clinical practice.

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Femoral Venous Doppler: A Marker of Venous Congestion

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