BackgroundPatients with acute respiratory distress syndrome (ARDS) who develop acute kidney injury have increased mortality and frequently require renal replacement therapy (RRT). The optimal timing for initiation of RRT after onset of ARDS to improve survival is not known.MethodsWe retrospectively reviewed clinical data on patients admitted to our health system over a 2-year period. Individual charts were carefully reviewed to ascertain that patients met the Berlin criteria for ARDS and to categorize RRT utilization. The Kaplan–Meier analysis was conducted to compare early (£48 hours postintubation) versus late (>48 hours postintubation) initiation of RRT. Associations between RRT initiation and mortality were evaluated using Cox proportional hazards regression.ResultsA total of 75 patients were identified with ARDS, 95% of whom received RRT. Mortality of patients who required RRT was 56%. The main indications for RRT initiation were fluid overload (75%), metabolic acidosis (64%), and hyperkalemia (33%). The Kaplan–Meier analysis comparing early initiation of RRT to late initiation of RRT showed no survival benefit. Cox proportional hazard models testing the association between timing of RRT initiation with survival and adjusting for sex, race, ethnicity, and Acute Physiology and Chronic Health Evaluation II score did not reach statistical significance (HR=0.94, 95% CI=0.48–1.86).ConclusionTiming of RRT initiation was not associated with a survival benefit. Prospective study in the utilization and outcomes of RRT in ARDS could assist in optimizing its usage in this population.

Within the coccidioidal endemic region, post-transplantation coccidioidomycosis was a definable risk among lung transplant recipients. Use of antifungals appeared to reduce this incidence of disease. Almost all cases resulted in pulmonary disease, suggesting that the lung is the primary site of infection.

Patient: Male, 61Final Diagnosis: Streptococcus pneumoniae pericarditisSymptoms: —Medication: —Clinical Procedure: PericardiocentesisSpecialty: Critical Care MedicineObjective:Rare diseaseBackground:Cardiac tamponade caused by pericardial effusion has a high mortality rate; thus, it is important to diagnose and treat this condition immediately. Specifically, bacterial pericarditis, although now very rare, is often fatal because of its fulminant process.Case Report:We present a case of a 61-year-old man with metastatic small cell lung cancer undergoing chemotherapy who presented with fatigue, poor appetite, and altered mental status. He was found to have a large-volume pericardial effusion with tamponade physiology. He underwent emergent pericardiocentesis. The pericardial effusion was nonmalignant, with cultures growing Streptococcus pneumoniae. It was only after his emergent pericardiocentesis that previous imaging from one month prior was able to be reviewed, which showed possible right upper lobe abscess.Conclusions:Most pericardial effusions in cancer patients are related to their malignancy, either due to direct metastasis or secondary physiologic effects. This case is a unique example of a lung cancer patient presenting with a pneumococcal pericardial effusion, which in itself is a rare phenomenon. This case report demonstrates the importance of considering early antibiotic therapy in patients presenting with pericardial effusion, especially given the high mortality rates of infectious pericardial effusions.

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