Tracheal Schwannoma Presenting as Subcutaneous Emphysema and Pneumomediastinum.

Primary tracheal schwannomas are rare benign tumours. This is a case report, and therefore, no specific methods or results are applicable. We here report a case of a tracheal schwannoma in an early adolescent girl presenting with subcutaneous emphysema and symptoms of airway obstruction. Tracheal resection and reconstruction by primary anastomosis were performed. Pathology confirmed the diagnosis of tracheal schwannoma. This is an unusual life-threatening presentation of a benign rare tracheal tumour with a challenging approach to management.

Fibrotic Cystic Lung Disease Post Hematopoietic Stem Cell Transplant: Who is the Culprit?

Pulmonary complications post hematopoietic stem cell transplant (HSCT) are associated with poor outcomes and require extensive management depending on the etiology. They usually present in the form of bronchiolitis obliterans syndrome, interstitial pneumonitis, or drug toxicity that can lead to fibrosis. Scant data exists regarding diffuse cystic lung disease following HSCT, and the existing literature only mentions mild cystic changes. We present the case of a 25-year-old man with stage IVB Hodgkin's lymphoma post allogeneic HSCT, who developed progressive traction bronchiectasis, with the appearance of extensive pulmonary cysts that followed significant fibrotic changes and discuss the possible etiologies behind it.

Increased incidence of massive hemorrhage at uncommon sites after initiation of systemic anticoagulation in critically ill patients with coronavirus disease 2019 (COVID-19) infection.

BACKGROUND: The management of the Coronavirus disease 2019 (COVID-19) infected patients continues to be challenging. Critically ill COVID patients are at increased risk of serious thrombotic events and hence increased mortality. On the other side, COVID-19 patients are also showing major life-threatening bleeds, especially when systemic anticoagulation is used. Pro-coagulant propensity in critically ill COVID-19 patients have been published, but very few have described the incidence of major bleeding and its characteristics. METHODS: In this study, we retrospectively observed the incidence of major bleed in 25 critically ill COVID-19 patients admitted to the Intensive Care Unit at the American University of Beirut Medical Center. Six cases were identified and described together with their outcome. RESULTS: Major bleeding occurred in six of the 25 studied patients. Four patients were on therapeutic anticoagulation at the onset of the bleed, two required embolization for bleeding control and one died from hemorrhagic shock. Half of the described cases had unusual sites of bleeding including gluteal and abdominal wall muscles. CONCLUSIONS: A high rate of major bleeding was witnessed in our sample of critically ill patients with COVID-19 infection, with the majority being on therapeutic anticoagulation. This rate may be higher than previously reported, necessitating additional attention from the treating physician when considering empiric therapeutic anticoagulation. Moreover, the uncommon sites of bleeding shed the light on the need for additional studies in our population to identify the predisposing risk factors and mechanisms behind it.

Lung Adenocarcinoma with Paraneoplastic Hyper-Eosinophilia Not Responding To Pembrolizumab.

BACKGROUND: Paraneoplastic hyper-eosinophilia associated with metastatic lung adenocarcinoma is a rare finding and has been associated with a poor prognosis when present. Early hyper-eosinophilia appearing following non-small cell lung cancer (NSCLC) treatment with immune checkpoint inhibitors (ICI) has been previously reported with contradictory outcomes. CASE SUMMARY: We present the case of an elderly man with newly diagnosed metastatic lung adenocarcinoma and baseline hyper-eosinophilia, treated with pembrolizumab, and showing evidence of significant and rapid disease progression suggestive of hyper-progressive disease, worsening baseline hyper-eosinophilia, and a fatal outcome within 1 month of therapy initiation. CONCLUSION: Pre-treatment hyper-eosinophilia could represent a predictive factor of an unfavorable response to ICI treatment in cases of NSCLC. Additional similar cases are needed to draw a more conclusive relationship.

The largest viable aortic aneurysm.

Time has allowed us to attain new therapeutic advances in both surgical and medical fields. Nevertheless, prolonging patients' life expectancies by using these new techniques exposes physicians to challenging and exceptional medical presentations that, in the near past, were not possibly attainable and would not have naturally occurred.

Black Urine and Methemoglobinemia in the Setting of Sepsis Due to Clostridium Perfringens.

Clostridium Perfringens is an anaerobic gram-positive bacillus able to produce different types of toxins and can cause septicemia. The mechanism is through translocation from a previously colonized gastrointestinal or genital tract. Massive intravascular hemolysis induced by this bacterium is a rare presentation reported in only 7% to 15% of cases of Clostridium Perfringens bacteremia with a mortality rate reaching 90%.We present the case of a middle-aged man with metastatic melanoma having black-colored urine as the first sign of massive hemolysis along with mild methemoglobinemia. Despite timely management, the patient progressed into septic shock with severe hypoxia and passed away. Postmortem, blood cultures grew clostridium perfringens. Black-colored urine and blood samples, sepsis-induced mild methemoglobinemia and acute massive hemolysis should raise concern for Clostridium Perfringens sepsis in the appropriate clinical settings.

Coronary Computed Tomographic Angiography Imaging as a Prognostic Indicator for Coronary Artery Disease: Data from a Lebanese Tertiary Center.

BACKGROUND: Coronary artery disease (CAD) is a major cause of death and disability worldwide. Coronary computed tomographic angiography (CCTA) is a noninvasive imaging technique with a high negative predictive value (NPV). Most studies were done in developed countries, where the prevalence of CAD does not reflect the actual disease burden in developing countries, such as Lebanon. METHODS: We retrospectively evaluated the prognostic value of CCTA in predicting acute myocardial events (AMEs) in 200 Lebanese patients. We determined if specific medical and radiological characteristics are linked with AME and looked for any association between the patient's medical risk factors and the type/location of detected atheromatous plaques. Patients' records were reviewed, and the follow-up period of 5-8 years ensued. Chi-square/Fisher test and Student's t-test were used, in addition to multinomial logistic regression to adjust for the confounding variables. P <0.05 was considered statistically significant. RESULTS: Our study showed that CCTA had a NPV that reaches 97.9% in asymptomatic patients, a positive predictive value (PPV) of 76.4% for symptomatic patients, a sensitivity of 88.9%, and a specificity of 52.5%. AMEs were significantly increased in patients with a mixed plaque type and/or a moderate-to-severe lumen reduction on CCTA. CONCLUSIONS: CCTA is a sensitive modality for plaque detection and is found to have a remarkably high NPV for asymptomatic patients. A CCTA, along with a low pretest clinical probability of CAD, can be sufficient to rule out an AME for up to 8 years.

Severe Cobalamin Deficiency Disguised as Schistocytes: A Case Report.

BACKGROUND Vitamin B12, also known as cobalamin (Cbl), is a major player in both erythropoiesis and myelination of the central nervous system. The 2 main manifestations of vitamin B12 deficiency are bone marrow failure and demyelinating disease. These manifestations also depend on the severity and duration of the deficiency. In severe cases, ineffective erythropoiesis, with intramedullary destruction of erythrocytes has been reported, and increased homocysteine level was shown to be a cause of this hemolysis, in vitro. CASE REPORT We present the case of a middle-aged man presented with worsening fatigue, pallor, and dyspnea on moderate exertion. He was found to have a macrocytic anemia associated with intravascular hemolysis and clinical hypothyroidism in the setting of Hashimoto's thyroiditis. Vitamin B12 measured as part of his anemia investigation, was found to be markedly deficient (less than 100 pg/mL). Replacement was started and a reversal of his anemia and hemolysis was shown with improvement in his hemoglobin level upon follow-up. CONCLUSIONS Although a rare presentation, severe vitamin B12 deficiency can lead to hemolysis and severe anemia that can be life threatening. Timely and appropriate diagnosis and replacement, lifelong in some cases, in addition to looking for the underlying cause of this deficiency, and excluding other concomitant hemolytic disorders, is crucial for the management of this reversible disease. Despite some in vitro early results, the exact underlying mechanism behind hemolysis is still unclear.

Indolent lung opacity: Ten years follow-up of pulmonary inflammatory pseudo-tumor.

Inflammatory pseudotumor (IPT) has always been considered a diagnostic challenge. Its rarity and resemblance to other more common pathological entities imposes that neither clinical nor radiological characteristics can lead to a definitive diagnosis. The surgical excision of the lesion is the ultimate approach for accurate diagnosis and cure. Moreover the true nature of IPT, its origin as a neoplastic entity or an over-reactive inflammatory reaction to an unknown trigger, has been a long debated matter. Surgery remains the treatment of choice. IPT is mostly an indolent disease with minimal morbidity and mortality. Local invasion and metastasis predict a poor prognosis. We hereby present a unique case of pulmonary IPT that was surgically excised, but recurred contralaterally, shortly thereafter. Despite no medical or surgical treatment for ten years, the lesion has remained stable in size, with neither symptoms nor extra-pulmonary manifestations.