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    15 March 2015, Volume 6 Issue 1
    Review Article
    The role of regulatory T cells in immune dysfunction during sepsis
    Chao Cao, Tao Ma, Yan-fen Chai, Song-tao Shou
    2015, 6(1):  5-9.  doi:10.5847/wjem.j.1920-8642.2015.01.001
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    BACKGROUND: Although regulatory T cells (Tregs) are key to the maintenance of immunologic homeostasis and tolerance, little is known about Treg-mediated immunosuppression in the stage of sepsis. This article aimed to review the current literature on the role of Tregs in the pathophysiology of septic response, attempting to investigate the role of Tregs in immune dysfunction during sepsis.
    DATA SOURCES: A literature search was conducted in January 2014 using the China National Knowledge Infrastructure and PubMed. Articles on the role of Tregs in immune dysfunction during sepsis were identified.
    RESULTS: The identified articles indicated that Treg levels can be used for the assessment of the course of sepsis. The inhibition of Treg activity can promote the recovery of immune function.
    CONCLUSION: Since the mechanism of Tregs is complex during the sepsis, more studies are needed.

    Original Articles
    Ultrasound diagnosis of malaria: examination of the spleen, liver, and optic nerve sheath diameter
    Yuanting Zha, Michelle Zhou, Anjali Hari, Bradley Jacobsen, Neha Mitragotri, Bianca Rivas, Olga Gabriela Ventura, Janice Boughton, John Christian Fox
    2015, 6(1):  10-15.  doi:10.5847/wjem.j.1920-8642.2015.01.002
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    BACKGROUND: Over 90% of all cases of malaria worldwide occur in Africa. Current methods of diagnosis are time and labor intensive, and could lead to delayed treatment.
    METHODS: In this study we investigated the effectiveness of measurements of spleen, liver, and optic nerve sheath diameter (ONSD) in identifying patients with malaria or severe malaria through the use of hand-held ultrasound devices. We recruited 40 adult patients with malaria and 16 adult control subjects at two hospitals in Mwanza, Tanzania. Ultrasonographic diagnosis was compared with rapid antigen diagnostic test and peripheral blood smear as the gold standards. An receiver operating characteristic curve test was performed to determine the most optimal diagnostic threshold for malaria and severe malaria, using each of the measurements for liver size, spleen size, and ONSD. The thresholds were determined to be >12 cm for spleen length and >15.1 cm for liver length, whereas ONSD was not significant in this study.
    RESULTS: The sensitivities for malaria diagnosis were 66.7% and 58.3% for liver and spleen length respectively, suggesting that these measurements may not be suitable for identifying patients with severe malaria. However, the high specificity of 90.9% for spleen length and the acceptable specificity of 75.0% for liver length suggest that these measurements can be used as a method to eliminate false-positive diagnoses (i.e. patients who do not have severe malaria but are classified as having it by a test with a high sensitivity), giving a high positive predictive value.
    CONCLUSIONS: We report a high specificity for spleen size and a moderate specificity for liver size in the ultrasonographic diagnosis of severe malaria. Thus when paired with a highly sensitive method of malaria diagnosis, ultrasonographic measurement of spleen and liver size is promising as part of a diagnostic algorithm for malaria. It could be used to stratify risk in patients diagnosed with malaria and assist in their triage. If no sensitive tests are available, ultrasound might be useful to suggest malaria as a cause of a patient's constellation of clinical symptoms.

    Evaluation of a simulation-based workshop on clinical performance for emergency physicians and nurses
    Chi Ho Chan, Tung Ning Chan, Man Cheuk Yuen, Wai Kit Tung
    2015, 6(1):  16-22.  doi:10.5847/wjem.j.1920-8642.2015.01.003
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    BACKGROUND: Simulation-based medical education has been growing rapidly and becomes one of the most popular teaching methods for improving patient safety and patient care. The Simulation Subcommittee of the Hong Kong College of Emergency Medicine organized an educational program emphasizing the team training, clinical decision-making and communication skills. This study aimed to evaluate the attitude of the participants toward a new training program and the change in the knowledge on clinical performance in emergency physicians and nurses after attending the educational program.
    METHODS: A course evaluation form was filled in by the participants at the end of the workshop. An assessment of 20 multiple-choice questions with 5 options was administered to the participants before and after the 2-day simulation-based training workshop.
    RESULTS: A total of 72 doctors and nurses working in the Accident and Emergency Department were enrolled. The average pretest and posttest scores were 12 and 14.3 respectively. The percentage improvement in the mean score of the pretest and posttest was 11.5%. The Chi-square test showed significant improvement in the pretest and posttest score grading (P=0.00). Paired t-test revealed significant difference between the mean scores of the pretest and posttest (P=0.00).
    CONCLUSIONS: Participants had positive attitude toward this new training program. Significant improvement of the knowledge on clinical performance in healthcare professionals in the Accident and Emergency Department was observed after the participation in this simulation-based educational program.

    Embryonic natural orifice transluminal endoscopic surgery in the treatment of severe acute pancreatitis complicated by abdominal compartment syndrome
    Hui-ming Zhu, Shao-qing Guo, Xiu-min Liao, Li Zhang, Li Cai
    2015, 6(1):  23-28.  doi:10.5847/wjem.j.1920-8642.2015.01.004
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    BACKGROUND: The study aimed to estimate the value of embryonal natural orifice transluminal endoscopic surgery (ENOTES) in treating severe acute pancreatitis (SAP) complicated with abdominal compartment syndrome (ACS).
    METHODS: The patients, who were randomized into an ENOTES group and an operative group, underwent ENOTES and laparotomy, respectively. The results and complications of the two groups were compared.
    RESULTS: Enterocinesia was observed earlier in the ENOTES group than in the operative group. Acute Physiology and Chronic Health Evaluation II (APACHE II) score of patients in the ENOTES group was lower than that of the operative group on the 1st, 3rd and 5th post-operative day (P<0.05). The cure rate was 96.87% in the ENOTES group, which was statistically different from 78.12% in the operative group (P<0.05). There were significant differences in complications and mortality between the two groups (P<0.01).
    CONCLUSION: Compared with surgical decompression, ENOTES associated with flexible endoscope therapy is an effective and minimal invasive procedure with less complications.

    Effect of harmless acute pancreatitis score, red cell distribution width and neutrophil/lymphocyte ratio on the mortality of patients with nontraumatic acute pancreatitis at the emergency department
    Bedia Gülen, Ertan Sonmez, Serpil Yaylaci, Mustafa Serinken, Cenker Eken, Ali Dur, Figen Tunali Turkdogan, Özgür Söğüt
    2015, 6(1):  29-33.  doi:10.5847/wjem.j.1920-8642.2015.01.005
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    BACKGROUND: Harmless acute pancreatitis score (HAPS), neutrophile/lymphocyte ratio and red blood cell distribution width (RDW) are used to determine the early prognosis of patients diagnosed with nontraumatic acute pancreatitis in the emergency department (ED).
    METHODS: Patients diagnosed with acute pancreatitis (K 85.9) in the ED according to the ICD10 coding during one year were included in the study. Patients with chronic pancreatitis and those who had missing data in their files were excluded from the study. Patients who did not have computed tomography (CT) in the ED were not included in the study.
    RESULTS: Ultimately, 322 patients were included in the study. The median age of the patients was 53.1 (IQR=36-64). Of the patients, 68.1% (n=226) had etiological causes of the biliary tract. The mortality rate of these patients within the first 48 hours was 4.3% (n=14). In the logistic regression analysis performed by using Balthazar classification, HAPS score, RDW, neutrophile/lymphocyte ratio, age, diabetes mellitus and systolic blood pressure, the only independent variable in determining mortality was assigned as Balthazar classification (OR: 15; 95% CI: 3.5 to 64.4).
    CONCLUSIONS: HAPS, neutrophile/lymphocyte ratio and RDW were not effective in determining the mortality of nontraumatic acute pancreatitis cases within the first 48 hours. The only independent variable for determining the mortality was Balthazar classification.

    Effect of low-dose glucocorticoid on corticosteroid insufficient patients with acute exacerbation of chronic obstructive pulmonary disease
    Wei-ping Sun, Guang-xiong Yuan, Yan-juan Hu, Li-zhen Liao, Lin Fu
    2015, 6(1):  34-39.  doi:10.5847/wjem.j.1920-8642.2015.01.006
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    BACKGROUND: This study aimed to investigate the prevalence rate of critical illness-related corticosteroid insufficiency (CIRCI) and the effect of low-dose glucocorticoid on prognosis of CIRCI in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD).
    METHODS: Since January 2010 to December 2012, 385 patients, who met the criteria of AECOPD, were enrolled in the Intensive Care Unit (ICU) of the First People's Hospital and Municipal Central Hospital of Xiangtan City. The AECOPD patients complicated with CIRCI screened by an adrenalcorticotrophic hormone test within 12 hours after admission to ICU were divided into a treatment group (n=32) and a control group (n=31) for a prospective, randomized and controlled clinical trial. Hydrocortisone (150 mg/d) or normal saline was injected intravenously for 7 days. The patients were followed up for 28 days after injection. The endpoint included 28-day survival time, non-shock time, ICU stay and the period of non-mechanical ventilation. The markers of inflammation C-reactive protein, tumor necrosis factor-α, interleukin 6 and procalcitonin were measured at baseline and 7 days after treatment. The variables were analyzed by Student's t test, the non-parametric statistical test, the Chi-square test or the Kaplan-Meier method with SPSS18.0 statistic software. A P value <0.05 was considered statistically significant.
    RESULTS: Totally 63 patients were diagnosed with CIRCI by an adrenalcorticotrophic hormone test and the prevalence rate was 16.4%. The shock rate of the AECOPD patients complicated with CIRCI was higher than that of the AECOPD patients without CIRCI (23.8% vs. 8.7%, P<0.01). Kaplan-Meier analysis revealed that the 28-day survival time of the treatment group was obviously longer than that of the control group (P<0.05). Compared with the control group, shock-free days within 28 days was longer in the treatment group (18.2±9.5 vs. 25.8±4.1, P<0.05). Treatment with low-dose glucocorticoid obviously decreased the markers of infection and inflammation (P<0.01), such as C-reactive protein (13.2±5.5 mg/L vs. 8.3±3.1 mg/L for the control group; 13.5±5.9 mg/L vs. 5.1±2.3 mg/L for the treatment group), tumor necrosis factor-α (26.1±16.2 μg/L vs. 17.5±11.7 μg/L for the control group; 25.0±14.8 μg/L vs. 10.4±7.8 μg/L for the treatment group) and procalcitonin (3.88 μg/L vs. 2.03 μg/L for the control group; 3.77 μg/L vs. 1.26 μg/L for the treatment group). Furthermore, the markers in the treatment group decreased more obviously than those in the control group (P<0.01).
    CONCLUSION: The prevalence rate of CIRCI was higher in the patients with AECOPD in the department of critical medicine, and low-dose glucocorticoid treatment for one week reduced the 28-day mortality, shock time and markers of infection and inflammation.

    Prognostic value of CD4+CD25+ Tregs as a valuable biomarker for patients with sepsis in ICU
    Kun Chen, Qiu-xiang Zhou, Hong-wei Shan, Wen-fang Li, Zhao-fen Lin
    2015, 6(1):  40-43.  doi:10.5847/wjem.j.1920-8642.2015.01.007
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    BACKGROUND: Sepsis is a common complication of infections, burns, traumas, surgeries, poisonings, and post-cardiopulmonary resuscitation. The present study aimed to investigate prognostic value of CD4+CD25+ regulatory T cells (Treg) in peripheral blood of patients with sepsis.
    METHODS: Periphery blood from 28 patients diagnosed with sepsis was collected on day 1 and 7 after hospitalization in the ICU of Shanghai Changzheng Hospital between December 2013 to April 2014. The blood was used for analyses of Treg ratio using flow cytometry and for analyses of blood routine test, C-reactive protein (CRP), bilirubin, procalcitonin (PCT), and coagulation. APACHE II and sequential organ failure assessment (SOFA) scores were also investigated. The results were compared between two outcome groups of survival or death to evaluate prognostic value for sepsis.
    RESULTS: The patients had an average age of 60.36±15.03 years, APACHE II score 16.68±7.00, and SOFA score 7.18±3.78. Among the 28 patients, 12 had severe trauma (42.9%), 10 had septic shock (35.7%), and 9 (32.2%) died. The median ratio of Tregs was 2.10% (0.80%, 3.10%) in the survival group vs. 1.80% (1.15%, 3.65%) in the death group (Z=-0.148,P=0.883) on day 1; however it was significantly changed to 0.90% (0.30%, 2.80%) vs. 5.70% (2.60%, 8.30%) (Z=-2.905, P=0.004).
    CONCLUSION: With better prospects for clinical application, dynamic monitoring of Tregs ratio in peripheral blood has potential value in predicting prognosis of sepsis.

    The risk of wound infection after simple hand laceration
    Gholamreza S Roodsari, Farhad Zahedi, Shahriar Zehtabchi
    2015, 6(1):  44-47.  doi:10.5847/wjem.j.1920-8642.2015.01.008
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    BACKGROUND: This prospective observational study aimed to determine the infection rate of simple hand laceration (SHL), and to compare infection rates between patients who were prescribed antibiotics and those who were not.
    METHODS: The study was performed at two urban hospitals enrolling 125 emergency department (ED) patients with SHL. Exclusion criteria included patients with lacerations for more than 12 hours, immunocompromized patients, patients given antibiotics, and patients with gross contamination, bites or crush injuries. Wound infection was defined as clinical infection at a follow-up visit (10-14 days) or wound was treated with antibiotics. Patient satisfaction was also measured using a visual analogue scale 1-10, asking the patients about wound appearance. Demographic data and wound characteristics were compared between the infected and non-infected wounds. The infection rates were also compared between patients who received prophylactic antibiotics and those who did not. The results were presented with medians and quartiles or percentages with 95% confidence intervals (CI).
    RESULTS: In the 125 patients with SHL [median age: 28 (18, 43); range: 1-102 years old; 36% female], 44 (35%, 95% CI: 27%-44%) were given antibiotics in the ED. Wound infection was reported in 6 patients (4.8%, 95%CI: 2%-10%). Age, gender, history of diabetes and wound closure were not associated with wound infection (P>0.05). The infection rate was not significantly different between patients with or without antibiotic prophylaxis [7% (3/44), 95% CI: 2%-10% vs. 4% (3/81), 95% CI: 1%-11%, P=0.66]. Patient's satisfaction with appearance of infected and non-infected wounds were significantly different [7.5 (6, 8) vs. 9 (8, 10), P=0.01].
    CONCLUSION: Approximately 5% of simple hand lacerations become infected. Age, gender, diabetes, prophylactic antibiotics and closure technique do not affect the risk of infection.

    Trauma patterns in patients attending the Emergency Department of Jazan General Hospital, Saudi Arabia
    Emad Hokkam, Abdelaziz Gonna, Ossama Zakaria, Amany El-shemally
    2015, 6(1):  48-53.  doi:10.5847/wjem.j.1920-8642.2015.01.009
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    BACKGROUND: Modern civilization and the sharp rise in living standards have led to dramatic changes in trauma pattern in Saudi Arabia. This study aimed to describe the different patterns of injuries of patients attending the Emergency Department of Jazan General Hospital (JGH) in the southwest corner of Saudi Arabia.
    METHODS: A total number of 1 050 patients were enrolled in the study. A pre-organized data sheet was prepared for each patient attended the Emergency Department of JGH from February 2012 to January 2013. It contains data about socio-demographics, trauma data, clinical evaluation results, investigations as well as treatment strategies.
    RESULTS: The mean age of the patients was 25.3±16.8 years. Most (45.1%) of the patients were at age of 18-30 years. Males (64.3%) were affected by trauma more common than females. More than half (60.6%) of the patients were from urban areas. The commonest kind of injury was minor injury (60%), followed by blunt trauma (30.9%) and then penetrating trauma (9.1%). The mean time from the incident to arrival at hospital was 41.3±79.8 minutes. The majority (48.2%) of the patients were discharged after management of trivial trauma, whereas 2.3% were admitted to ICU, 7.7% transferred to inpatient wards, and 17.7% observed and subsequently discharged. The mortality rate of the patients was 2.6%.
    CONCLUSION: Trauma is a major health problem, especially in the young population in Saudi Arabia. Blunt trauma is more frequent than penetrating trauma, with road traffic accidents accounting for the majority.

    Acute intoxication cases admitted to the emergency department of a university hospital
    Ertugrul Kaya, Aylin Yilmaz, Ayhan Saritas, Serdar Colakoglu, Davut Baltaci, Hayati Kandis, Ismail Hamdi Kara
    2015, 6(1):  54-59.  doi:10.5847/wjem.j.1920-8642.2015.01.010
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    BACKGROUND: This study aimed to describe the clinical and socio-demographic aspects of acute poisoning in 2010 in Duzce City, Northwest Anatolian Region of Turkey.
    METHODS: Acute poisoning was due to the intentional ingestion of drugs in young and adult people (≥16), who were treated at the Emergency Service of Duzce University Medical Hospital, Turkey from January 1, 2010 to December 31, 2010. In this retrospective and descriptive study, 95 patients were diagnosed with intoxications and 30 of them intentionally ingested drugs to commit suicide. Records of the patients diagnosed with intoxication were obtained from the Clinical Archive of the hospital. Their diagnoses were established according to the International Statistical Classification of Diseases and Related Health Problems. Codes X60-X84 of this classification were used to classify self-infringed drug injuries and drug poisoning.
    RESULTS: In this series, 35 (36.8%) patients were male and 60 patients (63.2%) female. The male/female ratio was 1.0/1.7. The mean age of the patients was 33.1±14.2 years; 17 (17.9%) patients were below 20 years old and 9 (9.5%) were older than 50 years. Of these patients, 29 (30.5%) were single, 7 (7.4%) divorced or separated, and 59 (62.1%) married. Their mean time for admission to the emergency service after the incident was 208±180 (15-660) minutes. The mean time for admission to the emergency service for patients with food intoxication after the incident was 142±160 minutes, for those with drug intoxication 173±161 minutes, for those with carbon monoxide (CO) intoxication 315±209 minutes, and for those with undefined intoxication 289±166 minutes (P=0.005). Most of the intoxication cases occurred in winter (41.1%, 39 of 95 patients). Admissions to the emergency service were most common in December and April (21 and 16 of 95 patients, respectively). Sixty-five (68.4%) cases were involved in non-deliberate poisoning, whereas 30 (31.6%) were involved in deliberate poisoning. Twenty-six of the 95 patients with acute poisonings had mortality risk at admission, however only one died from CO intoxication in the emergency service (1.1%). Suicide attempts were more common in females than in males (21 of 30 patients, 70%, P<0.05).
    CONCLUSION: In Duzce City of Turkey, most intoxication cases occurred in winter, especially in December. They had non-deliberate poisoning, but deliberate poisoning in suicide attempts was more common in females than in males.

    Relationship between intubation rate and continuous positive airway pressure therapy in the prehospital setting
    Nigel Knox, Ogedegbe Chinwe, Nyirenda Themba, Feldman Joseph, Ashtyani Hormoz
    2015, 6(1):  60-66.  doi:10.5847/wjem.j.1920-8642.2015.01.011
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    BACKGROUND: To determine whether the prehospital use of continuous positive airway pressure (CPAP) therapy is associated with a reduced rate of endotracheal intubation in patients with an acute respiratory disorder brought to the emergency department (ED).
    METHODS: We reviewed medical records of patients with acute respiratory distress who had been treated with CPAP in the Mobile Intensive Care Unit (MICU) from January 2010 to December 2011. These records were compared with those of patients who received standardized care without CPAP in the MICU from January 2004 to December 2004. Categorical variables were summarized as frequencies and compared between groups using Fisher's exact test or the Chi-square test. Continuous variables were summarized as medians (interquartile range), and comparison between the groups was made using Wilcoxon's rank-sum test. The relationship between CPAP and intubation rate was determined using multivariable logistic regression analysis of propensity scores. The results were presented as odds ratio (OR), 95% confidence interval (CI), and P value for test effect. The adequacy of the model was calibrated using Hosmer and Lemeshow's goodness-of-fit test. P<0.05 was considered statistically significant.
    RESULTS: The records of 785 patients were reviewed. Of the 215 patients treated with CPAP in the MICU, 13% were intubated after admission. In contrast, of the 570 patients who did not receive CPAP, 28% were intubated after ED admission. Unadjusted logistic regression analysis showed that patients who had been treated with CPAP were less likely to be intubated than those without CPAP treatment (OR=0.37, 95%CI, 0.24-0.57, P<0.0001). With propensity scores adjusted, multivariate logistic regression analysis showed that CPAP treatment was associated with a 62% reduction of intubation (OR=0.384, 95%CI, 0.25-0.60, P≤0.0001).
    CONCLUSIONS: In patients with acute respiratory disorder, there was a relationship between CPAP therapy and the decreased intubation rate. CPAP therapy was feasible in prehospital management of patients with respiratory distress.

    Regulatory effects of hydrogen sulfide on alveolar epithelial cell endoplasmic reticulum stress in rats with acute lung injury
    Zhi-wei Liu, Hai-ying Wang, Lan Guan, Bin Zhao
    2015, 6(1):  67-73.  doi:10.5847/wjem.j.1920-8642.2015.01.012
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    BACKGROUND: The present study was undertaken to examine the regulatory effect of hydrogen sulfide (H2S) on endoplasmic reticulum stress in alveolar epithelial cells of rats with acute lung injury (ALI) induced by oleic acid (OA).
    METHODS: Seventy-two male Sprague Dawley (SD) rats were divided into control group, oleic acid-induced ALI group (OA group), oleic acid-induced ALI with sodium hydrosulfide (NaHS) pretreatment group (OA+NaHS group), and sodium hydrosulfide treatment group (NaHS group). Rats of each group were further subdivided into 3 subgroups. Index of quantitative assessment of histological lung injury (IQA), wet/dry weight ratio (W/D) and H2S level of lung tissues were measured. The expressions of endoplasmic reticulum stress markers including glucose-regulated protein 78 (GRP78) and α-subunit of eukaryotic translation initiation factor-2 (elF2α) in lung tissues were measured by immunohistochemical staining and Western blotting.
    RESULTS: The IQA score and W/D ratio of lung tissues at the three time points significantly increased in rats injected with OA, but significantly decreased in other rats injected with OA and NaHS. The level of H2S in lung tissue at the three time points significantly decreased in rats injected with OA, but significantly increased in other rats injected with both OA and NaHS. GRP78 and elF2α decreased in rats injected with OA, but increased in other rats injected with both OA and NaHS, especially at 4-hour and 6-hour time points.
    CONCLUSION: The results suggested that H2S could promote alveolar epithelial cell endoplasmic reticulum stress in rats with ALI.

    Case Report
    Lingual angioedema after alteplase treatment in a patient with acute ischemic stroke
    Seyran Bozkurt, Engin Deniz Arslan, Ataman Köse, Cüneyt Ayrık, Arda Yılmaz, Güllü Akbaydoğan Dündar
    2015, 6(1):  74-76.  doi:10.5847/wjem.j.1920-8642.2015.01.013
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    BACKGROUND: In recent years, thrombolytic therapy has become the main treatment of ischemic stroke. But the increasing use of alteplase in ischemic stroke has made some complications more evident. Angioedema is a rare but potentially life-threatening complication of alteplase treatment. Only a few studies have examined the incidence of angioedema after treatment with alteplase for stroke.
    METHODS: A 75-year-old man complaining of right hemiparesis was admitted to our emergency department. He was diagnosed as having acute ischemic stroke, and alteplase infusion was given two hours after the onset of stroke symptoms. Immediately after the completion of infusion he was noted to have a large swollen tongue.
    RESULTS: His neurological symptoms resolved gradually within 4 hours, whereas his upper extremity strength improved to 4/5 and lower extremity 5/5. Lingual edema resolved within 16 hours without any complication. He died from presumed nosocomial infection 5 days later.
    CONCLUSIONS: Lingual angioedema may appear as a possible complication in patients who were treated with alteplase. The management of these patients should be very careful.