A & A Case Reports

Siddiqui, Ammar; Agrawal, Shubham; Sekhri, Nitin

doi: 10.1213/xaa.0000000000001720pmid: 37934660

A 21-year-old patient with intellectual disability was admitted for gastroenteritis due to serotonergic medication overdose, and subsequently developed serotonin syndrome. Her symptoms initially improved after the cessation of serotonergic medications, but worsened 5 days later after fentanyl administration during general anesthesia. On emergence, she had convulsions and was nonresponsive. Subsequent imaging and electroencephalography did not demonstrate intracranial pathology or seizure activity. We suspect she had an exacerbation of her serotonin syndrome. She recovered successfully after supportive care. This case demonstrates that common medications used during anesthesia such as fentanyl can provoke serotonin syndrome, even several days after serotonergic drug discontinuation.

Arain, Faisal D.; Singh, Asha

doi: 10.1213/xaa.0000000000001711pmid: 37921810

Ishii, Tomomi; Miyoshi, Hirotsugu; Kubo, Takashi; Tsutsumi, Yasuo M.; Horikawa, Yousuke T.; Tanaka, Hiroyuki

doi: 10.1213/xaa.0000000000001727pmid: 37948548

Ropivacaine is an amide local anesthetic with rare reports of anaphylaxis. To our knowledge, this is the first report of delayed nonimmune anaphylaxis induced by ropivacaine. A 70-year-old man underwent general anesthesia with a nerve block for a total knee arthroplasty. The patient developed symptoms of anaphylaxis 3.5 hours after receiving ropivacaine for femoral and tibial nerve blocks. A basophil activation test (BAT) revealed ropivacaine as the causative agent. Notably, anaphylaxis can be caused by medications even hours after their administration, and all administered drugs should be suspected of potentially causing anaphylaxis.

Sanchez Salcedo, Lisa; Manuel Baloira, Federico; Adrover, Alejo; Bianco, Juan C.; Garcia Guzzo, Maria Eugenia

doi: 10.1213/xaa.0000000000001730pmid: 37966353

Life-threatening anaphylaxis to tranexamic acid (TXA) is rare but critical in cardiac surgery. A 76-year-old patient undergoing elective ascending aorta replacement developed severe anaphylactic shock shortly after anesthesia induction. Subsequent skin prick tests confirmed a positive TXA reaction. While TXA and lysine derivatives were avoided in the second surgery, the patient experienced hyperfibrinolysis. Guided by rotational thromboelastometry, hemostatic therapy led to a successful outcome with minimal postoperative bleeding. This report emphasizes the importance of drug risk awareness and strategies to mitigate excessive bleeding in cardiac surgery.

Chapman, Kenneth B.; Tupper, Connor; Yousef, Tariq; van Helmond, Noud

doi: 10.1213/xaa.0000000000001718pmid: 37966349

A 67-year-old man presented with severe 9 of 10 intractable pain of the left shoulder joint after arthroplasty and revision surgeries, with associated weakness, atrophy, and limited range of motion in all directions. Dorsal root ganglion stimulation (DRG-S) at the left C4, C5, and C6 levels was used after failed conservative and interventional measures, resulting in significant improvement in pain, function, and quality of life measures through 6 months postimplantation. Larger studies should examine if DRG-S is effective in treating chronic arthritic joint pain as well as chronic postsurgical pain of the shoulder that is not predominantly neuropathic.

Rocha-Romero, Andrés

doi: 10.1213/xaa.0000000000001731pmid: 37991193

Recently, denervation therapies have drawn attention as a promising treatment, and cooled radiofrequency has been proposed as the best option to capture most of the genicular nerves. We present a rare case of synovial knee fistula after radiofrequency and its management. To the best of our knowledge, this is the first case reported in the literature. The treatment included immobilization and chemoprophylaxis. One week later, the fistula was closed, and 14 months later, the procedure was repeated without complications. Genicular radiofrequency ablation is an emerging technique, and providers should be aware of the reported complications to counsel patients and manage potential risks appropriately.

Dichtwald, Sara; Meyer, Avraham; Miller, Yuval; Mirit, Lahav

doi: 10.1213/xaa.0000000000001725pmid: 37934659

Anaphylaxis is a life-threatening, systemic, hypersensitivity reaction, manifested by urticaria, hypotension, and respiratory symptoms. Antigens that are cleared renally may have protracted exposure in patients with impaired renal function, resulting in prolonged and refractory anaphylactic shock. After administration of sugammadex, a 47-year-old man developed prolonged, refractory anaphylactic shock, with anuria due to acute kidney injury. The patient was treated with continuous, short-term, veno-venous hemodiafiltration. Initiating this therapy in patients with refractory anaphylactic shock and anuria due to an antigen that is excreted renally can expedite recovery.

Lee, Ariella T.; Cordova, Justin C.; Jamplis, Robert P.; Pomicter, Gregory R.

doi: 10.1213/xaa.0000000000001726pmid: 37948545

Posterior reversible encephalopathy syndrome (PRES) is a rare neurologic condition and a feared complication of eclampsia. It is evidenced by acute neurologic dysfunction secondary to cerebral edema and is typically reversible in nature. Although it is a relatively new diagnosis, an increasing amount of literature has described its occurrence, including an association with hypomagnesemia. We present a case wherein a 24-year-old parturient developed PRES and eclampsia in the setting of symptomatic hypermagnesemia, requiring management with lorazepam after seizures developed. Here we detail her clinical course, including the unique challenges of treating eclampsia and PRES in the setting of magnesium toxicity.

Thomas, Caroline; Tobes, Daniel; Trela, Kristin; Montes, Mariana; Cuppini, Candice; Petty, Kyle; Saini, Gurjit; Perdigao, Joana; Song, Tae; Dalton, Allison; Tung, Avery

doi: 10.1213/xaa.0000000000001728