Discussion: The case described herein illustrates the importance of high vigilance and suspicion in a patient with hematemesis after botulinum toxin injection for a vascular-esophageal fistula. In unstable patients, minimally invasive approaches to control bleeding from the esophagus through endoscopy with application of hemostatic clips and TEVAR are viable options.
the patient was taken urgently for a TEVAR. Right femoral access was achieved, however after initial angiogram the iliacs were noted to be stenotic and too small for anterograde graft deployment. An emergent subclavian cutdown was done and 2 GORE TAG thoracic stent grafts were inserted through the innominate starting from 1.5 cm distal to the left subclavian to 1.5 cm above the celiac axis. The patient was taken to the ICU and extubated the following day.
ACUTE LUNG HERNIATION: AN UNUSUAL COMPLICATION OF COPD EXACERBATION Syed Hussain, Maximillian Morvant; Department of Medicine, Ochsner Medical Center, New Orleans, LA.
Introduction: We herein report a patient who developed acute lung herniation, a relatively rare complication associated with the forceful cough experienced during COPD exacerbations. Case: A 64 year-old male with HFpEF, pulmonary HTN, HTN, COPD, DVT presented with worsening two-week history of cough and shortness of breath. Over the past few days prior, along with worsening cough he noted bruising and pain in right flank without any associated trauma. Initial read of CXR only noted concerns for bibasilar reticular opacities concerning for edema vs atelectasis. There were concerns for retroperitoneal hemorrhage which were addressed with CT abdomen/pelvis that incidentally noted intercostal herniation of the right lung between the 7th and 8th ribs with associated partially visualized hematoma in the right lateral and posterior chest wall soft tissues, most significant deep to the right latissimus dorsi muscle. Due to elevated perioperative risk and high risk of repair failure secondary to active COPD exacerbation, Cardiothoracic surgery was unable to intervene. Pulmonology consult noted high risk of strangulation, hemorrhage, further decompensation
and recommended against chest tube insertion with hopes that pleural effusion may tamponade off bleeding. There were concerns for poor prognosis. He continued to decompensate with increasing oxygen support and updated Xray showing collapsed right lung, so he underwent intubation. Fortunately, his lung herniation spontaneously resolved, but imaging still showed persistence of complicated pleural effusions which was ultimately able to be addressed with chest tube placement. Discussion: This case highlights importance of early diagnosis and consideration of acute lung herniation, a rare complication of COPD exacerbation, which carries a risk of pulmonary parenchymal necrosis, strangulation, incarceration or pneumothorax. It can be a diagnostic challenge as it can be easily missed on plain film X-rays. This complication is rarely seen in patients without the typical risk factors of recent trauma or prior surgery. In our patient, perioperative risk factors limited any interventions such as thoracotomy with chest wall reconstruction. Fortunately, early identification and multimodal regimen for cough control allowed for spontaneous recovery.
A CASE STUDY OF SECONDARY HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS Benjamin Horn; Department of Medicine, Louisiana State University, Shreveport, LA.
Introduction: Hemophagocytic Lymphohistiocytosis (HLH) is a syndrome of excessive inflammation and tissue destruction due to abnormal immune activation with diagnostic criteria utilizing the H-score for scoring of symptomatology. Median survival for patients with HLH is approximately 50% with treatment of Etoposide and Dexamethasone taper for 8 weeks under the HLH-94 treatment protocol.
Case: 74-year-old male with diabetes mellitus was admitted for possible sepsis. A presumptive diagnosis of HLH was made based on clinical picture and lab results as they met 5/9 criteria for diagnosis. Additional labs were sent for HLH including soluble CD25, TGs, CXCL9, NK cell activity, which did not return in time of management. Treatment was begun with Dexamethasone as the patient was not a candidate for Etoposide or Alemtuzumab. 7
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