INTRODUCTION:Sarcoidosis is a multisystem disorder of unknown etiology. Some cases are attributed to genetic factors, an inflammatory response by specific antigens including self-antigen, and autoimmune involvement. Ninety percent of patients with sarcoidosis have lung involvement, and a vast portion is asymptomatic. Most common initial symptoms are dry cough and dyspnea, however, manifestation can be unspecific and broad. Ocular manifestations like uveitis are a classical presentation. Cutaneous manifestations have also been associated with sarcoidosis but incidence is around 1.9 per 100,000 with a female predominance. Diagnosis can be performed from clinical, and radiological findings yet one of the most essential criteria is histopathological findings of non-caseating granulomas on a tissue biopsy. Here is a rare presentation of a Hispanic male with sarcoidosis after exposure to an unusual antigen.CASE PRESENTATION: A 32-year-old man came to the emergency department with dyspnea, dry cough, and bilateral eye redness of one week of evolution and ten days after the second dose of the SARS-CoV-2 vaccine. Before these symptoms, the patient experienced multiple desquamating tattoos and bilateral eye redness after the first dose of the vaccine, which presumed that resolved with tobramycin and dexamethasone eye drops. Physical examination was notable for tattoo peeling with surrounding erythematous papules and tenderness to palpation. Eye examination revealed an intact visual acuity bilaterally with hyperemia and conjunctival injection. Ophthalmology made the diagnosis of non-granulomatous bilateral anterior uveitis. Routine laboratories were unremarkable including angiotensin-converting enzyme levels except for erythrocyte sedimentation rate on 32mm/Hr and arterial blood gas with a partial pressure of oxygen of 72 mmHg. Chest radiograph revealed innumerable bilateral centrilobular nodules. Chest Computerized tomography showed bilateral centrilobular diffuse pulmonary nodules with associated mediastinal paratracheal and mediastinal lymphadenopathy. Skin biopsy revealed a nodular infiltrate of histiocytes with black foreign body deposits with non-caseating sarcoid granulomas. Treatment consisted of prednisone and azathioprine resulting in an improvement of symptoms the following days. DISCUSSION:The side effects of this novel ribonucleic acid vaccine are not well described yet, but our case raises the suspicion if the vaccine arouses or unmask autoimmune diseases like the one previously described.CONCLUSIONS: More studies and data are required on side effects to assess other possible complications, response to the vaccine, and which patients are at risk of developing autoimmune or serious health conditions.
ImportanceRetinal vein occlusion is the second most common retinal vascular disease. Bevacizumab was demonstrated in the Study of Comparative Treatments for Retinal Vein Occlusion 2 (SCORE2) to be noninferior to aflibercept with respect to visual acuity in study participants with macular edema due to central retinal vein occlusion (CRVO) or hemiretinal vein occlusion (HRVO) following 6 months of therapy. In this study, the cost-utility of bevacizumab vs aflibercept for treatment of CRVO is evaluated.ObjectiveTo investigate the relative cost-effectiveness of bevacizumab vs aflibercept for treatment of macular edema associated with CRVO or HRVO.Design, Setting, and ParticipantsThis economic evaluation study used a microsimulation cohort of patients with clinical and demographic characteristics similar to those of SCORE2 participants and a Markov process. Parameters were estimated and validated using a split-sample approach of the SCORE2 population. The simulated cohort included 5000 patients who were evaluated 100 times, each with a different set of characteristics randomly selected based on the SCORE2 trial. SCORE2 data were collected from September 2014 October 2019, and data were analyzed from October 2019 to July 2021.InterventionsBevacizumab (followed by aflibercept among patients with a protocol-defined poor or marginal response to bevacizumab at month 6) vs aflibercept (followed by a dexamethasone implant among patients with a protocol-defined poor or marginal response to aflibercept at month 6).Main Outcomes and MeasuresIncremental cost-utility ratio.ResultsThe simulation demonstrated that patients treated with aflibercept will have an expected cost $18 127 greater than those treated with bevacizumab in the year following initiation. When coupled with the lack of clinical superiority over bevacizumab (ie, patients treated with bevacizumab had a gain over aflibercept in visual acuity letter score of 4 in the treated eye and 2 in the fellow eye), these results demonstrate that first-line treatment with bevacizumab dominated aflibercept in the simulated cohort of SCORE2 participants. At current price levels, aflibercept would be considered the preferred cost-effective option only if treatment restored the patient to nearly perfect health.Conclusions and RelevanceWhile there will be some patients with CRVO-associated or HRVO-associated macular edema who will benefit from first-line treatment with aflibercept rather than bevacizumab, given the minimal differences in visual acuity outcomes and large cost differences for bevacizumab vs aflibercept, first-line treatment with bevacizumab is cost-effective for this condition.
Tracheal rupture after endotracheal intubation is a rare but life-threatening complication with an incidence of approximately 0.005%. Predisposing factor can be a weakness of the membranous trachea secondary to chronic illness or steroid use. Herein we present a case of a young woman who developed a distal tracheal rupture after emergent endotracheal intubation with devastating consequences. CASE PRESENTATION:A 48-year-old female with a medical history of hypertension, epilepsy, and panhypopituitarism secondary to a respected craniopharyngioma was admitted to the intensive care unit with a diagnostic impression of obstructive uropathy with septic shock and multiorgan failure. Supportive management with aggressive fluids resuscitation, antibiotics, dual vasopressor therapy, and endotracheal intubation was given. Hours later, the patient became hemodynamically unstable requiring increased vasopressor therapy with increased demand in ventilation parameters. Physical examination was positive for massive subcutaneous emphysema from her chest tracking through facial and neck planes. A chest computerized tomography (CT) scan was performed and showed a distal tracheal rupture as the most likely cause of the massive pneumothorax that progressed to tension subcutaneous emphysema. Upon acute neurological deterioration, a head CT scan was performed, revealing a left panhemispheric malignant ischemic stroke involving the left anterior, middle, and posterior cerebral arteries suggestive of a left internal carotid artery (ICA) complete occlusion. The patient had a National Institutes of Health Stroke Scale score above 20, a left hemisphere infarction, and a GCS 3/11, conferring a poor clinical outcome. As poor prognosis and poor quality of life were expected, the family members opted to withdraw life support. DISCUSSION: Malignant hemispheric infarction has a mortality rate as high as 80 percent with catastrophic neurologic sequelae. Its incidence is less than ten percent of all ischemic infarcts and it's generally caused by embolic occlusion of the ICA.CONCLUSIONS: To our knowledge, there are no malignant hemorrhagic strokes provoked by traumatic intubation resulted from tracheal rupture documented to this day. We presume the etiology of this event to be subcutaneous air that exerted enough pressure between the fascial and cervical planes to result in significant vascular compression. Tracheal rupture is one of the most feared immediate complications of intubation as it could result in increased morbidity and mortality. There is no established consensus for the treatment yet, but early surgical repair has been the mainstay of treatment. However, conservative management has been chosen in cases of small ruptures with similar outcomes.
INTRODUCTION:Cocaine is responsible for innumerable visits to the emergency department and a frequent cause of death. It is the most used drug worldwide after marihuana. An estimated 1.9 million people over the age of 12 had used cocaine in the last month. Toxicity can affect multiple systems such as the cardiovascular, respiratory, and central nervous systems. Lung damage is caused by different mechanisms such as direct cellular toxicity, thermal airway injury, barotrauma, inflammatory damage, and vasospasm leading to ischemia that could lead to respiratory failure. Here is an intriguing case secondary to this highly addictive drug.CASE PRESENTATION: A 28-year-old inmate with a history of hypertension, bronchial asthma, and illicit drug abuse arrived at the emergency department with episodes of hemoptysis. Symptoms began the day before his arrival, accompanied by shortness of breath, dizziness, and cough. Vital signs were tachycardia, tachypnea, and desaturation requiring oxygen supplementation. Physical exam was notable for bilateral wheezing and rhonchi. Initial laboratories were remarkable for leukocytosis and hypoxemia. The drug screen test was negative. Chest radiograph showed multiple nodular densities distributed in both lungs and alveolar infiltrates with air bronchograms in the right upper lobe. Chest computerized tomography revealed diffuse patchy opacities and ground glass bilaterally. Respiratory therapies and empirical antibiotics were started. The next day, the patient's symptoms markedly improved, including shortness of breath, hypoxemia, and hemoptysis. Cultures and tuberculosis workup came back negative. After the complete amelioration of symptoms, the patient admitted to consuming cocaine the day the symptoms began and related it to his inhaled intake. A Follow-up chest x-ray showed resolution of previously visualized diffuse patchy pulmonary opacities.DISCUSSION: Crack-lung is an acute pulmonary syndrome induced by cocaine, characterized by diffuse alveolar damage and hemorrhagic alveolitis that occurs within 48 hours after its consumption. Diagnosis can be challenging since it can mimic many diseases, so it is essential to consider those patients with a history of drug abuse who come to the emergency room. Its incidence is still unknown. Laboratory tests are nonspecific, and negative toxicology tests do not rule out this disease. Diagnosis requires a temporal relationship of cocaine use within 48 hours of symptom onset, radiological evidence, and a consistent clinical course.
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