Patient With Pulmonary Symptoms, Dysphagia, and Raynaud Disease.

A nonsmoking patient with gastroesophageal reflux disease and Raynaud disease had 4 weeks of dysphagia and a 4.54-kg weight loss over 3 months, cough productive of yellow sputum, and dyspnea on exertion. White blood cell count and creatine kinase and aldolase levels were elevated; antinuclear antibody assay findings were positive; and chest CT showed bibasilar pulmonary consolidations and ground glass opacities. What is the diagnosis and what would you do next?

Current controversies in the support of sepsis.

PURPOSE OF REVIEW: Sepsis has a high morbidity, with a mortality rate of over 50% in the septic shock patient. This review provides a comprehensive summary of the latest Surviving Sepsis Campaign and the recent evidence since its publication. The guidelines reflect literature from the past 5 years to optimize outcomes in patients with severe sepsis and septic shock. RECENT FINDINGS: The most relevant changes in the latest Surviving Sepsis Campaign include the use of a protocolized resuscitation with specific physiologic targets, preference of crystalloids for volume resuscitation, preferential use of norepinephrine as the initial vasopressor, addition of lactate and its clearance as a marker of tissue hypoperfusion, reduced emphasis on corticosteroids, and removal of activated protein C therapy. Since these latest guidelines, there have been many trials published to address the various measures that are advocated. We review the recent data on fluid resuscitation, targets of resuscitation, vasopressors, and trials of protocolized care versus usual care. SUMMARY: Severe sepsis remains a significant cause of morbidity and mortality in hospitalized patients. The International Surviving Sepsis Guidelines provide a framework for early recognition and treatment of this condition, with the goal of an improved outcome and mortality in severe sepsis. The recent evidence suggests that early identification, adequate volume resuscitation, and assessment of adequate circulation may be the key elements to decrease morbidity from severe sepsis and septic shock.

Fulminant myocarditis associated with novel H1N1 influenza A.

Myocarditis secondary to H1N1 influenza has been described in children, but only very rarely in adults. We describe a 36-year-old man with no significant medical history who presented with flu-like symptoms of 3-week duration. When he sought medical attention, he was already manifesting heart failure secondary to fulminant myocarditis, along with multiorgan failure. Despite aggressive management, including circulatory support with a catheter-based mechanical cardiac assist device (Impella 2.5 Cardiac Assist Device, Abiomed, Danvers, MA) as a bridge to cardiac transplant, and aggressive antiviral and antibacterial therapy, the patient died of cardiac arrest. An H1N1 polymerase chain reaction postmortem assay produced positive results, and a diagnosis of fulminant viral myocarditis and multiorgan system failure was established.

Bronchiectasis: new findings in the pathogenesis and treatment of this disease.

PURPOSE OF REVIEW: Bronchiectasis is an under-appreciated cause of chronic lung disease in the USA. We highlight developments in diagnosis and treatment of this debilitating disease. RECENT FINDINGS: A possible link between gastroesophageal reflux and development of nontuberculous mycobacterial lung disease was highlighted. Reflux is more common in patients with nontuberculous mycobacterial lung disease, and among those with established bronchiectasis more extensive disease was observed in those patients who also had reflux. Long-term mortality in bronchiectasis was significantly associated with age, lower body mass index, dyspnea, lack of vaccination, hypoxemia, hypercapnia, and other functional parameters. In a large, randomized clinical trial, addition of inhaled tobramycin to ciprofloxacin for acute exacerbations of Pseudomonas infection produced microbiologic improvement correlating with clinical outcomes but not overall improvement. A review noted that five macrolide trials reported reduced sputum volume, improved lung function, and better symptom control. Finally, articles suggested benefit from inhaled hyperosmolar agents (e.g. hypertonic saline and inhaled mannitol). SUMMARY: The possible link between gastroesophageal reflux and nontuberculous mycobacterial lung disease, and the microbiology and resistance patterns of bacteria observed in these patients were clarified. A large study of inhaled tobramycin for exacerbations was inconclusive, but macrolide therapy and hyperosmolar agents hold promise.