A Case Report of Anesthesia-induced Diffuse Alveolar Hemorrhage Presenting to the Emergency Department.

Introduction: The inhaled anesthetic sevoflurane is an uncommon etiology of diffuse alveolar hemorrhage (DAH). As DAH typically presents in the inpatient, postoperative setting, it has been infrequently reported in the anesthesiology literature and, to our knowledge, has not been reported in the emergency medicine literature to date. Case Report: We describe the presentation of a young, healthy male in respiratory distress to a busy urban emergency department (ED) after an outpatient surgical procedure. We highlight the etiology of post-anesthesia DAH and the acute management of this rare diagnosis in the ED. Conclusion: With outpatient surgical centers becoming an increasingly popular option for lower risk procedures, emergency physicians would benefit from understanding this presentation and its pathophysiology.

Fluorescence-guided nodal navigation during colectomy for colorectal cancer.

INTRODUCTION: Indocyanine green (ICG) fluorescence is an emerging technique in the surgical field. Among its various applications, it allows surgeons to have real-time visualization of the lymphatic drainage of an organ. The primary outcome of our study is the feasibility and safety of ICG-guided colorectal surgery. Our secondary outcome is the efficacy of ICG-guided lymphadenectomy and whether or not ICG positivity correlates with the identification of nodal metastasis. MATERIAL AND METHODS: We conducted a single-center prospective study including 32 patients who underwent surgery for colorectal cancer. For each case, ICG was injected into the tumor area either prior to or during surgery. Tumor specimens and excised lymph nodes were analyzed using hematoxylin and eosin (H&E) staining. RESULTS: In all patients, ICG injected in the tumor area allowed clear visualization of the lymphatic drainage. A total of 499 lymph nodes were collected, with a mean of 16 per patient. Fifty ICG positive lymph nodes outside the standard lymphadenectomy zone were examined; however, none of the nodes showed signs of nodal metastasis. CONCLUSIONS: ICG-guided colorectal surgery is safe, feasible and easily reproducible, with a relatively low cost and no radiation exposure. ICG can help the surgeon to visualize the anatomical structures. We did not find an oncological diagnostic advantage in the use of ICG-guided nodal navigation.

A lesson in clinicopathological correlation: Plaque-like myofibroblastic tumour presenting as a pruritic plaque in childhood.

Plaque-like myofibroblastic tumour (PLMT) is a rare skin condition which presents in childhood and infancy as a nodular fibrous plaque. Including our case, there are currently only 14 cases reported in the literature. Although it represents a well-defined clinicopathological diagnosis, there is significant under-reporting of this condition secondary to under-recognition and potential misdiagnosis as dermatofibroma.

The kidney, COVID-19, and the chemokine network: an intriguing trio.

On December 30th 2019, some patients with pneumonia of unknown etiology were reported in the Program for Monitoring Emerging Diseases (ProMED), a program run by the International Society for Infectious Diseases (ISID), hypothesized to be related to subjects who had had contact with the seafood market in Wuhan, China. Chinese authorities instituted an emergency agency aimed at identifying the source of infection and potential biological pathogens. It was subsequently named by the World Committee on Virus Classification as 2019-nCoV (2019-novel coronavirus) or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A number of studies have demonstrated that 2019-nCoV and the SARS-CoV shared the same cell entry receptor named angiotensin-converting enzyme 2 (ACE2). This is expressed in human tissues, not only in the respiratory epithelia, but also in the small intestines, heart, liver, and kidneys. Here, we examine the most recent findings on the effects of SARS-CoV-2 infection on kidney diseases, mainly acute kidney injury, and the potential role of the chemokine network.

The impact of the COVID-19 outbreak on liver transplantation programs in Northern Italy.

In January 2020, Novel Coronavirus Disease 2019 (COVID-19) resulted in a global pandemic, creating uncertainty toward the management of liver transplantation (LT) programs. Lombardy has been the most affected region in Italy: the current mortality rate of COVID-19 patients is 18.3% (10 022 deaths; April 10th) with hospitals in Lombardy having to expand the total number of ICU beds from 724 to 1381 to accommodate infected patients. There has been a drastic decrease in liver donors. From February 23rd until April 10th, 17 LTs were performed in Lombardy. Mean donor age was 49 years (range 18-74) whereas mean recipient age was 55 (13-69); mean MELD score was 12 (6-24). All donors underwent screening for SARS-CoV-2 prior to LT. Two patients tested positive after LT, and one patient died for COVID on POD 30. Sixteen patients are alive after an average of 30 days post-LT (range 3-46). 10 patients have been discharged. This study has found no specific reason concerning the safety of recipients, to stop LT programs. Several key lessons from our experience are reported. However, due to the complex circumstances which surround the viral outbreak, the cessation or a reduction in LT activity is a pragmatic requirement.

Unusual oral presentation of HSV-1 lesions in an adult liver transplant recipient.

Herpes Simplex Virus (HSV) hepatitis in liver transplant patients is a rarely reported infective complication of HSV with severe consequences, often leading to fulminant hepatitis if left untreated. The clinical signs are often atypical, leading to under-reporting in the literature and potential delays in treatment. Our case report describes such atypical mucocutaneous lesions in a liver transplant recipient. We highlight the need for further reports, especially those with images, in order to aid the diagnosis of HSV infection, and to allow prompt treatment to prevent complications such as HSV hepatitis.

Bevacizumab as Treatment for Epistaxis in Hereditary Hemorrhagic Telangiectasia: A Literature Review.

BACKGROUND: Severe, recurring epistaxis is the most common symptom of hereditary hemorrhagic telangiectasias (HHT). Current treatment modalities range from noninvasive treatments that frequently fail to achieve even short-term control to surgeries and systemic therapies that carry significant risk of complications. Recently, bevacizumab, a VEGF inhibitor, has been proposed as an alternative option to alleviate epistaxis symptoms in HHT. OBJECTIVE: To review the current literature regarding the use of bevacizumab for the treatment of epistaxis in patients with HHT and provide guidance on its usage for this indication. METHODS: A narrative literature review was performed to analyze various methods and dosages of bevacizumab administration for the treatment of HHT-related epistaxis, along with a review of current treatment modalities and their drawbacks. RESULTS: The current standard of care for HHT-related epistaxis consists of treatments that are largely ineffective or invasive with significant potential complications. Submucosal bevacizumab has demonstrated efficacy in reducing frequency, duration, and severity of epistaxis in those with HHT. CONCLUSION: Given the inadequacies and potential drawbacks of current treatments for epistaxis in HHT, there is a need for new therapeutic options. Submucosal bevacizumab has been effective with a limited risk profile in a number of studies and should now be considered as a treatment option for refractory epistaxis. Controlled studies are recommended to quantify optimal dosing, treatment schedule, and specific subpopulations that will respond best to this treatment.