No evidence of resistance to itraconazole in a prospective real-world trial of dermatomycosis in India.

BACKGROUND: The prevalence of superficial fungal infections in India is believed to have increased substantially in the past decade. We evaluated the treatment outcomes and risk factors associated with clinical response to a treatment course of itraconazole for the management of dermatomycosis in India. METHODS: In this real-world, prospective pilot study (August 2019 to March 2020), adult participants (18-60 years), diagnosed with T. cruris or T. corporis, received itraconazole 200 mg/day (any formulation) orally for 7 days, and were followed for an additional 7 days. RESULTS: The study was terminated early due to the COVID-19 pandemic. Of 40 enrolled participants (mean [SD] age, 35.5 [12.73] years; {62.5%}] male; 37 received itraconazole and 20 (50%) completed the study. The median (range) Clinical Evaluation Tool Signs and Symptoms total score at baseline was 5.5 (2-10). Clinical response of "healed" or "markedly improved" based on the Investigator Global Evaluation Tool at day 7 (primary objective) was 42.9% (12/28; 95% CI: 24.53%, 61.19%). Itraconazole minimum inhibitory concentration for identified microorganisms, T. mentagrophytes species complex (91.7%) and T. rubrum (8.3%), was within the susceptibility range (0.015-0.25 mcg/mL). At day 14, 8/13 (61.5%) participants achieved a mycological response, 2/13 participants (15.4%) had a mycological failure and 90% showed a clinical response. CONCLUSION: COVID-19 pandemic affected patient recruitment and follow-up, so the findings call for a careful interpretation. Nevertheless, this real-world study reconfirmed the clinical efficacy and microbial susceptibility to itraconazole for the fungi causing dermatophytosis in India. TRIAL REGISTRATION: Trial registration number: Clinicaltrials.gov NCT03923010.

Knowledge of undergraduate dental students in Riyadh about infection control and precautions against COVID-19: a cross-sectional study

Introduction: It is the responsibility of dentists to maintain a protocol preventing or reducing the spread of infection in dental clinics for their patients, their staff, and dentists themselves. This can be done by following the recommended infection control work practice procedures. Materials and methods: A cross-sectional study was conducted among 310 undergraduate dental students in Riyadh by using an online survey during October 2020 to December 2020. All dental universities in Riyadh were contacted and students from clinical levels were requested to fill up the survey forms. All the research proposals were submitted, and ethical clearance was obtained from the institutional ethical review board. An online written consent was obtained from all study participants and their contribution was completely voluntary. A structured, closed-ended, and self-administered questionnaire consisting of 22 items was developed after reviewing published literature and the guidelines issued by the Centre for Disease Control and health ministry, Saudi Arabia, towards COVID-19. A Shapirowilk's test (p < 0.05) and visual examination of the histograms indicated the non-normal distribution of the data. Descriptive statistics on frequency distribution and percentages have been determined for categorical variables. Mean, median and interquartile ranges and mean ranks were calculated for continuous variables (knowledge, awareness, and attitude). Non-parametric tests and Mann-Whitney U were used to compare the mean ranks between gender, nationality, and marital status. Whereas the Kruskal-Wallis test was used to compare mean ranks between different experiences, health sector, and qualification categories of study participants. Bivariate and multivariable analysis were performed for the factors associated with knowledge, attitude, and practice. All data were analyzed using IBM-SPSS (version 25 Armonk, NY: USA). A value of p < 0.05 was considered to be significant for all statistical tests.

Assessment of COVID-19 knowledge among various health professionals in Riyadh City, Saudi Arabia

Background: COVID-19 is a highly infectious respiratory disorder affecting millions around the world. Practitioners from various sectors of the medical field are deliberating and daily exchanging knowledge to understand this disease, along with ongoing research related to the vaccines and medications for combating it. Design and methods: This is a cross sectional study conducted among the health care professionals of Riyadh, Saudi Arabia using an online survey. A total 571 participants from Riyadh were used in this study and were contacted using social media.

SMARCA4-DEFICIENT UNDIFFERENTIATED TUMOR: A RARE THORACIC MALIGNANCY

SESSION TITLE: Rare Malignancies SESSION TYPE: Case Reports PRESENTED ON: 10/17/2022 03:15 pm - 04:15 pm INTRODUCTION: SMARCA4 deficient undifferentiated tumors (SMARCA4-DUT) are rare and aggressive neoplasms that are most commonly encountered in young male smokers and portend a poor prognosis (1,2). They are characterized by loss of SMARCA4, a subunit of chromatin remodeling complexes, and loss of the tumor suppressor brahma-related gene 1 (BRG1). We present a case of an elderly female with an extensive smoking history who was diagnosed with SMARCA4-DUT. CASE PRESENTATION: An 84 year old female with approximately 70 pack year smoking history, emphysema, ischemic cardiomyopathy, and coronary artery disease, presented to the emergency room with upper abdominal pain which started one day prior to admission. She endorsed an unintentional 10 pound weight loss in the past two months. The patient was admitted for an incarcerated ventral hernia for which she underwent repair. Of note, one and a half years ago, she was found to have a right lower lobe 7mm nodule but was unable to follow up due to the COVID pandemic. On this admission, a CT chest revealed a 4.2 x 3.8 x 3.7cm mediastinal mass and subcarincal lymphadenopathy. She underwent an EBUS with biopsy of the mediastinal mass and subcarinal lymph node. Cytology showed highly atypical epitheloid cells, concerning for a neoplasm with neuroendocrine differentiation and granulomas. Given the high suspicion for malignancy, she had a PET CT (figure 1) which showed FDG activity (SUV 11) in the mass with areas of necrosis and was referred to thoracic surgery. She underwent thoracoscopy with mediastinal mass resection and lymph node dissection and pathology showed diffuse sheets of epithelioid cells with large foci of necrosis. Neoplastic cells showed preserved INI (SMARCB1) expression, non-reactivity for NUT, and complete loss of BRG1 (SMARCA4) expression, consistent with a SMARCA4-DUT with positive margins (figure 2). She was referred to Radiation Oncology with plans to pursue further therapy thereafter. DISCUSSION: SMARCA4-DUT is a new and distinctive clinicopathological entity of aggressive thoracic tumors (1). The novelty of this class of tumors poses challenges in terms of treatment. Immune checkpoint inhibitors have shown compelling outcomes in case reports (3), however larger studies are needed to delineate optimal treatment regimens. CONCLUSIONS: SMARCA4-DUT are are rare but highly aggressive thoracic neoplasms. They present as large tumors and are smoking related. Prompt recognition may aid in early diagnosis. No definitive therapy exists but immunotherapy has shown promising results. Reference #1: Chatzopoulos, K., Boland, J.M. Update on genetically defined lung neoplasms: NUT carcinoma and thoracic SMARCA4-deficient undifferentiated tumors. Virchows Arch 478, 21–30 (2021). Reference #2: Roden AC. Thoracic SMARCA4-deficient undifferentiated tumor-a case of an aggressive neoplasm-case report. Mediastinum. 2021;5:39. Published 2021 Dec 25. Reference #3: Henon C, Blay JY, Massard C, Mir O, Bahleda R, Dumont S, Postel-Vinay S, Adam J, Soria JC, Le Cesne A. Long lasting major response to pembrolizumab in a thoracic malignant rhabdoid-like SMARCA4-deficient tumor. Ann Oncol. 2019 Aug 1;30(8):1401-1403. DISCLOSURES: No relevant relationships by Sathya Alekhya Bukkuri No relevant relationships by Erin Meier No relevant relationships by Mangalore Amith Shenoy No relevant relationships by Alexandra Zavin

SPONTANEOUS ENTEROCOCUS FAECALIS EMPYEMA IN A PATIENT WITH COVID-19

SESSION TITLE: Fellows' COVID-19 SESSION TYPE: Fellow Case Reports PRESENTED ON: October 18-21, 2020 INTRODUCTION: Since its discovery severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has infected millions of people worldwide causing the current coronavirus disease 2019 (Covid-19) pandemic. Presenting symptoms range from asymptomatic to mild disease to respiratory failure and death. Some patients develop a cytokine release like syndrome which manifests with increased markers of inflammation and is associated with acute respiratory distress syndrome (ARDS), multiorgan failure, and death. Treatment with immunomodulatory agents have been proposed to attenuate disease severity and mortality. However, literature is conflicting whether widespread immunosuppression is beneficial or detrimental (1,2). We report a case of a patient diagnosed with Covid-19 induced ARDS requiring extracorporeal membrane oxygenation (ECMO), initially treated with the interleukin-6 (IL-6) antagonist, tocilizumab, who later developed enteroccocus faecalis empyema. CASE PRESENTATION: A 34 year-old man with no prior medical history presented to our hospital with fevers and dyspnea. SARS-CoV-2 was detected via polymerase chain reaction assay. On hospital day two, the patient was intubated for acute hypoxemic respiratory failure. He was treated with hydroxychloroquine, azithromycin, and ceftriaxone. Laboratory data showed C-reactive protein 217.61 mg/L, estimated sedimentation rate 68 mm/1h, ferritin 15,424 ng/ml, IL-6 level 46 pg/ml. He received tocilizumab 400 mg on hospital days two and twenty-three. Despite this he continued to deteriorate (PaO2/FiO2 ratio 0.76) and veno-venous ECMO was initiated on hospital day nine. Chest x-ray performed on hospital day fourteen showed a right-sided pleural effusion which was drained via chest tube. Cultures grew enterococcus faecalis and his antibiotics were narrowed to intravenous vancomycin. Three weeks after his admission, he underwent tracheostomy placement. He continued to improve and ECMO was discontinued on hospital day thirty-four. The tracheostomy tube was eventually removed and he was discharged home on hospital day forty-two. DISCUSSION: CRS-like phenomena are increasingly recognized during severe disease in Covid-19. It is characterized by a proinflammatory cascade, with upregulation of interleukins, and tumor necrosis factor resulting in cytolytic cell dysfunction (3). Covid-19 associated CRS is associated with increased mortality and therefore targeting cytokines and chemokines is of particular interest as a therapeutic approach. While tocilizumab has FDA approval for treatment of rheumatoid arthritis and CRS in setting of chimeric antigen receptor T-cell therapy, the safety and efficacy in Covid-19 has yet to be established. Increased SARS-CoV-2 burden and superimposed bacterial infections are worrisome adverse effects(1). CONCLUSIONS: This case highlights the need to consider secondary bacterial infections in patients with clinical deterioration despite tocilizumab use. Reference #1: Ritchie AI, Singanayagam A. Immunosuppression for hyperinflammation in COVID-19: a double-edged sword?. Lancet. 2020;395(10230):1111. doi:10.1016/S0140-6736(20)30691-7 Reference #2: Radbel J, Narayanan N, Bhatt PJ. Use of Tocilizumab for COVID-19-Induced Cytokine Release Syndrome: A Cautionary Case Report [published online ahead of print, 2020 Apr 25]. Chest. 2020;S0012-3692(20)30764-9. doi:10.1016/j.chest.2020.04.024 Reference #3: Qin C, Zhou L, Hu Z, et al. Dysregulation of immune response in patients with COVID-19 in Wuhan, China [published online ahead of print, 2020 Mar 12]. Clin Infect Dis. 2020;ciaa248. doi:10.1093/cid/ciaa248 DISCLOSURES: No relevant relationships by Michael Bender, source=Web Response No relevant relationships by Mangalore Amith Shenoy, source=Web Response No relevant relationships by Alexandra Zavin, source=Web Response