A Rare Case of Aggressive Non-Hodgkin's Lymphoma of the Muscle in a Young Male Presenting as Necrotizing Myofasciitis.

Non-Hodgkin's lymphoma (NHL) involving skeletal muscle is generally found to be a secondary metastasis and extremely rarely as a primary site of malignancy. Furthermore, in HIV patients, an increased incidence of lymphomas may be identified within the first six months of highly active antiretroviral therapy (HAART) initiation unmasked by immune reconstitution inflammatory syndrome (IRIS). We illustrate an extremely rare instance of NHL of the skeletal muscle in a young immunocompromised male with HIV/AIDS presenting as necrotizing myofasciitis complicated by compartment syndrome and hemodialysis-refractory type B lactic acidosis. A young Hispanic male with AIDS was admitted for acute left thigh pain and was soon found to have abscess formation with compartment syndrome requiring thigh fasciotomy. During the course of the ICU stay, the patient's clinical status acutely worsened with sepsis-induced multiorgan failure, including acute renal and acute liver failure requiring N-acetylcysteine and severe refractory metabolic acidosis requiring renal replacement therapy. Repeat imaging demonstrated diffuse myonecrosis. Left thigh muscle biopsy confirmed aggressive NHL of skeletal muscle. Despite months of arduous medical management in ICU, doxorubicin, vincristine, cyclophosphamide chemotherapy with concurrent high-dose prednisone for the vented patient, and intermittent curves of improvement, our patient succumbed to the nature of the disease and subsequently died from severe sepsis from the immunocompromised state. Interestingly, our patient's initial CD4 count was 1, which improved to 96 after five months of HAART, raising concerns for IRIS lymphoma. Given such rapid improvement with chemotherapy, the possibility of IRIS-related lymphoma, and the surprising dearth of data for chemotherapy use in critically ill patients on mechanical ventilation, more research is needed in these topics to better approach such complicated patients.

Pulmonologist Education of the Teach-to-Goal Inhaler Technique for Those With Asthma and COPD.

BACKGROUND: Inhaler education for patients with asthma and patients with COPD is typically provided by non-pulmonologists. We studied inhaler education by pulmonologists to determine changes in clinical outcomes and inhaler use. METHODS: This was a retrospective study of 296 subjects diagnosed with asthma, COPD, or both that evaluated use of inhaler technique education and its impact on (1) inhaler/dosage change consisting of dosage change in the same class of inhaler and/or change in number of inhalers, (2) forced expiratory volume in one second/forced vital capacity (FEV1/FVC%), (3) disease symptom control, (4) out-patient visits, (5) urgent care visits (6) emergency department visits, and (7) hospital admissions. One group received inhaler technique education by a pulmonologist while the other group did not. RESULTS: The pulmonologist inhaler technique-educated group had significantly decreased relative risk for inhaler/dosage increase (relative risk 0.57 [95% CI 0.34-0.96], P = .03) and significantly increased odds for symptom control (odds ratio 2.15 [95% CI 1.24-3.74], P = .01) at 1-y follow-up as compared to the no education group. No differences occurred for FEV1/FVC%, out-patient visits, urgent care visits, emergency department visits, and hospital admissions. CONCLUSIONS: Pulmonologist education of inhaler technique for patients with asthma and patients with COPD was associated with decreased relative risk for inhaler/dosage increase and increased odds for symptom control. We recommend pulmonologists provide education of inhaler technique to patients with asthma and patients with COPD and not rely on non-pulmonologist education alone. Prospective research is needed to confirm the importance of proper inhaler techniques.

In-hospital outcomes of pulmonary hypertension in HIV patients: A population based cohort study.

BACKGROUND: Pulmonary hypertension (PH) is a known complication of HIV infection. Outcomes of HIV-infected patients with PH (HIV-PH) have not been well established. We aim to assess various in-hospital outcomes such as mortality, resource utilization, and health care burden associated with HIV patients with concurrent PH. MATERIALS AND METHODS: We used National Inpatient Sample (NIS) 2015 Quarter 4 through 2019 for this study. We identified patients using International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) diagnostic codes with both HIV and pulmonary hypertension. Cohorts were weighted by NIS-provided algorithm which allows for national estimates. Univariate and multivariate regression analyses were used to determine odds ratios. RESULTS: A total of 910,120 patients were identified with HIV, among which 28,175 (3.19%) were identified to have concurrent PH. When compared to HIV alone, HIV-PH patients were older (54.53(±11.61) vs. 49.44(±13.11), predominantly black (64.45% vs. 51.8%%), more often male (57.2%), all p < 0.001. HIV-PH cohort had higher comorbidities with higher Charlson Comorbidity Index (CCI) (7.07(±3.53) vs. 5.17(±3.65), had slightly longer LOS [adjusted mean difference (aMD) 0.79], higher healthcare burden corrected for inflation (aMD $17,065); all p < 0.001. In univariate regression analysis, patients with HIV-PH had significantly higher rates of developing heart failure (aOR 10.44), cardiogenic shock (aOR 5.67), cardiomyopathy (aOR 4.97), in-hospital cardiac arrest (aOR 1.94), respiratory failure (aOR 3.29), invasive mechanical ventilation (aOR 1.71), aspiration pneumonia (aOR 1.29), acute kidney injury (aOR 2.14). Lastly, patients with HIV-PH had higher in-hospital mortality within 30 days of admission (aOR 1.28) & overall in-hospital mortality (aOR 1.23); p < 0.005). CONCLUSION: In patients with concomitant HIV and PH, there is a higher burden of comorbidities, and is associated with worse outcomes including mortality. Through this study, we highlight outcomes that will better risk stratifying patients with concurrent HIV and PH.

Chronic obstructive pulmonary disease patients' experience using Trelegy as compared with other inhalers.

Introduction: Trelegy is a combination inhaler that is often reported to offer benefits over multiple inhalers. We compared Trelegy use with multiple inhalers for adherence, symptoms, medication beliefs, and medication attitudes. Methods: This cross-sectional survey of 58 patients compared the patient's experience with Trelegy (n = 18) versus any other inhaler (n = 40). Outcome variables consisted of Test of the Adherence to Inhalers scale, the Chronic obstructive pulmonary disease Assessment Test (CAT) scale, attitude items from the St. George's Respiratory Questionnaire, the Beliefs about Medicines Questionnaire (BMQ)-necessity subscale, and the BMQ-concerns subscale. Results: We found that patients using Trelegy had greater CAT symptoms (M = 19.8, SD = 7.75) in comparison with the any other inhaler group (M = 15.7, SD = 11.10; P = 0.04). We did not find any difference between the groups for adherence or any of the medication attitudes or beliefs. CAT score was positively correlated with the number of months patients were on their current inhaler (r s = 0.29, P < 0.05) and their use of a rescue inhaler (r s = 0.42, P < 0.01). Patients with more concern about their medications were negatively correlated with the use of a rescue inhaler (r s = -0.31, P < 0.05). Discussion: We found that patients using Trelegy had greater symptoms in comparison with the any other inhaler group, but did not differ for adherence, medication attitudes, or medication beliefs. Conclusion: We recommend that clinicians should regularly re-evaluate their Trelegy recommendations, as Trelegy use may not be the best therapy for certain patients. Also, a study with a larger sample size can be beneficial to confirm these findings.

COVID-19 Suspected myopericarditis without pulmonary involvement.

Myopericarditis is a rare consequence of COVID-19 infection. Although extremely rare, COVID-19 can present without pulmonary involvement, and there have been reports of isolated cardiac involvement in one prior case We report a case of a young African American man presenting with myopericarditis following a recently recovered COVID-19 infection. Complicated by ICU admission requiring vasopressors; with eventual resolution following initiation of aspirin and colchicine for myopericarditis. Life threatening myopericarditis can occur following resolution of COVID-19 disease. The degree of cardiac involvement correlates poorly to the severity of pulmonary involvement.

A Retrospective Analysis of COVID-19-infected Patients with Acute Hepatitis who Develop Acute Liver Failure in a Safety Net Hospital.

OBJECTIVE: In early 2019, a new coronavirus called SARS-CoV-2 emerged and changed the course of civilization. Our study aims to analyze the association between acute liver failure (ALF) and mortality in patients infected with COVID-19. A retrospective analysis of 864 COVID-19-infected patients admitted to Nassau University Medical Center in New York was performed. DESIGN: ALF is identified by acute liver injury (elevations in liver enzymes), hepatic encephalopathy and an international normalised ratio greater than or equal to 1.5. These parameters were analysed via daily blood work and clinical assessment. Multivariate logistic regression model predicting mortality and controlling for confounders such as age, coronary artery disease, intubation, hypertension, diabetes mellitus and acute kidney injury were used to determine the association of ALF with mortality. RESULTS: A total of 624 patients, out of the initial 864, met the inclusion criteria-having acute hepatitis and COVID-19 infection. Of those 624, 43 (6.9%) patients developed ALF during the course of their hospitalisation and their mortality rate was 74.4%. The majority of patients with ALF were male (60.6%). The logistic model predicting death and controlling for confounders shows COVID-19 patients with ALF had a nearly four-fold higher odds of death in comparison to those without ALF (p=0.0063). CONCLUSIONS: Findings from this study suggest that there is a significant association between mortality and the presence of ALF in patients infected with COVID-19. Further investigation into patients with COVID-19 and ALF can lead to enhanced treatment regimens and risk stratification tools, which can ultimately improve mortality rates during these arduous times.

CMV Pancreatitis in an Immunocompromised Patient.

INTRODUCTION: Cytomegalovirus (CMV) is a common double-stranded DNA (dsDNA) virus affecting a large majority of the world's population. In immunocompetent patients, CMV infection can range anywhere from an asymptomatic course to mononucleosis. However, in the immunocompromised patient, prognosis can be deadly as CMV can disseminate to the retina, liver, lungs, heart, and GI tract. We present a case of CMV pancreatitis afflicting an immunocompromised patient. Case Summary. A 45-year-old Hispanic female with no past medical history presented to the emergency department (ED) for three days of abdominal pain associated with nausea, vomiting, and diarrhea. ED vitals showed a sepsis picture with fever, tachycardia, low white blood cell (WBC) count with bandemia, and CT scan showing acute pancreatitis, cholelithiasis, gastritis, and colitis. The patient denied alcohol use and MRCP showed no stone impaction. Sepsis protocolled was initiated for biliary pancreatitis, and the patient was admitted to the medicine floors with appropriate consulting services. Over the course of admission, the patient responded poorly to treatment and had a steady decline in respiratory status. She tested positive for HIV with a severely depressed CD4 count (42 cells/McL) and high viral load (1,492,761 copies/ml) and started on appropriate prophylactic antibiotics and HAART therapy. The patient was moved to the Medical Intensive Care Unit (MICU) after acute respiratory failure secondary to ARDS requiring mechanical ventilation with initiation of ARDS protocol. The patient was hemodynamically unstable and required vasopressor support. Hospital course was complicated by melena which prompted an esophagogastroduodenostomy (EGD) with biopsy yielding CMV gastritis. Serum CMV viral load was also found to be positive along with an elevated lipase level, indicative of pancreatitis. Despite initiation of ganciclovir, the patient continued to have refractory hypoxia despite full ventilatory support and proning. Unfortunately, the patient was deemed too unstable for transfer to an ECMO facility. She eventually succumbed to respiratory failure. Discussion. CMV is a Herpesviridae virus that is prevalent among more than half of the world's population. Its effects range from no presenting symptoms to respiratory failure depending on immune status. CMV more commonly affects the retina, lungs, liver, and GI tract; however, in rare cases, it is known to affect the pancreas as well. Other more common causes of pancreatitis were ruled out during the progression of this patient, and an elevated lipase with high CMV viral load points towards CMV pancreatitis. CONCLUSION: This is one of only a few reported cases of CMV pancreatitis and warrants further study due to the massive prevalence of CMV in the entire world's population. Our case demonstrates the extent of dissemination of CMV in a severely immunocompromised patient by showing clear cut pancreatitis secondary to said viral infection with exclusion of other possible causes. Our hope is that clinicians will change their practice to include a more scrutinized study into causes of pancreatitis especially in their immunocompromised patients.

Thinking out of the box: management of valproic acid toxicity with carbapenems.

Valproic acid (VPA) is commonly used medication to treat seizure disorder and as prophylaxis for bipolar disorder. Acute VPA toxicity can cause varied symptoms ranging from mild drowsiness to severe cerebral oedema and coma. The therapeutic level of VPA is around 50-100 µg/mL and most of it is protein bound. It is mainly metabolised by liver and is eliminated via bile. The metabolites of VPA interfere with urea cycle and cause deficiency in carnitine leading to increase in ammonia levels. The use of carnitine to treat VPA toxicity is well known but it is still unclear if it lowers VPA levels. We report a case of VPA toxicity that did not respond to use of carnitine at 6000 mg orally but was successfully treated using meropenem leading to lowering of VPA levels and also clinical improvement of patient.

A 48-Year-Old Man With Excessive Drooling and Descending Paralysis Requiring Mechanical Ventilation.

CASE PRESENTATION: A 48-year-old man presented with a chief report of worsening dysphagia for 5 days. Initially, he had difficulty swallowing solids, but it has progressed to difficulty with liquids. There was associated sialorrhea, hypophonia, slurring of speech, hoarseness of voice, cough, and prominent upper extremity weakness. Of note, 2 weeks ago, the patient had an upper respiratory tract infection (including otitis media) that was treated with amoxicillin-clavulanate. His wife and son were also recently sick with an upper respiratory tract infection. His medical history included hypertension managed with amlodipine; he denied any history of TB, recent travel, or canned food ingestion. He denied fevers, stridor, dyspnea, rash, odynophagia, nausea, vomiting, or diarrhea.

Community acquired Klebsiella pneumoniae meningitis: a case report.

INTRODUCTION: Klebsiella pneumoniae meningitis is most commonly seen as a nosocomial infection and in post-neurosurgical patients. Reports of community acquired Klebsiella pneumoniae meningitis cases are rare in the United States. The objective of this case report is to discuss an uncommon pathogen causing meningitis, Klebsiella pneumoniae, its risk and prognostic factors and to emphasize the importance of early recognition and appropriate antibiotic treatment. CASE REPORT: We report a clinical case of adult community acquired Klebsiella pneumoniae meningitis with recovery. A 54-year-old diabetic male presented with two-week history of intermittent fevers, acute bilateral ear pain, headache and unsteady gait. Broad spectrum antibiotics were initiated. Klebsiella pneumoniae was isolated in the cerebrospinal fluid cultures. The patient recovered with only mild hearing loss in his left ear. CONCLUSION: Our case highlights the importance of suspecting Klebsiella pneumoniae in community acquired meningitis.

Goodpasture's Disease: An Uncommon Disease With an Atypical Clinical Course.

Goodpasture's disease is an uncommon composite of features including renal failure with pulmonary hemorrhage secondary to an autoimmune response that specifically targets these organ systems. We present a case of particular interest in regards to atypical presentation, and the uncommon treatment that the patient underwent. A 65-year-old Afghani female arrived with complaints of nausea, vomiting, loss of appetite, malaise, decreased urine output, exertional dyspnea, and cough. The patient presented initially with renal failure and unexpectedly developed respiratory failure after hemodialysis. Initial CT of thorax revealed diffuse bilateral pulmonary edema. Subsequently, the patient received a bronchoscopy demonstrating alveolar hemorrhage, which highlights a clinician's need to maintain a differential and reassess patients. Anti-GBM antibody in the serum was detected and the renal biopsy revealed evidence of the antibody on immunofluorescence. In regards to management, the patient could only be treated with plasmapheresis as she had contraindication to initiation of immunosuppression, after which she showed significant clinical improvement. We would like to highlight the benefit of plasmapheresis without concomitant immunosuppression and recommend such an approach to be considered in similar clinical scenarios, where contraindication for immunosuppressant therapy exists.

Emphysematous Pyelonephritis Associated With Emphysematous Gastritis and Air in the Portal Vein.

Emphysematous gastritis with portal venous air is a rare condition usually caused by gas forming organisms. This may be secondary to local spread of an infection through the mucosa or rarely hematogenous dissemination from a distant focus. We present a young diabetic woman with uncontrolled diabetes mellitus who was admitted with sepsis and severe abdominal symptoms. Investigation revealed emphysematous pyelonephritis due to E. coli infection associated with emphysematous gastritis and air in the portal tract. She improved with broad spectrum antibiotics, fluid resuscitation and electrolyte and diabetic management. To our knowledge this is the first report showing the association between emphysematous pyelonephritis and gastritis with air in the portal system.

Significance of bowel wall thickening on computed tomography scan: higher risk of pathology among African Americans compared to Hispanics.

PURPOSE: The aims of our study were to examine the role of colonoscopy as further workup for bowel wall thickening reported on computed tomography (CT) scans and to investigate whether there were significant differences in pathology found among the racial groups in our study population. METHODS: This is a retrospective study from March 2005 and January 2007 of all patients who have undergone colonoscopy for bowel wall thickening found on CT scans of the abdomen. RESULTS: Of 94 patients with bowel wall thickening on CT scans, 7 (8%) had adenocarcinoma, 5 (5%) had large adenomas, 3 (3%) had infectious colitis, 2 (2%) ischemic colitis, 1 (1%) had inflammatory bowel disease, and 1 (1%) had a benign stricture. Bowel wall thickening on CT scan predicted clinical pathology in 34% of African Americans, as compared to 14% of Hispanics. Patients with significant pathology were more likely to have anemia and lower albumin levels. CONCLUSION: Patients with bowel wall thickening found on CT scans should be referred for colonoscopy, given that significant pathology is found in 20% of the cases. African Americans were 2.5 times more likely to have clinically significant pathology as compared to Hispanics.