Nauman Siddiqui

Acute Amiodarone-induced Lung Toxicity

CLINICAL PRESENTATION A 62-year-old man was admitted to the hospital for abdominal surgery for biliary leak. On the postoperative period, he developed atrial fibrillation with rapid ventricular response that responded to intravenous amiodarone bolus (150 mg) followed by amiodarone drip at 1 mg/hr for 48 hours. One day later, patient developed progressive shortness of breath with hypoxemic respiratory failure, requiring noninvasive positive pressure ventilation and oxygen. Chest radiograph showed evidence of new onset bilateral alveolar-interstitial infiltrate and minimal pleural effusion. Computerized tomography angiogram of the chest revealed multifocal pulmonary ground-glass opacities and foci of consolidation (Figure 1, computerized tomography chest axial image 72 hours after amiodarone). The differential diagnosis includes atypical infection, congestive heart failure and acute amiodarone-induced lung toxicity. Cardiac examination was normal. Echocardiography and Doppler studies showed normal ejection fraction with no evidence of diastolic dysfunction. Patient underwent flexible fiberoptic bronchoscopy with bronchoalveolar lavage of the right upper lobe that showed no significant secretions or airway abnormality; however, the cell count and differential of the lavage showed the presence of 43% of neutrophils and 46% of macrophages, 70% of which were foamy macrophages (Figure 2, normal macrophages on left and foamy macrophage on right). Serum KL-6 level was not performed. Respiratory cultures showed no growth. Amiodarone-induced pulmonary toxicity occurs in approximately 5% of treated patients. It includes acute respiratory distress syndrome, chronic interstitial pneumonia, organizing pneumonia and solitary pulmonary mass. A characteristic finding in all patients exposed to amiodarone is the presence of numerous foamy macrophages in the air spaces, which are filled with amiodarone-phospholipid complexes because of the inhibition of phospholipase. Risk factors for amiodarone-induced lung toxicity includes daily dose greater than 400 mg/d, increased patient age, preexisting lung disease, thoracic or nonthoracic surgery and pulmonary angiography. Treatment is to discontinue amiodarone and institute systemic glucocorticoid therapy with slow taper over a 2to 6-month period.

Multisystem Side Effects of Amiodarone

A 60-year-old man with medical history of atrial fibrillation on amiodarone 400 mg/d for 8 years was admitted for increased shortness of breath. On his general physical examination, he had grayish discoloration of face. Further workup included computed tomography (CT) of chest and upper abdomen, and bronchoscopy revealed increased attenuation of the liver and lung infiltrates. Amiodarone is an iodinated benzofuran derivative class 3 antiarrhythmic agent. It has multiple side effects, affects most of the organ systems of the human body including, eyes, thyroid, lungs, liver, brain and skin. Our patient had skin, lung and liver involvement. The patient had striking slate gray pigmentation of the face (Figure 1). The grayish blue color (ceruloderma) is due to the deposition of the melatonin and lipofuscin in macrophages and endothelial cells in the dermis, which is induced by amiodarone. Diffuse alveolar and interstitial infiltrates (Figure 2) due to diffuse alveolar hemorrhage were shown by serial bronchoalveolar lavage. CT of the liver showed increased liver density (116 H [Hounsfield units], normal range of liver 30–70 H) compared with that of the spleen and surrounding tissues, consistent with amiodarone injury (Figure 2).

Nephropleural Fistula Effectively Managed with Serial Thoracentesis: A Case Report

Abstract Nephropleural fistulae are rare but serious thoracic complications of percutaneous nephrolithotomy (PCNL). Herein, we present the management of a 54-year-old female with a delayed presentation of nephropleural fistula. The role of serial thoracentesis as a safe, less invasive, less painful alternative to tube thoracostomy is highlighted. In select cases, this may represent an attractive management strategy for nephropleural fistula after PCNL.

Endobronchial Cartilage Rupture: A Rare Cause of Lobar Collapse.

Endobronchial cartilage rupture is a rare clinical condition, which can present in patients with severe emphysema with sudden onset shortness of breath. We present a case of a 62-year-old male who presented to our emergency department with sudden onset shortness of breath. Chest X-ray showed lung hyperinflation and a right lung field vague small density. Chest Computed Tomography confirmed the presence of right middle lobe collapse. Bronchoscopy revealed partial right middle lobe atelectasis and an endobronchial cartilage rupture. Endobronchial cartilage rupture is a rare condition that can present as sudden onset shortness of breath due to lobar collapse in patients with emphysema and can be triggered by cough. Bronchoscopic findings include finding a collapsed lung lobe and a visible ruptured endobronchial cartilage. A high index of suspicion, chest imaging, and early bronchoscopy can aid in the diagnosis and help prevent complications.

Enterococcus Faecalis Infective Endocarditis and Colorectal Carcinoma: Case of New Association Gaining Ground

Mostly Streptococcus bovis (S. bovis) bacteremia and endocarditis (60%) has been found to be associated with underlying colorectal cancer (CRC). Enterococcus faecalis (E. faecalis) bacteremia and endocarditis has no identifiable source in most of the cases. E. faecalis is part of normal gut flora that can translocate through the intestine and cause the systemic infection. With any intestinal lesion or tumor, the barrier is breached and the gut flora like E. faecalis can translocate and cause infection. A 55-years-old male known to have non-ischemic cardiomyopathy with implantation of automated implantable cardioverter defibrillator (AICD) and atrial fibrillation presented with weight loss, fever and back pain. He was diagnosed to have E. faecalis bacteremia and subsequent endocarditis and osteomyelitis of T7 - T8 and L4 - L5 vertebrae. He underwent colonoscopy for screening of malignancy because of his age and presenting symptoms suggestive of one. The colonoscopy found pedunculated polyp in sigmoid colon, and after biopsy the histology revealed an invasive well differentiated mucinous adenocarcinoma, with focal squamous differentiation. He underwent removal of AICD and antibiotic treatment for infective endocarditis and osteomyelitis. He underwent sigmoid colectomy with pathology of removed specimen showing adenocarcinoma with negative margins and lymph nodes. In many of the patients with E. faecalis endocarditis, if identifiable the source is genitourinary tract. But in most of the cases the source of E. faecalis bacteremia is unidentified. There is some evidence to suggest that in patients with unidentified source, colonoscopy may reveal a hidden early stage CRC or adenoma. We conclude that in cases of E. faecalis bacteremia and endocarditis with unidentified source, colonoscopy should be considered if feasible to rule out the diagnosis of CRC.

Successful Endoscopic Treatment of Bouveret Syndrome in a Patient with Choledochoduodenal Fistula Complicating Duodenal Ulcer

Introduction Cholecystoduodenal fistulas represent the most common type of bilioenteric fistulas while choledochoduodenal fistulas account for only 1–25% of cases. Bilioenteric fistula cases are associated with cholelithiasis and are rarely associated with duodenal peptic ulcers. Here we present the first case of Bouveret syndrome secondary to choledochoduodenal fistula complicating peptic duodenal ulcer managed successfully via endoscopic mechanical lithotripsy. Case 86-year-old male with a medical history significant for coronary artery disease and stage 3 colorectal cancer status after resection and chemoradiation presented with intractable sharp abdominal pain worse postprandially for one week in duration, associated with early satiety, anorexia, and 5 lbs weight loss in one week. CT abdomen showed possible choledochoduodenal fistula and a distended stomach. An esophagogastroduodenoscopy (EGD) was performed revealing a large 2.5–3 cm stone lodged in the duodenal bulb at the base of duodenal ulcer with a fistula opening beneath it. The stone was extracted in 2 pieces via mechanical lithotripsy. Endoscopic ultrasound of the CBD revealed Riglers triad. Conclusion Bouveret syndrome is mostly associated with cholecystoduodenal fistula and has high mortality and morbidity due to underlying comorbid conditions and elderly age. Patients are not always fit for surgical management, and endoscopic management is not always successful.

Images in the Medical ScienceLipoid Pneumonia

CLINICAL PRESENTATION A 55-year-old, nonsmoker, mentally disabled man presented with the history of cretinism, seizure, pica and bruxism. Patient presented with shortness of breath, dry cough and fever 3 days after ingestion of 10 ounces of bath oil. Chest x-ray showed bilateral lower lobe infiltrates, and chest computerized tomography scan showed patchy, bilateral lower lobe airspace infiltrates containing focal round areas of decreased density with measured Hounsfield unit of 284 as would be seen in fat (Figure 1, †, Hounsfield units: 284; *, Hounsfield units: 292). Patient was admitted to the hospital and started on empiric intravenous antibiotics and steroids. He underwent flexible fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial biopsy. Smears obtained from the BAL demonstrated macrophages with large vacuoles, ciliated columnar epithelium and polymorphonuclear leukocytes. An Oil Red O stain was positive for lipid material within the macrophages (Figure 2). Tissue biopsy samples revealed thickened alveolar walls with bubbly appearance and foamy macrophages consistent with lipoid pneumonia. All cultures remained negative. Lipoid pneumonia results from aspiration of oil products. It can be exogenous or endogenous depending on the source of lipid and acute or chronic depending on the recurrence of ingestion. Acute exogenous lipoid pneumonia occurs after aspirating large volume of oil, whereas chronic cases occur with repetitive aspiration of mineraland petroleumbased products. Diagnosis can be suggested by a chest computerized tomography scan showing changes that are bilateral and predominant in the posterior and lower zones of the lobes sparing the subpleural zones and a typical Hounsfield units in a range from2100 to23. Confirmation of the diagnosis can be made by staining BAL samples with Oil Red O stain for the presence of lipid material within the macrophages.

Evaluation and enhancement of medical knowledge competency by monthly tests: a single institution experience.

Background In-training examination (ITE) has been used as a predictor of performance at the American Board of Internal Medicine (ABIM) certifying examination. ITE however may not be an ideal modality as it is held once a year and represents snapshots of performance as compared with a trend. We instituted monthly tests (MTs) to continually assess the performance of trainees throughout their residency. Objective To determine the predictors of ABIM performance and to assess whether the MTs can be used as a tool to predict passing the ABIM examination. Methods The MTs, core competencies, and ITE scores were analyzed for a cohort of graduates who appeared for the ABIM examination from 2010 to 2013. Logistic regression was performed to identify the predictors of a successful performance at the ABIM examination. Results Fifty-one residents appeared for the ABIM examination between 2010 and 2013 with a pass rate of 84%. The MT score for the first year (odds ratio [OR] =1.302, CI =1.004–1.687, P=0.04) and second year (OR =1.125, CI =1.004–1.261, P=0.04) were independent predictors of ABIM performance along with the second-year ITE scores (OR =1.248, CI =1.096–1.420, P=0.001). Conclusion The MT is a valuable tool to predict the performance at the ABIM examination. Not only it helps in the assessment of likelihood of passing the certification examination, it also helps to identify those residents who may require more assistance earlier during their residency. It may also highlight the areas of weakness in program curriculum and guide curriculum development.