A previously healthy 23-year-old man developed acute-onset fever, headache, and a rapidly deteriorating altered mental status, occurring 11 days after the resolution of self-limiting respiratory symptoms. The cerebrospinal fluid and brain MRI findings were consistent with meningoencephalitis. A recent M. pneumoniae infection was confirmed using nasopharyngeal PCR and serological testing. Despite appropriate antimicrobial therapy, his neurological deterioration progressed. The addition of steroids and intravenous immunoglobulin resulted in a rapid and complete neurological recovery. This case underscores the immune-mediated pathogenesis of M. pneumoniae-associated meningoencephalitis, particularly in cases with a delayed neurological onset following respiratory prodromes. Clinicians should therefore consider early immunotherapy in conjunction with antibiotics, even in adult populations.

Cryptococcal meningitis is a life-threatening opportunistic infection in advanced HIV disease. Cryptococcal antigen (CrAg) detection by lateral flow assay (LFA) is the diagnostic cornerstone, offering high sensitivity and specificity. However, false-negative results may arise from the prozone effect - antigen excess disrupting antibody-antigen lattice formation. We report a 37-year-old man with newly diagnosed advanced HIV infection (CD4+ count 26 cells/µL) presenting with altered mental status. Initial CrAg LFA on serum and cerebrospinal fluid (CSF) was negative. India ink staining revealed encapsulated yeasts, prompting serial dilution retesting, which yielded positive CrAg at 1:10 and 1:20 (serum) and 1:40 (CSF). Cultures confirmed Cryptococcus neoformans in CSF and skin biopsy of violaceous papular lesions, establishing disseminated cryptococcosis. Despite induction therapy with liposomal amphotericin B and flucytosine, the patient died from progressive neurological deterioration. This case underscores the prozone effect as a critical diagnostic pitfall and the indispensable role of complementary methods and clinical-laboratory integration.

Delirium is an acute encephalopathic syndrome that is highly prevalent in critically ill adult patients. The occurrence of delirium carries serious negative implications for patient outcomes and is a frightening and distressing experience for patients. The significance of delirium occurrence as an indicator of acute illness severity and clinical deterioration is well recognised. This is reflected in the inclusion of altered mental status in a number of national illness severity scoring systems. An awareness and understanding of delirium in the critically ill adult is therefore of relevance to all adult nurses. This article provides an overview of delirium in the critically ill adult patient, discussing current knowledge and recommended practice across key areas. These include the definition and classification of delirium; the implications of delirium for patient outcomes and experience; the aetiology and pathophysiology of delirium; delirium assessment tools used with critically ill patients and recommended approaches to prevention and management. The article will enable practitioners to develop a current understanding of key areas relating to delirium in the critically ill adult patient and encourage a reflective approach to considering the implications for practice.

Serum glial fibrillary acidic protein (sGFAP) is an astroglial biomarker preliminarily investigated in acute ischemic stroke (AIS). We aimed to investigate its temporal pattern and clinical value in two German AIS cohorts. Using immunoassay, we measured sGFAP concentrations in 952 samples of 572 AIS patient and 32 samples of controls recruited in Halle [AIS n = 102, age: 70.9 (± 15.9) years, 52.0% males; controls n = 32, age: 47.6 (± 18.8) years, 59.4% males] and Würzburg [AIS n = 470, age 74.6 (± 12.8) years, 48.3% males]. In AIS patients, we stratified samples according to the time from symptom onset to blood sampling, namely at D1 (< 24 h), D2 (24-48 h), D3 (48-72 h) and D5-7 (96-144 h), and tested associations between biomarker levels and clinical data. sGFAP level was increased at all timepoints after AIS compared to control subjects (p < 0.001, age-adjusted p < 0.01) with significant changes over time (D1 < D2< D3 ≥ D5-7). We found increased sGFAP concentrations in AIS patients who had altered mental status on admission (p < 0.01), hemorrhagic transformation of AIS (HT, p < 0.001) as well as systemic infections such as pneumonia (p < 0.001). Higher D1 sGFAP concentrations were associated with higher likelihood of modified Rankin Scale > 2 at 3 months [aOR = 1.015 (95%CI = 1.005-1.025), p = 0.004] and a shorter survival at longest follow-up (median: 576 days, max 922 days) [highest tertile vs. lowest tertile HR = 2.94 (95%CI = 1.21-7.17), p = 0.018]. sGFAP is elevated after AIS and of informative value regarding the risk HT and infections, as well as on the clinical outcome at follow-up.

We report a case of a six-month-old female infant weighing 4.56 kg who presented with altered mental status, severe metabolic acidosis, and multiorgan dysfunction following chronic use of an over-the-counter topical cream containing salicylic acid. The patient had a longstanding pruritic rash treated at home with multiple daily applications of the same topical salicylic acid-containing cream. She developed symptoms consistent with salicylate toxicity in the absence of known ingestion, confirmed by an elevated serum salicylate concentration. Intensive care was required to manage profound metabolic derangements, hepatic dysfunction, coagulopathy, thrombocytopenia, and hypoalbuminemia with third-spacing. Management included intravenous fluids, calcium gluconate, sodium bicarbonate therapy with urine alkalinization, potassium optimization, and supportive care. Dermatology evaluation raised concern for ichthyosis versus severe atopic dermatitis, and genetic testing was nondiagnostic except for a variant of uncertain significance in SLC27A4. The patient improved without dialysis and was discharged with dermatologic care instructions and close subspecialty follow-up. This case highlights the risk of systemic toxicity from topical salicylates in infants, particularly in the presence of impaired skin barrier function, and underscores the importance of cautious use of over-the-counter topical products in vulnerable pediatric populations.

Fusobacterium necrophorum is a recognized cause of brain abscesses and has been classically associated with Lemierre syndrome. We report a case of a 17-year-old male patient who presented with seizures, fever, and altered mental status following treatment for sinusitis. Neuroimaging revealed a right frontal lobe abscess requiring surgical drainage. Anaerobic cultures from the abscess fluid grew F. necrophorum, while a respiratory polymerase chain reaction (PCR) panel from a nasopharyngeal swab detected Mycoplasma pneumoniae. Anaerobic cultures also yielded Paenibacillus barengoltzii from a separate soft tissue specimen, though its clinical significance remained uncertain. The patient improved with surgical drainage and targeted antimicrobial therapy. This case highlights concurrent detection of F. necrophorum and M. pneumoniae in a central nervous system infection and underscores the uncertainty regarding the pathogenic role of M. pneumoniae in such presentations.

Carbon monoxide poisoning is a potentially fatal yet frequently overlooked condition owing to its vague clinical manifestations and deceptively normal pulse oximetry readings. Exposure related to gas geysers represents an under-recognized source of carbon monoxide toxicity in the Indian subcontinent, particularly in confined and poorly ventilated bathroom environments. We describe two patients with acute carbon monoxide poisoning presenting with different neurological emergencies. The first case involved a 58-year-old man with a history of prior stroke who presented with altered mental status and generalized weakness, initially raising suspicion of an acute cerebrovascular event. The second case involved a 45-year-old woman who developed syncope preceded by tremors and headache while bathing. In both instances, pulse oximetry readings were normal (98%) despite significant underlying hypoxia. Arterial blood gas analysis with CO-oximetry confirmed elevated carboxyhemoglobin levels (33% and 24.1%, respectively). Administration of high-flow normobaric oxygen led to rapid symptomatic improvement and full recovery in both patients, without the need for hyperbaric oxygen therapy. These cases highlight important diagnostic challenges, particularly the unreliability of pulse oximetry and the critical role of environmental history in identifying carbon monoxide exposure. Gas geyser-associated carbon monoxide poisoning should be considered in patients presenting with unexplained neurological symptoms or syncope in enclosed bathroom settings. Prompt recognition and treatment are essential, as this represents a preventable cause of significant morbidity and mortality.

Background/Objectives: Urinary tract infections (UTIs) in older adults are common and potentially life-threatening conditions that often present with atypical symptoms. Early identification of prognostic factors is essential to improve clinical outcomes and reduce mortality in this vulnerable population. Methods: This retrospective, multicenter study included patients aged ≥65 years who were hospitalized with a diagnosis of UTI between January 2019 and December 2023. Diagnoses were established by infectious disease specialists based on clinical findings and microbiological confirmation in accordance with international guidelines. Only patients with urine cultures showing ≥100,000 CFU/mL bacterial growth were included. Demographic, clinical, laboratory, and microbiological data were analyzed. Multivariable logistic regression was used to identify independent predictors of in-hospital mortality. Results: A total of 1175 patients (median age: 75 years; 51.1% male) were included. The in-hospital mortality rate was 14.6%, and 25.6% required intensive care unit (ICU) admission. Multidrug-resistant (MDR) bacteria were detected in 63.6% of isolates, and bacteremia was present in 24.3% of cases. In multivariable analysis, MDR/ESBL positivity (OR: 2.09, 95% CI: 1.24-3.50, p = 0.005), bacteremia (OR: 2.10, 95% CI: 1.32-3.35, p = 0.002), and SOFA score (OR: 1.53, 95% CI: 1.42-1.65, p < 0.001) were independently associated with in-hospital mortality. Age and altered mental status were also significant predictors, while CRP and procalcitonin lost significance after adjustment. Conclusions: UTIs in elderly patients are associated with substantial morbidity and mortality. Multidrug-resistant pathogens, bacteremia, and disease severity play a central role in determining outcomes. Early identification of high-risk patients using clinical severity scores and microbiological data may improve risk stratification and guide timely, targeted therapeutic interventions.