Delayed Diagnosis of West Nile Meningoencephalitis in a Patient Receiving Rituximab for Rheumatoid Arthritis.

West Nile virus (WNV) neuroinvasive disease is associated with substantial morbidity and mortality. Clinical suspicion is usually confirmed with cerebrospinal (CSF) immunoglobulin M (IgM) detection using enzyme-linked immunoassay (ELISA) techniques. CSF polymerase chain reaction (PCR) is rarely used to confirm the disease and is not widely available. We present a detailed report of false-negative WNV IgM in a patient receiving rituximab therapy for rheumatoid arthritis. She was exposed to the virus during peak immunosuppression and strong clinical suspicion was confirmed with WNV PCR, illustrating the importance of such consideration with the recent incremental use of rituximab therapy. Despite the lack of specific anti-viral treatment for WNV, delayed consideration and diagnosis of WNV in those who are immunosuppressed would expose them to a wide panel of testing, with a subsequent increase in the cost of medical care.

Diffuse Alveolar Hemorrhage Secondary to Acute Mitral Regurgitation.

We describe acute mitral valve regurgitation in a young, previously healthy male patient presenting with diffuse alveolar hemorrhage. The patient initially presented with acute respiratory failure with refractory arterial hypoxemia despite mechanical ventilation. Bronchoscopy showed diffuse alveolar hemorrhage. The patient quickly developed cardiogenic shock, which required vasopressor infusion. Echocardiography showed severe mitral regurgitation and myxomatous mitral valve with anterior leaflet prolapse along with chordal rupture involving the anterior leaflet, which was flail. An Impella device was emergently placed, and the patient underwent mitral valve replacement with subsequent quick resolution of all symptoms.

Metastatic Cavitary Adenocarcinoma of the Lung in a Patient with Recent Aggressive Squamous Cell Carcinoma of the Chest Wall.

The concurrence of two histologically different primary malignancies is rare and diagnostically challenging. Management and monitoring for progression also add to the dilemma as management varies amongst various types of malignancies and radiological imaging cannot differentiate between different primaries. We present a case of 62-year-old male with history of invasive squamous cell carcinoma of chest wall who was found to have cavitary lesions on a chest CT. Initially thought to be metastatic, as squamous cell carcinoma is notorious to case cavitary lesions, on biopsy they turned out be a separate primary malignancy, i.e. adenocarcinoma of the lung. The case highlights, not only such a possibility, but also the need of research to find common chemotherapeutic drugs that can target both pathologies and save patients from side effects of additional anticancer therapies.

Pleural and Pulmonary Tuberculosis in a Patient Presenting with a Massive Exudative Pleural Effusion: A Diagnostic Challenge.

Worldwide, Mycobacterium tuberculosis (MTB) is the leading cause of death due to a single infectious agent. According to the CDC, there were 9,025 reported new cases of active TB in the U.S. in 2018. There are various diagnostic modalities available to diagnose infection with MTB, whether it is latent or active. We present a diagnostically challenging case of pulmonary and pleural TB in a patient with known risk factors. It serves as a reminder of the high false negative rate of many of the tests for TB.

Critical Illness Due to Covid-19: A Description of the Surge in a Single Center in Sioux Falls.

BACKGROUND: We aim to describe the basic demographics, clinical course and outcomes of critically ill patients with Covid-19 admitted to Avera McKennan Hospital and University Health Center Intensive Care Unit (ICU) between March 20 and May 4, 2020. METHODS: In this single centered, retrospective, observational study, we enrolled 37 critically ill adults with COVID-19 pneumonia admitted to the (ICU) between March 20 and May 4, 2020. Demographic data, admitting symptoms, laboratory values, co-morbidities, treatments and clinical outcomes were collected. Data was compared between survivors and non-survivors. We aim to describe our data and report the 28-day mortality as of June 1, 2020. RESULTS: Of 154 patients admitted with COVID-19 pneumonia during our study period, 37 (24 percent) were critically ill and required an ICU stay. The mean age was 58 years and 76 percent were men. Of these 37 patients, 28 (78 percent) had a chronic illness (diabetes in 43 percent, hypertension in 47 percent). In addition, 54 percent were associated with a local meat packing plant. Most common presenting symptoms were dyspnea (92 percent), cough (70 percent) and fever (68 percent). The mean PaO2/ FiO2 ratio was 143 (67-362). Significant lab findings include the following: 54 percent of patients had lymphocytopenia, the mean ferritin was 850 ng/mL (10-3528), the mean D-Dimer was 4.09 FEU ug/mL and the mean IL-6 was 96.5 pg/mL. At 28 days, 24 percent (nine) had died. Twenty-five (68 percent) patients required mechanical ventilation, with 10 (27 percent) of those patients requiring initiation of neuromuscular blocking agents for ventilator compliance. Of those four (40 percent) did not survive. In addition, 20 patients (54 percent) were proned. Pneumomediastinum or pneumothorax occurred in five of the 37 (14 percent). Renal replacement therapy was required in 6 of the 37 patients, 4 of whom (66 percent) died. Steroids were used in 70 percent of patients, tocilizumab in 59 percent, and hydroxychloroquine in 27 percent. All patients received antibiotics. Convalescent plasma became available for our 5th patient. A total of 29 (78 percent) received convalescent plasma, (86 percent of survivors and 56 percent non-survivors). Median ICU length of stay was 11 days for both survivors (1-49) and non-survivors (1-21). There were no differences in age, body mass index (BMI), or initial PaO2/FiO2 (P/F) among those two groups. Non-survivors (nine) included the two immune compromised patients in our cohort, two patients with pre-existing DNR/DNI status, and one death within two hours of admit. Compared with survivors, more of the non-survivors received vasopressors (78 percent vs 46 percent), dialysis (44 percent vs 7 percent) and hydroxychloroquine (44 percent vs 21 percent). The first 5 patients treated in the ICU did not survive. One month after the initial case was reported in South Dakota, our ICU experienced a six-week surge. At its highest, COVID-19-related census reached 63 percent of the ICU capacity (15/24). CONCLUSION: Mortality of critically ill patients with COVID-19 is high. Multi-organ, advanced and prolonged critical care resources are needed. Interpretation of our data is limited by a higher mortality of the earlier members of the cohort, a change in therapeutic practice over time and institution of social distancing.

Renal replacement therapy in patients with acute respiratory distress syndrome: a single-center retrospective study.

BACKGROUND: Patients with acute respiratory distress syndrome (ARDS) who develop acute kidney injury have increased mortality and frequently require renal replacement therapy (RRT). The optimal timing for initiation of RRT after onset of ARDS to improve survival is not known. METHODS: We retrospectively reviewed clinical data on patients admitted to our health system over a 2-year period. Individual charts were carefully reviewed to ascertain that patients met the Berlin criteria for ARDS and to categorize RRT utilization. The Kaplan-Meier analysis was conducted to compare early (£48 hours postintubation) versus late (>48 hours postintubation) initiation of RRT. Associations between RRT initiation and mortality were evaluated using Cox proportional hazards regression. RESULTS: A total of 75 patients were identified with ARDS, 95% of whom received RRT. Mortality of patients who required RRT was 56%. The main indications for RRT initiation were fluid overload (75%), metabolic acidosis (64%), and hyperkalemia (33%). The Kaplan-Meier analysis comparing early initiation of RRT to late initiation of RRT showed no survival benefit. Cox proportional hazard models testing the association between timing of RRT initiation with survival and adjusting for sex, race, ethnicity, and Acute Physiology and Chronic Health Evaluation II score did not reach statistical significance (HR=0.94, 95% CI=0.48-1.86). CONCLUSION: Timing of RRT initiation was not associated with a survival benefit. Prospective study in the utilization and outcomes of RRT in ARDS could assist in optimizing its usage in this population.

Coccidioidomycosis among persons undergoing lung transplantation in the coccidioidal endemic region.

BACKGROUND: Coccidioidomycosis, an endemic fungal infection, is more likely to be symptomatic and severe among those receiving allogeneic transplants. While several case series have been published for various transplanted organs, none has described the incidence and outcomes in those receiving lung transplants within the coccidioidal endemic region. METHODS: Patients receiving a heart-lung, single-lung, or bilateral-lung transplantation at the University of Arizona between 1985 and 2009 were retrospectively reviewed. RESULTS: Coccidioidomycosis occurred post transplantation in 11 (5.8%) of 189 patients. All but one patient was diagnosed with pulmonary coccidioidomycosis and only one had a history of prior coccidioidomycosis. Two patients received transplants from donors found to have coccidioidomycosis at the time of transplantation and one death was directly attributed to coccidioidomycosis. The risk of developing active coccidioidomycosis was significantly higher if the patient did not receive some type of antifungal therapy post transplantation (P<.001). CONCLUSION: Within the coccidioidal endemic region, post-transplantation coccidioidomycosis was a definable risk among lung transplant recipients. Use of antifungals appeared to reduce this incidence of disease. Almost all cases resulted in pulmonary disease, suggesting that the lung is the primary site of infection.

Patient with Small Cell Lung Carcinoma and Suspected Right Upper Lobe Abscess Presenting with a Purulent Pericardial Effusion.

BACKGROUND Cardiac tamponade caused by pericardial effusion has a high mortality rate; thus, it is important to diagnose and treat this condition immediately. Specifically, bacterial pericarditis, although now very rare, is often fatal because of its fulminant process. CASE REPORT We present a case of a 61-year-old man with metastatic small cell lung cancer undergoing chemotherapy who presented with fatigue, poor appetite, and altered mental status. He was found to have a large-volume pericardial effusion with tamponade physiology. He underwent emergent pericardiocentesis. The pericardial effusion was nonmalignant, with cultures growing Streptococcus pneumoniae. It was only after his emergent pericardiocentesis that previous imaging from one month prior was able to be reviewed, which showed possible right upper lobe abscess. CONCLUSIONS Most pericardial effusions in cancer patients are related to their malignancy, either due to direct metastasis or secondary physiologic effects. This case is a unique example of a lung cancer patient presenting with a pneumococcal pericardial effusion, which in itself is a rare phenomenon. This case report demonstrates the importance of considering early antibiotic therapy in patients presenting with pericardial effusion, especially given the high mortality rates of infectious pericardial effusions.