No abstract

Rationale:Red man syndrome (RMS) is the most common allergic reaction to vancomycin. It generally occurs during rapid infusion of vancomycin; only few cases have been reported as results of local vancomycin administration. We hereby report a rare case where RMS developed after insertion of vancomycin-loaded bone cement in a primary total knee replacement (TKR).Patient concerns:A 74-year-old woman was admitted for a left TKR due to severe osteoarthritis. Erythematous changes over face, trunk, and extremities developed after the use of vancomycin-loaded bone cement.Diagnoses:According to the clinical manifestations, the patient was diagnosed with vancomycin-induced RMS.Interventions:She was treated with fluid challenge and intravenous ephedrine, followed by intravenous diphenhydramine and hydrocortisone.Outcomes:The patient's symptoms and signs relieved within 1 h after treatment.Lessons:Vancomycin-induced RMS may occur after the routine use of vancomycin-loaded bone cement in the primary TKR replacement.

No abstract

A 73-year-old woman was admitted because of progressive shortness of breath over the previous two weeks, which affected her daily activities. She had a history of congestive heart failure (New York Heart Association functional class II), hypertension and scoliosis. Her medications included acetylsalicylic acid, amiloride, hydrochlorothiazide, atenolol, rosuvastatin and spironolactone. She had no orthopnea or productive cough. On physical examination, her heart sounds were normal, without murmur. An electrocardiogram showed normal sinus rhythm.During the patient's stay in hospital, intermittent hypoxemia was noted when she was eating or sitting upright; hypoxemia improved when the patient was lying down. Oxygen saturation was found to step-down gradually, from 90% (when the patient was supine) to 78% (45° recline) to 69% (90° upright), before recovering to 87% (return to supine).A transthoracic echocardiogram showed a mildly dilated left atrium with a mildly dilated aortic root (3.95 cm). No valvular abnormalities, pericardial effusion or atrial septal aneurysm were seen. Bubbles were seen in the left atrium and ventricle within three cardiac cycles on bubble echocardiography (Figure 1 and Appendix 1, available at www.cmaj.ca/lookup/suppl/ doi:10.1503/cmaj.141525/-/DC1), suggesting intracardiac shunting. Computed tomography of the chest showed no evidence of lung parenchymal disease or pulmonary embolism; however, scoliosis and a tortuous, dilated aortic root were noted. Right heart catheterization confirmed normal pulmonary pressure (mean pulmonary arterial pressure 12 mm Hg; mean right atrial pressure 4 mm Hg) and a normal Qp/Qs ratio (0.46). Direct measurement of oxygen saturation during cardiac catheterization showed a step-down pattern: peripheral arterial saturation (SPo 2 ) in pulmonary capillary wedge position, left ventricle and aorta were 99.7%, 85.5% and 88.6%, respectively, which is compatible with the presence of intracardiac right-to-left shunt through a patent foramen ovale. We diagnosed platypneaorthodeoxia syndrome.The patient was scheduled for transfer to a tertiary care centre for further surgical intervention. Because her oxygen saturation fluctuated between 80%-90% in the supine position, we questioned whether she would be able to tolerate the three-hour journey. Considering the pathophysiology of platypnea-orthodeoxia syndrome, we attempted to increase left ventricular enddiastolic pressure using a vasopressor to improve right-to-left shunting. We initially used low-dose dopamine (5 μg/kg per min). Unfortunately, tachycardia developed, and the patient's dyspnea and intermittent desaturation did not improve. The patient also felt chest discomfort from palpitations. We changed the vasopressor to norepinephrine (5 μg/hr), which improved the patient's condition -her oxygen saturation was greater than 95% when she was in a supine position.The patient was successfully transferred to the tertiary care hospital, where she underwent implantation of a septal occluder. A follow -up cardiac echocardiogr...