Catastrophic Cardiac Complications of Takayasu\u27s Arteritis.

Takayasu\u27s arteritis (TA) causes inflammation and necrosis of vessel walls, leading to aneurysm formation, extensive coronary damage and valvular abnormalities. We review a case of recurrent coronary, aortic and mitral valve involvement in a patient with TA and discuss the various treatment options available for such patients

A Not so Benign Beach Trip: Coral Induced Hypersensitivity Pneumonitis

The Florida Keys is famous for having the only living coral reef system in the continental US. Coral dust is a common, but rarely clinically significant allergen. We document here a case of a 50-year-old female who developed acute hypersensitivity pneumonitis (HP) secondary to coral dustA 50-year-old female with past medical history of hypertension and asthma presented to the hospital with 1 week of acute progressive shortness of breath which began during a vacation to the Florida Keys. She had completed a 7-day course of fluoroquinolone therapy for symptoms of cough and sputum production prior to presentation in the ED. Upon presentation, she was afebrile, hypertensive, and oxygen saturation was 70% on room air, with significant increased work of breathing. Bipap was initiated and she was admitted to the MICU. Initial lab studies were significant for leukocytosis with eosinophilia. Chest x-ray revealed extensive bilateral infiltrates. CT angiography of the chest was performed and was negative for pulmonary embolism but demonstrated bilateral ground glass opacities. The patient was then placed on antibiotic therapy for community acquired pneumonia, but her condition did not improve with standard treatment. Immunological workup was negative. Initial consideration for HP had been abandoned as there was no exposure to any mold, dust, mites, pollen, smoke, or local allergens in her history, however on re-evaluation it was noted that while at the beach on her vacation she had been exposed to coral dust. She was then started on steroid therapy with rapid improvement in her respiratory status. She was discharged home on 2L nasal cannula.Florida is home to north America’s only living coral reef; and approximately 2.25 million tourists annually. Currently, there are no published cases of coral dust HP. Per local news, if the winds are strong enough the coral dust is taken airborne and affects tourists who have a history of asthma or other allergies. Lack of awareness of coral dust as a possible allergen lead to a delayed diagnosis of this patient and unnecessary testing including rheumatologic profile, CTPE, antibiotics, and a prolonged hospital stay. Recognition of hypersensitivity pneumonitis is critical for treatment, as it has a distinct treatment paradigm involving steroids. The importance of a thorough history including social history is of critical importance even when evaluating patient’s in the critical care setting

The Utility of Intravenous Immunoglobulin (IVIG) in the Treatment of Anti-Melanoma Differentiation Associated Protein 5 (anti-MDA5) Dermatomyositis (DM)

Anti-MDA5 positive amyopathic dermatomyositis is a rare variant known to be associated with rapidly progressive interstitial lung disease without well-defined optimal therapy and variable prognosis. Our case explores the use of intravenous immunoglobin (IVIG) as a maintenance therapy for this rare entity.A 71-year-old male presented with nonspecific symptoms of fatigue, weight loss, and progressive dyspnea. Initial evaluation suggested ILD of unclear etiology on CT imaging and confirmatory biopsy. Approximately one year later, the patient presented with symmetric hand swelling with polyarthralgia and fissuring of the palmar surfaces. He was also noted to have violaceous and erythematous redness over his face, chest, and neck. This prompted the workup for amyopathic DM, more specifically anti-synthetase syndrome. He had negative serologies for Aldolase, ANA, Anti-Jo-1, RF, and anti-CCP. His CK was elevated and Anti-Mi-2 was not obtained. Further evaluation at confirmed the diagnosis of Anti-MDA5 DM. The patient was stared on pulse steroids, and a brief course of tacrolimus followed by IVIG. He had imaging and functional improvement. He is currently under consideration for adding rituximab onto his clinical regimen.Anti-MDA5 dermatomyositis can be a diagnostic challenge for most physicians and requires expert consultation for initiating treatment. The current treatment approach varies based on severity of presentation and patient tolerance of the available agents. One Japanese trial demonstrated that the overall 6-month survival rate for anti-MDA5 with ILD is 50%-60%. Although smaller trials have occurred, this case adds to the literature on the role of IVIG in Anti-MDA5 dermatomyositis associated ILD. treated with IVIG when compared to other immunosuppressive therapies such as intravenous cyclophosphamide. Agents such as tacrolimus and rituximab have also demonstrated good results with resolution of ILD. This case report highlights the importance of considering IVIG in patients with anti-MDA5 dermatomyositis. This is a rare subtype of dermatomyositis, with a severe ILD, and highlights the need for additional investigation and comparison of the available treatment strategies

Post-Extubation Stridor Complicating COVID-19-Associated Acute Respiratory Distress Syndrome: A Case Series.

Post-extubation stridor is a known complication of mechanical ventilation that affects a substantial number of all critical care patients and leads to increased morbidity and mortality. Common risk factors for the development of post-extubation stridor include female gender, older age, and prolonged length of mechanical ventilation. There may be an increased incidence of post-extubation stridor in patients who require mechanical ventilation to manage the respiratory complications of COVID-19. In this case series, we analyzed nine patients from across our institution who were intubated to manage acute respiratory distress syndrome (ARDS) secondary to COVID-19 and subsequently developed post-extubation stridor. The patients were predominantly females with prolonged intubations and multiple days of prone ventilation. While the patients in this case series possessed some of the well-described risk factors for post-extubation stridor, there may be risk factors specific to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection that make these patients more susceptible to the complication. The cuff leak test was performed on the majority of patients in the case series and did not successfully predict successful extubation in this population. Our analysis suggests that prophylactic corticosteroids given in the 24-48 hours prior to elective extubation in female COVID-19 patients who were intubated for more than six days with consecutive days of intermittent prone ventilation may be helpful in reducing the incidence of post-extubation stridor in this population. Overall, this case series elucidates the need for exceptionally close monitoring of COVID-19 patients upon extubation for the development of stridor