INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) is a widely used procedure for hepatobiliary and pancreatic disorders. Splenic injury, most commonly associated with trauma, is a rare complication of ERCP. We present a case of splenic laceration with hemorrhagic shock following ERCP for acute cholecystitis. CASE: An 84-year-old woman with a history of recent non-ST-elevation myocardial infarction followed by stent placement and currently on clopidogrel and apixaban presented for fever, abdominal pain, and vomiting. Physical exam showed right upper quadrant and epigastric tenderness. Laboratory studies revealed transaminitis and elevated bilirubin. CT imaging showed stones in the biliary fundus and biliary ductal dilation. The patient was diagnosed with acute cholecystitis and underwent ERCP with biliary sphincterotomy and endoscopic ultrasound-guided cholecystoduodenostomy. Post sphincterotomy bleeding was noted and hemostasis was achieved with epinephrine and one clip placement. In the post-procedure period, the patient experienced signs and symptoms of circulatory shock concerning for severe, acute blood loss. Patient was hypotensive and tachycardic. Hemoglobin was noted at 6.6 mg/dL, down from 9.9 mg/dL prior to the procedure. Repeat imaging revealed a severe splenic laceration with a shattered appearance, left upper quadrant hematoma, and hemoperitoneum. The patient then underwent an emergent splenic artery embolization for hemorrhagic shock and was adequately resuscitated with crystalloids, blood products, and apixaban was reversed. The patient remained hemodynamically stable following embolization and was weaned off pressors and successfully extubated. Given her recent percutaneous coronary intervention, her antiplatelet agents were cautiously reintroduced two days after the embolization to reduce the risk of stent thrombosis. Patient was discharged in stable condition. DISCUSSION: Splenic injury following ERCP is a rare procedural complication with fewer than 30 cases noted in the literature since 1988 (Wang et al. 2020). The mechanism of splenic injury is unknown, though it is proposed that tractional forces and scope position may result in tension on the spleen and adjacent vessels, leading to injury. The majority of prior cases were managed with splenectomy or conservative management, though splenic artery embolization, as presented here, has emerged as an intervention to successfully control splenic hemorrhage. This case underscores the importance of considering splenic injury in instances of significant abdominal pain and signs of hemorrhagic shock following ERCP. REFERENCE: Wang K, Fang Y, Huang A, Gao M. 2020. Splenic laceration following endoscopic retrograde cholangiopancreatography: a literature review and our experience. Laparosc Endosc Surg Sci. 3(3):80-84.

Electronic cigarettes (e-cigarettes) were originally developed in 2003 as healthier alternatives to conventional tobacco cigarettes. Their popularity has since significantly increased and both users and nonusers are exposed to their aerosol and product constituents. Although some evidence suggests that e-cigarette use may facilitate smoking cessation, definitive data are lacking and e-cigarettes are not approved by the Food and Drug Administration as a cessation aid. While e-cigarette aerosol contains fewer toxins than conventional cigarette smoke, studies evaluating whether e-cigarettes are less harmful are inconclusive. The health impact of e-cigarettes for both users and nonusers cannot be determined with currently available data, and there are both environmental concerns and issues regarding nonuser exposure. Most of the currently available data related to the health effects of e-cigarettes do not evaluate their effects on the general population and evidence regarding the systemic health effects of e-cigarettes is limited. In addition, there has been a recent rise in vaping-related lung injuries. Therefore, the detrimental effects of e-cigarette use should be further investigated, and every effort should be made to increase public awareness of the harmful effects of e-cigarettes.

Hemophagocytic lymphohistiocytosis (HLH) is associated to high mortality and morbidity. A condition often underrecognized, HLH should be in the differential diagnosis of patients presenting with fever, cytopenia, hypertriglyceridemia and high ferritin levels (>500 μg/L). Acquired or secondary HLH in adults is a heterogenous disease triggered by infectious, autoimmune, or neoplastic conditions. Infection associated HLH (IAHS) have been described in association to immunodeficiency and secondary to infections with endemic pathogens. Extensive investigation with microbiology, serology, urine antigens and biopsies of the bone marrow, lung or lymph nodes are often necessary. We present a series of three adult cases of HLH in patients admitted to the intensive care unit with a presumptive diagnosis of sepsis. Early recognition and treatment of this infection sometimes with concomitant administration of immunosuppressant therapy could impact the high mortality associated to this overlap syndrome.

SESSION TITLE: Critical Care 3 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Hemophagocytic lymphohistocytosis (HLH) is often under recognized which leads to high mortality and morbidity. Prompt recognition and treatment can decrease mortality. We present a case of HLH triggered by infection with Ehrlichia with reactivation of EBV. CASE PRESENTATION: A 28-year-old man with no past medical history presented with fever, chills, generalized musculoskeletal pains, nausea, vomiting, loose stools and headache. He went to hiking at Roanoke river and Greenway a week prior to presentation. Physical exam revealed blood pressure 123/69 mmHg, pulse 96/min, temperature 103 F, respiratory rate 36/min. Pertinent physical examination findings include cervical lymphadenopathy, generalized muscle tenderness with bilateral shin petechiae. Laboratory data revealed leukopenia 0.9, platelets 17, transaminitis (AST-457, ALT- 96), CK- 8663, fibrinogen 162, and ferritin 61,437. He was admitted for neutropenic fever and was empirically started on vancomycin, cefepime and doxycycline for tick borne infection. Bone marrow biopsy was performed due to concern for HLH revealed histocytes with intracellular RBC and WBC’s. Further workup is negative for any autoimmune disease, malignancies, but positive for IgG EBV and Ehrlichia. PCR for EBV DNA was positive with viral load 2096 copies/ml (normal < 200 copies/ml). Received a dose of Etoposide and Decadron but he started to improve clinically. Doxycycline was continued and rest of the antibiotics and chemotherapy was discontinued. Patient was discharge in stable condition and completed total 14 days of doxycycline treatment. Patient remained asymptomatic one month after hospital discharge. DISCUSSION: HLH is a life-threatening disorder characterized by unregulated hyperimmune response to antigen which results in phagocytosis of white cells, RBCs and platelets by mononuclear macrophages. It was first described in 1952 by Farquhar and Claireaux. Secondary causes of HLH is seen in adults from autoimmune diseases, infections and malignancies. Viral infections are the most common triggers: EBV, CMV, HIV. Elevated ferritin >10,000 μg/L has been demonstrated to be 90% sensitive and 96% specific for HLH (3). If left untreated mortality is high with median survival less than 2 months. HLH-1994 treatment protocol recommended an 8-week induction with IV dexamethasone and etoposide, and HLH-2004 protocol added cyclosporine to help prevent relapse.Most patients respond to early initiation of doxycycline 100 mg twice daily in Ehrlichiosis induced HLH and can be continued 4-5 days after clinically resolution of symptoms. If refractory then can use chemotherapeutic agents like etoposide, cyclosporine, intrathecal methotrexate, methylprednisolone. CONCLUSIONS: HLH should be in differential diagnosis in patients who present from endemic regions of tick borne infections with fever, cytopenia’s and especially with high ferritin levels (> 500 μg/L). Reference #1: Ehrlichia-Induced Hemophagocytic Lymphohistiocytosis: A Case Series. Zaher K et al. Blood 2014 124:4105 Reference #2: Ehrlichiosis-Induced Hemophagocytic Lymphohistiocytosis Presenting As Septic Shock - An Immune Response Gone Haywire And Its Lessons For The Icu Setting. N. G. Holtzman et al. Am J Respir Crit Care Med 189;2014: A6737 Reference #3: Hemophagocytic lymphohistiocytosis: review of etiologies and management. Melissa R George. J Blood Med. 2014; 5: 69–86. Published online 2014 Jun 12. https://doi.org/10.2147/JBM.S46255 DISCLOSURES: No relevant relationships by Venkateswara Kollipara, source=Web Response No relevant relationships by Umar Sofi, source=Web Response

Journal of Clinical UltrasoundVolume 45, Issue 9 p. 580-581 Letter to the Editor Pulmonary embolism: An unusual finding during endobronchial sonography Adrian Noriega Aldave MD, Corresponding Author Adrian Noriega Aldave MD adnoriegaa@gmail.com apnoriegaaldave@carilionclinic.org orcid.org/0000-0002-1777-3945 Department of Pulmonary/Critical Care Medicine, Carilion Clinic/Roanoke Memorial Hospital, Roanoke, VirginiaCorrespondence Adrian Noriega Aldave and Umar Sofi, Department of Pulmonary/Critical Care Medicine, Carilion Clinic/Roanoke Memorial Hospital, Roanoke, VA. Emails: adnoriegaa@gmail.com; apnoriegaaldave@carilionclinic.org; ufsofi@carilionclinic.orgSearch for more papers by this authorUmar Sofi MD, Corresponding Author Umar Sofi MD ufsofi@carilionclinic.org Department of Pulmonary/Critical Care Medicine, Carilion Clinic/Roanoke Memorial Hospital, Roanoke, VirginiaCorrespondence Adrian Noriega Aldave and Umar Sofi, Department of Pulmonary/Critical Care Medicine, Carilion Clinic/Roanoke Memorial Hospital, Roanoke, VA. Emails: adnoriegaa@gmail.com; apnoriegaaldave@carilionclinic.org; ufsofi@carilionclinic.orgSearch for more papers by this author Adrian Noriega Aldave MD, Corresponding Author Adrian Noriega Aldave MD adnoriegaa@gmail.com apnoriegaaldave@carilionclinic.org orcid.org/0000-0002-1777-3945 Department of Pulmonary/Critical Care Medicine, Carilion Clinic/Roanoke Memorial Hospital, Roanoke, VirginiaCorrespondence Adrian Noriega Aldave and Umar Sofi, Department of Pulmonary/Critical Care Medicine, Carilion Clinic/Roanoke Memorial Hospital, Roanoke, VA. Emails: adnoriegaa@gmail.com; apnoriegaaldave@carilionclinic.org; ufsofi@carilionclinic.orgSearch for more papers by this authorUmar Sofi MD, Corresponding Author Umar Sofi MD ufsofi@carilionclinic.org Department of Pulmonary/Critical Care Medicine, Carilion Clinic/Roanoke Memorial Hospital, Roanoke, VirginiaCorrespondence Adrian Noriega Aldave and Umar Sofi, Department of Pulmonary/Critical Care Medicine, Carilion Clinic/Roanoke Memorial Hospital, Roanoke, VA. Emails: adnoriegaa@gmail.com; apnoriegaaldave@carilionclinic.org; ufsofi@carilionclinic.orgSearch for more papers by this author First published: 22 September 2017 https://doi.org/10.1002/jcu.22525Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume45, Issue9November/December 2017Pages 580-581 RelatedInformation

Although Occam's razor is frequently invoked in medicine, it is useful to keep Hickam's dictum in mind, as well; essentially, patients can have a number of diseases at the same time. This idea was illustrated by the case of a 76-year-old woman with an irregular stellate pulmonary nodule in her right middle lobe (Figure 1A). She had been undergoing computed tomography (CT) of the abdomen and pelvis for follow-up of a renal angiomyolipoma that had been stable for many years and for investigation of documented calcifications within her spleen (Figure 1B) when the nodule was discovered incidentally.

SESSION TITLE: Imaging Case Report Posters SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM INTRODUCTION: Lung herniation occurs infrequently. Transdiaphragmatic Intercostal Herniation (TIH) of abdominal contents has rarely been reported. We present a complex case of lung, liver and colon herniation through the same intercostal space. CASE PRESENTATION: A 47 year-old man with a history of COPD and seizures, presented after a fall with dyspnea and right chest wall pain. Physical exam showed large ecchymosis over the right flank. Thoracic CT demonstrated herniation of the lung and a portion of the liver through the 8th rib space. Cardiothoracic surgery (CTS) recommended elective repair of the defect after optimization of pulmonary status. He was subsequently discharged home. A week later, he was readmitted with worsening dyspnea and a soft, reducible mass over the right posterior chest wall that decreased and increased in size with inspiration and expiration respectively. Thoracic CT revealed pleural effusion contiguous to the herniated lung with new airspace disease. Thoracentesis yielded a large amount of serosanguinous fluid. He was treated for HCAP and discharged with a chest brace. Two weeks later, he presented to the ER with severe abdominal pain. CT scan revealed interval enlargement of the above hernia, TIH of mesenteric fat and ascending colon with evidence of incarceration. He was emergently taken to the OR and underwent successful reduction and repair of the incarcerated hernia. He is now awaiting evaluation for the intercostal defect repair. DISCUSSION: Fewer than 300 cases and 40 cases of lung herniation and TIH have been reported in literature respectively.(1) The majority of cases are acquired and occur after a blunt trauma. While diaphragmatic injury should be suspected in all cases of intercostal herniation,(2) prompt and precise diagnosis can be made by CT scan. Although, small hernias seldom regress spontaneously,(3) management can be complex. Definitive treatment can be achieved through surgical repair.(1) CONCLUSIONS: Intercostal lung herniation is rare and even rarer in conjunction with TIH of abdominal contents. We present an intricate case with unexpected complications of pneumonia, pleural effusion and incarceration with the management challange of this rare entity. Reference #1: Sharma OP, et al. “TIH: review of the world literature and presentation of a case,” Journal of Trauma, vol. 50, no. 6, pp. 1140-1143, 2001 Reference #2: Sarkar D, et al. “TIH following Blunt Trauma,” Case Reports in Radiology, vol. 2012, Article ID 502765, 4 pages, 2012 Reference #3: Weissberg D. Lung hernia - a review. Adv Clin Exp Med 22: 611-613; 2013 DISCLOSURE: The following authors have nothing to disclose: Brijesh Patel, Umar Sofi No Product/Research Disclosure Information