Vasopressor support was required soon after admission, with increasing doses despite addition of hydrocortisone and fludrocortisone. Fevers persisted despite broad-spectrum antibiotics, and he eventually required continuous renal replacement therapy. Respiratory cultures eventually identified GAS. Given clinical context, clindamycin and intravenous immunoglobulin (IVIG) were initiated for presumed TSS. Within 24 hours of initiating these measures, his pressor requirement had dropped precipitously. Within 72 hours, vasopressors were discontinued, and he was successfully extubated.
infection, and TSS stemming from GAS pneumonia is an even rarer occurrence. Rapid recognition and diagnosis of TSS in the setting of adult GAS infection is crucial, as mortality rates can be high even with early intervention. This case demonstrates that the etiology of this syndrome is not always skin and soft tissue infections. A study in France highlighted a small percentage of pneumonias caused by GAS, but these infections had the highest risk of developing TSS. High suspicion should prompt the provider to administer a protein synthesis inhibitor such as clindamycin, in addition to penicillin or broad-spectrum antibiotic coverage and consideration of adjunctive IVIG.
Discussion: TSS is an uncommon sequela of GAS
UNDERSTANDING CEREBELLAR HIPPOCAMPAL AND BASAL NUCLEI TRANSIENT EDEMA WITH RESTRICTED DIFFUSION SYNDROME: AN OPIATE-RELATED NEUROLOGICAL EMERGENCY
Farhan Mohiuddin, Zunair Mohiuddin, Gurtaj Mahil, Alexandra Bartholomew, Catherine Loehr, Shane Sanne; Louisiana State University, New Orleans, LA.
Introduction: Cerebellar Hippocampal and Basal Nuclei Transient Edema with Restricted Diffusion (CHANTER) syndrome is a neurological condition first described in a 2019 case series. This syndrome is associated with opiate exposure and diagnosed based on distinct clinical and imaging findings. Clinically, patients present with symptoms of cerebellar edema, including acute decreased consciousness and obstructive hydrocephalus. Characteristic MRI findings include restricted diffusion in the cerebellar cortex, hippocampi, and basal nuclei. Case: A 34-year-old man with seizure disorder, drug use disorder, schizophrenia, bipolar disorder, asthma, and migraines was found unresponsive approximately nine hours after heroin use. He was treated with naloxone, lorazepam, and levetiracetam with the need for intubation for acute encephalopathy and respiratory failure. He was admitted to the intensive care unit for further evaluation. He unable to obtain an MRI due to retained bullet fragments from a previous trauma. A head CT scan suggested toxic/ metabolic encephalopathy and significant bilateral cerebellar edema with partial effacement of the basal cistern, posterior fossa fullness, and hypodensities in the bilateral basal ganglia without herniation. A follow-up head CT seven days later showed
evolving infarcts in the cerebellum, fourth ventricle effacement, and prominence of the temporal horns of the lateral ventricles, with additional infarcts in the bilateral basal ganglia. The patient was extubated eight days after admission and was able to follow some commands. His motor and verbal abilities continued to improve, and he was transferred to inpatient rehabilitation at discharge. Discussion: Initially documented in adults, CHANTER syndrome has also been observed in pediatric populations and affects males and females similarly. It shares clinical features with other conditions, such as ischemic stroke, hypoxic- ischemic encephalopathy, and various toxic encephalopathies. Diagnosis is primarily MRI-based, and treatment involves discontinuing the opiate, which typically leads to rapid clinical improvement. In severe cases with substantial cerebellar edema, surgical intervention with ventriculostomy may be necessary. Preventative strategies include careful opioid prescription management and early identification of substance abuse. Education for patients and healthcare providers on the risks associated with opioid use is critical in reducing the incidence of CHANTER syndrome.
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