Exploring a Rare Pulmonary Coinfection: Cryptococcal Pneumonia and Exophiala dermatitidis in an Immunocompetent Host.

Pulmonary cryptococcosis is becoming increasingly common in immunocompetent hosts, manifesting with variable clinical presentations ranging from asymptomatic colonization to severe pneumonia. Radiological findings are non-specific, such as nodular infiltrates, mass-like lesions, and mediastinal lymphadenopathy. We present a case of a 61-year-old woman with Cryptococcus neoformans pneumonia coinfected with Exophiala dermatitidis, an unusual occurrence in an immunocompetent host and the first of its kind. This coinfection posed significant diagnostic challenges due to the rare occurrence of each individual organism in immunocompetent patients as well as the difficulty of their laboratory diagnosis. Treatment regimens, particularly in coinfections, warrant careful consideration to mitigate mortality risk. This case underscores the importance of comprehensive diagnostic strategies and optimized treatment regimens for rare fungal coinfections in immunocompetent hosts.

Proactive Recruitment Strategy for Patient Identification for Lung Cancer Screening.

PURPOSE: We assessed low-dose computed tomography (LDCT) screening for lung cancer using a proactive patient education/recruitment program. METHODS: We identified patients aged 55-80 years from a family medicine group. In the retrospective phase (March-August, 2019), patients were categorized as current/former/never smokers, and screening eligibility was determined. Patients who underwent LDCT in the past year, along with outcomes, were documented. In the prospective phase (2020), patients in the same cohort who did not undergo LDCT were proactively contacted by a nurse navigator to discuss eligibility and prescreening. Eligible and willing patients were referred to their primary care physician. RESULTS: In the retrospective phase, of 451 current/former smokers, 184 (40.8%) were eligible for LDCT, 104 (23.1%) were ineligible, and 163 (36.1%) had an incomplete smoking history. Of those eligible, 34 (18.5%) had LDCT ordered. In the prospective phase, 189 (41.9%) were eligible for LDCT (150 [79.4%] of whom had no prior LDCT or diagnostic CT), 106 (23.5%) were ineligible, and 156 (34.6%) had an incomplete smoking history. The nurse navigator identified an additional 56/451 (12.4%) patients as eligible after contacting patients with incomplete smoking history. In total, 206 patients (45.7%) were eligible, an increase of 37.3% compared with the retrospective phase (150). Of these, 122 (59.2%) verbally agreed to screening, 94 (45.6%) met with their physician, and 42 (20.4%) were prescribed LDCT. CONCLUSIONS: A proactive education/recruitment model increased eligible patients for LDCT by 37.3%. Proactive identification/education of patients desiring to pursue LDCT was 59.2%. It is essential to identify strategies that will increase and deliver LDCT screening among eligible and willing patients.

Alpha1-antitrypsin Disease, Treatment and Role for Lung Volume Reduction Surgery.

Chronic obstructive pulmonary usually is subcategorized into 2 groups: chronic bronchitis and emphysema. The main cause of chronic bronchitis and emphysema is smoking; however, alpha1-antitrypsin also has been seen to cause emphysema in patients who are deficient. As symptoms and lung function decline, treatment modalities, such as lung volume reduction surgery, have been used in individuals with chronic obstructive pulmonary disease and upper lobe predominant emphysema. This article analyzes multiple published series where lung volume reduction surgery has been used in individuals with alpha1-antitrypsin deficiency and their overall outcomes.

Accuracy of non-invasive and minimally invasive hemodynamic monitoring: where do we stand?

One of the most important variables in assessing hemodynamic status in the intensive care unit (ICU) is the cardiac function and blood pressure. Invasive methods such as pulmonary artery catheter and arterial line allow monitoring of blood pressure and cardiac function accurately and reliably. However, their use is not without drawbacks, especially when the invasive nature of these procedures and complications associated with them are considered. There are several newer methods of noninvasive and minimally invasive hemodynamic monitoring available. In this manuscript, we will review these different methods of minimally invasive and non-invasive hemodynamic monitoring and will discuss their advantages, drawbacks and limitations.

Severe metabolic alkalosis-a diagnostic dilemma.

BACKGROUND: Cushing's syndrome due to ectopic ACTH secretion has been associated with many cancers; most commonly small cell carcinoma of the lung and bronchial carcinoid tumors. Usually, patients who confer this diagnosis have poor prognosis. CASE PRESENTATION: A 66-year-old female presented with worsening shortness of breath and weakness over three days. Initial laboratory derangements included severe hypokalemia and metabolic alkalosis. Treatment included high amounts of potassium chloride and acetazolamide. Imaging studies revealed anterior medial right upper lobe lung mass as well as suspicion for many liver metastases. Liver biopsy was sought and was positive for small cell carcinoma. CONCLUSION: We describe a case of severe metabolic alkalosis and hypokalemia in a patient with Cushing's syndrome due to ectopic ACTH secretion from small cell lung cancer. To our knowledge, this is the first case identified which exhibited such significant metabolic derangements in the form of serum and arterial blood bicarbonate. As prognosis is quite poor, we recommend swift diagnosis and management.

A Case of Chronic Cough in a Winemaker.

BACKGROUND: Fungi have been known to cause a variety of respiratory conditions, ranging from mold- associated asthma to allergic bronchopulmonary mycosis and invasive disease. More recently some fungal species have been implicated in a non-asthmatic chronic cough syndrome. CASE PRESENTATION: A 59-year-old male presented to the pulmonary clinic with chronic nonproductive cough. Workup included pulmonary function tests with methacholine challenge, sputum cultures, CT scans of the chest and therapeutic trial with proton pump inhibitors. Sputum cultures repeatedly showed Saccharomyces cerevisiae and patient had elevated specific IgA and IgG. Bronchoscopy was unremarkable, except for tracheal mucosa biopsies revealing acute and chronic inflammation. A one-month course of steroids provided temporary relief of chronic cough, but symptoms returned once steroids were discontinued. He also experienced temporary relief away from home. Upon further evaluation, the patient described his hobby of wine making which was believed to be the source of Saccharomyces cerevisiae. Once he stopped wine making at home and cleared his cellar, his symptoms stopped and have not returned since. CONCLUSION: We describe a rare presentation of non-asthmatic chronic cough associated with exposure to Saccharomyces cerevisiae. This is the first report of fungi associated chronic cough without asthmatic features outside of Japan and the first one associated with Saccharomyces cerevisiae. This report provides further evidence linking fungi with chronic cough syndrome without the features of asthma or allergic bronchopulmonary mycosis.

A Case Report Describing a Rare Presentation of Simultaneous Occurrence of MPO-ANCA-Associated Vasculitis and Rheumatoid Arthritis.

Background. Renal-limited myeloperoxidase vasculitis with simultaneous rheumatoid arthritis is reported as a rare occurrence. Review of literature suggests that most patients had a diagnosis of rheumatoid arthritis for several years prior to presenting with renal failure from myeloperoxidase vasculitis. Case Presentation. A 58-year-old Caucasian male presented to the hospital experiencing malaise, fevers, decreased oral intake, nausea, and vomiting for one week duration. His past medical history consisted of newly diagnosed but untreated rheumatoid arthritis, hypertension, and non-insulin-dependent diabetes mellitus. He was found to have acute renal failure, proteinuria, and hypoglycemia. Standard therapy, including intravenous fluids, did not improve his acute renal failure. A vasculitis workup resulted in a positive myeloperoxidase anti-neutrophil cytoplasmic antibody (MPO-ANCA). Renal biopsy revealed crescentic glomerulonephritis (GN) pauci-immune type, suggestive of MPO-ANCA-associated vasculitis (MPO-AAV). Treatment consisted of prednisone, cyclophosphamide, and seven cycles of plasmapheresis, in addition to hemodialysis for uremia. Upon discharge, he received hemodialysis for another week and continued treatment with cyclophosphamide and prednisone. Conclusion. Patients with longstanding rheumatoid arthritis may develop renal failure due to nonsteroidal anti-inflammatory medication use and AA type amyloidosis; however, necrotizing glomerulonephritis with crescent formation has been rarely reported. This stresses the importance of early recognition and swift initiation of treatment.