Mridula Krishnan

676: ATYPICAL PRESENTATION OF Q FEVER PRESENTING AS SEPTIC SHOCK AND RESPIRATORY FAILURE

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: The Q, in Q fever, stands for ‘Query’ as its cause was unknown in 1930s. In 2014, 139 cases were reported in United states and of which 39 (28%) cases were chronic. We report a case of chronic Q fever with rare presentation of Acute Respiratory Distress Syndrome, Septic Shock and hemolytic anemia. Methods: A 65 year old Hispanic male presented with anemia, developed acute dyspnea. Past medical history was significant for aortic dissection which was repaired over 10 years ago with a mechanical aortic valve and vascular grafts. Radiological imaging revealed bilateral multifocal infiltrates likely of infectious etiology. Patient required intubation and mechanically ventilation with vasopressor support for 12 days. Broad spectrum antibiotics (Vancomycin, Levofloxacin and Piperacillin-Tazobactam) were started for septic shock. Blood, Urine and Bronchoalveolar lavage cultures were negative. High dose steroids were started after direct Coombs test was positive. Doxycycline was added during his hospital course to cover for atypical pathogens and over the next few days, patient was successfully weaned off pressors and extubated. With addition of doxycycline, his procalcitonin trended down from 2.91 to 0.40 in 2 days. Further workup for atypical microorganisms returned with positive Q fever serology. His antibody titer for Phase 1 was 1:512 and Phase 2 was 1:128. During hospitalization, we discovered patient was exposed to raccoons in his backyard while gardening. Results: Q fever is a zoonotic infection caused by obligate intracellular pathogen, Coxiella burnetii, historically linked with exposure to farm animals. But there are emerging reports of Q fever in the urban population. Increased risk of chronicity and severity of symptoms have been reported with history of vascular surgery. This may have been the predisposing condition for severity of disease in our patient. Q fever can affect various organ systems with varying severity which presents a challenge in diagnosis. Usually it is a mild self-limiting illness however, acute respiratory distress syndrome, septic shock and hemolytic anemia have been reported with this infection. Q fever should be considered as a differential diagnosis when investigating patients with atypical pneumonia especially in scenarios involving exposure to animals or vascular repair. It’s important to recognize if patients have prosthetic valves/grafts, they will be treated as endocarditis with Doxycycline and Hydroxychloroquine for 18 to 24 months.

Factors Affecting Adjuvant Therapy in Stage III Pancreatic Cancer—Analysis of the National Cancer Database

Background: Adjuvant therapy after curative resection is associated with survival benefit in stage III pancreatic cancer. We analyzed the factors affecting the outcome of adjuvant therapy in stage III pancreatic cancer and compared overall survival with different modalities of adjuvant treatment. Methods: This is a retrospective study of patients with stage III pancreatic cancer listed in the National Cancer Database (NCDB) who were diagnosed between 2004 and 2012. Patients were stratified based on adjuvant therapy they received. Unadjusted Kaplan-Meier and multivariable Cox regression analysis were performed. Results: We analyzed a cohort included 1731 patients who were recipients of adjuvant therapy for stage III pancreatic cancer within the limits of our database. Patients who received adjuvant chemoradiation had the longest postdiagnosis survival time, followed by patients who received adjuvant chemotherapy, and finally patients who received no adjuvant therapy. On multivariate analysis, advancing age and patients with Medicaid had worse survival, whereas Spanish origin and lower Charlson comorbidity score had better survival. Conclusions: Our study is the largest trial using the NCDB addressing the effects of adjuvant therapy specifically in stage III pancreatic cancer. Within the limits of our study, survival benefit with adjuvant therapy was more apparent with longer duration from date of diagnosis.

An unusual presentation of recurring metastatic melanoma.

A 53-year-old non-distressed Caucasian female complains of dyspnea and palpitations for 5 days. Past medical history includes Stage IV melanoma with adequate resection 23 years prior. The patient suddenly became increasingly tachycardic in mild respiratory distress while maintaining hemodynamic stability. TTE depicted 10.5 × 7.5 × 9.5 cm3 mass within her left ventricle and a large volume of pericardial effusion, which progressed to cardiac tamponade. Pericardial window was performed. Metastatic involvement should be ruled out for all symptomatic patients with a history of melanoma.

Bent Metal in a Bone: A Rare Complication of an Emergent Procedure or a Deficiency in Skill Set?

Intraosseous (IO) access is an important consideration in patients with difficult intravenous (IV) access in emergent situations. IO access in adults has become more popular due to the ease of placement and high success rates. The most common sites of access include the proximal tibia and the humeral head. The complications associated are rare but can be catastrophic: subsequent amputation of a limb has been described in the literature. We report a 25-year-old female presenting with diabetic ketoacidosis (DKA) in whom emergent IO access was complicated by needle bending inside the humerus. Conventional bedside removal was impossible and required surgical intervention in operating room.