Ceftriaxone, a regularly used antibiotic for broad-spectrum coverage, is a rare cause of hemolytic anemia. Patients may present with truncal pain, nausea, vomiting, and an acute drop in hemoglobin within 48 hours of administration. Prompt recognition and initiation of treatment are essential. We describe a case of a 65-year-old woman being treated for osteomyelitis who developed hemolytic anemia, disseminated intravascular coagulation, and multi-system organ failure after being de-escalated from cefepime to ceftriaxone.

Invasive pulmonary aspergillosis (IPA) in liver transplant patients remains rare but exceedingly fatal. The diagnostic challenges associated with this condition are compounded by its infrequent onset within the first two weeks following transplantation. Moreover, therapeutic management is complex due to the intricate drug interactions between triazole antifungals and calcineurin inhibitor immunosuppressants. We present the case of a 63-year-old male who underwent uncomplicated liver transplantation (LT) and developed early-onset IPA. Despite maximal efforts, the patient expired. This report aims to underscore the vital importance of timely diagnosis and therapy in preventing the insidious progression of invasive disease and subsequent mortality.

The fungal pathogen Scedosporium apiospermum is a ubiquitous opportunistic pathogen found in soil and water that can cause severe infection in hosts with impaired immunity. Patients with systemic autoimmune diseases such as systemic lupus erythematosus (SLE) are already at risk for infections given their altered immunity. This can be exacerbated further in patients taking immune-suppressing medications to control their disease status. Here, we present a case of a rare and challenging clinical scenario of a woman with refractory multi-organ SLE on steroids who developed neurologic deficits found to have a brain abscess caused by a unique fungal etiology.

BACKGROUND: Patients with end-stage liver disease (ESLD) are at increased risk for hemorrhage and spontaneous retroperitoneal hematoma (sRPH) and also carry a high mortality rate. We sought to review the natural history of sRPH in patients with ESLD at a single center.
METHODS: All patients admitted to a single transplantation intensive care unit (TICU) at Froedtert and the Medical College of Wisconsin Transplant Center between June 2016 and August 2018 were retrospectively reviewed. Six ESLD patients with sRPH were studied. Clinical outcome measures were liver disease severity, sRPH treatment, and patient survival.
RESULTS: Six patients were included, four male and two female patients, with a median age of 56.5 years (range 30-67 years). All had alcohol-induced liver cirrhosis. The median Model for End-Stage Liver Disease (MELD) score at the time of sRPH diagnosis was 40 (range 30-43). The most commonly identified source of bleeding was from lumbar arteries. One patient had recurrent bleeding after embolization and underwent repeat embolization. Five patients died. The median time to death from the diagnosis of sRPH was 7.2 days (range 2-12 days). The patient who survived following embolization had the lowest MELD score.
CONCLUSIONS: Critically ill cirrhotic patients with sRPH have a significant mortality rate. Embolization is successful, albeit seldom. This is the largest retrospective series of sRPH in cirrhotic patients in the literature.

Emphysematous cystitis (EC) is a potentially life-threatening urinary tract infection (UTI) characterized by the presence of gas within the bladder wall and lumen. The extension of gas beyond the bladder wall is rare and indicative of severe disease. We present a case of septic shock secondary to EC with the extension of air through the paraspinal and psoas muscles and into the epidural space of the lumbar spinal canal. This finding of intraspinal air is a rare radiographic phenomenon known as pneumorrhachis (PR).

Air embolism is a rare but possibly life-threatening situation. Gas embolism can be arterial, occurring as a complication of a lung biopsy, arterial catheterization, or extracorporeal circulation in the context of cardiopulmonary bypass, or venous, as in cases of venous catheter manipulation (especially with a central venous catheter in a spontaneously breathing patient), pressurized venous infusions, or in a neurosurgical context. Various clinical manifestations are described in the literature, ranging from asymptomatic cases to obstructive shock. Clinical manifestations may include chest pain, dyspnea, nausea and vomiting, altered consciousness, focal neurological deficits, seizures, vertigo, and amaurosis. Physical examination findings may include hypotension and \"mill wheel murmur\" on chest auscultation. Early diagnosis and treatment are essential to improve the outcome of these patients. Approach and management include placing the patient in the left lateral decubitus and/or Trendelenburg position and on high-flow oxygen. Hyperbaric oxygen therapy is the definitive treatment for arterial gas embolism, which may reduce air emboli size, improve tissue oxygenation, and reduce ischemic lesion. Here, we report the case of a 62-year-old female patient with obesity, hypertension, dyslipidemia, and recovering from coronavirus disease 2019 (COVID-19) with obstructive shock due to venous gas embolism.

Mycotic aneurysms are a rare complication of systemic infections, where the arterial vessel wall becomes dilated secondary to bacterial, fungal, or viral infection. The incidence of mycotic aneurysms is rare but carries a significant mortality risk. Patients with mycotic aneurysms can have wide-ranging clinical presentations depending on the site of the aneurysm. Our case discusses one of the most encountered emergency department (ED) presentations, i.e., nausea and vomiting, as a presenting symptom of a patient found to have a mycotic aneurysm. A 56-year-old patient with a history of HIV, unknown viral load or CD4 count, and admitted IV drug use presented to the ED by ambulance with multiple episodes of nausea and non-bloody vomiting. The patient was noted to be afebrile but met systemic inflammatory response syndrome (SIRS) criteria, necessitating a further workup. CT of the abdomen and pelvis was notable for a saccular aneurysm involving the infrarenal aorta with a large thrombosed component. This case highlights the importance of early consideration of infected (mycotic) aneurysms in the appropriate patient setting, as delayed diagnosis increases the risk of rupture and death. In a case of non-specific nausea and vomiting, it is not unreasonable to assume this presentation could be attributed to a more benign process, delaying the diagnosis. It may, therefore, be prudent for emergency service providers to add mycotic aneurysms to the differential diagnosis for patients with appropriate risk factors, as presentations of mycotic aneurysms vary greatly.

Primary herpes simplex virus 1 (HSV-1) infection in children (beyond the neonatal period) may be asymptomatic or manifest as herpetic gingivostomatitis accompanied by fever and other symptoms. However, severe, health- and life-threatening infection is observed in rare cases, especially in at-risk patients. Children with atopic dermatitis may develop extensive eczema herpeticum (eruptio varicelliformis Kaposi). Herpes simplex eye infection, herpes simplex encephalitis, and disseminated (generalized) herpes infection also pose danger. We present a boy with exacerbated infantile seborrhoeic dermatitis (ISD) and eczema herpeticum complicated by streptococcal sepsis. HSV transmission should be limited if possible by avoiding direct contact with those who recently developed lesions. Communication with parents and explaining how to properly care for the skin in a child with skin diseases that disturb its barrier function protecting against external factors is particularly important. Also, parents should be informed that \"red flag\" symptoms in a child should be an indication for a pediatric consultation. In the event of infection, the duration of symptoms can be reduced by promptly initiated acyclovir therapy.

A 25-year-old female presented on the acute medical take with rapidly evolving ascending weakness, sensory loss, and areflexia after a prodromal diarrhoeal illness, ultimately critical care admission, tracheostomy, and intravenous immunoglobulin (IVIG) therapy. The patient had been diagnosed with Guillain-Barré Syndrome (GBS) six years previously, treated with intravenous Immunoglobulin, and discharged after a five-day in-patient stay without mechanical ventilation. On this occasion, a diagnosis of recurrent GBS was made, supported by cytoalbuminological dissociation in the cerebrospinal fluid (CSF). Investigations for infective precipitants were negative aside from a stool culture, positive for Cryptosporidium spp. DNA (deoxyribonucleic acid) two weeks earlier. There are no previously reported cases of GBS due to cryptosporidiosis on PubMed. The patient was treated with a course of IVIG and discharged from critical care after 66 days, requiring ongoing neurorehabilitation, which is likely to be prolonged.