COVID-19 and Blood Clots: A Report of Massive Pulmonary Embolism in COVID-19 Patient Supported on Veno-Venous ECMO and the Utility of Thrombolysis.

COVID-19 morbidity and mortality are not equivalent to other etiologies of acute respiratory distress syndrome (ARDS) as fulminant activation of coagulation can occur, thereby resulting in widespread microvascular thrombosis and consumption of coagulation factors. A 53-year-old female presented to an emergency center on two occasions with progressive gastrointestinal and respiratory symptoms. She was diagnosed with COVID-19 pneumonia and admitted to a satellite intensive care unit with hypoxemic respiratory failure. She was intubated and mechanically ventilated, but her ARDS progressed over the next 48 hours. The patient was emergently cannulated for veno-venous extracorporeal membrane oxygenation (V-V ECMO) and transferred to our hospital. She was in profound shock requiring multiple vasopressors for hemodynamic support with worsening clinical status on arrival. On bedside echocardiography, she was found to have a massive pulmonary embolism with clot-in-transit visualized in the right atrium and right ventricular outflow tract. After a multidisciplinary discussion, systemic thrombolytic therapy was administered. The patient's hemodynamics improved and vasopressors were discontinued. This case illustrates the utility of bedside echocardiography in shock determination, the need for continued vigilance in the systematic evaluation of unstable patients in the intensive care unit, and the use of systemic thrombolytics during V-V ECMO in a novel disease process with evolving understanding.

Factors Associated with Mortality in Patients with a Solid Malignancy Admitted to the Intensive Care Unit - A Prospective Observational Study.

PURPOSE: Several studies show conflicting results regarding the prognosis and predictors of the outcome of critically ill patients with a solid malignancy. This study aims to determine the outcome of critically ill patients, admitted to a hospital, with a solid malignancy and the factors associated with the outcomes. METHODS AND MATERIALS: All patients with a solid malignancy admitted to an intensive care unit (ICU) at a tertiary academic medical center were enrolled. Clinical data upon admission and during ICU stay were collected. Hospital, ICU, and six months outcomes were documented. RESULTS: There were 252 patients with a solid malignancy during the study period. Urogenital malignancies were the most common (26.3%) followed by lung cancer (23.5%). Acute respiratory failure was the most common ICU diagnosis (51.6%) followed by sepsis in 46%. ICU mortality and hospital mortality were 21.8% and 34.3%. Six months mortality was 38.4%. Using multivariate analysis, acute kidney injury, OR 2.82, 95% CI 1.50-5.32 and P=0.001, use of mechanical ventilation, OR 2.67 95% CI 1.37 - 5.19 and P=0.004 and performance status of ≥2 with OR of 3.05, 95% CI of 1.5-6.2 and P= 0.002 were associated with hospital mortality. There were no differences in outcome between African American patients (53% of all patients) and other races. CONCLUSION: This study reports encouraging survival rates in patients with a solid malignancy who are admitted to ICU. Patients with a poor baseline performance status require mechanical ventilation or develop acute renal failure have worse outcomes.

Predictors of outcome in patients with hematologic malignancies admitted to the intensive care unit.

PURPOSE: Several studies showed conflicting results about prognosis and predictors of outcome of critically ill patients with hematological malignancies (HM). The aim of this study is to determine the hospital outcome of critically ill patients with HM and the factors predicting the outcome. METHODS AND MATERIALS: All patients with HM admitted to MICU at a tertiary academic medical center were enrolled. Clinical data upon admission and during ICU stay were collected. Hospital, ICU, and 6 months outcomes were documented. RESULTS: There were 130 HM patients during the study period. Acute Leukemia was the most common malignancy (31.5%) followed by Non-Hodgkin's Lymphoma (28.5%). About 12.5% patients had autologous HSCT and 51.5% had allogeneic HSCT. Sepsis was the most common ICU diagnosis (25.9%). ICU mortality and hospital mortality were 24.8% and 45.3%, respectively. Six months mortality (available on 80% of patients) was 56.7%. Hospital mortality was higher among mechanically ventilated patients (75%). Using multivariate analysis, only mechanical ventilation (OR of 19.0, CI: 3.1-117.4, P: 0.001) and allogeneic HSCT (OR of 10.9, CI: 1.8-66.9, P: 0.01) predicted hospital mortality. CONCLUSION: Overall hospital outcome of critically ill patients with HM is improving. However those who require mechanical ventilation or underwent allogeneic HSCT continue to have poor outcome.

Role of Pulmonary Evaluation in Diagnosis of Neurosarcoidosis.

BACKGROUND: Neurosarcoidosis is a serious extra pulmonary manifestation of sarcoidosis. Its presentation ranges from peripheral or cranial neuropathy to central nervous system dysfunction. It can mimic stroke or multiple sclerosis. Due to the variation in clinical presentation, diagnosis is difficult and often delayed. OBJECTIVE: Determine the proportion of patients with neurosarcoidosis who have positive findings on chest CT, lung biopsy or lymph node biopsy. METHODS: Retrospective study at the Sarcoidosis and Interstitial Lung Disease Center at Wayne State University-Detroit Medical Center in Detroit, MI. Medical records of 424 patients were reviewed and 69 patients with neurosarcoidosis identified. RESULTS: We found that most patients diagnosed with neurosarcoidosis had normal PFT values except for reduction in DLCO. However, we also found that 71% of the patients had abnormal findings on chest CT consistent with sarcoidosis.  Additionally, 57% of the patients had non-caseating granuloma on hilar lymph node biopsy. CONCLUSION: Patients with neurosarcoidosis may not have any pulmonary symptoms. However, they are most likely to have abnormal chest CT, hilar lymphadenopathy and reduction in DLCO.  These data suggest that pulmonary evaluation is warranted in patients who are suspected to have neurosarcoidosis.

Coil embolization of pulmonary arteries as a palliative treatment of diffuse type I hepatopulmonary syndrome.

Hepatopulmonary syndrome is a serious complication of liver disease. Type I hepatopulmonary syndrome is associated with diffuse dilatation of the pulmonary vasculature, leading to severe hypoxemia. Liver transplantation is the treatment of choice for this condition. There are limited options for those who are not candidates for liver transplantation. We present the case of a patient who presented with severe hypoxemia requiring FIO2 of 0.95 with PaO2 of 59 mm Hg. Workup revealed 33% intrapulmonary right-to-left shunt. A pulmonary angiogram showed diffuse dilatation of the pulmonary arteries, especially in the lower lobes. The patient was diagnosed with type I hepatopulmonary syndrome. He was not a candidate for liver transplantation. The patient underwent sequential coil embolizations of the lower lobe pulmonary arteries. He was discharged home on 2 L of supplemental oxygen. This case demonstrates that coil embolization of dilated pulmonary arteries is a potential palliative treatment for patients with diffuse type I hepatopulmonary syndrome.

Azithromycin improves lung function in patients with post-lung transplant bronchiolitis obliterans syndrome: a meta-analysis.

INTRODUCTION: Azithromycin has been shown to reverse or halt the decline of forced expiratory volume in one s (FEV1) in patients with bronchiolitis obliterans (BOS) syndrome following lung transplant. The overall effect of azithromycin on the absolute values of FEV1 has not been compared between reported studies. We studied the effects of azithromycin on lung function in patients with post-lung transplant BOS syndrome. METHODS: A meta-analysis was performed using studies identified following an extensive database search. To be included, studies were published in English or French and explicitly reported percentage change in FEV1 or hazard ratios. RESULTS: A total of 10 studies were included in this review. One hundred and forty patients were evaluated after treatment with azithromycin for an average follow-up period of seven months. The mean percentage increase in FEV1 was 8.8 (CI 5.1-12.47) p < 0.001. The pooled hazard ratio was 0.25 (CI 0.06-0.56) p = 0.041 for a mean follow-up period of 2.9 yr. CONCLUSION: This study demonstrated a significant improvement in lung function in patients with BOS syndrome following lung transplant after seven months of treatment. It remains uncertain whether this improvement stays after seven months. We also found that patients on azithromycin were less likely to die from BOS syndrome compared with patients who were not on azithromycin.

Lung transplantation following hematopoietic stem cell transplantation: report of two cases and systematic review of literature.

BACKGROUND: Non-infectious pulmonary complications following hematopoietic stem cell transplantation (HSCT) are major cause of morbidity and mortality with limited treatment options. Lung transplantation (LT) has been rarely reported as a treatment option for selected HSCT recipients with these problems. OBJECTIVE: Describe the outcome of HSCT recipients who underwent LT. METHODS: Two cases of LT following HSCT from our institution are presented. Cases reported in literature were identified using English language PubMed/MEDLINE with keywords hematopoietic stem cell transplantation, bone marrow transplantation, or bronchiolitis obliterans cross-referenced with lung transplantation. We extracted data on baseline characteristics and survival data following LT. RESULTS: Total of 84 patients are analyzed. Age at time of LT was median of 22 yr (range 1-66). Seventy-nine patients were recipients of allogeneic HSCT. The indications for LT were bronchiolitis obliterans syndrome (BOS; 63 patients), pulmonary fibrosis (13 patients), BOS/pulmonary fibrosis (five patients), and graft-versus-host-disease (GVHD) of lung (three patients). The median time between HSCT and LT was 52.3 months (range 6-240). The median follow-up after LT was 36 months (range 0-168). During this time, BOS was documented in 25 patients. Relapse of hematological malignancy was reported in two patients, and new malignancy developed in four patients. At the end of follow-up, 60 patients were alive and 24 patients died. The probability of survival following LT at 24 and 36 months was 0.88 (95% CI 0.78-0.93) and 0.79 (95% CI 0.67-0.87), respectively. CONCLUSION: LT is a potential therapeutic option in selected patients with severe chronic pulmonary disease following HSCT. Further studies are needed to determine the appropriate timing and the outcome of this approach.

Interaction of folate intake and the paraoxonase Q192R polymorphism with risk of incident coronary heart disease and ischemic stroke: the atherosclerosis risk in communities study.

PURPOSE: To investigate the potential interaction between folate intake and the paraoxonase 1 (PON1) Q192R polymorphism with the risk of incident coronary heart disease (CHD) and ischemic stroke in the Atherosclerosis Risk in Communities study, a population-based prospective cohort of cardiovascular disease in 15,792 white and African-American subject. METHODS: Race-stratified Cox proportional hazards models were performed to examine the interaction between folate intake and the PON1 Q192R polymorphism. RESULTS: A significant inverse association between folate intake and risk of incident CHD among white subjects was found (hazard rate ratio, 1.30; 95% confidence interval, 1.09-1.56; P = .004; folate intake ≤155 µg vs ≥279 µg, reference group). An interaction effect was observed between the dominant genetic model and folate intake with regards to incident ischemic stroke in white subjects (hazard rate ratio, 0.68; 95% confidence interval, 0.91-0.99; and 1.24 from 1st-4th quartile, respectively; P-trend = .05). CONCLUSIONS: There was an interaction between folate intake and PON1 Q192 polymorphism with regard to the risk of ischemic stroke in white subjects. Future studies should investigate the interaction between additional polymorphisms within the PON1 gene and genetic variants in other folate metabolizing genes with folate intake on the risk of incident CHD and stroke.

Association of NOS3 Glu298Asp SNP with hypertension and possible effect modification of dietary fat intake in the ARIC study.

Endothelial nitric oxide synthase breaks down nitric oxide and has a key role in blood pressure regulation. Earlier studies have shown associations between single nucleotide polymorphisms (SNPs) in the NOS3 gene and hypertension. Studies also suggest that such associations may vary by dietary fat intake. We investigated associations between the NOS3 Glu298Asp SNP (rs1799983) and hypertension, as well as the interaction between NOS3 genotypes and dietary fat intake using data from baseline examination in white and African American participants in the Atherosclerosis Risk in Community (ARIC) study. Dietary fat intake was measured by a Food Frequency Questionnaire during the baseline examination in 15 792 individuals aged 45-64 years in ARIC study participants. Race-stratified unconditional logistic regression was performed to investigate the association between prevalent hypertension and NOS3 Glu298Asp genotypes. There was no significant interaction between dietary fat intake and NOS3 Glu298Asp genotype with regards to hypertension status in either African Americans or whites (P for interaction=0.3 and 0.4, respectively). We found a significant relationship between NOS3 Glu298Asp and triglycerides in African Americans. We did not find an association between the NOS3 Glu298Asp polymorphism and hypertension, and dietary fat intake did not interact with NOS3 genotypes to influence hypertension. We recommend further exploration of the relationship between NOS3 Glu298Asp and triglycerides in African Americans.