Hemorrhagic pneumonia and upper lobe pulmonary cavitary lesion caused by Streptococcus pyogenes.

A 33-year-old previously healthy man from Mexico who presented with massive hemoptysis, fevers, chills and found to have cavitary lesions in the right upper lobe of lung was highly suspicious for tuberculosis. The patient was treated with vancomycin, ceftriaxone, azithromycin and placed on isolation for suspected tuberculosis. Sputum AFB stains were negative and blood cultures grew Group A Streptococcus [GAS]. Antibiotics were narrowed down to ampicillin-sulbactam and the patient was discharged with significant clinical improvement. Strep A pyogenes is a rare cause of cavitary hemorrhagic pneumonia but is associated with high mortality. Clinical suspicion and early diagnosis are crucial in saving the patient.

Parasitic necrotizing pneumonia in an immunocompetent patient in United States.

A 59-year-old Baltimore native female, with a history of asthma and no history of travel outside of the USA, presented with productive cough and shortness of breath. Computed tomography scan showed left upper lobe consolidation of the lung with multiple tiny cavitations. She was empirically treated without improvement. Later, strongyloides were found in the sputum gram stain and she was treated with ivermectin. Pulmonary strongyloidiasis has been mainly described in patients who are immunosuppressed and have a history of travel to endemic areas, both of which were absent in our patient. Our case underlines the importance of considering strongyloides necrotizing pneumonia as a differential diagnosis of community-acquired pneumonia even in immunocompetent patients in the USA, especially if not responding to empiric treatment.

A rare case of cytomegalovirus causing respiratory failure and a large pericardial effusion.

Cytomegalovirus (CMV) infection is asymptomatic in the majority of immunocompetent patients. However, it can cause severe presentations, particularly in patients who are immunocompromised. We are reporting a rare association between respiratory failure secondary to cavitary pneumonia and a large pericardial effusion due to CMV infection in a patient with human immunodeficiency virus. The patient presented with hypoxic respiratory failure and a large pericardial effusion at risk of tamponade. After extensive investigation, the sole pathogen identified in the patient's bronchoalveolar lavage and pericardial fluid was CMV.

Reliability of focused cardiac ultrasound performed by first-year internal medicine residents at a community hospital after a short training.

The use of bedside ultrasound over the past few decades has created a new wave of options for visualizing pathological processes allowing for faster and better detection of disease. We aimed to evaluate the reliability of focused cardiac ultrasound (FCU) performed by first-year internal medicine residents at a community hospital after a short period of training. They received a two-hour lecture and initially performed a supervised FCU followed by ten unsupervised/independent FCUs each. The four parameters that were assessed were left systolic ventricular function, right systolic ventricular function, presence of pericardial effusion, and presence of IVC dilation. Interpretation and analysis of ultrasound images were then carried out by both the residents and an attending physician with expertise in FCU analysis and interpretation. Cohen's Kappa values were obtained comparing the results found by the interns versus the attending. Our findings indicate that more training is required for reliable analysis of FCU by first-year medical residents. Our results also emphasize the need to carefully evaluate the medical residents' FCU skills after the training.

A rare case of lamotrigine-induced acute interstitial nephritis.

Medications, especially non-steroidal anti-inflammatory drugs and antimicrobials, have been most commonly associated with acute interstitial nephritis (AIN); antiepileptic drugs (AEDs) are rarely known to cause AIN. This is a case of a 27-year-old male who was recently started on treatment with lamotrigine for bipolar disorder and was found to have rapidly progressive renal failure. Renal biopsy features were suggestive of AIN. Lamotrigine-induced AIN was suspected to be the most likely cause. Discontinuation of the drug and treatment with steroids resulted in complete renal recovery. Lamotrigine use has been recently gaining popularity, not only as an AED but also as a mood stabilizer. With the use of this drug becoming more popular, it is important to emphasize that - although rare - AIN is one of its potential complications.

Comparison between young males and females with acute myocardial infarction.

OBJECTIVE: To assess the differences between young males and females after acute myocardial infarction. METHODS: We retrospectively studied 236 patients (54 females and 182 males) after acute myocardial infarction and during hospital stay assessed the following parameters: risk factors; the treatment used; the pattern of coronary artery obstruction; left ventricular ejection fraction; complications; and, using a logistic regression model, the factors related to the occurrence of reinfarction and death. RESULTS: No significant difference was observed between the sexes in risk factors, pattern of coronary artery obstruction, and left ventricular function. The time interval between symptom onset and treatment was longer in females (p=0.03), who underwent thrombolysis (p=0.01) and angioplasty (p=0.03) less frequently than males did, but not myocardial revascularization. Female sex (OR = 5.98) and diabetes (OR = 14.52) were independent factors related to the occurrence of reinfarction and death. CONCLUSION: Young males and females after acute myocardial infarction did not differ in coronary risk factors, and clinical and hemodynamic characteristics. Females had their treatment started later, and they underwent chemical thrombolysis and angioplasty less frequently than males did. Female sex and diabetes were related to the occurrence of reinfarction and death.

Low-pressure cardiac tamponade masquerading as severe sepsis diagnosed with a bedside ultrasound and as the initial presentation of malignancy.

OBJECTIVE: We report a patient with low-pressure cardiac tamponade masquerading as sepsis and as the initial presentation of malignancy. A quick diagnosis was done by the intensivist performing a bedside ultrasound. BACKGROUND: The diagnosis of low-pressure cardiac tamponade is a challenge because the classic physical signs of cardiac tamponade can be absent. It is made even more challenging when the vital sign changes and physical examination findings mimic severe sepsis. One of the benefits of a bedside ultrasound in the assessment of a patient with an initial diagnosis of severe sepsis or septic shock is the rapid diagnosis of cardiac tamponade if it is present. DATA SOURCE AND SYNTHESIS: A 55-year-old male presented to the emergency department with weakness, cough, and syncope. His examination was notable only for dusky mottling of his cheeks, chest, and neck. Specifically, there was no jugular venous distension or pulsus paradoxus. A chest radiograph showed a right upper lobe infiltrate, whereas his electrocardiogram showed only sinus tachycardia. His white blood cell count and lactic acid were elevated. The sepsis protocol was started and a bedside ultrasound revealed signs of cardiac tamponade. The patient immediately improved after a pericardiocentesis. Analysis of the pericardial biopsy revealed adenocarcinoma, later determined to be from a pulmonary primary source. CONCLUSIONS: Because low-pressure cardiac tamponade is life-threatening and difficult to diagnose, evaluation of the pericardium with a bedside ultrasound should be considered in patients with syncope, severe sepsis, or shock.

Comparaçäo entre homens e mulheres jovens com infarto agudo do miocárdio / Comparison between young males and females with acute myocardial infarction

OBJECTIVE - To assess the differences between young males and females after acute myocardial infarction. METHODS - We retrospectively studied 236 patients (54 females and 182 males) after acute myocardial infarction and during hospital stay assessed the following parameters: risk factors; the treatment used; the pattern of coronary artery obstruction; left ventricular ejection fraction; complications; and, using a logistic regression model, the factors related to the occurrence of reinfarction and death. RESULTS - No significant difference was observed between the sexes in risk factors, pattern of coronary artery obstruction, and left ventricular function. The time interval between symptom onset and treatment was longer in females (p=0.03), who underwent thrombolysis (p=0.01) and angioplasty (p=0.03) less frequently than males did, but not myocardial revascularization. Female sex (OR = 5.98) and diabetes (OR = 14.52) were independent factors related to the occurrence of reinfarction and death. CONCLUSION - Young males and females after acute myocardial infarction did not differ in coronary risk factors, and clinical and hemodynamic characteristics. Females had their treatment started later, and they underwent chemical thrombolysis and angioplasty less frequently than males did. Female sex and diabetes were related to the occurrence of reinfarction and death

Abscesso hepático piogênico, origem provável em foco urinário: relato de um caso / Pyogenic liver abscess of probable urinary origin: report of a case

Relatou-se nesta trabalho o caso de um paciente que desenvolveu múltiplos abscessos piogênicos do fígado por via hematogênica a partir de um provável foco urinário demonstrado laboratoriamente. A mesma bactéria, Klebsiella sp, foi isolada nas hemoculturas, urinocultura e cultura da secreçäo do abscesso. Foi realizada a drenagem percutânea e antibioticoterapia havendo melhora rápida do quadro clínico, laboratorial e radiológico acompanhado pela ultra-sonografia (AU)/

Caracteristicas clínicas de indivíduos jovens com infarto agudo do miocárdio / Clinical characteristics of young peoplo with acute myocardial infarction

A prevalência do infarto agudo do miocárdio (IAM) em indivíduos jovens é baixa 4-8( por cento) e não dispomos de trabalhos que avaliem as características do IAM em um grande número de pacientes dessa população. O presente estudo teve como objetivo analisar os fatores de risco, caracteristicas angiográficas, tratamento e evolução hospitalar de indivíduos com IAM, com idades até 40 anos. Foram estudados 76 pacientes(61 homens e 15 mulheres), com idade média 36,9 mais ou menos 3,57 anos, admitidos no Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina de São Paulo, entre janeiro de 1996 e julho de 1999. O infarto foi de parede anterior em 35,5(por cento), inferior em 50 (por cento) e 14,5 ( por cento) tiveram IAM sem supradesnivelamento do segmento ST. O tabagismo foi o fator de risco ponderante ( 72,4 por cento). História de infarto prévio foi relatada em apenas 9,7 ( por cento). Artérias coronárias normais à cinecoronariografia ocorreram em 22,7(por cento) dos pacientes; 42,4(por cento) eram uniarteriais: 22,7(por cento), biarteriais e 12(por cento)triarteriais. Não houve lesões no tronco de coronária esquerda e a fração de ejeção média foi de 0,62 mais menos 0,16. A mortalidade hospitalar foi 2,6(por cento) (dois pacientes) e reinfarto ocorreu em quatro (5,2 por cento) doentes. Estes dados sugerem que pacientes jovens com IAM frequentemente são fumantes, têm incidência elevada de coronárias normais ou lesões uniarteriais e fração de ejeção normal, e bom prognóstico a curto prazo.