Thyrotoxic crisis or thyroid storm is a severe form of hyperthyroidism and a rare endocrinological emergency. The cornerstones of medical therapy in thyroid storm include decreasing the levels of circulating T3 in the blood as well as inhibiting the hormone’s peripheral effects through β-adrenergic blockade. Propranolol is the preferred agent for β-blockade in hyperthyroidism and thyroid storm due to its additional effect of blocking the peripheral conversion of inactive T4 to active form T3. We report a typical clinical scenario where propranolol was administered in treatment of thyroid storm but an uncommon adverse outcome: circulatory failure from cardiogenic shock warranting vasopressor and inotropic support. Caution with regard to the use long-acting β-blocking agents in patients with underling thyrocardiac disease may prevent this life-threatening adverse effect. Ultra–short-acting β-blockers that are easy to titrate maybe a suitable alternative in this subset of patients.

Approximately 10-15% of patients requiring mechanical ventilation will ultimately undergo tracheostomy (2). In a large prospective cohort study, up to 34% of patients who required mechanical ventilation for more than 48 hours needed tracheostomy placement (3). More than half of the patients who underwent tracheostomy also required PEG placement for prolonged nutritional needs (4,5). In this article, we review appropriate post-procedural care for PDT and PEG, as well as possible complications that can develop.

Percutaneous tracheostomy is a commonly performed procedure for patients in the intensive care unit (ICU) and offers many benefits, including decreasing ICU length of stay and need for sedation while improving patient comfort, effective communication, and airway clearance. However, there is no consensus on the optimal timing of tracheostomy in ICU patients. Ultrasound (US) and bronchoscopy are useful adjunct tools to optimize procedural performance. US can be used pre-procedurally to identify vascular structures and to select the optimal puncture site, intra-procedurally to assist with accurate placement of the introducer needle, and post-procedurally to evaluate for a pneumothorax. Bronchoscopy provides real-time visual guidance from within the tracheal lumen and can reduce complications, such as paratracheal puncture and injury to the posterior tracheal wall. A step-by-step detailed procedural guide, including preparation and procedural technique, is provided with a team-based approach. Technical aspects, such as recommended equipment and selection of appropriate tracheostomy tube type and size, are discussed. Certain procedural considerations to minimize the risk of complications should be given in circumstances of patient obesity, coagulopathy, or neurologic illness. Herein, we provide a practical state of the art review of percutaneous tracheostomy in ICU patients. Specifically, we will address pre-procedural preparation, procedural technique, and post-tracheostomy management.

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Fatal lactic acidosis has been reported while on the treatment with Nucleoside/nucleotide analogues (NA) for the treatment of hepatitis B, C and HIV. No cases of such a complication have been reported in hematopoietic stem cell transplant (HSCT) recipients. We present a 65-year male who underwent autologous HSCT for the treatment of multiple myeloma. Prior to transplant he was started on single agent tenofovir alafenamide (TAF) for treatment of resolved hepatitis B infection. He presented few weeks later with severe lactic acidosis. Other causes of lactic acidosis were excluded. The patient died of multi-organ failure despite stopping TAF and aggressive supportive care. The case demonstrates the need for increased awareness of this potential complication of NA treatment in the course of transplantation.

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Fibrosing mediastinitis (FM) is a rare fibroinflammatory disease classified as idiopathic or secondary. Most common infectious cause in the United states is histoplasma. Additional causes include malignancy, autoimmune, and sarcoidosis. CASE PRESENTATION: 45-year-old female presented with chest pain. A transthoracic echocardiogram (TTE) showed pericardial effusion with tamponade physiology and pericardial window with biopsy was done. Pathology showed fibrovascular tissue, adipose tissue with perivascular chronic inflammation. Cytology; negative for malignancy. Weakly positive Coxsackie titers were 1:16 and 1:8 for B1 & B2 respectively, negative bacterial, fungal, mycobacterial, and viral cultures. Negative Lyme antibody titers, mycoplasma IgG, cryptococcal and histoplasma antigens. Normal IgG levels. Negative rheumatological work up apart from weakly positive anti-nuclear antibody. Progressive symptoms of dyspnea despite treatment with anti-inflammatory medications. Subsequent CT showed mediastinal mass encasing the right pulmonary artery (PA) trunk (figure 1). Moderate to severe narrowing of the right PA seen on cardiac MRI. Bronchoscopy with EBUS guided TBNA revealed lymphocytes but no definite diagnosis. Endovascular biopsy of the mediastinal mass showed fibrillar sclerosing lesion with plasma cells and necrotizing granuloma. IgG staining positive for IgG4+ plasma cells but not enough to meet criteria for IgG4-related disease. Abundance of CD20+ve cells on histology. DISCUSSION: Patient did not meet criteria for IgG4-RD diagnosis. She tested negative for all secondary etiologies. Coxsackie virus infection causing chronic pericarditis leading to FM is our hypothesis. CONCLUSIONS: This represents the first report of FM caused by chronic pericarditis probably due to coxsackie viral infection.

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