Re-Positive SARS-CoV-2 With Respiratory Failure and Cerebrovascular Accident: Is This a Reinfection?

The coronavirus disease 2019 ( COVID-19) pandemic is a global pandemic where healthcare providers are concerned about the reinfection of recovered patients. The reinfection with COVID-19 is not common and considered less likely, but as time passes by, there are reports of patients becoming positive after having tested negative previously. Here, we report a case of a 28-year-old male with diabetes mellitus type 1, hypertension, and end-stage renal disease on hemodialysis who presented initially in April 2020 with nausea, vomiting, and dyspnea. His severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) came back positive. He left against medical advice but was followed as an outpatient in the dialysis unit where he continued with dialysis in isolation for positive COVID-19 as per the dialysis unit guidelines. He presented three months later with altered level of consciousness in the setting of diabetic ketoacidosis. He also had gastrointestinal bleed and cerebrovascular accident. There was a strong possibility of reinfection in this patient as he was tested negative after the initial infection and then tested positive three months later, presenting with a different set of symptoms and more severe disease on his second admission.

A Rare Case of COVID-19 Myocarditis With Cardiac Tamponade in a Young Diabetic Adult With Renal Failure.

A young male with long-standing type 1 diabetes mellitus, chronic kidney disease, and known ventricular hypertrophy presented with dyspnea and abdominal pain and was diagnosed with coronavirus disease 2019 (COVID-19) infection. On day nine of hospital admission, patient developed ventricular tachycardia with electrocardiogram (ECG) changes and elevation in troponin level consistent with myocarditis and development of cardiogenic shock. Bedside limited echo demonstrated signs of tamponade and patient underwent surgical pericardial window procedure. He was also noted to develop marked prolongation of corrected QT interval (QTc) while on amiodarone.

Occult pulmonary lymphangitic carcinomatosis presenting as 'chronic cough' with a normal HRCT chest.

A diagnosis of 'chronic cough' (CC) requires the exclusion of sinister pulmonary pathology, including infection and malignancy. We present a patient with a 3 month history of CC who had an extensive workup including a normal high resolution computed tomography of the chest (HRCT) 6 weeks prior to consultation at our center. He subsequently developed constitutional symptoms including weight loss and loss of appetite 5 weeks after initial consultation. A repeat HRCT chest and a subsequent whole body PET scan found that he had developed extensive pulmonary lymphangitic carcinomatosis (PLC) from a colon primary. Treatment of the colon cancer resulted in significant decrease in metastatic disease burden and cough resolution. PLC is a very rare cause of 'chronic cough' and incipient/occult PLC presenting with chronic cough and a normal initial HRCT chest has not been previously reported.

Cavitating Lung Disease: A Novel Presentation of IgG4-Related Disease.

BACKGROUND: Immunoglobulin (Ig) G4-related disease, previously referred to as IgG4-related sclerosing disease or hyper-IgG4 disease, may occur in the lung, involving alveolar parenchyma, airways, and pleura. Various pulmonary manifestations of IgG4-related disease have been reported, but to the best of our knowledge a cavitating lung disease has not been reported previously. CASE REPORT: We describe a 60-year-old man who presented with hemoptysis and cavitating lung disease with clinical, laboratory, and histopathologic findings compatible with IgG4-related disease. Other potential causes of cavitation were excluded. Treatment was initiated with oral prednisone and subsequently mycophenolate mofetil was added. Follow-up 1 year later shows stable pulmonary function with complete resolution of the cavitary lesions. CONCLUSIONS: We present a case of cavitating lung disease as a previously unreported manifestation of IgG4-related disease. Our patient had an excellent response to immunosuppression. An increased awareness of IgG4-related disease and its myriad of manifestations is very important for pulmonologists.

Severe Acute Orthopnea: Ipilimumab-Induced Bilateral Phrenic Nerve Neuropathy.

Ipilimumab is a monoclonal antibody used in the treatment of unresectable or metastatic melanoma. Several immune-related adverse events including potential fatal events have been reported following its use. We report a case of a 66-year-old man who presented with severe acute exertional dyspnea and orthopnea following administration of ipilimumab for metastatic melanoma. Although various peripheral neuropathy syndromes associated with ipilimumab have been reported, bilateral phrenic nerve paralysis has not been previously reported. This case also highlights the clinical features of bilateral phrenic nerve neuropathy. Pulmonologists have to be aware of these unusual immune-related respiratory adverse events in patients being treated with monoclonal antibodies.

Chiari 1 Malformation Presenting as Central Sleep Apnea during Pregnancy: A Case Report, Treatment Considerations, and Review of the Literature.

PURPOSE: Chiari malformation (CM) type-1 frequently causes obstructive or central sleep-disordered breathing (SDB) in both adults and children, although SDB is relatively rare as a presenting manifestation in the absence of other neurological symptoms. The definitive treatment of symptomatic CM is surgical decompression. We report a case that is, to our knowledge, a novel manifestation of central sleep apnea (CSA) due to CM type-1 with severe exacerbation and initial clinical presentation during pregnancy. METHODS: Case report from tertiary care comprehensive sleep medicine center with literature review of SDB manifestations associated with CM type-1. PubMed search was conducted between January 1982 and October 2013. RESULTS: We report a 25-year-old woman with severe CSA initially presenting during her first pregnancy that eventually proved to be caused by CM type-1. The patient was successfully treated preoperatively by adaptive servoventilation (ASV), with effective resolution of SDB following surgical decompression, and without recurrence in a subsequent pregnancy. Our literature review found that 58% of CM patients with SDB had OSA alone, 28% had CSA alone, 8 (10%) had mixed OSA/CSA, and 6 (8%) had hypoventilation. Of CM patients presenting with SDB, 50% had OSA, 42% had CSA, 8% had mixed OSA/CSA, and 10.4% had hypoventilation. We speculate that CSA may develop in CM patients in whom brainstem compression results in excessive central chemoreflex sensitivity with consequent hypocapnic CSA. CONCLUSION: Chiari malformation type-1 may present with a diversity of SDB manifestations, and timely recognition and surgical referral are necessary to prevent further neurological deficits. ASV therapy can effectively manage CSA caused by CM type-1, which may initially present during pregnancy.

Diffuse interstitial lung infiltrates in a smoker with human immunodeficiency virus infection.

Pulmonary Langerhans cell histiocytosis is a rare interstitial lung disease characteristically affecting middle-aged smokers. It has unpredictable clinical course and may be associated with malignant neoplasms. Opportunistic lung infections are frequently considered when patients with Human immunodeficiency virus (HIV) infection present with respiratory symptoms and an abnormal chest X-ray. Though fiberoptic bronchoscopy with bronchoalveolar lavage is diagnostic for infectious etiologies, surgical lung biopsies are preferred to diagnose noninfectious lung diseases and to help guide appropriate therapy. In the present study, we report a case of progressive bilateral lung infiltrates in a smoker with HIV infection which presented a diagnostic dilemma in view of coexistent HIV infection. Analysis of clinical symptomatology aided by surgical lung biopsy helped in diagnosis.

The utility of routine admission chest X-ray films on patient care.

BACKGROUND: Routine chest X-rays are the most widely obtained radiological studies during hospital admissions. In this study, we evaluated the utility of routine admission chest X-rays on patient care in patients admitted to The Brooklyn Hospital center. METHODS: We included consecutive patients admitted to the medical floors during a 4-month period who had a chest X-ray done on admission. The medical records of patients who had chest X-ray on admission were reviewed to identify any impact of chest X-ray on patient care during the course of hospitalization. RESULTS: Chest X-ray was noted to be done in 229 patients on admission. Chest X-rays of 100 (43.6%) patients were deemed medically necessary because of the presenting complaints which included cough (15.2%), fever (13.1%), dyspnea (6.1%), hemoptysis (1.7%), and combined symptoms (7.4%). Routine chest X-rays were done in 129 (56.3%) patients to rule out occult findings in the absence of any symptoms. Chest X-ray abnormalities were noted in 56 of 129 (43.4%) patients. In 51 of 56 patients, abnormalities were chronic, stable and previously known and did not contribute to patient care. In only 5 of 129 (3.87%) patients, there were findings which necessitated a change in patient care. CONCLUSION: We conclude that routine chest films rarely reveal clinically unsuspected findings. The overall impact on patient care based on these findings is small when compared to the risks associated with repeated exposure to radiation. We recommend that routine chest X-ray films should not be ordered solely because of hospital admission.