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1.
Clin Infect Dis ; 77(10): 1395-1405, 2023 11 17.
Article in English | MEDLINE | ID: mdl-37384794

ABSTRACT

BACKGROUND: The diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-associated multisystem inflammatory syndrome in adults (MIS-A) requires distinguishing it from acute coronavirus disease 2019 (COVID-19) and may affect clinical management. METHODS: In this retrospective cohort study, we applied the US Centers for Disease Control and Prevention case definition to identify adults hospitalized with MIS-A at 6 academic medical centers from 1 March 2020 to 31 December 2021. Patients MIS-A were matched by age group, sex, site, and admission date at a 1:2 ratio to patients hospitalized with acute symptomatic COVID-19. Conditional logistic regression was used to compare demographic characteristics, presenting symptoms, laboratory and imaging results, treatments administered, and outcomes between cohorts. RESULTS: Through medical record review of 10 223 patients hospitalized with SARS-CoV-2-associated illness, we identified 53 MIS-A cases. Compared with 106 matched patients with COVID-19, those with MIS-A were more likely to be non-Hispanic black and less likely to be non-Hispanic white. They more likely had laboratory-confirmed COVID-19 ≥14 days before hospitalization, more likely had positive in-hospital SARS-CoV-2 serologic testing, and more often presented with gastrointestinal symptoms and chest pain. They were less likely to have underlying medical conditions and to present with cough and dyspnea. On admission, patients with MIS-A had higher neutrophil-to-lymphocyte ratio and higher levels of C-reactive protein, ferritin, procalcitonin, and D-dimer than patients with COVID-19. They also had longer hospitalization and more likely required intensive care admission, invasive mechanical ventilation, and vasopressors. The mortality rate was 6% in both cohorts. CONCLUSIONS: Compared with patients with acute symptomatic COVID-19, adults with MIS-A more often manifest certain symptoms and laboratory findings early during hospitalization. These features may facilitate diagnosis and management.


Subject(s)
COVID-19 , Connective Tissue Diseases , Humans , Adult , United States/epidemiology , COVID-19/epidemiology , SARS-CoV-2 , Retrospective Studies , Systemic Inflammatory Response Syndrome/diagnosis , Systemic Inflammatory Response Syndrome/epidemiology
2.
Arthritis Care Res (Hoboken) ; 75(3): 648-656, 2023 03.
Article in English | MEDLINE | ID: mdl-35287250

ABSTRACT

OBJECTIVE: To assess the predictive significance of blood neutrophil count and the ratio between neutrophil and lymphocyte count (neutrophil-to-lymphocyte ratio [NLR]) for disease severity and mortality in systemic sclerosis (SSc). METHODS: Neutrophil and lymphocyte counts were prospectively measured in the Genetics versus Environment in Scleroderma Outcome Study (GENISOS) and the Scleroderma Lung Study II (SLS II). Forced vital capacity percent predicted (FVC%) and modified Rodnan skin thickness score (MRSS) were used as surrogate measures for disease severity. Longitudinal analyses were performed using generalized linear mixed models. Cox proportional hazards models evaluated the predictive significance of these cell counts for mortality. RESULTS: Of the 447 SSc patients in the GENISOS cohort at the time of analysis, 377 (84.3%) had available baseline blood neutrophil and lymphocyte counts. Higher baseline neutrophil count and NLR predicted lower serially obtained FVC% (b = -4.74, P = 0.009 and b = -2.68, P = 0.028, respectively) and higher serially obtained MRSS (b = 4.07, P < 0.001 and b = 2.32, P < 0.001, respectively). Longitudinal neutrophil and NLR measurements also significantly correlated with lower concurrently obtained FVC% measurements and higher concurrently obtained MRSS. Baseline neutrophil count and NLR predicted increased risk of long-term mortality, even after adjustment for baseline demographic and clinical factors (hazard ratio [HR] 1.42, P = 0.02 and HR 1.48, P < 0.001, respectively). The predictive significance of higher baseline neutrophil count and NLR for declining FVC% and increased long-term mortality was confirmed in the SLS II. CONCLUSION: Higher blood neutrophil count and NLR are predictive of more severe disease course and increased mortality, indicating that these easily obtainable laboratory studies might be a reflection of pathologic immune processes in SSc.


Subject(s)
Neutrophils , Scleroderma, Systemic , Humans , Lymphocytes , Disease Progression , Skin , Lymphocyte Count
3.
Am J Med Sci ; 363(6): 548-551, 2022 06.
Article in English | MEDLINE | ID: mdl-35369983

ABSTRACT

COVID- 19 has become a major pandemic affecting more than 11 million people worldwide. Common radiological manifestations of COVID-19 include peripheral based ground-glass or consolidative opacities; however, pneumothorax and pneumo-mediastinum are very rare manifestations; even more so within patients not on mechanical ventilation. We present a case series of 5 patients with COVID-19 who either presented with or developed spontaneous pneumothorax or pneumo-mediastinum within the course of hospitalization. With the exception of one patient, all other patients developed pneumothorax as a late manifestation in their illness; more than 10 days after initial symptom onset in COVID-19. From within this case series, all patients who developed spontaneous pneumothorax or pneumo-mediastinum during hospitalization subsequently succumbed to the illness. Spontaneous pneumothorax or pneumo-mediastinum may be an important late manifestation in COVID-19; even in spontaneously breathing patients. This may be related to development of cystic changes within the lung parenchyma. Although the clinical relevance of this finding is unknown; in our series, it portended a worse prognosis in the majority of patients.


Subject(s)
COVID-19 , Mediastinal Emphysema , Pneumothorax , COVID-19/complications , Humans , Mediastinal Emphysema/diagnostic imaging , Mediastinal Emphysema/etiology , Pandemics , Pneumothorax/diagnostic imaging , Pneumothorax/etiology , SARS-CoV-2
4.
ACR Open Rheumatol ; 4(4): 345-351, 2022 Apr.
Article in English | MEDLINE | ID: mdl-35048554

ABSTRACT

OBJECTIVE: The objective of this study was to assess the predictive significance of anti-Scl-70 (anti-topoisomerase I) antibodies, as determined by three different methods, for decline in forced vital capacity (FVC) within the first year of follow-up in patients with systemic sclerosis (SSc)-related interstitial lung disease (ILD). METHODS: Patients in the Genetics Versus Environment in Scleroderma Outcome Study cohort who had ILD (verified by imaging) and available FVC% at enrollment, plus 12 to 18 months thereafter, were examined. All patients had a disease duration of 5 years or less at enrollment. The annualized percentage change in FVC% at 1 year follow-up was the outcome variable. Anti-Scl-70 antibodies were determined by passive immunodiffusion (ID) against calf thymus extract, chemiluminescent immunoassay (CIA), and line blot immunoassay (LIA). RESULTS: Ninety-one patients with a mean disease duration of 2.36 years were included. Anti-Scl-70 antibodies by ID predicted a faster rate of FVC% decline (b = -0.06, P = 0.04). None of the other clinical or serological variables significantly predicted ILD progression. Interestingly, anti-Scl-70 antibodies as determined by CIA and LIA were not significant predictors of FVC decline (P = 0.26 and 0.64, respectively). The observed level of agreement between ID and LIA was moderate (κ = 0.568), whereas it was good between ID and CIA (κ = 0.66). CONCLUSION: Anti-Scl-70 antibodies determined by ID predicted faster FVC decline in patients with SSc-related ILD. Notably, both CIA and LIA for the same antibody did not predict rate of FVC decline at their current cutoffs of positivity. The discrepancy observed between anti-Scl-70 antibody assays can have relevant implications for clinical care and trial enrichment strategies in SSc-ILD.

6.
Chest ; 159(4): e225-e230, 2021 04.
Article in English | MEDLINE | ID: mdl-34022023

ABSTRACT

CLINICAL PRESENTATION: A 52-year-old man presented with hemoptysis of 2 weeks' duration. He had been experiencing hoarseness, right-sided pleuritic chest pain, subjective fevers, chills, night sweats, and 10 pounds weight loss for the previous 2 months. He additionally reported severe frontal headaches, nasal congestion, and intermittent epistaxis, which had been present for a year before his current presentation. He had worked in construction and denied tobacco or illicit drug use.


Subject(s)
Epistaxis/etiology , Granulomatosis with Polyangiitis/complications , Hemoptysis/etiology , Hoarseness/etiology , Pneumonia, Bacterial/complications , Pseudomonas Infections/complications , Weight Loss , Biopsy , Bronchoscopy , Diagnosis, Differential , Epistaxis/diagnosis , Granulomatosis with Polyangiitis/diagnosis , Hemoptysis/diagnosis , Hoarseness/diagnosis , Humans , Male , Middle Aged , Pneumonia, Bacterial/diagnosis , Pneumonia, Bacterial/microbiology , Pseudomonas Infections/diagnosis , Pseudomonas Infections/microbiology , Pseudomonas aeruginosa/isolation & purification , Tomography, X-Ray Computed
7.
Respir Med ; 181: 106379, 2021 05.
Article in English | MEDLINE | ID: mdl-33845325

ABSTRACT

BACKGROUND: Awake prone positioning has been recommended as an adjunctive measure in spontaneously breathing patients with hypoxemic respiratory failure during the COVID-19 pandemic. It remains uncertain as to how long this should be implemented, what variables to follow and who would be the ideal candidates for this adjunctive therapy. METHODS: A retrospective chart review of patients admitted from April to August 2020 within our institution with multifocal pneumonia and hypoxemic respiratory failure secondary to COVID-19 who underwent awake-proning for at least 3 hours was conducted. RESULTS: Improvement in respiratory parameters including ROX (SpO2/Fio2/ Respiratory Rate) indices and inflammatory markers within 4 days of institution of awake proning predicted a higher chance for success of this strategy in preventing need for mechanical ventilation. Moreover, benefits of awake proning were limited to patients with mild to moderate ARDS. CONCLUSIONS: Awake prone positioning can be safely performed with improvement in oxygenation. However, its institution may be beneficial only in patients with mild to moderate ARDS and requires careful evaluation of respiratory parameters and serum inflammatory markers to avoid a delay in endotracheal intubation and consequent increase in mortality rates.


Subject(s)
COVID-19/complications , Patient Positioning/methods , Prone Position/physiology , Respiratory Insufficiency/therapy , Adult , Aged , Biomarkers/blood , Female , Humans , Inflammation Mediators/blood , Intubation, Intratracheal , Male , Middle Aged , Respiration, Artificial , Respiratory Insufficiency/diagnosis , Respiratory Insufficiency/etiology , Respiratory Insufficiency/physiopathology , Respiratory Rate , Retrospective Studies , Severity of Illness Index , Treatment Outcome
8.
Ann Thorac Med ; 16(1): 102-109, 2021.
Article in English | MEDLINE | ID: mdl-33680130

ABSTRACT

INTRODUCTION: Electromagnetic navigational bronchoscopy (ENB) is an excellent tool to diagnose peripheral pulmonary nodules, especially in the setting of emphysema and pulmonary fibrosis. However, most of these procedures are done by interventional pulmonologists and academic tertiary centers under general anesthesia. Studies evaluating the diagnostic utility of this tool in safety-net community hospitals by pulmonologists not formally trained in this technology are lacking. The objective was to evaluate the diagnostic yield of ENB done in such a setting and its associated complications. METHODS: Retrospective chart review of consecutive ENB procedures over 5 years from 2014, since its inception in our institution-a safety-net community based hospital was performed. Multiple variables were analyzed to assess their impact on diagnostic yields. RESULTS: After exclusion criteria were applied, 72 patients with 76 procedures were eventually included within our study, with an overall 1-year diagnostic yield of 80.2%. Sensitivity for malignancy was 73% and negative predictive value of 65%. Primary lung cancer was the most common diagnosis obtained, followed by tuberculosis (TB). The overall complication rates were low, with only 1 patient (1.3%) requiring hospitalization due to pneumothorax needing tube thoracostomy. No deaths or respiratory failures were noted within the cohort. The only significant variable affecting diagnostic yield was forced expiratory volume in 1 s. The presence of emphysema did not affect diagnostic yield. CONCLUSIONS: ENB is safe and feasible with a high diagnostic success rate even when performed by pulmonologists not formally trained in interventional pulmonology in low resource settings under moderate sedation.

9.
Clin Respir J ; 15(6): 670-675, 2021 Jun.
Article in English | MEDLINE | ID: mdl-33608994

ABSTRACT

INTRODUCTION: The safety of bronchoscopy in obese patients and those with obstructive sleep apnea (OSA) is unclear. Our objective was to evaluate the incidence of complications during bronchoscopy under moderate sedation in obese patients and to assess the impact of OSA, body mass index (BMI), and duration of the procedure. METHODS: We performed a retrospective study in adult patients undergoing bronchoscopy from January 2010 to August 2019. All patients with BMI > 30 kg/m2 were included. Logistic regression analyses were used to identify the factors associated with all-complications and respiratory complications. RESULTS: A total of 345 obese patients were identified. The average BMI in our cohort was 35.3 ± 5.1 kg/m2 . During the pre-procedure risk assessment, 165 (47.8%) patients were labelled as "suspected OSA." The most common doses of sedation given during the bronchoscopies were fentanyl 50 mcg (34.5%) and midazolam 3 mg (33.6%). The incidence of major complications was 0.6% and minor complications were 41.2%. Minor respiratory (22.9%) and cardiac (26.4%) complications were common. No deaths occurred due to bronchoscopy. Factors that were associated with increased respiratory complications were female gender, suspected OSA, and bronchoscopy duration 20-30 minutes and bronchoscopy duration greater than 1 hour. CONCLUSION: Bronchoscopy under moderate sedation performed in obese patients is safe; however, increased risk may exist with females, increased procedure time, and suspected OSA.


Subject(s)
Bronchoscopy , Sleep Apnea, Obstructive , Adult , Body Mass Index , Female , Humans , Incidence , Obesity , Retrospective Studies
10.
Am J Med ; 134(5): 688-690, 2021 05.
Article in English | MEDLINE | ID: mdl-33316254

ABSTRACT

BACKGROUND: The association between coronavirus disease 2019 (COVID-19) and hypercoagulability has been extensively described, and pulmonary embolism is a recognized complication of COVID-19. Currently, the need for computed tomography pulmonary angiogram (CTPA) relies on the Wells score and serum D-dimer levels. However, because COVID-19 patients have a different thrombotic and inflammatory milieu, the usefulness of the Wells score deserves further exploration for this patient population. We aimed to explore the ability of the Wells score to predict pulmonary embolism in patients with COVID-19. METHODS: In this retrospective study, patients found to have a CTPA and a COVID-19 diagnosis during the same admission were selected for analysis. Age and sex, CTPA results, and associated D-dimer levels were entered in a database. The Wells score sensitivity and specificity were calculated at different values, and the area under the curve of the receiver operating characteristic curve measured. RESULTS: Of 459 patients with COVID-19, 64 had a CTPA and 12 (19%) had evidence of pulmonary embolism. Previous or current evidence of deep vein thrombosis, a Wells score above 4 points, and serum D-dimer levels 5 times above age-adjusted upper normal values were associated with pulmonary embolism. However, only 33% of patients with pulmonary embolism had a Wells score of 4 points or higher. The area under the curve of the receiver operating characteristic showed non-discriminating values (0.54) CONCLUSIONS: Although a Wells score of 4 or more points predicted pulmonary embolism in our cohort, the outcome can be present even with lower scores.


Subject(s)
COVID-19 , Computed Tomography Angiography/methods , Fibrin Fibrinogen Degradation Products/analysis , Pulmonary Embolism/diagnosis , COVID-19/blood , COVID-19/complications , COVID-19/diagnosis , COVID-19/epidemiology , Female , Humans , Male , Middle Aged , Predictive Value of Tests , Prognosis , Pulmonary Embolism/blood , Pulmonary Embolism/epidemiology , Pulmonary Embolism/etiology , ROC Curve , Research Design/standards , Retrospective Studies , SARS-CoV-2 , Sensitivity and Specificity , Severity of Illness Index , Thrombophilia/diagnosis , Thrombophilia/etiology , United States/epidemiology
12.
Respir Med ; 173: 106153, 2020 11.
Article in English | MEDLINE | ID: mdl-33017782

ABSTRACT

Since March 2019, E-cigarette or Vaping product associated lung injury (EVALI) has become an ongoing epidemic with more 2600 cases reported in the span of a few months in the United States. EVALI is defined as acute lung injury that develops secondary to the use of e-cigarettes or vaping products within the previous 90 days after exlusion of other possible inciting factors. Vitamin E acetate is believed to play a significant role in its pathogenesis. Treatment involves use of corticosteroids and further avoidance of these products. We describe a case series of 8 patients with EVALI, their clinical course and outcomes. All patients showed an excellent response to corticosteroids. In our experience, prognosis of EVALI is excellent, with complete resolution of symptoms in patients who followed up at 8 weeks.


Subject(s)
Acute Lung Injury/drug therapy , Acute Lung Injury/etiology , Adrenal Cortex Hormones/therapeutic use , E-Cigarette Vapor/adverse effects , Lung Injury/diagnostic imaging , Lung Injury/etiology , Vaping/adverse effects , Acute Lung Injury/diagnostic imaging , Adult , Female , Follow-Up Studies , Humans , Lung Injury/drug therapy , Male , Radiography, Thoracic , Tomography, X-Ray Computed , Treatment Outcome , Vitamin E/adverse effects , Young Adult
13.
Chest ; 158(3): e103-e106, 2020 09.
Article in English | MEDLINE | ID: mdl-32892884

ABSTRACT

CASE PRESENTATION: A 35-year-old woman with no known medical history presented to the ED with complaints of progressive dyspnea for several months. The patient also reported episodic cough with yellow to green sputum production. She denied fever, chills, weight loss, or hemoptysis. She also denied any history of previous lung diseases in her family. She denied any history of tobacco or recreational drug use or any exposures. She was originally from El Salvador and immigrated to the United States approximately 3 years earlier. She was evaluated in El Salvador at age 15 for "lung issues" but had never received a formal diagnosis.


Subject(s)
Calcinosis/diagnosis , Genetic Diseases, Inborn/diagnosis , Lung Diseases/diagnosis , Adult , Biopsy , Cough/diagnosis , Diagnosis, Differential , Diagnostic Imaging , Disease Progression , Dyspnea/diagnosis , Female , Humans
15.
Am J Med ; 133(6): 657-663, 2020 06.
Article in English | MEDLINE | ID: mdl-32179055

ABSTRACT

Since its introduction in the US market in 2007, the use of electronic nicotine delivery systems, colloquially referred to as e-cigarettes or "vaping" products, has increased substantially, particularly among high school children and young men. With the legalization of marijuana within multiple states in the United States and thus, coincident change in the public perception of its risk, the availability of multiple tetrahydrocannabinol (the psychoactive agent in marijuana)- and cannabidiol (a nonpsychogenic agent in marijuana)- containing vaping products has also increased tremendously. Since March 2019, there has been an ongoing epidemic of acute lung injury secondary to the use of e-cigarettes, with over 2600 cases and 60 deaths reported all over the United States; the term e-cigarette- or vaping product-associated lung injury is used. E-cigarette- or vaping product-associated lung injury is defined by the 1) presence of pulmonary infiltrates in imaging; 2) use of electronic nicotine delivery systems within the previous 90 days; and 3) absence of other possible causes such as infection, cardiac, neoplastic, or rheumatologic causes. A significant proportion of patients hospitalized with e-cigarette- or vaping product-associated lung injury have required admission in the intensive care unit, with mechanical ventilation needed in up to one-third of patients. Corticosteroids, supportive care, and further avoidance of vaping products remain the cornerstone of treatment. Although generally associated with an excellent prognosis, older patients and patients with underlying cardiac and pulmonary conditions are at risk for higher mortality and morbidity. This review article aims to describe e-cigarette- or vaping product-associated lung injury, its pathogenesis, clinical and radiological manifestations, and management.


Subject(s)
Lung Injury/etiology , Vaping/adverse effects , Electronic Nicotine Delivery Systems , Humans , Marijuana Use/adverse effects
16.
Chest ; 157(1): 119-141, 2020 01.
Article in English | MEDLINE | ID: mdl-31356811

ABSTRACT

Areas of diminished lung density are frequently identified both on routine chest radiographs and chest CT examinations. Colloquially referred to as hyperlucent foci of lung, a broad range of underlying pathophysiologic mechanisms and differential diagnoses account for these changes. Despite this, the spectrum of etiologies can be categorized into underlying parenchymal, airway, and vascular-related entities. The purpose of this review is to provide a practical diagnostic algorithmic approach to pulmonary hyperlucencies incorporating clinical history and characteristic imaging patterns to narrow the differential.


Subject(s)
Lung Diseases/diagnostic imaging , Tomography, X-Ray Computed , Algorithms , Artifacts , Diagnosis, Differential , Humans , Lung Diseases/physiopathology
19.
Respir Med ; 155: 86-96, 2019 08.
Article in English | MEDLINE | ID: mdl-31326738

ABSTRACT

Developmental lung anomalies represent a heterogeneous group of diverse, yet related abnormalities that involve the lung parenchyma, pulmonary vasculature or a combination of both-which usually present prenatally and in early childhood. However, a substantial number of cases go unnoticed during childhood and present either incidentally or with recurrent respiratory infections progressing into adulthood. Defective development of the tracheobronchial tree and the pulmonary vasculature are proposed to cause these developmental anomalies. Encountering these lung anomalies in adults is a diagnostic challenge given their rarity and they are often mistaken as other serious pathological conditions, resulting in unnecessary diagnostic tests and procedures. The developmental lung anomalies in adults can be broadly divided into three categories: bronchopulmonary anomalies encompassing congenital bronchial atresia, bronchogenic cysts, congenital lobar emphysema and congenital pulmonary airway malformations. Vascular anomalies include pulmonary agenesis-aplasia- hypoplasia complex, unilateral absence of the pulmonary artery, pulmonary artery sling, partial anomalous pulmonary venous return, pulmonary venous varix and pulmonary arteriovenous malformations. Finally combined lung parenchymal-vascular anomalies of the lung involve hypogenetic lung (scimitar) syndrome and bronchopulmonary sequestration. This article discusses the spectrum of these developmental anomalies of the lung, their etiopathogenesis, clinical and radiographic presentations in adults and management in brief.


Subject(s)
Lung/abnormalities , Abnormalities, Multiple , Adult , Bronchogenic Cyst , Bronchopulmonary Sequestration , Child , Humans , Lung/diagnostic imaging , Lung Diseases , Pulmonary Artery/abnormalities , Pulmonary Emphysema/congenital
20.
Chest ; 155(2): e51-e54, 2019 02.
Article in English | MEDLINE | ID: mdl-30732703

ABSTRACT

CASE PRESENTATION: A 45-year-old woman presented for evaluation for 3 months of coughing and dyspnea. A recent chest CT scan done for workup of her symptoms revealed a 2-cm right-sided pulmonary nodule. She had a medical history of Sjögren syndrome, hypertension, and obesity. She also noted a weight loss of 30 lb over the last 3 years. She denied smoking, alcohol consumption, illicit drug use, or occupational exposures. A chest radiograph done 3 years prior did not reveal any pulmonary nodules. She had no personal or family history of arteriovenous malformations, hamartomas, or any malignancies and had been up to date with her breast cancer screening. She was treated with courses of hydroxychloroquine and mycophenolate mofetil for her Sjögren syndrome and did not have a history of opportunistic pulmonary infections. She denied any recent travel or exposure to TB.


Subject(s)
Amyloidosis/diagnostic imaging , Amyloidosis/pathology , Lymphoma, B-Cell, Marginal Zone/diagnostic imaging , Lymphoma, B-Cell, Marginal Zone/pathology , Multiple Pulmonary Nodules/complications , Sjogren's Syndrome/complications , Amyloidosis/therapy , Female , Humans , Lymphoma, B-Cell, Marginal Zone/therapy , Middle Aged , Multiple Pulmonary Nodules/diagnostic imaging , Sjogren's Syndrome/diagnostic imaging , Tomography, X-Ray Computed
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