Experiences of adult epilepsy patients with COVID-19 infections and vaccinations

Objective: To assess the course of COVID-19 infections and the tolerability of the mRNA vaccines of Moderna and Pfizer/BioNTech and the viral vector vaccines from Astra Zeneca and Johnson & Johnson in adult patients with epilepsy (PWE). Method(s): From July 2020 to July 2021, we consecutively included adult outpatients with confirmed epilepsy. These PWE were interviewed about COVID-19 infections and vaccinations. Results of follow-up visits were added until the cut-off date (December 31, 2021). The data of COVID-19-infected without vaccinations or fully vaccinated PWE without COVID-19 infections were analyzed. Full vaccination was defined as a double vaccination with the Pfizer/BionTech, Moderna, or Astra Zeneca vaccines or a single Johnson & Johnson vaccination. Result(s): At cut-off, 612 of 1152 PWE fulfilled the inclusion criteria: 51 PWE had been infected without vaccination and 561 had full vaccination without infection. Among the infected PWE, 76.5% presented with symptoms;9.8% had a severe course (one death). The leading symptoms were influenza-like disorders (48.7% of infected PWE with symptoms), anosmia (28.2%), and ageusia (20.5%). Seizure increases or relapses after sustained seizure freedom occurred in 7.8%. Adverse events (AEs) were reported by 113 vaccinated PWE (20.1% of all vaccinated PWE). The leading AEs were fatigue, fever, and headache. The AE rate per vaccine was 14.0% for Pfizer/BionTech, 32.7% for Moderna, 25.8% for Astra Zeneca, and 46.2% for Johnson & Johnson. Of the AEs, 93.3% lasted <=1 week. Seizure increase or relapse occurred in 1.4% and was significantly less frequent than in the infected group (p= 0.0016). Conclusion(s): The course of COVID-19 infections and the tolerability of the vaccines were similar as in the general population, yet, seizure worsening occurred more often after the infection than after the vaccination.Copyright © 2023, The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, part of Springer Nature.

Seroprevalence of SARS-CoV- 2 in children of school-going age in district Swabi, Pakistan

Introduction: Earlier estimates of SARS-CoV- 2 do not accurately account for the extent of undiagnosed infections in children, who typically experience mild or asymptomatic disease. The purpose of this study was to estimate the seroprevalence of SARS-CoV- 2 antibodies in children from District Swabi, one of the populous districts of Pakistan, and to identify symptoms most frequently associated with seropositivity. Methodology: We used ELISA to test for the presence of antibodies, IgM and IgG, in blood samples collected from 246 children of school-going age (5-16 years old) selected randomly from the district of Swabi, Pakistan. This study was approved by Khyber Medical University, Peshawar, Ethical Board, and Advanced Studies Review Board. Data were collected on a purposefully built questionnaire. Result(s): Overall, 2.0% of our participants were seropositive for IgM, whereas 23.1% were seropositive for IgG. Older age, female gender, and contact history were significantly associated with higher seropositivity. Symptoms associated with seropositivity were: fever (98.0%), cough (90.0%), sore throat (79.0%), coryza (68.0%), myalgia (61.0%), loss of sense of smell and taste (49.0%), and vomiting or diarrhoea (8.0%). Although 77.6% of our IgG seropositive participants recalled experiencing flu-like symptoms, none of the participants in this study had visited the doctor or were tested for SARS-COV- 2. We found IgG titres to be significantly higher in symptomatic children. Conclusion(s): The number of undiagnosed infections in children may be substantially larger than the official accounts. Sparse data are available regarding coronavirus disease in children, particularly in low middle-income countries (LMIC). The most frequently symptoms were fever, cough, sore throat, coreza, myalgia, loss of sense of smell and taste and lastly vomiting and diarrhoea. Serological studies provide valuable insight into the immunological status of a population, and can prove vital when considering future strategies.

Impact of Influenza in South-East Asia

Influenza infection is asymptomatic in up to 75% of cases, but outbreaks result in significant morbidity. Reports found that severe influenza complications tend to occur among the very young (<5 years) and very old (>65 years), especially those with underlying co-morbidities like diabetes mellitus and heart disease. Even with no co-morbidity, some older persons with severe influenza may require hospitalisation or intensive care, with increased risk of myocardial infarction and stroke. In South-East Asia, influenza was often seen as a mild problem and was not deemed notifiable until the appearance of the Influenza A(H1N1) pandemic in 2009. For decades the data made available were based on extrapolated estimates collected mainly from paediatric populations, resulting in inconsistent findings. Following expanded surveillance across the region using national surveillance systems for influenza-like illness (ILI) and severe acute respiratory illness (SARI), and better diagnostic methods, improved estimates of disease burden was achieved in South-East Asia. However, two studies conducted in 2008-2010 reported findings ranging from 2-3% to 11%. With regards to increased risk of complications, the estimated global annual attack rates for influenza were 5-10% in adults and 20-30% in children, resulting in 3-5 million cases of severe illness and 290,000-650,000 deaths. A study In Singapore reported that influenza is associated with annual excess mortality rates (EMR) of 11-14.8 per 100 000 person-years, especially affecting the elderly;these rates are comparable to that of the USA. As for hospitalisation rates of children under 5 years with seasonal influenza, the USA estimated a rate of 1.4 per 100,000. Comparable rates were reported in Singapore (0.7-0.9), Thailand (2.4), Viet Nam (3.9-4.7), and the Philippines (4.7). In 2018, an updated study reported a mean annual influenza-associated respiratory EMR of 4.0-8.8 per 100 000 individuals, with South-East Asia showing a high mortality rate of 3.5-9.2 per 100,000 individuals. It was already estimated in Thailand in 2004 that influenza resulted in USD23-63 million in economic costs, with the main contribution from lost productivity due to missed workdays. Thus, comparable to countries in temperate climate, the clinical and socioeconomic impact of influenza in South-East Asia appear to be just as substantial. With the emergence of the COVID-19 pandemic in 2020, global influenza incidence dropped dramatically. In South-East Asia, the trend in influenza detections was similar to the rest of the world, with numbers slightly higher than average in early 2020, followed by a quick drop-off by the end of April 2020. After April 2020, the detection rate remained low until late July 2020, when Influenza A(H3N2) predominated in Cambodia, Malaysia, the Philippines, Singapore, Thailand and Timor-Leste;influenza B in Lao People's Democratic Republic but with an upsurge in A(H3N2) activity. Following a two-year hiatus, influenza outbreaks began to re-emerge significantly since early 2022. From February through August 2022, influenza activity in the southern hemisphere remained lower than in pre-COVID-19 pandemic years, but was at the highest level compared to similar periods since the start of the COVID-19 pandemic. Reasons for the reduction during the COVID-19 pandemic include non-pharmaceutical interventions (NPIs), reduced population mixing and reduced travel, and possibly viral interference between SARS-CoV-2 and influenza virus in the same host. In general, the reduction in influenza detections however does not appear to be associated with lack of testing. The World Health Organisation (WHO) continues to recommend that vaccination is the most effective way to prevent infection and severe outcomes caused by influenza viruses. Although influenza vaccine is not commonly used in most countries in South-East Asia, its burden is similar in other parts of the world where influenza vaccine is now routinely used. Currently, the countries in South-East Asia that are providing free influenza vacc na ion for those at high risk include Thailand, Singapore, the Philippines and Lao People's Democratic Republic.Copyright © 2023

Opportunistic Respiratory Pathogens in Symptomatic Non- Covid-19 Adults during a Presumptive Influenza Season

Intro: It is hypothesized that metagenomics could contribute to the effective sentinel surveillance of emerging infections to identify plausible cause of respiratory symptoms in the population. Method(s): This study forms part of a longitudinal household cohort study involving the collection of respiratory symptoms and vaccination history in Hong Kong. As a pilot, selected households were provided with swab collection kit for collecting nasopharyngeal and throat samples when there was an influenza-like illness (ILI) during a 4-month presumptive period of the year's winter influenza season. Sequence-Independent Single Primer Amplification (SISPA) and nanopore metagenomic sequencing were performed. After basecalling, demultiplexing, and quality filtering, taxonomic classification was done. Unclassified and host reads were removed and only taxon with over 0.1% abundance were included in the analysis. Finding(s): Between December 2021 and April 2022, of 101 collection kits delivered, 36 (36%) participants returned the samples. Two (6%) had previous COVID-19 diagnosis and almost all (97%) received at least one dose of COVID-19 vaccination. Metagenomics sequencing was performed on 13 samples collected from participants when ILI was present. Of the 1,592,219 reads obtained, 5308 taxa were identified and 136 had over 0.1% abundance, including 128 bacteria, 6 fungi, and 1 virus, which was a bacteriophage. The five most abundant genera of bacteria included Neisseria (19%), Streptococcus (10%), Haemophilus (9%), Veillonella (3%), and Rothia (3%). Haemophilus parainfluenzae was the most abundant species with 97,542 (6%) reads, followed by Neisseria meningitides (5%). Other bacteria identified included Rothia mucilaginosa, Acinetobacter baumannii, Lautropia mirabilis, Veillonella atypica, Streptococcus salivarius, and Streptococcus pneumonia. Inter-participant abundance profile was significantly different (p<0.001). Conclusion(s): The absence of viral infections identified echoed the extremely low proportion (3/21986, or 0.01%) of respiratory specimens testing positive for influenza virus by the government laboratory during the same period. The metagenomic profile could be useful for identifying the likely ILI-causing pathogen.Copyright © 2023

Recurrent Liver Abscess in a Non-Toxic Patient

Introduction: Liver abscesses are caused by direct spread from peritonitis, biliary tract infection or via hematogenous seeding from a distant source. Most are polymicrobial, however Escherichia coli and Klebsiella pneumoniae are the most common offending pathogens. Patients usually present with pain, fever, and clinical signs of infection. We describe a case of spontaneous liver abscess in a non-toxic patient that recurred 10 years after a previous abscess. Case Description/Methods: A 73-year-old-man with a history of type 2 diabetes mellitus, hypertension, CAD status post CABG and PCI 3 years ago, and abdominal aortic aneurysm status post endovascular aneurysm repair presented with 2 weeks of dark urine. After receiving his COVID-19 booster and influenza vaccinations, he developed flu-like symptoms with a self-resolving fever of 101.8degreeF. He had dark amber urine without dysuria or hematuria. Later, he experienced generalized weakness and decreased oral intake. Outpatient labs showed elevated liver function tests, and he was told to present to the ED. On arrival, he was afebrile with stable vitals. Physical exam was unremarkable. Laboratory evaluation showed a hemoglobin of 11.7 g/dL, sodium of 133 mEq/L, creatinine of 1.4 mg/dL, aspartate aminotransferase of 117 U/L, alanine aminotransferase of 212 U/L, alkaline phosphatase of 825 U/L, total bilirubin of 4.1 mg/dL, and direct bilirubin of 2.1 mg/dL. Triple-phase CT showed a 2.8 cm mass in the right liver lobe with linear enhancement. Ultrasound showed mixed echogenicity measuring 3.6 x 2.9 x 3.3 cm in segment 8 of the liver. On further evaluation, patient had an E. coli abscess diagnosed 10 years prior, managed with antibiotics and drainage. At that time, the abscess was within the right inferior liver lobe, similar to his current abscess. LFTs downtrended. Abscess was aspirated, with culture growing oxidase negative, gramnegative rods, likely E. coli. Patient started on ceftriaxone and metronidazole, to undergo colonoscopy as an outpatient and rule out colonic bacterial translocation. Discussion(s): Pyogenic liver abscess can result in significant morbidity and mortality because of worsening infection and sepsis. Abscesses occur because of spread from adjacent infection or after recent surgeries. Recurrence is very rare. Here, we describe a very unusual case of a pyogenic liver abscess growing E. coli in a non-toxic patient, with the same location and causative organism as an abscess managed 10 years prior. (Figure Presented).

Lactulose Works in the Large Bowel: But How Does It Improve Hepatic Encephalopathy in a Patient Without a Large Bowel?

Introduction: Lactulose is a non-absorbable disaccharide which acts in the large bowel, and is commonly used in the treatment of hepatic encephalopathy. We present an interesting case of altered mental status due to hepatic encephalopathy successfully managed with lactulose in a patient with history of total colectomy. Case Description/Methods: A 67-year-old male with non-alcoholic cirrhosis and inflammatory bowel disease (IBD) post total proctocolectomy with a continent ileostomy known as a Kock-pouch (K-pouch) presented to the hospital with flu like symptoms and altered mental status. He was subsequently found to be positive for COVID-19. At the time of initial evaluation, the patient was obtunded with an elevated ammonia level of 91 umol/L. Colorectal surgery was consulted as the patient was not able to empty his K-pouch. Recently, he complained of inability to catheterize and with bleeding from the stoma. Initial catheterization with a Water's tube yielded 400 cc of effluent. Nasogastric tube was placed through which he was receiving lactulose 30 mg q8 hours. The patient's mental status improved within 24 hours. The patient ultimately underwent flexible pouchoscopy with endoscopic dilation and placement of a 22 French mushroom catheter for decompression of the K-pouch. Discussion(s): Lactulose is a non-absorbable disaccharide composed of galactose and fructose. The small intestine does not have the enzymes required to breakdown lactulose so it reaches the large bowel in its original form. In the large bowel, it is metabolized by colonic bacteria into monosaccharides and then to volatile fatty acids, hydrogen and methane. Lactulose decreases both the production and absorption of ammonia mainly through the presence of gut bacteria. The question arises as to how lactulose decreased ammonia levels in this patient without a large bowel. One proposed mechanism is the translocation of bacteria normally found in the large bowel to the small intestine. Small Intestinal Bacterial Overgrowth (SIBO), is a condition causing an increased number of bacteria in the small intestine. Patients with IBD and structural abnormalities are at increased risk of developing SIBO. Lactulose is commonly used in the diagnosis through the administration of lactulose and subsequent measurements of hydrogen and methane gas in expired air. This condition, in our patient with history of ulcerative colitis and colectomy, is a proposed mechanism of the efficacy of lactulose in the treatment of hepatic encephalopathy.

Cases of Covid-19 in Patients Withi Mmune-Mediated Rheumatic Diseases after Vaccination against Sars-Cov-2 in Manaus-Amazon

Objectives: Immunization against SARS-CoV-2 is an effective strategy to reduce morbidity and mortality in the face of the COVID-19 pandemic. People with Immune-mediated Rheumatic Diseases (IMRD) also benefited from this campaign. However, there is a limited amount of data on the outcome of vaccination in these patients, in terms of those who were infected by the virus. This study had the objective to evaluate the rate of COVID-19 cases in patients with IMRD after vaccination against SARS-CoV-2. Method(s): Observational, longitudinal and ambidirectional study with follow-up of subgroups of patients with IMRD immunized with vaccines made available by the National Immunization Plan (inactivated adsorbed vaccine registered by the Instituto Butantan (IB), recombinant vaccines registered by Bio Manguinhos/ Fiocruz and by Janssen, and Pfizer/BioNTech). Sociodemographic data and questionnaires on flu syndrome, laboratory confirmation of infection and need for hospitalization and outcomes were collected and stored via an online platform. This study is associated to the SAFER Project from the Brazilian Society of Rheumatology and it was approved by the local Research Ethics Committee. Result(s): A total of 223 patients aged over 18 years, mean age 42.79 +/- 15.18 years, were included. All were within the inclusion/exclusion criteria, with 83% being female. The main IMRD included were systemic lupus erythematosus (39%) and rheumatoid arthritis (33.6%). After the 1st dose, 1.45% of patients had COVID-19, 50% sought health services (emergency care), without the need for hospitalization and after the 2nd dose, 1.5% had the disease, of which none sought health services, required hospitalization or had a negative outcome. After the 3rd dose,: 2.9%were infected with SARS-CoV-2 one month later, 15.6% two to three months later and 5.5% four to six months later, all with laboratory confirmation;only 4% presenting any serious complication;there were no deaths. After the 4th dose, 9.1%of patients had COVID-19, of which 40%were hospitalized, without the need for assisted ventilation;half of these patients had a serious complication, but there no deaths. Conclusion(s): In this study, we observed the effectiveness of the vaccine in preventing severe cases of COVID-19 and complications of SARS-CoV-2 infection.

Cognitive bias in the context of epidemic

In connection with the scope and duration of the COVID-19 pandemic, the clinical judgement of clinicians and medical practitioners could be influenced such that diagnostic errors (delays and inaccuracies) may ensue. We hereby recall through two clinical scenarios the constant need for practitioners to take a step back in reflecting of the diagnostic process to avoid the <<tunnel effect>> which may result in delaying common and frequent infectious diseases. The flu-like symptoms presented by these patients (fever, myalgia and asthenia...) quickly prompted our emergency room colleagues to suspect SARS-CoV-2 infection. However, further investigations including imagery and blood cultures revealed completely different but common infectious disease conditions, which are potentially fatal.Copyright © 2020 Editions Medecine et Hygiene. All rights reserved.

How Will Demographic Change Affect the Disease Burden of Future Epidemics?

Intro: The burden of infectious diseases is influenced by the structure of the population at risk. Population ageing may have implications for the disease burden of future epidemics. Moreover, changing household structures induced by population ageing may influence the dynamics of disease transmission and burden of infections transmitted via close contact interactions. We aim to investigate the impact of demographic change on the disease transmission dynamics and future disease burden and illustrate this for COVID-19 and influenza-like illness (ILI). Method(s): We simulate the Belgian population between 2020 and 2050 using an individual-based model with census data. The simulated population structures were used as input for an infectious disease model that distinguishes between exposure to infection in the household versus exposure in the community at large. We mimicked outbreaks of COVID-19 and ILI of varying total final size. Finding(s): The simulated population ages between 2020 and 2050, which also affects household size and composition. As the proportion of elderly people in the population increases, the overall attack rate slightly decreases because older age groups have fewer contacts and are therefore less likely to incur and transmit infections. Despite the lower per-person attack rate, the estimated disease burden increases as morbidity and mortality increases with the age at infection. Conclusion(s): The demographic changes induced by population ageing have an impact on the burden of future outbreaks of COVID-19 and ILI in Belgium. The shifting age distribution implies that the elderly, a population group with increased morbidity and mortality in case of infection, make up an increasing proportion of the total population. Population ageing also leads to an increasing proportion of single-person households and collective households (e.g. nursing homes) in the population. Since the household attack rate varies by household size and composition, the living arrangements of the elderly population influences the disease burden of future epidemics to some extent.Copyright © 2023

SARS-CoV-2 INFECTION AMONG PERSONS WHO INJECT DRUGS AND THEIR PARTNERS IN KENYA

Background: Despite increased social vulnerability and barriers to care, there has been a paucity of data on SARS-CoV-2 incidence among key populations in sub-Saharan Africa. We seek to characterize active infections and define transmission dynamics of SARS-CoV-2 among people who inject drugs (PWID) and their sexual and injecting partners from Nairobi and the coastal region in Kenya. Method(s): This was a nested cross-sectional study of SARS-CoV-2 infection from April to July 2021 within a cohort study of assisted partner services for PWID in Kenya. A total of 1000 PWID and their partners (500 living with and 500 living without HIV) were recruited for SARS-CoV-2 antibody testing, of whom 440 were randomly selected to provide self-collected nasal swabs for real-time PCR testing. Whole genome sequencing (WGS) was completed on a limited subset of samples (N=23) with cycle threshold values 32.0. Phylogenetic tree construction and analysis was performed using the Nextstrain pipeline and compared with publicly available SARS-CoV-2 sequences from GenBank. Result(s): A total of 438 (99.5%) participants provided samples for SARS-CoV-2 PCR testing. Median age was 37 (IQR 32-42);128 (29.2%) were female;and 222 (50.7%) were living with HIV. The overall prevalence of SARS-CoV-2 infection identified by RT-PCR was 86 (19.6%). In univariate analyses, there was no increased relative risk of SARSCoV- 2 infection related to positive HIV status, frequenting an injection den, methadone treatment, unstable housing, report of any high-risk exposure, or having a sexual or injecting partner diagnosed with COVID-19 or who died from COVID-19 or flu-like illness. Eight samples were successfully sequenced via WGS and classified as WHO variants of concern: 3 Delta, 3 Alpha, and 2 Beta. Seven were classified into clades predominantly circulating in Kenya during 2021. Notably, two sequences were identical and matched identically to another Kenyan sequence, which is consistent with, though not indictive of, a transmission linkage. Conclusion(s): Overall, the risk of SARS-CoV-2 infection in this population of PWID and their partners was not significantly associated with risk factors related to injection drug use. At a genomic level, the SARS-CoV-2 strains in this study were consistent with contemporary Kenyan lineages circulating during the time and not unique to PWID. Prevention efforts, therefore, must also focus on marginalized groups for control given the substantial amount of mixing that likely occurs between populations.

COVID-19 as a probable cause of acute pancreatic injury

Acute pancreatic pseudocysts are increasingly recognized as complications in patients with coronavirus disease 2019 (COVID-19). There-fore, it is important for healthcare providers to be aware of this phenomenon to ensure proper diagnosis and treatment. Up to 17% of patients with severe acute respiratory syndrome corona-virus 2 (SARS-CoV-2) infection have been shown to develop pancreatic lesions. These pancreatic lesions can be caused directly by the cytopathic effects of the viral infection or indirectly by systemic responses to inflammation or respiratory failure. Several studies have shown that angio-tensin-converting enzyme 2 (ACE2) is the functional receptor used by SARS-CoV-2 to gain access to target cells, while ACE2 receptors are expressed in significant amounts in the pancreas. In this article, we present 2 cases of COVID-19. patients that presented with similar pancreatic lesions. The first case was a 47-year-old lady who presented to the emergency department (ED) with flu-like symptoms for ten days. Incidental findings on computed tomography (CT) scan showed a large, multiloculated cystic mass in the pancreatic tail. The second case was an 81-year-old Caucasian lady who presented to the outpatient clinic with multiple chronic complaints after an acute COVID-19 infection four months prior. Abdominal CT scan with oral contrast revealed multiple hypodense masses on the pancreas measuring 0.3 cm in diameter. The cases we reported in this article showed the degree of COVID-19's effect on the gastrointestinal system, with pancreatic injury occurring during the early phases of the acute phase of the infection and lasting up to 4 months post-resolution of the infection.Copyright © 2023, The Indonesian Foundation of Critical Care Medicine. All rights reserved.

Severe Headache as an Early Manifestation of Brain Involvement in a Patient with Covid-19 Infection

Purpose of study COVID-19 primarily affects the respiratory system from flu-like syndrome to acute hypoxic respiratory failure. Neurological manifestations are uncommon and can result in serious complications. We report a unique case of sudden onset of rapidly progressive encephalopathy in the setting of COVID-19. Methods used Reviewed the manifestations, clinical course, and outcome for a patient presenting with altered mental status secondary to COVID-19. Summary of results A 48-year-old with no significant past medical history presented to the emergency department complaining of severe headache for four days. His vital signs on presentation showed a blood pressure of 154/90, pulse of 114 bpm, temperature of 99.6 degreeF, and oxygen saturation of 97% on room air. Physical exam was unremarkable. Lab work showed elevated D-dimer 8,500 ng/L, Elevated ESR:42, LDH:340 and Ferritin:692. White blood count: 7.59 uL, Platelets 50 x 103 uL. Computer tomography angiography (CTA) of the chest showed bilateral multifocal pneumonia. CT Head was performed and was negative for an acute hemorrhage, hydrocephalus or territorial infarcts. Patient spiked a fever shortly after admission 103degreeF. Patient was started on Ceftriaxone and Azithromycin. Blood and urine cultures were positive for Klebsiella pneumonia. Patient was re-evaluated in the morning and was found altered with associated neck stiffness. Antibiotics were switched to cover for suspected meningitis. Neurology was consulted and recommended lumbar puncture. Within a few hours, the patient's mental status deteriorated and was found to be hypertensive with a blood pressure of 220/110. Repeat CT Head was negative. The patient was tested and found to be positive for COVID-19. Patient further decompensated within a few hours and became unresponsive, pulseless. ACLS was performed and the patient was transferred to the intensive care unit. Conclusions This case report highlights the heterogenous presentation in patients with COVID-19 and the importance of recognizing a new onset, severe headache as the only initial presentation. Headaches in some cases may precede the respiratory symptoms or may be the only manifestations in COVID-19 patients and it is crucial to be aware of the neurological complications and the rapid decompensation these patients may undergo if not recognized early.

BREAKTHROUGH HIV-1 INFECTION IN SETTING OF LONG-ACTING CABOTEGRAVIR FOR PrEP

Background: Long-acting cabotegravir (CAB-LA) is highly effective as HIV PrEP and superior to daily oral F/TDF in sexually active adults. We report a 28-yearold gender diverse patient assigned male at birth who acquired HIV-1 91 days after transitioning from F/TAF to CAB-LA despite on-time dosing. Method(s): Electronic medical records were reviewed to assess patient history and CAB-LA administration details. Plasma 4th generation HIV-1/2 Ag/Ab combination immunoassay and HIV-1 RNA quantitative PCR were performed at each injection visit. Result(s): Patient was on daily F/TAF for ten months prior to CAB-LA with acceptable adherence, missing 1 dose per week. Their medical history included hypothyroidism on levothyroxine and unconfirmed hypogonadism with illicit use of IM testosterone cypionate complicated by significantly elevated total testosterone levels. They were sexually active with cisgender men, endorsing condomless oral and anal sex with one primary partner and 20-30 unique partners per month. In the past 6 months, patient was diagnosed with syphilis and mpox. Patient was given 600mg of CAB-LA into their left gluteal medius on Day 0, 27, and 91. Day 0 and 27, plasma HIV 1/2 Ag/Ab was non-reactive and HIV-1 RNA PCR was not detected. Patient reported flu-like illness on Day 76 with positive SARS-COV-2 PCR;they completed a five-day course of nirmatrelvirritonavir with rapid resolution of symptoms. At the third injection of 600mg CAB-LA on Day 91, their plasma HIV 1/2 Ag/Ab was non-reactive but the HIV-1 RNA PCR test was detected at 1.48log c/mL. On repeat testing on Day 100, plasma HIV 1/2 Ag/Ab was reactive with HIV-1 Ab detected on differentiation assay and HIV-1 RNA PCR was detected at 1.30 log c/mL. Patient's primary partner was living with HIV resistant to NRTIs (65R, 118I) and INSTIs (92G) with undetectable plasma HIV-1 RNA for the past 24 months. Patient's viremia was below the threshold to perform standard HIV-1 sequencing;HIV-1 DNA qualitative PCR and HIV-1 proviral DNA resistance testing are currently pending. Patient ultimately started on F/TAF/DRV/COBI and DTG on Day 112. Conclusion(s): This patient's history suggests HIV-1 infection despite on-time and appropriate CAB-LA injections. To our knowledge, this is the first case of CAB-LA PrEP failure outside the setting of a clinical trial and highlights the diagnostic and management challenges that may arise with such breakthrough infections in the real world.

Treating Lymphoma in the Pandemic Era: What We Learned from Our Experience at Fondazione Irccs Istituto Nazionale Dei Tumori

From March 2020 to May 2022, when SARS-CoV2 pandemic started spreading in Italy, 15 consecutive patients with non-Hodgkin Lymphoma (NHL) have been treated at the Pediatric Unit of Fondazione IRCCS Istituto Nazionale dei Tumori. Three of 15 patients developed COVID19 while on treatment [1 Burkitt lymphoma (BL), 1 anaplastic large cell lymphoma, 1 lymphoblastic T-cell lymphoma (T-LL)] and one patient at diagnosis [gray zone lymphoma (GZL), previously misdiagnosed as Hodgkin lymphoma]. Median age at diagnosis was 12 years;3 were male. Median positivity time of the nasal swab was 58 days (range 9-107 days). All patients remained asymptomatic or paucisymptomatic (flu-like symptoms) while positive. The first positive patient with T-LL, was in the induction phase of the Euro-LB-02 protocol guidelines: he succeeded in completing the whole treatment during the 107 days of swab positivity, experiencing mild toxicities (grade 2 transaminases and grade 3 lipase increase, both reversible) without significant delays. For this reason, we reduced the total dose of the first HD-MTX (protocol M) and administer the subsequent doses in 6 hours infusion instead of 24 with no further toxicities. After this first experience, all the subsequent patients have been treated accordingly, without major deviations from the established protocols. Minor precautions: the patient with refractory GZL received IEP course instead of IGEV as second-line treatment to avoid severe subsequent immunosuppression;the patient with BL omitted the fourth course of Rituximab during the period of swab positivity. Overall, we did not observe outstanding toxicities except for a toxic MTX level with subsequent reversible acute renal failure. Main teaching from these pilot experiences, which may translate into guidelines: 1) SARS-CoV2 infection is not an absolute contraindication to the oncological treatments. This is of main importance for the patients affected by lymphoma whose dose-intensity has a prognostic value. 2)We need to pay caution during HD-MTX treatment;indeed, we observed unexpected similar toxicities in other patients treated with HD-MTX for other solid malignancies. 3) The clearance of SARS-CoV2 might be exceptionally prolonged with persistent positivity of the nasal swabs for a longer time than the matched healthy population due to the immunosuppression characterizing lymphoma patients. For this reason and given the importance of maintaining the dose-intensity, specific treatments aiming at speeding up the clearing process are warmly suggested. (Figure Presented) Figure 1: (: 091) ITHACA study design and blood sampling time points. (OHT = Orthotopic Heart Transplant).Copyright © 2022 Elsevier Ltd. All rights reserved.

Patient Factors Associated with Death of COVID-19 Patients in an Urban Emergency Department

Objectives: We aim to identify demographics, chief complaints, and comorbidities among patients who tested positive for COVID-19 in the University Medical Center New Orleans (UMCNO) ED and to identify which variables are associated with death. Background(s): On March 9, 2020, the novel coronavirus (COVID-19) breached Louisiana state lines, spreading to all 64 parishes within a month with New Orleans as the epicenter. Louisiana Department of Health data reveal that Black and elderly patients are disproportionately affected by the virus. Despite these findings, it is still largely unknown what other patient characteristics are associated with COVID-19 outcomes in the Louisiana population. Method(s): A retrospective chart review of the first 500 patients >/= 18 years old testing positive for COVID-19 at UMCNO-ED was conducted. We queried for patient characteristics, clinical care practices, and hospital courses. Data was stored in RedCap. Descriptive and multivariate analyses were conducted using de-identified patient data in Microsoft Excel and SAS 9.4. Logistic regression was used for associations with death. Reported odds ratios are unadjusted as no confounding variables were identified. Result(s): The 500-patient sample was predominantly female (56%) and Black (88%). The leading range for BMI was >35 (35%) and for age was 50-59 years (25%, mean=49). Of the 23 patients who died, 83% were black, and the leading age range was 60-69 (36%, mean=63). Pre-existing health conditions in descending order of frequency included: obesity, hypertension, and diabetes for the entire cohort (n=500), and diabetes, hypertension, and obesity for patients who expired (n=23). Common chief complaints in descending order of frequency were fever, flu-like symptoms, and cough for the entire cohort, and shortness of breath, fever, and cough for those who expired. The following patient characteristics were found to be associated with death: age > 65 (OR, 4.9;95% CI, 2.1;p=0.0002), shortness of breath (OR, 2.9;95% CI, 1.2;p=0.02), and history of diabetes (OR, 6.2;95% CI, 2.5;p=0.0001). Conclusion(s): Our study described the predominant demographics, pre-existing health conditions, and chief complaints of the first 500 patients to test positive for COVID-19 at UMCNO-ED. The factors associated with a higher likelihood of COVID-19-related death were identified. Further investigation into the health disparities experienced between patient populations is warranted, as they may be associated with higher incidences of COVID-19 infection and mortality.Copyright © 2023

Transverse myelitis as neurologic sequelae in a COVID-19 recovered patient

Background: Months after the initial report of an unknown cause of pneumonia outbreak in Wuhan, China, the SARS-COV-2 continues its rampant spread globally. This novel corona virus has been known to cause severe respiratory illness. It is important to be wary of the complications that would soon present at the Out-patient centers after being cured from the infection. Case: This is a case of a 59-year-old, female who came in at the Out-Patient Clinic with progressive bilateral pins and needles sensation of the feet after recovering from COVID-19 infection followed by a sensory level on T7-T10. Case Report: Here we present a case of transverse myelitis as a complication of COVID-19 infection, the first to have occurred after recovery from the virus. With the success of treatments and recoveries, possible post infectious sequelae could be the next wave that could come into the present picture of the pandemic. Conclusion(s): Post infectious transverse myelitis after recovering from COVID-19 is a possibility and that documentation of such cases and other complications must be reported.Copyright © 2022

COVID-19 and Spontaneous Coronary Artery Dissection: Association or Causality

Clinical Information Patient Initials or Identifier Number: JS Relevant Clinical History and Physical Exam: A 55-year old woman was brought to emergency department complaining of sudden onset squeezing chest pain radiating to her arm and jaw and associated with giddiness. She had flu like illness a day prior to her presentation associated with malaise, arthralgia and dry cough. She had history of hypertension. Physical examination revealed dual heart sounds and clear lung fields to auscultation. Relevant Test Results Prior to Catheterization: Electrocardiogram (ECG) showed normal sinus rhythm and the cardiac enzymes were elevated;high sensitivity troponin-I, 23000 ng/L (range0-10 ng/L). RNA PCR was positive for SARS-CoV-2 (COVID-19). D-Dimer was 303microgram/L (normal <500). Transthoracic echocardiogram showed severe hypokinesis of the mid inferolateral wall with left ventricular ejection fraction (LVEF) 52%. Chest X-ray showed no focal consolidation. [Formula presented] [Formula presented] Relevant Catheterization Findings: Invasive coronary angiogram showed tortuous coronary arteries with abrupt narrowing of mid- distal Ramus Intermiedius and discrete lesion of mid PDA. SCAD (spontaneous Coronary dissection) of Ramus Intermedius and mid PDA (posterior descending artery) was suspected, and patient was treated conservatively. Repeat coronary angiography, few months later showed complete resolution of SCAD with normal appearance of affected vessels. [Formula presented] [Formula presented] [Formula presented] Interventional Management Procedural Step: After obtaining an informed consent right Radial access was achieved with 6F Terumo sheath using over the wire technique. 1% lignocaine was used as local anaesthetic. 5F JL 3.5 (Judkin's) and JR 4 catheters were used to engage left main stem (LMS) and right coronary artery (RCA) and selective coronary angiography was performed. No percutaneous coronary intervention was performed. After the procedure hemoband (TR band) was applied to access site. Patient remained hemodyanamically stable throughout the procedure. [Formula presented] [Formula presented] [Formula presented] Conclusion(s): SCAD is a potential cause of type II myocardial infarction in patients with COVID-19, but more studies are needed to establish causality. Infection-related SCAD may occur at any time during index events and could be difficult to diagnose. Conservative management seems like a safe strategy.Copyright © 2023

Aspergillus overlap syndromes: From allergic bronchopulmonary aspergillosis to invasive pulmonary aspergillosis

Case report Background: Aspergillus is a saprophytic mold that can cause a broad variety of pulmonary syndromes, categorized in three branches: allergic bronchopulmonary aspergillosis (ABPA), chronic pulmonary aspergillosis (CPA) and invasive pulmonary aspergillosis (IPA). Although these three pathologies involve damaged lung tissue and presence of Aspergillus, it is uncommon to find more than one of them in the same patient. In recent years, overlap of these syndromes is being recognized in some patients, primarily in those treated with immunosuppressive agents, such as long term use of corticosteroids. Case report: We report a case of a 54 year old woman diagnosed with ABPA in 2014, that, following treatment for her pathology with steroids and benralizumab (monoclonal antibody against interleukin- 5), developed IPA, that required hospital admission and treatment with antifungal agents. Since the diagnosis of ABPA, she had been treated with oral corticosteroids and antifungal agents in 2 occasions (2014 and 2017) and omalizumab (monoclonal antibody against IgE) in 2016. Omalizumab had to be discontinued after second administration due to flu-like symptoms, headache, joint and neck pain. In February 2020 due to lack of control of her illness with 15 mg oral prednisone daily, she initiated treatment with benralizumab, being hospitalized after the onset of this new medication as a result of an asthmatic exacerbation. Due to COVID pandemic, she reinitiated benralizumab in June 2020, and continued ever since the administration at home every 2 months in association with 7.5 mg oral Prednisone daily. Following clinical worsening of the patient, a thorax CT scan was performed in September 2021, where a nodule accompanied by a "halo" sign was visualized. The patient was admitted to hospital to start new treatment with higher dose of corticosteroids, antifungal therapy, supplementary oxygen and benralizumab was discontinued. Conclusion(s): To our knowledge, this is the first case of IPA secondary to ABPA in a patient treated with a monoclonal antibody and long term oral corticosteroids. Physicians should be aware of this possible overlap syndromes so that appropriate therapy can be instituted.

Profile of patients hospitalized during the Omicron wave at Hassan II Agadir hospital

Introduction: The first case of omicron infection was declared by the Moroccan Ministry of Health and Social Protection on December 15, 2021. Five days later, the Hassan II Hospital began receiving cases of COVID-19. The objective of our study is to describe the clinical, vaccination and evolutionary profile of patients hospitalized during the Omicron wave. Material(s) and Method(s): This was a descriptive and analytical cross-sectional study of the records of patients hospitalized in the COVID-19 conventional service at the Hassan II regional hospital of Agadir, from 20/12/2021 to 06/02/2022. The data analysis was done by SPSS statistical software version 20. Result(s): 112 patients were hospitalized, of which 56.3% were men. The mean age was 56.4 years. Diabetes was in 44.9% of patients, hypertension in 15.4% and heart disease in 14.1%. Influenza-like syndrome was present in 79.5% of patients. The abnormalities of biological parameters were : elevated C-reactive protein 48,2%, lymphopenia 33% et hyperferritinemia 32,1%. Chest CT Scan was indicated in 5.4% of patients. 69.6% had received at least one dose of COVID-19 vaccine, and 23.2% were not vaccinated. The average length of hospital stay was 5.21 days. The evolution was favorable in 83.9% of the patients, 14.3% were transferred to the intensive care unit, and 1.8% died. Conclusion(s): During the Omicron wave, comorbidities in elderly subjects and abnormalities of biological parameters are a predictive factor of hospitalization, but the evolution in most cases remains favorable.