Platypnea Orthodeoxia Due to a Patent Foramen Ovale and Intrapulmonary Shunting After Severe COVID-19 Pneumonia.

BACKGROUND Platypnea orthodeoxia syndrome (POS) presents with positional dyspnea and hypoxemia defined as arterial desaturation of at least 5% or a drop in PaO2 of at least 4 mmHg. Causes of POS include a variety of cardiopulmonary etiologies and has been reported in patients recovering from severe COVID-19 pneumonia. However, clinical presentation and outcomes in a patient with multiple interrelated mechanisms of shunting has not been documented. CASE REPORT An 85-year-old man hospitalized for hypertensive emergency and severe COVID-19 pneumonia was diagnosed with platypnea orthodeoxia on day 28 of illness. During his disease course, the patient required supplemental oxygen by high-flow nasal cannula but never required invasive mechanical ventilation. Chest imaging revealed evolving mixed consolidation and ground-glass opacities with a patchy and diffuse distribution, involving most of the left lung. Echocardiography was ordered to evaluate for intracardiac shunt, which revealed a patent foramen ovale. Closure of the patent foramen ovale was not pursued. Management included graded progression to standing and supplemental oxygen increases when upright. The patient was discharged to a skilled nursing facility and his positional oxygen requirement resolved on approximately day 78. CONCLUSIONS The present case highlights the multiple interrelated mechanisms of shunting in patients with COVID-related lung disease and a patent foramen ovale. Eight prior cases of POS after COVID-19 pneumonia have been reported to date but none with a known patent foramen ovale. In patients with persistent positional oxygen requirements at follow-up, quantifying shunt fraction over time through multiple modalities can guide treatment decisions.

How patients' self-disclosure about sickle cell pain episodes to significant others relates to living with sickle cell disease.

OBJECTIVES: This cross-sectional study examines to whom and how fully sickle cell disease (SCD) patients talk to others about sickle cell pain, how helpful it is to talk with others about these pain episodes, and the association between talking to others about sickle cell pain episodes and patients' psychological adjustment and coping strategies in managing the disease. METHODS: A convenience sample of 73 African American patients with SCD (30 men and 43 women), were recruited from two SCD clinics at the time of routine medical visits. Most participants had been diagnosed with hemoglobin SS, and they reported an average number of 8.61 pain episodes in the previous 12 months. Participants were asked to whom, how fully, and how helpful it was to talk to significant others about SCD pain episodes experienced in the last 12 months. Patients also completed measures of their psychological adjustment as well as how they would manage a future sickle cell pain episode. Self-report ratings were made on Likert-type scales. RESULTS: Based on paired samples t-tests, participants talked significantly more fully about their thoughts and feelings concerning pain episodes to God and to their primary medical providers than to either their parents, siblings, or an intimate partner/close friend. Bivariate correlations indicated that amount and helpfulness of talking about pain episodes to God and to parents were significantly associated with better psychological adjustment on selected measures. Also, bivariate correlations indicated that helpfulness in talking with siblings, intimate partner/close friend, and primary medical providers was positively related with willingness to go to a physician in the event of a future pain episode. CONCLUSIONS: The results document to whom and how helpful it is to talk with others about SCD pain episodes and how SCD disclosure is related to strategies for managing this disease.

Infectious disease emergencies: frontline clinical pearls.

This article reviews various infectious disease emergencies from an internist's perspective. Key epidemiologic, diagnostic, and therapeutic points are reviewed with an emphasis on timely and appropriate initial management. The content serves to highlight essential points that are discussed in subsequent articles in this issue and to elucidate pearls that may facilitate timely and appropriate management.

Prevalence of vitamin D deficiency in adults with sickle cell disease.

Vitamin D deficiency has been linked to fracture risk and chronic musculoskeletal pain. Adults with sickle cell disease have a high prevalence of low bone density and chronic pain with poorly defined etiologies. We recognized that vitamin D deficiency may represent a treatable etiology and sought to determine the prevalence of vitamin D deficiency in adults with sickle cell. We measured 25-hydroxy vitamin D levels in adults at 2 university-based sickle cell disease-management programs. Regression was performed in 142 patients to identify predictors of low vitamin D. Mean vitamin D levels were 9.0 ng/mL at Eastern Virginia Medical School and 12.8 ng/mL at University of Chicago; 139 of 142 (98%) had suboptimal levels (<30 ng/mL) and 85/142 (60%) were severely deficient (<10 ng/mL). Vitamin D level was not related to age, sex, hydroxyurea use, sickle cell type, or date of lab draw. Vitamin D deficiency was, therefore, nearly ubiquitous in our patient population, with a majority being severely deficient. Further studies are warranted to evaluate the effects of vitamin D repletion on clinical outcomes such as bone density, chronic musculoskeletal pain, and functional status. Clinicians caring for patients with sickle cell disease should be aware of and screen for this important clinical state.