INTRODUCTION: Gout associated with systemic inflammatory response syndrome is well described but underappreciated in clinical practice. A prospective analysis of cases admitted to the hospital estimate that 4.5% are associated with fever. We present a case of a critically ill patient with persistent fever of unknown origin diagnosed with polyarticular gout two months into his hospitalization. CASE PRESENTATION:A 67-year-old man with a history of gout, atrial fibrillation, and type 2 diabetes was admitted with a left MCA territory stroke and underwent emergent thrombectomy. He had a period of relative neurologic recovery but became encephalopathic necessitating intubation for airway protection. He developed aspiration pneumonia and progressive renal failure requiring dialysis and underwent percutaneous tracheostomy. Over a period of several weeks, he demonstrated recurrent fevers and persistent leukocytosis and received multiple courses of empiric broad spectrum antimicrobials. Serial cultures, evaluation for atypical pathogens, cross-sectional imaging, lumbar puncture, and autoimmune serologies did not identify an etiology, and he was trialed on bromocriptine for presumed central fever. Repeat physical exam elicited multiple swollen and tender joints. Arthrocentesis was performed and notable for monosodium urate crystals. Acute polyarticular gout was diagnosed, and he was started on dexamethasone and later switched over to anakinra (due to uncontrolled hyperglycemia), with resolution of fevers and articular symptoms. After defervescing his neurologic status significantly improved and he was able to successfully liberate from the ventilator. He was ultimately discharged to rehab on hospital day 112.DISCUSSION: Fever is present in up to 70% of ICU patients and when prolonged is associated with increased morbidity and mortality. This case highlights the difficulty of recognizing non-infectious etiologies of fever in the critically ill patient and the potential harms in a missed diagnosis. These include unnecessary antimicrobial exposure, invasive procedures, and prolonged hospital stay. Sedation and encephalopathy often complicate history-taking and diagnosis. Here, careful physical examination led to the diagnosis of an underappreciated manifestation (fever) of a common condition (gout). While the incidence of gout flares in the ICU is unknown, medical stress, dehydration, and diuretics are frequent triggers and common in critically ill patients. Treatment may be challenging as high rates of renal insufficiency can preclude the use of common therapies such as NSAIDs or colchicine, and steroids may potentiate issues with glycemic control.CONCLUSIONS: Polyarticular gout should be routinely considered as a possible cause of fever in the ICU.

Objective To investigate incidence and risk factors for postoperative complications after rectovaginal fistula (RVF) repairs, based on different surgical routes. Methods This retrospective cohort study utilized CPT codes to identify RVF repairs performed during 2005 to 2017 from the American College of Surgeons National Surgical Quality Improvement Program database. Demographic/clinical characteristics were compared among different surgical routes. Logistic regression was performed to identify associations. Results Among 1398 RVF cases, 1391 were included for final analysis: 159 (11.4%) were performed transabdominally (group 1), 253 (18.2%) transperineally (group 2), and 979 (70.4%) transvaginally/transanally (group 3). Group 1 was older compared with groups 2 and 3 (58.72 ± 15.23 years vs 44.11 ± 13.51 years vs 46.23 ± 14.31 years, P < 0.0001). Race/ethnicity was comparable in all groups with non–Hispanic-White most common. Comparably, group 1 had higher preoperative comorbidities: hypertension requiring medication (P < 0.0001), chronic obstructive pulmonary disease (COPD) (P = 0.0347), preoperative infection (P = 0.002), functional dependence (P = 0.0001), and longer time between hospital admission to operation (P < 0.0001). Group 1 also had longer operating time (P < 0.0001); more American Society of Anesthesiologist ≥ 3 classification (P < 0.0001); and more likely inpatient status (P < 0.0001). The overall incidence of any postoperative complications was 13.2% (25.2%, group 1 vs 15.8%, group 2 vs 10.6%, group 3; P < 0.0001). The most common postoperative complications included unplanned readmission, postoperative superficial surgical site infection, and reoperation. The incidence of severe postoperative complications was 7.9% (17%, group 1 vs 7.1%, group 2 vs 6.6%, group 3, P < 0.0001): group 1 had highest rates of pulmonary embolism (P = 0.0004), deep venous thrombosis (P = 0.0453), bleeding requiring transfusion (P < 0.0001), stroke (P = 0.0207), unplanned reintubation (P = 0.0052), and death (P = 0.0004). Group 1 also had highest rates of minor postoperative complications like urinary tract infection (P = 0.0151), superficial surgical site infection (P = 0.0189), and pneumonia (P = 0.0103). In addition, group 1 had the greatest postoperative length of stay (P < 0.0001). In multivariate analysis, age (P = 0.0096), inpatient status at the time of surgery (P = 0.0004), and operating time >2 to 3 hours (P = 0.0023) were significant predictors of postoperative complications within 30 days after surgery. Conclusions The overall incidence of complications after RVF repairs+/−concomitant procedures was 13.2%. The overall incidence of severe complications was 7.9%. The abdominal approach had more postoperative complications but it was not an independent predictor of postoperative complications after RVF repair.

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INTRODUCTION: Thymomas are rare neoplasms arising from thymic tissue, occurring in about 0.15 of 100,000 persons/year cases. They are slow growing but when invasive tend to spread locally to surrounding structures. Endobronchial metastasis of thymomas are rare, and to our knowledge, there are only 21 such cases published and only one case treated with endobronchial brachytherapy. Here, we present a case of recurrent endobronchial thymoma.