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The epidemiology and mycology of invasive candidiasis in the ICU is well‐described in certain types of critically ill patients but not in others. One population that has been scarcely studied is non‐neutropenic patients admitted specifically to medical ICUs. Even less is known about the broader category of medical ICU patients without active oncological disease. This group constitutes a very large share of the patients requiring critical care across the globe, especially in the era of the SARS‐CoV‐2 pandemic. We analysed medical ICU candidaemia episodes that occurred in non‐oncological patients in our tertiary academic centre in the United States from May 2014 to October 2020 to determine the incidence and species distribution of the associated isolates. We then separately considered non‐COVID‐19 and COVID‐19 cases and compared their characteristics. In the non‐COVID‐19 group, there were 38 cases for an incidence of 1.1% and rate of 11/1000 admissions. In the COVID‐19 group, there were 12 cases for an incidence of 5.1% and rate of 51/1000 admissions. In the entire sample, as well as separately in the non‐COVID‐19 and COVID‐19 groups,Candida albicans accounted for a minority of isolates. Compared to non‐COVID‐19 patients with candidaemia, COVID‐19 patients had lower ICU admission SOFA score but longer ICU length of stay and central venous catheter dwell time at candidaemia detection. This study provides valuable insight into the incidence and species distribution of candidaemia cases occurring in non‐oncological critically ill patients and identifies informative differences between non‐COVID‐19 and COVID‐19 patients. [ABSTRACT FROM AUTHOR]

The early years of the acquired immunodeficiency syndrome (AIDS) epidemic introduced the global medical community to Kaposi's sarcoma (KS), a heretofore seldom encountered angiosarcomatous neoplasm associated with human herpesvirus-8. At that time, clinicians treating these KS patients were routinely exposed to the pulmonary manifestations of this malignancy, including characteristic airway lesions, peribronchovascular opacities, and the typically hemorrhagic pleural effusions. They also witnessed uncommon complications of pulmonary KS such as chylous effusions, diffuse alveolar hemorrhage, and immune reconstitution inflammatory syndrome. Since the advent of highly active antiretroviral therapy, the incidence of KS has steadily declined and with that so has clinician familiarity with this disease. Herein, we present four KS cases recently encountered at our institution that illustrate both typical manifestations of pulmonary KS as well as its thoracic complications. The case descriptions are followed by a review of these clinical entities with the aim of restoring awareness among frontline physicians of what is now a rare but not quite extinct AIDS-defining neoplasm. [ABSTRACT FROM AUTHOR]

TO THE EDITOR: Wichmann and colleagues' case series from Germany ([1]) was a welcome addition to the growing literature on the postmortem pulmonary histologic characteristics of lung disease related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), even though the finding of diffuse alveolar damage in terminal cases does little to illuminate the process in its earlier stages. Wichmann and colleagues' findings do not advance the theory that critically ill patients with COVID-19 are unusually predisposed to VTE and therefore merit an unprecedented approach to anticoagulation. Autopsy findings and venous thromboembolism in patients with COVID-19. [Extracted from the article]

The great majority of patients admitted to the intensive care unit (ICU) for critical gastrointestinal bleeding (GIB) will have a predictable etiology. Once the site is localized to the upper versus the lower gastrointestinal tract, the number of typically encountered etiological possibilities is quite limited. On rare occasions, the cause of GIB requiring ICU care is not one of the standard considerations, potentially leading to diagnostic and therapeutic delays. Within a short time period, three patients were admitted to our institution's medical ICU each with a different unexpected cause of GIB. All three cases generated a variety of instructive images, which are used in the present series to illustrate these conditions and the role of radiology in their evaluation and management. [ABSTRACT FROM AUTHOR]

Since granulomatous inflammation in sarcoidosis is CD4 T-helper lymphocyte mediated, in HIV patients sarcoidosis typically becomes manifest as a form of immune reconstitution inflammatory syndrome (IRIS). In a series of 11 HIV+ patients, sarcoidosis was discovered after ART-induced marked increases in the CD4 count and decreases in viral load. [Extracted from the article]

Primary effusion lymphoma (PEL) is a rare mature B‐cell non‐Hodgkin's lymphoma arising in body cavities and presenting with effusions. It has been described predominantly in patients with impaired immunity from the acquired immunodeficiency syndrome and is associated with the Human Herpesvirus‐8 (HHV‐8). Seldom has PEL been diagnosed in persons negative for the human immunodeficiency virus (HIV), and in such cases it has occurred primarily in the setting of posttransplant immunosuppression. We report an instructive case of a Caribbean‐American HIV‐negative orthotopic heart transplant recipient with a history of HHV‐8‐associated Kaposi's sarcoma who developed HHV‐8 viremia and PEL of the pleural space early in the posttransplant course. This case highlights the importance of considering PEL in the differential diagnosis of a new pleural effusion in a transplant recipient at risk for HHV‐8‐associated disease. [ABSTRACT FROM AUTHOR]

• Despite a superficial resemblance, care should be taken not to reflexively conflate COVID-19 lung disease with the more familiar entity of ARDS. • There is reason to believe that there are histopathological differences between COVID-19 lung disease and ARDS known to complicate influenza • From the pulmonology perspective, this distinction has major treatment implications. • The argument for corticosteroid use, which is ineffective in ARDS caused by influenza, in COVID-19 lung disease rests on this separation. The SARS-CoV-2 pandemic has introduced the medical community to a lung disease heretofore unknown to most clinicians. In much of the discourse about COVID-19 lung disease, the more familiar clinical entity of ARDS has been used as the guiding paradigm. Reflecting on studies in ARDS, particularly that due to influenza, and on data from the SARS-CoV and MERS epidemics, many authorities, including within the discipline of infectious diseases, were initially passionate in their opposition to the use of corticosteroids for lung involvement in COVID-19. The voice of the pulmonology community—the community of lung experts—has continued to be among the quietest in this conversation. Herein we offer our perspective as academic pulmonologists who encountered COVID-19 in its first United States epicenter of New York City. We encourage a conceptual separation between early COVID-19 lung involvement and ARDS. We draw on history with other immune cell-mediated lung diseases, on insights from the SARS-CoV experience, and on frontline observations in an attempt to allay the skepticism towards corticosteroids in COVID-19 lung disease that is likely to persist even as favorable study results emerge. [ABSTRACT FROM AUTHOR]

A 53-year-old woman with no significant past medical history came to her local ED after a witnessed generalized tonic-clonic seizure. CT scan imaging of the head revealed a left frontal lobe hypodensity concerning for a mass with surrounding edema. In the previous month, she had undergone ambulatory evaluation for a subacute cough that had more recently become productive of bloody sputum. Outpatient chest radiography had demonstrated a new right lung opacity, shown on subsequent CT scan imaging to be a right upper lobe (RUL) consolidation. She was prescribed a course of doxycycline, after which sputum expectoration improved but a nonproductive cough remained. Repeat thoracic imaging was pending at the time the seizure occurred. The patient had no history of chronic lung disease or recurrent infections. There were no constitutional symptoms. She did not take any home medications on a regular basis. She was a lifetime nontobacco user. She denied use of alcohol and illicit drugs. She had previously worked in a medical office but was now spending most of her time helping her husband take care of their house and property in Kingston, New York, a town of about 23,000 people in the Hudson River Valley. She was born in the United States and had not traveled recently. She had no pets. There was no history of recent dental procedures. She was transferred to our institution for neurosurgical evaluation. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 63-year-old African-American woman presented with progressive dyspnoea for the duration of two weeks. Topics discussed include the elimination of the possibility of viral pericarditis after the absence of essential changes to the electrocardiography (ECG) conducted to the patient, the presence of mycobacterium avium complex (MAC) to the sputum samples, and the diagnosis for cardiac sarcoidosis to the patient.

Tuberculosis and sarcoidosis are both granulomatous diseases centered on the lung but capable of myriad extrapulmonary manifestations. Because of substantial similarity in their presentations, these two entities can be notoriously challenging to differentiate. This can be particularly true of countries in which tuberculosis is rarely encountered because of a reflexive tendency to ascribe granulomatous inflammation in the lung to sarcoidosis, especially if the granulomas are non-necrotizing. However, as our case from a non-endemic country reminds, sarcoidosis can be comfortably diagnosed only after convincing exclusion of infectious causes of granulomas. Distinguishing these two diseases is of utmost importance as, despite their overlapping presentations, they have completely non-overlapping treatments which can lead to harm if erroneously applied. At the end of our discussion, we summarize the clinical features favoring one diagnosis over the other. [ABSTRACT FROM AUTHOR]

Background: The Centers for Disease Control and Prevention and New York State Department of Health recently identified the Capital District of New York (CDNY) as an emerging endemic area for blastomycosis. However, no clinical or epidemiological description of blastomycosis in the CDNY has been published.Methods: We performed a retrospective analysis of blastomycosis cases at Albany Medical Center (AMC) and Albany Stratton Veterans Affairs Medical Center (VAMC) from January 1, 2000, through June 1, 2019. Patients were identified via an institution-approved informatics system at the hospital's microbiology laboratory.Results: We identified 20 patients diagnosed with blastomycosis over the past 2 decades. There was a nearly 9-fold increase in the annual number of cases in 2016-2019 compared with 2000-2015. The majority of patients resided in the CDNY (90%), and 65% lived within the Mohawk River valley. Most cases (85%) were assumed to be malignancies or non-mycotic infections prior to diagnosis, with median time between presentation and diagnosis of 53 days.Conclusions: Our data support recent reports that blastomycosis is an emerging disease in the CDNY. Most patients were misdiagnosed as malignancy or non-mycotic infection, which led to treatment delays. [ABSTRACT FROM AUTHOR]

Background: The aging of the US population has been associated with an increase in intensive care unit (ICU) utilization and correspondingly, invasive mechanical ventilation (IMV) among the oldest-old (age ≥80 years). While previous studies have examined ICU and IMV outcomes in the elderly, very few have focused on patient-centered outcomes, specifically home return, in the oldest-old. We investigated the rate of immediate home return following IMV in the medical ICU in previously home-dwelling oldest-old patients relative to that of a comparison group of 50-70-year olds. Methods: Data were extracted retrospectively from patient records at Elmhurst Hospital Center in Elmhurst, NY, USA, encompassing the period from January 2009 to May 2014 and Jacobi Medical Center in the Bronx, NY, USA, from January 2010 to March 2014. Medical ICU admissions within those date ranges were screened for possible inclusion into one of two study groups based on age: ≥80 years old and 50-70 years old. The primary end point was hospital discharge: home return versus no home return (death or nonhome discharge). Cox proportional hazards' regression models were used to estimate crude and multivariable-adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) for failure to return home. Results: A total of 375 patients were included in the analysis: 279 (74%) patients aged 50-70 years and 96 (26%) patients aged ≥80 years. Compared to 50-70-year olds, being ≥80 years old was associated with a nearly two-fold greater risk of no home return: adjusted HR: 1.96,95% CI 1.43-2.67. The oldest-old was at significantly increased risk of both being discharged to a skilled nursing facility or subacute rehabilitation (adjusted HR: 2.19,95% CI 1.33-3.59) as well as of dying in the hospital (adjusted HR: 1.81,95% CI 1.21-2.71). Conclusion: Previously home-dwelling oldest-old are at significantly increased risk of failing to return home immediately following medical ICU admission with IMV as compared to patients aged 50-70 years. These results can help medical ICU staff establish appropriate expectations when addressing the families of their oldest patients. Further studies are needed to evaluate the potential for delayed home return among the oldest old and to assess the ability of frailty indices to predict home return within this ICU population. [ABSTRACT FROM AUTHOR]

We report the first known case of malignant pleural effusion (MPE) as the sole presenting feature of clinically occult primary fallopian tube carcinoma (PFTC). A 57-year-old healthy woman was admitted with dyspnea. Evaluation demonstrated a right pleural effusion, fluid of which was malignant. The immunohistochemical profile, including negative calretinin, favored metastatic adenocarcinoma over mesothelioma but could not identify the primary tumour site. Pleural biopsy was not pursued as it would not have helped localize the primary. Chest, abdomen and pelvic computed tomography (CT) demonstrated only borderline lymphadenopathy in the left para-aortic lymph node chain that was hypermetabolic on positron emission tomography. Ultrasound and CT showed normal adnexal anatomy. These findings, coupled with an elevated serum CA-125, prompted empiric neoadjuvant chemotherapy targeting epithelial ovarian carcinoma (EOC) followed by surgery, which revealed a tiny left PFTC with negative peritoneal washings. Sampled left para-aortic lymph nodes were positive. The pleural effusion resolved after chemotherapy. Malignant pleural disease without peritoneal involvement is more characteristic of PFTC than of EOC, in which MPE is common but almost always accompanies peritoneal carcinomatosis. The extensive lymphatic supply of the fallopian tube promotes distant metastasis of small, seemingly localized tumours. This case is a reminder that the clinician should not be dissuaded from considering carcinoma of Müllerian origin, especially PFTC, as the cause of a MPE even in the face of normal gynecologic imaging. Appropriately broad immunohistochemical staining and careful attention to even minimal lymphadenopathy can be invaluable in pinpointing the primary tumour site in such patients. [ABSTRACT FROM AUTHOR]

Urinary bladder carcinoma (UBC) is the ninth most common malignancy and the second most common urological malignancy after prostate cancer in men. Thoracic metastases occur in more than half of those with muscle-invasive disease, and these generally assume the form of multiple solid parenchymal lesions characteristic of hematogenous seeding of the lung. Unusual patterns of thoracic spread of UBC have also been described albeit sporadically in the form of case reports and series. The aim of our case series is to provide illustrations of several atypical patterns of thoracic involvement by UBC such as isolated mediastinal lymphadenopathy, cavitary lung metastases, malignant pleural effusion, endobronchial disease, and pulmonary tumor embolism. This review is meant to highlight the intersection of the fields of urological oncology and thoracic radiology in the care of patients with UBC. [ABSTRACT FROM AUTHOR]

An 80-year-old man presented because of superficial head trauma sustained after falling from bed. On review of systems, he reported worsening dyspnea on exertion, nonproductive cough, and weight loss over the preceding 2 to 3 months. There was no report of chest pain or leg swelling. He had a past medical history of hypertension, coronary artery disease, subclinical hypothyroidism, and renal cell carcinoma treated with partial right nephrectomy approximately 1 year before this presentation. Two months earlier he had been evaluated in the dermatology clinic for painful, dystrophic fingernails. At that time he was diagnosed with acropachy with onycholysis and suspected superinfection, and after failing to improve with vinegar soaks and topical antimicrobials, he underwent surgical nail removal on the second and fourth digits of the right hand. Histological examination of the operative specimens revealed dystrophic nails with negative fungal stains. His medications included levothyroxine, hydrochlorothiazide, and clopidogrel. He had never smoked and had done clerical work until retirement. He was originally from Colombia. [ABSTRACT FROM AUTHOR]

Klebsiella pneumoniae is an increasingly recognized cause of a unique invasive syndrome manifesting as pyogenic liver abscess and hematogenous extrahepatic dissemination to a variety of sites, including the lung. Originally described only in Asia, this entity has now been reported across continents and ethnicities. Intrathoracic complications of invasive Klebsiella pneumoniae liver abscess syndrome (IKPLAS) have been characterized sporadically but have not been the subject of an all-encompassing investigation. Review of the English-language literature yields no reports of the acute respiratory distress syndrome as a consequence of IKPLAS. Herein we report what, to our knowledge, is the first such description. [ABSTRACT FROM AUTHOR]

Of note, 5 patients (71%) had small pleural effusions prior to OHT, and there was a progression in 3 patients, showing evidence of concordance of effusion side pre-and post OLT. B CONCLUSIONS: b The majority of post-OHT patients at our institution had radiologically apparent pleural effusions during the post-OHT hospitalization, but only a very small minority underwent pleural fluid analysis. [Extracted from the article]

Among non-HIV PCP admissions, diagnosis of cancer was present in 54%, connective tissue disease in 9%, solid organ/stem cell transplant in 7%, and immune disorders in 5%. Among non-HIV PCP admissions, rates of other comorbid disorders increased between 2005 and 2014 (cancer 52% to 62%, connective tissue disease 8% to 14%, solid organ/stem cell transplant 7% to 8%, immune disorders 4% to 8%; Ptrend< 0.001). Overall mortality in patients with PCP was 12%, and was significantly higher with non-HIV PCP (21%) than with HIV-PCP (9%; P< 0.001). [Extracted from the article]

Among patients with liver cirrhosis prior to liver transplantation, CO production as measured by blood carboxyhemoglobin (COHb) levels were noted to be even higher in patients with Hepato-pulmonary syndrome (HPS) compared to those who has not. Among patients without HPS, the mean COHb levels prior to transplant was 2.5% which decreased to 1.95% (p=0.0003) after transplant with mean delta change of 0.55. After liver transplant, COHb levels significantly decreased in all patients but much more so in patients with HPS compared to without HPS as shown by the substantial difference in delta change. [Extracted from the article]

A 66-year-old woman presented with acute onset of fever, chills, and productive cough associated with right-sided chest pain. During a recent hospitalization for dyspnea, she had been diagnosed with Coombs-positive autoimmune hemolytic anemia and had been taking a tapering dose of prednisone starting approximately 6 weeks prior to admission. In the interim, her dyspnea had resolved on treatment with steroids. At the time of presentation, her prednisone dose was 40 mg. Additional medical history included VTE, for which the patient was receiving anticoagulation therapy, and steroid-induced diabetes mellitus. Many years earlier, she had been treated for TB in her home country. The patient had immigrated to Queens, New York, from a Nepalese village 8 years prior. While still in Nepal, she had worked on a farm and had been in close proximity to cows. In Queens, she lived with her family in a house with a small garden but had no pets. Recent travel included a visit to Nepal 9 months ago and a trip to Syracuse, New York, one month prior to presentation. She was a never smoker and did not consume alcohol. [ABSTRACT FROM AUTHOR]

A 47-year-old man with no significant past medical history, originally from Indonesia, was brought to the ED of an urban US medical center after being found collapsed on the sidewalk in respiratory distress and with an altered sensorium. Upon arrival to the ED, he was tachypneic, with increased work of breathing and an oxygen saturation of 88% on 100% nonrebreather mask, so he was immediately intubated. Following intubation, he became profoundly hypotensive, requiring aggressive crystalloid resuscitation and vasopressor support. Broad-spectrum antimicrobials were administered, including ceftriaxone, vancomycin, levofloxacin, and oseltamivir. Further history elicited subsequently from family members revealed that the patient had returned from a 2-week vacation in Indonesia 6 days prior to presentation. According to relatives, he appeared to be in his usual state of health upon his return and was not seen by anyone thereafter, but in the interim he reportedly had an episode of epistaxis, and text messages received from him became progressively more bizarre. [ABSTRACT FROM AUTHOR]