Gastrointestinal perforation in a critically ill patient with COVID-19 pneumonia.

Gastrointestinal complications in critically ill patients during the COVID-19 pandemic pose a diagnostic and treatment dilemma. We present a case of a 74-year-old male who was brought to our emergency department with worsening shortness of breath, fever, and dry cough and was found to have COVID-19 pneumonia. Early in his hospital course, he was admitted to the intensive care unit, and was found to have significant abdominal distension with large amounts of simple fluid on bedside ultrasound. Bedside paracentesis returned succus and enteric feeds, and a methylene blue test confirmed a likely gastrointestinal perforation. The patients' family refused surgical intervention and the patient underwent bedside drainage. This case represents several critical dilemmas clinicians faced during the recent surge of the COVID-19 pandemic.

Safe extubation during the COVID-19 pandemic.

Extubation of patients with Coronavirus Disease 2019 (COVID-19) is a high risk procedure for both patients and staff. Shortages in personal protective equipment (PPE) and the high volume of contact staff have with COVID-19 patients has generated an interest in ways to reduce exposure that might be feasible especially during pandemic times and in resource limited healthcare settings. The development of portable barrier hood devices (or intubation/extubation boxes) is an area of interest for many clinicians due to the theoretical reduction in aerosolization of SARS-CoV-2, the causative virus for COVID-19. We present a review of the current literature along with recommendations concerning safe extubation during the COVID-19 pandemic. In addition, a focused summary on the use of portable barrier hood devices, during the recent surge of COVID-19 is highlighted.

Severe Pulmonary Hypertension Due to Adult-Onset Still's Disease.

A 29-year-old female with adult-onset Still's disease (AOSD) presented with progressive shortness of breath both on rest and on exertion, increased abdominal girth, and swelling in both legs. She was on oral prednisone and was recently started on canakinumab (interleukin-1 antagonist) for joint pain and rash of AOSD. Echocardiogram showed severely dilated right ventricle, dilated pulmonary artery, moderately reduced right ventricular systolic function, but with normal left ventricular systolic function. Computed tomography with contrast ruled out pulmonary embolism. Blood tests ruled out other rheumatologic diseases. The patient was diagnosed with right-sided heart failure likely secondary to AOSD. Right heart catheterization was needed but could not be performed because of severely dilated pulmonary artery. The patient was transferred to a higher center for further management and possible cardiopulmonary transplant.

Mixed dust pneumoconiosis occurring in an unusual setting.

Mixed dust pneumoconiosis secondary to domestic wood smoke exposure is a cause of pneumoconiosis in women from developing countries, but is rarely seen in the USA. An elderly female non-smoker, who immigrated to the USA from Pakistan 10 years previously, presented with a worsening non-productive cough and dyspnoea on exertion. She did not have any occupational or environmental exposures other than utilising firewood for cooking while living in Pakistan. Radiographs revealed multiple bilateral pulmonary nodules associated with hilar and mediastinal adenopathy. A video-assisted thoracoscopic biopsy revealed ill-defined nodules in a perivascular subpleural deposition, carbon pigment deposition around the terminal bronchioles, dust macules and negatively birefringent needles on polarised light microscopy with mixed dust nodules outnumbering the silicotic nodules consistent with mixed dust pneumoconiosis. This case illustrates the need for awareness of this condition among physicians caring for women who lived in areas where biomass exposure is common.

Altered mental status and complete heart block: an unusual presentation of aspirin toxicity.

Aspirin is one of the most commonly used medications. We report a patient who presented with severe weakness, altered mental status and complete heart block requiring temporary pacing. Despite the patient's family denying that the patient used aspirin, an arterial blood gas that revealed a respiratory alkalosis and metabolic acidosis suggested the diagnosis of salicylate toxicity. The salicylate level was extremely elevated and the patient was successfully treated with haemodialysis. Our case illustrates that salicylate toxicity should be considered in a patient with a combined metabolic acidosis and respiratory alkalosis. A prompt salicylate level should be obtained. This is also the first case of salicylate toxicity causing complete heart block in an adult. The heart block resolved with treatment of the salicylate toxicity.

Brucellosis presenting as septic shock.

Brucellosis generally presents with fever, malaise, weight loss and bone pain with either an abrupt or insidious onset. A 76-year-old man presented in April 2010 with fever of 103°F, severe tachycardia, tachypnoea and a blood pressure of 80/50 mm Hg requiring fluids and vasopressor support with norepinephrine. The patient had brucellosis in 1956 which was treated for 'many weeks' with tetracycline and streptomycin. He has had no recurrences since that time. He denies recent travel outside the USA or consumption of raw dairy products. Blood cultures grew Brucella melitensis. He was treated with gentamycin, doxycycline and rifampin for 1 week and discharged home on doxycycline and rifampin. He relapsed after 2 days, requiring re-admission and a 4-week course of gentamycin. This case is most unusual in that the brucellosis presented with septic shock after a 50-year quiescence and required prolonged therapy with gentamycin to induce remission.

Chest tube drainage of transudative pleural effusions hastens liberation from mechanical ventilation.

BACKGROUND: Pleural effusions occur frequently in patients requiring mechanical ventilatory support. Treatment of the precipitating cause and resolution of the pleural effusion may take considerable time. We retrospectively studied the effect of chest tube drainage of transudative pleural effusions on the liberation of patients from mechanical ventilatory support. METHODS: Patients in the medical ICU (MICU) at Maimonides Medical Center between January 1, 2009, and October 31, 2009, requiring mechanical ventilatory support with a transudative pleural effusion, were studied retrospectively. They were divided into two groups: standard care and standard care plus chest tube drainage. Chest tubes were placed under ultrasound guidance by trained intensivists. Duration of mechanical ventilatory support was the primary end point. Secondary end points included measures of oxygenation, amount of fluid drained, and complications associated with the chest tube. RESULTS: A total of 168 patients were studied; 88 were treated with standard care and 80 underwent chest tube drainage. Total duration of mechanical ventilatory support was significantly shorter for patients who had chest tube drainage: 3.8±0.5 days vs 6.5±1.1 days for the standard group (P=.03). No differences in oxygenation were noted between the two groups. The average amount of fluid drained was 1,220 mL. No significant complications were caused by chest tube drainage. CONCLUSIONS: Chest tube drainage of transudative pleural effusions resulted in more rapid liberation from mechanical ventilatory support. It is a very safe procedure when performed under ultrasound guidance by experienced personnel. TRIAL REGISTRY: ClinicalTrials.gov; Identifier: NCT0114285; URL: www.clinicaltrials.gov.