Survival Against the Odds-Hemophagocytic Lymphohistiocytosis Amidst the Shadows of Disseminated Histoplasmosis: A Case Report and Literature Review.

Hemophagocytic lymphohistiocytosis (HLH) secondary to Histoplasma capsulatum is rare, impacting <1% globally, with a mortality rate of up to 31%. Herein, we present a rare case of HLH secondary to H capsulatum, affecting a 57-year-old female with rheumatoid arthritis. Extensive investigations were unrevealing and despite broad-spectrum antibiotics, her condition worsened, leading to respiratory failure requiring extracorporeal membrane oxygenation (ECMO) support, shock requiring multiple vasopressors, and acute kidney injury (AKI) requiring hemodialysis. Diagnosis confirmed disseminated histoplasmosis (DHP), prompting Amphotericin B and methylprednisolone treatment, resulting in significant improvement and discharge with posaconazole therapy. Secondary HLH, primarily arising from severe infections like DHP, is discussed. Limited research exists on this condition in human immunodeficiency virus (HIV)-seronegative individuals. Diagnosis involves HLH-2004 and HScore criteria. Managing histoplasmosis-associated HLH remains challenging due to multiorgan failure risks and treatment complexities and needs further research.

Recurrent Bioprosthetic Valve Serratia marcescens Endocarditis in Intravenous Drug Users.

BACKGROUND We report 2 cases of recurrent right-sided endocarditis in 2 young patients known to be intravenous (i.v.) drug users. We highlight the importance of early diagnosis and management, especially in recurrent infection, which has a higher mortality rate and poor prognostic outcome despite antibiotic treatment. CASE REPORT A 30-year-old woman with a medical history of active i.v. drug use and tricuspid valve replacement owing to Serratia marcescens endocarditis 2 months prior to presentation was admitted to the Intensive Care Unit for septic shock. The patient did not respond to i.v. fluids and required vasopressors. Blood cultures returned positive for S. marcescens again. The antibiotic regimen consisted of meropenem and vancomycin. The patient underwent redo sternotomy, explant of old tricuspid valve bioprosthesis, debridement of tricuspid valve annulus, and bioprosthetic valve replacement. She continued antibiotic treatment during hospital admission for 6 weeks. In another similar case, a 30-year-old woman, also an i.v. drug user, was admitted to the hospital for tricuspid bioprosthetic valve S. marcescens endocarditis after tricuspid valve replacement 5 months prior to her presentation with S. marcescens endocarditis. Her antibiotic regimen consisted of meropenem and vancomycin. She was eventually transferred to a tertiary cardiovascular surgery center for further case management. CONCLUSIONS In the setting of recurrent bioprosthetic valve S. marcescens endocarditis, it is suggested that treatment should be more focused on source control, including cessation of i.v. drug abuse and providing appropriate antibiotic treatment to prevent recurrence because, in the case of recurrence, morbidity and mortality risk can increase significantly.

Limbic Encephalitis as a Presenting Complication for Small Cell Lung Cancer.

Limbic encephalitis (LE) is a rare neurological paraneoplastic complication that occurs secondary to malignant tumors. It is commonly presented as refractory seizures that are resistant to most anti-epileptics. We are presenting a unique case of small cell lung cancer complicated with LE. The challenging part of our case is that the patient had a history of seizure disorder in the past, and she was treated initially as an anti-epileptic treatment failure. A 68-year-old patient with a history of epilepsy was admitted to the ICU with resistant status epilepticus (SE), and respiratory failure secondary to pneumonia. Further workup revealed that the patient has small cell lung carcinoma. An extensive workup done to investigate resistant seizures revealed that she had a rare type of paraneoplastic autoantibodies (Anti-Hu) in the cerebrospinal fluid, which supported the diagnosis of the paraneoplastic autoimmune LE. High dose steroids helped to decrease the seizures episodes, but the family decided to proceed with palliative measures only at the end. Diagnosing LE requires ruling out other common causes of SE. Treatment options include treating underlying cancer as well as means of immunosuppression or antibody removal by tacrolimus and cyclophosphamide and even intravenous immunoglobulin (IVIG) or plasma exchange. It is important to consider LE in the differential diagnosis when managing patients with resistant SE in the ICU, even if the brain imaging and cerebrospinal fluid (CSF) analysis were within normal limits.

A series of two cases of rare tumors: Solitary fibrous tumor of the pleura.

Solitary fibrous tumors of the pleura (SFTPs) are rare neoplasms of mesenchymal origin most commonly arising in the pleura and have a benign biological behavior in the majority of cases. Most patients with SFTPs are asymptomatic; however, symptoms are mostly related to the mass effect within the thoracic cavity. Chest computed tomography (CT) scanning is the radiographic test of choice, but findings lack specificity. Surgical resection is the treatment of choice for most patients. Long-term survival after resection of benign SFTPs is excellent. In this case series, we present two females, one presented with shortness of breath (SOB) and nonproductive cough and the other one was referred because of abnormal x-ray findings. The histological as well as the immunohistochemical examination revealed the mass to be a solitary fibrous tumor of the pleura.

Rasburicase induced severe hemolysis and methemoglobinemia in a Caucasian patient complicated by acute renal failure and ARDS.

Rasburicase is a recombinant urate-oxidase enzyme and is a very important medication for tumor lysis syndrome. Methemoglobinemia and hemolysis are known side effects of rasburicase that result from oxidative stress caused by hydrogen peroxide, a byproduct generated during the breakdown of uric acid to allantoin. Patients with G6PD deficiency have a decreased tolerance to oxidative stress and are therefore at a greater risk of hemolysis and methemoglobinemia with rasburicase. Our patient is a 56-year-old Caucasian male with a recent diagnosis of grade 2-3a non-Hodgkin's lymphoma who presented to our emergency department with shortness of breath and dark discoloration of urine. Patient was discharged 36 hours ago from our hospital after he was given a first course of R-CHOP regimen and a dose of rasburicase. On further evaluation, patient was found to have severe anemia with hemolytic picture, hyperkalemia and acute kidney injury. He also had a discrepancy of the transcutaneous saturation (75%) and the saturation in an arterial blood gas value (99%). His methemoglobin level was found to be 11.9%. We were aware that methylene blue is a contraindication in patients with G6PD deficiency but considering patient being Caucasian and low risk for it and his deteriorating respiratory condition, it was decided to offer the treatment and patient received 1 dose of methylene blue which failed to improve his methemoglobinemia. He was also given vitamin C and 8 units of packed red blood cell throughout his stay in the hospital. Patient's hospital course was complicated by ARDS needed to be on mechanical ventilation support for 4 days and acute renal failure secondary to pigment nephropathy and acute tubular necrosis which required a hemodialysis support. Even if rasburicase induced methemoglobinemia and hemolysis are not very common complications, clinicians who prescribe and follow patients should detect this serious complication early and manage it accordingly. Our case can be used as a reminder that patients should be followed closely and given the right instructions on discharge to treat these complications which are associated with severe consequences. It is also vital to assume a diagnosis of G6PD deficiency until proven otherwise in a patient who presents with rasburicase induced hemolysis and avoid administration of methylene blue even if the patient is from a low risk ethnicity for G6PD as in our patient.

Pulmonary vein thrombosis secondary to tuberculosis in a non-HIV infected patient.

Our patient is a 67-year-old male with a past medical history significant for hypertension and hyperlipidemia came to a hospital with hemoptysis. He was also having cough and shortness of breath for the last 1 month. He said that his hemoptysis was about 1 cup per day mixed with yellowish sputum. He noticed around 20 pounds of weight loss in the last 1 month. He also complained of night sweats but had no fever. He had no history of travel outside the USA. He has never been incarcerated before, but he endorsed that his son has been to Jail before and he visited him twice a year in patient's home. But he also said that his son has never been diagnosed with TB. He smoked 1.5 packs per day for the last 50 years and quit smoking 2 months ago. His medication include hydrochlorothiazide, lisinopril, gabapentin, aspirin and trazodone. On examination, vital signs were within the normal range except a hearty rate of 106 beats/minute. He had slightly pale conjunctiva, non-icteric sclera and had wet tongue and buccal mucosa. There was decreased air entry with crepitations in the right side of the posterior chest but no wheezes or rales. No peripheral lymphadenopathy, no peripheral edema or sign of fluid collection in the abdomen. Chest x ray showed multiple cavitary lesion in the right upper lobe area. CT scan of the chest with PE protocol showed pulmonary venous partial thrombosis in the right upper lobe. Multiple cavitary lesions with hilar and mediastinal lymphadenopathy. There are also smaller nodular lesions in the left chest too. Small right pleural effusion with multiple calcified granulomata in the left upper lobe. QuantiFERON gold test was found to be positive. Sputum AFB smear was found to be strongly positive and it is sensitive to rifampin. Echocardiography showed no valvular lesions with preserved ejection fraction (>65%) and normal right ventricular size and normal right ventricular systolic pressure. Liver enzymes and renal function tests were found within the normal limit. HIV test was negative. Patient was started with intensive phase anti-tuberculosis treatment with rifampin, isoniazid, ethambutol, pyrazinamide with vitamin B6. He was also started with anticoagulation with heparin and warfarin considering the tuberculosis being the cause of the pulmonary vein thrombosis. Patient was also given supportive treatment and he made a gradual improvement and was discharged with anti-tuberculosis treatment and warfarin. Patient needed to be placed on a higher dose of warfarin as it was difficult to keep him therapeutic with lower doses. He was also advised to follow with infectious disease and anticoagulation clinic. Patient was found to have a significant increase in liver enzymes and bilirubin on follow up and the anti-TB medications were stopped to be restarted one by one with a follow up of his liver enzymes and liver function tests. He was also continued with warfarin.

Urinothorax Caused by Xanthogranulomatous Pyelonephritis.

Xanthogranulomatous pyelonephritis is a rare form of chronic pyelonephritis that generally afflicts middle-aged women with a history of recurrent urinary tract infections. Its pathogenesis generally involves calculus obstructive uropathy and its histopathology is characterized by replacement of the renal parenchyma with lipid filled macrophages. This often manifests as an enlarged, nonfunctioning kidney that may be complicated by abscess or fistula. This case details the first reported case of xanthogranulomatous pyelonephritis complicated by urinothorax, which resolved on follow-up chest X-ray after robot-assisted nephrectomy.

Atypical rapid onset Scleroderma Renal Crisis (SRC) complicated with diffuse alveolar hemorrhage and pleuro-pericardial effusions in a patient with recently diagnosed breast cancer and a positive anti-RNA polymerase III Ab.: A case report.

Scleroderma associated Pulmonary-Renal Syndrome is a rare but severe complication with a poor prognosis and high mortality. A high index of suspicion is needed for early recognition of this potential complication in patients with systemic sclerosis and institution of appropriate treatment. With more data showing an increased association between scleroderma and malignancy, a heightened vigilance should also be exercised in patients with malignancy and scleroderma-like presentation. We report of a case rapid onset systemic sclerosis complicated by acute renal failure and diffuse alveolar hemorrhage in a woman with stage IIB right breast cancer and elevated RNA Polymerase III IgG Ab. To our knowledge, this the first case of a patient with breast cancer associated with systemic sclerosis and pulmonary-renal syndrome.

Mechanical ventilation management by pulmonologists and surgeons in patients with adult respiratory distress syndrome.

BACKGROUND: Treatment of patients with acute respiratory distress syndrome (ARDS) is complex, and management by a specialist with expertise in pulmonary mechanics may improve outcomes. We compared mechanical ventilation management of patients with ARDS by pulmonologists and surgeons. METHODS: We retrospectively reviewed 97 patients with an ICD-9 diagnosis of ARDS at 2 community hospitals. We collected information on demographics and all necessary parameters to calculate the acute physiology, age, and chronic health evaluation (APACHE II) score. Main outcomes included mortality and total days spent in the intensive care unit (ICU) and on mechanical ventilation. All outcomes were adjusted for APACHE II score using multiple logistic regression. RESULTS: Mechanical ventilation was managed by a pulmonologist in 62 patients and by a surgeon in 35 patients. Mortality rate was 35.5% (n = 22) in the patients treated by pulmonologists and 45.7% (n = 16) in patients treated by surgeons (P = 0.32). This result was unaffected by adjustment for APACHE II score. However, those surviving spent fewer days in the ICU (median of 10 vs 16 days; P = 0.07) and fewer days on mechanical ventilation (median of 7 vs 15 days; P = 0.003) when treated by pulmonologists. These results were unaffected by adjustment for APACHE II score. CONCLUSIONS: We found that patients who survived with ARDS spent fewer days on mechanical ventilation, and there was a trend for spending fewer days in the ICU when mechanical ventilation is managed by a pulmonologist compared with a surgeon. There was a lower mortality rate in the pulmonologist group, although this did not reach statistical significance. A small sample size and the retrospective design limit our findings. Further study using a multicenter design to determine if a disease specific specialist improves efficiency of care is needed because if our findings are confirmed, it would translate into significant cost savings.