Case report of parapneumonic effusion and mesothelial subdiaphragmatic cyst: relationship or coincidence?

Parapneumonic pleural effusions are common in patients with pneumonia. When colonized by pathogenic bacteria or other microorganisms, these effusions can progress to empyema. Additionally, empyema formation may result in extension of the infection into the infradiaphragmatic region, further complicating the clinical scenario. Many subphrenic collections are found to be mesothelial cysts, which are congenital in origin. However, data regarding the potential association between mesothelial diaphragmatic cysts and parapneumonic effusions are limited. We herein describe a toddler with pneumonia complicated by parapneumonic effusion and a lung abscess with a subphrenic collection. After abscess drainage and a full course of antibiotics, imaging revealed clear lung parenchyma with an interval resolution of the effusion and a persistent unchanged subphrenic collection that was confirmed to be mesothelial diaphragmatic cyst. This case highlights the fact that not every subphrenic collection associated with parapneumonic effusion is a communicated collection formed by seeding. Such a collection can instead be an incidental cyst, which is congenital in origin and known as a mesothelial diaphragmatic cyst. A diaphragmatic mesothelial cyst is an uncommon benign congenital cyst that is unrelated to an adjacent parapneumonic effusion. It is usually incidental and can be monitored without invasive intervention.

Cholera Infection Risks and Cholera Vaccine Safety in Pregnancy.

Introduction: Discuss the impact of cholera infection on pregnant women, fetus, and neonates and review the safety of cholera vaccines in pregnancy. Methods: This study was carried out as a narrative review during November 2022. A thorough literature review was conducted on the following databases: PubMed, Scopus, SciELO, CINAHL, Web of Science, and ScienceDirect. The following parameters were assessed from the included studies: type of cholera vaccine, cholera symptoms, cholera treatment, effect of cholera on pregnancy, effect of cholera treatment on pregnancy, effect of cholera vaccine on pregnancy, risk factors for fetuses and neonates, and prevention of cholera. The authors independently extracted data from the 24 included studies. Results: Cholera infection is a serious threat on pregnancy as it could lead to increased stillbirths and neonatal death. Fetal death was shown to occur mainly in the third trimester as most of the pregnant women infected with cholera had spontaneous abortions even after controlling for other confounding variables such as maternal age, dehydration level, and vomiting. Neonatal death was attributed mainly to congenital malformations and low Apgar scores with no improvements. Besides, cholera vaccines have shown to be safe in pregnancy and have proven to lower fetal and neonatal malformations among vaccinated compared to nonvaccinated pregnant women. Conclusion: This narrative summarizes the different complications due to cholera infection in pregnancy. It also reviews the safety of cholera vaccine administration in pregnant women.

A review of monkeypox infection during pregnancy.

The present study aimed to review monkeypox infection during pregnancy: its epidemiology and etiology, transmission, clinical manifestations and complications, diagnosis, management, antenatal testing and delivery, prevention, awareness, and recommendations. Monkeypox can spread via vertical transmission. The usual clinical symptoms include fever, rash (vesicles, crust), new genital lesions, or sore throat. It is only recommended to use cidofovir in pregnant patients when they are severely infected with monkeypox. All woman who are at high risk of exposure for monkeypox need to be vaccinated with the smallpox vaccine regardless of their pregnancy status. Monitoring includes regular non-stress test monitoring in addition to ultrasound performed at various stages of pregnancy. High index of suspicion, informed physicians, reporting of cases, and support of research are all needed for the management of monkeypox infection during pregnancy.

COVID-19 associated respiratory failure complicating a pericardial effusion in a patient with sideroblastic anemia.

BACKGROUND: COVID-19 disease has been associated with several cardiovascular complications that rarely occur in the acute phase of the disease. CASE REPORT: A 13-year-old pediatric patient with congenital sideroblastic anemia associated with YARS2 mutation presenting with COVID-19 infection and worsening pericardial effusion followed by a respiratory failure refractory to supplemental oxygen therapy leading to cardiac arrest. DISCUSSION: This case highlights the rapid deterioration that can occur in children with serious hematologic disorders in the context of COVID-19 especially when complicated with pericardial effusion. CONCLUSION: The importance of pericardiocentesis early in order to allow better ventilation in any significant pericardial effusion case associated with COVID-19 infection and the need for prompt care escalation to centers where ECMO is available.

Epidemiology and Survival of Colorectal Cancer in Lebanon: A Sub-National Retrospective Analysis.

BACKGROUND: Scarce data exist about colorectal cancer (CRC) presentation and outcomes in Lebanon. The aim of this study is to describe the characteristics of Lebanese patients diagnosed with colorectal cancer, particularly the method of detection, age of onset, stage at presentation, treatment modalities, and survival. METHODS: This is a retrospective study of a cohort of patients with CRC, diagnosed between 2005 and 2010, admitted to 6 major university-affiliated medical centers in Lebanon. RESULTS: The total sample consisted of 586 patients (median age: 64 years; M:F ratio: 1.25). The most common presenting symptoms were changes in bowel habits, abdominal pain, and blood per rectum. Only 3% had been diagnosed by screening colonoscopy. Of the patients diagnosed with CRC younger than 50 years of age, 72.5% had a positive family history (P = .07). More than two-thirds of patients had an advanced stage of the disease III and IV at presentation. The Kaplan-Meier-estimated survival rate was 0%, 44.5%, 70.2%, and 78.5% for those with stage IV, III, II, and I, respectively (P = .0001), and did not vary by age nor gender of the patient. There was no differential in survival estimate for patients with stage II and III by number of chemotherapy cycles received. However, there was a significant difference in median survivorship for patients with metastatic stage IV disease; those who received less than or equal to 9 cycles had a median survivorship of 2 years (CI: 1.31-2.68) compared to 4 years (CI: 2.36-5.63) for those who received more than 9 cycles (P = .047). The cox regression showed while controlling for age and gender that patients diagnosed at stage IV had a hazard ratio of 8.81 (3.20-24.22) compared to those who were diagnosed at stage I (P = .047). CONCLUSIONS: Lebanese patients affected by colorectal cancer tend to present with advanced disease stages, leading to poor prognosis and survival.

The burden of Arcanobacterium haemolyticum pharyngitis: A systematic review and management algorithm.

INTRODUCTION: Arcanobacterium haemolyticum causes pharyngotonsillitis in children and young adults. It is rarely isolated in pharyngeal swabs as testing for it is not routine. Data on complications, management, and antibiotic susceptibility testing is limited. We sought to review the available literature on the presentation and management of A. haemolyticum pharyngotonsillitis in this age group. METHODS: A systematic review of eligible studies reporting pharyngotonsillitis and related complications in children and young adults caused by A. haemolyticum was conducted. Literature from case reports, case series, and available cohorts was compiled. Data were analyzed using descriptive statistics. RESULTS: The initial database search yielded 63 articles, after applying exclusion criteria 17 studies were included. 191 patients were identified with a median age of 16.5 years. The most common presentation was throat pain reported in 93.7% of patients. Tonsillar exudates, fever at presentation and rash were present in more than half of the reviewed cases. The diagnosis was established by a positive culture on a pharyngeal swab in 98.8% of swabs collected. Complications described included peritonsillar abscesses, Lemierre's syndrome, pneumonia, and sepsis. Penicillin was the first line antibiotic in 81% of patients followed by macrolides in 19 patients (18%). CONCLUSIONS: A. haemolyticum occurs in children and young adults and may result in complications. Our review supports its susceptibility to penicillin. We suggest a diagnostic and management algorithm to guide clinicians in targeted testing and aid with decision making regarding timely and appropriate antibiotic therapy, in an effort to reduce the burden of its complications.

Improvement in Pulmonary Function Following Discontinuation of Vaping or E-Cigarette Use in Adolescents with EVALI.

Introduction: In 2019, an alarming number of cases coined as e-cigarette, or vaping, product use-associated lung injury (EVALI) were described in adolescents ranging from mild respiratory distress to fulminant respiratory failure. Limited data have been published on outcomes at short-term follow-up. We aimed to describe pulmonary manifestations, function, and radiologic findings after corticosteroid therapy in a cohort of adolescent patients. Methods: A retrospective chart analysis of all patients presenting to our institution between July 2019 and December 2019 with EVALI was conducted. Patients who had pulmonary follow-up were included. Spirometry was performed before discharge from the hospital and during outpatient follow-up. A paired t-test was used to compare serial spirometry data between visits. Results: Eight patients (6 males) were included. Two patients required intubation with mechanical ventilation, 2 required bilevel positive airway pressure, and 3 required oxygen supplementation. All patients received glucocorticoids (3 receiving pulse dosing). Initial spirometry revealed decreased forced expiratory volume in one second and forced vital capacity with clinically and statistically significant improvement at follow-up (mean follow-up was 46.5 days). Radiographic manifestations also improved after vaping was discontinued. Conclusion: In our cohort of patients with EVALI, at short-term follow-up, all normalized their spirometry parameters and showed clinical resolution of symptoms.

Pulmonary manifestations and outcomes in paediatric ANCA-associated vasculitis: a single-centre experience.

OBJECTIVES: ANCA-associated vasculitis (AAV) usually involves the renal and respiratory systems, but the paediatric literature on pulmonary manifestations and outcomes is limited. We aimed to describe pulmonary manifestations and outcomes after therapy in a cohort of paediatric AAV (pAAV) patients. METHODS: A retrospective chart review of all patients <19 years presenting to our institution with AAV between 1/2008 and 2/2018 was conducted. Patient demographics, clinical presentation, diagnostic testing, therapy and pulmonary outcomes over the first 3 years after presentation were evaluated. RESULTS: A total of 38 patients were included; all had ANCA positivity by immunofluorescence. A total of 23 had microscopic polyangiitis (MPA), 13 had granulomatosis with polyangiitis and 2 had eosinophilic granulomatosis with polyangiitis. A total of 30 (79%) had pulmonary manifestations, with cough (73%) and pulmonary haemorrhage (67%) being the most common. Abnormalities were noted in 82% of chest CT scans reviewed, with nodules and ground-glass opacities being the most common. At 6, 12 and 36 months follow-up, respectively, 61.8%, 39.4% and 29% of patients continued to show pulmonary manifestations. Five MPA patients with re-haemorrhage are described in detail. CONCLUSION: MPA was more common than granulomatosis with polyangiitis, with pulmonary involvement being common in both. MPA patients had more severe pulmonary manifestations. Chest CT revealed abnormal findings in a majority of cases. A subgroup of young MPA patients experienced repeat pulmonary haemorrhage. Treatment modality and response were comparable in different subtypes of AAV, except for this young MPA group. Additional prospective studies are needed to better understand the different phenotypes of pAAV.

Lung biopsy in the diagnosis of pediatric ANCA-associated vasculitis.

OBJECTIVE: To investigate pulmonary histopathologic features in a cohort of pediatric patients with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) who underwent a lung biopsy as part of their evaluation. We report the safety and the findings of lung biopsies in this population. METHODS: After IRB approval, we performed a retrospective chart review of all patients <18 years of age presenting to our institution with a diagnosis of pediatric AAV (pAAV) who underwent lung biopsy. We reviewed histopathologic features, serologies, the timing of biopsy, and complications. RESULTS: Fourteen patients met inclusion criteria, nine patients with microscopic polyangiitis (MPA), and five patients with granulomatosis with polyangiitis (GPA). All patients had positive ANCA serology. 13/14 patients required admission on initial presentation for respiratory symptoms; 11/13 required respiratory support. The indication for biopsy was confirmation of diagnosis before initiating therapy in 11 patients (78%), part of the infectious evaluation in two (14%), and part of interstitial lung disease evaluation in one (7%). 11/14 (78%) biopsies had findings consistent with AAV diagnosis: 6/9 (67%) of the MPA patients compared with 5/5 (100%) of the GPA patients. The most common findings on histopathology were vascular inflammation and signs of alveolar hemorrhage. The only reported complication after lung biopsy was pneumothorax in four patients (28%). CONCLUSION: Lung biopsy had a higher diagnostic yield in GPA compared with MPA patients. In our cohort, a diagnosis of AAV could be made with clinical features and positive serology but was confirmed by lung histopathology in the majority of cases. Obtaining a lung biopsy for diagnostic purposes in pAAV should be reserved for uncertain cases where the diagnosis cannot be confirmed clinically and with serology.

Exercise-induced laryngeal obstruction (EILO) in children and young adults: From referral to diagnosis.

OBJECTIVE: To identify different presentations, referral patterns, comorbidities, and laryngoscopy findings in children and young adults with exercise-induced laryngeal obstruction (EILO). METHODS: We performed a retrospective chart review of 112 patients, age <26 years, with EILO between 2013 and 2016. RESULTS: Of the 112 patients who met criteria, 91 were female and 21 were male. Patients were most frequently referred by pulmonologists (60.7%). The majority of patients (93%) participated in organized sports, most of them at a competitive level. The mean age at symptom onset was 13.8 ± 3.3 years, and the mean age of diagnosis was 15.4 ± 3.0 years. Sixty-seven (59.8%) patients presented with a prior diagnosis of asthma, the majority of whom had failed asthma treatment. The most common symptoms reported were dyspnea (93.8%), wheezing/stridor (78.6%), and throat tightness (48.2%). Ninety-one (81.3%) patients had spirometry performed, with 46 (51.1%) showing inspiratory loop flattening. On flexible laryngoscopy, 87 (78.4%) of 111 patients had paradoxical vocal fold motion. Supraglottic involvement was observed to obstruct the airway in 26 (23.9%) patients, with patterns of obstruction similar to those observed in children with laryngomalacia. CONCLUSION: Most patients participated in competitive sports, were female, and presented with exertional dyspnea. Most patients were diagnosed with exercise-induced asthma but treated unsuccessfully. Almost one-quarter of our patients showed supraglottic collapse obstructing the airway. Exercise-induced laryngeal obstruction is a more descriptive term than paradoxical vocal fold motion or vocal cord dysfunction, which only describe vocal fold involvement. The time to diagnosis of EILO was shorter than previously reported, suggesting that awareness of this condition is increasing. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:E400-E406, 2020.