Ethambutol-induced bullous skin lesions in mycobacterium kansasii lung infection.

Mycobacterium kansasii is the second most common cause of nontuberculous mycobacterial (NTM) lung disease after Mycobacterium avium complex infection in the United States.[1] The first-line therapy for M. kansasii is a three-drug regimen including rifampin, isoniazid, and ethambutol. We present a case of a patient with pulmonary M. kansasii who developed bullous skin lesions while receiving this regimen and again after rechallenge with ethambutol. In patients with intolerance to one of the first-line antibiotics, a multidisciplinary team approach to starting second-line agents is needed. Ethambutol should be included in the differential diagnosis of drug-induced bullous skin lesions in treated patients with NTM, who develop new onset rash with blisters or ulceration.

Endobronchial blastomycoses: A rare pathogen in a unique location.

A middle-aged woman from Southwest Virginia presented to pulmonary clinic with 4 months of dry cough. Further imaging with Computed Tomography (CT) of the chest showed an infiltrative lung mass. The patient underwent bronchoscopy that showed an endobronchial lesion on right and left main stem bronchi. Endobronchial biopsy of the lesion showed acute and chronic granulomatous inflammation and tissue cultures grew Blastomycoses dermatitides. We hereby present a rare case of endobronchial blastomycoses with pulmonary infiltrates presenting as chronic cough.

Spontaneous posterior lung herniation: A case report and literature review.

Intercostal lung hernias are uncommon and usually a consequence of trauma or surgery. True spontaneous lung hernias are extremely rare, with only 51 cases identified over the past four-and-half decades. We report a case of nontraumatic chest wall ecchymosis secondary to spontaneous posterior-lateral lung herniation followed by a review of the literature. Interesting radiographic images are presented. The pathophysiology and therapeutic options of this condition are discussed. The case highlights that advanced chronic obstructive pulmonary disease (COPD) may be an etiological factor for the development of this rare entity, with cough being the precipitating event. Given the increasing prevalence of COPD, the authors believe further awareness of this pathology is needed.

Pneumocystis jirovecii pneumonia in newly diagnosed treatment-naïve chronic lymphocytic leukaemia.

A 78-year-old man with newly diagnosed treatment-naïve chronic lymphocytic leukaemia (CLL) was referred to a pulmonary clinic for 1 month of dry cough and dyspnoea on exertion. Further workup with CT of the chest showed patchy ground-glass opacities predominantly on the right side. The patient was started on empiric antibiotic for presumed community-acquired pneumonia but did not have any improvement in his symptoms and eventually required supplemental oxygen. Bronchoscopy with bronchoalveolar lavage from the right middle lobe showed Pneumocystis jirovecii cysts on Grocott methenamine silver stains. The patient was HIV negative. He was placed on P. jirovecii pneumonia (PJP) treatment with clindamycin and primaquine due to history of significant allergy to sulfa drugs. The patient's symptoms completely resolved after a 21-day course of treatment and no longer needed supplemental oxygen. This case highlights the importance of keeping PJP infection in differential diagnosis in both treated and untreated patients with CLL with dyspnoea and pulmonary infiltrates.

Prospective Randomized Controlled Pilot Study of High-Intensity Lightbox Phototherapy to Prevent ICU-Acquired Delirium Incidence.

Background This study aimed to evaluate the role of disturbed circadian rhythm in potentiating intensive care unit (ICU)-acquired delirium.Previous studies have demonstrated bright light therapy (BLT) as an effective modality to improve sleeping patterns and cognitive function in non-critically ill patients. However, its benefit in the ICU has not been clearly established. In this study, we aimed to evaluate the application of daily high-intensity phototherapy at the bedside to deter ICU delirium incidence and duration. Methodology This was a single center, prospective study conducted in ICUs at the Carilion Roanoke Memorial Hospital in Roanoke, VA. Adults patients admitted to the ICU from July 9, 2018 to March 20, 2020 were included in the study. The patients were subjected to 30-minute BLT session (10,000 lux) at the bedside starting at 0700 while in the ICU. Patients were randomized into either the control group (standard hospital lighting) or phototherapy group. Data were analyzed using Wilcoxon rank sum test for continuous variables, Pearson chi-square test for categorical variables, and logistic regression for multivariable analysis that examined significant risk factors for ICU delirium. Results Delirium incidence between BLT (18%) and control (17.5%) groups was non-significant. Total number of delirium-free, coma-free days, as determined by Confusion Assessment Method for the ICU, demonstrated no differences between groups with a median of 28 days (p = 0.516). In multivariable analysis, patients with a Sequential Organ Failure Assessment Score >3 also showed no significant change in ICU delirium incidence when provided bedside BLT compared to those with standard hospital lighting (odds ratio: 0.08; 95% confidence interval: 0.002-1.40; p = 0.867). Conclusions In this randomized control pilot study, daily morning 10,000 lux BLT of 30-minute duration alone was not associated with a significant decrease in ICU-acquired delirium incidence or duration compared to standard hospital lighting. Future studies should consider a nuanced approach to better elucidate the role of disturbed circadian rhythm in influencing ICU-acquired delirium by not only undertaking BLT during the day but also minimizing nighttime light exposure.

Idiopathic pulmonary vein thrombosis?

Idiopathic pulmonary vein thrombosis (PVT) is a rare disease which is likely under-diagnosed because of nebulous presentations. Accurate diagnosis is essential to prevent complications.

A case of asymptomatic pancytopenia with clinical features of hemolysis as a presentation of pernicious anemia.

Pernicious anemia is an autoimmune disease with a variety of clinical presentations. We describe a case of pernicious anemia presenting with pancytopenia with hemolytic features. Further workup revealed very low vitamin B12 levels and elevated methylmalonic acid. It is important for a general internist to identify pernicious anemia as one of the cause of pancytopenia and hemolytic anemia to avoid extensive workup. Pernicious anemia can present strictly with hematological abnormalities without neurological problems or vice versa as in our case.