Ameer Rasheed

590: A RARE CASE OF “NON-CRYPTOGENIC ORGANIZING PNEUMONIA” CRYPTOGENIC ORGANIZING PNEUMONIA

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Organizing pneumonia (OP) is a particular type of inflammatory reaction of the lung which gives rise to a clinico-pathological syndrome. It is called “secondary” when a cause such as an infection, a drug toxicity, or a connective tissue disease can be identified, or “cryptogenic” when no cause is identified. The clinical picture is usually characterized by the subacute onset of fever, fatigue, cough and dyspnea, with multiple subpleural areas of consolidation. We present a case of fulminant organizing pneumonia presenting as ARDS in a patient with Psoriasis Methods: 70 years old female with past medical history of HTN, DM, hypothyroidism and Psoriasis presented with progressive shortness of breath for 1 week. She had no history of smoking and worked as probation officer. She was febrile. She had bibasilar crackles on auscultation and had chronic skin changes of lower extremities. X-ray chest showed increased density involving both lung bases. Laboratory data showed leukocytosis of 16.7, creatinine of 1.7 and normal liver function test. ESR, CRP and Dimer were elevated. CT with contrast showed no evidence of PE, bilateral ground glass opacities and consolidative process of right lower lobe. She was put on mechanical ventilation for severe hypoxemic respiratory failure. Despite being adequately treated with antibiotics she continued required increasing PEEP and FIO2. Her cultures were negative. Diagnosis of organizing pneumonia was considered given her history of psoriasis. Antibiotics were discontinued and she was started on Solumedrol. Her PF ratio improved suggesting improving gas exchange. X-ray chest progressively improved and she was successfully liberated. She was switched to oral prednisone and was discharged home. Results: COP may be accociated with some autoimmune conditions such as rheumatoid arthritis, SLE and Scleroderma but no association has been described with Psoriasis. Psoriasis is an inflammatory skin disease that causes hyperproliferation of the keratinocytes. There is a link between psoriasis and ARDS, UIP and Sarcoidosis based on case reports. Only 2 cases have been reported for COP during a psoriasis exacerbation phase. Recently, severe COP has bee described as an entity-overlapping ARDS, acute to subacute onset with rapid progression. It may present as widespread opacities corresponding criteria of ALI or ARDS requiring mechanical ventilation. Delay in diagnosis and initiation corticosteroids treatment is may cause progression to death.

Hypothermia-Related Acute Pancreatitis

Acute pancreatitis (AP) is an inflammatory disease presenting from mild localized inflammation to severe infected necrotic pancreatic tissue. In the literature, there are a few cases of hypothermia-induced AP. However, the association between hypothermia and AP is still a myth. Generally, mortality from acute pancreatitis is nearly 3–6%. Here, we present a 40-year-old chronic alcoholic female who presented with acute pancreatitis induced by transient hypothermia. A 40-year-old chronic alcoholic female was hypothermic at 81°F on arrival which was improved to 91.7°F with warming blanket and then around 97°F in 8 h. Laboratory tests including complete blood count, lipid panel, and comprehensive metabolic panels were within the normal limit. Serum alcohol level was 0.01, amylase 498, lipase 1,200, ammonia 26, serum carboxyhemoglobin level 2.4, and β-HCG was negative. The entire sepsis workup was negative. During rewarming period, she had one episode of witnessed generalized tonic-clonic seizure. It was followed by transient hypotension. Fluid challenge was successful with 2 L of normal saline. Sonogram (abdomen) showed fatty liver and trace ascites. CAT scan (abdomen and pelvis) showed evidence of acute pancreatitis without necrosis, peripancreatic abscess, pancreatic mass, or radiopaque gallstones. The patient was managed medically and later discharged from the hospital on the 4th day as she tolerated a normal low-fat diet. In our patient, transient hypothermia from chronic alcohol abuse and her social circumstances might predispose to microcirculatory disturbance resulting in acute pancreatitis. Early and aggressive fluid resuscitation prevents complications.

Catamenial anaphylaxis: a woman under monthly progesterone curse

Catamenial or cyclical anaphylaxis is a complex clinical syndrome with poorly reported incidence and prevalence in the literature review. The underlying mechanism is still a myth although a few proposed hypotheses are stated. Early recognition of these symptoms will bring optimal treatment and prevent unnecessary intubation and complications. Here, we present a 48-year-old woman without significant medical and family history with recurrent angioedema in the setting of catamenial anaphylaxis or cyclical anaphylaxis in the setting of progesterone hypersensitivity.