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At the end of 2019, a novel coronavirus (CoV) appeared in Wuhan, China and has since spread to several countries and regions throughout the world. The disease caused by the novel CoV has been officially named CoV disease 2019 (COVID-19). This study provides additional data for the presence of anti-SARS-CoV-2 IgM and IgG antibodies in COVID-19 patients in Vietnam. The study also presents the development of a lateral flow immunoassay (LFA) strip for rapid simultaneous detection of the IgA/IgM/IgG antibodies against the SARS-CoV-2 virus in COVID-19 patients. The properties of the LFA test strip were evaluated by testing specimens from COVID-19 positive and negative patients confirmed by real-time PCR. Reproducibility and repeatability reached 100%. The LFA test strip did not show any cross-reactivity with 13 different pathogens and did not interfere with anticoagulants. The sensitivity and specificity of the LFA test strips were evaluated with 633 clinical samples and were found to be 91.06% and 98.74%, respectively. The Kappa statistics showed almost perfect agreement and correlation between our test strip and real-time PCR results (k coefficient = 0.902). From the obtained results, it could be suggested that the LFA test strip is a useful tool for rapid detection of antibodies against SARS-CoV-2 to accelerate epidemiological surveillance, to determine the situation of exposure to SARS-CoV-2, and to increase the diagnostic accuracy of the real-time PCR method for COVID-19. © 2023 Ngo, et al.
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Background. COVID-19 associated pulmonary aspergillosis (CAPA) is a known complication of COVID-19 which carries a high mortality rate. While there are proposed diagnostic criteria, CAPA remains likely underdiagnosed. Our objectives are to evaluate markers of disease severity, bacterial coinfections, and outcome measures in order to assess the clinical impact of CAPA in patients admitted with COVID-19. Methods. A retrospective chart review was performed on all adult patients admitted to a single-center, tertiary hospital from March 1, 2020 to May 1, 2022 with a positive COVID-19 PCR and probable or proven CAPA based on ECMM/ ISHAM consensus criteria. Admission data, ICU status, time to CAPA diagnosis, respiratory cultures, and 90-day mortality were identified. Results. 14 patients met criteria for probable CAPA. 10 of 14 patients (71.4%) were immediately admitted to the ICU. By day 14, 13 patients (92.9%) were intubated. The average time from admission to CAPA diagnosis was 31.3 days. 12 patients were diagnosed by BAL galactomannan, while 2 patients were diagnosed by growth on respiratory culture. 12 patients (85.7%) also had bacterial growth on respiratory cultures. The most common pathogen was Staphylococcus aureus, which was seen in 6 patients. All-cause mortality was 42.8%, or 6 of 14 patients, at day 90. In patients with a CAPA diagnosis, the average length of ICU stay was 36.4 days and average total hospital length of stay was 43.6 days, compared to 6.3 and 12.5 days, respectively, for all patients admitted with COVID-19 disease. Conclusion. CAPA is a rare complication of COVID-19 but had substantial negative impacts on affected patients. The late onset of CAPA may be a result from longer hospitalizations and increased healthcare-associated infections. The association of CAPA with bacterial coinfections is consistent with literature on other viral infections such as influenza predisposing to secondary pneumonias. As the majority of cases were diagnosed by galactomannan rather than culture, providers should have a low threshold for testing in patients with protracted hospitalization for COVID-19. This case series emphasizes the poor outcomes associated with CAPA and its burden on already strained hospital resources, highlighting the need for improved disease awareness and further study.
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SESSION TITLE: COVID-19 Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Coronavirus Disease 2019 (COVID-19) infection ranges from asymptomatic to severe disease as defined by WHO. Emerging fungal infections such as mucormycosis and aspergillosis have been described in critically ill patients, most notably in India, when treated with steroids due to severe COVID-19 [1]. We present a unique case of an atypical presentation of mucormycosis in a non-severe COVID-19 patient not treated with corticosteroids. CASE PRESENTATION: A 19-year-old male with type 1 diabetes mellitus presented to the emergency room for evaluation of shortness of breath, nausea and fatigue. History was significant for insulin noncompliance with home blood glucose in the 300s and a positive COVID-19 test one day prior to arrival. Initial vitals positive for tachycardia, tachypnea and hypertension while on room air. Labs showed leukocytosis 14,000 cells/uL, bicarbonate 7.2 mmol/L, anion gap 24.8, glucose 428 mg/dL, beta-hydroxybutyrate 58 mg/dL and nucleic acid amplification COVID-19 positive. Physical exam showed left eyelid and facial swelling, nasal congestion without sinus tenderness or other deformity, and kussmaul breathing pattern. CT face confirmed left periorbital cellulitis. Transfer to tertiary center for Ophthalmology evaluation was attempted but refused due to capacity. He was started on diabetic ketoacidosis treatment as well as broad spectrum antibiotics with the assistance of Infectious Disease, however COVID-19 treatments were held due to mild illness. Despite these interventions, he became stuporous and amphotericin was started. MR Brain showed findings suggestive of cavernous sinus thrombosis, acute ischemia and local mass effect. ENT then performed an endoscopic antrostomy with ethmoidectomy and biopsies were taken. Pathology resulted as invasive fungal sinusitis with 90° branching hyphae confirming mucormycosis and a lumbar drain was placed with intrathecal amphotericin started for concern of mucormycosis meningitis. The patient was ultimately transferred to a tertiary care center where he expired. DISCUSSION: Mucormycosis, an angioinvasive fungal infection affecting the immunocompromised and diabetics, is rare but deadly. The estimated prevalence in the United States is 0.16 per 10,000 hospital discharges [2] and bears a mortality rate of 46%. Recent systematic reviews report 275 cases of COVID associated mucormycosis with 233 in India [1] with 76.3% receiving corticosteroids prior to diagnosis [3], likely contributing to an immunocompromised state. Our case demonstrates that despite not receiving corticosteroids, even those with mild COVID-19 are at risk for this disease. CONCLUSIONS: Patients with diabetes, immunocompromised states, and now COVID-19, presenting with orbital symptoms warrant consideration of mucormycosis. Prompt management of the underlying condition, IV amphotericin, and possible debridement may increase survival. Reference #1: John TM, Jacob CN, Kontoyiannis DP. When Uncontrolled Diabetes Mellitus and Severe COVID-19 Converge: The Perfect Storm for Mucormycosis. J Fungi (Basel). 2021 Apr 15;7(4):298. doi: 10.3390/jof7040298. PMID: 33920755;PMCID: PMC8071133. Reference #2: Kontoyiannis DP, Yang H, Song J, et al. Prevalence, clinical and economic burden of mucormycosis-related hospitalizations in the United States: a retrospective study. BMC Infect Dis. 2016;16(1):730. Published 2016 Dec 1. doi:10.1186/s12879-016-2023-z Reference #3: Singh AK, Singh R, Joshi SR, Misra A. Mucormycosis in COVID-19: A systematic review of cases reported worldwide and in India. Diabetes Metab Syndr. 2021 Jul-Aug;15(4):102146. doi: 10.1016/j.dsx.2021.05.019. Epub 2021 May 21. PMID: 34192610;PMCID: PMC8137376 DISCLOSURES: No relevant relationships by james abraham No relevant relationships by christian ALMANZAR ZORRILLA No relevant relationships by Grace Johnson No relevant relationships by Thanuja Neerukonda No relevant relationships by Blake Spain No relevant re ationships by Michael Su No relevant relationships by Steven Tran No relevant relationships by Margarita Vanegas No relevant relationships by Alexandra Witt
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Background. Patients who are admitted to the hospital with Coronavirus Disease 2019 (COVID-19) often have protracted hospitalizations complicated by bacterial or fungal co-infections. This also raises the question whether there is some feature of COVID-19 that predisposes to development of specific co-infections. To begin answering that question, we sought to review the distribution of microorganisms identified in bacterial and respiratory cultures in patients admitted with COVID-19. Methods. In a retrospective review of all patients admitted with COVID-19 in the year 2020 at a single academic tertiary medical facility, all positive blood and respiratory cultures were reviewed. Common contaminants were removed. Duplicate growth of the same organism within the same patient was not counted as a separate event. Results. 787 patients were admitted with COVID-19 for the specified time frame. There were 131 and 147 unique events of documented bacterial or fungal growth seen in blood cultures and respiratory tract cultures, respectively. The most commonly identified organism in blood cultures was Staphylococcus aureus (3.94% of patients with COVID-19), followed closely by Enterococcus (2.41%), Klebsiella (1.65%), and Escherichia (1.27%). Staphylococcus aureus was also the most frequently isolated organism in respiratory cultures (7.24% of patients with COVID-19), followed by Pseudomonas (3.43%), Klebsiella (1.78%), Serratia (0.89%), and Stenotrophomonas (0.89%). Conclusion. This suggests that the distribution of pathogens implicated in coinfections in this patient population may not be substantially different from what might be expected in patients admitted for reasons outside of COVID-19. Further investigation with a larger patient population would provide more generalizable data, including patients admitted for reasons outside of COVID-19.
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Case Report We report here a case of a 26-year-old woman at week 29 of a pregnancy who was transferred to our hospital for OBGYN care after on the same day she presented to an outside facility for one day of vaginal bleeding. At the transferring facility she was noted to be hypertensive with concerns for pre-eclampsia, acute kidney injury and non-reactive nonstress test. She had not had any pre-natal care or screenings done. Upon arrival she was normotensive but became obtunded and emergently taken to the OR. She was found to have a 50% placental abruption with uterine atony, hemorrhaging, and unfortunately fetal demise. She tested positive for SARS-CoV-2 on screening though she had no initial respiratory symptoms. Following extubation, she was noted to have very labored breathing, continued disorientation, and repeatedly stated that she was blind. She was subsequently re-intubated both to protect her airway and due to her work of breathing. Chest imaging showed bilateral patchy opacifications of her lungs and she was initiated on treatments for COVID19 pneumonia. She was lymphopenic at this time with an absolute lymphocyte count of 800 cells/mm. She had not been vaccinated against SARS-CoV-2. Over her hospitalization, she underwent extensive workup. For her complaints of vision loss she underwent ophthalmologic exam which did not find uveitis or other changes consistent with syphilis but rather for ischemic central retinal vein occlusions. She had persistent hypoxic respiratory failure and ultimately necessitated tracheostomy due to prolonged dependence of mechanical ventilation support. Approximately 1 month after her hospitalization, she developed a new left lower lung opacification as well as scattered tree-in-bud nodular findings on chest CT imaging. On bacterial and culture workup she grew methicillin-susceptible Staphylococcus aureus as well as Aspergillus species (identification still pending). She was treated with a short course of cefazolin for bacterial pneumonia and was started on a 3-month course of isavuconazonium sulfate for probable COVID-19-associated pulmonary aspergillosis (CAPA). After a two-month long hospitalization, she had gradual clinical improvement and was transferred to a skilled nursing facility for long-term care. In this case, the devastating impact of COVID-19 disease in a young, unvaccinated, and pregnant woman is clearly seen, as are multiple sequelae. She unfortunately lost her pregnancy and developed severe visual impairments and several opportunistic respiratory infections. Her placental abruption, ischemic retinal vein occlusions and pulmonary aspergillosis were all felt to be directly attributable to her COVID19 disease. The case presented here serves as a cautionary tale that even the young are at risk for severe COVID-19 disease. Healthcare professionals should continue to advocate for screening and vaccination for these high-risk individuals.
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Case Report A 45-year-old man with a history of end-stage renal disease s/p kidney transplant 14 months prior presented with severe headaches, neck pain, nausea, and vomiting for the past week. He takes tacrolimus, mycophenolate mofetil, and prednisone. Exam was notable for fever of 38.1°C, photophobia, and neck pain induced with forward flexion. Noncontrasted CT head found no intracranial processes. Lumbar puncture demonstrated an opening pressure of 45 cm H20 with CSF showing 108 WBCs with 67% neutrophils, normal glucose, and protein elevated to 112 mg/dL. Due to our high suspicion for cryptococcal meningitis, he was started on induction therapy with amphotericin B and flucytosine. CSF and serum cryptococcal antigens later returned positive at 1:320 and 1:2560, respectively. CSF culture also grew Cryptococcus neoformans/gattii complex. He underwent serial lumbar punctures and completed 14 days of induction therapy. He was transitioned to fluconazole consolidation after CSF cultures cleared and opening pressures on lumbar puncture had normalized. After induction, he acutely developed a severe leukopenia to 100 cells/mm3 along with profuse diarrhea. Over the next 1-2 days, he had progressive cough and dyspnea followed by hypotension, tachycardia, and hypoxemia, at which point he was diagnosed with SARS-CoV-2. He had completed his SARS-CoV-2 vaccinations 4 months prior to hospitalization. He was started on broad spectrum antibiotics and dexamethasone, placed on high-flow oxygen, and transferred to the intensive care unit. He was diagnosed with Klebsiella pneumoniae bacteremia. He developed progressive multi-organ failure and suffered a cardiac arrest. After discussion with family, the patient was transitioned to comfort care and passed away. Patients on immunosuppressive therapy are high risk for severe outcomes from both opportunistic infections and common infections that may affect the immunocompetent. It was critical to maintain a broad differential on this patient's presentation, as while cryptococcal meningitis is classically a disease of advanced HIV/AIDS, it may also occur in patients with alternative causes of immunosuppression. These patients often have other features that complicate therapy, such as an inability to reduce immunosuppression to control the disease, or drug interactions between antifungals and their immunosuppressive medications. This patient also suffered other complications from his chronic immunosuppression;a poor response to his initial SARS-CoV-2 vaccination and predisposition to more severe COVID-19 disease. Both leukopenia and diarrhea are common findings in COVID-19, which provoked the Klebsiella pneumoniae bacteremia. This unfortunate case demonstrates the need to always remain vigilant for both opportunistic and routine infections in an immunocompromised patient, especially in the setting of an ongoing viral pandemic.
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Introduction: The national opioid epidemic has become a key focus of various health agencies. Recent data suggest increases in overdose deaths, primarily driven by synthetic opioids, during the 2019 novel coronavirus disease pandemic. A leading strategy in mitigating risk from the opioid public health crisis, including opioid use disorder (OUD), is via increased promotion and access to the lifesaving, opioid overdose-reversing medication, naloxone. Pharmacists have been recognized as integral in addressing this emergency;however, literature evaluating outcomes from multifaceted clinical pharmacy specialist (CPS) interventions and involvement are lacking. Research Question or Hypothesis: A quality improvement project was undertaken with the expectation that CPS involvement would result in increased naloxone prescribing proportions (quantity of OUD patients with an active prescription for naloxone within the past year divided by the quantity of patients with OUD), improved patient access to care, and increased clinical interventions. Study Design: A before and after evaluation was conducted. Methods: CPSs spearheaded a variety of interventions to increase naloxone prescribing in patients with OUD, including naloxone informational letters, focused education with prescribers, review of clinical dashboards identifying OUD patients indicated to receive naloxone, CPS naloxone prescribing, and automated naloxone medication orders integrated into electronic health record progress note templates. Naloxone prescribing proportions were compared before and after implementation of these interventions. Other measures evaluated were number of encounters, patients and clinical interventions completed by the CPSs. The evaluation period for both groups was three months. Prescribing proportions were compared through statistical analysis with chi-squared for nominal data. Results: Naloxone prescribing proportions increased from 21.9% to 56.0% (p<0.01). Number of encounters, patients and clinical interventions completed increased by 45%, 74%, and 36%, respectively. Conclusion: The significant increase in naloxone prescribing proportions and numerically increased encounters, patients, and clinical interventions suggest the value of CPS involvement in targeting the opioid epidemic.