The importance in early identification of a herpetic endobronchial mass.

We present a case of a 78 year old female that required intubation for hypercapnic, hypoxic respiratory failure, found to have an obstructing mass in the right main stem bronchus positive for Herpes Simplex (HSV) I and II on biopsy and immunohistochemistry (IHC). Herpetic endobronchial masses are described rarely, and having them on the differential when investigating endobronchial masses can promote prompt treatment and decrease unnecessary investigations. Our goals in highlighting this report include incidence of HSV pneumonia [7], the need to include it as part of the differential diagnosis in working up endobronchial masses, especially in intubated patients, and the various modalities of treatment.

Transection of lung as rare complication of pigtail catheter placement.

Pigtail catheters and chest tubes are commonly used for effective resolution of pneumothoraces and drainage of simple pleural effusions. Given their small calibers, better flexibility and more ease at the time of insertion, pigtail catheters are associated with lower risks of complications when compared to traditional chest tubes. Commonly reported complications of the pigtail catheters include the higher probability for clogging, kinking, and obstruction. Rare complications as air embolism, penetration of the heart and transection of the lungs are seldom reported in the literature. We present a case of an 81-year-old female presented with covid-19 pneumonia who developed bilateral spontaneous pneumothoraces requiring bilateral pigtail insertion. The patient developed worsening hypoxia and chest imaging revealed that the left pigtail was transected into the lung parenchyma. With this case report, we hope to bring to light a rare complication of pigtail placement.

Searching for the Culprit: When Diabetic Ketoacidosis Presents With Insulin Autoantibodies.

OBJECTIVE: The main objective was to describe and review a unique case that presented with diabetic ketoacidosis, positive insulin autoantibodies (IAAbs, which are found in Hirata disease and are usually present with hypoglycemia), and laboratory findings characteristic of type B insulin resistance syndrome (TBIRS) and systemic lupus erythematosus. Confirmation of TBIRS was obtained in Germany as immunoassay for insulin receptor antibodies (IRAbs) is not available in the United States. METHODS: A literature review on TBIRS and cases that present with IAAbs and IRAbs simultaneously was conducted. RESULTS: We found 6 cases presenting with hypoglycemia, both antibodies, and treatment attempts with various management approaches that were different from the proposed National Institutes of Health (NIH) protocol for TBIRS. Our case is distinct because of the demographic background, presentation with diabetic ketoacidosis, comparatively lower insulin requirement, and no significant hypoglycemic episodes in the third phase. CONCLUSION: We propose that access to IRAb immunoassays may be important for diagnosing milder cases of TBIRS, while IAAbs may provide prognostic and therapeutic insights. Despite completely different presentation from other TBIRS patients reviewed, we observed that the proposed NIH protocol consisting of dexamethasone, rituximab, and cyclophosphamide was successfully employed in our patient. Thus, we propose that our case and the findings regarding antibody testing and the NIH treatment regimen may assist clinicians with earlier recognition and effective management of milder cases of TBIRS.

Gardener's Nightmare: A Rare Case of Myroides-Induced Septic Shock.

Myroides species, an uncommon clinical isolate, generally found in contaminated sources of environment, is an emerging source of infections, especially amongst immunocompromised patients. Though only 54 cases have been reported to our knowledge, the emergence of pan-resistance to antibiotics remains a concern that may burden healthcare and require awareness. We present the case of an elderly female who despite being home-bound, without any environmental exposure, contracted Myroides septicemia that progressed to septic shock and showed resistance to usual empiric antibiotics. In our case, the patient was exposed to contaminated soil via her family and was successfully treated with carbapenem. The case provides awareness amongst clinicians to suspect this emerging yet threatening infection within immunocompromised patients.

A review of the characteristics and outcomes of 900 COVID-19 patients hospitalized at a Tertiary Care Medical Center in New Jersey, USA.

INTRODUCTION: There is a paucity of literature surrounding the in-hospital mortality and associated risk factors among coronavirus disease 2019 (COVID-19) affected patient populations in our geographical area, northern New Jersey. MATERIAL AND METHODS: A retrospective observational cohort study was performed in a tertiary care academic medical center with two locations in Paterson and Wayne serving Passaic County in northern New Jersey. The study included all 900 patients with a positive reverse transcriptase-polymerase chain reaction (RT-PCR) nasopharyngeal swab sample for severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) viral test. We determined the in-hospital 75-day mortality of patients treated in the intensive care unit (ICU) compared to the medical-surgical floor unit. RESULTS: Overall in-hospital 75-day mortality was 40.7% (n = 367). The ICU group had a 77.1% (n = 237) mortality and the floor group a 21.9% (n = 130) mortality. The ICU group of patients had a higher incidence of cardiac injury, acute renal injury, liver failure, vasopressor use and the elevation of serum markers: ferritin, lactate dehydrogenase, interleukin 6 (IL-6), D-dimer, procalcitonin, and C-reactive protein compared to the floor group. Multiple logistic regression analyses revealed that age > 65 years, elevated IL6, acute renal injury, cardiac injury, and invasive mechanical ventilation were risk factors associated with mortality. CONCLUSIONS: Age > 65 years, elevated IL6, acute renal injury, cardiac injury, and invasive mechanical ventilation were risk factors associated with mortality in our COVID-19 patients.

Role of the combined CHADS2 score and echocardiographic abnormalities in predicting stroke in patients with paroxysmal atrial fibrillation.

The purpose of the study was to determine if adding echocardiographic abnormalities (EA) to the CHADS2 score is superior to the CHADS2 score alone in predicting ischemic stroke in patients with atrial fibrillation (AF). We then determined if the presence of these criteria in patients with cryptogenic stroke (CS) could be used "backwards" to predict paroxysmal AF. Of 1633 patients with ischemic stroke admitted from January 2003 to December 2008, we retrospectively analyzed CHADS2 and/or EA prior to stroke in 276 patients with stroke with documented AF. We then assessed the presence of these abnormalities in 169 patients with CS. Additionally, the follow up electrocardiogram (ECG) in patients with CS for six months post stroke were reviewed. In AF stroke patients, 88.8% (245/276) had CHADS2 ≥ 2 alone prior to the stroke, however the ability to predict stroke increased to 97.5% (269/276) with addition of EA. Of 169 patients with CS, 63.1% (106/169) had CHADS2 ≥ 2 and/or EA prior to this stroke. Of 63 patients with six-month follow-up ECG available, AF was detected in six (9.5%) patients, all with high CHADS2 or EA. We found that the combined use of CHADS2 criteria and EA is more sensitive in determining the occurrence of ischemic stroke and the need for anticoagulation in patients with AF (97.5% compared to 88.8%). The detection of concealed AF in 9.5% of patients with CS on follow up ECG and the presence of high CHADS2 and EA in these patients emphasize the need for long-term event monitoring in these patients.

Coronary anomaly and coronary artery fistula as cause of angina pectoris with literature review.

Coronary artery fistulas are rare anomalies of the coronary arteries that may sometimes cause symptoms by shunting blood flow away from the myocardial capillary network. We report the case of a 46-year old lady which shows the right coronary cusp giving rise to left main coronary artery called anomalous origin of a coronary artery (AOCA), and also a fistula between the left coronary artery and pulmonary artery. We describe our diagnostic approach and review the literature on the epidemiology, pathophysiology, the diagnostic modalities, and treatment options.