Thyrotoxic periodic paralysis-still a diagnostic challenge.

Thyrotoxic periodic paralysis is a life-threatening complication characterized by acute paralysis of proximal muscles with severe hypokalemia in patients with a known or undiagnosed history of thyrotoxicosis. A 24-year-old man was brought to the emergency room with 1 month of progressively worsening lower-extremity weakness followed by urinary retention. He demonstrated severe motor weakness in proximal muscles with absent reflexes. Laboratory testing showed a dangerously low potassium of 1.3 mmol/L. Further testing to establish an etiology revealed a new diagnosis of thyrotoxicosis, and the patient was also started on the antithyroid medication methimazole and propranolol. Immediate oral and intravenous potassium supplementation was initiated to normalize the serum potassium levels to 4.7 mmol/L; that was followed by the gradual recovery of his motor function. This case report highlights the need for early consideration of endocrine and metabolic causes of acute flaccid paralysis.

Nonhepatic Hyperammonemia With Septic Shock: Case and Review of Literature.

Elevated ammonia levels lead to cerebral edema, encephalopathy, seizures, coma, and death. Hyperammonemia is primarily associated with liver disease; however, there are rare cases without liver disease. Noncirrhotic hyperammonemia is primarily due to increased production and/or decreased elimination of ammonia. We present a rare case of a 35-year-old female with severe acute noncirrhotic hyperammonemia associated with gram-negative septic shock and a suspected undiagnosed partial urea cycle enzyme deficiency. She had elevated blood and urine amino acid levels speculated to be due to an underlying urea cycle defect, which was unmasked in the setting of septic shock with urea splitting bacteria leading to severely elevated ammonia levels. Ammonia levels were rapidly corrected with hemodialysis, as other conventional treatments failed. We highlight the importance of considering noncirrhotic causes of hyperammonemia in patients with elevated ammonia levels and intact liver function. Prompt treatment should begin with reducing the catabolic state, nitrogen scavenging, replacing urea cycle substrates, decreasing intestinal absorption, and augmented removal of ammonia with renal replacement therapy.

Cystic Lung Disease as a Sequela of Severe COVID-19: Case Series.

Coronavirus disease 2019 (COVID-19) presented in December 2019 and has persisted since. The global pandemic has given rise to a novel acute disease process with a continually rapidly increasing prevalence of chronic disease and associated complications. There is minimal information on the long-term pulmonary complications of this disease. We present a series of 9 patient case reports and their respective imaging admitted with COVID-19 acute respiratory distress syndrome (ARDS) to highlight the cystic lung disease complications which may arise due to severity and disease progression. Our aim is to raise awareness of the sequela of COVID-19 ARDS, including its potentially catastrophic long-term consequences to the respiratory tract involving cystic lung disease.

From Chest Wall Resection to Medical Management: The Continued Saga of Parapneumonic Effusion Management and Future Directions.

Pleural space infections have been described since the time of Hippocrates and to this day remains a significant pathology. Every year in the USA approximately there are one million hospital admissions for pneumonia with 20%-40% associated with some form of pleural space infections leading to pleural effusions with increased morbidity and mortality. Often, management of these effusions mandate combination of medical treatment and surgical drainage with debridement and decortication. There has been a lot of ongoing research regarding the safety and efficacy of intrapleural fibrinolytics in the management of complicated pleural effusions and empyema. Till this day, areas of debate and controversies exist among clinicians treating pleural space infection. Empyema is historically considered a surgical disease. There have been societies and guidelines for the management of infected parapneumonic effusions with antibiotics and chest tube drainage as an initial empiric treatment modality. With the advances in the use of Intrapleural fibrinolytics and minimally invasive procedures such as video-assisted thoracoscopic surgery (VATS), empyema a surgical disease is now more favoring medical management. Surgical option, such as open thoracotomy, is reserved for patients who failed conservative management and chronic empyema. The aim of this comprehensive review is to shed light on the evolution of various management strategies from the era of Hippocrates to current day practice and how there continues to be a paradigm shift in treating empyema as a surgical condition to a medical disease.

Where Did the Pericardial Effusion Go? A Case of Cardiopulmonary Resuscitation Acting as Treatment for Pericardial Tamponade.

Pericardial tamponade results in multiple organ dysfunction and can lead to cardiac arrest. Cardiopulmonary resuscitation (CPR), a life-saving measure performed on patients in cardiac arrest, can lead to thoracic organ damage. However, CPR rarely acts as a therapeutic treatment for pericardial tamponade. Our case describes a patient admitted with pericardial tamponade in whom CPR provided therapeutic treatment with pericardial rupture and resolution of the tamponade.

A comprehensive review of obstructive sleep apnea.

Obstructive sleep apnea (OSA) is a complex disorder characterized by collapse of the upper airway during sleep. Downstream effects involve the cardiovascular, pulmonary, and neurocognitive systems. OSA is more prevalent in men than women. Clinical symptoms suggest the diagnosis of OSA but none is pathognomonic of the condition. With rising awareness of OSA and the increasing prevalence of obesity, OSA is increasingly recognized as a major contributor to cardiovascular morbidity including systemic and pulmonary arterial hypertension, heart failure, acute coronary syndromes, atrial fibrillation, and other arrhythmias. Pulmonary manifestations include the development of chronic thromboembolic disease, which can then lead to chronic thromboembolic pulmonary hypertension (CTEPH). Neurocognitive morbidities include stroke and neurobehavioral disorders. Screening for OSA includes the use of symptom questionnaires and the diagnosis is confirmed by polysomnography. Management primarily includes the use of continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP) devices during sleep. Alternate options such as mandibular devices and surgical procedures are considered for certain patient populations.

Pulmonary Barotrauma Resulting from Mechanical Ventilation in 2 Patients with a Diagnosis of COVID-19 Pneumonia.

BACKGROUND Invasive mechanical ventilation can cause pulmonary barotrauma due to elevated transpulmonary pressure and alveolar rupture. A significant proportion of COVID-19 patients with acute respiratory distress syndrome (ARDS) will require mechanical ventilation. We present 2 interesting cases that demonstrate the possibility of COVID-19-associated ARDS manifesting with pulmonary barotrauma at acceptable ventilatory pressures. CASE REPORT The first patient was a 71-year-old man who was intubated and placed on mechanical ventilation due to hypoxemic respiratory failure from SARS-CoV-2 infection. His partial pressure of O2 to fraction of inspired oxygen ratio (PaO2/FiO2) was 156. He developed subcutaneous emphysema (SE) and pneumomediastinum on day 5 of mechanical ventilation at ventilatory settings of positive end-expiratory pressure (PEEP) ≤15 cmH2O, plateau pressure (Pplat) ≤25 cmH2O and pulmonary inspiratory pressure (PIP) ≤30 cmH2O. He was managed with 'blow-hole' incisions, with subsequent clinical resolution of subcutaneous emphysema. The second patient was a 58-year-old woman who was also mechanically ventilated due to hypoxemic respiratory failure from COVID-19, with PaO2/FiO2 of 81. She developed extensive SE with pneumomediastinum and pneumothorax while on mechanical ventilation settings PEEP 13 cmH2O and PIP 28 cmH2O, Pplat 18 cmH2O, and FiO2 90%. SE was managed with blow-hole incisions and pneumothorax with chest tube. CONCLUSIONS Clinicians should be aware of pulmonary barotrauma as a possible complication of COVID-19 pulmonary disease, even at low ventilatory pressures.

Paradoxical Thromboembolic Ischemic Stroke Following Tissue Plasminogen Activator Instillation for Clogged Central Venous Dialysis Catheter.

Central venous catheters including dialysis catheters are a potential source of venous thrombosis and pose a risk for paradoxical embolic events including ischemic stroke and systemic embolism in patients with a patent foramen ovale (PFO). The adult population with a PFO and patients with a central venous dialysis catheter (CVDC) are at increased risk of a paradoxical embolic event. Since bubble study is not routinely done during echocardiogram in a patient with CVDC, it is difficult to identify at-risk patients for paradoxical embolic events during catheter manipulation, especially for clogged CVDC. We report a rare case of a 79-year-old lady with end-stage renal disease on hemodialysis (HD) using a CVDC who developed a paradoxical embolic ischemic stroke following the use of tissue plasminogen activator (tPA) for unclogging a dialysis catheter. We aimed to highlight the existing risks of thromboembolism associated with the long-term use of central CVDC, especially the potential risk of paradoxical embolism and ischemic stroke with the use of tPA for management of clogged dialysis catheters. We emphasize the questionable need for a bubble study echocardiogram in all patients requiring long-term dialysis catheters.

Subacute Aspergillosis "Fungal Balls" Complicating COVID-19.

Severe acute respiratory syndrome coronavirus-2 infection (SARS-CoV-2), commonly known as COVID-19 (coronavirus disease-2019), began in the Wuhan District of Hubei Province, China. It is regarded as one of the worst pandemics, which has consumed both human lives and the world economy. COVID-19 infection mainly affects the lungs triggering severe hypoxemic respiratory failure, also providing a nidus for superimposed bacterial and fungal infections. We report the case of a 73-year-old male who presented with progressive dyspnea; diagnosed with SARS-CoV-2-related severe acute respiratory distress syndrome and complicated with lung cavitations growing Aspergillus sp. COVID-19, to our knowledge, has rarely been associated with subacute invasive pulmonary aspergillosis with aspergillomas. Subacute invasive pulmonary aspergillosis as a superimposed infection in patients with SARS-CoV-2 is a rare entity. By reporting this case, we would like to make the readers aware of this association.

Corticosteroids for treating sepsis in children and adults.

BACKGROUND: Sepsis occurs when an infection is complicated by organ failure. Sepsis may be complicated by impaired corticosteroid metabolism. Thus, providing corticosteroids may benefit patients. The original review was published in 2004 and was updated in 2010 and 2015 prior to this update. OBJECTIVES: To examine the effects of corticosteroids on death in children and adults with sepsis. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, LILACS, ClinicalTrials.gov, ISRCTN, and the WHO Clinical Trials Search Portal, on 25 July 2019. In addition, we conducted reference checking and citation searching, and contacted study authors, to identify additional studies as needed. SELECTION CRITERIA: We included randomized controlled trials (RCTs) of corticosteroids versus placebo or usual care (antimicrobials, fluid replacement, and vasopressor therapy as needed) in children and adults with sepsis. We also included RCTs of continuous infusion versus intermittent bolus of corticosteroids. DATA COLLECTION AND ANALYSIS: All review authors screened and selected studies for inclusion. One review author extracted data, which was checked by the others, and by the lead author of the primary study when possible. We obtained unpublished data from the authors of some trials. We assessed the methodological quality of trials and applied GRADE to assess the certainty of evidence. Review authors did not contribute to assessment of eligibility and risk of bias, nor to data extraction, for trials they had participated in. MAIN RESULTS: We included 61 trials (12,192 participants), of which six included only children, two included children and adults, and the remaining trials included only adults. Nine studies are ongoing and will be considered in future versions of this review. We judged 19 trials as being at low risk of bias. Corticosteroids versus placebo or usual care Compared to placebo or usual care, corticosteroids probably slightly reduce 28-day mortality (risk ratio (RR) 0.91, 95% confidence interval (CI) 0.84 to 0.99; 11,233 participants; 50 studies; moderate-certainty evidence). Corticosteroids may result in little to no difference in long-term mortality (RR 0.97, 95% CI 0.91 to 1.03; 6236 participants; 7 studies; low-certainty evidence) and probably slightly reduce hospital mortality (RR 0.90, 95% CI 0.82 to 0.99; 8183 participants; 26 trials; moderate-certainty evidence). Corticosteroids reduced length of intensive care unit (ICU) stay for all participants (mean difference (MD) -1.07 days, 95% CI -1.95 to -0.19; 7612 participants; 21 studies; high-certainty evidence) and resulted in a large reduction in length of hospital stay for all participants (MD -1.63 days, 95% CI -2.93 to -0.33; 8795 participants; 22 studies; high-certainty evidence). Corticosteroids increase the risk of muscle weakness (RR 1.21, 95% CI 1.01 to 1.44; 6145 participants; 6 studies; high-certainty evidence). Corticosteroids probably do not increase the risk of superinfection (RR 1.06, 95% CI 0.95 to 1.19; 5356 participants; 25 studies; moderate-certainty evidence). Corticosteroids increase the risk of hypernatraemia (high-certainty evidence) and probably increase the risk of hyperglycaemia (moderate-certainty evidence). Moderate-certainty evidence shows that there is probably little or no difference in gastroduodenal bleeding, stroke, or cardiac events, and low-certainty evidence suggests that corticosteroids may result in little to no difference in neuropsychiatric events. Continuous infusion of corticosteroids versus intermittent bolus We are uncertain about the effects of continuous infusion of corticosteroids compared with intermittent bolus administration. Three studies reported data for this comparison, and the certainty of evidence for all outcomes was very low. AUTHORS' CONCLUSIONS: Moderate-certainty evidence indicates that corticosteroids probably reduce 28-day and hospital mortality among patients with sepsis. Corticosteroids result in large reductions in ICU and hospital length of stay (high-certainty evidence). There may be little or no difference in the risk of major complications; however, corticosteroids increase the risk of muscle weakness and hypernatraemia, and probably increase the risk of hyperglycaemia. The effects of continuous versus intermittent bolus administration of corticosteroids are uncertain.

HHV-6 Infection in an Immunocompetent Patient with Multi-organ Failure.

Human herpesvirus 6 (HHV-6) is a double-stranded DNA virus part of the Herpesviridae family that colonizes nearly 100% of the human population. The virus is known to be the etiologic agent of roseola infantum, a self-limited disease in childhood and reactivation of the virus later in life is linked to potentially severe manifestations, including encephalitis, in immunosuppressed patients. It is rare in immunocompetent patients, but there have been several reports of encephalitis due to HHV-6 reactivation. We describe here a case of altered mental status and multi-organ failure in an immunocompetent woman, whose cerebrospinal fluid (CSF) was positive for HHV-6 DNA by polymerase chain reaction (PCR).