Hafiz Abdul Moiz Fakih

Coronary artery bypass grafting in a patient with active idiopathic cryoglobulinemia: revisiting the issue

Background Cryoglobulinemia is a cold-reactive autoimmune disease. It is of distinctive importance in cardiac surgery because of the use of hypothermic cardiopulmonary bypass (CPB). Cryoglobulins, which activate at variable levels of hypothermia, can cause precipitation during surgery leading to possibly severe leukocytoclastic or necrotizing vasculitis, clinically manifested as ischemic events, such as cutaneous ulcerations, glomerulonephritis, arthritis, or peripheral neuropathies among the most reported associated comorbidities. Management of CPB and systemic protection in this rare but unique scenario requires individualized planning. We report the case of a patient with active cryoglobulinemia who was preoperatively managed with plasmapheresis. He underwent hypothermic coronary bypass with no precipitation and flare during and after surgery. Case presentation We describe the case of a 59-year-old Caucasian male with clinically significant idiopathic cryoglobulinemia and history of recurrent skin lesions and toe amputations secondary to cold exposure. He presented with 2-h duration of chest pain and new onset atrial fibrillation. After cardiac catheterization, a diagnosis of three-vessel coronary artery disease was established and coronary artery bypass grafting (CABG) was scheduled. Because of a high risk of flare-up during surgery, the patient was preemptively treated with two sessions of plasmapheresis before bypass. He then underwent hypothermic CABG. The pre- and perioperative course was unremarkable without any clinical evidence of precipitation. The patient was discharged on day 6 postoperatively without any complications. Conclusion Preoperative plasmapheresis before hypothermic coronary bypass can prevent fatal cryoglobulinemia-related complications in patients with active disease.

Bosutinib induced pleural effusions: Case report and review of tyrosine kinase inhibitors induced pulmonary toxicity

Tyrosine kinase inhibitors are known to cause pulmonary complications. We report a case of bosutinib related bilateral pleural effusions in a patient with chronic myeloid leukemia. Characteristics of the pleural fluid are presented. We also discuss other tyrosine kinase inhibitors induced pulmonary toxicities, including pulmonary hypertension and interstitial lung disease.

Transudative pleural effusion of malignant etiology: Rare but real

A 62-year-old female presented to the emergency room with one-month history of epigastric abdominal pain, nausea and vomiting. She endorsed progressive dyspnea over two weeks. CT of the abdomen demonstrated bilateral pleural effusions and pancreatic inflammation, so the working diagnosis was pancreatitis. A diagnostic thoracentesis was performed and the pleural fluid analysis was classified as transudate by Lights criteria. Given the atypical features in history and concern for malignancy, fluid was sent for cytological examination and immunohistochemistry which suggested a mucinous malignancy. EGD revealed poorly differentiated signet ring cell adenocarcinoma of stomach. Patient underwent placement of indwelling pleural catheters for symptomatic improvement and was discharged to hospice. The decision whether to routinely send transudative effusions for cytological evaluation remains controversial. This case demonstrates the importance of using clinical judgement to guide that decision.

Sarcoidosis—the great masquerader

A 36-year-old Caucasian female presented with acute left-sided facial weakness with intermittent fevers. She was diagnosed with idiopathic Bell’s Palsy. After 3 weeks, she again presented with acute right sided facial weakness (Figure 1A). A history of pain in the bilateral preauricular and mandibular area was elicited. She was found to have bilateral parotid gland enlargement. Her eye exam was suggestive of bilateral uveitis as evidenced by bilateral conjunctival injection and posterior synechiae. A chest CT demonstrated mediastinal and hilar adenopathy (Figure 1B). Endobronchial ultrasound guided needle aspiration of the mediastinal lymph nodes was suggestive of a granulomatous process (Figure 1C). Based on these findings, a diagnosis of Heerfordt’s syndrome was made. She was started on prednisone 30 mg PO daily and has had a near complete resolution of her right sided facial palsy and her mediastinal and hilar lymphadenopathy. Heerfordt’s syndrome is an infrequent expression of sarcoidosis (0.3% all of sarcoid cases). It is distinguished by the presence of low grade fever, anterior uveitis, facial nerve palsy and parotid gland enlargement. Facial nerve palsy in Heerfordt’s syndrome has an acute onset in 25–50% cases and this palsy can be unilateral or bilateral. The challenge in our patient was that she presented with the constellation of this syndrome over a period of two months. A detailed knowledge of this syndrome may help the physician in making the correct diagnosis, avoid unnecessary testing and initiation of early treatment.

A nasoenteral feeding tube barking up the wrong tree

A 58-year-old woman with multiple co-morbidities, including a history of kidney and pancreas transplant, was admitted to the intensive care unit for management of septic shock. She had a prolonged course and had a small-bore nasoduodenal feeding tube placed under electromagnetic sensing device guidance. She soon developed abdominal distention with absence of bowel sounds followed by hemodynamic compromise. An abdominal X-ray (Fig. 1) revealed an abnormal air pattern in the right upper quadrant (blue star) and the feeding tube

Bilateral adrenal hemorrhage

A 42-year-old woman with history of B cell acute lymphoblastic leukemia, currently receiving chemotherapy, was admitted to the hospital with altered mental status. She was found to be hypotensive and in acute hypercapnic respiratory failure requiring mechanical ventilation. She was treated with broad-spectrum antibiotics, fluid resuscitation, vasopressor support, and stress dose steroids but continued to be hypotensive with a lactate of 16 mmol/L. A computed tomography scan of the abdomen revealed bilateral stranding around the adrenal glands indicative of bilateral adrenal hemorrhage (Fig. 1). The patient was started on a corticosteroid infusion. Despite these interventions the patient rapidly progressed to multi-organ failure and died. Blood cultures came back positive for methicillin-resistant Staphylococcus aureus (MRSA).

1751: ACUTE EMPHYSEMATOUS GASTRITIS AND MULTIORGAN DYSFUNCTION CAUSED BY SARCINA IN A HEALTHY ADULT

Learning Objectives: We report a case of a previously healthy 38 year old man who presented with abdominal pain, pneumobilia and sepsis and underwent emergent gastric wedge resection for acute Emphysematous Gastritis (EG). Examination of surgical specimens revealed significant overgrowth with Sarcina bacteria. To our knowledge, this is the only report of EG caused by Sarcina species. Methods: A 38 year old healthy man presented to an outside hospital with abdmonial pain. Initial imaging with CT scan was unremarkable. Despite IV hydration, his symptoms continued to worsen with metabolic acidosis and leukocytosis. Repeat CT scan revealed pneumobilia, distended stomach, and significant airspace disease. He was given broad-spectrum antibiotics and transferred to our hospital, where he was intubated and underwent emergent gastric wedge resection. His post-operative ICU course was complicated by septic shock requiring vasopressors, prolonged intubation, ARDS, persistent fevers, TPN, a DVT, and ICU delirium. He ultimately recovered and tolerated an enteral diet. He was transferred from ICU post-op day 13 and to acute rehab. Results: EG is a rare and very serious infection of the stomach wall caused by gas-forming organisms and resulting in transmural infarction of the stomach wall, with a mortality rate of 55% based on the 39 case reports that have been published. Sarcina is a genus of gram positive, anaerobic bacteria in the Clostridium cluster. They are known to cause significant gastric pathology in veterinary medicine and are increasingly recognized as a potentially pathogenic organism in humans. Only 22 case reports of Sarcina infection in humans have been reported, but the majority of these have come since 2011, with most cases causing only mild gastrointestinal symptoms. Our hypothesis as to how our patient developed EG secondary to Sarcina infection was by ingestion of contaminated venison. He is a hunter who had eaten days-old, unrefrigerated deer meat prior to the onset of his illness. After consumption of the meat, and before hospitalization, the patient began complaining of gastroenteritis-symptoms.

1950: AN UNUSUAL CAUSE OF PULMONARY ARTERY DISSECTION.

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) during bronchoscopy once again helped to localize a new BGF in the superior segment of the right lower lobe (RLL). Successful management was achieved with the placement of a 10 x 20 mm Aero Stent totally occluding the superior segment of the RLL with no signs of leak. The patient’s clinical status improved with no future development of BGF’s. Results: With the aid of MB, localization of difficult to identify BGF’s is made possible. Management with rigid bronchoscopy may include combinations of bone fragments, fibrin glue and stent placement can be used to stabilize the patient allowing them to become better candidates for surgery. In our case they were used for final management and ST didn’t require additional surgeries.