Tracheobronchomalacia: An Unreported Pulmonary Complication of Acute Pancreatitis

Acute Pancreatitis (AP) is a common disease with systemic complications, specifically pulmonary complications that are well-documented [1]. Here we present, to the best of our knowledge, the first reported case of tracheobronchomalacia as a respiratory complication of AP. A 54-year-old white male with multiple chronic comorbidities developed necrotizing acute pancreatitis (NAP) following a surgical procedure. Internal Medicine evaluated and managed his NAP according to protocol. Within one week of NAP onset, the patient developed rapid respiratory distress. Chest radiography and ABGs were unable to diagnose ARDS. A CT scan with IV contrast was completed to investigate a pulmonary embolus and found the tracheal diameter variations during inspiration and expiration of the respiratory cycle consistent with tracheobronchomalacia (TBM). The patient’s respiratory status continued to deteriorate requiring endotracheal intubation and mechanical ventilation with weaning trials proving to be futile. The patient eventually developed fungemia and expired after his family opted for palliative extubation. Airway collapse related to TBM is an under-recognized diagnosis which should be suspected in patients with NAP who develop acute respiratory distress in whom no specific etiology has been determined

Primary Diffuse Large B-cell Lymphoma of the Sigmoid Colon

Primary gastrointestinal lymphoma is the most common type of extra-nodal lymphoma, representing about 30%-50% of all extra-nodal involvement. The stomach is the most common site, with the colon and rectum accounting for a minority of occurrences. Primary colorectal lymphoma is uncommon, representing only 0.3% of all large intestinal malignancies and approximately 3% of gastrointestinal (GI) lymphomas, with the majority of these being B-cell non-Hodgkin lymphoma and diffuse large B-cell lymphoma (DLBCL) being the most common subtype. We present a case of an 85-year-old male who presented with symptoms suggestive of bowel obstruction, who, after further evaluation, was diagnosed with primary non-Hodgkin lymphoma of the colon, DLBCL subtype

Prognostic Role of Albumin Level in Heart Failure: A Systematic Review and Meta-Analysis

BACKGROUND: Hypoalbuminemia (HA) is common in HF, however, its pathophysiology and clinical implications are poorly understood. While multiple studies have been published in the past decade investigating the role of serum albumin in HF, there is still no consensus on the prognostic value of this widely available measure. The objective of this study is to assess the prognostic role of albumin in heart failure (HF) patient. METHODS: Unrestricted searches of MEDLINE, EMBASE, Cochrane databases were performed. The results were screened for relevance and eligibility criteria. Relevant data were extracted and analyzed using Comprehensive Meta-Analysis software. The Begg and Mazumdar rank correlation test was utilized to evaluate for publication bias. RESULTS: A total of 48 studies examining 44,048 patients with HF were analyzed. HA was found in 32% (95% confidence interval [CI] 28.4%-37.4%) HF patients with marked heterogeneity (I2 = 98%). In 10 studies evaluating acute HF, in-hospital mortality was almost 4 times more likely in HA with an odds ratios (OR) of 3.77 (95% CI 1.96-7.23). HA was also associated with a significant increase in long-term mortality (OR: 1.5; 95% CI: 1.36-1.64) especially at 1-year post-discharge (OR: 2.44; 95% CI: 2.05-2.91; I2 = 11%). Pooled area under the curve (AUC 0.73; 95% CI 0.67-0.78) was comparable to serum brain natriuretic peptide (BNP) in predicting mortality in HF patients. CONCLUSION: Our results suggest that HA is associated with significantly higher in-hospital mortality as well as long-term mortality with a predictive accuracy comparable to that reported for serum BNP. These findings suggest that serum albumin may be useful in determining high-risk patients

Fragmentation of Ventricular Extrasystoles: A Potential New Electrocardiographic Window to Uncover Patients at Risk

Fragmented QRS (fQRS) is a marker of conduction block due to myocardial scar that presents in electrocardiography (ECG) as an additional one or more R wave (R\u27) or notching in the S wave nadir in contiguous leads. However, fQRS description on premature ventricular contractions (PVCs) has not been previously described. We describe a case of a 67-year-old male with a past medical history of prediabetes, hypertension and coronary artery disease who presented after an ophthalmic procedure with asymptomatic PVCs and episodes of bigeminy. Initial ECG showed an isolated fQRS in V2. However, during PVCs significant extrasystoles fragmentation was seen in other coronary territories. Upon reviewing his most recent cardiac catheterization, it showed a 40% ostial and 70% distal left anterior descending stenosis with a mid-segment patent stent, 95% first diagonal stenosis and totally occluded proximal right coronary artery. Identification of diffuse fQRS known to be associated with myocardial scar, sustained arrhythmic events and sudden cardiac death, particularly when seen in the inferior leads, became extremely relevant in our patient. We noted that ejection fraction reduction from 52% to 34% on his last coronary intervention was crucial to decide if an implantable cardioverter-defibrillator would be needed. PVC fragmentation might be a new ECG marker that could uncover both scar and arrhythmia potential in patients at risk of adverse cardiac events

A Rare Case of Tolosa-Hunt Syndrome

Tolosa-Hunt syndrome is a rare neurological disorder with an incidence of one case per million. It is a granulomatous inflammatory condition that affects the cavernous sinus and is characterized by painful ophthalmoplegia and headaches. We present a 57-year-old male veteran with past medical history of alcohol use disorder, hepatitis c, hypertension and tobacco use who presented with complaints of double vision and headaches for 2 days. The patient also had a history of well controlled cluster headaches treated with sumatriptan. But, he reported that from several days prior to admission, the headaches were getting more frequent, sharp, localized to the left side, and preventing him from sleeping. On physical exam, vitals were stable, the neck was supple, the pupils were equal in size and reactive to light but limited left eye abduction and external rotation were noted. The remainder of physical exam was unremarkable including the remaining cranial nerves. Computerized tomography (CT) head was done which showed no evidence of acute stroke. Magnetic resonance imagining (MRI) brain was performed which showed an asymmetric bulge of the left cavernous sinus which raised suspicion for cavernous sinus inflammation. Systemic high dose steroid trial was given. Patient’s symptoms improved within 72 hours and diagnosis of Tolosa-Hunt Syndrome was confirmed. According to the National Organisation for Rare Disorders (NORD) the average age of onset for this condition is 41 years. The pathogenesis is thought to be inflammation of unknown etiology. The criteria for diagnosis fo Tolosa-Hunt syndrome is given by International Headache Society, which includes: Unilateral headache; MRI or biopsy demonstrating granulomatous inflammation of cavernous sinus, superior orbital fissure or orbit; ipsilateral nerve palsy involving one or more of 3rd, 4th and/or 6th cranial nerves; no alternate diagnosis based on the symptoms; specific history of ipsilateral headache localized to the ipsilateral brow and eye and it should occur 2 week before the oculomotor palsy or along with it. Our patient met all the criteria mentioned above. Ruling out other causes of headache and ophthalmoplegia is important in making the diagnosis. A differential diagnosis includes cavernous sinus thrombosis, stroke, vasculitis, myasthenia gravis, Miller Fisher variant of GBS, multiple sclerosis and idiopathic intracranial hypertension. Currently, inadequate data is available to determine the best route and duration of treatment with steroids. Our patient received oral steroid 100 mg for 3 days followed by slow steroid taper and had improvement in symptoms. Although a rare disorder, it is important to consider Tolosa-Hunt syndrome in the differential diagnosis of patients who presents with headaches and visual changes, especially after ruling out other common causes

Factors That Affect Prevalence of Small Intestinal Bacterial Overgrowth in Chronic Pancreatitis: A Systematic Review, Meta-Analysis, and Meta-Regression

OBJECTIVES: Small intestinal bacterial overgrowth (SIBO) can complicate chronic pancreatitis (CP) and interfere with management. Its predisposing factors in CP and treatment response are unknown. In this review, we evaluated factors affecting disease burden. METHODS: A computerized search of PubMed and EMBASE databases from inception through May 2019 was done for studies correlating SIBO with CP. Studies were screened, and relevant data were extracted and analyzed. Pooled prevalence, odds ratio (OR), and meta-regression were performed using the random effects model as classically described byBorenstein et al. (2009). SIBO\u27s relation to diabetes mellitus (DM), pancreatic exocrine insufficiency (PEI), narcotic use, and proton-pump inhibitor use was investigated. Treatment response was pooled across studies. P value \u3c 0.05 was considered significant. RESULTS: In 13 studies containing 518 patients with CP, SIBO prevalence was 38.6% (95% confidence interval [CI] 25.5-53.5). OR for SIBO in CP vs controls was 5.58 (95% CI 2.26-13.75). Meta-regression showed that PEI and the diagnostic test used were able to explain54%and43%of the variance in SIBO prevalence across studies, respectively.DMand PEI were associated with increased SIBO in CP withOR (2.1, 95% CI 1.2-3.5) and OR (2.5, 95% CI 1.3-4.8), respectively. Symptomatic improvement was reported in 76% of patients after SIBO treatment. DISCUSSION: SIBO complicates 38% of CP with OR of 5.58 indicating a predisposition for this condition. PEI correlates with SIBO in CP and might play a role in pathophysiology. DM and PEI are associated with increased SIBO in CP. Treatment of SIBO may lead to symptomatic improvement

Oral Vancomycin Prophylaxis for the Prevention of Clostridium Difficile Infection: A Systematic Review and Meta-Analysis

Objective: Recently, oral vancomycin prophylaxis (OVP) has been suggested for the prevention of Clostridium difficile infection (CDI). We conducted a systematic review and meta-analysis to investigate the efficacy and safety of this approach. Design: Systematic review and meta-analysis. Methods: We conducted a computerized search of MEDLINE, EMBASE, and Cochrane databases from inception to March 2019 for publications investigating OVP for CDI prevention. Results were screened for eligibility. Relevant data were extracted and analyzed. Publication bias was assessed using the Egger test. Results: Ultimately, 8 retrospective studies and 1 prospective study examining 2174 patients, published between 2016 and 2019 were included in the review. OVP was associated with decreased CDI (odds ratio, 0.263; 95% confidence interval, 0.13-0.52) with considerable heterogeneity (I2 = 61%). Meta-regression showed that total daily dose of OVP correlated with CDI, explaining 100% of heterogeneity between studies. Furthermore, 3 studies evaluated the risk of vancomycin-resistant enterococci (VRE) infection after OVP and found no significant increase. Conclusion: Our results suggest that OVP might decrease CDI rates in at-risk populations, although this conclusion should be interpreted with caution. Higher daily doses of OVP might increase CDI. Although the use of OVP in high-risk patients may reduce CDI, this suggestion has yet to be validated by prospective blinded randomized controlled trials