Identifying asymptomatic healthcare workers with COVID-19 in a community hospital: an institution's experience.

The outbreak related to SARS-CoV-2 or COVID-19 has been classified as a pandemic. Many healthcare institutions enacted policies to limit the spread within their facility. As hospitals begin to return to normal particularly with elective procedures, a common concern is how an organization should react in the event that healthcare workers test positive for COVID-19. When our organization had a cluster of positive inpatient healthcare workers, we elected to test all direct patient care healthcare workers. Through this process we learned two valuable lessons that have redefined our practice: 1) the recognition that aggressive contact tracing provides greater yield than testing everyone and 2) organizations must implement effective social distancing both within each department and how departments interact with each other to limit the scope of contract tracing.

Vitamin A and Hydrochlorothiazide Causing Severe Hypercalcemia in a Patient With Primary Hyperparathyroidism.

OBJECTIVE: To report a case of severe hypercalcemia, exacerbated by vitamin A supplementation and hydrochlorothiazide, in a patient with primary hyperparathyroidism. METHODS: Clinical and laboratory findings are presented along with response to therapy. RESULTS: A 68-year-old white female presented to the emergency department complaining of nausea, vomiting, and altered mental status. Laboratory findings revealed calcium 15.8 mg/dL (8.4-10.2), albumin 4.1 g/dL (3.8-4.8), and parathyroid hormone 62 pg/mL (14-64). Serum calcium improved after intravenous hydration with normal saline. Prior to this hospitalization, over-the-counter medications were significant for calcium (600 mg daily), vitamin A (11 000 IU daily), and vitamin D (800 IU daily).The patient's prescription medications were significant for hydrochlorothiazide (12.5 mg daily). Twenty-four-hour urine calcium was subsequently found to be 146 mg (35-250). Myeloma, lymphoma, and sarcoidosis were ruled out as the etiology for hypercalcemia. The diagnosis of primary hyperparathyroidism was confirmed. She was treated surgically for primary hyperparathyroidism. The right and left superior parathyroid showed hypercellular parathyroid on pathology. The patient was normocalcemic after surgery. CONCLUSION: Previous reports suggest that very high doses of vitamin A is required to cause hypercalcemia. This case suggests that in a setting of primary hyperparathyroidism and hydrochlorothiazide therapy, vitamin A may contribute to the development of severe hypercalcemia in patients who are on calcium and vitamin D supplements. Given their biologic effects, public awareness needs to be created regarding the injudicious use of vitamins.

Central Venous Line Insertion Revealing Partial Anomalous Pulmonary Venous Return: Diagnosis and Management.

Central venous line malposition is a well-known complication of line insertion. Rarely, it can be mal-positioned in an anomalous pulmonary vein. We present an unusual case of a 56-year-old woman that was found to have partial anomalous pulmonary venous return on central venous line insertion. In this report, we describe a systematic approach to diagnosis and management of this unusual situation.

Amiodarone Induced Interstitial and Organizing Pneumonia Reversed with Steroids.

Amiodarone is a widely used antiarrhythmic agent for supraventricular and ventricular tachyarrhythmias. It is known to cause pulmonary toxicity, which can manifest in a variety of presentations, ranging from asymptomatic to fatal. We present a case of chronic interstitial pneumonia with organizing pneumonia induced by amiodarone that was successfully treated with drug cessation and use of corticosteroids. The patient experienced complete resolution of symptoms and full recovery of lung function after the course of steroids.

Cerebral fat embolism: Use of MR spectroscopy for accurate diagnosis.

Cerebral fat embolism (CFE) is an uncommon but serious complication following orthopedic procedures. It usually presents with altered mental status, and can be a part of fat embolism syndrome (FES) if associated with cutaneous and respiratory manifestations. Because of the presence of other common factors affecting the mental status, particularly in the postoperative period, the diagnosis of CFE can be challenging. Magnetic resonance imaging (MRI) of brain typically shows multiple lesions distributed predominantly in the subcortical region, which appear as hyperintense lesions on T2 and diffusion weighted images. Although the location offers a clue, the MRI findings are not specific for CFE. Watershed infarcts, hypoxic encephalopathy, disseminated infections, demyelinating disorders, diffuse axonal injury can also show similar changes on MRI of brain. The presence of fat in these hyperintense lesions, identified by MR spectroscopy as raised lipid peaks will help in accurate diagnosis of CFE. Normal brain tissue or conditions producing similar MRI changes will not show any lipid peak on MR spectroscopy. We present a case of CFE initially misdiagnosed as brain stem stroke based on clinical presentation and cranial computed tomography (CT) scan, and later, MR spectroscopy elucidated the accurate diagnosis.

A 62-year-old women with persistent severe asthma, skin rash, and eosinophilia.

A 62-year-old white woman was admitted with shortness of breath, wheezing, and cough. While in the hospital a generalized pruritic skin rash developed on her trunk and upper and lower extremities. She did not have any fevers, chills, or night sweats. The patient was known to have chronic, difficult-to-control asthma despite being compliant with a treatment regimen consisting of inhaled albuterol, high-dose inhaled steroids, salmeterol, and montelukast. Her medical history was significant for hypertension and gout. She had no family history of asthma. The patient was a life-long nonsmoker and did not drink alcohol. During this hospitalization, she was started on prednisone 40 mg/d po in addition to her home medications.

A pneumonia that will not go away.

Pneumonia is a common diagnosis with significant morbidity and mortality. However, pneumonia is a commonly overdiagnosed entity, with many similar-appearing conditions. A young, previously healthy woman was misdiagnosed with a variety of respiratory tract infections over the course of five months before establishing the correct diagnosis - chronic eosinophilic pneumonia.

Tracheobronchopathia osteochondroplastica.

A 71-year-old patient presented for cough, generalized body aches, and fever. Pulmonary work-up included computed tomography scan of the chest, which showed an irregular anterior tracheal wall. Flexible bronchoscopy showed the presence of multiple sessile nodules in the anterior and lateral walls of the trachea and mainstem bronchi, sparing the posterior membranous wall and the airways distal to the mainstem bronchi. Bronchoalveolar lavage grew Mycobacterium avium-intracellulare and the patient was started on appropriate treatment. Biopsy of the lesions showed no malignancy or inflammation. An 18-month follow-up confirmed stability of these lesions pathognomonic of tracheobronchopathia osteochondroplastica, a rare benign condition of the large airways. Fewer than 400 patients with this disorder have been described to date.