The unpredictability of labile blood pressure: Afferent baroreflex failure in a critical patient with multiple thyroid surgeries and COVID-19 infection.

The carotid sinus-arterial baroreflex is essential in maintaining blood pressure (BP) regulation. Afferent baroreflex failure (ABF) can present with labile changes in BP within seconds and can be secondary to neck surgery or radiation. We present here the first case, to our knowledge, of ABF precipitated by thyroidectomy, in a patient with active COVID-19 pneumonia, causing difficult control of severely labile BP in a critical care unit. Contributing factors included her critical illness state with upregulation of IL-6 leading to pituitary-adrenal axis alteration, her thyroidectomy further exacerbating autonomic dysfunction, as well as downregulation of ACE2 via COVID-19 infection. Management was achieved with a combination of midodrine and clonidine catered to specific BP thresholds. Additional research with a multidisciplinary approach is warranted to fully optimize the treatment of ABF in patients with neck surgery and or inflammatory conditions such as COVID-19.

Crazy vaping and crazy-paving, a case of E-Cigarette/Vaping-Associated Lung Injury (EVALI) with chest CT showing crazy-paving pattern.

E-cigarettes are devices that generate an aerosol by heating a fluid containing multiple chemicals, such as nicotine, additives, and flavorings. They were developed to aid in smoking cessation and were promoted as socially acceptable, healthier, cheaper than conventional cigarettes. Multiple lung disorders related to e-cigarette use are reported, and they range from mild cases of pneumonitis to life-threatening lung disorders that may require intubation and mechanical ventilation. Most of the complications are due to the generation of various unknown and potentially harmful chemicals within the aerosol generated in the e-cigarette. These disorders are known collectively as e-cigarette/Vaping-associated lung injury (EVALI). E-cigarettes are marketed as safer alternatives to traditional cigarettes, with the highest rates of use are noted in young smokers. Given the significant prevalence of e-cigarettes use and their pulmonary complications, EVALI should be considered a potential etiology in the broad differential diagnosis of patients with pulmonary disease and a history of vaping. Herein, we present a case of cryptogenic organizing pneumonia with a chest C.T. showing a crazy-paving pattern in a patient with a history of vaping.