Pulmonary Kaposi Sarcoma as an Unusual Etiology of Acute Hypoxemic Respiratory Failure in the Era of Highly Active Antiretroviral Therapy: A Case Report.

Kaposi sarcoma (KS) is caused by human herpesvirus 8 (HHV-8). Epidemic KS is described in the human immunodeficiency virus (HIV) population with acquired immune deficiency syndrome (AIDS). It primarily affects the skin, but it may uncommonly disseminate to involve extracutaneous sites such as the gastrointestinal (GI) tract, liver, and lungs. In this case report, the authors report a 26-year-old homosexual male who was admitted with acute hypoxemic respiratory failure. He was diagnosed with an HIV infection about five months before index presentation, and he was commenced on highly active antiretroviral therapy (HAART). Physical examination was remarkable for diffuse cutaneous nodules over the lower extremities, back, and oropharynx. Chest imaging revealed diffuse bilateral infiltrates, mediastinal adenopathy, and a persistent bilateral pleural effusion. Extensive diagnostic workup was negative for underlying infectious etiology. Transbronchial biopsy demonstrated proliferated spindle cells that stained positive for HHV-8 in keeping with pulmonary KS. Skin biopsies also concurred with the diagnosis of cutaneous KS. Interestingly, the cluster of differentiation 4 (CD4) count was 647 cells/mm3, and HIV viral load (VL) was 500 copies/ml. This case demonstrated an atypical natural history of pulmonary KS in an HIV patient as pulmonary and disseminated mucocutaneous KS occurred with a relatively higher CD4 count (≥500 cells/mm3). It also reminds pulmonologists and infectious disease specialists to consider pulmonary KS as a differential diagnosis of acute hypoxemic respiratory failure in HIV patients, even in the absence of other clinical and laboratory criteria that define the AIDS stage.

Intramuscular Versus Buccal Midazolam for Pediatric Seizures: A Randomized Double-Blinded Trial.

BACKGROUND: We compared the efficacy and safety of intramuscular with buccal midazolam as first-line treatment for active seizures in children brought to the emergency department. METHODS: In a double-blind, double-dummy randomized trial, patients with an active seizure lasting more than five minutes received blinded treatments on arrival. We employed deferred consent. The proportion of patients with cessation of seizure within five minutes of drug administration was the primary efficacy outcome; proportions needing additional medication to control seizure, duration of seizure activity, and side effects were secondary outcomes. RESULTS: We enrolled 150 children presenting with active seizure, age range 4.5 to 167.5 months. Cessation of seizure occurred in 61% of the intramuscular and 46% of the buccal treatment groups, (P = 0.07, difference 15.5%, 95% confidence interval for the difference -1.0 to 32.0%). Proportions requiring additional anti-seizure treatment were 39% in the intramuscular and 51% in the buccal groups. Mean duration of seizure activity after administration of study medication was 15.9 minutes (S.D. 28.7) in the intramuscular and 17.8 minutes (S.D. 27.5) in the buccal group. One patient in the intramuscular group developed respiratory depression and hypotension; there were no side effects attributed to investigational treatment in the buccal group. CONCLUSIONS: Efficacy and safety of intramuscular midazolam as first-line treatment for pediatric seizures compare favorably to that of buccal midazolam.

Advances in medicine and positive natural selection: Prosthetic valve endocarditis due to biofilm producer Micrococcus luteus.

Over the past years there has been a considerable increase in the use of aortic bioprostheses for treating aortic valve disease. With the increasing use of implanted medical devices, the incidence of prosthetic valve endocarditis has also increased. This is accompanied by a shift in the microbiology of infectious endocarditis. Micrococcus species are usually regarded as contaminants from skin and mucous membranes that rarely cause infectious diseases, however, they have the capacity to create biofilms from prosthetic materials and hence, to cause disease. We report the case of a 54-year-old woman who developed native valve infective endocarditis due to Micrococcus luteus. To our knowledge, only 18 cases of M. luteus prosthetic valve endocarditis have been described, none in the English literature.

Targeted temperature management after cardiac arrest: Updated meta-analysis of all-cause mortality and neurological outcomes.

BACKGROUND: Cardiac arrest carries high mortality and morbidity burden. Different studies showed conflicting data regarding outcomes of targeted temperature management (TTM) for cardiac arrest. The purpose of this meta-analysis is to systematically determine the effect of TTM on all-cause mortality and neurological outcomes after cardiac arrest. METHODS: We conducted a systematic search for randomized controlled trials in Pubmed, Cochrane & ScienceDirect. Primary outcomes were neurological outcome and all-cause mortality. RESULTS: Nine randomized controlled trials utilizing data for in-hospital and out-of-hospital cardiac arrest were selected for meta-analysis. Total number of patients included was 1592. Mortality was lower in targeted temperature management group (OR 0.637, 95% CI 0.436-0.93, p-value 0.019, I2 = 44.78%, n = 1592). Therapeutic hypothermia group also demonstrated reduction in poor neurological outcomes (OR 0.582, 95% CI 0.363-931, p-value 0.024, I2 = 56.79%, n = 1567). Subgroup analysis was conducted, after excluding in-hospital cardiac arrest patients, and demonstrated reduction in poor neurological outcome (OR 0.562, 95% CI 0.331-0.955, p-value 0.033, I2 = 61.78%, n = 1480) and mortality in out-of-hospital cardiac arrest patients (OR 0.674, 95% CI 0.454-999, p-value 0.049, I2 = 43.8%, n = 1505). CONCLUSION: Targeted temperature management after cardiac arrest may be associated with improvement in all-cause mortality and reduction in poor neurological outcome.