The Southwest Respiratory and Critical Care Chronicles

The use of ultrasound to determine volume status and identify sites of edema in patients with heart failure

Vivie Tran, Subash Swarna, Kenneth Nugent — Tue, 28 Jan 2025 00:00:00 -0800

The management of patients with congestive heart failure requires an accurate working diagnosis and frequent assessment of responses to treatment. In addition, the prediction of short-term and long-term outcomes is important to both the clinician and the patient. The development of pulmonary edema usually represents an acute deterioration of cardiac status and requires immediate attention. The development of peripheral edema usually represents chronic heart failure and warrants evaluation and possibly therapeutic adjustments. Noninvasive tests to identify sites of extravascular fluid formation can help the clinician manage his or her patients. Lung ultrasound can identify B-lines that usually represent pulmonary edema. Ultrasound studies of the inferior vena cava and its dimensions can help determine volume status and make decisions regarding fluid management. This review outlines the use of ultrasound to determine sites of edema formation in patients with heart failure.

Key words: ultrasound, inferior vena cava, pulmonary edema, congestive heart failure

Addison's disease in pregnancy

Tue, 28 Jan 2025 00:00:00 -0800

Addison's disease presents a unique challenge when it occurs during pregnancy due to its potential for maternal and fetal complications if left untreated. This review synthesizes present information about the pathophysiology and clinical aspects of Addison's disease during pregnancy using information from case reports. Pregnancy-induced physiological changes can complicate the diagnosis of adrenal insufficiency as clinical symptoms of the disease overlap with typical pregnancy symptoms; a high index of suspicion is therefore necessary. Diagnostic tests include short synacthen tests and measurement of serum electrolytes, adrenocorticotropic hormone levels, and cortisol levels. Adequate hormone supplementation is crucial for ensuring maternal and fetal well-being. Pregnancy and Addison's disease can have favorable outcomes with proper management, highlighting the importance of early diagnosis and treatment.

The latest advancements in diabetes technology: a comprehensive guide for patients

Shazia Ahmad, Barbara Mantilla — Tue, 28 Jan 2025 00:00:00 -0800

Cutaneous coccidioidomycosis presenting as a facial rash

Nicole Remmert, Pablo Feuillet, Barath Rangaswamy — Tue, 28 Jan 2025 00:00:00 -0800

Coccidioidomycosis is a fungal infection caused by the inhalation of Coccidioides immitis and Coccidioides posadasii spores. After inhalation, the infection can spread hematogenously or through lymphatics to any organ, so the clinical presentation of coccidioidomycosis can vary greatly. A 38-year-old man with obesity was referred to an infectious disease clinic due to a cutaneous coccidioidomycosis infection of his face. The patient initially presented to his primary care physician with symptoms of fatigue, knee pain, and a facial rash that had persisted for a couple of months. Initial treatment involved a course of oral antibiotics, yielding no improvement. Subsequently, the patient sought evaluation at a dermatologist's office for multiple lesions on his face and scalp. Another round of oral antibiotics and topical mupirocin ointment was prescribed. The lesions were biopsied, and a culture tested positive for Coccidioides immitis. He was then referred to infectious disease for management.
The physical examination revealed a scaling, erythematous rash located on the right cheek, forehead, and scalp. Vital signs were normal. A chest computed tomography was positive for multiple pulmonary nodules consistent with a history of coccidioidomycosis infection. Laboratory results revealed a cocci IgM titer of 1.2, IgG titer of 8.8, and an antibody by complement fixation titer of 1:128. The patient was started on oral fluconazole 200 mg daily, which was later increased to 400 mg twice daily. The patient began to show improvement in his skin lesions. We report an unusual presentation of cutaneous coccidioidomycosis as a facial rash. Clinicians, especially in endemic areas, should be aware of the differing presentations of Coccidioides infections.

Keywords: cutaneous coccidioidomycosis; Coccidioides immitis, fluconazole

Surgical management and multidisciplinary care of Dieulafoy’s lesion in Klippel-Trenaunay-Weber Syndrome

Sulaiman Karim, Lauren Pert, Afnan Khan, Ariel Santos — Tue, 28 Jan 2025 00:00:00 -0800

A man in his early 40’s with Klippel-Trenaunay-Weber syndrome (KTWS) was referred to the surgical team for treatment of massive upper gastrointestinal bleeding. This syndrome is a rare congenital condition that leads to abnormal development of blood vessels, bones, and soft tissues. Although venous malformations are common in KTWS, gastrointestinal involvement is rare but can cause life-threatening bleeding. In this case, a series of diagnostic tests, including endoscopic and angiographic examinations, failed to identify the etiology of the bleeding. Surgical intervention was required after conservative and interventional radiologic therapies proved unsuccessful. A Dieulafoy’s lesion was identified in the proximal stomach and later confirmed histologically. The patient required a multidisciplinary care involving gastroenterology, interventional radiology, and general surgery for successful management.

The pathogenesis of Dieulafoy’s lesion is not well understood, and interventions vary from endoscopic to surgical management. The treatment of Dieulafoy’s lesion is not well- described in patients with KTWS, especially in cases in which endoscopic treatments have failed.

Keywords: Klippel-Trenaunay Syndrome; Dieulafoy’s lesion; gastrointestinal bleeding; radiology, interventional; endoscopy; surgical treatment

Intraluminal duplication cyst of the terminal ileum imitating acute appendicitis: a rare clinical case presentation

Devin Bird, Vishaal Kondoor, Dylan Murray, Jason Nirgiotis, Richard Murray — Tue, 28 Jan 2025 00:00:00 -0800

Duplication cysts are rare congenital cystic lesions that form along the gastrointestinal tract at various locations. They may be asymptomatic, present with ambiguous symptoms, or mimic other clinical presentations, such as acute appendicitis. We present a unique case of an 11- year-old boy with a preliminary diagnosis of acute perforated appendicitis and abdominal abscess; however, the patient’s appendix was unremarkable during surgery, and he was later found to have an intraluminal duplication cyst within the distal ilium extending into the ileocecal valve. Follow-up imaging with abdominal ultrasound helped guide the diagnosis, and an ileocecal resection proved to be curative.

Keywords: Enteric duplication cyst, intraluminal duplication cyst, appendicitis, ultrasound, case report

Congenital methemoglobinemia in old age

Muhammad Talha sherani, Karamat Ali, Lailamah Rehman — Tue, 28 Jan 2025 00:00:00 -0800

Chest infections and ischemic heart disease are the most common causes of shortness of breath and cyanosis in old age. However, the hemoglobinopathies should be considered if the cardiac cause is ruled out, cyanosis that is not responding to oxygen therapy and antibiotic treatment. A 75-year-old retired soldier was admitted to the inpatient department of a tertiary care hospital with symptoms of cyanosis, shortness of breath and fever. Cyanosis was acrocyanosis in nature and not relieved on oxygen therapy.

An initial diagnosis of Lower respiratory tract infection was initiated. However, the cyanosis showed no signs of improvement. Alternate diagnosis was considered, and the patient was started on treatment of ischemic heart disease that included nitrates which further led to worsening of his condition. Blood methemoglobin levels were raised which established the diagnosis of methemoglobinemia. The fast-moving dark brown color band of Hb M on gel electrophoresis confirmed the diagnosis of Hb M. The patient was started on IV ascorbic acid with the patient showing clinical improvement within 36 hours.

The patients presenting with unexplained acrocyanosis should not be treated with oxidizing agents like nitrates, irrespective of age and management of another disease, unless the cause of cyanosis has been established.

A late diagnosis and treatment of coarctation of aorta six months after presenting with aortic dissection

Maxwell Sheedy, Cihan Cevik, Magdiel Trinidad-Hernandez — Tue, 28 Jan 2025 00:00:00 -0800

Coarctation of the aorta (CoA) is a congenital condition causing narrowing of the aorta, typically just after the left subclavian artery. Most patients with CoA are diagnosed at birth or during infancy. However, they can also be undiagnosed later in adulthood with minimal symptoms to show or treatment-resistant hypertension. However, some patients may also present with life-threatening medical emergencies that may lead to an undiagnosed CoA. This case is a 40-year-old man with hypertension who presented with a late diagnosis of CoA on computed tomography imaging six months after ascending aorta dissection repair. The patient's CoA was repaired via an endovascular approach with stent placement and post-dilatory balloon angioplasty. His CoA segmental blood pressure gradient was 25 mmHg and decreased to 3 mmHg post-procedure. The patient has done well post-procedure, and his blood pressure had been within normal limits.

Key words: Aortic coarctation, aortic dissection, hypertension, congenital heart defect

Dengue virus in Texas

Barbara Mora — Tue, 28 Jan 2025 00:00:00 -0800

Estimands: bridging the gap between study objectives and statistical analysis

Shengping Yang, Gilbert Berdine — Tue, 28 Jan 2025 00:00:00 -0800

Partial intestinal obstruction and hematuria as the initial presentation of bladder cancer in a Hispanic woman with a complex medical history

Mahmoud Abdelnabi, Sebastian Sanchez, Diego Bernal, Neha Mittal — Tue, 28 Jan 2025 00:00:00 -0800