Pregnancy-associated Spontaneous Pneumomediastinum: A Contemporary Review

Spontaneous pneumomediastinum (SPM), also referred to as mediastinal emphysema, is defined as the presence of free air in the mediastinal cavity without a clear and identifiable cause. Spontaneous pneumomediastinum, in general, is a relatively rare condition, more so in the setting of pregnancy or labor. Clinically, SPM may present as dyspnea, chest pain, and subcutaneous swelling, which may be of serious concern in the setting of pregnancy. A comprehensive literature review revealed that the majority of patients are primiparas, of a younger age, and have term or longer durations of pregnancy. The second stage of labor was found to be most commonly associated with the development of SPM. The pathomechanism suggests that performing the Valsalva maneuver during the active stages of labor may play a role in the development of SPM. Once diagnosed, patients with SPM in pregnancy are admitted to the hospital, treated conservatively, and followed until resolution. SPM must be diagnosed and managed promptly due to rare but serious complications. In addition, dyspnea or chest pain with an unknown etiology should include SPM in the differential diagnosis, especially in the setting of pregnancy and labor

Conversion Disorder (Functional Neurological Symptom Disorder) Masquerading as Multiple Sclerosis: A Case Report.

Conversion disorder, also referred to as functional neurological symptom disorder, is a DSM-5 identified somatic disorder that presents with one or more neurological symptoms that does not clinically correlate with recognized neurological or medical conditions brought on by intense stress, emotions, or an associated psychiatric disorder. Multiple sclerosis (MS) is the most common immune-mediated inflammatory demyelinating disease of the central nervous system and usually presents in young adults with clinical manifestations that range from cognitive abnormalities, eye movement problems, motor and sensory impairments such as weakness and numbness, bowel/bladder dysfunction, fatigue, and/or pain. This case report presents a patient with functional neurological symptom disorder presenting with clinical signs associated with MS

Wellens\u27 Syndrome Presenting as Epigastric Pain and Syncope: An Unusual Presentation

Wellens\u27 syndrome, also regarded as left anterior descending coronary T-wave syndrome, is an electrocardiography (EKG) pattern that indicates critical proximal left anterior descending artery (LAD) stenosis. It is characterized by deeply inverted T-waves or biphasic T-waves in the anterior precordial chest leads in a patient with unstable angina. Patients typically present with symptoms consistent with acute coronary syndrome. We present a unique case of Wellens\u27 syndrome with no angiographic findings of significant stenosis in the proximal LAD but with significant occlusion of the proximal circumflex artery and initial presentation with a chief complaint of epigastric pain and syncope. Physicians need to recognize these characteristic EKG changes during the pre-infarction stage, as they represent myocardial necrosis. Many of these patients eventually develop extensive anterior myocardial infarction with marked left ventricular dysfunction and death if coronary angiography and coronary revascularization are not performed within a few weeks. If Wellens\u27 is seen, patients should undergo urgent cardiac catheterization

It\u27s Getting Hot in Here: A Rare Case of Heat Stroke in a Young Male.

Heat stroke is a severe acute illness characterized by a core temperature greater than 40°C (104°F) and central nervous system manifestations, such as delirium, convulsions, or coma, resulting from exposure to environmental heat or strenuous physical activity. Early recognition and treatment including aggressive cooling and management of life-threatening systemic complications, such as cardiac arrest, rhabdomyolysis and acute renal failure, are essential to reduce morbidity and mortality. Herein we describe a case of heat stroke in a 23-year-old male who suffered cardiac arrest in which prompt initiation of cooling measures prevented permanent neurological sequelae, provided swift neurological recovery and resolution of impending multi-organ dysfunction syndrome

Disseminated Varicella-Zoster Virus Infection Complicated by Encephalitis and Ramsay Hunt Syndrome in an HIV Patient

Varicella-zoster virus (VZV) is a human α-herpesvirus which cause primary varicella infection (chicken pox) or herpes zoster infection (shingles) after reactivation of the dormant virus. VZV infection is usually self-limited but disseminated infection can be seen in immunocompromised individuals. It can also get complicated by central nervous system (CNS) involvement. We describe a case of a 51-year-old male with human immunodeficiency virus (HIV) who presented with altered mental status and deficits in his right-sided cranial nerves of VI, VII, and VIII. The patient also had disseminated vesicular-pustular rash all over his body at different stages of healing. A diagnosis of disseminated VZV infection complicated by encephalitis and Ramsay Hunt syndrome was made and the patient was treated with intravenous acyclovir and oral prednisone with a rapid improvement. The coexistence of these conditions is rare. The purpose of this report is to increase awareness of the coexistence of these two conditions in HIV infected patients

A Broken Heart: Cardiac Arrest As the Initial Presentation of Myasthenic Crisis

Myasthenic crisis is a life-threatening condition commonly associated with respiratory failure and may present in unusual ways. However, there is paucity in the literature about the cardiac manifestations of myasthenia gravis. We present a case of a 61-year-old male who presented to the emergency room with upper respiratory infection symptoms who soon thereafter suffered sudden cardiac arrest. He was found to have shortened PR interval pre and post arrest onelectrocardiogram (EKG). Only past medical history, discovered post cardiac arrest, was myastenia gravis. All other causes of cardiac arrest were ruled out, and it was deemed to be due to a manifestation of myastenia gravis. The patient was treated with intravenous steroids and plasmapheresis with resolution of shortened PR interval. It is hypothesized that striatial muscle antibodies may trigger inflammation in cardiac muscle and cause conduction abnormalities. In addition, anti-Kv1.4 antibodies have been associated with EKG abnormalities, including QT prolongation and T-wave inversion. To our knowledge, we are the first to report myasthenic crisis manifesting with isolated cardiac arrest with pulseless electrical activity and a shortened PR interval

“Saw-Tooth Sign” in upper airway disorders — a case report

Pomiar spirometryczny pętli przepływ−objętość jest powszechnym badaniem umożliwiającym wykluczenie obturacyjnych chorób układu oddechowego. Pętle przepływ−objętość pokazują przepływ powietrza, odnosząc się do objętości płuc podczas maksymalnego wdechu i maksymalnego wydechu. Uważa się, że widoczne sporadycznie na pętlach przepływ-objętość wahania przepływu, nazywane „zębami piły”, są spowodowane obturacyjnymi procesami zachodzącymi w górnych drogach oddechowych, związanymi z ich zapadaniem się. Obszernie opisane w związku z powstawaniem obturacyjnego bezdechu sennego, wahania przepływu są związane także z innymi chorobami. Uważa się, że objaw „zębów piły” powstaje na skutek nagłych zmian ciśnienia wewnątrz światła przewodu. Pętle przepływ−objętość dostarczają istotnych informacji dotyczących wzorów wentylacji, ponadto, mogą wskazywać na ukryte choroby górnych dróg oddechowych. W pracy opisano przypadek pacjenta, u którego wystąpił objaw „zębów piły” na pętli przepływ−objętość.Spirometry flow-volume loop measurement is the screening test of choice to rule out obstructive lung diseases. Flow oscillations occasionally seen on flow volume loops, referred to as a “saw-tooth” sign, are thought to be due to an upper airway obstructive processes associated with upper airway collapsibility. Widely described in obstructive sleep apnea syndrome, flow oscillations have also been linked to many other upper airway pathologies. The mechanism by which flow oscillations occur is centered on the inspiratory and expiratory flow of air. It has been theorized that the mechanism of flow oscillations result from rapid intermittent changes in driving pressure or airway resistance. Since visual inspection of the flow volume loop can reveal presence of flow oscillations clinicians should be aware of this phenomenon and the presence of flow loop oscillations should clue physicians to rule out upper airway pathology

Pulmonary arterial hypertension: a current review of pharmacological management

Pulmonary hypertension (PHTN) is a rare and devastating disease characterized by progressive increases in pulmonary arterial pressure and pulmonary vascular resistance, which eventually leads to right ventricular failure and death. At present there is no cure for pulmonary arterial hypertension (PAH); however over the past decade targeted pharmaceutical options have become available for the treatment of PAH. Prior to evaluation for therapeutic options a definitive diagnosis of pulmonary arterial hypertension must be made via comprehensive physical exam and definitive diagnostic testing. Screening test of choice remains echocardiography and gold standard for definitive diagnosis is right heart catheterization. Once the establishment of a diagnosis of PAH is made therapeutic options may be a possibility based on a diagnostic algorithm and disease severity of the PAH patient. There are different classes of medications available with different mechanisms of actions which net a vasodilatory effect and improve exercise tolerance, quality of life as well and survival

Socioeconomic status and its relationship to chronic respiratory disease

  Socioeconomic status (SES) is defined as an individual’s social or economic standing, and is a measure of an individual’s or family’s social or economic position or rank in a social group. It is a composite of several measures including income, education, occupation, location of residence or housing. Studies have found a lower SES has been linked to disproportionate access to health care in many diseases. There is emerging data in pulmonary diseases such as COPD, asthma, cystic fibrosis, pulmonary hypertension and other chronic respiratory conditions that allude to a similar observation noted in other chronic diseases. In the setting of COPD, SES has an inverse relationship with COPD prevalence, mortality, health utilization costs and HRQoL. Asthma and cystic fibrosis show an increased severity and hospitalizations in relationship to a lower SES. Similar observations were seen in sarcoidosis, PHTN and obstructive sleep apnea. There remains a limited data on non-CF bronchiectasis and interstitial lung diseases. Population SES may be gauged by various measures such as education, occupation, marital status but no value is more indicative than income. Currently guidelines and management algorithms do not factor the effect of SES in the disease process. Despite the great amount of data available, a standardized method must be created to include SES in the prognostic calculations and management of chronic pulmonary diseases.

Socioeconomic Status and Its Relationship to Chronic Respiratory Disease

Socioeconomic status (SES) is defined as an individual’s social or economic standing, and is a measure of an individual’s or family’s social or economic position or rank in a social group. It is a composite of several measures including income, education, occupation, location of residence or housing. Studies have found a lower SES has been linked to disproportionate access to health care in many diseases. There is emerging data in pulmonary diseases such as COPD, asthma, cystic fibrosis, pulmonary hypertension and other chronic respiratory conditions that allude to a similar observation noted in other chronic diseases. In the setting of COPD, SES has an inverse relationship with COPD prevalence, mortality, health utilization costs and HRQoL. Asthma and cystic fibrosis show an increased severity and hospitalizations in relationship to a lower SES. Similar observations were seen in sarcoidosis, PHTN and obstructive sleep apnea. There remains a limited data on non-CF bronchiectasis and interstitial lung diseases. Population SES may be gauged by various measures such as education, occupation, marital status but no value is more indicative than income. Currently guidelines and management algorithms do not factor the effect of SES in the disease process. Despite the great amount of data available, a standardized method must be created to include SES in the prognostic calculations and management of chronic pulmonary diseases