Leadership in Action: A Student-Run Designated Emphasis in Healthcare Leadership

Morcel Hamidy, BS¹

Kishan Patel, BS¹

Sonul Gupta, BS¹,

Manparbodh Kaur, BS¹

Jordan Smith, MD²

Haeli Gutierrez, BS¹

Mohamed El-Farra, MS¹

Natalie Albasha, BS MS¹

Priya Rajan, BA¹

Secilia Salem, BS¹

Somiya Maheshwari, BS¹

Kendrick Davis, PhD³

Brigham C Willis, MD, MEd⁴

¹Medical Student, UC Riverside School of Medicine

²Resident, Loma Linda Pediatric Residency Program

³Associate Dean of Assessment and Evaluation, UC Riverside School of Medicine

⁴Senior Associate Dean of Medical Education, UC Riverside School of Medicine

Abstract 

Background: Throughout medical school students are exposed to a variety of fields within medicine, but structured leadership and teaching opportunities are limited. There is a need for more training to prepare students of all backgrounds to be future leaders in all healthcare realms, especially critical care medicine, in order to address the lack of diversity seen in leadership positions.

Methods: Implemented entirely by students with faculty guidance, the Kern model was applied to develop a student-run longitudinal Designated Emphasis in Healthcare Leadership. This program was implemented at a medical school leading the nation in creating opportunities for diverse and underrepresented groups in medicine. Students are involved in structured leadership lectures, projects, and mentorship, and there is an emphasis on learning by doing. A survey was sent out to all present and past student participants to assess its acceptability and effectiveness.

Results: A post-participation survey found that a total of 96% of participants identified themselves as healthcare leaders, felt confident leading a team, and felt comfortable working with a diverse team. Further, 96% of participants agreed or strongly agreed they would recommend the program to other medical students. Qualitative feedback revealed that participants felt they learned how to “apply leadership skills to the healthcare setting” and were provided an “environment to grow and practice vital leadership skills that will help [them] be effective clinicians.”

Conclusions:  Our initial research shows that introducing a longitudinal leadership program into Medical Education may allow participants to start developing personal and professional leadership qualities. The program is well-received by the students and preliminary data shows that there may be increase in leadership capabilities when participating in this program. Such a program can enable future healthcare providers to become leaders in their own fields, so that they can hone interpersonal communication skills, bridge the gap of representation in leadership positions, and lead teams effectively.

Introduction 

Responding to critical care emergencies requires effective coordination and management of multiple healthcare providers. Hence, leadership skills and multidisciplinary teamwork are recognized as significant curricular milestones and learning objectives for pulmonary and critical care medicine (PCCM) learners by the Accreditation Council for Graduate Medical Education (ACGME) (1). Effective communication and leadership acumen are critical non-medical aspects of successful patient management in the intensive care unit (ICU), often leading to increased performance and improve patient outcomes (2,3). Despite this, leadership training opportunities are variable from program to program, with no clear consensus on the components of effective leadership curricula. As a result, there are no guidelines on a standardized leadership curricula in critical care medicine or undergraduate medical education (4,5).

There has been some progress within the undergraduate medical education community to integrate healthcare leadership into medical curricula. The number of MD-MBA dual degree programs grew by 25% from 2011 to 2012 alone (6). However, only a fraction of medical schools provide students with opportunities for medical leadership training, with courses typically being elective (7). The Association of American Medical Colleges (AAMC) stated that graduating medical students should learn “leadership skills that enhance team functioning, the learning environment, and/or the health care delivery system” (8). In 2015, a survey showed that 46 out of 88 allopathic medical schools had some form of leadership curriculum.7,9 The curricula of these schools included: mentoring programs (65.1%), dual degree programs (54.5%), workshops (48.8%), seminar/lecture series (41.9%), courses (41.9%), or single seminars (18.6%). However, despite the rise in importance of leadership education, only 19% percent of those institutions offered a longitudinal leadership education throughout medical school (9).

There is also a need to address inequities in healthcare leadership. A recent AAMC report on diversity and inclusion in Medical School Deans found that only 11% of US Medical School Deans are underrepresented in medicine (URiM). Further, the report highlighted that this number has been stagnant over the past 30 years, growing from 7% in 1991 to only 11% in 2020 - an alarming trend highlighting the barriers to ensuring appropriate representation in our healthcare leadership positions (10). The UC Riverside School of Medicine (UCR SOM) has been at the forefront of bridging the gaps in inequities. It was recently named the sixth most diverse medical school in the nation based on metrics of student enrollment of underrepresented in medicine background, percent of graduates practicing in primary care and rural medicine, and percent of graduates eventually working in underserved regions (US News). The UCR SOM led these metrics with an outstanding 34.1% student population from underrepresented in medicine backgrounds. Hence, programs led at the UCR SOM reflect a growing trend attempting to bridge gaps in leadership representation (11).

To address these needs, we created a student-run leadership program using the Kern Six-Step Model highlighting competencies considered fundamental to leadership development (12). The goal was to develop longitudinal leadership training at the undergraduate medical education level to train future providers to have confidence and readiness to manage interdisciplinary teams in complex medical situations, such as the ICU. As a student-run program with support of faculty, we report a detailed description of the Healthcare Leadership Program (HLP) in the hopes that it may be helpful to implement a standardized leadership training model at other institutions.

Methods

To implement the Healthcare Leadership Program (HLP) as a Designated Emphasis within Medical Education, students met with a faculty mentor to establish topics and activities (Appendix A and Appendix B) that met credit requirements set by the School of Medicine. A leadership structure (Appendix C) that focused on student oversight was then established. In addition to the lecture and workshop curriculum, students were expected to actively participate in mentorship and projects. This amounted to a total of 30 units distributed across the four-year program, allowing for 320 contact hours with 304 required hours to obtain a Designated Emphasis in Healthcare Leadership. Upon completion, students are given a distinction on their Medical Student Performance Evaluation (MSPE) and their diplomas. Selection of students was done through an application (Appendix D) and interview process.

Special attention was taken to accept students from a variety of diverse backgrounds in order to help bridge inequities currently seen in healthcare leadership. This was done through an interviewing process and holistic review of applicants. The number of students increased annually as the program grew stronger and obtained more resources. The initial cohort started with 8 total students throughout all medical school years, and currently the number of students per year is capped at 10 students per year due to restraints in educational resources available. The current attrition rate is 4% of students deciding to not continue with the program.

For the first-year curriculum (Appendix A), students were expected to complete a minimum of 14 hours. The aim of the year was to build a strong leadership foundation by teaching leadership fundamentals, helping students understand their own strengths, and how to effectively collaborate with peers. Activities included students learning about their own strengths and weaknesses through a formalized StrengthsFinder assessment. Students were also taught to improve efficiency and reduce waste in organizations through LEAN/6 Sigma White and Yellow Belt training. Further, guest speakers supplemented learning by teaching topics including communication skills, leading meetings, conflict resolution, and networking. A full list of topics taught during the 2018-2019 academic year are included in Appendix A.

For the second-year curriculum (Appendix B), students were expected to complete a minimum of 10 hours. During the second-year, we focused on growing students into healthcare leaders. The curriculum focused on healthcare leadership and medical management by teaching the most common and relevant principles from Masters in Business Administration (MBA), Masters in Public Policy (MPP), and Masters in Public Health (MPH) programs. The goals and objectives for the students were taught through mixed media including online lectures, lecturer workshops, and discussions with community leaders. A full list of topics taught during the 2019-2020 academic year are included in Appendix B.

For the third and fourth-year curriculum, the focus was to have student leaders practice what they learned in the first two years and apply it to the professional world. For the third and fourth year, students engage in selectives. Selectives are 3 weeks during the third year totaling 12 units for 120 hours and 4 weeks during the fourth year totaling 16 units for 160 hours. The selective was comprised of five different parts including hands-on experience in a clinical setting, observation of current practices, formal report of possible improvements, resource summaries, and continued participation in mentorship programs. Selectives are self-created by HLP students, with the help of HLP board members and faculty advisors. Third and fourth-year students were assessed via a form included in Appendix E.

It is important to note that in this student-run program, the students themselves were responsible for coordinating and executing the lectures. The majority of lectures were given by students from previous cohorts, and this cycle continued where each cohort was responsible for educating the following cohort. Occasionally, guest lecturers were asked to come and teach the students. The material was saved and uploaded to an online drive for the following years to be able to access in order to maintain fidelity of the curriculum.

Outside of the structured curriculum, each student is required to work on a project of their choice in the first two years of medical school. The goal of this requirement is to allow student leaders to gain experience in navigating bureaucracies, innovation, and building teamwork and networking skills through hands-on experience on a topic they feel passionate about. Students pay special attention to initial measurements to identify baseline data, implementation of intervention, and collecting results, with an ultimate goal of publishing the project. At the end of the project, students make a formal presentation to the HLP Board and School of Medicine Leadership.

This project also prepares students for their fourth-year capstone projects. During this time students have the opportunity to spend four weeks at a clinical site, observing current operating procedures in an effort to identify strengths that they can employ in their future practice, and weaknesses that could be improved. Students are assigned a faculty advisor and are responsible for designing one intervention aimed at improving efficiency and reducing waste, based on their observations. After incorporating feedback, students have the opportunity to implement their proposed project at the site.

HLP is made up of general members and executive board members, all exclusively students. Appendix C highlights the structure of the executive board which is made up of three tiers. The first tier includes the Member Development Officer, Operations Officer, Medical Education Officer, and Community Relations Officer who are primarily responsible for first year HLP general members. The second tier consists of the Chief Innovation Officer, Chief Operations Manager, Chief Medical Education Officer, and Chief Community Relations Officer and are responsible for the second year HLP students in addition to managing the officers in tier one. In tier three, the Chief Executive Officer oversees the rest of the officer board and manages communication with the School of Medicine Leadership and administration. Finally, the HLP Alumni Advisory Board is a network of graduated HLP medical students who offer guidance and support to the executive board. The specific responsibilities of the executive board positions can be found in Appendix C.

In addition to lectures and workshops, students are expected to participate in formal mentorship. Mentorship pairing occurred in the first year, after students shared a biography of their past experiences, interests, and passions. The Community Relations Officers met with each individual student to discuss their interests and career aspirations. The Officer then works with the rest of the Executive Board and Advisors in helping place students with the right mentor. Students in the program are connected with local CEO’s, CMO’s, Dean’s, Business Specialists, and Residency Program Directors. The mentor-mentee relationship is cultivated over the duration of the medical student’s training, as the students finalize their career path and passion projects.

Aligning with Kern Model Step 6: Evaluation and Feedback (12), surveys were sent out periodically to evaluate the effectiveness of the curriculum. A survey was sent out regarding all first-year lectures which was completed by the entire cohort (Appendix F). Results of this survey helped plan the first-year lectures for the next cohort. A survey was also sent out to assess the effectiveness of the program as a whole, which was completed by the entire HLP Cohort (Appendix G). The Institutional Review Board (IRB) did not review our project as it was conducted for the purposes of course improvement and evaluation, and therefore, IRB review was not required.

Results

The program was implemented with a total cohort of 25 participants. A post-participation survey (Appendix G) was sent to participants to understand their personal growth and learning throughout the program. Participant responses to various questions detailing their healthcare leadership education through HLP was noted using a questionnaire using a 1 through 5 scale, with 1 indicating very low, 2 indicating low, 3 indicating neutral, 4 indicating high, and 5 indicating very highly. Results are shown in Table 1.

Table 1. Participant questionnaire responses to various questions detailing their healthcare leadership education through HLP was noted using a questionnaire using a 1 through 5 scale, with 1 indicating very low, 2 indicating low, 3 indicating neutral, 4 indicating high, and 5 indicating very highly. The entire cohort of 25 students was surveyed.

Participants were also asked to note if they strongly disagree, disagree, neutral, agree, or strongly agree with statements reflecting on their personal capabilities as a leader. Results are included in Figure 1.

Figure 1. Results for the question “how strongly do you agree with the following statements” pertaining to personal leadership capabilities. The entire cohort of 25 students was surveyed. The y-axis represents the number of students that agree with the above statements.  

All 25 students of the cohort were surveyed for this data collection.

A total of 96% of participants agreed or strongly agreed that they identified themselves as a healthcare leader, felt confident leading a team, and felt comfortable working with a diverse team. Further, 96% of participants agreed or strongly agreed they would recommend the program to other medical students.

Students were given the opportunity to share comments throughout the survey. Participants felt they learned how to “apply leadership skills to the healthcare setting” and were provided an “environment to grow and practice vital leadership skills that will help [them] be effective clinicians.” Other comments highlight community building within HLP, such as “I have been able to meet people who are very much like-minded. That in itself is very nourishing.” Anecdotal evidence also suggests that students value HLP’s curriculum as it “prepares students for professional goals” and allows for “hands-on experience in grant writing and research.”

A prevailing theme among participants was that students enjoyed the autonomy of the program to explore their interests and passions. Students stated that, “Individuals lead in different manners and to only provide one cookie-cutter set of leadership instruction would be limiting to the diverse members of HLP” and that they enjoy the “flexibility to pursue anything [they] want under the large umbrella of leadership.”

However, with this flexibility and fluidity of the program, came some critiques as well. One student noted that, “The curriculum seems scattered to me … while it is good to learn a diversity of information, a lack of direction leaves the curriculum feeling disorganized.” Another recommendation was the desire for more networking opportunities with faculty and other students: “A lot of our speakers are Faculty, and I think we can learn some new perspectives and tools if we branch beyond our networks.” The current model of HLP was that the second, third, and fourth-year medical students help network to find mentors for the first-year students. Some students noted that perhaps we should, “encourage the first years to do so by hosting a seminar-like session where we could encourage networking [because] by doing it for them, we are limiting their own involvement and learning.”

The results of the Healthcare Leadership Program were also measured by the success of the projects that have started within the program. The dual nature of students being facilitators as well as learners was unique to HLP, as students played an active role in their education. Hands-on experience was integral and allowed students to participate in passion-driven specific ventures. 

For example, members of HLP participated in a Quality Improvement project at a Student-Run Free Clinic. After first observing the clinic flow, HLP members came together to brainstorm ways to optimize clinic efficiency and proposed a number of interventions. The team then presented changes to the Board of the Free Clinic, received approval, and implemented the interventions. This project improved the workflow and optimized efficiency of the Free Clinic, resulting in a statistically significant decrease in patient door-to-door times. Students then published this data at the American Medical Association Research Symposium December 2020 (Appendix H).

Discussion

Many demanding specialties, particularly PCCM, require extensive leadership skills. Despite this, most medical schools lack any formal, longitudinal leadership training integrated into the curriculum9. One possible reason for the lack of leadership curricula may be that there is a lack of consensus on what leadership competencies should be emphasized (13,14). Many have proposed a curriculum that focuses on emotional intelligence, self-reflection, and communication skills to be among the most effective (13,15,16,17). Our program encourages these skills via lectures as well as hands-on projects where they put leadership skills learned into practice in interdisciplinary clinical settings. Our program is focused on drawing out the passions and interests possessed by medical students, and teaching them to sharpen their leadership skills to be effective leaders. HLP is focused on a “learning-by-doing” model (17), where students are first equipped with the tools, they need to be effective and then allowed to practice these skills in projects they care about. 

HLP is an innovative Designated Emphasis that has been ongoing for four years. As a student led organization, the development has been flexible and adaptable to student needs and interests, with guidance by appropriate mentors for different topics. Our preliminary data shows HLP to be well received by the current cohort, in which 96% of students identified themselves as a healthcare leader. Further, 96% of participants agreed or strongly agreed they would recommend the program to other medical students. HLP is a dynamic, ever-changing program, where we utilize the innate skills and passions of use students to constantly reshape the curricula to fit the needs of the students in that cohort. Feedback is encouraged in every step of the program, as all students share the growth-mindset ideology of utilizing feedback to better the program.

As a new, developing program, HLP has some limitations. The program covers the most common leadership positions, but it does not cover all possible avenues of leadership, and some of the more unique positions may not be explored as in depth. Another limitation is that due to current resources, only a limited number of applicants can be accepted into the Designated Emphasis. In particular, one of the most limiting resources is available and engaged mentors. A strong and significant network of physician leaders is imperative for the program’s success.

It is our hope that HLP can be used as a template and be incorporated into the medical education curriculum at other schools as a Designated Emphasis, Selective, Thread, or Interest Group. The organized curriculum can be used as a guided lecture series throughout medical school but can also be utilized in PCCM residency programs. The program gives great exposure to what different leadership programs may look like, including Master’s and other graduate programs, and can be used as a guide for medical students and residents to focus their interests. Additionally, the HLP will create opportunities for building strong leadership skills early on that can help prepare future PCCM physicians of tomorrow.

Acknowledgements

We would like to acknowledge the founders of the Healthcare Leadership Program at UC Riverside School of Medicine: Matt Gomez MD, Nekisa Haghighat MD, MPH, Frances Tao MD, MPH, and Cassidy Lee MS, MPP, along with the help of their faculty advisor, Paul Lyons MD. We would also like to thank Ms. Elisa Cortez for her help with literature review.

References

1. Fessler HE, Addrizzo-Harris D, Beck JM, Buckley JD, Pastores SM, Piquette CA, Rowley JA, Spevetz A. Entrustable professional activities and curricular milestones for fellowship training in pulmonary and critical care medicine: report of a multisociety working group. Chest. 2014 Sep;146(3):813-834. [CrossRef] [PubMed]
2. Schmutz J, Manser T. Do team processes really have an effect on clinical performance? A systematic literature review. Br J Anaesth. 2013 Apr;110(4):529-44. [CrossRef] [PubMed]
3. Hunziker S, Johansson AC, Tschan F, Semmer NK, Rock L, Howell MD, Marsch S. Teamwork and leadership in cardiopulmonary resuscitation. J Am Coll Cardiol. 2011 Jun 14;57(24):2381-8. [CrossRef] [PubMed]
4. Clyne B, Rapoza B, George P. Leadership in Undergraduate Medical Education: Training Future Physician Leaders. R I Med J (2013). 2015 Sep 1;98(9):36-40. [PubMed]
5. Rosenman ED, Shandro JR, Ilgen JS, Harper AL, Fernandez R. Leadership training in health care action teams: a systematic review. Acad Med. 2014 Sep;89(9):1295-306. [CrossRef] [PubMed]
6. Goyal R, Aung KK, Oh B, Hwang TJ, Besancon E, Jain SH. AM last page. Survey of MD/MBA programs: opportunities for physician management education. Acad Med. 2015 Jan;90(1):121. [CrossRef] [PubMed]
7. Neeley SM, Clyne B, Resnick-Ault D. The state of leadership education in US medical schools: results of a national survey. Med Educ Online. 2017;22(1):1301697. [CrossRef] [PubMed]
8. AAMC organization. Core entrustable professional activities for entering residency. https://www.aamc.org/system/files/c/2/482194-epa4toolkit.pdf. Accessed October 21, 2021.
9. Richard K, Noujaim M, Thorndyke LE, Fischer MA. Preparing Medical Students to Be Physician Leaders: A Leadership Training Program for Students Designed and Led by Students. MedEdPORTAL. 2019 Dec 13;15:10863. [CrossRef] [PubMed]
10. U.S. medical school deans by Dean type And Race/ethnicity (URIM vs. non-URiM). AAMC. https://www.aamc.org/data-reports/faculty-institutions/interactive-data/us-medical-school-deans-trends-type-and-race-ethnicity (accessed March 21, 2022)..
11. Morse R, Castonguay A, Vega-Rodriguez, J, Brooks E, Hines K. Most Diverse Medical Schools. https://www.usnews.com/best-graduate-schools/top-medical-schools/medical-school-diversity-rankings. Published March 30, 2020 (accessed March 21, 2022).
12. Thomas PA, Kern DE, Hughes MT, Chen BY. Curriculum Development for Medical Education: A Six-Step Approach. Baltimore, MD: Johns Hopkins University Press;2015:1-300.
13. Stoller JK. Developing physician-leaders: a call to action. J Gen Intern Med. 2009 Jul;24(7):876-8. [CrossRef] [PubMed]
14. Lobas JG. Leadership in academic medicine: capabilities and conditions for organizational success. Am J Med. 2006 Jul;119(7):617-21. [CrossRef] [PubMed]
15. Stoller JK. Developing physician-leaders: key competencies and available programs. J Health Adm Educ. 2008 Fall;25(4):307-28. [PubMed]
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17. Reese, H. W. (2011). The learning-by-doing principle. Behavioral Development Bulletin. 2011;17(1):1-19. [CrossRef]

Cite as: Hamidy M, Patel K, Gupta S, Kaur M, Smith J, Gutierrez H, El-Farra M, Albasha N, Rajan P, Salem S, Maheshwari S, Davis K,  Willis BC. Leadership in Action: A Student-Run Designated Emphasis in Healthcare Leadership. Southwest J Pulm Crit Care Sleep 2022;24(3):46-54. doi: https://doi.org/10.13175/swjpccs 007-22 PDF

MSSA Pericarditis in a Patient with Systemic Lupus Erythematosus Flare

Antonious Anis MD

Marian Varda DO

Ahmed Dudar MD

Evan  D. Schmitz MD

Saint Mary Medical Center

Long Beach, CA 90813

 

Abstract

Bacterial pericarditis is a rare yet fatal form of pericarditis. With the introduction of antibiotics, incidence of bacterial pericarditis has declined to 1 in 18,000 hospitalized patients. In this report, we present a rare case of MSSA pericarditis in a patient that presented with systemic lupus erythematosus flare, which required treatment with antibiotics and source control with pericardial window and drain placement.

Abbreviations

• ANA: Anti-nuclear Antibody
• Anti-dsDNA: Anti double stranded DNA 
• IV: intravenous
• MSSA: Methicillin-sensitive staphylococcus aureus
• SLE: systemic lupus erythematosus 
• TTE: Transthoracic Echocardiogram

Case Presentation

History of Present Illness

31-year-old female with history of SLE, hypertension and type 1 diabetes mellitus presented with several days of pleuritic chest pain.

Physical Examination

Vitals were notable for blood pressure 204/130. She had normal S1/S2 without murmurs and had trace bilateral lower extremity edema.

Laboratory and radiology

Admission labs were notable for creatinine of 1.8, low C3 and C4 levels, elevated anti-smith, anti-ds DNA and ANA titers. ESR was elevated at 62. Troponin was normal on 3 separate samples 6 hours apart. CT Angiography of the chest showed moderate pericardial effusion (Figure 1).

Figure 1. CT Angiography of the chest on admission with moderate pericardial effusion (arrows).

Transthoracic echocardiography (TTE) showed a moderate effusion, but no tamponade physiology.

Hospital Course

Given the ongoing lupus flare, pleuritic chest pain, elevated ESR, normal troponin and pericardial effusion, the patient’s chest pain was thought to be caused by acute pericarditis secondary to SLE flare. The patient was treated with anti-hypertensives, though her creatinine worsened, which prompted a kidney biopsy, that showed signs of lupus nephritis. The patient was treated with methylprednisolone pulse 0.5 mg/kg for three days, then prednisone taper. Her home hydroxychloroquine regimen was resumed. The patient became febrile on hospital day 15 and blood cultures were obtained. These later revealed MSSA bacteremia, which is thought to be secondary to thrombophlebitis from an infected peripheral IV line in her left antecubital fossa. On hospital day 16, the patient complained of worsening chest pain and had an elevated troponin of 2, but no signs of ischemia on EKG. Repeat echo was performed, which showed increase in size of the pericardial effusion and right ventricular collapse during diastole, concerning for impending tamponade (Figure 2).

Figure 2. Video of the transthoracic echocardiography showing a pericardial effusion (top arrow) with RV collapse during diastole (bottom arrow), concerning for impending cardiac tamponade.

The patient remained hemodynamically stable. Pericardial window was performed. 500 cc of purulent fluid was drained, and a pericardial drain was placed. Intra-operative fluid culture grew MSSA. The drain was left in place for 13 days. The patient was treated with a 4-week course of oxacillin. Blood cultures obtained on hospital day 28 were negative. A repeat echo was normal. The patient was discharged without further complications.

Discussion

Bacterial pericarditis is a rare, but fatal infection, with 100% mortality in untreated patients (1). After the introduction of antibiotics, the incidence of bacterial pericarditis declined to 1 in 18,000 hospitalized patients, from 1 in 254 (2). The most implicated organisms are Staphylococcus, Streptococcus, Hemophilus and M. tuberculosis (3).  Historically, pneumonia was the most common underlying infection leading to purulent pericarditis, especially in the pre-antibiotic era (2). Since the widespread use of antibiotics, purulent pericarditis has been linked to bacteremia, thoracic surgery, immunosuppression, and malignancy (3).

Acute pericarditis is a common complication in SLE with incidence of 11-54% (4), though few cases of bacterial pericarditis were reported in SLE patients. The organisms in these cases were staphylococcus aureus, Neisseria gonorrhea and mycobacterium tuberculosis (5). Despite these reports, acute pericarditis secondary to immune complex mediated inflammatory process remains a much more common cause of pericarditis than bacterial pericarditis in SLE (6). There’s minimal data to determine whether the incidence of bacterial pericarditis in patients with SLE is increased compared to the general population; however, there is a hypothetically increased risk for purulent pericarditis in SLE given the requirement for immunosuppression. Disease activity is yet another risk factor for bacterial infections in SLE, which is thought to be a sequalae of treatment with high doses of steroids (7). In this case, the patient had an SLE flare on presentation with SLEDAI-2K score of 13. Both immunosuppression and bacteremia may have precipitated this patient’s infection with bacterial pericarditis.   

Diagnosis of bacterial pericarditis requires high index of suspicion, as other etiologies of pericarditis are far more common. In this case, we initially attributed the patient’s pericarditis to her SLE flare. The patient’s fever on hospital day 15 prompted the infectious work up. MSSA pericarditis was diagnosed later after the pericardial fluid culture grew MSSA. Delay in the diagnosis can be detrimental as patients may progress rapidly to cardiac tamponade. 

Treatment requires surgical drainage for source control along with antibiotics (8). In our case, the patient required pericardial window and placement of a drain for 13 days. In bacterial pericarditis, the purulent fluid tends to re-accumulate; therefore, subxiphoid pericardiostomy and complete drainage is recommended (8). In some cases, intrapericardial thrombolysis therapy may be required if adhesions develop (8). With appropriate source control and antibiotics therapy, survival rate is up to 85% (8). 

Conclusion

Bacterial pericarditis is a rare infection in the antibiotic era, though some patients remain at risk for acquiring it. Despite the high mortality rate, patients can have good outcomes if bacterial pericarditis is recognized early and treated.

References

1. Kaye A, Peters GA, Joseph JW, Wong ML. Purulent bacterial pericarditis from Staphylococcus aureus. Clin Case Rep. 2019 May 28;7(7):1331-1334. [CrossRef] [PubMed]
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3. Kondapi D, Markabawi D, Chu A, Gambhir HS. Staphylococcal Pericarditis Causing Pericardial Tamponade and Concurrent Empyema. Case Rep Infect Dis. 2019 Jul 18;2019:3701576. [CrossRef] [PubMed]
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6. Buppajamrntham T, Palavutitotai N, Katchamart W. Clinical manifestation, diagnosis, management, and treatment outcome of pericarditis in patients with systemic lupus erythematosus. J Med Assoc Thai. 2014 Dec;97(12):1234-40. [PubMed]
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8. Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2015 Nov 7;36(42):2921-2964. [CrossRef] [PubMed]

Cite as: Anis A, Varda M, Dudar A, Schmitz ED. MSSA Pericarditis in a Patient with Systemic Lupus Erythematosus Flare. Southwest J Pulm Crit Care Sleep. 2022;24(2):32-35. doi: https://doi.org/10.13175/swjpccs057-21 PDF

January 2022 Critical Care Case of the Month: Ataque Isquémico Transitorio in Spanish

Mohammad Abdelaziz Mahmoud DO MD

Bo Gu MD

Benito Armenta BA

Nikita Samra

Doctors Medical Center of Modesto and Emanuel Medical Center

Modesto and Turlock, CA USA

History of Present Illness:

The patient is a previously healthy 61-year-old Spanish-speaking woman who was unable to speak after awakening. Per Emergency Medical Service she was found to be aphasic upon their arrival. While in the Emergency Room the patient was able to speak, alert and oriented x4, with all her symptoms spontaneously resolved. The patient denied fever, chills, blurred vision, headache or any history of migraines, TIA, or stroke.

The patient had a similar event about two weeks earlier which also spontaneously resolved. During that time, the patient had a non-contrast CT head and an MRI of the brain, both of which were unremarkable. Her home medications include aspirin 81 mg and atorvastatin 40 mg daily.

Past Medical History, Family History and Social History

The patient denies tobacco use or use of illicit drugs.  She reports that she will occasionally drink alcohol. There is no family history of strokes.

Physical Examination

• Vitals:  BP 123/80 mm Hg, T-max of 36.5° C, heart rate 72 bpm, SpO2 97%
• HEENT: scleral icterus.
• Lungs: clear
• Heart: regular rhythm
• Abdomen: soft without organomegaly, masses or tenderness
• Skin: jaundiced 
• Neurological examination:
  • Alert and oriented x4 with no focal neurological deficit observed
  • Cranial nerves II to XII were intact
  • Normal motor function
  • Normal speech
  • No facial asymmetry or facial droop
  • Normal mood and affect

Which of the following laboratory tests should be ordered? (click on the correct answer to be directed to the second of eight pages)

1. None. She should be sent home
2. Serum calcium/phosphorus 
3. Liver function studies
4. 1 and 3
5. All of the above

Cite as: Mahmoud MA, Gu B, Armenta B, Samra N. January 2022 Critical Care Case of the Month: Ataque Isquémico Transitorio in Spanish. Southwest J Pulm Crit Care. 2022;24(1):1-5. doi: https://doi.org/10.13175/swjpcc051-21 PDF 

Rapidly Fatal COVID-19-associated Acute Necrotizing Encephalopathy in a Previously Healthy 26-year-old Man

Robert A. Raschke MD and Cristian Jivcu MD

HonorHealth Scottsdale Osborn Medical Center

Scottsdale, AZ USA

Case Presentation

A 26-year-old man presented to our Emergency Department at 0200 on the day of admission with chief complaints of subjective fever, leg myalgias, and progressive dyspnea of one week duration. An oropharyngeal swab PCR had revealed SARS-CoV-2 RNA three days previously. He had not received a SARS CoV-2 vaccination, but had made an appointment to receive it just a few days prior to the onset of his symptoms.

The patient had no significant past medical history, was taking no medications except for ibuprofen and acetaminophen over the past week, and did not take recreational drugs. He specifically denied headache and had no prior history of seizure.

On admission, his HR was 150 bpm (sinus), RR 22, BP 105/46 mmHg, temp 40.2° C. and SpO₂ 92% on room air. He was ill-appearing, but alert and oriented, his neck was supple and lung auscultation revealed bilateral rhonchi, but physical examination was otherwise unremarkable.

A CBC showed WBC 17.3 10³/uL, hemoglobin 13.9 g/dl, and platelet count 168 K/uL. A complete metabolic profile was normal except for the following: Na 135 mmol/L, creatinine 1.7 mg/dL, AST 95 and ALT 134 IU/L. D-dimer was 1.08 ug/ml (normal range 0.00-0.50 ug/ml), and ferritin 783 ng/ml. A urine drug screen was negative. Chest radiography showed subtle bilateral pulmonary infiltrates. CT angiography of the chest was negative for pulmonary embolism but showed bilateral patchy infiltrates consistent with COVID19 pneumonia. One liter NS bolus and dexamethasone 10mg were given intravenously, acetaminophen administered orally, and the patient was admitted to telemetry.

Shortly thereafter, the patient experienced a brief generalized seizure associated with urinary incontinence. He was stuporous post-ictally, exhibiting only arm flexion to painful stimuli. A stroke alert was called and radiographic studies emergently obtained. CT of the brain was normal and CT angiography of the head and neck showed no large vessel occlusion or flow-limiting stenosis, and a CT perfusion study (Figure 1) showed patchy Tmax prolongation in the right cerebellum and bilateral parietal occipital lobes “which may reflect artifact or relative ischemia” with no matching core infarct.

Figure 1. CT perfusion study showing mild bilateral posterior distribution ischemia (Tmax > 6 secs) without matching core infarct (CBF<30%), interpreted by a neuroradiologist as possible artifact.

The patient was transferred to the ICU at 10:00, and experienced a 40-second generalized tonic-clonic seizure shortly thereafter. Lorazepam 2mg was administered intravenously. The HR was 104, RR 21, BP 105/61, temp 36.5 C. and SpO₂ 96% on 2L /min nasal canula oxygen. On neurological examination, the Glasgow Coma Scale was 3, right pupil was 3mm, left pupil 2mm - both reactive, the gaze was disconjugate and directed downward, there was no blink to visual threat, and glabellar ridge pressure did not elicit grimace, but minimal arm flexion. The gag reflex was positive. Peripheral reflexes were 2+ with down-going toes bilaterally. Levetiracetam 1000mg bolus was administered intravenously. Glucose was 147 mg/dL. An EEG obtained at 12:00 showed diffuse bilateral slowing without seizure activity. A presumptive diagnosis of post-ictal encephalopathy was made. The patient seemed to be protecting his airway and nasal canula oxygen was continued.

The patient’s condition was not noted to significantly change over the next 12 hours. There were no episodes of hypoxia, hypotension or hypoglycemia. Around 0100 on the second day of hospitalization, the patient exhibited extensor-posturing and appeared to be choking on his oral secretions. HR rose to 135, BP 155/99, RR 12 and temp 37.8 C. His SpO₂ fell into the mid 80% range. He no longer had a gag or cough reflex and he was emergently intubated without complication. MRI (Figure 2) and MRV of the brain were emergently obtained. 

Figure 2. A: T2-weighted image demonstrating bilateral thalamic and L occipital white matter hypoattenuation. B: DWI and GRE images showing bilateral thalamic infarctions with hemorrhage. C: Representative DWI images of cerebrum and cerebellum and pons showing widespread diffusion restriction.

The MRI showed extensive diffusion restriction involving bilateral thalami, cerebellar hemispheres, pons, and cerebral hemispheres with scattered hemorrhage most obvious/confluent in the bilateral thalami.

Normal flow voids were present in intracranial arteries and venous structures. Partial effacement of the lateral and third ventricles was noted, with early uncal herniation. The MRV showed no evidence of dural venous sinus thrombosis.

At 05:00 of the second hospital day, it was noted that the patient’s pupils were dilated and unreactive and his respiratory rate was 16 – equal to the respiratory rate set on the ventilator. BP fell to 85/45 and norepinephrine infusion was started to maintain MAP >65 mmHg. STAT CT brain (Figure 3) showed hemorrhagic infarcts of the bilateral thalami with surrounding edema, interval development of low attenuation of the bilateral cerebrum and cerebellum, and mass effect with total effacement of fourth ventricle, basal cisterns and cerebral sulci consistent with severe cerebral edema.

Figure 3. STAT CT brain from 05:30 on the second hospital day showing bilateral thalamic infarctions and diffuse cerebral edema with effacement of the sulci and loss of grey/white differentiation.

Two neurologists confirmed the clinical diagnosis of brain death, including an apnea test. A venous ammonia level ordered that morning was not drawn. An autopsy was requested by the physicians, but not able to be obtained.

Discussion

Acute necrotizing encephalopathy (ANE) is a rarely-reported clinical-radiographic syndrome lacking pathopneumonic laboratory test or histological findings (1-3). It is characterized by an acute febrile viral prodrome, most commonly due to influenza or HHV-6, followed by rapidly progressive altered mental status and seizures. The most specific finding of ANE is necrosis of the bilateral thalami, appearing on MRI as hypoattenuated lesions on T2 and FLAIR images with diffusion restriction on DWI, and often with hemorrhage demonstrated on GRE images (as shown in figure 2 above). Symmetric multifocal lesions are typically seen throughout various other locations in the brain including the cerebral periventricular white matter, cerebellum, brainstem and spinal cord. Mizuguchi (who first described ANE in 1995) proposed elevation of serum aminotransferase without hyperammonemia, and cerebrospinal albuminocytologic dissociation (elevated CSF protein without leukocytosis) as laboratory criteria supporting the diagnosis of ANE (1,2). These were only partially evaluated in our patient. The mortality of ANE is 30% and significant neurological sequelae are common in survivors (2).

The clinical, radiographic and laboratory findings in our case are all characteristic of ANE, but our work-up was abbreviated by the patient’s fulminant presentation. The differential diagnosis includes hyper-acute forms of acute disseminated encephalomyelitis (ADEM) or acute hemorrhagic leukoencephalitis that may also occur after a viral prodrome and may be associated with diffuse white matter lesions (4,5), although bilateral thalamic necrosis is not characteristic of either of these entities. Examination of cerebral spinal fluid (CSF) for pleocytosis, oligoclonal bands, and testing for the myelin oligodendrocyte glycoprotein IgG autoantibody and the aquaporin-4 IgG serum autoantibody would have been indicated to further evaluate for the initial presentation of a relapsing CNS demyelinating disease (5,6). CSF examination would also have been helpful in ruling out viral encephalitis affecting the thalami, such as that caused by West Nile Virus (WNV) (7). An acute metabolic encephalopathy with diffuse brain edema, such as that caused by severe hyperammonemia associated with late-onset ornithine transcarbamylase deficiency (8) was not ruled out. Arterial or venous thromboembolism associated with COVID-19 were effectively ruled out by CT angiogram, CT perfusion and MRI and MRV findings.    

We found five previous case reports of ANE as a complication of COVID-19, ranging 33-59 years of age (9-13). The onset of altered mental status occurred 3, 4, 7,10 and 21 days after onset of COVID-19 symptoms and rapidly progressed to coma. Two had generalized seizures, one myoclonus and another “rhythmic movements” of an upper extremity. All had bilateral hypoattenuation of the thalami on CT and MRI with variable involvement of temporal lobes, subinsular regions, cerebellum, brainstem and supratentorial grey and white matter. Two patients had EEGs that showed generalized slow waves. All underwent examination of CSF with negative PCR tests for various common encephalopathy viruses including herpes simplex virus 1&2 and WNV - four reported CSF protein and cell counts, three of which demonstrated albuminocytologic dissociation. Three patients received IVIG. Two patients died on days 5 and 8 after onset of neurological symptoms. Two recovered after prolonged ICU care and the outcome of the third patient was not reported. ANE may be less rare than these few case reports suggest. A retrospective study carried out at 11 hospitals in Europe describes radiographic findings of 64 COVID-19 patients with neurological symptoms (14). The most common finding was ischemic stroke, but 8 patients had MRI findings consistent with encephalitis and two had findings characteristic of ANE.

The pathogenesis of ANE is unknown. Ten cases of fatal ANE with brain biopsy are reported (1,15-19). These showed diffuse cerebral edema, and hemorrhagic necrosis invariably involving the thalami. An exudative small vessel vasculopathy with endothelial necrosis was found in 7/10 patients (This could perhaps explain the early CT perfusion findings interpreted as artifactual in our patient). Demyelination or inflammatory infiltration of the brain or leptomeninges was absent. There has been conjecture that these pathological findings might be due to disruption of the blood brain barrier caused by hypercytokinemia but there is scant supportive evidence (20). 

There is no proven treatment for ANE. Corticosteroids, IVIg and plasma exchange have been previously used (3,9-11,21). Clinical trials are unlikely given the rarity of the disorder.

It was unfortunate that this young man had not availed himself of SARS CoV-2 vaccination. We did not make a pre-mortem diagnosis of ANE between his first abnormal CT brain at 0100 and his death at 06:00. We would have performed an LP, measured serum ammonia and given a trial of corticosteroids and IVIg if we had had more time.

References

1. Mizuguchi M, Abe J, Mikkaichi K, Noma S, Yoshida K, Yamanaka T, Kamoshita S. Acute necrotising encephalopathy of childhood: a new syndrome presenting with multifocal, symmetric brain lesions. J Neurol Neurosurg Psychiatry. 1995 May;58(5):555-61. [CrossRef] [PubMed]
2. Mizuguchi M. Acute necrotizing encephalopathy of childhood: a novel form of acute encephalopathy prevalent in Japan and Taiwan. Brain Dev. 1997 Mar;19(2):81-92. [CrossRef] [PubMed]
3. Wu X, Wu W, Pan W, Wu L, Liu K, Zhang HL. Acute necrotizing encephalopathy: an underrecognized clinicoradiologic disorder. Mediators Inflamm. 2015;2015:792578. [CrossRef] [PubMed]
4. Marchioni E, Ravaglia S, Montomoli C, et al. Postinfectious neurologic syndromes: a prospective cohort study. Neurology. 2013 Mar 5;80(10):882-9. [CrossRef] [PubMed]
5. Manzano GS, McEntire CRS, Martinez-Lage M, Mateen FJ, Hutto SK. Acute Disseminated Encephalomyelitis and Acute Hemorrhagic Leukoencephalitis Following COVID-19: Systematic Review and Meta-synthesis. Neurol Neuroimmunol Neuroinflamm. 2021 Aug 27;8(6):e1080. [CrossRef] [PubMed]
6. López-Chiriboga AS, Majed M, et al. Association of MOG-IgG Serostatus With Relapse After Acute Disseminated Encephalomyelitis and Proposed Diagnostic Criteria for MOG-IgG-Associated Disorders. JAMA Neurol. 2018 Nov 1;75(11):1355-1363. [CrossRef] [PubMed]
7. Guth JC, Futterer SA, Hijaz TA, Liotta EM, Rosenberg NF, Naidech AM, Maas MB. Pearls & oy-sters: bilateral thalamic involvement in West Nile virus encephalitis. Neurology. 2014 Jul 8;83(2):e16-7. [CrossRef] [PubMed]
8. Cavicchi C, Donati M, Parini R, et al. Sudden unexpected fatal encephalopathy in adults with OTC gene mutations-Clues for early diagnosis and timely treatment. Orphanet J Rare Dis. 2014 Jul 16;9:105. [CrossRef] [PubMed]
9. Poyiadji N, Shahin G, Noujaim D, Stone M, et al.  COVID19-associated acute necrotizing encephalopathy: CT and MRI features.  Radiology. 2020;296:E119-E120. [CrossRef]
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11. Delamarre L, Galion C, Goudeau G, et al. COVID-19-associated acute necrotising encephalopathy successfully treated with steroids and polyvalent immunoglobulin with unusual IgG targeting the cerebral fibre network. J Neurol Neurosurg Psychiatry. 2020 Sep;91(9):1004-1006. [CrossRef] [PubMed]
12. Dixon L, Varley J, Gontsarova A, Mallon D, Tona F, Muir D, Luqmani A, Jenkins IH, Nicholas R, Jones B, Everitt A. COVID-19-related acute necrotizing encephalopathy with brain stem involvement in a patient with aplastic anemia. Neurol Neuroimmunol Neuroinflamm. 2020 May 26;7(5):e789. [CrossRef] [PubMed]
13. Elkady A, Rabinstein AA. Acute necrotizing encephalopathy and myocarditis in a young patient with COVID-19. Neurol Neuroimmunol Neuroinflamm Sep 2020, 7 (5) e801. [CrossRef]
14. Kremer S, Lersy F, Anheim M, et al. Neurologic and neuroimaging findings in patients with COVID-19: A retrospective multicenter study. Neurology. 2020 Sep 29;95(13):e1868-e1882. [CrossRef] [PubMed]
15. Kirton A, Busche K, Ross C, Wirrell E. Acute necrotizing encephalopathy in caucasian children: two cases and review of the literature. J Child Neurol. 2005 Jun;20(6):527-32. [CrossRef] [PubMed]
16. Mastroyianni SD, Gionnis D, Voudris K, Skardoutsou A, Mizuguchi M. Acute necrotizing encephalopathy of childhood in non-Asian patients: report of three cases and literature review. J Child Neurol. 2006 Oct;21(10):872-9. [CrossRef] [PubMed]
17. Nakano I, Otsuki N, Hasegawa A. Acute Stage Neuropathology of a Case of Infantile Acute Encephalopathy with Thalamic Involvement: Widespread Symmetrical Fresh Necrosis of the Brain. Neuropathology 1993;13: 315-25. [CrossRef]
18. Yagishita A, Nakano I, Ushioda T, Otsuki N, Hasegawa A. Acute encephalopathy with bilateral thalamotegmental involvement in infants and children: imaging and pathology findings. AJNR Am J Neuroradiol. 1995 Mar;16(3):439-47. [PubMed]
19. San Millan B, Teijeira S, Penin C, Garcia JL, Navarro C. Acute necrotizing encephalopathy of childhood: report of a Spanish case. Pediatr Neurol. 2007 Dec;37(6):438-41. [CrossRef] [PubMed]
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21. Okumura A, Mizuguchi M, Kidokoro H, et al. Outcome of acute necrotizing encephalopathy in relation to treatment with corticosteroids and gammaglobulin. Brain Dev. 2009 Mar;31(3):221-7. [CrossRef] [PubMed]

Cite as: Raschke RA, Jivcu C. Rapidly Fatal COVID-19-associated Acute Necrotizing Encephalopathy in a Previously Healthy 26-year-old Man. Southwest J Pulm Crit Care. 2021;23(5):138-43. doi: https://doi.org/10.13175/swjpcc039-21 PDF

Utility of Endobronchial Valves in a Patient with Bronchopleural Fistula in the Setting of COVID-19 Infection: A Case Report and Brief Review

Nazanin Sheikhan, MD¹, Elizabeth J. Benge, MD¹, Amanpreet Kaur, MD¹, Jerome K Hruska, DO², Yi McWhorter DO³, Arnold Chung MD⁴

¹Department of Internal Medicine, HCA Healthcare; MountainView Hospital, Las Vegas, NV, USA

²Department of Pulmonology, HCA Healthcare; MountainView Hospital, Las Vegas, NV, USA

³Department of Anesthesiology Critical Care Medicine, HCA Healthcare; MountainView Hospital, Las Vegas, NV, USA

⁴MountainView Cardiovascular and Thoracic Surgery Associates, HCA Healthcare; MountainView Hospital, Las Vegas, NV, USA

Abstract

Patients with COVID-19 pneumonia frequently develop acute respiratory distress syndrome (ARDS), and in severe cases, require invasive mechanical ventilation. One complication that can develop in patients with ARDS who are mechanically ventilated is a bronchopleural fistula (BPF). Although rare, the frequency of BPF in patients with COVID-19 pneumonia is increasingly recognized. Here, we present a 48-year old man with BPF associated with COVID-19 pneumonia. Treatment with a commercial endobronchial valve (EBV) system resulted in reduced air leak allowing for tracheostomy placement. Our case adds to a growing body of evidence suggesting that the presence of COVID-19 pneumonia does not hinder the utility of EBV’s in the treatment of BPF’s.

Abbreviation List

• ARDS = acute respiratory distress syndrome
• BIPAP = Bilevel Positive Airway Pressure
• BPF = Bronchopleural Fistula
• COVID-19 = Coronavirus Disease-2019
• CT = Computed Tomography
• CTA = Computed Tomography Angiography
• EBV = Endobronchial Valve
• HFNC = High Flow Nasal Cannula
• ICU = Intensive Care Unit
• RML = Right Middle Lobe
• RUL = Right Upper Lobe
• SARS-CoV-2 = Severe Acute Respiratory Syndrome Coronavirus-2
• VATS = Video-Assisted Thoracoscopic Surgery

Introduction

The COVID-19 pandemic has resulted in over one hundred million infections worldwide, in addition to millions of deaths (1). A less common sequelae of COVID-19 is bronchopleural fistula (2). A bronchopleural fistula is an abnormal sinus tract that forms between the lobar, main stem, or segmental bronchus, and the pleural space (3). BPF is typically treated by surgical repair, via a video-assisted thoracoscopic surgical approach (VATS) (3). Bronchoscopic approach with placement of airway stents, coils or transcatheter occlusion devices can be considered for those who are not suitable for surgical intervention (3).  A newer therapeutic modality for bronchopleural fistulae are endobronchial valves, which have been used successfully to treat COVID-19 patients diagnosed concurrently with bronchopleural fistulae (4). 

Here, we present a case of a critically ill patient developing a bronchopleural fistula with a concurrent COVID-19 infection, whose respiratory status was stabilized with an endobronchial valve.  To our knowledge, this is one of four case reports of a bronchopleural fistula arising in the setting of COVID-19.

Brief Review of Endobronchial Valves in COVID-19

Several other studies report success using endobronchial valves to treat bronchopleural fistulae in patients with COVID-19 pneumonia. One case series documents two cases of COVID-19 pneumonia complicated by bacterial super-infections, in which both patients experienced pneumothorax and persistent air leaks after mechanical invasive ventilation.  Both patients were successfully treated via EBV positioning. These researchers speculate that the severe inflammation associated with COVID-19 related ARDS induces inflammatory-related tissue frailty, pre-disposing lung tissue to damage via barotrauma, and the subsequent development of BPF (5).  

Another case documents the treatment of a 49-year-old male with COVID-19 pneumonia who was treated with steroids and tocilizumab. He also had a 3-week history of persistent air leak, which was successfully treated with an EBV. This team emphasizes that the thick, copious sections evident in patients afflicted by COVID-19 pose a risk for EBV occlusion. They highlight the importance of medically optimizing the patient and draining the air leak to mitigate the potential of this procedural complication developing (4).

In conjunction with the treatment course presented in our case, these case reports provide compelling evidence indicating that endobronchial valves can be successfully used to treat persistent air leaks in patients with COVID-19 pneumonia.

Case Presentation

Our patient is a 48-year-old male with a medical history significant for essential hypertension and Type 1 diabetes mellitus who presented to the emergency department complaining of acute onset generalized weakness, shortness of breath, and a near-syncopal event that had occurred the day prior. Vital signs on admission showed an oxygen saturation of 86% on ambient air, respiratory rate of 18 breaths per min, heart rate of 111 beats per min with a temperature of 37.6°C. He was tested for SARS-CoV-2 on admission and was found to be positive.

Initial computed tomography (CT) chest showed diffuse bilateral ground-glass opacities compatible with COVID-19 pneumonia. On admission, his inflammatory markers were elevated, with C-reactive protein 4.48 mg/dL, ferritin 1230 ng/ml, lactate dehydrogenase 281 IU/L, and D-dimer 0.76 mg/L. He received 1 dose of tocilizumab, convalescent plasma, as well as 5-day course of Remdesivir. His oxygen requirement increased as well as his work of breathing requiring High Flow Nasal Cannula (HFNC) and subsequently Bilevel Positive Airway Pressure (BiPAP); patient was transferred to the medical intensive care unit (ICU) 17 days after admission requiring intubation. Computed tomography angiography (CTA) chest could not be obtained to rule out pulmonary embolism as patient was too unstable. Patient was started on Heparin drip empirically which had to be discontinued due to gastrointestinal bleeding. He had worsening oxygenation, ventilator asynchrony, with P:F ratio of 47, requiring high-dose sedation and neuromuscular blockade, as well as prone positioning. Repeat CT chest on day 21 demonstrated bilateral pneumothoraces and pneumomediastinum as well as interval worsening of diffuse ground glass infiltrates (Figure 1), requiring bilateral chest tube placement.

Figure 1. Computed tomography chest showing pneumomediastinum, bilateral pneumothoraces, and diffuse ground glass attenuation of the lungs bilaterally.

On the 34th day of admission, he developed a right-sided tension pneumothorax likely secondary to ongoing severe ARDS, requiring replacement of dislodged right chest tube. Patient subsequently had worsening of right pneumothorax requiring an additional second chest tube placement. Patient developed persistent air leak concerning for right bronchopleural fistula. On hospital day 42, patient underwent intrathoracic autologous blood patch with persistence of large air leak. After interdisciplinary conference with cardiothoracic surgery, pulmonary, and the ICU team, it was decided that patient is not a surgical candidate hence interventional pulmonology was consulted for EBV placement to facilitate chest tube removal and ventilator weaning.

Patient underwent fiberoptic bronchoscopy on hospital day 52; pulmonary balloon was used to sequentially block the right mainstem, bronchus intermedius, and basilar segments. The air leak was recognized to be coming from right middle lobe (RML) and the apex of the right upper lobe (RUL) status post placement of two endobronchial valves in the medial and lateral segments of the RML (Figure 2).

Figure 2. Bronchoscopic view of endobronchial valves.

The RUL could not be entered secondary to angulation and technical inability of the instruments to achieve a sharp bend. Post-bronchoscopy, patient had 50 mL reduction in air leak resulting in improvement of his ventilator settings such that a tracheostomy could be safely performed. Left-sided chest tube was removed with resolution of pneumothorax. Repeat CT chest on hospital day 115 demonstrated persistent right bronchopleural fistula (Figure 3).

Figure 3. Computed tomography chest showing bronchopleural fistula in the right middle lobe and collapsed and shrunken right middle lobe with endobronchial occlusion stents at the central airway. Yellow arrow showing endobronchial valves and red arrows showing bronchopleural fistula

The patient is currently pending transfer to a long-term acute care hospital for aggressive physical therapy and eventual transfer to a tertiary center for lung transplantation evaluation.

Discussion

Scientific research has moved at an unprecedented speed in an attempt to shed light on the manifestations of COVID-19. The most common presentation of COVID-19 includes cough, fever, shortness of breath, and new onset anosmia and ageusia (6).

Common complications include coagulopathy, pulmonary emboli, and in severe cases, acute respiratory distress syndrome (7). Bronchopleural fistulae have emerged as a rare but known complication of COVID-19. This pathology is traditionally seen as a post-surgical complication arising from lobectomy or pneumonectomy (8). All cause mortality secondary to bronchopleural fistulae are high; with mortality rates ranging from 18-67% (8).

A relatively novel therapeutic modality for bronchopleural fistulae are endobronchial valves, which have been used in patients who are not candidates for surgery, such as our patient (9). They work as a one-way valve that allow the pathologically trapped air to exit the respiratory system, but not enter (4).

Differential diagnoses for bronchopleural fistulae include alveolar pleural fistulas and empyema (11). Alveolar pleural fistulas are abnormal communications between the pulmonary parenchyma, distal to a segmental bronchus, and the pleural space, while bronchopleural fistulas are more proximal; representing abnormal connections between a mainstem, lobar, or segmental bronchus and the pleural space (12). These pathologies are differentiated with direct visualization on bronchoscopy, as was demonstrated in our patient (12).

There are currently no official statistics on the epidemiology of bronchopleural fistulae in COVID-19. A disappointing aspect of our case was the lack of complete resolution of the patient’s air leak after the placement of the endobronchial valve. While the patient’s condition did improve after the valve was placed, he continued to suffer from respiratory illness related to his bronchopleural fistula. Although complete remission was not achieved, the endobronchial valve placement did facilitate respiratory recovery sufficient enough to facilitate a tracheostomy. The patient was then stabilized for eventual transfer to a long-term acute care facility, where he will undergo physical therapy and await lung transplantation. It is important to emphasize that while the endobronchial valve was not curative, it stabilized the patient for possible future curative treatments.  

Conclusion

Despite their rarity, bronchopleural fistulas are a pulmonary complication of COVID-19. Although the insertion of the endobronchial valve in our patient resulted in a reduction of the air leak as opposed to complete resolution, this case still emphasizes a therapeutic benefit of endobronchial valves in such instances. Overall, our case demonstrates the importance of clinical vigilance in the face of unusual pulmonary complications related to COVID-19, and that treatment of these complications requires flexibility and creativity.

References

1. WHO Coronavirus (COVID-19) Dashboard [Internet]. World Health Organization. World Health Organization; [cited 2021May31]. Available from: https://covid19.who.int/ 
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10. Musani AI, Dutau H. Management of alveolar-pleural fistula: a complex medical and surgical problem. Chest. 2015 Mar;147(3):590-592. [CrossRef] [PubMed]
11. Mehta HJ, Malhotra P, Begnaud A, Penley AM, Jantz MA. Treatment of alveolar-pleural fistula with endobronchial application of synthetic hydrogel. Chest. 2015 Mar;147(3):695-699. [CrossRef]  [PubMed]

Acknowlegements

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities. 

Cite as: Sheikhan N, Benge EJ, Kaur A, Hruska JK, McWhorter Y, Chung A. Utility of Endobronchial Valves in a Patient with Bronchopleural Fistula in the Setting of COVID-19 Infection: A Case Report and Brief Review. Southwest J Pulm Crit Care. 2021;23(4):109-14. doi: https://doi.org/10.13175/swjpcc046-21 PDF