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Objective. To study risk factors, clinical and radiological features and effectiveness of the treatment of invasive aspergillosis (IA) in adult patients with COVID-19 (COVID-IA) in intensive care units (ICU). Materials and methods. A total of 60 patients with COVID-IA treated in ICU (median age 62 years, male - 58%) were included in this multicenter prospective study. The comparison group included 34 patients with COVID-IA outside the ICU (median age 62 years, male - 68%). ECMM/ISHAM 2020 criteria were used for diagnosis of CAPA, and EORTC/MSGERC 2020 criteria were used for evaluation of the treatment efficacy. A case-control study (one patient of the main group per two patients of the control group) was conducted to study risk factors for the development and features of CAPA. The control group included 120 adult COVID-19 patients without IA in the ICU, similar in demographic characteristics and background conditions. The median age of patients in the control group was 63 years, male - 67%. Results. 64% of patients with COVID-IA stayed in the ICU. Risk factors for the COVID-IA development in the ICU: chronic obstructive pulmonary disease (OR = 3.538 [1.104-11.337], p = 0.02), and prolonged (> 10 days) lymphopenia (OR = 8.770 [4.177-18.415], p = 0.00001). The main location of COVID-IA in the ICU was lungs (98%). Typical clinical signs were fever (97%), cough (92%), severe respiratory failure (72%), ARDS (64%) and haemoptysis (23%). Typical CT features were areas of consolidation (97%), hydrothorax (63%), and foci of destruction (53%). The effective methods of laboratory diagnosis of COVID-IA were test for galactomannan in BAL (62%), culture (33%) and microscopy (22%) of BAL. The main causative agents of COVID-IA are A. fumigatus (61%), A. niger (26%) and A. flavus (4%). The overall 12-week survival rate of patients with COVID-IA in the ICU was 42%, negative predictive factors were severe respiratory failure (27.5% vs 81%, p = 0.003), ARDS (14% vs 69%, p = 0.001), mechanical ventilation (25% vs 60%, p = 0.01), and foci of destruction in the lung tissue on CT scan (23% vs 59%, p = 0.01). Conclusions. IA affects predominantly ICU patients with COVID-19 who have concomitant medical conditions, such as diabetes mellitus, hematological malignancies, cancer, and COPD. Risk factors for COVID-IA in ICU patients are prolonged lymphopenia and COPD. The majority of patients with COVID-IA have their lungs affected, but clinical signs of IA are non-specific (fever, cough, progressive respiratory failure). The overall 12-week survival in ICU patients with COVID-IA is low. Prognostic factors of poor outcome in adult ICU patients are severe respiratory failure, ARDS, mechanical ventilation as well as CT signs of lung tissue destruction.Copyright © 2022, Interregional Association for Clinical Microbiology and Antimicrobial Chemotherapy. All rights reserved.
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CASE: A 4-year-old girl sustained a traumatic atlantoaxial rotatory subluxation. She presented at the treating facility 8 months after injury with cervical deformity, neck pain, gait instability, and decreased cervical motion. Her delay in presentation was partially because of international Corona Virus of 2019 (COVID-19) travel restrictions. The case was successfully treated with halo traction, followed by halo vest immobilization. CONCLUSION: Chronic atlantoaxial rotatory fixation can be treated nonsurgically with closed reduction and halo traction, but is associated with operative risks. Optimal pin placement is challenging in the pediatric skull and may be improved with a preoperative or intraoperative computed tomography (CT) scan. Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.
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Background: Only recently studies have been able to demonstrate the safety and efficacy of purification therapies in inflammatory diseases. Here we present the management of a young (21y) male patient in severe cardiogenic shock due to COVID-19 perymyocarditis admitted to the ICU at Bolzano Central Hospital. November 30th 2020 the patient developed high fever (>40 C) and diarrhea. After unsuccessfully being treated orally with a macrolide he was admitted to a peripheral hospital the 4th of December. The day after he deteriorated, required transfer to the ICU, endotracheal intubation and pharmacological cardiovascular support (Norepinephrine, Levosimendan). Antimicrobial treatment was started with piperacillin/tazobactam, linezolid and metronidazole. Despite multiple radiological and microbiological diagnostic attempts the origin of this severe septic shock remained unclear. December 6th the patient was transferred to Bolzano Central Hospital for VA-ECMO evaluation. Method(s): The transesophageal echocardiography revealed 15-20% of EF, lactate (5,2 mmol/l), cardiac enzymes (TropT 1400 mcg/l) and inflammatory parameters (PCT 35 ng/ml, IL-6 685 pg/ml) were elevated. We performed cardiac monitoring via Swan-Ganz catheter. The cardiac index was 1,6 l/min/m2. The peak dosage for Norepinephrine reached 7,5mg/h (1,47 mcg/kg/min). At Bolzano ICU we facilitate the pharmacological therapy with milrinone, vasopressin and low dose epinephrine. Furthermore, we impost continuous hemodiafiltration with CytoSorb filter. Result(s): Only hours after the start of filtration therapy the patient improved and we were able to gradually reduce catecholamine therapy, lactate values decreased. A VA-ECMO implantation was no more necessary. December 10th, we saw a stable patient without ventilatory or cardiovascular support, at echocardiography we revealed a normal EF. Conclusion(s): Clinically we saw a young patient in severe septic/cardiogenic shock due to perimyocarditis. Yet diagnostic attempts (CT-scan, multiple blood/urinary/liquor cultures) remained negative. Despite multiple negative PCR tests for SARS-CoV2 infection we performed specific immunoglobulin analysis and received a positive result for IgM. We therefore conclude on a COVID-19 associated perymyocarditis. Furthermore, this case illustrates the potential benefit of cytokine filtration and elimination in COVID-19 patients with altered IL6 levels.
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Background: Ever since the beginning of the COVID-19 pandemic, physicians started investigating the clinical features and lab markers that can assist in predicting the outcome among hospitalized COVID-19 patients. Aim(s): This study aimed to investigate the association between initial chest CT scan findings and adverse outcomes of COVID-19. Material(s) and Method(s): This was a single centre;hospital (inpatient) based prospective cohort study involving 497 COVID-19 patients admitted to the hospital. The adverse outcome included death and mechanical ventilation. We collected data about 14 identifiable parameters available for the HRCT scan. Result(s): Among 14 studied parameters, only 8 features differed significantly among the patients who had favourable and unfavourable outcomes. These features included number of lobes of lungs involved (3 versus 5, p = 0.008), CT Severity score (16 versus 20, p = 0.004), air bronchogram (p=0.003), crazy paving (p=0.029), consolidation (p=0.021), and pleural effusion (p=0.026). We observed that high CT scores coupled with the diffuse distribution of lung lesions were responsible for poor prognosis in most patients. Conclusion(s): Several features of HRCT when combined can accurately predict adverse outcomes among participants and help in triaging the patient for admission in ICU.Copyright © 2023, Dr Yashwant Research Labs Pvt Ltd. All rights reserved.
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Background: This study aimed to evaluate the outcomes of preclinical studies on the safety and immunogenicity of an inactivated COVID-19 vaccine candidate to warrant further clinical evaluation. Method(s): SARS-CoV-2 positive nasopharyngeal swab specimens were confirmed by real-time polymerase chain reaction and next-generation sequencing. The safety and immunogenicity tests of the COVID-19 vaccine were carried out in rats and Rhesus monkeys, and Balb/C mice and Rhesus monkeys, respectively. Result(s): The candidate vaccine was well tolerated and induced promising levels of SARS-CoV-2- specific IgG1, IgG2a, and Granzyme B in Balb/C mice, and anti-SARS-CoV-2 spike IgG and neutralizing antibodies in Rhesus monkeys. Based on cVNT results, the inactivated vaccine in 0.5 and 1 microg/100 microL doses was able to induce a neutralizing effect against the SARS-CoV-2 virus up to a dilution of 1:512 and 1:1000. The protective efficacy of the vaccine candidate was challenged with 2 x108 PFU of live viruses and confirmed by lung CT scan and histopathological evaluations compared to the control group. Repeated intramuscular injection of the candidate vaccine was generally well-tolerated in Rats and Rhesuses. No significant side effects were observed in rats injected with ten full human doses and in the Rhesus monkeys with three full human doses. Conclusion(s): Based on the findings presented in this study, it is recommended that this vaccine be moved into human testing commencing with a phase I clinical trial.Copyright © 2021 Muslim OT et al.
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Trauma-related hyoid fractures are rare entities. These fractures represent only 0.002% of head and neck region fractures. Victims of hanging and strangling constitute the great majority of cases. Fractures associated with trauma are extremely rare. These fractures are difficult to diagnose and can easily be overlooked during physical examination. However, they are also important traumas since airway safety is endangered in these rare cases. We describe a case of a young male presenting with isolated neck injury associated with hitting an electric cable while riding a motorbike. Tenderness was present in the anterior neck region at physical examination, but movement was not restricted and no respiratory difficulty was determined. Isolated hyoid fracture was detected at tomography of the neck performed in the emergency department. Hyoid bone fractures should not be forgotten in patients with pain and tenderness in the anterior neck region following blunt trauma to the neck.©Copyright 2020 by Emergency Physicians Association of Turkey - Available online at www.jemcr.com.
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Objectives: Airway hemorrhage (AH) frequently complicates extracorporeal membrane oxygenation (ECMO) treatment. Inflammation, coagulopathy and antithrombotic therapy are contributing factors. Patients with COVID-19- associated ARDS (CARDS) supported with ECMO present all these features. We aim to characterize the incidence and the clinical and prognostic impact of AH. Method(s): Review of a cohort of patients with CARDS treated with ECMO support at a single ECMO centre between March 2020-February 2022 (n=92). AH was defined as a clinically significant hemorrhage fit demanded interruption of anticoagulation, transfusional support or bronchoscopy. Univariate analysis was performed using GraphPadPrism. Result(s): One third (n= 31) of patients with CARDS treated with ECMO had clinically significant AH. Patients who developed AH had significantly longer ICU length-of-stay (LoS), ECMO run and invasive mechanical ventilation (IMV) duration. Significant differences in coagulation and inflammatory markers were detected between patients with early (<72h) versus late (>9 days) onset of AH (Table 1). Mortality at day 90, demographics, comorbidities, CT scan pattern and clinical severity indexes were similar between patients with and without AH (NAH). Conclusion(s): In patients with severe CARDS treated with ECMO support, the occurrence of airway hemorrhage leads to clinically important morbidity but does not increase mortality. Distinct pathways may be involved in the development of early v. late AH. (Table Presented).
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OBJECTIVE: To meta-analyze diagnostic performance measures of standardized typical CT findings for COVID-19 and examine these measures by region and national income. METHODS: MEDLINE and Embase were searched from January 2020 to April 2022 for diagnostic studies using the Radiological Society of North America (RSNA) classification or the COVID-19 Reporting and Data System (CO-RADS) for COVID-19. Patient and study characteristics were extracted. We pooled the diagnostic performance of typical CT findings in the RSNA and CO-RADS systems and interobserver agreement. Meta-regression was performed to examine the effect of potential explanatory factors on the diagnostic performance of the typical CT findings. RESULTS: We included 42 diagnostic performance studies with 6777 PCR-positive and 9955 PCR-negative patients from 18 developing and 24 developed countries covering the Americas, Europe, Asia, and Africa. The pooled sensitivity was 70% (95% confidence interval [CI]: 65%, 74%; I2 = 92%), and the pooled specificity was 90% (95% CI 86%, 93%; I2 = 94%) for the typical CT findings of COVID-19. The sensitivity and specificity of the typical CT findings did not differ significantly by national income and the region of the study (p > 0.1, respectively). The pooled interobserver agreement from 19 studies was 0.72 (95% CI 0.63, 0.81; I2 = 99%) for the typical CT findings and 0.67 (95% CI 0.61, 0.74; I2 = 99%) for the overall CT classifications. CONCLUSION: The standardized typical CT findings for COVID-19 provided moderate sensitivity and high specificity globally, regardless of region and national income, and were highly reproducible between radiologists. CRITICAL RELEVANCE STATEMENT: Standardized typical CT findings for COVID-19 provided a reproducible high diagnostic accuracy globally. KEY POINTS: Standardized typical CT findings for COVID-19 provide high sensitivity and specificity. Typical CT findings show high diagnosability regardless of region or income. The interobserver agreement for typical findings of COVID-19 is substantial.
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During the waves of the coronavirus disease (COVID-19) pandemic, emergency departments were overflowing with patients suffering with suspected medical or surgical issues. In these settings, healthcare staff should be able to deal with different medical and surgical scenarios while protecting themselves against the risk of contamination. Various strategies were used to overcome the most critical issues and guarantee quick and efficient diagnostic and therapeutic charts. The use of saliva and nasopharyngeal swab Nucleic Acid Amplification Tests (NAAT) in the diagnosis of COVID-19 was one of the most adopted worldwide. However, NAAT results were slow to report and could sometimes create significant delays in patient management, especially during pandemic peaks. On these bases, radiology has played and continues to play an essential role in detecting COVID-19 patients and solving differential diagnosis between different medical conditions. This systematic review aims to summarize the role of radiology in the management of COVID-19 patients admitted to emergency departments by using chest X-rays (CXR), computed tomography (CT), lung ultrasounds (LUS), and artificial intelligence (AI).
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Autoimmune pulmonary alveolar proteinosis (PAP) is a rare disease, especially in pediatrics, but important to consider, as it may avoid unnecessary and/or invasive investigations and delayed diagnosis. This case report highlights an adolescent girl with rapid onset dyspnea but an unremarkable physical exam and initial testing. However, due to a high index of suspicion, a chest computed tomography (CT) scan was done, revealing a "crazy paving" pattern, which then prompted expedited assessment. This finding, however, is not as specific as often discussed and has a broad differential diagnosis, which will be reviewed in detail as part of this case. Furthermore, this report demonstrates a diagnostic approach for PAP that avoids lung biopsy, previously considered to be required for diagnosis of PAP, but is increasingly becoming unnecessary with more advanced blood tests and understanding of their sensitivity and specificity. Additionally, management strategies for PAP will be briefly discussed.Copyright © 2022 Canadian Thoracic Society.
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Introduction: Mucinous adenocarcinomas of the appendix are defined as epithelial neoplasms often causing cystic dilation of the appendix due to accumulation of gelatinous material. Pseudomyxoma peritonei is an extremely rare complication of appendiceal mucinous adenocarcinomas with an estimated incidence rate of one to 2 people per million per year. Here-in we present a unique case of enterocutaneous fistula formation secondary to percutaneous biopsy of an enlarging omental mass in the setting of pseudomyxoma peritonei. Case Description/Methods: A 50-year-old male with a past medical history of metastatic appendiceal mucinous adenocarcinoma presented to the ED with abdominal pain, nausea, and vomiting. The patient had previously undergone 2 debulking surgeries over the past 2 years prior to admission and has since been on FOLFOX therapy. Due to the COVID pandemic, the patient did not follow-up in the 2 years period from previous admission. A CT scan was now notable for a new enlarging omental mass despite the recent debulking surgery. Given the enlarging mass, a decision was made to pursue a percutaneous biopsy of the mass due to concern for potential new malignancy. Two weeks after the biopsy, the patient presented to our facility due to worsening erythema and drainage from the biopsy site. The patient met SIRS criteria, thus broad-spectrum antibiotics were initiated. A CT of the abdomen and pelvis with oral and IV contrast was obtained, which demonstrated a 9 cm abscess or continuation of intra-abdominal multilocular cystic lesion/ pseudomyxoma peritonei. The surgical team was consulted. Patient had 100 cc of purulent and mucinous drainage expressed from biopsy site. The patient was then placed for transfer to a hospital capable of advanced surgical management for evaluation and potential resection of fistula formation. The patient had a successful reductive surgery and intraoperative chemotherapy (Figure). Discussion(s): Given the rarity of pseudomyxoma peritonei, appropriate management is not always straightforward. A literature review yielded no previous reports of enterocutaneous fistula as a complication of percutaneous drainage in the setting of pseudomyxoma peritonei. We recommend that percutaneous drainage not be sought in individuals with this diagnosis due to potential for fistula formation.
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Background: There is still no specific treatment strategy for COVID-19 other than supportive management. The potential biological benefits of ozone therapy include reduced tissue hypoxia, decreased hypercoagulability, modulated immune function by inhibiting inflammatory mediators, improved phagocytic function, and impaired viral replication. This study aimed to evaluate the effect of intravenous ozonated normal saline on patients with severe COVID-19 disease. Method(s): In this study, a single centralized randomized clinical trial was conducted on 80 hospitalized patients with severe COVID-19. The patients were selected by random allocation method and divided into two groups A and B. In group A (control group), patients were given standard drug treatment, and in group B (intervention group), patients received ozonated normal saline in addition to the standard drug treatment. In the intervention group, 400 mL of normal saline was weighed by 40 mug/ kg of body weight and was injected into patients within 15 to 30 minutes (80 to 120 drops per minute). This process was done daily every morning for a week. Primary and secondary outcomes of the disease included changes in the following items: length of hospital stay, inflammatory markers including C-reactive protein (CRP), clinical recovery, arterial blood oxygen status, improvement of blood disorders such as leukopenia and leukocytosis, duration of ventilator attachment, and rapid clearance of lung lesions on CT scans. The need for intensive care unit (ICU) hospitalization, the length of ICU stay, and the mortality rate in patients of the two groups was compared. Result(s): According to the results of the initial outcome variable analysis, the probability of discharge of patients who received the normal ozonated saline intervention was 33% higher than patients who did not receive this intervention;however, this relationship was not statistically significant (HR = 0.67, 95%, CI = 0.42-1.06, P value = 0.089). The chance of ICU hospitalization in patients of the intervention group was three times more than that of the comparison group, but this relationship was not significant (odds ratio = 4.4 95% CI = 1.32-14.50, P value = 0.016). The use of ozonated normal saline was found to increase the risk of death by 1.5 times but this relationship was not statistically significant (odds ratio = 1.5, 95% CI = .24-9.75, P value = 0.646). Ozonated normal saline had a significant effect on changes in respiration rate (in the intervention group the number of breaths was decreased) and the erythrocyte sedimentation rate (in the intervention group the erythrocyte sedimentation rate was increased);however, it had no significant effect on other indicators. Conclusion(s): The present study showed that ozone therapy in hospitalized patients with severe COVID-19 could help improve some primary and secondary outcomes of the disease. Governments and health policymakers should make ozone therapy an available care service so that the need for advanced treatment facilities decreases;consequently, this measure may improve patient safety, prevent lung tissue destruction, and control cytokine storms in patients. Additionally, health decision-makers need to aim for the effective clinical improvement of patients, especially severe ones, and the reduction of their mortality. However, further large-scale multicenter studies with larger sample sizes considering drug side effects and other variables influencing the clinical course of COVID-19 can provide more information on the effectiveness and importance of ozone therapy.Copyright © 2023 The Author(s);Published by Kerman University of Medical Sciences.
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Intro: Mucormycosis is known to effect patients with immunocompromised status from a variety of causes such as diabetes mellitus, hematologic malignancy, and HIV infection. Most common form of presentation is rhinocerebral infection. However, isolated presentation of renal mucormycosis is rare. With the ongoing COVID-19 pandemic and use of high-dose steroids and antibiotics, there have been increasing reports of bacterial and fungal coinfections in COVID-19 positive patients. We report a rare case of isolated renal mucormycosis, post COVID-19 infection, in a healthy individual presenting as unilateral right non-functioning pyonephrotic kidney. Method(s): A conscious, well oriented, afebrile 37 years old female patient presented with the complaints of right flank pain for one month. Patient was diagnosed as a case of post COVID-19 renal infarct with perinephric collection, right non-functioning pyonephrotic kidney. She had no previous comorbidities. Routine investigations, chest X-ray and CT scan were done. Finding(s): CT scan findings reveal a large right perinephric hyperdense collection inseparable from right kidney involving the internal oblique, psoas and quadratus lumborum muscles. Right simple nephrectomy was done and specimen was sent for histopathology and fungal culture. Histopathology report showed necrotizing granulomatous inflammation with broad, aseptate, irregularly branched fungal hyphae morphologically resembling Mucor species and fungal culture also confirmed Mucor species.Copyright © 2023
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Introduction: Enteral feeding is a physiologic process of providing adequate nutrition and has been shown to improve both mortality and quality of life in patients with inadequate oral intake. Improved critical care medicine and recent wave of Coronavirus Disease 2019 (COVID-19) has left us with a large proportion of patients needing alternative enteral nutrition. Although rare, intussusception is an important differential for patients presenting with acute abdominal pain post makeshift percutaneous endoscopic gastrostomy (PEG) tube placement. Case Description/Methods: A 58-year-old male was admitted to the hospital for coffee ground emesis over three days accompanied with epigastric pain. He had right sided hemiparesis secondary to cerebrovascular accident with PEG tube for enteral nutrition. Examination was significant for epigastric tenderness with normal bowel sounds. PEG tube aspiration revealed bile-tinged fluid. Significant labs included white blood cell count of 11,600 /mm3, hemoglobin 10.2 g/dL, and lactic acid of 2.3 mmol/L. A computerized tomography of the abdomen with IV contrast showed a small segment duodeno-duodenal intussusception at the horizontal segment around the distal end of the tube was noted (Figure A). An urgent esophagogastroduodenoscopy (EGD) revealed a Foley catheter acting as a makeshift PEG tube extending across the pylorus into the duodenum. The distal tip of the Foley catheter was visualized with an inflated balloon seen in the third portion of the duodenum (Figure B) The inflated catheter balloon acted as a lead point causing intussusception in a ball-valve effect. The balloon was deflated, and the catheter was replaced (Figure C) with a 20 Fr PEG tube. Discussion(s): Gastric outlet obstruction is an uncommon complication reported in few cases caused by migration of the gastrostomy tube. Rarely this migrating gastrostomy tube can invaginate the duodenum or the jejunum causing intussusception. Only handful of cases have been reported in the literature. Patients usually present with epigastric pain, vomiting or rarely hematemesis. CT scan of the abdomen is the investigation of choice. Amidst the pandemic and supply shortage, Foley catheters have been deemed as a viable alternative to gastrostomy tubes and are being used more often. It is important to recognize this rare complication and use of balloon catheter should raise further suspicion. Timely endoscopic intervention can help avoid bowel necrosis and surgical intervention.
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Introduction: Nirmatrelvir/ritonavir is a new medication approved for the treatment of COVID-19 infection. It prevents viral replication by inhibiting the SARS-CoV-2 main protease. While mild adverse effects were described, including dysgeusia, diarrhea, hypertension and myalgia1, there were no reported cases of pancreatitis. Case Description/Methods: An 81-year-old female with a past medical history of hypertension and COPD presented to the hospital complaining of abdominal pain and nausea for one day. She had no history of alcohol, tobacco or marijuana use, recent travel, or trauma. Her medications included lisinopril and prednisone, and she had completed a 5-day course of nirmatrelvir/ritonavir for the treatment of COVID-19 infection 2 days prior to presentation. On abdominal exam, she had left upper and lower quadrant tenderness. Blood tests revealed an amylase of 1333 U/L, lipase of 3779 U/L, triglycerides of 297 mg/dL and calcium of 8.7 mg/dL. CT scan revealed an indurated pancreatic body and tail with peripancreatic fluid along the paracolic gutter. Ultrasound of the abdomen and MRCP did not reveal any acute findings. IgG subclasses 1-4 were normal. Discussion(s): According to the revised Atlanta criteria, the patient had clinical findings consistent with acute pancreatitis. Common causes such as gallstone, alcohol, autoimmune and hypertriglyceridemiainduced pancreatitis were ruled out. There were no masses or structural abnormalities on imaging that might have explained her diagnosis. There have been at least 2 reported cases of lisinopril and prednisone induced pancreatitis, however according to Badalov et al.2 both of these medications are class III drugs that lack any rechallenge in the literature. Moreover, the patient had been taking these medications for many years, making them an unlikely cause of the presenting diagnosis. There are no reports of nirmatrelvir/ritonavir associated pancreatitis or known pharmacologic interaction with her home medications, and a meta-analysis conducted by Babajide et al. revealed no association between acute pancreatitis and COVID-19 infection (3). Given the negative findings stated above and the recent initiation of a new medication, nirmatrelvir/ritonavir was the likely cause of acute pancreatitis.
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Introduction: Disseminated histoplasmosis (DH) presents as primarily lung manifestations with extrapulmonary involvement in immunocompromised hosts. Granulomatous hepatitis as first presentation of DH in an immunocompetent host is uncommon. Case Description/Methods: 25-year-old female presented with one month of fever, fatigue, myalgias, 30-pound weight loss, cough, nausea, vomiting, and epigastric pain. She has lived in the Midwest and southwestern US. Presenting labs: TB 1.9 mg/dL, AP 161 U/L, AST 172 U/L, ALT 463 U/L. Workup was negative for COVID, viral/autoimmune hepatitis, sarcoidosis, tuberculosis, and HIV. CT scan showed suspected gallstones and 9 mm left lower lobe noncalcified nodule. EUS showed a normal common bile duct, gallbladder sludge and enlarged porta hepatis lymph nodes which underwent fine needle aspiration (FNA). She was diagnosed with biliary colic and underwent cholecystectomy, with white plaques noted on the liver surface (A). Liver biopsy/FNA showed necrotizing granulomas (B) and fungal yeast on GMS stain (C). Although histoplasmosis urine and blood antigens were negative, histoplasmosis complement fixation was >1:256. She could not tolerate itraconazole for DH, requiring amphotericin B. She then transitioned to voriconazole, discontinued after 5 weeks due to increasing AP. However, her symptoms resolved with normal transaminases. At one year follow up, she is asymptomatic with normal liver function tests. Discussion(s): DH is a systemic granulomatous disease caused by Histoplasma capsulatum endemic to Ohio, Mississippi River Valley, and southeastern US. DH more commonly affects immunocompromised hosts with AIDS, immunosuppressants, and organ transplant. Gastrointestinal involvement is common in DH (70-90%) with liver involvement in 90%. However, granulomatous hepatitis as primary manifestation of DH is rare (4% of liver biopsies). Hepatic granulomas are seen in < 20%. Patients may present with nonspecific systemic symptoms. Serum/urine antigens may be negative. Gold standard for diagnosis is identifying yeast on tissue stains. Recommended treatment is amphotericin B followed by 1 year of itraconazole. However, shorter treatment duration may be effective in immunocompetent hosts. This case is unique in that granulomatous hepatitis was the first presentation of DH in our immunocompetent patient diagnosed on EUS FNA and liver biopsy. Clinicians must have a high degree of suspicion for DH in patients with fever of unknown origin especially in endemic areas regardless of immunologic status. (Table Presented).
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The global pandemic of coronavirus infection (COVID-19) has set complex diagnostic tasks for doctors of polyclinics and hospitals. Considering the simultaneous pandemic spread of two infectious diseases - COVID-19 and HIV infection, the problem of studying the clinical features of combined COVID-19/HIV infection becomes urgent. The aim of the study was to determine the features of the diagnosis and course of COVID-19 against the background of HIV infection in patients undergoing inpatient treatment. Material and methods. The study was conducted on the basis of the temporary Clinical Medical Center COVID-19 of the A.I. Yevdokimov Moscow State University of Medicine and Dentistry of the Ministry of Healthcare of the Russian Federation in Moscow from October 2020 to January 2022. The study included 31 233 patients with COVID-19 complicated by pneumonia. To analyze the features of the course of combined COVID-19/HIV infection, a group of 51 HIV-infected patients was identified. The diagnosis of COVID-19 was determined based on the detection of SARS-CoV-2 RNA by PCR in nasal/oropharyngeal smears and/or according to computed tomography of the lungs (CT). During the study, age, gender, anamnesis, objective examination data were analyzed, taking into account the results of CT scans of the chest organs, data from routine laboratory blood tests, oxygen support regimens, treatment outcomes and duration of detection of SARS-CoV-2 RNA. All patients were treated according to the Temporary Clinical Guidelines for the Diagnosis and Treatment of COVID-19, 14 version dated 12/27/2021. Results. The number of patients with combined HIV infection and SARS-CoV-2 out of the total number of hospitalized COVID-19 patients (n=31 233) was 0.16%. Upon admission, 30 (59%) patients reported having HIV infection and receiving antiretroviral therapy (ART). HIV infection was first diagnosed in 21 patients at 2-3 weeks of inpatient treatment. The average age of patients with SARS-Cov-2/HIV co-infection was 1.5 times less than in patients without HIV (41.1+/-5.3 and 64.4+/-10.1, respectively) (p<=0.05). Concomitant pathology (hypertension, type 2 diabetes mellitus, chronic kidney disease and chronic lung diseases) was less common (51%) in the group of combined infection than in the group without HIV (83%). However, in 41% of patients with coinfection, chronic viral hepatitis B, C was detected, in contrast to 0.3% of cases of COVID-19 patients without HIV. 26 (51%) patients were discharged with improvement, while the average bed-day did not differ from patients without HIV infection (13.4+/-4.5 days and 11.7+/-5.2, respectively) (p>=0.05). 7 (24%) patients at the time of discharge (16.8+/-4.2 days) with clinical and laboratory improvement maintained a positive result of PCR RNA on SARS-Cov-2. In 22 (43%) patients with coinfection, hospitalization was fatal for 3 to 21 days of treatment, with ARDS with respiratory and multiple organ failure, which is 3.6 times higher than in patients without HIV infection. The analysis showed that, regardless of the result of PCR on SARS-CoV-2 RNA, in non-specialized hospitals, HIV testing is indicated for young patients with fever for more than 14 days, with lung damage in the form of bilateral interstitial changes according to CT, a history of chronic hepatitis C, B, with progressive severity of the condition on against the background of COVID-19 therapy. Early consultation of an infectious disease specialist, examination of sputum/lavage by PCR for pathogens of opportunistic infections and the appointment of ART and drugs for the treatment of opportunistic diseases will improve the quality of medical care for patients in a non-core HIV hospital will improve the prognosis of COVID-19.Copyright © Eco-Vector, 2022.
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Introduction: Pancreatitis is a very common gastrointestinal disease that results in hospital admission. Early detection and treatment leads to better outcomes. This is the first reported case of pancreatitis secondary to elevated tacrolimus in a patient with prior renal transplantation after receiving Paxlovid for a COVID-19 infection. Case Description/Methods: A 57-year-old male with past medical history of 4 renal transplants secondary to posterior urethral valves who presented to the emergency room with acute onset epigastric pain for 24 hours. He was on tacrolimus 5 mg every 48 hours monotherapy for his immunosuppression. 10 days prior to his presentation he had developed chills and anxiety. He tested positive for COVID-19 at that time on a home rapid test. His symptoms had not significantly improved and given his immunosuppressed state he was given Paxlovid (Nirmatrelvir/ritonavir). He took 2 days of Paxlovid, however after his second day of treatment he developed severe epigastric pain requiring him to go to the emergency room. On admission his labs were notable for a lipase of 150 U/L (ULN 63 U/L). He underwent a CT scan was notable for an enlarged pancreatic head and neck with peripancreatic fat stranding (Figure). He also had a right upper quadrant ultrasound without any cholelithiasis and only trace sludge noted. His creatinine was noted to be 1.81 mg/dl which was above his baseline of 1.2 mg/dl. His tacrolimus trough level resulted at a level 45.6 ng/ml and later peaked at 82.2 ng/ml. His liver enzymes were normal. He was treated as acute pancreatitis with hydration and his tacrolimus was held with overall clinical improvement. Discussion(s): Tacrolimus is one of the most common medications used in solid organ transplantation. It is a calcineurin inhibitor that inhibits both T-lymphocyte signal transduction and IL-2 transcription. It is metabolized by the protein CYP3A and levels are monitored closely. Paxlovid is currently prescribed as an antiviral therapy for COVID-19 infection. The ritonavir compound in Paxlovid is potent inhibitor of CYP3A. Currently the guidelines do not recommend Paxlvoid as a therapeutic in patients taking tacrolimus as there is concern about increased drug levels. There have been several case reports of pancreatitis in setting of tacrolimus. This case report helps to demonstrate the need for close monitoring of therapeutics levels, especially in medications with high risk of drug to drug interaction to help prevent serious side effects such as tacrolimus induced pancreatitis.
ABSTRACT
Background/Aims A 72-year-old lady presented in primary care with complaints of generalised body aches, bilateral leg weakness and constitutional symptoms following a first dose of COVID-19 vaccine. Blood tests showed slightly raised inflammatory markers. She was initially diagnosed with polymyalgia rheumatica and was started on 40mg prednisolone with minimal improvement. Methods The examination in the rheumatology clinic was unremarkable. Investigations revealed raised white cell count, consistent with high dose steroid treatment, and elevated monocytes. There was mild improvement in inflammatory markers. The working diagnosis was of self-limiting viral illness. Further testing discovered strongly positive MPO ANCA (115 IU/ml), and the patient received three pulses of 500mg methylprednisolone for suspected vasculitis arranged by the medical team. There was no evidence of renal involvement. The diagnosis made at this point was autoimmune inflammatory disorder with unclear aetiology. At the subsequent clinic visit she reported mild shortness of breath, but no other symptoms suggestive of either vasculitis or connective tissue disease. Repeat ANCA showed significant reduction in MPO titre following pulse steroid treatment. CT of chest, abdomen and pelvis demonstrated a localised lobular/ nodular deformity of the liver. Viral hepatitis screen was negative. CA19-9 was raised at 100 U/ml. Liver biopsy was reported as poorly differentiated carcinoma without specific localising immunohistochemical features. Results The patient underwent hemi-hepatectomy for histologically confirmed pT2pNXM0R0 liver cholangiocarcinoma in a tertiary centre followed by adjuvant chemotherapy with capecitabine. With treatment, her MPO ANCA and CA19-9 levels declined. An interval CT scan of chest, abdomen and pelvis performed ten months after the surgery, showed no recurrence of malignancy. Given the fact that the patient's MPO ANCA fell following the treatment of cholangiocarcinoma, it is likely that positive MPO ANCA is associated with underlying malignancy rather than an active vasculitis. Conclusion This unusual case describes an evolution of the diagnostic process guided by non-specific symptoms and ANCA positivity, arriving at an unexpected diagnosis of malignancy. Although ANCA is a sensitive and specific marker of vasculitides, it can be positive in other conditions particularly hepatitis B, inflammatory bowel disease and autoimmune liver disorders. Malignancy can also be associated with ANCA in the absence of vasculitis. In one study, of 118 ANCA positive patients without ANCA-associated vasculitis, four were found to have malignancy. In a study of 1024 patients who had ANCA tested, 61 patients were found to have malignancy, predominantly haematological and lung cancers. However, after adjustment for sex, age and time of blood draw, no association was found between ANCA status and incidence of cancer. Interestingly, paraneoplastic vasculitis such as polyarteritis nodosa (PAN) has been described in the context of underlying cholangiocarcinoma, and is associated with ANCA rise. Moreover, patients with raised ANCA and PAN also have raised CA 19- 9.
ABSTRACT
Introduction: Although Gastrointestinal fistula is a well-recognized complication of acute pancreatitis, it has been rarely reported. Here we present a rare case of spontaneous gastro-pancreatic fistula following acute pancreatitis. Case Description/Methods: 42 y/o female with PMH of SLE with a recent prolonged hospitalization for acute drug-induced pancreatitis with pseudocyst came to ED with fever, abdominal pain, nausea, and vomiting. She was tachycardic, had leukocytosis, and was positive for COVID-19. CT Scan A/P showed multiple infected peripancreatic collections with communication of the left upper quadrant collection with the gastric lumen (Figure). The patient was hospitalized, Kept NPO, and started on fluids and antibiotics. IR evaluated and put 2 pigtail catheters for drainage of peripancreatic collections. The tip of the pigtail catheter in the left peripancreatic/retroperitoneal collection was in the gastric lumen. The surgery team recommended continuing with conservative treatment with parenteral nutrition, and IV antibiotics as the patient were nontoxic with no signs of free perforation, and pancreatitis would more likely erode a staple or suture line and would put the patient at further risk of free perforation if repair attempted. IR was successful in pulling the drain out of the gastric lumen on the second attempt to allow gastric perforation to heal. Antibiotics were upgraded as per the culture and sensitivity results of the drain fluid. Repeated multiple bedside leak tests and CT scans with oral contrast continue to be positive for patent gastro-pancreatic fistula. Pigtails catheter continues to drain significant necrotic collection. The patient continues to be hospitalized and is being managed conservatively with Parenteral nutrition, and IV antibiotics. Discussion(s): Fistula of the GI tract following acute pancreatitis can be caused by multiple reasons. Necrosis of the bowel may occur concomitantly with the pancreatic or peripancreatic tissue. Furthermore, enzyme-rich fluid and necrosis can lead to vascular thrombosis, which compromises the blood supply of the segmental GI tract, eventually leading to bowel necrosis. GI fistulas are more common in patients with necrotizing pancreatitis with infected pancreatic necrosis. Despite pharmacologic suppression of pancreatic exocrine secretion and advances in endoscopic and percutaneous therapeutic techniques, pancreatic fistula continues to be a source of morbidity and mortality following pancreatitis and requires multidisciplinary treatment.