28. Fellows’ Case Files: Harvard – MGH & BIDMC

Featured

Welcome back to our Pulm PEEPs Fellows’ Case Files series! We are joined this week by a fellow and the program director from the Harvard combined PCCM fellowship at Massachusettes General Hospital and Beth Israel Deaconess Medical Center. Listen in for a great learning case and let us know on Twitter, if you have a great case to share!

Meet our Guests

Brian Rosenberg is a third year fellow at the Harvard MGH/BI program. He completed his undergraduate degree at Harvard, received his MD  from Yale where he also got a PhD in cell biology, and then did his internal medicine residency at Columbia University Medical Center in NYC.

Asha is an Assistant Professor Medicine at Beth Israel Deaconess Medical Center and Harvard Medical School, and is the Program Director of the Harvard MGH/BI combined fellowship. She is also the Director of the Pulmonary Consult Service at BIDMC, was a Rabkin Fellow in Medical Education and has received multiple leadership and teaching awards

30. Fellows’ Case Files: University of Mississippi Medical Center

We’re excited to be back with another episode in our Pulm PEEPs Fellows’ Case Files series! This is a particularly exciting case since it is our first episode where some intrepid fellows reached out to us with an interesting case they had encountered. If you have a great case, please let us know and you can follow in their footsteps! Pack your bags, and let’s head to Mississippi to learn about another great pulmonary and critical care case.

Meet our Guests

Meredith Sloan is a pulmonary and critical care fellow at the University of Mississippi. She completed her medical school at the Medical University of South Carolina College of Medicine, and her residency at the University of Mississippi.

Kevin Kinloch is a senior fellow at the University of Mississippi Medical Center where he also completed his internal medicine residency. He completed medical school at Meharry Medical College.

Jessie Harvey is an Associate professor of Medicine at the University of Mississippi and is the Pulmonary and Critical Care Program Director. She is also the Director of the MICU, and has been at MMC since medical school. She is a dedicated educator and leads the POCUS curriculum for IM residents and PCCM fellows

Patient Presentation

A 65-year-old man presented to the ED with worsening hemoptysis over the last several days after a recent lung biopsy. The patient is an active smoker with at least a 50-pack-year history, and he had been having a cough with small-volume hemoptysis. He ultimately had a chest CT that revealed a large LUL mass (10.3 x 6.4 cm). Given this suspicious mass, three days prior to his ED presentation, he was taken for bronchoscopy with BAL, transbronchial biopsies, endobronchial biopsy, EBUS guided TBNA of 11L, along with TBNA, brushing and radial EBUS TBNA of his left upper lobe mass.

Key Learning Points

**Spoilers Ahead** If you want to think through the case on your own we advise listening to the episode first before looking at these points.

Staging procedures for masses

  • Enough tissue so we can make a diagnosis and do molecular testing
  • Highest staging when getting your biopsy

POCUS for respiratory failure

  • Absence of lung slidings
    • Especially post procedure
  • The presence of a new pleural effusion after a procedure could indicate hemothorax
    • Hematocrit sign – an echogenic layering of material in an effusion
  • New B-lines, especially if prior there were only A-lines
    • Cardiogenic or non-cardiogenic pulmonary edema, alveolar hemorrhage, or infection
  • Diaphragmatic function
    • Excursion
    • Diaphragm thickness

References and Further Reading

1.Scorsetti M, Leo F, Trama A, D’Angelillo R, Serpico D, Maerelli M, Zucali P, Gatta G, Garassino MC. Thymoma and thymic carcinomas. Critical Reviews in Oncology/Hematology. 2016; 99:332-350.

2. Singh TD, Wijdicks EFM. Neuromuscular respiratory failure. Neurol Clin 2021; 39:333-353.

Radiology Rounds – 11/22/22

We are back with another #RadiologyRounds for you!

A middle-aged male presents with sub-acute fatigue, fevers and dyspnea on exertion. His admission labs are notable for severe neutropenia (ANC < 500)

This patient has evidence of a halo sign which represents local vessel invasion or hemorrhage

The patient undergoes evaluation. RVP, sputum culture and serum galactomannan and 1-3-B-d-glucan are negative. A BAL with transbronchial biopsies are obtained.

The patient was found to have pulmonary mucormycosis and was started on IV liposomal amphotericin-B.

Want to learn more about this case? Take a listen to our Fellow’s Case Files from Baylor College of Medicine

29. Long COVID Roundtable

This week on Pulm PEEPs, Dave and Kristina are joined by Jason Maley and Ann Parker, two pulmonary and critical care physicians who are leaders in treating patients with Long COVID, or Post-Acute Sequelae of SARS-CoV-2. Both of them help run the Long COVID clinics at their respective institutions and are part of broader consortiums dedicated to patient care. They also both participate in research to improve outcomes for patients with Long COVID and Post-Intensive Care Syndrome. In this conversation, we cover the diagnosis of Long COVID, common symptoms, abnormal test findings, possible mechanisms of disease, the impacts of variants and vaccines, treatments, and the natural history of this condition. We hope this will be helpful for providers, patients, and family members.

Meet Our Guests

Jason Maley is an Assistant Professor of Medicine at Beth Israel Deaconess Medical Center and Harvard Medical School. He is the Director of the BIDMC Critical Illness and COVID-19 Survivorship Program, and the Co-Chair of the American Academy of Physical Medicine and Rehabilitation Postacute Sequeleae of SARS-CoV-2 infection (PASC) initiative. He is NIH funded to study post-COVID patients.

Ann Parker is an Assistant Professor of Medicine at Johns Hopkins and is the Co-Director of the Johns Hopkins Post-Acute COVID-19 team. She is NIH funded with her research focusing on survivors of respiratory failure and critical illness.

Key Learning Points

Long COVID or Post-Acute Sequelae of SARS-CoV-2 or Post-COVID condition

  • Long COVID was first described this way by patients so this is the common nomenclature that is used. It is also referred to as Post-Acute Sequelae of SARS-CoV-2 or Post-COVID condition
  • Defined by patients that have not returned to their baseline health 3 months after their acute episode of COVID-19
  • Major organizations in describing this disease and doing research are:
    • World Health Organization
    • Multiple patient-led organizations
    • CDC – INSPIRE
    • NIH – RECOVER

Post-COVID Clinic

  • Seeing patients across the spectrum of illness. Not all patients had to be critically ill or hospitalized
    • The standard patient has changed over time and now the vast majority had a mild initial illness, but afterward had unusual and persistent symptoms
  • Patients are generally referred by their PCP or self-referred
  • The criteria for being seen in clinic are very loose to make sure patients are not excluded
    • Many patients do not have a confirmed case of COVID since patients early in the pandemic often did not have a positive test available, and now many people are testing positive at home
  • Initial records review to make sure that can help patients
  • Standardized questionnaires
    • Screening for physical impairment, mental health impairment, and cognitive impairment
  • Rehabilitation and multi-disciplinary based approach
  • It is extremely important to be aware of the bias in patient populations in Post-COVID clinics
    • The population that can make it to clinic may not, and does not, represent all patients who have had COVID or have Long COVID. Patients may be limited in their ability to get to clinic based on their physical condition, financial resources, location, support, and language barriers.

Overlap of Long COVID and PICS

  • These conditions are very similar and certainly have a lot of overlap
  • For patients coming out of the ICU, screening should start with looking for known PICS symptoms.
    • These domains are mental health, physical impairment, and cognitive function
  • There may be some unique aspects, such as:
    • Severe persistent fatigue
    • Extreme changes in taste and smell

Common symptoms

  • Many symptoms are complex and multifactorial
  • Neuropsycholgoicl impairment – termed “brain fog”
    • Difficulty with concentration, and cognition
  • Anxiety
  • Depression
  • Persistent shortness of breath
    • Dyspnea can be reported even with just talking for long periods of time
    • “Deep breaths are just not satisfying”
  • Cough
  • Chest pain
  • Dysautonomia
    • Palpitations, dizziness, orthostasis
  • Fatigue
  • Post-exertional malaise
  • Cognitive blunting or “brain fog”
  • Changes in sleep
  • Headaches

Common findings on testing in patients with Long COVID

  • Shortness of breath
    • Some may have impaired diffusion (low DLCO) on PFTs
    • However, often patients have normal or near-normal PFTs
    • 10 – 20 % have air trapping on inspiratory/expiratory chest CTs that could indicate bronchiolitis
    • One study showed that CPETs showed impaired oxygen extraction
      • Preserved cardiac output to exercise and no evidence of deconditioning
      • This study indicated an issue at the peripheral level (ex: vascular, mitochondrial) with oxygen extraction.

Variants

  • It is very difficult to say if variants differ in rates of Long COVID given that often patients do not get sequencing to know the variant and because there is overlap in the timing of variants
  • Further testing will continue on this going forward

Vaccines

  • Reduced risk of Long COVID with vaccination
    • Boosting further decreases the risk compared to just the initial vaccination
  • There is a variable response to getting vaccinated if a patient has Long COVID
    • Most patients tolerate it well and some patients have relief of symptoms
    • There are some patients who can develop worsened Long COVID symptoms

References and further reading

  1. Chippa V, Aleem A, Anjum F. Post Acute Coronavirus (COVID-19) Syndrome. In: StatPearls. StatPearls Publishing; 2022. Accessed November 14, 2022. http://www.ncbi.nlm.nih.gov/books/NBK570608/
  2. Crook H, Raza S, Nowell J, Young M, Edison P. Long covid—mechanisms, risk factors, and management. BMJ. 2021;374:n1648. doi:10.1136/bmj.n1648
  3. Durstenfeld MS, Sun K, Tahir P, et al. Use of Cardiopulmonary Exercise Testing to Evaluate Long COVID-19 Symptoms in Adults: A Systematic Review and Meta-analysis. JAMA Network Open. 2022;5(10):e2236057. doi:10.1001/jamanetworkopen.2022.36057
  4. Nalbandian A, Sehgal K, Gupta A, et al. Post-acute COVID-19 syndrome. Nat Med. 2021;27(4):601-615. doi:10.1038/s41591-021-01283-z
  5. Soriano JB, Murthy S, Marshall JC, Relan P, Diaz JV. A clinical case definition of post-COVID-19 condition by a Delphi consensus. Lancet Infect Dis. 2022;22(4):e102-e107. doi:10.1016/S1473-3099(21)00703-9
  6. Sudre CH, Murray B, Varsavsky T, et al. Attributes and predictors of long COVID. Nat Med. 2021;27(4):626-631. doi:10.1038/s41591-021-01292-y

Radiology Rounds – 11/8/22

This week’s #RadiologyRounds is brought to you by our newest contributor, Nick Ghionni! We’ll dive into a classic Radiology Sign and talk about what it represents, and how it helps inform your differential.

In this case, the patient underwent a biopsy that showed no malignancy but grew NTM! Given that NTM can be superimposed on malignancy, repeated biopsies were done that corroborated. She is being treated with close monitoring.

Radiology Rounds – 10/25/22

This week’s #RadiologyRounds is coming from the pulmonary clinic. Follow us on Twitter to see the case and answer our polls live!

Given the patient’s weight loss and persistent symptoms despite trying some empiric therapies, a chest CT was obtained. PFTs were also ordered 🙂

The patient’s CT had tree-in-bud opacities, nodular consolidations, scattered micronodular opacities, and airway thickening.

The pt had an induced sputum but could not produce a sample. She underwent bronchoscopy + lavage and her AFB smear was positive with negative TB NAAT. The culture ended up growing M. chimaera! Does that explain her symptoms? Here are the diagnostic criteria for pulmonary NTM:

All other testing was negative and the patient was diagnosed with pulmonary NTM. After a long discussion about treatment (an interesting topic for another day!!) she was started on triple antibiotic therapy and after 9 months her cough had resolved and she was gaining weight.

27. Live from CHEST 2022

We are thrilled today here at Pulm PEEPs to be coming to you live from the CHEST 2022 Annual Meeting. We are joined by three fantastic speakers, and CHEST leaders to discuss the highlights and events of the conference, and to share some great learning points along the way. The episode is being released immediately after recording this morning, Monday 10/17/22, so if you’re at the conference now make sure to listen for some extremely timely recommendations. If you’re not here in Nashville, we’ve highlighted some learning points that you can take away and some wisdom on how to maximize your conference experience for the next time!

Meet Our Guests

Subani Chandra is an Associate Professor at Columbia University. She is the Vice Chair of Medicine for Education and the internal medicine residency program director. She is also the incoming Chair of the Training and Transitions Committee at CHEST, and the chair of the CHEST Scientific Program Committee for CHEST 2022.

Matt Siuba is an Assistant Professor of Medicine and intensivist at the Cleveland Clinic, where he is the associate program director for the Critical Care Medicine fellowship. He founded and runs the website Zentensivist.com, and is well known as a fantastic educator both in person via many different online formats.

Todd Rice is an Associate Profess of Medicine at Vanderbilt University, where he is also the Medical Director of the ICU. In addition, he is the Vice President for Clinical Trial Innovation and Operations in the Vanderbilt Institute for Clinical and Translational Research. He is also a past president of The American Society of Parenteral and Enteral Nutrition, and most relevant to today, the Associate Editor of Critical Care for Chest.

Radiology Rounds – 10/11/22

For #RadiologyRounds this week we have a mystery case from the pulmonary clinic complete with imaging and exploration of PFTs. Follow along for some great clinical pearls and teaching points about lung function tests. Graphics made with the help of outstanding educator Kaitlin Seitz.

What imaging views would you get next?

A) Supine and prone

B) Inspiratory and expiratory

C) High resolution

D) With contrast

What test would you get next?

A) Bronchoscopy

B) ECHO

C) PFTs

D) Lung US

What do these PFTs show?

A) Restriction concerning for ILD

B) Restriction concerning for obesity

C) Restriction concerning for weakness

D) Mixed obstruction and restriction

The patient was referred to neurology and ultimately diagnosed with severe mixed sensory and motor chronic axonal polyneuropathy.

26. A Case of AMS, Renal Failure, and Hemolysis

This week on Pulm PEEPs, we have another great case episode. We’re switching up the format a bit, and instead of introducing our guests in the beginning, we’ll bring them in consultants as we need to. Luckily, we’re joined by Pulm PEEPs Associated Editor Luke Hedrick to walk us through the case. Let us know your thoughts and if you have any other pearls to add!

Meet Our Guests

Rakhi Naik an Associate Professor of Medicine at Johns Hopkins Hospital and the Associate Director for the Hematology / Oncology Fellowship program. She also has a Masters in Health Sciences from the Johns Hopkins Bloomberg School of Public Health. She has expertise in an array of non-malignant hematology disorders and focuses specifically on sickle cell in her research. She is also an outstanding and dedicated educator and serves as the Chair of the American Society of Hematology Hematology-Focused Training Program Consortium to develop innovative training pathways for non-malignant heme.

Patient Presentation

A 60-year-old woman with a past medical history of hypertension, diabetes, stage 4 chronic kidney disease, COPD, HFpEF, chronic pain on methadone, hyperparathyroidism s/p parathyroidectomy that was c/b hypothyroidism now on thyroid hormone replacement, and a recent admission for nonconvulsive status epilepticus is brought to an outside hospital by EMS with encephalopathy and shaking. 

When EMS gets her to the other hospital her GCS was 5, so she was intubated for airway protection and started on fentanyl and midazolam drips. Details of labs and imaging are scarce, but we know that she had a CT head that was normal, a CXR with a report of pulmonary edema, and labs with a Cr of 2.4, serum bicarbonate of 14, and a pH from a VBG of 7.1 with pCO2 of 38.

Key Learning Points

*Spoilers ahead* The infographic below highlighting key points gives away the diagnosis in this case so if you want to work through the case on your own, we recommend listening to the episode first.

References and further reading

  1. George JN. Thrombotic Thrombocytopenic Purpura. New England Journal of Medicine. 2006;354(18):1927-1935. doi:10.1056/NEJMcp053024
  2. Joly BS, Coppo P, Veyradier A. Thrombotic thrombocytopenic purpura. Blood. 2017;129(21):2836-2846. doi:10.1182/blood-2016-10-709857
  3. Kremer Hovinga JA, Coppo P, Lämmle B, Moake JL, Miyata T, Vanhoorelbeke K. Thrombotic thrombocytopenic purpura. Nat Rev Dis Primers. 2017;3(1):1-17. doi:10.1038/nrdp.2017.20
  4. Scully M, Cataland SR, Peyvandi F, et al. Caplacizumab Treatment for Acquired Thrombotic Thrombocytopenic Purpura. New England Journal of Medicine. 2019;380(4):335-346. doi:10.1056/NEJMoa1806311
  5. Sukumar S, Lämmle B, Cataland SR. Thrombotic Thrombocytopenic Purpura: Pathophysiology, Diagnosis, and Management. J Clin Med. 2021;10(3):536. doi:10.3390/jcm10030536