Acute and Critical Care

Original Articles

Rapid response system
Analysis of avoidable cardiopulmonary resuscitation incidents with a part-time rapid response system in place: Jun Yeun Cho, Dong Seon Lee, Yun Young Choi, Jong Sun Park, Young-Jae Cho, Ho Il Yoon, Jae Ho Lee, Choon-Taek Lee, Yeon Joo Lee; Acute Crit Care. 2021;36(2):109-117. Published online April 16, 2021; DOI: https://doi.org/10.4266/acc.2020.01095

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Background
Although a rapid response system (RRS) can reduce the incidence of cardiopulmonary resuscitation (CPR) in general wards, avoidable CPR cases still occur. This study aimed to investigate the incidence and causes of avoidable CPR.
Methods
We retrospectively reviewed the medical records of all adult patients who received CPR between April 2013 and March 2016 (35 months) at a tertiary teaching hospital where a part-time RRS was introduced in October 2012. Four experts reviewed all of the CPR cases and determined whether each event was avoidable.
Results
A total of 192 CPR cases were identified, and the incidence of CPR was 0.190 per 1,000 patient admissions. Of these, 56 (29.2%) were considered potentially avoidable, with the most common cause being doctor error (n=32, 57.1%), followed by delayed do-not-resuscitate (DNR) placement (n=12, 21.4%) and procedural complications (n=5, 8.9%). The percentage of avoidable CPR was significantly lower in the RRS operating time group than in the RRS non-operating time group (20.7% vs. 35.5%; P=0.026). Among 44 avoidable CPR events (excluding cases related to DNR issues), the rapid response team intervened in only three cases (6.8%), and most of the avoidable CPR cases (65.9%) occurred during the non-operating time.
Conclusions
A significant number of avoidable CPR events occurred with a well-functioning, part-time RRS in place. However, RRS operation does appear to lower the occurrence of avoidable CPR. Thus, it is necessary to extend RRS operation time and modify RRS activation criteria. Moreover, policy and cultural changes are needed prior to implementing a full-time RRS.

Citations

Citations to this article as recorded by

Changes in the incidence of cardiopulmonary resuscitation before and after implementation of the Life-Sustaining Treatment Decisions Act
Hyunjae Im, Hyun Woo Choe, Seung-Young Oh, Ho Geol Ryu, Hannah Lee
Acute and Critical Care.2022; 37(2): 237. CrossRef
A Review of the Commercially Available ECG Detection and Transmission Systems—The Fuzzy Logic Approach in the Prevention of Sudden Cardiac Arrest
Michał Lewandowski
Micromachines.2021; 12(12): 1489. CrossRef

Ethics
Transcultural Adaptation and Validation of Quality of Dying and Death Questionnaire in Medical Intensive Care Units in South Korea: Jun Yeun Cho, Jinwoo Lee, Sang-Min Lee, Ju-Hee Park, Junghyun Kim, Youlim Kim, Sang Hoon Lee, Jong Sun Park, Young-Jae Cho, Ho Il Yoon, Jae Ho Lee, Choon-Taek Lee, Yeon Joo Lee; Acute Crit Care. 2018;33(2):95-101. Published online May 31, 2018; DOI: https://doi.org/10.4266/acc.2017.00612

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Background
Providing palliative care to dying patients in the intensive care unit (ICU) has recently received much attention. Evaluating the quality of dying and death (QODD) is important for appropriate comfort care in the ICU. This study aimed to validate the Korean version of the QODD questionnaire.
Methods
This study included decedents in the ICUs of three tertiary teaching hospitals and one secondary hospital from June 2016 to May 2017. ICU staff members were asked to complete the translated QODD questionnaire and the visual analogue scale (VAS) questionnaire within 48 hours of patient death. The validation process consisted of evaluating construct validity, internal consistency, and interrater reliability.
Results
We obtained 416 completed questionnaires describing 255 decedents. The QODD score was positively correlated with the 100-VAS score (Pearson correlation coefficient, 0.348; P<0.001). An evaluation of the internal consistency presented favorable results (calculated Cronbach’s alpha if a given item exceeded 0.8 in all items). The interrater reliability revealed no concordance between doctors and nurses.
Conclusions
The QODD questionnaire was successfully translated and validated in Korean medical ICUs. We hope further studies that use this valuable instrument will be conducted in Korea.

Citations

Citations to this article as recorded by

Factors associated with the quality of dying and death and missed nursing care
Shahin Gahramani, Mokhtar Mahmoudi, Nouri, Sina Valiee
International Journal of Palliative Nursing.2024; 30(4): 190. CrossRef
A systematic review of instruments measuring the quality of dying and death in Asian countries
Shuo Xu, Yue Fang, Hanzhang Chen, Kang Sun, Chen Zhang, Yang Liu
Quality of Life Research.2023; 32(7): 1831. CrossRef
Translation, Validity and Internal Consistency of the Quality of Dying and Death Questionnaire for Brazilian families of patients that died from cancer: a cross-sectional and methodological study
Bianca Sakamoto Ribeiro Paiva, Talita Caroline de Oliveira Valentino, Mirella Mingardi, Marco Antonio de Oliveira, Julia Onishi Franco, Michelle Couto Salerno, Helena Palocci, Tais Cruz de Melo, Carlos Eduardo Paiva
Sao Paulo Medical Journal.2023;[Epub] CrossRef
Russian nurses’ readiness for transcultural care of palliative patients
Nataliya Kasimovskaya, Natalia Geraskina, Elena Fomina, Svetlana Ivleva, Maria Krivetskaya, Nina Ulianova, Marina Zhosan
BMC Palliative Care.2023;[Epub] CrossRef
Change in perception of the quality of death in the intensive care unit by healthcare workers associated with the implementation of the “well-dying law”
Ye Jin Lee, Soyeon Ahn, Jun Yeun Cho, Tae Yun Park, Seo Young Yun, Junghyun Kim, Jee-Min Kim, Jinwoo Lee, Sang-Min Lee, Jong Sun Park, Young-Jae Cho, Ho Il Yoon, Jae Ho Lee, Choon-Taek Lee, Yeon Joo Lee
Intensive Care Medicine.2022; 48(3): 281. CrossRef
Factors Associated with Quality of Dying and Death in Korean Intensive Care Units: Perceptions of Nurses
Haeyoung Lee, Seung-Hye Choi
Healthcare.2021; 9(1): 40. CrossRef
Validation of the Chinese Version of the Quality of Dying and Death Questionnaire for Family Members of ICU Patients
Xing-ping Han, Xu Mei, Jing Zhang, Ting-ting Zhang, Ai-ni Yin, Fang Qiu, Meng-jie Liu
Journal of Pain and Symptom Management.2021; 62(3): 599. CrossRef
Validation of the Quality of Dying and Death Questionnaire among the Chinese populations
Ying Wang, Mandong Liu, Wallace Chi Ho Chan, Jing Zhou, Iris Chi
Palliative and Supportive Care.2021; 19(6): 694. CrossRef
The quality of dying and death for patients in intensive care units: a single center pilot study
Yanghwan Choi, Myoungrin Park, Da Hyun Kang, Jooseon Lee, Jae Young Moon, Heejoon Ahn
Acute and Critical Care.2019; 34(3): 192. CrossRef
Factors Associated With Quality of Death in Korean ICUs As Perceived by Medical Staff: A Multicenter Cross-Sectional Survey
Jun Yeun Cho, Ju-Hee Park, Junghyun Kim, Jinwoo Lee, Jong Sun Park, Young-Jae Cho, Ho Il Yoon, Sang-Min Lee, Jae-Ho Lee, Choon-Taek Lee, Yeon Joo Lee
Critical Care Medicine.2019; 47(9): 1208. CrossRef

Nursing/Quality Improvement
Transcultural Adaptation and Validation of the Family Satisfaction in the Intensive Care Unit Questionnaire in a Korean Sample: Youlim Kim, Jinsoo Min, Gajin Lim, Jung-Kyu Lee, Hannah Lee, Jinwoo Lee, Kyung Su Kim, Jong Sun Park, Young-Jae Cho, You Hwan Jo, Hogeol Rhu, Kyu-seok Kim, Sang-Min Lee, Yeon Joo Lee; Korean J Crit Care Med. 2017;32(1):60-69. Published online February 28, 2017; DOI: https://doi.org/10.4266/kjccm.2016.00962

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Background
A number of questionnaires designed for analyzing family members’ inconvenience and demands in intensive care unit (ICU) care have been developed and validated in North America. The family satisfaction in the intensive care Unit-24 (FS-ICU-24) questionnaire is one of the most widely used of these instruments. This study aimed to translate the FS-ICU-24 questionnaire into Korean and validate the Korean version of the questionnaire.
Methods
The study was conducted in the medical, surgical, and emergency ICUs at three tertiary hospitals. Relatives of all patients hospitalized for at least 48 hours were enrolled for this study participants. The validation process included the measurement of construct validity, internal consistency, and interrater reliability. The questionnaire consists of 24 items divided between two subscales: satisfaction with care (14 items) and satisfaction with decision making (10 items).
Results
In total, 200 family members of 176 patients from three hospitals completed the FS-ICU-24 questionnaire. Construct validity for the questionnaire was superior to that observed for a visual analog scale (Spearman’s r = 0.84, p < 0.001). Cronbach’s αs were 0.83 and 0.80 for the satisfaction with care and satisfaction with decision making subscales, respectively. The mean (± standard deviation) total FS-ICU-24 score was 75.44 ± 17.70, and participants were most satisfied with consideration of their needs (82.13 ± 21.03) and least satisfied with the atmosphere in the ICU waiting room (35.38 ± 34.84).
Conclusions
The Korean version of the FS-ICU-24 questionnaire demonstrated good validity and could be a useful instrument with which to measure family members’ satisfaction about ICU care.

Citations

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The Effect of a Multifaceted Family Participation Program in an Adult Cardiovascular Surgery ICU*
Hye Jin Yoo, JaeLan Shim
Critical Care Medicine.2021; 49(1): 38. CrossRef
Psychometric validation of the Chinese patient- and family satisfaction in the intensive care unit questionnaires
Veronica Ka Wai Lai, Johnson Ching-Hong Li, Anna Lee
Journal of Critical Care.2019; 54: 58. CrossRef
Survey of family satisfaction with intensive care units
Jinsoo Min, Youlim Kim, Jung-Kyu Lee, Hannah Lee, Jinwoo Lee, Kyung Su Kim, Young-Jae Cho, You Hwan Jo, Ho Geol Ryu, Kyuseok Kim, Sang-Min Lee, Yeon Joo Lee
Medicine.2018; 97(32): e11809. CrossRef

Basic science and research
The Anti-Inflammatory Effect of Arginine-Vasopressin on Lipopolysaccharide-Induced IκBα/Nuclear Factor-κB Cascade: Jisoo Park, Eun Young Eo, Kyoung-Hee Lee, Jong Sun Park, Jae-Ho Lee, Chul-Gyu Yoo, Choon-Taek Lee, Young-Jae Cho; Korean J Crit Care Med. 2015;30(3):151-157. Published online August 31, 2015; DOI: https://doi.org/10.4266/kjccm.2015.30.3.151

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Background
Arginine vasopressin (AVP) is widely used as a vasopressor agent. Some recent studies have suggested that AVP may exert an immunomodulatory effect. However, the mechanism about the anti-inflammatory effect of AVP is not well known. We investigated the effect of AVP on the ihibitor of kappa B (IκBα)/nuclear factor-kappa B (NF-κB) pathway in RAW 264.7 cells.
Methods
Cultured RAW 264.7 cells were pretreated with AVP and stimulated with lipopolysaccharide (LPS). To evaluate the effect of AVP on inflammatory cytokines, the concentration of interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) were assessed by an enzyme-linked immunosorbent assay technique. The expression of IκBα and nuclear translocation of NF-κB p65 were measured by Western blotting, and IκB kinase (IKK) activity was analyzed by an in vitro immune complex kinase assay. To confirm the AVP effect on IκBα/NF-κB cascade and via V2 receptor, we added tolvaptan (V2 receptor antagonist) after AVP pretreatment.
Results
The increase of IL-6 and TNF-α in LPS-stimulated RAW 264.7 cells was suppressed by a treatment with AVP. Pretreatment of AVP inhibited increasing of IKK activity and IκBα degradation induced by LPS in RAW 264.7 cells. Furthermore, LPS induced and NF-κB transcription was inhibited by AVP pretreatment. The observed changes in IKK activity, IκBα degradation and NF-κB transcription by AVP was abolished by tolvaptan treatment.
Conclusions
Our results suggest that AVP showed anti-inflammatory effect on LPS-induced IκBα/NF-κB cascade in mouse macrophages via V2 receptors.

Citations

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Validity of mental and physical stress models
Erin Hendry, Brady McCallister, Dan J. Elman, Roy Freeman, David Borsook, Igor Elman
Neuroscience & Biobehavioral Reviews.2024; 158: 105566. CrossRef
Osmoregulatory neurons clockwork is altered during metabolic disorder induced by high energy diet in the Sand rat Psammomys obesus
Hanane Touati, Saliha Ouali-Hassenaoui, Aicha Dekar-Madoui, Nadir Benhafri, Lydia Boumansour, Etienne Challet, Paul Pévet, Patrick Vuillez
Biological Rhythm Research.2023; 54(2): 153. CrossRef
Microbial and Host Metabolites at the Backstage of Fever: Current Knowledge about the Co-Ordinate Action of Receptors and Molecules Underlying Pathophysiology and Clinical Implications
Luigi Santacroce, Marica Colella, Ioannis Alexandros Charitos, Marina Di Domenico, Raffaele Palmirotta, Emilio Jirillo
Metabolites.2023; 13(3): 461. CrossRef
Birth triggers an inflammatory response in the neonatal periphery and brain
Alexandra Castillo-Ruiz, Carla D. Cisternas, Hannah Sturgeon, Nancy G. Forger
Brain, Behavior, and Immunity.2022; 104: 122. CrossRef
Comprehensive biology of antipyretic pathways
Prajitha N, Athira SS, Mohanan PV
Cytokine.2019; 116: 120. CrossRef
Oxytocin and Vasopressin Systems in Obesity and Metabolic Health: Mechanisms and Perspectives
Cherlyn Ding, Faidon Magkos
Current Obesity Reports.2019; 8(3): 301. CrossRef

Pulmonary
Percutaneous Dilatational Tracheostomy in Critically Ill Patients Taking Antiplatelet Agents: Sung Jin Nam, Ji Young Park, Hongyeul Lee, Taehoon Lee, Yeon Joo Lee, Jong Sun Park, Ho Il Yoon, Jae Ho Lee, Choon Taek Lee, Young Jae Cho; Korean J Crit Care Med. 2014;29(3):183-188. Published online August 31, 2014; DOI: https://doi.org/10.4266/kjccm.2014.29.3.183

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BACKGROUND
Percutaneous dilatational tracheostomy (PDT) has been considered as an alternative to surgical tracheostomy in intensive care units (ICU), and is widely used for critically ill patients who need prolonged mechanical ventilation. Few studies have reported on PDT performed in critically ill patients taking antiplatelet agents. Our goals are to assess not only the feasibility and safety of PDT, but also bleeding complications in the patients receiving such therapy.
METHODS
In a single institution, PDTs were performed by pulmonologists at the medical ICU bedside using the single tapered dilator technique and assisted by flexible bronchoscopy to confirm a secure puncture site. From March 2011 to February 2013, the patients' demographic and clinical data, procedural parameters, outcomes and complications were analyzed and compared complications between patients taking antiplatelet agents and those not.
RESULTS
PDTs were performed for 138 patients; the median age was 72 years, mean body mass index was 20.3 +/- 4.8 kg/m2, and mean acute physiology and chronic health evaluation II score was 24.4 +/- 9.4. Overall, the procedural success rate was 100% and the total procedural time was 25 +/- 8.5 min. There were no periprocedural life-threatening complications, and no statistical difference in the incidence of bleeding complications between patients who had taken antiplatelet agents and those had not (p = 0.657).
CONCLUSIONS
PDT performed in critically ill patients taking antiplatelet agents was a feasible procedure and was implemented without additional bleeding complications.

Citations

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Open tracheostomy in patients with dual platelet aggregation inhibitors
Lorena Zapata-Contreras, Carlos Eduardo Hoyos-Cuervo, María Cristina Florián-Pérez
Colombian Journal of Anesthesiology.2019; 47(3): 189. CrossRef
Safety of Percutaneous Dilatational Tracheotomy in Patients on Dual Antiplatelet Therapy and Anticoagulation
Enzo Lüsebrink, Konstantin Stark, Mattis Bertlich, Danny Kupka, Christopher Stremmel, Clemens Scherer, Thomas J. Stocker, Mathias Orban, Tobias Petzold, Nikolaus Kneidinger, Hans-Joachim Stemmler, Steffen Massberg, Martin Orban
Critical Care Explorations.2019; 1(10): e0050. CrossRef
Safety and Feasibility of Percutaneous Dilatational Tracheostomy in the Neurocritical Care Unit
Dong Hyun Lee, Jin-Heon Jeong
Journal of Neurocritical Care.2018; 11(1): 32. CrossRef
Comparison of outcomes between vertical and transverse skin incisions in percutaneous tracheostomy for critically ill patients: a retrospective cohort study
Sung Yoon Lim, Won Gun Kwack, Youlim Kim, Yeon Joo Lee, Jong Sun Park, Ho Il Yoon, Jae Ho Lee, Choon-Taek Lee, Young-Jae Cho
Critical Care.2018;[Epub] CrossRef

Pharmacology
The Optimal Dose of Midazolam for Promoting Sleep in Critically Ill Patients: A Pilot Study: Se Joong Kim, Jisoo Park, Yeon Joo Lee, Jong Sun Park, Ho Il Yoon, Jae Ho Lee, Choon Taek Lee, Young Jae Cho; Korean J Crit Care Med. 2014;29(3):166-171. Published online August 31, 2014; DOI: https://doi.org/10.4266/kjccm.2014.29.3.166

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BACKGROUND
Many critically ill patients treated in the intensive care unit (ICU) experience sleep disruption. Midazolam is commonly used for the sedation of critically ill patients. This pilot study is aimed to identify the optimal dose of midazolam for achieving sound sleep in critically ill patients.
METHODS
This prospective study was conducted in the medical ICU of a tertiary referral hospital. Polysomnography recording was performed over 24 hours to assess the quantity and quality of sleep in patients sedated with midazolam.
RESULTS
A total of five patients were enrolled. Median total sleep time was 494.0 (IQR: 113.5-859.0) min. The majority of sleep was stage 1 (median 82.0 [IQR 60.5-372.5] min) and 2 (median 88.0 [60.5-621.0] min) with scant REM (median 10.0 [6.0-50.5] min) and no stage 3 (0.0 min) sleep. The median number of wakings in 1 hour was 16.1 (IQR: 7.6-28.6). The dose of midazolam showed a positive correlation with total sleep time (r = 0.975, p = 0.005).
CONCLUSIONS
The appropriate quantity of sleep in critically ill patients was achieved with a continuous infusion of 0.02-0.03 mg/kg/h midazolam. However, the quality of sleep was poor. Further study is required for the promotion of quality sleep in such patients.

Citations

Citations to this article as recorded by

Effect of prolonged sedation with dexmedetomidine, midazolam, propofol, and sevoflurane on sleep homeostasis in rats
Brian H. Silverstein, Anjum Parkar, Trent Groenhout, Zuzanna Fracz, Anna M. Fryzel, Christopher W. Fields, Amanda Nelson, Tiecheng Liu, Giancarlo Vanini, George A. Mashour, Dinesh Pal
British Journal of Anaesthesia.2024; 132(6): 1248. CrossRef
Reliability of the Korean version of the Richards-Campbell Sleep Questionnaire
Jae Kyoung Kim, Ju-Hee Park, Jaeyoung Cho, Sang-Min Lee, Jinwoo Lee
Acute and Critical Care.2020; 35(3): 164. CrossRef
Pharmacological interventions to improve sleep in hospitalised adults: a systematic review
Salmaan Kanji, Alexandru Mera, Brian Hutton, Lisa Burry, Erin Rosenberg, Erika MacDonald, Vanessa Luks
BMJ Open.2016; 6(7): e012108. CrossRef
Sedation in Critically Ill Patients
Mark Oldham, Margaret A. Pisani
Critical Care Clinics.2015; 31(3): 563. CrossRef

Quality Improvement
Successful Implementation of a Rapid Response System in the Department of Internal Medicine: Yeon Joo Lee, Jin Joo Park, Yeonyee E Yoon, Jin Won Kim, Jong Sun Park, Taeyun Kim, Jae Hyuk Lee, Jung Won Suh, You Hwan Jo, Sangheon Park, Kyuseok Kim, Young Jae Cho; Korean J Crit Care Med. 2014;29(2):77-82. Published online May 31, 2014; DOI: https://doi.org/10.4266/kjccm.2014.29.2.77

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Background
A rapid response system (RRS) aims to prevent unexpected patient death due to clinical errors and is becoming an essential part of intensive care. We examined the activity and outcomes of RRS for patients admitted to our institution’s department of internal medicine.
Methods
We retrospectively reviewed patients detected by the RRS and admitted to the medical intensive care unit (MICU) from October 2012 through August 2013. We studied the overall activity of the RRS and compared patient outcomes between those admitted via the RRS and those admitted conventionally.
Results
A total of 4,849 alert lists were generated from 2,505 medical service patients. The RRS was activated in 58 patients: A (Admit to ICU), B (Borderline intervention), C (Consultation), and D (Do not resuscitate) in 26 (44.8%), 21 (36.2%), 4 (6.9%), and 7 (12.1%) patients, respectively. Low oxygen saturation was the most common criterion for RRS activation. MICU admission via the RRS resulted in a shorter ICU stay than that via conventional admission (6.2 vs. 9.9 days, p = 0.018).
Conclusions
An RRS can be successfully implemented in medical services. ICU admission via the RRS resulted in a shorter ICU stay than that via conventional admission. Further study is required to determine long-term outcomes.

Citations

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Effectiveness of Rapid Response Team implementation in a tertiary hospital in Egypt: an interventional study
Rania Hosny, Rasha Saad Hussein, Wafaa Mohamed Hussein, Sally Adel Hakim, Ihab Shehad Habil
BMJ Open Quality.2024; 13(3): e002540. CrossRef
Characteristics and Prognosis of Hospitalized Patients at High Risk of Deterioration Identified by the Rapid Response System: a Multicenter Cohort Study
Sang Hyuk Kim, Ji Young Hong, Youlim Kim
Journal of Korean Medical Science.2021;[Epub] CrossRef
Effects of a Rapid Response Team on the Clinical Outcomes of Cardiopulmonary Resuscitation of Patients Hospitalized in General Wards
Mi-Jung Yoon, Jin-Hee Park
Journal of Korean Academy of Fundamentals of Nursing.2021; 28(4): 491. CrossRef
Rapid response systems in Korea
Bo Young Lee, Sang-Bum Hong
Acute and Critical Care.2019; 34(2): 108. CrossRef
Effect of a rapid response system on code rates and in-hospital mortality in medical wards
Hong Yeul Lee, Jinwoo Lee, Sang-Min Lee, Sulhee Kim, Eunjin Yang, Hyun Joo Lee, Hannah Lee, Ho Geol Ryu, Seung-Young Oh, Eun Jin Ha, Sang-Bae Ko, Jaeyoung Cho
Acute and Critical Care.2019; 34(4): 246. CrossRef
Differences in the Clinical Characteristics of Rapid Response System Activation in Patients Admitted to Medical or Surgical Services
Yeon Joo Lee, Dong Seon Lee, Hyunju Min, Yun Young Choi, Eun Young Lee, Inae Song, Yeonyee E. Yoon, Jin Won Kim, Jong Sun Park, Young-Jae Cho, Jae Hyuk Lee, Jung-Won Suh, You Hwan, Kyuseok Kim, Sangheon Park
Journal of Korean Medical Science.2017; 32(4): 688. CrossRef

Case Report

Acute Respiratory Failure from Invasive Pulmonary Aspergillosis in an Immunocompetent Adult: A Case Report: Jong Sun Park, Jae Joon Yim, Seok Chul Yang, Chul Gyu Yoo, Young Whan Kim, Sung Koo Han, Young Soo Shim, Sang Min Lee; Korean J Crit Care Med. 2009;24(3):172-175.; DOI: https://doi.org/10.4266/kjccm.2009.24.3.172

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Abstract PDF: Invasive pulmonary aspergillosis has traditionally been known as a disease of an immunocompromised host. We report here on a case of an immunocompetent 73-year-old male who presented with dyspnea and he was finally diagnosed as suffering with invasive pulmonary aspergillosis. He died from progressive respiratory failure and secondary bacterial sepsis despite of voriconazole treatment. Invasive pulmonary aspergillosis should be considered as one of the differential diagnoses in patients with atypical pneumonia that does not respond to the usual antibiotics therapy, and even if the patient does not have an obvious history of an immunosuppressive status. An early suspicion with prompt treatment is important to improve the patient outcome.

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