Image Description: Abdominal computed tomography scan. Sagit | Figure 1

JIMHICR

Image Description: Abdominal computed tomography scan. Sagittal section showing free air with free fluid.
Case Description: Electrolyte abnormalities are an underrecognized cause of respiratory failure in the intensive care unit. One such abnormality is a relatively rare phenomenon of hypermagnesemia resulting in paralysis. A 73-year-old Caucasian male patient presented to the emergency department with diffuse abdominal pain of 2-day duration. He received magnesium citrate and gastrointestinal cocktail for his constipation after initial imaging showed constipation. In view of acute worsening, follow-up computed tomography of the abdomen was done, which showed free air in upper abdomen along with free fluid. Hence, he was taken for emergent laparotomy with repair of pyloric ulcer perforation with omental patch. Post procedure course was complicated by sepsis, acute kidney injury, and respiratory failure with hypoxemia and hypercapnia. On physical examination the patient had flaccid paralysis in all his extremities along with absent brain stem reflexes. Extensive workup including imaging of brain failed to reveal diagnosis. On postoperative day 1, the patient was noted to have magnesium level of 9.2 mg/dL (1.6-2.3 mg/dL), which was thought to be cause of flaccid paralysis and respiratory failure. In view of his acute oliguric kidney injury, he was initiated on intermittent hemodialysis, until his magnesium levels were back to its physiologic limits. His paralysis gradually improved over next 48 to 72 hours and he was liberated from ventilator successfully.

Acute Respiratory Failure From Hypermagnesemia Requiring Prolonged Mechanical Ventilation

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This report details a case of hypermagnesemia associated with using milk of magnesia. A 73-year-old man with end-stage renal disease, diabetes, hypertension, peripheral vascular disease, coronary artery disease, and past coronary artery bypass grafting was given multiple daily doses of milk of magnesia for constipation. After developing persistent nausea and vomiting, he was transported to the emergency department and during transit to the hospital, developed severe bradycardia followed by asystolic cardiac arrest. Resuscitation efforts were successful; however, he developed atrial fibrillation with severe widening of the QRS and diffuse ST elevation, hypothermia, hypotension and apnoea requiring intubation. Initial diagnoses included ST-elevation myocardial infarction, cardiogenic and/or septic shock and hyperkalaemia. However, serum magnesium was later found to be >4.1 mmol/L (equivalent to >10 mg/dL). He underwent haemodialysis (HD) to remove serum magnesium with remarkable overall improvement. Severe hypermagnesemia can manifest with severe bradycardia and asystole, shock, hypothermia and respiratory failure and can mimic acute coronary syndromes complicated with cardiogenic shock or septic shock. Clinicians should be aware of this life-threatening condition in patients with significant renal dysfunction. Timely treatment with HD is highly effective and lifesaving.

Image Description: (A) Angiogram of left anterior descending coronary artery showing 100% occlusion without evidence of atherosclerotic coronary artery disease concerning for a septic embolus (blue arrow). (B) Transesophageal echo view showing medium-sized, 1.3 cm (L) × 1.0 cm (W), mobile vegetation on the atrial aspect of the tip of the anterior leaflet of mitral valve (red arrow). (C) Gross specimen showing vegetation involving the mitral valve leaflets. Case Description: Acute myocardial infarction (AMI) is a rare but recognized and potentially serious complication of infective endocarditis (IE). This case describes the challenges surrounding the management of AMI in the setting of septic coronary embolism, brain, spleen, and kidney infarcts due to septic emboli from native mitral valve IE.

Axial CT images focusing on the nose shows findings of bilateral choanal atresia (arrows). There are air-fluid levels in the posterior aspect of the nasal cavity bilaterally. Choanal atresia is the most common congenital abnormality of the nasal cavity. Newborns present either with respiratory distress with bilateral disease or failure to pass a nasogastric tube in unilateral disease. Coronal atresia can either be bony or membranous.

Electrolyte abnormalities are an underrecognized cause of respiratory failure in the intensive care unit. One such abnormality is a relatively rare phenomenon of hypermagnesemia resulting in paralysis. A 73-year-old Caucasian male patient presented to the emergency department with diffuse abdominal pain of 2-day duration. He received magnesium citrate and gastrointestinal cocktail for his constipation after initial imaging showed constipation. In view of acute worsening, follow-up computed tomography of the abdomen was done, which showed free air in upper abdomen along with free fluid. Hence, he was taken for emergent laparotomy with repair of pyloric ulcer perforation with omental patch. Post procedure course was complicated by sepsis, acute kidney injury, and respiratory failure with hypoxemia and hypercapnia. On physical examination the patient had flaccid paralysis in all his extremities along with absent brain stem reflexes. Extensive workup including imaging of brain failed to reveal diagnosis. On postoperative day 1, the patient was noted to have magnesium level of 9.2 mg/dL (1.6-2.3 mg/dL), which was thought to be cause of flaccid paralysis and respiratory failure. In view of his acute oliguric kidney injury, he was initiated on intermittent hemodialysis, until his magnesium levels were back to its physiologic limits. His paralysis gradually improved over next 48 to 72 hours and he was liberated from ventilator successfully.