Nader Mahmood

Cardiac troponin I levels and alveolar-arterial oxygen gradient in patients with community-acquired pneumonia.

BACKGROUND Patients with community-acquired pneumonia (CAP) appear to have cardiac stress as demonstrated by elevated B-type natriuretic peptide (BNP). We hypothesised that myocardial stress and decrease in oxygenation might also lead to elevations of cardiac troponin I (cTnI) levels in serum. OBJECTIVE The aim of this study was to see if cTnI was associated with the alveolar-arterial oxygen gradient (DeltaA-a), a marker of severity in CAP. METHODS Retrospective cohort study of 901 CAP patients with no evidence of acute coronary syndrome presenting to a large, tertiary-care, urban teaching hospital over a 3-year period. RESULTS A strong linear trend between log(10)cTnI and DeltaA-a was observed (r(2)=0.76) with a statistically significant Spearman correlation coefficient (r(s)=0.75; p<0.0001) between cTnI and DeltaA-a. A cTnI value of 0.5 ng/ml discriminated mild CAP from moderate-severe CAP with an OR=208 (95% CI: 50.5-408; p<0.0001). CONCLUSIONS These data suggest that decreased blood O(2) levels as suggested by elevated DeltaA-a may lead to acute myocardial damage and that cTnI may be useful as a biomarker to stratify risk in subjects with CAP.

Frequency of hypoxic events in patients on a mechanical ventilator.

Background: Mechanical ventilation is an important tool in the management of respiratory failure in the critically ill patient. Although mechanical ventilation can be a life-saving intervention, it is also known to carry several side-effects and risks. Adequate oxygenation is one of the primary goals of mechanical ventilation. However, while on mechanical ventilation, patients frequently experience hypoxic events resulting from various causes, which need to be properly evaluated and treated. Materials and Methods: Data were obtained by prospectively reviewing all intensive care admissions during the period from March 2009 to March 2010 at a 651-bed urban medical center. Patients who developed hypoxemia (oxygen saturation ≤88% and a PaO2≤60 torrs) while on mechanical ventilation were investigated for the cause of hypoxic event. Results: During the study period, 955 patients required mechanical ventilation from which 79 developed acute hypoxia. The causes of acute hypoxia in decreasing order of occurrences were pulmonary edema, atelectasis, pneumothorax, pneumonia, ARDS, endotracheal tube malfunction, airway bleeding, and pulmonary embolism. Conclusions: Appropriate evaluation of all hypoxic events must begin at the bedside. A step-by-step approach must include a thorough physical examination. Evaluation of the endotracheal tube can immediately reveal dislodgement, bleeding, and secretions. Correlation of physical examination findings with those on chest radiograph is essential. Each hypoxic event requires a different intervention depending on its etiology. Instead of simply increasing the fraction of oxygen in the inspired air to overcome hypoxia, a concerted effort in appropriate problem solving can reduce the likelihood of an incorrect diagnosis and management response.

Broadening of the red blood cell distribution width is associated with increased severity of illness in patients with sepsis

Background: Sepsis is a pro-inflammatory state caused by systemic infection. As sepsis progresses, multiple organ systems become affected with subsequent increase in mortality. Elevated red cell distribution width (RDW) has been seen with changes of other inflammatory markers and thus could potentially serve as a means of assessing sepsis severity. In this study, we examine the association of RDW with APACHE II score and in-hospital mortality. Meterials and Methods: We conducted a retrospective study involving a cohort of patients with sepsis. The study period spanned 2 years with a cohort of 349 patients. Data were collected to determine if RDW is associated with APACHE II scores and in-hospital mortality in this cohort. Results: RDW correlated weakly (rs = 0.27), but significantly (P < 0.0001) with APACHE II scores; coefficient of determination (r2 = 0.09). The odds ratios for the association of RDW with APACHE II were calculated over the RDW range 12-20% at a dichotomized level of APACHE II, i.e., <15 and ≥15. At a RDW ≥16%, multivariate analysis including all potential confounders indicated that RDW was independently associated with an APACHE II score of ≥15. Similarly, mortality was associated with RDW ≥16%. Conclusion: A prognostic biomarker for sepsis in the form of a routine blood test may be of considerable clinical utility. The results of our study suggest that RDW may have value in differentiating between more severe and less severe cases of sepsis. Future studies with larger samples are needed to confirm these findings.

Pulmonary Hydatid Cyst with Complicating Aspergillus Infection Presenting as a Refractory Lung Abscess

Background Hydatid disease is rare in the United States. Rarely the hydatid cyst can become infected with mycotic organisms, such as Aspergillus. We describe a young male who presents with clinical features of suppurative lung abscess whose workup diagnosed hydatid cyst complicated by Aspergillus co-infection. Case presentation A 27-year-old Peruvian male was hospitalized because of fever, chills, and productive cough of three months’ duration. Clinical features were consistent with a suppurative lung abscess. Significant findings included leukocytosis with eosinophilia and a chest x-ray showing a large lingular lobe thick walled cavity with a wavy irregular fluid level. The patient ultimately underwent surgical resection of the lingular lobe. Examination of the surgical specimen revealed the cavity to be a hydatid cyst. Histologic examination of the cyst wall showed intense inflammation and several septate hyphae of Aspergillus species. The patient recovered fully and has remained in good health. Conclusion A thick-walled cavity and a wavy meniscus constitute unusual features for an ordinary pyogenic lung abscess and suggests other possibilities. Endogenous cases of hydatid disease are uncommon in the United States, with the majority of cases occurring in immigrants. There are few published case reports describing incidental findings of Aspergillus in a hydatid cyst. The rare occurrence of such a condition can lead to a delay in diagnosis and treatment.

Pulmonary Mucormycosis - A Disease Against Time

Abstract SESSION TYPE: Infectious Disease Case Report Posters IIPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PMINTRODUCTION: Pulmonary mucormycosis, a rare fungal infection with a high mortality rate, has been reported in patients with diabetic ketoacidosis, diabetes mellitus, and immunosupression due to chemotherapy, steroids, and hematological malignancies. Without early recognition and management, it can be ultimately fatal. We report a rare case of isolated pulmonary mucormycosis.CASE PRESENTATION: 65-year-old Caucasian male presented with shortness of breath for 2 days associated with chills, nonproductive cough, right upper pleuritic chest pain, and 4 days of polyuria and polydipsia. Patient was recently admitted and discharged on tapering prednisone for COPD exacerbation. Patient had 30 pack year smoking history. On presentation he was febrile, tachycardic, tachypneic and normotensive with physical findings consistent with right upper lobe (RUL) infiltrate. Lab investigations showed leukocytosis. Serum chemistry showed acute kidney injury (AKI) and hyperglycemia with a normal anion gap. Chest x-ray demonstrated RUL infiltrate. Patient was started on IV fluids, insulin drip, and piperacillin-tazobactam, vancomycin and ciprofloxacin. In ICU, patients vitals deteriorated requiring mechanical ventilation. Initially all cultures showed no growth. Ciprofloxacin and vancomycin were changed to moxifloxacin and linezolid with addition of tobramycin. RUL infiltrate steadily worsened with suspicion of cavitation or abscess formation. CT chest showed necrotizing RUL infiltrate. Patient developed multi-organ failure and DIC requiring aggressive management. Bronchoscopy and BAL of the RUL showed mucosal edema and dark brown secretions . Few weeks later BAL results yielded a mold with cultures positive for Rhizopus species. Posaconazole and amphoterocin B were used to treat Rhizopus. Surgery for lobectomy could not be performed due to multilobar involvement. Gradually necrotizing pneumonia resulted in right sided pneumothorax. Chest tube was placed with non-resolving severe air leak. Repeat bronchoscopy showed bronchopleural fistula and necrotizing tissue. After multiple family meetings, comfort care decision was made, after which patient passed away.DISCUSSION: Rhizopus is genus of class Zygomycetes. It can cause tissue infarctions ranging from cutaneous, rhinocerebral, and sinopulmonary to disseminated and frequently fatal infections, especially in immunocompromised hosts. Ischemic necrosis of tissues can prevent delivery of antifungal agents to the foci of infection. Surgical debridement is critical for treatment but is only possible if disease is localized. Combination of posaconazole, amphotericin B and capsofungin is used for medical management.CONCLUSIONS: Pulmonary mucormycosis is a rapidly progressive rare disease that carries a high mortality over a short period of time. Dissemination, multiorgan failure and invariably death follows, if not recognized early.1) Francis Y. Pulmonary Mucormycosis Arch Intern Med. 1999;159:1301-1309DISCLOSURE: The following authors have nothing to disclose: Muhammad Ali, Hasan Zaidi, Aasiya Haroon, Nader Mahmood, Mourad IsmailNo Product/Research Disclosure InformationSt. Josephss Regional Medical Center/Seton Hall Universtiy, Paterson, NJ.