Comparison of pulse-dose and high-dose corticosteroids with no corticosteroid treatment for COVID-19 pneumonia in the intensive care unit.

Corticosteroid dosing in the range of 0.5-2 mg/kg/day of methylprednisolone equivalents has become a standard part of the management of intensive care unit (ICU) patients with COVID-19 pneumonia based on positive results of randomized trials and a meta-analysis. Alongside such conventional dosing, administration of 1 gm of methylprednisolone daily (pulse dosing) has also been reported in the literature with claims of favorable outcomes. Comparisons between such disparate approaches to corticosteroids for Coronavirus disease 2019 (COVID-19) pneumonia are lacking. In this retrospective study of patients admitted to the ICU with COVID-19 pneumonia, we compared patients treated with 0.5-2 mg/kg/day in methylprednisolone equivalents (high-dose corticosteroids) and patients treated with 1 gm of methylprednisolone (pulse-dose corticosteroids) to those who did not receive any corticosteroids. The endpoints of interest were hospital mortality, ICU-free days at Day 28, and complications potentially attributable to corticosteroids. Pulse-dose corticosteroid therapy was associated with a significant increase in ICU-free days at Day 28 compared to no receipt: adjusted relative risk (aRR): 1.45 (95% confidence interval [CI]: 1.05-2.02; p = 0.03) and compared with high-dose corticosteroid administration (p = 0.003). Nonetheless, receipt of high-dose corticosteroids-but not of pulse-dose corticosteroids-significantly reduced the odds of hospital mortality compared to no receipt: adjusted Odds ratio (aOR) 0.31 (95% CI: 0.12-0.77; p = 0.01). High-dose corticosteroids reduced mortality compared to pulse-dose corticosteroids (p = 0.04). Pulse-dose corticosteroids-but not high-dose corticosteroids-significantly increased the odds of acute kidney injury requiring renal replacement therapy compared to no receipt: aOR 3.53 (95% CI: 1.27-9.82; p = 0.02). The odds of this complication were also significantly higher in the pulse-dose group when compared to the high-dose group (p = 0.05 for the comparison). In this single-center study, pulse-dose corticosteroid therapy for COVID-19 pneumonia in the ICU was associated with an increase in ICU-free days but failed to impact hospital mortality, perhaps because of its association with development of severe renal failure. In line with existing trial data, the effect of high-dose corticosteroids on mortality was favorable.

A 44-year-old stone worker with progressive dyspnea: lessons from a new twist on an old foe.

Silicosis is typically an indolent lung disease caused by long-standing occupational exposure to respirable crystalline silica, classically in professions such as sandblasting and mining.  An increasingly popular industry that has earned particular interest because of its association with silicosis is customization and installation of artificial stone countertops for domestic applications. In addition to causing a spike in cases of chronic and accelerated silicosis, both quite familiar to respiratory clinicians, outbreaks of artificial stone silicosis have brought to the fore a historically rare entity known as acute silicosis, or silicoproteinosis, a more rapid presentation of the disease. Failure to suspect this uncommon condition can lead to diagnostic confusion and therefore ineffective treatment as was true initially of the patient we describe herein.  The case description is followed by a clinical, radiological, and pathological overview of acute artificial stone silicosis (or silicoproteinosis), which is an emerging pneumoconiosis with sparse coverage in the literature to date.  This case also adds to the few existing reports on the use of therapeutic whole lung lavage for silicoproteinosis.

Epidemiology and Mycology of Candidaemia in non-oncological medical intensive care unit patients in a tertiary center in the United States: Overall analysis and comparison between non-COVID-19 and COVID-19 cases.

The epidemiology and mycology of invasive candidiasis in the ICU is well-described in certain types of critically ill patients but not in others. One population that has been scarcely studied is non-neutropenic patients admitted specifically to medical ICUs. Even less is known about the broader category of medical ICU patients without active oncological disease. This group constitutes a very large share of the patients requiring critical care across the globe, especially in the era of the SARS-CoV-2 pandemic. We analysed medical ICU candidaemia episodes that occurred in non-oncological patients in our tertiary academic centre in the United States from May 2014 to October 2020 to determine the incidence and species distribution of the associated isolates. We then separately considered non-COVID-19 and COVID-19 cases and compared their characteristics. In the non-COVID-19 group, there were 38 cases for an incidence of 1.1% and rate of 11/1000 admissions. In the COVID-19 group, there were 12 cases for an incidence of 5.1% and rate of 51/1000 admissions. In the entire sample, as well as separately in the non-COVID-19 and COVID-19 groups,Candida albicans accounted for a minority of isolates. Compared to non-COVID-19 patients with candidaemia, COVID-19 patients had lower ICU admission SOFA score but longer ICU length of stay and central venous catheter dwell time at candidaemia detection. This study provides valuable insight into the incidence and species distribution of candidaemia cases occurring in non-oncological critically ill patients and identifies informative differences between non-COVID-19 and COVID-19 patients.

Withdrawal: Characteristics of early pleural effusions after orthotopic heart transplantation: comparison with coronary artery bypass graft surgery.

Anant Jain (2021) Characteristics of early pleural effusions after orthotopic heart transplantation: comparison with coronary artery bypass graft surgery, (https://doi.org/10.4081/monaldi.2021.1740). The above article from the Monaldi Archives for Chest Disease published online on 24 November 2021, has been withdrawn by agreement between the journal's Editors-in-Chief, the Authors and PAGEPress Scientific Publications. This action has been agreed upon due to an administrative error by the publisher which caused the article to be published as an Accepted Article. The author is not responsible for this error. The publisher regrets any confusion this error may have caused.

Hammering home the sickle: an instructive case of endobronchial anaplastic large cell lymphoma.

It is extremely unusual for primary pulmonary lymphoma, an uncommon occurrence in any form, to be of T-cell origin and to manifest as an endobronchial lesion. Each of these characteristics is rare individually, so cases that combine them are exceptional. We report a patient in whom primary pulmonary anaplastic large cell lymphoma, a T-cell neoplasm, presented with obstruction of the left upper lobe bronchus, resulting in left upper lobe atelectasis and creating the radiographic luftsichel sign. We briefly discuss anaplastic large cell lymphoma as a whole, place our case in the context of previously published literature on endobronchial anaplastic large cell lymphoma, and review the genesis of the luftsichel sign.

Microbiological Laboratory Testing in the Diagnosis of Fungal Infections in Pulmonary and Critical Care Practice. An Official American Thoracic Society Clinical Practice Guideline.

Background: Fungal infections are of increasing incidence and importance in immunocompromised and immunocompetent patients. Timely diagnosis relies on appropriate use of laboratory testing in susceptible patients.Methods: The relevant literature related to diagnosis of invasive pulmonary aspergillosis, invasive candidiasis, and the common endemic mycoses was systematically reviewed. Meta-analysis was performed when appropriate. Recommendations were developed using the Grading of Recommendations Assessment, Development, and Evaluation approach.Results: This guideline includes specific recommendations on the use of galactomannan testing in serum and BAL and for the diagnosis of invasive pulmonary aspergillosis, the role of PCR in the diagnosis of invasive pulmonary aspergillosis, the role of ß-d-glucan assays in the diagnosis of invasive candidiasis, and the application of serology and antigen testing in the diagnosis of the endemic mycoses.Conclusions: Rapid, accurate diagnosis of fungal infections relies on appropriate application of laboratory testing, including antigen testing, serological testing, and PCR-based assays.

Of onions and men: Report of cavitary community acquired pneumonia due to Burkholderia cepacia complex in an immunocompetent patient and review of the literature.

Burkholderia cepacia complex consists of highly antibiotic resistant gram negative bacilli that are plant symbionts and also potential agents of human infection.  This bacterial family's claim to fame in clinical medicine is as the scourge of cystic fibrosis patients, in whom it is a notorious respiratory pathogen.  Outside of cystic fibrosis, it rarely comes to mind as an etiology of community acquired pneumonia with or without lung cavitation in immunocompetent hosts.  We describe a case of an otherwise healthy, community-dwelling man who presented with subacute cavitary lung disease, the causative organism of which turned out to be Burkholderia cepacia complex.  Our report is accompanied by a review of the literature, which identified an additional eleven cases in the same category.  We analyze all of the available cases for the emergence of any identifiable patterns or peculiarities.

Three's company: A woman with rash, uterine mass and cystic lungs.

Cystic lung disease encompasses a wide variety of clinical entities, the diagnosis of which is sometimes straightforward and other times obscure.  To narrow the list of possibilities, it behooves the physician to consider the context in which the cystic lung disease is uncovered. Clues to the diagnosis might be provided by findings that are not initially obvious and are not located in the thorax. We describe an instructive case of a woman with cystic lungs detected during a search for malignancy prompted by a diagnosis of dermatomyositis. Malignancy was indeed uncovered in the form of endometrial carcinoma, the management of which eventually also established the etiology of cystic lung disease. In the discussion we attempt to connect the patient's autoimmune disease, uterine cancer, and lung cysts. The potential interplay among these three components of her presentation makes for intriguing mechanistic speculation.

Primary effusion lymphoma of the pleural space: Report of a rare complication of cardiac transplant with review of the literature.

Primary effusion lymphoma (PEL) is a rare mature B-cell non-Hodgkin's lymphoma arising in body cavities and presenting with effusions. It has been described predominantly in patients with impaired immunity from the acquired immunodeficiency syndrome and is associated with the Human Herpesvirus-8 (HHV-8). Seldom has PEL been diagnosed in persons negative for the human immunodeficiency virus (HIV), and in such cases it has occurred primarily in the setting of posttransplant immunosuppression. We report an instructive case of a Caribbean-American HIV-negative orthotopic heart transplant recipient with a history of HHV-8-associated Kaposi's sarcoma who developed HHV-8 viremia and PEL of the pleural space early in the posttransplant course. This case highlights the importance of considering PEL in the differential diagnosis of a new pleural effusion in a transplant recipient at risk for HHV-8-associated disease.

Pulmonary Kaposi's Sarcoma and Its Complications in the HAART Era: A Contemporary Case-Based Review.

The early years of the acquired immunodeficiency syndrome (AIDS) epidemic introduced the global medical community to Kaposi's sarcoma (KS), a heretofore seldom encountered angiosarcomatous neoplasm associated with human herpesvirus-8. At that time, clinicians treating these KS patients were routinely exposed to the pulmonary manifestations of this malignancy, including characteristic airway lesions, peribronchovascular opacities, and the typically hemorrhagic pleural effusions. They also witnessed uncommon complications of pulmonary KS such as chylous effusions, diffuse alveolar hemorrhage, and immune reconstitution inflammatory syndrome. Since the advent of highly active antiretroviral therapy, the incidence of KS has steadily declined and with that so has clinician familiarity with this disease. Herein, we present four KS cases recently encountered at our institution that illustrate both typical manifestations of pulmonary KS as well as its thoracic complications. The case descriptions are followed by a review of these clinical entities with the aim of restoring awareness among frontline physicians of what is now a rare but not quite extinct AIDS-defining neoplasm.

Unusual causes of gastrointestinal bleeding in the intensive care unit through the radiology lens.

The great majority of patients admitted to the intensive care unit (ICU) for critical gastrointestinal bleeding (GIB) will have a predictable etiology. Once the site is localized to the upper versus the lower gastrointestinal tract, the number of typically encountered etiological possibilities is quite limited. On rare occasions, the cause of GIB requiring ICU care is not one of the standard considerations, potentially leading to diagnostic and therapeutic delays. Within a short time period, three patients were admitted to our institution's medical ICU each with a different unexpected cause of GIB. All three cases generated a variety of instructive images, which are used in the present series to illustrate these conditions and the role of radiology in their evaluation and management.

Barking up the wrong tree: Vascular tree-in-bud due to intravascular lymphoma.

A 59-year-old previously healthy woman presented with a six-month history of fever, nonproductive cough, and weight loss. The cause of these symptoms remained obscure despite a thorough, month-long hospitalization. On presentation, she was normotensive with a pulse of 98 beats/minute, respiratory rate of 20 breaths/minute, and a temperature of 39.4C. She was emaciated. Physical examination was notable for faint bibasilar crackles on lung auscultation. Initial laboratory testing revealed pancytopenia. Peripheral smear demonstrated normocytic, normochromic anemia without immature cells or schistocytes. Other notable laboratory findings included elevated levels of lactate dehydrogenase, elevated ferritin, and elevated levels of fasting serum triglycerides. A comprehensive laboratory evaluation for connective tissue disease was negative. Plain chest radiography was normal while computed tomography (CT) of the chest demonstrated sub-centimeter nodules in a branching centrilobular pattern as well as in a peri-lymphatic distribution without associated lymphadenopathy or organomegaly. The above constellation of laboratory abnormalities raised concern for hemophagocytic lymphohistiocytosis (HLH). Soluble IL-2 (CD25) receptor levels were markedly elevated. Bronchoscopy with transbronchial biopsies of the right lower lobe was performed, revealing intravascular lymphoma associated with HLH. Our case emphasizes the need for clinicians to consider vascular causes of tree - in-bud nodules in addition to the conventional bronchiolar causes. The case also is a reminder of the need to conduct an exhaustive search for malignancy, in patients with HLH.