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Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening inflammatory syndrome of severe immune system activation. It is a diagnostic challenge with high morbidity and mortality. We present a case of HLH due to anaplasmosis infection. A 54-year-old man with chronic obstructive pulmonary disease presented with fever, nausea, vomiting, dyspnea, and arthralgias for 6 days. He had a rapidly progressive clinical decline requiring intubation for acute respiratory failure and dialysis for acute renal failure. He tested positive for anaplasmosis. His workup met criteria for HLH. He was treated with doxycycline and a steroid taper with clinical improvement allowing for extubation and renal recovery. Patients with persistent fevers, hepatosplenomegaly, cytopenias, and hyperferritinemia should be worked up for HLH.

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Patients hospitalized with COVID-19 infection are at a high general risk for in-hospital mortality. A simple and easy-to-use model for predicting mortality based on data readily available to clinicians in the first 24 hours of hospital admission might be useful in directing scarce medical and personnel resources toward those patients at greater risk of dying. With this goal in mind, we evaluated factors predictive of in-hospital mortality in a random sample of 100 patients (derivation cohort) hospitalized for COVID-19 at our institution in April and May, 2020 and created potential models to test in a second random sample of 148 patients (validation cohort) hospitalized for the same disease over the same time period in the same institution. Two models (Model A: two variables, presence of pneumonia and ischemia); (Model B: three variables, age > 65 years, supplemental oxygen ≥ 4 L/min, and C-reactive protein (CRP) > 10 mg/L) were selected and tested in the validation cohort. Model B appeared the better of the two, with an AUC in receiver operating characteristic curve analysis of 0.74 versus 0.65 in Model A, but the AUC differences were not significant (p = 0.24. Model B also appeared to have a more robust separation of mortality between the lowest (none of the three variables present) and highest (all three variables present) scores at 0% and 71%, respectively. These brief scoring systems may prove to be useful to clinicians in assigning mortality risk in hospitalized patients.

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Data on patient-related factors associated with pneumothorax among critically ill patients with COVID-19 pneumonia is limited. Reports of spontaneous pneumothorax in patients with coronavirus disease 2019 (COVID-19) suggest that the COVID-19 infection could itself cause pneumothorax in addition to the ventilator-induced trauma among mechanically ventilated patients. Here, we report a case series of five mechanically ventilated patients with COVID-19 infection who developed pneumothorax. Consecutive cases of intubated patients in the intensive care unit with the diagnosis of COVID-19 pneumonia and pneumothorax were included. Data on their demographics, preexisting risk factors, laboratory workup, imaging findings, treatment, and survival were collected retrospectively between March and July 2020. Four out of five patients (4/5; 80%) had a bilateral pneumothorax, while one had a unilateral pneumothorax. Of the four patients with bilateral pneumothorax, three (3/4; 75%) had secondary bacterial pneumonia, two had pneumomediastinum and massive subcutaneous emphysema, and one of these two had an additional pneumoperitoneum. A surgical chest tube or pigtail catheter was placed for the management of pneumothorax. Three out of five patients with pneumothorax died (3/5; 60%), and all of them had bilateral involvement. The data from these cases suggest that pneumothorax is a potentially fatal complication of COVID-19 infection. Large prospective studies are needed to study the incidence of pneumothorax and its sequelae in patients with COVID-19 infection.

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Severe mitral valve stenosis caused by rheumatic heart disease presenting initially as massive hemoptysis has become a rare occurrence in contemporary western medicine. Massive hemoptysis can be due to multiple disease processes including airway diseases such as bronchiectasis, pulmonary parenchymal disease of infectious or autoimmune etiology, pulmonary AVM's, hematologic disorders, and numerous drugs and iatrogenic injuries. It is less associated with congestion from rheumatic heart disease due to the earlier detection and subsequent management of cardiac valve disease preventing the sequela of more severe disease. We describe a case of a 59 year-old woman with hemoptysis, who was found to have severe mitral stenosis consistent with rheumatic heart disease. We demonstrate the appearance of pulmonary venous congestion can be seen on bronchoscopic examination in severe mitral stenosis and discuss the significance of the Wilkins score to help guide management.

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INTRODUCTION: Pneumonia remains a continuing target for performance measurement and quality improvement. The aim of this analysis was to examine 30-day all-cause readmissions after pneumonia to identify reasons for readmission and potential opportunities for improvement. METHODS: A retrospective chart review was performed on patients readmitted within 30 days after an index pneumonia hospitalization at the University of Connecticut Health Center in 2011. RESULTS: There were 54 readmissions involving 40 patients and only five (12.5%) patients had readmissions that were deemed potentially preventable. Reasons for readmissions were CHF exacerbation (3), malnutrition (1), and pericardial tamponade (1). Of the 49 non-preventable readmissions, 16 were related to pneumonia/bronchitis. Four out of 16 had known aspiration risks, while the rest had comorbidities including cystic fibrosis, COPD, CHF, HIV, and sickle cell disease. Other readmissions were secondary to underlying co-morbid conditions. CONCLUSION: These results suggest that most 30-day readmissions after hospitalization for pneumonia may not be preventable.

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Acute adult T-cellleukemia/lymphoma (ATLL) is a hematologic malignancy that usually entails a poor prognosis; median survival is only six months. Significant immunosuppression is commonly seen in these patients. Lung involvement in ATLL is usually documented either radiographically or as an autopsy finding. Few proven cases of ante mortem extensive lung infiltration have been described in the scientific literature. We present a fatal case of acute respiratory failure as a result of histologically proven lung infiltration by malignant lymphocytes in a patientwith acuteATLL. Although the most common cause of death i n patients with ATLL is respiratory failure in the setting of an infectious process, it should be kept in mind that patients with ATLL with acute respiratory failure may have malignant lung infiltration as a potential cause.

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Streptococcusanginosusis a member of the Streptococcus millerigroup, known to cause suppurative infections of the deep tissues. There have been very few case reports of the bacteria presenting with concomitant lung and brain abscesses. We describe a patient with new, onset seizures, subsequently diagnosed with S. anginosuslungandbrain abscesses.

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The ehrlichioses are emerging zoonotic infections. They have a very nonspecific clinical presentation. The diseases generally present as undifferentiated fever, but thrombocytopenia, leucopenia, and transaminitis are important laboratory features. Ehrlichiosis as a cause of acute respiratory distress syndrome (ARDS) has been infrequently described in the literature. Physicians should be aware of this life-threatening but treatable entity. We present a patient who developed ARDS shortly after being diagnosed with and initiating treatment for human granulocytic ehrlichiosis (HGE). A 54-year-old woman presented with fever, hypotension, and pancytopenia, with peripheral smear diagnostic of ehrlichiosis. She was started on doxycycline therapy following which she developed ARDS which resolved with methylprednisone. The fatality for HGE has been estimated as 7-10%. ARDS secondary to Ehrlichia has been shown to respond dramatically to steroids.

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Thyrotoxic Hypokalemic Periodic Paralysis (THPP) is a rare complication of thyrotoxicosis and can sometimes be fatal. It needs early recognition for proper management and prevention of recurrences. Here we describe two cases presenting with acute onset of paresis, low potassium levels, low levels of thyroid-stimulating hormones (TSH), and elevated thyroid hormone levels.

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