Bronchopleural Fistula Resolution with Endobronchial Valve Placement and Liberation from Mechanical Ventilation in Acute Respiratory Distress Syndrome: A Case Series

Patients who have acute respiratory distress syndrome (ARDS) with persistent air leaks have worse outcomes. Endobronchial valves (EBV) are frequently deployed after pulmonary resection in noncritically ill patients to reduce and eliminate bronchopleural fistulas (BPFs) with persistent air leak (PAL). Information regarding EBV placement in mechanically ventilated patients with ARDS and high volume persistent air leaks is rare and limited to case reports. We describe three cases where EBV placement facilitated endotracheal extubation in patients with severe respiratory failure on prolonged mechanical ventilation with BPFs. In each case, EBV placement led to immediate resolution of PAL. We believe endobronchial valve placement is a safe method treating persistent air leak with severe respiratory failure and may reduce days on mechanical ventilation

A Comprehensive Review of Current Treatments and Therapies for Idiopathic Pulmonary Arterial Hypertension

There are several classifications of Pulmonary Hypertension, one of them being Pulmonary Arterial Hypertension (PAH). In cases in which the cause of PAH is unknown, the disease is referred to as Idiopathic Pulmonary Arterial Hypertension (IPAH). IPAH is an extremely rare disease, making it difficult to treat. However, over the past few decades’ treatments have expanded and improved. Treatments commonly used in clinical practice include one or more of the following, calcium channel blockers, prostacyclin derivatives, endothelin receptor antagonists, phosphodiesterase 5 inhibitors, guanylate cyclase stimulators, and in extreme cases lung transplants (single or double) or heart and lung transplants. The aim of this paper is to review the treatments and therapies available for IPAH because new information has been added after FDA approval of new medications. This article also raises ideas of possible future clinical trials to look at how these medications would work in a combination therapy

Two patients with daptomycin induced eosinophilic pneumonia with different presentations and treatment

We present two cases of daptomycin-induced eosinophilic pneumonia with characteristic chest x ray, CT scan and bronchoalveolar lavage (BAL) findings. It is not a commonly seen complication of Daptomycin but when it happens, it could cause a diagnostic and treatment dilemma. Patients could present acutely with hypoxic respiratory failure or a less dramatic chronic presentation is also possible. Our two patients presented with acute hypoxic respiratory failure and presentation resembles that of an infectious etiology. Diagnosis is confirmed by bronchoscopy with BAL in one of them and the other was treated empirically as the clinical and radiologic presentation was typical. Treatment includes removal of the offending agent, daptomycin. Corticosteroids are used if symptoms are severe and can result in rapid clinical improvement. There is no agreed upon dose and duration of steroids and we suggest a long taper of steroids for patients who present with severe symptoms and a short course steroid for patients with milder symptoms

Pulmonary vein thrombosis secondary to tuberculosis in a non-HIV infected patient

Tuberculosis has been suggested as an independent risk factor for thromboembolism due to a hypercoagulable state induced by changes in clotting factors, protein C and vascular endothelium. Pulmonary vein thrombosis (PVT) is a rare, potentially serious and life-threatening condition that can be caused by tuberculosis. Its rare occurrence is due to a rich network of venous collateral vessels that drain the lung. PVT can also occur following lobectomy for malignancy, lung transplantation, radiofrequency catheter ablation for atrial fibrillation, sclerosing mediastinitis and following metastatic cancer, such as liposarcoma. Pulmonary vein thrombosis is difficult to diagnose clinically and requires a combination of conventional diagnostic modalities. Systemic anticoagulation, treatment of the predisposing pathology and monitoring of the thrombosis are parts of management of pulmonary vein thrombosis. We present a case of pulmonary vein thrombosis due to tuberculosis. Our patient is a 67-year-old Caucasian male with a past medical history significant for hypertension and hyperlipidemia who came to our hospital with hemoptysis, cough and shortness of breath 1-month duration. He also noticed around 20 pounds of weight loss and night sweats but had no fever. He had no history of travel outside the USA and has never been incarcerated before, but he endorsed that his son has been in Jail before but the son has never been diagnosed with TB. He quit smoking 2 months ago. He was tachycardic, tachypneic and had decreased air entry with crepitation in the right side of the posterior chest. Chest x ray showed multiple cavitary lesions in the right upper lobe area. CT scan of the chest with contrast showed pulmonary venous partial thrombosis in the right upper lobe with multiple cavitary lesions with hilar and mediastinal lymphadenopathy. Sputum AFB was positive for mycobacterium tuberculosis and was sensitive for rifampicin. Patient was treated with systemic anticoagulation and anti-tuberculosis medications. Patient’s hospital course was complicated by development of elevated liver enzymes at which time the anti-TB medications were stopped to be restarted one by one with a follow up of his liver enzymes and liver function tests. Our case shows that presentation of patients with PVT is non-specific and needs a very high index of suspicion for proper diagnosis and management to prevent further complications as it is associated with limb and life-threatening complications. It also illustrates the importance of considering PVT in a patient with tuberculosis

Massive hemoptysis due to recurrence of bronchial to pulmonary vascular malformation: A case report

Bronchial dieulafoy lesions are quite rare with relatively few case reports in the literature. Symptoms may vary but the lesion is often associated with hemoptysis and may present as massive hemoptysis. We present a case of a 69-year-old male with a recurrent episode of hemoptysis three years after treatment for a bronchial dieulafoy lesion. The bronchoscopy done three years prior during an initial episode of hemoptysis showed a visible dieulafoy deep within a subsegmental branch of the right lower lobe. This case is unique because there are no other reports within the literature of a delayed recurrence several years after previous treatment of a bronchial dieulafoy lesion, which in our case was due to bronchial to pulmonary vascular malformation. Bronchial arteriography revealed a bronchial artery to pulmonary artery vascular malformation, which was successfully treated with coil embolization

Carbon Monoxide: A Rare Cause of Myocardial Ischemia

In an acute care setting, chemical asphyxiants (CA) are a vice which cause debilitating injury. Carbon monoxide (CO) is one well known CA which causes hypoxic injury to cardiovascular and neurological tissue. CO poisoning is one of the leading causes of death in USA. As many as 6% of patients who get admitted with CO poisoning in the USA have acute myocardial infarction. A strong positive correlation of CO Hb concentration has been established with increased incidence of MIs. We present a case of a 75-year-old male with complaints of chest discomfort, dyspnea, diaphoresis that was attributed to CO poisoning. Over the course of his stay he had two sets of positive serial troponins and was diagnosed with a non-ST elevation MI. Most of the recent literature focuses on ST elevation and T wave inversions in patients with CO poisoning. Contrary to this, our patient did not exhibit any EKG changes at any point during his hospital course. CO poisoning can cause fatal complications including an MI

Hypoxic respiratory failure due to hyperammonemic encephalopathy induced by concurrent use of valproic acid and topiramate, a case report and review of the literature

Valproic acid (VPA) is widely used for the treatment of epilepsy, migraine, and a variety of psychiatric symptoms, including bipolar disorder, borderline personality disorder, and alcohol withdrawal. Valproate is associated with severe idiosyncratic adverse effects, the most notable being valproate-induced hyperammonemic encephalopathy (VHE). Topiramate is also a broad-spectrum anticonvulsant that is also extensively used for migraine prophylaxis, as a mood stabilizer, and for alcohol dependency. There is increased occurrence of VHE when valproate is used with other medications like phenytoin, phenobarbital, and topiramate. Our case report is on a young patient who was on valproic acid and topiramate and developed metabolic encephalopathy with hypoxic respiratory failure. We reviewed the causes and management of the hyperammonemic encephalopathy. We believe that clinicians should be aware of possible hyperammonemic encephalopathy in any patient who is taking valproic acid and presenting with impaired consciousness and cognitive decline. We also underline the importance of early recognition and high index of suspicion of encephalopathy related to hyperammonemia

Two patients with daptomycin induced eosinophilic pneumonia with different presentations and treatment

We present two cases of daptomycin-induced eosinophilic pneumonia with characteristic chest x ray, CT scan and bronchoalveolar lavage (BAL) findings. It is not a commonly seen complication of Daptomycin but when it happens, it could cause a diagnostic and treatment dilemma. Patients could present acutely with hypoxic respiratory failure or a less dramatic chronic presentation is also possible. Our two patients presented with acute hypoxic respiratory failure and presentation resembles that of an infectious etiology. Diagnosis is confirmed by bronchoscopy with BAL in one of them and the other was treated empirically as the clinical and radiologic presentation was typical. Treatment includes removal of the offending agent, daptomycin. Corticosteroids are used if symptoms are severe and can result in rapid clinical improvement. There is no agreed upon dose and duration of steroids and we suggest a long taper of steroids for patients who present with severe symptoms and a short course steroid for patients with milder symptoms

Rasburicase induced severe hemolysis and methemoglobinemia in a Caucasian patient complicated by acute renal failure and ARDS

Rasburicase is a recombinant urate-oxidase enzyme and is a very important medication for tumor lysis syndrome. Methemoglobinemia and hemolysis are known side effects of rasburicase that result from oxidative stress caused by hydrogen peroxide, a byproduct generated during the breakdown of uric acid to allantoin. Patients with G6PD deficiency have a decreased tolerance to oxidative stress and are therefore at a greater risk of hemolysis and methemoglobinemia with rasburicase. Our patient is a 56-year-old Caucasian male with a recent diagnosis of grade 2-3a non-Hodgkin's lymphoma who presented to our emergency department with shortness of breath and dark discoloration of urine. Patient was discharged 36 hours ago from our hospital after he was given a first course of R-CHOP regimen and a dose of rasburicase. On further evaluation, patient was found to have severe anemia with hemolytic picture, hyperkalemia and acute kidney injury. He also had a discrepancy of the transcutaneous saturation (75%) and the saturation in an arterial blood gas value (99%). His methemoglobin level was found to be 11.9%. We were aware that methylene blue is a contraindication in patients with G6PD deficiency but considering patient being Caucasian and low risk for it and his deteriorating respiratory condition, it was decided to offer the treatment and patient received 1 dose of methylene blue which failed to improve his methemoglobinemia. He was also given vitamin C and 8 units of packed red blood cell throughout his stay in the hospital. Patient's hospital course was complicated by ARDS needed to be on mechanical ventilation support for 4 days and acute renal failure secondary to pigment nephropathy and acute tubular necrosis which required a hemodialysis support. Even if rasburicase induced methemoglobinemia and hemolysis are not very common complications, clinicians who prescribe and follow patients should detect this serious complication early and manage it accordingly. Our case can be used as a reminder that patients should be followed closely and given the right instructions on discharge to treat these complications which are associated with severe consequences. It is also vital to assume a diagnosis of G6PD deficiency until proven otherwise in a patient who presents with rasburicase induced hemolysis and avoid administration of methylene blue even if the patient is from a low risk ethnicity for G6PD as in our patient

Emphysematous cystitis

Emphysematous cystitis is a rare form of complicated urinary tract infection characterized by gas inside the bladder and in the bladder wall. While the exact mechanisms underlying gas formation are not clear, gas-producing pathogens are clearly implicated in severe infection. E coli and Klebsiella pneumoniae are the most common organisms associated with emphysematous cystitis; others include Proteus mirabilis, and Enterobacter and Streptococcus species