37-Year-Old Tracheostomized Woman With Overdistended Tracheostomy Cuff and Difficulty Ventilating.

CASE PRESENTATION: A 37-year-old woman with a medical history of myasthenia gravis resulting in progressive respiratory failure requiring continuous mechanical ventilation via tracheostomy, as well as multiple cardiac arrests leading to severe anoxic brain injury, was brought to the hospital from a nursing home because of difficulties with ventilation and oxygenation. On presentation to the ED, the patient was found to be agitated and tachypneic on a ventilator, generating low tidal volumes despite elevated peak airway pressures. Before the current presentation, the patient had been mechanically ventilated at a long-term acute care facility for the past 5 years. More recently, staff has noted intermittent loss of tidal volumes, temporarily responding to overinflation of tracheostomy cuff. Additionally, the tracheostomy tube was exchanged for an extra-long tracheostomy tube to improve tidal volumes; however, the problem persisted, prompting the current presentation.

A Rare but Life-Threatening Case of Fournier's Gangrene Caused by Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitor, Empagliflozin.

Fournier's gangrene (FG) is a rare but severe infection in the soft tissue, leading to necrosis in the perineum, perianal and genitourinary area. This infection can spread rapidly in the body and lead to multi-organ failure, septic shock, and death. This life-threatening infection is usually caused by polymicrobial agents like Group A - Beta Hemolytic Streptococcus- Streptococcus pyogenes, Staphylococcus aureus, Escherichia coli, Klebsiella pneumonia, Proteus, and anaerobes like Bacteroides and Clostridium perfringes. Risk factors related to the development of FG are obesity, uncontrolled diabetes, lack of education, poor personal hygiene, especially in the genital region, history of fungal infection, recurrent urinary tract infection, smoking, immunosuppression, and medication. In 2018, a safety warning was issued by The U.S. Food and Drug Administration (FDA) on sodium-glucose cotransporter-2 (SGLT2) inhibitors, causing a rare but serious adverse outcome of FG in patients with type 2 diabetes mellitus. It is established that the increased urinary glucose concentration caused by SGLT-2 inhibitors creates a suitable environment for the growth of the infection in the urinary and genital area, leading to the development of FG. Here we present a case of life-threatening FG in an obese female with a past medical history of type 2 diabetes mellitus with recurrent history of genital yeast infection four months after starting an SGLT2 inhibitor, empagliflozin. This study aims to understand the relationship between the FG and SGLT-2 inhibitor, overall the benefits of SGLT2 inhibitors outweighs the risk manyfold, therefore, raising awareness among clinician to be vigilant, keep a high index of suspicion and focus on the safe use of SGLT2 inhibitors, especially before and after prescribing SGLT-2 inhibitor with a close follow-up to prevent its serious and life-threatening emergency like Fournier's gangrene and necrotizing fasciitis.

Endobronchial Foreign Bodies Presenting as Intermittent Chest Pain and Productive Cough.

A 51-year-old male presented with intermittent chest pain for one month and productive cough with yellow sputum for seven days. He had a history of chronic kidney disease stage G3, depression, and polysubstance abuse. His chest X-ray revealed mild hazy opacity in the right lower lobe, followed by a chest computed tomography without contrast that indicated multiple nodular opacities in the left mainstem bronchus with clear lungs. The patient underwent flexible bronchoscopy where the left mainstem bronchus was found to be completely occluded by three clear plastic bags, about 1 x 0.5 cm in size containing whitish content consistent with the appearance of crack cocaine. A high index of suspicion is crucial in patients with suspected foreign body aspiration as prompt extraction of foreign bodies may prevent complications.

A Rare Case of Empyema Complicated With Bronchopleural Fistula Secondary to Mucormycosis in a Young Immunocompromised Diabetic Patient With COVID-19.

Mucormycosis is an opportunistic fungal infection caused by the zygomycetes Mucor and Rhizopus. Most documented conditions and risk factors that predispose to mucormycosis are uncontrolled diabetes mellitus (DM), with or without ketoacidosis, hematological malignancies (HM), transplantation, immunosuppression, and chronic sinusitis. Pulmonary empyema secondary to Mucor in coronavirus disease 2019 (COVID-19)-infected patients is rarely documented. Here we present an extremely rare case of pulmonary empyema secondary to Mucor infection complicated by bronchocutaneous fistula in a human immunodeficiency virus (HIV)-infected patient in the setting of acute COVID-19 infection.

A Case of Bilateral Hemorrhagic Pleural Effusion Due to Dual Antiplatelet Therapy in a Dialysis Patient.

Etiologies of hemorrhagic pleural effusions (hemithoraces) are multifactorial. They can be traumatic, non-traumatic, or idiopathic in nature. In this report, we present a rare case of a 64-year-old male with end-stage renal disease (ESRD) on chronic hemodialysis and dual antiplatelet therapy (DAPT), due to a recent history of coronary arterial stent placement, who presented with progressive shortness of breath for one month. The CT of the chest revealed bilateral large pleural effusions (left > right) with a complete collapse of the left lung and partial collapse of the right lung. Ultrasound-guided left-sided thoracentesis revealed hemorrhagic pleural effusions. After the discontinuation of DAPT, drainage from the right-sided pleural effusion via a pigtail catheter showed continued drainage of pleural fluid without hemorrhage. The effusion on the left side was also noted to have resolved on the repeat chest X-ray. Prompt recognition of this rare cause of any hemorrhagic pleural effusion is essential for patients on dialysis to avoid complications. This report focuses on the possible etiology and potential complications of a hemorrhagic pleural effusion, followed by a brief discussion on the rare but significant association involving the incidence of a hemorrhagic pleural effusion in a dialysis patient receiving DAPT.

Cocaine Hurts Your Kidneys Too: A Rare Case of Acute Interstitial Nephritis Caused by Cocaine Abuse.

Cocaine is a powerfully addictive recreational drug that is extracted from the leaves of the Erythroxylon coca plant native to Central and South America. It is a widely abused substance, despite being banned since the early 19th century due to fatalities. Cocaine may result in acute kidney injury (AKI) by different mechanisms, but acute interstitial nephritis (AIN) is scarcely recognized as the cause of acute kidney injury (AKI). Here, we present a case of AKI from both AIN and acute tubular necrosis (ATN) following cocaine insufflation. The purpose of this article is to review the rare but significant association of AIN associated with cocaine use. The nature of the treatment of cocaine-related kidney disease may differ from other causes of acute kidney insult. Prompt recognition of the underlying cause of renal dysfunction is vital for this group of patients to prevent the rapid deterioration of renal function.

Pantoea agglomerans: An Elusive Contributor to Chronic Obstructive Pulmonary Disease Exacerbation.

The ubiquitously present gram-negative bacteria Pantoea agglomerans is not a commonly known human pathogen. Recently, increasing recognition of the species as a human pathogen has led to controversy as limited documented cases of P. agglomerans bacteremia and infections have been reported in the literature, with most cases reported among immunocompromised patients or the pediatric population. Here, we present the case of a 54-year-old female with P. agglomerans and Enterococcus faecium bacteremia along with chronic obstructive pulmonary disease.