Thyroid Cancer Presenting as Aspiration Pneumonia: A Tale of Retrosternal Goiters.

Abnormal enlargement of the thyroid gland is called goiter. Structurally, it can be nodular or diffuse. Usually, it presents as an anterior cervical mass; however, less commonly, it presents as a retrosternal mass causing symptoms of compression on the surrounding structures. Most patients with goiter are asymptomatic due to the euthyroid nature of the disease. However, sometimes they can be hypo or hyperthyroid depending on the etiology of the goiter. Here, we present the case of a patient without any previously known goiter who presented to the hospital with shortness of breath and was found to have hypoxic respiratory failure as his first noticed sign of thyroid disease. Diagnostic workup revealed retrosternal goiter causing compression effect on the esophagus and trachea resulting in dysphagia and aspiration. The patient was treated with feeding tube placement, followed by surgical resection of the mediastinal mass.

A Case of Pulmonary Tumor Thrombotic Microangiopathy: A Rare and Fatal Phenomenon.

Pulmonary tumor thrombotic microangiopathy (PTTM) is a pulmonary hypertensive arteriopathy thought to be caused by activation of the coagulation cascade at the surface of circulating tumor microemboli along with intimal proliferation in small pulmonary arteries in patients with metastatic carcinomas. The subsequent stenosis of the pulmonary vasculature leads to pulmonary hypertension (PH) and, cor pulmonale with eventual respiratory compromise leading to respiratory failure. PTTM is always a nearly fatal disease with most cases diagnosed postmortem. Most cases reported on this condition are from Japan where the incidence of gastric malignancy is relatively higher than other parts of the world. We report a case of a Caucasian man with a classic presentation of PTTM to help make physicians aware of this rare, rapidly progressive and usually fatal phenomenon.

Purpura fulminans due to Streptococcus pneumoniae bacteraemia in an unsplectomised immunocompetent adult without primary hypocomplementaemia.

Invasive pneumococcal disease occurs in high-risk patient population which includes patients with asplenia and primary hypocomplementaemia. Pneumococcal sepsis can rarely cause disseminated intravascular coagulation (DIC) and intravascular thrombosis of small and medium sized vessels called purpura fulminans which is associated with a high mortality rate. We present the case of an immunocompetent woman in her 50s with an intact spleen who presented with septic shock from Streptococcus pneumoniae bacteraemia. Her hospital course rapidly progressed to multiorgan dysfunction, DIC and purpura fulminans. She was treated aggressively with broad spectrum antibiotics, coagulation factor replacement, multiple vasopressor support, renal replacement therapy and mechanical ventilator support. Despite aggressive measures, she succumbed to the multiorgan failure.

Chemical Meningitis and Status Epilepticus Caused by Accidental Epidural Administration of Digoxin.

Intrathecal administration of digoxin occurs very rarely. Some case reports of inadvertently administering it when performing spinal/epidural anesthesia were described. We report for the first time a case of a chemical meningitis and status epilepticus caused by accidental epidural administration of digoxin. A 26-year-old female underwent epidural anesthesia for a planned cesarean section (CS). Post operatively the patient became lethargic, agitated and encephalopathic, she was intubated and transferred to our hospital intensive care unit (ICU). She had seizures on admission. Electroencephalogram (EEG) was performed and showed generalized slowing and status epilepticus with a focus noted in the right temporal region which resolved after antiepileptic medication administration. A lumbar puncture (LP) was performed; cerebro-spinal fluid (CSF) was suggestive for meningitis. However, there was no evidence for viral or bacterial infections. Within a day of admission, the referring hospital informed us that the patient received 250 mcg of digoxininadvertently-through epidural injection. The patient remained intubated for four days. She became more responsive and alert and was eventually extubated. After extubation, the patient was responsive and full neurological exam and brain imaging were normal. She was discharged from the hospital after seven days.

An overview of alpha-1 antitrypsin deficiency.

Alpha-1 Antitrypsin Deficiency is a common hereditary disorder that results from abnormal Alpha Antitrypsin production. This predisposes patients to early onset emphysema especially when exposed to tobacco smoke. Early recognition is important. Smoking cessation and augmentation therapy are currently the only treatments available to slow the disease process. Surgical intervention may be palliative when medical and rehabilitation efforts have failed. This paper summarizes the current literature and presents an overview of AATD.