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Introduction: The Covid-19 pandemic has led to an uncomfortable and often recurrent situation in foot care services in the UK which frequently manifests in the older, White British, overweight, lone male population who often are manual workers. Result(s): These patients are unaware of local or national health promotion campaigns (e.g. iDEAL group's ACT NOW campaign, Diabetes UK's Putting Feet First) so have little awareness and education regarding potential foot problems. They are not aware of 5-to drive, eat 5 portions of fruit and vegetables a day, check your feet every day or walk 10,000 steps initiatives. They do not access public health materials and do not follow social media platforms, magazines, or newspapers. Therefore when they present in clinic, often after an emergency appointment with their GP, or an attendance at A&E, they present with significant soft tissue damage or systemic infection, frequently catastrophic tissue loss and serious co-morbidity (often in the form of renal or cardiac failure). Many require immediate hospital admission, intra-venous antibiotics, surgical debridement, vascular intervention and/or amputation. Unfortunately for some early mortality (often from an overwhelming cardio-vascular event) is the reality before they get as far as a major amputation. Discussion(s): Patients with more long-term conditions have increased risk of missing GP appointments (after controlling for number of appointments made) and are at increased risk of all-cause mortality, with those with long-term mental-health conditions who miss >2 appointments per year having >8x risk of all-cause mortality compared with those similar diagnoses who missed no appointments (McQueenie et al. 2019).
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Objectives: In the Covid-19 era, there was a surge in the cases of a life-threatening infection of rhinosinonasal mucormycosis. Mucormycosis, popularly known as black fungus, is an infection caused by mycetes mucorales, an aseptate hyphae. Presently, computed tomography (CT) and magnetic resonance imaging (MRI) are commonly used imaging modalities for the management of patients with rhinosinonasal mucormycosis. The present study was aimed to evaluate the role of 18F- FDG PET/CT in the detection of recurrent or residual disease in post-surgical or post antifungal therapy in these patients for further management. Method(s): A total of 10 patients were included in this pilot study of Covid-19 positive patients and histologically proven mucormycosis (by KOH mount). 18F- FDG PET/CT was performed to assess the disease status in 6 postoperative/ post debridement patients and response to antifungal therapy in 4 patients, at an interval of 40 (range = 27-66) days post intervention. Result(s): The mean age of the patients was 45.0 +/- 11.65 years. The male: female ratio was 9:1. The common clinical presentation was ipsilateral facial or orbital pain and swelling. Covid-19 infection was positive in all the patients except one who had CT finding with HRCT score of 10/25 and hence was considered as post Covid-19 infection. Six out of 10 patients were diabetic on oral hypoglycaemic agents or insulin. All patients had a baseline CT/MRI for staging the initial extent of the disease. Surgical debridement was done in 6 out of the 10 patients followed by antifungal therapy (Liposomal Amphotericin B and Pozaconazole). Remaining four patients were treated with antifungal therapy. PET/CTwas performed after an average of 40 days of surgical/medical intervention, in whom clinical symptoms persisted or worsened even on antifungal therapy. 18F-FDG PET/CT showed metabolically active residual disease in all the patients with a mean SUVmax of 9.78 +/- 4.03. Conclusion(s): In the era of ongoing Covid-19 infection, black fungus has been a debilitating disease with high mortality and morbidity. Present study demonstrated that 18F-FDG PET/CT can be an efficient imaging tool for an early surgical/ medical treatment response assessment and restaging.
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Upper extremities are frequently involved in fire burns due to the natural protective reflexes. The presence of bilateral Dupuytrenʼs disease and COVID-19 disease in patients with circumferential upper extremity burns can negatively impact the outcome, through severe contracture and a tendency to hypoxia or infections, which affects normal wound healing. Enzymatic debridement with a concentrate of proteolytic enzymes enriched in bromelain prevents compartment syndrome development in such patients, reduces blood loss, surgery duration, and appears to favor a more rapid recovery. © 2022, Amaltea Medical Publishing House. All rights reserved.
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Objective: Diabetic foot ulcers (DFUs) are complications of diabetes mellitus. COVID-19 pandemic has massively impacted human health. We studied effect of COVID-19 on outcome of DFUs. Method(s): We recruited 483 people with DFU from June 2020-April 2022 (pandemic group) together with a matched group of 227 people with DFU from March 2019-March 2020 (pre-pandemic group). Matching was done with respect to glycemic control (Average HbA1c in pandemic group 9.15%;pre-pandemic group 8.92%), and renal status. Primary endpoint was outcome of ulcers- healed or undergone amputation. Primary outcome was further sub analyzed in the 3 waves of COVID-19 Secondary endpoint was healing of individual types of DFUs. Basic anthropometric data with site, nature and Wegner's grading of DFUs were collected. Diagnosis of peripheral neuropathy was done by monofilament testing and peripheral arterial disease by handheld Doppler and ABI. Standardized treatment protocol including glycemic control, infection control, debridement, dressing, offloading was provided. All patients were monitored for >6 months. Result(s): In pandemic cohort of 483 patients 323(66.9%) patients had healed ulcers, 70(14.5%) had minor amputation, 11(2,2%) had major amputation, 29(6%) lost to follow up, 22(4.6%) had not healed and 28 are in follow up (5.8%). Rate of healing of DFU in pandemic group was higher (66.9%) than control group (53.5%). Similarly, rate of amputation in pandemic group was less (16.7%) than pre-pandemic group (23.4%). Among healed ulcers in pandemic group, non-infected neuropathic ulcers healed better (77.8%;199/256) than other types (54.6%;124/227) [p< 0.00001]. Similarly, rate of amputation (major/minor) in ischemic and neuroischemic ulcers in pandemic group was more (32.3%;11/34) than other types (15.6%;70/449) [p= 0.011]. Rate of healing of foot ulcers in 1st wave was 65.4% (53/81), 2nd wave 75.2% (158/210), 3rd wave 58.3% (112/192). Neuropathic ulcers though less prevalent in first two waves (49.8%;145/291) than 3rd wave (57.8%;111/192) healing rate was more in first two (79.3%;115/145 vs 75.6%;84/111). [p=0.488 (statistically not significant]. Ischemic and neuroischemic ulcers were more in 3rd wave (7.8%;15/192) than first two waves (6.5%;19/291) and undergone more amputation (46.7%;7/15 vs 15.7%;3/19). [p=0.58 (statistically not significant;due to small sample size]. Discussion/Conclusion: COVID-19 pandemic (mainly first two waves) accounted for travel restrictions contributing to better healing of neuropathic ulcers whereas ischemic and neuroischemic ulcers worsened and underwent more amputation as patients could not seek intervention. Conversely, in third wave withdrawal of COVID restrictions lead to worsening of DFUs leading to less healing and more amputation.Copyright © 2023
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Background: Acute invasive fungal rhinosinusitis (AIFRS) is a rare aggressive life-threatening infection that affects immunocompromised individuals. Recently, an increase in the incidence of this infection has been reported in patients who have SARS-CoV-2 infection or recently recovered. This study was to assess the outcome and define risk factors that might affect the outcome in SARS-CoV-2-related AIFRS. A prospective observational study included 54 patients diagnosed with SARS-CoV-2-related AIFRS. Controlling the predisposing factors, systemic antifungal, and early surgical debridement was performed. The mortality rate was calculated. Age, sex, underlying risk factors, the extent of the disease, debridement technique, and other biochemical variables were evaluated regarding their impact on survival. Patients were followed up for 3 months. Result(s): Fifty-four patients with a mean age of 48.1 years. Diabetes mellitus was the most common comorbidity affecting 52 patients (96.3%). Intracranial and intraorbital extension had a predictive value for mortality (P value 0.050 and 0.049 respectively). However, only intracranial extension was the independent predictor of mortality. Biochemical variables were higher than the normal range, but only serum ferritin level above 165 ng/ml was an independent predictor of mortality in patients with AIFR. The mortality rate was 38.9%. Conclusion(s): The extent of the disease has a major impact on survival, so early diagnosis of AIFRS within patients infected with SARS-CoV-2 or recently recovered is essential to reduce mortality.Copyright © 2022, The Author(s).
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To assess the risk factors causative of ROCM post COVID-19. To determine the clinical manifestations, causative factors leading to surge in ROCM & factors contributing to poor prognosis in ROCM cases occurring in Western Rajasthan post COVID-19. In a Retrospective observational study, 56 post COVID-19 ROCM patients were analyzed from 'May-June 2021' at M.D.M. Hospital, Jodhpur. All patients after onset of disease were assessed as per selection criteria, included patients were examined for risk factors and clinical manifestations & then were statistically evaluated. Median age was 53 years with male to female ratio 2.7:1. Uncontrolled diabetes was noted in at least 85% patients. Steroid use was seen in 66%. Other major contributing factor to ROCM was the occupation; Out of 56 patients 69% were FARMERS.72% had no history of COVID-19 vaccination. Only 3% had no underlying disease. Overall mortality rate was 16% .2 determinants were associated with poor prognosis: higher HbA1c-Out of 7 cases of orbital exenteration, 6 (85%) had HbA1c > 12. 36% took immoderate amounts of Steam inhalation. Maxillary sinuses were the most involved sites (94%). Orbital involvement was seen in 33 and 12% were PL negative. Palatal involvement & intracranial involvement were seen in 14% and 7% respectively. Bilateral disease was seen in 28%. Uncontrolled DM & Humid working conditions came out to be the main predisposing factors for ROCM. Facial pain is considered to be the most common presenting complain. Maxillary sinus is the most involved site.
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Purpose To assess whether transcutaneous retrobulbar Amphotericin B (TRAMB) injection can halt disease progression and reduce the requirement of exenteration in post-COVID 19 Rhino-orbital cerebral Mucormycosis (ROCM)) with limited orbital disease. Methods Retrospective series from a single center included 22 patients with KOH proved post-COVID 19 ROCM with radiographic evidence of limited orbital involvement were evaluated from May 2021 to October 2021. TRAMB was given along with systemic intravenous Amphotericin B injection and sinus debridement. Demographic profile, clinical data, operative notes, blood and radiological investigations were evaluated. The primary outcome was to assess the halt in the progression of orbital disease. The primary outcome measure was to assess the halt of the disease progression and the secondary outcome was improvement in the clinical signs and symptoms. Results The mean age was 50.36 ± 9.72 years and 77.3% were men. The Stagewise distribution was twelve (54.5%) patients in stage 3a, four (18.2%) patients in stage 3b, four (18.2%) in stage 3c, one (4.5%) patient in stage 3d and one (4.5%) had stage 4 disease. Improvement in lid edema and conjunctival chemosis were noticed and it was statistically significant (p value < 0.01), similarly visual acuity and ocular motility showed significant improvements (p value 0.04 and < 0.01 respectively). 1 patient died and 1 patient required exenteration later. Twenty patients showed halting of orbital disease after TRAMB injection. Conclusion TRAMB can be an alternative adjuvant therapeutic option to preserve the globe in patients with limited orbital disease but not at all replacement for exenteration.
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The aim of this study is to evaluate the prevalence, pathogenesis and management of mucormycosis in post covid 19 patients in our tertiary care covid dedicated hospital. A prospective cross sectional study was done in 70 patients who were admitted in the covid department of BJ Medical College, Civil hospital Ahmedabad and presented with mucormycosis during admission or after discharge over a period of 10 months from March 2020 to December 2020. Middle aged to elderly population were found to be most commonly affected with mucormycosis. It was found that majority of the affected population was uncontrolled diabeteic and had a delayed presentation to hospital due to ongoing covid pandemic crisis. Covid infection had major effect on the hormonal balance of the body as evident from the uncontrolled blood glucose levels of affected patients. In patients with mucormycosis, early detection, surgical debridement, suitable antifungal therapy, and control of risk factors like diabetes mellitus are the main parameters of successful management of this lethal infection. Early diagnosis and treatment of mucormycosis can be life saving as it is a rapidly progressing disease and have been proven fatal.
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Rhino orbital cerebral mucormycosis is a medical emergency; though rare it's a life threatening infection in patients. It commonly occurs in immunocompromised patients due to various causes. A retrospective study was conducted in tertiary care centre wherein 30 non-covid, diabetic patients were treated for mucormycosis. All underwent intensive debridement and diabetic management along with antifungal- amphotericin. All the cases improved with aggressive therapy: medical and surgical. Early recognition and treatment is needed to prevent morbidity and mortality.
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Funding: None. Synopsis: 61-year-old male who initially presented to an outside facility with streptococcal pneumoniae meningitis and bacteremia. Of note, he had history of COVID-19 pneumonia a month prior. On hospital day 15, he reported sudden onset lower back pain prompting imaging which demonstrated a contained rupture of an infrarenal aortic aneurysm that had significantly evolved in comparison to admission imaging where his infrarenal aorta had the largest dimension measuring 2.9cm. We present the successful application of neoaortoiliac system (NAIS). Method(s): Proceeding with midline laparotomy we encountered dense adhesive disease due to his history of surgery for colon cancer. After adhesiolysis, we exposed the aorta and aneurysm with severe surrounding inflammatory changes. 20cm of femoral vein was harvested, reversed, and joined for a span of 4cm using an Endo GIA 45mm vascular load to create our neoaorta. Proximal and distal clamp zones were developed. Upon entering the aneurysm, a foul smell was encountered, revealing that the noxious process had destroyed the posterior wall of the aorta and paraspinal tissues. Our neoaorta was anastomosed in end-to-end fashion to the infrarenal aorta and subsequently to the common iliac arteries. Flow was initially restored to the hypogastric arteries and then the external iliac arteries. The retroperitoneum was closed over our repair and covered with omentum. Result(s): On post-operative day 2, he had hematochezia;intraoperatively, the IMA was noted to be 1mm in size, though had brisk back-bleeding and was ultimately ligated. A flexible sigmoidoscopy revealed ischemic sloughing of the sigmoid colon near his previous anastomosis from his colon cancer resection though no transmural necrosis. He remains on high-dose ceftriaxone to complete a 6-week course and metronidazole for 10 days due to his sigmoid mucosal ischemia per infectious disease recommendations. He is now post-operative day 10 and remains in the ICU. Conclusion(s): Mycotic aortic aneurysms constitute 1-1.8% of aortic aneurysms. The standard of treatment is aggressive debridement of involved aortic wall and periaortic tissue, in-situ or extra-anatomic reconstruction, coverage with an omental flap and long-term antibiotic therapy. NAIS is resistant to infection and aneurysmal dilation, however, is a time-consuming procedure with a mean completion time of 8 hours. Dorweiler et al. demonstrated that vascular reconstruction with femoral vein in infected aortoiliofemoral fields has a mortality of 9-10% with negligible rate of late complications (graft stenosis, thrombosis, and dilation) and that venous morbidity after femoral vein harvest is well tolerated. Clagett et al. demonstrated that NAIS fashioned from greater saphenous vein had a failure rate requiring intervention of 64% compared to 0% for those constructed with deep femoral vein. Lastly, it is important to note that our patient was previously COVID-19 positive. This case demonstrates that the sequela of COVID-19 may have been a significant factor in our patient's pathophysiology. As we continue to learn about the effects of COVID-19 on vascular pathology, we must keep a large repertoire of operative techniques at hand in order to treat complex presentations of vascular emergencies. [Formula presented] [Formula presented] [Formula presented] Institution: Orlando Health, Orlando, FLCopyright © 2022
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During the COVID-19 pandemic, several complications arose in infected patients, one of them being mucormycosis, which is an extremely aggressive fungal disease with a high mortality rate, especially in patients with compromised immune systems. Most cases of mucormycosis are caused by the fungus Rhizopus oryzae, also known as black fungus, with 90% of cases affecting the rhinocerebral site. The treatment tools used are based on high doses of amphotericin B and posaconazole, associated with surgical resections when possible. However, even with aggressive antifungal treatment, the estimated attributable mortality rate is high [1]. In the absence of surgical debridement of the infected tissue, antifungal treatment alone is not curative. So there is a need for development of adjuvant treatments. Antimicrobial Photodynamic Therapy (aPDT) may constitute an auxiliary therapeutic option for mucormycosis [2]. Due to the lack of reports on the photodynamic inactivation of R. oryzae, we investigated different protocols Photodithazine (PDZ) as a photosensitizer. The response on the fungus growing rate under distinct treatment parameters as photosensitizer concentration, incubation time, and association with surfactant, will be presented for both white and black hyphal phases, and infective spore phase. Preliminary results show the potential use of photodynamic therapy for the inactivation and growth control of the R. oryzae.Copyright © 2023
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The base of skull forms the first line of barrier to be breached in the transition of rhino-orbito-palatal forms of mucormycosis to intracranial forms with various neurological deficit. The pattern of base of skull erosion has prognostic implications in overall recovery and survival of the patient. The aim of the study was to assess the pattern of skull base involvement in cases of rhino-orbital-cerebral mucormycosis (ROCM) in terms of clinical presentations, radiological findings, intraoperative illustrations and post operative recovery. This is a retrospective single centre study of Covid associated Mucormycosis (CAM) patients with skull base involvement at a tertiary referral centre of central India from May 2021 to October 2021. Amongst a total of 248 patients of CAM, 54 patients with skull base involvement were included in our study. The cases were stratified into basifrontal-BF (15%), basisphenoid-BS (20%), orbital apex-OA (15%), basiocciput-BO (26%), frontal bone osteomyelitis-FBO (22%) and sphenoid bone osteomyelitis-SBO (2%), based on their pattern of involvement of skull base and intracranial spread. Early ethmoid and cribriform plate involvement progressed to frontal lobe abscess while early maxillary disease progressed to developed temporal lobe abscess. The orbital apex lesions had early onset cavernous sinus thrombosis. Analysis of clinical manifestations and postoperative follow up revealed an emerging pattern where Posterosuperior lesions of paranasal sinuses (Ethmoid, roof of maxilla and orbit) progressing to BF, BS, OA, FBO and SBO had poorer treatment outcome than Anteroinferior (Floor of maxillary sinus, palate) based lesions which involved BO of skull base. The inferiorly located diseases had better prognosis, less duration of hospital stay, lesser mortality and decreased need for second surgery. There exists a temporal relation of the initial site of fungal load in sinonasal region to their subsequent intracranial spread. Classification into subtypes helped in disease stratification which helped in prognostication and surgical planning. Early intervention by multidisciplinary team improved survival outcome.
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Patients with hidradenitis suppurativa (HS) often present to our tertiary service with severe perianal disease that is extremely debilitating. We are able to provide a holistic service for our patients through our perianal virtual clinic (PVC), a weekly service comprising dermatologists, colorectal surgeons, gastroenterologists and a gastroenterology clinical nurse specialist. Virtually, we discuss and optimize the management of patients who have a diagnosis of either HS or gastrointestinal/ cutaneous Crohn disease (CD), or both. Through discussion of the medical management, review of pelvic magnetic resonance imaging scans and the discussion of surgical treatment in detail with our colleagues, we are able to streamline treatment for these complex patients. We provide a review of the activity in this service over the last 2 years, from January 2019 to December 2020. As part of the clinical work in our tertiary hidradenitis clinic, we routinely treat patients with significant perianal HS. These patients have discharging sinus tracts and fistulating disease in apocrine gland-bearing areas. A proportion have gastrointestinal or cutaneous CD. From a medical perspective, these patients have often failed multiple therapeutic interventions, and surgery can provide a useful adjunct to treatment. Surgical intervention involves extensive laying open and debridement of disease, including biopsy, and seton control of anal fistulae. Perianal skin cancer can be identified at the time ofsurgery, a complication known to affect those with chronic inflammation and those on immunosuppressive drugs. In the last 2 years, following surgery, one patient has been diagnosed with cutaneous squamous cell carcinoma (SCC), one with SCC in situ and one with extramammary Paget disease. In reviewing the activity of the PVC, we discussed 26 patients with HS and severe perianal disease in 2019 and 42 patients in 2020, despite interruption to the service due to the COVID-19 pandemic in 2020. This increase in activity reflects our expanded service and the severity and complexity of the patients referred. We identify those that may benefit from early surgery and also take referrals of patients with both HS and CD that may need optimization of medical therapy. In total, eight patients were admitted under the joint care of the colorectal and dermatology teams for surgery in 2019 and seven in 2020. The PVC has become an important one-stop service in the optimization of complex treatment for patients with perianal HS and/or CD referred to our tertiary service.
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According to a published literature from the end of 2019 to the start of April 2021, India contributed approximately 71% of the global cases of mucormycosis in patients with COVID-19. In addition to this, hyperglycemia in diabetics, steroid therapy, and consequent metabolic acidosis and diabetic keto acidosis along with other risk factors such as prolonged hospitalization with or without mechanical ventilators increase the chance of infection. Aims and Objectives In our study, we suggested the risk factors, clinical features, appropriate investigations, and effective treatment to control the infection of post-COVID-19 rhino-orbital mucormycosis. After taking history of the patients (age, residential area, date of admission, symptoms of illness, comorbidities, ex-diabetes, hypertension or other major illness, treatment history during COVID infection or other regular medications of the patient, and ex-history of steroid intake), we noted the related clinical features of rhino-orbital mucormycosis of the patients.
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Toxic epidermal necrolysis (TEN), is an acute, life-threatening emergent disease involving the skin and mucous membranes with serious systemic complications. It is characterized by widespread epidermal sloughing. Drugs are the most common triggers of TEN, but infection, vaccination, radiation therapy and malignant neoplasms can all induce it in susceptible patients. We report two cases in whom a hair dye and a COVID-19 vaccine (BioNTech, Pfizer) were believed to be the causative agents. These patients have to undergo repeated debridements of the necrotic tissue. In this manuscript the anesthetic management of TEN patients is discussed. Detailed preoperative evaluation, aggressive fluid and electrolyte replacement, avoidance of hypothermia during debridement, minimizing anesthetic agents and limiting traumatic procedures are key points in the management.Copyright © 2023 Faculty of Anaesthesia, Pain and Intensive Care, AFMS. All rights reserved.
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Since the Coronavirus Disease (COVID-19) pandemic, there have been several unusual presentations of mucormycosis in India, especially amongst immune-competent adults. COVID-19 infection has been found to have profound effects on the patient's immunity and some patients, though asymptomatic for COVID-19, can be infected by mucormycosis and develops dangerous complications. Skin involvement of the orbital, zygomatic and maxillary areas is a common occurrence in extensive cases of rhino-orbital mucormycosis, however, isolated involvement of the alar skin is an extremely rare occurrence in such patients. Paediatric cutaneous mucormycosis is by itself a rare entity, seen majorly in children with history of allogeneic hematopoietic stem cell transplantations, chemotherapeutic treatment, or patients with human immunodeficiency virus infections, herpes and other life-threatening viral infections. Patients receiving long-term steroid therapy are also predisposed to invasive fungal infections. This case was about a 10-year-old boy presented with a black crusted lesion over the nose to the otolaryngology outpatient department. The patient had history of contact with a COVID-19 positive individual. Examination revealed a necrotic patch over the palate and Non Contrast CT Scan of (NCCT) the paranasal sinuses showed pansinusitis. A KOH mount showed fungal elements and the patient underwent emergency debridement of nasal skin with endoscopic sinus and palatal debridement. Injectable liposomal Amphotericin-B was started. Over a period of one month, the patient showed significant clinical improvement. Though rare, sinonasal mucormycosis can present in the form of a cutaneous lesion which is an unconventional symptom. A general awareness amongst healthcare professionals, with a multidisciplinary approach, timely diagnosis and specialist intervention can improve outcomes in this sinister disease.Copyright © 2023 Journal of Clinical and Diagnostic Research. All rights reserved.
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BackgroundThere has been a rapid rise in the number of COVID-19-associated rhino-orbital mucormycosis (CAROM) cases especially in South Asian countries, to an extent that it has been considered an epidemic among the COVID-19 patients in India. As of May 13, 2021, 101 CAROM cases have been reported, of which 82 cases were from India and 19 from the rest of the world. On the other hand, pulmonary mucormycosis associated with COVID-19 has a much lesser reported incidence of only 7% of the total COVID-19-associated mucormycosis cases (Singh AK, Singh R, Joshi SR, Misra A, Diab Metab Syndr: Clin Res Rev, 2021). This case report attempts to familiarize the health care professionals and radiologists with the imaging findings that should alarm for follow-up and treatment in the lines of CAROM.Case presentationRhino-orbital mucormycosis (ROM) is a manifestation of mucormycosis that is thought to be acquired by inhalation of fungal spores into the paranasal sinuses. Here, we describe a 55-year-old male, post COVID-19 status with long standing diabetes who received steroids and ventilator therapy for the management of the viral infection. Post discharge from the COVID-19 isolation ICU, the patient complained of grayish discharge from the right nostril and was readmitted to the hospital for the nasal discharge. After thorough radiological and pathological investigation, the patient was diagnosed with CAROM and managed.ConclusionUncontrolled diabetes and imprudent use of steroids are both contributing factors in the increased number of CAROM cases. Our report emphasizes on the radiological aspect of CAROM and reinforces the importance of follow-up imaging in post COVID-19 infection cases with a strong suspicion of opportunistic infections.