Deep sedation is sometimes needed in acute respiratory distress syndrome. Ketamine is a sedative that has been shown to have analgesic and sedating properties without having a detrimental impact on hemodynamics. This pharmacological profile makes ketamine an attractive sedative, potentially reducing the necessity for other sedatives and vasopressors, but there are no studies evaluating its effect on these medications in patients requiring deep sedation for acute respiratory distress syndrome. Materials and methods: This is a retrospective, observational study in a single center, quaternary care hospital in southeast Texas. We looked at adults with COVID-19 requiring mechanical ventilation from March 2020 to September 2020. Results: We found that patients had less propofol requirements at 72 h after ketamine initiation when compared to 24 h (median 34.2 vs 54.7 mg/kg, p = 0.003). Norepinephrine equivalents were also significantly lower at 48 h than 24 h after ketamine initiation (median 38 vs 62.8 mcg/kg, p = 0.028). There was an increase in hydromorphone infusion rates at all three time points after ketamine was introduced. Conclusions: In this cohort of patients with COVID-19 ARDS who required mechanical ventilation receiving ketamine we found propofol sparing effects and vasopressor requirements were reduced, while opioid infusions were not.

Histoplasmosis and Tuberculosis are two disease entities which may have similar presentations in the immunocompromised patient. Here we present a case of disseminated histoplasmosis in a patient with advanced HIV.CASE PRESENTATION: A 60-year-old male with no known past medical history who presented with fatigue, anorexia, dizziness, and 25 pound weight loss over the last 3 months. He is originally from Ethiopia, but he has been living in Texas for more than 20 years. He denied fever, chills, night sweats, chest pain, or cough. Vitals T100.5, P88, BP 127/62, RR 20, SpO2 100% on RA. Physical Exam was notable for sarcopenia, clear lungs and benign abdomen. Initial laboratories were notable for Na 122, WBC 2.1, Hgb 11.4, platelets of 71. Fourth generation HIV 1/2 screening was positive, and differentiation immunoassay was positive for HIV-1, with CD4 count 14 cells/uL. CT-Chest demonstrated numerous bilateral pleural and subpleural pulmonary nodules in a miliary pattern (Figure 1). Chest x-ray showed innumerable diffuse nodular opacities (Figure 2). Bronchoscopy fluid was AFB smear positive in 1/3 AFB cultures, but TB-PCR negative and culture negative to date. GMS stain of bronchial specimens showed numerous small intracellular fungal organisms, consistent with histoplasmosis. Histoplasma urinary antigen was positive above the limit of quantification. Patient was treated with Amphotericin B with clinical improvement, including resolution of fever and hyponatremia. He was discharged on oral itraconazole with close follow-up to initiate antiretroviral therapy.DISCUSSION: Histoplasma capsulatum is a dimorphic fungus endemic to the Ohio and Mississippi river valleys, including the south-central United States, as well as central and south Africa. In patients with HIV (PWH), disseminated histoplasmosis usually occurs in those with CD4 count less than 150 cells/Ul and can be misdiagnosed as tuberculosis (TB) (1). Among PWH, primary pulmonary manifestations in disseminated disease are overall more common with TB than those with histoplasmosis (2), the latter associated with hepatosplenomegaly and abdominal complaints. Specifically, miliary pattern of distribution on thoracic imaging has been reported in patients with HIV and histoplasmosis. Though dual infection is rare in patients without HIV, coinfection with TB and histoplasmosis may occur in up to 8-15% of PWH with histoplasmosis (3), which complicates diagnosis and treatment.CONCLUSIONS: Histoplasmosis should be included in the differential diagnosis for PWH and miliary nodules, particularly in endemic areas of the United States. PWH with miliary histoplasmosis should be evaluated for coinfection with TB given the impact on infection control and treatment.

Empyema is defined as the presence of purulent material in the pleural space. Lung abscesses are characterized by necrosis of the lung parenchyma, often leading to an isolated cavity. They are usually identified by imaging. Here we present a case of a difficult case of a pulmonary abscess which was initially mistaken for an empyema.CASE PRESENTATION: Case Presentation:A 48-year-old female with no known past medical history, originally from India, but had been living in Europe and then Texas for the last ten years, who had an uncomplicated tooth extraction eight months prior, now presenting with the 3-month onset of symptoms including 10lb weight loss, intermittent fevers, night sweats, and productive cough with yellow foul-smelling sputum. VS: T 98.9, P 89, BP 97/61, RR 18, SpO2 98% on room air. Physical exam was significant for rales in the RLL posteriorly. The metabolic panel was unrevealing. Blood counts showed WBC 6.4, Hgb 7.7. HIV negative. CT chest was obtained (Fig. 1), which demonstrated an RLL 9cm lesion with signs of necrosis but notably no air-fluid levels and 'Tree in Bud' opacities on the RUL. She was started on empiric coverage for gram-negative and anaerobic bacteria. She underwent IRguided pigtail chest tube placement with drainage of 450 cc of purulent material. Fluid studies were exudative with 61K WBC, 93%N. Sputum AFB x 3 and fungal cultures were negative. Chest tube output was minimal for two days. On POCUS, a small collection was seen. One dose of Dornase 5mg was given through a chest tube with no increased output. Repeat CT chest was performed (Fig. 2), which demonstrated the decreased size of the pulmonary abscess. She remained afebrile, without leukocytosis. Cardiothoracic surgery was consulted; deemed no plan for surgery. The chest tube was removed, and she was then discharged on PO Amoxicillin/Clavulanic acid for four weeks. Cultures from the lesion grew fusobacterium nucleatum, streptococcus pneumoniae, and klebsiella oxytoca. She was seen in pulmonary clinic, asymptomatic, with imaging demonstrating complete resolution of the abscess. DISCUSSION:The distinction between lung abscess and empyema is vital, as they portend to different clinical outcomes, and their management is different(1). The distinction can be made using imaging, mainly CT. Empyema's are treated with direct chest tube drainage and intrapleural fibrinoytics, whereas lung abscess are treated with antibiotics. In large collections or when medical management fails, drainage or surgery may be necessary, though there are limited prospective data on drainage(2). The role of fibrinolytic in the management of pulmonary abscess are not known, with only case reports offering guidance(3). CONCLUSIONS:The role and safety of fibrinolytic therapy in pulmonary abscess needs to be evaluated and potential surgery may be avoided in select cases.

Bilateral retrocerebellar arachnoid cysts are exceedingly rare. We report a case of a 38-year-old woman, who presented with progressive vertigo and was found to have bilateral retrocerebellar arachnoid cysts. The patient's clinical presentation was most consistent with benign positional peripheral vertigo, while the cysts were thought to be incidental findings. We review the literature on bilateral retrocerebellar arachnoid cysts and discuss their management.

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