Tracheobronchitis Due to Invasive Aspergillus fumigatus in a Male With HIV With Minimal Imaging Findings.

Aspergillus tracheobronchitis (AT) is a rare manifestation of invasive aspergillosis. We present a case of tracheobronchitis caused by Aspergillus fumigatus in a 33-year-old male with neutropenia and known human immunodeficiency virus (HIV) infection with acquired immunodeficiency syndrome (AIDS). A 33-year-old male with HIV/AIDS presented to the hospital with symptoms of productive cough for over two months associated with subjective fevers, chills, and body aches. Computed tomography (CT) of the chest was significant for scattered sub-centimeter bilateral upper lobe nodules but otherwise normal. The patient underwent an extensive evaluation for his respiratory symptoms, including an initial sputum culture, which grew Haemophilus parainfluenzae in addition to preliminary fungal growth, prompting further evaluation with bronchoscopy. Bronchoscopy revealed diffuse adherent obstructive pseudomembranous plaques in the trachea and bilateral upper lobe segmental bronchi. Bronchoalveolar lavage cultures later grew Aspergillus fumigatus. Tracheobronchitis due to Aspergillus species is a rare cause of infection in patients with HIV. We believe that this case underscores the importance of further evaluation utilizing bronchoscopy in patients with AIDS who have respiratory symptoms despite mild abnormalities on chest CT. This approach can be used to rule out atypical endobronchial infections such as tracheobronchitis due to Aspergillus species.

The characteristics and outcomes of patients with idiopathic pulmonary fibrosis admitted to the ICU with acute respiratory failure.

BACKGROUND: To date, studies have provided conflicting results regarding the outcomes of patients with Idiopathic Pulmonary Fibrosis (IPF) admitted to the ICU with acute respiratory failure (ARF). OBJECTIVE: To understand the characteristics and outcomes of these patients. METHODS: Retrospective study using a large single-center ICU database. We identified 48 unique patients with IPF admitted for ARF from 2001-2012. RESULTS: The most common causes of ARF were IPF exacerbation and pneumonia. The overall hospital mortality rate was 43.8% and was 56.7% in those who required invasive mechanical ventilation (IMV). In patients requiring IMV for IPF exacerbation, the mortality rate was 81.3%. In multiple regression analysis, the presence of diabetes mellitus was associated with decreased mortality whereas the need for IMV was associated with increased mortality. CONCLUSIONS: Although the overall mortality rate for IPF patients with ARF has improved, the need for IMV due to IPF exacerbations is associated with increased mortality.

Mortality Trends of Idiopathic Pulmonary Fibrosis in the United States From 2004 Through 2017.

BACKGROUND: The burden of idiopathic pulmonary fibrosis (IPF)-related mortality in the United States in recent years is not well characterized. RESEARCH QUESTION: What are the trends in IPF-related mortality rates in the United States from 2004 through 2017? STUDY DESIGN AND METHODS: We used the Multiple Cause of Death Database available through the Centers for Disease Control and Prevention website, which contains data from all deceased US residents. IPF-related deaths were identified using International Classification of Diseases, 10th revision, codes. We examined annual trends in age-adjusted mortality rates stratified by age, sex, race, and state of residence. We also evaluated trends in place of death and underlying cause of death. RESULTS: From 2004 through 2017, the age-adjusted mortality decreased by 4.1% in men (from 75.5 deaths/1,000,000 in 2004 to 72.4 deaths/1,000,000 in 2017) and by 13.4% in women (from 46.3 deaths/1,000,000 in 2004 to 40.1 deaths/1,000,000 in 2017). This overall decrease was driven mainly by a decline in IPF-related mortality in patients younger than 85 years. The decreasing trend also was noted in all races except White men, in whom the rate remained stable. The most common cause of death was pulmonary fibrosis. The percentage of deaths occurring in the inpatient setting and nursing homes decreased, whereas the percentage of deaths occurring at home and hospice increased. INTERPRETATION: From 2004 through 2017, the IPF age-adjusted mortality rates decreased. This may be explained partly by a decline in smoking in the United States, but further research is needed to evaluate other environmental and genetic contributors.

A Delayed Diagnosis of Hemorrhagic Shock in a Patient with Alcoholic Cirrhosis and Ascites on Bedside Ultrasound.

Undifferentiated shock is a common and challenging problem in critical care. We present a case of hemorrhagic shock due to splenic and hepatic lacerations diagnosed by bedside paracentesis, initially misclassified as septic shock due to suspected spontaneous bacterial peritonitis (SBP). Case. A 47-year old man with a history of reported alcoholic cirrhosis and ongoing heavy alcohol use was brought to the emergency room after a syncopal event. He was found to be anemic (hemoglobin 9.9 g/dl) and hypotensive with a blood pressure of 64/34. Despite crystalloid infusion he remained hypotensive and required vasopressor support with norepinephrine. Bedside ultrasound revealed moderate ascites and as there was no evidence of active bleeding, his shock was attributed to sepsis due to SBP. A bedside paracentesis was performed which revealed gross blood. A repeat hemoglobin returned at 4.4 g/dl. Massive transfusion protocol was initiated and interventional radiology was emergently consulted due to concerns for intraabdominal hemorrhage; general surgery deemed the patient too unstable for surgical intervention. Angiogram revealed a splenic laceration and possible hepatic laceration, both embolized successfully. Internal medicine practitioners should keep the differential of hemorrhagic shock due to intraabdominal organ injury in mind for patients with undifferentiated shock.