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Journal of General Internal Medicine ; 37:S453, 2022.
Article in English | EMBASE | ID: covidwho-1995835


CASE: 66yo woman with a past medical history of hypertension and monoclonal gammopathy of undetermined significance was sent from clinic in winter for 4 days of worsening fevers and sinus congestion unrelieved by over-the- counter medications. COVID and flu negative. Patient has had no sick contacts or recent travel and has pet cats but no recent scratches. Initial chest x-ray showed no acute processes, but patient was continuing to have fevers up to 103 with mild dyspnea and chills so a CT chest was completed which showed ground glass opacities in the right middle lobe. Blood and sputum cultures were obtained, and patient was started on ceftriaxone and azithromycin for community acquired pneumonia. Urine strep and legionella antigens were also acquired, both negative. Over the next two days, she continued to have high fevers and chills at nights with leukocytosis, thrombocytopenia, hyponatremia, and notable worsening of mild elevation of liver enzymes on admission. Cultures were negative and patient had no other indication of an infection aside from the cyclical fevers therefore empiric doxycycline was added for coverage of atypical infections. Over the next two days, she continued to have nightly fevers up to 103 so ID was consulted for fever of unknown origin. On repeat exposure assessment, patient revealed that she lived with multiple animals including cats, dogs, parakeets, chickens, geese and a pony. Patient was continued on doxycycline while additional lab tests were sent for atypical infections including Rickettsia typhi, Coxiella brunetti (Q fever), and Brucella spp given patient's history of exposure to multiple animals at home. Patient was discharged on doxycycline after being afebrile for 48hrs with declining white count and liver enzymes. Lab results confirmed the diagnosis with high titers for Rickettsia typhi IgG and IgM. IMPACT/DISCUSSION: This case illustrates an atypical presentation of murine typhus with pneumonia in winter. There are several key teaching points in this case: 1. Ricketssia typhi infections have largely nonspecific symptoms therefore it should should be included in differential diagnoses of febrile illnesses with thrombocytopenia and elevated liver enzymes 2. Although a complete history is acquired on admission, it is important to revisit and review information again when a clinical diagnosis has not been established 3. Defeverscence after starting doxycycline can take anywhere from 4 to 66hrs so fevers during this timeframe is not an indication of failure of therapy CONCLUSION: Murine typhus presents with non-specific symptoms so it should be included in the differential diagnosis of patients with fevers of unknown origin with potential exposure to flea-bearing animals. The optimal therapy is doxycycline 100mg twice a day for seven days. Patients should also be advised to treat their animals for fleas to prevent recurrent infections.

Diabetic Medicine ; 39(SUPPL 1):18, 2022.
Article in English | EMBASE | ID: covidwho-1868592


Aims: Previous UK population research identified multiple risk factors for increased covid-19 mortality in people with type 2 diabetes but it is unclear if these are general to respiratory infections or specific to covid-19. We aimed to compare risk factors associated with death from covid-19 (pre-vaccination roll-out) and pneumonia. Methods: In UK routine primary care data (CPRD), we followed adults with type 2 diabetes from 01/09/2019-31/ 01/2020 (pneumonia mortality cohort n = 609,079) and 01/02/2020-31/ 10/2020 (covid-19 mortality cohort n = 587,933). Multivariable Cox proportional hazards models were used to identify risk factors in each cohort. Results: We observed 2,690 deaths (0.5%) due to covid- 19, and 1,612 deaths due to pneumonia (0.3%). For covid- 19 mortality, we replicated previously reported risk factor associations for male sex, older age, higher deprivation, higher BMI, renal impairment, previous stroke and cardiovascular disease. These features were also associated with higher pneumonia mortality. A differential effect was observed for ethnicity: compared to people of white ethnicity, black and south Asian groups had higher covid-19 mortality (adjusted hazard ratio [aHR] 2.07 [95%CI 1.81-2.38], p < 0.001, and 1.50 [1.33-1.70], p < 0.001 respectively), but lower pneumonia mortality (aHR 0.43 [95%CI 0.31-0.60], p < 0.001, and 0.54 [0.43-0.68], p < 0.001 respectively). Higher HbA1c was a stronger risk factor for covid-19 mortality than pneumonia mortality (aHRs [95%CI] HbA1c >86 vs 48-53 mmol: 1.30 [1.09-1.54], p = 0.004 for covid- 19, 1.10 [0.86-1.42], p = 0.442 for pneumonia). Conclusions: In type 2 diabetes, clinical risk factors for covid-19 and pneumonia mortality are largely similar, but non-white ethnicities have disproportionately higher risk of covid-19 mortality compared to lower risk of pneumonia mortality, which needs further exploration.

Diabetic Medicine ; 38(SUPPL 1):12-13, 2021.
Article in English | EMBASE | ID: covidwho-1238413


Aim: Diabetes has consistently been shown to increase the risk of poor covid-19 outcomes. Rather than a simple additive effect of diabetes and age-related risk, recent studies suggest a disproportionately higher relative mortality risk in younger people. Better understanding the interaction between age and diabetes could help inform complex prioritisation decisions around covid-19 vaccination. Methods: We triangulate evidence on heterogeneity of diabetes effect by age on covid-19 mortality from large UK studies. Two population-based studies (OpenSAFELY [n = 17,278,392, 8.8% diabetes] and QCOVID [n = 6,083,102, 7.0% diabetes]), report age-specific hazard ratios (HR) associated with diabetes for covid-19 mortality. We also examine age-specific HRs in severe covid-19 (n = 19,256 critical care patients in England, 18.3% diabetes). To aid interpretability, we translate risk estimates into covid-age;the additional years of covid-19 mortality risk added to an individual's chronological age if diabetes is present. Results: Additional covid-19 mortality risk associated with diabetes is markedly higher in younger than older people across all studies. This reflects the higher relative risk associated with diabetes in younger age groups (HRs for diabetes >5 in ages <50 in OpenSAFELY and QCOVID). For a person aged 40 with diabetes, additional mortality risk is equivalent to 20 years of chronological age, meaning risk is similar to that of a person without diabetes aged 60. For a person aged 70 with diabetes, additional mortality risk from diabetes is equivalent to an additional 5 years, so their covid age is 75. Conclusion: The disproportionate covid-19 mortality risk in younger people with diabetes should be considered to ensure they are appropriately prioritised for vaccination.