Determining the Association Between the Origin of Sepsis and the Severity of Sepsis in Intensive Care Unit (ICU) Patients Using Acute Physiology and Chronic Health Evaluation (APACHE) IV.

Objective The objective of this study is to compare the outcomes of hospital mortality, the requirement of invasive ventilation, vasopressor requirement, duration of vasopressor requirement, and duration of intensive care unit (ICU) stay among the different causes of sepsis and to determine which cause of sepsis had the most severe outcomes. Methods A retrospective chart review was done in critically ill adult patients who were admitted with sepsis to the ICU from July 2017 until July 2019. Acute Physiology and Chronic Health Evaluation (APACHE) IV scores were calculated on patients admitted to ICU on day one of ICU admission. Each patient was then evaluated for outcomes of hospital mortality, need for invasive ventilation, requirement of vasopressors, duration of vasopressors, and duration of ICU stay. The outcomes were then compared between the different sources of sepsis to determine which source of sepsis had the highest severity. Results In total, 176 patients were included in the study. Ninety-three patients were admitted with respiratory sepsis, 26 patients were admitted with gastrointestinal sepsis, 31 patients were admitted with urosepsis, and 26 patients were admitted with other miscellaneous causes of sepsis. The hospital mortality was highest in the respiratory sepsis group at 32%, with a trend towards statistical significance with a P value of 0.057. ICU stay duration was highest in patients with respiratory sepsis at six days, with a statistically significant P value of < 0.001. The need for invasive ventilation was highest in patients with respiratory sepsis at 64%, with a statistically significant P value of < 0.001. The requirement of vasopressor support was highest in patients with respiratory sepsis at 47% and the duration of vasopressors was highest in both respiratory and gastrointestinal sepsis at three days, however, there was no statistical significance. Conclusion Among the different origins of sepsis, the patients with respiratory sepsis had the most severe outcomes, with the highest need for invasive ventilation and the highest ICU stay duration.

Determining the Need for Additional Testing With Quantiferon TB Gold in Patients With Positive Tuberculin Skin Tests and a History of BCG Vaccination.

OBJECTIVE:  To determine if the QuantiFERON-TB Gold (QFT) testing can be obviated for the diagnosis of latent tuberculosis infection (LTBI) in patients with a positive tuberculin skin test (TST) and a history of Bacillus Calmette-Guerin (BCG) vaccination by identifying high-risk features in patients with positive TST and a history of BCG vaccination who are associated with positive QFT. METHODS:  Retrospective chart review was done for 76 adult patients by dividing them into two groups. Group 1 consisted of true positive TST patients who had BCG vaccination and were positive for QFT. Group 2 consisted of false positive TST patients who had BCG vaccination but were negative for QFT. The two groups were compared to determine if the high-risk features of TST induration diameter of 15mm and more, TST induration of 20mm and more, recent immigration to the US, the advanced age of more than 65 years, country of origin with high TB burden, known exposure to active TB, and smoking history were more prevalent in Group 1 compared to Group 2. RESULTS:  Group 1 had 23 patients and Group 2 had 53 patients. Group 1 had a higher prevalence of patients with PPD induration of more than 10mm than Group 2, which was statistically significant with a P value of 0.03. Other risk factors of advanced age, exposure to active TB and smoking did not show statistically significant differences between Groups 1 and 2.  Conclusion: This study also confirms that if the TST induration is more than 10mm in patients with a history of BCG vaccination, the TST induration is likely because of LTBI and is less likely because of cross-reaction with BCG vaccination.

Black Pleural Effusion as a Complication of Acute Pancreatitis.

Transient and reactive pleural effusion is a known consequence of acute pancreatitis. Usually, the pleural effusion is unilateral, transudate, straw-colored, and self-resolving. We report a rare case of massive left-sided black pleural effusion as a complication of acute pancreatitis with the background of chronic pancreatitis being secondary to alcohol abuse. The pleural effusion resulted in hypoxic respiratory failure. However, the patient had significant improvement after drainage of the pleural effusion and the appropriate management of sepsis with broad-spectrum antibiotics. The patient had a significant improvement and recovery with conservative management without the need for endoscopic therapy or surgical intervention.

Hemidiaphragmatic Paralysis Post Stroke Leading to Hypercapneic Respiratory Failure.

Unilateral diaphragmatic paralysis is a rare complication after stroke. We report a case of right-sided hemidiaphragmatic paralysis after stroke in a 51-year-old man who presented with shortness of breath and orthopnea. Chest X-ray (CXR) revealed an elevated right-sided hemidiaphragm. The weakened diaphragmatic contraction from paralyzed right hemidiaphragm resulted in persistent atelectasis of the right lung base and inadequate alveolar ventilation leading to the development of right basal pneumonia with hypercapneic respiratory failure. However, the patient had a remarkable improvement with the appropriate institution of non-invasive ventilation and medical management with intravenous antibiotics.

Infected Right Ventricle Thrombus as a Cause of Persistent Sepsis.

The presentation of fevers in a patient with active intravenous (IV) drug use is often challenging, as there is a wide range of both infectious and noninfectious disorders that can cause fevers. A thorough diagnostic workup is essential in identifying the etiology of these fevers. We report a rare case of an infected right ventricular (RV) thrombus as a cause of persistent fever and sepsis in a 46-year-old patient with IV drug use. The patient continued to have persistent bacteremia inspite of appropriate IV antibiotics. Hence, the patient warranted a cardiothoracic surgical excision of the infected RV thrombus following which the patient showed remarkable improvement.