Search

A 74-year-old man presented to the ED with acute chronic exertional dyspnea of 5-day duration. As part of his previous evaluation, 5 months earlier, he had undergone cardiopulmonary stress testing, routine laboratory evaluation, and chest radiography that were unremarkable. Over the subsequent months, he had waxing and waning exercise capacity until his incident hospitalization; the exercise was limited to 40 meters. He reported associated nonproductive cough, 15-pound unintentional weight loss over the past 5 months, night sweats, easy fatigability, and early satiety. A chest radiograph was performed that showed a left hilar, mass-like consolidation with loss of the left heart border that was associated left-sided pleural effusion and left lower lung zone consolidation. On physical examination, he was afebrile and normotensive with a sinus tachycardia of 125 beats per minute. He was noted to be tachypneic with a respiratory rate of 24 breaths per minute and saturation of 95% on room air. Examination of the chest showed diminished breath sounds over left lower lung fields with scattered end expiratory wheezing.

BACKGROUND: SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) continues to be a global challenge due to the lack of definitive treatment strategies. We sought to determine the efficacy of early administration of anti-interleukin 6 therapy in reducing hospital mortality and progression to mechanical ventilation. METHODS: This was a retrospective chart review of 11,512 patients infected with SARS-CoV-2 who were admitted to a New York health system from March to May 2020. Tocilizumab was administered to subjects at the nasal cannula level of oxygen support to maintain an oxygen saturation of >88%. The Charlson comorbidity index was used as an objective assessment of the burden of comorbidities to predict 10-year mortality. The primary outcome of interest was hospital mortality. Secondary outcomes were progression to mechanical ventilation; the prevalence of venous thromboembolism and renal failure; and the change in C-reactive protein, D-dimer, and ferritin levels after tocilizumab administration. Propensity score matching by using a 1:2 protocol was used to match the tocilizumab and non-tocilizumab groups to minimize selection bias. The groups were matched on baseline demographic characteristics, including age, sex, and body mass index; Charlson comorbidity index score; laboratory markers, including ferritin, D-dimer, lactate dehydrogenase, and C-reactive protein values; and the maximum oxygen requirement at the time of tocilizumab administration. Mortality outcomes were evaluated based on the level of oxygen requirement and the day of hospitalization at the time of tocilizumab administration. RESULTS: The overall hospital mortality was significantly reduced in the tocilizumab group when tocilizumab was administered at the nasal cannula level (10.4% vs 22.0%; P = .002). In subjects who received tocilizumab at the nasal cannula level, the progression to mechanical ventilation was reduced versus subjects who were initially on higher levels of oxygen support (6.3% vs 18.7%; P < .001). There was no improvement in mortality when tocilizumab was given at the time of requiring non-rebreather, high-flow nasal cannula, noninvasive ventilator, or invasive ventilator. CONCLUSIONS: Early use of anti-interleukin 6 therapy may be associated with improved hospital mortality and reduction in progression to more severe coronavirus disease 2019.

We describe an interesting rare case of a 61-year-old woman who was admitted to our hospital for exertional dyspnea, non-productive cough, and generalized weakness of six months duration. Her computed tomography was significant for ground-glass opacities combined with bibasilar consolidations and numerous pulmonary cysts. There can be a significant overlap in imaging findings of post-coronavirus disease 2019 (COVID-19) lung disease and interstitial lung disease from autoimmune diseases. We review in extensive detail the differential diagnosis for these imaging findings from a pulmonologist's perspective and discuss investigations required for further workup. Our patient underwent transbronchial biopsy and was eventually diagnosed with lymphocytic interstitial pneumonia with Sjogren predominant mixed connective tissue disease. We also review in detail the current literature and prognosis for this interesting disease.

Case Presentation A 54-year-old man sought treatment at the ED for a productive cough with green phlegm of approximately 6 months’ duration that was accompanied by a 10-pound weight loss, night sweats, and occasional subjective fevers. He had made several prior visits to the ED for the cough and was hospitalized 4 months earlier for similar symptoms, at which time he underwent a bronchoscopy with BAL and was discharged with antibiotics for presumed pneumonia. He did not report any itching, rashes, sinus infections, joint swelling, joint pain, or GI symptoms. His long-term medications included omeprazole and amlodipine. The patient had a past medical history of grade III follicular lymphoma for which he completed six cycles of bendamustine 4 years before presentation and had been in remission since. He was a never smoker, had a recent travel history to the Dominican Republic 8 months before admission, and had no recent sick contacts.

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) myocarditis has recently been described in case reports. A systematic review in early 2021 found fourteen case reports of myocarditis or myopericarditis secondary to this viral infection. We describe an interesting case of proven non-ischemic cardiac dysfunction in the setting of acute infection. Despite steroid treatment, which has been suggested to have favorable outcomes, our patient did not survive. CASE PRESENTATION: We present a case of a 77-year-old man with extensive electrophysiologic and ischemic cardiac disease who presented to the hospital for generalized weakness, malaise, and shortness of breath. The patient's cardiac history was significant for atrial flutter s/p ablation, coronary artery disease s/p coronary artery bypass graft in the distant past, peripheral artery disease s/p right lower extremity revascularization, and carotid stenosis s/p carotid endarterectomy. SARS-CoV-2 PCR test was positive. The patient had increasing hypoxia which required non-invasive ventilation and eventually, tracheal intubation and mechanical ventilation. The hospital course was complicated by the development of persistent chest pain associated with elevated cardiac enzymes. EKG showed diffuse ST-segment depressions. An echocardiogram revealed diffuse left ventricular hypokinesis and a reduced ejection fraction of 20% which was not present previously. In this setting, the patient was ruled in for acute coronary syndrome and underwent cardiac catheterization. Cardiac catheterization demonstrated patent grafts and no significant obstructive disease. A presumptive diagnosis of myocarditis was made. The patient's clinical status deteriorated despite optimal medical treatment, and he developed hemodynamically unstable atrial fibrillation that did not respond to pharmacologic treatment or cardioversion and resulted in cardiogenic shock and, ultimately, his death. DISCUSSION: SARS-CoV-2 myocarditis has been described in select case reports internationally. Many of these cases are described in patients with no previously identified comorbid conditions. This case suggests that in patients with underlying electrophysiologic dysfunction, SARS-CoV-2 myocarditis is associated with poor outcomes. CONCLUSIONS: The mechanism of the effect of SARS-CoV-2 on the heart is unclear and includes myocarditis or myopericarditis. In our patient, cardiac catheterization which was performed during his hospitalization confirmed no ischemic disease and suggested the presence of myocarditis which was ultimately fatal in the setting of refractory cardiogenic shock. Further research is needed into the optimal management of myocarditis associated with SARS-CoV-2. REFERENCE #1: Sawalha K, Abozenah M, Kadado AJ, et al. Systematic Review of COVID-19 Related Myocarditis- Insights on Management and Outcome. Cardiovasc Revasc Med. Feb 2021;23:107-113. REFERENCE #2: Purdy A, Ido F, Sterner S, et al. Myocarditis in COVID-19 presenting with cardiogenic shock: a case series. Eur Heart J Case Rep. Feb 2021;5(2):ytab028. REFERENCE #3: Fried JA, Ramasubbu K, Bhatt R, et al. The Variety of Cardiovascular Presentations of COVID-19. Circulation. 2020;141(23):1930-1936. DISCLOSURES: No relevant relationships by Sravani Gajjala, source=Web Response No relevant relationships by Stacey Jou, source=Web Response No relevant relationships by Zein Kattih, source=Web Response No relevant relationships by Rosaline Ma, source=Web Response No relevant relationships by Akhilesh Mahajan, source=Web Response No relevant relationships by Vinayak Shenoy, source=Web Response

Deglutition syncope is a relatively rare cause of syncope that belongs to the category of neurally mediated reflex syncopal syndromes. The phenomenon is related to vagal reflex in context to deglutition causing atrioventricular block and acute reduction in cardiac output leading to dizziness or syncope. We present case series of two cases of deglutition syncope, of which first was managed medically and second with pacemaker implantation.

Background Seasonal influenza is a respiratory illness caused by the influenza virus. During the 2017–2018 flu season, the Centers for Disease Control and Prevention noted approximately 959,000 hospitalizations and 79,400 deaths from influenza. We sought to evaluate the educational quality of informational videos pertaining to seasonal influenza on the popular social media forum, YouTube. Methods Using the keywords “seasonal influenza,” all videos from 28 January to 5 February 2017 were included and analyzed for characteristics, source, and content. The source was further classified as healthcare provider, alternative-medicine provider, the patient and/or their parents, company, media, or professional society. Videos about other categories of influenza (e.g. swine or Spanish) or in foreign languages were excluded. A total of 10 blinded reviewers scored each video independently. Results Overall, 300 videos were analyzed, with a median of 341.50 views, 1.00 likes, 0 dislikes, and 0 comments. Based on the average scores of videos by source, there was statistically significant difference in the average score among videos by video source ( p

Streptococcus pneumoniae is a bacterium responsible for a spectrum of diseases including lobar pneumonia, meningitis, otitis media, and sinusitis. Invasive pneumococcal disease is responsible for significant morbidity and mortality across the world. Concerted efforts led to the development of two vaccinations, Pneumova × 23 and Prevnar 13, for the prevention of pneumococcal disease. The Advisory Committee on Immunization Practices of the US Centers for Disease Control and Prevention provides vaccination schedules for predisposed adults, but the proposed schedules remain a challenge to health-care providers. We performed a systematic review in PubMed and these specialty group websites to present the pathophysiology of pneumococcal disease, outline different pneumococcal vaccinations, and condense recommendations for vaccination administration.