UNASSIGNED: The acquired communication between the aorta and the pulmonary artery is a rare and potentially life-threatening condition. Its diagnosis is challenging and may require a multimodality imaging approach.
UNASSIGNED: A 67-year-old Caucasian man, admitted for acute respiratory failure unresponsive to medical therapy and non-invasive ventilation, was diagnosed with an aortopulmonary fistula (APF) complicating a pseudoaneurysm of the aortic root. This condition developed after Bentall cardiac surgery, which entailed the use of a straight Dacron aortic graft coupled with a mechanical prosthesis. A multimodal imaging approach, combining echocardiography and computed tomography angiography, was diagnostic and supported the development of a surgical treatment strategy. The patient underwent successful surgical closure of the APF and correction of the aortic pseudoaneurysm.
UNASSIGNED: Aortopulmonary fistula can result in rapid clinical deterioration if left untreated. The combination of echocardiography and computed tomography angiography techniques allowed for the diagnosis and surgical correction of the APF.

UNASSIGNED: Mitochondrial myopathy is a group of diseases caused by abnormal mitochondrial structure or function. The mitochondrial myopathy impacts muscles of the whole body and exhibits variable symptoms. Respiratory muscle deficits deteriorate pulmonary function in patients with severe pneumonia.
UNASSIGNED: We report the case of a male patient with severe pneumonia-induced respiratory failure. He was abnormally dependent invasive ventilator-assisted ventilation after his condition had improved. Then we found abnormal ventilator waveform and a decline in muscle strength of him. Mitochondrial myopathy was ultimately confirmed by muscle pathological biopsy and body fluid genetic testing. Vitamin B complex, coenzyme Q10, Neprinol AFD, l-arginine, and MITO-TONIC were used to improve mitochondrial function and muscle metabolism. After treatment, discomfort associated with chest tightness, fatigue, cough, and sputum disappeared, and the patient was discharged.
UNASSIGNED: This case presented an uncommon cause of difficult weaning and extubation-acute onset of mitochondrial myopathy. Muscle biopsy and genetic testing of body fluid are essential for diagnosing mitochondrial myopathy. The A3243G mutation in the MT-TL1 gene of mitochondrial DNA contributes to pathogenesis of this case.

Epiploic appendagitis (EA) is an uncommon intraabdominal pathology resulting in transient, localized pain. The condition is caused by ischemia of one of the epiploic appendages, which are distributed axially along the length of the colon. EA is often mistaken for other more common etiologies of an acute abdomen. Generally, the patients experience focal abdominal pain with no further symptoms or laboratory abnormalities. The authors encountered a 79-year-old male with severe sepsis and acute respiratory failure requiring intubation. He recovered rapidly after the identification and removal of a single EA. This paper reports the first case of EA leading to the systemic dysregulation of sepsis.

BACKGROUND: The extensive availability of ultrasound (US) technology has increased its use for point-of-care applications in many health care settings. During anaesthesia and surgery, acute respiratory failure or pulmonary oedema are common life-threatening events that, if not recognized and treated appropriately, result in a high mortality rate.
METHODS: We report a patient under anaesthesia whose lung US examination showed multiple vertical artefacts (B-lines) in the lung tissue, indicating pulmonary oedema. The respiratory state improved with the resolution of the pulmonary oedema after our treatment.
CONCLUSIONS: We believe that US of the lungs may be a useful tool for dynamic respiratory monitoring at the bedside during anaesthesia.

We report a case of post-extubation respiratory failure due to insufficient airway mucus expectoration that was successfully treated using mechanical insufflation-exsufflation (MI-E). A 32-year-old woman with a long-term history of steroid therapy for Blau syndrome was admitted to our intensive care unit with refractory hypoxemia due to pneumonia associated with the novel coronavirus disease 2019. Mechanical ventilation with veno-venous extracorporeal membrane oxygenation (VV-ECMO) was required due to severe hypoxemia. She was weaned from VV-ECMO on the 10th day and extubated on the 13th day. A few hours after extubation, she presented respiratory distress due to massive pulmonary atelectasis caused by sputum accumulation as a result of the impaired cough reflex. MI-E was applied to facilitate coughing and sputum expectoration. MI-E dramatically improved the atelectasis and prevented reintubation. This case suggests that MI-E, which is primarily used to treat chronic neuromuscular diseases, may also be effective in treating acute respiratory failure.

Respiratory syncytial virus (RSV) is the most common etiology of bronchiolitis in young children. While most children clinically improve with care at home, RSV is the leading cause of hospitalization among infants aged 12 months or less. Common modalities of treatment for children with immune dysregulation include respiratory support and best supportive care, which may include immunoglobulin therapy. All immunoglobulin therapies adhere to Food and Drug Administration (FDA) - established standards for antibodies against measles, polio, and diphtheria, but there are no required standards for problematic respiratory viral pathogens, including RSV and others. ASCENIV is an approved IVIG that is manufactured from blending normal source plasma with plasma from donors that possess high antibody titers against RSV and other respiratory pathogens of concern. ASCENIV was developed, in part, to the unmet need that exists in immunocompromised patients who lack sufficient antibodies against problematic viral pathogens. ASCENIV is not a currently approved treatment for severe RSV and other viral infections. There is a lack of research regarding its potential benefits in the acute treatment period for RSV and in the pediatric population. Therefore, this case series was developed to describe real-world experiences of ASCENIV use in this less well studied clinical scenario. This case series reviews three pediatric patients ≤ 5 years of age with immune dysregulation and who were severely ill with RSV. Despite receiving best supportive care, and standard immunoglobulin therapy for some, the patients\' clinical status continued to decline. All patients received ASCENIV in an intensive care setting. Each patient had ultimately recovered due to the various medical interventions done. This case series demonstrated that ASCENIV (500mg/kg) administration may have contributed to the treatment outcomes of a less well studied age-cohort of patients. In addition, no adverse side effects were observed after ASCENIV administration. Further analysis of the benefits of ASCENIV for the acute and preventative treatment in patients younger than 12 years of age with immune dysregulation should continue to be explored.

(1) Background: Although Non-Invasive Ventilation (NIV) is effective in preventing mortality and endotracheal intubation in patients with Acute Respiratory Failure (ARF) linked to a neuromuscular disorder, its efficacy can be affected by patient intolerance. A High-Flow Nasal Cannula (HFNC) appears to have a significant advantage over NIV as far as patient tolerance is concerned. The aim of the study was to investigate HFNC\'s safety profile in a group of consecutive Neuromuscular Disease (NMD) patients intolerant to NIV who were admitted to an Intermediate Respiratory Care Unit (IRCU) for ARF. (2) Methods: The clinical course of nine NMD patients intolerant to NIV and switched to HFNC was reported. HFNC was provided during daytime hours and NIV during the night-time to the NIV-intolerant patients. HFNC was utilized 24 h a day in those patients who were intolerant of even nocturnal NIV. (3) Results: HFNC was simple to use and it was well tolerated by all of the patients. Three out of nine patients experienced treatment failure, consisting of the need for ETI and/or death during their IRCU stay. The remaining 6 had a favorable outcome. Treatment failure was linked to the utilization of HFNC 24 h a day. (4) Conclusion: HFNC during the daytime hours, together with nocturnal NIV, seems to be a safe therapeutic approach for NMD patients with ARF. A round-the-clock use of HFNC tends to be linked to a high likelihood of failure.

The coronavirus disease 2019 has been demonstrated to be a trigger for multiple immune-mediated diseases, such as antineutrophil cytoplasmic antibody-associated vasculitis. Associated vasculitis consists of rare autoimmune disorders that predominantly affect small vessels, leading to endothelial injury and tissue damage. We present a case of a newly diagnosed microscopic polyangiitis temporally associated with coronavirus disease 2019 infection in a previously healthy woman and a literature review. A 66-year-old female presented to the Emergency Room with fever, edema on her legs, productive cough, dyspnea, and hemoptysis. A chest computerized tomography scan revealed bilateral diffuse alveolar opacities with the appearance of diffuse alveolar hemorrhage. Blood analysis revealed a moderate normocytic, normochromic anemia with a hemoglobin of 6.6 g/dL, platelet count of 347 k/dL, leucocytes of 12,000/dL, a creatinine of 3.91 mg/dL (basal Cr: 0.9 mg/dL), and a Blood Urine Nnitrogen of 78 mg/dL. A urine sediment demonstrated glomerular hematuria, with mixed shapes of red blood cells. She was admitted to the intensive care unit and a bedside bronchoscopy revealed progressive bleeding with a bronchioalveolar lavage positive for diffuse alveolar hemorrhage. Given the critical involvement of the lungs and kidney function, the diagnostic approach revealed a positive p-anti-neutrophil cytoplasmic antibody on immunofluorescence and an anti-MPO (myeloperoxidase) level of 124.6 IU/mL. A renal biopsy demonstrated pauciimmune focal and segmental glomerulosclerosis. A diagnosis of microscopic polyangiitis triggered by severe acute respiratory syndrome coronavirus 2 infection was made, and immediate treatment with pulse-dose steroids and cyclophosphamide was initiated. The patient needed renal replacement therapy and was discharged for follow-up with nephrology and rheumatology services. The diagnostic approach of associated vasculitis can be more challenging in the coronavirus disease era. Atypical features in the pulmonary imaging and a rapid deterioration of the renal function should arise the clinical suspicion of the presence of an added condition to the coronavirus disease infection. Autoimmune conditions such as associated vasculitis should be evaluated even in the absence of previous autoimmune history. Prompt diagnosis and treatments must be prioritized to avoid end-organ definite damage. Further, larger and more collaborative studies are needed to confirm the potential role of coronavirus disease 2019 as a trigger of associated vasculitis.

BACKGROUND: Histoplasmosis is a fungal disease caused by Histoplasma capsulatum. Histoplasma capsulatum var capsulatum is found in Martinique. Cluster cases following working in deserted house, have been described in Martinique. Cases of acute pulmonary histoplasmosis have been described in immunosuppressed individuals, or in case of substantial exposure to reservoirs of Histoplasma capsulatum; however, cases of acute histoplasmosis are rare in immunocompetent individuals.
METHODS: We report a series of 4 cases of sporadic acute pulmonary histoplasmosis in immunocompetent subjects. Investigation revealed definite exposure in one patient and 3 cases with potential exposure. The diagnosis was microbiological and histological in 3 patients and histological in one patient. All subjects had positive serology to histoplasmosis. Pulmonary involvement was in the form of nodules and micronodules in 3 cases and ground glass lesions in one case. Patients were treated with itraconazole for 3 months and all had a favourable outcome.
CONCLUSIONS: We report a series of 4 cases of acute pulmonary histoplasmosis in immunocompetent individuals, occurring in a context where exposure was uncertain. This raises the problem of occult exposure in the Caribbean. Interventions to raise awareness and encourage caution are warranted targeting the population of the French West Indies and French Guiana.

BACKGROUND: The risk of barotrauma associated with different types of ventilatory support is unclear in COVID-19 patients. The primary aim of this study was to evaluate the effect of the different respiratory support strategies on barotrauma occurrence; we also sought to determine the frequency of barotrauma and the clinical characteristics of the patients who experienced this complication.
METHODS: This multicentre retrospective case-control study from 1 March 2020 to 28 February 2021 included COVID-19 patients who experienced barotrauma during hospital stay. They were matched with controls in a 1:1 ratio for the same admission period in the same ward of treatment. Univariable and multivariable logistic regression (OR) were performed to explore which factors were associated with barotrauma and in-hospital death.
RESULTS: We included 200 cases and 200 controls. Invasive mechanical ventilation was used in 39.3% of patients in the barotrauma group, and in 20.1% of controls (p<0.001). Receiving non-invasive ventilation (C-PAP/PSV) instead of conventional oxygen therapy (COT) increased the risk of barotrauma (OR 5.04, 95% CI 2.30 - 11.08, p<0.001), similarly for invasive mechanical ventilation (OR 6.24, 95% CI 2.86-13.60, p<0.001). High Flow Nasal Oxygen (HFNO), compared with COT, did not significantly increase the risk of barotrauma. Barotrauma frequency occurred in 1.00% [95% CI 0.88-1.16] of patients; these were older (p=0.022) and more frequently immunosuppressed (p=0.013). Barotrauma was shown to be an independent risk for death (OR 5.32, 95% CI 2.82-10.03, p<0.001).
CONCLUSIONS: C-PAP/PSV compared with COT or HFNO increased the risk of barotrauma; otherwise HFNO did not. Barotrauma was recorded in 1.00% of patients, affecting mainly patients with more severe COVID-19 disease. Barotrauma was independently associated with mortality.
BACKGROUND: this case-control study was prospectively registered in clinicaltrial.gov as NCT04897152 (on 21 May 2021).