Situs Inversus Totalis in the Critical Care Unit: A Case Report and Literature Review.

Situs inversus is a rare congenital disorder where the reversal of some of the major thoracic or abdominal organs is present. In this disorder, alterations in the fetus's organ lateralization lead to a complete reversal in the arrangement of the internal organs. Most of the time, they are found incidentally when having a procedure or imaging modality. Little has been written regarding the challenges encountered while providing critical care to these patients. Here we present the case of a 68-year-old male patient admitted to the intensive care unit (ICU) with hypoxemic respiratory failure secondary to pneumonia who underwent diagnostic bronchoscopy for organism identification and was confirmed to have situs inversus totalis. Situs inversus totalis represents a challenge at different levels of care to these patients, including in the ICU. Limitations in critical care can be seen upon imaging identification, and during routine procedures performed at the ICU. Confusion might appear while performing bedside point of care ultrasound, obtaining vascular access, performing electrocardiogram, and sample identification, among others. The case brings the relevance of being able to recognize this rare disorder, which can be diagnosed even in advanced age since it might present the clinician with challenges at the time of providing care to patients.

Diagnosis and Management of a Massive Eight-Centimeter Acquired Tracheoesophageal Fistula.

Here, we present the case of a 61-year-old veteran Hispanic male with recurrent aspiration pneumonitis, aerophagia, tympanic abdominal bloating, and a positive Ono's sign; symptoms present were secondary to diagnosed tracheoesophageal fistulas (TEFs). TEFs are abnormal connections between the esophagus and the trachea. In adult cases, several risk factors have been identified for acquired cases, which include infection, trauma, and cancer. Diagnosis of TEF can be challenging and, in most cases, requires high suspicion. Currently, there are no established guidelines for diagnosing and managing TEF. Clinical assessment and various imaging techniques are essential in the diagnostic process. This article will discuss the etiology, clinical presentation, diagnostic approaches, and management options for acquired TEFs.

An Unexpected Cause of Sepsis: Keep Pursuing the Source of Infection.

An 86-year-old man was found with altered mental status, fever and aphasia. His physical exam revealed nuchal rigidity but no other meningeal signs. Because the patient's mental status was declining, he was intubated and placed in mechanical ventilation. His head CT scan was unremarkable, without evidence of mass effect. A lumbar puncture yielded cerebrospinal fluid that was remarkable for the presence of gram-positive cocci in pairs. His blood cultures showed gram-negative bacilli. Given the presence of these organisms, a polymicrobial infection was suspected. An abdomino pelvic CT scan showed a multi-septated abscess within the right hepatic lobe. CT-guided percutaneous drainage was performed and a specimen for culture obtained, which grew Klebsiella pneumoniae. After receiving intravenous antibiotics and supportive care, the patient showed clinical improvement. In this patient, there was a central nervous system infection secondary to bacteremia in the setting of an intrabdominal infection. The inquiring clinician should take note that whenever a polymicrobial infection is evidenced, more than one site of infection should be considered in the differential diagnosis.

Hypoxemic Respiratory Failure Secondary to Zika Virus Infection.

An 80-year-old man experienced general weakness, myalgias, arthralgias, fever, chills, and diarrhea for one week. He had hypotension and tachycardia. He also had leukocytosis, thrombocytopenia, increased creatinine levels, elevated liver enzymes, elevated creatine phosphokinase (CPK) levels, and metabolic acidosis with hypoxemia, for which he was admitted to the Intensive Care Unit (ICU). His chest x-ray showed decreased lung volumes. Ceftriaxone and levofloxacin were empirically started to cover leptospirosis and community acquired pneumonia, respectively. The patient continued with clinical deterioration and the antibiotic therapy was changed to linezolid, cefepime, and doxycycline. He required endotracheal intubation and mechanical ventilation support due to progressive hypoxemic respiratory failure. A bronchoscopy showed no evidence of bacterial infectious process. The patient developed clinical improvement with successful extubation afterwards (4 days after initial intubation). He was later discharged home with physical therapies. A serum specimen was tested with real-time polymerase chain reaction (RT-PCR) technique, producing a positive result only for Zika virus. Confirmatory molecular diagnostic testing was performed at the Center for Disease Control (CDC).

Misleading Diagnosis of Idiopathic Pulmonary Fibrosis: A Clinical Concern.

Diagnosis of Sjogren syndrome should be based on consideration of the clinical presentation, a pulmonary function test, blood and rheumatology laboratory findings, radiographic imaging patterns, and biopsy results.

A Forgotten Cause of Cardiac Tamponade.

Although purulent pericarditis is rare, it is essential to recognize its clinical features due to the high mortality rate in patients with a missed diagnosis.

Endometrial cancer in Puerto Rico: incidence, mortality and survival (1992-2003).

BACKGROUND: Endometrial cancer is the most common gynecologic malignancy in Puerto Rico and the United States (US). METHODS: We compare the age-specific and age-adjusted incidence and mortality rates and the survival of endometrial cancer in Puerto Rico with that of non-Hispanic whites (NHW), non-Hispanic blacks (NHB) and Hispanics in the US. Data from the Puerto Rico Central Cancer Registry and the Surveillance, Epidemiology, and End Results program were analyzed from 1992-2003. RESULTS: Age-standardized incidence rates of endometrial cancer increased significantly (p < 0.05) in Puerto Rico (APC = 2.8%) and among NHB (APC = 1.9%) and remained constant (p > 0.05) for NHW (APC = -0.1%) and Hispanics in the US (APC = 0.4%). Mortality trends remained constant in all racial/ethnic groups (p > 0.05). For 1999-2003, women in Puerto Rico had similar incidence of endometrial cancer as Hispanics (Standardized rate ratio [SRR] = 0.94, 95% CI = 0.87-1.01), although their risk was lower than that of NHW (SRR = 0.56, 95% CI = 0.53-0.59) and NHB (SRR = 0.91, 95% CI = 0.84-0.98). Meanwhile, women in Puerto Rico had 15% higher risk of death than Hispanic women (SRR = 1.15, 95% CI = 1.03-1.30) similar risk than NHW (SRR = 0.93, 95% CI = 0.83-1.03), and lower risk than NHB (SRR = 0.51, 95% CI = 0.46-0.57). Puerto Rico (63.1%) and NHB (56.8%) had a lower 5-year survival than NHW (78.4%) and Hispanics (79.5%). An age-adjusted Cox proportional hazards model showed that compared with women in Puerto Rico, Hispanic women in the United States had 37% lower mortality risk (HR = 0.63, 95% CI = 0.56-0.71) and NHW had 53% lower mortality risk (HR = 0.47, 95% CI = 0.43-0.52) after 5 years of diagnosis; NHB women had 22% higher mortality risk than women in Puerto Rico (HR = 1.22, 95% CI = 1.09-1.36). CONCLUSIONS: The lower burden of endometrial cancer in Puerto Rico suggests the presence of protective factors or lower exposure to risk factors in this population, although increases in incidence suggest changes in the occurrence of lifestyles and environmental risk factors. Meanwhile, the lower five-year survival from endometrial cancer among Puerto Ricans suggests a health disparity for this group in areas such as quality of care and/or differences in terms of stage at diagnosis and associated comorbidities. Assessment of disease risk factors and characteristics, and access and response to treatment is required to further understand these results.