Septic Shock: Acute Generalised Exanthematous Pustulosis

Septic Shock: Acute Generalised Exanthematous Pustulosis An illusion of Septic Shock: Acute Generalised Exanthematous Pustulosis with Multi organ Dysfunction Acute Generalised Exanthematous Pustulosis (AGEP) is a rare cutaneous eruption, most often caused by commonly used antibiotics. It is characterized by an acute onset of non-follicular sterile pustular rash and erythema within hours or days of drug exposure and usually resolves spontaneously within 1-2 weeks once the drug is discontinued. Hemodynamic involvement in the form of shock is rare. Here, we present a severe case of AGEP, manifesting with systemic involvement and hemodynamic instability resulting into shock with multi-organ dysfunction. The associated drugs were Erythromycin and Fluconazole with a possible combined effect of these two drugs that resulted in systemic involvement. Our patient improved markedly, both his hemodynamically and dermatologically, after discontinuation of the drugs and with systemic steroid therapy. BACKGROUND Why you think this case is important why did you write it up? Acute Generalised Exanthematous Pustulosis (AGEP) is a rare condition which presents with rapid onset of several non-follicular sterile pustules occurring diffusely on an edematous and erythematous background (1) (2). Systemic manifestations are typically restricted to fever and leukocytosis. Reversible mild hepatic and kidney injury have been reported in some cases (1) (3). AGEP is caused by drugs in 90% of the cases (3) and spontaneously resolves rapidly after the offending agent has been discontinued. Topical steroids are used for symptom relief and systemic steroids have been used in atypical severe presentations with systemic involvement (4) (5). Here we describe a unique case of Erythromycin and Fluconazole induced severe form of AGEP presenting with shock requiring vasopressors and multi-organ dysfunction requiring CVVHD. Despite prompt discontinuation of the offending agent, patients condition continued to deteriorate until systemic steroids were initiated. CASE PRESENTATION Presenting features, medical/social/family history A 61-year-old man with morbid obesity, COPD, hypertension, and Type 2 diabetes mellitus was admitted to the hospital for acute onset rapidly progressive diffusely erythematous rash within the deep folds of his pannus and scrotum, which was refractory to over-the-counter topical therapy. There was concern for erythrasma so he was started on erythromycin and fluconazole. Within three days, the patients rash spread diffusely across his trunk and extremities to form erythematous morbilliform papules which coalesced to form plaques. Within 12 hours of noticeably worsening rash, the patient acutely decompensated, became short of breath and developed metabolic and respiratory acidosis, requiring transfer to the Intensive Care Unit. He was initially started on BiPAP, however due to increasing somnolence he was intubated. He was noted to be hypotensive with blood pressure of 66/42 mmHg, not responsive to intravenous fluid resuscitation. Patient was started on vasopressor support with norepine phrine. On laboratory analysis, he was found to have leukocytosis (WBC 31.10 10^3/uL), a mixed metabolic and respiratory acidosis, lactic acidosis, as well as hepatic injury with AST of 4902 units/ml and an ALT of 3073 units/ml. He subsequently developed acute renal failure with a creatinine of 3.06 mg/dL, hyperkalemia of 6.3 mmol/L and phosphorus of 7.0 mg/dL and was started on CVVHD. INVESTIGATIONS If relevant More detailed The patient was thoroughly evaluated for an infectious source with radiographic studies and blood and urine cultures, however all work up was negative. Skin biopsy was performed which showed diffuse spongiosis, as well as numerous subcorneal pustules filled with a mixed inflammatory infiltrate, predominately consisting of neutrophils, with some associated lymphocytes consistent with AGEP. DIFFERENTIAL DIAGNOSIS If relevant Other differentials included septic shock, pustular psoriasis, Toxic epidermal necrolysis, Stevens- Johnson syndrome TREATMENT If relevant Erythromycin and Fluconazole were immediately discontinued upon acute decompensation. Due to concern for septic shock initially, he was started on broad spectrum antibiotics, with Vancomycin, Meropenem and Micafungin. However, when the infectious work up was negative, antibiotics were discontinued. With suspicion of AGEP, he was treated with methylprednisolone 80 mg every 8 hours for three days and eventual slow taper on oral steroids. OUTCOME AND FOLLOW-UP The patient had marked improvement in both hemodynamics and rash once started on steroids. He no longer required vasopressor agents and was extubated on Day 3 of methylprednisolone. He required four days of CVVHD and had complete recovery of both kidney and liver function. He was maintained on oral prednisone with slow taper for 2 weeks. DISCUSSION Include a very brief review of similar published cases Acute Generalised Exanthematous Pustulosis (AGEP) is a relatively rare cutaneous condition provoked by drugs- mainly by anti-infective agents, less commonly by infections (3)(4) and sometimes the cause remains unclear. It is believed to be a T-cell mediated neutrophilic inflammation and the histological hallmark is a spongiform subcorneal/intraepidermal pustule. The rash typically starts in the intertriginous area, as seen in our patient, or the face and rapidly spreads to involve the rest of the body. Systemic manifestations are typically just limited to include fever and neutrophilic leucocytosis and organ involvement is rare. In a few patients, mild hepatic and kidney dysfunction has been reported (1)(6)(3). Our case of AGEP was an atypical presentation with severe systemic involvement leading to hemodynamic instability and multi-organ dysfunction, thereby giving an illusion of septic shock. To the best of our knowledge,ÂÂ   there have been only a few reported cases of AGEP w ith such severe presentation and none of these cases were associated with the use of Erythromycin and Fluconazole (7)(8)(9).ÂÂ   In most of the severe presentations, Vancomycin was the culprit medication (7)(8)(9). It is possible that the combined effect of Erythromycin and Fluconazole which are both hepatically metabolized and alter each others metabolism leading to increased drug levels resulted in the drug reaction being severe with systemic involvement as an affect. Other differentials to consider would be pustular psoriasis, Stevens-Johnson syndrome and Toxic epidermal necrolysis. The patient had no history of psoriasis and the concern for SJS and TEN was low based on the history, lack of mucosal involvement and the timing of the drug eruption within a few days of the antibiotics was more in favour of AGEP which was later confirmed by the biopsy results. Treatment of AGEP involves prompt removal of the offending agent which typically leads to improvement in symptoms within a few days. Topical steroids can be used for symptom relief. Systemic steroids are not indicated , but have been used in rare cases with severe presentations such as in our case, but currently there is not enough data to support the use of systemic steroids to reduce the duration of the symptoms and early recovery (11)(5)(4)(10). LEARNING POINTS/TAKE HOME MESSAGES 3 to 5 bullet points this is a required field AGEP is a rare cutaneous drug eruption which can be severe and mimic septic shock. It should be suspected in patients being managed as septic shock with negative infectious work up and the patients condition continues to deteriorate while on anti-infective agents. Several medications have been known to cause AGEP, but it is unclear as to which factors contribute to its severity. Discontinuation of the culprit agent might not always result in clinical improvement , especially in severe cases and there might be a role for systemic steroids to promote early clinical recovery.

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Public/ Private Parents these days try to find the best school for their child’s needs. Some parents can’t choose between public and public schools, because of their differences. Public and private schools have a lot of difference like cost, admissions, teachers, students, and special needs. Public schools don’t have tuition as all people know. State, Federal, and local taxes fund public schools. So when you pay taxes, you are paying for child’s education. Also you are paying for the other kids in your community. Unlike public schools, private schools have tuition. The National Association of Independent Schools says that the median tuition in the United States is $12,000 for first to third, $13,000 for grades sixth to eighth, and $15,000 for grades nine to twelve. For boarding schools it’s like another $8,000 for each group (Education World). Another difference is the admission. Public schools admit all children. This includes students with special needs. You can enroll your child in public schools by just filling out the necessary paperwork. Some private schools on the other hand are selective. Private schools are not forced to accept every child. In many schools admission is very cutthroat. The teachers are another difference in public and private schools. The teachers in public schools are usually state certified. That just means that the teacher has gone through training required by the state. In private schools teachers may not be required to have to train. Instead they have subject area expertise and an undergraduate or graduate degree in the subject they teach. Also teachers in private schools often report better working condctions. The students in public schools are usually the kids from the neighboring community. Also public schools usually have more racially and ethnically diverse populations. On the other hand a process determines students that go to private schools. All students must apply and be accepted in order to attend. Some people may say that this can create a fairly homogenous student body. Another difference is the special needs. Public schools by law must educate all children. They also have to provide the necessary programs to meet the child’s special needs. Public schools have teachers who are trained to work with students who have specific needs, because of this law. However, private schools don’t have to accept kids with specific needs. As a result most private schools do not have special education programs. Also in private schools extra resources to help children with special needs may come at an additional cost (Greatschools).

Pork Barrel

Pork barrel literally takes the meaning of setting apart budgets, which initially were taken from the people's money, for the realization of the proposed development projects of the members of the Congress of the Philippines. It usually is intended to benefit a group of citizens of a certain politician in return of their political support, which were either in the form of campaigning or in the voting process. To have these purposes be done neatly is a challenge for every politician.The temptation gets the otter of them at times, and this heads into the downside of having a pork barrel. Normally, in the English language, either addition or omission of words or letters always brings about another meaning into a word/group of words. Just like when pork barrel and scam meets halfway, its result you would never want to hear. But if every politician Just works with conscience, then we won't have any fear in mind regarding the collision of the words. But if otherwise, then it would not prod uce good feedbacks from the people.The Idea of whether or not to abolish the pork barrel is too hard to decide. But if I were to, I would have chosen not to take it away from the system of government. Yes, I may have stated downfalls In some parts of this essay, but I have a larger picture captured in mind. The outcome of abolishing this system I would always fear. What would happen to the Filipino people if the pork barrel for the betterment of the nation Is abolished? Every people must remember this system had its ups In terms of building roads and bridges, program for farmers, scholarships or deserving people, among others.Now, if the pork barrel Is to be scrapped, then It should be a challenge to the government to ensure that those who benefit from the program will not be affected. And that Is exactly what would happen If It Is abolished, there will be no guarantee that these people will continue their education and receive other significant assistance. Thus, the solution for It shall not be termination, but to have a greater commitment and accountability In Its utilization. Pork Barrel A cure, a treat, an alliance, a devastation or just a play. What do we really know about that so called Pork Barrel? All nation introduce to there governance the power of pork barrel stating that it’s a program serving righteous benefits for the society that concentrates on the people’s cost. But as a result of what they said Pork Barrel, I, you, we can’t see a single glimpse of faith brought by them. How can we say were free when we know that our hands and feet are tightly chained, how can we say were free when we know that were controlled by our very own governance who have no pardon for any citizens that relives faith in there own way.Why do Australia, Germany, United Kingdom, Eastern and Central Europe stated that they walk in on the path of righteousness, do that show that we have a bunch of prod, foolish and culprits in our public officials. It’s stated that the government is our government so how the government is working to help people over come co mplex problem if there the one who giving them and courses them in the path of lies and faults. A very good example is The Intriguing Controversy of the Year, The Pork Barrel Scam of Mrs.Janet Lim Napoles whom to be the brains of the lost of more than 10 Billion pesos in the funding of the Nation. And not only she is involve there’s still senators and congressman involve, how can they hold on trough this even then there are peoples supporting and trusting them all the way. Upon all happenings, evidence and controversies Mrs. Janet Lim Napoles can be voted not guilty, what is this happenings do our government just playing and fooling around to this crisis.Majority of the people is grieving for the lost wealth and opportunities just imagine all that money can do, it can feed million of people, can give hundred of thousand opportunities, can build off thousands of houses, can heal hundreds of illnesses, and help our only one nation from devastation. Now knowing these possibiliti es that can do so much, who can upholds this kind of cruel and unjustified act. After they say it’s for our own good how come they manage to control everything? How can we make an act if they have all the choices in life?But then I manage to conquer that after all that mischief I still need to thanks Mrs. Janet Lim Napoles not because of her cruelty and unjustified act people in the world won’t know the alliance and power of the whole Filipino people by means of the abuse of one. Now this day we should do what we know is right and stand on our two very own feet, we should know the path of what is fair and what is not because in the end were still humans and we can’t do every thing. So now a question will be leaven â€Å"Should you fight for what is right or stay on what you know is vogue? †

Capital Punishment And Its Effect On Society - 1425 Words

Capital Punishment has been a topic of debate since it was reinstated in 1976. Some say that in a free society, capital punishment is an unnecessary form of cruel and unusual punishment in violation of our constitution. Others claim that capital punishment serves the primary purpose of deterring crime and punishing society’s most homicidal offenders. The biggest question when it comes to capital punishment is, is it worth it? Does Capital punishment have a deterrent effect on society? Or does it hurt more than help society? An over whelming majority of researchers have found that the death penalty not only has an effect on society but also a huge effect on the justice system. In past years research has shown that capital punishment has†¦show more content†¦In â€Å"The deterrence effect Capital Punishment: New evidence on an old controversy†, David Philips tells us that in the past researchers only looked at yearly statistics on the deterrent effect of capita l punishment. Through new research Phillips has found that there is a short-term effect on capital punishment. If publicized executions deter homicides for only a brief time, then for researchers to detect the deterrent effect they must look at weekly and monthly statics instead of yearly. Philips has shown us that the murder rates are significantly less the week after an execution has been performed. Through the research done by Jonna Shepard, her statics show that the amount of time one spends on death row before being executed has an effect on the amount of deterrence as well. The average number of years that an executed offender has spent on death row has increased from approximately 1 year in 1981 to almost 12 years in 1999(Shepard). Reasons for the increase in wait time is because prisoners on death row try to delay their executions as long as possible with multiple appeals and requests for stays. In today’s society we are all about instant gratification therefore, when someone’s wait time on death row is shorter it tends to have more of an effect on us because it is almost immediate punishment for the crime committed. When criminals have a longer wait time on death