Hemorrhage bilateral

It has been forty-five minutes since CH s arrival, and he has been given lorazepam 4 mg twice and loaded with 1500 mg of phenytoin. He received another 400 mg dose of phenytoin 15 minutes ago, but is still unarousable. His jerking movements have slowed down, but his temperature is now 39.9°C (103.8°F), and his blood pressure has dropped to 124/62 mm Hg. His oxygen saturation is 91% on 4 L oxygen via nasal cannula. Bilateral crackles are heard upon auscultation of his lungs. A CT scan of his head is obtained which shows no evidence of hemorrhage, tumor, or mass effect. 

Bilateral adrenal hemorrhage or infarction—usually due to anticoagulant therapy, coagulopathy, thromboembolic disease, or meningococcal infection. Causes acute adrenal insufficiency. 

Acute adrenal hemorrhage, either unilateral (17) or bilateral (18), has been observed repeatedly after corticotropin administration, and causes an acute abdominal crisis. Although it is usually seen in children, hemorrhage can also occur in adults (SEDA-17, 451). 

Dunlap SK, Meiselman MS, Breuer RI, Panella JS, Ficho TW, Reid SE Jr. Bilateral adrenal hemorrhage as a complication of intravenous ACTH infusion in two patients with inflammatory bowel disease. Am J Gastroenterol 1989 84(10) 1310-2. 

It was noted that she had gram-negative rods on her blood smear her blood culture grew penicillin-sensitive Streptococcus pneumoniae, in 6 hours. At autopsy, she was noted to have Streptococcus pneumoniae endocarditis of the right ventricle, focal ischemia of the left ventricle, bilateral pleural effusions, hepatic congestion with thrombosis, renal congestion, bilateral adrenal hemorrhage, and necrosis. Death was due to septic shock from Streptococcus pneumoniae. 

A 15-year-old woman developed impaired consciousness and psychomotor agitation and 10 minutes later reactive bilateral mydriasis and decerebration. A CT scan showed diffuse brain edema and subarachnoid hemorrhage. She had hyponatremia (119 mmol/1) and was considered brain dead 32 hours later. 

Fig. 29.4. Axial CT (a) and T2-weighted MR brain (b) slices in a patient with deep cerebral venous thrombosis with bilateral deep hemorrhagic infarction.

Experimental evidence indicates that COX modulates BBB permeability in neuroinflammatory conditions, ischemia, and hemorrhage. The COX inhibitor, KBT-3022, prevented brain edema induced by bilateral carotid occlusion and recirculation in gerbils (Yamamoto et al., 1996). In the collagenase model of intracerebral hemorrhage, the brain water content of rats treated with the COX-2 inhibitor, celecoxib, decreased both in lesioned and nonlesioned hemispheres in a dose-dependent manner, which was accompanied with reduced perihematomal cell death (Chu et al., 2004). Delayed damage to the BBB and vasogenic edema, which follow ischemic stroke, were significantly diminished by administration of... 

Optic neuritis (retrobulbar or papillitis) bilateral VA reduction from 20/100 to 5/400, dense central scotomata optic disc edema/ hyperemia, dilated retinal veins, peripapillary hemorrhages late optic atrophy. 

Aplastic anemia due to azathioprine therapy after comeal transplantation has reportedly caused bilateral macular hemorrhage (18). 

Sudhir RR, Rao SK, Shanmugam MP, Padmanabhan P. Bilateral macular hemorrhage caused by azathioprine-induced aplastic anemia in a corneal graft recipient. Cornea 2002 21(7) 712-14. 

The onset of visual loss can be sudden and dramatic, with color vision defects in the red-green or blue-yellow spectra, as well as variable field defects. In acute cases, disc edema is accompanied by sphnter hemorrhages. Retrobulbar neuritis with ethambutol can be predominantly axial, presenting with reduced visual acuity and central scotoma, or periaxial, with peripheral field defects. In non-acute tjrpes the fundi and discs appear normal (13). Visual defects can be unilateral or bilateral. 

Optic neuropathy has only rarely been reported in association with penicillamine (73). In one patient, blurred vision occurred as a result of the development of bilateral choroidal hemorrhage complicating penicillamine-induced thrombocytopenia (123). 

Acute renal insufficiency together with diffuse alveolar hemorrhage and bilateral pulmonary infiltrates was suspected to have been caused by penicillamme (500 mg/day for 6 months) in a 34-year-old white woman, who took penicillamine for progressive systemic sclerosis (234). Because of disseminated intravascular coagulation, a biopsy was not made and the role of penicillamine remained uncertain. 

A 56-year-old woman with systemic sclerosis taking penicillamine 750 mg/day had homogeneous antinuclear antibodies and antibodies to native DNA. Her manifestations of vasculitis were glomerulonephritis with renal insufficiency, pulmonary hemorrhage, and bilateral hemothorax (that is similar to Goodpasture s syndrome). 

Miosis occurs from direct contact of vapor with the eyes. It may also occur from moderate to severe exposure of skin to liquid agent or from a liquid droplet near the eye. Miosis will begin with seconds or minutes following vapor exposure and may not be complete for many minutes if the exposure concentration is low. In unprotected individuals, miosis is bilateral and is often accompanied by complaints of pain, dim and blurred vision, conjunctival injection, nausea, and occasionally vomiting. On occasion, subconjunctival hemorrhage is also present. 

Spontaneous intracerebral hemorrhage occurred in a 72-year-old woman who had been taking GB 50 mg three times daily for 6 months (54). Bilateral subdural hematomas were discovered in a 33-year-old woman who had been taking 60 mg of GB twice daily for 2 year, acetaminophen, and occasionally an ergotamine/caffeine preparation (55). Bleeding time was elevated, but had normalized when checked approx 1 month after discontinuation of the product. 

A course of ECT generally consists of 6 to 12 treatments administered either unilaterally or bilaterally two to three times weekly. A rapid therapeutic response (10 to 14 days) has been reported. Although there are no absolute contraindications to the use of ECT, several conditions are associated with increased risk. These include increased intracranial pressure, cerebral lesions, recent myocardial infarction, recent intracerebral hemorrhage, bleeding, or otherwise unstable vascular condition. The use of an anesthetic as well as a nondepolarizing neuromuscular blocking agent decreases the morbidity associated with ECT. ... 

CMV retinitis, the most commonly recognized CMV disease associated with AIDS, usually is associated with a painless progressive loss of vision. Patients initially may complain of blurry vision, loss of visual acuity, or floaters. CMV retinitis usually begins unilaterally, but bilateral involvement may occur. Untreated, CMV retinitis invariably leads to blindness. The diagnosis of CMV retinitis is made by funduscopic examination and identification of characteristic findings. Lesions characteristic of CMV retinitis include a fluffy white perivascular exudate frequently associated with hemorrhage. Early diagnosis and treatment are crucial to prevent further visual deterioration. 

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