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Gastric volvulus is a rare and life-threatening condition that involves the abnormal rotation of the stomach around its axis by more than 180°. The association between acute gastric volvulus and atrial fibrillation with rapid ventricular response is rare with only few cases that have been reported. Our patient was an 86-year-old female who presented with upper abdominal pain, distension, nausea, and shortness of breath. Clinical and laboratory workup revealed acute gastric volvulus with diaphragmatic hernia. On presentation, she was also in atrial fibrillation with rapid ventricular response. She was successfully treated by laparotomy with reduction of the gastric volvulus and repair of the diaphragmatic hernia, with significant improvement.

Mansoor Mehmood,1 Hazem L Abu Grara,1 Joshua S Stewart,2 Faisal A Khasawneh3 1Department of Internal Medicine, Texas Tech University Health Sciences Center, 2Surgical Intensive Care Unit, Northwest Texas Hospital, 3Section of Infectious Diseases, Department of Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, TX, USA Background: It is considered standard practice to use disposable or patient-dedicated stethoscopes to prevent cross-contamination between patients in contact precautions and others in their vicinity. The literature offers very little information regarding the quality of currently used stethoscopes. This study assessed the fidelity with which acoustics were perceived by a broad range of health care professionals using three brands of stethoscopes. Methods: This prospective study used a simulation center and volunteer health care professionals to test the sound quality offered by three brands of commonly used stethoscopes. The volunteer's proficiency in identifying five basic ausculatory sounds (wheezing, stridor, crackles, holosystolic murmur, and hyperdynamic bowel sounds) was tested, as well. Results: A total of 84 health care professionals (ten attending physicians, 35 resident physicians, and 39 intensive care unit [ICU] nurses) participated in the study. The higher-end stethoscope was more reliable than lower-end stethoscopes in facilitating the diagnosis of the auscultatory sounds, especially stridor and crackles. Our volunteers detected all tested sounds correctly in about 69% of cases. As expected, attending physicians performed the best, followed by resident physicians and subsequently ICU nurses. Neither years of experience nor background noise seemed to affect performance. Postgraduate training continues to offer very little to improve our trainees' auscultation skills. Conclusion: The results of this study indicate that using low-end stethoscopes to care for patients in contact precautions could compromise identifying important auscultatory findings. Furthermore, there continues to be an opportunity to improve our physicians and ICU nurses' auscultation skills. Keywords: auscultation skills, acoustics, training programs

Cavitary pneumonia in immunocompromised patients is a challenging entity. Establishing accurate diagnosis and starting effective antibiotics are essential steps towards improving outcome. A 58-year-old stem cell transplant patient was admitted to the hospital with necrotizing pneumonia caused by nocardia. The disease progressed despite of aggrieve antimicrobial therapy. Nocardiosis continues to be a difficult disease to diagnose and treat.

case presentation A 52-year-old African American man with untreated AIDS and active intravenous drug abuse presented with a three-day history of bilateral upper abdominal pain radiating to the back, which was associated with loss of appetite and generalized weakness. There was no fever or night sweats, and no vomiting, diarrhea, dysuria or hematuria. He denied cough, shortness of breath or chest pain. He also denied nasal congestion or headache. Physical examination showed a cachectic middle-age man. Vital signs included temperature of 98.4°F (36.9°C), blood pressure 123/76 mmHg, heart rate 83 beats/min and a respiratory rate of 18 breaths/min. His lungs were clear to auscultation and his heart examination revealed normal heart sounds with no murmurs or gallops. Abdominal palpation revealed tenderness in the right upper quadrant and right costovertebral angle. He exhibited no rashes or lymphadenopathy. Laboratory results revealed a white blood cell count of 3.3×109/L with absolute neutrophil count of 2×109/L and hemoglobin level of 96 g/L. The patient’s CD4 cell count was 20 cells/μL and HIV viral load was >105 copies/mL. Urine showed pyuria and a high leukocyte esterase level, but no hematuria. His serum creatinine level was 106.08 μmol/L. The patient was started empirically on meropenem, but his symptoms persisted. A transthoracic echocardiogram showed normal ejection fraction and no valvular abnormalities or vegetations. Urine and blood cultures were negative. A computed tomography (CT) scan (Figure 1) and CT-guided biopsy were performed (Figure 2). What is your diagnosis?

The immunosuppression required after solid organ or hematopoietic transplantation leaves some patients vulnerable to lymphoprol iferative disorders that are difficult to treat. Several factors may play a role in the development of these malignancies, some of which may initially be nonspecific and have overlapping manifestations, but are, nevertheless, associated with exceedingly high mortality rates. This article describes a case of post-transplant lymphoproliferative disorder in a patient who underwent a stem cell transplant for chronic lymphocytic leukemia.

Case presentation A 19-year-old woman with a medical history significant for poorly controlled diabetes mellitus (DM) (hemoglobin A1C 11.2%) presented with a 12-day history of right-sided pleuritic chest pain. One month earlier, she had developed sudden-onset fever, dry cough and shortness of breath. At the time, she did not have any gastrointestinal symptoms including epigastric pain, heartburn, vomiting or retching. She denied sick contacts and had no preceding symptoms of an upper respiratory tract infection. She was seen at a local emergency department and was released home on a 10-day course of oral doxycycline (100 mg every 12 h) to treat a community-acquired pneumonia (CAP). After an initial two-week improvement, her complaints relapsed, with fevers, dry cough, poor appetite and the above-described chest pain. The patient did not smoke and she denied alcohol abuse or illicit drug use. On presentation to the hospital, she was febrile (temperature 38.2°C), her oxygen saturation was 86% on room air and she was thin. She was awake and oriented but in obvious pain. She had no jugular venous distention. Her heart sounds were regular without murmurs or gallops. The lung examination revealed reduced air entry over the right lung base with bronchial breath sounds and egophony. The abdomen was soft without tenderness or distension and she had no evidence of subcutaneous emphysema or lymphadenopathy. There were no lower limb edema and no joint swelling or deformities. The laboratory tests revealed a white blood cell count of 26.0×109/L and a hemoglobin level of 119 g/L. Blood chemistry showed normal kidney and liver function. Tests for HIV and pregnancy were negative. Chest imaging included a chest x-ray and a contrasted chest computed tomography scan (Figures 1 and 2). The patient was admitted to hospital with severe sepsis due to CAP complicated by an empyema and was started on intravenous broad-spectrum antibiotics, vancomycin (15 mg/kg every 12 h) and piperacillin/tazobactam (3.375 g every 6 h). She underwent computed tomography-guided drainage 48 h afterwards. An interventional radiologist performed the procedure under strict sterile techniques. Cytopathology (Figure 3) and cultures were ordered on the drained fluid. What is your diagnosis?

Numerous snakebites are reported every spring and summer in the United States especially in the Southwestern part of the country. This is usually associated with significant morbidity but fatalities are rare. Most victims are male and the majority of bites are on the extremities.A search for all cases coded with a discharge diagnosis of snakebite injury revealed 90 patients admitted to Northwest Texas Hospital, the trauma center in Amarillo, Texas, between January 2002 and December 2012. These charts were retrospectively reviewed and data extracted including patient demographics, severity of snakebite, treatment given, and ultimate outcome.Ninety patients were admitted to the hospital due to snakebite. It was a rattlesnake in 83 cases. The mean age of the victims was 29.7 years and 74 of them were male. Fifty-one bites were on the upper extremities, thirty-eight bites were on the lower extremities and one bite was on the abdominal wall. About 95% of the lower extremity bites were moderate or severe compared to 74.5% of the upper extremity bites, Cramer's coefficient 0.3, p=0.02. Thirty-one patients had complications and twenty patients required surgical intervention. Eighty-eight patients received a median of 10 vials of antivenin that was well tolerated. Median hospital length of stay was 3 days. None of the patients died.Rattlesnake bites cause significant morbidity although mortality is rare. Early administration of antivenin and appropriate supportive measures and monitoring for complications with surgical intervention when needed leads to improved patient outcomes.

Aside from examination for Clostridium difficile, the yield of stool testing in hospital-onset diarrhea is poor. Clinical practice guidelines discourage overzealous stool testing in patients with diarrhea that develops after the third hospital day. However, the adoption of this recommendation into clinical practice is limited. Furthermore, the effect of microbiology laboratory improvements on hospital-onset diarrhea testing is largely unknown.A retrospective cohort study was conducted in a university-affiliated community-hospital and included all adult inpatients who developed diarrhea after hospitalization.132 adult patients (53% female) developed diarrhea after hospitalization in 2013. The cohort's mean age was 55.6 years. 46.2% of patients developed diarrhea in the first 3 days of hospitalization. Testing for parasites was negative in all examined 67 samples. Testing for C. difficile was positive in 13 cases (10.8%) out of 120 tested samples. Testing for other pathogens was positive in 1 sample (Campylobacter) out of 129 samples. Stool samples tested in the first 3 days of hospitalization were more likely to be positive (64.3 vs 35.7%, p = 0.1). Change in management was reported in 9 out of 14 patients (64.3%) with positive stool testing compared with 31 out of 118 patients (26.3%) with negative stool testing, p = 0.01.Despite improvements in stool samples' testing, the yield continues to be low, especially in hospital-onset diarrhea past the third hospital day. Physicians' embracement of the '3-day rule' continues to be poor.

Given the number of similar-appearing conditions among a widely heterogeneous group of pulmonary diseases, pneumonia is a commonly overdiagnosed entity, which makes establishing a diagnosis for a specific disease particularly challenging. This article describes the presentation, history, work-up and eventual diagnosis of a 28-year-old woman who was diagnosed with a variety conditions over a span of five months.

A 48-year-old man with diabetes mellitus and alcoholic cirrhosis presented with a throbbing headache of 1-month duration. The patient did not have a history of intravenous drug use. On physical examination, he was afebrile but disoriented with nuchal rigidity. Head CT scan was negative. Lumbar puncture (LP), performed after the first dose of cefotaxime was given, showed a white cell count (WCC) of 84 620 cells/μL with 96% neutrophils. MRI of the brain revealed multiple ring-enhancing lesions consistent with brain abscess (figure 1). Figure 1 Left panel …

Case presentation A 68-year-old Hispanic woman presented with a third episode of cystitis. She complained of multiple episodes of dysuria, frequency and suprapubic discomfort for the past six months. She denied fevers, chills, hematuria and flank pain. There was no history of nephrolithiasis and she had no other complaints. Her symptoms responded to oral levofloxacin, administered for 14 days after each episode of infection; however, they recurred a few weeks thereafter. Her medical history was significant for diabetes mellitus that was well controlled on oral hypoglycemic agents. She did not smoke, had immigrated to the United States 45 years previously and had a negative purified protein derivative test on intake. She was married with three healthy children, was a homemaker and had no contact with animals. On examination, the patient was afebrile, with a temperature of 37.6°C. Her blood pressure was 126/78 mmHg, heart rate was 82 beats/min and her oxygen saturation was 97% on room air. She was awake, alert and not in acute distress. Her skin was intact with no rashes or lymphadenopathy. She had clear lung fields, regular heart sounds without murmurs and soft nontender abdomen with no organomegaly. She had no renal angle tenderness and no lymphadenopathy. Her neurological examination was nonfocal. Blood tests revealed a hemoglobin level of 97 g/L and white blood cell count of 8.4×109 cells/L. She had chronic kidney disease with a creatinine level of 133 μmol/L. Her liver function tests were normal. Urinalysis revealed a white blood cell count of >100 cells per highpower field, with hematuria and proteinuria. Routine urine culture was negative. A computed tomography scan of the abdomen and pelvis showed normal kidney size with no stones, and a thickened urinary bladder wall with no ascites or lymphadenopathy. The patient underwent cystoscopy and biopsy (Figures 1 and 2). What is your diagnosis?

Prolonged survival in HIV infection is accompanied by an increased frequency of non-HIV-related comorbidities. It is suggested that cardiovascular diseases (CVD) occur earlier among HIV-positive patients compared with HIV-negative patients, and at a higher rate. Several factors have been proposed which can be categorized into traditional and nontraditional risk factors. Immune dysfunction is a nontraditional risk factor that contributes significantly to cardiovascular pathology. Markers of inflammation are elevated in HIV-infected patients, and elevations in markers such as high-sensitivity C-reactive protein, D-dimer, and interleukin-6 (IL-6) have been associated with increased risk for cardiovascular disease. However, the data currently suggest the most practical advice is to start antiretroviral therapy early and to manage traditional risk factors for CVD aggressively. A better understanding of the mechanisms of CVD in this population and further efforts to modify chronic inflammation remain an important research area.

1Department of Internal Medicine, Texas Tech University Health Sciences Center; 2Amarillo Pathology Group; 3Section of Infectious Diseases, Department of Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, Texas, USA Correspondence: Dr Faisal A Khasawneh, Section of Infectious Diseases, Department of Internal of Medicine, Texas Tech University Health Sciences Center, 1400 South Coulter Street, Amarillo, Texas 79106, USA. Telephone 806-354-5480, fax 806-354-5765, e-mail faisal.khasawneh@ttuhsc.edu A 39-year-old female immigrant from Yemen presented with several months’ history of diarrhea. The stool was loose in consistency and brown in colour. There was no blood or mucus noted. She reported a dull periumbilical abdominal pain, poor appetite and weight loss but had not experienced any fever, nausea or vomiting. The patient immigrated to the United States after she was married, 18 years previously. She reported a negative tuberculin skin test at the time of intake. On physical examination, she was cachectic but afebrile, with a normal heart rate and blood pressure. Chest auscultation revealed clear lung fields and regular heart sounds. The abdomen was soft, not tender and without organomegaly. She had no skin rash and no lymphadenopathy. Laboratory test results revealed a hemoglobin level of 85 g/L and a white blood cell count of 9.4×109 cells/L without eosinophilia. Her blood chemistry, including kidney and liver function tests, were within normal limits. Stool microscopy for ova and parasites and stool culture were unrevealing. An abdominal computed tomography scan showed segmental thickening in the right colon (Figure 1A). Colonoscopy was performed and tissue biopsies were obtained. Hematoxylin and eosinstained slides are shown in Figures 1B and 1C. What is your diagnosis?

Faisal A Khasawneh,1 Adnanul Karim,2 Tashfeen Mahmood,3 Subhan Ahmed,4 Sayyed F Jaffri,3 Mansoor Mehmood2 1Section of Infectious Diseases, 2Department of Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, TX, 3Department of Internal Medicine, Deaconess Hospital, Evansville, IN, 4Section of Nephrology, Department of Internal Medicine, University of Oklahoma, Tulsa, OK, USA Background: Antibiotic de-escalation is a potential strategy advocated to conserve the effectiveness of broad-spectrum antibiotics. The aim of this study was to examine the safety and feasibility of antibiotic de-escalation in patients admitted with bacteremic pneumonia. Methods: A retrospective chart review was done for patients with bacteremic pneumonia admitted to Northwest Texas Hospital in Amarillo, TX, USA, during 2008. Antibiotic de-escalation was defined as changing the empiric antibiotic regimen to a culture-directed single agent with a narrower spectrum than the original regimen. Results: Sixty-eight patients were admitted with bacteremic pneumonia. Eight patients were not eligible for de-escalation. Among the 60 patients who were eligible for de-escalation, the treating physicians failed to de-escalate antibiotics in 27 cases (45.0%). Discharge to a long-term care facility predicted failure to de-escalate antibiotics, while an infectious diseases consultation was significantly associated with antibiotic de-escalation. The average daily cost of antibacterial therapy in the de-escalation group was $25.7 compared with $61.6 in the group where de-escalation was not implemented. The difference in mean length of hospital stay and mortality between the two groups was not statistically significant. Conclusion: Antibiotic de-escalation is a safe management strategy but unfortunately is not widely adopted. Although bacterial resistance poses a significant threat and is rising, antimicrobial de-escalation has emerged as a potential intervention that can conserve the effectiveness of broad-spectrum antibiotics without compromising the patient's outcome. This practice is becoming important in the face of slow development of new anti-infective agents. Keywords: bacteremia, antibiotic de-escalation strategy, lung infection

Background. Ventilator-associated pneumonia (VAP) is a worrisome, yet potentially preventable threat in critically ill patients. Evidence-based clinical practices targeting the prevention of VAP have proven effective, but the most optimal methods to ensure consistent implementation and compliance remain unknown.Methods. A retrospective study of the trend in VAP rates in a community-hospital’s open medical intensive care unit (MICU) after the enactment of a nurse-led VAP prevention team. The period of the study was between April 1, 2009, and September 30, 2012. The team rounded on mechanically ventilated patients every Tuesday and Thursday. They ensured adherence to the evidence-based VAP prevention. A separate and independent infection control team monitored VAP rates.Results. Across the study period, mean VAP rate was 3.20/1000 ventilator days ±5.71 SD. Throughout the study time frame, there was an average monthly reduction in VAP rate of 0.27/1000 ventilator days,P<0.001(CI: −0.40–−0.13).Conclusion. A nurse-led interdisciplinary team dedicated to VAP prevention rounding twice a week to ensure adherence with a VAP prevention bundle lowered VAP rates in a community-hospital open MICU. The team had interdepartmental and administrative support and addressed any deficiencies in the VAP prevention bundle components actively.

Presentation A 47-year-old Indian immigrant with a medical history significant for diabetes presented with severe sepsis due to complicated methicillin susceptible Staphylococcus aureus (MSSA) bacteraemia. His transoesophageal echocardiogram was negative. His condition improved markedly on intravenous nafcillin and his follow-up blood cultures were negative. In spite of the above, he continued to complain of throbbing pain in different muscle groups in his lower limbs (LL). Physical examination showed tender and swollen thighs and left calf. Overlying skin was normal. CT of the LL in the second week of illness was negative but a follow-up …

A 39-year-old immigrant from South-East Asia presented with several months of worsening upper back pain. He described night sweats and weight loss put denied any other complaints. On admission, computed tomography scan showed destruction of the 5th thoracic vertebral body with paraspinous soft tissue mass that narrowed the central canal (Figure 1, upper panel). Decompression surgery was done. Surgical samples for culture and histopathological examination were obtained (Figure 1 …

The aim of this study was to examine the safety and efficacy of antibiotic de-escalation in patients admitted with bacteremic urinary tract infection (UTI). A retrospective chart review of patients admitted to a community-hospital in West Texas with bacteremic UTI during the year 2008. Antibiotic de-escalation was defined as changing the intravenous empiric antibiotic regimen to a culture-directed single agent, given intravenously or orally, with a narrower spectrum than the original empiric regimen. Ninety-seven patients were admitted with bacteremic UTI. Thirty-two patients were not eligible for de-escalation. Among the 65 patients who were eligible for de-escalation, the treating physicians failed to de-escalate antibiotics in 31 cases (47.7 %). Fluoroquinolones’ resistance, bacteria other than Escherichia coli and discharge to long-term care facilities predicted failure to de-escalate antibiotics. On multivariate analysis, discharge to long-term care facility was the only risk factor that predicted failure to de-escalate antibiotics. The difference between mean hospital length of stay and mortality between the above two groups was not statistically significant. Antibiotic de-escalation is under-recognized and sporadically practiced. In patients admitted with bacteremic UTI, empiric antibiotic regimen can be changed to a culture-directed single antibiotic without an increase in hospital length of stay or patients’ mortality.

Mucormycosis is an infection that can manifest in many forms and is an emerging complication in several health care procedures. Portals of entry can be attributed to surgical procedures and medical devices such as chest tubes; however, the skin and gastrointestinal tract are the most common sites of infection and outbreaks have been traced to adhesive bandages, wooden tongue depressors and ostomy bags. This article describes the presentation, work-up, diagnosis and treatment of an East Asian immigrant who was admitted with acute hypoxemic respiratory failure.Cavitary lung processes pose a formidable diagnostic challenge. Causes vary widely and include cavitary pneumonia, vasculitis and malignancy. In some cases, patient history and basic work-up may yield a diagnosis, but in others, an extensive work-up, including tissue biopsy, may be necessary to establish the cause. The authors present a case of cavitary pneumonia that complicated an open lung biopsy. It developed in the hospital and was caused by mucormycosis, a potential emerging infection causing health care-associated infections.

Yue Dai,1 James W Walker,1 Ruba A Halloush,2 Faisal A Khasawneh3 1Department of Internal Medicine, Texas Tech University Health Sciences Center, 2Amarillo Pathology Group, 3Section of Infectious Diseases, Department of Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, TX, USA Background: Mucorales are ubiquitous filamentous fungi that can cause a devastating, invasive infection. This order has become an increasingly important pathogen during the last two decades, due to the dramatic increase in patients with predisposing factors. The aim of this retrospective study was to report the clinical characteristics, therapeutic options, and outcomes of patients diagnosed with mucormycosis in community hospitals in Amarillo, Texas, and to reflect on the role of infectious disease (ID) physicians in managing this potentially life-threatening problem. Patients and methods: This was a retrospective chart review of patients hospitalized with mucormycosis in two community hospitals in Amarillo between January 1, 2001 and December 31, 2011. Results: Ten patients were diagnosed with mucormycosis during the study period, with a mean age of 58.8 years. There were five cases of pulmonary infection, two cases of cutaneous infection, two cases of rhinocerebral infection, and one case of gastrointestinal infection. Poorly controlled diabetes was the most common risk factor, identified in six patients, followed by hematological malignancy, immunosuppression, and trauma. ID physicians were consulted in all cases, albeit late in some cases. Nine patients received antifungal therapy, and five patients received surgical debridement. Lipid formulations of amphotericin B were prescribed for eight patients, used alone in two cases, and combined with caspofungin and posaconazole in one and five cases, respectively. One patient was treated with posaconazole alone. Eight patients were discharged from the hospital alive. The mortality rate at 6-month follow-up was 40%. Conclusion: Mucormycosis is an emerging fungal infection that continues to carry significant morbidity and mortality. At-risk patient populations are on the rise, and include those with poorly controlled diabetes mellitus. Early diagnosis, in consultation with an ID physician, and an aggressive combined approach with surgical debridement and combined antifungal therapy is pivotal in improving patients' outcomes. Keywords: mucormycosis, treatment, outcome, community hospitals

Background Anaerobes are a major component of gut flora. They play an important role in the pathogenesis of infections resulting from breaches in mucus membranes. Because of the difficulties in cultivating and identifying it, their role continues to be undermined. The purpose of this paper is to report a case of Prevotella loescheii bacteremic skin and soft tissue infection and review the literature. Case presentation A 42-year-old Caucasian man was admitted for an elective bariatric surgery. A lengthy intensive care unit stay and buttocks decubitus ulcers complicated his post-operative course. After being transferred to a long-term care facility, the decubitus ulcer became secondarily infected with multiple bacteria including P. loescheii; an anaerobe that grew in blood and wound cultures. The patient was treated successfully with aggressive surgical debridement, antibiotics and subsequent wound care. Conclusion P. loescheii colonizes the gut and plays an important role in periodontal infections. In rare occasions and under suitable circumstances, it can infect skin and soft tissues as well as joints. Given the difficulties in isolating anaerobes in the microbiology lab, considering this bacterium alongside other anaerobes in infections of devitalized tissue is indicated even if cultures were reported negative.

Enteral nutrition is the preferred route of feeding in critically ill patients. It has multiple advantages over parenteral nutrition and potentially improves patients’ outcome. Enteral nutrition is delivered via gastric or postpyloric (small intestine) feeding tubes. The latter option used to be a more challenging choice to achieve unless the feeding tube is placed endoscopically or by interventional radiology. Multiple technical advances have facilitated postpyloric feeding, including a new electromagnetically visualised jejunal feeding tube system (CORTRAK Enteral Access System). We are presenting a case of a 50-year-old woman who suffered a nasopharyngeal perforation caused by this novel technology. The complication was recognised promptly and managed successfully with conservative measures. This case illustrates the importance of recognising patients at high risk for feeding tube placement complications, meticulous placement technique and appropriate follow-up once the tube has been inserted.

NISIN and Clostridium difficile : A Potentially Effective Treatment for an Increasingly Problematic Disease

Background Some comprehensive cancer centers in industrialized countries have reported improved outcomes in their cardiopulmonary arrest (CPA) patients. Little is known about the outcomes and predictors of CPA in cancer centers in other parts of the world. The objective of this study was to examine the predictors of CPA outcome in a comprehensive cancer center closed medical-surgical intensive care unit (ICU) located in Amman, Jordan. Methods In this retrospective single-center cohort study, we identified 104 patients who had a CPA during their stay in the ICU between 1/1/2008 and 6/30/2009. Demographic data and CPA-related variables and outcome were extracted from medical records. Comparisons between different variables and CPA outcome were conducted using logistic regression. Results The mean age of the group was 49.7 ± 15.3 years. The mean APACHE II score was 23.7 ± 8.0. Thirty six patients (34.6%) were resuscitated successfully but 8 of them (7.7% of the cohort) left the ICU alive and only 6 out of the 8 (5.8% of the cohort) left the hospital alive. The following variables predict resuscitation failure: acute kidney injury (OR 1.7, CI: 1.1 – 2.6), being on mechanical ventilation (OR 3.8, CI: 1.3 – 11), refractory shock (OR 4.7, CI: 1.8 – 12) and CPR duration (OR 1.1, CI: 1.1 – 1.2). Conclusion Survival among cancer patients who develop CPA in the ICU continues to be poor. Once cancer patients suffered a CPA in the ICU multiple factors predicted resuscitation failure but CPR duration was the only factor that predicted resuscitation failure and ICU as well as hospital mortality.

Introduction Linezolid-induced black hairy tongue has been rarely reported. The purpose of this paper is to report a case of linezolid-induced black hairy tongue and review the literature. Case presentation A 56-year-old Caucasian man was admitted with community-acquired pneumonia that failed to respond to levofloxacin 750mg daily. He was started on linezolid and meropenem and was subsequently discharged home on oral linezolid 600mg every 12 hours and intravenous ertapenem 1g daily. On a follow-up clinic visit, day 14 of linezolid therapy, he complained of dysgeusia and his tongue examination was consistent with black hairy tongue. After he finished his antibiotic course, his complaints resolved with regular tongue brushing. Conclusion Black hairy tongue is characterized by abnormal hypertrophy and elongation of filiform papillae. Five reported cases of linezolid-induced black hairy tongue were identified in a MEDLINE search (from January 2000 to June 2012). The Naranjo Probability Scale revealed a probable adverse drug reaction of linezolid-induced black hairy tongue. Potential contributing factors included other antibiotics, drug–drug interaction and poor oral hygiene. Health care professionals should be aware of the possibility of linezolid-induced black hairy tongue. Thorough history for other possible contributing factors should be obtained. Patients on linezolid should be counseled to perform good oral hygiene.

Following a motor vehicle accident, a 70-year-old white female was admitted with lower limb fractures that required operative repair. The postoperative course was complicated by sepsis. Vancomycin and piperacillin/tazobactam were initiated empirically. Five days later, she developed a pruritic maculopapular rash in the groin and axilla. The rash progressed to a non-hemorrhagic vesicles and bullae on an erythematous base and spread to involve the trunk, palms and the inner aspects of the lips. Skin biopsy and direct immunofluorescence testing were consistent with vancomycin-induced linear IgA bullous dermatosis. Vancomycin was stopped with complete resolution of the lesions in the subsequent 2 weeks. Being aware of vancomycin-induced linear IgA bullous dermatosis in patients who develop a blistering skin rash while receiving this antibiotic should lead to timely interventions. Stopping vancomycin promptly and encouraging early skin biopsy to confirm the diagnosis will prevent disease progression and avoid unnecessary costs and suffering.

The aim of this study was to determine the outcome of lumbar punctures (LPs) in critically ill medical patients and how likely the results were to change case management.A retrospective review was conducted on the medical records of all 168 patients who underwent LP during their medical intensive care unit (MICU) admission at a university hospital during a 4.5-year period beginning in January 2000.Lumbar puncture was performed a mean of 2.8 days after MICU admission. The most common symptoms that prompted LP were changes in mental status and fever. Seventy-four percent of patients were on antibiotics at the time of LP, and 98% of patients had a computed tomography scan of the head performed before the procedure. Lumbar puncture confirmed meningitis in 47 (30%) patients and provided a specific bacteriologic diagnosis in 5 (3%) patients. The results of the procedure led to a change in management in 50 (30%) patients. The presence of meningeal signs and use of antibiotics at the time of the procedure were the factors that predicted change in management.Although the likelihood that LP will yield a specific bacteriologic diagnosis in critically ill patients is low, the procedure frequently provides important information that can lead to a change in case management, most commonly de-escalation of antibiotic therapy.

A 22-year-old mentally challenged Asian immigrant presented to the emergency room with new onset seizures. He complained of worsening headache for several weeks. He had no cough, fever or weight loss. He immigrated to the USA 7 years ago and his tuberculin skin test was negative at intake. Physical examination revealed a lethargic orally intubated patient. He had stable vital signs. He had equal and reactive pupils. He did not have neck rigidity and the rest of his examination was within normal limits. His human immune deficiency virus (HIV) test was negative. Head …

Caring for critically ill patients requires rapid and accurate diagnosis followed by prompt interventions. The physical examination remains an important part of the assessment of such patients, but it has been shown to have a low sensitivity and specificity in judging left ventricular function and intravascular volume. Invasive hemodynamic monitoring has similarly been shown to have significant limitations and has failed to demonstrate a mortality benefit in several recent studies. In some studies, it has been shown to be harmful. Focused transthoracic echocardiography (TTE) has emerged as a noninvasive and portable imaging technique that is capable of providing rapid and accurate information about the heart at the bedside. It can be used to complement the physical examination and result in marked improvement in diagnostic accuracy. Focused TTE can be used as a screening and monitoring tool. Studies have shown that clinicians can be trained to determine left ventricular function, detect pericardial effusions, predict intravenous fluid responsiveness, and identify important valvular defects in a relatively short period. This article describes the indications for focused TTE, provides evidence that clinicians can be rapidly taught the technique, reviews how the focused studies affect management, and discusses the advantages and limitations of this tool.

To test for synergy between daptomycin (DAP) and rifampin (RIF) against RIF-resistant methicillin-resistant Staphylococcus aureus (MRSA) isolates.Synergy testing using time-kill assay (TKA) was performed on 6 clinically, and genetically unique RIF-resistant MRSA isolates. The isolates were identified out of 489 (1.2%) samples collected during April 2003 to August 2006, from patients at the Ochsner Medical Center in New Orleans, Louisiana, United States of America.Synergy testing of DAP plus RIF by TKA showed that 5 isolates were indifferent, but one isolate was antagonistic.Our in vitro study failed to demonstrate synergy between DAP plus RIF, against our RIF-resistant MRSA isolates. Clinical failure of this combination should prompt the clinician to consider antagonism, as one of the potential causes.

1Department of Internal Medicine; 2Section of Infectious Diseases, Department of internal medicine, Texas Tech University Health Sciences Center, Amarillo, Texas, USA Correspondence: Dr Faisal A Khasawneh, Section of Infectious Diseases, Department of Internal Medicine, Texas Tech University Health Sciences Center, 1400 South Coulter Street, Amarillo, Texas 79106, USA. Telephone 806-690-7074, fax 806-354-5765, e-mail faisal.khasawneh@ttuhsc.edu CASE PRESENTATION A 55-year-old male immigrant from Iraq presented with progressive shortness of breath and hypotension. The illness started with diarrhea and headache, and began three weeks after the first cycle of chemotherapy (cyclophosphamide, doxorubicin, vincristine and prednisone) was administered for the patient’s newly diagnosed lymphoma. On presentation, he was in septic shock and respiratory failure requiring mechanical ventilation. The patient had altered sensorium and neck rigidity. He had no rashes and no lymphadenopathy. His white blood cell count was 16.9×109 cells/L with 8% eosinophilia. Chemistry tests showed acute kidney injury with a creatinine level of 168.0 μmol/L. Chest x-ray showed multilobar pneumonia. His blood and sputum cultures grew Escherichia coli. Lumbar puncture performed 24 h after presentation showed pleocytosis and elevated protein level; however, the culture was negative. A diagnostic test was performed. What is your diagnosis?

Key Clinical Message We describe a case of pneumococcal round pneumonia in an elderly smoker and it demonstrates the role of inflammatory biomarkers and follow-up imaging in ruling out more ominous diagnoses.