Hospital Damas

Abstract Introduction Coronavirus disease (COVID-19), caused by the SARS-CoV-2 virus, led to the 2019 global pandemic. While it primarily affects the lower respiratory tract, it is increasingly recognized to cause extrapulmonary sequelae that can last months to years, collectively termed Post-COVID Syndrome. Further studies are needed to clarify these long-term complications. Common manifestations include anosmia, dysgeusia, chronic cough, and dyspnea; however, new presentations continue to emerge, significantly impairing quality of life. Case Discussion An 81-year-old Puerto Rican male with a 20-pack-year smoking history presented to the outpatient clinic with progressive exertional dyspnea after a COVID-19 infection in May 2023. He reported no prior respiratory limitations. Albuterol provided only partial relief. He denied fever, weight loss, dysphagia, hemoptysis, pleuritic pain, trauma, or recent surgery. On examination, he was in no acute distress, but percussion and auscultation revealed absent right diaphragmatic excursion. Chest X-ray and CT demonstrated new right hemidiaphragm elevation. A sniff test confirmed a lack of excursion, consistent with phrenic nerve paralysis. Baseline spirometry test revealed an obstructive pattern with possible restriction due to decreased FEV1/FVC and FVC. Gabapentin 300 mg daily was initiated for suspected neuropathic diaphragmatic dysfunction. After 3 months, the patient reported marked improvement in exertional tolerance. Repeat spirometry showed an FEV1 increase of 330 mL and an FVC increase of 200 mL, with an FEV1/FVC ratio of 78, confirming resolution of the obstruction. Overall, lung function improved from moderate to severe mixed physiology to isolated moderate restriction. Flow-volume loops normalized, and examination confirmed improved diaphragmatic excursion. Discussion Dyspnea is the most persistent symptom of Post-COVID Syndrome, but not always due to fibrosis or airway disease. In this case, abnormal imaging revealed unilateral diaphragmatic paralysis from phrenic nerve dysfunction, leading to restrictive physiology. Treatment with gabapentin was associated with both symptomatic and spirometric recovery, suggesting a potential role for neuromodulatory therapy in post-viral diaphragmatic dysfunction. This abstract is funded by: None

Abstract Introduction Insulinoma represents an uncommon pancreatic neuroendocrine tumor, occurring in approximately 1 to 4 cases per million population each year. Its recognition can be delayed in patients with diabetes or critical illness, where metabolic stress and exogenous medications can confuse the biochemical picture. Sulfonylurea exposure can prolong insulin secretion and, in the setting of impaired renal clearance, mask an underlying insulinoma. In pulmonary-critical care practice, hypoglycemia in a patient with obesity hypoventilation syndrome, and respiratory failure presents unique diagnostic and therapeutic challenges. Case Presentation Case of a 54-year-old female with obesity hypoventilation syndrome, severe obstructive sleep apnea, chronic hypercapnic respiratory failure, hypothyroidism, and Type II Diabetes Mellitus that required intensive care unit admission due to acute-on-chronic hypercapnic respiratory failure. While this admission, she developed recurrent fasting and nocturnal hypoglycemia consistent with Wipple's triad. Recent sulfonylurea exposure complicated the diagnostic process in the presence of renal dysfunction, which may have prolonged the duration of hypoglycemia and masked laboratory confirmation of insulinoma. Continuous glucose monitoring (CGM) demonstrated recurrent hypoglycemia despite high-rate dextrose 10% infusion, high-dose glucocorticoids, and octreotide. Diazoxide was held initially due to patient fluid overload and risk of worsening hypoventilation. After aggressive diuresis and clinical stabilization, diazoxide was initiated with carbohydrate-adjusted nutrition, leading to descalation of therapy and resolution of hypoglycemia. Discussion Our cases represent the diagnostic complexity when evaluating hypoglycemia in critically ill patients with pulmonary comorbidities. Obesity hypoventilation-related chronic hypercapnia limited the patient's ability to tolerate prolonged fasting or fluid shifts, and concurrent sulfonylurea exposure confounded the metabolic workup. The need to withhold diazoxide due to volume overload highlights the delicate cardiopulmonary balance required in ICU management. Recognizing the possibility of insulinoma in this context prevented premature attribution of hypoglycemia to medication error or malnutrition. Conclusion Clinicians in critical care must remain alert to rare endocrine causes of recurrent hypoglycemia in complex ICU patients. Sulfonylurea toxicity and impaired renal clearance can mimic or mask insulinoma, delaying diagnosis. A multidisciplinary approach with endocrinology, integration of CGM findings, and cautious metabolic support are key to avoiding neurological complications and directing further evaluation once respiratory status allows. This abstract is funded by: None

Abstract Introduction Pulmonary sequestration is a rare congenital lung malformation characterized by a segment of nonfunctioning lung parenchyma that lacks communication with the tracheobronchial tree and receives its arterial supply from the systemic circulation. It accounts for approximately 0.5 - 0.6% of all congenital pulmonary malformations. Most cases are identified during infancy or childhood; therefore, diagnosis in adulthood is exceedingly uncommon. Case Presentation A 59-year-old female, followed in the pulmonary clinic for obstructive sleep apnea, was incidentally found to have a pulmonary nodule with apparent calcification on chest radiograph (CXR). Chest CT scan reveals an aberrant arterial vessel arising from the anterior aspect of the descending thoracic aorta at T8-T9 that courses posterolaterally toward the left hilum and drains into the left lower hilar pulmonary vein. This vessel measures approximately 12 mm in diameter and shows atheromatous calcification, suggesting chronic vascular changes and supporting the notion that this is a long-standing process. However, the patient has remained asymptomatic, and the physical examination has been unremarkable. Discussion This case provides insight into a rare presentation of atypical arterial supply pattern to the normal lung, with vascular changes suggestive of a long-standing, stable variant. Although typically diagnosed in childhood, congenital anomalies such as sequestration should be considered in adults with unexpected radiographic findings, especially when lesions appear atypical or calcified. Recognition of the characteristic systemic arterial supply and pulmonary venous drainage on imaging is crucial for diagnosis and for preoperative planning if symptoms develop. We highlight that calcified pulmonary nodules on CXR can also be associated with pulmonary malformations, which are less common but must be identified, as patients can develop symptoms and be complicated by recurrent infections or hemoptysis. Therefore, detailed imaging and early identifications allows for appropriate management and better long-term outcomes. This abstract is funded by: none