ABSTRACT
BACKGROUND: The knowledge of bedside diagnostic EUS in critically ill patients is limited. OBJECTIVE: To investigate the indications, feasibility, safety, and clinical utility of diagnostic EUS in the intensive care unit (ICU). DESIGN: Retrospective. SETTING: Tertiary-care referral teaching hospital. PATIENTS: All consecutive patients who had EUS done in the ICU within a 6-year period. INTERVENTION: Bedside EUS and EUS-guided FNA. MAIN OUTCOME MEASUREMENTS: EUS indications, complications, and impact on management. RESULTS: A total of 64 EUS procedures were performed in 63 patients (38 men, 25 women; age range 27-78 years); 1 patient underwent 2 separate EUS procedures. EUS was performed while the patients were mechanically ventilated in 70% (45/64) of cases. Indications for EUS included jaundice (n = 24), mass of unknown etiology (n = 25), unexplained pancreatitis (n = 7), and staging of known cancer (n = 3). In 5 cases, EUS was used as an alternative to other imaging modalities because of morbid obesity (n = 3) or contraindication to intravenous contrast material (n = 2). Complications included reversible oxygen desaturation (n = 4), nonsustained ventricular tachycardia (n = 1), and transient hypotension (n = 1). Overall, EUS influenced management in 97% (62/64) of cases. LIMITATIONS: Retrospective, single-center study. CONCLUSION: ICU-based EUS can be performed with few intraprocedural complications and can be a valuable diagnostic modality in the ICU setting. It appears to be particularly useful for determining the etiology of jaundice, masses of unknown etiology, and pancreatitis. It may have particular value as a diagnostic technique on selected patients with unstaged cancer and when morbid obesity or the inability to use intravenous contrast material precludes the use of other imaging modalities in the critically ill patient.
Subject(s)
Critical Care/methods , Endosonography , Point-of-Care Systems , Adult , Aged , Endoscopic Ultrasound-Guided Fine Needle Aspiration , Endosonography/adverse effects , Feasibility Studies , Female , Humans , Intensive Care Units , Jaundice/diagnostic imaging , Jaundice/etiology , Male , Middle Aged , Mycoses/diagnostic imaging , Neoplasms/diagnostic imaging , Obesity, Morbid/complications , Pancreatitis/diagnostic imaging , Renal Insufficiency/complications , Retrospective StudiesABSTRACT
With increasing numbers of immune-compromised patients with malignancy, hematologic disease, and HIV, as well as those receiving immunosupressive drug regimens for the management of organ transplantation or autoimmune inflammatory conditions, the incidence of fungal infections has dramatically increased over recent years. Definitive diagnosis of pulmonary fungal infections has also been substantially assisted by the development of newer diagnostic methods and techniques, including the use of antigen detection, polymerase chain reaction, serologies, computed tomography and positron emission tomography scans, bronchoscopy, mediastinoscopy, and video-assisted thorascopic biopsy. At the same time, the introduction of new treatment modalities has significantly broadened options available to physicians who treat these conditions. While traditionally antifungal therapy was limited to the use of amphotericin B, flucytosine, and a handful of clinically available azole agents, current pharmacologic treatment options include potent new azole compounds with extended antifungal activity, lipid forms of amphotericin B, and newer antifungal drugs, including the echinocandins. In view of the changing treatment of pulmonary fungal infections, the American Thoracic Society convened a working group of experts in fungal infections to develop a concise clinical statement of current therapeutic options for those fungal infections of particular relevance to pulmonary and critical care practice. This document focuses on three primary areas of concern: the endemic mycoses, including histoplasmosis, sporotrichosis, blastomycosis, and coccidioidomycosis; fungal infections of special concern for immune-compromised and critically ill patients, including cryptococcosis, aspergillosis, candidiasis, and Pneumocystis pneumonia; and rare and emerging fungal infections.
Subject(s)
Antifungal Agents/therapeutic use , Critical Care/standards , Critical Illness/therapy , Lung Diseases, Fungal/therapy , Practice Guidelines as Topic , Respiratory Care Units/standards , Societies, Medical , Adult , Humans , United StatesABSTRACT
Phyllodes tumor (PT) of the breast is an uncommon fibroepithelial tumor accounting for 0.37% of primary breast cancers. Most PT are <5.0 cm, averaging 4-7 cm. We present a case of PT measuring 28 cm in diameter with an extreme computed tomography image with tumor size larger than the adjacent thoracic circumference. A 59-year-old uninsured woman without significant medical history presented with a massive ulcerated chest wall tumor. The mass was resected, and microscopic examination demonstrated spindled cells within a myxoid stroma, consistent with PT.
Subject(s)
Breast Neoplasms/pathology , Delayed Diagnosis/economics , Delayed Diagnosis/psychology , Phyllodes Tumor/pathology , Breast Neoplasms/drug therapy , Breast Neoplasms/surgery , Female , Humans , Middle Aged , Phyllodes Tumor/drug therapy , Phyllodes Tumor/surgery , Time Factors , Treatment OutcomeABSTRACT
Blastomycosis occurred in six patients in five households. In each instance one or more dogs living with the family or living near the family also developed blastomycosis. The recognition of canine blastomycosis helped in the early diagnosis of human cases. Because both dogs and patients were probably infected at the same place, canine blastomycosis may be an important epidemiologic marker, alerting physicians to the possible presence of concomitant blastomycosis in humans.
