RESUMEN
A 71-year-old female presented to the emergency department with worsening dyspnea, dry cough, malaise, weight loss, fever, chills, and diaphoresis for one week. The patient had been hospitalized four weeks prior with right knee methicillin-resistant Staphylococcus aureus (MRSA) bursitis and was initially treated with IV vancomycin but was switched to IV daptomycin at the time of discharge for convenience of dosing. On presentation to the ED, vitals were normal. Physical examination revealed bilateral scattered rhonchi and crepitations. Chest X-ray revealed new patchy bilateral interstitial and airspace opacities concerning for multifocal pneumonia. Labs were pertinent for mild peripheral eosinophilia. CT chest revealed moderate diffuse ground glass opacities involving both lungs, with subpleural predominance and some areas of septal thickening seen as well. Daptomycin-induced pneumonitis was suspected, and empiric antibiotics were discontinued. The patient subsequently underwent fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial lung biopsy. BAL fluid showed leukocytosis and eosinophilia of 25 mm3. Right upper lobe biopsy demonstrated foci of alveolar spaces with collections of eosinophils and histiocytes consistent with acute eosinophilic pneumonia. The patient was started on oral prednisone and albuterol breathing treatments with significant improvement after 48 hours from admission. She was discharged on albuterol inhalers and prednisone taper. Acute eosinophilic pneumonia (AEP) is a lung condition that can be rapidly progressive, leading to significant morbidity and mortality. Daptomycin-induced AEP can mimic community-acquired pneumonia, resulting in delayed diagnosis and management. Recognizing the temporal association between drug initiation and the development of symptoms is crucial in the diagnosis of drug-induced AEP. If it is recognized and treated in a timely manner, the prognosis is generally excellent, with rapid and complete clinical recovery as demonstrated by our case.
RESUMEN
Zoning and applying Limits of Acceptable Change (LAC) are two promising strategies for managing tourism in Marine Protected Areas (MPAs). Typically, these management strategies require the collection and integration of ecological and socioeconomic data. This problem is illustrated by a case study of Koh Chang National Marine Park, Thailand. Biophysical surveys assessed coral communities in the MPA to derive indices of reef diversity and vulnerability. Social surveys assessed visitor perceptions and satisfaction with conditions encountered on snorkelling tours. Notably, increased coral mortality caused a significant decrease in visitor satisfaction. The two studies were integrated to prescribe zoning and "Limits of Acceptable Change" (LAC). As a biophysical indicator, the data suggest a LAC value of 0.35 for the coral mortality index. As a social indicator, the data suggest that a significant fraction of visitors would find a LAC value of under 30 snorkellers per site as acceptable. The draft zoning plan prescribed four different types of zones: (I) a Conservation Zone with no access apart from monitoring or research; (II) Tourism Zones with high tourism intensities at less vulnerable reefs; (III) Ecotourism zones with a social LAC standard of <30 snorkellers per site, and (IV) General Use Zones to meet local artisanal fishery needs. This study illustrates how ecological and socioeconomic field studies in MPAs can be integrated to craft zoning plans addressing multiple objectives.
