Pericardial tamponade results in multiple organ dysfunction and can lead to cardiac arrest. Cardiopulmonary resuscitation (CPR), a life-saving measure performed on patients in cardiac arrest, can lead to thoracic organ damage. However, CPR rarely acts as a therapeutic treatment for pericardial tamponade. Our case describes a patient admitted with pericardial tamponade in whom CPR provided therapeutic treatment with pericardial rupture and resolution of the tamponade.
INTRODUCTION:We present a case of a middle-aged female with antiphospholipid syndrome (APS) presenting as atypical pneumonia and alveolar hemorrhage later confirmed to have APS-induced vasculitis.CASE PRESENTATION: 65 years female with APS with positive anti-cardiolipin beta2 glycoprotein antibodies presented to the Emergency Department (ED) with complaints of worsening dyspnea, chronic cough, intermittent fever over the last 2-3 weeks. She had oxygen saturation of 85%, fever of 101 F with rest vitals stable. Lung exam revealed diffuse bilateral crackles. Lab showed pancytopenia. Diffuse non-consolidated bilateral opacities was seen in chest imaging. Few hours later, she developed respiratory failure requiring intubation. She was started on pulse steroid and broad-spectrum antibiotics for atypical pneumonia. Bronchoscopy yielded evidence of hemorrhage. Infectious workup and other serology were negative. She improved clinically & underwent videoassisted thoracoscopic surgery for wedge biopsy of lung before discharge. Biopsy results were followed which showed necrotizing capillaritis with patchy intra-alveolar hemorrhage, hemosiderin-laden macrophages and fibrin.DISCUSSION: APS is an autoimmune condition with persistently elevated antiphospholipid antibodies (lupus anticoagulant, anticardiolipin or anti-B2-glycoprotein-I) commonly manifests with systemic thrombosis. These antibodies may result in pulmonary microvascular injury thus rarely (2%) presents as diffuse alveolar hemorrhage (DAH) [1]. In patients presenting with DAH, underlying etiology can be diagnosed through a detailed history and physical, pertinent serology, chest imaging, bronchoscopy with lavage, and biopsy in case of uncertain diagnosis. Out of 3 major pathological findings in DAH (pulmonary capillaritis, bland hemorrhage, or diffuse alveolar damage), pulmonary capillaritis is closely associated with autoimmune diseases and thus frequently identified in patients with APL (55%); but absence of capillaritis does not rule out APS [1]. Lung biopsy in pulmonary capillaritis may show neutrophilic infiltration of the pulmonary capillary and hemorrhage within the alveoli. Capillaritis may be observed more often than microvascular thrombosis ( 60% vs 11% vs 29% combined) [1]. All patients with capillaritis have strong positive titer of aPL [2]. Diagnosis can be made with biopsy after correlating with clinical presentation, laboratory data along with immunofluorescence studies. Diagnosis is challenging in case of transbronchial biopsy because of small tissue samples [2]. Routine lung biopsy is not required for diagnostic confirmation given the riskbenefit ratio as these patients are at a higher risk of thrombosis or bleeding due to anticoagulation [1, 2].CONCLUSIONS: DAH may be an initial presentation of APS. Typical biopsy findings are sufficient to establish the diagnosis of small vessel vasculitis given the high pretest probabilities.
INTRODUCTION: Aspiration of foreign bodies is not uncommon and mostly accidental with the highest prevalence in young children [1]. Occurrence in adults is rare and usually as a result of diminished consciousness, sedation, trauma, and neuromuscular disorders. We present a case of a 70 year old patient receiving chronic mechanical ventilation who had multiple episodes of hypoxia due to a dislodged oral care sponge.
CASE PRESENTATION:A 70 year-old bedbound male with chronic mechanical ventilation (via tracheostomy?) after traumatic brain injury, and recurrent pneumonia was admitted for pneumonia. On admission, respiratory cultures grew Carbapenem resistant Acinetobacter Bumanii and Pseudomonas Aeruginosa with negative urinalysis and blood cultures. Chest radiograph showed bilateral lower lobe opacities. He was treated with vancomycin, polymyxin B, and meropenem. However, his FiO2 fluctuated between 40% and 60% and despite being on antibiotics he was persistently febrile. He continued to have copious secretions requiring frequent suctioning without any new infiltrates on repeat chest radiograph. A Computer tomography (CT) of the chest was performed which showed a tubular structure extending from the right main bronchus to the bronchus intermedius (Image 1). Bronchoscopy was done and the object was found to be the head of an oral care sponge. After foreign body removal his respiratory status improved and fevers resolved.DISCUSSION: Oral care in mechanically ventilated patients has been studied extensively and there are many guidelines recommend to minimize ventilator associated pneumonia. Extreme care must be taken by providers as defective products or aggressive technique can result in fragments being dislodged into the oral cavity and can result in aspiration especially in patients with chronic tracheostomy. In patients with tracheostomy, diminished airway protective mechanisms and a deflated balloon can result in an increased risk of foreign body aspiration. Aspiration of a foreign body is a significant cause of morbidity as it can cause asphyxiation or trauma to the airway resulting in pneumothorax, bleeding, and infections [2]. In patients with diminished consciousness the signs of foreign body aspirations can be subtle such a mild cough, fevers, frequent infections, or increasing oxygen and they may not be able to provide a proper history.CONCLUSIONS: This case highlights the need for vigilance regarding potential complications from providing oral care in the elderly who have diminished ability to protect their airway.
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