Think Outside the Box: A Rare Presentation of Schistosomiasis in the United States.

Millions of people across the world are infected with schistosomiasis. But, the vast majority of them are asymptomatic. Milder symptoms can include headache, lethargy, and fever. In serious cases, ascites, hepatosplenomegaly, and death can occur. Schistosomiasis is a highly prevalent parasitic infection worldwide, mainly in tropical areas of Africa, Asia, and Latin America. We present a case of a 69-year-old female with notable travel history to the Philippines, who reported to the emergency department with a symptomatic presentation of chronic schistosomiasis with the involvement of biliary and pancreatic ducts.

Fungal infections following liver transplantation.

With increasing morbidity and mortality from chronic liver disease and acute liver failure, the need for liver transplantation is on the rise. Most of these patients are extremely vulnerable to infections as they are immune-compromised and have other chronic co-morbid conditions. Despite the recent advances in practice and improvement in diagnostic surveillance and treatment modalities, a major portion of these patients continue to be affected by post-transplant infections. Of these, fungal infections are particularly notorious given their vague and insidious onset and are very challenging to diagnose. This mini-review aims to discuss the incidence of fungal infections following liver transplantation, the different fungi involved, the risk factors, which predispose these patients to such infections, associated diagnostic challenges, and the role of prophylaxis. The population at risk is increasingly old and frail, suffering from various other co-morbid conditions, and needs special attention. To improve care and to decrease the burden of such infections, we need to identify the at-risk population with more robust clinical and diagnostic parameters. A more robust global consensus and stringent guidelines are needed to fight against resistant microbes and maintain the longevity of current antimicrobial therapies.

Current state of medical tourism involving liver transplantation-the risk of infections and potential complications.

Liver transplant has been shown to significantly improve mortality and quality of life in various liver diseases such as acute liver failure, end-stage liver disease, and liver cancer. While the organ transplant demand is continuing to rise, the organ donation supply remains unmatched. The organ shortage, high cost, and long waiting lists have stimulated a desire for routes that may be unethical. This process which is named transplant tourism is the term used to describe traveling to another country to purchase an organ for transplant. Liver transplant tourism has been associated with post-transplant complications and higher mortality compared to a domestic liver transplant. Improper pre-and post-transplant infectious screening, inadequate opportunistic infection prophylaxis, and loss to follow-up were noted in patients who travel abroad for a liver transplant. It is crucial to understand the risk of transplant tourism to prevent morbidity and mortality.

Bee Attack or Heart Attack: Kounis Syndrome.

Kounis syndrome (KS) is defined as an allergic or hypersensitivity reaction leading to coronary vasospasm and acute coronary syndrome. The inflammatory mediators released during the body's reaction to an allergen causes vasoconstriction, plaque rupture, platelet aggregation, and even thrombosis of an existing coronary stent. Over the years, many allergens including drugs, environmental exposures, and animal and insect bites have been implicated in KS. Patients may present with elevated cardiac enzymes and electrocardiographic changes. We describe a case of a patient with no prior cardiac history who presented to the emergency department seeking treatment after multiple bee stings. The patient had non-specific electrocardiogram (ECG) changes and elevated cardiac enzymes consistent with a non-ST-elevation myocardial infarction. The patient underwent a pharmacologic stress test and myocardial perfusion imaging, which showed a perfusion defect consistent with ischemia. Selective right and left coronary angiography revealed a critical lesion at the proximal left circumflex artery. This was managed with percutaneous coronary intervention utilizing a bare-metal stent.

An Unusual and Rare Presentation of Pulmonary Aspergillosis: Endobronchial Aspergilloma.

Aspergillosis is a wide spectrum of the disease process that is caused by the fungus Aspergillus. Endobronchial aspergilloma is a very rare type of aspergillosis which is not yet included in the classification of aspergillosis. Due to its rare nature and a limited number of cases, there are no current treatment guidelines. Here we present the case of a 57-year-old female with an endobronchial aspergilloma. The patient was started on intravenous voriconazole and subsequently discharged on oral voriconazole.

Pulmonary Hypertension in Pregnancy: A Review.

Pulmonary hypertension (PH) is a disease, which targets the pulmonary vasculature affecting the heart and the lungs, and is characterized by a vast array of signs and symptoms. These manifestations of PH in pregnancy are highly variable and non-specific hence, it is prudent to have a very keen and high index of suspicion while evaluating these patients. This rare disease can be extremely debilitating and can be associated with a poor overall prognosis. Pregnancy in women with PH puts them at an elevated risk because the physiological changes associated with pregnancy are not well endured leading to even higher morbidity and mortality in these patients. Although there are various modalities for evaluation and workup of PH, right heart catheterization (RHC) remains the gold standard. A mean pulmonary artery pressure (PAP) of more than 20 mm of Hg is considered diagnostic. It is indeed heartening to see that in the past decade many novel therapeutic modalities have emerged and along with a better understanding of the disease process have proved to be promising in terms of reducing the adverse outcomes and preventing death in this population of patients.

Hemothorax After a Renal Biopsy With Ablation, a Rare Complication: A Case Report and Review of the Literature.

Renal biopsy is an important diagnostic test which is used to extract kidney tissue with the help of a biopsy needle. It is frequently performed under ultrasonography or CT guidance. As with every other procedure, renal biopsy also carries some risks. Common complications of renal biopsy are damage to adjacent organs. Hemothorax is an exceedingly rare complication of renal biopsy. We report a case of a middle-aged female who developed a left-sided hemothorax after undergoing percutaneous renal biopsy with ablation and conducted a literature review of this rare complication.

Shrinking Lung Syndrome: A Rare Manifestation of Systemic Lupus Erythematosus.

Shrinking lung syndrome (SLS) is a pulmonary complication of systemic lupus erythematosus (SLE) characterized by dyspnea, pleuritic chest pain, and progressive decrease in lung volumes with no evidence of pleural or interstitial disease on chest CT. We present a 51-year-old female with a 14-year history of SLE with symptoms of progressive shortness of breath, pleuritic chest pains, low grade fevers, and productive cough which was unresponsive to multiple courses of antibiotics. After careful review of her course of SLE and timeline of symptoms, she was diagnosed with SLS. Even though rare, clinicians should have a high suspicion of SLS in patients with a long-term history of SLE and worsening dyspnea. Early treatment can be initiated to help reduce long-term morbidity and mortality and maintain the quality of life.

An Intriguing Case of Acute Encephalopathy: Lesson Learned from a Constipated Man.

Hyperammonemia is a common cause of encephalopathy encountered in an intensive care unit (ICU). Absence of pre-existing liver disease may misguide a clinician and cases of non-cirrhotic hyperammonemia may be missed in ICU leading to life-threatening outcomes such as cerebral edema and herniation. A critical care physician must look beyond liver cirrhosis as a cause of hyperammonemia so that infrequent but potentially reversible causes of encephalopathy are not missed, and patient treatment is not jeopardized.

A Case Series of Vaping-Induced Lung Injury in a Community Hospital Setting.

Acute and subacute injury to the lung parenchyma can be caused by multiple products. Over the past few years, vaping (also known as E-cigarettes) has become a popular trend and has been considered "safer" alternative to smoking cigarettes, especially among young adults. The use of E-cigarettes has rapidly increased, and according to the most recent report by CDC released at the end of December 2019, 2,506 cases and more than 54 associated deaths due to vaping/E-cigarette-associated lung injury were reported. Though vitamin E acetate and tetrahydrocannabinol (THC) have been found in most of the bronchoalveolar lavage samples, there are still small numbers of cases that have not reported to using THC-containing compounds. Research looking into other possible constituents in E-cigarettes that can account for the etiology of disease and effects of vaping as it relates to pulmonary physiology still remains limited and uncertain. We hereby present a case series of 5 patients who were admitted primarily for respiratory symptoms of cough, dyspnea, and fevers and were diagnosed with vaping-induced pulmonary injury.

Weaning from Mechanical Ventilator in a Long-term Acute Care Hospital: A Retrospective Analysis.

BACKGROUND: Prolonged Mechanical Ventilation (PMV) is associated with a higher cost of care and increased morbidity and mortality. Patients requiring PMV are referred mostly to Long-Term Acute Care (LTAC) facilities. OBJECTIVE: To determine if protocol-driven weaning from mechanical ventilator by Respiratory Therapist (RT) would result in quicker weaning from mechanical ventilation, cost-effectiveness, and decreased mortality. METHODS: A retrospective case-control study was conducted that utilized protocol-driven ventilator weaning by respiratory therapist (RT) as a part of the Respiratory Disease Certification Program (RDCP). RESULTS: 51 patients on mechanical ventilation before initiation of protocol-based ventilator weaning formed the control group. 111 patients on mechanical ventilation after implementation of the protocol formed the study group. Time to wean from the mechanical ventilation before the implementation of protocol-driven weaning by RT was 16.76 +/- 18.91 days, while that after the implementation of protocol was 7.67 +/- 6.58 days (p < 0.0001). Mortality proportion in patients after implementation of protocol-based ventilator weaning was 0.21 as compared to 0.37 in the control group (p=0.0153). The daily cost of patient care for the LTAC while on mechanical ventilation was $2200/day per patient while it was $ 1400/day per patient while not on mechanical ventilation leading to significant cost savings. CONCLUSION: Protocol-driven liberation from mechanical ventilation in LTAC by RT can significantly decrease the duration of a mechanical ventilator, leading to decreased mortality and cost savings.

A Case Report of Secondary Spontaneous Pneumothorax Induced by Vape.

Electronic cigarettes (referred here as E-cigarettes or vapes) are devices that contain heated nicotine/cannabinol vaporized aerosol solution for consumption. While long-term toxicities of E-cigarettes are unknown, the acute adverse events of vaping that have occurred are concerning. There have been variations of pneumonitis presentations so far, however, very few case reports have been shown to have a complication of a pneumothorax. We hereby present a case of a 35-year-old male who presented with spontaneous pneumothorax and pneumonitis due to vaping.

Metformin Use and Metformin-associated Lactic Acidosis in Intensive Care Unit Patients with Diabetes.

Metformin is a very potent anti-diabetic drug that has become the drug of choice for the treatment of type 2 diabetes. In addition to its glucose-lowering properties, it also reduces all-cause mortality through its anti-inflammatory and cardioprotective effects. Although metformin-associated lactic acidosis (MALA) is a very rare event, the mortality associated with it is close to 50%. As it is excreted through the kidney, MALA is frequently seen in patients on metformin with risk factors for developing acute kidney injury. Metformin increases the plasma lactate level in a concentration-dependent manner by inhibiting mitochondrial respiration, usually in the presence of a secondary event that disrupts lactate production or clearance. The incidence of acute kidney injury is very high in critically ill patients contributed by circulatory defects as well as contrast-induced nephropathy, the incidence of which is also high in this subset of the population. Because of this potential risk, metformin is frequently discontinued in diabetic patients admitted to the intensive care unit. Blood glucose variability and hypoglycemia, however, are both related to poor intensive care unit (ICU) outcomes and in order to prevent this in diabetic patients admitted to ICU, oral hypoglycemic agents are frequently switched to intravenous or subcutaneous insulin regimens, which allows for closer monitoring and better blood glucose control.

Gastrointestinal Histoplasmosis Presenting as an Acute Abdomen with Jejunal Perforation.

INTRODUCTION: Gastrointestinal histoplasmosis (GH) is a well-described albeit uncommon disease. It is found almost exclusively in the immunocompromised host, especially those with untreated HIV and low CD4 counts. Presentation with intestinal perforation is seen mostly commonly in the colon. We present a patient with jejunal perforation, and there have been only 3 previous cases reported in the literature. CASE: A 39-year-old male with known, untreated HIV presented to the ED with an acute abdomen after experiencing worsening intermittent abdominal pain for 2 months before that was associated with nausea, vomiting, diarrhea, and weight loss. CT of the abdomen and pelvis revealed evidence of gas in the mesentery, small bowel thickening, edema, and free fluid in the abdomen. Emergency exploratory laparotomy was conducted. Intraoperative findings included a perforated jejunum that was studded with nodular lesions as well as mesenteric masses. Histopathologic exam of these mesenteric masses and jejunal lesions were positive for histoplasmosis. CONCLUSION: Disseminated histoplasmosis is a life-threatening disease that occurs nearly exclusively in immunocompromised hosts. Untreated, mortality is as high as 80%. This rare presentation with jejunal perforation highlights the need for awareness of histoplasmosis involvement throughout the entirety of the GI tract.

Pneumothorax Causing Pneumoperitoneum: Role of Surgical Intervention.

The most common cause of a pneumoperitoneum is a perforation of a hollow viscus and the treatment is an exploratory laparotomy; nevertheless, not all pneumoperitoneums are due to a perforation and not all of them need surgical intervention. We hereby present a case of pneumoperitoneum due to a diaphragmatic defect, which allowed air from a pneumothorax to escape through the diaphragmatic hernia into the abdominal cavity.

Pulmonary complications of hepatic diseases.

Severe chronic liver disease (CLD) may result from portal hypertension, hepatocellular failure or the combination of both. Some of these patients may develop pulmonary complications independent from any pulmonary pathology that they may have. Among them the hepatopulmonary syndrome (HPS), portopulmonary hypertension (PPH) and hepatic hydrothorax (HH) are described in detail in this literature review. HPS is encountered in approximately 15% to 30% of the patients and its presence is associated with increase in mortality and also requires liver transplantation in many cases. PPH has been reported among 4%-8% of the patient with CLD who have undergone liver transplantation. The HH is another entity, which has the prevalence rate of 5% to 6% and is associated in the absence of cardiopulmonary disease. These clinical syndromes occur in similar pathophysiologic environments. Most treatment modalities work as temporizing measures. The ultimate treatment of choice is liver transplant. This clinical review provides basic concepts; pathophysiology and clinical presentation that will allow the clinician to better understand these potentially life-threatening complications. This article will review up-to-date information on the pathophysiology, clinical features and the treatment of the pulmonary complications among liver disease patients.

Recurrent Pleural Effusions Occurring in Association with Primary Pulmonary Amyloidosis.

Recurrent pleural effusions occurring in association with immunoglobulin light chain amyloidosis and not associated with amyloid cardiomyopathy are rare. These portend an overall poor prognosis with mean survival time of approximately 1.8 months. We hereby report a case of a 59-year-old Caucasian female with recurrent pleural effusions and an ultimate diagnosis of pulmonary amyloidosis in association with plasma cell myeloma. The optimal treatment for recurrent pleural effusions in amyloidosis has not been determined; however, our patient responded to therapy with Cyclophosphamide-Bortezomib- (Velcade-) Dexamethasone (CyBorD) and had no repeat hospitalizations or recurrence of pleural effusion at four-month follow-up after initiation of therapy.