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1.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927726

ABSTRACT

Cocaine use has a significant public health impact, causing over 1.2 million ER visits annually. Cocaine can cause a wide range of pulmonary pathology, including diffuse alveolar hemorrhage (“Crack Lung”), barotrauma, bronchiectasis, granulomatous disease, and pulmonary vascular disease. Acute eosinophilic pneumonia (AEP) is a rare and potentially life-threatening complication of cocaine use that can be successfully treated if identified. We describe a case of persistent fevers, hypoxemia, and air space opacities due to AEP related to cocaine use.A 34-year-old male with a history of polysubstance abuse was found unresponsive, apneic, and surrounded by vomitus at a party, where he had smoked marijuana and cocaine and injected heroin. Upon hospital arrival, he was hypotensive and severely hypoxic and was intubated. He had severe rhabdomyolysis, lactic acidosis, acute kidney injury, and acute liver injury. His chest radiograph demonstrated diffuse bilateral alveolar infiltrates. COVID-19 was ruled out. Sputum cultures grew Klebsiella and E. Coli;Streptococcus Pneumoniae urine antigen was positive. He received IV fluids, vasopressors, and broad spectrum antibiotics for septic shock and aspiration pneumonia in the setting of drug overdose. His septic shock and hypoxemia improved, allowing tracheostomy and gastrostomy to be performed. Despite prolonged courses of antibiotics, he had persistent fevers, worsening infiltrates on chest radiograph, and persistent hypoxemia. CT imaging demonstrated diffuse, bilateral ground glass opacities and consolidations, with reticulation and interlobular septal thickening. Viral, bacterial, and fungal cultures collected via bronchoscopy were negative, however, cell count revealed 315 WBC / mm3, with 27% eosinophils. He was started on methylprednisolone 80mg IV every eight hours and had resolution of fevers and improvement in oxygenation and infiltrates. 1 month after discharge, he was decannulated and did not require supplemental oxygen. DiscussionThis case highlights an important aspect of assessing fever in the ICU despite broad spectrum antibiotics in patient with drug overdose. In the above , bronchoscopy unmasked an eosinophilic pneumonia allowing a rapid transition to trach collar and prevention of progression to pulmonary fibrosis. (Figure Presented).

2.
American Journal of Respiratory and Critical Care Medicine ; 205:1, 2022.
Article in English | English Web of Science | ID: covidwho-1880827
3.
American Journal of Respiratory and Critical Care Medicine ; 205:1, 2022.
Article in English | English Web of Science | ID: covidwho-1880136
4.
Journal of Investigative Medicine ; 70(4):1164-1165, 2022.
Article in English | EMBASE | ID: covidwho-1868770

ABSTRACT

Purpose of Study Acute appendicitis (AA) is the most common abdominal surgical emergency in pediatrics. There was a precipitous drop in pediatric visits to hospitals, including the emergency department, since the US declared COVID-19 a national emergency. Managing AA during the pandemic remains a challenge as fear of COVID exposure can lead to delays in presentation and surgery, as well as a shift to conservative management. Alvarado score (AS) is a ten-point clinical scoring system to identify AA and the American Association for the Surgery of Trauma (AAST) grading system (I-V) are validated tools for AA diagnosis and severity. There are no studies on prevalence and severity of AA during the COVID- 19 pandemic in an urban multiethnic community. Objective To compare prevalence and severity of AA before and during the COVID-19 pandemic. Methods Used This was a retrospective chart review of patients admitted to Flushing Hospital Medical Center and Jamaica Hospital Medical Center with the diagnosis of AA from March 2018 to March 2021. Charts were reviewed for demographics, clinical, imaging and surgical data to determine AS and AAST. AS grouped from 1-6 (less likely to require surgery) and 7-10 (more likely to require surgery). AAST scoring was based on most severe criteria if grading discrepancies were found between pathology, surgical and computed tomography findings. Leukocytosis was defined as white blood cell count >10. G1 identified AA cases March 2018 - February 2020 and G2 March 2020 - March 2021. Data was analyzed using SPSS software, p<0.05 considered significant. Summary of Results Of 239 patients with AA over 3 years, G1 totaled 184 (77%) in 2 years pre-pandemic and G2 had 55 (23%) during first year pandemic. Mean age, gender and ethnicity were similar for G1 and G2. AS and AAST were compared for G1 and G2, table 1. G2 had significantly greater overall AS of >7 (p=0.038) and higher AAST (p=0.016). Only three patients tested positive for SARS-CoV-2 and 9 (16%) of G2 were transferred to a tertiary care center. Conclusions Although there was a decline in number of AA evaluated in our emergency department, the severity of AA was heightened during the pandemic. Healthcare providers need to have a high index of suspicion of increased severity with complications of AA. (Table Presented).

5.
American Journal of Respiratory and Critical Care Medicine ; 203(9):1, 2021.
Article in English | Web of Science | ID: covidwho-1407428
6.
American Journal of Respiratory and Critical Care Medicine ; 203(9):1, 2021.
Article in English | Web of Science | ID: covidwho-1407296
7.
American Journal of Respiratory and Critical Care Medicine ; 203(9):1, 2021.
Article in English | Web of Science | ID: covidwho-1407057
10.
Critical Care Medicine ; 49(1):124-124, 2021.
Article in English | Web of Science | ID: covidwho-1326503
11.
American Journal of Respiratory and Critical Care Medicine ; 203(9), 2021.
Article in English | EMBASE | ID: covidwho-1277661

ABSTRACT

The COVID19 pandemic has pushed healthcare workers to utilize available therapeutics, often with limited evidence. Theoretically, IL6 inhibitors could help to stop or reverse the damage caused by COVID19 cytokine storm. Published evidence from the United States is conflicting and is largely from academic institutions and nonminority populations. This study assessed the clinical utility of open-label tocilizumab in two multiethnic community hospitals in Queens, NY.Tocilizumab (8mg/kg) was given to 114 patients for treatment of COVID19- related respiratory failure between April 4 and May 19 2020 (96% received 1 dose). A retrospective cohort study was performed to determine 28-day clinical success, defined as achieving a score of 1 using a 6-point scale (1=no O2 requirement or discharged home on 2L/min;2=low-flow O2 in hospital ≤6L/min;3=O2 >6 to ≤15L/min;4=high-flow, CPAP, or BiPAP;5=mechanically ventilated (MV);6=expired). The decision to administer tocilizumab was made by a committee based on unstable or worsening respiratory status. Mean patient age was 60 years (SD=11);77(67%) were male. 25% were Asian, 23% black (31% black Hispanic), 36% white (73% white Hispanic), and 14% other. A majority of patients had at least 1 significant comorbidity, including HTN 56%, DM 40%, HLD 43%, and COPD/asthma 16%. Median days of symptoms at dose was 14(IQR 10-19);SpO2 on RA at admission was 82%(IQR 67-88%). Baseline status by ordinal scale was as follows: 2= 9(8%);3=33(29%);4=38(33%);5=34(30%) (IQR 1-2 days on vent). Median CRP=19.9, d-dimer=1658, ferritin=593, and LDH=1561. 28-day success was achieved in 35(31%) patients;62(55%) patients expired or were MV on day 28. Of patients who were on high-flow, CPAP, BiPAP or MV at baseline, 80% expired or were on MV on day 28. Estimated mortality in all hospitalized patients during the time frame at these hospitals was 36%. No significant differences were seen in labs, comorbidities or age between patients who did and did not have clinical success. Higher baseline ordinal scale score was predictive of mortality.Tocilizumab provided little to no clinical utility, especially in those with high oxygenation needs at time of dosing (success rate <20%). The main limitation is lack of a control group;however mortality was strikingly high. This in part may be due to the demographic and clinical characteristics of our sample.

12.
American Journal of Respiratory and Critical Care Medicine ; 203(9), 2021.
Article in English | EMBASE | ID: covidwho-1277636

ABSTRACT

New York City was one of the first epicenters of the COVID19 pandemic in the United States, and continues to be the hardest hit in terms of the number of total hospitalizations and deaths. As the pandemic has spread, it has become evident that the virus disproportionately affects minority populations and may result in more adverse outcomes. The multi-ethnic communities of Queens, NY, some of which include large proportions of low socio-economic and immigrant families, provide a unique opportunity to observe the COVID19 experience at the height of the pandemic. This information allows clinicians and researchers to learn more about the presentation and course of disease in a diverse sample. An estimated 2800 patients admitted for COVID19 were seen between March 10 and May 31 2020 (not including asymptomatic positive patients). A sample of 1651 were included in these preliminary analyses (806 from hospital A and 845 from hospital B).Most patients were male(62%) with mean age 67(16.1). Ethnicities were 33% Hispanic, 24% Black, 18% Asian, 17% White, and 8% other/unknown. At presentation, half had HR>100 and/or RR>20;25% had fever>100.5F. Symptoms included dyspnea(69%), cough(60%), fever(58%), weakness/fatigue(42%), myalgia(24%), AMS/confusion(21%), and GI complaints(20%). Comorbidities were HTN(65%), DM(43%), HLD(43%), CAD(19%), CKD(15%), CVA(10%) and COPD/asthma(10%). Complications included sepsis(44%), AKI/ARF(36%), intubation(24%), and arrhythmias(7%). Disposition included 29% home, 18% to skilled nursing facility, and 36% expired.In our cohort of mainly minority patients from low to middle class urban neighborhoods, presence of comorbidies was higher than in other reported cohorts in the region. Though presenting symptoms were similar to other New York City hospitals, clinical course was poorer, with over 1/3 of patients expiring. Further analyses will concentrate on predictors of poor outcome within and between racial/ethnic groups in the complete cohort of eligible patients.

13.
American Journal of Respiratory and Critical Care Medicine ; 203(9), 2021.
Article in English | EMBASE | ID: covidwho-1277529

ABSTRACT

Introduction: Apnea in the first weeks of life in a term infant can lead to extensive evaluation. Several respiratory viral infections are known to be associated with apnea. A paucity of data exists on SARS-CoV-2 in infants. We describe a 2-week-old girl presenting with apnea coinfected with SARS-CoV-2 and influenza B. Case: 2-week-old girl presented with an apneic episode lasting three minutes while lying supine after a feed with stiffening of the body and turning red in color. She experienced nasal congestion in preceding two days not associated with fever, cough or vomiting. She was born at term with birth weight 3365 grams (75%ile), length 48.9 cm (50%ile) and head circumference 33.5 cm (25-50%ile). The mother tested COVID-19 negative at time of delivery. Within the same household are two school age siblings. At admission, the weight was 4082 grams, temperature 37.2C, pulse 154 beats per minute and respiratory rate 33 breaths per minute. The heart and lung examinations were normal and there were no neurological deficits. Laboratory findings disclosed white blood cell count of 16.9 K/uL, serum glucose 113 mg/dL, calcium 11.3 mg/dL, total carbon dioxide 18 mmol/L, O2 saturation in room air 100% and CRP <0.05 mg/dL. Urinalysis was negative. Chest x-ray revealed hyperinflated lungs with prominent central markings, no focal consolidation, no pleural abnormality and unremarkable cardiothymic silhouette suggestive of a viral process. SARS-CoV-2 PCR-NP and influenza B tested positive. Influenza A, respiratory syncytial virus and human metapneumovirus were negative. Electrocardiogram traced normal sinus rhythm without abnormal QT interval. She had an uneventful clinical course and was subsequently discharged after two days of observation. Discussion: Brief resolved unexplained event (BRUE) was the admitting diagnosis. BRUE is when an infant younger than 12 months stops breathing associated with change in muscle tone, color or is unresponsive, transient in nature and with no known cause. Positive SARS-CoV-2 and influenza B test results excluded this diagnosis. In house exposure to school age siblings or by community spread present likely modes of transmission. Since our patient is younger than six months, she was not protected by influenza vaccine. The patient did not have fever, cough, leukopenia or elevated CRP as previously reported in children with COVID-19. Effects of SARS-CoV-2 on young infants are not completely known. SARSCoV-2 may also be the cause of apnea. Coinfection does not increase frequency of apnea. Full recovery was demonstrated.

14.
American Journal of Respiratory and Critical Care Medicine ; 203(9), 2021.
Article in English | EMBASE | ID: covidwho-1277274

ABSTRACT

Here we present a case of a middle-aged female with extensive past cardiac history, on methotrexate, who presented with respiratory failure. The case illustrates the complicated diagnostic struggles that clinicians have encountered during the pandemic and provokes the possibility of COVID19 as a potential risk factor for PCP pneumonia. A 62-year-old female presented to a New York City Hospital in July 2020 with hypoxic respiratory failure. She had a past medical history of coronary artery disease s/p stent and CABG, rheumatoid arthritis on methotrexate, hypertension, hyperlipidemia, diabetes mellitus, and chronic kidney disease. She was s/p a two month course of antibiotics for sternal wound infection. At presentation, her SpO2 was 75% on room air. She endorsed worsening shortness of breath for 3 weeks. Admission labs were significant for GFR=20, elevated LFTs 2-3xULN, CRP=19.2, troponin=0.5, BNP=45,000 and ANC=1.1. Chest x-ray demonstrated perihilar infiltrates sparing the left upper lobe. She was placed on bipap. COVID19 nasal swab was negative, antibodies were positive. She was intially treated for CHF exaccerbation. During the course of admission, she developed worsening hypoxemia requiring intubation and shock requiring vasopressors. She underwent bronchoscopy with BAL, which revealed lymphocyte count of 42% suspicious for methotrexate toxicity. Steroids were initiated for the treatment of both potential COVID19 and methotrexate toxicity. She developed progressive white out leading to pneumothoraces requiring chest tube insertion. The patient expired. Culture from BAL eventually grew PCP. This patient's case was extremely challenging and introduces thought-provoking questions regarding cooccurrence of PCP and COVID19. There have been a few case reports of PCP coinfection with COVID19. These infections can have significant overlap in terms of the initial imaging and symptoms (bilateral ground glass opacities associated with progressive hypoxemia over weeks). Bronchoscopy is useful for confirming PCP amidst this diagnostic challenge. There has been speculation that lymphopenia associated with COVID19 may result in susceptibility to PCP. PCP infections have commonly been associated with lymphopenia (low CD4) in HIV patients. Most viral infections can predispose patients to fungal and bacterial super-infection. This case raises the question of whether PCP prophylaxis may be considered in patients with COVID19 and other risk factors for development of PCP, such as immunosuppression.

15.
Critical Care Medicine ; 49(1 SUPPL 1):124, 2021.
Article in English | EMBASE | ID: covidwho-1193961

ABSTRACT

INTRODUCTION: The SARS-CoV2 pandemic experienced its height in the New York City (NYC) area in April of 2020. Flushing Hospital is a predominantly minority community hospital in Queens, NY, at that time the borough with the largest number of COVID-19 cases in NYC. An unexpectedly high incidence of pneumothorax (PTX) and pneumomediastinum (PMX) cases were noted during our experience. METHODS: This is a single-center, retrospective, casecontrol study of patients admitted between March 10 and April 30, 2020 who were PCR SARS-CoV2 positive with respiratory failure. Presented here is our preliminary data on the first 196 charts reviewed. Presence of PTX and/ or PMX was determined by investigator review of all chest imaging during patient admission. Demographic and clinic characteristics of patients were extracted. RESULTS: Of the 196 patients, 7 (3.6%) developed both PTX+PMX, 7 (3.6%) only PTX, and 8 (4.1%) only PMX, for a total incidence rate of 11.3% for PTX+/-PMX. Patients with PMX+/-PTX had 40% mortality, those with PTX+/-PMX had 64% mortality, and those with neither had a 42% mortality rate (difference between PTX group and no PTX/PMX group, X2=2.61, p=.11). Obesity, HTN, COPD/asthma, CAD, CHF, and CKD were not significantly higher in the PTX+/- PMX groups. Diabetic patients were more likely to develop PTX+/-PMX (16% vs. 7%, p=.05). Patients who developed PTX+/-PMX were more likely to be intubated (83% vs. 33%, p<.005);however, tidal volume (Vt) and maximum PEEP were not associated with development of PTX+/-PMX. Males were more likely to develop PTX+/-PMX than females (15% vs. 6%, p=.05). Median d-dimer was significantly higher in the PTX+/-PMX group (22,522 vs. 5,628, p<.005). CONCLUSIONS: The overall occurrence of PTX+/-PMX was 11.3% in patients with COVID-19 respiratory failure. Mortality in patients with PTX was 50% higher than in patients without PTX (64% vs. 42%). Of the clinical characteristics collected, diabetes and elevated d-dimer was highly associated with the development of PTX+/-PMX, and surprisingly Vt and PEEP played no statistically significant role. Although this is a preliminary analysis of approximately the first 20% of our data, the results are indicative of a substantial incidence of PTX and PMX in patients with COVID-19 and sheds light on predictors and clinical course.

16.
Critical Care Medicine ; 49(1 SUPPL 1):103, 2021.
Article in English | EMBASE | ID: covidwho-1193922

ABSTRACT

INTRODUCTION: SARS-CoV-2 is associated with systemic inflammation and hypoxic respiratory failure believed to be caused by a dysregulated immune response with heightened cytokine release. Recent literature suggests that the use of tocilizumab, an interleukin-6 (IL-6) receptor antagonist, may help to decrease oxygen requirements for patients in respiratory failure secondary to SARS-CoV-2. However, as an immunomodulator, tocilizumab has been associated with serious and fatal infections due to bacterial, invasive fungal, viral, protozoal, or other opportunistic pathogens. METHODS: We reviewed a series of 113 patients with SARS-CoV-2 pneumonia associated with acute hypoxic respiratory failure who received at least one dose of openlabel tocilizumab (8 mg/kg) in our healthcare system. Ten (9%) of these patients subsequently developed positive blood cultures a median of 13.4 days after receiving a first dose of tocilizumab. Patient characteristics included average age 60 years, 70% male, 60% hypertension, 30% diabetes, 30% hyperlipidemia, 75% overweight or obese, and 80% received concomitant corticosteroids. None of the patients had a history of HIV, other immunosuppressive disease, or neutropenia. Nine (90%) had blood cultures collected at admission, all of which had no growth. Of the 10 who developed a BSI, isolated organisms included four (40%) Staphylococcus aureus;three (30%) Candida species;one Enterococcus faecalis;one Enterobacter aerogenes;and one Streptococcus anginosus. Sources were identified in seven patients. The patient with urinary source grew <10,000 colony-forming units/mL gram positive cocci and one patient with C. albicans fungemia had C. albicans in the sputum which would normally be considered colonization or contamination. Seventy percent of patients who developed a BSI expired by day 28. RESULTS: Our findings suggest that clinicians should consider the risk of infection versus the benefit of use of tocilizumab in the setting of cytokine storm. Clinicians may want to consider treatment of cultures that would normally be considered contamination or colonization in patients receiving tocilizumab, due to the increased risk of immunosuppression. Mortality in these patients was high (70%), which may have in part been due to a clinical course complicated by BS.

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