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- Complicated Postcardiac Injury Syndrome Secondary to an Intracardiac Foreign Body. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):98A.
Cardiovascular Student/Resident Case Report Posters IISESSION TYPE: Medical Student/Resident Case ReportPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: We present the case of a 43 year old female with chest pain, pericarditis, pleural effusions, and an intracardiac foreign body with subsequent thrombus. This case highlights an unusual complication and an undescribed cause of post cardiac injury syndrome.Our patient's course began 6 months prior to presentation following a varicose vein ablation. She had multiple hospital admissions over several months. Her symptoms included pleuritic chest pain, pleural effusions, leukocytosis and dyspnea. Initially, she was diagnosed with idopathic and recurrent pericarditis after negative ECGs, coronary angiogram, CTAs, and cardiac MRI. The patient was readmitted four months later to the pulmonary service with bilateral pleural effusions. A thoracentesis demonstrated an exudative effusion, and autoimmune and thyroid serologies were negative. A cardiac MRI showed a RA mass, 2.2 x 1.1 cm, anterior to a thin linear band of tissue extending into the RA. A TEE noted a mass in the RA at the tip of a guidewire or pacing lead near the superior lateral wall of the RA below the entrance of the SVC. (fig. 1) Cardiothoracic surgery excised a several centimeter plastic cannula with associated mass (fig.2). Intraoperatively, pericarditis, thickened pericardium, and a plastic cannula projecting through the RA appendage stuck in the pericardium were noted.We have a 43 year old female presenting with recurrent chest pain, pericarditis, and pleural effusions with a RA mass secondary to an intracardiac foreign body. Many cases of foreign bodies have been described, but we feel this case is particularly interesting in presentation, echocardiography, and inability to be identify the object with CT or MRI. Of greater interest, is the serositis highlighting the described immunological response seen in PCIS. Typically, PCIS is seen following cardiothoracic surgery and less frequently myocardial infarctions. It is characterized by pleural and pericardial effusions (left sided, exudative, lymphocytic, bloody with a normal pH), pleuritic chest pain, fevers, and leukocytosis, which are seen here. A PubMed search demonstrated no cases associated with intracardiac foreign bodies.This case brings attention to not only a very unusual presentation and diagnosis of an intracardiac foreign body but also provides a previously undescribed cause of PCIS. Given the number of intravascular procedures and cardiac procedures performed in modern medicine, it is important to appreciate all potential complications, which includes PCIS. The serositis is consistent with a complicated PCIS based on her symptoms, pleural fluid analyses, and exclusion of alternativesReference #1: Light, Richard W (2001). Pleural Effusions Following Cardiac Injury and Coronary Artery Bypass Graft Surgery. Seminars in Respiratory and Critical Care Medicine 22(6)Reference #2: Stelzner TJ (1983) The pleuropulmonary manifestatins of the Postcardiac Injury Syndrome. Chest 8(4)DISCLOSURE: The following authors have nothing to disclose: Dane Langsjoen, Kipp Slicker, Juan SanchezNo Product/Research Disclosure Information.
- Lung Transplantation for Emphysema: Is There Something New in Mortality Risk Factors? [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):983A.
Lung Transplantation PostersSESSION TYPE: Original Investigation PosterPRESENTED ON: Wednesday, October 29, 2014 at 01:30 PM - 02:30 PMPURPOSE: Emphysema is the most common indication for lung transplantation. We aim to review the results of our experience in a 5 year period and to identify risk factors for mortality.METHODS: A retrospective analysis was undertaken of the 63 consecutive lung transplants for emphysema performed in our institution between 2005 and 2010. Follow up was complete and averaged 2.9 years.RESULTS: Mean age of recipients was 56.7 (+/-8 years). Recipient's diagnoses were: 56 (88.9%) chronic obstructive pulmonary disease, 6 (9.5%) alpha 1 antitrypsin deficiency and 1 (1.6%) cutis laxa syndrome. Brain death donors represented 53 (84.1%) and non-heart beating donors 10 (15.9%). Ex-Vivo assessment was performed in 6 cases (9.5%). Bilateral procedures were performed in 37 (58.7%) patients. Cardiopulmonary bypass was required in 14 (22.2%) cases, mainly due to secondary pulmonary hypertension (12, 85.7%). Time to extubation was less than 48 hours in 36 (57.1%) patients. Most common complications were acute rejection (24, 38.1%), cardiovascular (22, 34.9%), primary graft disfunction (PGD) (20, 31.7%), pleuro-pulmonary (16, 25.4%), drug-related (15, 23.8%) and infections 14 (22.2%). The frequency of chronic lung allograft dysfunction (CLAD) at 1, 3 and 5 years was 3.2%, 14.3% and 6.3%, respectively. Bilateral lung transplantation was associated with less presence of CLAD (p<0.004). Overall survival at 1, 3 and 5 years was 77.8%, 68.9% and 58.6%, respectively. Forced expiratory volume in 1 second (FEV1) improved (p<0.001) and seems to stabilize after 6 months of the transplantation. Univariate analysis showed that body mass index greater than 25 (p<0.025), grade 3 PGD (p< 0.006) and non-heart beating donors (p<0.013) are associated with a higher mortality.CONCLUSIONS: Bilateral lung transplantation for emphysema results in less presence of CLAD. Body mass index greater than 25, grade 3 PGD and non-heart beating donors, are risk factors for mortality.CLINICAL IMPLICATIONS: Provide data about mortality risk factors in a group of patients where lung transplantation has evolved in the last decadeDISCLOSURE: The following authors have nothing to disclose: Daniel Valdivia, Lucas Hoyos, Lidia Macias, David Gomez, Rosalia Laporta, Jose Luis Campo, Andres VarelaNo Product/Research Disclosure Information.
- Candida Surgical Site Infections Post Lung Transplant. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):981A.
Lung Transplantation PostersSESSION TYPE: Original Investigation PosterPRESENTED ON: Wednesday, October 29, 2014 at 01:30 PM - 02:30 PMPURPOSE: Limited data exists regarding the incidence of candida surgical site infection (SSI) (incisional infections) in the lung transplant recipient (LTR). The objective of this study was to investigate the risk factors and outcomes in lung transplant recipients who develop candida SSIs.METHODS: Retrospective chart review of lung transplant recipients from January 2000 to November 2013 (n=1053) was performed and demographic and microbiological data was obtained.RESULTS: Five patients (n=3 IPF, n=1 CF, n=1 PHTN) developed Candida SSI early after transplant. The majority of patient were hospitalized pre transplant (n=4), with n=3 exposed to antibiotics and high dose steroids and n=1 exposed to azathioprine in the 3 months prior to transplant. None of the patients were exposed to antifungal medications prior to transplant. The majority of the recipients were diabetic (n=4). ECMO bridge to transplant was used in 3 patients and 2 patients needed ECMO support post transplant. All patients underwent a double lung transplant on cardiopulmonary bypass (median sternotomy n=4, clamshell n=1) with 2 patients needing to have an open chest post transplant. The intraoperative swab was positive for candida in n = 1 recipient and n =3 donor. Pretransplant sputum was positive for candida in n=3 recipients. None of the patients had a history of invasive candida infections prior to transplant. The majority of patients received prophylaxis with inhaled amphotericin B and PO itraconazole after lung transplant. One patient received IV micafungin for prophylaxis. All the sternal wound cultures grew Candida albicans. Treatment for candida infections varied with n=1 PO fluconazole and n=4 IV micafungin or PO voriconazole. Two of the sternal wound infections needed surgical wound debridement with removal of sternal wires. Only one patient had candida mediastinitis needing debridement but none of the patients had osteomyelitis. The mean duration of ICU stay was 19.2 days (16-24 days) and the mean duration of hospital stay was 62.2 days (29-95days) in the cohort. All patients survived initial hospitalization and were discharged from the hospital.CONCLUSIONS: Sternal candida wound infections are uncommon post lung transplant. History of diabetes, exposure to steroids, antibiotics may be associated with candida SSIs.CLINICAL IMPLICATIONS: Though uncommon, candida SSI may be associated with significant morbidity. Larger cohorts are needed to further explore risk factors and outcomes associated with candida SSIs.DISCLOSURE: The following authors have nothing to disclose: Shruti Gadre, Marie Budev, Christine KovalNo Product/Research Disclosure Information.
- Bronchial Pinch Bronchoscopy: A Novel Technique to Resect Carcinoid Tumor of the Bronchus Intermedius. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):88A.
Cardiothoracic Surgery PostersSESSION TYPE: Original Investigation PosterPRESENTED ON: Wednesday, October 29, 2014 at 01:30 PM - 02:30 PMPURPOSE: Most carcinoid tumors arisng from bronchus intermedius and growing into the right upper lobe (RUL) orifice tend to end up with a pneumonectomy. Excision of tumor is done by cold blade transecting the bronchus intermedius with avoidance of cutting into tumor. Attempt at serial sampling of the proximal bronchus margin until negative for tumor will allow for saving the RUL, or completion pneumonectomy otherwise. A novel technique is described to bypass the nuance of serial proximal bronchial margin sampling after distal resection, and still allows for definitive salvage of the RUL, avoiding a pneumonectomy.METHODS: A simultaneous bronchoscopic-assisted pinching method (Bronchial Pinch Bronchoscopy) allows for the surgeon under bronchoscopic guidance, to extrinsically pinch the bronchus intermedius and reduce the usually mobile tumor away from the RUL orifice.RESULTS: This step allows for the tumor, if it is mobile, to be safely reduced back into the bronchus intermedius, allowing for a stapling device to be applied proximal to the extrinsic pinch, guaranteeing a negative margin and salvage of the RUL instead of a pneumonectomy.CONCLUSIONS: In the common situation where the carcinoid tumor is originating from the bronchus intermedius and "growing" pass the RUL orifice, traditional operative techniques by the thoracic surgeon involves intraoperative cut down of the juncture of RUL and bronchus intermedius, with risks of cutting into tumor. The mess and imprecision would lead to sampling of the proximal margin for tumor presence, and more than likley result in a pneumonectomy. This novel technique of combined endoscopic bronchoscopy with extrinsic pinching of the bronchus intermedius--Bronchial Pinch Bronchoscopy, will allow a mobile carcinoid to be reduced distally away from the RUL orifice and with confidence, fire a stapling device proximal to the extrinsic pinch, increasing the chance of a negative margin and ultimately saving the RUL, and the patient from a pneumonectomy.CLINICAL IMPLICATIONS: The novel technique of Bronchial Pinch Bronchoscopy can be applied for mobile carcinoid tumors in main bronchus with simultaneous endoscopic confirmation of successful reduction of tumor distally. This can potentially increase the ease of a successfully stapled proximal bronchial margin negative of tumor, and in special circumstances like this, avoidance of a pneumonectomy.DISCLOSURE: The following authors have nothing to disclose: Peter Tsai, Venkata Bandi, Sandeep Markan, Kalpalatha GuntupalliNo Product/Research Disclosure Information.
- Bilateral Pulmonary Emboli as an Indirect Complication of Gastric Bypass Surgery. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):888A.
Pulmonary Vascular Disease Student/Resident Case Report Posters ISESSION TYPE: Medical Student/Resident Case ReportPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: Micronutrient deficiencies are a well known complication of gastric bypass surgery, with one such micronutrient being vitamin B12. As this vitamin's defeciency is associated with increased serum levels of homocystine, we are reporting a case of a patient who suffered multiple venous thromboses, including pulmonary emboli, in the setting of vitamin B12 defeciency secondary to gastric bypass surgery.CASE PRESENTATION: Our patient is a 54 years old lady who had morbid obesity managed with gastric bypass surgery in 1977. She presented to our emergency room complaining of nausea and anorexia for the preceeding 10 days associated with 10 lbs weight loss. In addition, she had exertional dyspnea, projectile vomiting and diarrhea. An EKG did not show any acute changes, and cardiac enzymes were within normal limits, ruling out myocardial ischemia. CT with contrast of the abdomen revealed superior mesenteric vein thrombosis along with portal vein thrombosis. CT angiography of the chest was also obtained, which showed multple bilateral pulmonary emboli. However, Doppler ultrasound of upper and lower extremities did not demonstrate any evidence of thromboses. In light of the emboli found, heparin infusion was started with a UFH target of 0.7. On the third day of admission, warfarin was initiated. Hypercoaguable workup showed factor II level to be slightly elevated, and the prothrombin 20210A mutation was negative. Her homocysteine level was found to be 96 "normal range 4-10 μmol/L" and she was a compound hetereozygote for MTHFR mutation. Vitamin B12 was 102 pg/ml and folic acid was 2.7 ng/ml. Oral replacement was initiated. The patient has done clinically well in outpatient follow up.DISCUSSION: Weight-reduction surgeries are an effective and widely accepted measure of rapid weight loss. As the population undergoing such surgeries is increasing, the side effects are becoming more easily identifiable. Vitamin defeciencies being a known side effect and preventable with oral supplements may have an underestimated impact. The patient's compliance and education are mandatory in such circumstances to prevent fatal complications such as multiple venous thromboses and embolization from vitamin B12 defeciency.CONCLUSIONS: Hyperhomocystenemia is a well known thrombogenic state. Vitamin B12 defeciency is an infrequent but significant cause that has to be prevented in the setting of gastric bypass surgery patients. Physicians have to recognize this risk factor in every gastric bypass surgery patient who develop thromboses or emboli.Reference #1: Nodular regenerative hyperplasia, portal vein thrombosis, and avascular hip necrosis due to hyperhomocysteinaemia O Buchel, T Roskams, B Van Damme, F Nevens, J Pirenne, J Fevery. Gut 2005;54:1021-1023. doi: 10.1136/gut.2004.055921Reference #2: Venous thrombosis associated with pernicious anaemia. A report of two cases and review MARTA BARRIOS & CAROL ALLIOT. Hematology, April 2006; 11(2): 135-138 DISCLOSURE: The following authors have nothing to disclose: Aahd Kubbara, Shipeng Yu, Danae Hamouda, Youngsook YoonNo Product/Research Disclosure Information.
- Combined Off-Pump Lung Transplantation and Multivessel Coronary Artery Bypass Surgery Through Minimally Invasive Approach. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):86A.
Cardiothoracic Surgery PostersSESSION TYPE: Original Investigation PosterPRESENTED ON: Wednesday, October 29, 2014 at 01:30 PM - 02:30 PMPURPOSE: Significant coronary artery disease is usually considered as a contraindication for lung transplantation (LTx). A surgical technique of concomitant off-pump lung transplant and coronary artery bypass grafting (CABG) is described.METHODS: Patient 1. 64-year-old man with interstitial lung disease, asbestosis andcoronary artery disease. LAS: 94.9. Off-pump bilateral sequential LTx and an off-pump two-vessel CABG through bilateral antero-axillary thoracotomies. The left internal mammary artery was harvested through the left thoracotomy. After left pneumonectomy, a saphenous vein graft was anastomosed to the descending aorta under side-biting clamp. A left off-pump LTx followed by off-pump anastomosis of the saphenous vein graft to the obtuse marginal branch was performed. A right off-pump LTx was then performed. Lastly, off-pump anastomosis of the left internal mammary artery-left anterior descending coronary artery anastomosis was performed. The ischemic time was 261 minutes for the left lung and 424 minutes for the right lung. Patient 2. 63-year-old man with interstitial lung disease, mantle radiation to his mediastinum for Hodgkin lymphoma, and left main coronary artery disease. LAS: 35.7. Off-pump single left LTx and an off-pump two-vessel CABG through a left antero-axillary thoracotomy. After the left pneumonectomy, a saphenous vein graft was anastomosed to the descending aorta. An off-pump left LTx, followed by off-pump anastomoses of the saphenous vein graft to the ramus intermedius and sequentially to the left anterior descending coronary artery was performed. The ischemic time was 236 minutes.RESULTS: Patient 1 was extubated on postoperative day (POD) 3 and was discharged home on POD 18. At 6-month follow up, he is doing well with FVC: 2.59 liters (59%) and FEV 1 1.52 Liters (46%). Patient 2 was extubated on POD 1 and was discharged home on POD 22. Postoperative CT angiography showed widely patent grafts (Figure 1). At 4-year follow up, he is doing well with FVC 2.77 liters (65%) and FEV1 2.42 liters (82%).CONCLUSIONS: Combined off-pump LTx and multi-vessel off-pump CABG through minimally invasive approach is technically feasible, and can provide excellent outcomes for this sick patient population.CLINICAL IMPLICATIONS: Novel surgical technique is described to perform concomitant lung transplant and coronary artery bypass through minimally invasive approach. Lung transplant surgeons can learn to improve their surgical skills.DISCLOSURE: The following authors have nothing to disclose: Yoshiya Toyoda, Norihisa Shigemura, Akira ShioseNo Product/Research Disclosure Information.
- Application of Cabrol Technique in Coronary Artery Bypass Grafting. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):85A.
Cardiothoracic Surgery PostersSESSION TYPE: Original Investigation PosterPRESENTED ON: Wednesday, October 29, 2014 at 01:30 PM - 02:30 PMPURPOSE: In coronary artery bypass surgery, proximal anastomosis between the ascending aorta and an arterial or venous graft may be conducted by side-to-side maneuver (Cabrol-type). We evaluated the long-term clinical outcome and aortocoronary graft patency of Cabrol-type proximal anastomosis in coronary artery bypass grafting (CABG).From 2002 to 2012, 460 patients (age, 64.7 ± 8.3 years) underwent CABG using Cabrol technique. The graft configuration included the anastomosis of saphenous vein (SV) to saphenous vein (n = 266), SV to radial artery (RA) (n = 65), RA to SV (n = 108), RA to RA (n = 8), and others (n = 11) (Figure). The mean follow-up duration was 50.3 ± 32.3 months. Postoperatively, coronary computed tomography angiography (CTA) was checked in 362 patients (78.7%).RESULTS: The operative mortality was 3.9%. The actuarial rate of the overall survival at 1, 5, and 10 years was 97.7% ± 0.7%, 88.6% ± 1.6%, and 70.4% ± 4.0%, respectively. The actuarial MACCE-free survival at 1, 5, and 10 years was 97.7% ± 0.7%, 89.9% ± 1.6%, and 84.2% ± 2.8%, respectively. Of 301 patients who used LITA (in situ) to LAD anastomosis, 712 grafts (mean, 2.4 grafts per patient) were used in Cabrol-type anastomosis. The 1-, 2-, 5-, and 8-year patency of graft in Cabrol-type anastomosis was 91.4% ± 1.2%, 88.8% ± 1.4%, 80.7% ± 2.2%, and 76.3% ± 3.7%, respectivelyCONCLUSIONS: This alternative proximal anastomosis technique in CABG demonstrated relatively comparable patency of aortocoronary graft.CLINICAL IMPLICATIONS: This Cabrol type proximal anastomosis technique can minimize ascending aortic injury and more effectively use graft length in CABG.DISCLOSURE: The following authors have nothing to disclose: Chan-Young NaNo Product/Research Disclosure Information.
- A Case of Plastic Bronchitis in an Adult Following Cardiopulmonary Bypass Surgery. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):798A.
Bronchology/Interventional Procedures Student/Resident CasesSESSION TYPE: Medical Student/Resident Case ReportPRESENTED ON: Tuesday, October 28, 2014 at 07:30 AM - 08:30 AMINTRODUCTION: Plastic bronchitis is a rare respiratory condition seen in children with an underlying bronchial disease with mucus hypersecretion or a cardiac defect. The disease is characterized by marked airway obstruction due to formation of large gelatinous or rigid bronchial casts. Type I casts, which are composed of inflammatory cells and fibrin, are associated with pulmonary diseases with bronchial inflammation. Type II casts, which are acellular and composed mainly of mucin, are associated with congenital heart disease especially following surgical repair.CASE PRESENTATION: A 54 year-old man without prior lung disease presented with angina, severe multi-vessel coronary artery disease, mitral regurgitation, and decompensated heart failure. Within hours of cardiopulmonary bypass surgery, he developed hypoxemic and hypercapnic respiratory failure with drastically elevated peak inspiratory pressures on mechanical ventilation. Chest x-ray revealed bilateral infiltrates. Airway inspection showed thick, rubbery, glue-like casts in the trachea and throughout the entire endobronchial tree, which could not be readily cleared by flexible bronchoscopy. Therefore, the patient underwent emergent extracorporeal membrane oxygenation and rigid bronchoscopy to remove the extensive plugs. Histology revealed proteinaceous and mucoid material with few inflammatory cells, consistent with type II plastic bronchitis. The patient subsequently required daily flexible bronchoscopy for a week to remove segmental and subsegmental plugs using forceps, brushes, and suctioning. He also received treatments with bronchodilators, N-acetylcysteine, Dornase Alfa, Budesonide, antibiotics, and intrapulmonary percussive ventilation. With these measures, the burden and viscosity of secretions declined, and the patient was successfully extubated.DISCUSSION: Various treatments for plastic bronchitis have been described, but the mainstay of therapy is extraction of the thick mucus plugs. Commonly, the bronchial casts are too soft and friable to remove with forceps but too thick to suction. We describe a novel technique of twirling the casts around a cytology brush allowing for more effective, intact removal. Mucolytic agents also likely enhanced extraction of the casts.CONCLUSIONS: Type II plastic bronchitis is rare and described mostly in children with congenital cardiac defects mainly following surgical repair. Plastic bronchitis is quite rare in adults, and this case likely has a similar underlying mechanism which resulted in life-threatening respiratory failure requiring significant bronchoscopic interventions.Reference #1: Madsen P et al. Plastic bronchitis: new insights and a classification scheme. Paediatr Respir Rev. 2005 Dec;6(4):292-300Reference #2: Eberlein MH et al. Plastic bronchitis: a management challenge. Am J Med Sci. 2008 Feb;335(2):163-9Reference #3: Kunder R et al. Pediatric plastic bronchitis: case report and retrospective comparative analysis of epidemiology and pathology.Case Rep Pulmonol. 2013;2013:649365DISCLOSURE: The following authors have nothing to disclose: Jason Lee, Gaurav Singh, Vibha Mohindra, Weichia Chen, Allison FriedenbergNo Product/Research Disclosure Information.
- Gaseous Bowel Distention: An Atypical Sign of Acquired Tracheoesophageal Fistula (TEF). [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):784A.
Bronchology/Interventional Student/Resident Case Report Posters ISESSION TYPE: Medical Student/Resident Case ReportPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: Tracheoesophageal Fistula (TEF) is a rare (≤ 1%) but serious complication of tracheostomy caused by mucosal ischemia/abrasion secondary to prolonged intubation and use of high tracheal cuff pressures (≥ 30 cm H2O). We describe a challenging case of a patient on chronic ventilator support who presents with, multiple admissions for ventilator associated pneumonia (VAP), associated with gaseous bowel distention, was eventually found to have TEF on flexible bronchoscopy.A 31 y/o man on chronic ventilator support was brought to the ICU for worsening hypoxemia and hypotension. He had h/o quadriplegia secondary to a gunshot wound, chronic ventilator dependent respiratory failure with established tracheostomy and PEG for past 5 years. Patient was diagnosed with severe sepsis secondary to VAP after chest X-ray and CT scan showed increased bibasilar infiltrates. This presentation was similar to one of his multiple previous admissions. Patient was found to have worsening abdominal distention, with bubbling from the PEG site. CT scan of the abdomen and pelvis without contrast showed distention of multiple loops of small bowel and proximal colon, suggestive of an ileus pattern, with no evidence of obstruction (see images). Abdominal X-rays from the prior 8 months showed continued distention of the intestinal loops without focal mechanical obstruction. His tracheal cuff pressures from last 6 months ranged from 24-30 cm H2O. Subsequently, a diagnosis of TEF was considered, but CT scan of the neck failed to show TEF. Flexible bronchoscopy, showed two small indentations on the posterior tracheal wall at the site of the tracheostomy cuff with intermittent drainage (see images). Patient was diagnosed with TEF. Considering patient being a poor surgical candidate, a longer tracheostomy tube was inserted to bypass the fistulae and tracheal cuff pressure to be maintained at < 25 cm H2O.DISCUSSION: This case illustrates challenges related to the diagnosis of TEF. Abdominal gaseous distension is a known clinical manifestation of TEF with esophageal atresia in the neonatal period, due to airflow through the fistula into the esophagus. However, while reported in neonates, it has not been reported as a clue in diagnosing TEF in older populations.CONCLUSIONS: With increasing use of tracheostomy in recent times, awareness of potential complications and their management is needed. TEF is primarily managed surgically or by stent placement, however, placement of a longer tracheostomy tube to bypass TEF with use of total parenteral nutrition (TPN) may be an option in certain patient populations. Reference #1: Intermmittent Gaseous Bowel Distention: Atypical Sign of Congenital Tracheoesophageal Fistula. Pediatric Pulmonology 44:244-248Reference #2: Acquired Tracheo-oesophageal fistula in adults. Continuing Education in Anaesthesia : Critical Care and pain. Volume 6 November 3 2006DISCLOSURE: The following authors have nothing to disclose: Karan Mahajan, Sameer Patel, Sanjay ShahNo Product/Research Disclosure Information.
- Emerging Clarithromycin Resistant Mycobacterium fortuitum in Post Cardiac Surgery Sternal Wound Infection. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):352A.
Surgery Student/Resident Case Report PostersSESSION TYPE: Medical Student/Resident Case ReportPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: Mycobacterium fortuitumsternal wound infection following cardiac surgery is a rare occurrence but has considerable morbidity because of emergence of resistant strains. We present a patient who was successfully treated for sternal wound infection caused by a Clarithromycin resistant M. fortuitum (CRMF).CASE PRESENTATION: A 62-year-old male with history of dyslipidemia, hypertension, asthma, and nicotine dependence underwent coronary artery bypass grafting and left ventricular aneurysmorrhaphy after having myocardial infarction. He developed a small wound at the cephalic end of the sternotomy scar draining thick, brown, odorless discharge three weeks postoperatively. He was immediately taken to the operating room for debridement of a track which was noticed extending from the cephalic end. No organisms were seen on direct staining but after two days, many acid fast bacilli were identified in the aerobic culture. Patient's empirical antibiotics were switched to clarithromycin, levofloxacin and linezolid. Two weeks after discharge, the organism was identified as Mycobacterium fortuitum by High Performance Liquid Chromatography (HPLC) with resistance to clarithromycin and sulfamethoxazole/trimethoprim (TMP/SMZ). With a six month course of levofloxacin and doxycycline, the patient had an excellent recovery including wound closure. No recurrence was noted during two years of follow-up.Infection due to M. fortuitum is often resistant to all the standard anti-tuberculosis drugs, but clarithromycin, TMP/SMZ, doxycycline, and ciprofloxacin are usually recommended in combination according to in the vitro sensitivity data. Many M. fortuitum used to be susceptible to clarithromycin, but studies have shown that all isolates of M. fortuitum contain an erythromycin methylase gene, erm, which may induce macrolide resistance and contribute in an emergence of clarithromycin resistant strains. Consequently combination therapy is recommended for M. fortuitum with at least two susceptible medications in the era of emerging CRMF.CONCLUSIONS: A high index of suspicion based on clinical presentation is essential to diagnose Clarithromycin resistant M. fortuitum (CRMF) post cardiac surgery sternal infection for proper long term therapy. Beside surgical debridement appropriate blend of antibiotics based on sensitivity will ensure complete healing and prevent recurrence.Reference #1: Muthusami JC, Vyas FL, Mukundan U, Jesudason MR, Govil S, Jesudason SRB. Mycobacterium fortuitum: An iatrogenic cause of soft tissue infection in surgery. ANZ J Surg 2004;74:662-666.Reference #2: Unai S, Miessau J, Karbowski P, Bajwa G, Hirose H. Sternal wpund infection caused by Mycobacterium chelonae. J Card Surg 2013;28:687-692.Reference #3: Shah AK, Gambhir RPS, Hazra N, Katoch R. Non tuberculous mycobacteria in surgical wounds-a rising cause of concern? Indian J Surg 2010;72:206-210.The following authors have nothing to disclose: Hafiz Abdul Moiz Fakih, Shahbaz Ahmad, Emmanuel EluezeNo Product/Research Disclosure Information.