A novel member of human RNA coronavirus, which is an enveloped betacoronavirus, has been termed severe acute respiratory syndrome coronavirus-2 (SARS COV-2). The illness caused by SARS COV-2 is ...referred to as the coronavirus disease 2019 (COVID-19). It is a highly contagious disease that has resulted in a global pandemic. The clinical spectrum of COVID-19 ranges from asymptomatic illness to acute respiratory distress syndrome, septic shock, multi-organ dysfunction, and death. The most common symptoms include fever, fatigue, dry cough, dyspnea, and diarrhea. Neurological manifestations have also been reported. However, the data on the association of Guillain-Barré syndrome (GBS) with COVID-19 are scarce. We report a rare case of a COVID-19-positive 36-year-old immunocompromised male who presented with clinical features of GBS. His clinical examination showed generalized weakness and hyporeflexia. The cerebrospinal fluid (CSF) analysis showed albuminocytological dissociation. Intravenous immunoglobulin (IVIG) was administered based on the high clinical suspicion of GBS. The patient’s neurological condition worsened with progression to bulbar weakness and ultimately neuromuscular respiratory failure requiring mechanical ventilation. His nerve conduction studies were consistent with demyelinating polyneuropathy. He received five plasma exchange treatments and was successfully weaned from mechanical ventilation. A brain and cervical spine magnetic resonance imaging was obtained to rule out other causes, which was normal. COVID-19 is believed to cause a dysregulated immune system, which likely plays an important role in the neuropathogenesis of GBS.
Pulmonary tumor embolism (PTE) and pulmonary tumor thrombotic microangiopathy (PTTM) are rare etiologies for rapidly progressive dyspnea in the setting of undiagnosed metastatic cancer. They occur ...most frequently in association with adenocarcinomas, with PTE being most frequently associated with hepatocellular carcinoma and PTTM being most commonly reported with gastric adenocarcinoma. Pulmonary tumor embolism and PTTM appear to be a disease spectrum where PTTM represents an advanced form of PTE. Pulmonary tumor embolism and PTTM are mostly identified postmortem during autopsy as the antemortem diagnosis remains a clinical challenge due to the rapidly progressive nature of these rare diseases. We report 2 cases of rapidly progressive respiratory failure leading to death, due to tumoral pulmonary hypertension resulting from PTE and PTTM, diagnosed postmortem. Both of the patients were middle-aged females, nonsmokers, and had a gastrointestinal source of their primary malignancy.
Coronavirus disease 2019 (COVID-19) caused by a novel human coronavirus has led to a tsunami of viral illness across the globe, originating from Wuhan, China. Although the value and effectiveness of ...extracorporeal membrane oxygenation (ECMO) in severe respiratory illness from COVID-19 remains unclear at this time, there is emerging evidence suggesting that it could be utilized as an ultimate treatment in appropriately selected patients not responding to conventional care. We present a case of a 32-year-old COVID-19 positive male with a history of diabetes mellitus who was intubated for severe acute respiratory distress syndrome (ARDS). The patient’s hypoxemia failed to improve despite positive pressure ventilation, prone positioning, and use of neuromuscular blockade for ventilator asynchrony. He was evaluated by a multidisciplinary team for considering ECMO for refractory ARDS. He was initiated on venovenous ECMO via dual-site cannulation performed at the bedside. Although his ECMO course was complicated by bleeding, he showed a remarkable improvement in his lung function. ECMO was successfully decannulated after 17 days of initiation. The patient was discharged home after 47 days of hospitalization without any supplemental oxygen and was able to undergo active physical rehabilitation. A multidisciplinary approach is imperative in the initiation and management of ECMO in COVID-19 patients with severe ARDS. While ECMO is labor-intensive, using it in the right phenotype and in specialized centers may lead to positive results. Patients who are young, with fewer comorbidities and single organ dysfunction portray a better prognosis for patients in which ECMO is utilized.
Hepatitis C virus (HCV)-induced cirrhosis is a major cause of hepatocellular carcinoma (HCC) worldwide. HCC is an aggressive malignancy in which tumor thrombus can invade portal vein, hepatic veins ...and inferior vena cava (IVC) in the later stages. Our case brings to attention, HCV patient population who might need long-term follow-up to ensure HCV clearance. Physicians should ensure appropriate follow-up after treatment of HCV and should emphasize on the ongoing screening for HCC in patients with cirrhosis or advanced fibrosis, regardless of antiviral treatment outcome.
Airway obstruction from an enlarged pulmonary artery (PA) is not a common occurrence. We present a rare case of respiratory failure secondary to right bronchus obstruction from a dilated right PA. A ...54-year-old male with a known history of pulmonary hypertension (PH) and obstructive sleep apnea (OSA) presented with worsening dyspnea. He was found to have collapse of his right middle and lower lobes. Intubation was required for respiratory failure. To our knowledge, this is the first case to be reported in the literature where PH caused PA dilatation to such a degree as to cause bronchial obstruction and subsequent lobar collapse.
Transbronchial biopsy (TBB) is one of the commonly performed procedures by pulmonologists in everyday practice. Although the procedure has a very low-risk profile, complications often develop in ...certain patients. Pneumothorax is one such complication pertaining to TBB. As only a small percent of procedures get complicated by pneumothorax, handful of cases have been reported with its delayed occurrence in the past 5 decades. The purpose of our report is to highlight another uncommon yet interesting case of delayed iatrogenic pneumothorax in an immunocompromised patient after TBB. Although the chain of events behind the pathophysiology of delayed pneumothorax largely remain a mystery, its development has been linked to altered immune mechanics as they are frequently recognized in immunocompromised patients.
Hypothyroidism is characterized by decreased hormone production, which results in various clinical manifestations in different organ systems. Muscular symptoms are common in patents with clinical ...hypothyroidism which includes muscle cramps, myalgia, and mild to moderate elevation of creatinine kinase less than five times the upper limit of normal. However, rhabdomyolysis due to hypothyroidism is rare and in most of the reported cases a precipitating factor has been found. We report a unique case of a 35-year-old male with no past medical history who presented with rhabdomyolysis due to newly diagnosed hypothyroidism without any precipitating factors and was treated successfully with intravenous fluids and levothyroxine.
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FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UL, UM, UPUK
Introduction Gastrointestinal bleeding (GIB) complicating septic shock (SS) presents a therapeutic challenge in intensive care units. Large-scale data regarding utilization, length of stay, and cost ...outcomes of this association are lacking. Methods We queried the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample from 2003 to 2012, and identified all adult patients aged ≥18 years hospitalized for SS by the International Classification of Diseases, Ninth Revision (ICD-9) diagnostic code for SS and GIB. We compared the baseline characteristics and outcomes among patients with SS plus GIB to patients with SS without GIB. Results The weighted sample size from 2003 to 2012 was 119,684 admissions for SS. Among them, 6,571 (5.4%) patients were found to have a GIB. The mean age of the SS population with and without GIB was (mean/standard error of mean) 70.85 (0.43) vs. 67.43 (0.13) P < 0.001, respectively. The incidence of GIB over the course of 10 years has remained stable; however, the mortality associated with GIB among SS patients is found to be declining especially from 2008 (59.2%) to 2012 (45.1%) (P < 0.01). Patients with SS and GIB compared to patients with SS and no GIB were found to have a longer length of stay 20.56 (0.61) vs. 15.76 (0.13) P < 0.001, higher mortality 54% vs. 45% P < 0.001, and higher admission costs in United States dollar ($) (mean/SEM) $192,524.89 (7,378.20) vs. $142,688.55 (1,336.65) P < 0.001. Univariate analysis demonstrated that comorbid conditions like peptic ulcer disease and cirrhosis had significant odds ratios {1.56 and 1.709, P = 0.016 and 0.046 respectively} for the occurrence of GIB with SS. Gastroesophageal reflux disease was found to be associated with a lower incidence of GIB odds ratio: 0.57, P = 0.0008. The cause of sepsis (pneumonia, urinary tract infection, or abdominal infections) was not a significant distinguishing factor for the incidence of GIB in SS. Conclusion GIB continues to affect the patients with SS admitted in intensive care units in the United States. We found an incidence of 5.4% of GIB in patients with SS, and it was associated with worse outcomes.
Fusobacterium necrophorum plays a causal role in a rare and life-threatening condition, Lemierre's syndrome. It is characterized by infection involving the posterior compartment of the lateral ...pharyngeal space complicated by septic suppurative thrombophlebitis of the internal jugular vein with F. necrophorum bacteremia and metastatic abscesses, primarily to the lung and pulmonary septic emboli. Herein, we present a very rare case of oropharyngeal infection complicated by Lemierre's syndrome with characteristic septic emboli to the lungs presenting as sore throat in a previously healthy patient. A 23-year-old woman presented with sore throat and was found to be in sepsis and acute kidney injury. She was found to have septic emboli in lung and Streptococcus anginosus and F. necrophorum in blood. She was diagnosed with Lemierre's syndrome and successfully treated with antibiotics. Lemierre's syndrome should be included in the differential diagnosis in young patients who deteriorate in the setting of a sore throat. If the suspicion is high, throat swabs from young patients with nonstreptococcal group A tonsillitis should be cultured anaerobically on selective medium to detect the presence of F. necrophorum. While clinicians of the infectious disease team may be familiar with this condition other departments including internal medicine and critical care team may less so. Unless clinicians are aware of this syndrome, diagnosis and treatment can be delayed leading to higher morbidity and mortality.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Achromobacter xylosoxidans, a gram-negative bacillus with low virulence has rarely been reported to cause clinically significant infections. We report an unusual case of MDR Achromobacter ...xylosoxidans/denitrificans bacteremia from a peripherally inserted central catheter (PICC) and subsequent fatal pleural empyema due to MDR Escherichia coli and Streptococcus anginosus. A 44-year-old male presented to the hospital with chief complaints of chest tightness associated with a productive cough. He was found to have pleural empyema secondary to MDR E. coli and S. anginous. Three months prior to current presentation, he had a history of MDR A. xylosoxidans originating from a PICC. The patient expired even after appropriate management. Thoracic empyema continues to cause significant morbidity and mortality despite the improvement of antimicrobial therapy and the existence of multiple options for drainage of the infected pleural space. The bacteriology of thoracic empyema has been changing since the introduction of antibiotics. Typical antibiotics used to treat these MDR pathogens have become obsolete. Therefore, physicians should be aggressive in their diagnostic approach to pleural empyema, since the isolation of MDR aerobic gram-negative bacilli or multiple pathogens from the pleural fluid is associated with a poor prognosis and indicates a need for more aggressive antimicrobial chemotherapy. Also, the association of indwelling medical devices and MDR Achromobacter bacteremia should be known.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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