Early Detection and Assessment of Covid-19.

Background: Since the Covid-19 global pandemic emerged, developing countries have been facing multiple challenges over its diagnosis. We aimed to establish a relationship between the signs and symptoms of COVID-19 for early detection and assessment to reduce the transmission rate of SARS-Cov-2. Methods: We collected published data on the clinical features of Covid-19 retrospectively and categorized them into physical and blood biomarkers. Common features were assigned scores by the Borg scoring method with slight modifications and were incorporated into a newly-developed Hashmi-Asif Covid-19 assessment Chart. Correlations between signs and symptoms with the development of Covid-19 was assessed by Pearson correlation and Spearman Correlation coefficient (rho). Linear regression analysis was employed to assess the highest correlating features. The frequency of signs and symptoms in developing Covid-19 was assessed through Chi-square test two tailed with Cramer's V strength. Changes in signs and symptoms were incorporated into a chart that consisted of four tiers representing disease stages. Results: Data from 10,172 Covid-19 laboratory confirmed cases showed a correlation with Fever in 43.9% (P = 0.000) cases, cough 54.08% and dry mucus 25.68% equally significant (P = 0.000), Hyperemic pharyngeal mucus membrane 17.92% (P = 0.005), leukopenia 28.11% (P = 0.000), lymphopenia 64.35% (P = 0.000), thrombopenia 35.49% (P = 0.000), elevated Alanine aminotransferase 50.02% (P = 0.000), and Aspartate aminotransferase 34.49% (P = 0.000). The chart exhibited a maximum scoring of 39. Normal tier scoring was ≤ 12/39, mild state scoring was 13-22/39, and star values scoring was ≥7/15; this latter category on the chart means Covid-19 is progressing and quarantine should be adopted. Moderate stage scored 23-33 and severe scored 34-39 in the chart. Conclusion: The Hashmi-Asif Covid-19 Chart is significant in assessing subclinical and clinical stages of Covid-19 to reduce the transmission rate.

Risk Factors for Liver Cirrhosis-Related Readmissions in the Largest Ethnic Minority in United States.

BACKGROUND: There are very limited data available on 30-day readmissions for ethnic minority patients with cirrhosis. The aim of the study was to identify the risk factors for 30-day readmission in ethnic minority patients admitted for cirrhosis. METHODS: We did a retrospective review of 1,373 electronic medical records of patients with cirrhosis admitted from 2009 to 2011. Several parameters including alcohol use history, discharge location and cirrhosis severity scores - model for end-stage liver disease (MELD) score and Child-Pugh-Turcotte (CPT) at first admission were assessed. Statistical analysis was done using Chi-square test and t-test for categorical and continuous variables, respectively. RESULTS: There were 79 patients in the readmission group (63% male, 54% Hispanics and 22% African Americans) and 104 in the no readmission group (62% male, 58% Hispanics and 24% African Americans). History of alcohol use within a month prior to admission (55% vs. 33%, P = 0.002), platelet count at discharge (89,000 vs. 124,000, P = 0.003), and discharge with more than seven medications per day (7.3 vs. 5.2, P = 0.005) were identified as risk factors for readmissions by multivariate analysis. CONCLUSION: Platelet count, active alcohol use and more than seven medications at discharge are predictors of readmission. These parameters can guide future interventions to reduce readmission rate and health care costs related to cirrhosis readmissions.

An Unusual Triad of Hemophagocytic Syndrome, Lymphoma and Tuberculosis in a Non-HIV Patient.

BACKGROUND Lymphoma complicated with hemophagocytic syndrome and tuberculosis has been rarely reported. The clinical and radiological presentation of these potentially fatal conditions can be easily confused and there is a potential for misdiagnosis. CASE REPORT We present a 58-year-old Hispanic female who was admitted to the hospital with dizziness and fever. Her initial admission diagnosis was severe sepsis secondary to community acquired pneumonia. She was started on intravenous antibiotics. Due to mediastinal lymphadenopathy, lymphoma was considered as a differential diagnosis for which she underwent bronchoscopy and endobronchial ultrasound-guided sampling of her mediastinal lymph nodes. Lymph node aspirate was suggestive of lymphoma. Initial cultures were negative. Her clinical course was complicated with respiratory failure, cytopenia, and rapidly progressive cervical lymphadenopathy. The patient underwent cervical lymph node excision and bone marrow biopsy. The pathology of the lymph nodes confirmed T cell lymphoma, and bone marrow revealed hemophagocytosis. The patient was started on chemotherapy but she continued to deteriorate and died on day 20 of her hospital admission. Post-mortem results of cultures from a cervical lymph node biopsy and PCR were positive for Mycobacterium tuberculosis. CONCLUSIONS We suggest an aggressive tissue diagnosis with staining for acid-fast bacilli for early diagnosis in patients presenting with hemophagocytic syndrome secondary to lymphoma as coexisting tuberculosis is a consideration. Tuberculosis re-activation should be considered in patients from an endemic region who present with lymphoma and a deteriorating clinical condition.

Legionnaires' Disease: Clinicoradiological Comparison of Sporadic Versus Outbreak Cases.

BACKGROUND: In 2015, New York City experienced the worst outbreak of Legionnaires' disease in the history of the city. We compare patients seen during the 2015 outbreak with sporadic cases of Legionella during the past 5 years. METHODS: We conducted a retrospective chart review of 90 patients with Legionnaires' disease, including sporadic cases of Legionella infection admitted from 2010 to 2015 (n = 55) and cases admitted during the 2015 outbreak (n = 35). RESULTS: We saw no significant differences between the 2 groups regarding demographics, smoking habits, alcohol intake, underlying medical disease, or residence type. Univariate and multivariate analyses showed that patients with sporadic case of Legionella had a longer stay in the hospital and intensive care unit as well as an increased stay in mechanical ventilation. Short-term mortality, discharge disposition, and most clinical parameters did not differ significantly between the 2 groups. CONCLUSIONS: We found no specific clinicoradiological characteristics that could differentiate sporadic from epidemic cases of Legionella. Early recognition and high suspicion for Legionnaires' disease are critical to provide appropriate treatment. Cluster of cases should increase suspicion for an outbreak.

Spontaneous Regression of Endobronchial Carcinoid Tumor.

Spontaneous regression (SR) of cancer refers to partial or complete disappearance of a malignant tumor in the absence of treatment or in the presence of therapy, which is considered inadequate to exert a significant influence on the growth of neoplastic disease. SR is a very rare phenomenon in primary lung cancers. Follow-up of these patients is generally either by imaging or bronchoscopy. We present a patient with SR of an endobronchial carcinoid, followed by serial bronchoscopies and biopsy over a 24-month period.

A Missing Guide Wire After Placement of Peripherally Inserted Central Venous Catheter.

BACKGROUND Central venous catheterization is a common tool used in critically ill patients to monitor central venous pressure and administer fluids and medications such as vasopressors. Here we present a case of a missing guide wire after placement of peripherally inserted central catheter (PICC), which was incidentally picked up by bedside ultrasound in the intensive care unit.  CASE REPORT A 50-year-old Hispanic male was admitted to the intensive care unit for alcohol intoxication. He was managed for septic shock and required placement of a peripherally inserted central line in his left upper extremity for antibiotics and vasopressor administration. A bedside ultrasound performed by the intensivist to evaluate upper extremity swelling revealed a foreign body in the left arm. Percutaneous procedure by Interventional radiologist was required for retrieval of the guidewire. CONCLUSIONS Guide wire related complications are rarely reported, but are significantly associated with mortality and morbidity. The use of ultrasound guidance placement of PICC lines decreases the risk of complications, provides better optimal vein selection, and enhances success.

Perioperative Evaluation of Patients with Pulmonary Conditions Undergoing Non-Cardiothoracic Surgery.

This review describes the perioperative management of patients with suspected or established pulmonary conditions undergoing non-cardiothoracic surgery, with a focus on common pulmonary conditions such as obstructive airway disease, pulmonary hypertension, obstructive sleep apnea, and chronic hypoxic respiratory conditions. Considering that postoperative pulmonary complications are common and given the increasing number of surgical procedures and the size of the aging population, familiarity with current guidelines for preoperative risk assessment and intra- and postoperative patient management is recommended to decrease the morbidity and mortality. In particular, smoking cessation and pulmonary rehabilitation are perioperative strategies for improving patients' short- and long-term outcomes. Understanding the potential risk for pulmonary complications allows the medical team to appropriately plan the intra- and postoperative care of each patient.

Benazepril-Induced Agranulocytosis: A Case Report and Review of the Literature.

BACKGROUND: Angiotensin-converting enzyme inhibitors are widely used drugs, and in appropriately selected patients, serious side effects are infrequent. Commonly seen side effects include cough, rash, hyperkalemia, renal dysfunction, and angioedema. Historically, dose-related agranulocytosis has been associated with captopril. Benazepril, a relatively more potent angiotensin-converting enzyme inhibitor, is rarely associated with agranulocytosis. CASE REPORT: Here, we report a case of drug-induced agranulocytosis due to benazepril, with complete recovery of white blood cell count upon discontinuation of the drug. All tests for other causes of agranulocytosis were unremarkable. This report highlights a serious and rare side effect associated with benazepril. CONCLUSIONS: Benazepril is a commonly employed anti-hypertensive medication, and we report an unusual condition associated with this medication in order to increase vigilance among caregivers. In such cases, prompt recognition and discontinuation of the causative drug can make the difference between a recovery and a fatal outcome associated with drug-induced agranulocytosis.

A Woman in Her 30s With a Past History of HIV Disease Presented With Recurrent Fever, Night Sweats, and Small Bilateral Pulmonary Nodules.

A woman in her 30s presented with recurrent low-grade fever and cough (onset, 1 week). She reported occasional night sweats and weight loss of approximately 20 pounds over the past 4 months. She denied nausea, vomiting, diarrhea, or any urinary complaints. Her past medical history was significant for chronic hepatitis C and HIV infection, the latter diagnosed in 2001. She was noncompliant with highly active antiretroviral therapy for more than 4 years and had pneumocystis pneumonia 2 years prior to this presentation. She had a 10-pack per year smoking history and reported active use of cocaine and heroin. The patient denied any occupational exposures.

A Case Report of Cannabis Induced Hemoptysis.

As the principal route of marijuana use is by inhalation, potential harmful consequences on pulmonary structure and function can be anticipated. Here, we present a case of hemoptysis attributed to smoking cannabis in a 38-year-old man. The patient experienced an episode of hemoptysis and shortness of breath immediately after smoking marijuana. Chest radiograph and computed tomography (CT) scans of the chest showed bilateral diffuse ground-glass opacities. A fiber optic bronchoscopy confirmed bilateral diffuse bleeding from respiratory tract. Additional evaluation of hemoptysis indicated no infection or immunological responses. Urine toxicology was positive for cannabis. Chronic marijuana smoking causes visible and microscopic injury to the larger airways responsible for symptoms or chronic bronchitis. We review the beneficial and deleterious effects of marijuana and describe a case of significant hemoptysis attributed to smoking marijuana. In addition to other respiratory complications of marijuana use, physicians should educate their patients about this potentially lethal effect of marijuana smoking in the form of hemoptysis.

Early Recognition of Foreign Body Aspiration as the Cause of Cardiac Arrest.

Foreign body aspiration (FBA) is uncommon in the adult population but can be a life-threatening condition. Clinical manifestations vary according to the degree of airway obstruction, and, in some cases, making the correct diagnosis requires a high level of clinical suspicion combined with a detailed history and exam. Sudden cardiac arrest after FBA may occur secondary to asphyxiation. We present a 48-year-old male with no history of cardiac disease brought to the emergency department after an out-of-hospital cardiac arrest (OHCA). The patient was resuscitated after 15 minutes of cardiac arrest. He was initially managed with therapeutic hypothermia (TH). Subsequent history suggested FBA as a possible etiology of the cardiac arrest, and fiberoptic bronchoscopy demonstrated a piece of meat and bone lodged in the left main stem bronchus. The foreign body was removed with the bronchoscope and the patient clinically improved with full neurological recovery. Therapeutic hypothermia following cardiac arrest due to asphyxia has been reported to have high mortality and poor neurological outcomes. This case highlights the importance of early identification of FBA causing cardiac arrest, and we report a positive neurological outcome for postresuscitation therapeutic hypothermia following cardiac arrest due to asphyxia.

A Case Report of an Elderly Woman With Thrombocytopenia and Bilateral Lung Infiltrates: A Rare Association Between Diffuse Alveolar Hemorrhage and Idiopathic Thrombocytopenic Purpura.

Etiologies for diffuse alveolar hemorrhage are wide and range from infectious to vasculitis and malignant processes. Idiopathic thrombocytopenic purpura is an autoimmune disorder characterized by persistent thrombocytopenia, with a relatively indolent course in young patients, but a more complicated progression and high associated mortality in the older patients. Diffuse alveolar hemorrhage, complicating idiopathic thrombocytopenic purpura, is a very uncommon association, with only 2 reported cases in the literature. We present a 69-year-old healthy woman presenting with petechial rash, progressive dyspnea, and bilateral alveolar infiltrates. She was found to have idiopathic thrombocytopenic purpura associated with diffuse alveolar hemorrhage. The patient had an excellent response to high doses of pulse steroids and immunoglobulins. A high index of suspicion for noninfectious pulmonary diseases should be considered in patients with autoimmune diseases presenting with pulmonary infiltrates and hypoxia. Flexible bronchoscopy with sequential lavage is a relatively safe procedure in patients with coagulopathy and should be attempted to detect and confirm the diagnosis; absence of hemoptysis should not preclude the diagnosis.

Ciprofloxacin-Induced Thrombotic Thrombocytopenic Purpura: A Case of Successful Treatment and Review of the Literature.

A 49-year-old African American woman was admitted to our hospital with abdominal pain, nausea, vomiting, lethargy, and confusion. She was receiving ciprofloxacin for a urinary-tract infection prior to admission. Laboratory examination revealed anemia, thrombocytopenia, elevated lactate dehydrogenase, and serum creatinine. Peripheral smear showed numerous schistocytes, and the patient was diagnosed with thrombotic thrombocytopenic purpura (TTP). Ciprofloxacin was identified as the offending agent. The patient received treatment with steroids and plasmapheresis, which led to rapid clinical recovery. This is the first case to our knowledge of successfully treated ciprofloxacin-induced TTP; previously reported cases had fulminant outcomes. Quinolones are an important part of the antibiotic armamentarium, and this case can raise awareness of the association between quinolones and TTP. A high index of suspicion for detection and early and aggressive management are vitally important for a successful outcome.