The Harms of Unnecessary CT Pulmonary Angiography: A Case Report and Literature Review.

Pulmonary embolism (PE) poses a significant health risk in the United States, with high mortality rates. Clinicians maintain a low threshold for suspecting PE, potentially leading to deviation from guideline-recommended algorithms and unnecessary computed tomography pulmonary angiography (CTPA). This case discusses a 46-year-old woman who presented with symptoms suggestive of PE following a prolonged road trip. Despite a low Wells score and negative D-dimer results, she underwent CTPA, resulting in an unnecessary and harmful interventional radiology-guided thrombectomy. This highlights the importance of adhering to guidelines in PE diagnosis to mitigate potential harms associated with the overuse of available medical tools.

A Neurocritical Case Study of Intracerebral Hemorrhage Unveiling Multiple Myeloma Through the Lens of Hickam's Dictum.

Multiple myeloma (MM) is a hematologic malignancy characterized by clonal proliferation of plasma cells in the bone marrow, often leading to various end-organ damages. Here, we report the case of a 73-year-old previously healthy woman who was initially diagnosed with an intracerebral hemorrhage secondary to a potential hypertensive emergency. However, further evaluation revealed a diagnosis of MM. This case points out the importance of comprehensive evaluations in neurocritical care and challenges the notion of simplistic diagnostic explanations, illustrating the relevance of Hickam's dictum in clinical practice. It highlights the need for clinicians to consider a broad range of potential etiologies in similar cases, ultimately leading to tailored management strategies and improved patient outcomes.

A Case Report of Pulmonary Vein Stenosis Within the Labyrinth of Fibrosing Mediastinitis.

This case centers on a 76-year-old male experiencing exertional dyspnea and hemoptysis, with a medical history marked by recurrent pulmonary embolism and chronic obstructive pulmonary disease (COPD). Notably, he resides in a histoplasmosis-endemic area. A computed tomography (CT) pulmonary embolism scan revealed notable findings, including an enlarged right lower pulmonary artery, vascular congestion, atelectasis, and a mass exerting pressure on the right lower pulmonary vein. Biopsy results identified the mass as fibrosing mediastinitis, likely attributed to histoplasmosis. A transthoracic echocardiogram indicated right ventricular dilatation, impaired function, and a right ventricular systolic pressure of 63 mm Hg. During right heart catheterization, the patient displayed disparate pulmonary artery wedge pressures (PAWPs) between the right and left sides. This discrepancy was linked to a blunted back wave from the left atrium to the catheter, induced by pulmonary vein compression. Although an infrequent phenomenon, the recorded asymmetry in PAWPs played a crucial role in guiding accurate patient management. The absence of subsequent evaluation of PAWP on the left side could have altered the treatment plan, potentially delaying appropriate patient care. This case emphasizes the necessity of thorough exploration with right heart catheterization when clinical symptoms warrant, highlighting the importance of standardized practices in such procedures.

A Rare Case of Spontaneous Pneumothorax Leading to Cerebral Air Embolism.

Cerebral arterial air embolism (CAE), a rare subtype of air embolism, carries a 21% mortality rate. We present a unique case involving a 69-year-old female with a history of usual interstitial pneumonia (UIP) who suffered a transient ischemic attack (TIA) due to CAE. Unlike typical cases, CAE in this instance resulted from spontaneous pneumothorax, not the more common iatrogenic causes. Adding complexity, an unexpected discovery emerged during evaluation: a patent foramen ovale, contributing to paradoxical embolism. This underscores the vital need to consider CAE as a differential diagnosis in UIP patients with neurological symptoms, highlighting its rarity and diagnostic challenges.

Unusual Presentation of Multiple Lung Nodules in a Patient With Supraglottic Squamous Cancer: A Rare Infectious Cause Revealed.

Pulmonary nodules are commonly encountered in medical practice, necessitating thorough evaluation due to their diverse etiologies. Identifying the underlying cause is of utmost importance, particularly in patients with a history of extrapulmonary cancer, to differentiate between metastasis and other etiologies. We present a rare case of a 24-year-old male with supraglottic squamous cancer who developed multiple pulmonary nodules, which surprisingly were caused by a rare infectious agent. The patient presented with bilateral infiltrates on imaging, raising strong suspicion of metastatic disease from primary cancer. However, bronchoscopy and biopsy revealed no malignancy but confirmed the presence of Corynebacterium amycolatum, leading to a change in the treatment approach from palliative to curative. This case highlights the importance of considering other etiologies, especially infections, in patients with cancer and pulmonary nodules. Accurate diagnosis is crucial to guide appropriate management decisions and optimize patient outcomes.

Paradoxical Worsening of Pulmonary Hypertension Following Closure of Arteriovenous Fistula: A Case Report and Literature Review.

This case report presents the atypical instance of a 59-year-old female patient with end-stage renal disease (ESRD) who was initially referred to the pulmonary clinic for evaluation due to a low diffusing capacity of the lung for carbon monoxide (DLCO). Pulmonary hypertension (PH) was suspected, and a subsequent right heart catheterization (RHC) confirmed PH attributed to group 5 PH, leading to the decision to close the unused arteriovenous fistula (AVF) to manage PH. Unexpectedly, a follow-up RHC showed a worsening of PH with elevated pulmonary capillary wedge pressure (PCWP), revealing an additional component of post-capillary group 2 PH. This case emphasizes the significance of recognizing a low DLCO as a potential trigger for PH assessment, especially in patients with comorbidities like ESRD. Furthermore, it highlights the unusual yet critical occurrence of PH exacerbation following AVF closure.

Rare Manifestation of Idiopathic Tracheobronchopathia Osteochondroplastica: Misdiagnosed and Untreated Entity?

Tracheobronchopathia osteochondroplastica (TBPO) is a rare benign disease of unknown cause, in which multiple cartilaginous or bony submucosal nodules project into the trachea and proximal bronchi. It usually occurs in men in their fifth decade and can cause airway obstruction, bleeding and chronic cough; patients are more prone to post-obstructive pneumonia and chronic lung infection in some instances. We report a case of a 69-year-old female who presented with shortness of breath and lower extremity swelling over the past couple of weeks. Echocardiography (ECHO) was consistent with heart failure with preserved ejection fraction, and she was treated with diuretics accordingly. Imaging revealed persistent pleural effusions bilaterally, more pronounced on the right side. During the course of her hospitalization, the patient coded once and had to be resuscitated. She had bronchoscopy done and pathology was consistent with TBPO. In this condition, there are numerous osseous or cartilaginous submucosal nodules in the trachea and the main bronchus and nodules are formed due to the deposition of calcium phosphate that results in the proliferation of osseous and cartilaginous structures resulting in the obstruction of large airways. Treatment for the most part is supportive and resolves around bronchodilators for symptomatic relief.

Argatroban Treatment and Decreased Fibrinogen in a Septic Patient.

Disseminated intravascular coagulation (DIC) is a consumptive coagulopathy associated with multiple conditions. Diagnosis is based upon clinical and laboratory findings with assessment of fibrinogen, platelets, D-dimer, prothrombin time/international normalized ratio and activated partial thromboplastin time. Herein, we report a case of a 39-year-old female patient diagnosed with endocarditis complicated by pulmonary septic emboli. For anticoagulation, the patient initially was treated with a heparin drip, but the patient remained subtherapeutic despite increasing dosage. The patient was transitioned to argatroban and developed an acute drop in the fibrinogen level. With concern for possible DIC, argatroban was held with a repeat panel six hours later revealing a significantly improved fibrinogen level. It was discovered that the Clauss method, which measures the capability of fibrinogen to form a clot after a high concentration of thrombin is added to diluted plasma, was used to measure fibrinogen at our institute. Argatroban may falsely reduce measured fibrinogen levels in vitro, caused by this method.

Paroxysmal Sympathetic Hyperactivity in a Young Male with Glioblastoma Multiforme.

Paroxysmal sympathetic hyperactivity (PSH) is a rare syndrome that is a recognized complication of severe brain injury. It is characterized by episodic hypertension, hyperthermia, tachycardia, tachypnea, diaphoresis, and specific posturing. It is prevalent in an intensive care unit (ICU) setting where high acuity illnesses can mask the symptoms of PSH. Herein, we report a case of PSH in a patient with a past medical history significant for glioblastoma multiforme (GBM) status post hemicraniectomy, radiation, and chemotherapy.

A Challenging Case of Coexisting Type A and Type B Lactic Acidosis: A Case Report.

The etiology of lactic acidosis can potentially be misleading, especially in a critically ill patient with malignancy. Type B lactic acidosis represents a rare and often lethal complication of malignancy. When differentiating the types of lactic acidosis, Type A is due to marked tissue hypoperfusion and Type B is due to causes in the setting of a normal perfused state. We report the case of a 56-year-old male with newly diagnosed poorly differentiated neuroendocrine metastatic carcinoma and renal cell carcinoma who presented with a decreased level of consciousness and appetite. The patient was started on a sepsis protocol from an initial intensive care unit (ICU) admission. Broad spectrum antibiotics were initiated, and despite management, his mentation and respiratory status worsened, leading to intubation and mechanical ventilation. The patient continued to have elevated lactic acid and white count levels throughout the hospital course. After extensive workup and an ICU stay of 16 days, a decision was made to pursue comfort care measures and the patient passed away shortly thereafter. The patient's persistently elevated lactic acidosis may have resulted from the inherent malignancy. The literature mentions glycolysis with enhanced metabolism as a proposed mechanism. One theory states that these changes enable cancer cells to acquire and metabolize nutrients in a way that favors proliferation over efficient adenosine triphosphate (ATP) production, resulting in elevations of lactate production. Patients presenting to the ICU with elevated lactic acid levels need to be thoroughly worked up for all potential causes. In our case, the underlying malignancies likely caused the persistently elevated lactic acidosis, despite subtherapeutic treatment and resuscitative measures.

Pneumocystis Jirovecii (carinii) pneumonia causing lung cystic lesions and pneumomediastinum in non-HIV infected patient.

Pneumomediastinum is a rare, potentially life-threatening complication of PCP that occurs in HIV-positive and HIV-negative patients. We are presenting a rare case pneumomediastinum caused by pneumocystis Jirovecii pneumonia in a HIV-negative patient with history of diffuse B-cell lymphoma on R CHOP chemotherapy. What is unique about our case is that the patient developed pneumomediastinum while in the hospital, on atovaquone that improved when switched to clindamycin and primaquine with improvement in her respiratory status. Another interesting point is that diagnosis was entertained due to the characteristic CT scan finding of ground glass opacities with cystic lung lesions and pneumomediastinum in an immunocompromised patient who was started on empirical treatment for PCP. The diagnosis was eventually confirmed with PCP PCR.

Hypoxaemia in a pregnant lady.

A pregnant lady at gestational age of 32 weeks presents with refractory hypoxaemia in this case report http://ow.ly/MM9C301zeVx.

The c-myc x E2F-1/p21 interactive gene expression index augments cytomorphologic diagnosis of lung cancer in fine-needle aspirate specimens.

Morphological analysis of cytologic samples obtained by fine-needle aspirate (FNA) or bronchoscopy is an important method for diagnosing bronchogenic carcinoma. However, this approach has only about 65 to 80% diagnostic sensitivity. Based on previous studies, the c-myc x E2F-1/p21WAF1/CIP1 (p21 hereafter) gene expression index is highly sensitive and specific for distinguishing normal from malignant bronchial epithelial tissues. In an effort to improve sensitivity of diagnosing lung cancer in cytologic specimens, we used Standardized Reverse Transcriptase Polymerase Chain Reaction (StaRT-PCR) to measure the c-myc x E2F-1/p21 index in cDNA samples from 14 normal lung samples (6 normal lung parenchyma and 8 normal bronchial epithelial cell [NBEC] biopsies), and 16 FNA biopsies from 14 suspected tumors. Based on cytomorphologic criteria, 11 of the 14 suspected tumors were diagnosed as bronchogenic carcinoma and three specimens were non-diagnostic. Subsequent biopsy samples confirmed that the three non-diagnostic samples were derived from lung carcinomas. The index value for each bronchogenic carcinoma was above a cut-off value of 7000 and the index value of all but one normal sample was below 7000. Thus the c-myc x E2F-1/p21 index may augment cytomorphologic diagnosis of bronchogenic carcinoma biopsy samples, particularly those considered non-diagnostic by cytomorphologic criteria.