United States


Introduction
Co-infection with Influenza A and Methicillin-Resistant Staphylococcus aureus (MRSA) is a rare but devastating clinical scenario, especially in the elderly with multiple comorbidities. This case report describes a 77-year-old female who rapidly deteriorated from a co-infection of Influenza A and MRSA, resulting in fatal hemorrhagic pneumonia or diffuse alveolar hemmorhage (DAH). This case emphasizes the need for heightened clinical vigilance, prompt diagnosis, and aggressive management in such vulnerable populations (1).

Case Presentation
A 77-year-old female with a medical history notable for type 2 diabetes mellitus, hypertension, mild coronary artery disease (clean catheterization in 2021), and recently diagnosed dementia, was transferred to the Emergency Department (ED) from a psychiatric facility. The transfer to ED was prompted by hypoxia, with an oxygen saturation reading in the low 80s. The patient had been admitted to the psychiatric facility just 2 days before her ED admission for suicide evaluation. She did not attempt suicide, but her progressive cognitive decline was causing her significant distress, leading her to have suicide ideation. She had been experiencing mild cough and congestion for several days even prior to her transfer to pschiatric facility. However, on the morning of her admission to the ED, she complianed of significant dyspnea and chest tightness, leading to her transfer to the hospital. Patient was a former smoker but quit smoking several years ago. As per her daughter she had been upto date on her appointments with her PCP and was generally healthy and compliant with all her medications. She was taking baby aspirin but denied taking any blood thinners or chemotherapy medications.

Upon arrival at the ED, the patient was found to be confused and somnolent but arouseable. She was noted to be in significant distress due to her acute hypoxic respiratory failure and was immediately placed on BiPap. On admission, she was febrile with a temperature of 100 F, tachycardic with a heart rate of 99 beats per minute and a blood pressure of 123/66. Patient denied any hemoptysis or bloody emesis but was noted to have dried bloody secretions in her mouth. On lung examination, she had coarse crackles and wheezes bilaterally, more pronounced on the right side. Laboratory tests showed initial hemoglobin of 13.3 g/dL, severe leukopenia (with a total white blood count of 1.88 k/uL and absolute neutrophil counT of 0.60 k/uL) and bandemia (total band percentage of 19.0). The platelet count was 136 k/uL with initial lactate of 3.64 which trended upto 4.64 mmol/L and a procalcitonin level of 47.26 ng/ml. Coagulation profile showed an international (INR) of 1.36 and a prothrombin time (PT) of 16.5 and a partial thrombolastin time (PTT) of 29.4. Serum and urine toxicology were negative and salycilate, acetaminophen and alcohol levels were within normal limits. Radiological imaging revealed a complete whiteout of the right mid to lower lung lobe, concerning for right lobe pneumonia. The patient’s condition rapidly deteriorated; she became hypotensive and unresponsive, necessitating emergent intubation. During intubation, blood was observed in her lungs, prompting an emergent bedside bronchoscopy which confirmed active pulmonary hemorrhage.

The patient was septic on arrival but rapidly developed shock and was immediately transferred to the Intensive Care Unit (ICU) where she was started on two vasopressors to manage her hypotension. She was also started on broad spectrum antibiotics with vancomycin and meropenem. While attempts were being made to stop her alveolar hemorrage via bedside bronchoscopy, her Influenza A nasal swab came back positive. She was also started on oseltamivir. However, despite aggressive measures, including multiple runs of epinephrine and cold saline to control the alveolar bleeding, the hemorrhage continued unabated. The patient was deemed too unstable for transfer to Interventional Radiology for embolization. Her condition remained refractory to all interventions and she was eventually transitioned to comfort care, passing away shortly thereafter.

Postmortem laboratory investigations which included blood cultures, bronchoalveolar lavage (BAL), revealed a co-infection with Influenza A and MRSA. This combination is known to be particularly lethal due to the synergistic pathogenic mechanisms leading to severe necrotizing hemorrhagic pneumonia .(1,3) The presence of Influenza A likely predisposed the patient to a secondary bacterial infection with MRSA, creating a cascade of respiratory compromise and hemorrhagic manifestations and that proved impossible to halt with available medical interventions (1).

Discussion
The case of our patient illustrates the severe consequences of co-infection with Influenza A and MRSA, particularly in an elderly individual with multiple comorbid conditions. Influenza A infection can impair the respiratory epithelium, reduce immune responses, and create an environment conducive to secondary bacterial infections, such as MRSA (4) . Once established, MRSA can cause necrotizing pneumonia, characterized by rapid tissue destruction, extensive inflammation, and hemorrhage (3) .

Elderly patients, particularly those with underlying comorbidities like diabetes mellitus, hypertension, coronary artery disease, and cognitive impairments, are at higher risk of severe outcomes from respiratory infections (4). The immunosuppressive effects of diabetes and advanced age can exacerbate the severity of infections and impair the patient&#39;s ability to mount an effective immune response (4) . The pathophysiology involves several mechanisms: Influenza A virus damages the respiratory epithelium, reducing mucociliary clearance and creating a nidus for bacterial colonization and invasion (4). MRSA exploits this breach, leading to severe secondary infections. MRSA produces several virulence factors, including Panton-Valentine leukocidin (PVL), which can cause necrotizing pneumonia with tissue necrosis and hemorrhage (3) . The combination of these pathogens leads to a severe inflammatory response, often resulting in alveolar hemorrhage, rapid respiratory failure, and high mortality (1) . However, the absence of these virulence factors does not neceassary decrease the risk of developing complications. For instance, a young healthy 46-year-old woman succumbed to death within a few hours of arrival due to co-infection, even though the PCR assay did not detect PVL. ( number)

Managing such cases presents significant challenges. Early recognition and differentiation between primary viral pneumonia and secondary bacterial infections are crucial (4) . Empiric broad-spectrum antibiotics, including coverage for MRSA, are recommended in severe cases of community-acquired pneumonia during influenza season (4) . However, rapid progression to hemorrhagic pneumonia, as seen in this patient, limits the efficacy of medical management (3). Despite advanced medical interventions, the rapid progression and severe hemorrhagic manifestations in such co-infections often outpace therapeutic measures. The case underscores the need for aggressive early treatment strategies and the potential role of antiviral and antibacterial prophylaxis in high-risk populations (2) .

Prevention of such fatal outcomes requires a multifaceted approach. Influenza vaccination is critical in preventing primary viral infections. Annual vaccination can reduce the incidence and severity of influenza infections (4) . Strict infection control practices in healthcare settings, especially in long-term care and psychiatric facilities, are essential to prevent the spread of MRSA and other nosocomial pathogens (4). Prompt identification and isolation of infected individuals can prevent the spread of influenza and MRSA (4) . Early use of antiviral medications for influenza and empiric antibacterial therapy, including MRSA coverage, in suspected severe cases of respiratory infection can mitigate disease progression (2).

Further research is needed to better understand the synergistic effects of influenza and MRSA co-infection and to develop more effective treatment protocols (1). Increased awareness among clinicians about the potential for such severe co-infections can lead to earlier diagnosis and intervention, potentially improving outcomes (2) . The role of steriods in such cases also needs to be studied further. Despite administeration of stress-dose steriod in some cases patients condition continued to deteriorate. The same is true for the use of ECMO. Given the severity of pulmonary hemorrage and coagulopathy patients develop, they are not considered candidates for ECMO. 

Conclusion
This case highlights the lethal potential of co-infection with Influenza A and MRSA, particularly in elderly patients with multiple comorbidities. The rapid progression to hemorrhagic pneumonia, as demonstrated, poses formidable challenges to clinical management. Heightened vigilance, early diagnosis, and aggressive treatment are crucial. Preventive measures, including vaccination and strict infection control practices, are paramount in protecting vulnerable populations. Further research and increased clinical awareness are necessary to improve outcomes in such devastating cases (1) .

References
Toolsie, O., Tehreem, A., &amp; Diaz-Fuentes, G. (2019). &quot;Influenza A pneumonia associated with diffuse alveolar hemorrhage.&quot; American Journal of Case Reports, 20, 592-596.

Randolph, A. G., Vaughn, F., Sullivan, R., Rubinson, L., Thompson, B. T., Yoon, G., ... &amp; Project, N. E. C. C. (2011). &quot;Critically ill children during the 2009–2010 influenza pandemic in the United States.&quot; Pediatrics, 128(6), e1450-e1458.

Klugman, K. P., &amp; Madhi, S. A. (2012). &quot;Rapidly lethal necrotizing hemorrhagic pneumonia.&quot; Critical Care Medicine, 40(12), 1235-1244.

Chakrabarti, B., Davies, P. D. O., &amp; Dewan, P. (2017). &quot;How a mild influenza B infection can kill: A case of necrotizing pneumonia.&quot; Lung India, 34(5), 448-450.

AMA Research Challenge 2024 

Case Report: Rapidly Fatal Hemorrhagic Pneumonia in an Elderly Patient with Co-Infection of Influenza A and MRSA


Introduction
Co-infection with Influenza A and Methicillin-Resistant Staphylococcus aureus (MRSA) is a rare but devastating clinical scenario, especially in the elderly with multiple comorbidities. This case report describes a 77-year-old female who rapidly deteriorated from a co-infection of Influenza A and MRSA, resulting in fatal hemorrhagic pneumonia or diffuse alveolar hemmorhage (DAH). This case emphasizes the need for heightened clinical vigilance, prompt diagnosis, and aggressive management in such vulnerable populations (1).

Case Presentation
A 77-year-old female with a medical history notable for type 2 diabetes mellitus, hypertension, mild coronary artery disease (clean catheterization in 2021), and recently diagnosed dementia, was transferred to the Emergency Department (ED) from a psychiatric facility. The transfer to ED was prompted by hypoxia, with an oxygen saturation reading in the low 80s. The patient had been admitted to the psychiatric facility just 2 days before her ED admission for suicide evaluation. She did not attempt suicide, but her progressive cognitive decline was causing her significant distress, leading her to have suicide ideation. She had been experiencing mild cough and congestion for several days even prior to her transfer to pschiatric facility. However, on the morning of her admission to the ED, she complianed of significant dyspnea and chest tightness, leading to her transfer to the hospital. Patient was a former smoker but quit smoking several years ago. As per her daughter she had been upto date on her appointments with her PCP and was generally healthy and compliant with all her medications. She was taking baby aspirin but denied taking any blood thinners or chemotherapy medications.

Upon arrival at the ED, the patient was found to be confused and somnolent but arouseable. She was noted to be in significant distress due to her acute hypoxic respiratory failure and was immediately placed on BiPap. On admission, she was febrile with a temperature of 100 F, tachycardic with a heart rate of 99 beats per minute and a blood pressure of 123/66. Patient denied any hemoptysis or bloody emesis but was noted to have dried bloody secretions in her mouth. On lung examination, she had coarse crackles and wheezes bilaterally, more pronounced on the right side. Laboratory tests showed initial hemoglobin of 13.3 g/dL, severe leukopenia (with a total white blood count of 1.88 k/uL and absolute neutrophil counT of 0.60 k/uL) and bandemia (total band percentage of 19.0). The platelet count was 136 k/uL with initial lactate of 3.64 which trended upto 4.64 mmol/L and a procalcitonin level of 47.26 ng/ml. Coagulation profile showed an international (INR) of 1.36 and a prothrombin time (PT) of 16.5 and a partial thrombolastin time (PTT) of 29.4. Serum and urine toxicology were negative and salycilate, acetaminophen and alcohol levels were within normal limits. Radiological imaging revealed a complete whiteout of the right mid to lower lung lobe, concerning for right lobe pneumonia. The patient’s condition rapidly deteriorated; she became hypotensive and unresponsive, necessitating emergent intubation. During intubation, blood was observed in her lungs, prompting an emergent bedside bronchoscopy which confirmed active pulmonary hemorrhage.

The patient was septic on arrival but rapidly developed shock and was immediately transferred to the Intensive Care Unit (ICU) where she was started on two vasopressors to manage her hypotension. She was also started on broad spectrum antibiotics with vancomycin and meropenem. While attempts were being made to stop her alveolar hemorrage via bedside bronchoscopy, her Influenza A nasal swab came back positive. She was also started on oseltamivir. However, despite aggressive measures, including multiple runs of epinephrine and cold saline to control the alveolar bleeding, the hemorrhage continued unabated. The patient was deemed too unstable for transfer to Interventional Radiology for embolization. Her condition remained refractory to all interventions and she was eventually transitioned to comfort care, passing away shortly thereafter.

Postmortem laboratory investigations which included blood cultures, bronchoalveolar lavage (BAL), revealed a co-infection with Influenza A and MRSA. This combination is known to be particularly lethal due to the synergistic pathogenic mechanisms leading to severe necrotizing hemorrhagic pneumonia .(1,3) The presence of Influenza A likely predisposed the patient to a secondary bacterial infection with MRSA, creating a cascade of respiratory compromise and hemorrhagic manifestations and that proved impossible to halt with available medical interventions (1).

Discussion
The case of our patient illustrates the severe consequences of co-infection with Influenza A and MRSA, particularly in an elderly individual with multiple comorbid conditions. Influenza A infection can impair the respiratory epithelium, reduce immune responses, and create an environment conducive to secondary bacterial infections, such as MRSA (4) . Once established, MRSA can cause necrotizing pneumonia, characterized by rapid tissue destruction, extensive inflammation, and hemorrhage (3) .

Elderly patients, particularly those with underlying comorbidities like diabetes mellitus, hypertension, coronary artery disease, and cognitive impairments, are at higher risk of severe outcomes from respiratory infections (4). The immunosuppressive effects of diabetes and advanced age can exacerbate the severity of infections and impair the patient's ability to mount an effective immune response (4) . The pathophysiology involves several mechanisms: Influenza A virus damages the respiratory epithelium, reducing mucociliary clearance and creating a nidus for bacterial colonization and invasion (4). MRSA exploits this breach, leading to severe secondary infections. MRSA produces several virulence factors, including Panton-Valentine leukocidin (PVL), which can cause necrotizing pneumonia with tissue necrosis and hemorrhage (3) . The combination of these pathogens leads to a severe inflammatory response, often resulting in alveolar hemorrhage, rapid respiratory failure, and high mortality (1) . However, the absence of these virulence factors does not neceassary decrease the risk of developing complications. For instance, a young healthy 46-year-old woman succumbed to death within a few hours of arrival due to co-infection, even though the PCR assay did not detect PVL. ( number)

Managing such cases presents significant challenges. Early recognition and differentiation between primary viral pneumonia and secondary bacterial infections are crucial (4) . Empiric broad-spectrum antibiotics, including coverage for MRSA, are recommended in severe cases of community-acquired pneumonia during influenza season (4) . However, rapid progression to hemorrhagic pneumonia, as seen in this patient, limits the efficacy of medical management (3). Despite advanced medical interventions, the rapid progression and severe hemorrhagic manifestations in such co-infections often outpace therapeutic measures. The case underscores the need for aggressive early treatment strategies and the potential role of antiviral and antibacterial prophylaxis in high-risk populations (2) .

Prevention of such fatal outcomes requires a multifaceted approach. Influenza vaccination is critical in preventing primary viral infections. Annual vaccination can reduce the incidence and severity of influenza infections (4) . Strict infection control practices in healthcare settings, especially in long-term care and psychiatric facilities, are essential to prevent the spread of MRSA and other nosocomial pathogens (4). Prompt identification and isolation of infected individuals can prevent the spread of influenza and MRSA (4) . Early use of antiviral medications for influenza and empiric antibacterial therapy, including MRSA coverage, in suspected severe cases of respiratory infection can mitigate disease progression (2).

Further research is needed to better understand the synergistic effects of influenza and MRSA co-infection and to develop more effective treatment protocols (1). Increased awareness among clinicians about the potential for such severe co-infections can lead to earlier diagnosis and intervention, potentially improving outcomes (2) . The role of steriods in such cases also needs to be studied further. Despite administeration of stress-dose steriod in some cases patients condition continued to deteriorate. The same is true for the use of ECMO. Given the severity of pulmonary hemorrage and coagulopathy patients develop, they are not considered candidates for ECMO. 

Conclusion
This case highlights the lethal potential of co-infection with Influenza A and MRSA, particularly in elderly patients with multiple comorbidities. The rapid progression to hemorrhagic pneumonia, as demonstrated, poses formidable challenges to clinical management. Heightened vigilance, early diagnosis, and aggressive treatment are crucial. Preventive measures, including vaccination and strict infection control practices, are paramount in protecting vulnerable populations. Further research and increased clinical awareness are necessary to improve outcomes in such devastating cases (1) .

References
Toolsie, O., Tehreem, A., & Diaz-Fuentes, G. (2019). "Influenza A pneumonia associated with diffuse alveolar hemorrhage." American Journal of Case Reports, 20, 592-596.

Randolph, A. G., Vaughn, F., Sullivan, R., Rubinson, L., Thompson, B. T., Yoon, G., ... & Project, N. E. C. C. (2011). "Critically ill children during the 2009–2010 influenza pandemic in the United States." Pediatrics, 128(6), e1450-e1458.

Klugman, K. P., & Madhi, S. A. (2012). "Rapidly lethal necrotizing hemorrhagic pneumonia." Critical Care Medicine, 40(12), 1235-1244.

Chakrabarti, B., Davies, P. D. O., & Dewan, P. (2017). "How a mild influenza B infection can kill: A case of necrotizing pneumonia." Lung India, 34(5), 448-450.

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Cryptococcal Pneumonia in a Patient with recent COVID19 infection 

Background 

COVID-19 has been linked to numerous opportunistic infections, including various fungal diseases such as Aspergillosis, Mucormycosis, Histoplasmosis, Blastomycosis, and Cryptococcus. Here we present a case of pulmonary cryptococcus infection in a patient who developed severe worsening cryptococcal infection with recent COVID-19 infection. 

Case Presentation 

A 77-year-old Caucasian male presented to the emergency department for shortness of breath, progressive generalized weakness, and hypotension. His past medical history is significant for diabetes mellitus II, polymyalgia rheumatica requiring prednisone use (5 mg daily), and hypertension. He was diagnosed with COVID-19 infection two weeks before these current symptoms, required admission to an outlying facility, and was treated for pneumonia. After discharge, he completed his antibiotic course, but one week later, he noticed worsening symptoms. He was seen a day prior at the clinic where it was revealed that the patient had an elevated white blood count, acute kidney injury, and a chest radiograph showing bilateral pulmonary infiltrates. Chest CT with contrast revealed extensive, severe bilateral airspace disease with necrotizing pneumonia. He was admitted to the hospital and started on antibiotics including anti-fungal coverage. Pulmonology was consulted, a bronchoscopy was performed, and serology testing came positive for cryptococcal antigen. He was started on fluconazole with improvement in symptoms. He was discharged home with pulmonology and infectious disease follow-up. 

Discussion 

Severe COVID-19 infection can cause ARDS and intense inflammation creating the need for corticosteroids. High-dose corticosteroids along with comorbidities like Diabetes Mellitus make the patients susceptible to opportunistic infections. Our patient has a history of Polymyalgia Rheumatica, for which he has been taking low-dose corticosteroids, as well as Diabetes Mellitus. In addition to this, he has been administered high-dose corticosteroids for treatment of recent COVID-19 infection. These factors made him susceptible to Cryptococcal infection. The literature review showed many cases of aspergillosis and COVID-19 infection, but pulmonary cryptococcal was less documented. In COVID-19 patients with rapidly worsening respiratory failure and not responding to traditional treatment suspicion of superimposed fungal infection should be considered. Diagnosis can be made with the detection of cryptococcal antigen as broncho-alveolar lavage cultures are not very sensitive or specific. The first-line treatment for pulmonary cryptococcus is fluconazole or amphotericin B/flucytosine in patients with CNS involvement. 

Pulmonary cryptococcal infection is difficult to diagnose as it can mimic multiple conditions including lung cancer, tuberculosis, and bacterial pneumonia with consolidation. Early recognition and diagnosis of pulmonary cryptococcal infection can prevent morbidity and mortality.

Cryptococcal Pneumonia in a Patient with Recent COVID19 Infection.

Abstract Title
Microscopic Polyangiitis and the Impact of Steroid Treatment on Lung Compliance 

Background
Microscopic polyangiitis (MPA) is a small-vessel vasculitis characterized by systemic infiltration, primarily targeting the renal and pulmonary systems. While diffuse alveolar hemorrhage (DAH) is among its most lethal pulmonary manifestations, the spectrum of lung pathology in MPA is extensive, necessitating immediate immunosuppressive therapy.
Our case study focuses on an elderly woman who initially presents with MPA-induced rapid progressive glomerulonephritis (RPGN) but subsequently develops an array of vasculitis-related pulmonary insults requiring endotracheal intubation. Following a brief course of immunosuppression, her lungs demonstrate rapid physiologic recovery. This case highlights the role of induction therapy with steroids in enhancing lung compliance, leading to a more profound respiratory recovery in MPA patients without DAH-related pulmonary symptoms.

Case Presentation
The patient, a woman in her mid-60s with a history of hypertension, chronic anemia, and Raynaud’s phenomenon, was referred to the emergency department by her primary care provider for a creatinine level of 16.53 and potassium level of 6.3. Immediate hemodialysis was initiated, and an autoimmune workup for acute renal failure was conducted. Labs and renal biopsy revealed RPGN induced by MPA.
Within two weeks, the patient's oxygen demand increased, and clinical presentation and imaging raised concerns for DAH, leading to intubation. A subsequent bronchoscopy and bronchoalveolar lavage showed no active hemorrhage. Induction therapy with two days of pulse-dose steroids (methylprednisolone [MTP]) followed by five days of low-dose steroids was initiated. The patient's ventilator settings rapidly improved post-MTP therapy, with decreased pressure support and FiO2 requirements. She was extubated within a week and discharged on MTP and rituximab.

Discussion
This case features an uncharacteristic pulmonary presentation of MPA, marked by acute hypoxemic respiratory failure not due to DAH but due to various small-vessel disease components. The patient's rapid recovery post-MTP induction was objectively measured through improved markers of lung compliance, including reduced daily driving pressures, decreased peak pressures, and increased dynamic compliance.
These findings suggest that current guidelines for induction therapy with steroids could benefit pulmonary MPA patients without DAH, especially in ventilated patients, by improving lung compliance.

Microscopic Polyangiitis and the Impact of Steroid Treatment on Lung Compliance 

Background
Pulmonary adenocarcinoma has become the most common histological subtype of non-small cell lung cancer. It originates in the glandular cells of lung tissue. It is characterized by slow growth and a tendency to metastasize. Early detection is crucial for prognosis and effective treatment. In its early stages, it typically appears on tomography as ground-glass nodular lesions; however, it can manifest in various ways, posing a diagnostic challenge.

Case Presentation
A 76-year-old female Jehovah's Witness, accountant, with controlled type II diabetes, arterial hypertension, and a hysterectomy for myomatosis at age 45. She began experiencing a dry cough in August 2021, which progressed over a year to the point of causing dyspnea,
accompanied by a weight loss of 10 kilograms, denying any fever or night sweats. She was referred to a tertiary hospital where an initial diagnosis of multinodular disease was made (Fig. 1 and 2), and a bronchoscopy was performed, revealing only a positive result for galactomannan in bronchoalveolar lavage. Treatment with itraconazole was started without improvement. Due to persistent symptoms, a new bronchoscopy was performed in August 2022, which
documented adenocarcinoma cells in bronchial fluid cytology but not in biopsy, leading to another biopsy via Video Assisted Thoracoscopic Surgery, with the following results:

Histopathological Report: Pulmonary adenocarcinoma with a lipidic, mucinous pattern,immunohistochemistry: TTF1 negative, CK7 and CK20 positive, enteric variety. Negative mutation panel. PDL1 0%.

Given the clinical stage IV due to multinodular pulmonary disease without mutations, chemotherapy with carboplatin/pemetrexed was decided upon. After the third cycle of chemotherapy, a new chest CT scan showed an unusual response pattern with multiple cystic lesions where the previous lesions had been (November 2022). Due to clinical stability, the same chemotherapy regimen was maintained, with a follow-up CT scan planned for February2023.

Discussion
The unusual change from nodules to cystic lesions in pulmonary adenocarcinoma represents a rare diagnostic challenge. This case provides valuable insight into the atypical variants of the disease and their clinical implications, addressing from the initial clinical presentation to diagnostic confirmation

Pulmonary Adenocarcinoma: Atypical Presentation and Unusual Tomoghraphic Patterns

Introduction: 
Tracheobronchopathia osteochondroplastica (TO) is a rare idiopathic benign disease of the large airways with a clinical prevalence of 0.2% to 0.7%. It is characterized by osteocartilaginous nodules that arise from the anterolateral aspects of the airway walls and project into the lumen of the trachea and bronchi. While typically asymptomatic, patients may experience dyspnea, excessive mucus production, or hemoptysis. The gold standard for diagnosis is a computed tomography (CT) scan and bronchoscopy, which often discover TO secondary to another condition. While no specific treatments exist for TO, the prognosis is generally favorable. This case report discusses a presentation of a male whose potential TO was incidentally discovered while evaluating his pleural effusion. 

Case Presentation:
A 70-year-old nonsmoker male with diabetes mellitus, end-stage renal disease on hemodialysis, and atrial fibrillation (not on anticoagulation) presented for continued evaluation of his unexplained bilateral pleural effusion.

The patient underwent a thoracentesis that confirmed an exudative pleural effusion (protein = 3.5 g/dl and LDH > 2/3 upper limit of normal). A follow-up CT scan of the chest revealed that the pleural effusion was more prominent on the left side, bibasilar atelectasis, compressive and rounded left lower lobe (LLL) atelectasis, scattered calcified granulomas, and left-sided pulmonary infiltrates.

To further evaluate, a bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial biopsy was conducted the following month. Although the BAL and transbronchial biopsy results were negative, the bronchoscopy revealed yellowish tracheal nodules and bronchial nodules in the right mainstem and left upper lobe bronchi, suggesting potential Tracheobronchopathia Osteochondroplastica.

Discussion:
TO is often a difficult condition to diagnose due to its benign nature and unknown etiology. This patient’s bronchoscopy revealing yellowish nodules along his tracheal and bronchial walls, CT showing potential calcifications, and biopsy indicating no malignancies collectively suggest a possible presentation of TO. There are no established follow-up guidelines, and it may be useful to see if the nodules increase in size or number over time and how this progression could affect the patient's symptoms and long-term outcomes. More work is needed to see if TOs are associated with or increase the risk for lung pathologies, such as pleural effusions, among other systemic diseases.

Conclusion:
As TOs have very few effects, a diagnosis of TO is often made incidentally when evaluating other primary conditions. This patient’s presentation suggestive of tracheobronchopathia osteochondroplastica contributes to the limited literature on how TO may present.


References:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5474380/
https://www.mayoclinicproceedings.org/article/S0025-6196(19)30101-6/fulltext

Unveiling Hidden Nodules: An Incidental Discovery of Tracheobronchopathia Osteochondroplastica

Title: Breaking Barriers in Amniotic Fluid Embolism Management with Interventional Radiology

Introduction: 
Amniotic fluid embolism (AFE) is a rare obstetric emergency with high mortality rates. Prompt recognition and supportive, multidisciplinary treatment is vital for enhancing patient outcomes. This case highlights the successful treatment of AFE with interventional radiology (IR). 

Background: 
Amniotic fluid embolism is a rare medical emergency that can occur during labor and postpartum. The pathogenesis is theorized to be due to a release of inflammatory cytokines reacting to amniotic fluid in the maternal bloodstream, causing cardiovascular collapse, respiratory failure, and disseminated intravascular coagulation (DIC) [1]. Diagnosis is based on clinical findings of hypoxia, hypotension, and coagulopathy in peripartum or postpartum women [2].

Treatment is supportive, including respiratory, cardiac, hemostatic, and hemodynamic resuscitation. This requires a multidisciplinary team to be heavily involved in the patient’s care, with primary contributions from obstetrics, critical care, cardiology, and pulmonology [3]. 

The prognosis is grim. Studies suggest maternal mortality ranges from 20% to 60% [4]. With placenta accreta spectrum disorder, mortality doubles [5]. 

Case: 
Our patient is a 27-year-old now G2P2 female with a history of placenta accreta who developed seizure-like activity, hypotension, and respiratory distress shortly after delivery, all concerning for AFE. Initial labs revealed a fibrinogen of 69 and INR of 1.2, findings consistent with disseminated intravascular coagulation (DIC). She developed pulseless ventricular tachycardia that spontaneously resolved and was transferred to our facility for further workup.

Upon arrival, she was cyanotic, tachypneic, tachycardic, and hypotensive. CXR revealed pulmonary edema. Bedside echocardiogram revealed an ejection fraction of 35-40%. Troponins were elevated at 50,000. MTP was subsequently activated. 

Plans were made to undergo CTA C/A/P to exclude a pulmonary embolism; however, due to hemodynamic instability, she was taken to the IR suite for embolization of the bilateral uterine and internal iliac arteries. Following the procedure, her vital signs normalized without vasopressor support. 

Later that evening, she became hypotensive and tachycardic. CXR was concerning for flash pulmonary edema. She developed two episodes of supraventricular tachycardia that responded to vagal maneuvers. Intubation was performed for hypoxemia and respiratory distress. 

After a multidisciplinary discussion, the decision was made to take the patient for a repeat diagnostic pelvic angiogram, which revealed brisk arterial extravasation from the left inferior epigastric artery which was not conspicuous on the initial angiogram. IR then performed coil embolization of the left inferior epigastric artery. A conventional pulmonary arteriogram was also performed to exclude a large pulmonary embolus given her worsening hypoxemia. 

She was subsequently stabilized and remained so for the duration of her admission, receiving a total of 14 pRBCs, 13 FFP, 3 platelets, and 3 cryoprecipitates.

Discussion:
IR’s prompt identification and treatment of arterial extravasation were monumental in stabilizing the patient and mitigating the risk of further deterioration. In obstetric emergencies, especially those involving severe hemorrhage, rapid and precise interventions are crucial. IR offers minimally invasive techniques that can effectively and quickly control emergent bleeding and provide patient stabilization without the need for vasopressor support or general anesthesia.

There is currently no specific research or case documentation highlighting the significance of IR procedures in managing AFE. Further studies are warranted to analyze the significance of incorporating IR into the standard management of AFE across medical facilities. 

While interventional radiology may not traditionally be a primary component of the management for AFE, its inclusion in this case demonstrates its ability to significantly optimize patient outcomes and warrants more frequent consideration in similar emergencies.

Conclusion: 
The prompt integration of IR into our multidisciplinary approach played a pivotal role in the successful management of AFE, highlighting the significant impact IR can have on optimizing patient outcomes. 

References:
Cavoretto PI, Rovere-Querini P, Candiani M. Toward Risk Assessment for Amniotic Fluid Embolisms. JAMA Netw Open. 2022;5(11):e2242850. Published 2022 Nov 1. doi:10.1001/jamanetworkopen.2022.42850
Sundin CS, Mazac LB. Amniotic Fluid Embolism. MCN Am J Matern Child Nurs. 2017;42(1):29-35. doi:10.1097/NMC.0000000000000292 
Pacheco LD, Clark SL, Klassen M, Hankins GDV. Amniotic fluid embolism: principles of early clinical management. Am J Obstet Gynecol. 2020;222(1):48-52. doi:10.1016/j.ajog.2019.07.036
Clark SL. Amniotic fluid embolism. Obstet Gynecol. 2014;123(2 Pt 1):337-348. doi:10.1097/AOG.0000000000000107
Mazza GR, Youssefzadeh AC, Klar M, et al. Association of Pregnancy Characteristics and Maternal Mortality With Amniotic Fluid Embolism. JAMA Netw Open. 2022;5(11):e2242842. Published 2022 Nov 1. doi:10.1001/jamanetworkopen.2022.42842

Breaking Barriers with Amniotic Fluid Embolism Management with Interventional Radiology

Abstract Title: Unique Presentation of Diabetic Striatopathy in an Elderly Female
Background:
Diabetic striatopathy (DS), also known as hyperglycemic chorea-ballism or nonketotic hyperglycemic hemichorea-hemiballism, is a rare neurological complication predominantly seen in individuals with type 2 diabetes experiencing poorly controlled hyperglycemia. Radiologically, DS is identified by specific hyperintensities in the basal ganglia on T1-weighted MRI, and striatal hyperdensity on CT scan; a hallmark of the disease's impact on central nervous system function. Management of DS primarily focuses on rapid correction of hyperglycemia and symptomatic control of chorea. Despite strict glucose control, recurrence rates have shown to be 18.2%, making the timely diagnosis of DS a crucial component in patient management.
Case Presentation:
This report is based upon the clinical case of a 79-year-old female with a medical history of type 2 diabetes mellitus, hypertension, hyperlipidemia and dementia who presented to the emergency department (ED) with altered mental status displaying confusion, but no evidence of chorea. Preliminary workup was performed in the ED and was significant for mild tachycardia, tachypnea, and elevated blood pressure. Pertinent laboratory findings revealed hyponatremia of 130 mEq/L, hyperkalemia of 6.5mEq/L, hypocarbia with CO2 of 8mEq/L, increased anion gap of 29, elevated glucose of 796 mg/dL, increased blood urea nitrogen and creatinine of 67 mg/dL and 2.7 mg/dL. Furthermore, brain CT was performed and revealed an acute left basal ganglia hemorrhage. The patient was first admitted to the intensive care unit and then stabilized and moved to the neurological step-down unit. Repeat brain CT confirmed the diagnosis of diabetic striatopathy. Lantus was initially administered aggressively to achieve rapid glucose control and was titrated down by 5 units nightly until appropriate serum glucose was achieved. In addition, the patient was started on Glipizide, Metformin, and 10 units of Humalog sliding scale as needed. The patient's blood glucose levels showed impressive improvement during the course of her hospitalization. She was hospitalized for 10 days and her condition gradually improved. 
Discussion:
This case is a unique presentation of DS in an elderly patient with uncontrolled type 2 diabetes mellitus. Awareness of the risk factors and clinical manifestations of DS is vital for accurate assessment and effective management. Furthermore, given the likelihood of recurrence, documenting a prior diagnosis of DS is imperative for optimizing future care in patients with a history of DS.

Diabetic Striatopathy in an Elderly Female

Background: The anterior cruciate ligament (ACL) is the most commonly injured ligament of the human body. Most ACL tears occur secondary to pivot shift injuries on the planted foot. A sudden change in direction on the flexed knee with valgus stress may tear the ligament and precipitate a cascade of osseous collisions. Bone contusions on both surfaces of the knee joint, termed kissing contusions, may result. Kissing contusions are most common in the lateral compartment of the knee following an ACL tear. As energy increases, additional contusions may occur in the medial compartment. Patellotibial contusions represent a third, less common contusion pattern. This clinical vignette aims to introduce the clinical presentation and implications of patellotibial contusions. 

Case Presentation: A 22-year-old male presents to the emergency department following a fall. Upon physical examination, a positive anterior drawer sign was noted. MR imaging confirmed the diagnosis of an acute ACL tear. Three kissing contusions were of note within the knee joint, consistent with patellotibial contusion. 

Discussion: Patellotibial contusions are a less common ACL tear contusion pattern at MR imaging that usually results from an axial load such as a jump or fall. In addition to lateral and medial sided contusions, impaction of the inferior patella with the anteromedial tibial rim occurs. Not all patellotibial contusions result in the classic three pairs of kissing contusions. In fact, most patients present with five total contusions: kissing contusions laterally, kissing contusions medially, and an unpaired contusion of the anteromedial tibial plateau. One of the reasons proposed for lack of edema in the patella is that it is a sesamoid bone with a thick peripheral cortex, which may make the patella more resistant to bone marrow edema. Furthermore, patellotibial contusions are often associated with other knee injuries. While tears of the lateral meniscus are less common than those of the medial meniscus in the setting of most ACL tears, patellotibial contusions have an increased risk of tears of the posterior horn lateral meniscus. In addition, posterolateral corner (PLC) injuries are strongly associated with patellotibial contusions. As the anteromedial aspect of the knee narrows during patellotibial impaction, the posterolateral aspect of the knee joint must widen. If undetected on imaging, PLC injuries pose a greater risk of ACL reconstructing failure. Recognizing a patellotibial contusion on MR imaging will direct the physician to search for these associated injuries.


Patellotibial Contusion in an Acute Anterior Cruciate Ligament Tear

Background
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAVs) are a group of autoimmune disorders that result in systemic inflammation with distinct clinical manifestations. These further categorize this pathology into three unique subtypes. First, Granulomatosis with Polyangiitis (GPA) (previously Wegener's Granulomatosis) is associated with the PR3–ANCA autoantibody and is known for its inflammatory destruction of upper and lower respiratory tracts, as well as renal small vessels. Second, Microscopic Polyangiitis (MPA) is another type of AAV that may present similarly to GPA; however, distinct features that separate this subtype include the absence of upper respiratory involvement and the MPO–ANCA antibody predominance. Finally, Eosinophilic Granulomatosis with Polyangiitis (EGPA) (previously Churg-Strauss syndrome) is also associated with MPO-ANCA. However, this rare type of AAV presents with asthma and eosinophilia.  The pathogenesis of all three types of AAVs includes destructive inflammation that begins intravascularly and progresses to tissue destruction and end-organ damage. Early management strategies typically involve glucocorticosteroids, and rituximab and cyclophosphamide are frequently included in patients with severe disease. 

Case Presentation
Here, we present a clinical case of MPO–ANCA positive vasculitis with a benign presentation of epigastric pain and poor appetite that rapidly progresses into systemic inflammation with pulmonary and renal manifestations. In this case, an 81-year-old female with no known medical history presents with mild chronic epigastric pain and poor appetite. Clinically, the patient was stable and well-appearing, with no apparent signs of deterioration at the bedside. Early laboratory investigations were consistent with mild anemia and chronic kidney disease. Lung imaging demonstrated diffuse airspace opacities and tree-in-bud pulmonary nodules.  Screening for infectious etiologies, including bacterial (including tuberculosis), viral, and fungal, were negative. As inflammatory markers continued to uptrend, secondary inflammatory etiologies were explored, resulting in the discovery of a positive MPO–ANCA autoantibody test.  This was followed by rapid deterioration into acute hypoxemic respiratory failure, requiring mechanical ventilation, and complicated by diffuse alveolar hemorrhage, in addition to severe anemia requiring multiple transfusions and acute kidney failure.

Discussion
This clinical case highlights the rapidly progressing nature of AAVs and the frequent benign presentations that can masquerade as this aggressive pathology. As the literature continues to evolve and offer recommendations on the management of these rare autoimmune diseases, early recognition, diagnosis, and intervention are essential to minimize mortality and morbidity rates and offer patients a relapse-free prognosis and improved clinical outcomes.


A Rapidly Progressing Case in an 81-year old Female

Background
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) encompasses autoimmune disorders marked by inflammation and damage to small- and medium-sized blood vessels, alongside the presence of circulating ANCA. Prompt diagnosis and treatment are critical for patient survival, necessitating interventions like hemodynamic support, high-dose corticosteroids, immunosuppressants, and plasmapheresis (PLEX).
Case Presentation
We report a case of a 65-year-old female with a history of hypertension and Chronic Kidney Disease (CKD) Stage 4, secondary to rapidly progressive glomerulonephritis caused by Microscopic Polyangiitis. She presented to the emergency department with a productive cough, subjective fever, chills, body aches, and generalized weakness. Her initial vitals were stable. Laboratory results indicated normocytic anemia, leukocytosis, and acute kidney injury on CKD. Chest X-ray revealed left multifocal pneumonia. She was treated with intravenous Ceftriaxone and Azithromycin and transfused with one unit of packed red blood cells (PRBC). On the following day, she developed shortness of breath and acute hypoxic respiratory failure, necessitating 6L nasal cannula oxygen. Persistent symptomatic anemia without overt bleeding led to the suspicion of diffuse alveolar hemorrhage (DAH) amidst her rapid progressive glomerulonephritis. A CT scan of the chest, abdomen, and pelvis disclosed extensive multilobar airspace disease. Methylprednisolone 1g IV daily was initiated, followed by prophylactic intubation. Bronchoscopy confirmed DAH. The patient was started on Rituximab and underwent five sessions of PLEX. She was subsequently weaned off mechanical ventilation and discharged to a subacute rehabilitation facility, with instructions to follow up with Nephrology, Rheumatology, and her primary care physician.
Discussion
The triad of dyspnea, anemia, and lung infiltrates was pivotal in raising suspicion of DAH in this patient. Previous studies have noted a correlation between age at presentation and mortality risk in AAV patients with DAH. Hemoptysis is not always present and may be absent in up to 33% of cases. Prompt and aggressive treatment is essential to prevent complications in ANCA vasculitis patients. The mainstays of remission induction therapy in AAV include corticosteroids and cyclophosphamide or rituximab. PLEX serves as an adjunct to immunosuppressive therapy, effectively removing circulating pathogenic antibodies that contribute to vascular damage.

An Atypical Presentation of Diffuse Alveolar Hemorrhage in Microscopic Polyangiitis

Background
Hydroxychloroquine is a medication that is used as an antimalarial or a disease-modifying anti-rheumatic drug. It has rare side effects like cardiomyopathy, hematological abnormalities, and dermatological manifestations. Hydroxychloroquine-induced hepatotoxicity is a rare yet serious adverse effect, requiring further investigation and should be considered a differential diagnosis in patients with connective tissue diseases and acute liver issues.

Case Presentation
This is a 31-year-old female with a history of uveitis and systemic lupus erythematous (SLE), which was diagnosed two months prior to presentation with a positive anti-dsDNA and anti-Smith antibodies after having initial findings of uveitis, joint pain, and hair loss. She was started on Hydroxychloroquine 200 mg twice daily a month after being diagnosed. A month after Hydroxychloroquine initiation, she developed abdominal pain and vomiting. Subsequently, she took two doses of acetaminophen, dextromethorphan, and phenylephrine, one in the morning and one in the evening for one day at the recommended dosage. The following day, at urgent care, she was diagnosed with viral gastritis and received one gram of acetaminophen. Three days later, in the emergency room, she had acute liver failure with peak aspartate aminotransferase – 4731 U/L and alanine aminotransferase – 5109 U/L. She endorsed minimal social alcohol use, and tested negative for Human Immunodeficiency Virus, Cytomegalovirus, Hepatitis A, B, and C. Liver biopsy showed portal tracts with mild-moderate expansion by mixed inflammatory infiltrates including scattered eosinophils with mild interface activity focally close to bridging inflammation – findings consistent with drug-induced liver injury. Hydroxychloroquine was held, and she was admitted for conservative management. Repeat liver function tests showed down trending during the patient’s hospitalization – normalizing two months post-discharge.

Discussion
Hepatotoxicity due to hydroxychloroquine use is rare but has been reported in eight other cases. The mean age of onset was 31.6 years old, mean cumulative dose used was 342 mg daily, and mean duration of hydroxychloroquine use was 53.8 days. Two patients expired, while the others recovered after discontinuing hydroxychloroquine. The mechanism of hydroxychloroquine-induced hepatotoxicity is unclear but may be related to its metabolism by cytochrome P450 in the liver. Hydroxychloroquine may share a similar pathophysiologic mechanism of toxicity as chloroquine due to their similar molecular structure. A study showed that rats treated with both bacterial lipopolysaccharide and chloroquine developed signs of liver injury, suggesting that the quinolone class of drugs can induce liver injury in those with concurrent inflammatory conditions. Early detection and termination of hydroxychloroquine is crucial in preventing progression to fulminant hepatic failure.

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