Letters to the Editor

2. Deepak N A, Patel ND. Differential diagnosis of acute liver failure in Access this article online India. Ann Hepatol 2006;5:150‑6. Quick Response Code: 3. Singh V, Bhalla A, Sharma N, Mahi SK, Lal A, Singh P, et al. Website: Pathophysiology of jaundice in amoebic liver abscess. Am J Trop Med www.ijccm.org Hyg 2008;78:556‑9. 4. Kamarasu K, Malathi M, Rajagopal V, Subramani K, Jagadeeshramasamy D, Mathai E, et al. Serological evidence for wide DOI: distribution of spotted fevers & typhus fever in Tamil Nadu. Indian J 10.4103/ijccm.IJCCM_244_18 Med Res 2007;126:128‑30. 5. Poomalar GK, Rekha R. Scrub typhus in pregnancy. J Clin Diagn Res 2014;8:1‑3. How to cite this article: Mahto SK, Sheoran A, Goel A, Agarwal N. This is an open access journal, and articles are distributed under the terms of the Creative Uncommon cause of acute liver failure with encephalopathy. Indian J Crit Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to Care Med 2018;22:619-20. remix, tweak, and build upon the work non‑commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. © 2018 Indian Journal of Critical Care Medicine | Published by Wolters Kluwer ‑ Medknow

Pseudo Bulbar Palsy: A Rare Cause of Extubation Failure

Sir, Extubation Failure (EF) following weaning trials is a well known entity in Intensive Care Units (ICUs). The varied prevalence (2%–25%) of EF depends on the population studied and the time frame (24–72 h) included for analysis.[1] Airway edema and nonresolution of the primary disease are a common cause. Swallowing dysfunction as a cause of EF may at times account for more than 50% of patients.[1] We report an unusual presentation of lacunar with presenting with EF. An 80‑year‑old woman a known case of hypertension and Type 2 diabetes mellitus with good premorbid functional status, presented with 10 days history of intermittent fever associated with chills and rigor, nausea, and episodes of loose stools. History also included increased urinary urgency and Figure 1: Indirect laryngoscopy showing vocal cord palsy frequency and urinary incontinence. Four days after the illness, she developed shortness of breath. She was referred to our ICU on the 8th day of her illness. In our initial assessment, she was conscious, oriented, and cooperative. Her limb power as assessed both at distal and at proximal joints were 5/5, with flexor plantars and normal deep tendon reflexes. She had dysphonia at presentation. She had distressed breathing, bilateral basal crepts on auscultation, shock with cold peripheries, and ongoing noradrenaline dose of 0.2 mics/kg/min. She was managed as per the ICU protocols. She was weaned off the ventilator, and after a successful spontaneous breathing trial, she was extubated. Within 2 h of extubation, she had stridor, drooling of saliva, and . Airway edema was suspected. Measures taken to reduce edema included adrenaline nebulizations and systemic steroid, to which she did not show any improvement. She was re‑intubated and subsequently tracheostomized. Upper airway Figure 2: Hyperintensities noted in centrum semi ovale, thalmi, cortical bronchoscopy was done which was suggestive of hypotonic areas in T2 flair pharyngeal muscle with no vocal cord movements. Indirect laryngoscopy (IDL) performed by ears, nose, and throat neurological examination revealed a brisk jaw jerk reflex with surgeon validated the above findings [Figure 1]. Further bulbar weakness clinically evident as swallowing dysfunction.

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clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Ritu Singh, Monalisa Nayak, Sunil Kumar Jena, Afzal Azim Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Address for correspondence: Dr. Afzal Azim, Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Figure 3: Hyperintensities noted in bilateral cortical and subcortical Medical Sciences, Lucknow, Uttar Pradesh, India. areas in T2 flair E‑mail: [email protected]

Her laboratory parameters including sodium were within References normal limits throughout her stay in ICU. Magnetic resonance 1. Rothaar RC, Epstein SK. Extubation failure: Magnitude of the problem, imaging (MRI) brain was done which was suggestive of impact on outcomes, and prevention. Curr Opin Crit Care 2003;9:59‑66. multiple foci of confluent long hyperintensities in bilateral 2. Puvanendran K, Wong PK, Ransome GA. Syndrome of Dejerine’s cortical and subcortical areas [Figures 2 and 3]. After 2 weeks fourth reich. Acta Neurol Scand 1978;57:349‑53. 3. Huang CY, Broe G. Isolated facial palsy: A new lacunar syndrome. of ICU stay, she was discharged with a tracheostomy tube J Neurol Neurosurg Psychiatry 1984;47:84‑6. in situ, and routine tracheostomy care was taught to the 4. Besson G, Bogousslavsky J, Regli F, Maeder P. Acute pseudobulbar or relatives. She has been advised for a 2 weekly follow‑up. suprabulbar palsy. Arch Neurol 1991;48:501‑7. Informed consent was taken from the relatives of the patient. This is an open access journal, and articles are distributed under the terms of the Creative The isolated pseudo bulbar weakness with no limb weakness Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to is a rare entity with only a few reported cases.[2,3] Unilateral remix, tweak, and build upon the work non‑commercially, as long as appropriate credit lacunar stroke limited to corticonuclear pathways may be is given and the new creations are licensed under the identical terms. asymptomatic. When symptomatic, unilateral pathway damage Access this article online usually produces only lower facial weakness, and mostly Quick Response Code: [4] without significant limb weakness. Other symptoms of Website: , drooling, speech abnormities, nasal regurgitation, www.ijccm.org and emotional liability are common.[3] Our case report highlights an atypical presentation of stroke as a cause of DOI: EF. A high clinical suspicion, vocal cord palsy on IDL and 10.4103/ijccm.IJCCM_78_18 microangiopathic changes in MRI, confirmed our diagnosis.

Declaration of patient consent How to cite this article: Singh R, Nayak M, Jena SK, Azim A. Pseudo The authors certify that they have obtained all appropriate bulbar palsy: A rare cause of extubation failure. Indian J Crit Care Med patient consent forms. In the form the patient(s) has/have 2018;22:620-1. given his/her/their consent for his/her/their images and other © 2018 Indian Journal of Critical Care Medicine | Published by Wolters Kluwer ‑ Medknow

Unusual Cause of Hypotension in a Polytrauma Victim: A Case of Fahr’s Syndrome

Sir, On arrival at the emergency department, the patient was Shock in polytrauma patient is believed to be due to conscious, responding but tachypneic (respiratory rate 30 hemorrhage until proven otherwise.[1] A 28‑year‑old male breaths/min) with bilateral equal air entry and in the state patient presented to the trauma center with a history of of shock (blood pressure was 80/40 mmHg, and heart rate blunt trauma to the chest and abdomen following fall from was 130/min). Pupils were bilaterally equal and reactive. height. He had a medical history of seizure disorder for He was resuscitated in the emergency department (ED) with the past 5 years for which he was on antiepileptic drugs. 2 L of crystalloids and two units of packed red blood cells.

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