Intensive Care Unit and Hospital Outcomes of Patients Admitted with Blastomycosis: A 14-Year Retrospective Study.

INTRODUCTION: Blastomycosis is an uncommon; potentially life-threatening granulomatous fungal infection. The aim of this study is to report hospital and intensive care unit (ICU) outcomes of patients admitted with blastomycosis. METHODS: All patients admitted for treatment of blastomycosis at the Mayo Clinic-Rochester, Minnesota between 01/01/2006 and 09/30/2019 were included. Demographics, comorbidities, clinical presentation, ICU admission, and outcomes were reviewed. RESULTS: A total of 84 Patients were identified with 90 unique hospitalizations primarily for blastomycosis. The median age at diagnosis was 49 (IQR 28.1-65, range: 6-85) years and 56 (66.7%) were male. The most frequent comorbidities included hypertension (n = 28, 33.3%); immunosuppressed state (n = 25, 29.8%), and diabetes mellitus (n = 21, 25%). The lungs were the only organ involved in 56 (66.7%) cases and the infection was disseminated in 19 (22.6%) cases. A total of 29 patients (34.5%) underwent ICU admission due to complications of blastomycosis. ICU related events included mechanical ventilation (n = 20, 23.8%), acute respiratory distress syndrome (ARDS) (n = 13, 15.5%), tracheostomy (n = 9, 10.7%), renal replacement therapy (n = 8, 9.5%), and extracorporeal membrane oxygenation (ECMO) (n = 4, 4.8%). A total of 12 patients (14.3%) died in the hospital; all of whom had undergone ICU admission. In-hospital mortality was associated with renal replacement therapy (RRT) (P = 0.0255). CONCLUSION: Blastomycosis is a serious, potentially life-threatening infection that results in significant morbidity and mortality with a 34.5% ICU admission rate. RRT was associated with in-hospital mortality.

Impact of acute left ventricular apical thrombus on cardioversion for atrial fibrillation.

Among patients undergoing cardioversion for atrial fibrillation, the presence of left ventricular thrombus is a relatively uncommon and challenging clinical dilemma. While left atrial appendage thrombus is a contraindication to cardioversion, there is paucity of data regarding the safety of cardioversion in with the presence of left ventricular apical thrombus. Also, thrombus characteristics such as protrusion and mobility on echocardiography are known risk factors for systemic embolism. In this article, we present a case highlighting the management of atrial fibrillation in the setting of left ventricular dysfunction, acute heart failure, and echocardiographic evidence of acute left ventricular apical thrombus.

Primary Nephrotic Syndrome in Adults as a Risk Factor for Pulmonary Embolism: An Up-to-Date Review of the Literature.

Patients with nephrotic syndrome are at an increased risk for thrombotic events; deep venous thrombosis, renal vein thrombosis, and pulmonary embolism are quite common in patients with nephrotic syndrome. It is important to note that nephrotic syndrome secondary to membranous nephropathy may impose a greater thrombotic risk for unclear reasons. Increased platelet activation, enhanced red blood cell aggregation, and an imbalance between procoagulant and anticoagulant factors are thought to underlie the excessive thrombotic risk in patients with nephrotic syndrome. The current scientific literature suggests that patients with low serum albumin levels and membranous nephropathy may benefit from primary prophylactic anticoagulation. A thorough approach which includes accounting for all additional thrombotic risk factors is, therefore, essential. Patient counseling regarding the pros and cons of anticoagulation is of paramount importance. Future prospective randomized studies should address the question regarding the utility of primary thromboprophylaxis in patients with nephrotic syndrome.

A puzzle of hemolytic anemia, iron and vitamin B12 deficiencies in a 52-year-old male.

A 52-year-old male with no significant past medical history reports increasing generalized fatigue and weakness for the past 2 weeks. Physical examination reveals jaundice and pallor without organomegaly or lymphadenopathy. His hemoglobin was 5.9 g/dL with a mean corpuscular volume of 87.1 fL and elevated red blood cell distribution width of 30.7%. His liver function test was normal except for elevated total bilirubin of 3.7 mg/dL. Serum LDH was 701 IU/L, and serum haptoglobin was undetectable. Further investigation revealed serum vitamin B12 of <30 pg/mL with elevated methylmalonic acid and homocysteine level. In addition, serum ferritin and transferrin saturation were low. The patient was diagnosed with hemolytic anemia secondary to vitamin B12 deficiency with concomitant iron deficiency anemia.

Human immunodeficiency virus and pulmonary arterial hypertension.

Human immunodeficiency virus- (HIV-) related pulmonary arterial hypertension (PAH) is a rare complication of HIV infection. The pathophysiology of HIV-related PAH is complex, with viral proteins seeming to play the major role. However, other factors, such as coinfection with other microorganisms and HIV-related systemic inflammation, might also contribute. The clinical presentation of HIV-related PAH and diagnosis is similar to other forms of pulmonary hypertension. Both PAH-specific therapies and HAART are important in HIV-related PAH management. Future studies investigating the pathogenesis are needed to discover new therapeutic targets and treatments.

Breast osteosarcoma 29 years after radiation therapy for epithelial breast cancer.

Radiation therapy has a solid role in the management of breast adenocarcinoma. It significantly reduces the rates of disease recurrence. Nevertheless, radiation therapy is not without side effects and patients who have undergone breast irradiation are at increased risk for lung disease, sarcomas, acute leukemia and esophageal cancer. We present a case of radiation-induced breast osteosarcoma 29 years after radiation therapy and lumpectomy for breast adenocarcinoma. The patient had several disease recurrences after surgical resection and was found to have pulmonary metastases.

Primary diffuse large B-cell lymphoma of the ascending colon.

Primary colorectal lymphoma is a rare malignancy accounting for 3% of all gastrointestinal lymphomas and 0.1-0.5% of all colorectal malignancies. Among primary colorectal lymphomas, the most common histological subtype of colorectal lymphoma is diffuse large B-cell lymphoma. We report a case of an 84-year old Caucasian female who was admitted to the hospital because of a 2 days history of altered mental status. In the emergency department the patient was found to have acute kidney injury and hypercalcemia. On physical examination a large lower quadrant abdominal mass was palpated. Computed tomography scan of abdomen confirmed the presence of a mass along the cecum and proximal ascending colon. Colonoscopy showed a large ulcerated mass and biopsy was consistent with diffuse large B-cell lymphoma. The patient underwent colectomy but refused to receive chemotherapy.

An uncommon cause of gastrointestinal bleeding in an 84-year-old female.

The estimated annual incidence for drug-induced thrombocytopenia is 10 per million. Although fatal consequences are uncommon, life-threatening hemorrhage can occur due to spontaneous bleeding. We report a case of 84-year-old Caucasian female who presented to the emergency department with multiple episodes of bloody bowel movements. One week prior to this admission, she was started on trimethoprim-sulfamethoxazole for the treatment of skin abscess. On admission laboratory results showed platelet count of 4 × 10(3)/mm(3) and hemoglobin of 10.2 g/dL. Because of unstable vital signs, the patient was transferred to the intensive care unit where she received multiple units of platelet and blood transfusion. Drug-induced thrombocytopenia due to TMP/SMX was suspected. Intravenous methylprednisolone was started as well as immune globulin with good clinical response.

Ibuprofen-induced hemolytic anemia.

Drug-induced immune hemolytic anemia is a rare condition with an incidence of 1 per million of the population. We report the case of a 36-year-old female who presented to the emergency department complaining of shortness of breath and dark colored urine. Physical examination was significant for pale mucous membranes. The patient reported using ibuprofen for a few days prior to presentation. Complete blood count performed before starting ibuprofen revealed normal platelets and hemoglobin values. On admission, the patient had evidence of hemolytic anemia with hemoglobin of 4.9 g/dL, hematocrit of 14.2%, lactate dehydrogenase 435 IU/L, and reticulocytosis 23.2%. Further testing ruled out autoimmune disease, lymphoma, and leukemia as etiologies for the patient's new onset hemolytic anemia. Ibuprofen was immediately stopped with a gradual hematologic recovery within 3 days.

Amiodarone-induced cirrhosis of liver: what predicts mortality?

Introduction. Amiodarone has been used for more than 5 decades for the treatment of various tachyarrhythmias and previously for the treatment of refractory angina. There are multiple well-established side effects of amiodarone. However, amiodarone-induced cirrhosis (AIC) of liver is an underrecognized complication. Methods. A systematic search of Medline from January 1970 to November 2012 by using the following terms, amiodarone and cirrhosis, identified 37 reported cases of which 30 were used in this analysis. Patients were divided into 2 subsets, survivors versus nonsurvivors, at 5 months. Results. Aspartate aminotransferase was significantly lower (P = 0.03) in patients who survived at 5-months (mean 103.33 IU/L) compared to nonsurvivors (mean 216.88 IU/L). There was no statistical difference in the levels of prothrombin time, total bilirubin, alanine aminotransferase, alkaline phosphatase, gamma-glutamyl transpeptidase, cumulative dose, and latency period between the two groups. The prevalence of DM, HTN, HLD, CAD, and CHF was similar in the two groups. None of the above-mentioned variables could be identified as a predictor of survival at 5 months. Conclusion. AIC carries a mortality risk of 60% at 5 months once the diagnosis is established. Further prospective studies are needed to identify predictors of AIC and of mortality or survival in cases of AIC.

An uncommon cause of shortness of breath in a young puerpera.

Acute postpartum dyspnea in a young, previously healthy adult encompasses numerous conditions. One should be aware of various differential diagnoses including delayed postpartum preeclampsia-induced pulmonary edema where the occurrence is rare but a significant one due its deleterious consequences. We report a case of 26-year-old gravida 1/para 1 female who presented to the hospital with progressive dyspnea after 1 week of normal spontaneous vaginal delivery. On physical examination, her blood pressure was severely elevated. Her clinical signs and symptoms were consistent with pulmonary edema, but diagnostic tests excluded the cardiogenic causes. Further test revealed proteinuria. The patient was diagnosed with delayed postpartum preeclampsia.

Scrotal pain as the first manifestation of scrotal leiomyoma: a case report.

Primary scrotal leiomyoma is derived from smooth muscle cells of tunica dartos. A 37-year-old Thai man, barber by profession, presented with left scrotal pain and subsequently, a solid mass is reported. As a relatively rare neoplasm, the initial diagnosis and differential diagnosis are intricate. The management was surgical excision. The well circumscribed 1 cm mass appeared as homogeneous, whorled-like, with interlacing fascicles of spindled muscle cells, and a strong positive desmin immunoreactivity. Upon follow-up, pain had disappeared one year after surgery. Reassurance and careful re-examination to reduce anxiety was also needed.

Clinical features of familial Parkinson's disease in Thai patients.

BACKGROUND: Parkinson's disease (PD) is the second most common neurodegenerative disease. Most cases are sporadic, but family history is also observed in certain cases. This study aimed to describe the clinical features of familial PD in Thai patients. METHOD: The study included five female and three male patients from a Malay family of consanguineous parents who were evaluated for clinical study. Every patient was examined initially at the outpatient unit of the family medicine department. The diagnosis was later confirmed by a team of neurologists at the division of neurology, department of medicine. The patients were first seen and evaluated in 1999, with subsequent evaluation in 2005 and 2008. RESULTS: Clinical features such as tremor, rigidity, bradykinesia and postural instability were similar to those of the classical idiopathic PD, but age of onset was earlier. The interval between the onset of parkinsonism and first presentation was 1-3 years, and PD was diagnosed within 1-4 years of the onset of parkinsonism. The median age at disease onset was 31 years (range 27 to 49 years). The severity of clinical symptoms and signs was different among affected family members, from stage I to IV of the Hoehn and Yahr stage scale. Motor dysfunction and other complications were observed. The family history suggested that the condition was being passed on only from the maternal side. CONCLUSIONS: The clinical features of familial PD are generally indistinguishable from classical PD, although the diagnosis may be difficult in atypical presentations such as palpitation, anxiety and insomnia. The disease tends to develop earlier in younger siblings. Family members were at greater risk of autosomal recessive disorders that are homozygous for a particular recessive gene mutation due to consanguineous parents. On the other hand, specific ethnicity, very early onset of symptoms, rapid progression of the disease, and high family incidence suggested autosomal dominant inheritance. Since each family member displayed different symptoms and signs, this may have indicated variable penetrance of the PD gene, but the results are not conclusive due to lack of medical records from other relatives and genetic studies.