A 20-Year-Old Man with e-Cigarette or Vaping Product Use-Associated Lung Injury (EVALI) and Thrombotic Coagulopathy.

BACKGROUND In 2019, the US Centers for Disease Control and Prevention (CDC) described the criteria for the diagnosis of e-cigarette or vaping product use-associated lung injury (EVALI), which may be caused by contamination of delta-9-tetrahydrocannabinoid (THC) e-liquids with vitamin E acetate. This report describes a case of a 20-year-old man with a history of recreational drug use that included vaping, who presented with EVALI and a coagulopathy associated with thrombotic events. CASE REPORT We present a 20-year-old patient who worked at a cannabidiol (CBD) manufacturing facility with a history of e-cigarette use and polysubstance abuse in remission who presented with respiratory and gastrointestinal symptoms accompanied by 50-pound weight loss over 6 months. The patient had been vaping with nicotine and THC-containing e-cigarettes multiple times per day for 1.5 years. He met the CDC surveillance criteria for EVALI, consisting of respiratory symptoms and infiltrates on imaging within 90 days of vaping, and was found to have eosinophilic pneumonia secondary to THC-containing e-cigarette use. Additionally, thrombi were detected in the pulmonary arteries, right saphenous vein, and right ventricle. A segmental infarct was noted in the inferior pole of the left kidney. CONCLUSIONS We present the second case report potentially linking e-cigarette use with clinically significant thrombogenesis, the first with both arterial and venous thromboses. This report demonstrates the importance of taking a history of e-cigarette use in patients presenting with lung injury. Although EVALI and the diagnostic criteria have only recently been described, systemic effects, including coagulopathy, are now being reported.

Analysis of Emergent Nonhospital-Based Retina Consultation Requests in an Academic Nonhospital-Associated Retina Practice.

PURPOSE: To evaluate the outcomes of after-hour encounters concerning patients referred by eye physicians to on-call retina services for emergent evaluation not seen in or referred by an emergency department. DESIGN: Retrospective study. PARTICIPANTS: Patients seeking treatment at 3 private practice institutions over a 2-year period between 2017 and 2018. METHODS: A retrospective chart review was conducted comprising all patients who sought treatment emergently and after clinic hours from 3 academic nonhospital-associated retina-only private practice institutions over a 2-year period. MAIN OUTCOME MEASURES: Patient presenting symptoms, diagnosis given at time of after-hours appointment, duration of symptoms, source of after-hours consultation (patient or provider), procedure performed at appointment, and appointments that led to surgery. RESULTS: Nine hundred eighty-seven charts were reviewed. Provider referrals accounted for 49.13% (n = 485) and patient-derived referrals accounted for 50% (n = 493) of appointments. New patients accounted for 27.6% (n = 146) of patient-derived and 85.2% (n = 413) of provider-derived referrals. The most common presenting symptoms were flashes and floaters (42.5%; n = 420), decrease in visual acuity (32.1%; n = 317), generalized eye pain (7.4%; n = 73), visual field disturbance (4.3%; n = 42), and postoperative ocular pain (3.4%; n = 34). An in-office procedure was performed at the time of examination in 18% of encounters (n = 178), with most of these being laser retinopexy. Surgery was performed within 24 hours in 18% (n = 180), within 48 hours in 20.6% (n = 203), within 72 hours in 21.7% (n = 214), and within 96 hours in 22.6% (n = 223) of the appointment. When combined with procedures, 36.2% (n = 358) of encounters led to urgent intervention within 24 hours. If a provider called about an existing patient, 37.5% of these appointments (n = 27) led to surgery versus 12.8% (n = 49) if an existing patient self-referred. If a provider called about a new patient, 31.7% of these appointments (n = 131) led to surgery versus 10% (n = 14) if a new patient self-referred. CONCLUSIONS: At these 3 private practice retinal specialty clinics, 41% of after-hours appointment requests resulted in an intervention within 96 hours, and 36% of these patients underwent an intervention within 24 hours.

Overlooking Recurrent Acute Rheumatic Fever in Adulthood.

Acute rheumatic fever in an adult is a rare entity. We present a 29-year-old man of mixed ancestry, including Native Hawaiian and other Pacific Islander, who presented with a 6-week history of migratory polyarthralgia and fever with a recent history of purulent lower extremity wounds and a remote history of acute rheumatic fever in childhood. The diagnosis of recurrent acute rheumatic fever was confirmed by elevated Antistreptolysin-O titers and Anti-DNase B titers. This case presentation showcases a Native Hawaiian and other Pacific Islander with acute rheumatic fever in both childhood and adulthood following pyoderma infection, with a delay in diagnosis and management for both episodes. The patient had an excellent response to naproxen without developing complications and was restarted on secondary antibiotic prophylaxis. Health care providers in the Pacific region should understand the relationship between pyoderma and acute rheumatic fever in addition to including acute rheumatic fever in the differential diagnosis of polyarthralgia in an adult.

Extraocular and Intraocular Infections Following Strabismus Surgery: A Review.

An extensive literature review of various types of infections following strabismus surgery was facilitated by using the search engines PubMed and Google Scholar. In both search engines, the phrases "infection following strabismus surgery," "infection strabismus surgery," "complications of strabismus surgery," "endophthalmitis strabismus surgery," and "strabismus scleral perforation" were used for the review. The type of infection, surface involved, and site of the infection determined the type of therapy. Infections involving deeper tissues, such as periocular infection or orbital cellulitis, required systemic therapy. Sub-Tenon's abscesses required incision and drainage, as well as systemic antibiotics. The development of endophthalmitis following strabismus surgery was rare, but was usually devastating to the visual result. Symptoms of an adverse intraocular condition began by mean postoperative day 3, but the definitive diagnosis and treatment of endophthalmitis was not made until mean postoperative day 6. Despite early detection of this latter type of infection and early surgical intervention with vitreous paracentesis and intraocular injection of antibiotics, the visual result was extremely poor in more than two-thirds of the reported cases. Although there is no known way to truly prevent all infections following strabismus surgery, several techniques may be prudent for the strabismus surgeon to adopt to decrease the bacterial load and minimize the risk of infection. The surgeon should be encouraged to consider preoperative use of povidone-iodine on the operative field and avoid scleral perforation during surgery. [J Pediatr Ophthalmol Strabismus. 2019;56(4):214-221.].