Measles remains a major cause of childhood morbidity worldwide despite the availability of an effective vaccine. Beyond its acute clinical manifestations, measles induces profound but transient immune dysfunction, predisposing affected children to secondary and opportunistic infections. Visceral leishmaniasis (VL) is a systemic protozoal infection caused by Leishmania species and is characterized by prolonged fever, hepatosplenomegaly, pancytopenia, and high mortality if left untreated. The coexistence of severe measles and VL poses a significant diagnostic challenge because of their overlapping clinical and laboratory features. We report the case of a previously healthy three-year-old boy admitted to the pediatric intensive care unit with severe PCR-confirmed measles complicated by acute respiratory failure and hemodynamic instability requiring invasive mechanical ventilation and vasoactive support. Persistent fever, progressive hepatosplenomegaly, and cytopenias despite initial intensive management prompted further investigation, which demonstrated positive rK39 antigen testing and elevated anti-Leishmania antibody titers, establishing the diagnosis of VL. The patient was successfully treated with liposomal amphotericin B, vitamin A supplementation, IV immunoglobulin, and supportive intensive care, resulting in complete clinical recovery without sequelae. To the best of our knowledge, no pediatric case of measles-VL co-infection has been documented previously. This case highlights the diagnostic complexity of persistent systemic inflammation and cytopenias in children with severe measles and illustrates the importance of considering endemic opportunistic infections when the clinical course is atypical or prolonged. The favorable outcome emphasizes the value of early recognition, timely pathogen-directed therapy, and multidisciplinary management, while reinforcing the critical role of measles vaccination in preventing severe disease and its infectious complications.

Hantavirus infection is an uncommon but potentially life-threatening zoonotic disease that requires early recognition in the emergency department. This letter summarizes the epidemiology, transmission, clinical manifestations, diagnostic approaches, and current management of hantavirus pulmonary syndrome (HPS) and hemorrhagic fever with renal syndrome (HFRS). Although the initial presentation is often nonspecific, rapid progression to respiratory failure, shock, or acute kidney injury may occur, necessitating prompt diagnosis and aggressive supportive care. Serologic testing remains the primary diagnostic modality, while treatment is largely supportive, with extracorporeal membrane oxygenation reserved for selected patients with severe HPS. Increased awareness among emergency physicians and timely implementation of infection-control measures are essential to improve patient outcomes and reduce mortality.

The fourth biennial European Respiratory Society (ERS) Respiratory Failure and Mechanical Ventilation Conference was held in Rotterdam in February 2026. The 3-day conference included symposia, practical workshops, meet the expert sessions, oral and poster abstract presentations and collaborative research roundtables on acute and chronic respiratory failure in adults and children. The conference was an opportunity to attend sessions delivered by experts and for early career members to expand their knowledge, skills and professional networks. In this review, early career members of ERS Assembly 2 (Respiratory Intensive Care) summarise the 16 conference symposia, which covered a broad range of multidisciplinary subjects.

As the burden of pediatric critical illness is heaviest in low- and middle-income countries (LMIC), educating trainees in recognizing and treating the sickest children may attenuate high mortality rates, morbidity and hospital length of stay. Remote education is increasingly utilized to provide effective teaching across borders. We describe the efforts of an international collaborative group created to supplement pediatric critical care education through online didactics. An essential part of this has been integrating case presentations into the curriculum to supplement traditional topic-based teaching. Ninety-five case presentations have been performed, of which acute respiratory failure, infectious disease without sepsis and neurologic disease were the most common pathologies discussed. In addition, we considered issues such as the applicability of guidelines developed in high-income countries (HIC) and the ethical complexity of caring for critically ill children in LMIC, which often have limited resources. Case presentations also allow a deeper appreciation of the circumstances in which colleagues provide care for critically ill children in RLS and foster bidirectional learning. Discussion of cases with international faculty can enrich discussions, strengthen global bonds and promote collaboration among the larger community.

Acute nontraumatic mediastinitis is a rare and potentially life-threatening condition. In children, management strategies remain poorly standardized. Here, we describe four pediatric cases: two originating from cervical infections (descending necrotizing mediastinitis [DNM]) and two with indeterminate source. The first two patients presented with febrile otorhinolaryngologic symptoms, one complicated by secondary respiratory failure and the other by possibly toxin-related symptoms. The third presented with varicella and scarlet fever-like rash, complicated by multiorgan involvement secondary to a probable toxic shock syndrome. The fourth case presented with fever without focus and shoulder pain. Three patients developed secondary pleural effusions. In three cases, diagnosis was confirmed by computed tomography (CT) scan and in one case by MRI. None had necessitated surgical drainage. All patients were managed conservatively with prolonged antibiotic therapy and achieved complete recovery without sequelae. These cases suggest that, in selected pediatric patients, a conservative, antibiotic-based approach can be both safe and effective.

Acute mountain sickness (AMS) is common after ascent to altitude, yet individual susceptibility remains difficult to predict and diagnosis relies on subjective report. Sleep disturbances and nocturnal hypoxaemia at altitude may provide insight, but their relationship to AMS is incompletely understood. In a sub-study of a randomized, placebo-controlled trial, 112 healthy, lowland-dwelling volunteers rapidly ascended to 3810 m. AMS was assessed using the 2018 Lake Louise Scoring System (LLSS); sleep scores were recorded separately. Overnight monitoring used the WatchPAT300 device to measure oxygen saturation, oxygen desaturation index, respiratory disturbance index, apnoea-hypopnoea index and inferred sleep stage. Thirty-eight participants (34%) developed AMS by the 2018 LLSS criteria. Compared with unaffected individuals, those with AMS had lower mean nocturnal S p O 2 , greater cumulative time with S p O 2  < 70%, and higher oxygen desaturation index and respiratory disturbance index on nights 2 and 3. Respiratory disturbance indices improved only in participants without AMS, while AMS-positive subjects demonstrated persistent reductions in estimated deep sleep, and higher self-reported sleep disturbance scores. A sensitivity analysis applying 1993 LLSS criteria identified 64 subjects (58%) with AMS, and strengthened between-group differences in nocturnal S p O 2 , but not respiratory indices. In exploratory multivariable analysis, cumulative time with S p O 2  < 70% and first-night sleep disturbance score at altitude remained independently associated with AMS. In summary, nocturnal hypoxaemia was associated with AMS status under both 2018 and 1993 criteria, while failure of respiratory index normalization and impaired sleep architecture are associated with AMS persistence, suggesting a longitudinal signal of failed acclimatization. These findings support further examination of sleep-related metrics in relation to AMS assessment.

The use of therapeutic plasma exchange in tandem with continuous renal replacement therapy (CRRT) and extracorporeal membrane oxygenation (ECMO) has been well described; however, evidence showing the use of extracorporeal photopheresis (ECP) in tandem is lacking. Here we report a consult to perform ECP in tandem with CRRT for a 26-year-old female with a history of severe aplastic anemia who underwent allogeneic hematopoietic stem cell transplant, complicated by steroid-refractory acute graft-versus-host disease, vaso-occlusive disease, thrombotic microangiopathy, adenoviremia, and acute renal and respiratory failure. We performed six tandem ECP procedures (seven total) over 19 days, until the patient's decline resulted in compassionate discontinuation of care. During our procedures, CRRT managed the ionized calcium and adjusted the calcium infusion rate accordingly. We encountered red blood cell and optic bowl sensor alarms during ECP. This case, to our knowledge, is the first to describe the inpatient use of ECP in tandem with CRRT.

Alveolar regeneration failure due to alveolar stem cell senescence is a defining feature of idiopathic pulmonary fibrosis (IPF), yet the epithelial mechanisms underlying this dysfunction remain incompletely understood. Recent single-cell and lineage-tracing studies have identified distinct transitional epithelial states, such as pre-alveolar type-1 transitional cells, damage-associated transient progenitors, and alveolar-basal intermediates, which normally serve as intermediates during type 2 alveolar cell (AT2) to type 1 alveolar cell (AT1) differentiation. While these states are transient and successfully resolved during acute lung injury, these populations persist abnormally in IPF lungs, exhibiting features of senescence, cell-cycle arrest, and impaired differentiation.We review recent evidence showing how premature alveolar epithelial senescence, suppression of developmental regenerative programmes, and sustained transforming growth factor-β signalling within the fibrotic niche contribute to this disruption. These factors promote the accumulation of dysfunctional transitional cells, such as cytokeratin (KRT)8[+]/KRT17[+] basaloid cells, which fail to regenerate alveolar epithelium and instead contribute to fibrosis and bronchiolisation through pathological crosstalk with macrophages and fibroblasts. Notably, similar transitional states appear in COVID-19-associated acute respiratory distress syndrome, but they typically exhibit minimal features of senescence and resolve during regeneration, underscoring the pathological importance of accelerated epithelial senescence in IPF.Understanding the molecular checkpoints that regulate transitional cell fate may offer novel strategies to restore regenerative capacity in fibrosing lung diseases.

Congenital tuberculosis (TB) is a rare condition, and diagnosis is challenging due to its nonspecific clinical presentation and rarity. It has a very high case-fatality rate (estimated at 30%-50%). We report the case of a 2-week-old male neonate, born from an uncomplicated diamniotic, dichorionic twin pregnancy at 36 weeks 1 day's gestation, who presented with poor feeding and low-grade fever. Blood, urine, and cerebrospinal fluid (CSF) cultures, as well as nasopharyngeal and CSF viral polymerase chain reactions were negative. However, persistent poor feeding and rising inflammatory markers prompted continued hospitalization. On the fourth day of admission, he developed acute hypoxemic, hypercarbic respiratory failure with apneas and progressive lung parenchymal disease requiring intubation. The diagnosis of congenital TB was confirmed through endotracheal aspirates. He was initiated on TB treatment but ultimately developed a paradoxical reaction, requiring readmission and initiation of corticosteroids. His mother, father, and twin brother were initially asymptomatic. His twin was subsequently admitted to the hospital and was diagnosed with congenital TB as well. His mother was ultimately diagnosed with genitourinary TB based on an endometrial biopsy. This case contributes to the limited literature on congenital TB, highlighting the broad clinical spectrum and complications in managing the disease. Additionally, the unique presentation of disseminated congenital TB in an infant with an asymptomatic mother and a fraternal twin who initially did not require hospitalization underscores the importance of heightened awareness of tuberculosis during pregnancy, particularly in populations at risk, to facilitate early diagnosis and prevent perinatal transmission.

Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma. Hematologic malignancies are known precipitants of disseminated intravascular coagulation (DIC), and the coexistence of these conditions is associated with poor outcomes; however, large-scale data specifically examining concurrent DLBCL and DIC are limited. We performed a retrospective cohort study using the National Inpatient Sample (NIS) to evaluate in-hospital mortality among adult hospitalizations with DIC and/or DLBCL identified using ICD-10 codes. Adults aged ≥ 18 years with a diagnosis of DLBCL and/or DIC were included. In-hospital mortality among patients with concurrent DLBCL and DIC was 54.1%, significantly higher than mortality observed in patients with either condition alone (p < 0.001). In multivariable analysis restricted to patients with both DLBCL and DIC, independent predictors of increased mortality included HIV/AIDS (aOR 4.266, 95% CI: 1.886-9.649; p < 0.001), septic shock (aOR 3.201, 95% CI: 2.305-4.443; p < 0.001), mechanical ventilation (aOR 2.948, 95% CI: 2.175-3.995; p < 0.001), vasopressor use (aOR 2.759, 95% CI: 1.789-4.255; p < 0.001), chronic kidney disease (aOR 2.523, 95% CI: 1.596-3.989; p < 0.001), acute kidney injury (aOR 1.884, 95% CI: 1.347-2.637; p < 0.001), Black race (aOR 2.221, 95% CI: 1.418-3.477; p < 0.001), and Asian or Pacific Islander race (aOR 2.383, 95% CI: 1.329-4.271; p = 0.004) compared to White patients. Bleeding events, thromboembolic complications, stem cell transplantation, and CAR-T therapy were not independently associated with mortality. These findings demonstrate that among patients with DLBCL, the development of DIC is associated with markedly elevated in-hospital mortality, driven predominantly by critical illness, organ dysfunction, and comorbidity burden rather than bleeding or thrombosis alone. Racial disparities in outcomes were independently observed after adjusting for illness severity and comorbidities, warranting further investigation. Early recognition of DIC in patients with DLBCL and aggressive management of systemic complications, particularly septic shock, respiratory failure, and renal dysfunction, may help mitigate disease severity and improve outcomes.