Adebayo Fasanya

Acute fibrinous and organizing pneumonia in a patient with Sjogren’s syndrome

Acute fibrinous and organizing pneumonia (AFOP) is a histological pattern characterized by intra-alveolar fibrin deposition and associated organizing pneumonia. AFOP has been associated with many rheumatologic disorders in the literature but has not been described in association with Sjogrens syndrome. This paper shows a rare association of AFOP with Sjogrens syndrome. Patients symptoms promptly improved after treatment with steroid.

May-Thurner Syndrome With Pulmonary Embolism as the First Presentation Rather Than Deep Vein Thrombosis.

May-Thurner syndrome (MTS) is a rare disease that causes deep vein thrombosis (DVT) in young females (age 20 to 50). DVT is caused by mechanical obstruction of the left common iliac vein by the right common iliac artery resulting in stasis rather than a primary hypercoagulable state. Although MTS is found in 22% of cadavers, it causes <5% of lower extremity venous disorder. Greater than 70% compression is needed to cause DVT. MTS patients usually present with acute left leg edema. Many cases are recurrent with a past workup negative for other etiologies of DVT or pulmonary embolism (PE). Cases rarely present as PE rather than DVT. We present a case of this syndrome at a younger-than-typical age with PE as the first presentation. Femoral stick venogram is the gold standard for diagnosing MTS as therapeutic procedures can be done concurrently. Anticoagulation therapy alone is insufficient to prevent recurrence.

Cytomegalovirus Cutaneous Infection in an Immunocompromised Patient.

Cytomegalovirus (CMV), a member of the Herpesviridae family, is an opportunistic infection with a typically benign course in the healthy host but has a more ominous course in the immunocompromised population. CMV infection commonly affects the visceral organs, particularly the respiratory and the gastrointestinal tract. CMV cutaneous lesions are rare and can be easily missed. We present a case of a 76-year-old woman presenting with a diffuse non-pruritic macular lesion with scattered vesicles and bullae, which was initially treated as a varicella zoster virus infection and herpes simplex viral infection, but was later found on biopsy to be due to cytomegalovirus. She has a history of Sjögrens syndrome, interstitial lung disease, and being on chronic immunosuppression therapy. This case highlights the importance of considering CMV infection in the differential diagnosis of vesicular skin lesions in immunocompromised patients. Based on a PubMed search for “cutaneous cytomegalovirus”, “cutaneous CMV”, “cytomegalovirus skin”, and “skin CMV” in material published in the last 20 years (from 1996 to 2016) and reviewing any applicable referenced material outside of those dates, cases of cutaneous CMV are not well documented.

Mesenchymal cystic hamartoma of the lung

Mesenchymal cystic hamartoma, although first reported as early as 1980s, remains a very rare lung disease. There have been less than 20 cases reported to date. Mesenchymal cystic hamartoma usually has an indolent course, but it could potentially result in morbidity and mortality. Biopsy is needed to confirm the diagnosis because it is essential to rule out other possibilities including malignancy.

Pathogenesis and Epidemiology of Venous Thromboembolic Disease.

Venous thromboembolism is the formation of a blood clot in the vein. It mainly consists of 2 life-threatening conditions-deep venous thrombosis and pulmonary embolism. Deep venous thrombosis is a potentially dangerous condition with grave sequelae, the worst of which is pulmonary embolism. Venous thromboembolism can also lead to multiple other conditions with significant morbidity and mortality that include extension of thrombi, pulmonary hypertension, recurrence, and postthrombotic syndrome. An update on the epidemiology, etiology, and pathogenesis of venous thromboembolism will be reviewed in this article.

Deep Venous Thrombosis of the Upper and Lower Extremity

Upper and lower extremity deep venous thrombosis (DVT) is defined as a blood clot within the deep veins of the affected extremities. These blood clots can either occur spontaneously or be associated with specific risk factors. Regardless of the cause, DVT is associated with significant morbidity and mortality and has the potential for lethal complications. The most notable complication is the potential for development of pulmonary embolism from a lower extremity DVT. As studies have reported, more than 90% of acute pulmonary emboli arise from the proximal veins. Venous thromboembolism is also associated with a significant economic burden on the health care system and the individual patient. In this article, we review DVT of the upper and lower extremity including risk factors, signs and symptoms, diagnosis, and management.

1254: CONTINUATION, MONITORING, AND APPROPRIATENESS OF ANTIPSYCHOTICS IN THE CRITICALLY ILL

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Continuation of unnecessary and potentially inappropriate medication therapy has been demonstrated previously to be of concern especially during transitions of care between ICU and ward. The rising exposure of ICU patients to antipsychotics(AS) for the treatment of delirium may predispose patients to unwanted adverse events, especially if continued unnecessarily after delirium has resolved. This quality improvement project aimed to describe the prescription and continuation of AS in ICU survivors at a tertiary care center. Methods: This study was a retrospective, quality improvement project, with data collection period from December 1, 2016 through February, 28 2017. IRB exempt status was granted. Patients were identified based on a medical intensive care unit (MICU) database which includes all admissions. Patients were excluded if they were prescribed any AS agent prior to admission, pregnant, < 18 years old, or incarcerated. The primary objective was to quantify the frequency of AS initiation during admission in the MICU and subsequent continuation upon discharge to the ward. Secondary objectives included frequency of AS continuation upon discharge out of hospital, frequency of QTc monitoring and adverse events, appropriateness of AS prescribing, and description of AS prescribing practices. Results: 236 patients admitted to the MICU during the study period were screened, 160 were excluded. 76 (32%) patients were started on an AS during their MICU admission. 43 (56%) patients who were started on an AS in the MICU were continued on AS upon discharge to the ward and 32 (42%) patients had an AS continued upon hospital discharge. One patient died as a direct result of giving AS, 16 patients had QTc prolongation, one patient developed neuroleptic malignant syndrome, and one patient required intubation and readmission to the ICU. Incidence of delirium (based on CAM-ICU status) was 49% in the study period. AS were prescribed appropriately (CAM-ICU positive) in 36% of cases and inappropriately (CAM-ICU negative) in 64% of cases. The most common AS prescribed was haloperidol in 24 (32%) of patients. Conclusions: There is a high rate of continuation of AS both at the time of discharge to the ward and at the time of hospital discharge in ICU survivors which can result in unintended adverse drug events including death. The point of transition between ICU and the ward is an important time for discontinuation of AS agents if found to be inappropriate or no longer warranted.

Venous Thromboembolism and Pulmonary Embolism Response Teams: An Overview

Venous thromboembolism is a common disease with a wide array of signs and symptoms. It has been cited as the third leading cause of cardiovascular death, and if left untreated, it leads to death in 1 in 4 patients. Sophisticated diagnostic tools have allowed physician to become more accurate in diagnosing pulmonary embolism and deep vein thrombosis. The advent of new oral anticoagulants, the emergence of pulmonary embolism response teams, and protocols demonstrate recent achievements in the management of venous thromboembolism. The focus of this article is to discuss the treatment of venous thromboembolism.