A Case of Cavitary Mycobacterium chimaera.

Mycobacterium chimaera is a nontuberculous mycobacterium typically associated with heater-cooler units used in cardiac bypass procedures and is usually of low virulence. Here we present a patient with advanced Mycobacterium chimaera infection without typical risk factors.

Acute Fulminant Hepatic Failure and Renal Failure Induced by Oral Amiodarone: A Case Report and Literature Review.

Amiodarone is a class III antiarrhythmic agent that inhibits adrenergic stimulation by blocking alpha and beta receptors. It prolongs action potential and refractory period in myocardial tissue. Its remarkably long half-life is associated with a myriad of adverse events. Here, we present an 85-year-old male patient who was started on amiodarone for atrial flutter. After three oral doses, he developed fulminant hepatic failure and acute renal failure, which resolved after stopping amiodarone. While fulminant hepatic failure is rare, it has been seen in less than 2% of patients. Alternative theories behind susceptibility to amiodarone-induced hepatic injury and acute kidney injury are discussed here.

E-cigarette or Vaping Product Use-associated Lung Injury: A Case of an Adult Female Leading to Hospitalization.

E-cigarette or vaping is an alternative to traditional cigarette use with potentially devastating consequences. The most recent update from the Centers for Disease Control and Prevention reports a total of 2,561 cases of vaping associated pulmonary injury as of December 27, 2019. This case described a 41-year-old female who presented with a clinical picture suggesting of bronchitis; however, a diagnosis of e-cigarette or vaping product use-associated lung injury was made.

Fractional Exhaled Nitric Oxide Testing: Diagnostic Utility in Asthma, Chronic Obstructive Pulmonary Disease, or Asthma-chronic Obstructive Pulmonary Disease Overlap Syndrome.

Asthma and chronic obstructive pulmonary disease (COPD) can present as unique conditions or as a combination known as asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS). These condition(s) can be categorized as obstructive conditions, causing inflammation of small airways leading to decrease airflow, mucus production, and bronchoconstriction. Asthma and COPD affect every age, gender, ethnicity, and socioeconomic status, thus increasing mortality and morbidity burden in our society. Fractional exhaled nitric oxide (FeNO) is an endogenous gaseous molecule which can be measured in the human breath test because of airway inflammation. It has been studied extensively as a marker of inflammation and has been incorporated into an algorithm for asthma management. The purpose of this study was to investigate whether FeNO testing can lead to a change in the diagnosis. A retrospective chart review of 95 patients with asthma, COPD, and ACOS was performed, and FeNO levels were recorded. Out of 95 patients, 36%, 24%, and 22% of the patients had an initial diagnosis of asthma, COPD, and ACOS, respectively. After the FeNO testing, the number of patients with the final diagnosis of asthma and ACOS increased, and COPD decreased. Our results support the utility of FeNO as a viable marker in diagnosing and managing complex cases of asthma, COPD, and ACOS.

A Case of A Sleepy Taxi Driver Presenting with Narcolepsy.

Narcolepsy is a sleep disorder, which can manifest in childhood, or adolescence by causing excessive daytime sleepiness, hallucinations, sleep attacks or cataplexy. Although presentation can vary, nearly all patients present with excessive daytime sleepiness (EDS). There is often a significant delay in diagnosis, which may lead to a misdiagnosis. Timely diagnosis and management may dramatically improve quality of life and symptoms. If missed, a patient may be at risk of accidents at home, work or while operating motor vehicle or machinery. This particular case describes a 42-year-old male, taxicab driver, who has been living with this undiagnosed condition his entire life along with examining real life consequences of his condition due to his occupation.

Does Playing Video Games Before Bedtime Affect Sleep?

Sleep serves a vital role in our ability to function on a daily basis and may be affected by various activities such as playing video games. Teenagers are one of the largest consumers of video games and if played before bedtime may lead to the release of certain neurotransmitters which may, in turn, alter sleep architecture and reduce sleep efficiency. The purpose of this study is to measure 1) sleep efficiency 2) sleep latency 3) time spent in rapid eye movement (REM) stage with and without playing video games 30 minutes to 60 minutes before bedtime. For this study, one patient was recruited. The study was completed using a television, video game console, and a video game (Red Dead Redemption 4), Apnea Risk Evaluation System (ARES) nocturnal polysomnogram (NPSG) unit, a bed and a blanket situated in a quiet room, a computer, printer, and a notebook for data recording. REM time and sleep latency were also measured. There were 45.6 minutes of REM with video games and 56.4 minutes of REM without video games. This was equivalent to 13.06% and 15.74% of the total sleep time, respectively. The sleep latency with video games was shorter than without video games (11.4 and 23 minutes, respectively). Result suggests that there is no significant difference in sleep efficiency with and without video games. However, sleep latency decreased, and REM increased with video games.

Identifying Alpha-1 Antitrypsin Deficiency Based on Computed Tomography Evidence of Emphysema.

Introduction Chronic obstructive pulmonary disease (COPD) is most commonly caused by smoking tobacco or cigarettes. However, alpha-1 antitrypsin deficiency (AATD) is the only genetic disorder known to cause COPD and these patients often present with emphysema earlier in life and with more severe disease. Additionally, AATD patients are often misdiagnosed with other lung disorders, and the diagnosis is often delayed for up to a decade. Furthermore, several clinicians may see the patient before genetic testing is performed and an official diagnosis is made. We hypothesized that patients with radiographic emphysema on computed tomography (CT) scan of the chest would represent an enriched population of patients with a higher prevalence of alpha-1 antitrypsin (AAT) carrier or heterozygous state. Methods We evaluated 250 in-patients with chest computed tomography (CT) findings of emphysema, and per clinical guidelines, all were tested for AAT with Alphakit finger stick blood collection kits. Sampling 250 patients provided power to detect a carrier prevalence of 20% +/- 1.0%. Results A total of 250 patients were recruited of which 53% were male, 91% Caucasian, 7% African American, and 16% active smokers. They smoked an average of 39 packs per year. The prevalence of carrier status (Pi*MS or Pi*MZ) was 6.8% (95% CI (4%, 11%)). The mean forced expiratory volume in one second (FEV-1) was 53%, predicted among Pi*MM patients (n=126) and not significantly different from the Pi*MS group (50%, n=13). 69% of Pi*MM were diagnosed with asthma or COPD, vs. 79% of Pi*MS (n=14) and 100% Pi*MZ (n=3), but the difference was not significant (p=0.4). Conclusion In the population studied, compared to a cohort of patients with abnormal pulmonary function tests (PFTs), radiographically evident emphysema did not identify patients at higher risk of being heterozygous or homozygous for AAT deficiency.

A Case of Off-label Sodium Oxybate in an 11-Year-Old with Narcolepsy.

Narcolepsy is a rare chronic condition which affects sleep architecture. It may manifest in childhood or adolescence by causing excessive daytime sleepiness, sleep attacks, and hallucinations. Research suggests that there is a significant delay in diagnosis with the mean age being 10 to 15 years from onset of symptoms. Although narcolepsy is predominantly associated with loss of hypocretin (orexin), the role of genetics is complementary to the diagnosis. In addition, clinical manifestations of symptoms vary in presentation and severity from case to case. Therefore, this report provides an opportunity to review pediatric narcolepsy including the diagnostic workup and clinical response to sodium oxybate. This particular case describes an 11-year-old boy meeting the clinical and diagnostic criteria for narcolepsy. Clinically, the patient had a very positive response to treatment with sodium oxybate, which at the time of initiating therapy was off-label for patients under the age of 18.

A Case of Dermatomyositis Causing Cryptogenic Organizing Pneumonia.

Cryptogenic organizing pneumonia (COP), also known as idiopathic bronchiolitis obliterans organizing pneumonia (BOOP), is a rare inflammatory condition. It often presents as sequelae of existing chronic inflammatory diseases such as rheumatoid arthritis, systemic lupus erythematosus, and various connective tissue conditions. This case describes a 28-year-old African American female who presented with a complex clinical picture involving chronic inflammatory processes and the pulmonary system. The initial evaluation suggested pneumonia to be the underlying cause of respiratory symptoms; however, ultimately, a diagnosis of BOOP with dermatomyositis was made.

Idiopathic Pulmonary Fibrosis: A Case of Mistaken Identity.

Diffuse parenchymal lung diseases (DPLD), also known as interstitial lung diseases (ILD), are a group of lung disorders affecting alveolar epithelium, pulmonary capillary endothelium, and surrounding lung tissue. Over time due to injury, the tissue around the air sacs becomes fibrotic leading to poor oxygen exchange, eventually resulting in the patient experiencing shortness of breath. This case describes a 69-year old male who presented in 2017 with a complex clinical picture involving both cardiac and pulmonary systems. Drug toxicity was initially thought to be the cause of the patients interstitial lung process; however, ultimately, a diagnosis of UIP was made.

Nitrofurantoin Toxicity: A Near Case of Mistaken Identity.

Nitrofurantoin is one of the most utilized antibiotics to treat bladder and urinary tract infections (UTIs). Despite the clinical benefits, it requires vigilant monitoring, as it can cause damage to multiple organs, especially the lungs and the liver. This case is an example of clinical vigilance, which provided tremendous benefit for the patient.

Low Dose Naltrexone and Lung Cancer: A Case Report and Discussion.

Low dose naltrexone (LDN) has been promising as a complementary medication for patients with a broad range of medical disorders. Although not a proven cure, evidence from clinical trials supports LDN as being a valuable adjunct for disorders in which the immune system plays a centralized role. Additionally, clinical trials have proposed a unique mechanism(s) allowing LDN to affect tumors including non-small cell lung cancer (NSCLC) at the cellular level by augmenting the immune system. We present a case of a 50-year-old male with a prolonged survival and a past medical history of prostate and lung cancer.

Mycobacterium Chimaera: A Rare Presentation.

Mycobacterium chimaera is an indolent nontuberculous mycobacterium which is abundant in soil, dust, and water. Although lacking recognition garnered by other mycobacteria (i.e., M. tuberculosis), it has been recognized as an emerging opportunistic threat to patients undergoing coronary bypass surgery and open heart procedures requiring extracorporeal devices. Here, we present a case of an individual initially seen in the inpatient setting without a history of such procedures or other risk factors commonly associated with mycobacterium-laden infections.

Off-label Sodium Oxybate in Childhood Narcolepsy: A Comprehensive Report.

Narcolepsy is a sleep disorder that can manifest in childhood or adolescence by causing excessive sleepiness, hallucinations, sleep attacks, or cataplexy. There is often a significant delay in diagnosis with the mean time being 15 years from the onset of symptoms, which may lead to further exacerbations and a high comorbidity burden. Although narcolepsy is predominantly associated with loss of hypocretin (orexin), the role of genetics is poorly understood and, therefore, is complementary to the diagnosis but not confirmatory. We present the case of a child who was misdiagnosed as suffering from schizophrenia only to later uncover narcolepsy with cataplexy. Even though she did not meet strict criteria for narcolepsy type 1, her history and objective data were consistent enough to make an official diagnosis. In addition, her clinical response to treatment was very positive, further supporting narcolepsy as the most likely underlying condition. This presentation highlights the importance of continued education and research to reduce the risk of delay in diagnosis or misdiagnosis.

A Pediatric Case of Narcolepsy Presenting as Syncope.

Narcolepsy is a chronic genetic and sleep disorder that is caused by a protein deficiency. This may affect the patients' sleep architecture and the brain's ability to control circadian rhythms. Individuals with this condition feel rested after waking but then feel tired and sleepy as the day progresses. Typical onset is during adolescence, but there is often a significant delay in diagnosis, which may markedly hinder an individual's quality of life. This case provides an opportunity to shed light on this often underdiagnosed or misdiagnosed condition by presenting a case of a remarkable individual who has persevered to be successful with the help of a timely diagnosis and aggressive off-label therapy.

Early respiratory abnormalities in emergency services police officers at the World Trade Center site.

The effects of exposure to the environment around the World Trade Center after the attack of September 11, 2001, are not fully described. We evaluated 240 police first-responders; respiratory symptoms occurred in 77.5% but resolved or improved in around three fourths of subjects by the time of their evaluation (mean 69 days after the attack). Cough was the most common symptom (62.5%). Spirometric abnormalities were mild and occurred in 28.8%. Independent risk factors for abnormal spirometry were previous pulmonary disease or symptoms (adjusted odds ratio, 2.76) and intensity of exposure (AOR, 2.32). Previous pulmonary conditions were associated with obstructive defects (P<0.002). Exposure intensity was associated with a lower forced vital capacity (P<0.03) and a higher prevalence of abnormal spirometry (P<0.03). Officers with dyspnea, chest discomfort, or wheeze were more likely to have abnormal spirometry (P=0.04). A significant minority of officers had symptoms a few months after the exposure. Long-term effects of this respiratory tract exposure will need additional evaluation.