Everolimus induced organizing pneumonia in a patient with tuberous sclerosis complex.

Organizing pneumonia is characterized by a distinct histologic pattern in the lung interstitium and presents clinically as hypoxemia, fever, cough, and dyspnea that is not attributable to concurrent infection. Typical etiologies of this condition include inflammatory disease, malignancy, toxic inhalation, and an array of medications including the mTOR inhibitor everolimus. In this report, we describe the case of a female with tuberous sclerosis complex on everolimus therapy for renal angiomyolipomas who presented to the hospital with persistent cough, dyspnea, and fevers and bilateral lower lobe opacities on chest X-ray despite multiple courses of antibiotic therapy. Bronchoscopy was performed with transbronchial biopsies, and results demonstrated a lymphocytic predominance and pathologic findings of intraluminal plugs composed of fibroblasts and myofibroblasts consistent with organizing pneumonia. Everolimus therapy was discontinued and patient completed a steroid course with resolution of symptoms. To our knowledge, this is the first published case of organizing pneumonia secondary to everolimus in a patient with tuberous sclerosis complex.

A case of left atrial compression secondary to angioedema.

Angioedema due to angiotensin-converting enzyme (ACE) inhibitors is an uncommon, but deadly adverse reaction with an overall incidence of 0.1%-0.2%. Rapid accumulation of interstitial fluid and vasodilation classically involves the mucus membranes of the mouth and face but has the ability to affect other areas. We describe a case of angioedema secondary to ACE inhibitor that affected the esophagus causing left atrial compression and hemodynamic compromise.

Optimization of an empiric vancomycin dosing algorithm for improved target concentration attainment in patients with thermal injury.

OBJECTIVE: Vancomycin empirical dosing studies in thermally injured patients have netted low successful target attainment and most excluded renal dysfunction, limiting applicability. In a previous study, the authors performed a retrospective analysis of 124 patients' measured pharmacokinetic parameters to calculate optimal dose and interval for intermittent infusion regimens and find predictors of clearance and total daily dose. The objective of this study was to improve the accuracy of attaining goal therapeutic targets with initial vancomycin regimens in patients with thermal injury through retrospective modeling. METHODS: In this phase 2 study, variables collected and calculated regimens in phase 1 were utilized to try and create an improved empiric vancomycin dosing algorithm in patients with thermal injury. Logistic regression was utilized to determine best predictors of dosing vancomycin every 6 and 8h. The strongest models were built as individual algorithms and tested for accuracy of target attainment. Each algorithm produced a regimen for each patient that was then tested utilizing each patient's actual measured pharmacokinetic parameters. RESULTS: Univariable logistic regression of 41 variables identified 27 and 23 to be predictive of dosing every 8 or 6h, respectively. The most predictive multivariable model for dosing every 8h consisted of creatinine clearance (CrCl)≥80ml/min, Acute Kidney Injury Network classification <1, and total body surface area burned≥10 percent. For dosing every 6h, CrCl≥80ml/min, age≤40years old, days since injury≤6, and serum creatinine (SCr)≤0.8 were most predictive. Based on the top 5 multivariable models for each dosing interval, 7 algorithms were built to produce recommended regimens. The highest performing algorithm resulted in trough concentrations of <10mg/L (23%), 10-20mg/L (65%), 15-20mg/L (26%), and >20mg/L (11%); area under the concentration curve (AUC)>400mghr/L (83%); and AUC >400mghr/L without having a trough >20mg/L (72%). CONCLUSIONS: The algorithm that resulted in the highest target attainment without overdosing recommended 15mg/kg dosed every 24h for CrCl≥30, every 12h for CrCl 31-79, every 8h for patients with CrCl≥80ml/min, and every 6h only if the patient with a CrCl≥80ml/min is also≤40 years old and has a SCr≤0.8. Caution is warranted for groups underrepresented in this study, such as those with very low CrCl, a low BMI, or receiving renal replacement therapy. This algorithm should be validated in other centers for patients with thermal injuries.

Predictors for Identifying Burn Sepsis and Performance vs Existing Criteria.

Sepsis is the largest cause of mortality in thermally injured patients. Traditional systemic inflammatory response syndrome (SIRS) criteria do not aid diagnosis of sepsis in burn centers. Studies have attempted identification of the best indicators of sepsis in the thermal injured patient, but predictive variables are inconsistent across the various studies. Currently, consensus guidelines lack evidential support as to which patients will benefit most from prompt antimicrobial therapy. The purpose of our study was to evaluate novel diagnostic parameters for thermal injured patients with known sepsis and compare these parameters with existing diagnostic criteria. This study was a retrospective, electronic medical record review. Baseline demographics were analyzed utilizing chi-square, Mann-Whitney U test, or t test. Each patient served as their own control. Generalized linear mixed modeling was utilized for univariable and multivariable analysis. Several models with ≤6 variables each were built with the top performing variables. Performance was analyzed using area under receiver operating curves, sensitivity, specificity, positive predictive value, and negative predictive value. Three hundred and ninety-nine patients were screened. Twenty-nine patients remained after exclusions, leaving 198 blood culture results (62 positive) for analysis. Forty variables were statistically significant during univariable analysis. From multivariable analysis, the best performing model was: Temperature > 39°C or < 36°C, heart rate > 130 beats/min, 10% decrease in mean arterial pressure, and gastric residual volumes twice the feeding rate. Meeting at least one variable of the presented model best identified incidence of sepsis with positive bloodstream infections and outperformed current models in our patients.

Pulmonary Air Embolism: An Infrequent Complication in the Radiology Suite.

BACKGROUND Air embolism can occur in a number of medical-surgical situations. Venous air embolism is frequently lethal when a substantial amount enters the venous circulation rapidly and can lead to significant morbidity if crossover to the systemic arterial circulation occurs. The diagnosis of massive air embolism is usually made on clinical grounds by the development of abrupt hemodynamic compromise. The true incidence, morbidity, and mortality of this event is unknown given the difficulties in diagnosis. CASE REPORT An inadvertent antecubital venous injection of 150 mL of air using a contrast power injector during a computed tomography (CT) is reported. Immediate imaging (CT) showed a significant amount of air in the right atrium and right ventricular cavity, and air mixed with contrast in the main pulmonary artery and proximal divisions of the pulmonary circulation. Patient condition deteriorated requiring mechanical ventilation for 48 hours. Condition improved over the next few days and patient was successfully extubated and discharged home. CONCLUSIONS Air embolism is a rare complication, the potential for this to be life threatening makes prevention and early detection of this condition essential. This condition should be suspected when patients experience sudden onset respiratory distress and/or experience a neurological event in the setting of a known risk factor. Treatment options include Durant's maneuver; left-lateral decubitus, head-down positioning; to decrease air entry into the right ventricle outflow tract, hyperbaric therapy, 100% O2 and supportive care.

Patient Demographics and Socioeconomic Characteristics of an Ambulatory Care Clinic Served by a University PCCM Training Program.

OBJECTIVES: Continuity clinics are an important aspect of pulmonary medicine fellowship training. We provide a description of a pulmonary outpatient clinic in an inner city, county-owned, university-affiliated hospital. METHODS: This is a descriptive study of administrative data on consecutive patient visits to the University of Tennessee Regional One Health at Memphis ambulatory clinic (Medplex) between January 2000 and August 2006. We describe demographics, socioeconomic characteristics, and the frequency of a pulmonary diagnosis of the outpatient population served by our training program. Continuous data were described by mean ± standard deviations and categorical data were described by percentage. RESULTS: The dataset included 2549 patients, 81% were African American with a mean age of 48.7 ± 13.7, 64.4% were women. Female/male body mass index was 34.6 ± 11.6 vs. 29.2 ± 10.3. Tenncare (Medicaid) covered 59.6 % of patients, whereas 11.1% were uninsured. CONCLUSIONS: We provide evidence that one clinical setting may not be enough exposure to the entire lung pathology for pulmonary trainees. There is a need for further, larger, and prospective data collections to evaluate and guide changes regarding the structure of training programs.

Intravenous gammaglobulin as rescue therapy in a patient with sickle cell and septic shock.

INTRODUCTION: We present a case involving a patient with sickle cell and hyposplenism, in which refractory septic shock quickly responded after the infusion of intravenous gammaglobulin (IV-GG) given as an adjuvant-rescue therapy CASE DESCRIPTION: A 30-year-old African-American female with history of Sickle Cell disease was admitted for acute chest syndrome, septic shock and respiratory failure. Despite aggressive therapy the patient remained on two vasopressors and with persistent bacteremia. Within one day of starting IV-GG, both vasopressors (norepinephrine and vasopressin) were able to be discontinued. DISCUSSION: Patients with hyposplenism have functional opsonization failure. Infusion of IV-GG has been shown to improve such function in patients with hyposplenism. We were able to document a temporal association between IV-GG rescue therapy and septic shock improvement. CONCLUSION: The utilization of intravenous gammaglobulin should be considered in patients with sickle cell disease and hyposplenism as an adjuvant therapy for refractory septic shock.