Submassive Pulmonary Embolism in Mild COVID-19 Without Lung Infiltrates.

A 66-year-old man who had been diagnosed with mild coronavirus 2019 (COVID-19) infection nine days prior presented to the emergency room with acute-onset chest pain and shortness of breath. Chest CT angiogram (CTA) revealed pulmonary emboli (PE) in the right and left pulmonary arteries with right heart strain; lung parenchyma showed no infiltrates. Although severe COVID-19 infection is associated with thrombotic complications, data regarding the occurrence of PE in mild cases of COVID-19 is scarce. However, even mild cases of COVID-19 are reported to have revealed lung infiltrates, particularly ground-glass opacities, on imaging. The possibility of the lungs being the primary source of COVID-19-associated coagulopathy has been raised. We report an uncommon case of submassive PE occurring in mild COVID-19, without any associated lung infiltrates. This case indicates that mild COVID-19, without significant lung parenchymal involvement, can also cause a hypercoagulable state, resulting in venous thromboembolism (VTE).

An Older Woman With Transient Cough, Mild Airway Obstruction, and Lung Nodules.

CASE PRESENTATION: A 66-year-old woman with no significant medical history presented initially to her primary care physician's office with a 2-weeks history of productive cough and associated wheezing after cough paroxysms. Empiric antibiotic was started, with no improvement. Chest radiograph was performed, which showed bilateral nodular opacities (Fig 1). The patient's cough resolved in 6 weeks after empiric treatment with oral steroids, inhaled steroids, and bronchodilators. A follow-up chest radiograph done at 6 weeks showed persistent abnormalities, and she was referred for a pulmonary evaluation. She denied any fevers, cough, hemoptysis, shortness of breath, wheezing, loss of appetite, or weight loss at that time. She had no significant medical problems and was not on any medications at that time. She was a nonsmoker. She worked in an office setting and denied any occupational or recreational exposures or recent travels. There was no family history of lung diseases or cancer.

A Middle-Aged Woman With Hematochezia, Hypotension, and Leg Cramps.

CASE PRESENTATION: A 57-year-old woman with a history of mantle cell lymphoma presented to the ED with complaints of vomiting, bleeding per rectum, and leg cramps, that started 6 h prior to her arrival. She had received chemotherapy a week prior. Her leg cramps were not associated with pain or swelling of the legs; she also denied any trauma to the legs. She did complain of mild lower abdominal pain at presentation. Review of systems was negative for fever, chills, diarrhea, chest pain, and dizziness. She denied using alcohol or nonsteroidal anti-inflammatory drugs. The patient was tachycardic with a systolic BP (SBP) of 85 mm Hg and was administered 1-L normal saline, with improvement in her SBP to 90 mm Hg. The hematocrit level was 24%, the WBC count was 0.3 × 109/L, and the platelet count was 6 × 109/L in the ED. On arrival in the ICU, she was noted to have an SBP of 70 mm Hg. Resuscitation with IV fluids was initiated, followed by transfusion of packed RBCs and platelets, based on the blood counts. Despite aggressive fluid resuscitation and improvement in her hemoglobin, the patient remained persistently hypotensive. The diagnosis of underlying septic shock because of neutropenia was considered; the patient was started on vasopressors and empirical broad-spectrum antibiotics, with improvement in her BP. After this, the patient was sent to radiology for a CT scan of the abdomen and pelvis with contrast to evaluate for mesenteric infarction, enteric or colonic bleeding, and the need for arterial embolization.

Treating a Patient with Your Hands Tied: Acute Chest Syndrome in a Jehovah's Witness.

Acute chest syndrome (ACS), a vaso-occlusive crisis in patients with sickle cell anemia, is a life-threatening condition and a leading cause of death in these patients. It is treated with analgesics, antibiotics, intravenous fluid, supplemental oxygen (or ventilatory support in severe cases) with simple or exchange transfusion, being the mainstay of therapy. We report a young Jehovah's Witness (JW) patient with sickle cell anemia who presented with ACS. Her religious beliefs precluded the use of blood products. Despite concomitant hemolytic and aplastic crisis and a hemoglobin nadir of 3.1 g/dL, the patient was treated successfully with supportive care - including mechanical ventilation, sedation, paralysis, and erythropoiesis stimulation - and survived. A maximal supportive strategy consisting of ventilatory support with a high fraction of inspired oxygen, sedation, paralysis, erythropoiesis stimulation, and limitation of blood draws can result in the successful treatment of JW patients who refuse blood products.

A 50-Year-Old Woman With Confusion and Facial Rash.

CASE PRESENTATION: A 50-year-old woman presented to the ED with a 3-day history of increasing confusion. Prior to her presentation, the patient had been in her usual state of health as reported by her family. She had a history of bipolar disorder and attention-deficit/hyperactivity disorder but had stopped her psychiatric medications for the past 4 days secondary to loss of insurance coverage. History was limited due to the patient's altered state and confusion, and was obtained from family. There was no history of headache, loss of consciousness, weakness of extremities, seizures, fever, or recent trauma. The patient's medical history also included cocaine abuse. The patient's family believed she had been abstinent from cocaine use for several years.

A 60-Year-Old Woman With Acute Chest Pain and Bilateral Pleural and Pericardial Effusions.

CASE PRESENTATION: A 60-year-old woman presented with acute-onset, progressively worsening shortness of breath and pleuritic chest pain for 3 days. She also complained of a dry cough, but no fever or chills. There was no history of swelling of the feet; nor was there a history of nausea or diarrhea. She was a lifelong nonsmoker and had no history of recent travel or sick contacts. Her medical history included hypertension and ulcerative colitis. The ulcerative colitis was in remission and she had not been taking medications for this for over 7 years. Her home medications included alendronate, amlodipine, aspirin, atenolol, and vitamin D3 supplements. She had no allergies.

Renal Function, Weaning, and Survival in Patients With Ventilator-Dependent Respiratory Failure.

BACKGROUND: Acute kidney injury in acute critical illness has been associated with poor weaning and survival outcomes. The relation between renal dysfunction as defined by creatinine clearance (CrCl) and weaning from prolonged mechanical ventilation (PMV) is not known. The objective of this study was to determine the relation of measured CrCl to weaning and survival in patients on PMV. METHODS: We retrospectively studied 167 patients on PMV admitted to a long-term acute care facility for weaning over a 3-year period. Data obtained included age, gender, admission blood urea nitrogen (BUN), serum creatinine, CrCl, random urine creatinine (RUCr), and 24-hour urinary creatinine (24UCr). Renal dysfunction was defined as normal (CrCl > 90 mL/min), mild (CrCl 60-90 mL/min), moderate (CrCl 30-59 mL/min), and severe (CrCl < 30 mL/min). Primary outcome measured was liberation from PMV, defined as being off ventilator for >7 days. Survival, defined as being alive at discharge, time to wean, and time to discharge alive were secondary outcomes. The association between the studied parameters and outcomes was determined by unpaired t test. The predictive value of studied parameters for weaning and survival was determined by multivariate logistic regression analysis. P < .05 was statistically significant. RESULTS: Mean age was 68.5 (14) years; 49% were males; 64% were liberated and 65.8% survived. Blood urea nitrogen, RUCr, 24Ucr, and CrCl had a significant association with successful weaning. These parameters (except BUN) also had a significant association with survival. A better outcome occurred with CrCl > 90 mL/min. CONCLUSION: Measured CrCl has a significant relation to successful weaning and survival in patients on PMV and may be useful in prognosticating their outcome.

Mediastinal angiosarcoma presenting as diffuse alveolar hemorrhage.

Angiosarcomas are malignant vascular tumors. Angiosarcomas arising in the thorax such as angiosarcoma of the lungs, heart and mediastinum are extremely rare. There are no reports of mediastinal angiosarcomas presenting with diffuse alveolar hemorrhage, which is a clinical syndrome characterized by the presence of hemoptysis, dyspnea, hypoxia, diffuse lung infiltrates and anemia. Usually, diffuse alveolar hemorrhage is caused by pulmonary capillaritis. Local invasion is more common with these tumors than distant metastasis. These tumors are very aggressive and have a poor response to treatment modalities including surgical resection, chemotherapy, and radiation. Consequently, they carry a poor prognosis. Due to the rarity of these tumors, no standard chemotherapy or radiation protocol exists. We report a case of diffuse alveolar hemorrhage caused by a previously unreported entity: angiosarcoma of the mediastinum.

Can Creatinine Height Index Predict Weaning and Survival Outcomes in Patients on Prolonged Mechanical Ventilation After Critical Illness?

OBJECTIVE: Malnutrition is common in chronic critically ill patients on prolonged mechanical ventilation (PMV) and may affect weaning. The creatinine height index (CHI), which reflects lean muscle mass, is regarded as the most accurate indicator of malnutrition. The objective of this study was to determine the impact of CHI in comparison with other traditional nutritional indices on successful weaning and survival in patients on PMV after critical illness. METHODS: Records of 167 patients on PMV following critical illness, admitted for weaning, were reviewed. Parameters studied included age, gender, body mass index (BMI), percentage ideal body weight (%IBW), total protein, albumin, prealbumin, hemoglobin (Hb), and cause of respiratory failure. Number successfully weaned and number discharged alive and time to wean and time to discharge alive were determined from records. The CHI was calculated from 24-hour urine creatinine using a standard formula. Unpaired 2-sample t test was performed to determine the association between the studied nutritional parameters and outcomes. Predictive value of studied parameters for successful weaning and survival was determined by multivariate logistic regression analysis to model dichotomous outcome of successful weaning and survival. RESULTS: Mean age was 68 ± 14 years, 49% were males, 64% were successfully weaned, and 65.8% survived. Total protein, Hb, and CHI had a significant impact on successful weaning. Weight, %IBW, BMI, and CHI had a significant effect on survival. Of all parameters, CHI was most strongly predictive of successful weaning and survival. CONCLUSIONS: The CHI is a strong predictor of successful weaning and survival in patients on PMV.

Spontaneous Tumor Lysis Syndrome due to Uterine Leiomyosarcoma with Lung Metastases.

Tumor lysis syndrome (TLS) is an oncologic emergency characterized by a combination of metabolic derangements (hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia) caused by rapid turnover from cell destruction in certain cancers. These metabolic derangements can lead to seizures, cardiac arrhythmias, renal failure, and death. TLS is usually seen after the initiation of chemotherapy for hematologic malignancies. TLS occurring spontaneously, without initiation of chemotherapy, is rare and its occurrence in solid tumors is rarer still. We report a case of spontaneous TLS in a patient with leiomyosarcoma of the uterus, with metastasis to lung. Such a case has never been reported before.

A Woman in Her 50s With a Mass in One Lung and a Cavitary Lesion in the Other.

CASE PRESENTATION: A woman in her 50s with no significant medical history presented with low-grade fever and cough of 3 days' duration, which was productive of blood-streaked sputum. She was an active smoker, with a 30 pack-year history of smoking. She denied chest pain, chronic cough, exertional dyspnea, or constitutional symptoms.

An Elderly Man With Pancreatic Neuroendocrine Tumor and a Cavitary Right Upper Lobe Lung Mass.

CASE PRESENTATION: An elderly man presented to the ED from a nursing care facility after transient loss of consciousness. Three weeks previously, the patient had been diagnosed with a high-grade pancreatic neuroendocrine tumor (NET) with metastases to the liver after being hospitalized for weakness. A chest radiograph at that time had revealed a right upper lobe mass that was presumed to represent a metastatic lesion (Fig 1); CT of the chest demonstrated similar findings (Fig 2). The patient had recovered consciousness on arrival to the ED and was diagnosed clinically as having had a syncopal episode from dehydration due to poor intake. On review of systems, the patient reported shortness of breath and a cough productive of scant mucoid sputum of 1 week's duration. He had no complaints of fever but complained of weakness and poor appetite. In addition, his medical history was significant for hypertension, diabetes mellitus, and congestive heart failure with systolic dysfunction. He was a former smoker. Prior to his recent illness and hospitalization, he lived at home with his family and was independent in his activities of daily living.

Tuberculous pleural effusion occurring concurrently with asbestos-related pleural disease.

An eighty-four-year-old man presented with progressive exertional dyspnea, productive cough and weight loss for two months. His physical exam was notable for diminished breath sounds at the right base, with dullness to percussion. Chest-x-ray showed moderate right-sided pleural effusion and bilateral calcified pleural plaques as well as diaphragmatic plaques consistent with asbestos-related pleural disease (ARPD). Pleural fluid was exudative with predominantly mononuclear cells, negative acid fast bacilli stain, negative cultures, and negative cytology for malignant cells. Due to recurrence of the effusion, 4 weeks after drainage, thoracoscopic pleural biopsy was planned but pleural fluid cultures came back positive for mycobacteria tuberculosis. Patient was started on anti-tubercular therapy but treatment had to be stopped due to liver toxicity. Patient subsequently developed pneumonia and deteriorated despite antibiotic therapy and expired.

Acute Respiratory Failure due to Neuromyelitis Optica Treated Successfully with Plasmapheresis.

Neuromyelitis Optica (NMO) is a demyelinating autoimmune disease involving the central nervous system. Acute respiratory failure from cervical myelitis due to NMO is known to occur but is uncommon in monophasic disease and is treated with high dose steroids. We report a case of a patient with NMO who developed acute respiratory failure related to cervical spinal cord involvement, refractory to pulse dose steroid therapy, which resolved with plasmapheresis.

An Unusual Cause of a Solitary Lung Cavity.

Sarcoidosis is a systemic granulomatous disease of unknown etiology. Pulmonary involvement is common, but lung nodules in sarcoidosis are uncommon, and solitary nodules that cavitate are extremely rare. Nodular sarcoidosis is usually found in young, healthy, predominantly female individuals. These lesions need to be differentiated from multiple other conditions, including neoplasms and granulomatous infections. A thorough workup for other etiologies of cavitary lung lesions is required for diagnosis. Despite an ominous presentation, nodular cavitary sarcoidosis portends a favorable outcome. We report a patient who presented with a solitary cavitary nodular lung lesion that was diagnosed as sarcoidosis after extensive workup.

Idiopathic pulmonary haemosiderosis with celiac disease (Lane-Hamilton syndrome) in an adult - a case report.

Idiopathic pulmonary haemosiderosis (IPH) is a rare disorder of unknown cause characterised by haemoptysis, diffuse alveolar infiltrates and iron-deficiency anaemia. IPH predominantly affects children; it is rare in adults, in whom it usually manifests before 30 years. In adults, course is protracted with a better prognosis, in contrast to children. Even rarer is the Lane-Hamilton syndrome, a condition in which IPH is associated with celiac disease. Only 15 cases of Lane-Hamilton syndrome affecting adults are reported in literature. Treatment of IPH is based on anecdotal case reports and case series because of its rare occurrence. High-dose steroids reportedly reduce morbidity and mortality and delays or stops disease progression; more effectively in adults than children. In Lane-Hamilton syndrome, a gluten-free diet for the celiac disease in addition to steroids for IPH, is the mainstay of therapy. The optimal treatment duration of steroid therapy is not known but anecdotally a more prolonged course results in improved outcome. We report a case of a young woman who presented with exertional dyspnoea, intermittent haemoptysis, severe anaemia and lung infiltrates but no gastrointestinal complaints. After extensive work-up, she was diagnosed with Lane-Hamilton syndrome based on a diagnosis of IPH made from lung biopsy and concomitant celiac disease because of positive anti-gliadin antibody and endomyosial antibody and jejunal biopsy. She was treated with sustained low-dose steroid therapy for a year and a gluten-free diet with resolution of her symptoms, anaemia and lung infiltrates. At 4 years of follow-up, she remains stable, without recurrence.

Seminoma Presenting as a Mediastinal Mass in an Elderly Patient.

Primary mediastinal germ cell tumors are relatively rare and represent 10% - 20% of all mediastinal tumors. About one-third of these are primary mediastinal seminomas, occurring in males in their third and fourth decades, with the median age of presentation ranging between 20 and 30 years of age. We report an unusual case of a 69-year old male with mediastinal seminoma, who presented at an age much higher than the usual affected patient and responded well to the conventional mode of therapy for this tumor. A review of literature pertaining to clinical presentation, diagnosis, and management is also presented.

An Unusual Cause of Acute-Onset Chest Pain: Spontaneous Pneumomediastinum.

Spontaneous pneumomediastinum (SPM) is the presence of air in the mediastinum without any precipitating factor or predisposing disease. It is an uncommon, usually benign condition predominantly seen in young males. It typically presents with chest pain or dyspnea. It occurs after intrathoracic pressure changes leads to alveolar rupture and dissection of air along the tracheobronchial tree. It is reported to occur in 1/30,000 to 1/40,000 hospital admissions. Despite its low incidence, SPM should be considered in the differential diagnosis of acute chest pain or dyspnea in young patients. Diagnosis requires a high index of suspicion, as evidence of its occurrence may not be present on examination or chest X-ray. Patients with SPM respond well to medical treatment, with no recurrence in the majority of cases. We report a case of a young healthy male who developed a spontaneous pneumomediastinum and pneumopericardium while playing volleyball and did well with conservative management.

Cardiopulmonary exercise testing in the assessment of exertional dyspnea.

Dyspnea on exertion is a commonly encountered problem in clinical practice. It is usually investigated by resting tests such as pulmonary function tests and echocardiogram, which may at times can be non-diagnostic. Cardiopulmonary exercise testing (CPET) measures physiologic parameters during exercise which can enable accurate identification of the cause of dyspnea. Though CPET has been around for decades and provides valuable and pertinent physiologic information on the integrated cardiopulmonary responses to exercise, it remains underutilized. The objective of this review is to provide a comprehensible overview of the underlying principles of exercise physiology, indications and contraindications of CPET, methodology and interpretative strategies involved and thereby increase the understanding of the insights that can be gained from the use of CPET.