Heart in Heart: A Case Report of Giant Left Atrial Appendage Aneurysm

Left atrial appendage aneurysm (LAAA) is a rare cardiac anomaly. The cause mostly due to congenital, but can be acquired also. Patient may remain asymptomatic or may present with variable symptom. It can predispose to hazardous adverse events, including atrial fibrillation, myocardial infarction, cardiac dysfunction and life-threatening systemic thromboembolism. Simple imaging, electrocardiography and echocardiography can diagnose this rare cardiac anomaly. We are reporting a case who presented to us at 5 years of age with palpitation, chest pain and dizziness with arrythmia that developed one month back; he visited our outpatient department of the National Heart Foundation Hospital & Research Institute Hospital, Dhaka, Bangladesh on 13th February 2020. We diagnosed left atrial appendage aneurysm with mitral valve prolapse with atrial arrhythmia thereafter surgical resection of aneurysmal part along with mitral valve annuloplasty done by mid sternotomy and maze therapy. Postoperative period was uneventful and discharged after 6th post operative day.

Azithromycin and cefixime combination versus azithromycin alone for the out-patient treatment of clinically suspected or confirmed uncomplicated typhoid fever in South Asia: a randomised controlled trial protocol

Background: Typhoid and paratyphoid fever (enteric fever) is a common cause of non-specific febrile infection in adults and children presenting to health care facilities in low resource settings such as the South Asia.  A 7-day course of a single oral antimicrobial such as ciprofloxacin, cefixime, or azithromycin is commonly used for its treatment. Increasing antimicrobial resistance threatens the effectiveness of these treatment choices. We hypothesize that combined treatment with azithromycin (active mainly intracellularly) and cefixime (active mainly extracellularly) will be a better option for the treatment of clinically suspected and culture-confirmed typhoid fever in South Asia.

Methods: This is a phase IV, international multi-center, multi-country, comparative participant-and observer-blind, 1:1 randomised clinical trial. Patients with suspected uncomplicated typhoid fever will be randomized to one of the two interventions: Arm A: azithromycin 20mg/kg/day oral dose once daily (maximum 1gm/day) and cefixime 20mg/kg/day oral dose in two divided doses (maximum 400mg bd) for 7 days, Arm B: azithromycin 20mg/kg/day oral dose once daily (max 1gm/day) for 7 days AND cefixime-matched placebo for 7 days. We will recruit 1500 patients across sites in Bangladesh, India, Nepal, and Pakistan. We will assess whether treatment outcomes are better with the combination after one week of treatment and at one- and three-months follow-up.

Discussion: Combined treatment may limit the emergence of resistance if one of the components is active against resistant sub-populations not covered by the other antimicrobial activity. If the combined treatment is better than the single antimicrobial treatment, this will be an important result for patients across South Asia and other typhoid endemic areas.

Clinicaltrials.gov registration: NCT04349826 (16/04/2020)

Azithromycin and cefixime combination versus azithromycin alone for the out-patient treatment of clinically suspected or confirmed uncomplicated typhoid fever in South Asia: a randomised controlled trial protocol

Background: Typhoid and paratyphoid fever (enteric fever) is a common cause of non-specific febrile infection in adults and children presenting to health care facilities in low resource settings such as the South Asia.  A 7-day course of a single oral antimicrobial such as ciprofloxacin, cefixime, or azithromycin is commonly used for its treatment. Increasing antimicrobial resistance threatens the effectiveness of these treatment choices. We hypothesize that combined treatment with azithromycin (active mainly intracellularly) and cefixime (active mainly extracellularly) will be a better option for the treatment of clinically suspected and culture-confirmed typhoid fever in South Asia. Methods: This is a phase IV, international multi-center, multi-country, comparative participant-and observer-blind, 1:1 randomised clinical trial. Patients with suspected uncomplicated typhoid fever will be randomized to one of the two interventions: Arm A: azithromycin 20mg/kg/day oral dose once daily (maximum 1gm/day) and cefixime 20mg/kg/day oral dose in two divided doses (maximum 400mg bd) for 7 days, Arm B: azithromycin 20mg/kg/day oral dose once daily (max 1gm/day) for 7 days AND cefixime-matched placebo for 7 days. We will recruit 1500 patients across sites in Bangladesh, India, Nepal, and Pakistan. We will assess whether treatment outcomes are better with the combination after one week of treatment and at one- and three-months follow-up. Discussion: Combined treatment may limit the emergence of resistance if one of the components is active against resistant sub-populations not covered by the other antimicrobial activity. If the combined treatment is better than the single antimicrobial treatment, this will be an important result for patients across South Asia and other typhoid endemic areas. Clinicaltrials.gov registration: NCT04349826 (16/04/2020).

Bacterial Isolates from Tracheal Aspirates and their Anti-microbial Susceptibility in Mechanically-Ventilated Children with Pneumonia Admitted to an Urban Critical Care Ward

Background and Aims: Data on Bacterial isolates from tracheal aspirates in children with severe pneumonia requiring intubation and mechanical ventilation especially in developing countries are very limited. We examined the microbial spectrum of bacteria isolated from tracheal aspirate of those children. The antibiotic susceptibility profiles of those bacteria were also examined.Methods: We evaluated the data of all mechanically ventilated children aged 0-59 months admitted to Intensive Care Unit (ICU) of “Dhaka Hospital” of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) between August 2009 and July 2013 having their tracheal aspirate culture done. Data were extracted from electronic medical records of the Dhaka Hospital.Results: Among 836 admitted pneumonia children in the ICU, we identified 35 children who fulfilled the inclusion criteria. Among them 34 (97%) had positive bacterial growths: Klebseilla species in 14 (40%), Escherichia coli in 11 (31%), Acinetobacter in 8 (23%) and Streptococcus species in 8 (23%). Additionally, Enterococcus, Staphylococcus aureus, Pseudominas and Proteus species were identified in 6 (17%), 4 (11%), and 2 (6%) of the children respectively. The susceptibility of the gram-negatives, except Klebseilla, to ampicillin, cotrimoxazole, gentamycin, ciprofloxacin, azithromycin, and ceftriaxone ranged from 0- 54%, while that for ceftazidime and amikacin ranged from 12-80%. The sensitivity of Klebseilla to these antibiotics ranged from 0-100%.Conclusions: Our data suggests that gram-negative bacteria, Klebseilla followed by Escherichia coli, and Acenetobacter are the predominant bacteria associated with severe pneumonia in ventilated children. The increased number of infections caused by Gram-negative bacteria is being accompanied by rising rates of multi-drug resistance which underscores the importance of aggressive antimicrobial therapy in the management of such children.Bangladesh Crit Care J September 2014; 2 (2): 60-64

A young child with bilateral diaphragmatic palsy after bilateral bidirectional Glenn shunt

A 13-months old boy was admitted in National Heart Foundation Hospital and Research Institute on 3 August 2011 with the diagnosis of Dextrocardia, A-V discordance, DORV, large perimembranous VSD, severe infundibular and valvular PS, bilateral SVC. He was operated on 10 August 2011. Bilateral bidirectional Glenn shunt was done off pump along with interruption of PDA. Antegrade pulmonary blood flow was minimized by tight PA banding. Baby was extubated 3 hours after surgery but had to reintubate immediately due to intense respiratory distress. Subsequent three trials of extubation failed. Chest x-ray revealed elevation of both the hemidiaphragm. Ultrasonogram of abdomen and Bronchogram along with fluoroscopy done and bilateral diaphragmatic palsy was diagnosed. Tracheostomy was done on 25th August 2011. Plication of left hemidiaphragm was done on 27th August and right hemidiaphragm plication was done on 10th September 2011. Though it took long period of time we managed to take him out of ventilator on 57th postoperative day. He was oxygen dependent for a period of time and finally he managed to take his own breath without tracheostomy tube from 67th postoperative day. After a long eventful postoperative hospital stay he was discharged home on 78th postoperative day. Discharge Chest x-ray revealed well expanded lung with flattened diaphragm. Echo revealed well functioning bilateral Glenn shunt. Tracheostomy wound healed nicely and there was no evidence of tracheal stenosis.