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Case Report: Most common causes of shortness of breath are asthma, COPD, CHF, pulmonary embolism, diffuse lung parenchymal diseases and obesity hypoventilation syndrome. Rare conditions can be bronchiectasis, constrictive pericarditis, kyphoscoliosis, tracheomalacia, cardiomyopathies and so on. We present a rare case of tracheal stenosis presenting with repeated hospital admissions followed by intubations and resolution after spontaneous expectoration. A 52-year-old female with a history of end stage renal disease on hemodialysis, resistant hypertension, and COVID pneumonia on supplemental oxygen, presented with dyspnea associated with yellowish productive sputum for one day. She was admitted one week prior due to the same complaint associated with encephalopathy due to hypercapnia, required endotracheal intubation, got extubated four days later, was provisionally diagnosed with asthma and volume overload, and discharged home. During the admission of interest, the patient's examwas normal except severe hypertension with BP of 192/101, bilateral crackles and rhonchi. Arterial blood gasses (ABGs) again showed hypercapnia. CT thorax showed evidence of left lower lobe pulmonary infiltrate and ground-glass opacities. Due to repeated admissions for hypercapnic respiratory failure, suspicion for persistent anatomic or pathologic abnormality was high. Reexamination of CT thorax suggested subglottic stenosis and she underwent fiberoptic laryngoscopy which revealed grade 3 subglottic stenosis. On day three, she became hypoxic and unresponsive, ABGs revealed PCO2 of 150, and got intubated again. Soon after intubation, the patient had spontaneous expectoration of a large piece of firm, fleshy, blood-tinged, thick, luminal tissue. On the histologic examination, the material was found to be a plug of fibrin with small to moderate numbers of inflammatory cells embedded in the matrix. Follow-up CT neck and chest revealed resolution of previously visualized tracheal stenosis. She underwent repeat direct laryngoscopy and flexible bronchoscopy which did not show any tracheal stenosis. The patient remained hemodynamically stable and was discharged home. Tracheal stenosis is challenging to diagnose. Examples of tracheal stenosis due to pseudomembrane formation are rare in medical literature, and the expectoration of fibrin material after intubation in a person with this condition is even rarer. A similar case has been described before with an identical situation of coughing up soft tissue and comparable histopathology report. Our case highlights the importance of critical analysis for broad differentials, adding up pieces of the puzzle to explain the missing link. This patient came with recurrent episodes of dyspnea that were misdiagnosed as volume overload, pneumonia, and asthma exacerbations. CT chest findings of possible subglottic stenosis were the missing link in this case which steered further work-up and led to the final diagnosis. Copyright © 2023 Southern Society for Clinical Investigation.
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Case Report Learning Objective Recognizing Covid Myocarditis in Post covid syndrome Case Presentation A 56-year-old female with a medical history of hypertension and unvaccinated to COVID presented with sudden onset of chest pain radiating to the arm, 7/10 intensity aggravated with excretion, associated with palpitation and worsening bilateral leg swelling for last two weeks. She was recently tested positive for COVID infection four weeks ago. However, she did not seek medical treatment as she was asymptomatic at the time of infection. In the ER, she was diagnosed with A.Fib with RVR in hypotension needing two liters of oxygen and volume overload state with mildly elevated Troponin and EKG showing LBBB, grossly elevated BNP, all her inflammatory markers, and white cell counts within the reference range. She was admitted to ICU with cardiogenic shock needing two pressors and IV amiodarone. Urgent LHC was performed, showing normal coronary arteries with severely reduced EF of less than 20% with global hypokinesia on LV gram. Impella device was placed, and gradual diuresis with pressor support was administered. Overall hemodynamics improved, and pressors were weaned with continued aggressive diuresis. She improved well and was discharged with lifevest and an outpatient cardiology follow-up plan. Discussion The clinical features of myocarditis are usually non-specific, such as myalgias with a history of recent upper respiratory infection and typical age at onset varying between 20 to 50 years. New-onset HF over two weeks to three months with classical symptoms and non-specific changes EKG showing bundle branch block, atrioventricular (AV) block, or ventricular arrhythmias. Myocarditis should be suspected with or without cardiac signs and symptoms with elevated cardiac biomarkers, ECG changes suggestive of acute myocardial injury, arrhythmia, or global or regional abnormalities of LV systolic function, mainly if the clinical findings are new and unexplained. The clinical presentation of myocarditis is highly variable and can mimic other noninflammatory cardiac disorders;a high level of clinical suspicion is required. Conclusion We conclude that this new-onset HF with no evidence of acute coronary disease or any cardiac and familial risk factors with recent COVID infection makes us think that viral myocarditis is a possible cause of this acute presentation. Cardiovascular magnetic resonance (CMR) imaging is indicated in patients with suspected myocarditis if T2-based and T1- based imaging meet Lake Louise Criteria. Viral myocarditis should be an important consideration in patients with Covid- 19 and those who have recovered from even minor infections.
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Learning Objective Pneumomediastinum possible sequelae of post-COVID presentation with minor COVID infection Case presentation A 42-year male with Covid-19 pneumonia presented following an episode of presyncope with associated severe weakness and hemoptysis. The patient had Covid-19 pneumonia two months earlier and needed no hospitalization. At this presentation, he tested negative for Covid-19, with a 30-pound diet-related weight loss, brain fog, occasional shortness of breath, and night sweats since his infection. Respiratory rate 23/minute, occasional wheezing. Besides normal hemoglobin, WBC 12.7 with elevated ANC, normal electrolytes except slightly elevated chloride, D-Dimer of 0.85, ferritin of 907.8, CRP of 19.6, normal BNP, and normal troponin. Chest CTA demonstrated ground-glass opacities, small anterior pneumothoraxes, and moderate pneumomediastinum with a cystic lesion in the right upper lobe that may reflect a pneumatocele. Head CT and EKG were unrevealing. He was managed conservatively with breathing treatments and cough suppressants. The patient complained of neck pain the next day, and a repeat chest x-ray revealed subcutaneous emphysema in the neck area. Despite this, the patient had no further clinical manifestations during his hospital stay with stable pneumomediastinum and pneumothorax on follow-up chest x-rays with a reduction in subcutaneous neck emphysema. He denied repeat episodes of hemoptysis or presyncope and was subsequently discharged three days after admission with a followup chest x-ray in two weeks. Discussion Post-Covid complications including cough, dyspnea, and pulmonary fibrosis may contribute to alveolar barotrauma and subsequent pneumomediastinum, which may contribute to serious complications, including cardiac tamponade. Pneumatoceles are air-filled cavitary lesions usually seen post-infection, trauma, or more extensive cystic disease of the lung. The evolution happens post pneumonia, inflammation, and narrowing of the bronchus leads to the formation of an endobronchial ball valve, leading to the distal dilatation of bronchi and alveolar space. The obstruction is thought to be caused by inflammatory exudates in the airway lumen, permitting air to enter the cystic space but not to leave it. Subsequent enlargement of the pneumatocele occurs either due to pressure from the adjacent pneumatocele or intraluminal inflammatory exudates. 2 This case demonstrates the need to consider pneumomediastinum as a complication even in non-serious Covid infections with no acute hypoxic respiratory failure presentation. Conclusion Many case reports have detailed spontaneous pneumomediastinum in patients with active Covid-19 pneumonia, especially in intubated patients. Few publications have linked pneumomediastinum to post-Covid pneumonia. Pneumomediastinum should be an important consideration in patients with active Covid-19 and those who have recovered from even minor infection.
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Case Report Role of PA pressure monitoring in preventing recurrent hospital admissions in HF Case presentation A 67-year-old male with a past medical history of nonischemic cardiomyopathy, HFrEF NYHAIII StageC, hypertension, and DM with recent LHC in 2019 showed mild diffuse atherosclerosis was managed conservatively. He received an implantable PA monitoring device (CardioMEMS) in March 2021 to remotely monitor his home PA pressures on a daily basis. The average diastolic PA pressures were in the range of 5-10 mmHg since insertion of the ambulatory device with routine HF medication and lifestyle modifications. The daily monitoring system began to sense gradually raising diastolic PA from 19-22 mmg Hg. The patient was contacted to screen for any acute worsening of heart failure. He reported worsening of shortness of breath and a decrease in appetite corresponding to raising End DP PA pressure by the CardioMEMS. The patient was advised to 2X Lasix and report to the outpatient clinic. In the next 3-4 days, Diastolic PA began trending upward, peaking in the range of 25-30 mmg Hg. The patient was scheduled for an urgent outpatient visit;at this, we noted that there were no signs of fluid overload in the peripheries or any significant weight gain but worsening of his shortness of breath with all other examinations appearing normal. The patient's diuretics regiment was further intensified in this encounter. Subsequent ambulatory pulmonary diastolic pressure begins to trend down towards his usual range of 10 mmHg with the improvement of the patient's symptom of shortness of breath. His diuretics were gradually stepped down, and he continued to maintain his usual state health with improvement in his clinical outcomes. Discussion In clinical practice, ambulatory hemodynamic monitoring of a patient with cardioMEMS made clinicians take medicine one step closer to the patient's home and intercept treatment earlier, even before any worsening clinical signs, helping avoid hospitalization and at the same time improve patients quality of life in HF. GUIDE-HF study of 1000 patients reported that hemodynamics-guided management of heart failure did not result in lowering the composite endpoint rate of mortality but indicated a possible benefit primarily driven by a lower heart failure hospitalization rate compared with the control group.2 In this new era of COVID, we can mitigate the need for our patients to come to the medical facility frequently and to be able to keep our advanced HF patients safe and healthy at home. Conclusion Ambulatory hemodynamic monitoring based on pulmonary pressure guided therapy for HF has shown beyond doubt that lower PA pressure, lower rates of heart failure are associated with hospital admission. These devices can sense very early changes in patient clinical conditions even before any early signs of fluid overload appear. Above all, it builds a huge patient-provider trust by knowing your patients' hemodynamics the best.