INTRODUCTION: Despite recent advances in the diagnosis and treatment of asthma, status asthmaticus continues to be associated with significant morbidity and mortality. An estimated 60% of patients with status asthmaticus admitted to the intensive care unit require intubation1. Ketamine, Magnesium, and Heliox are some of the rescue therapies described in the literature for refractory status asthmaticus2. Sevoflurane is an inhaled anesthetic that has been successfully used for refractory status asthmaticus, however, its use has been largely limited to case reports3. We present the unique case of a 45-year-old male who received sevoflurane in anticipation for veno-venous extracorporeal membrane oxygenation (VV-ECMO) for refractory status asthmaticus.CASE PRESENTATION: A 45-year-old male with a past medical history of severe persistent asthma was admitted for acute asthma exacerbation. He denied any previous intubations and reported active cigar smoking. Chest x-ray demonstrated hyperinflation. Despite treatment with inhaled bronchodilators, high dose systemic steroids, and non-invasive positive pressure ventilation, he was intubated for worsening hypercapnic respiratory failure. He subsequently required rescue therapies including ketamine, epinephrine, magnesium, and aminophylline. Despite this, he continued to remain hypercarbic and acidotic with severe bronchospasm and elevated peak pressures (PPrs) to 100 mmhg with optimization of the ventilator to keep plateau pressures under 30 mmhg. Serial arterial blood gases (ABGs) showed a severe hypercarbia (PaCO2 >100 mmhg) and acidosis (pH<7.1). PaO2 remained above 55mmhg. Cardiothoracic surgery was consulted for evaluation of extracorporeal oxygenation by the means of VV-ECMO. The patient was transported to the OR and given inhaled sevoflurane perioperatively prior to cannulation. Serial ABGs were obtained prior to planned cannulation and revealed significant improvement of hypercarbia (PaCO2<70mmhg) and acidosis (pH>7.3). He was deemed not a candidate for VV-ECMO and returned to the ICU. He exhibited marked improvement over the next few hours and was extubated 5 days later. DISCUSSION:The potential bronchodilator properties of sevoflurane, an inhaled anesthetic almost limited to use in the operating room, allowed for improvement of respiratory dynamics and deferral of ECMO initiation. Physicians must consider the inhalational volatile anesthetic sevoflurane and its bronchodilator properties as a rescue therapy for severe refractory status asthmaticus.CONCLUSIONS: A trial of sevoflurane could be reasonable in patients planned for ECMO cannulation. The growing body of case reports should prompt consideration of a formal study of inhalational volatile anesthetics as rescue therapies in severe asthma exacerbations. Additionally, further research is required on how to safely use inhaled anesthetics in the ICU setting where its use is currently limited.
Trichosporon asahii is a fungal species that is ubiquitous in nature is increasingly being recognized as a lifethreatening pathogen that has no effective antifungal therapy. We present a unique case of Trichosporon Asahii and Mycobacterium Kansasii necrotizing pneumonia with pulmonary abscesses and empyema. CASE PRESENTATION:Patient is a 64-year-old female with a past medical history of diabetes, hypertension and multiple strokes who presented with left sided weakness and dysarthria that started 7 hours prior to arrival. She was found to be in Afib with RVR, scoring 1 point on the NIH stroke scale. During her evaluation, she became acutely dyspneic and hypoxic, requiring intubation for acute hypoxic respiratory failure. A Computed Tomography of the brain revealed multiple acute ischemic infarcts and chronic infarcts. Her initial chest CT on admission showed multifocal pneumonia with left upper lobe cavitation and significant upper lobe predominant emphysema with bullae likely related to her long-standing smoking history. Acid fast bacilli culture revealed Mycobacterium Kansasii and the patient was treated with Rifampin, Ethambutol, and Isoniazid. She had a complicated hospital course, including AKI with ATN, requiring hemodialysis and a tracheostomy for airway protection and a percutaneous endoscopic gastrostomy for her nutritional requirements. She was in septic shock and was placed on broad spectrum antibiotics, vasopressors and stress-dose steroids. Multiple cultures were sent, including urine, blood, sputum and a BAL sample. Repeat CT showed LUL necrotizing pneumonia with pulmonary abscesses and empyema. One month after positive Mycobacterium culture, the patient's sputum culture grew Trichosporon Asahii and she was started on voriconazole. Later during the hospital course, she entered PEA arrest and was seen with copious blood from endotracheal tube and ultimately expired.DISCUSSION: While usually linked to superficial skin infections, Trichosporon species can be opportunistic pathogens that can cause hemorrhagic and necrotizing bronchopneumonia as a result of vascular invasion. Risk factors for invasive Trichosporon infections include immunosuppression, malignancy, central catheterization, prior antibiotic therapy, and intensive care unit admission. Studies suggest that voriconazole is the drug of choice in treatment, however, this recommendation relies primarily on in vitro susceptibility testing and limited case reports. Our case represents the first case of Trichosporon asahii infection with concurrent respiratory bacterial infection with Mycobacterium kansasii.CONCLUSIONS: With increasing cases of opportunistic Trichosporon infections documented in the literature, clinicians must be aware of the organism's clinical presentation, risk factors that enhance colonization, and appropriate therapies. Further studies need to be conducted to determine the optimal medical therapy.
Brain abscess usually occurs as a result of predisposing factors such as HIV or other immunosuppressive state, systemic infection, or disruption in the protective barrier surrounding the brain, including trauma, operative procedures, mastoiditis, sinusitis or dental procedure. We report a very unique case of subdural empyema and abscess with associated mastoiditis and sinus thrombosis in the setting of a retained cotton swab. CASE PRESENTATION:Patient is a 47-year-old male with a past medical history of hypertension who presented with left arm weakness and numbness and left-sided facial droop. Computed Tomography (CT) of the brain showed an ill-defined hypodense 3.4 cm posterior right parietal lobe mass. Magnetic Resonance Imaging (MRI) was significant for an acute/subacute 2.8 x 3.1x 2 cm subdural empyema with extra-axial mass with smooth ring enhancement with associated thrombosis of the right transverse and sigmoid sinuses with right mastoiditis and medial erosion of air cells. A chronic left occipital abscess was also visualized on MRI with contrast. The patient was started on ceftriaxone, flagyl and vancomycin for empiric coverage and was managed in the ICU for septic shock. A decision was made not to anticoagulate due to the high risk of bleeding with an infectious etiology. HIV testing was negative. The patient was taken for right craniectomy with empyema evacuation and tympanomastoidectomy. During the surgical procedure, a posterior canal incision was made to the mastoid cortex and a cotton swab was found and retracted; it was attached to granulation tissue coming through the ear drum. Pathology confirmed cotton material representing a cotton swab. Gram stain showed gram positive cocci in pairs and surgical culture grew Anaerococcus species. DISCUSSION:The most common organism occurring in cases of contiguous spread of middle ear, mastoid, or sinus infection are streptococcus species, however, staphlococcal and polymicrobial abscesses caused by anaerobes, gram negative bacilli, and uncultured bacteria have been reported. Anaerococcus are gram positive strictly anaerobic bacteria that can occur in pairs, tetrads, or short chains. While many species are found as part of the normal flora of skin, oral cavity or gut, specimens isolated from abscesses have been reported. This is the first case to our knowledge of subdural empyema and abscess associated sinus thrombosis in the setting of retained cotton swab and isolation of Anaerococcus species.CONCLUSIONS: Warnings against the using cottons swabs in the ear canal exist due to the risk of foreign body, worsening cerumen impaction, and tympanic membrane rupture. Our case highlights the risk of cotton swab use in the ear. Physicians should be aware that resulting complications can include subdural empyema and abscess associated with transverse and sigmoid sinus thrombosis.
The United States is in an epidemic of electronic cigarette or vaping product use-associated lung injury (EVALI) which is characterized by a combination of respiratory, constitutional and gastrointestinal symptoms1. The most common presenting signs and symptoms include dyspnea, cough, fever, tachypnea, tachycardia, hypoxia, malaise, and emesis2. Two predominant patterns of acute lung injury have been recognized in EVALI: Diffuse Alveolar Damage and Organizing Pneumonia. Radiographic findings in the literature for patients diagnosed with EVALI include a pattern of bilateral and symmetric ground glass opacities with subpleural and areas of lobular sparing3. We present a unique case of severe EVALI isolated to a single lung that has not been documented in the literature and was managed conservatively. CASE PRESENTATION:A 36-year-old male with a history of vaping nicotine products presented with acute onset of dyspnea, hypoxia and tachycardia. Prior to switching to vaping, he admitted to a 7 pack-year smoking history of cigarettes. He endorsed using a JuulÓ vaping device for two years before switching to another product, FumeÓ, for 2 months prior to presentation. On physical exam, the patient was tachypneic and in severe respiratory distress with crackles in the right lung. Vital signs were significant for a heart rate of 129 and oxygen saturation of 90% on ambient air. COVID PCR and viral respiratory panel testing were negative. CT of the chest showed diffuse right sided nonspecific reticulonodular pattern with some bronchiectatic changes. Our patient requested conservative management due to financial concerns. Thus we elected to treat without antibiotics and systemic steroids. Supportive treatment included bronchodilators and supplemental oxygen. He improved clinically over the next five days despite our unusual conservative approach. A repeat CT of the chest at that time showed marked interval resolution of radiographic findings. DISCUSSION: Our case highlights that clinicians must be able to recognize that unilateral organizing pneumonia in the setting of recent vaping can be a manifestation of EVALI. Anecdotal literature supports the use of systemic glucocorticoids but an exact treatment of EVALI is not yet known1. The approach in our patient with significant hypoxia and radiographic lung involvement reinforces that supportive treatment of EVALI, as opposed to aggressive measures with empiric antibiotics and systemic glucocorticoids, can lead to similar outcomes without the risk of adverse effects of those medications.CONCLUSIONS: A conservative approach can likely decrease financial burdens for patients and medical institutions and still yield positive medical results. Further longitudinal research is required to determine the benefit of empiric treatment of EVALI and radiographic studies to database future unilateral presentations of EVALI.
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