Syncope Following Treatment of UTI: A Case of Acute Hemolytic Anemia, Methemoglobinemia and Acute Renal Dysfunction Following Phenazopyridine Use in a Patient With G6PD Deficiency.

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an X-linked recessive genetic disorder which commonly affects males. It is due to a defect in the red blood cell enzyme, G6PD. Lack of G6PD makes the RBCs vulnerable to oxidant stress resulting in hemolysis. The severity of hemolytic anemia varies among individuals with G6PD deficiency. Here we present a case of an 80-year-old man admitted with syncope and jaundice. He was treated with phenazopyridine for a UTI 2 weeks ago. Subsequent investigation revealed G6PD deficiency as well as methemoglobinemia. Historically, phenazopyridine has been associated with causing methemoglobinemia and triggering hemolysis in G6PD deficient individuals. However, only a few cases have been reported in the last 60 years, making it a very rare occurrence.

Pulmonary Barotrauma Resulting from Mechanical Ventilation in 2 Patients with a Diagnosis of COVID-19 Pneumonia.

BACKGROUND Invasive mechanical ventilation can cause pulmonary barotrauma due to elevated transpulmonary pressure and alveolar rupture. A significant proportion of COVID-19 patients with acute respiratory distress syndrome (ARDS) will require mechanical ventilation. We present 2 interesting cases that demonstrate the possibility of COVID-19-associated ARDS manifesting with pulmonary barotrauma at acceptable ventilatory pressures. CASE REPORT The first patient was a 71-year-old man who was intubated and placed on mechanical ventilation due to hypoxemic respiratory failure from SARS-CoV-2 infection. His partial pressure of O2 to fraction of inspired oxygen ratio (PaO2/FiO2) was 156. He developed subcutaneous emphysema (SE) and pneumomediastinum on day 5 of mechanical ventilation at ventilatory settings of positive end-expiratory pressure (PEEP) ≤15 cmH2O, plateau pressure (Pplat) ≤25 cmH2O and pulmonary inspiratory pressure (PIP) ≤30 cmH2O. He was managed with 'blow-hole' incisions, with subsequent clinical resolution of subcutaneous emphysema. The second patient was a 58-year-old woman who was also mechanically ventilated due to hypoxemic respiratory failure from COVID-19, with PaO2/FiO2 of 81. She developed extensive SE with pneumomediastinum and pneumothorax while on mechanical ventilation settings PEEP 13 cmH2O and PIP 28 cmH2O, Pplat 18 cmH2O, and FiO2 90%. SE was managed with blow-hole incisions and pneumothorax with chest tube. CONCLUSIONS Clinicians should be aware of pulmonary barotrauma as a possible complication of COVID-19 pulmonary disease, even at low ventilatory pressures.

Subacute Aspergillosis "Fungal Balls" Complicating COVID-19.

Severe acute respiratory syndrome coronavirus-2 infection (SARS-CoV-2), commonly known as COVID-19 (coronavirus disease-2019), began in the Wuhan District of Hubei Province, China. It is regarded as one of the worst pandemics, which has consumed both human lives and the world economy. COVID-19 infection mainly affects the lungs triggering severe hypoxemic respiratory failure, also providing a nidus for superimposed bacterial and fungal infections. We report the case of a 73-year-old male who presented with progressive dyspnea; diagnosed with SARS-CoV-2-related severe acute respiratory distress syndrome and complicated with lung cavitations growing Aspergillus sp. COVID-19, to our knowledge, has rarely been associated with subacute invasive pulmonary aspergillosis with aspergillomas. Subacute invasive pulmonary aspergillosis as a superimposed infection in patients with SARS-CoV-2 is a rare entity. By reporting this case, we would like to make the readers aware of this association.

Neisseria cinerea in a Post-splenectomy Patient: A Rare Potentially Fatal Bacteremia.

Neisseria cinerea is a commensal which usually resides in the human respiratory tract. Very rarely, the organism finds its way into the bloodstream causing severe bacteremia. So far, very few cases of Neisseria bacteremia have been reported. We report a case of a 78-year-old male, post-splenectomy, who presented with high fever, cough and shortness of breath. The patient was initially managed for septic shock with fluid resuscitations, vasopressors and broad-spectrum antibiotics. Later, the blood cultures grew gram-negative coccobacilli, Neisseria cinerea. The patient was successfully treated with intravenous ceftriaxone. This is the first case ever of Neisseria cinerea bacteremia in a post-splenectomy patient and ninth case overall. This case illustrates that the physicians should maintain heightened awareness for Neisseria cinerea bacteremia in post-splenectomy patients.

Pseudochylothorax and diaphragmatic weakness secondary to a misplaced central venous catheter.

A 20-year-old woman admitted with an aspirin overdose was encephalopathic and was intubated for airway protection. Under sonographic guidance, a right internal jugular central venous catheter was inserted for volume resuscitation. She was agitated and required treatment with a propofol infusion. Her salicylate levels improved and she was successfully extubated 12 h after intubation. One day later she developed severe dyspnoea and a right-sided pleural effusion and required immediate reintubation. The effusion was drained and was consistent with a chylothorax. A CT scan of the chest revealed that the central venous catheter traversed the mediastinum with its tip in the right pleural space. The propofol infusion was draining into the pleural space. A video-assisted thoracoscopic surgery was performed to drain the pleural effusion and repair the punctured vessel. She was extubated within a day and discharged home 1 day later without any pleural fluid.

Methylene blue reverses recalcitrant shock in ß-blocker and calcium channel blocker overdose.

ß-blocker and calcium channel blocker toxicity generally present with bradycardia and hypotension. A 69-year-old woman presented after a suicide attempt with a ß-blocker and calcium channel blocker overdose. Her blood pressure was 69/35 mm Hg and her HR was in the 40s. She was treated with calcium chloride, glucagon, a dextrose-insulin infusion and three vasopressors, but remained hypotensive. She suffered two cardiac arrests and required a transvenous pacemaker. When all interventions failed, she was started on a methylene blue infusion for refractory vasodilatory shock which resulted in a dramatic improvement in her blood pressure. The patient was successfully weaned off all vasopressors and from mechanical ventilation without any end-organ damage.

Brucellosis presenting as septic shock.

Brucellosis generally presents with fever, malaise, weight loss and bone pain with either an abrupt or insidious onset. A 76-year-old man presented in April 2010 with fever of 103°F, severe tachycardia, tachypnoea and a blood pressure of 80/50 mm Hg requiring fluids and vasopressor support with norepinephrine. The patient had brucellosis in 1956 which was treated for 'many weeks' with tetracycline and streptomycin. He has had no recurrences since that time. He denies recent travel outside the USA or consumption of raw dairy products. Blood cultures grew Brucella melitensis. He was treated with gentamycin, doxycycline and rifampin for 1 week and discharged home on doxycycline and rifampin. He relapsed after 2 days, requiring re-admission and a 4-week course of gentamycin. This case is most unusual in that the brucellosis presented with septic shock after a 50-year quiescence and required prolonged therapy with gentamycin to induce remission.

Chest tube drainage of transudative pleural effusions hastens liberation from mechanical ventilation.

BACKGROUND: Pleural effusions occur frequently in patients requiring mechanical ventilatory support. Treatment of the precipitating cause and resolution of the pleural effusion may take considerable time. We retrospectively studied the effect of chest tube drainage of transudative pleural effusions on the liberation of patients from mechanical ventilatory support. METHODS: Patients in the medical ICU (MICU) at Maimonides Medical Center between January 1, 2009, and October 31, 2009, requiring mechanical ventilatory support with a transudative pleural effusion, were studied retrospectively. They were divided into two groups: standard care and standard care plus chest tube drainage. Chest tubes were placed under ultrasound guidance by trained intensivists. Duration of mechanical ventilatory support was the primary end point. Secondary end points included measures of oxygenation, amount of fluid drained, and complications associated with the chest tube. RESULTS: A total of 168 patients were studied; 88 were treated with standard care and 80 underwent chest tube drainage. Total duration of mechanical ventilatory support was significantly shorter for patients who had chest tube drainage: 3.8±0.5 days vs 6.5±1.1 days for the standard group (P=.03). No differences in oxygenation were noted between the two groups. The average amount of fluid drained was 1,220 mL. No significant complications were caused by chest tube drainage. CONCLUSIONS: Chest tube drainage of transudative pleural effusions resulted in more rapid liberation from mechanical ventilatory support. It is a very safe procedure when performed under ultrasound guidance by experienced personnel. TRIAL REGISTRY: ClinicalTrials.gov; Identifier: NCT0114285; URL: www.clinicaltrials.gov.