Evaluation of leukopenia during sepsis as a marker of sepsis-defining organ dysfunction.

BACKGROUND: Although both leukocytosis and leukopenia have been considered Systemic Inflammatory Response Syndrome criteria, leukopenia is not generally considered a normal response to infection. We sought to evaluate the prognostic validity of leukopenia as a sign of sepsis-defining hematological organ dysfunction within the Sepsis-3 framework. We hypothesized that leukopenia is associated with higher risk of mortality than leukocytosis among patients with suspected infection. METHODS: We performed a retrospective cohort study using the Medical Information Mart v1.4 in Intensive Care-III database. Multivariable regression models were used to evaluate the association between leukopenia and mortality in patients with suspected infection defined by Sepsis-3. RESULTS: We identified 5,909 ICU patients with suspected infection; 250 (4.2%) had leukopenia. Leukopenia was associated with increased in-hospital mortality compared with leukocytosis (OR, 1.5; 95% CI 1.1-1.9). After adjusting for demographics and comorbidities in the Sepsis-3 consensus model, leukopenia remained associated with increased risk of mortality compared with leukocytosis (OR 1.6, 95% CI 1.2-2.2). Further adjustment for the platelet component of the SOFA attenuated the association between leukopenia and mortality (OR decreased from 1.5 to 1.1). However, 83 (1.4%) of patients had leukopenia without thrombocytopenia and 14 had leukopenia prior to thrombocytopenia. CONCLUSIONS: Among ICU patients with suspected infection, leukopenia was associated with increased risk of death compared with leukocytosis. Due to correlation with thrombocytopenia, leukopenia did not independently improve the prognostic validity of SOFA; however, leukopenia may present as a sign of sepsis prior to thrombocytopenia in a small subset of patients.

A chocolate effusion - An unusual cause of elevated adenosine deaminase in the pleural fluid.

BACKGROUND: Thoracic Endometriosis Syndrome (TES) is a rare diagnosis characterized by ectopic endometrial tissue in the chest. Pleural fluid adenosine deaminase (ADA) is thought to be highly specific for tuberculous pleural effusions, particularly when >40 IU/L (international units/liter). RESULTS: A 36-year-old woman from Cameroon (immigrated 10 years ago) with no past medical history presented to the emergency department with increasing abdominal swelling over months found to have on imaging ascites, a left adnexal lesion, a large right-sided pleural effusion and peritoneal studding. Sampling of the pleural fluid revealed dark brown fluid which on analysis was a non-specific exudate with an adenosine deaminase >100. Exploratory laparotomy by gynecology-oncology revealed a large amount of hemorrhagic ascites, multiple endometriotic implants, and a right ovarian endometrioma. Ultimately the patient was taken for video-assisted thoracoscopy (VATS) and decortication. The VATS revealed a diaphragmatic tear was seen suggesting the etiology of the pleural fluid was trans-diaphragmatic passage of blood through the defect. There was no evidence of malignancy or granulomas. Stains and subsequent cultures were negative on all specimens for Mycobacterium tuberculosis. DISCUSSION: Our case demonstrates a rarity of an ADA >100 IU/L due to TES rather than tuberculosis. In conclusion, ADA analysis, as with any lab test, should be interpreted within clinical context as false positives may occur. Several weeks following presentation the patient was discharged without any intrapleural catheter and near complete expansion of the lung. She was started on leuprolide and medroxyprogesterone and has no recurrent effusion or ascites in over two years since initial presentation.

E-cigarette, or vaping, product use-associated lung injury: a review.

BACKGROUND: E-cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) is a disease entity related to the use of battery-operated or superheating devices that create an aerosolized form of nicotine and tetrahydrocannabinol (THC) and/or other substances for inhalation. METHODS: We performed a literature review to document epidemiology, pathogenesis and risk factors, diagnosis, clinical presentation, evaluation and management of EVALI. RESULTS: In the summer of 2019, an outbreak of EVALI cases brought this disease entity into the national spotlight. Since being recognized as a serious pulmonary disease with public health implications, more than 2600 cases have been reported to CDC with 68 deaths as of February 2020. The pathophysiology of EVALI remains unknown. Substances such as Vitamin E acetate have been implicated as a possible causes of lung injury. The CDC has established case definitions of "confirmed EVALI" cases to help guide identification of the disease and assist in surveillance. While clinical judgement by healthcare providers is imperative in the identification of EVALI cases, the heterogeneous presentations of EVALI make this difficult as well. Ultimately most investigative studies should be aimed at ruling out other disease processes that can present similarly. Treatment is centered around removing the offending substance and providing supportive care. CONCLUSIONS: EVALI is a serious pulmonary disease with public health implications. Diagnosis requires a high degree of suspicion to diagnose and exclusion of other possible causes of lung disease. It may be beneficial to involve a pulmonary specialist early in the management of this disease which is generally supportive care.

A Case of Stroke due to Pulmonary Venous Thrombosis.

Pulmonary vein thrombosis (PVT) is a rare but potentially lethal disease. It most commonly occurs as a complication of malignancy, post-lung surgery or atrial fibrillation. Thrombi are typically detected using a variety of imaging modalities including transesophageal echo, CT-scan, magnetic resonance imaging (MRI) or pulmonary angiography. Treatment consists of anticoagulation. Here we report a case of a middle-aged male with systolic left ventricular dysfunction who presented with a stroke due to embolization from a pulmonary vein thrombus diagnosed on CT scan. Etiology of the thrombosis was felt to be secondary to severe systolic dysfunction. Based upon this case report, we believe that pulmonary venous embolism should be considered as a cause of cryptogenic stroke in patients with a significantly reduced cardiac systolic function.