Karim El-Kersh

Viral infection in community-acquired pneumonia: a systematic review and meta-analysis

The advent of PCR has improved the identification of viruses in patients with community-acquired pneumonia (CAP). Several studies have used PCR to establish the importance of viruses in the aetiology of CAP. We performed a systematic review and meta-analysis of the studies that reported the proportion of viral infection detected via PCR in patients with CAP. We excluded studies with paediatric populations. The primary outcome was the proportion of patients with viral infection. The secondary outcome was short-term mortality. Our review included 31 studies. Most obtained PCR via nasopharyngeal or oropharyngeal swab. The pooled proportion of patients with viral infection was 24.5% (95% CI 21.5–27.5%). In studies that obtained lower respiratory samples in >50% of patients, the proportion was 44.2% (95% CI 35.1–53.3%). The odds of death were higher in patients with dual bacterial and viral infection (OR 2.1, 95% CI 1.32–3.31). Viral infection is present in a high proportion of patients with CAP. The true proportion of viral infection is probably underestimated because of negative test results from nasopharyngeal or oropharyngeal swab PCR. There is increased mortality in patients with dual bacterial and viral infection. Viral infection is present in a high proportion of patients with community-acquired pneumonia http://ow.ly/X03pK

Enteral nutrition as stress ulcer prophylaxis in critically ill patients: A randomized controlled exploratory study

Purpose: We investigated whether early enteral nutrition alone may be sufficient prophylaxis against stress‐related gastrointestinal (GI) bleeding in mechanically ventilated patients. Materials and methods: Prospective, double blind, randomized, placebo‐controlled, exploratory study that included mechanically ventilated patients in medical ICUs of two academic hospitals. Intravenous pantoprazole and early enteral nutrition were compared to placebo and early enteral nutrition as stress‐ulcer prophylaxis. The incidences of clinically significant and overt GI bleeding were compared in the two groups. Results: 124 patients were enrolled in the study. After exclusion of 22 patients, 102 patients were included in analysis: 55 patients in the treatment group and 47 patients in the placebo group. Two patients (one from each group) showed signs of overt GI bleeding (overall incidence 1.96%), and both patients experienced a drop of >3 points in hematocrit in a 24‐hour period indicating a clinically significant GI bleed. There was no statistical significant difference in the incidence of overt or significant GI bleeding between groups (p = 0.99). Conclusion: We found no benefit when pantoprazole is added to early enteral nutrition in mechanically ventilated critically ill patients. The routine prescription of acid‐suppressive therapy in critically ill patients who tolerate early enteral nutrition warrants further evaluation. Highlights:GI bleeding has low incidence in the critically ill mechanically ventilated patients.Adding PPI to enteral nutrition may not offer an added prophylaxis against stress‐related GI bleeding.Our study supports the protective role of enteral nutrition in ICU.

A 63-Year-Old Man With a Chronic Cough and an Endobronchial Lesion

63-year-old man with an extensive smoking history presented with a complaint of persistent dry cough for 3 months. His past medical history was signifi cant for severe COPD with an FEV 1 at 40% predicted (stage III by GOLD [Global Initiative for Obstructive Lung Disease] criteria). The patient was retired and a current cigarette smoker, and he had no pets. There was no history of prior malignancy or recent travels. He had no fever, night sweats, or weight loss. He was not receiving any angiotensinconverting enzyme inhibitors. There were no symptoms suggestive of upper airway cough syndrome or gastroesophageal refl ux disease. Physical Examination Findings The patient was afebrile with stable vital signs. BP was 127/87 mm Hg, heart rate was 85 beats/min, and oxygen saturation was 94% on room air. A complete physical examination was remarkable for yellow nicotine stains on the fi ngernails without clubbing, wide subcostal angle, distant heart sounds, and prolonged expiratory phase bilaterally, with left-sided monophasic expiratory wheezing best heard over the left upper lobe. Diagnostic Studies CBC was normal, apart from a normocytic anemia, with hemoglobin level of 12 g/dL (normal, 14-18 g/dL). Complete metabolic panel results, includ ing electrolytes, renal, and liver function testing, were within normal limits. No acute abnormalities were detected on chest radiograph. Because of the presence of localized wheezing on physical examination, an endobronchial lesion was suspected, and a CT scan of the chest was obtained. The chest CT scan showed emphysematous changes with an upper lobe predom inance and an ovoid low-density endobronchial lesion in the distal left mainstem bronchus measuring 2.3 cm in maximum diameter ( Fig 1 ).

Pulmonary IgG4+ Rosai-Dorfman disease

Rosai-Dorfman disease (RDD) is a rare non-malignant proliferation of histiocytes of unknown aetiology that mainly affects lymph nodes. Here we report a case of RDD that presented a diagnostic dilemma due to its atypical presentation and the overlap with IgG4 disease. Our case presented with interstitial lung involvement without lymphadenopathy. Open lung biopsy suggested the diagnosis of RDD. However, the predominant IgG4 positive plasma cells together with the absence of lymphadenopathy were not typical of RDD. Within 1 year, the patient developed diffuse lymphadenopathy and immunohistochemical staining of lymph node aspirates confirmed the diagnosis. Despite trials of corticosteroid therapy, the disease progressed.

Rarity revisited: cryptococcal peritonitis

Cryptococcal peritonitis is a rare disease. Although the respiratory tract is considered to be the usual port of entry for the organism, the gastrointestinal tract can also serve as the potential site of entry. Here, we present a case of cryptococcal peritonitis that developed in an HIV-negative patient with underlying liver cirrhosis. We reviewed the literature and a total of 61 cases of cryptococcal peritonitis were identified. Liver cirrhosis, HIV/AIDS and end-stage renal disease on continuous ambulatory peritoneal dialysis were the major risk factors for developing crytococcal peritonitis.

Severe Central Sleep Apnea in Vici Syndrome

Vici syndrome is a rare congenital multisystem disorder due to recessive mutations in the key autophagy regulator EPG5. Vici syndrome is characterized by agenesis of the corpus callosum, hypopigmentation, immunodeficiency, cataracts, and cardiomyopathy, with variable additional multisystem involvement. Here we report on a 5-year-old girl who presented with global developmental delay, seizures, callosal agenesis, cataracts, sensorineural hearing loss, hypopigmentation, and immunodeficiency with a low CD4 count and recurrent infections. EPG5 sequencing (prompted by suggestive clinical features) revealed a homozygous missense mutation, c.1007A>G (p.Gln336Arg). The patient was referred to our center for evaluation of nocturnal apnea. Overnight polysomnography showed severe central sleep apnea (CSA) with an overall apnea-hypopnea index of 100.5 events per hour of sleep (central apnea index of 97.5, mixed apnea index of 2, and obstructive hypopnea index of 1). The patient responded to bilevel positive airway pressure therapy with a backup rate with normalization of the apnea-hypopnea index and maintenance of oxygen saturation >90%. Despite successful control of the severe CSA, the patient was eventually started on nocturnal oxygen therapy due to excessive upper airway secretions and the high risk of possible aspiration with positive airway pressure therapy. This is the first report of EPG5-related Vici syndrome associated with CSA. We discuss the polysomnographic findings in our patient in the context of a brief literature review of the reported sleep abnormalities in Vici syndrome.

Predictive Role of Admission Lactate Level in Critically Ill Patients with Acute Upper Gastrointestinal Bleeding.

BACKGROUND The predictive role of lactate in critically ill patients with acute upper gastrointestinal bleeding (UGIB) remains to be elucidated. OBJECTIVE The primary objective of this study was to assess the value of lactate level on admission to predict in-hospital death in patients with UGIB admitted to the intensive care unit (ICU). The secondary objective was to assess whether lactate level adds predictive value to the clinical Rockall score in these patients. METHODS This was a retrospective cohort study that included 133 patients with acute UGIB admitted to the ICU. Inclusion criteria were age > 18 years and presence of UGIB on admission to the ICU. RESULTS Mean age was 55.4 years old and 64.7% were male. The most common cause of gastrointestinal bleeding was peptic ulcer disease, followed by erosive esophagitis/gastritis. The in-hospital mortality was 22.6%. Median lactate level in survivors and nonsurvivors was 2.0 (interquartile range [IQR] 1.2-4.2 mmol/L) and 8.8 (IQR 3.4-13.3 mmol/L; p < 0.01), respectively. The receiver operating characteristic (ROC) area to predict in-hospital death for clinical Rockall score and lactate level (0.82) was significantly higher than the ROC area for the clinical Rockall score alone (0.69) (p < 0.01). CONCLUSIONS In patients admitted to the ICU with acute UGIB, lactate level on admission has a high sensitivity but low specificity for predicting in-hospital death. Lactate level adds to the predictive value of the clinical Rockall score. Given its high sensitivity, lactate level can be used in addition to other prediction tools to predict outcomes in patients with UGIB.

Postgraduate Education Corner: Pulmonary, Critical Care, and Sleep PearlsA 63-Year-Old Man With a Chronic Cough and an Endobronchial Lesion

63-year-old man with an extensive smoking history presented with a complaint of persistent dry cough for 3 months. His past medical history was signifi cant for severe COPD with an FEV 1 at 40% predicted (stage III by GOLD [Global Initiative for Obstructive Lung Disease] criteria). The patient was retired and a current cigarette smoker, and he had no pets. There was no history of prior malignancy or recent travels. He had no fever, night sweats, or weight loss. He was not receiving any angiotensinconverting enzyme inhibitors. There were no symptoms suggestive of upper airway cough syndrome or gastroesophageal refl ux disease. Physical Examination Findings The patient was afebrile with stable vital signs. BP was 127/87 mm Hg, heart rate was 85 beats/min, and oxygen saturation was 94% on room air. A complete physical examination was remarkable for yellow nicotine stains on the fi ngernails without clubbing, wide subcostal angle, distant heart sounds, and prolonged expiratory phase bilaterally, with left-sided monophasic expiratory wheezing best heard over the left upper lobe. Diagnostic Studies CBC was normal, apart from a normocytic anemia, with hemoglobin level of 12 g/dL (normal, 14-18 g/dL). Complete metabolic panel results, includ ing electrolytes, renal, and liver function testing, were within normal limits. No acute abnormalities were detected on chest radiograph. Because of the presence of localized wheezing on physical examination, an endobronchial lesion was suspected, and a CT scan of the chest was obtained. The chest CT scan showed emphysematous changes with an upper lobe predom inance and an ovoid low-density endobronchial lesion in the distal left mainstem bronchus measuring 2.3 cm in maximum diameter ( Fig 1 ).

Effect of Sleep State and Position on Obstructive Respiratory Events Distribution in Adolescent Children.

STUDY OBJECTIVES This study aimed to examine the effect of sleep state (rapid eye movement [REM] versus non-rapid eye movement [NREM]) and position (supine versus non-supine position) on obstructive respiratory events distribution in adolescent population (ages 12 to 18 y). METHODS This was a retrospective study that included 150 subjects between the ages of 12 to 18 y with an apnea-hypopnea index (AHI) > 1/h. Subjects using REM sleep-suppressant medications and subjects with history of genetic anomalies or craniofacial syndromes were excluded. RESULTS The median age was 14 y with interquartile range (IQR) of 13 to 16 y, 56% of patients were males and the median body mass index (BMI) z-score was 2.35 (IQR: 1.71-2.59) with 77.3% of patients fulfilling obesity criteria. Respiratory obstructive events were more common in REM sleep. The median REM obstructive AHI (OAHI) was 8.9 events per hour (IQR: 2.74-22.8), whereas the median NREM OAHI was 3.2 events per hour (IQR: 1.44-8.29; p < 0.001). African American adolescents had more REM obstructive events with median REM OAHI of 13.2 events per hour (IQR: 4.88-30.6), which was significantly higher than median REM OAHI of 4.94 (IQR: 2.05-11.36; p = 0.004) in white adolescents. Obstructive events were more common in supine position with higher median supine OAHI of 6.55 (IQR: 4-17.73) when compared to median non-supine OAHI of 2.94 (IQR: 1-6.54; p < 0.001). CONCLUSIONS This study shows that sleep related obstructive respiratory events in the adolescents (12 to 18 y of age) occur predominantly in REM sleep and in supine position.

Mounier-Kuhn Syndrome. Imaging and Bronchoscopic Findings

A 35-year-old male presented for evaluation of recurrent lower respiratory tract infections. Computed tomography (CT) scan showed tracheobronchomegaly involving the entire trachea and main bronchi. Diverticula were evident mainly in the posterior tracheal wall (Figure 1). Varicose and cystic bronchiectasis extended to the distal bronchi (Figure 2). Serum a1-antitrypsin level, serum IgE level and other serum immunoglobulins levels were normal. Fiberoptic bronchoscopy was consistent with the CT findings (Figure 3). In absence of secondary causes for tracheobronchial enlargement, the diagnosis of Mounier-Kuhn syndrome was made. Mounier-Kuhn syndrome is characterized by tracheobronchial dilation secondary to atrophy of the muscular and elastic tissues in the trachea and main bronchial walls (1). It is more common in men, especially African Americans. Most of the cases are sporadic, but familial cases have been described with a possible recessive inheritance (2). It has three subtypes: type 1 has subtle symmetrical dilation of trachea and major bronchi; type 2 has more obvious dilation with eccentric diverticula; type 3 has diverticula that extend to the distal bronchi. Treatment ranges from respiratory physiotherapy for airway clearance to endobronchial stenting in severe cases (1). n