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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 While the COVID-19 pandemic killing millions world-wide, definitive therapy is not yet available. However, vaccines were shown to effectively reduce COVID-19 related mortality. Side effects of COVID vaccination include thrombosis. Most of the vaccine-related thrombosis took place after the Oxford-AstraZeneca and Johnson & Johnson vaccines. Our case, however, developed thrombosis after receiving the Moderna mRNA vaccine. A 62 y/o female with hypertension and paroxysmal atrial fibrillation had retroperitoneal hematoma thought to be due to an aneurysm posterior to the pancreatic head and underwent embolization. Following this, she developed bilateral pulmonary embolism (PE) secondary to iliac vein thrombosis which was thought to be a direct result of compression from the hematoma. She was started on anticoagulation (rivaroxaban) at that time and monitored closely for possible bleeding. Unfortunately, she stopped rivaroxaban after one month due to financial reasons. A year later, the patient presented to the hospital with chest tightness for 3 days, one week after she took her 2nd dose of Moderna vaccine. 2 days later, she started having left-sided chest tightness and dizziness. She has no family history of clotting disorder, recent surgery, and has no known malignancy. On admission, she was hemodynamically stable with normal oxygen saturation in room air. Blood work showed normal platelet count and coagulation panel. CT angiogram of the chest showed PE in the right middle lobe segmental branch without right ventricular strain. She did not have troponin elevation or EKG changes. Apixaban was initiated through a financial assistance program on discharge. Although vaccine-related thrombosis remains at the top of the differential diagnosis for our patient, a history of prior thromboembolic event a year earlier and lack of adherence to anticoagulation may have enhanced this lady's resurgence of thrombosis. Having a high degree of suspicion following COVID vaccination is always important to make an early diagnosis and prevent serious consequences of thromboembolism. It is possible that the immune-modulatory effects of the mRNA vaccines can enhance the recurrence of thrombosis in persons with previous history of the condition.
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Case Report Hypercoagulability in the setting of COVID 19 infection is well known, but data about arterial thrombosis in this context is limited. There have also been rare instances of aortic thrombosis in the setting of acute pancreatitis. We present the case of a 64-year-old female who was admitted for acute hypoxic respiratory failure due to COVID pneumonia. A few days earlier, the patient was admitted for a bout of acute pancreatitis that was medically managed but left the hospital against medical advice. During this admission, she was found to be covid positive but was asymptomatic. Chest imaging showed bilateral interstitial opacities. The patient was readmitted due to worsening hypoxia and received dexamethasone, antibiotics and prophylactic heparin on admission. The patient didn't receive remdesivir due to acute kidney injury. Oxygen requirements increased over the next 2 days. On hospital day 3 , the patient developed right lower limb pain not relieved with analgesics with symptoms suggestive for acute limb ischemia. CT angiography of the abdominal aorta and lower extremities revealed significant clot burden in infrarenal aorta and acute occlusion of bilateral popliteal arteries and right profunda femoral artery likely due to aortic clot emboli. Vascular surgery was consulted and proceeded with thrombectomy in the infrarenal aorta, bilateral common iliac arteries and bilateral lower extremity arteries with compartment fasciotomy of the lower extremities. Unfortunately, the patient developed severe septic shock and passed away a few hours after the surgery. Although rare, there have been a few other case reports where aortic thrombosis was caused by COVID 19 or acute pancreatitis. In our patient, both pancreatitis and COVID 19 likely have played a role in aortic thromboembolism leading to critical limb ischemia. Once diagnosed, arterial occlusion is a medical emergency and needs urgent attention and immediate intervention! Physicians should be aware of the possibility of arterial occlusion in the context of Covid 19, especially if acute pancreatitis preceded Covid 19 infection.
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Background West Nile Virus is the most common cause of arboviral diseases and is endemic in the US. It can cause clinical presentation ranging from asymptomatic infection to neuroinvasive disease. Factors like old age, hematologic malignancies, and organ transplantation result in more severe disease. Case presentation An 85-year-old male farmer with coronary artery disease, congestive heart failure (CHF) and diabetes presented with sore throat, cough and shortness of breath. He was treated for CHF exacerbation and discharged but returned with fatigue, headache, Nausea, and vomiting. Imaging of the head and chest, inflammatory markers, COVID-19 PCR,and metabolic panel were all negative, . Then he became febrile, lethargic, and had altered mentation. He exhibited asymmetric weakness, bilateral positive Babinski and neck rigidity. Intravenous ceftriaxone, vancomycin, bactrim, and acyclovir were all initiated for meningoencephalitis of unclear etiology. CSF analysis showed 51 WBC, 0 RBC, 49% granulocytes, 55 glucose and 74 proteins. He was transferred to ICU with a glasgow coma score of 6-7 but was on a 'DO NOT INTUBATE' status. He developed acute anuric kidney injury which prompted emergent hemodialysis and vasopressor support had to be initiated. Family elected for palliative care, and he passed away shortly after. A day later, West Nile serology was reported positive as IGM in CSF. Also, both IgG and IgM were positive in serum Discussion This case demonstrates a rare, severe presentation of West Nile infection. Most persons infected with West Nile (WNV) virus are asymptomatic;symptoms are seen in only about 20 to 40 percent of infected patients [1] Serologic surveys and extrapolations from blood donor screening data indicate that neuroinvasive disease following infection is infrequent, with estimates ranging from 1 in 140 to 1 in 256 infections resulting in meningitis or encephalitis [2] The patient's risk factors for severe infection include elderly age and male sex. Age in particular is the most important risk factor for neurologic progression of disease.[3] The diagnosis can be suspected in patients who have altered mental status, signs of meningitis, unexplained fever, and focal neurologic deficit, especially when it presents in late summer months and has no obvious etiology. The CSF West Nile IgM antibody detection via ELISA is diagnostic as was in our case. The treatment is mainly supportive. The preventive measures including mosquito control, personal protective devices are of substantial importance. Vaccines are not available. [4 5 6] Conclusion The high index of suspicion is necessary to diagnose WNV neuroinvasive diseases especially in patients with atypical presentation. Seasonal clues must be considered.
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Learning Objective Recognize the signs and symptoms of West Nile Virus Meningoencephalitis. Case presentation A 42-year-old female with no known chronic medical illnesses presented with 5 days of fever, confusion, and generalized body aches and weakness. She became more confused and agitated in the 2 days before she presented to the ED and she complained of headache, nausea, and vomiting. Patient had been confused, wandering around, and had involuntary jerking movements affecting her upper and lower extremities. She denied chest pain, shortness of breath, cough, urinary symptoms, or diarrhea. Patient tested negative on a Covid-19 PCR test, returned to ED with confusion, and was started on empiric antibiotics with ceftriaxone and vancomycin, acyclovir for meningitis, and clonazepam and Keppra for myoclonus. Fever and leukocytosis indicated sepsis and sepsis protocol was initiated. Patient was intubated 3 days after admission to control her condition. Urinalysis was negative for significant infection. CT of head showed no acute findings, and CT of chest/abdomen/pelvis showed no evidence of pneumonia or inflammatory processes. Meningitis PCR screen came back negative. Lumbar puncture showed increased white blood cells in CSF of 65 with 43% neutrophils, 40% lymphocytes, and increased total protein. Gram stain and CSF culture were both negative. HSV PCR came back negative so acyclovir was discontinued. CSF analysis for West Nile Virus IgG was positive although the WNV IgG was negative in the blood. Subsequently both IgM samples of the CSF and blood resulted as positive. The CSF pleocytosis and elevated protein supported the diagnosis of recent West Nile Virus infection with resulting meningoencephalitis. Antibiotics were discontinued. Patient was extubated after 4 days and physical therapy, speech therapy, and tube feeding were started. The patient was discharged in stable condition with a plan for home physical therapy. Discussion Since the West Nile Virus was first reported in the U.S. in 1999, it has become the most common cause of meningoencephalitis in the U.S. WNV can have varied presentations, ranging from asymptomatic to severe neurologic deficits (flaccid paralysis, seizures, or altered mental status) due to encephalitis or meningitis. The mortality rate for neuroinvasive WNV is approximately 9%, with that rate increasing in elderly populations. In addition, the neurological illnesses caused by WNV often result in long-term sequelae, further highlighting the need for early diagnosis and management. While current management for WNV are primarily supportive, novel treatments such as interferon therapy, ribavirin, and intravenous immunoglobulin (IVIG) are being explored and show potential. Conclusion We conclude that although neuroinvasive WNV is rare, occurring in less than 1% of infected individuals, it should be suspected due to the severity of morbidity and mortality especially during mosquito seasons.