Modified Early Warning Score (MEWS) as a predictor of intensive care unit admission in cancer patient on chemotherapy with positive blood culture: A retrospective cohort study.

BACKGROUND: Although the usefulness of the Modified Early Warning Score (MEWS) in predicting clinical deterioration or the need for intensive care unit (ICU) admission has been evaluated in several studies, only few reports have considered the immune status of the patient. Patients receiving chemotherapy for cancer are at risk of sepsis. This study aimed to assess the validity of MEWS in predicting clinical deterioration, ICU admission, and mortality among immunocompromised cancer patients on chemotherapy (CPOC). METHODS: This retrospective cohort study was conducted at a tertiary care center in Jeddah, Saudi Arabia. Subjects aged>14 years with positive blood cultures, who were hospitalized between June 2016 and June 2017, were included. MEWS was calculated at different time intervals: before, after, and at the time (0-time) of positive blood culture. RESULTS: Overall, 192 patients were enrolled, including 89 CPOC and 103 immunocompetent individuals (controls). ICU admission rate was significantly lower in the CPOC group than in the control group (21 % vs. 50 %, P < .001). Positive MEWS rate (score ≥4) at 0-time was lower in the CPOC group, but the difference was not significant (39.7 % vs. 60.3 %, P = .129). In the CPOC group, positive MEWS rate (score ≥4) had a sensitivity, specificity, positive predictive value, and negative predictive value of 52.6 %, 70 %, 32.3 %, and 84 %, respectively, which was comparable to that observed in the control group. Furthermore, the receiver operating characteristic curve in the CPOC group showed that MEWS calculated 12-36 h before positive blood culture was a significant predictor of ICU admission. The optimal threshold of MEWS with the best sensitivity and specificity was ≥ 3 for the CPOC group and ≥ 4 for the control group to predict ICU admission. MEWS was a generally poor predictor of mortality. CONCLUSION: MEWS ≥ 3 calculated 12-36 h before positive blood culture is the best predictor of ICU admission for CPOC.

A Rare Case of Thyroid Metastasis Secondary to Hidden Undiagnosed Lung Adenocarcinoma.

The majority of thyroid lesions are primary in origin while secondary metastases to thyroid are considered a rare incidence. However, presentation of such cases with no signs of lung cancer can be extremely challenging to diagnose. Here, we present a 64-year-old man, an ex-smoker of 70 pack-years, who presented with a complaint of hoarseness of voice with associated dyspnea, choking episodes, weight loss, and hemoptysis. With no investigation abnormalities indicating lung adenocarcinoma, he was transferred to the Otolaryngology Department as being suspicious of thyroid cancer. A laryngoscopy demonstrated an immobile right vocal cord and pooling of secretions while a computed tomography (CT) scan showed a right thyroid lobe nodule, upper mediastinal lymphadenopathy, and pleural effusion. The patient underwent a total thyroidectomy. Biopsies from the lymph nodes and lung were obtained, and all demonstrated lung adenocarcinoma. Thus, a diagnosis of primary lung adenocarcinoma with thyroid and mediastinal lymph nodes metastases was established. Despite being a rare clinical presentation, thyroid metastasis should be considered and evaluated for a primary origin according to the associated clinical history and presentation.

Herpes Zoster Eruption in an Otherwise Healthy Child: A Case Report.

Varicella-zoster virus (VZV; human herpesvirus 3) is a herpesvirus that causes infection in humans. The reactivation of latent VZV manifests as herpes zoster or shingles. In immunocompetent children, reactivation is rare, as increasing age is the most common risk factor for reactivation. The complications of infection include post-herpetic neuralgia and neurological sequelae as well as a bacterial infection of the crusted skin. We present a case of an otherwise healthy 13-year-old child with herpes zoster and multiple risk factors, who was managed successfully, in order to expand the limited literature. The patient presented with a painful vesicular rash, which appeared as multiple grouped vesicles on an erythematous base spreading over the right half of the face. The diagnosis of herpetic (varicella) vesiculobullous dermatitis was confirmed by biopsy and the patient was started on acyclovir and clindamycin with gradual improvement and resolution of his symptoms. Reactivation of VZV is considered a consequence of decreased cell-mediated immunity. However, the reason for reactivation in immunocompetent children remains unclear. In the present case, the patient may have become exposed in utero, through vaccination, or as a result of major facial trauma sustained at the age of six years.

Hoarseness of Voice as a Rare Presentation of Tuberculosis: A Case Report Study.

BACKGROUND: Having hoarseness of voice as the first clinical manifestation of tuberculosis is rare. This atypical presentation causes some confusion since other more common conditions, such as laryngeal carcinoma, present similarly and might require more invasive tests to confirm the diagnosis. CASE PRESENTATION: A 38-year-old male presented to the otorhinolaryngology clinic with a four-month history of change in voice. Laryngoscopy demonstrated a right glottic mass, raising suspicion of laryngeal cancer. The computed tomography showed a mass and incidental finding of opacities in lung apices. Chest x-ray demonstrated findings suggestive of tuberculosis. Polymerase chain reaction and culture of sputum samples confirmed the diagnosis and the patient was started on anti-tuberculosis treatment. CONCLUSION: Despite accounting for only 1% of pulmonary tuberculosis cases and having a similar presentation to laryngeal carcinoma, we recommend considering laryngeal tuberculosis when evaluating hoarseness of voice in endemic areas.

Q Fever Endocarditis in a Saudi Child: A Case Report and Literature Review.

Q fever is a zoonotic disease that is caused by Coxiella burnetii, a gram-negative coccobacillary bacterium. Human infection primarily occurs following the inhalation of aerosols containing C. burnetii. The infection can either present in an acute or chronic form. The three main presentations are flu-like syndrome, atypical pneumonia, and hepatitis. Chronic Q fever mainly affects the heart where the disease manifests as endocarditis. In this case report, the patient was born at term with congenital heart defects, namely double outlet right ventricle (DORV), ventricular septal defects (VSD), and coarctation of the aorta. He underwent coarctation repair and pulmonary artery binding. At the age of three years, he presented with palpitation, sudden high-grade fever, myalgia, and dyspnea. Endocarditis was suspected due to a history of a surgical repair of congenital heart defects. Blood cultures were negative, however, a diagnosis of Q fever endocarditis was confirmed based on serologic titers. Q fever endocarditis is a challenging diagnosis since the echocardiography findings are often nonspecific. Moreover, Q fever can present as negative-culture endocarditis with low sensitivity of blood and tissue polymerase chain reaction (PCR) for C. burnetii. Hence, the modified Duke criteria has considered phase 1 immunoglobulin G (IgG) titers of 1:800 or more as diagnostic for infective endocarditis. Although uncommon, physicians should maintain a high index of suspicion for Q fever endocarditis, especially among patients with pre-existing structural heart disease and associated symptoms and risk factors such as animal exposure.