Corticosteroid dosing in the range of 0.5–2 mg/kg/day of methylprednisolone equivalents has become a standard part of the management of intensive care unit (ICU) patients with COVID‐19 pneumonia based on positive results of randomized trials and a meta‐analysis. Alongside such conventional dosing, administration of 1 gm of methylprednisolone daily (pulse dosing) has also been reported in the literature with claims of favorable outcomes. Comparisons between such disparate approaches to corticosteroids for Coronavirus disease 2019 (COVID‐19) pneumonia are lacking. In this retrospective study of patients admitted to the ICU with COVID‐19 pneumonia, we compared patients treated with 0.5–2 mg/kg/day in methylprednisolone equivalents (high‐dose corticosteroids) and patients treated with 1 gm of methylprednisolone (pulse‐dose corticosteroids) to those who did not receive any corticosteroids. The endpoints of interest were hospital mortality, ICU‐free days at Day 28, and complications potentially attributable to corticosteroids. Pulse‐dose corticosteroid therapy was associated with a significant increase in ICU‐free days at Day 28 compared to no receipt: adjusted relative risk (aRR): 1.45 (95% confidence interval [CI]: 1.05–2.02; p = 0.03) and compared with high‐dose corticosteroid administration (p = 0.003). Nonetheless, receipt of high‐dose corticosteroids—but not of pulse‐dose corticosteroids—significantly reduced the odds of hospital mortality compared to no receipt: adjusted Odds ratio (aOR) 0.31 (95% CI: 0.12–0.77; p = 0.01). High‐dose corticosteroids reduced mortality compared to pulse‐dose corticosteroids (p = 0.04). Pulse‐dose corticosteroids—but not high‐dose corticosteroids—significantly increased the odds of acute kidney injury requiring renal replacement therapy compared to no receipt: aOR 3.53 (95% CI: 1.27–9.82; p = 0.02). The odds of this complication were also significantly higher in the pulse‐dose group when compared to the high‐dose group (p = 0.05 for the comparison). In this single‐center study, pulse‐dose corticosteroid therapy for COVID‐19 pneumonia in the ICU was associated with an increase in ICU‐free days but failed to impact hospital mortality, perhaps because of its association with development of severe renal failure. In line with existing trial data, the effect of high‐dose corticosteroids on mortality was favorable.
Silicosis is typically an indolent lung disease caused by long-standing occupational exposure to respirable crystalline silica, classically in professions such as sandblasting and mining. An increasingly popular industry that has earned particular interest because of its association with silicosis is customization and installation of artificial stone countertops for domestic applications. In addition to causing a spike in cases of chronic and accelerated silicosis, both quite familiar to respiratory clinicians, outbreaks of artificial stone silicosis have brought to the fore a historically rare entity known as acute silicosis, or silicoproteinosis, a more rapid presentation of the disease. Failure to suspect this uncommon condition can lead to diagnostic confusion and therefore ineffective treatment as was true initially of the patient we describe herein. The case description is followed by a clinical, radiological, and pathological overview of acute artificial stone silicosis (or silicoproteinosis), which is an emerging pneumoconiosis with sparse coverage in the literature to date. This case also adds to the few existing reports on the use of therapeutic whole lung lavage for silicoproteinosis.
Mycobacterium avium complex (MAC) infections rarely affect the pleura, accounting for 5–15% of pulmonary MAC. We report a case of MAC pleural effusion in an otherwise immunocompetent young patient. A 37-year-old healthy female with no past medical history was admitted to the hospital with two weeks of right sided pleuritic chest pain, productive cough, and fever. She was febrile, tachycardic, and tachypneic with signs of right sided pleural effusion which were confirmed by chest X-ray and chest CT. Thoracentesis revealed lymphocytic predominant exudative fluid. The patient underwent pleural biopsy, bronchoscopy with bronchoalveolar lavage, and video assisted thoracoscopic surgery (VATS), all of which failed to identify the causative organism. Six weeks later, MAC was identified in the pleural fluid and pleural biopsy by DNA hybridization and culture. The patient was started on clarithromycin, ethambutol, and rifampin. After six months of treatment, she was asymptomatic with complete radiological resolution of the effusion. The presence of lymphocytic effusion should raise the suspicion for both tuberculous and nontuberculous mycobacterial disease. Pleural biopsy must be considered to make the diagnosis. Clinicians must maintain a high index of suspicion of MAC infection in an otherwise immunocompetent patient presenting with a unilateral lymphocytic exudative effusion.
Background: The use of Non-Invasive Ventilation (NIV) in acute asthma exacerbation remains controversial. Comparative data on patient characteristics that benefit from NIV in asthma exacerbation to those patients that fail NIV remains limited. Our study compares some of these patient characteristics and examines if NIV is safe and effective in carefully selected patients. Methods: Following institutional review board approval, we extracted from the electronic medical record and conducted a retrospective chart-based review of those patients who received NIV in the emergency room for a diagnosis of asthma exacerbation from January 2017 to December 2018. Results and Conclusion:The rate of failure of NIV overall was low, at 9.17%, with younger patients more likely to fail NIV (P = 0.03) and need invasive mechanical ventilation. Surprisingly, baseline asthma severity did not impact NIV failure rate, and neither did body mass index, smoking history, and a host of clinical characteristics. Understandably, the length of stay was significantly longer in the group of patients that failed NIV. There were no adverse events, such as an increased rate of barotrauma events in either group. In conclusion, this study contributes to the growing body of evidence that NIV is a safe and effective adjunct to routine care in the management of patients with asthma exacerbation.
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