Invasive pseudomembranous upper airway and tracheal Aspergillosis refractory to systemic antifungal therapy and serial surgical debridement in an Immunocompetent patient.

BACKGROUND: The development of respiratory infections secondary to Aspergillus spp. spores found ubiquitously in the ambient environment is uncommon in immunocompetent patients. Previous reports of invasive upper airway aspergillosis in immunocompetent patients have generally demonstrated the efficacy of treatment regimens utilizing antifungal agents in combination with periodic endoscopic debridement, with symptoms typically resolving within months of initiating therapy. CASE PRESENTATION: A 43-year-old previously healthy female presented with worsening respiratory symptoms after failing to respond to long-term antibiotic treatment of bacterial sinusitis. Biopsy of her nasopharynx and trachea revealed extensive fungal infiltration and Aspergillus fumigatus was isolated on tissue culture. Several months of oral voriconazole monotherapy failed to resolve her symptoms and she underwent mechanical debridement for symptom control. Following transient improvement, her symptoms subsequently returned and failed to fully resolve in spite of increased voriconazole dosing and multiple additional tissue debridements over the course of many years. CONCLUSIONS: Invasive upper airway aspergillosis is exceedingly uncommon in immunocompetent patients. In the rare instances that such infections do occur, combinatorial voriconazole and endoscopic debridement is typically an efficacious treatment approach. However, some patients may continue to experience refractory symptoms. In such cases, continued aggressive treatment may potentially slow disease progression even if complete disease resolution cannot be achieved.

JAK2 V617F-positive acute myeloid leukaemia (AML): a comparison between de novo AML and secondary AML transformed from an underlying myeloproliferative neoplasm. A study from the Bone Marrow Pathology Group.

The JAK2 V617F mutation is characteristic of most Philadelphia chromosome-negative myeloproliferative neoplasms (MPNs) and occurs rarely in de novo acute myeloid leukaemia (AML). We sought to characterize AMLs that harbour this mutation and distinguish those that arise de novo (AML-DN) from those that reflect transformation of an underlying MPN (AML-MPN). Forty-five patients with JAK2 V617F-mutated AML were identified; 15 were AML-DN and 30 were AML-MPN. AML-MPN cases were more likely to have splenomegaly (P = 0·02), MPN-like megakaryocytes and higher mean JAK2 V617F VAF at diagnosis (P = 0·04). Mutations involving TET2 were exclusively identified in AML-DN patients. Mutations of genes affecting DNA methylation were more common in AML-DN (P < 0·01). A complex karyotype was more frequent in AML-MPN cases than in AML-DN (P < 0·01), with AML-DN more likely to display a normal karyotype (P = 0·02). Bone marrow histology after recovery from induction chemotherapy in AML-DN cases revealed no morphological evidence of any previously occult MPNs, while this was evident in most of the AML-MPN specimens (P < 0·01). These findings in this largest study of JAK2 V617F-mutated AMLs indicate that AML-DN is distinct from AML-MPN.

The use of inhaled nitrous oxide for analgesia in adult ED patients: a pilot study.

BACKGROUND: Oligoanalgesia challenges emergency department (ED) health care providers and remains an area of patient dissatisfaction. Nitrous oxide (NO) is a safe, quick-acting, and well-tolerated sedative agent with analgesic and anxiolytic properties that make it ideal for ED use. OBJECTIVES: We seek to test the effectiveness of a self-administered and self-contained NO device as an analgesic agent in the ED and assess patient and staff satisfaction with this method. METHODS: We enrolled 85 patients 18 years and older in a prospective observational study of patients presenting to the ED with moderate to severe pain (≥30 mm on a 100-mm visual analog scale). Subjects received a mixture of 50% NO via a self-administered portable delivery device. Primary outcome was the reduction in baseline pain scores at 20, 40, and 60 minutes. Secondary outcomes were patient, nurse, and physician satisfaction as reported on a brief satisfaction questionnaire. RESULTS: There was a significant reduction in mean pain scores from baseline to 20 minutes that was sustained through the 60-minute period. Most subjects (93%; 95% confidence interval [CI], 85%-97%) and nurses (97%; 95% CI, 90%-99%) reported that the NO delivery system was easy to use and were satisfied with the level of pain relief and would use NO in the future (82%; 95% CI, 73%-89%). Physicians and nurses were also satisfied with the analgesic effects of NO (82%; 95% CI, 73%-89%). CONCLUSIONS: The portable NO device is an effective analgesia adjunct for ED patients presenting with painful conditions, and patients, ED nurses, and emergency physicians are satisfied with its use. Nitrous oxide coupled with a nurse-driven analgesia protocol may provide a novel solution for improvement in ED analgesia rates and overall patient satisfaction with ED pain management.

Double-blind, Randomized, Placebo-controlled Study Evaluating the Use of Platelet-rich Plasma Therapy (PRP) for Acute Ankle Sprains in the Emergency Department.

BACKGROUND: Over 23,000 people per day require treatment for ankle sprains. Platelet-rich plasma (PRP) is an autologous concentration of platelets that is thought to improve healing by promoting inflammation through growth factor and cytokine release. Studies to date have shown mixed results, with few randomized trials. OBJECTIVES: To determine patient function among patients randomized to receive standard therapy plus PRP, compared to patients who receive standard therapy plus sham injection (placebo). METHODS: Prospective, randomized, double-blinded, placebo-controlled trial. Patients with severe ankle sprains were randomized. Severity was graded on degree of swelling, ecchymosis, and ability to bear weight. PRP with lidocaine and bupivacaine was injected at the point of maximum tenderness by a blinded physician under ultrasound guidance. The control group was injected in a similar fashion with sterile 0.9% saline. Both groups had visual analog scale (VAS) pain scores and Lower Extremity Functional Scale (LEFS) on days 0, 3, and 8. LEFS and a numeric pain score were obtained via phone call on day 30. All participants were splinted, given crutches, and instructed to not bear weight for 3 days; at this time patients were reevaluated. RESULTS: There were 1156 patients screened and 37 were enrolled. Four withdrew before PRP injection was complete; 18 were randomized to PRP and 15 to placebo. There was no statistically significant difference in VAS and LEFS scores between groups. CONCLUSION: In this small study, PRP did not provide benefit in either pain control or function over placebo.

Aberrant Cytokeratin 20 Reactivity in Epithelioid Malignant Mesothelioma: A Case Report.

Malignant mesothelioma is an uncommon neoplasm that should be distinguished from the more common pulmonary adenocarcinomas and other metastatic lesions. Although diagnosis is based on morphologic features, immunohistochemical stains such as Calretinin, WT-1, CK-5/6, D2-40, Ber-Ep4, and MOC-31 are routinely used. Other organ-specific immunohistochemical markers are used when metastases from unknown primary lesion is suspected clinically. Here, we report a case of pleural epithelioid malignant mesothelioma expressing CK20. A 68-year-old male presented to the Emergency Department with nonproductive cough and progressive shortness of breath. Chest x-ray showed a large left-sided pleural effusion. Metastasis from a gastrointestinal primary was clinically suspected. Cytopathologic examination of the pleural fluid demonstrated atypical cells singly and in clusters with round nuclei, prominent nucleoli, and dense cytoplasm. The cell block demonstrated single and clusters of atypical cells positive for calretinin, D2-40, WT-1, CK-5/6, and CK7. Ber-EP4, MOC-31, TTF-1, Napsin-A, and CDX-2 were negative. CK20 was diffusely positive. A diagnosis of atypical mesothelial proliferation with aberrant CK20 expression was made. A subsequent pleural biopsy demonstrated sheets of highly atypical cells that were diffusely and strongly positive for the mesothelial markers and CK20. Multiple studies have shown malignant mesotheliomas to lack CK20 reactivity. To our knowledge, this is the first case report of a diffuse and strong CK20-positive mesothelioma. Such aberrant expressions should be kept in mind when cases are histologically atypical or lack reactivity for multiple mesothelial markers, especially when a gastrointestinal primary malignancy is suspected.

Amyloidosis diagnosed in cytology specimen of pleural effusion: A case report.

Amyloidosis is a rare condition resulting from extracellular deposition of amyloid, a fibrillary material derived from various precursor proteins. Involvement of the pleura by amyloidosis is a rare but serious complication. Pleural amyloidosis is primarily diagnosed by identifying amyloid deposition by histology on pleural biopsy specimens. Hereby, we report a case of systemic amyloidosis where we were able to identify amyloid in a pleural effusion specimen sent for cytopathology evaluation. A 59-year-old male with newly diagnosed multiple myeloma and systemic amyloidosis underwent therapeutic thoracentesis. The H&E stained cell block sections revealed a single, less than one millimeter focus of waxy material surrounded by a rim of reactive mesothelial cells suspicious for amyloid deposit in a background of fibrin, lymphocytes, and reactive mesothelial cells. The focus stained salmon pink with Congo-red special stain and showed apple-green birefringence under polarized light. Our finding suggests that pleural involvement in patients with systemic amyloidosis can be identified on effusion specimens and avert the need for more invasive procedures like pleural or pulmonary parenchymal biopsies.

Metastatic Alveolar Soft Part Sarcoma of the Spinal Cord: A Case Report and Review of Literature.

BACKGROUND: Alveolar soft part sarcoma (ASPS) is a rare, malignant soft-tissue neoplasm typically seen in young adults that possesses an unusual tendency to metastasize. Metastases to the intramedullary compartment of the spinal cord, however, are exceptionally rare and have not been described in the literature. CASE DESCRIPTION: We report the case of a 23-year-old woman with disseminated ASPS to the lung and brain who presented with progressive lower-extremity weakness and loss of sensation after radiation and chemotherapy. Magnetic resonance imaging revealed a 1.3-cm avidly enhancing lesion within the central thoracic spinal cord at T3. A T2-T4 laminectomy was undertaken and resulted in a gross total resection. Histopathologically, the mass was composed of organoid nests containing epithelioid cells with eosinophilic, granular cytoplasm separated by sinusoidal spaces. Immunohistochemistry demonstrated convincing positive TFE3 staining. Postoperative imaging confirmed the complete resection of the mass, and her examination was notable for intact sensation and impaired motor function that gradually improved. CONCLUSIONS: A review of the literature found that the reported case represents the first instance of primary or metastatic ASPS in the spinal cord. Metastatic ASPS should thus be included in the differential diagnosis in patients with known disease and neurologic impairment or back pain. Imaging of the spine should then be considered.

Phencyclidine Intoxication Case Series Study.

BACKGROUND: Phencyclidine (PCP) is a synthetic compound derived from piperidine and used as an anesthetic and hallucinogenic. Little has been recently published regarding the clinical presentation of PCP intoxication. PCP use as a recreational drug is resurging. OBJECTIVE: Our objective was to describe clinical findings in patients presenting to the emergency department (ED) under the influence of PCP. METHODS: This was a case series study conducted at a tertiary care center with an annual census of 100,000 patients/year. Emergency physicians, residents, physician assistants, and research assistants identified patients with possible PCP intoxication. Self-reported PCP use, report by bystanders or Emergency Medical Services (EMS) staff, was used in this process. A structured data collection form was completed, documenting both clinical and behavioral events observed by the treating team during the ED visit. RESULTS: We collected data on 219 patients; 184 were analyzed; two patients were excluded secondary to incomplete data. The mean age of patients was 32.5 years (±7 years) with 65.2 % being males. PCP use was self-reported by 60.3 % of patients. Of the 184 patients, 153 (83.1 %) received a urine drug screen (UDS); 152 (98.7 %) were positive for PCP. On arrival, 78.3 % of patients were awake and alert, and 51.6 % were oriented to self, time/date, and place. Mean physiological parameters were the following: heart rate 101.1 bpm (±24.3), RR 18.9 bpm (±3.4), BP 146.3 (±19.4)/86.3 (±14.0) mmHg, 36.9° C (±0.5), and pulse oximetry 98.2 % (±1.9). Clinical findings were the following: retrograde amnesia in 46 (25 %), horizontal nystagmus in 118 (64.1 %), vertical nystagmus in 90 (48.9 %), hypertension in 87 (47.3 %), and agitation in 71 (38.6 %). Concomitant use of at least one other substance was reported by 99 (53.8 %) patients. The mean length of stay in the ED for all subjects was 261.1 (±172.8) minutes. Final disposition for 152 (82.6 %) patients was to home. Of the 184 patients, 14 (7.6 %) required admission; 12 were referred to Crisis Response Center. CONCLUSION: Patients with PCP intoxication tended to be young males. The prevalent clinical signs and symptoms were the following: retrograde amnesia, nystagmus, hypertension, and psychomotor agitation. Co-use of other substances was the norm. Most patients presenting to the ED with PCP intoxication do well and can be discharged home after a period of observation.

Ultrasound-guided radial artery access by a non-ultrasound trained interventional cardiologist improved first-attempt success rates and shortened time for successful radial artery cannulation.

BACKGROUND: Use of the radial artery for cardiac catheterization and percutaneous coronary intervention (PCI) continues to expand. Cannulating the radial artery can be one of the most challenging aspects of the radial approach. Ultrasound-guided vascular access may be a method to improve first-attempt success rates and shorten time to radial artery access. METHODS: Fifty consecutive patients underwent ultrasound-guided radial artery access (UGRAA) by a senior interventional cardiologist with little prior experience with UGRAA. The operator had 20 run-in cases before enrolling subjects. Time to establish access and number of attempts required for each patient were recorded. Ultrasound was also used to measure radial arterial diameter and the distance between the skin and the anterior wall of the radial artery. RESULTS: All patients had successful UGRAA, 80% on the first attempt and 92% on the first or second attempt. The median time for access was 35 seconds, with an interquartile range of 31-55 seconds. CONCLUSION: UGRAA improved first-attempt success rates and shortened the time needed for radial artery cannulation when compared to historical data of palpation-directed radial artery access. A large randomized trial of palpation versus UGRAA will be required to confirm this finding. Furthermore, this technique is easy to learn and incorporate into everyday practice in the cardiac catheterization lab.