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Bleeding : case report A 72-year-old man developed bleeding following anticoagulation therapy with heparin and apixaban [not all routes, dosages and durations of treatment to reaction onset stated]. The man had a significant history of myasthenia gravis, type 2 diabetes, atrial fibrillation and pulmonary embolism. He had been experiencing diffuse muscle weakness, worsening dysarthria and altered mental status for 2 days. Three months before, after having dysphagia and progressive weakness, he became bedbound with the requirement of percutaneous endoscopic gastrostomy (PEG). He was prescribed a daily dose of prednisone and pyridostigmine for management of his symptoms. Following the presentation, he was admitted to ICU for acute respiratory failure and septic shock secondary to the myasthenic crisis, proteus UTI, pseudomonas pneumonia and acute renal failure. He had been receiving anticoagulant therapy with apixaban. On arrival, he was immediately intubated, followed by administration of broad-spectrum antibiotics, immune-globulin [IVIG] and IV heparin in substitution of apixaban. After the development of the abdominal pain, nasogastric (NG) tube was placed. His haemoglobin decreased after NG tube placement; therefore, it required multiple transfusions. Significant amount of blood was suctioned from the NG tube. Treatment with anticoagulant was discontinued for some time. On hospital day 3, living maggots were observed in the contents suctioned through the NG tube and same were seen inside the nostrils. On performing nasal endoscopy, the maggots were seen to be feeding on the large blood clot formed that was supposed to be formed following insertion of NG tube. The man received lidocaine and oxymetazoline during nasal endoscopy. The extraction of maggots and the blood clots was carried out successfully. Lidocaine was also applied additionally to the nasal airway. Repeat endoscopy revealed resolution of nasal myiasis and complete extraction of the blood clot. No recurrence was observed during his hospitalisation. He received further treatment with plasmapheresis and immune-globulin for myasthenia gravis. However, the extubation was not successful because of the profound weakness of respiratory muscles and extended duration of intubation, due to which he underwent tracheostomy. Finally, he was discharged and was put on a long-term acute care facility for recovery. Katabi A, et al. Nasal myiasis in myasthenic crisis, a case report and literature review. Respiratory Medicine Case Reports 31: 101212, Jan 2020. Available from: URL: http:// 803504782 doi.org/10.1016/j.rmcr.2020.101212

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Reactions 3 Oct 2020 No. 1824