Cough Disguised as Airway Centered Interstitial Fibrosis

Introduction:Airway centered interstitial fibrosis (ACIF) is a rare form of interstitial lung disease (ILD). ACIF has been seen in patients who have hypersensitivity pneumonitis, gastroesophageal reflux disease (GERD), and connective tissue diseases. Studies have also found it associated with inhalational exposures. It is characterized by small airway centered interstitial fibrosis and metaplastic bronchiolar epithelium encompassing fibrotic bronchioles.Case Description:A 44-year-old female with a past medical history of GERD presented to the pulmonary office with chronic productive cough for the past 4 years with worsening dyspnea on exertion. She previously worked in the textile industry and housekeeping. She indicated that she was an obsessive cleaner having chronic exposure to multiple household cleaning products. She also had two sisters who died at a young age from systemic lupus erythematosus. She was initially treated with a proton pump inhibitor for a cough secondary to GERD however her symptoms did not improve. She had a computed tomography (CT) of the chest which revealed bronchiectasis at the bases of the lungs bilaterally concerning for early ILD. Pulmonary function testing was remarkable for a decreased diffusion capacity for carbon dioxide. Bronchoscopy was unfortunately nondiagnostic. Rheumatologic workup was remarkable for a positive anti-nuclear antibody (ANA) however antibodies for all other connective tissue diseases were negative. She underwent an open lung biopsy which revealed fibrosis with prominent peribronchial metaplasia, lymphoid hyperplasia, and chronic pleuritis consistent with ACIF. She was started on prednisone and mycophenolate and reduced her exposure to household cleaning products with improvement in her symptoms.Discussion:Given our patient’s history of GERD, positive ANA, and inhalational exposures, she had many risk factors for developing ACIF. ACIF is typically seen in females with a mean age of 57 years old however our patient presented at a slightly younger age. The progression of ACIF is variable but it has been found to have a better prognosis than idiopathic pulmonary fibrosis. Overall, it is important to have a high index of suspicion for ACIF in patients who present with a history of GERD, inhalational exposures, or connective tissue diseases. Diagnosis often requires surgical lung biopsy but prompt treatment for these individuals could improve their long-term prognosis

Acute Interstitial Nephritis Secondary to Lamotrigine: A Case Report

INTRODUCTION: Over the past few years, lamotrigine has become more popular as both an antiepileptic and a mood stabilizer. Common side effects of this medication include headache, tremor, blurry vision or gastrointestinal complaints. More serious complications can include Steven-Johnson Syndrome or aseptic meningitis. Although acute interstitial nephritis (AIN) is usually associated with non-steroidal antiinflammatory (NSAID) medications or antibiotics, there are a handful of cases of this condition being associated with lamotrigine. METHODS: A 25 year old male initially presented to the emergency department with fever, bilateral flank pain and decreased urination. Medical history was only remarkable for bipolar 2 disorder, for which he was started on lamotigine a few months prior. Upon arrival to the hospital, he was febrile but hemodynamically stable. His lab work was remarkable for a creatinine doubled from his baseline, a leukocytosis and eosinophilia. Imaging was consistent with bilateral pyelonephritis. He was initiated on antibiotics and admitted for further management. Over the course of the next few days, the patient’s creatinine progressively increased with minimal urine output. He developed a diffuse maculopapular rash of unknown etiology. He was ultimately started on hemodialysis. After his infectious work up was negative, he was started on pulse dose steroids. Subsequent rheumatologic work up was negative. Kidney biopsy revealed interstitial nephritis with granulomatous features and vasculocentric distribution. The patient’s lamotrigine was discontinued out of concern for a possible hypersensitivity syndrome. His renal function and diffuse rash subsequently improved. He was then discharged to home with full recovery of his kidney function. RESULTS: This is a rare case of acute interstitial nephritis developing after initiation of lamotrigine. AIN can occur from one day to several months after initiation of an offending agent and is often associated with elevated creatinine and decreased urine output. This condition is typically associated with NSAIDS or antibiotics; however, there are rare cases of lamotrigine being the underlying culprit. Therefore, in patients with new-onset renal failure in the setting of current lamotrigine therapy, AIN should always be considered

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

A Rare Case of Urinothorax Due to Spontaneous Renal Calyx Rupture

Introduction:Pleural effusion of extra-vascular origin (PEEVO) occurs when fluid from an extrapleural space migrates to the pleural cavity. This fluid can originate from the genitourinary tract, abdomen, central nervous system, or the biliary tract. Transudative effusions of extra-vascular origin consist of fluid which contains urine, peritoneal dialysate, central venous catheter infusate, cerebrospinal fluid or glycinothorax seen as complication from transurethral surgery. Described below is a rare case of a urinothorax due to spontaneous renal calyx rupture.Case Description:An 80-year-old male with a remote history of bladder cancer presented to emergency department with several days of shortness of breath. He was noted to be hypoxic and in moderate respiratory distress on physical exam. Computed Tomography (CT) of the chest revealed a left-sided pleural effusion and retroperitoneal fluid in the upper abdomen; he was given diuretics and antibiotics for community-acquired pneumonia and transferred to our institution. Subsequent CT angiogram of the abdomen showed bilateral hydronephrosis with left sided perinephric stranding and fluid likely secondary to calyx rupture. He subsequently underwent left-sided thoracentesis that yielded 1.8 liters of serosanguinous fluid. Fluid studies revealed a pH of 8.12, lactate dehydrogenase of 239, glucose of 115, and pleural fluid-to-serum creatinine ratio of 1.15, leading to a diagnosis of urinothorax secondary to a forniceal rupture.Discussion:Urinothorax, or the presence of urine in the pleural space, is a very unusual cause of pleural effusion. The mechanism behind this condition involves the leakage of urine into the retroperitoneal space, which then migrates to the pleural space via diaphragmatic lymphatics and/or anatomical defects in the diaphragm. Urionthoraces can further be classified into obstructive (caused by obstructive uropathies) or traumatic in origin. To our knowledge, urinothorax due to spontaneous renal calyx rupture has rarely been reported. These effusions are typically transudative and exhibit a low pH; however, this is not true in all cases. The diagnosis can ultimately be confirmed by a pleural fluid-to-serum creatinine ratio greater than one and is effectively treated with adequate drainage of the pleural space and correction of the underlying urologic pathology