A 49-Year-Old Woman With Persistent Bilateral Pleural Effusions.

CASE PRESENTATION: A 49-year-old woman presented to the ED with sudden onset abdominal pain, nausea, and vomiting. Her medical history included an uncomplicated gastric lap band surgery 9 years ago and subsequent removal of lap band after 6 years. She had a Roux-en-Y gastric bypass and cholecystectomy 5 months prior to the current presentation. The patient had been diagnosed with asthma and was prescribed an inhaled corticosteroid that she used only as needed. The patient denied smoking and heavy alcohol consumption. She was currently employed as a scrub technician in a local surgical center.

A young man presenting with encephalopathy and seizures secondary to SARS-CoV-2.

COVID-19 has now emerged from a respiratory illness to a systemic viral illness with multisystem involvement. There is still a lot to learn about this illness as new disease associations with COVID-19 emerge consistently. We present a unique case of a neurological manifestation of a patient with structural brain disease who was COVID-19 positive and developed mental status changes, new-onset seizures and findings suggestive of viral meningitis on lumbar puncture. We also review the literature and discuss our case in the context of the other cases reported. We highlight the value of considering seizures and encephalopathy as one of the presenting features of COVID-19 disease.

Amiodarone Toxicity Presenting with Acute Onset of Systemic Inflammatory Response Syndrome and Multiorgan Failure Mimicking Sepsis.

BACKGROUND Amiodarone, an anti-arrhythmic medication, has been associated with the development of multiple organ toxicities. Most of these toxicities develop insidiously. However, in rare cases, these toxicities manifest with more acute symptoms. We present an unusual case of amiodarone toxicity which manifested with multiorgan failure and systemic inflammatory response syndrome that mimicked sepsis. CASE REPORT A 73-year-old man who was being treated with chronic oral amiodarone for atrial fibrillation presented with flu-like symptoms and fever, pulmonary infiltrate, acute kidney injury, and thrombocytopenia. The patient did not improve with antibiotics and fluid resuscitation. The results of an extensive infectious and non-infectious workup were negative. His symptoms worsened during hospitalization, which correlated with the loading of intravenous amiodarone given for his acute worsening of atrial fibrillation. Amiodarone-induced drug toxicity was contemplated by the treating medical team. Amiodarone was stopped, and the patient was treated with steroids, which improved his symptoms and organ dysfunctions. Subsequent bronchoscopy with lung biopsy showed foamy macrophages with organizing pneumonia and fibrinoid changes. CONCLUSIONS This case highlights an atypical and rare presentation of a complication of chronic amiodarone use that presented with acute onset of fever, systemic inflammatory response syndrome, and multiorgan failure masquerading as sepsis. The patient's symptoms and organ dysfunctions improved with the discontinuation of amiodarone and institution of steroids.

Lung ultrasound in early SARS-CoV-2 pneumonia and the LUS-CoV criteria.

There is a scarcity of data on lung ultrasound (LUS) in SARS-CoV-2 pneumonia. As with many other pulmonary conditions, ultrasound may be a better diagnostic tool than routine chest radiography. In an era where computed tomography scanning is deferred because of the potential for cross-contamination, we evaluated the ability of LUS to detect a pattern of lung injury in SARS-CoV-2 pneumonia. A limited anterolateral LUS was performed to limit time spent in isolation rooms by ultrasound operators. We chose to use a hand-held ultrasound device due to portability and superior confidence in infection control. Both linear and phased array probes were used to obtain images of the pleura and lung. Of 69 patients who had lung ultrasound images saved and were included in the analysis, 36 were positive for SARS-CoV-2. Multifocal confluent B-lines, pleural irregularities, and the absence of moderate or large pleural effusions were the predominant pattern observed in most (86%) of SARS-CoV-2-positive patients. We evaluated the accuracy of the above criteria (LUS-CoV) and report a high sensitivity (91%) and specificity (86%) for SARS-CoV-2 pneumonia. In conclusion, a characteristic sonographic pattern of multifocal confluent B-lines with irregular pleural markings was seen on LUS in patients with SARS-CoV-2 pneumonia.

Comparison of 99mTc Injected Activity with Prescribed Activity in Four Types of Nuclear Medicine Exams.

BACKGROUND: 99mTc is a radioactive isotope that is obtained by eluting a 99Mo/99mTc generator. (PINSTECH, Islamabad) and used for radionuclide scanning. OBJECTIVES: The objective of this work is to study the uncertainties in 99mTc activity that exist due to time delay between injection preparation and administration to patients, during the process of gamma camera scanning. METHODS: Lead canisters were used for storing elution vials and dose calibrator for measuring 99mTc activity in mCi. The activity of preparing 99mTc injection and its administration to patients were compared with the prescribed values of activity recommended in the Society of Nuclear Medicine procedure guidelines. RESULTS: This study showed that uncertainty in the activity existed in one thyroid patient, 38 bone patients, 5 renal patients and 45 cardiac patients. CONCLUSION: This uncertainty in activity exists due to time delay between injection preparation and administration to patients, as well as due to residual radionuclide that is not injected into patients and remains in the syringe.

Facile synthesis and antimicrobial activity of CdS-Ag2S nanocomposites.

In this study CdS-Ag2S nanocomposites for antibacterial activity were synthesized via facile co-precipitation method using PVP as capping agent. The prepared nanocomposites have particle sizes in the range of 50-100 nm (SEM) and PVP addition has good influence on the morphology of nanocomposites. The antimicrobial activity of pure Ag2S, CdS and CdS-Ag2S composites was evaluated against Pseudomonas aeruginosa, Staphylococcus aureus and Escherichia coli. The results demonstrate that antibacterial activity was significantly improved due to increasing ratio of CdS into CdS-Ag2S nanocomposites in comparison to pure Ag2S and CdS.

Efficient biosensing through 1D silver nanostructured devices using plasmonic effect.

The current work explores the excitation of surface plasmon polaritons (SPPs) on a one dimensional (1D) silver nano-grating device, simulated on glass substrate, which can sense a very small change in the refractive index of an analyte adjacent to it. The most recent modeling technique finite element analysis is applied in this work by using a COMSOL RF module. The models of 1D grating devices of different slit widths with fixed periodicity and film thickness are simulated. The data is collected and then used to study higher refractive index unit per nanometer (RIU/nm) as well as the effect of the widths of the slits on the RIU. A number of investigations are done by the simulated data, like a dip in the transmission spectra of p-polarized light. This dip is due to SPP resonance with the variation of slit width. Furthermore, the most fascinating part of the research is the COMSOL modeling that provides an opportunity to look into factors affecting higher RIU/nm, while visualizing the cross-sectional view of the grating device and strong electric field enhancement at the surface of the metallic device. When the slit width is almost equal to half of the periodicity of the grating device, SPP resonance increases and it is at maximum for the slit width equal to two-thirds of the periodicity, because the coupling efficiency is at maximum.

Failing phrenics: an obscure cause of exertional dyspnea: Case report and literature review.

INTRODUCTION: Idiopathic phrenic nerve palsy is a rare cause of exertional dyspnea. We present a case of a patient presenting with worsening dyspnea of an unknown etiology found to be related to bilateral phrenic nerve palsy. DISCUSSION: Forty-two-year-old man presented to our emergency department with exertional dyspnea, orthopnea, and a left lower lobe consolidation treated initially as bronchitis by his primary physician as an outpatient, then subsequently as pneumonia at another institution, with no improvement in symptomatology. After admission to our hospital, CT chest demonstrated only supradiaphragmatic atelectatic changes. Echocardiography was normal. Bronchoscopy was contemplated however the patient could not lie flat. A fluoroscopic sniff test demonstrated diaphragmatic dysfunction and pulmonary function tests revealed restrictive pulmonary disease with evidence of neuromuscular etiology. Nerve conduction studies confirmed bilateral phrenic neuropathy. He was referred to a specialized neuromuscular disease center where subsequent workup did not demonstrate any specific etiology. A sleep study confirmed sleep disordered breathing suggestive of diaphragmatic paralysis and he was discharged on bi-level positive pressure ventilation. CONCLUSION: This is a unique case of exertional dyspnea and orthopnea from diaphragmatic paresis caused by bilateral phrenic nerve palsy where the initial workup for pulmonary and cardiovascular etiologies was essentially unremarkable. Shortness of breath and orthopnea caused by phrenic neuropathy is a rare condition, yet has a variety of etiologies. Our case suggests a template to the diagnostic approach, management, and follow up of bilateral phrenic nerve palsy.

Boerhaave Syndrome, Pneumothorax, and Chylothorax in a Critically Ill Patient with Tuberous Sclerosis Complex.

Tuberous sclerosis complex (TSC) is an autosomal dominant, variably expressed multisystem disease. The predominant pulmonary features of TSC are identical to those of lymphangioleiomyomatosis (LAM). Pneumothorax, multifocal micronodular pneumocyte hyperplasia, and chylothorax are rare complications of TSC. We report a young male with pneumothorax, lung nodules, and chylous effusion who developed empyema thoracis after esophageal rupture. Hospital course was complicated by respiratory failure. Family opted to transfer to hospice care. Chylothorax is a rare complication of TSC with few scattered reports mostly in female patients. Patients with TSC are usually managed by multispecialists and it is important to be aware of the rare pulmonary manifestations of this disease. A male patient with TSC having lung nodules presenting with chylothorax and empyema thoracis from Boerhaave syndrome makes our case unique.

Disseminated Histoplasmosis and Secondary Hemophagocytic Syndrome in a Non-HIV Patient.

Histoplasma duboisii, a variant of Histoplasma capsulatum that causes "African histoplasmosis," can be resistant to itraconazole, requiring intravenous amphotericin B treatment. Rarely, these patients do not respond to intravenous antifungal therapy, and in such cases, patients may progress to develop secondary hemophagocytic lymphohistiocytosis (HLH). We present a case of a 34-year-old male patient with sickle cell disease who presented with a 5-month history of an enlarging painless axillary mass, persistent low grade fevers, night sweats, weight loss, and anorexia. An excisional biopsy of the right axillary lymph node revealed yeast and granulomas consistent with histoplasma infection. He was started on oral itraconazole. After 4 weeks of therapy, laboratory evaluation revealed worsening anemia, thrombocytopenia, and transaminitis. Due to failure of oral therapy, he was admitted for intravenous amphotericin B treatment. During his hospital course anemia, thrombocytopenia, and transaminitis all worsened. A bone marrow biopsy was done that was consistent with HLH. His clinical status continued to deteriorate, developing multiorgan failure and disseminated intravascular coagulation. He unfortunately had a cardiorespiratory arrest after eight days of admission and passed away.

Unusual Presentation of Recurrent Pyogenic Bilateral Psoas Abscess Causing Bilateral Pulmonary Embolism by Iliac Vein Compression.

BACKGROUND: Psoas abscesses are a known cause of back pain, but they have not been reported as a cause of acute lower extremity thromboses and bilateral pulmonary emboli. We report a patient with bilateral psoas abscesses causing extensive pulmonary emboli through compression of the iliac vein. CASE REPORT: A 47-year-old man presented with bilateral leg swelling over 4 weeks. Physical examination revealed a thin male with bilateral leg swelling, extending to the thigh on his left side. He had hemoglobin of 10.5 g/dl, leukocytosis of 16 000/ml, and an elevated D-dimer. A computed tomography (CT) angiogram of his chest showed extensive bilateral pulmonary emboli and infarcts. He remained febrile with vague flank pain, prompting a CT of his abdomen and pelvis that showed large, multiloculated, septated, bilateral psoas abscesses with compression of the left femoral vein by the left psoas abscess and a thrombus distal to the occlusion. Two liters of pus was drained from the left psoas abscess by CT-guidance, and although the Gram staining showed Gram-positive cocci in clusters, cultures from the abscess and blood were negative. A repeat CT showed resolution of the abscesses, and the drain was removed. He was discharged to a nursing home to complete a course of intravenous antibiotics and anticoagulation. CONCLUSIONS: Although the infectious complications of psoas abscesses have been described in the literature, the mechanical complications of bilateral psoas abscesses are lacking. It is important to assess for complete resolution of psoas abscesses through follow-up imaging to prevent venous thromboembolic events.

Severe Uncompensated Metabolic Alkalosis due to Plasma Exchange in a Patient with Pulmonary-Renal Syndrome: A Clinician's Challenge.

Metabolic alkalosis secondary to citrate toxicity from plasma exchange is very uncommon in patients with normal renal function. In patients with advanced renal disease this can be a fatal event. We describe a case of middle-aged woman with Goodpasture's syndrome treated with plasma exchange who developed severe metabolic alkalosis. High citrate load in plasma exchange fluid is the underlying etiology. Citrate metabolism generates bicarbonate and once its level exceeds the excretory capacity of kidneys, the severe metabolic alkalosis ensues. Our patient presented with generalized weakness, fever, and oliguria and developed rapidly progressive renal failure. Patient had positive serology for antineutrophilic cytoplasmic antibodies myeloperoxidase (ANCA-MPO) and anti-glomerular basement membrane antibodies (anti-GBM). Renal biopsy showed diffuse necrotizing and crescentic glomerulonephritis with linear glomerular basement membrane staining. Patient did not respond to intravenous steroids. Plasma exchange was started with fresh frozen plasma but patient developed severe metabolic alkalosis. This metabolic alkalosis normalized with cessation of plasma exchange and initiation of low bicarbonate hemodialysis. ANCA-MPO and anti-GBM antibodies levels normalized within 2 weeks and remained undetectable at 3 months. Patient still required maintenance hemodialysis.

Encephalopathy and hypotonia due to baclofen toxicity in a patient with end-stage renal disease.

BACKGROUND: Baclofen is a centrally acting gamma-aminobutyric acid agonist used for the symptomatic relief of skeletal muscle spasm and spasticity in traumatic spinal cord lesions, multiple sclerosis, cerebral palsy, and stroke. It is also used in the treatment of chronic hiccups and cocaine abuse. Baclofen-induced central nervous system depression is rare at the usual therapeutic doses. However, patients with impaired renal function are at a higher risk of developing baclofen toxicity, even at a lower dose. CASE REPORT: A 57-year-old woman with end-stage renal disease on hemodialysis was admitted to our emergency department with progressive confusion and a generalized decrease in muscular tone. There was no obvious metabolic or infectious etiology that could have explained her condition. A comprehensive laboratory and imaging workup was negative. A review of her medication showed that she had recently been prescribed baclofen for muscular spasm. She was diagnosed with baclofen toxicity and was treated with emergent hemodialysis, which improved her mental status and her decreased muscle tone. Repeated sessions of hemodialysis administered on her second and third days of admission ultimately produced sustained clinical improvement and a complete return to her baseline mental status. She was subsequently discharged home with instructions to stay off baclofen. CONCLUSIONS: Baclofen toxicity is an under-diagnosed condition, especially in patients with renal dysfunction. Physicians should consider baclofen toxicity in patients with suboptimal kidney function on baclofen who present with altered mental status. Emergent hemodialysis and intensive care unit monitoring is recommended.

Complete heart block and persistent lactic acidosis as an initial presentation of non-hodgkin lymphoma in a critically ill newly diagnosed AIDS patient.

A 66-year-old male with newly diagnosed untreated acquired immunodeficiency syndrome (AIDS) presented with chronic nonspecific complaints of weakness, fatigue, myalgia, and weight loss. His initial EKG showed complete heart block necessitating temporary pacemaker placement. He had no previous history of cardiac disease. He was also found to have a persistent lactic acidosis and imaging studies showed abdominal lymphadenopathy. The patient underwent biopsy of these lymph nodes and was found to have diffuse large B-cell lymphoma. The hospital course was complicated by respiratory failure requiring mechanical ventilator support and cardiac arrest. Patient remained critically ill; he was not a candidate for chemotherapy and, after a month of hospitalization, he died. Lactic acidosis and heart block as an initial presentation of non-Hodgkin lymphoma in an AIDS patient are an unusual and unique presentation.

Age-specific frequency of screen-detected hepatitis C virus seropositivity in men from the Punjab province of Pakistan.

Pakistan is a South Asian country with a high population seroprevalence of anti-hepatitis C virus (anti-HCV) antibody. In administrative districts of its most populous province, Punjab, the frequency of seropositivity for HCV in different age groups of adult men, the usual bread winners for their families, is not known. This study describes the frequency and age-distribution of seropositivity for anti-HCV antibodies in 58,680 clinically healthy, adult men, from nine districts of the Punjab province in Pakistan, undergoing pre-employment health screening. Laboratory records belonging to these men, screened by enzyme-linked immunosorbent assay 3 for antiHCV antibodies in serum, were analysed and frequencies were calculated. A total of 4034 (6.9%) were seropositive for HCV. The highest frequency of HCV seropositivity was noted in men from Multan (9.6%), followed by Lahore (9.4%) district. The lowest (5.0%) was noted among men residing in Bahawalpur district. There was a progressive increase in seroprevalence with increasing age in men from all districts. Further research needs to be initiated to describe differential HCV risk factor distribution in various districts and sustainability of relatively low seroprevalence noted in younger men.