INTRODUCTION: Acute onset macroglossia is a rare yet life-threatening complication that may result from numerous etiologies including patient positioning while under anesthesia, oropharyngeal packing, local trauma, postoperative from surgery in the oral cavity, or secondary to allergic or nonallergic angioedema. Several management strategies have been described including utilization of reduction glossectomy. We present a rare case of acute onset macroglossia likely caused by traumatic intubation with multiple attempts and further potentiated by prone positioning. CASE PRESENTATION:Patient is a 55-year-old female with a past medical history of hypertension, COPD, OSA, HFpEF who presented with a one-week history of worsening shortness of breath. Vital signs showed T 97.6, BP 140/89, RR 24, O2 saturation 96% on 40% FiO2 on BiPAP. Physical exam demonstrated decreased air entry bilaterally with faint wheezing and crackles. Imaging suggested findings of pulmonary edema.Patient was treated for a working diagnosis of COPD and HF exacerbation with nebulizer treatments, steroids, and diuretics. Initial ABG showed pH 7.287, pCO2 77, pO2 124. However, her requirements on BiPAP worsened and a repeat ABG showed pH 7.156, pCO2 105.9, pO2 91 on 60% FiO2. Due to the underlying acidosis and deteriorating mental status, decision was made to intubate. Patient underwent a difficult intubation by anesthesia with at least three failed attempts due to patient's airway being hypertrophied and anterior. They were finally able to place a 6 Fr ETT over a bougie. Hospital course was further complicated by deteriorating respiratory status with ARDS and patient underwent multiple proning sessions. Around Day 7, patient was noted to have a protruding tongue that was undergoing excessive swelling. At its worse, the tongue was protruding three to four inches. The tongue was kept wet and covered with gauze. After stabilization, patient finally underwent tracheostomy about three weeks after intubation. Her status stabilized and she was transferred to another hospital for OMFS and ENT evaluation. Patient was treated with lingual compressive wraps as well as dexamethasone to normalization in a couple weeks.DISCUSSION: A review of literature did not show any cases that attributed multiple failed intubation attempts correlating with development of macroglossia. However, there have been some case reports attributing macroglossia to prone positioning. Typically, when macroglossia is of this magnitude, it requires reduction glossectomy by OMFS. However, our patient was treated conservatively with lingual compression wraps and steroids with return of tongue to baseline size making our case unique.CONCLUSIONS: Macroglossia is an extremely rare, yet almost forgotten complication that may be seen in intubated patients. The potential for it to be detrimental for the patient should always be in the back of our minds.

INTRODUCTION: Emphysematous pyelonephritis (EPN) is an uncommon acute severe necrotizing infection of the renal parenchyma and its surrounding tissues that results in the presence of gas in the renal parenchyma, collecting system, or perinephric tissue. The clinical course of EPN can be life threatening if not managed astutely. The primary organisms responsible include Escherichia coli and Klebsiella Pneumoniae. We present a rare and uncommon case of severe EPN that was managed conservatively with good outcome. CASE PRESENTATION:A 63-year-old Hispanic female with a past medical history of uncontrolled diabetes and hypertension presented with a four-day history of abdominal pain, nausea, vomiting and diarrhea. Vital signs showed T 38.2 C, HR 99, BP 103/ 58 mmHg and saturating 100% on RA. Palpation and percussion of the left flank region elicited pain. Lab findings were significant for hyponatremia (132), hypochloremia (95), elevated BUN and Creatinine (43/2.4), hyperglycemia (264), elevated CRP 36.5. Initial lactic acid was found to be 2.8. Urinalysis showed findings suggestive of a UTI. Patient also was incidentally found to have COVID-19 Ag and PCR positive. Chest X-ray showed mild interstitial prominence. Emergent renal ultrasound reported scattered foci of air in the left renal upper pole calyces and proximal ureter. CT Abdomen Pelvis with contrast showed air in the bladder and left ureter and kidney. Despite adequate initial resuscitation with IV fluids and IV piperacillin-tazobactam, her lactic acid increased peaking at 8.5 and she was promptly moved to MICU for hemodynamic monitoring. With a working diagnosis of EPN and SARS-CoV-2 infection, she was switched to Meropenem, placed on IV fluids and her pain was managed supportively. Urology was consulted who recommended close monitoring and plan for emergent intervention if condition worsened. However, since patient started to recover, she did not undergo intervention. Antibiotics were de-escalated to Ceftriaxone after blood cultures grew sensitive Escherichia coli. Patient's condition improved and she was discharged with outpatient follow-up with urology.DISCUSSION: Based on CT findings, emphysematous UTI's are characterized into Class I to IV with increasing mortality associated as you move towards class IV. Our patient initially presented with Class I and as a result was promptly started on antibiotics. If EPN had progressed anymore, she would have needed a percutaneous drainage, or even nephrectomy in refractory cases, in addition to antibiotic therapy. However, due to prompt care and aggressive monitoring provided to her, she was able to improve without further interventions. The rarity of the condition and the decision-making involved while managing the disease makes this case unique.CONCLUSIONS: Emphysematous pyelonephritis is an uncommon severe infection of the renal parenchyma, which with early diagnosis can be managed conservatively.