Shrinivas Kambali

Herpes Simplex Pneumonia in an Immunocompetent Patient With Progression to Organizing Pneumonia

Background. Organizing pneumonia is an uncommon diffuse interstitial lung disease that affects the terminal and respiratory bronchioles, alveolar ducts, and alveoli. Most cases are idiopathic, but some are associated with infections. We present an uncommon case of organizing pneumonia associated with herpes simplex virus-1 (HSV-1). Case. A 39-year-old man with hypertension presented with dyspnea, fever, and productive cough for 2 weeks. He was treated for 5 days for acute bronchitis as an outpatient with no improvement. His examination revealed mild respiratory distress, O2 saturation 92% on room air, and right sided crackles. Labs included a white blood cell count of 19 300/µL. His chest x-ray showed bilateral infiltrates greater on the right. Bronchoalveolar lavage was positive for HSV-1; transbronchial biopsies showed focal pneumonitis with plentiful intra-alveolar macrophages. His respiratory status progressively deteriorated, and he was intubated for mechanical ventilation. He received 10 days of intravenous (IV) antibiotics and 14 days of IV acyclovir. He was readmitted 10 days later with worsening symptoms and was intubated for respiratory failure. His CT chest showed diffuse, patchy consolidation of both lungs, right more than left. Open lung biopsy showed extensive organizing pneumonia, diffuse alveolar damage, intra-alveolar macrophages, and pleural fibrosis; he was treated with IV corticosteroids. He was extubated after 10 days; within 2 weeks his chest x-ray was markedly improved. Discussion. Organizing pneumonia is usually idiopathic; infection is one of the secondary causes. To our knowledge this is only the second reported case associated with HSV. This association may have important pathogenic and therapeutic implications.

Prolonged Refractory Hypotension Secondary to Amlodipine Overdose A Therapeutic Challenge

Calcium channel blocker overdose is one of the leading causes of overdose death among cardiovascular medications. We present a patient with the highest reported dose of amlodipine ingestion in combination pill. She was asymptomatic initially and soon became hypotensive and obtunded. She was intubated for airway protection, gastric lavage was done, and activated charcoal was given. She was resuscitated with 4L 0.9% normal saline, calcium chloride, glucagon, insulin, and glucose infusions. Her hypotension worsened necessitating use of norepinephrine 200 µg/min, phenylephrine 200 µg/min, dopamine 50 µg/kg/min, and vasopressin 0.06 U/min concurrently. She continued to improve and was weaned off vasopressors and mechanical ventilation. Few cases of extremely high-dose ingestion have been reported. Patients may be normotensive but rapidly progress to shock depending on ingested dose. High doses are associated with shock, bradycardia, pulmonary edema, renal failure, and heart failure. The primary goal is to main...

Spontaneous ventral herniation of the gallbladder.

CLINICAL PRESENTATION A 59-year-old man presented to the emergency department with a 5-day history of increasing abdominal pain, nausea and constipation. Medical history was relevant for a left colostomy for diverticulitis with reversal and chronic obstructive pulmonary disease. On physical examination, he was obese with no acute distress. Abdominal examination revealed normal bowel sounds, a soft abdomen and a palpable mass that was mildly tender in the right upper quadrant, with a positive cough impulse. Computed tomography of the abdomen showed a gallbladder herniation through a right anterior abdominal wall defect just off the midline, away from the previous colostomy site with no signs of bowel obstruction. (Figure 1, gallbladder marked on the image with a star ✩, liver with a plus sign+and spleen with a circle⃝.) The gallbladder wall was not thickened, it was not distended, and no intraluminal calculus was identified. Only a few cases of gallbladder herniation have been reported; some were internal through the foramen of Winslow and others were incisional hernias. Most of the cases were incisional hernias or herniation through an abdominal wall defect. There were a few cases that were associated with gall bladder carcinoma or gall bladder distension. In our case, herniation did not occur through a natural orifice or through an acquired defect. Most patients presented with abdominal pain as in our patient. Ultrasound and computed tomography were commonly used for diagnosis. To the best of our knowledge, only 3 cases of spontaneous herniation through the abdominal wall have been reported; in 2 of them the gallbladder was dilated and in the third it was chronically inflamed. Spontaneous normal gall bladder herniation through ventral abdominal wall is very rare and remains a diagnostic challenge.