Shih-Yi Lee

RADIOLOGIC PULMONARY FINDINGS, CLINICAL MANIFESTATIONS AND SERIOUS COMPLICATIONS IN SCRUB TYPHUS: EXPERIENCES FROM A TEACHING HOSPITAL IN EASTERN TAIWAN

SUMMARY Background: Scrub typhus (tsutsugamushi disease) is an endemic infectious disease in eastern Taiwan caused by Orientia tsutsugamushi. Methods: A total of 136 cases of scrub typhus were diagnosed from patients’ blood samples. Medical records were reviewed and clinical manifestations and chest X-rays were analyzed. Results: Scrub typhus was diagnosed in 136 patients, with a mean age of 40.7 ± 21.5 years. The most common symptom was fever in 134 patients (98.5%), and the most common sign was eschar in 82 (60.3%). Chest X-rays were performed in 115 cases and showed abnormalities in 63 patients (54.8%). Patients with chest X-rays abnormalities had an increased incidence of cough (p < 0.001), septic shock (p = 0.006), congestive heart failure (p < 0.001), acute respiratory failure (p < 0.001), severe jaundice (p = 0.03) and acute renal failure (p = 0.007), and requirement for intensive care unit treatment (p < 0.001) and prolonged length of hospital stay (p = 0.002), compared with patients without chest X-rays abnormalities. Patients aged ≤ 16 years had an increased incidence of meningoencephalitis (p = 0.006) compared with the others. Patients aged ≥ 65 years had a higher incidence of complications and requirement for intensive care unit care (p = 0.02) compared with the other two groups. Conclusion: Patients with abnormal chest X-rays had higher rates of serious complications. Central nervous system infection was most frequent in pediatric patients. Patients aged ≥ 65 years had a higher incidence of serious complications. Physicians should have increased awareness of scrub typhus when caring for patients with acute febrile illness in endemic areas. [International Journal of Gerontology 2009; 3(4): 223–232]

Connecting Palliative Care and Intensive Care in Taiwan

SUMMARY One of the major responsibilities of an intensivist is the end-of-life care of critically ill patients who are dying despite intensive care therapy. We reviewed the history of the development of palliative care in Taiwan and recommend how palliative care can be introduced into intensive care practice in Taiwan. [International Journal of Gerontology 2008; 2(2): 33–34]

Intrathoracic Tracheal Obstruction Caused by a Carotid Mycotic Aneurysm in a Patient with Deep Neck Infection – A Case Report

Upper airway obstruction secondary to a carotid mycotic aneurysm has not been previously reported. We describe a patient with a mycotic aneurysm associated with a deep neck infection and presenting with acute tracheal obstruction. Recognition of this condition is important to avoid inadvertent rupture of the aneurysm in the course of diagnostic aspiration or surgical drainage. Physical findings, including a pulsating mass and an arterial bruit, in addition to appropriate imaging studies, may be helpful in suggesting the diagnosis. In particular, both neck and chest contrast-enhanced computed tomography scans may give important clues to the presence of a vascular lesion. In a patient with an infected neck mass and tracheal compression, a common carotid mycotic aneurysm should be considered in the differential diagnosis.

Effect of long term intermittent nocturnal non-invasive positive pressure ventilation on patient with severe kyphoscoliosis and hypoxaemia

Kyphoscoliosis is one of the causes of restrictive lung disease. It can lead to chronic hypercapnic respiratory failure and hypoxaemia. The benefits of long term intermittent nocturnal non-invasive positive pressure ventilation (NIPPV) to these patients have been shown in regard to improved vital capacity, total lung capacity, muscle strength and daytime oxygenation. In our case, we found long term intermittent nocturnal NIPPV also had a beneficial effect on exercise capacity and pulmonary hypertension. This is good for patients with kyphoscoliosis not only in terms of their survival but also for their quality of life. We recommend long term intermittent nocturnal NIPPV as a routine intervention for severe kyphoscoliosis with hypoxaemia, and transthoracic echocardiography as a routine evaluation tool for determining the response of pulmonary hypertension to management.

The Radiological Manifestations of the Aberrant Air Surrounding the Pleura: In the Embryological View

The radiological manifestations of the aberrant air surrounding the pleura are varied because of the air outlining the organs in and out of the visceral space. The continuity of the visceral space from the neck, mediastinum to the retroperitoneum is originated from embryological development, which is compatible with the findings through laboratory experiments, cadaveric anatomy, and thoracic computer tomography image. We reviewed the embryo development to understand the anatomy of body cavity, which can determine the radiological findings of pneumomediastinum and pneumothorax.

Experience of using activated protein C in a patient with emphysematous pyelonephritis receiving percutaneous nephrostomy drainage.

Summary Drotrecogin alfa, a type of recombinant human activated protein C, has potential to reduce the mortality in severe sepsis, but may simultaneously increase the risk of serious bleeding events. Here, we report an 81-yearold female suffering from emphysematous pyelonephritis who recovered after appropriate management, including antibiotics, percutaneous nephrostomy drainage and administration of activated protein C. This case showed that percutaneous nephrostomy drainage is not an absolute contraindication in the prescribing of activated protein C in patients with severe sepsis.

Cardiac tamponade caused by epithelioid haemangioendothelioma

Epithelioid haemangioendothelioma (EHE) is a tumour of vascular endothelial origin. The rarity of EHE has limited the complete understanding of the disease. Here, a unique case of EHE complicated with cardiac tamponade with an unusual initial presentation, scoliosis, is reported. The discordant findings between a Tc99m bone scan and 2-fluoro-2-deoxy-d-glucose positron emission tomography (FDP PET) also serve to impart another lesson about investigating bone metastasis in EHE.

The Experience of a Novel Glycylcycline Antibiotic for a Patient with Infection Caused by Multiple Drug-Resistant Pathogens: What is the Benefit?

SUMMARY We report a 75-year-old man with septic shock induced by ventilator-associated pneumonia caused by multiple drug-resistant Acinetobacter baumannii and catheter-related infection by vancomycin-resistant enterococci. He failed to respond to the initial management, including antibiotics (linezolid, imipenem, sulbactam and colistin) and hemodynamic-guided fluid challenge. However, his condition improved dramatically after the antibiotic regimen was changed to tigecycline and ceftazidime. In addition to the superiority of the antibacterial effect of tigecycline, fluid control can be achieved more easily while using a single antibiotic instead of multiple drugs, which is also important for care of a critically ill elderly man with compromised cardiorespiratory or renal function. Here, we present a patient infected with multiple drug-resistant pathogens, who improved clinically after being treated with tigecycline, to demonstrate the benefits of this antibiotic. (International Journal of Gerontology 2008; 2(3): 124-127)

Acute Abdomen in Post-chemotherapy Acute Monoblastic Leukemia

SUMMARY A neutropenic patient with an acute abdomen could confuse the medical doctor in the decision making of whether or not a surgical intervention is essential to resolve the medical problem. Here, we report a 62-year- old female with acute monoblastic leukemia that was complicated by neutropenic fever and abdominal pain on the 13 th day after receiving the first chemotherapy consisting of 1-beta-D-arabinofuranosylcytosine and idarubicin. Abdominal computed tomography revealed colitis involving the entire ascending colon. Neutropenic enterocolitis with Enterobacter cloacae septicemia was the final diagnosis. She received conserva- tive management with close observation and recovered eventually. We discuss the etiologies of acute abdomen in patients receiving chemotherapy and their differential diagnosis. (International Journal of Gerontology 2007; 1(4): 164-167)

Microscopic Polyangiitis Caused by Propylthiouracil in a Patient with Hyperthyroidism-A Case Report

he etiology of hemoptysis can be grouped into 3 major categories: disease from the airways, the pulmonary parenchyma, and the pulmonary vasculature. Small vessel pulmonary vasculitis, such as microscopic polyangiitis (MPA), is 1 of the diseases diffusely affecting the pulmonary parenchyma in the presentation of the hemoptysis. Propylthiouracil (PTU) is 1 of the etiologies of MPA with an unclear mechanism. Herein, we describe a woman with PTU-induced ANCA-positive vasculitis who developed pulmonary hemorrhage with respiratory failure and crescentic glomerulonephritis. We initiated mechanical ventilation, and medical treatment, including highdose steroid pulse therapy and oral cyclophosphamide, and discontinued PTU. Her condition improved and she was discharged. She has been in stable condition without further sequelae.