Richard W. Carlson

Alcohol Withdrawal Syndrome

In susceptible patients, alcohol withdrawal syndrome (AWS) is often precipitated by other medical or surgical disorders, and AWS can adversely affect the course of these underlying conditions. Although the mortality rate of AWS has decreased over the past few decades, significant risk for morbidity and death remain if management is complicated by a variety of conditions. This review of AWS focuses on the scope of the clinical problem, historical features, pathophysiology, clinical presentation, and approaches to therapy, with particular emphasis on severe AWS that requires management in the intensive care unit.

Toxigenic and Metabolic Causes of Ketosis and Ketoacidotic Syndromes

Ketoacidotic syndromes are frequently encountered in acute care medicine. This article focuses on ketosis and ketoacidotic syndromes associated with intoxications, alcohol abuse, starvation, and certain dietary supplements as well as inborn errors of metabolism. Although all of these various processes are characterized by the accumulation of ketone bodies and metabolic acidosis, there are differences in the mechanisms, clinical presentations, and principles of therapy for these heterogeneous disorders. Pathophysiologic mechanisms that account for these disorders are presented, as well as guidance regarding identification and management.

Acute Complications of Cocaine Intoxication

The advent of crack cocaine has changed the face of acute cocaine intoxication. Repeated doses of highly concentrated, rapidly delivered drug can give rise to an array of potentially fatal cardiovascular, neurologic, and respiratory complications.

Maternal Sepsis and Septic Shock

The year 2015 marked the 200th anniversary of the birth of Ignaz Semmelweis, the Hungarian physician who identified unhygienic practices of physicians as a major cause of childbed fever or puerperal sepsis. Although such practices have largely disappeared as a factor in the development of chorioamnionitis and postpartum or puerperal endometritis, it is appropriate that this article on sepsis in pregnancy acknowledges his contributions to maternal health. This review describes the incidence and mortality of sepsis in pregnancy, methods to identify and define sepsis in this population, including scoring systems, causes, and sites of infection during pregnancy and parturition and management guidelines.

Diffuse Large B-Cell Lymphoma Presenting as Multiple Lymphomatous Polyposis of the Gastrointestinal Tract

Primary gastrointestinal (GI) lymphomas constitute 5%-10% of all gastrointestinal tumors. Involvement of the entire GI tract as multiple polypoid lesions is very rare. Multiple lymphomatous polyposis is a distinctive and rare type of malignant GI lymphoma. Multiple lymphomatous polyposis is thought to represent mantle cell lymphoma of the GI tract. Approximately 60 cases of MLP have been reported so far. We report the first case of diffuse large B-cell lymphoma presenting as multiple lymphomatous polyposis of the GI tract in a 49-year-old patient with HIV and describe the clinicopathologic features. The patient was treated with a combination therapy of highly active antiretroviral therapy and CHOP (cyclophosphamide/doxorubicin/vincristine/prednisone) and exhibited complete remission.

Streptococcus acidominimus isolated from a multiloculated empyema in a critically ill adult man with pneumonia: Case report and review of literature

We describe a 55-year-old man with a medical history of hypertension and schizophrenia who presented to the medical intensive care with delirium and respiratory failure requiring intubation. Chest radiography showed a complete opacification of the right hemithorax. Subsequent chest computed tomography with contrast confirmed a multiloculated right pleural effusion, compressive atelectasis, and mediastinal shift to the left. This patient required multiple tube thoracostomies and a video-assisted thoracoscopic decortication to adequately drain the multiloculated empyemas. Streptococcus acidominimus, a common bacterial pathogen in veterinary medicine, was isolated. The organism is an uncommon cause of invasive disease in humans. This is the first case report in which S. acidominimus was isolated from a multiloculated empyema in a critically ill patient causing significant morbidity and must be considered as a potential but rare pathogen.

Chlamydia pneumonia: An innocent bystander or a major mediator of inflammation in the development of coronary artery disease?

C b t m t f oronary artery disease (CAD) is a leading cause of morbidity and mortality worldwide in which inflammation is an important but oorly understood factor in the development of atheroclerosis. Several risk factors for CAD, including hyertension, dyslipidemia, tobacco abuse, diabetes, nd positive family history, have been well docuented but do not completely explain how inflamation contributes to the progression of atheroclerosis. There is growing evidence that microbial nfections and immunologic mechanisms could be mplicated as possible inflammatory mediators in he pathogenesis of atherosclerosis. In one study ooking at inflammatory and infectious markers for ngiographic CAD and myocardial infarction, the uthors found that C-reactive protein, an inflammaory marker, is elevated 2-fold in patients with CAD nd 4-fold in patients with acute myocardial infarcion, although the stimulus for elevated C-reactive rotein levels was unclear. There have been several eta-analyses and prospective studies looking speifically at Chlamydia pneumonia as a possible inflamatory mediator by evaluating DNA and immunolobulin-A and G serology, although causality was ot established. In the current issue of Heart & Lung, Pesonen et l advanced the theory that microbial infections uch as C. pneumonia may potentially play a major ole in the pathogenesis of CAD by invoking an

Malignant Catatonia Warrants Early Psychiatric-Critical Care Collaborative Management: Two Cases and Literature Review

Malignant catatonia (MC) is a life-threatening manifestation which can occur in the setting of an underlying neuropsychiatric syndrome or general medical illness and shares clinical and pathophysiological features and medical comorbidities with the Neuroleptic Malignant Syndrome (NMS). The subsequent diagnosis and definitive therapy of MC are typically delayed, which increases morbidity and mortality. We present two cases of MC and review recent literature of MC and NMS, illustrating factors which delay diagnosis and management. When clinical features suggest MC or NMS, we propose early critical care consultation and stabilization with collaborative psychiatric management.