Mild Pulmonary Edema Research Articles

Autopsy Findings of Endocardial Fibroelastosis in an Adult

Background: Endocardial fibroelastosis (EFE) is commonly presented with diffuse endocardial thickening due todeposition of collagen and elastin, usually affecting the left ventricle of the heart. Case presentation: A 59-year-oldgentleman who had no known medical illness had collapsed while performing house chores at home. Autopsyexamination showed cyanosed lips and nail beds. The heart weighed 360 gm with distinct presence of whitish,firm and thickened endocardium of the left ventricle. The anterior descending coronary artery showed an almostcomplete occlusion by atheroma, in keeping with coronary artery disease. Mild pulmonary oedema was present.Histological examination revealed fibroelastosis forming plaque-like covering of the inner ventricle, with patchymyocardial fibrosis. Numerous ‘heart failure’ cells were present in the intraalveolar spaces. Conclusions: Thiscase showed remarkable autopsy findings of EFE in adult with evidence of congestive heart failure episodes inhis lifetime.

Abstract 13939: Catecholamine-Induced Cardiomyopathy and Limb Ischemia in Pheochromocytoma

Case Presentation: A 40-year-old woman who was 4 weeks pregnant presented with nausea and vomiting. Blood pressure (BP), heart rate, and temperature were 180/104 mmHg, 85 beats/min, 36.1℃ (96.98 ℉), Hypoxemia and mild pulmonary edema were observed. Echocardiography showed severe left ventricular dysfunction and normal dimension with ejection fraction < 10 %. As BP was decreased despite inotropic agents with aggravated hypoxemia, deteriorated acute kidney injury, mechanical ventilation, venous arterial extracorporeal membrane oxygenation (VA-ECMO), and continuous renal replacement therapy were initiated. Coronary angiography revealed normal coronary arteries and the possibility of myocarditis was low because endomyocardial biopsy showed rare inflammatory infiltration. After a few days, other parameters including cardiac function were improved and VA-ECMO was stopped, however, ischemic signs of the right lower leg progressed. To rule out rhabdomyolysis and compartment syndrome, CT angiography was done and about 4.9 cm sized left adrenal mass was found (A). The results of catecholamines are as follows: plasma metanephrine, 1862.6 (< 98.6 pg/mL); normetanephrine, 993.8 (< 164.9 pq/mL); 24hr urine metanephrine, 1396.2 (36~229 mcg/24hr); normetanephrine, 835.8 (95~650 mcg/24hr). A diagnosis of pheochromocytoma was made and left adrenalectomy was done, Pheochromocytoma was demonstrated in biopsy. Unfortunately, due to severe vasoconstriction and rhabdomyolysis, her right leg was not completely recovered, so amputation was done below knee (B). Discussion: Pheochromocytomas are catecholamine secreting tumors derived from chromaffin cells in the adrenal medulla. Catecholamine-induced vasoconstriction, microvascular hypoxia, muscle ischemia, direct toxic effects are considered to contribute to cardiomyopathy and limb ischemia in rare situations. Timely clinical suspicion, prompt diagnosis, and therapeutic intervention are critical.

Reentry spontaneous pneumomediastinum at high altitude: a two-case report

We describe two cases of spontaneous pneumomediastinum (SPM) that occurred in healthy, high-altitude native adolescent males when returning to their home from sea level. Both attended the Emergency Department of the Hospital Víctor Ramos Guardia in Huaraz, Ancash (3,052 m a.s.l.), in February 2020. Case 1 was a 16-year-old man who returned home (2,964 m a.s.l.) after twelve days at sea level (Lima). Six hours after returning, he went to work in the field. He then presented fatigue, cough, chest pain, dyspnea, and subcutaneous emphysema. Case 2 was a 17-year-old man who returned home (3,140 m a.s.l.) two weeks after staying at sea level (Barranca). Twelve hours after returning, he went to work in the field. He then presented cough, dyspnea, chest pain, sore throat, and subcutaneous emphysema. Both patients developed hypoxemia, and SPM was diagnosed with the help of chest X-rays. Case 2 was associated with mild high-altitude pulmonary edema. Both patients had no previous history of trauma, illicit drug use, comorbidity, and high-altitude-related diseases. Disease management was conservative, symptomatic, supportive, and based on clinical observation. When a healthy young patient comes to an emergency department because of chest pain, dyspnea, and subcutaneous emphysema, we should consider the possibility of SPM and immediately request frontal and lateral chest X-rays that include the cervical region. A differential diagnosis enables physicians to provide adequate and accurate treatment to patients with SPM.

Sex-Specific Physiological Responses to Ultramarathon.

Despite a growing body of literature on the physiological responses to ultramarathon, there is a paucity of data in females. This study assessed the female physiological response to ultramarathon and compared the frequency of perturbations to a group of race- and time-matched males. Data were collected from 53 contestants of an ultramarathon trail race at the Ultra-Trail du Mont-Blanc (UTMB®) in 2018/19. Before and within 2 h of the finish, participants underwent physiological assessments, including blood sampling for biomarkers (creatine kinase-MB isoenzyme [CK-MB], cardiac troponin I [cTnI], brain natriuretic peptide [BNP], and creatinine [Cr]), pulmonary function testing (spirometry, exhaled NO, diffusing capacities, and mouth pressures), and transthoracic ultrasound (lung comet tails, cardiac function). Data from eight female finishers (age = 36.6 ± 6.9 yr; finish time = 30:57 ± 11:36 h:min) were compared with a group of eight time-matched males (age = 40.3 ± 8.3 yr; finish time = 30:46 ± 10:32 h:min). Females exhibited significant pre- to postrace increases in BNP (25.8 ± 14.6 vs 140.9 ± 102.7 pg·mL -1 ; P = 0.007) and CK-MB (3.3 ± 2.4 vs 74.6 ± 49.6 IU·L -1 ; P = 0.005), whereas males exhibited significant pre- to postrace increases in BNP (26.6 ± 17.5 vs 96.4 ± 51.9 pg·mL -1 ; P = 0.002), CK-MB (7.2 ± 3.9 vs 108.8 ± 37.4 IU·L -1 ; P = 0.002), and Cr (1.06 ± 0.19 vs 1.23 ± 0.24 mg·dL -1 ; P = 0.028). Lung function declined in both groups, but males exhibited additional reductions in lung diffusing capacities (DL CO = 34.4 ± 5.7 vs 29.2 ± 6.9 mL⋅min -1 ⋅mm Hg -1 , P = 0.004; DL NO = 179.1 ± 26.2 vs 152.8 ± 33.4 mL⋅min -1 ⋅mm Hg -1 , P = 0.002) and pulmonary capillary blood volumes (77.4 ± 16.7 vs 57.3 ± 16.1 mL; P = 0.002). Males, but not females, exhibited evidence of mild postrace pulmonary edema. Pooled effect sizes for within-group pre- to postrace changes, for all variables, were generally larger in males versus females ( d = 0.86 vs 0.63). Ultramarathon negatively affects a range of physiological functions but generally evokes more frequent perturbations, with larger effect sizes, in males compared to females with similar race performances.

Budd-Chiari Like Syndrome in a Dog: Hematology, Biochemistry, Histopathology and CT Scan Angiography Findings

A nine months old mix breed dog was presented by lethargy, symptoms of abdominal pain, mild respiratory distress and abrupt onset of massive and hemorrhagic ascitesthat responded to medical treatments partially. The dog had a history of car accidentthree months earlier. Mild non-regenerative microcytic anemia,hypoalbuminemia, hypoproteinemia, elevated liver enzymes, mild pulmonary edema and high protein transudate in abdominal cavity weredetected. Abdominal ultrasonography demonstrated hepatomegaly and intra-abdominal fluid collection. Histopathological examination of the liver biopsy showed a diffuse sinusoidal distension with some area of hepatocyte necrosis. The histopathological findings, together with increased level of liver enzymes, and moderate panhypoproteinemia, high protein transudate and abdominal pain were all in favorof the diagnosis of post-sinusoidal hypertension secondary to obstruction of hepatic venous outflow (Budd-Chiari-like syndrome). CT angiography confirmed a massive thrombosis in caudal vena cava and pulmonary artery. Unfortunately, 24 hours after CT scan study the patient was spontaneously expired. However, because the owner did not give his consent for the autopsy, the detailed data is not acquired. In conclusion, obstruction of venous blood flow and Budd-Chiari like syndrome must be considered in dogs with ascites, hepatomegaly, and symptoms abdominal pain.

The Effect of an Olympic Distance Triathlon on Pulmonary Diffusing Capacity and its Recovery 24 Hours Later.

The Olympic distance triathlon includes maximal exercise bouts with transitions between the activities. This study investigated the effect of an Olympic distance triathlon (1.5-km swim, 40-km bike, 10-km run) on pulmonary diffusion capacity (DLCO). In nine male triathletes (age: 24 ± 4.7 years), we measured DLCO and calculated the DLCO to alveolar volume ratio (DLCO/VA) and performed spirometry testing before a triathlon (pre-T), 2 hours after the race (post-T), and the day following the race (post-T-24 h). DLCO was measured using the 9-s breath-holding method. We found that (1) DLCO decreased significantly between pre- and post-T values (38.52 ± 5.44 vs. 35.92 ± 6.63 ml∙min-1∙mmHg-1) (p < 0.01) and returned to baseline at post-T-24 h (38.52 ± 5.44 vs. 37.24 ± 6.76 ml∙min-1∙mmHg-1, p > 0.05); (2) DLCO/VA was similar at the pre-, post- and post-T-24 h DLCO comparisons; and (3) forced expiratory volume in the first second (FEV1) and mean forced expiratory flow during the middle half of vital capacity (FEF25-75%) significantly decreased between pre- and post-T and between pre- and post-T-24-h (p < 0.02). In conclusion, a significant reduction in DLCO and DLCO/VA 2 hours after the triathlon suggests the presence of pulmonary interstitial oedema. Both values returned to baseline 24 hours after the race, which reflects possible mild and transient pulmonary oedema with minimal physiological significance.

AN UNCOMMON CONCURRENCE OF BABESIOSIS AND ACETAMINOPHEN OVERDOSE: CASE REPORT

TOPIC: Pulmonary Manifestations of Systemic Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Babesiosis is a tick-borne illness caused by B. microti and other species and transmitted by the Ixodes tick. Acute respiratory distress syndrome (ARDS) can be a manifestation of babesiosis. CASE PRESENTATION: A 69 year old female with the past medical history of HTN, HLD and hypothyroidism who presented to hospital for 1 week of intermittent fever and generalized body aches. Patient denied any tick bites. She started to have intermittent fever around 40°C, nonproductive cough and generalized body aches, associated with night sweats, nausea, diarrhea. She took 1000mg Tylenol every 4 hours for fever and body aches for 1 week without improvement.Upon admission laboratory values were significant for hemolytic anemia (Hgb 9.4 g/dL, reticulocyte count 1.2%, LDH 4896 U/L, haptoglobin < 8mg/dL, total bilirubin 2.3 mg/dL), thrombocytopenia (platelet 38× 103/mm3) and leukopenia (WBC 2.7× 103/mm3), significantly elevated acetaminophen level (22.6), transaminitis (ALT 365 IU/L, AST 579 IU/L) and elevated INR (1.4). Blood parasite smear was positive for blood parasites (Malaria/Babesia: 9.6% RBC infected). Babesia Microti DNA RT-PCR was positive, Babesia Microti Ab (IgM) ≥ 1:320, Babesia Microti Ab (IgG) was 1:512, E. Chaffeensis Ab Ig G <1:64, E. Chaffeensis Ab Ig M <1:20, Lyme Ab Scr-Q <0.90. HIV and blood culture was negative. SARS-CoV-2 RNA was negative.Patient was admitted and received Acetylcysteine for acetaminophen toxicity, atovaquone, azithromycin, doxycycline for Babesia and borreliosis coverage. On day 2 of admission, acetaminophen level decreased to less than 10, transaminitis slowly improved. But patient developed shortness of breath, cough and hypoxia. Concerning severe babesiosis induced ARDS, chest CT angiogram was ordered and showed no evidence of pulmonary embolism but mild pulmonary interstitial edema. 2D Echo showed normal left ventricular systolic function and mild diastolic dysfunction. Patient received IV Lasix, symptoms improved and the CXR on day 6 showed pulmonary edema resolved.In the following days, patient continued to receive treatment for babesiosis, blood parasitemia cleared but Hgb decreased to 6.7 g/dL, patient received transfusion and Hgb level remained 7.9 g/dL on the day of discharge. 5 days after discharge, patient's Hgb level increased to 9 g/dL. 1 month after discharge, Hgb level increased to 12g/dL and transaminase level returned to normal. DISCUSSION: ARDS is a life-threatening condition characterized by severe hypoxemia due to pulmonary gas exchange failure. Though uncommon, tick-borne diseases could present with ARDS. Moreover, acetaminophen toxicity has also been linked to acute lung injury, making the correct diagnosis challenging. Early recognition and intervention led to a favorable outcome. CONCLUSIONS: ARDS can be an early onset manifestation after initiation of treatment for babesiosis and usually resolves with supportive treatment. REFERENCE #1: Autoimmune hemolytic anemia associated with babesiosis.Roshni Narurkar, Aleksandra Mamorska-Dyga, John C. Nelson and Delong Liu.Biomarker Research (2017) 5:14. REFERENCE #2: Yousef Nassar, Seth Richter. Babesiosis Presenting as Acute Liver Failure. Case Rep Gastroenterol 2017;11:769–773. REFERENCE #3: Boustani MR, Lepore TJ, Gelfand JA, Lazarus DS. Acute respiratory failure in patients treated for babesiosis. Am J Respir Crit Care Med. 1994 Jun;149(6):1689-91. doi: 10.1164/ajrccm.149.6.8004331.PMID: 8004331 Review. DISCLOSURES: No relevant relationships by Heather Bernstein, source=Web Response No relevant relationships by ALKA FARMER, source=Web Response No relevant relationships by CUIPING LI, source=Web Response No relevant relationships by Vinay Nakhate, source=Admin input No relevant relationships by kiritkumar parmar, source=Web Response No relevant relationships by Lin Zheng, source=Web Response

Evaluation of extravascular lung water in patients with acute respiratory distress syndrome by syndecan-1 combined with lung ultrasonography

To investigate the value of plasma syndecan-1 (SDC-1) combined with lung ultrasonography in evaluating the degree of extravascular lung water in patients with acute respiratory distress syndrome (ARDS). From July 2018 to July 2019, 50 patients with ARDS admitted to the department of intensive care unit of Wuxi People's Hospital Affiliated to Nanjing Medical University were enrolled. After admission, pulse indicator continuous cardiac output (PiCCO) catheter was established for all patients. PiCCO indexes, including extravascular lung water index (EVLWI) and pulmonary vascular permeability index (PVPI) were monitored by one doctor. Another doctor performed lung ultrasound examination, and calculated the sum of the number of B-lines under 10 ultrasound sections of upper blue point, lower blue point, diaphragm point, Plaps point and rear blue point of both lungs. Then the level of plasma SDC-1 was detected by enzyme linked immunosorbent assay (ELISA). Pearson correlation method was used to analyze the correlation between the number of ultrasonic B-lines, plasma SDC-1 level and EVLWI and PVPI. Taking 10 mL/kg EVLWI as the boundary value, the degree of pulmonary edema in patients with ARDS was divided into mild pulmonary edema and severe pulmonary edema. The receiver operator characteristic curve (ROC curve) was drawn, and the number of B-lines, SDC-1 and the predictive value of the combination of the above two indicators on the severity of pulmonary edema in patients with ARDS were analyzed. The cardiac index (CI) and central venous pressure (CVP) of 50 patients with ARDS were (46.84±6.00) mL×s-1×m-2 and (8.12±1.80) mmHg (1 mmHg = 0.133 kPa), cardiogenic pulmonary edema was excluded. In 50 patients with ARDS, EVLWI was (10.82±2.92) mL/kg, PVPI was 3.02±0.69, the number of ultrasound B-lines was 40.90±13.05, and plasma SDC-1 was (568.25±118.14) μg/L. Pearson correlation analysis showed that the number of ultrasound B-lines in patients with ARDS was significantly positively correlated with EVLWI and PVPI (r1 = 0.802, r2 = 0.799, both P < 0.01). Plasma SDC-1 was also positively correlated with EVLWI and PVPI (r1 = 0.732, r2 = 0.576, both P < 0.01). ROC curve analysis showed that the number of B-lines and SDC-1 had good predictive value for the severity of pulmonary edema in patients with ARDS. The area under ROC curve (AUC) and 95% confidence interval (95%CI) were 0.891 (0.803-0.979) and 0.875 (0.772-0.978), respectively. When the cut-off of B-lines was 40.50, the sensitivity and specificity were 82.1% and 86.4%, respectively. When the cut-off of SDC-1 was 559.37 μg/L, the sensitivity and specificity were 85.7% and 81.8%, respectively. Combining the number of B-lines with SDC-1 could further improve the predictive value of pulmonary water in patients with ARDS. The AUC (95%CI) was 0.958 (0.890-1.000), and the sensitivity and specificity were 92.9% and 91.8%, respectively. The level of plasma SDC-1 and the number of pulmonary ultrasonic B-lines have a good correlation with the degree of extravascular lung water in patients with ARDS. The combined application of the two noninvasive indexes can be used to evaluate the degree of extravascular lung water in patients with ARDS.

Internal Jugular Vein Thrombosis: Atypical Presentation of COVID-19

Background: COVID-19 is associated with elevated inflammatory markers and a hypercoagulability state leading to venous thromboembolism. We present an atypical presentation of a young female with Internal Jugular Vein (IJV) thrombosis, a cause attributable to the disease. Case: A 47-year-old female with a past medical history of diabetes mellitus, hypertension, bronchial asthma, morbid obesity, uterine cancer and iron deficiency anemia (IDA) presented to the hospital with neck swelling and pain on the right side for the last week. The patient had a low-grade fever of 100.3 degrees F at home with neck discomfort, productive cough and sore throat. She was seen in the Emergency Department about 1 week back for cough and was discharged. A computerized tomography (CT) scan of the neck and soft tissue with contrast showed the right IJV almost entirely thrombosed from its origin at the skull base to the right subclavian vein and mild pulmonary edema suspected by diffuse ground glass opacity within the lungs. The patient was receiving intravenous iron therapy for IDA through a porta-catheter, placed 7 months ago. The right central vein subcutaneous porta-catheter access was removed, begun on systemic anticoagulation with Warfarin. SARS-CoV-2 RT-PCR was not done in this visit. On follow up, Anti-SARS-CoV-2 antibodies were positive. A repeat CT scan of the neck after 6 months of anticoagulation was done, and the thrombus was resolved. Conclusion: We would like to emphasize more about the hypercoagulability in SARS-CoV-2 patients and broaden our vision for all possibilities of thrombosis, like the IJV thrombosis in our patient. We recommend a full hypercoagulability workup and imaging for prompt diagnosis and management of thromboembolic events in SARS-CoV-2 patients. There should be a low threshold for the SARS-CoV-2 PCR test and a vigilant attitude while we discover more of the disease.

Nitrate-nitrite toxicosis associated with duckweed (Portulaca Oleracea L.) (Portulacaceae) consumption in a herd of sheep in Kenya

Background: Nitrate-nitrite toxicosis associated with the consumption of duckweed (Portulaca oleracea L.) (Portulacaceae) was diagnosed in a small herd comprising of 11 sheep in Korayo Sub Location, Rangwe Sub County of Homabay County in Kenya. Methods: The clinical signs were dyspnea, froth from the mouth, labored breathing, incoordination, tachycardia, increased urination, neck, fore and hind limb distension, aggressive movements, bloat, convulsions, and coma, before death. Results: All the 11 sheep died of intoxication before institution of therapy. Brownish mucous membranes and chocolate colored and poorly clotted blood were the significant necropsy observations. Mild pulmonary edema was characterized by the presence of limited froth in the trachea and bronchioles. At postmortem, the liver of the sheep was grossly congested, and the cardiac pericardium was inflamed. There was gastritis, enlarged, and congested kidneys with pin-point hemorrhages. Diphenylamine tests carried out on the fed duckweed and on ruminal duckweed contents were positive for nitrates. Duckweed (Portulaca oleracea) fed on sheep had 7.4% nitrate on dry matter basis (DM), whereas ruminal contents had 5.38% nitrate on DM basis. Chocolate-colored blood collected during postmortem had a methemoglobin fraction of 86%. Nitrate levels in pastures of 0.5% and above have been shown to be potentially dangerous, with acute poisoning likely to occur at times when the levels are above 1%. Death in sheep can occur when blood methemoglobin levels are in the range of 67%–90%. Conclusion: The observations from the present study are indicative of death in a herd of sheep due to nitrate-nitrite poisoning associated with the consumption of duckweed (Portulaca oleracea).

Prognostic value of pulmonary oedema assessed by lung ultrasound in patient with acute heart failure

It is very important to assess pulmonary oedema in patients with acute heart failure. The aim of the study was to investigate the accuracy of lung ultrasound in evaluating pulmonary oedema and to explore lung ultrasound in predicting the prognosis. One hundred twenty-four acute heart failure patients were divided into 3 groups, according to the total number of lung ultrasound B-lines groups: B-lines < 15 was the mild pulmonary oedema group (33 cases), 15 ≤ B-lines < 30 was the moderate pulmonary oedema group (33 cases), and B-lines ≥ 30 was the severe pulmonary oedema group (58 cases). The PiCCO monitoring system was used in 11 patients and measured 26 times in different clinical situations. EVLWI have a higher positive correlation with B-lines (r = 0.95), compared with NT-proBNP and E/e' (r = 0.72, r = 0.62). During 1 year of follow-up, a multivariate cox regression analysis showed that age, E/e' and B-lines ≥ 30 at admission (C-index of 75%) were risk factors for prognosis. 12-month event-free survival showed a significantly worse outcome was observed in patients with ≥ 30 B-lines at admission. B-lines have a good correlation with EVLWI; age, E/e' and B-lines ≥ 30 at admission were risk factors for prognosis.

A RARE PRESENTATION OF GROUP C STREPTOCOCCUS ENDOCARDITIS WITH DIFFUSE SEPTIC EMBOLI

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Group C beta-hemolytic Streptococcus (GCS) typically causes skin and soft tissue infections, pharyngitis, and wound infections. However, the incidence of bacteremia from GCS has increased significantly over the past decade1. Most cases of GCS bacteremia and complications including endocarditis, meningitis, and septic arthritis occur in older adults with underlying chronic illnesses2. We present the unusual case of GCS endocarditis with diffuse septic emboli causing multi-organ failure in a young female. CASE PRESENTATION: A 24-year-old female with a history of intravenous drug use was admitted with altered mental status after IV drug use. On presentation, patient was afebrile with no leukocytosis, and examination was significant for tachycardia, extreme agitation, hyperalgesia, and hallucinations. Preliminary workup revealed thrombocytopenia, acute kidney injury, acute liver injury, and troponinemia. Chest radiographs showed cardiomegaly with concern for mild pulmonary edema. Toxicology screen was positive for amphetamines and cannabinoids but negative for opioids. Echocardiogram revealed a 1.9cm x 1.8cm echodensity attached to the basal free wall of the right ventricle near the level of the tricuspid valve. Blood cultures were positive for GCS, meeting 2 major Duke criteria for infective endocarditis. Her clinical course was complicated by septic shock and acute hypoxic respiratory failure requiring intubation. Repeat chest imaging revealed diffuse patchy airspace opacities with superimposed interstitial predominance. Computed tomography of the chest showed a bronchovascular distribution of wedge-shaped consolidative opacities scattered diffusely throughout bilateral lungs. Imaging findings also included hepatosplenomegally and evidence of embolization to the kidneys. She showed clinical improvement with intravenous antibiotics and mechanical ventilation and is under evaluation by cardiothoracic surgery for valve repair and vegetation excision. DISCUSSION: Though GCS bacteremia and endocarditis are typically seen in older adults with comorbidities, this case highlights the rapid progression and clinical sequelae of GCS bacteremia in a young female with IV drug use. Tricuspid valve vegetations are commonly seen in IV drug use-associated endocarditis, however a vegetation in the right ventricle arising from the basal free wall is exceedingly rare. The location of the vegetation likely contributed greatly to the rapid showering of emboli and severity of symptoms in this case. CONCLUSIONS: Though GCS is not an organism frequently associated with IV drug use, it should now be considered given the rising incidence of GCS bacteremia and the severity of disease it may cause1. Reference #1: Lother S, Jassal D, Lagacé-Wiens P, Keynan Y. Emerging Group C and Group G Streptococcal Endocarditis: A Canadian Perspective. Int J Infect Dis 2017; 65: 128-132 Reference #2: Berenguer J, Sampedro I, Cercenado E, et. al. Group-C Beta-Hemolytic Streptococcal Bacteremia. Diagn Microbiol Infect Dis 1992; 15(2): 151-155 DISCLOSURES: No relevant relationships by Gold Adkins, source=Web Response No relevant relationships by Aria Bryan, source=Web Response No relevant relationships by Shine Raju, source=Web Response No relevant relationships by Pallavi Sharma, source=Web Response No relevant relationships by Catalina Teba, source=Web Response

Extravascular Lung Water And Lung Diffusing Capacity In Response To Ultra-endurance Exercise Performed At Moderate Altitude

PURPOSE: Strenuous exercise performed at altitude increases cardiac output and pulmonary arterial and capillary pressures to levels that may exceed a tolerable alveolar-capillary load, thereby evoking fluid leakage into the interstitial space. Accordingly, this study aimed to determine whether running an ultramarathon at moderate altitude increases extravascular lung water (EVLW) and whether this inhibits the transfer of gas across the alveolar-capillary membrane. METHODS: Cardiac biomarkers (cTnI & BNP), exhaled nitric oxide (ExNO), echocardiographic signs of EVLW, and lung (DLco) and alveolar-capillary membrane (Dm) diffusing capacity for carbon monoxide (determined via a single-breath DLco/DLno method) were assessed in 53 runners (10 Females; Age:41±10y BMI:23±2kg/m2) before, 1-4h and 24h after a 100km (CCC: 6,100m of ascent, altitude range of 1,035-2,584m) or 170km (UTMB: 10,000m of ascent, altitude range of 1,035-2,565m) mountain ultramarathon. RESULTS: Participants finished the ultramarathon in 27±12h with an average heart rate of 124±13bpm. Cardiac biomarkers were increased acutely after the race (cTnI: 0.01±0.00 vs. 0.04±0.01ng/ml, p<0.01; BNP: 21±2 vs. 123±12pg/ml, p<0.01), while ExNO decreased (25.6±2.0 vs. 14.5±1.3 ppb, p<0.01). Signs of EVLW increased after the race (average comet tails count: 2±1 vs. 7±1, p<0.01) while DLco decreased (31.6±1.0 vs. 28.6±0.9 ml/min/mmHg, p<0.01) but Dm remained unchanged (171.4±7.6 vs. 167.2±8.8 ml/min/mmHg, p>0.05). Cardiac biomarkers, ExNO, EVLW and Dm were similar to baseline values after 24h of recovery, while DLco remained mildly reduced (30.6±1.6 ml/min/mmHg, p<0.05). CONCLUSIONS: These data suggest a mild and transient increase in cardiac biomarkers and extravascular lung water occur after completing an ultramarathon at moderate altitude, but this has minimal impact on the transfer of gas across the alveolar-capillary membrane, despite an overall reduction in lung diffusion. In some subjects an exaggerated increase in extravascular lung water and decrease in alveolar-capillary membrane diffusion was observed, suggesting that some individuals may have an increased propensity for developing mild exercise-induced pulmonary edema at altitude.

Nitrate Poisoning due to Ingestion of Cabbages (Brassica oleracea var. capitata L.) (Brassicaceae) in Kitui County, Kenya.

Nitrate toxicosis associated with consumption of cabbages (Brassica oleracea var. capitata L.) (Brassicaceae) was diagnosed in a small herd comprising of ten goats in Matinyani ward, Kitui West sub-County of Kitui County in Kenya. The clinical signs were ataxia, ruminal tympany, bluish-brown mucous membranes, rapid and difficult breathing, incoordination, head pressing, aggressive movements, jugular distension, increased heart rates, tremors, and coma. Six goats died of intoxication. Dark brown/chocolate-colored and poorly clotted blood was the prominent necropsy finding. There was limited froth in the trachea and bronchi consistent with mild pulmonary oedema. There were liver congestion, pericarditis, and enlarged and congested kidneys with pinpoint haemorrhages. Four other affected goats were treated with intramuscular antihistamines and oral administration of ivermectin. No further mortality was observed after the treatment. Cabbages fed to goats had 6.6% nitrate on dry matter (DM) basis , while ruminal contents had 5.55% nitrate on dry matter basis (DM). Dark brown blood collected at postmortem had a methemoglobin fraction of 78%. Forage nitrate levels of 0.5% and above are potentially dangerous, with acute poisoning likely to occur if the nitrate level exceeds 1%. Death can occur when blood methemoglobin levels rise up to 67–90%. Findings from the current study are indicative of nitrate-nitrite toxidrome associated with ingestion of cabbages.

Hook Breathing Facilitates SaO2 Recovery After Deep Dives in Freedivers With Slow Recovery.

To facilitate recovery from hypoxia, many freedivers use a breathing method called “hook breathing” (HB) after diving, involving an interrupted exhale to build up intrapulmonary pressure. Some divers experience a delay in recovery of arterial oxygen saturation (SaO2) after diving, interpreted as symptoms of mild pulmonary edema, and facilitated recovery may be especially important in this group to avoid hypoxic “blackout.” We examined the influence of HB on recovery of SaO2 in freedivers with slow recovery (SR) and fast recovery (FR) of SaO2 after deep “free immersion” (FIM) apnea dives to 30 m depth. Twenty-two male freedivers, with a mean (SD) personal best in the discipline FIM of 57(26) m, performed two 30 m deep dives, one followed by HB and one using normal breathing (NB) during recovery, at different days and weighted order. SaO2 and heart rate (HR) were measured via pulse oximetry during recovery. The SR group (n = 5) had a faster SaO2 recovery using HB, while the FR group (n = 17) showed no difference between breathing techniques. At 105 s, the SR group reached a mean (SD) SaO2 of 95(5)% using HB, while using NB, their SaO2 was 87(5)% (p < 0.05), and 105–120 s after surfacing SaO2 was higher with HB (p < 0.05). In SR subjects, the average time needed to reach 95% SaO2 with HB was 60 s, while it was 120 s at NB (p < 0.05). HR was similar in the SR group, while it was initially elevated at HB in the FR group (p < 0.05). We conclude that HB efficiently increases SaO2 recovery in SR individuals, but not in the FR group. The proposed mechanism is that increased pulmonary pressure with HB will reverse any pulmonary edema and facilitate oxygen uptake in divers with delayed recovery.

Histological Changes in the Lung and Liver of Mice Treated with Brake Pad Particles

In the present study, the effects of brake pad particles of lung and liver histological sections were evaluated for (60) adult male mice. The animals were divided into three groups ( A,B,C) according to the periods of exposure (4, 8, and 12) weeks respectively exposed to brake pad particles in addition to the control groups (F) exposed to fresh air only. A special inhalation chamber designed locally has been used to expose the animals. The exposure to brake pad particles was (2.228) µg/m³ for 30 min/day, 5 days/week for (4,8and12) weeks respectively.&#x0D; The examination in group (A) of the histological sections of the lung showed the thickness of interalveolar septa. Also, a congestion of alveolar capillary was marked indicating pulmonary emphysema. The infiltration of alveolar macrophages showed the engulfed foreign particles (pad particles) within their cytoplasm, and peribronchial fibrosis. Group (B) showed the presence of pad particles (anthracosis), whereas the bronchial tree showed bronchitis with the bronchus-hyperplasia of mucin-producing cells (epithelial hyperplasia). Still another section showed an infiltration of mononuclear leukocytes and focal lobar necrosis. The third group (C), in turn, revealed acute interstitial bronchopneumonia with peribronchial focal necrosis and mild pulmonary edema with alveolar anthracosis.&#x0D; As regards the liver, group (A) showed mild central venous congestion. Group (B), on the other hand, gave acute hepatitis, congestion of the central vein hyaline degeneration and mitotic figure having 2-3 nuclei. Severe congestion of the central vein with vascular amyloid deposition and most of the hepatocytes revealed coagulate necrosis in group (C). These changing tissues increased with increasing the exposure periods and were clearer in group (C) which was exposed for 12 weeks.&#x0D; The continuous exposure to brake pad particles lead to damaging important body organs tissues and effect on human health, these particles can be considered as a type of pollutants added to air pollutants in different cities of Iraq.&#x0D;

Histological Changes in the Lung and Liver of Mice Treated with Brake Pad Particles

In the present study, the effects of brake pad particles of lung and liver histological sections were evaluated for (60) adult male mice. The animals were divided into three groups ( A,B,C) according to the periods of exposure (4, 8, and 12) weeks respectively exposed to brake pad particles in addition to the control groups (F) exposed to fresh air only. A special inhalation chamber designed locally has been used to expose the animals. The exposure to brake pad particles was (2.228) µg/m³ for 30 min/day, 5 days/week for (4,8and12) weeks respectively.&#x0D; The examination in group (A) of the histological sections of the lung showed the thickness of interalveolar septa. Also, a congestion of alveolar capillary was marked indicating pulmonary emphysema. The infiltration of alveolar macrophages showed the engulfed foreign particles (pad particles) within their cytoplasm, and peribronchial fibrosis. Group (B) showed the presence of pad particles (anthracosis), whereas the bronchial tree showed bronchitis with the bronchus-hyperplasia of mucin-producing cells (epithelial hyperplasia). Still another section showed an infiltration of mononuclear leukocytes and focal lobar necrosis. The third group (C), in turn, revealed acute interstitial bronchopneumonia with peribronchial focal necrosis and mild pulmonary edema with alveolar anthracosis.&#x0D; As regards the liver, group (A) showed mild central venous congestion. Group (B), on the other hand, gave acute hepatitis, congestion of the central vein hyaline degeneration and mitotic figure having 2-3 nuclei. Severe congestion of the central vein with vascular amyloid deposition and most of the hepatocytes revealed coagulate necrosis in group (C). These changing tissues increased with increasing the exposure periods and were clearer in group (C) which was exposed for 12 weeks.&#x0D; The continuous exposure to brake pad particles lead to damaging important body organs tissues and effect on human health, these particles can be considered as a type of pollutants added to air pollutants in different cities of Iraq.&#x0D;

Non‐Invasive Pulmonary Gas Exchange Measurements Following Deep Breath‐Hold Diving

Breath‐hold diving is a ubiquitous activity, with recreational, fishing, military and competitive divers. During a dive, immersion and the increasing hydrostatic pressure of descent facilitate cardiovascular adjustments that promote a blood volume shift into the heart and chest vasculature, further augmenting autonomic responses (i.e. diving bradycardia, peripheral vasoconstriction, and splenic contraction) to conserve O2. Exceeding the compliant capacity of the lung and associated tissues can result in pulmonary injury called squeeze, which is characterized by post‐dive coughing, wheezing and hemoptysis. To provide insight into the consequences of such lung squeeze, our objective was to evaluate the time‐course of a maximal deep dive on pulmonary gas exchange, pulmonary artery systolic pressures (PASP), and ultrasound lung comets (ULCs). Ten healthy trained breath‐hold divers (33±9 yr; 80±15 kg; 185±9 cm) performed a maximal effort dive (55±12 m; range 40–76 m). Pulmonary gas exchange and PASP were performed at baseline, and repeated at 10 and 60 min post dive. Pulmonary gas exchange was non‐invasively measured by collecting end‐tidal PO2 and PCO2 during steady‐state breathing, and derived arterial PO2 via pulse oximetry. O2 deficit was defined as the difference between end‐tidal and calculated arterial PO2; consistent with the Bohr effect by utilizing end‐tidal PCO2. The ULCs were collected bilaterally, parasternal to mid‐axillary, at baseline and again 2.5 h post dive. Following the dive, although there was an impairment of pulmonary gas exchange, evident by an increase in O2 deficit from 10.9±4.5 mmHg at baseline to 22.9±5.1 mmHg 10‐min post dive (p=0.02), this deficit had normalized by 60‐min post. There was persistent hyperventilation up to 60 min post dive, reflected by reductions in end‐tidal PCO2 (p=0.02). PASP was unaltered post‐dive. Although ULCs trended to increase from baseline to 2.5 h post dive (3.7±3 to 10.4±13.2 comets; p=0.09), the delta change in ULC from baseline to post‐dive was positively correlated with depth (r=0.67, p=0.04) and, to a lesser extent, with both change in SpO2 (r=−0.62, p=0.06) and O2 deficit (r=0.58, p=0.08). The findings of this novel study suggest impairment in pulmonary gas exchange is present following diving to depth, even up to 10 min after surfacing. The mechanism(s) driving the slight hyperventilation are unclear, but potentially could be mediated via mild pulmonary edema and/or stimulation of juxtapulmonary capillary receptors. Together, there is transient impairment in gas exchange and associations with ULC during ‘modest’ dives. The development of pathological pulmonary edema, and severe and sustained impairment in pulmonary gas exchange, would seem likely at the forefront of breath‐hold diving performances (e.g, &gt;100 m). There remains little data regarding safe return‐to‐dive practices following a squeeze, and non‐invasive pulmonary gas exchange monitoring could provide valuable utility.Support or Funding InformationCanada Research Chair, NSERCThis abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Amyloid Cardiomyopathy in the Emergency Department

BackgroundCardiac amyloidosis is an underdiagnosed cause of restrictive cardiomyopathy resulting from the infiltration of the myocardium by amyloid proteins. Case ReportWe report the case of an 83-year-old woman who presented with increasing dyspnea and lower-extremity swelling. She reported a medical history of unspecified heart failure. Evaluation in the Emergency Department (ED) revealed evidence of heart failure on physical examination, low-voltage electrocardiogram, chest x-ray study with mild pulmonary edema, and laboratory evaluation with elevated brain natriuretic peptide and troponin. Bedside cardiac ultrasound illustrated severe concentric ventricular hypertrophy and interventricular septal wall thickening with “sparkling” hyperechoic appearance of the myocardium, mildly reduced left ventricular ejection fraction, and small pericardial effusion. Inpatient comprehensive echocardiogram and follow-up nuclear medicine cardiac amyloid pyrophosphate study were suggestive of cardiac amyloidosis. Why Should an Emergency Physician Be Aware of This?Emergency physicians commonly treat acute on chronic systolic heart failure with diuresis and reductions in preload and afterload with nitrates. Identifying amyloid cardiomyopathy in the ED is of clinical significance because treatment should include loop diuretics but should avoid β-blockers, angiotensin-converting enzyme inhibitors, calcium channel blockers, and digoxin. Atrioventricular nodal blocking agents may have detrimental effects in cardiac amyloidosis because the cardiac output in this patient population is dependent on heart rate due to a significantly reduced stroke volume from the concentric hypertrophy minimizing diastolic filling. Also, caution should be taken when initiating nitrates in amyloid cardiomyopathy because further reducing preload in an already preload-depleted state can result in hypotension.

A rare case of fatal rectal bleeding from diverticular diseases of the jejunum

Diverticulosis is a condition which balloon-like sacs developing in the intestinal wall commonly in the colon. Even though diverticulosis is usually asymptomatic, rare complications are the abdominal pain, infection, perforation, bleeding and intestinal obstruction. Colonoscopy and barium enema X-ray studies can confirm the diagnosis. It is rare to find diverticulosis in the small intestine. Bleeding is usually mild because diverticulum is usually formed at the antimesenteric border. When a diverticulum develops in mesenteric border, ulceration of its mucosa can erode into mesenteric blood vessels and may lead to massive bleeding. A 54-year-old male who was suffering from diabetes mellitus, hypertension and ischemic heart diseases developed abdominal pain and bleeding perrectum. Flexible sigmoidoscopy showed inflamed patches of bowel and upper gastrointestinal endoscopy revealed gastric erosions. Rectal bleeding persisted and the patient needed a transfusion of 25 pints of blood. CT angiogram revealed bleeding focus at the region of duodeno-jejunal junction. The patient died while he was getting transferred for Digital Subtraction Angiography. Postmortem examination showed external and internal pallor, mild pulmonary oedema and three sites of U- shaped bowel adhesions in the jejunum. All three loops had small pouches which opened into the intestinal lumen. One pouch which was present at the mesenteric border of the jejunum had an ulcer eroded into mesenteric blood vessels. This case is a very rare example of jejunal diverticulosis on mesenteric border causing fatal haemorrhage. When there is a history of massive rectal bleeding, small bowel diverticulosis is also should be considered in clinical practice as well as in forensic pathology practice.