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Introduction Febrile neutropenia is a commonly encountered medical emergency in patients undergoing cancer treatment and can delay and modify the course of treatment and even lead to dire outcomes, including death. The cause of fever in a post-chemotherapy-induced neutropenic patient can be confusing to treating physicians. A review of the literature demonstrated that blood culture results could determine the cause of febrile neutropenia in only approximately 10% to 25% of patients. The objective of our study was to measure the incidence of positive blood cultures, urine cultures, and other body fluid cultures resulting in chemotherapy-induced neutropenia and further classify fever episodes into three neutropenic fever syndromes, such as microbiologically documented, clinically suspected, or unknown causes of fever, respectively. Methods We conducted a prospective observational study on 399 chemotherapy-induced neutropenic fever episodes with the aim of classifying them into one of the three neutropenic syndromes. We tried to document the cause of the fever in these patients. We also noted the type of cancer treatment regimen they were on and correlated their clinical profile with their body fluid cultures, including blood cultures, urine cultures, and other body fluid cultures. We then categorized each fever episode into one of three neutropenic syndromes. Results We studied 399 febrile neutropenic episodes. We were able to microbiologically document the cause of fever in 39% of the cases, and we obtained growth in 51 out of 399 blood cultures (13%), which was comparable to the available literature, and urine culture showed growth in 62 out of 399 cultures (16%), while other body cultures such as pus culture, bile culture, and bronchioalveolar lavage cultures collectively showed growth in 42 out of 399 episodes (10%). The most common bacteria isolated in both blood and urine cultures were Escherichia coli. Cumulatively, including blood, urine, and body fluid cultures, we were able to classify 39% (155 out of 399 cases) of febrile neutropenic episodes as microbiologically documented. The cause of fever was clinically suspected by means of careful history taking and an extensive physical examination in 31% (125 out of 399) without growth evidence in blood cultures, urine cultures, or any other body fluid culture. The cause of fever remained unknown in 119 cases (30%) of patients and was classified under the unknown cause of fever. Conclusions We conclude by stating that the study of fever in a neutropenic patient should include a thorough history and clinical evaluation of blood, urine, and other body fluid cultures instead of solely relying on blood culture results. We recommend further classifying patients into one of the three neutropenic fever syndromes, such as those that are microbiologically documented, clinically suspected, or unknown. Our blood cultures were able to give us a 13% positivity rate, whereas microbiologically, we were able to isolate an organism likely causing fever in 39% of patients. The cause of fever was suspected clinically in 31% of patients, but we were unsuccessful in microbiologically documenting any culture growth in blood, urine, or any other body fluid culture. The cause of fever remained a mystery and unknown to us without any microbiological or clinical cues in 119 cases (30%) of febrile neutropenic episodes.
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Statins are the primary class of medication used to lower serum cholesterol concentration for both primary and secondary prevention of cardiovascular disease. Muscle pain is a frequent adverse effect of statins. Severe myonecrosis leading to clinical rhabdomyolysis is rare. We encountered a 63-year-old male with a medical history of hypertension, type 2 diabetes mellitus, and coronary artery disease with angioplasty in 2008 and 2020. He was started on rosuvastatin 40 mg (0-0-1) along with dual anti-platelets post angioplasty and was discharged home. He traveled back to his hometown and noticed progressive symmetric muscle weakness with decreased urine output. After visiting another hospital he presented to us with severe proximal muscle weakness and acute renal failure. Laboratory investigations were initiated which demonstrated clinically significant derangement in serum creatinine phosphokinase, serum creatinine, urine myoglobin along with deranged liver enzymes. He was subjected to nerve conduction studies for his muscle weakness which was normal and electromyography showed abnormal spontaneous muscle activity in all examined muscles (fibrillations, positive sharp waves, and pseudomyotonic discharges) suggestive of an irritable myopathy. The medication was stopped and he was treated with eight cycles of hemodialysis until his muscle weakness and laboratory parameters improved. He was then discharged with some improvement in muscle weakness. On two week follow-up, the patient showed partial improvement after discontinuation of all lipid-lowering medication.
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This article reviews the use of thoracic ultrasound in the intensive care unit (ICU). The focus of this article is to review the basic terminology and clinical applications of thoracic ultrasound. The diagnostic approach to a breathless patient, the blue protocol, is presented in a simplified flow chart. The diagnostic application of thoracic ultrasound in lung parenchymal and pleural diseases, role in bedside procedures, diaphragmatic assessment, and lung recruitment are described. Recent updates discussed in this review help support its increasingly indispensable role in the emergent and critical care setting.
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Primary hyperparathyroidism is the third most commonly encountered endocrine disorder after diabetes and thyroid diseases. There has been a constant debate between medical and surgical management of the disorder. Guidelines clearly indicate surgical management over medical management in symptomatic patients and asymptomatic patients below 50 years of age. The problem is identification of symptoms can be difficult as there is a large overlap in the presentation of symptomatic and asymptomatic patients. Here, a 74-year-old veteran presented with scrotal edema and a perineal abscess. He had urinary incontinence secondary to urological procedures which were done for nephrolithiasis, which were detected incidentally on imaging. He had multiple vertebral compression fractures and required referral to neurosurgery. He had worsening renal function and cognitive impairment. On review of his medical records he was found to have a long-standing history of medically managed hyperparathyroidism, which was complicated due to non-compliance to follow-up outpatient visits. He constantly declined elective parathyroidectomy but unfortunately had to undergo several other invasive procedures with multiple hospital visits due to the complications of hyperparathyroidism. Safe medical management of hyperparathyroidism requires a religious follow-up and compliance to outpatient visits. He was started on Denosumab which we attribute to be contributory to his skin infections although evidence to support the same is insufficient.
