Long-term outcomes and predictors of mortality in patients with pulmonary embolism undergoing catheter-directed thrombolysis: a 10-year retrospective study.

BACKGROUND: Data regarding long-term outcomes of catheter-directed thrombolysis (CDT) post intermediate risk pulmonary embolism (PE), the choice of anticoagulation, and factors affecting mortality are not well studied. METHODS: We conducted a ten-year retrospective observational chart review of patients undergoing CDT for intermediate-risk PE. Patients were followed for a period of 1 to a maximum of 5 years from the PE event. Multivariate regression analysis was used to identify independent predictors of mortality post-CDT. RESULTS: We had a total of 373 patients in our study. Significant 5-year mortality was observed (18.7 %) in our patient population, with a 9.2 % cardiopulmonary cause of death. Rate was highest in patients without anticoagulation (78.5 %) and least in patients on apixaban [10.9 %, absolute risk reduction - 63.8 % (40.91 % - 86.60 %)]. Age, female sex and no anticoagulation were independently associated with mortality. CONCLUSION: CDT for intermediate-risk PE has a high 5-year mortality with no anticoagulation as the only modifiable risk factor.

Pulmonary Langerhans Cell Histiocytosis: An Unusual Differential for a Solitary Lung Nodule.

Background: Pulmonary Langerhans cell histiocytosis (LCH) commonly presents as bilateral reticulonodular and cystic lung changes on chest imaging. Isolated lung nodule presentation is rare. Case Presentation. Our patient was an elderly male and an active smoker, who was referred to the pulmonology clinic for an incidental 19 mm lung nodule seen on a chest CT scan. A CT-guided transthoracic needle biopsy was performed to rule out malignancy. The biopsy sample showed marked inflammatory infiltrate with abundant eosinophils and epithelioid histiocyte-like cells suggestive of Langerhans cell histiocytosis. Antibodies against CD1a and Langerhans were positive which confirmed the diagnosis. During follow-ups, the patient had reduced smoking, and the lung nodule had decreased in size to 14 mm. Conclusion: An isolated lung nodule in a patient with a smoking history always warrants a malignancy workup. Characteristic pathological findings with immunostaining are necessary to differentiate pulmonary LCH in these cases. Failure to perform immunostaining in such cases may lead to missing this vital diagnosis.

Vasoreactive pulmonary artery hypertension in non-fibrotic hypersensitive pneumonitis.

Group III pulmonary hypertension (PH) is common in patients with hypersensitivity pneumonitis (HSP). Group I PH and vasoreactivity in HSP have not been reported. We describe a case of an elderly veterinarian woman who presented with progressive shortness of breath and desaturation on exertion. The patient was diagnosed with non-fibrotic HSP after consistent findings on chest CT, transbronchial biopsy and a positive HSP serological panel. The patient relocated her birds, and prednisone was started. Due to persistent symptoms, she underwent a right heart catheterisation, which showed PH with vasoreactivity; subsequently, nifedipine was started. Over a 9-month follow-up, there was an improvement in symptoms and a complete resolution of PH and CT scan changes. Our case highlights the rare possibility of group I PH in HSP. It illustrates the importance of confirming the aetiology of PH and initiating treatment early to resolve symptoms.

A Rare Case of Late-Onset Ertapenem-Induced Encephalopathy.

Encephalopathy is a rare side effect associated with carbapenem antibiotics, typically presenting within one week of initiating treatment. It is almost exclusively seen in patients with poor renal function. We present a case of a middle-aged male with a history of cerebral vascular accident and normal renal function admitted for agitation, delirium, and insomnia more than two weeks after starting ertapenem to treat osteomyelitis. He was empirically treated for meningitis on admission, and ertapenem was discontinued. After an extensive negative workup for infectious and neurological etiologies of encephalopathy, a presumptive diagnosis of ertapenem-induced encephalopathy was made. The patient returned to his baseline mental status five days after discontinuing ertapenem. The nature of his neurological symptoms and timely resolution after stopping ertapenem is consistent with ertapenem-induced encephalopathy and represents a notably delayed symptom onset compared to previously described cases.

A Case of Rosai-Dorfman Disease Presenting as an Isolated Pleural Plaque.

Rosai-Dorfman disease (RDD) is a rare non-Langerhans histiocytic disorder primarily involving lymph nodes. Extranodal RDD has a heterogenous presentation, and isolated pulmonary involvement is rare. We report the only case of RDD presenting as an isolated pleural mass. Our patient was a 55-year-old female with multiple comorbidities who presented with chest pain. Imaging revealed an enlarging pleural-based lesion. She underwent resection of the pleural mass, showing an atypical histiocytic infiltrate in a prominent background of collagenous fibrosis. Immunohistochemistry shows CD1a-negative and S100-positive atypical histiocytic cells demonstrating emperipolesis, confirming the diagnosis of RDD. She is currently on six-month CT surveillance with no recurrence of the disease. This case highlights the unique pulmonary presentation of RDD. It also underscores that observations may be appropriate in isolated asymptomatic pleural involvement cases.

Idiopathic hypereosinophilic syndrome presenting as cardiac tamponade and multiorgan dysfunction.

Idiopathic hypereosinophilic syndrome is characterised by the overproduction of eosinophils with tissue infiltration, leading to multiorgan dysfunction. Its heterogenous presentation makes the diagnosis challenging and easy to miss. A woman in her 70s was admitted with chest pain and shortness of breath. Diagnostic testing showed elevated cardiac enzymes, an ejection fraction of 45% and pericardial effusion. Pericardiocentesis helped her symptoms significantly. Cardiac catheterisation revealed patent coronary arteries. She was diagnosed with myopericarditis and discharged on non-steroidal anti-inflammatory drugs. She returned the following week with worsening chest pain, dyspnoea and diarrhoea. Chest imaging showed bilateral infiltrates. Diagnostic testing showed eosinophilic predominance in peripheral blood (59%), pericardial fluid (37%) and bronchoalveolar lavage (31%). After a negative infectious workup, she was started on glucocorticoids and responded favourably. She was discharged on steroids. Mepolizumab was initiated outpatient, and steroids were discontinued. Mepolizumab was discontinued after 2 years while monitoring her symptoms and eosinophil counts.

Mitral Annular Disjunction: A Scoping Review.

Mitral annular disjunction (MAD) is the atrial displacement of the mitral valve (MV) hinge point, especially along the posterior mitral leaflet, which leads to inhomogeneous blood flow into the left ventricle, causing chronic fibrotic changes, malignant arrhythmias, and even sudden cardiac arrest. Some studies suggest that MAD is a part of normal heart morphology; however, the origin is still controversial. MAD commonly occurs with MV prolapse and myxomatous degenerative MV disease. In almost 20% of cases, MAD can occur independently as well. The prevalence of MAD in normal hearts varies from 8.6% to 96%, depending on the imaging modality and the cutoff used to define MAD. Transthoracic echocardiography is often the initial screening test, but the low sensitivity of transthoracic echocardiography to identify MAD makes it easy to miss the diagnosis altogether. More advanced imaging, especially cardiac MRI, is the gold standard for diagnosing MAD and risk stratification. MAD is an independent predictor of malignant arrhythmia. Among patients with MAD, risk stratification is based on the age at diagnosis, previous syncopal attacks, premature ventricular contractions, papillary muscle fibrosis, and longitudinal disjunction distance. Most asymptomatic patients are managed conservatively; however, radiofrequency ablation should be considered in patients with high-risk or symptomatic MAD due to the risk of ventricular arrhythmias and sudden cardiac death.

A Case of Immunoglobulin G4-Related Disease Presenting as a Parapharyngeal Mass.

Immunoglobulin G4-related disease (IgG4-RD) is a fibroinflammatory condition characterized by tissue infiltration with lymphocytes and IgG4-secreting plasma cells. The presentation of IgG4-RD is heterogenous, making it difficult to diagnose. IgG4-RD presenting as a parapharyngeal mass is extremely rare. This report discusses the case of a 69-year-old African American female presenting with intermittent bilateral frontal headaches. Initial imaging revealed an ill-defined parapharyngeal mass encasing the left internal carotid artery and left internal jugular vein. Subsequent biopsy and immunohistochemistry showed a high concentration of IgG4-positive plasma cells with storiform fibrosis, despite normal serum IgG4 levels. The patient opted for conservative management. The localized parapharyngeal mass has remained stable over two years on annual imaging. This case report highlights that IgG4-RD can have varied and nonspecific presentations requiring high clinical suspicion to diagnose. Histopathology and IgG4 staining are vital to confirm the diagnosis of IgG4-RD, particularly in atypical cases not meeting the standard inclusion criteria.

Spontaneous Resolution of Recurrent Pleural Effusion in Atraumatic Splenic Rupture.

Spontaneous splenic rupture is an uncommon cause of acute-onset left-sided pleural effusion. It is often immediate with a high preponderance for recurrence, sometimes even requiring splenectomy. We report a case of spontaneous resolution of recurrent pleural effusion presenting a month after the initial atraumatic splenic rupture. Our patient was a 25-year-old male without significant medical history who was taking Emtricitabine/Tenofovir for pre-exposure prophylaxis. He presented to the pulmonology clinic for left-sided pleural effusion, diagnosed in the emergency department a day prior. He had a history of spontaneous grade III splenic injury one month before, where he was diagnosed with cytomegalovirus (CMV) and Epstein-Barr virus (EBV) co-infection on polymerase chain reaction (PCR) testing and was managed conservatively. The patient underwent thoracentesis in the clinic, which showed exudative lymphocyte predominant pleural effusion and no malignant cells. The remainder of the infective workup was negative. He was readmitted two days later with worsening chest pain, and imaging revealed re-accumulation of pleural fluid. The patient declined thoracentesis, and a chest X-ray was repeated a week later, showing worsening pleural effusion. The patient insisted on continuing conservative management, and he was seen a week later with a repeat chest X-ray that showed near resolution of pleural effusion. Splenomegaly and splenic rupture can lead to pleural effusion due to posterior lymphatic obstruction, which can be recurrent. There are no current guidelines on management, and treatment options include watchful monitoring, splenectomy, or partial splenic embolization.

Cystic Lung Disease Presenting as Recurrent Non-traumatic Chylothorax: Case Report and a Mini-Review.

Malignancy and infections are the most common causes of recurrent chylothorax. Cystic lung disease, especially sporadic pulmonary lymphangioleiomyomatosis (LAM), is a rare condition that may manifest as recurrent chylothorax. We present a case of a 42-year female who presented with dyspnea on exertion secondary to recurrent chylothorax, requiring three thoracenteses within a few weeks. Chest imaging showed multiple bilateral thin-walled cysts. Thoracentesis revealed milky-colored pleural fluid, which was exudative and lymphocytic predominant. Infectious, autoimmune, and malignancy workup was negative. Vascular endothelial growth factor-D (VEGF-D) levels were sent for testing, which came back elevated (2001 pg/ml). A presumptive diagnosis of LAM was made based on recurrent chylothorax, bilateral thin-walled cysts, and elevated VEGF-D levels in a reproductive age group woman. Given quick reaccumulation of chylothorax, she was started on sirolimus. After initiating therapy, there was a significant improvement in the patient's symptoms, with no recurrence of chylothorax in the five years of follow-up. Awareness of different forms of cystic lung diseases is vital to establish an early diagnosis, which may prevent disease progression. Rarity and heterogeneity of presentation often make the diagnosis challenging, requiring a high degree of suspicion.

A Case of the Unveiling of Pulmonary Pseudoaneurysm Masquerading as a Lung Mass.

Pulmonary artery pseudoaneurysm (PAP) is an abnormal dilatation of the pulmonary vessels. They can mimic the appearance of lung nodules on chest X-rays and noncontrast CT imaging of the chest. We present a case of PAP masquerading as a lung mass for five years before presenting as a pulmonary hematoma. Our patient was an elderly male who presented to the emergency department with dizziness and weakness. He had been on regular follow-ups with annual noncontrast CT scans for a stable lung mass for the past five years. A contrast-enhanced chest CT scan on presentation showed a right lower lobe pseudoaneurysm ruptured into the pleural space with hemothorax, which was confirmed on subsequent chest CTA. The patient underwent an emergent right lower lobe resection and recovered uneventfully. Differentiating a PAP from a lung nodule is challenging and is often missed even by radiologists. A nodule or mass along the pulmonary arterial tree should raise suspicion and trigger further contrast-enhanced imaging, especially angiography, to confirm the diagnosis.

Life-Threatening Acidosis With Metformin and Dapagliflozin Combination Therapy: A Case Report.

Euglycemic keto-acidosis is a known complication of dapagliflozin. However, acidosis can be life-threatening when dapagliflozin is used as a combination therapy with metformin. Our patient was a 64-year-old male, with a history of well-controlled type 2 diabetes mellitus on metformin and dapagliflozin, admitted with vomiting and diarrhea for several days. On presentation, the patient was hypotensive and severely acidotic (pH < 6.7; bicarbonate <5 mmol/L) with an anion gap of 47. Other labs included elevated lactate (19.48 mmol/L), creatinine of 10.39 mg/dL, and elevated beta-hydroxybutyrate levels. The patient was intubated and started on dual vasopressors, insulin drip, and i.v. hydration. Due to worsening acidosis, bicarbonate drip and, subsequently, continuous dialysis was started. The patient's acidosis normalized after two days of dialysis, and he was extubated by day three and discharged by day seven. Dapagliflozin leads to keto-acidosis due to increased hepatic ketogenesis and adipose tissue lipolysis. It also promotes natriuresis, glycosuria, and free water loss. Recurrent vomiting and poor oral intake with concomitant lactic acidosis with metformin can lead to life-threatening acidosis. Clinicians should remain cognizant of the possibility of severe acidosis with the combination therapy of dapagliflozin and metformin in severe dehydration. Adequate hydration may prevent this life-threatening complication.

Identification of patients for a delayed extubation strategy versus elective tracheostomy for postoperative airway management in major oral cancer surgery: A prospective observational study in seven hundred and twenty patients.

OBJECTIVES: Tracheostomy (TT) and delayed extubation (DE) are two approaches to postoperative airway management in patients after major oral cancer surgery. We planned a study to determine the safety of overnight intubation followed by extubation the next morning (DE) compared to elective TT and to identify factors that were associated with a safe DE (maintenance of a patent airway). MATERIAL AND METHODS: We conducted a prospective observational study in a tertiary referral cancer care center. We included adult patients undergoing elective major oral cancer surgery under general anesthesia with tracheal intubation. The decision regarding postoperative airway management using either TT or DE was made according to the usual practice at our center. RESULTS: We screened a total of 4477 patients, 720 patients were included. DE was performed in 417 patients (58.4%) and TT in 303 patients (42.4%). On multivariable analysis, T1-T2 tumor stage, absence of extensive resection, primary closure or reconstruction using fasciocutaneous flap, absence of preoperative radiation, no neck dissection or unilateral neck dissection and shorter duration of anesthesia were independent predictors for a safe DE. Overall complications (4.3% versus 22.5%, p = 0.00) and airway complications (1.7% versus 8.7%, p = 0.00) were lower in the DE compared to the TT group respectively. DE was associated with a shorter hospital stay (7.2 ± 3.7 versus 11.5 ± 7.2 days, p = 0.00), time to oral intake and speech compared to TT. CONCLUSIONS: A DE strategy after major oral cancer surgery is a safe alternative to TT in a select group of patients.

Anesthesia for oral surgeries during the COVID-19 pandemic.

The severe acute respiratory syndrome corona virus 2(SARS-Cov2) virus replicates in the nasal cavity, nasopharynx, and the oropharynx. During oral surgery, the risk of viral transmission is high during instrumentation in these areas, while performing airway management procedures, the oral surgery itself, and related procedures. During the corona virus disease 2019 (COVID-19) pandemic, patients with an oral pathology usually present for emergency procedures. However, patients with oral cancer, being a semi-emergency, may also present for diagnostic and therapeutic procedures. When elective surgeries are resumed, these patients will come to the operating room. In asymptomatic patients, the false-negative rate can be as high as 30%. These patients are a source of infection to the healthcare workers and other patients. This mandates universal precautions to be taken for all patients presenting for surgery. Lesions along the airway, distorted anatomy secondary to cancer therapy, shared airway with the surgeon, surgical handling of the airway and the risk of bleeding, make airway management challenging in these patients, especially while wearing personal protective equipment. Airway management procedures, oral surgery, use of cautery, and other powered surgical instruments in the aero digestive tract, along with constant suctioning are a source of significant aerosol generation, further adding to the risk of viral transmission. Maintaining patient safety, while protecting the healthcare workers from getting infected during oral surgery is paramount. Meticulous advance planning and team preparation are essential. In this review, we discuss the challenges and recommendations for safe anesthesia practice for oral surgery during the COVID-19 pandemic, with special emphasis on risk mitigation.

Massive Engorgement of a Hemangioma of the Tongue After General Anesthesia Using a Supraglottic Airway Device: A Case Report.

We report a case of massive engorgement of an asymptomatic tongue hemangioma with the use of a supraglottic airway device (SGA) during general anesthesia for transurethral resection of a tumor on the lateral wall of the urinary bladder. This was probably a result of obstruction of the venous drainage of the hemangioma due to the pressure exerted by the inflated cuff of the SGA. The SGA was removed and the trachea was intubated and the engorgement resolved completely in a few hours.

Opioid-free anesthesia-caution for a one-size-fits-all approach.

Post-operative pain management should ideally be optimized to ensure patient's mobilization and ability to partake in effective pulmonary exercises for patient's early recovery. Opioids have traditionally been the main mode for analgesia strategy in the perioperative period. However, the recent focus on opioid crisis in the USA has generated a robust discussion on rational use of opioids in the perioperative period and also raised the concept of "opioid-free anesthesia" in certain circles. Opioid-related adverse drug events (ORADE) and questionable role of opioids in cancer progression have further deterred some anesthesiologists from the routine perioperative use of opioids including their use for breakthrough pain. However, judicious use of opioid in conjunction with the use of non-opioid analgesics and regional anesthetic techniques may allow for optimal analgesia while reducing the risks associated with the use of opioids. Importantly, the opioid epidemic and opioid-related deaths seem more related to the prescription practices of physicians and post-discharge misuse of opioids. Focus on patient and clinician education, identification of high-risk patients, and instituting effective drug disposal and take-back policies may prove useful in reducing opioid misuse.

Supraglottic jet oxygenation and ventilation - A novel ventilation technique.

Supraglottic jet oxygenation and ventilation (SJOV) is a novel minimally invasive supraglottic technique of jet ventilation which has shown superior results in maintaining oxygenation without any major complications. Theoretically, it could maintain PaO2 and PaCO2 within physiological limits for as long as required, the maximum duration reported till now is 45 min. The distinct advantage of SJOV over techniques of nasal oxygenation is its ability to record EtCO2 during the periods of ventilation. In addition, it also provides reliable airway access by the blind passage of the endotracheal tube into the trachea with a high success rate even in Cormack-Lehane-III (CLIII) grading patients. Potential complications seen with SJOV include nasal bleed and sore throat. No studies have shown to cause severe barotrauma. In this article, we review the evidence regarding oxygenation, ventilation, indications, airway patency and complications of SJOV in comparison to other more commonly used supraglottic oxygenation and ventilation devices.

A novel technique for insertion of ProSeal™ laryngeal mask airway: Comparison of the stylet tool with the introducer tool in a prospective, randomised study.

BACKGROUND AND AIMS: The ProSeal™ laryngeal mask airway (PLMA) has a soft cuff which tends to fold on itself during insertion, resulting in reduced first-attempt success rate. We compared the standard introducer technique of PLMA insertion with a novel method to prevent folding of the cuff using a Rüsch™ Stylet. METHODS: This randomised superiority trial included 120 American Society of Anesthesiologists I-II patients between 18 and 80 years, undergoing elective surgeries under general anaesthesia using a PLMA for airway management. The PLMA was inserted using the standard introducer tool in sixty patients (Group IT), while in sixty other patients, a Rüsch™ Stylet was inserted through the drain tube up to its tip. (Group ST). The primary outcome was first-attempt success rate. Secondary outcomes included overall insertion success, number of attempts, total time to successful insertion, presence of air leaks, haemodynamic response to insertion and quality of fit assessed using Brimacombe's fibre-optic scoring. Continuous variables were compared using independent t-test or Mann-Whitney U-test and categorical variables were analysed using Chi-square test or Fisher's exact test. RESULTS: First-attempt success rate of insertion was higher in Group ST compared to Group IT (95% vs. 82%, P = 0.04). Favourable grade of placement was better in Group ST (86.7% vs. 52.5%, P < 0.001). Overall insertion success rates and haemodynamic responses were comparable between the groups. CONCLUSIONS: PLMA insertion using the stylet tool has a higher first-attempt insertion success and superior placement compared to insertion using the conventional introducer tool.

Role of organochlorine pesticides in children with idiopathic seizures.

Background. Organochlorine pesticides (OCP) are persistent organic pollutants that have been implicated in causing several deleterious effects in humans. These are known neurotoxins in high doses, but the role of environmentally acquired OCPs in the body to induce seizures in children has not been investigated yet. Objectives. To assess the serum levels of OCPs in children aged 2-12 with idiopathic seizure and to find out any association between the two are our objectives. Methods. It was a cross-sectional pilot study. Twenty developmentally normal children aged 2-12, presenting with idiopathic generalized seizures, were recruited. Twenty age-matched controls without any history of seizures were also taken. Their serum levels of α, ß, and γ hexachlorocyclohexane (HCH); and aldrin; dieldrin; p,p-dichlorodiphenyltrichloroethane (DDT), o,p-DDT, and p,p dichlorodiphenyldichloroethylene (DDE); and α and ß endosulfan were analysed using gas chromatography (GC). Mann-Whitney U test was used to compare OCP levels between the groups. Spearman correlation was used to find the correlation between individual pesticide levels with age and seizure duration. Results. Levels of ß, γ, and total HCH were significantly higher among cases as compared to the control group (P ≤ 0.05). Conclusion. There exists a possible association between idiopathic seizures and high serum levels of OCPs, especially HCH.