'Malignant' hypertension from hyperaldosteronism: a case report.

Adrenocortical carcinomas (ACC) are rare with an incidence of 0.7-2 per million population per year and account for only 0.05%-2% of all malignant tumors. While majority of the functional ACC present as Cushing syndrome, recurrent hyperaldosteronism from metastatic ACC is exceedingly rare. We describe a 67-year old female presented with hypertensive urgency & hypokalemia as a result of hyperaldosteronism from an 8-cm right ACC. She underwent a radical right nephrectomy with adrenalectomy that normalized her blood pressure. However, a few years later she presented again with resistant hypertension from hyperaldosteronism, raising the suspicion of recurrence of ACC. A contrast-enhanced CT scan showed a normal left adrenal gland but revealed pulmonary metastases of ACC based on a lung biopsy. Chemotherapy was complicated with side effects leading to refusal of further chemotherapy, henceforth requiring high dose of spironolactone for blood pressure control. Despite curative surgery, metastatic functional ACC should be considered in patients presenting with secondary hypertension from recurrent hyperaldosteronism, due to its high recurrence rate. Besides standard cancer surveillance after a curative surgery, meticulous monitoring of blood pressure is a simple yet crucial way to detect cancer recurrence early.

A Rare Cause of Pulmonary Edema in the Postoperative Period.

With the increasing longevity of the population, the annual rates of hip arthroplasties performed have been steadily increasing over the past decade. Given the presence of medical comorbidities in the older patients, the peri-operative care of these individuals requires multi-specialty care, now more than ever. Hip arthroplasty is generally well tolerated, with early mortality after the procedure being <1%. Bone cement implantation syndrome (BCIS) is an entity that is occasionally encountered during or after the surgery. It is characterized by hypoxemia, hypotension, cardiac arrhythmias, and cardiac arrest leading to death, in severe cases. We report a case of a middle-aged female who developed refractory hypotension and pulmonary edema while undergoing hemiarthroplasty for a pathological femoral neck fracture and experienced cardiac arrest in the immediate postoperative period. Critical care physicians must familiarize themselves with promptly diagnosing and managing BCIS.

Pulmonary Tuberculosis in a Patient with Cystic Fibrosis.

CONTEXT: Mycobacterium tuberculosis (MTB) infection is rarely seen in cystic fibrosis (CF) patients. CASE REPORT: We report a 24-year-old CF patient with fever, cough, hemoptysis, and weight loss of 1week duration prior to admission. Past sputum cultures grew methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa. The patient was treated with broad spectrum antibiotics based on previous culture data, but failed to improve. Chest radiograph and computed tomography (CT) chest revealed chronic collapse of the anterior subsegment of right upper lobe and multiple bilateral cavitary lesions which were worse compared to prior films. MTB was suspected and was confirmed by positive acid-fast bacilli (AFB) smears and cultures. After receiving first-line antituberculous drugs, the patient's condition markedly improved. CONCLUSION: MTB is an infrequent finding, but considered a potential pathogen in CF patients, and may lead to serious pulmonary complications if there is a delay in diagnosis and treatment.

The impact of vaccination on influenza-related respiratory failure and mortality in hospitalized elderly patients over the 2013-2014 season.

BACKGROUND: Seasonal Influenza ("the flu") is a respiratory illness caused by influenza viruses. Yearly influenza vaccination is considered to be protective against illness and/or severity of illness and is recommended by CDC for all individuals > 6 months of age. However, the effectiveness of influenza vaccine in older individuals has come under question. OBJECTIVES: To describe the clinical characteristics and treatment outcomes of patients admitted to an academic tertiary care Veterans Administration hospital with influenza during the 2013-2014 influenza season and determine the impact, if any, of prior influenza vaccination upon patient outcomes. METHODS: Medical electronic records were searched for all patients admitted to the Little Rock Veterans Administration Hospital with proven influenza during the 2013-2014 influenza season. Cohorts of vaccinated and non-vaccinated patients were then compared to determine the impact of prior influenza vaccination upon respiratory-failure and mortality. RESULTS: Seventy patients met selection criteria. Mean age was 66 years. Sixty-four (91%) patients had at least one underlying co-morbid condition; these conditions included COPD, congestive heart failure, diabetes, and cancer. 60/70 (85%) tested positive for Influenza A, and 43 tested positive for H1N1. Oseltamivir was initiated in 55 (78%) patients. Forty-four percent of the patients had been vaccinated. When separated by vaccination status, those who had been vaccinated had higher rates of ICU admission, need for mechanical or non-invasive ventilation, and mortality. All but mortality reached statistical significance. CONCLUSION: The data suggest that there was no protective effect from prior vaccination in preventing hospital admission, respiratory failure, and mortality in this population of older men admitted to the hospital with influenza.

Tuberculosis reinfection in a pregnant cystic fibrosis patient.

Cystic Fibrosis (CF) is a multisystem disease predominantly affecting the airways and predisposing patients to recurrent infections with various multidrug resistant organisms. Mycobacterium tuberculosis (MTB) infection is rarely seen, but considered a potential pathogen in CF patients. We report a 26 year old pregnant CF patient on Ivacaftor who was admitted with symptoms suggestive of tuberculosis. Three years prior to the current admission, she had completed four drug anti- MTB therapy for pulmonary tuberculosis and was considered cured as her sputum cultures after six months of treatment were negative. Genotype analysis revealed the current MTB strain to be different from the strain causing the previous infection. After receiving first line anti-tuberculous regimen for nine months, the patient's condition markedly improved culminating in an uneventful pregnancy and delivery. To our knowledge, this is the only reported case of reinfection tuberculosis in a CF patient.

Acute airway obstruction due to spontaneous intrathyroid hemorrhage precipitated by anticoagulation therapy.

Acute airway compromise due to hemorrhage in of thyroid gland is a rare life-hreating condition. The increasing use of anticoagulants for various reasons is likely increased the occurrence of this this complication. We describe an elderly patient on anticoagulation for atrial fibrillation, which developed swelling on the right side of neck causing acute airway obstruction requiring emergency intubation for airway protection. Computed tomographic scan showed massive intrathyroid hemorrhage along with substernal extension. She had supratherapeutic INR which was appropriately corrected emergently. She underwent resection of the thyroid gland which showed multinodular goiter without any evidence of malignancy. Our case illustrates the rare but lethal bleeding complication of anticoagulants in critical anatomical area and we request physicians should be wary of similar conditions.

CT pulmonary angiography: an over-utilized imaging modality in hospitalized patients with suspected pulmonary embolism.

AIMS: To determine if computed tomographic pulmonary angiography (CTPA) was overemployed in the evaluation of hospitalized patients with suspected acute pulmonary embolism (PE). METHODS: Data were gathered retrospectively on hospitalized patients (n=185) who had CTPA for suspected PE between June and August 2009 at our institution. RESULTS: CTPA was done in 185 hospitalized patients to diagnose acute PE based on clinical suspicion. Of these, 30 (16.2%) patients were tested positive for acute PE on CTPA. The Well's pretest probability for PE was low, moderate, and high in 77 (41.6%), 83 (44.9%), and 25 (13.5%) patients, respectively. Out of the 30 PE-positive patients, pretest probability was low in 2 (6.6%), moderate in 20 (66.7%), and high in 8 (26.6%) (p=0.003). Modified Well's criteria applied to all patients in our study revealed 113 (61%) with low and 72 (39%) with high clinical pretest probability. When modified Well's criteria was applied to 30 PE-positive patients, 10 (33.3%) and 20 (66.6%) were found to have low and high pretest probability, respectively (p=0.006). D-dimer assay was done in 30 (16.2%) of the inpatients with suspected PE and all of them were found to have elevated levels. A lower extremity duplex ultrasound confirmed deep venous thrombosis in 17 (9.1%) of the patients with suspected PE, at least 1 week prior to having CTPA. CONCLUSION: Understanding the recommended guidelines, evidence-based literature, and current concepts in evaluation of patients with suspected acute PE will reduce unnecessary CTPA examinations.

Isoproterenol as an adjunct for treatment of idiopathic ventricular fibrillation storm in a pregnant woman.

Idiopathic ventricular fibrillation is a rare entity seen in a very small subset of patients presenting to the emergency department. Management of ventricular arrhythmias in pregnant women is similar to that in nonpregnant women, but special consideration is given to avoid adverse fetal effects when selecting antiarrhythmic agents. Electrical defibrillation is the intervention of choice in both pregnant and nonpregnant patients with ventricular fibrillation of all etiologies. This was not associated with any significant adverse effects for mother or fetus. Although lidocaine and sotalol are Food and Drug Administration category B antiarrhythmics used in pregnancy, Food and Drug Administration category C antiarrhythmics such as ß-blockers and category D drugs such as amiodarone can be used as pharmacologic adjuncts to facilitate termination of recurrent ventricular fibrillation where other agents have failed. Isoproterenol has been used to terminate recurrent ventricular fibrillation in patients with Brugada syndrome and torsades de pointes resistant to magnesium therapy. This case report describes a previously healthy 32-year-old pregnant woman with recurrent idiopathic ventricular fibrillation that failed to respond to standard therapy including electrical defibrillation, intravenous lidocaine, metoprolol, and amiodarone but eventually terminated with isoproterenol infusion.

Beware of undetected hypoglycaemia.

Hypoglycaemia leading to altered consciousness level in patients with diabetes is a commonly encountered problem in the emergency department. Prompt diagnosis and the institution of appropriate therapy usually results in a significant improvement in the patient's condition. Capillary blood glucose evaluation is routinely used on patients presenting to the emergency department. However, the limitations of this test are not widely known. This case report draws attention to spuriously normal glucose readings with a capillary blood glucose evaluation device in certain patients who have significant hypoglycaemia confirmed on arterial blood gas analysis and laboratory venous blood analysis.