Intralobar pulmonary sequestration presenting as recurrent left lower lobe pneumonia.

This case discusses the diagnosis and management of pulmonary sequestration. Typically discovered incidentally on imaging, it can be a cause of recurrent pulmonary infections causing severe morbidity to the patient. Surgical management is indicated when found to prevent the complications of recurrent infections, including pulmonary necrosis, abscess, or fistula formation.

Sarcoidosis and burn pit exposure in military deployers to Iraq, Afghanistan, and Southwest Asia.

BACKGROUND AND AIM: Inhalational exposures have been hypothesized to play a role in the pathogenesis of sarcoidosis. Herein, we describe a cohort of US Military personnel diagnosed with sarcoidosis during or after deployment to Southwest Asia and Afghanistan, who experienced complex inhalational exposures to burn-pits and desert dust. METHODS: Consecutive military personnel at four sub-specialty clinics across the United States were screened for deployment to Southwest Asia and Afghanistan and diagnosis of sarcoidosis based on 1999 ATS/ERS/WASOG Statement on Sarcoidosis. Detailed demographic, deployment and exposure data was collected. The data combined was analyzed after de-identification and local IRB approval. RESULTS: Twenty-one patients met our case definition. Seventeen patients were male and 62% had extrapulmonary involvement, including 38% with musculoskeletal involvement.  Conclusions: Our study suggests that the sarcoidosis in military personnel to Southwest Asia can be diagnosed many years after deployment. To our knowledge, this is the first case series to describe a group of military personnel diagnosed with sarcoidosis and exposures specific to military deployment to Southwest Asia.

Tension hydrothorax in a patient with a history of pulmonary tuberculosis.

A tension hydrothorax is a massive pleural effusion that leads to hemodynamic instability. Here we present a case of tension hydrothorax secondary to poorly differentiated carcinoma. A 74-year-old male smoker presented after a one-week history of dyspnea and unintentional weight loss. Physical exam demonstrated tachycardia, tachypnea, and decreased breath sounds diffusely over the right lung. Imaging revealed a massive pleural effusion causing mass effect on the mediastinum with tension physiology. Chest tube placement revealed an exudative effusion with negative cultures and cytology. Pleural biopsy revealed atypical epithelioid cells consistent with poorly differentiated carcinoma.

A Woman With Progressive Dyspnea and Seronegative Rheumatoid Arthritis.

CASE PRESENTATION: A 66-year-old woman with a medical history of seronegative rheumatoid arthritis on long-standing methotrexate and adalimumab therapy was referred to the pulmonary clinic for abnormal chest imaging. The patient was also under evaluation by rheumatology physicians for increased fatigue, nonproductive cough, and recurrent sinus infections. At the time of the initial pulmonary visit, the patient complained of acute onset of bilateral blurry vision and subsequently was diagnosed with anterior uveitis and received ophthalmic steroids with significant improvement. The patient's biologic therapy was discontinued because of a concern for possible drug toxicity. Over the course of 4 months, the patient experienced worsening dyspnea with exertion. She was a lifelong nonsmoker and had no history of recent travel. However, on review of possible environmental exposures, patient stated using feather pillows and bedding for several decades.

Malpositioned nephrostomy tube with associated hemorrhagic pleural effusion.

Pleural effusion of extra-vascular origin has a large differential diagnosis. Ultrasonography can be utilized alongside pleural fluid analysis to determine a pleural effusion's complexity and size, thus helping aid in both diagnostic and therapeutic management. We describe the case of a 38-year-old male with a prior medical history of neurogenic bladder and nephrolithiasis with percutaneous nephrostomy tube placed one week prior to presentation. Using ultrasonography, the nephrostomy tube was determined to be positioned within the pleural cavity with a resultant hemorrhagic pleural effusion.

Hypersensitivity Pneumonitis With and Without Autoimmune Features: A Clinical Comparative Analysis.

BACKGROUND: Hypersensitivity pneumonitis (HP) is an interstitial lung disease (ILD) caused by an immunological reaction to repeated inhalational exposure to antigens. The etiology and exact immunopathology are poorly understood. Autoimmunity overlapping with HP has been described but the role of concomitant autoimmunity in the clinical course and outcome of the HP is not clearly established. In this study, we examined patients diagnosed with HP and compare them to patients with concomitant HP and autoimmunity. METHODS: Patients were retrospectively screened from a single-center ILD registry. Patients > 18 years with an established multidisciplinary diagnosis of HP were included in the study. Patients with HP without autoimmune features and patients with HP with autoimmune features (HPAF) were assessed. We compared the demographics, clinical characteristics, treatment, and outcomes between the two groups. We used a Cox proportional hazards model to compare lung transplant-free survival outcomes of patients with HPAF to those with non-HPAF HP patients. RESULTS: Of 73 patients with HP, 43 were diagnosed with HPAF. Patients with HPAF had a higher echocardiographic probability of pulmonary hypertension as compared to non-HPAF HP patients [48.8 vs 23.3%, p = 0.028, Crude odds ratio (cOR) = 3.14]. Symptomatically, those with HPAF reported a higher prevalence of arthritis as compared to non-HPAF HP (20.9 vs 3.3%, p = 0.040, cOR = 7.68). No significant differences between pulmonary function tests, oxygen requirements, mortality, and lung transplantation rates were found between the two groups. There was no statistically significant difference in transplant-free survival (p = 0.836). CONCLUSION: Patients with HPAF had a higher echocardiographic probability of pulmonary hypertension as compared to patients with non-HPAF HP. The clinical characteristics and outcomes did not differ between the two groups and concomitant autoimmunity among the HP group did not portend a poorer prognosis.

Clinical Characteristics and Outcomes of COVID-19 Acute Respiratory Distress Syndrome (ARDS) Survivors in Early Pandemic: A Single Healthcare System Retrospective Study.

INTRODUCTION:  Acute respiratory distress syndrome (ARDS) management in the intensive care unit (ICU) has attracted strong interest since the start of the COVID-19 pandemic. Our retrospective study aims to describe the outcomes and predictors of mortality of ARDS associated with COVID-19 within one university-based healthcare system. METHODS:  We identified 165 patients within our healthcare system during the months of April 2020 through July 2020, who were admitted to our medical ICUs and eligible for our study. Baseline patient characteristics, ICU and hospital course information, ICU interventions, ventilator settings, and hospital complications were collected and analyzed using descriptive statistical techniques. RESULTS:  Our cohort had an average age of 64. No significant difference in mortality was identified with male vs. female gender or BMI. Most of the patient cohort was identified as black (68.2%). The overall mortality of our cohort was 38.2%. Hyperlipidemia, coronary artery disease, and chronic obstructive pulmonary disease were all associated with higher mortality. There was a significant difference in mortality between those with higher observed ventilator plateau pressures at 24 hours and higher driving pressures at 24 hours. CONCLUSION:  COVID-19-associated ARDS is associated with significant mortality. Physicians should be aware of pre-existing conditions potentially related to worse outcomes so that they receive an appropriate level of care in a timely manner. Ventilator management should focus on maintaining low intra-thoracic pressure changes. Prospective studies are needed to guide COVID-19-associated ARDS management.

Diffuse pulmonary calcification in allergic bronchopulmonary aspergillosis.

Allergic bronchopulmonary aspergillosis (ABPA) is a condition that most often occurs in patients with asthma or cystic fibrosis. The diagnosis is usually confirmed by the combination of clinical, radiographic, and immunologic criteria as there is not individual test to establish the diagnosis. We describe the case of a 64-year-old male with a prior medical history of moderate persistent asthma who presented with worsening cough and was found to have IgE positive for Aspergillus fumigatus with findings of diffuse bilateral pulmonary calcifications on HRCT.

Prevalence and Characteristics of Hyperthyroidism Among Patients With Sarcoidosis in the United States.

OBJECTIVE: We aimed to determine the prevalence and clinical characteristics of self-reported hyperthyroidism in patients with sarcoidosis. METHODS: A national registry-based study investigating 3836 respondents to the Sarcoidosis Advanced Registry for Cures questionnaire in the period between June 2014 and August 2019 was conducted. This registry is generated from a web-based questionnaire that is self-reported by patients with sarcoidosis. We compared patients with sarcoidosis who had hyperthyroidism with those who did not. We used multivariate logistic regression analysis to study the association between hyperthyroidism and different cardiac manifestations in patients with sarcoidosis. RESULTS: Three percent of the study respondents self-reported having hyperthyroidism and were generally middle-aged Caucasian women. Compared with patients without hyperthyroidism, patients with hyperthyroidism had more sarcoidosis-related comorbidities (59% vs 43%, P = .001) and more steroid-related comorbidities (56% vs 44%, P = .01), but there was no difference in the sarcoidosis-specific treatments they received, which included corticosteroids. Patients with hyperthyroidism reported sarcoidosis involvement of the heart (26.6% vs 14.9%, P = .005), kidneys (14.9% vs 8%, P = .033) and sinuses (17.7% vs 10.2%, P = .030) more frequently. Cardiac manifestations that were more frequently reported in patients with hyperthyroidism included atrial arrhythmias (11.3% vs 6.3%, P = .046), ventricular arrhythmias (17.2% vs 7.5%, P < .001), congestive heart failure (10.4% vs 5%, P = .017), and heart block (9.4% vs 4.7%, P = .036). CONCLUSION: Hyperthyroidism is infrequent in patients with sarcoidosis but is potentially associated with different cardiac manifestations. We suggest considering routine screening for hyperthyroidism in patients with sarcoidosis, especially in those with cardiac involvement. Further studies are needed to investigate the impact of identifying and treating hyperthyroidism in patients with sarcoidosis.

Pre-Existing Psychiatric Illness Is Associated With an Increased Risk of Delirium in Patients With Acute Respiratory Distress Syndrome.

BACKGROUND: Patients with acute respiratory distress syndrome (ARDS) are highly susceptible to developing delirium for a multitude of reasons. Previous studies have linked pre-existing depression with an increased risk of postoperative delirium in patients undergoing cardiac and non-cardiac surgery. However, the evidence regarding the association between pre-existing psychiatric illnesses and delirium in ARDS patients is unknown. In this study, we aim to determine the relationship between pre-existing psychiatric illness and the risk of development of delirium amongst ARDS patients. STUDY DESIGN AND METHODS: We performed a retrospective study of a mixed group of patients admitted to the intensive care unit (ICU) between January 2016 and December 2019 with a diagnosis of ARDS per the Berlin definition. The study group was divided into 2 cohorts: subjects with delirium and subjects without delirium. Comparison between the 2 groups was conducted to examine the impact of pre-existing psychiatric illnesses including major depressive disorder (MDD), generalized anxiety disorder (GAD), bipolar disorder, schizophrenia, or post-traumatic stress disorder. Multivariable logistic regression analysis was performed adjusting for benzodiazepine use, sedatives, analgesics, sequential organ failure assessment score, and corticosteroid use to determine the association between pre-existing psychiatric disorders and delirium. RESULTS: 286 patients with ARDS were identified; 124 (43%) of whom were diagnosed with ICU delirium. In patients diagnosed with ICU delirium, 49.2% were found to have preexisting psychiatric illnesses, compared to 34.0% without any preexisting psychiatric illness (OR = 1.94, P = 0.01). In a subgroup analysis of individual psychiatric illnesses, GAD and MDD were associated with the development of delirium (OR = 1.88, P = 0.04 and OR = 1.76, P = 0.05 respectively). INTERPRETATION: ARDS patients with preexisting psychiatric illnesses, particularly GAD and MDD are associated with an increased risk of developing ICU delirium. Clinicians should be aware of the effect of psychiatric co-morbidities on developing delirium in critically ill patients.

Factors Associated With Inpatient Endoscopy Delay and its Impact on Hospital Length-of-Stay and 30-Day Readmission.

BACKGROUNDS AND AIMS: Inpatient endoscopy delay (IED) negatively impacts the delivery of high-quality care. We aimed to identify factors associated with IED and evaluate its effect on hospital length-of-stay (LOS) and readmission. METHODS: This was a retrospective analysis of all inpatient endoscopies performed between November 2017 and November 2019 at a tertiary care center. IED was defined as the number of days elapsed between anticipated versus actual procedure day. Data were extracted from the endoscopy documentation software and via electronic chart review. Multivariate logistic regressions were modeled to determine variables associated with IED and hospital readmission. RESULTS: A total of 4239 inpatients (mean age, 58.3 years; 50.3% women) underwent endoscopic procedures during the study period of which 819 patients (19.3%) experienced a delay. IED resulted in a median prolonged LOS of 2 days (interquartile range, 1-2 days). Patients with IED were less likely to have an etiology identified on endoscopy (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.63-0.86; P < .001). The 2 most common causes for delays were poor bowel preparation (n = 218; 27%) and lack of endoscopy personnel/unit availability (n = 197; 24.4%). Independent predictors of IED included: older age (OR, 1.1; 95% CI, 1.01-1.03; P = .03), female sex (OR, 1.20; 95% CI, 1.03-1.40; P = .02), use of antithrombotics (OR, 1.30; 95% CI, 1.08-1.57; P = .006), opioids (OR, 1.23; 95% CI, 1.04-1.44; P = .012), being on contact isolation (OR, 1.38; 95% CI, 1.09-1.75; P = .008), and colonoscopy (OR, 1.50; 95% CI, 1.27-1.77; P < .001). Conversely, inpatients admitted to a dedicated GI medicine service were less likely to have IED (OR, 0.79; 95% CI, 0.65-0.96; P = .02). IED was the only independent predictor of 30-day readmission (OR, 1.22; 95% CI, 1.02-1.47; P = .03). CONCLUSIONS: IED occurred frequently, unfavorably prolonged LOS, and was an independent risk factor for 30-day readmission. We provide a comprehensive analysis of actionable variables associated with IED that can be targeted to improve inpatient endoscopy delivery.

Rasmussen's aneurysm: a rare and potentially fatal cause of hemoptysis.

Rasmussen's aneurysm is a rare and fatal cause of hemoptysis secondary to infection with pulmonary tuberculosis. The most commonly involved vessels include the bronchial arteries, but rarely can involve the pulmonary artery. We report the case of a 62-year-old female from the Philippines with undiagnosed pulmonary tuberculosis who presented with massive hemoptysis. After hemodynamic stabilization, Rasmussen's aneurysm was diagnosed by computed tomography of the chest with angiography, confirmed with invasive angiography. She was treated definitively with glue embolization of the affected artery.

Euglycemic Diabetic Ketoacidosis in Pregnancy: A Case Report and Review of Current Literature.

Diabetic ketoacidosis (DKA) in pregnancy is associated with high fetal mortality rates. A small percentage of DKA occurs in the absence of high glucose levels seen in traditional DKA. Prompt recognition and management is crucial. We report a case of a 30-year-old pregnant woman with type 1 diabetes mellitus admitted with euglycemic DKA (blood glucose <200 mg/dL). Initial laboratory testing revealed a severe anion gap acidosis with pH 7.11, anion gap 23, elevated ß-hydroxybutyric acid of 9.60 mmol/L, and a blood glucose of 183 mg/dL-surprisingly low given her severe acidosis. The ketoacidosis persisted despite high doses of glucose and insulin infusions. Due to nonresolving acidosis, her hospital course was complicated by spontaneous intrauterine fetal demise. Euglycemia and severe acidosis continued to persist until delivery of fetus and placenta occurred. It was observed that the insulin sensitivity dramatically increased after delivery of fetus and placenta leading to rapid correction of ketoacidosis. This case highlights that severe ketonemia can occur despite the absence of severely elevated glucose levels. We discuss the mechanism that leads to this pathophysiologic state and summarize previously published case reports about euglycemic DKA in pregnancy.

Ten-year weight gain is associated with elevated fasting insulin levels and precedes glucose elevation.

BACKGROUND: Numerous studies have examined the relationship between endogenous insulin and weight change with mixed results. This study examined the relationship between fasting insulin levels, insulin resistance (IR), and 10-year weight change by glycaemic stage. METHODS: Using data from the US National Health and Nutrition Examination Survey 2011-2014, 3840 participants were divided into 6 groups based on fasting glucose and fasting insulin levels. Fasting insulin concentrations were dichotomized into <25th percentile (normal) and ≥25th percentile (elevated). Ten-year weight change associated with fasting insulin was assessed by glycaemic stage. RESULTS: Average weight change over a 10-year period was higher in individuals with elevated insulin levels compared to the first quartile (1.40 lbs. vs 11.12 lbs, P < .0001). Across all groups, a 1 µU increase in fasting insulin levels resulted in a 0.52-pound increase in weight (P < .0001). Similarly, an increase in HOMA-IR was associated with increase in weight (1.32 lbs per IR unit, P < .0001). Marginal increases in weight were most pronounced in the normal insulin groups compared to elevated insulin groups and diminished as glycaemic stage progressed. CONCLUSIONS: Elevated fasting insulin level was positively associated with weight gain. The impact of fasting insulin and IR on weight gain preceded hyperglycaemia and diminished as glycaemic stage progressed.