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1/28. ARDS in a patient with homozygous beta-thalassemia due to yersiniosis.

    We report a case of yersinia enterocolitica sepsis syndrome and the acute respiratory distress syndrome in a chronically transfused adolescent with beta-thalassemia. This manifestation of serious Y. enterocolitica infection has not previously been reported. dyspnea, hypoxia, and fever were the principal features of the clinical presentation. The acute onset of respiratory symptoms occurred after appendectomy. Chest radiographs revealed frontal bilateral infiltrates and alveolar consolidation to three quadrants. Y. enterocolitica was identified from blood and intraoperative appendix cultures. Although there was no need for mechanical ventilation, a remarkable persistence of clinical and X-ray findings was noted. Therapy with high levels of oxygen, and intravenous amikacin and piperacillin/tazobactam led to a favorable outcome.
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2/28. Epstein-Barr virus-associated adult respiratory distress syndrome in a patient with AIDS: a case report and review.

    BACKGROUND: Epstein-Barr virus (EBV) infection has been associated with fatal pneumonitis in immunocompetent patients. We present a case of fatal adult respiratory distress syndrome caused by EBV infection in a patient with acquired immunodeficiency syndrome (AIDS), to our knowledge the first such reported case, along with a survey of archival autopsy cases to assess baseline expression of EBV in AIDS patients. DESIGN: The case patient's autopsy material was studied exhaustively for infectious agents by culture, histochemistry, and immunohistochemistry, with negative results. Formalin-fixed paraffin-embedded lung, spleen, lymph node, and liver tissue were further studied by in situ hybridization using a probe for EBV early rna (EBER, Kreatech). The same method was applied to lymphoid tissues from eight other archival AIDS autopsy cases. Case patient tissues were also examined by electron microscopy. RESULTS: Strikingly numerous lymphocytes were positive for EBV early rna in the case patient's spleen, lymph nodes, and hepatic portal areas. In addition to positive lymphocytes in the lung, EBV-infected pneumocytes were also present. Electron microscopy also demonstrated viral material in lymphocytes and pneumocytes. Of the archival cases studied, only one spleen was found to have rare positive lymphocytes. CONCLUSION: Primary or reactivation EBV infection may represent a previously underreported cause of morbidity and mortality in AIDS patients. autopsy tissues from AIDS patients do not routinely show overexpression of EBV early rna by in situ hybridization, making this technique ideal for assessing the contribution of EBV to terminal events in these patients.
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3/28. Acute respiratory distress syndrome due to tuberculosis in a child after allogeneic bone marrow transplantation for acute lymphoblastic leukemia.

    We report the occurrence of tuberculosis in a 10-year-old Taiwanese boy, approximately 4 months after he received a matched-related bone marrow transplantation from his sister for acute T-cell lymphoblastic leukemia. After transplantation, grade III acute graft-versus-host disease developed and the patient was treated with prednisolone and cyclosporine. Marrow failure was noted on day 77 post-transplantation, however, after an episode of herpes zoster infection. Interstitial pneumonia, diagnosed on the basis of chest x-ray and computed tomography findings, occurred on day 120. Histologic examination of an open-lung biopsy specimen showed caseating granulomas and a few acid-fast bacilli. The patient died of acute respiratory distress syndrome, despite immediate implementation of antituberculosis therapy. sputum cultures grew mycobacterium tuberculosis 5 weeks later. This report demonstrates that the possibility of tuberculosis needs to be considered in immunocompromised patients, and that appropriate prophylaxis should be instituted in areas where tuberculosis is endemic.
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4/28. Rapidly evolving adult respiratory distress syndrome with eosinophilia of unknown cause in previously healthy active duty soldiers at an Army training center: report of two cases.

    BACKGROUND: Two previously healthy soldiers presented with rapidly evolving adult respiratory distress syndrome (ARDS) within days of their return from the National Training Center at Fort Irwin, california. There have been six similar cases reported in the National Training Center area, five with fatal outcomes. methods: Both patients were treated in an intensive care unit setting. Extensive diagnostic testing was performed, and patients were treated empirically with doxycycline, ceftriaxone, and ribavirin. RESULTS: Both patients had complete recovery. intensive care unit course was notable for circulatory collapse, respiratory distress requiring ventilatory support, approximately 10% eosinophils on bronchoalveolar lavage, and dramatic peripheral eosinophilia. All cultures, including serology cultures for hantavirus, were negative. CONCLUSION: There have been no previously described syndromes comprising "viral" prodrome, rapid progression to ARDS, and eosinophilia. Based on the geographic, temporal, and clinical similarity of these two cases, we believe that they share a common, yet undetermined, cause. Both environmental exposures and any undescribed pathogens warrant further investigation.
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5/28. Libman-Sacks endocarditis in a pregnant woman with acute respiratory distress syndrome.

    BACKGROUND: Sterile fibrinous vegetations on the mitral valve (Libman-Sacks endocarditis) might be found in one-third of patients with antiphospholipid antibodies. Usually of minor hemodynamic significance, these vegetations might complicate acute respiratory distress syndrome in pregnancy. CASE: Despite delivery and aggressive medical therapy, a 17-year-old primigravida with pyelonephritis and acute respiratory distress syndrome suffered rapid decompensation. echocardiography showed mitral valve vegetations with severe regurgitation. blood cultures were negative, but antinuclear antibody test and lupus anticoagulant were positive. The patient died of massive cerebral infarction and brainstem herniation. autopsy found a patent foramen ovale and Libman-Sacks endocarditis. CONCLUSION: With rapid decompensation of acute respiratory distress syndrome in pregnancy, despite aggressive medical therapy, complicating processes must be considered, especially with antiphospholipid antibodies, which can be associated with sterile heart vegetations and subsequent fatal thromboembolism.
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6/28. herpes simplex virus 1 pneumonia: conventional chest radiograph pattern.

    The aim of this study was to describe the findings on plain chest radiographs in patients with herpes simplex virus pneumonia (HSVP). The study was based on 17 patients who at a retrospective search have been found to have a monoinfection with herpes simplex virus. The diagnosis was established by isolation of the virus from material obtained during fiberoptic bronchoscopy (FOB) which also included broncho-alveolar lavage and tissue sampling. Fourteen patients had a chest radiograph performed within 24 h of the date of the FOB. Two radiographs showed no abnormalities of the lung parenchyma. The radiographs of the other 12 patients showed lung opacification, predominantly lobar or more extensive and always bilateral. Most patients presented with a mixed airspace and interstitial pattern of opacities, but 11 of 14 showed at least an airspace consolidation. Lobar, segmental, or subsegmental atelectasis was present in 7 patients, and unilateral or bilateral pleural effusion in 8 patients, but only in 1 patient was it a large amount. In contradiction to the literature which reports a high correlation between HSVP and acute respiratory distress syndrome (ARDS), 11 of 14 patients did not meet the pathophysiological criteria for ARDS. The radiologist may suggest the diagnosis of HSVP when bilateral airspace consolidation or mixed opacities appear in a susceptible group of patients who are not thought to have ARDS or pulmonary edema. The definite diagnosis of HSV pneumonia can be established only on the basis of culture of material obtained by broncho-alveolar lavage.
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7/28. Fatal inhalational anthrax with unknown source of exposure in a 61-year-old woman in new york city.

    A 61-year-old woman who was a new york city hospital employee developed fatal inhalational anthrax, but with an unknown source of anthrax exposure. The patient presented with shortness of breath, malaise, and cough that had developed 3 days prior to admission. Within hours of presentation, she developed respiratory failure and septic shock and required mechanical ventilation and vasopressor therapy. Spiral contrast-enhanced computed tomography of the chest demonstrated large bilateral pleural effusions and hemorrhagic mediastinitis. blood cultures, as well as dna amplification by polymerase chain reaction of the blood, bronchial washings, and pleural fluid specimens, were positive for bacillus anthracis. The clinical course was complicated by liver failure, renal failure, severe metabolic acidosis, disseminated intravascular coagulopathy, and cardiac tamponade, and the patient died on the fourth hospital day. The cause of death was inhalational anthrax. Despite epidemiologic investigation, including environmental samples from the patient's residence and workplace, no mechanism for anthrax exposure has been identified.
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8/28. Fulminant infection and toxic shock syndrome caused by streptococcus pyogenes.

    Two patients presented to the Emergency Department (ED) with features of toxic shock syndrome, including hypotension, acute respiratory distress syndrome (ARDS), renal and hepatic insufficiency and disseminated intravascular coagulation (DIC). Computed tomography (CT) scan identified the source of infection in one patient. At laparotomy, pelvic peritonitis and massive edema of the pelvic retroperitoneal tissue was found. The other patient had myonecrosis of the forearm necessitating amputation. Intra-operative cultures of tissue in each case yielded streptococcus pyogenes, Group A. These patients were treated early with clindamycin and intensive supportive care as well as surgery, and both made a full recovery. Because of the necessity of early recognition of the varied presentation of these infections, the clinical features as well as essential interventions are emphasized. We review the pathophysiology of invasive Group A streptococcal infection to increase awareness of these uncommon but fulminant and often lethal infections.
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9/28. Pulmonary granulomatosis associated with insoluble fillers in a heroin addict.

    We report a case of acute respiratory distress syndrome (ARDS) and pulmonary granulomatosis after intravenous injection of heroin. This 46-year-old male had a 2-year history of heroin addiction. The recent admission was due to loss of consciousness after intravenous injection of diluted heroin with unknown filler. Initial chest X-ray revealed a picture of ARDS. blood routine and biochemistry were normal except for leukocytosis. urine morphine test was positive. The blood and sputum culture yielded no pathogens. After supportive treatment, his condition improved, and the follow-up chest X-ray showed diffuse micronodules in both lung fields. Subsequently, open-lung biopsy of the right upper and lower lobes on the 26th hospital day showed large amounts of foreignbody granulomas distributed over perivascular areas, bronchiolar areas and interstitium. Staining for bacteria, fungi, and mycobacteria was all negative. The morphology of foreign-bodies could be divided into 2 types: 1) periodic acid-Schiff (PAS)-positive, aggregated fine crystals in round form; and 2) PAS-negative, yellow long crystals. The pathological diagnosis of pulmonary granulomatosis was made based on the finding of filler foreign bodies. The nature of these foreign bodies remained undetermined. The case suggests that pulmonary granulomatosis with the radiographic appearance of chronic interstitial pneumonia can occur in patients with a history of heroin use.
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10/28. documentation of legionella pneumophila and mycobacterium tuberculosis co-existence in a patient with acute respiratory distress syndrome.

    BACKGROUND: Bacterial lung infections are common causes of ARDS and, despite intensive research for decades, the mortality rate remains very high. Only two reports suggest the co-existence of legionnaires' disease and pulmonary tuberculosis based mainly on clinical presentation and serologic results for Legionella and positive cultures for mycobacterium tuberculosis (M. tuberculosis). MATERIALS AND methods: A variety of specimens from a 61-year-old man was used for detection of legionella pneumophila (L. pneumophila) and M. tuberculosis by PCR. Further identification of the pathogens was carried out by sequence analysis. RESULTS: L. pneumophila region mip was detected in bronchial washings, bronchoalveolar lavage and urine specimens of the patient. M. tuberculosis regions IS6110 and mtp40 were detected in endo-bronchial secretions and bronchoalveolar lavage. CONCLUSION: By using polymerase chain reaction (PCR) and dna sequencing we documented L. pneumophila and M. tuberculosis co-existence, in multiple specimens of a patient presenting with acute respiratory distress syndrome (ARDS). Furthermore, the efficacy of the specific antibiotic treatment, based on the PCR results, suggest the co-existence of these two pathogens.
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