Pavan Irukulla

Cryptococcal meningitis masquerading as normal pressure hydrocephalus in an immune-competent adult

We report a case of acute cryptococcal meningitis (CM) masquerading as normal pressure hydrocephalus (NPH) in an immune-competent female. An 85-year-old human immunodeficiency virus-negative female presented to the emergency room for altered mental status and difficulty walking. She was increasingly lethargic, with urinary incontinence and gait instability. A previous computed tomography was reported to have ventricular dilatation out of proportion to the degree of cortical atrophy. Magnetic resonance scan of the brain revealed ventricular dilatation and subtle debris layering the occipital horns of the lateral ventricles. A working diagnosis of NPH had been made considering the clinical symptoms and imaging. She became febrile to 103°F. Lumbar puncture was then performed which showed increased protein, decreased glucose, and mononuclear pleocytosis. India ink preparation of the cerebrospinal fluid was positive for Cryptococcus along with a positive cryptococcal antigen test. The patient was started on treatment for CM, but the patient continued to deteriorate further and died on the same day. Blood cultures subsequently grew Cryptococcus neoformans as well.

Successful strategy to decrease indwelling catheter utilization rates in an academic medical intensive care unit

HighlightsMultidisciplinary team approach reduces indwelling urinary catheter utilization ratio in a complex intensive care unit environment.Education of the health care providers and strict criteria to define appropriate indications for the use of indwelling urinary catheters in the intensive care unit are necessary to decrease the catheter‐associated urinary tract infection rate.Decreasing the indwelling urinary catheter utilization ratio is one of the most important determining factors to decrease the catheter‐associated urinary tract infection rate.Implementation of this kind of approach can decrease the incidence of catheter‐associated urinary tract infection. Background: Duration of indwelling urinary catheterization is an important risk factor for urinary tract infections. We devised a strategy to decrease the utilization of indwelling urinary catheters (IUCs). We also highlight the challenges of managing critically ill patients without IUCs and demonstrate some of the initiatives that we undertook to overcome these challenges. Methods: A retrospective observational outcomes review was performed in an adult medical intensive care unit (ICU) between January 2012 and December 2016. This period included a baseline and series of intervals, whereby different aspects of the strategies were implemented. IUC utilization ratio and catheter‐associated urinary tract infection (CAUTI) rates were calculated. Results: Our IUC utilization ratio had a statistically significant decrease from 0.92 (baseline) to 0.28 (after 3 interventions) (P < .0001). Similarly, CAUTI rates had a statistically significant decrease from 5.47 (baseline) to 1.08 (after 3 intervention) (P = .0134). These rates sustained a statistically significant difference over the 2‐year follow‐up period from the last intervention. Incontinence‐associated dermatitis (IAD) was identified as a potential complication of not using an IUC. There was no statistically significant change in the IAD rates during 2013‐2016. Conclusions: Our interventions demonstrated that aggressive and comprehensive IUC restriction protocol and provider training can lead to a successful decrease in IUC use, leading to a lower IUC utilization ratio and CAUTI rate in a large complex academic ICU setting.

1619: SEPSIS-INDUCED ISOLATED RIGHT VENTRICULAR STRESS CARDIOMYOPATHY MASQUERADING AS PULMONARY EMBOLISM.

Learning Objectives: Stress cardiomyopathy (SC) is a type of transient non-ischemic acute cardiomyopathy which is characterized by wall motion abnormalities of the heart in which intense physical or emotional stress can lead to sudden and severe heart muscle weakness. We present a rare case of sepsis/ respiratory distress induced stress cardiomyopathy with isolated right ventricle (RV) involvement, which was initially thought to be secondary to pulmonary embolism. Methods: A 84 year old woman with past medical history of chronic obstructive pulmonary disease (COPD) presented to the emergency room with shortness of breath and lethargy. The patient was started on anticoagulation for suspected pulmonary embolism (PE) and was admitted to the intensive care unit for hemodynamic instability requiring vasopressor support and respiratory failure. Echocardiogram (ECHO) showed severely decreased RV function, RV ballooning and normal left ventricular (LV) wall motion. Computed tomography angiography showed small chronic sub-segmental PE in the right upper lobe, which was not significant enough to cause the degree of hemodynamic instability in this patient. ECHO done two weeks prior to admission showed normal RV function. Electrocardiogram showed new V2-V4 “T” wave inversions with rising serum troponin levels. Coronary angiography showed clean coronary arteries. Cultures confirmed the diagnosis of urinary tract infection leading to sepsis and with appropriate treatment of sepsis and COPD exacerbation, patient showed clinical improvement and improved RV function on repeat ECHO. Results: SC most commonly involves the apical segment of the left ventricle. Isolated involvement of the RV has rarely been described in the literature, apart from few sporadic cases. To the best of our knowledge, this is the first case of isolated of RV stress cardiomyopathy masquerading as massive PE on initial presentation. This case makes it imperative to further study this new, emerging variant of SC in the future since it can be easily misdiagnosed as massive PE potentially leading to inappropriate thrombolytic therapy.