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Abstract

Learning Objectives: Background: Achalasia is an esophageal motility disorder characterized by absence of esophageal peristalsis and impaired relaxation of the lower esophageal sphincter (LES). It can lead to severe esophageal dilation and compression of the posterior aspect of trachea. Respiratory distress and respiratory failure can follow. We report a case of respiratory distress attributed to an exacerbation of COPD and HCAP before the precipitating etiology of achalasia and mega-esophagus was identified. Case: An 81 year old female with COPD presented with increasing shortness of breath, hypoxia and fever. She was tachycardic and tachypneic, with diffuse wheezes and rhonchi. She had recently been discharged after a 3 day hospital stay for COPD exacerbation. Chest x-ray revealed a left lower lobe infiltrate and the patient was treated for a presumed healthcare associated pneumonia. On hospital day 2, she had three episodes of post-prandial desaturations. Due to an underlying anxiety disorder and the development of stridor, ENT was consulted to rule out vocal cord dysfunction (VCD). During a swallowing evaluation, she developed respiratory failure and was emergently intubated. VCD was ruled out. GI was consulted when a naso-gastric tube could not be inserted. EGD revealed food in the esophagus and dilation of the entire esophagus. Subsequent history from family members revealed that the patient had a history of dysphagia, including increased dyspnea following meals. Discussion: The initial absence of typical symptoms associated with achalasia; dysphagia, regurgitation, chest pain, pyrosis and weight loss, and the patient's history of COPD and anxiety were confounding factors that led to a delay in diagnosis. In acute respiratory failure secondary to achalasia, it is important to immediately decompress the esophagus. Induced vomiting, E-wald tube lavage or EGD can be therapeutic. Definitive treatment requires pneumatic dilation or Botox injection of the LES. Laparoscopic cardiomyotomy with partial fundoplication can improve dysphagia in non-responders.Learning Objectives: Varicella is a mild and self limited disease in children, but in immunocompromised individuals and pregnant women, it is associated with significant morbidity and mortality.Pneumonia is the most worrisome complication of adult varicella infection with a mortality rate ranging between 10-50%.A 58 year old male with relapsed CLL on chemotherapy, presented with cough, progressive shortness of breath on minimal exertion, chest tightness, fever, malaise, myalgia and worsening disseminated rash for 5 days. He was a former heavy smoker and had chickenpox in childhood.No recent known contact with anyone with chickenpox. Vital signs demonstrated tachycardia (117 bpm), temperature 103F, respiratory rate of 35 and SpO2 of 88% on room air. Physical exam revealed a generalized rash at various stages of healing and small ulcers in the oral cavity. Disseminated Varicella infection was diagnosed. Initially oxygen saturation remained 95-100% on 2L/min via nasa...