Multiple Blebs Research Articles

Aneurysm Wall Enhancement Can Predict Rupture Point in Intracranial Aneurysms With Multiple Blebs.

Ruptured aneurysms visualized by vessel wall MRI (VW-MRI) exhibit characteristic aneurysm wall enhancement (AWE). A secondary bulge of the aneurysmal wall, called a bleb, is often the site of rupture in ruptured aneurysms. We hypothesized that a higher degree of AWE would identify the rupture point in aneurysms with multiple blebs. AWE was quantitatively analyzed in consecutive ruptured intracranial aneurysms with multiple blebs (31 aneurysms with a total of 72 blebs) using VW-MRI. A 3-dimensional T1-weighted fast spin-echo sequence was obtained after contrast media injection, and the contrast ratio of the aneurysm wall against the pituitary stalk (CRstalk) was calculated as the AWE indicator. Bleb characteristics, including CRstalk and wall shear stress (WSS), were compared between ruptured and unruptured blebs. Odds ratios with 95% confidence intervals for ruptures were calculated by conditional logistic regression analysis. Ruptured blebs had a higher CRstalk and lower WSS compared with unruptured blebs. CRstalk remained significantly associated with the bleb rupture status in the conditional logistic regression (adjusted odds ratio 3.9, 95% CIs 1.6-9.7). AWE is associated with the bleb rupture status independent of WSS. Contrast-enhanced VW-MRI may be a useful noninvasive tool for identifying the rupture point and guiding the treatment strategy.

Biophysical modeling identifies an optimal hybrid amoeboid-mesenchymal phenotype for maximal T cell migration speeds.

Despite recent experimental progress in characterizing cell migration mechanics, our understanding of the mechanisms governing rapid cell movement remains limited. To effectively limit tumor growth, antitumoral T cells need to rapidly migrate to find and kill cancer cells. To investigate the upper limits of cell speed, we developed a new hybrid stochastic-mean field model of bleb-based cell motility. We first examined the potential for adhesion-free bleb-based migration and show that cells migrate inefficiently in the absence of adhesion-based forces, i.e., cell swimming. While no cortical contractility oscillations are needed for cells to swim in viscoelastic media, high-to-low cortical contractility oscillations are necessary for cell swimming in viscous media. This involves a high cortical contractility phase with multiple bleb nucleation events, followed by an intracellular pressure buildup recovery phase at low cortical tensions, resulting in modest net cell motion. However, our model suggests that cells can employ a hybrid bleb- and adhesion-based migration mechanism for rapid cell motility and identifies conditions for optimality. The model provides a momentum-conserving mechanism underlying rapid single-cell migration and identifies factors as design criteria for engineering T cell therapies to improve movement in mechanically complex environments.

Neonatal purpura fulminans: A rare, life-threatening, and rapidly progressing disorder of coagulation

Background: Neonatal purpura fulminans (NPF) is a life-threatening rare disease, which can be caused by deficiencies of protein C or protein S in a congenital or acquired manner. It is characterized by thrombosis of microvasculature, peri-vascular hemorrhage, and disseminated intravascular coagulation (DIC) occurring in the neonatal period. Clinical Description: A term female baby presented at 40 h of life with multiple purpuric rashes over the left foot which over 1 day extended until the knee. Over the next 3 days, there was rapid progression to involve extensive areas of necrosis with gangrene of toes of left foot, both forearms, bilateral temporal areas, peri-orbital regions, and left ear, in addition to multiple hemorrhagic blebs. Management and Outcome: Investigations showed anemia and thrombocytopenia with normal leucocyte count. DIC was suspected (INR 2), sepsis screen was negative, and fresh frozen plasma (FFP) was transfused 8th hourly. Arterial and venous Doppler was normal and blood culture showed no growth. Suspecting NPF, protein C, protein S, and anti-thrombin levels were sent, which showed a low protein C and protein S value. Mutations involving factor V Leiden, prothrombin gene, and MTHFR gene were not detected. The baby was started on low molecular weight heparin and, FFP and platelet concentrate replacement were continued, but she succumbed to the illness. Conclusion: NPF is a rare life-threatening entity that is fatal without prompt recognition of the condition. Therefore, it is necessary to recognize it early and initiate treatment.

Combined Internal Limiting Membrane Peeling and Subretinal Balanced Salt Solution Injection: A Novel Technique to Unfold Congenital Falciform Folds.

To describe a novel surgical technique to unfold congenital falciform folds. A retrospective, interventional case series was performed where a novel technique was applied to treat five cases of congenital falciform folds. Twenty-five-gauge vitrectomy was performed along with the removal of all vitreous adhesions. The internal limiting membrane was peeled from the macula and around the macular fold area. A Tano diamond-dusted membrane scraper was used to stretch the folded retina mechanically. Then, subretinal balanced salt solution was injected using a 38-gauge subretinal needle to create multiple blebs around the folded retina. Finally, 20% sulfur hexafluoride gas was used for tamponade. Follow-up was conducted for a minimum of 6 months. Vision improved from preoperative mean best-corrected visual acuity logMAR 1.44 (20/550) ± 0.32 to postoperative mean best-corrected visual acuity logMAR 0.75 (20/112) ± 0.17 ( P value = 0.0208) after intervention. There was a reduction in the macular fold. Postoperatively, a macular hole with retinal detachment developed in one of five (20%) eyes. The novel technique of vitrectomy with combined internal limiting membrane peeling and subretinal balanced salt solution injection is visually rewarding in treating congenital falciform folds.

INTRAOPERATIVE BLEB BEHAVIOR IN SUBRETINAL GENE AUGMENTATION THERAPY FOR INHERITED RETINAL DISEASES.

In subretinal gene therapy for inherited retinal diseases (IRDs), blebs may not propagate predictably in the direction of the injection cannula. We evaluated factors that influenced bleb propagation among various IRDs. Retrospective review of all subretinal gene therapy procedures performed by a single surgeon between September 2018 and March 2020 for various IRDs. Main outcome measures were directional bias of bleb propagation and intraoperative foveal detachment. Desired injection volumes and/or foveal treatment were successfully achieved in all 70 eyes of 46 patients with IRD regardless of IRD indication. Bullous foveal detachment was associated with retinotomy closer to the fovea, posterior bleb bias, and greater bleb volumes ( P < 0.01). Blebs biased anteriorly or posteriorly based on disease indication ( P = 0.04) and age ( P < 0.001). Retinotomy location ≤ 3.7 mm (approximately two disk diameters) from the fovea favored foveal detachment ( P < 0.001). Multiple retinotomies and blebs allowed greater surface area coverage in some eyes, but intersecting blebs did not propagate further. Bleb formation and propagation are predictable based on patient age, retinotomy location, disease indication, and how tangentially fluid is directed into the subretinal space.

The morphology and differentiation of stromal cells in the cortex of follicles in the bursa of Fabricius of the chicken.

Mesenchymal reticular cells (MRCs) form a supporting system in the cortex of the bursal follicle. The stellate-shaped MRCs exhibit a low electron density, which is helpful for their identification. A remarkable feature of MRC is the formation of multiple blebs in the nuclear envelope. The large, irregularly shaped blebs-which are perinuclear spaces-may be detached from the nuclear membrane, creating a sac-like granular endoplasmic reticulum (GER). Inside the bleb, membrane-bound bodies originate from cytoplasmic impressions. The cytoplasm contains a few round mitochondria, in which the internal membranes form either ovoid vesicles or the entire internal structure is indistinct. These mitochondria may be associated with the blebs. The classical Golgi complex with cis and trans faces cannot be recognized, but the accumulation of very small vesicles occurs around two or three stacked flat cisterns. The MRC forms a continuous layer along the corticomedullary basal lamina (CMBL), and during cell migration between the cortex and medulla, it may contribute to the temporary closure of the gap in the CMBL. At the outer surface of the cortex, transitory cells between the MRC and fibrocytes of the interfollicular connective tissue are present, and both cells can produce GER by blebbing. This finding suggests that MRCs and fibrocytes may have a common origin. The other stromal cell is the macrophage (Ma), which may fuse together to form multinucleated giant cells. The definition of histological classification of the third type of stromal cell is questionable, but certain morphological features may be referred to as progenitors of MRCs.

Unfolding falciform folds and their consequences - To touch or not to touch.

Background:Falciform folds are congenital tractional retinal folds due to strong contractile forces and hyperextensibility of retina resulting in temporal dragging of the macula and often associated with familial exudative vitreoretinopathy and retinal detachment (RD). Retinologists are reluctant to treat these entities in view of their poor visual recovery.Purpose:To describe a novel surgical technique to unfold the falciform folds.Synopsis:This video demonstrates innovative surgical techniques to remove both pre-retinal and sub-retinal adhesions and unfold these folds, managing its consequences and visual recovery. We describe cases of congenital falciform folds with poor visual acuity, where we did vitrectomy, membrane adhesion removal, peeling of the internal limiting membrane (ILM) the macula, mechanical stretching of the folded retina by Tanno scraper or Finesse flex loop, then sub-retinal injection of balanced salt solution (BSS) by 38 gauge sub-retinal needle o create multiple blebs around the folded retina and finally sulphur hexafluoride tamponade. Post-operative macular hole with RD can be a complication. When this falciform fold is complicated by RD, there is risk of intraoperative subretinal migration of infusion cannula and therefore the need for peripheral relaxing retinectomy for redundant retinal fold as well as silicone oil as endotamponade. Vision improved in all our patients after the surgery.Highlights:Both long-standing pre-retinal adhesions as well as sub-retinal adhesions are responsible for he tformation of congenital falciform folds. For pre-retinal adhesions, vitrectomy with removal of all the adhesions along with peeling of the sticky ILM and then mechanical stretching of folded retina by Tanno scraper or Finesse flex loop are necessary. To remove sub-retinal adhesions, sub-retinal injection of BSS is necessary to stretch the folded retina from behind, but it should be done away from the retina to avoid formation of macular hole.Online Video Link: https://youtu.be/9h8IE3abKIM

Curious Colonoscopy Findings in a Patient With Autosomal Dominant Polycystic Kidney Disease

Question: A 48-year-old woman with a history of autosomal dominant polycystic kidney disease, a prior episode of acute pancreatitis, gastroesophageal reflux disease, and hypertension reports increased abdominal fullness and epigastric abdominal pain for which she was hospitalized. During that admission, her lipase was within normal limits and her gallbladder and pancreas were difficult to visualize on ultrasound examination. A computed tomography scan of her abdomen revealed multiple kidney and liver cysts of varied sizes. The cause of her pain was eventually determined to be from her underlying kidney and liver pathology, and she was discharged home. The patient later underwent average-risk screening colonoscopy, at which time, multiple blebs were seen in the ascending colon and hepatic flexure (Figure A, B). What is the most likely explanation of her findings on colonoscopy? Look on page 1596 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The colonoscopy revealed external compression from a few of the many cysts as a sequela from her polycystic liver disease (Figure A, B). At first sight, one may confuse these findings for pneumatosis intestinalis, gas-filled intramural cysts that can be found in both the small bowel and colon, or colonic varices.1Gupta P. McCauley R. Pneumatosis, benign and serious.in: Johnson L.R. Encyclopedia of gastroenterology. Elsevier, New York2004: 194-198Crossref Google Scholar,2Mathur V. Kaur G. Prajapat R.K. et al.Colonoscopic findings in patients of portal hypertension due to different etiologies and their correlation.J Assoc Physicians India. 2021; 69: 11-12Google Scholar However, pneumatosis intestinalis is not likely in this patient because she did not have the typical presentation of lower gastrointestinal bleeding associated with bowel obstruction or ischemia. Similarly, there was no evidence of portal hypertension to suggest colonic varices. The computed tomography scan of her abdomen (Figure C) completed at her most recent hospitalization revealed hepatomegaly measuring 28.2 cm with innumerable simple cysts in the right and left hepatic lobes. Polycystic liver disease is the most common extrarenal finding of autosomal dominant polycystic kidney disease.3Hogan M.C. Abebe K. Torres V.E. et al.Liver involvement in early autosomal-dominant polycystic kidney disease.Clin Gastroenterol Hepatol. 2015; 13: 155-164.e6Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar The resulting hepatomegaly often causes compression of nearby organs, as shown in this patient. Few cases exist where compression of the bowel has led to significant obstruction or ischemia. Disease burden is particularly pronounced in women. A cross-sectional analysis has determined that liver volumes, disease severity, and impact on quality of life are more evident in women.2Mathur V. Kaur G. Prajapat R.K. et al.Colonoscopic findings in patients of portal hypertension due to different etiologies and their correlation.J Assoc Physicians India. 2021; 69: 11-12Google Scholar Patients with severe presentations, as in the case, typically require both kidney and liver transplantation.

Bilateral primary spontaneous pneumothorax with multiple bleb performed by VATS and wedge resection: A rare case in Indonesian adult and review article.

BackgroundBilateral primary spontaneous pneumothorax (PSP) is a rare case of lung disease.Case presentationA 20-year-old man with a complaint of shortness of breath is suspected of having PSP and tuberculosis. The patient underwent water seal drainage installation in both lung cavities, but showed no improvement. Multiple blebs were found after a few days. A wedge resection with VATS became an option. The patient had improved lung function after the procedure.DiscussionThe WSD installation showed lungs improvement. However, when trained for lung expansion, the lung condition became bad. After wedge resection with the help of VATS on multiple blebs, the lung had a significant improvement.ConclusionWedge resection could be considered in PSP patients with multiple blebs.

Wedge resection on recurrent pneumothorax, failed lung expansion after needle aspiration: A case report.

BackgroundPneumothorax has several classifications, including based on etiology, location, extent, and degree of collapse as well as by mechanism and type.Case presentationA 61-years-old man with the main complaint of sudden shortness of breath after lifting a birdcage. The complaint worsened, and it was accompanied by nausea, sweating, and decreased vital signs. The patient was in a life-threatening condition with a tension pneumothorax and treated with needle aspiration (NA). On the second day of treatment, a clinical evaluation showed recurrent dyspnea. Lung physical examination and chest X-ray evaluation showed recurrent pneumothorax with subcutaneous emphysema. Installation of chest tube drainages (CTD) with active continuous suction of −20 cmH2O. High-resolution CT (HRCT) showed right pneumothorax with multiple blebs, bullae, and bronchopleural fistula. Video-assisted thoracic surgery (VATS) was carried out to repair bronchopleural fistula (BPF). However, pre-surgery found multiple bullae and multiple fistulas accompanied by adhesion to the chest wall, thus the procedure could not be conducted. As an alternative, thoracotomy was performed, followed by wedge resection and fistula reparation.DiscussionDiagnosis of pneumothorax is based on clinical manifestations. Conservative management by providing oxygen or NA/CTD insertion. Needle aspiration is a simple and alternative treatment and performed for an outpatient indication, whereas CTD requiring hospitalization and is performed by experts. Management aims to restore clinical symptoms, restore lung expansion and prevent a recurrence.ConclusionThe choice of thoracoscopy/VATS or thoracotomy needs to be considered according to the indications so that complications do not occur and have a good prognosis.

CHEST IMAGING FOR EARLY DIAGNOSIS OF COVID-19 ON A PATIENT WITHOUT RESPIRATORY SYMPTOMS: A CASE REPORT

Background: The Coronavirus 2019 disease (COVID-19) is transmitted through droplet and aerosol from the respiratory tract of an infected person; and fomites from infected linen and surface. On August 1, 2020, in Yogyakarta, there were 741 confirmed positive cases of COVID-19, and it is still possible to increase. In the time of understanding COVID-19, there are many cases with atypical presentation, including gastrointestinal symptoms.&#x0D; Objective: To describe a COVID-19 case without respiratory symptoms and the role of radiology in detecting COVID-19.&#x0D; Case Description: A 55-year-old male patient came to the hospital complaining of nausea and loss of appetite. Based on the results of the physical examination, there was flatulence. Initial investigations revealed a non-reactive SARS CoV 2 IgG and IgM result. Further non-contrast MSCT Thorax showed infiltrates with bilateral sub-pleural posterolateral consolidation, particularly the left, showing typical pneumonia. Multiple blebs were also found, denoting bronchiectasis. Confirmatory RT-PCR result was positive for SARS CoV 2.&#x0D; Conclusion: COVID-19 usually presents with common respiratory symptoms. However, some patients also experience gastrointestinal symptoms that initially were not detected as COVID-19. In time of COVID-19 pandemic, persistent gastrointestinal symptoms in a high-risk patients warrant further chest imaging and RT-PCR of SARS CoV-2 to detect or exclude the possibility of COVID-19 diagnosis.

Gastrointestinal mucormycosis due to Rhizopus microsporus following Streptococcus pyogenes toxic shock syndrome in an HIV patient: a case report

BackgroundGastrointestinal (GI) mucormycosis is a rare and often deadly form of mucormycosis. Delayed diagnosis can lead to an increased risk of death. Here, we report a case of GI mucormycosis following streptococcal toxic shock syndrome in a virologically suppressed HIV-infected patient.Case presentationA 25-year-old Thai woman with a well-controlled HIV infection and Grave’s disease was admitted to a private hospital with a high-grade fever, vomiting, abdominal pain, and multiple episodes of mucous diarrhea for 3 days. On day 3 of that admission, the patient developed multiorgan failure and multiple hemorrhagic blebs were observed on all extremities. A diagnosis of streptococcal toxic shock was made before referral to Siriraj Hospital – Thailand’s largest national tertiary referral center. On day 10 of her admission at our center, she developed feeding intolerance and bloody diarrhea due to bowel ischemia and perforation. Bowel resection was performed, and histopathologic analysis of the resected bowel revealed acute suppurative transmural necrosis and vascular invasion with numerous broad irregular branching non-septate hyphae, both of which are consistent with GI mucormycosis. Peritoneal fluid fungal culture grew a grayish cottony colony of large non-septate hyphae and spherical sporangia containing ovoidal sporangiospores. A complete ITS1–5.8S-ITS2 region DNA sequence analysis revealed 100% homology with Rhizopus microsporus strains in GenBank (GenBank accession numbers KU729104 and AY803934). As a result, she was treated with liposomal amphotericin B. However and in spite of receiving appropriate treatment, our patient developed recurrent massive upper GI bleeding from Dieulafoy’s lesion and succumbed to her disease on day 33 of her admission.ConclusionDiagnosis of gastrointestinal mucormycosis can be delayed due to a lack of well-established predisposing factors and non-specific presenting symptoms. Further studies in risk factors for abdominal mucormycosis are needed.

Natural history of persistent subretinal fluid following the successful repair of rhegmatogenous retinal detachment.

To provide a detailed description of the natural history of persistent subretinal fluid (SRF) after successful repair of rhegmatogenous retinal detachment (RRD) and its association with visual outcome. This was a prospective long-term follow-up for eyes undergoing scleral buckling (SB) surgery for macula-off RRD. Examinations were carried out preoperatively and postoperatively at 1, 3, 6, 9 and 12mo, until persistent SRF had completely resolved. One month postoperatively, optical coherence tomography (OCT) was used to classify SRF into three patterns: bleb-like loculated (BL), shallow-diffused (SD), and multiple blebs (MB). Serial OCT imaging was used to evaluate morphological changes in SRF until its complete disappearance. Patients were divided into two groups depending on the presence or absence of persistent SRF. A total of 59 patients (59 eyes) were included. There were no statistical differences between two groups at baseline, except for the proportion of patients with high myopia and a younger age. One month after surgery, OCT detected persistent SRF in 49 eyes (83.1%). The 3 morphological patterns of SRF were observed in 27 eyes (55.1%) with BL, 13 eyes (26.5%) with SD, and 9 eyes (18.4%) with MB. The mean time for complete absorption differed significantly across the three SRF patterns (F=8.097, P=0.001), which was 8.8±6.1, 20.1±12.1, and 16.7±10.2mo in BL, SD, and MB, respectively. In 9 of the 13 eyes with SD, the pattern transformed into MB type. In cases involving MB, the size and number of blebs decreased gradually until they had been completely absorbed. Eyes with persistent SRF were more likely to demonstrate disruption of the ellipsoid zone (49.0% vs 10%, P=0.034). The final best-corrected visual acuity of two groups was 0.37±0.11 (with SRF) vs 0.34±0.12 (without SRF) logMAR (P=0.499), respectively. High preoperative myopia and younger age are associated with persistent SRF. BL is the most commonly observed pattern with the shortest duration and gradually disappeared. Most cases involving SD SRF transform into MB type during resolution. The size and number of the MBs decrease gradually until they were completely absorbed. The absence of persistent SRF may contribute to slow visual recovery in the short-term but does not influence the final visual outcome.

Use of patient derived urine renal epithelial cells to confirm pathogenicity of PKHD1 alleles

BackgroundPKHD1 is the main genetic cause of autosomal recessive polycystic kidney disease (ARPKD), a hereditary hepato-renal fibrocystic disorder which is the most important cause of end-stage renal disease during early childhood. ARPKD can also present in adulthood with milder phenotypes. In this study, we describe a 24-year-old woman with atypical polycystic kidney, no family history of renal disease and no obvious extra-renal manifestations who was referred for genetic investigation.MethodsWe used a combination of next generation sequencing, Sanger sequencing and RNA and microscopy studies performed on urine-derived renal epithelial cells (URECs) to provide a genetic diagnosis of ARPKD.ResultsA next generation sequencing panel of cystic ciliopathy genes allowed the identification of two heterozygous sequence changes in PKHD1 (c.6900C > T; p.(Asn2300=) and c.7964A > C; p.(His2655Pro)). The pathogenicity of the synonymous PKHD1 variant is not clear and requires RNA studies, which cannot be carried out efficiently on RNA extracted from proband blood, due to the low expression levels of PKHD1 in lymphocytes.Using URECs as a source of kidney-specific RNA, we show that PKHD1 is alternatively spliced around exon 43, both in control and proband URECs. The variant p.(Asn2300=) shifts the expression ratio in favour of a shorter, out-of-frame transcript. To further study the phenotypic consequence of these variants, we investigated the ciliary phenotype of patient URECs, which were abnormally elongated and presented multiple blebs along the axoneme.ConclusionsWe confirm the power of URECs as a tool for functional studies on candidate variants in inherited renal disease, especially when the expression of the gene of interest is restricted to the kidney and we describe, for the first time, ciliary abnormalities in ARPKD patient cells.

Blebs in intracranial aneurysms: prevalence and general characteristics

BackgroundBlebs are rupture risk factors in intracranial aneurysms (IAs), but their prevalence, distribution, and associations with clinical factors as well as their causes and effects on aneurysm vulnerability remain unclear.MethodsA...

A rare case of pregnancy with primary spontaneous pneumothorax posted for emergency cesarean section

Spontaneous pneumothorax during pregnancy is a rare condition. Only 56 cases have been reported in the English literature. A primigravida at 32 weeks pregnancy presented with breathing difficulty, left chest pain, and cough for 2 days. She was diagnosed to have left primary spontaneous pneumothorax and multiple unruptured blebs and bullae of the right lung. A left chest tube was inserted which relieved her symptoms. However, after 3 weeks, she again developed breathing difficulty so she was planned for an emergency cesarean section. The anesthesia was challenging as she could lie down only in the 60° propped-up position. With spinal anesthesia, desired level of block could not be achieved. General anesthesia also could not be given as it will cause further rupture of blebs and bullae. Therefore, the operation was performed under epidural anesthesia using injection ropivacaine in the same 60° propped-up position.

2017 An Uncommon Etiology for Gastrointestinal Bleed in Elderly: Blue Rubber Bleb Nevus Syndrome

INTRODUCTION: Blue rubber bleb nevus syndrome (BRBNS) is a rare congenital anomaly characterized by multiple venous malformations that can appear anywhere on the body, but most often involve the skin and gastrointestinal (GI) tract. GI bleeding usually presents in childhood or early adulthood as iron deficiency anemia. We report a case of BRBNS as a rare presentation of GI bleeding in an elderly patient with no prior history of cutaneous or GI tract involvement of the disease. CASE DESCRIPTION/METHODS: 87-year-old man with a past medical history of hypertension, coronary artery disease and atrial fibrillation (on Xarelto) was transferred to our hospital for evaluation of melena. He presented to an outside institution initially with complaints of dizziness and black tarry stools for 5 days prior to admission. He was hypotensive, labs were significant for hemoglobin (Hgb) of 5.5 g/dL and a positive stool occult blood test. Anticoagulation was discontinued. He underwent esophagogastroduodenoscopy (EGD), which showed friable mucosa in the duodenal bulb but no active source of bleeding. He received 8 units of packed red blood cells (PRBC), but his Hgb only improved to 7 g/dL. A repeat EGD was also unrevealing. He then underwent a nuclear scan, which showed a focus of bleed in left hemi-abdomen, but it was unclear if it was from the small or large bowel. On presentation to our hospital, his Hgb was 6.6 g/dL and he continued to have melena, requiring multiple PRBC transfusions. Push endoscopy revealed diffuse discontinuous multiple vascular blebs of the mucosa in the mid jejunum (Figure 1a), one of which was found bleeding (Figure 1b). Successful hemostasis was achieved with cauterization of the bleeding bleb with argon plasma coagulation (APC) (Figure 1c,d) and a hemoclip placement 2 cm distal to the lesion. Post-procedure, his Hgb remained stable above 8 g/dL throughout the hospitalization. DISCUSSION: Although BRBNS lesions can occur anywhere from mouth to anus, the small bowel is the most common site of GI tract involvement. Its presentation can vary from iron deficiency anemia to massive hemorrhage, intestinal torsion, and rupture. Some patients require lifelong iron replacement and repeated blood transfusions. Push endoscopy is the most important diagnostic modality for GI lesions. Treatment depends on the severity of lesions and can range from supportive therapies such as iron supplementation and blood transfusion to more invasive therapies such as mucosal resection, APC, sclerotherapy or bowel resection.

Multiple subretinal fluid blebs after pars plana vitrectomy for rhegmatogenous retinal detachment repair.

To investigate the incidence of and clinical risk factors for multiple subretinal fluid (SRF) blebs after pars plana vitrectomy (PPV). This study examined patients who underwent PPV (25- or 27-gauge) to repair a primary rhegmatogenous retinal detachment (RRD). Clinical characteristics, including age, sex, axial length, symptom duration, and postoperative best-corrected visual acuity (BCVA), were compared between eyes with and without multiple SRF blebs. Intentional drainage retinotomy and cryotherapy use were also performed. Main outcome measures were the effect of these parameters on multiple SRF bleb incidence 1month after surgery. A total of 108 eyes of 106 patients (76 men and 32 women; mean age = 58.9 ± 9.0years) were included. Multiple SRF blebs were observed in 8 eyes (7.4%). Logistic regression analysis showed that creation of intentional drainage retinotomy and 27-gauge PPV are risk factors for the development of multiple SRF blebs. The number and size of blebs spontaneously decreased over time, and SRF had completely resolved in 5 eyes (62.5%) 1year after surgery. Multiple SRF blebs developed even after small gauge vitrectomy. The SRF did not affect postoperative BCVA and gradually absorbed without treatment.

EARLY SURGICAL INTERVENTION CAN BE NECESSARY: PERSISTENT MASSIVE HEMOPTYSIS DESPITE EMBOLIZATION AND BLOCKADE

SESSION TITLE: Critical Care 5 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Massive hemoptysis is a life-threatening condition due to the potential for asphyxiation or exsanguination. Commonly causes are bronchiectasis, bronchogenic carcinoma and infectious etiologies such as tuberculosis and pneumonia. Management involves localization of the bleeding source via bronchoscopy or computerized tomographic (CT) angiography with subsequent non-surgical or surgical intervention to control the bleeding. We present a case of massive hemoptysis secondary to bronchiectasis, unresponsive to bronchoscopic intervention and bronchial artery embolization (BAE), requiring definitive surgical lobectomy. CASE PRESENTATION: A 67-year-old male was admitted for evaluation of persistent hemoptysis in setting of moderate chronic obstructive pulmonary disease (COPD) and recent percutaneous biopsy of liver mass. Examination revealed rales in right lower lung base. CT of the thorax showed emphysematous changes with multiple blebs and lower-lobe honeycomb fibrotic thickening. Continued episodes of hemoptysis prompted bronchoscopic evaluation. Right lower lobe visualization revealed active bleeding from lateral and posterior segments. Despite epinephrine administration and iced saline lavage, bleeding persisted. Balloon tamponade with an endobronchial blocker was introduced into the right lower lobe and left in place. Interventional radiology consulted for arteriographic embolization. Balloon deflation after 24 hours revealed active persistent bleed. Cardiothoracic surgery was consulted and performed an emergent lobectomy. Gross pathology revealed no pleural disruption to support the notion that liver biopsy might have precipitated hemoptysis. Microscopy revealed reactive pneumocytes and significant airway ectasia. DISCUSSION: Angiography followed by BAE is the preferred management for massive hemoptysis in poor surgical candidates. In COPD both bronchiectatic and cryptogenic hemoptysis responds favorably to BAE. It has been reported as definitive treatment in both cystic and non-cystic fibrosis bronchiectasis. BAE is effective in controlling hemoptysis with success rates ranging from 70-90%. Recurrence rates vary from 10 to 57%.(1) Early recurrences occur secondary to lack of localization and inadequate embolization of all the feeding vessels. Despite high operative risks, our patient was managed with emergent lobectomy due to persistent bleeding. Emergent surgery in massive hemoptysis is associated with mortality rates up to 40%. BAE can be used as a bridge to stabilize patients before surgical treatment with an elective mortality rate 18%. (2) A retrospective analysis comparing the mortality and morbidity cohort of patients who underwent surgery after BAE vs those with early surgical intervention found no difference in outcomes.(3) CONCLUSIONS: Early surgical consultation is warranted for life-threatening massive hemoptysis in the setting of unsuccessful endobronchial blockade and BAE. Reference #1: Panda A, Bhalla AS, Goyal A. Bronchial artery embolization in hemoptysis: a systematic review. Diagn Interv Radiol. 2017;23(4):307-17. Reference #2: Fruchter O, Schneer S, Rusanov V, Belenky A, Kramer MR. Bronchial artery embolization for massive hemoptysis: long-term follow-up. Asian Cardiovasc Thorac Ann. 2015;23(1):55-60. Reference #3: Alexander GR. A retrospective review comparing the treatment outcomes of emergency lung resection for massive hemoptysis with and without preoperative bronchial artery embolization. Eur J Cardiothorac Surg. 2014;45(2):251-5. DISCLOSURES: No relevant relationships by Francis Christian, source=Web Response No relevant relationships by Sardar Ijaz, source=Web Response No relevant relationships by Kellie Jones, source=Web Response No relevant relationships by Erin Shirley, source=Web Response

Tuberculosis-like respiratory infection in 245-million-year-old marine reptile suggested by bone pathologies.

An absence of ancient archaeological and palaeontological evidence of pneumonia contrasts with its recognition in the more recent archaeological record. We document an apparent infection-mediated periosteal reaction affecting the dorsal ribs in a Middle Triassic eosauropterygian historically referred to as ‘Proneusticosaurus’ silesiacus. High-resolution X-ray microtomography and histological studies of the pathologically altered ribs revealed the presence of a continuous solid periosteal reaction with multiple superficial blebs (protrusions) on the visceral surfaces of several ribs. Increased vascularization and uneven lines of arrested growth document that the pathology was the result of a multi-seasonal disease. While visceral surface localization of this periosteal reaction represents the earliest identified evidence for pneumonia, the blebs may have an additional implication: they have only been previously recognized in humans with tuberculosis (TB). Along with this diagnosis is the presence of focal vertebral erosions, parsimoniously compared to vertebral manifestation of TB in humans.