A Case of Rapidly Progressive Coccidioidal Meningitis in an Immunocompetent Patient.

A 50-year-old male with a history of a dull headache and neck pain for a few weeks presented to the ER with complaints of progressive weakness and difficulty walking. Physical examination revealed a lethargic, confused patient with abnormal tremors at rest. Initial lab work was significant for elevated hemoglobin, hematocrit, and hyponatremia. Additionally, CT imaging was significant for prominent ventricles. Several serologies and polymerase chain reaction (PCR) tests were ordered to determine the etiology of the patient's meningitis. On day 10 of admission, serology results returned positive for Coccidioides antibodies. The patient was started on an IV fluconazole treatment and underwent a ventriculoperitoneal shunt and Ommaya reservoir placement procedure. Cases of coccidioidal meningitis are rarely noted in recent literature. We present this clinical case of coccidioidomycosis dissemination into the central nervous system (CNS) to highlight the rare localization of the fungal infection in a baseline immunocompetent patient.

Dilemma of Treating Acute Myeloid Leukemia Patient After Kidney Transplant in the COVID-19 Era

Context: The incidence of malignancy increases after solid organ transplantation, which might be related to recipients' age and immunosuppressive drugs;this is accounted as the 3rd leading cause of death. Therefore, understanding cancer facts after transplantation is mandatory for transplant recipients' long-term care. Objective: A case study of a secondary acute myeloid leukemia (AML) patient after renal transplant complicated by COVID-19 infection. Design: A case report. Setting: Hematology Unit/Oncology Center, Mansoura University, Egypt. Patient: A 53-year-old male patient with a history of renal transplant due to end-stage renal failure since 2001. He was on steroids, cyclosporine (CSA), and mycophenolate mofetil since then. On December 31st, 2019, AML diagnosis (FAB-M4 AML) was confirmed by bone marrow aspiration (BMA), biopsy, and immunophenotyping (IPT). Cytogenetic and molecular analyses were negative for t(8;21), t(15;17), t(16;16), and FLT3 mutation. Interventions: He received induction chemotherapy with dose-adjusted 7+3, and immunosuppressant doses were reduced to steroids 10 mg and CSA 75 mg. BMA at D+28 showed complete remission (CR). The response was consolidated by 2 cycles of 5+2. On May 4th, 2020, CBC showed leukocytosis and anemia;BMA showed normocellular marrow with 5% blasts. Thus, he received 5 days of mitoxantrone with etoposide, and BMA reassessment was in CR. The patient's performance (PS) worsens after chemotherapy, so he continued subcutaneous cytarabine. On June 30th, 2020, the patient presented with fever and dyspnea. Relapse was confirmed by IPT and FLT-3 positivity. Chest high-resolution computed tomography (HRCT) showed bilateral mild pleural effusion and cardiomegaly. COVID-19 PCR was positive. Main Outcome Measures: The challenge was how to deal with relapse, COVID-19, and poor PS and kidney condition. He received dose-adjusted hydroxyurea with supportive measures, anticoagulant, and continued steroids. Results: Unfortunately, on August 4th, 2020, the patient was admitted to the ICU with disturbed consciousness and hyperleukocytosis with progression of HRCT and died. Conclusions: Our case had a unique presentation as the diagnosis of AML was very late after renal transplant. Managing the case was challenging as there is no consensus for this category of patients with the dilemma associated with their disease and the additional COVID-19 burden. Further studies are needed to validate a chemotherapy protocol for these patients.

The orthopaedic experience of COVID-19: A literature review.

This literature review aims to provide an account of the changes to orthopaedics in the era of COVID-19. Herein, the authors explored the use of telemedicine in orthopaedics as well as changes in surgical protocols, screening methods, work priorities and orthopaedic education. There was increased utilisation of telemedicine in orthopaedic training and outpatient cases as a means to provide continuity in education and care. The need to implement social distancing measures, coupled with the reduced availability of staff, has dictated that the practice of orthopaedics shifts to focus on acute care whilst redistributing resources to front-line specialities. This was facilitated by the cancellation of electives and the reduction of outpatient clinics. Thus, it is demonstrated that major changes have been implemented in many aspects of orthopaedic practice in order to address the challenges of the COVID-19 pandemic.

High-dose methylprednisolone in nonintubated patients with severe COVID-19 pneumonia.

BACKGROUND: Recent trials with dexamethasone and hydrocortisone have demonstrated benefit in patients with coronavirus disease 2019 (COVID-19). Data on methylprednisolone are limited. METHODS: Retrospective cohort of consecutive adults with severe COVID-19 pneumonia on high-flow oxygen (FiO2  ≥ 50%) admitted to an academic centre in New York, from 1 March to 15 April 2020. We used inverse probability of treatment weights to estimate the effect of methylprednisolone on clinical outcomes and intensive care resource utilization. RESULTS: Of 447 patients, 153 (34.2%) received methylprednisolone and 294 (65.8%) received no corticosteroids. At 28 days, 102 patients (22.8%) had died and 115 (25.7%) received mechanical ventilation. In weighted analyses, risk for death or mechanical ventilation was 37% lower with methylprednisolone (hazard ratio 0.63; 95% CI 0.47-0.86; P = .003), driven by less frequent mechanical ventilation (subhazard ratio 0.56; 95% CI 0.40-0.79; P = .001); mortality did not differ between groups. The methylprednisolone group had 2.8 more ventilator-free days (95% CI 0.5-5.1; P = .017) and 2.6 more intensive care-free days (95% CI 0.2-4.9; P = .033) during the first 28 days. Complication rates were not higher with methylprednisolone. CONCLUSIONS: In nonintubated patients with severe COVID-19 pneumonia, methylprednisolone was associated with reduced need for mechanical ventilation and less-intensive care resource utilization without excess complications.

A case of coronavirus disease 2019 in acquired immunodeficiency syndrome patient: a case report and review of the literature.

Coronavirus disease 2019 (COVID-19) is a respiratory illness caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus that was identified in December 2019. The impact of COVID-19 virus on Acquired Immunodeficiency syndrome (AIDS) patients has been reported with variable outcome. We reported a patient that was immunosuppressed by AIDS disease and chemotherapy for cancer who contracted SARS-CoV-2 infection and had a mild disease. We did literature review for the cases published that had human immunodeficiency virus (HIV) infection and COVID-19 disease and analyzed the characteristics and outcomes of the reported cases. Our review yielded three case reports and four case series for patients with HIV infection and COVID-19 disease. The majority of patients had mild disease, and some had critical disease or death. Those who had severe disease usually had other comorbidities. The findings from the case reports and case series indicate that the risk of death or severe disease from COVID-19 in HIV positive patients was lower than observed in the general population, which may indicate a possible protective effect of uncontrolled HIV in preventing the complications associated with the massive inflammatory response.