Blastomyces dermatitidis is an endemic mold infection commonly seen in the midwestern of the USA and rarely affects pregnant women. The most common presentation is a pulmonary infection with variable degrees of severity. Of note, the clinical and radiographic findings of pulmonary blastomycosis can be mistaken for other pulmonary pathologies, thus earning the title of ‘the great pretender’. The treatment of choice of infected pregnant patients is amphotericin B, which is known to produce electrolyte imbalances. However, it infrequently causes severe, prolonged and profound hypokalemia and hypomagnesemia. We present the case of a 27-year-old pregnant patient with pulmonary blastomycosis presenting with a lung mass suspicious of malignancy and treated with amphotericin B with subsequent prolonged refractory hypokalemia and hypomagnesemia. Keywords pulmonary blastomycosis pregnancy biopsy computed tomography angiography liposomal amphotericin B
e19038 Background: Sepsis is associated with increased mortality in patients with hematologic malignancies, especially in those receiving cytotoxic chemotherapy. The development of new therapies also increases the risk of infections in Philadelphia negative myeloproliferative neoplasms (MPN). However, the clinical implications and costs of sepsis in patients with polycythemia vera (PV), essential thrombocytosis (ET), and primary myelofibrosis (PMF) have not been reported at a national level. Therefore, we aimed to determine the outcomes, hospitalization costs, and predictors of mortality in patients with MPN and sepsis. Methods: We retrieved adult patients with MPN from the Nationwide Inpatient Sample database from 2016-2018. We used the ICD-10 codes to identify and compare patients with and without sepsis. The main outcomes were hospital mortality and predictors of mortality. We computed the chi-squared test and the Mann-Whitney U-test. Mortality predictors are estimated using multivariate logistic regression and logistic fixed-effect methods to control for admission cohort and hospital time invariant characteristics. All analyses were performed using Stata Statistical Software version 14 (StataCorp, College Station, TX). Results: A total of 86,723 patients with MPN were identified. The majority of them were white (66.9%), female (54.3%), with a median age of 62 (IQR 47-76). The most common MPN was ET (84.3%), followed by PV (14.2%). Sepsis was diagnosed in 16,146 (18.6%) of the MPN patients. There was a significantly higher mortality in the sepsis group vs. the non-sepsis group (7.4% vs. 1.8%; p < 0.001), longer LOS (8 vs. 4 days; p < 0.001), and higher median hospitalization cost (US$74,128 vs. US$39,987; p < 0.001). In the multivariable analysis, sepsis was associated with higher mortality (OR: 4.74; CI 95%: 4.33-5.18; p < 0.001). Among the MPN, those with PMF and sepsis had a higher risk of death (OR: 2.21; CI 95%: 1.72-2.82; p < 0.001). Other significant variables associated with mortality were age > 65 (OR: 2.51; CI 95%: 2.14-2.95; p < 0.001), concomitant chronic heart failure (CHF) (OR: 1.57; CI 95%: 1.39-1.77; p < 0.001), chronic kidney disease (CKD) (OR: 1.22; CI 95%: 1.10-1.35; p < 0.001), and weight loss (OR: 2.12; CI 95%: 1.79-2.51; p < 0.001). There was no significant association with sex and race/ethinicity. Conclusions: On patients with MPN, sepsis was associated with higher mortality, hospitalization costs, and LOS. Additionally, those with increased age, CHF, CKD, weight loss, and PMF were also at increased risk of death. There should be more emphasis on assessing the risk of sepsis on MPN to prevent worse outcomes and higher costs. Further studies should focus on identifying the specific causes of sepsis in MPN and promoting early recognition.
Introduction: Thromboembolism is a well-recognized complication of patients with Philadelphia negative myeloproliferative neoplasms (MPN), potentially due to an endothelial injury caused by the activation of inflammatory cytokines. Among the MPNs, Polycythemia vera (PV) seemed to be the most associated with thrombotic events; however, essential thrombocytosis (ET) and primary myelofibrosis (PMF) are also at higher risk than the general population. Furthermore, arterial and venous thromboembolisms account for higher mortality in this population, causing approximately 45% of all disease-associated fatal events. Previous studies have explored the combined outcomes of venous thromboembolism (VTE) on MPN patients; however, none of them focused primarily on pulmonary embolism (PE). Therefore, we aimed to identify any potential demographic, socioeconomic, or clinical characteristics associated with PE in a large cohort of MPN patients admitted to US hospitals. Methods: We inquired the Nationwide Inpatient Sample database to identify patients diagnosed with MPN from 2016-2018. We used the ICD-10 codes to identify the different types of MPN and compare patients with and without PE. The main outcomes were risk factors associated with PE and in-hospital mortality. We computed the chi-squared test and the Mann-Whitney U-test to compare the outcomes of patients with and without PE. We first conducted a univariate analysis. Clinically relevant characteristics and variables with a significant association (p<0.05) with the development of PE in the univariate analysis were considered for the multivariate model. We identified the risk factors associated with PE using multivariate logistic regression. Our analyses were conducted using Stata Statistical Software version 14 (StataCorp, College Station, TX). Results: Among 82,087 identified patients with MPN, most of them were white (67.4%), female (54.6%), and had a median age of 63 (IQR 49-76). Of them, 1982 (2.4%) had a PE event during admission. There were no significant differences in age and sex between PE patients and non-PE patients. While there were higher proportions of White (68.3% vs. 67.4%) and Black patients (18.6% vs. 17%) in the PE group, there was a lower proportion of Hispanics (8.7% vs. 9.7%; p=0.007). Patients with PE also had a higher median Elixhauser comorbidity index (5 vs. 4, p<0.001). There were fewer Medicare beneficiaries (48.5% vs. 52.4%) and a higher proportion of private insurance usage (26.8% vs. 22.3%; p<0.001) in the PE patients compared to those without PE. In the multivariate analysis, age, sex, race, or income quartile were not significantly associated with PE development. Compared to PV, patients with PMF had a protective effect for developing PE (OR: 0.35; CI 95%: 0.22-0.54). The comorbidities associated with higher odds for having a PE were coagulopathies (OR: 1.99; CI 95%: 1.71-2.30) and obesity (OR: 1.47; CI 95%: 1.29-1.67). See Table 1 for all the variables. Patients with PE had a higher length of stay (6 days vs. 5 days; p<0.001) and higher mortality than the non-PE group (6.1% vs. 2.8%; p<0.001). Conclusions: In this large epidemiological study, we found that patients with MPN and PE had higher mortality than those without PE. Risk factors associated with the development of PE were concomitant obesity and coagulopathy. In addition to the known preventive therapies such as aspirin, phlebotomy, and cytoreductive agents, this study highlights the importance of controlling modifiable factors such as obesity in MPN patients. Future studies should confirm our findings and investigate strategies to prevention PE in this vulnerable population. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.
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