Competing interests The authors declare that they have no competing interests. Authors’ contributions All authors participated in the conception, design, data collection and interpretation, manuscript preparation and literature search.”
“Background Since the outbreak of the H1N1 influenza pandemic in April 2009, an enormous body of literature presented various aspects of this new disease. Most of the reports describe epidemiological characteristics [1, 2] or the medical course and outcomes of patients with H1N1 [3–5], and are therefore APR-246 chemical structure presented mostly in the internal medicine or critical care medicine literature [6–9]. Recently, our acute care surgery service was confronted with 3 patients

who presented with relatively common surgical emergencies; however, due to concurrent CP673451 nmr H1N1 check details infection, their hospital course was unexpectedly and dramatically extraordinary. Case 1 A healthy 19-year-old man fell from a 3-meter-long ladder and hit his head. At the scene he was comatose with a Glasgow Coma Score of 4; a right dilated and unresponsive pupil and no other obvious injuries were identified. He was intubated, ventilated and transferred to our trauma center. His family members reported that he complained of having a sore throat in the preceding 2 days. On admission, the initial significant physical findings

were a fever of 39.5°C, a heart rate of 150 beats/min and normal blood pressure. A large right fronto-parietal subcutaneous hematoma and a dilated right pupil were revealed. The chest X-ray was consistent with bilateral infiltrates that were presumed to be lung contusions or the result of aspiration. An abdominal ultrasound did not show intra-peritoneal, pelvic or pericardial fluid. A CT scan of the brain revealed a large fronto-parietal epidural hematoma on the right with a significant

mass effect, and multiple fractures of the frontal and temporal bones. A CT scan of the abdomen and pelvis was normal, and a CT scan of the chest showed the same bilateral, bibasilar infiltrates that were seen on the initial chest X-ray (figure 1). The patient underwent an emergency craniotomy with evacuation of the epidural hematoma and insertion of an intracranial pressure monitoring catheter (ICP). During the operation, due Temsirolimus in vivo to a significant yet unexplained decrease in the blood pressure the patient underwent an intraoperative trans-esophageal echocardiography that demonstrated a severe global left ventricular dysfunction with an ejection fraction of 15%. At that point the differential diagnosis was either of acute myocarditis related to a suspected streptococcal throat infection, cardiac contusion or catecholamine induced cardiomyopathy [10]. The patient was transferred to the intensive care unit (ICU); he was sedated, pharmacologically paralyzed, mechanically ventilated and required large doses of vasopressors to maintain a normal blood pressure.