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No abstract available. Article truncated after 150 words. History of Present Illness: Our patient is a 76-year-old gentleman who was referred based on an abnormal CT scan. He has a history of metastatic melanoma and had begun immunotherapy with pembrolizumab 10 months prior to admission. He had low grade fevers and chills and some dyspnea on exertion and dry cough. He also had a 6-8 pound weight loss over 4 weeks. PMH, SH and FH: He has a history of hairy cell leukemia since 2009; squamous and basal cell cancers; and diabetes on insulin. He is a retired commercial banker and has a 15 pack-year smoking history. Physical Examination: Physical examination showed and SpO2 of 90% on room air. His lungs were clear. He had numerous depigmented lesions on his skin. Radiography: A thoracic CT scan was performed (Figure 1) and compared to a scan done 3 months prior which was considered unremarkable. Which of the following best ...

No abstract available. Article truncated after first page. History of Present Illness: A 74-year-old man was referred for a recently identified right pleural effusion and dyspnea on exertion. Past Medical History, Family History and Social History: He has a history of anemia, hypertension, and prostate cancer with a prostatectomy in 2015. He is a life-long nonsmoker and has no occupational exposures. Family history is noncontributory. Physical Examination: He had diminished breath sounds at the right lung base and a palpable spleen. Otherwise the physical examination was unremarkable. Laboratory: CBC: hemoglobin 8.5 g/dL, white blood count 7.7 X 109 cells/L, platelets 357 X 109 cells/L. Radiography: A chest X-ray showed a right pleural effusion. Representative images from the CT scan are shown in Figure 1. Which of the following is the most likely diagnosis? 1. Empyema; 2. Lung cancer; 3. Tuberculosis; 4. Usual interstitial pneumonia; 5. Valley fever (coccidioidomycosis). ...

Rationale: Chronic rejection, manifested pathologically as airway fibrosis, is the major problem limiting long-term survival in lung transplant recipients. Airway hypoxia and ischemia, resulting from a failure to restore the bronchial artery (BA) circulation at the time of transplantation, may predispose patients to chronic rejection. To address this possibility, clinical information is needed describing the status of lung perfusion and airway oxygenation after transplantation.Objectives: To determine the relative pulmonary arterial blood flow, airway tissue oxygenation and BA anatomy in the transplanted lung was compared with the contralateral native lung in lung allograft recipients.Methods: Routine perfusion scans were evaluated at 3 and 12 months after transplantation in 15 single transplant recipients. Next, airway tissue oximetry was performed in 12 patients during surveillance bronchoscopies in the first year after transplant and in 4 control subjects. Finally, computed tomography (CT)-angiography studies on 11 recipients were reconstructed to evaluate the post-transplant anatomy of the BAs.Measurements and Main Results: By 3 months after transplantation, deoxygenated pulmonary arterial blood is shunted away from the native lung to the transplanted lung. In the first year, healthy lung transplant recipients exhibit significant airway hypoxia distal to the graft anastomosis. CT-angiography studies demonstrate that BAs are abbreviated, generally stopping at or before the anastomosis, in transplant airways.Conclusions: Despite pulmonary artery blood being shunted to transplanted lungs after transplantation, grafts are hypoxic compared with both native (diseased) and control airways. Airway hypoxia may be due to the lack of radiologically demonstrable BAs after lung transplantation. [ABSTRACT FROM AUTHOR]

Haematological patients with neutropenic fever are frequently evaluated with chest computed tomography (CT) to rule out invasive fungal infections (IFI). We retrospectively analysed data from 100 consecutive patients with neutropenic fever and abnormal chest CT from 1998 to 2005 to evaluate their chest CT findings and the yield of diagnostic approaches employed. For their initial CTs, 79% had nodular opacities, with 24.1% associated with the halo sign. Other common CT abnormalities included pleural effusions (48%), ground glass opacities (37%) and consolidation (31%). The CT findings led to a change in antifungal therapy in 54% of the patients. Fifty-six patients received diagnostic procedures, including 46 bronchoscopies, 25 lung biopsies and seven sinus biopsies, with a diagnostic yield for IFI of 12.8%, 35.0% and 83.3%, respectively. In conclusion, chest CT plays an important role in the evaluation of haematological patients with febrile neutropenia and often leads to a change in antimicrobial therapy. Pulmonary nodules are the most common radiological abnormality. Sinus or lung biopsies have a high-diagnostic yield for IFI as compared to bronchoscopy. Patients with IFI may not have sinus/chest symptoms, and thus, clinicians should have a low threshold for performing sinus/chest imaging, and if indicated and safe, a biopsy of the abnormal areas., (© 2009 Blackwell Verlag GmbH.)

Purpose of Review: To provide a better understanding and summarize recent advances in the diagnosis and treatment of Mycobacterium tuberculosis (MTB) infection in solid organ transplant (SOT) candidates and recipients., Recent Findings: Despite advances in SOT medicine, MTB causes substantial morbidity and mortality in SOT recipients, with reported prevalence rates of 0.4-6%. The primary source of posttransplant MTB is reactivation of pretransplant latent MTB infection. The short-term mortality rate in SOT recipients with drug-susceptible active MTB is 30%. In immunocompromised persons with extensively drug-resistant MTB, the mortality rate approaches 100%. Clinical presentation is often atypical with more than half of SOT recipients presenting with extrapulmonary or disseminated disease. Pretransplant latent MTB infection screening and treatment is the cornerstone for preventing reactivation and dissemination of active MTB posttransplant. Treatment of active MTB in SOT recipients is problematic, given significant drug toxicity and interaction with immunosuppressive agents., Summary: A high degree of suspicion for latent and active MTB infection in SOT candidates and recipients is warranted to establish a timely diagnosis and initiate life-saving appropriate therapy.

Cardiac complications are the leading cause of perioperative morbidity and mortality following noncardiac surgery. The annual cost of perioperative cardiovascular events exceeds 20 billion US dollars. A strategic preoperative evaluation holds the potential to reduce perioperative cardiac events and healthcare costs; however, our current understanding of the pathophysiological basis of postoperative acute coronary syndromes is limited. Although significant advances continue to facilitate early and reliable noninvasive detection of high-risk coronary anatomy, the most appropriate interventions remain unclear. Pharmacotherapy, revascularization, safer anesthesia and early detection of perioperative heart failure may all reduce perioperative morbidity and mortality, although the evidence base is incomplete and controversial. A close working relationship between the primary care physician, cardiologist, surgeon and anesthesiologist will facilitate rational, tailored and optimized management decisions that constitute our best opportunity to reduce perioperative cardiovascular risk.

The incidence of methicillin-resistant Staphylococcus aureus (MRSA) infections in patients admitted to the intensive care unit has dramatically increased in recent years, with an associated increase in morbidity and mortality and the costs of caring for patients with MRSA infections. Although indiscriminate and inappropriate use of antibiotics has contributed to this phenomenon, horizontal transmission of MRSA between patients and health care providers is the principal cause of this observed increase. This article discusses the pathogenesis, epidemiology, treatment, and prevention of MRSA infections in critically ill patients.