Acute Respiratory Distress Syndrome Secondary to Enterovirus-Human-Rhinovirus Infection in an Adult.

Enterovirus-human-rhinovirus (EV-HRV) are small RNA viruses that are airborne and can spread by direct contact or fomites and usually cause the common cold, asthma and chronic obstructive pulmonary disease exacerbation. EV-HRV-associated acute respiratory distress syndrome (ARDS) is common in children but is a rare cause of ARDS in adults. ARDS is defined according to the Berlin criteria and can be mild, moderate or severe depending on the PaO 2 to FiO2 ratio. We report a case of a 70-year-old female with cardiac comorbidities, emphysema, second-hand smoking of 25 years, on methotrexate for rheumatoid arthritis presenting with ARDS secondary to EV-HRV infection. Despite initial treatment with appropriate antibiotics, steroids, low tidal volume mechanical ventilation, rescue maneuvers such as ventilation in prone positioning, paralyses, and inhaled nitric oxide, she passed away. EV-HRV causes upper respiratory tract infections but causes cytokine releases such as IL-1, IL-6, and IL-8 in the lower respiratory tract and in the blood which can cause ARDS. Very few cases of EV-HRV ARDS in immunocompetent adults are reported in the literature. Female sex is also associated with EV-HRV ARDS. No antiviral therapy exists for patients critically ill with EV-HRV; however, one case of successful treatment with high-dose intravenous vitamin C (HIVC) is reported in the literature. EV-HRV is one of the most common viruses identified in patients admitted with viral pneumonia in the intensive care unit. It should not be forgotten as a cause of ARDS.

Concealed Foreign Body Shrouding Airway Mimicking Mass Causing Extubation Failure, Hypoxia, and Stridor.

Foreign body (FB) aspiration can present with acute life-threatening asphyxiation to recurrent infections with lung damage. Although most esophageal FBs pass spontaneously, sharp ones can get embedded requiring treatment. Tracheobronchial FBs and hypopharyngeal FBs are occasionally seen as well. We present a case of an oropharyngeal FB presenting with signs of stroke, pulmonary embolism, pulseless, and causing airway compression and extubation failure. Old age and neurocognitive disability are important predisposing factors of FB airway obstruction (FBAO), with food being the most common cause. The classic triad of cough, dyspnea, and cyanosis is seen in only a small percentage of patients with FBAO. Laryngeal edema, soft tissue collapse, and laryngospasm are among the common causes of upper airway obstruction and extubation failure. Laryngeal traumatism that can occur during emergency intubations can cause post-extubation stridor that can be treated with corticosteroids. Dentures and blood have been reported to cause post-extubation complications but oropharyngeal FB causing airway compression and leading to extubation failure has not been reported before. We recommend FB to be considered in the differential diagnosis of immediate hypoxia and extubation failure regardless of the history of a witnessed aspiration event as it is an easily fixable cause and can be missed in the initial history of presentation. A high degree of suspicion for this should be maintained as it is easy to miss. Computed tomography of the neck can aid in the diagnosis.

A Review of the Incidence Diagnosis and Treatment of Spontaneous Hemorrhage in Patients Treated with Direct Oral Anticoagulants.

Anticoagulation carries a tremendous therapeutic advantage in reducing morbidity and mortality with venous thromboembolism and atrial fibrillation. For over six decades, traditional anticoagulants like low molecular weight heparin and vitamin K antagonists like warfarin have been used to achieve therapeutic anticoagulation. In the past decade, multiple new direct oral anticoagulants have emerged and been approved for clinical use. Since their introduction, direct oral anticoagulants have changed the landscape of anticoagulants. With increasing indications and use in various patients, they have become the mainstay of treatment in venous thromboembolic diseases. The safety profile of direct oral anticoagulants is better or at least similar to warfarin, but several recent reports are focusing on spontaneous hemorrhages with direct oral anticoagulants. This narrative review aims to summarize the incidence of spontaneous hemorrhage in patients treated with direct oral anticoagulants and also offers practical management strategies for clinicians when patients receiving direct oral anticoagulants present with bleeding complications.

Critical Illness Due to Covid-19: A Description of the Surge in a Single Center in Sioux Falls.

BACKGROUND: We aim to describe the basic demographics, clinical course and outcomes of critically ill patients with Covid-19 admitted to Avera McKennan Hospital and University Health Center Intensive Care Unit (ICU) between March 20 and May 4, 2020. METHODS: In this single centered, retrospective, observational study, we enrolled 37 critically ill adults with COVID-19 pneumonia admitted to the (ICU) between March 20 and May 4, 2020. Demographic data, admitting symptoms, laboratory values, co-morbidities, treatments and clinical outcomes were collected. Data was compared between survivors and non-survivors. We aim to describe our data and report the 28-day mortality as of June 1, 2020. RESULTS: Of 154 patients admitted with COVID-19 pneumonia during our study period, 37 (24 percent) were critically ill and required an ICU stay. The mean age was 58 years and 76 percent were men. Of these 37 patients, 28 (78 percent) had a chronic illness (diabetes in 43 percent, hypertension in 47 percent). In addition, 54 percent were associated with a local meat packing plant. Most common presenting symptoms were dyspnea (92 percent), cough (70 percent) and fever (68 percent). The mean PaO2/ FiO2 ratio was 143 (67-362). Significant lab findings include the following: 54 percent of patients had lymphocytopenia, the mean ferritin was 850 ng/mL (10-3528), the mean D-Dimer was 4.09 FEU ug/mL and the mean IL-6 was 96.5 pg/mL. At 28 days, 24 percent (nine) had died. Twenty-five (68 percent) patients required mechanical ventilation, with 10 (27 percent) of those patients requiring initiation of neuromuscular blocking agents for ventilator compliance. Of those four (40 percent) did not survive. In addition, 20 patients (54 percent) were proned. Pneumomediastinum or pneumothorax occurred in five of the 37 (14 percent). Renal replacement therapy was required in 6 of the 37 patients, 4 of whom (66 percent) died. Steroids were used in 70 percent of patients, tocilizumab in 59 percent, and hydroxychloroquine in 27 percent. All patients received antibiotics. Convalescent plasma became available for our 5th patient. A total of 29 (78 percent) received convalescent plasma, (86 percent of survivors and 56 percent non-survivors). Median ICU length of stay was 11 days for both survivors (1-49) and non-survivors (1-21). There were no differences in age, body mass index (BMI), or initial PaO2/FiO2 (P/F) among those two groups. Non-survivors (nine) included the two immune compromised patients in our cohort, two patients with pre-existing DNR/DNI status, and one death within two hours of admit. Compared with survivors, more of the non-survivors received vasopressors (78 percent vs 46 percent), dialysis (44 percent vs 7 percent) and hydroxychloroquine (44 percent vs 21 percent). The first 5 patients treated in the ICU did not survive. One month after the initial case was reported in South Dakota, our ICU experienced a six-week surge. At its highest, COVID-19-related census reached 63 percent of the ICU capacity (15/24). CONCLUSION: Mortality of critically ill patients with COVID-19 is high. Multi-organ, advanced and prolonged critical care resources are needed. Interpretation of our data is limited by a higher mortality of the earlier members of the cohort, a change in therapeutic practice over time and institution of social distancing.

Pulmonary hypertension in end-stage renal disease.

Pulmonary hypertension associated with end-stage renal disease (ESRD) is an important yet under-recognized condition and can lead to life-threatening complications. The pathogenesis of pulmonary hypertension is peculiar in ESRD, and understanding it is important to recognize such patients at the earliest and commence appropriate treatment. Many studies have discovered the prevalence of pulmonary hypertension to be up to 80% in ESRD and have been associated with increased mortality. WHO has classified pulmonary hypertension in renal failure to be in group 5, a group defined by unclear multifactorial etiologies. Moreover, there is an improvement with renal transplant and closure of AV fistula, thus confirming the contribution from these. The pharmacological management of pulmonary hypertension in this unique population is not very different from other etiologies. However, one should understand that pulmonary hypertension as such, could be multifactorial, and other secondary causes of pulmonary hypertension should also be recognized and treated accordingly. In this article, we will discuss the concept of pulmonary hypertension in ESRD in detail and the options of treatment.

Colonic Mucosal Ulceration and Gastrointestinal Bleeding Associated with Sevelamer Crystal Deposition in a Patient with End Stage Renal Disease.

End stage renal disease (ESRD) population account for 1.9 per patient year of hospital admissions annually. ESRD population are at increased risk of bleeding secondary to use of anticoagulation during hemodialysis and uremia induced platelet dysfunction. Gastrointestinal bleeding accounts for 3-7% of all deaths in ESRD population. Lower gastrointestinal bleeding refers to blood loss from a site in the gastrointestinal tract distal to the ligament of Treitz. It is usually suspected when a patient complains of hematochezia. It is different from patients presenting with hematemesis that suggests bleeding from upper gastrointestinal tract. Common causes of lower gastrointestinal bleed include diverticulosis, ischemia, hemorrhoids, neoplasia, angiodysplasia, and inflammatory bowel disease. ESRD patients are known to retain phosphate alone or in combination with calcium which has been associated with high mortality. Sevelamer is a phosphate binder used widely in ESRD population. The known side effects of sevelamer include metabolic acidosis, vomiting, nausea, diarrhea, dyspepsia, abdominal pain, constipation, flatulence, fecal impaction, and skin rash. We are reporting a unique case of a 56-year-old female with end stage renal disease on sevelamer hydrochloride who presented with gastrointestinal bleeding and underwent a right hemicolectomy found to have sevelamer-induced mucosal ulceration and crystal deposition in the colonic mucosa. This case report highlights the fact that, with widespread use of this medication in the patients with chronic kidney diseases, physicians should be aware of this underrecognized entity in the differential diagnosis of gastrointestinal bleed in ESRD patients.

Group A Streptococci-Associated Necrotizing Fasciitis following Cat Bite in an Immunocompromised Patient.

Necrotizing soft tissue infections are characterized clinically by fulminant tissue destruction, systemic signs of toxicity, and high mortality. Accurate diagnosis and appropriate treatment must include early surgical intervention and antibiotic therapy. Mortality rate is very high and could be even higher in an immunocompromised host. We present a 57-year-old female with history of rheumatoid arthritis on oral corticosteroid and methotrexate therapy with painful swelling of the left hand following a cat bite that was diagnosed as having group A streptococcus pyogenes-associated necrotizing fasciitis. Treatment with ampicillin-sulbactam, Clindamycin, and surgical debridement was performed. In spite of all the adequate therapy she succumbed to death from streptococcal toxic shock and related complications after thirty-two days of treatment in intensive care unit. Necrotizing fasciitis is an uncommon but life-threatening complication in immunocompromised hosts. Tissue infections in cat bite wounds are commonly caused by pathogenic bacterium known as Pasteurella multocida. Group A streptococcal infections are not reported following cat bites. A high index of suspicion must be maintained to suspect group A streptococcal associated necrotizing fasciitis following cat bites and an early medical and surgical intervention should be made for any best possible outcome.

Long-acting Muscarinic Antagonist Versus Inhaled Corticosteroid when Added to Long-acting ß-agonist for COPD: A Meta-analysis.

The purpose of this study was to systematically review the efficacy and safety of long-acting ß-agonist/long-acting muscarinic antagonist (LABA/LAMA) and LABA/inhaled corticosteroid (ICS) combinations in patients with advanced chronic obstructive pulmonary disease (COPD). Randomized clinical trials of at least 12 weeks of duration comparing LABA/LAMA and LABA/ICS combinations were included. We chose forced expiratory volume in 1 second (FEV1), St. George's Respiratory Questionnaire (SGRQ) score, Transitional Dyspnea Index (TDI), COPD Assessment Test (CAT) score, COPD exacerbations, mortality, and other safety parameters as outcome assessment criteria. We included six randomized controlled trials with a total of 4,319 patients. Most patients did not have a history of exacerbation. LABA/LAMA was associated with greater improvement in FEV1 than LABA/ICS (mean difference (MD) 0.09L, 95%confidence interval (CI) 0.07 to 0.11L; high certainty). Two treatments appeared clinically equivalent in improving SGRQ (MD -0.12, 95%CI -1.16 to 0.92; high certainty), TDI (MD 0.15, 95%CI -0.05 to 0.35; high certainty), and CAT scores (MD 0.28 95%CI -0.29 to 0.85; moderate certainty). LABA/LAMA was associated with an absolute reduction of approximately 8% in the incidence of pneumonia compared with LABA/ICS (risk ratio 0.41, 95%CI 0.18 to 0.94; moderate certainty). There was no significant difference in safety and exacerbation outcomes. However, equivalence of two treatments could not be concluded due to imprecision especially for mortality, cardiac serious adverse events, and severe exacerbations. Our findings support the use of dual long-acting bronchodilators for patients with advanced COPD but without frequent exacerbations given the excess risk of pneumonia with LABA/ICS.

C1q Nephropathy: The Unique Underrecognized Pathological Entity.

C1q nephropathy is a rare glomerular disease with characteristic mesangial C1q deposition noted on immunofluorescence microscopy. It is histologically defined and poorly understood. Light microscopic features are heterogeneous and comprise minimal change disease (MCD), focal segmental glomerulosclerosis (FSGS), and proliferative glomerulonephritis. Clinical presentation is also diverse, and ranges from asymptomatic hematuria or proteinuria to frank nephritic or nephrotic syndrome in both children and adults. Hypertension and renal insufficiency at the time of diagnosis are common findings. Optimal treatment is not clear and is usually guided by the underlying light microscopic lesion. Corticosteroids are the mainstay of treatment, with immunosuppressive agents reserved for steroid resistant cases. The presence of nephrotic syndrome and FSGS appear to predict adverse outcomes as opposed to favorable outcomes in those with MCD. Further research is needed to establish C1q nephropathy as a universally recognized distinct clinical entity. In this paper, we discuss the current understanding of pathogenesis, histopathology, clinical features, therapeutic options, and outcomes of C1q nephropathy.

Invasive Saccharomyces cerevisiae infection: a friend turning foe?

We report a very rare case of acute pyelonephritis in a 51-year-old female with a history of chronic kidney disease (CKD) and diabetes caused by a normally benign and a well-known human commensal organism, Saccharomyces cerevisiae that is very often prescribed as a probiotic in modern medical practice. The causal role of S. cerevisiae was confirmed by its isolation in blood, urine, stool as well as vaginal swabs thus proving its virulent nature in suitable situations.

An under recognized cause of chest pain.

Aortic intramural hematoma (IMH) is related to but is pathologically distinct from aortic dissection. In this potentially lethal entity, there is hemorrhage into the aortic media in the absence of an intimal tear. With recent advances in imaging techniques, IMH is now increasingly recognized. The limited data available suggest that the clinical course of IMH mimics that of acute aortic dissection, and mortality rates are similar. Physicians need to be cognizant regarding this entity when they are evaluating chest pain. Here we report a case of IMH, in a 63-year-old female, which was managed conservatively.