Coronavirus Disease 2019-Induced Tracheomegaly: A Case Report

Tracheomegaly is a medical condition where the tracheal diameter is greater than the upper limits of normal. Tracheomegaly can be classified as primary or secondary. Primary tracheomegaly is usually congenital. Secondary tracheomegaly can be due to multiple causes, including connective tissue disease, infections, autoimmune diseases like sarcoidosis, and prolonged mechanical ventilation. Here, we describe the first reported case of tracheomegaly secondary to coronavirus disease 2019 (COVID-19) pneumonia and COVID-induced interstitial lung disease (ILD). While many cases of tracheomegaly are asymptomatic, patients can have symptoms like cough, dyspnea, hemoptysis, or even respiratory failure. Tracheomegaly is associated with a higher risk of recurrent lower respiratory tract infections, chronic cough, bronchiectasis, and tracheobronchomalacia. Early recognition of COVID-19-induced tracheomegaly can help initial early management and reduce the incidence of infections.

Call for a Global Vaccine Plan to Combat Current and Future Pandemics: One for ALL and ALL for One

The emergence of SARS-CoV-2 in late December 2019 has taken the world by storm. In March 2020, the World Health Organization (WHO) named this virus COVID-19. To date, it has infected approximately 186 million people worldwide and is attributed as the cause of death of more than 5 million people (and this number is only increasing.) The global effort to develop vaccines and therapeutics occurred at the fastest pace yet, with several vaccines' approval under emergency authorization use. There are also several post-marketing side effects, including myocarditis, cerebral venous embolism, and Guillain Barre Syndrome. Global vaccine disparity complicates the control of pandemic challenges. Several highly infectious variants have emerged, and more variants are feared to emerge if global vaccination plans are not developed soon.

A Case Report on Mycobacterium abscessus: An Emerging Pathogen

The incidence of infections by rapidly growing mycobacteria has increased in recent decades. nontuberculous mycobacteria(NTM) represent over 190 species and subspecies and can cause both pulmonary and extrapulmonary symptoms. The Mycobacterium abscessus complex (MABC)is among the most drug-resistant mycobacterial species, and prompt diagnosis and effective eradication are burdensome. We present the clinical course of a 55-year-old female who was diagnosed with M. abscessus and explore her clinical diagnosis and possible treatment options. This case report emphasizes the challenges clinicians face in the prompt diagnosis of M. abscessus and discusses the treatment options in light of the recent guidelines.

Obstructive Sleep Apnea in Adults: What Primary Care Physicians Need to Know

Obstructive sleep apnea (OSA) remains a prominent disease state characterized as the recurrent collapse of the upper airway while sleeping and is estimated to plague 936 million adults globally. Although the initial clinical presentation of OSA appears harmless, it increases the risk of cardiovascular diseases such as heart failure, stroke, and hypertension; metabolic disorders; and an overall decrease in quality of life, in addition to increasing mortality. Current treatment of OSA includes lifestyle changes, behavioral modification, mandibular advancement devices, surgical treatment, and continuous positive airway pressure, which remains the gold standard. It is crucial to identify OSA early on and initiate treatment to mitigate the adverse health risks it imposes. This review will discuss the pathophysiology, epidemiology, management strategies, and medical treatment of OSA.

Severe Photosensitivity Reaction After Pirfenidone Use

Idiopathic pulmonary fibrosis is a chronic and progressive disease with a significant mortality rate. Pirfenidone is one of two oral antifibrotic therapies approved to treat idiopathic pulmonary fibrosis (IPF). Pirfenidone helps decrease disease progression in patients with IPF and reduces vital capacity. This has led to widespread use of this medication in recent years. In this case report, we present a 60-year-old male who started treatment with pirfenidone for IPF and had severe skin reactions after initiation of therapy.

Utilizing Artificial Intelligence in Critical Care: Adding A Handy Tool to Our Armamentarium

We have witnessed rapid advancement in technology over the last few decades. With the advent of artificial intelligence (AI), newer avenues have opened for researchers. AI has added an entirely new dimension to this technological boom. Researchers in medical science have been excited about the tantalizing prospect of utilizing AI for the benefit of patient care. Lately, we have come across studies trying to test and validate various models based on AI to improve patient care strategies in critical care medicine as well. Thus, in this review, we will attempt to succinctly review current literature discussing AI in critical care medicine and analyze its future utility based on prevailing evidence.

Cocaine-Induced Bronchial Laceration: A Rare Incidence

Tracheobronchial injuries are either traumatic or iatrogenic but can be lethal in a high dependency setting if not managed promptly. There are few reported cases of cocaine-induced airway damage and barotrauma due to thermal or ischemic injury and increased intra-alveolar pressure. We present a sui generis case of cocaine-induced bronchial laceration with pneumomediastinum which was challenging to diagnose based on the patient’s recent history of hospitalization, as well as the patient’s reluctance to share the history of cocaine use. The patient was successfully managed conservatively. Here, we discuss the mechanism involved and the various treatment options available, along with the role of early involvement of the multidisciplinary team to deliver the best possible outcome.

Foreign Body Aspiration Getting Weird: Crack Pipe Aspiration

Inhalation of cocaine derivatives is associated with a number of pulmonary and systemic complications. We report a case of less recognized complication, the aspiration of a metallic object used as a screen for crack cocaine abuse. A 42-year-old female presented with a two-day history of gradually worsening cough and a history of “food aspiration.” Her lung examination revealed wheezing and fine crackles with diminished air entry at the left base. A chest X-ray revealed an 8 mm radiopaque foreign body overlying the region of the left lower lobe bronchus, with a confirmatory computed tomography scan of the chest. An urgent bronchoscopy revealed a metallic foreign body impacted into the left lower lobe bronchus proper, soon after the takeoff of the superior segment, which was removed with forceps. The patient signed out against medical advice soon after. Though relatively uncommon, this case highlights a possible complication associated with crack cocaine abuse that may require emergent intervention.

Hemothorax After a Renal Biopsy With Ablation, a Rare Complication: A Case Report and Review of the Literature

Renal biopsy is an important diagnostic test which is used to extract kidney tissue with the help of a biopsy needle. It is frequently performed under ultrasonography or CT guidance. As with every other procedure, renal biopsy also carries some risks. Common complications of renal biopsy are damage to adjacent organs. Hemothorax is an exceedingly rare complication of renal biopsy. We report a case of a middle-aged female who developed a left-sided hemothorax after undergoing percutaneous renal biopsy with ablation and conducted a literature review of this rare complication.

An Intriguing Case of Pneumoperitoneum In a Patient With COVID-19: Do All Pneumoperitoneum Cases Need Surgery?

Pneumoperitoneum is pneumatosis in the potential space of the abdominal cavity. It is generally considered a surgical emergency and is mostly due to perforated hollow viscus. Rarely, pneumoperitoneum might occur even in the absence of bowel perforation. We hereby present a case of pneumoperitoneum in a patient with COVID-19 pneumonia and pneumomediastinum, which was managed non-surgically.

A Complicated Case of a Paravalvular Leak Following Mitral Valve Replacement

Paravalvular leaks (PVL) are an uncommon sequelae of valve replacement but can be seen as a complication of both mechanic and prosthetic valves. Patients with PVL may remain asymptomatic or have detrimental complications, which include heart failure, hemodynamically significant hemolysis, and endocarditis. Management depends on the clinical presentation and the degree of the valvular leak. We hereby present a case report of a patient with a complicated clinical course secondary to a PVL of the mitral valve. The patient had a recent mitral valve replacement and presented with symptoms of heart failure that was refractory to standard medical therapy. Valvular abnormality was not seen with initial trans-thoracic echocardiogram (TTE), but with high clinical suspicion, a trans-esophageal echocardiogram (TEE) was done confirming a PVL. The patient’s condition continued to deteriorate; he became hemodynamically unstable with end-organ damage. Cardiothoracic surgery was consulted for surgical repair of the PVL. The patient, however, remained too unstable for surgery and the family opted for comfort measures per the patient’s wishes.

Hyperparathyroidism and increased fractional excretion of phosphate predict allograft loss in long-term kidney transplant recipients

BACKGROUND

After kidney transplantation, fibroblast growth factor-23 (FGF-23) normally returns to baseline within 1 year whereas hyperparathyroidism persists in most kidney transplant (KT) recipients. As a result, serum phosphate remains relatively low in association with increased serum calcium and urinary phosphate excretion when compared to chronic kidney disease patients. The relationship between mineral metabolism and outcomes in long-term KT recipients has not been extensively studied. This study investigated whether the alteration in mineral metabolism influenced graft survival in long-term KT recipients.

METHODS

This study included 273 KT recipients after 1 year of transplantation. Mineral parameters were obtained at the time of enrolment and patients were followed prospectively for an average of 71 months.

RESULTS

Graft loss (death-censored) occurred in 41 (15%) patients. In univariate analysis, deceased donor transplantation, decreased serum albumin and estimated glomerular filtration rate, increased serum phosphate, parathyroid hormone (PTH), FGF-23 and fractional excretion of phosphate (FePi) predicted future allograft loss. After adjustments for cardiovascular disease risk factors, donor type, dialysis vintage, serum albumin and allograft function, only increased PTH and FePi remained associated with the outcome. Relationships between increased serum phosphate and FGF-23 with graft survival were lost after adjustments. Adjusted survival curves revealed the association between PTH > 90 pg/mL and FePi > 20% with worse graft survival.

CONCLUSIONS

Hyperparathyroidism and increased FePi predicted allograft loss in long-term KT recipients.

Mineral and bone disorder after kidney transplantation

After successful kidney transplantation, accumulated waste products and electrolytes are excreted and regulatory hormones return to normal levels. Despite the improvement in mineral metabolites and mineral regulating hormones after kidney transplantation, abnormal bone and mineral metabolism continues to present in most patients. During the first 3 mo, fibroblast growth factor-23 (FGF-23) and parathyroid hormone levels decrease rapidly in association with an increase in 1,25-dihydroxyvitamin D production. Renal phosphate excretion resumes and serum calcium, if elevated before, returns toward normal levels. FGF-23 excess during the first 3-12 mo results in exaggerated renal phosphate loss and hypophosphatemia occurs in some patients. After 1 year, FGF-23 and serum phosphate return to normal levels but persistent hyperparathyroidism remains in some patients. The progression of vascular calcification also attenuates. High dose corticosteroid and persistent hyperparathyroidism are the most important factors influencing abnormal bone and mineral metabolism in long-term kidney transplant (KT) recipients. Bone loss occurs at a highest rate during the first 6-12 mo after transplantation. Measurement of bone mineral density is recommended in patients with estimated glomerular filtration rate > 30 mL/min. The use of active vitamin D with or without bisphosphonate is effective in preventing early post-transplant bone loss. Steroid withdrawal regimen is also beneficial in preservation of bone mass in long-term. Calcimimetic is an alternative therapy to parathyroidectomy in KT recipients with persistent hyperparathyroidism. If parathyroidectomy is required, subtotal to near total parathyroidectomy is recommended. Performing parathyroidectomy during the waiting period prior to transplantation is also preferred in patients with severe hyperparathyroidism associated with hypercalcemia.