Background: Community-acquired pneumonia (CAP) is a frequent cause of death worldwide. As recently described, CAP shows different biological endotypes. Improving characterization of these endotypes is needed to optimize individualized treatment of this disease. The potential value of the leukogram to assist prognosis in severe CAP has not been previously addressed. Methods: A cohort of 710 patients with CAP admitted to the intensive care units (ICUs) at Hospital of Mataró and Parc Taulí Hospital of Sabadell was retrospectively analyzed. Patients were split in those with septic shock (n = 304) and those with no septic shock (n = 406). A single blood sample was drawn from all the patients at the time of admission to the emergency room. ICU mortality was the main outcome. Results: Multivariate analysis demonstrated that lymphopenia <675 cells/mm3 or <501 cells/mm3 translated into 2.32- and 3.76-fold risk of mortality in patients with or without septic shock, respectively. In turn, neutrophil counts were associated with prognosis just in the group of patients with septic shock, where neutrophils <8850 cells/mm3 translated into 3.6-fold risk of mortality. Conclusion: lymphopenia is a preserved risk factor for mortality across the different clinical presentations of severe CAP (sCAP), while failing to expand circulating neutrophils counts beyond the upper limit of normality represents an incremental immunological failure observed just in those patients with the most severe form of CAP, septic shock.

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Patient: Male, 63Final Diagnosis: Hypertensive cardiovenic pulmonary edemaSymptoms: Shortness of breathMedication: —Clinical Procedure: —Specialty: General and Internal MedicineObjective:Management of emergency careBackground:Pulmonary edema is the accumulation of fluid in the lung secondary to increased hydrostatic pressure. Hypertensive cardiogenic pulmonary edema presents with a sudden onset of severe dyspnea, tachycardia, and tachypnea, and can occur when the systolic blood pressure exceeds 160 mmHg in association with acute decompensated congestive cardiac failure (CCF). A case is presented of hypertensive cardiogenic pulmonary edema treated with high-dose nitroglycerin and includes a review of the literature.Case Report:A 63-year-old Hispanic male with a medical history of hypertension, coronary artery disease, heart failure with a reduced ejection fraction of 35%, chronic kidney disease (CKD) and diabetes mellitus, presented as an emergency with acute, severe dyspnea. The patient was initially managed with 100% oxygen supplementation and intravenous (IV) high-dose nitroglycerin (30 mcg/min), which was titrated every 3 minutes, increasing by 15 mcg/min until a dose of 120 mcg/min was reached. After 18 minutes of aggressive therapy, the patient’s condition improved and he no longer required mechanical ventilation.Conclusions:Hypertensive cardiogenic pulmonary edema is a challenging clinical condition that should be diagnosed and managed as early as possible, and distinguished from respiratory failure due to other causes. Although hypertensive cardiogenic pulmonary edema is usually managed acutely with high-dose diuretics, this case has highlighted the benefit of high-dose IV nitroglycerin, and review of the literature supports this treatment approach.

There are multiple well-recognized environmental factors that contribute to asthma exacerbation. Exposures to many of them will get unrecognized and most of the time will remain constant without knowing it is the causative agent. For an early identification of exposures and causative agents, a systematic approach needs to be taken in consideration by the encountering physician. Multiple questionnaires had been implementing and discussing organic and inorganic factors as well intrinsic and extrinsic factors. It is well-recognized that environmental exposures can cause worsening of asthma, other allergic conditions and even more severe pulmonary diseases. Asthma is a very prevalent disease with increased incidence nowadays. In the last decade, multiple new medications had been discovered for the treatment of moderate-to-severe persistent asthma, which most of them target the cellular component of the disease such as eosinophils and specific Immunoglobins. In the era of personalized medicine, environmental and occupational factors in asthma are key players that need to be recognized early in this patient population. In this chapter will go over model of effects, mechanism of action of these environmental factors, recognition, course of action and management of this patient population.

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