Ceftolozane/tazobactam for pulmonary exacerbation in a 63-year-old cystic fibrosis patient with renal insufficiency and an elevated MIC to Pseudomonas aeruginosa.

Cystic fibrosis (CF) is a progressive genetic disorder caused by mutations in a gene encoding the cystic fibrosis transmembrane regulator (CFTR) protein leading to persistent and difficult to treat lower airway infections. Multi-drug resistant Pseudomonas aeruginosa is becoming increasingly more common as a cause of pulmonary exacerbations, and newer agents such as ceftolozane/tazobactam (C/T) are being sought for treatment. There is currently little published data regarding its use in cystic fibrosis, particularly in the setting of reduced renal clearance. This report details the case of a 63-year-old female with cystic fibrosis and chronic kidney disease stage III (estimated creatinine clearance of 25-30 ml/min, Cockroft-Gault) who was successfully treated for a pulmonary exacerbation with C/T 3 g (2000 mg/1000 mg) infused intravenously every 8 h when the P. aeruginosa minimum inhibitory concentration (MIC) was elevated at 8 mcg/mL. Serum samples were collected to determine concentrations by a validated high-performance liquid chromatography assay. The steady state 1-hr post-infusion peak (Cmax) and trough (Cmin) concentrations for ceftolozane were 145.04 mcg/mL and 82.08 mcg/mL, and 15.93 mcg/mL and 3.20 mcg/mL for tazobactam, respectively. The patient's symptoms resolved and her lung function returned to baseline. She completed 14 days of therapy and tolerated the infusion well without any infusion-related or adverse events.

Role of Transbronchial Needle Aspiration (Conventional and EBUS Guided) in the Diagnosis of Histoplasmosis in Patients Presenting with Mediastinal Lymphadenopathy.

OBJECTIVES: The superior performance of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the diagnosis and staging of malignancy has been demonstrated, with some investigators suggesting the same for sarcoidosis. The role of EBUS-TBNA in the diagnosis of histoplasmosis is not clear, however. In this study we estimate the diagnostic yield of conventional TBNA (cTBNA) and EBUS-TBNA for the diagnosis of histoplasmosis in patients with mediastinal lymphadenopathy. METHODS: Retrospective chart review was conducted on 452 consecutive patients who underwent cTBNA or EBUS-TBNA for mediastinal lymphadenopathy from January 1, 2005 to December 31, 2014 at Methodist Le Bonheur Healthcare-affiliated hospitals in Memphis, Tennessee. Data collection included demographic information, reason for the procedure, size of the lymph nodes, procedures performed, and the final diagnosis. RESULTS: Among 452 cases reviewed, 146 underwent cTBNA and 306 underwent EBUS-TBNA. Final diagnoses include malignancy (41.5%), sarcoidosis (11.2%), and histoplasmosis (8.1%). Among 146 patients who underwent cTBNA, a final diagnosis was obtained by this modality in 58 patients (39.7%). The diagnostic rate for cTBNA for malignancy was 68% (40/59), 30% (4/13) for sarcoidosis, and 43% (6/14) for histoplasmosis. In 306 patients who underwent EBUS-TBNA, 188 had a final diagnosis (61.4%) obtained by this modality. For EBUS-TBNA, the diagnostic rates were 79.5% (101/127) for malignancy, 74% (28/38) for sarcoidosis, and 78% (18/23) for histoplasmosis. CONCLUSIONS: EBUS-TBNA had a higher yield than cTBNA for the diagnosis of histoplasmosis. Clinicians practicing in areas with a high prevalence of histoplasmosis and sarcoidosis should use EBUS-TBNA, whenever available, for this reason.

Paradoxical Hemodynamic Instability After Pericardial Window.

Paradoxical hemodynamic instability (PHI), also called postoperative low cardiac output syndrome (LCOS), is a rare but fatal complication after drainage of a pericardial effusion (PEf). This condition usually develops within hours postprocedure and appears unrelated to the method of drainage. The exact mechanism of this condition is not well understood. We present a case of an 84-year-old patient with no previous cardiac or cancer history who presented with acute shortness of breath (SOB). Computed tomography (CT) ruled out pulmonary embolism and echocardiography confirmed early tamponade. Following emergent subxiphoid pericardiectomy, the patient developed hemodynamic instability and shock and subsequent multiorgan failure. Repeat echocardiography revealed left ventricular (LV) hypercontractility and new right ventricular (RV) dilatation with akinesis. The patient's condition continued to deteriorate in spite of maximal doses of pressors. The patient died after the family's request to discontinue further extraordinary measures.

Pleural Small Cell Lung Carcinoma: An Unusual Culprit in Pleural Effusion.

BACKGROUND: Small cell lung carcinoma (SCLC) usually presents as lung or mediastinal lesions. It is very rare for SCLC to present primarily as an isolated pleural effusion with no lung or mediastinal lesions. CASE REPORT: We report the case of a 77-year-old white male with a 60-pack year history of smoking, chronic obstructive pulmonary disease (stage IV), and asbestos exposure who presented with shortness of breath and left lateral chest pain for 7 days. On physical examination, he was very short of breath, with a prolonged expiratory phase on chest auscultation. Laboratory results were normal except for leukocytosis and chest radiograph revealing left-sided pleural effusion. Computerized tomography (CT) scanning of the chest with IV contrast showed left-sided pleural effusion without any lung or mediastinal lesions. Thoracentesis was performed and fluid was sent for analysis. Repeat CT chest/abdomen/pelvis, done immediately following thoracocentesis, did not show any masses or lymphadenopathy. Fluid analysis, including cytology and immunostain pattern, was consistent with small cell carcinoma. CONCLUSIONS: Small cell lung cancer presenting as an isolated pleural effusion is extremely rare. It requires close attention to cytology and immunohistochemistry of pleural fluid samples. It also has implications for management and should be managed as limited-stage SCLC.

Patient Demographics and Socioeconomic Characteristics of an Ambulatory Care Clinic Served by a University PCCM Training Program.

OBJECTIVES: Continuity clinics are an important aspect of pulmonary medicine fellowship training. We provide a description of a pulmonary outpatient clinic in an inner city, county-owned, university-affiliated hospital. METHODS: This is a descriptive study of administrative data on consecutive patient visits to the University of Tennessee Regional One Health at Memphis ambulatory clinic (Medplex) between January 2000 and August 2006. We describe demographics, socioeconomic characteristics, and the frequency of a pulmonary diagnosis of the outpatient population served by our training program. Continuous data were described by mean ± standard deviations and categorical data were described by percentage. RESULTS: The dataset included 2549 patients, 81% were African American with a mean age of 48.7 ± 13.7, 64.4% were women. Female/male body mass index was 34.6 ± 11.6 vs. 29.2 ± 10.3. Tenncare (Medicaid) covered 59.6 % of patients, whereas 11.1% were uninsured. CONCLUSIONS: We provide evidence that one clinical setting may not be enough exposure to the entire lung pathology for pulmonary trainees. There is a need for further, larger, and prospective data collections to evaluate and guide changes regarding the structure of training programs.

Wait!!! No Steroids for this Asthma .

BACKGROUND: Strongyloides stercoralis (SS) is a parasite seen in certain parts of the USA and in people from other endemic areas. In these patients steroids might precipitate or exacerbate asthma. Apart from worsening of asthma, serious complications like hyperinfection syndrome and even death can occur in these patients if treated with steroids. Treatment is either ivermectin or albendazole based on severity of the disease. Clinicians have to be very careful when prescribing steroids in patients presenting with an exacerbation of asthma from areas endemic for Strongyloides stercoralis. CASE REPORT: A young woman with history of asthma presented with complaints of nausea, vomiting, abdominal pain, wheezing, and dry cough. Physical examination revealed diffuse expiratory wheezing and mild diffuse abdominal pain without rebound or guarding. Laboratory results showed leukocytosis with eosinophilia. Stool studies showed Strongyloides stercoralis. Imaging revealed ground-glass opacities in the right upper and lower lobe along with an infiltrate in the lingular lobe on the left side. Bronchoscopy showed Strongyloides stercoralis. The patient was diagnosed with hyperinfection syndrome due to Strongyloides stercoralis most probably exacerbated by prednisone given for her asthma. Steroids were then discontinued and the patient was started on ivermectin. The patient improved with treatment. Repeat stool examination was negative for Strongyloides stercoralis. CONCLUSIONS: Clinicians have to be very careful when prescribing steroids in patients presenting with an exacerbation of asthma who are from areas endemic for Strongyloides stercoralis and should test for it (preferably with serology test) before starting treatment.

Intravenous gammaglobulin as rescue therapy in a patient with sickle cell and septic shock.

INTRODUCTION: We present a case involving a patient with sickle cell and hyposplenism, in which refractory septic shock quickly responded after the infusion of intravenous gammaglobulin (IV-GG) given as an adjuvant-rescue therapy CASE DESCRIPTION: A 30-year-old African-American female with history of Sickle Cell disease was admitted for acute chest syndrome, septic shock and respiratory failure. Despite aggressive therapy the patient remained on two vasopressors and with persistent bacteremia. Within one day of starting IV-GG, both vasopressors (norepinephrine and vasopressin) were able to be discontinued. DISCUSSION: Patients with hyposplenism have functional opsonization failure. Infusion of IV-GG has been shown to improve such function in patients with hyposplenism. We were able to document a temporal association between IV-GG rescue therapy and septic shock improvement. CONCLUSION: The utilization of intravenous gammaglobulin should be considered in patients with sickle cell disease and hyposplenism as an adjuvant therapy for refractory septic shock.

Psychiatric disorder does not preclude adequate continuous positive airway pressure titration.

Obstructive sleep apnea (OSA) is a highly prevalent disorder associated with significant morbidity and multiple complications. A large proportion of patients with OSA also have a coexisting primary psychiatric disorder. The effect of psychiatric disorders on the ability to tolerate continuous positive airway pressure (CPAP) titration is not known. In this study, whether the presence of psychiatric disorders precludes the patients' ability to tolerate CPAP titration for OSA was investigated. A retrospective chart review on a sample of 284 patients who underwent sleep studies in a single-center, university-based Veterans Affairs hospital was performed. A total of 143 patients with OSA who underwent titration of CPAP therapy were identified. The prevalence of psychiatric disorders between patients who tolerated titration and those who did not tolerate it was compared using the χ² test. The percentages of patients with psychiatric disorders who tolerated and did not tolerate CPAP were 33.6% and 33.3%, respectively. No statistically significant difference between the 2 groups (χ² = 0.051 with 1 degree of freedom; P = 0.82) was found. The predominantly male patient population, exclusion of mild OSA, lack of data about the level of control of the psychiatric symptoms and the sleep technicians not being blinded to the patients' psychiatric diagnoses were some of the limitations of this study. No significant difference existed in the prevalence of psychiatric disorders between patients intolerant to CPAP titration and those who tolerated CPAP for OSA.

Abdominal pathology in patients with diabetes ketoacidosis.

INTRODUCTION: The objective is to describe the incidence and nature of significant abdominal pathologies in patients with diabetes ketoacidosis (DKA) and abdominal pain. METHODS: Retrospective chart review (N = 86) of patients with DKA from January 1, 2005, to January 31, 2010, was performed. Data included demographics, co-morbidities, compliance, chief complaints and physical findings, blood count, metabolic profile, lactic acid, glycosylated hemoglobin (HbAlC), amylase, lipase, anion gap, arterial gases, imaging and final diagnosis. Continuous variables were described as mean ± standard deviation and compared with the Student's t test. Categorical variables were expressed as percentages (%) and compared with the Mantel-Haenszel χ test. Univariate analysis was conducted among patients with and without significant abdominal pain and also with and without significant abdominal pathology. Two lipase strata were created at 400 U. Multivariate model to identify limits (confidence interval) of the estimated risk imposed by the predictor found significant in univariate analysis. A P value of ≤ 0.05 was considered significant. Stat View 5.0 (SAS Institute, Cary, NC) was used for the statistical analysis. RESULTS: In patients with abdominal pain, 17% had significant abdominal pathology mainly acute pancreatitis (AP). Serum amylase and lipase level were found to be an indicator of significant underlying pathology (both P values ≤0.001). The logistic model created showed that patients with lipase level ≥400 U have a 7% increased risk of having AP with confidence interval of 0.01 to 0.6. CONCLUSION: Patients with DKA and abdominal pain with lipase >400 U have an increased risk of significant underlying abdominal pathology (AP).

Diabetic ketoacidosis presenting with acute pancreatitis and visceral vein thrombosis.

Abdominal pain is a frequent manifestation in patients presenting with Diabetic Ketoacidosis (DKA). Usually it is attributed to severe metabolic acidosis but it can be due to underlying abdominal pathologies (i.e., pancreatitis, appendicitis). We report a case of a 19-year-old female who presented with DKA and severe abdominal pain and was found on further examination to have underlying pancreatitis and visceral vein thrombosis. The patient improved with treatment for the mentioned co-morbidities, including anticoagulation.

Obstructive sleep apnea and immunity: relationship of lymphocyte count and apnea hypopnea index.

OBJECTIVES: The impact of chronic poor quality sleep on immunity as seen in obstructive sleep apnea (OSA) has not been evaluated. We aim to explore the relationship between lymphocytes, neutrophil, and total leukocyte counts with severity stratified apnea hypopnea index (AHI) in patients with OSA. METHODS: A retrospective review of 119 patients' medical records diagnosed with OSA from October 2005 to July 2006 was performed. Data collected included demographics, comorbidities, total leukocyte, neutrophil, and lymphocyte count, body mass index (BMI), AHI, and Epworth sleepiness scores (ESS). Three AHI strata were constructed: mild (5-14), moderate (15-29), and severe (>30). Data were fitted in a linear regression model on which lymphocyte counts were the dependent variable against age, BMI, and AHI. An interaction product was also explored (age*BMI). All tests were two-sided; a P < 0.05 was considered statistically significant. We used Statview Version 5.01 (SAS Institute, Inc., Cary, NC) for the analysis. RESULTS: Our study showed a linear association among AHI and BMI (P = 0.0017), but did not show association between lymphocyte count with either BMI (P = 0.33) or AHI (P = 0.90). A negative association between lymphocytes and age (P = 0.02) that persisted after adjustments for BMI and AHI was found. An interaction product (age*AHI) was not associated with lymphocyte count (P = 0.87). No correlation was found between peripheral blood count (P = 0.29) or neutrophil counts (P = 0.38) and AHI. CONCLUSION: We found OSA-induced sleep interruption not associated with lymphocyte, neutrophil, or peripheral blood cell count alterations. This information is useful for researchers evaluating the influence of sleep disruption on immunity.