A 19-year-old woman with a history of asthma presented with acute confusion following a near-drowning event 2 weeks prior to admission. She was found to have severe thrombocytopenia and microangiopathic hemolytic anemia (MAHA). The treatment for thrombotic thrombocytopenic purpura (TTP) was started on the day of admission due to high clinical suspicion. Subsequent workup confirmed a diagnosis of TTP with no clear etiology except the near-drowning incident. TTP following a near-drowning event has never been reported in the literature. Furthermore, she developed refractory TTP that required reinitiation of therapeutic plasma exchange and rituximab. After discharge, the patient had been doing well over a year of follow-up without remission.

Drowning remains a significant global health concern, claiming over 300,000 lives annually, with a disproportionate impact on young individuals in low-and middle-income countries. Conventional mechanical ventilation, while common, falls short in addressing the hypoxemia and hypercapnia often observed in severe near-drowning cases. Veno-venous extracorporeal membrane oxygenation (vvECMO) emerges as a critical intervention for cardiopulmonary failure post-drowning. This case report delves into the pivotal role of ischemia-reperfusion injury (IRI) in a near-drowning-related pathology. Following the initial insult, reoxygenation exacerbates the inflammatory cascade, resulting in a surge of pro-inflammatory mediators. In this context, CytoSorb®, a hemoadsorption cartridge, demonstrates promise by effectively removing these mediators from circulation. This report outlines its application in a critically ill adolescent patient who experienced near-drowning, presenting a compelling case for CytoSorb as an adjunctive therapy in managing IRI-induced hyperinflammation.

Scedosporium apiospermum species complex are widely distributed fungi that can be found in a variety of polluted environments, including soil, sewage, and decaying vegetation. Those opportunistic pathogens with strong potential of invasion commonly affect immunosuppressed populations However, few cases of scedosporiosis are reported in immunocompetent individuals, who might be misdiagnosed, leading to a high mortality rate. Here, we reported an immunocompetent case of systemtic infection involved in lung, brain and spine, caused by S. apiospermum species complex (S. apiospermum and S. boydii). The patient was an elderly male with persistent fever and systemtic infection after near-drowning. In the two tertiary hospitals he visited, definite diagnosis was extremely difficult. After being admitted to our hospital, he was misdiagnosed as tuberculosis infection, before diagnosis of S. apiospermum species complex infection by the metagenomic next-generation sequencing. His symptoms were alleviated after voriconazole treatment. In the present case, the details associated with its course were reported and published studies on Scedosporium spp. infection were also reviewed, for a better understanding of this disease and reducing the misdiagnosis rate.

Scedosporium/Lomentospora species exist as saprophytic moulds that can potentially lead to serious infections in patients who have experienced near-drowning incidents. Scedosporium species are distributed across different regions of the world while Lomentospora prolificans has quite a restricted geographic distribution. We aimed to systematically review scedosporiosis cases after near-drowning, their clinical manifestations, underlying diseases, treatments, outcomes and its impact through disability-adjusted life years (DALYs). Five available sources were searched from 1 January 2007, to 20 April 2022. Thirty-eight studies, including 41 patients, were evaluated. Mean age was 33.6 ± 18.6 years (range 1-68), and 28 were male (68.3%). Central nervous system (CNS) dissemination predominated (36/41; 87.8%), presenting mainly as multiple brain abscesses (26/41; 63.4%), followed by lung involvement (22/41; 56.4%). Scedosporium apiospermum species complex was the most causative agent (38/41; 92.7%). Overall mortality was 51.2%. Half of the patients (18/37) were cured after receiving proper treatment, and in most cases, voriconazole alone or in combination with surgery or other antifungals caused survival. The mean survival time was 123 ± 27 days. Mean DALYs in 1980-2022 were 46.110 ± 3.318 (39.607-52.612). Time to diagnosis was estimated to be 120 days, and there was no association between time to diagnosis and outcome. Voriconazole is a potentially effective therapy, and combination of surgery and antifungal treatment may lead to more favourable outcome. Advances in early diagnosis and appropriate antifungal therapy may have contributed to reducing its mortality.

UNASSIGNED: Scedosporium spp. is a saprophytic fungus that may cause invasive pulmonary infection due to the aspiration of contaminated water in both immunosuppressed and immunocompetent hosts.
UNASSIGNED: Herein, we report a fatal case of pulmonary infection caused by Scedosporium species associated with a car crash and near-drowning in a sewage canal. Scedosporium aurantiacum isolated from bronchoalveolar lavage was identified by PCR-sequencing of β-tubulin genes. The minimum inhibitory concentration values for amphotericin B, itraconazole, posaconazole, isavuconazole were >16 µg/ml, and >8 µg/ml for anidulafungin, micafungin, and caspofungin. Voriconazole was found to be the most active agent with a MIC of 1 µg/ml.
UNASSIGNED: This report, as the first case of pulmonary scedosporiosis after near-drowning in Iran, highlights the importance of high suspicion in near-drowning victims, prompt identification of Scedosporium spp., and early initiation of appropriate antifungal therapy.

Hemolysis may be an infrequent cause of hemodialysis blood leak alarms. We report the case of an unresponsive adult male who was placed on hemodialysis with a high-flux dialyzer. Within five minutes, the blood leak alarm sounded. The care team discontinued treatment and made two additional attempts to reinitiate hemodialysis with different machines, blood tubing lots, and brands of high-flux dialyzers, but continued to receive blood leak alarms. Laboratory studies were consistent with severe hemolysis. The attending nephrologist subsequently ordered continuous veno-venous hemofiltration, which was initiated and continued into the following day without incident or alarm. The patient later expired from complications of near-drowning. In the event of significant hemolysis, continuous kidney replacement therapy or hemodialysis with a low-flux dialyzer, and a lower ultrafiltration rate may be indicated.

BACKGROUND: Gastroesophageal (GE) junction injuries are rare in the pediatric population. A complete GE junction separation in a child secondary to trauma has not reported in the literature yet.
METHODS: A 14-year-old boy presented with a complete GE junction avulsion after a near-drowning experience. He underwent immediate damage control surgery and delayed gastric pull-up esophageal reconstruction in 3-months. At the most recent clinic visit 5 months from the reconstruction, he can tolerate a regular diet without difficulty and is gaining weight and recovering well.
CONCLUSIONS: Complete GE junction injuries and avulsions are rare with limited data to guide management. These injuries are associated with mortality rates from 25% to 33%, therefore, high index of suspicion, prompt recognition and careful surgical planning is needed for favorable outcomes.

Herein, we describe a fatal case of central nervous system (CNS) pseudallescheriasis following near-drowning. A 13-year-old boy, who had been successfully resuscitated after near-drowning, presented with a transient episode of mental confusion during a hospital stay after recovering from severe aspiration pneumonia and respiratory failure. A magnetic resonance imaging (MRI) scan of the brain showed a small brain abscess in the left basal ganglia and ventriculitis in the left lateral ventricle. The brain abscess and ventriculitis did not respond to 4 weeks of antibiotic treatment and appeared even worse on a follow-up MRI. A diagnosis of CNS pseudallescheriasis was only possible with invasive stereotactic biopsy and aspiration of the abscess that showed the presence of hyphae and Scedosporium apiospermum. CNS pseudallescheriasis did not respond to multiple combinations of antifungal agents, including amphotericin B, isoconazole, itraconazole, and voriconazole. Two ventricular drainages and insertion of Ommaya reservoirs with intraventricular injection of voriconazole were insufficient to halt the infection. The patient passed away from sudden septic shock 2 months after identification of the brain abscess and ventriculitis. The patient\'s diagnosis was delayed because multiple examinations of the cerebrospinal fluid did not show positive cultures and could only be obtained from the aspirates of stereotactic biopsy. Physicians should be aware of CNS pseudallescheriasis associated with near-drowning because of the difficulty of diagnosis and the high mortality rate (70%) owing to poor responses to currently available antifungal agents.

BACKGROUND: Aeromonas pneumonia associated with near-drowning, though uncommon, is serious and a major morbidity factor for patients.
METHODS: A healthy 30-year-old man nearly drowned in a pound. He was admitted to the medical intensive care unit and required intubation and mechanical ventilation. He was given antibiotic therapy in the form of amoxicillin/clavulanic acid. After a brief stable period post immersion, he rapidly developed fever and respiratory failure. The thoracic scan revealed bilateral alveolar infiltrates and led to a fibreoptic bronchoscopy. Aeromonas veroniiandPseudomonas aeruginosa were found on culture of the bronchial aspirate. A change of antibiotic therapy appropriate to these bacteria led to clinical improvement and allowed complete withdrawal of ventilation.
CONCLUSIONS: Rapid respiratory deterioration following near-drowning should raise the suspicion of pulmonary infection with the bacteria usually found in the respiratory tract during ventilation but without overlooking the possibility of unusual organisms, particularly Aeromonas.It is usuallysensitive to third generation cephalosporins and fluoroquinolones. Ideally, Aeromonas should be sought in pulmonary aspirates and samples of the water where immersion occurred.

To investigate long-term neurocognitive outcomes after a near-drowning incident in children who were deemed neurologically intact on discharge from hospital.
A prospective cohort study of near-drowning children.
95 drowning and near-drowning admissions, 0-16 years of age, from January 2009 to December 2013, to The Children\'s Hospital at Westmead, Sydney, NSW, Australia.
23 children both met the criteria and had parental consent for the study.
Identification of the long-term deficits in behaviour, executive function, motor skills, communicative skills and well-being over a 5-year period. Assessment was undertaken at 3-6 months, 1 year, 3 years and 5 years after near-drowning at clinic visits. Physical developmental screening and executive function screening were done using Behavior Rating Inventory of Executive Function-Preschool version (BRIEF-P) and BRIEF.
95 drowning and near-drowning episodes occurred during the study period. 10 (11%) children died, 28 were admitted to the paediatric intensive care unit and 64 directly to a ward. 3 children died in emergency department, 7 children had severe neurological deficit on discharge from the hospital. 23 were subsequently recruited into the study; 5 (22%) of these children had abnormalities in behaviour and/or executive function at some during their follow-up.
Children admitted to hospital following a near-drowning event warrant long-term follow-up to identify any subtle sequelae which might be amenable to intervention to ensure optimal patient outcome.