Fever and rash: Do not MIS the diagnosis

Case description A 25-year-old patient was admitted for high fever (T: 39degreeC) since 1 week and a generalized maculopapular rash since 3 days. The eruption spread from his legs to his chest but spared his face. There were also papules on his hand palms while his foot soles were deeply erythematous. The patient described a sore throat, dry cough, slight retrosternal discomfort and muscle pain the week before. He also noticed a redness of his eyes since 2 days. There was no recent travelling, sexual intercourse and no animals at home. He was vaccinated against measles and COVID-19. His last proven COVID-19 infection dated from 8 months earlier. He was not taking medication and had no past medical history. Clinically, the patient had a generalized maculopapular eruption, multiple cervical lymphadenopathy, cheilitis, bilateral conjunctivitis and a hepatosplenomegaly. Labs showed a CRP at 312 mg/L, neutrophil count at 13.000/mm c, platelet count at 169.000/mm c, total bilirubin at 1,7 mg/dL (mostly direct), ASAT 100 U/L, ALAT 150 U/L, GGT 202 U/L and LDH 348 U/L. Creatinine level was 1,17 mg/dL. Troponine count was 187ng/L. D-dimers were elevated at 3069 ng/mL and ferritin level was also elevated at 3268 microgramme/L. There was a slight disturbance of INR (1,9). NT-ProBNP level was 1911 pg/mL. Urine analysis was normal and blood cultures were negative. Chest X-ray was negative. Abdominal ultrasound confirmed a hepatosplenomegaly. A transthoracic echocardiography showed an ejection fraction of 51% without signs of pericarditis. Serology for Hepatitis A, C, HIV, CMV, Syphilis, Mycoplasma were negative. The patient was immune for Hepatitis B and measles. PCR for measles was negative. He had already been in contact with Parvovirus B19 (IgG positive) and EBV (IgM and IgG positive with presence of anti EBNA). His serology for COVID-19 was positive with high levels of anti-nucleocapsid and anti-spike S1 antibodies but PCR on nasopharyngeal swab was negative. Autoimmune serology were negative (ANA, ANCA). We suspected the presence of a multisystem inflammatory syndrome of the adult (MIS-A) with cardiac involvement because of the Kawasaki-like dermatological presentation and the high inflammatory levels. We had no proof of a more recent SARS-CoV-2 infection than the infection of 8 months earlier. A cardiac monitoring was proposed and the patient was treated by intravenous immunoglobulin and corticosteroids. His general state improved rapidly and he was discharged after 10 days of hospitalization with a tapering dose of corticosteroid given orally. Conclusion(s): MIS-A is a novel syndrome secondary to SARS-Cov-2 infection, in the beginning mostly described in children (MIS-C) but also described in adults. There is fever, high inflammation, and severe illness with multisystem organ involvement (>=2). Cardiac involvement is present in most of the cases. Serology is often positive but PCR can be negative, suggesting the presence of a dysregulation of the immune system more than an acute infection. The mortality rate is 1-2% so physicians should be able to recognize this disease in order to give the best treatment.

Nirmatrelvir-ritonavir chez les patients greffés rénaux infectés par le SARS-CoV-2 : l’expérience d’une cohorte belge

Introduction Le nirmatrelvir-ritonavir (NR) a démontré son efficacité et sa sécurité pour prévenir la survenue de formes sévères de COVID-19 chez les patients à risque de progression. Néanmoins, peu de données existent chez les greffés rénaux. De plus, le ritonavir interagit avec de nombreux médicaments, notamment avec les inhibiteurs de la calcineurine (IC). Description Nous avons inclus dans cette étude monocentrique rétrospective tous les patients traités par NR entre le 28/04/2022 et le 03/06/2022. Méthodes Le traitement par NR était de 5jours (jour 1 à jour 5) à la dose recommandée. Le traitement usuel (notamment immunosuppresseur) était adapté selon les recommandations de la Société Française de Pharmacologie et Thérapeutiques. Un suivi standardisé biologique et clinique a été réalisé. Résultats Quatorze patients ont été inclus (Tableau 1). Comparées à celles du jour 0 (veille de l’initiation du NR), les concentrations médianes de créatinine plasmatique et les charges virales de SARS-CoV-2 au jour 7 étaient respectivement similaires (p=0,866) et fortement diminuées (p=0,002). Deux patients ont eu une insuffisance rénale aigue rapidement résolutive dans un contexte de diarrhée et de sepsis urinaire. Les concentrations résiduelles d’IC sont restées relativement stables avec néanmoins 5 patients qui ont présenté des taux supra-thérapeutiques au premier dosage post reprise de l’IC. Après un suivi médian de 34jours, aucun patient n’est mort ni n’a présenté de pneumonie virale. Deux patients ont dû être hospitalisés pour sepsis urinaire (au jour 2 et 11). Nous avons néanmoins observé 2 cas de récidive précoce de symptômes associée à une réaugmentation de la charge virale après traitement par NR (au jour 10 et 21). Conclusion L’utilisation du NR est possible chez les greffés rénaux sous condition d’un respect strict des adaptations thérapeutiques recommandées. 14 % de la cohorte a présenté une récidive précoce en cours d’investigation.

Safety of systemic anti-cancer treatment in oncology patients with non-severe COVID-19: a cohort study.

BACKGROUND: The viral pandemic coronavirus disease 2019 (COVID-19) has disrupted cancer patient management around the world. Most reported data relate to incidence, risk factors, and outcome of severe COVID-19. The safety of systemic anti-cancer therapy in oncology patients with non-severe COVID-19 is an important matter in daily practice. METHODS: ONCOSARS-1 was a single-center, academic observational study. Adult patients with solid tumors treated in the oncology day unit with systemic anti-cancer therapy during the initial phase of the COVID-19 pandemic in Belgium were prospectively included. All patients (n = 363) underwent severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) serological testing after the first peak of the pandemic in Belgium. Additionally, 141 of these patients also had a SARS-CoV-2 RT-PCR test during the pandemic. The main objective was to retrospectively determine the safety of systemic cancer treatment, measured by the rate of adverse events according to the Common Terminology Criteria for Adverse Events, in SARS-CoV-2-positive patients compared with SARS-CoV-2-negative patients. RESULTS: Twenty-two (6%) of the 363 eligible patients were positive for SARS-CoV-2 by RT-PCR and/or serology. Of these, three required transient oxygen supplementation, but none required admission to the intensive care unit. Hematotoxicity was the only adverse event more frequently observed in SARS-CoV-2 -positive patients than in SARS-CoV-2-negative patients: 73% vs 35% (P < 0.001). This association remained significant (odds ratio (OR) 4.1, P = 0.009) even after adjusting for performance status and type of systemic treatment. Hematological adverse events led to more treatment delays for the SARS-CoV-2-positive group: 55% vs 20% (P < 0.001). Median duration of treatment interruption was similar between the two groups: 14 and 11 days, respectively. Febrile neutropenia, infections unrelated to COVID-19, and bleeding events occurred at a low rate in the SARS-CoV-2-positive patients. CONCLUSION: Systemic anti-cancer therapy appeared safe in ambulatory oncology patients treated during the COVID-19 pandemic. There were, however, more treatment delays in the SARS-CoV-2-positive population, mainly due to a higher rate of hematological adverse events.

Late Breaking Abstract - Impact of an improvised system on preserving oxygen supplies in patients with COVID-19

Background: Patients with coronavirus disease (COVID-19) can develop severe hypoxemia. Meeting the soaring demands of oxygen may be a challenge. Objective: To test the efficacy of an easily handmade system, the double-trunk mask (DTM), in reducing oxygen consumption while maintaining patient's oxygenation level. Methods: Hospitalized adults with COVID-19 and hypoxemia treated with low-flow oxygen therapy we recruited. The standard oxygen delivery system was replaced by the DTM with nasal cannula for 30 minutes with an oxygen output adapted to maintain an identical oxygen saturation by pulse oximetry. The standard oxygen delivery system was then reinstated for 30 minutes. Primary outcome was the absolute change in oxygen flow between the standard delivery systems and the DTM. Secondary outcomes were changes in blood gases, vital parameters and patient comfort. Results: Eleven patients were analyzed (mean age 61 years;27% male). Compared with standard delivery systems, the oxygen output was significantly reduced with the DTM (median, 5 vs 1.5 L/min (95% CI -4 to -1.5, p=0.003)) when oxygen saturation and arterial oxygen tension remained stable. The DTM was also associated with a significant but slight increase in arterial carbon dioxide tension (median, 36 mmHg vs 37 mmHg, p=0.006), and respiratory rate (median, 26 vs 30 breaths/min, p=0.05). Other parameters were unaltered. The DTM was generally judged less comfortable than the baseline oxygen delivery system, especially in patients requiring low oxygen flow at baseline. Conclusions: The DTM is a simple and efficient system to reduce oxygen consumption. This may have clinical implications in places where oxygen supplies are limited.

Clinical characteristics and humoral immune response in healthcare workers with COVID-19 in a teaching hospital in Belgium.

BACKGROUND: Healthcare workers (HCWs) are at high risk of acquiring COVID-19 and could play a role in nosocomial transmission. Since 4th February 2020, Belgian Health authorities reported more than 90,568 cases, of which 8.3% were HCWs. Data on clinical characteristics, sources of infection and humoral immune response of HCWs with COVID-19 remain scarce. AIM: To analyse the clinical characteristics, humoral immune response, sources of contamination, and outcomes among HCWs with COVID-19. METHODS: This retrospective study included 176 HCWs with laboratory-confirmed COVID-19 in a teaching hospital in Belgium. Between 1st March and 31st May 2020, all HCWs with symptoms suspected of COVID-19 were tested by reverse transcription polymerase chain reaction on a nasopharyngeal swab. Serological testing was performed between 55 and 137 days after the onset of symptoms. FINDINGS: Median age was 40.8 years and 75% were female. Median delay between onset of symptoms and diagnosis was 4.39 days. Most frequent symptoms were cough and headache (both 75%). Fever accounted for 68.7%. Most represented professions were nurses (42%). HCWs were mainly infected by patient contact (32.9%); 7.6% required hospitalization and 1.7% were admitted to the intensive care unit. Unfortunately, one HCW died (0.5%). Total antibodies were positive in 109/126 (86.5%). CONCLUSIONS: Clinical presentation of COVID-19 in HCWs does not differ from the general population. However, outcomes were more favourable with a mortality rate lower than that reported in Belgian COVID-19 patients in general (16%). The main source of infection was the hospital setting. Our positive antibodies rate was high but lower than previously reported.