ABSTRACT
We aimed to assess the prognostic role of the neutrophil/lymphocyte ratio (NLR) in community-acquired pneumonia (CAP) via a single-center retrospective cohort of hospitalized adult patients from 1/2009 to 12/2019. Patients were dichotomized into lower NLR (≤12) and higher NLR (>12). The primary outcome was mortality. ICU admission and hospital- and ICU-free days were secondary outcomes. The pneumonia severity index (PSI) and the NLR's ability to predict outcomes was also tested. An NLR ≤12 was observed in 2513 (62.2%) patients and >12 in 1526 (37.8%). After adjusting for PSI, the NLR was not associated with hospital mortality (odds ratio [OR] 1.115; 95% confidence interval [CI] 0.774, 1.606; p = 0.559), but it was associated with a higher risk of ICU admission (OR 1.405; 95% CI 1.216, 1.624; p < 0.001). The PSI demonstrated acceptable discrimination for mortality (area under the receiver operating characteristic curve [AUC] 0.78; 95% CI 0.75, 0.82) which was not improved by adding the NLR (AUC 0.78; 95% CI 0.75, 0.82, p = 0.4476). The PSI's performance in predicting ICU admission was also acceptable (AUC 0.75; 95% CI 0.74, 0.77) and improved by including the NLR (AUC 0.76, 95% CI 0.74, 0.77, p = 0.008), although with limited clinical significance. The NLR was not superior to the PSI for predicting mortality in hospitalized CAP patients.
ABSTRACT
Chylothorax is a relatively rare condition characterized by the accumulation of chyle, a milky lymphatic fluid, within the pleural space. It occurs because of disruption or obstruction of the thoracic duct or its tributaries, leading to chyle leakage into the pleural cavity. We present an interesting case of chylothorax that occurred as a complication post-chest tube insertion. A 66-year-old patient presented with hypotension and shortness of breath. Initial chest X-ray in the emergency room showed a right-sided hydropneumothorax requiring chest tube placement. Later on, the patient was transferred to the medical intensive care unit for respiratory failure. Chest tube drainage was initially serosanguineous but later changed to milky-white drainage. Pleural fluid analysis showed a triglyceride level of 208, confirming chylothorax. Conservative treatment was initiated with a low-fat diet and octreotide. The plan was to schedule the patient for thoracic duct embolization in view of continuous chylous drainage, but due to family preference, the procedure was deferred. This case report provides an overview of chylothorax, including etiologies and diagnostic options, and shows the importance of taking a multidisciplinary approach to finalize management strategies.
ABSTRACT
Nephrotic syndrome is a condition characterized by proteinuria, hypoalbuminemia, edema, hyperlipidemia, and a hypercoagulable state. Nephrotic syndrome may lead to several complications, including, but not limited to, increased risk of infection, respiratory distress, and thromboembolism. There are several etiologies of nephrotic syndrome with various predisposing factors ranging from idiopathic, autoimmune diseases, infections (human immunodeficiency virus, hepatitis C virus, hepatitis B virus), drugs, and heavy metal poisoning. Here, we report the case of a 37-year-old male who presented with worsening exertional dyspnea and bilateral lower extremity swelling. He was found to have simultaneous multiple acute thromboses in both the venous and arterial systems in the setting of worsening renal function. Further investigation revealed that the patient had membranous nephropathy. Initiation of anticoagulation and immunosuppression made a significant difference in his survival. Vascular thromboembolic (VTE) complications may be the initial presentation that prompts patients with nephrotic syndrome to seek medical care. As such, clinicians must have a high index of suspicion in patients presenting with concurrent VTE and nephrotic-range proteinuria. In addition, given that treatment modalities for the various etiologies of nephrotic syndrome differ considerably, it is also essential to distinguish the type of nephrotic syndrome in a patient, which dictates the treatment algorithm.
ABSTRACT
Severe acute respiratory syndrome coronavirus 2 infection has been a global public health crisis for the past two years. Vaccination has been a mainstay preventive approach among other strategies such as hand washing, social distancing, and wearing facemasks. Here, we present a case of concomitant calcium pyrophosphate deposition disease flare and septic arthritis of the right knee following coronavirus disease 2019 (COVID-19) booster vaccination in a 69-year-old African American male who presented with a painful swollen right knee with associated fever, chills, and rigors three days post-vaccination. Right knee synovial fluid aspirate appeared turbid with elevated white cell count, positive for both intra and extracellular calcium pyrophosphate crystals, and positive for beta-hemolytic Streptococcus group C. The swollen joint improved with right knee arthroscopic irrigation and intravenous antibiotics on admission. The patient subsequently completed a total of six weeks of antibiotics with clinical improvement and normalization of inflammatory markers. No reported incidence of gout or pseudogout post-COVID-19 vaccination has been reported despite reported cases of gout flares with other vaccines. Improper aseptic vaccination technique has been implicated as a possible cause of septic arthritis post-vaccination. Healthcare providers must discuss such adverse events with their patients prior to vaccine administration.
ABSTRACT
The lung is a common site for metastatic cancers such as colorectal and breast cancer but an uncommon site for prostate cancer. The treatment modalities for primary and metastatic lung malignancies differ considerably; therefore, it is essential to distinguish between them. Here, we present a patient with solitary metastatic lung cancer with prostate as the primary source, which was initially considered a primary lung nodule considering his risk factors. The patient later developed other lung nodules and successfully underwent resection of these nodules with no bone involvement at the time. Follow-up computed tomography (CT) of the chest revealed two other new lung nodules and pleural effusion, and magnetic resonance imaging (MRI) of the pelvis showed bone involvement. The patient was started on gonadotropin-releasing hormone therapy with subsequent downtrending prostate-specific antigen (PSA). Although uncommon, prostate cancer can metastasize to the lungs; hence, clinicians must always have a high index of suspicion when a patient presents with a lung nodule, especially with a prior history of prostate cancer.
