Patient: Female, 58-year-old Final Diagnosis: Giant bullae • spontaneous pneumothorax • subcutaneous emphysema Symptoms: Crepitus • dysphagia • dysphonia • facial swelling Medication: — Clinical Procedure: — Specialty: Critical Care Medicine • Pulmonology Objective: Unusual clinical course Background: Vanishing lung syndrome (VLS), also known as idiopathic giant bullous emphysema, is a rare manifestation of chronic obstructive pulmonary disease (COPD) and usually occurs in middle-aged smokers. This report presents a 58-year-old female smoker with COPD and VLS who presented with spontaneous pneumothorax. The pneumothorax was managed with a chest tube and was later complicated by massive subcutaneous emphysema. Case Report: A 58-year-old woman with a past medical history of long-term smoking and COPD presented with worsening shortness of breath. Upon initial evaluation, she had tachypnea and hypoxia (SpO 2 93%). Chest radiography revealed a new right-sided pneumothorax on top of extensive bullous disease, which the patient already had. The drainage of the pneumothorax was successful with a pigtail catheter. However, during the following night, after insertion of the pigtail catheter, the patient developed massive subcutaneous emphysema, which was confirmed with imaging. The patient remained hemodynamically stable, and diffuse subcutaneous crepitus was present on examination. The pigtail catheter was repositioned, resulting in complete resolution of the subcutaneous emphysema in the following 2 weeks. Conclusions: This case highlights the importance of a timely diagnosis and management of the possible presentations and complications of VLS. Complications such as pneumothorax are life-threatening and require urgent management, taking precedence over the curative treatment for VLS, surgical bullectomy.
Cryptococcal meningitis (CM) is a fungal infection most commonly seen in immunocompromised patients and rarely affecting immunocompetent patients. Cryptococcal meningitis can present with varying complications, such as disseminated disease and neurological complications that include intracranial hypertension, cerebral infarcts, and vision loss. Delayed diagnosis of CM contributes to the disease's mortality in the immunocompetent patient. We would like to present the case of a 27-year-old apparently immunocompetent woman admitted for CM with initial improvement and then neurological decline concerning for cryptococcal–postinfectious inflammatory response syndrome.
BACKGROUND: As part of the response to increasing critical care capacity during the unprecedented surge of COVID-19 infections, NYC Health + Hospital systems identified and resourced areas in the hospital that could deliver critical care as "Flex" ICUs to complement the traditional ICUs to manage the rapid influx of critically ill patients. OBJECTIVE: Comparison of clinical features and outcomes of mechanically ventilated COVID-19 patients admitted to the traditional and "Flex" ICUs during the surge of the pandemic. METHODS: Retrospective comparative cohort study of patients with confirmed SARS-CoV-2 infection on mechanical ventilation admitted to traditional ICU and 'Flex' ICU. Univariate and multivariate analyses were conducted to detect factors associated with death from COVID-19 patients in mechanical ventilation by the Cox proportional hazards regression model. RESULTS: Out of the 312 patients on mechanical ventilation, 111(35.6%) were admitted to the traditional ICU, and 201(64.4%) to the 'Flex' ICU. The mortality rate was higher in the 'Flex' ICU compared with the traditional ICU (H.R., 1.37, 95% CI, 1.05-1.81, p<0.05), but the adjusted risk model was not significantly associated with increased mortality (adjusted, H.R., 1.29, 95% CI, 0.97-1.71, p=0.078). CONCLUSION "Flex" ICUs played a crucial role in critically ill patients' management during the pandemic. The mortality risk of patients in the "Flex" ICU was comparable to traditional ICUs in the adjusted analysis. While there is enough evidence for Intensivist managed ICUs to have better outcomes, our study demonstrates the feasibility of non-intensivist leading "Flex" ICUs during a crisis.
Myxedema coma is a life-threatening, critical condition in which many organ systems can be severely affected. It is considered the most severe presentation of hypothyroidism and should be treated immediately. Here, we discuss the case of a 58-year-old patient who presented with altered mental status, bradycardia, and hypothermia, the critical characteristics considered in this disorder after inhalation injury. In order to avoid a fatal outcome, aggressive therapy should be initiated upon presentation. This case will depict the typical presentation, the specific cause pertinent to this patient’s condition, and the management of the acute condition of myxedema coma.
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