Indian Journal of Critical Care Medicine August 2014 Vol 18 Issue 8

or TEN in which a fluoroquinolone was the offending agent have been reported. Of these, 26 were associated with ciprofloxacin, whereas only one was associated with ofloxacin.[5] Here, we are reporting a patient with TEN induced by ingestion of oral ofloxacin which is not a common cause of TEN.

Gaurang Gupta

Department of dermatology, Om Premia Hospital, Palwal, Haryana, India

Correspondence: Dr. Gaurang Gupta, Department of Dermatology, Om Premia Hospital, 56 km stone, Palwal, Haryana India. Email: [email protected]

Figure 1: Sheet like peeling of skin

References 1. 2. 3. 4. 5.

Lissia M, Mulas P, Bulla A, Rubino C. Toxic epidermal necrolysis (Lyell’s disease). Burns 2010;36:152-63. Harr T, French LE. Toxic epidermal necrolysis and Stevens-Johnson syndrome. Orphanet J Rare Dis 2010;5:39. Correia O, Delgado L, Ramos JP, Resende C, Torrinha JA. Cutaneous T-cell recruitment in toxic epidermal necrolysis. Further evidence of CD8+lymphocyte involvement. Arch Dermatol 1993;129:466-8. Melde SL. Ofloxacin: A probable cause of toxic epidermal necrolysis. Ann Pharmacother 2001;35:1388-90. Van Bambeke F, Tulkens PM. Safety profile of the respiratory fluoroquinolone moxifloxacin: Comparison with other fluoroquinolones and other antibacterial classes. Drug Saf 2009;32:359-78. Access this article online

Figure 2: Crusting and erosive lesions over lip

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The pathogenesis of Stevens-Johnson syndrome (SJS)/TEN is not fully understood, but is believed to be immune-mediated. The clinical, histopathological, and immunological findings in SJS/TEN support the concept, that SJS and TEN are specific drug hypersensitivity reactions in which cytotoxic T lymphocytes play a role in the initiation phase.[3] The histopathology of SJS/TEN lesions show that keratinocyte apoptosis followed by necrosis is the pathogenic basis of the widespread epidermal detachment observed in SJS/TEN.[2] The risk of death for patients with TEN can be accurately predicted by the TEN-specific severity-of-illness score. We calculated that our patient had a final score of 2 and a mortality risk of 12.1%. The frequency of fluoroquinolone use has been increasing owing to their broad antibacterial spectra and few adverse effects. Until now, these drugs have seldom been implicated in patients with TEN, but the incidence of fluoroquinolone-induced cutaneous reactions may be on the increase.[4] Until date, a total of 31 cases of SJS 546

DOI: 10.4103/0972-5229.138166

Internal jugular vein thrombosis from rhino-cerebral mucormycosis: Be careful before cannulation Sir, Rhino-cerebral mucormycosis is a relatively uncommon fungal infection of the nasal cavity and para-nasal

Indian Journal of Critical Care Medicine August 2014 Vol 18 Issue 8

Figure 1: Thrombus in the right internal jugular vein seen in ultrasound image

sinuses that can rapidly progress to the central nervous system and orbit. [1] Immunocompromised patients such as uncontrolled diabetic, bone marrow transplant and those on cancer chemotherapy are at high risk of developing this condition. This condition has also been seen in the absence of clinical risk factors.[2] A 47-year-old female patient was admitted in our hospital with complains of rhinorrhea, ptosis, proptosis and gradually progressive visual loss. Subsequently, she was diagnosed to be a case of rhino-cerebral mucormycosis in the background of uncontrolled diabetes mellitus. Magnetic resonance imaging head shows involvement of the left maxillary and ethmoid sinuses with involvement of the ipsilateral orbit. A thrombus was noted in the cavernous sinus also. She was started on intravenous amphotericin B, and appropriate glucose control measures were also taken. Anesthesia team was requested for central venous access as she had poor peripheral venous access. An ultrasound guided right sided internal jugular vein (IJV) cannulation was planned. On ultrasound scanning of the neck vein, a thrombus in the entire length of right IJV in the neck was noticed [Figure 1]. On the left side, even larger size of a thrombus almost completely occluding the IJV was noticed. We abandoned the procedure and asked for a radiological evaluation of the neck veins. An ultrasound Doppler revealed the presence of thrombus in both IJV.

give rise to septic and pulmonary embolism. As these patients require long-term intravenous drug therapy anesthesiologists are often asked to put a central venous access. When a thrombus is in situ, there will always be a significant possibility that the thrombus may dislodge distally at time of venipuncture, guide wire insertion or catheter insertion. because of nonavailability of ultrasound machine in many circumstances, IJV cannulation is being performed by anatomical landmark technique. These patients may be at risk of embolic complications from “blind” IJV cannulation. Hence looking for and exclusion of IJV thrombosis before neck vein cannulation is very important for safety of the patients. Hence, we recommend that blind IJV cannulation should be avoided in these patients, and an ultrasound Doppler screening may be made before attempting IJV cannulation.

Rinoy Chandran, Pallavi Mishra, D. K. Pawar, Souvik Maitra, Jineesh Valakkada1

Departments of Anaesthesiology and 1Radio diagnosis, All India Institute of Medical Sciences, New Delhi, India

Correspondence: Dr. Souvik Maitra, Department of Anaesthesiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029, India. E-mail: [email protected]

References 1. 2.

3. 4. 5.

Galetta SL, Wulc AE, Goldberg HI, Nichols CW, Glaser JS. Rhinocerebral mucormycosis: Management and survival after carotid occlusion. Ann Neurol 1990;28:103-7. Elinav H, Zimhony O, Cohen MJ, Marcovich AL, Benenson S. Rhinocerebral mucormycosis in patients without predisposing medical conditions: A review of the literature. Clin Microbiol Infect 2009;15:693-7. McDevitt GR Jr, Brantley MJ, Cawthon MA. Rhinocerebral mucormycosis: A case report with magnetic resonance imaging findings. Clin Imaging 1989;13:317-20. Ball E, Morris-Stiff G, Coxon M, Lewis MH. Internal jugular vein thrombosis in a warfarinised patient: A case report. J Med Case Rep 2007;1:184. Boedeker CC, Ridder GJ, Weerda N, Maier W, Klenzner T, Schipper J. Etiology and therapy of the internal jugular vein thrombosis. Laryngorhinootologie 2004;83:743-9.

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Mucormycosis tends to involve blood vessel and leads to vascular thrombosis. Cavernous sinus thrombosis and internal carotid artery thrombosis has been reported even in clinically stable patients.[3] IJV thrombosis is a rare but potentially fatal condition. Trauma to the vein, coagulopathy, neck infection and malignancy are most important causes of IJV thrombosis.[4,5] It can

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DOI: 10.4103/0972-5229.138167

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Internal jugular vein thrombosis from rhino-cerebral mucormycosis: Be careful before cannulation.

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