ABSTRACT
The patient presented with fever and appetite loss. Computed tomography (CT) revealed a moderate grade 2 pneumonia. Besides, further blood examination showed his HB antigen as negative, anti-HBs/c anti-body as positive, and HBV DNA level as 1.0 LIU/mL. Therefore, he was diagnosed with COVID-19. Administered treatments comprised oxygen inhalation and steroid therapy, including pulses, remdesivir, and baricitinib, which improved pneumonia. Interestingly, one month posttreatment, his HBV DNA level in-creased to 1.4 LIU/mL, followed by a further increase to 1.7 LIU/Ml, showing an improvement. Tenofovir alafenamide fumarate was thus administered. In clinical practice, immunosuppressive therapy is used for patients with moderate-to-severe COVID-19 pneumo-nia. However, close attention should also be paid to the elevation of blood HBV DNA levels during and after treatment.Copyright © 2022 The Japan Society of Hepatology.
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Background: More than a year has passed since the first coronavirus vaccines were widely used. However, some healthcare workers are infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) despite full vaccination. The immune effect of SARSCoV- 2 vaccines attenuates in a few months in contrast to other universal vaccines, such as the hepatitis B vaccine, which have an immune effect that lasts for a longer time. In addition, the neutralizing antibody (Ab) titers can be measured only in limited medical institutions. In this study, we aimed to investigate the factors that predict SARS-CoV-2 infection in healthcare workers after vaccination. Method(s): In this study, we enrolled one thousand one hundred and thirty-three healthcare workers (826 women, 307 men) after second inoculation of the BNT162b2 vaccine (Pfizer /BioNTech) in February- April 2021. Medical checkups and self-reported questionnaires were used to collect medical histories and demographic characteristics. The Alinity SARS-CoV-2 IgG II Quant (Abbott) quantitative IgG spike protein serology assay was examined in a cohort of participants 1, 4, 6 months after the second vaccination, and 1 month after the third vaccination of the BNT162b vaccine. Lower Ab titers were defined under median at each time point. The relationships between SARS-CoV-2 infection and these factors were analyzed. Result(s): The mean observation period was four hundred and fortyeight days. The median titers at 1, 4, 6 months after the second vaccination were 9293 U/mL (interquartile range [IQR], 5840-14392 U/mL), 1658 U/mL (IQR, 999-2676) and 832 U/mL (IQR, 523-1300), respectively. The risk factors for lower Ab titers were age (60 years older, odds ratio [OR], 2.08), presence of current illness (OR 1.52), smoking habit (OR 2.36), and no fever after the second vaccination (OR 2.44). The median titers at 1 month after the third vaccination was 13780 U/mL (IQR, 9085-22722), and the risk factor for lower Ab titers was hepatitis B surface Ab (HBsAb) negative (OR 1.38). The total 1-year cumulative infection rate was 4.9%. The median infection period was three hundred and twenty days (IQR, 298-365) after the second vaccination. The risk factors of infection were age (30 s and 40 s), and HBsAb negative. The 1-year cumulative infection rate of 30-40 s and other ages were 6.6% and 3.7%, respectively (p<0.01). The 1-year cumulative infection rate of HBsAb negative participants with 30-40 s and other age were 7.7% and 4.9%, respectively (p = 0.064), while that of HBsAb positive participants with 30-40 s and other age were 6.7% and 1.7%, respectively (p<0.01). Conclusion(s): HBsAb and age can become prognostic factors to be infected with SARS-CoV-2 after vaccination. Especially, HBsAb negative people under 50 years old should pay attention to SARSCoV- 2 infection even after second vaccination.
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Organ transplant recipients show weaker immune responses to vaccines than immunocompetent individuals, which may be related to the repertoire of HLAbound vaccine antigens presented to T lymphocytes. The HLA evolutionary divergence (HED) metric, which quantifies pairwise allele divergence at each HLA locus, provides a primary measure of the breadth of the immunopeptidome. We recently showed that high class I HED of the donor is a strong and independent driver of allograft rejection in a large cohort of liver transplant recipients. Here, in the same cohort, we explored the relation between HED, the size of the predicted immunopeptidome derived from vaccine antigens, and the quality of vaccine responses. We analyzed humoral response to the SARS-CoV-2 BNT162b2 vaccine (n = 310 patients;undetectable anti-spike IgG titers considered as no response, <=250 BAU/mL as moderate and >250 BAU/mL as strong response) and Hepatitis B virus (HBV) vaccine (n = 424 patients;anti-HBs IgG <10 mIU/mL considered as no response, 10-100 mIU/mL as moderate and >=100 mIU/mL as strong response). HED at HLA-A, -B, -C, -DRB1, -DQA1 and -DQB1 loci were measured using the Grantham distance. NetMHCIIpan-4.0 was used to predict the binding to HLA-DQ molecules of all possible 15mer peptides derived from the Spike and HBS sequences. For each vaccine, HED at the DQB1 locus, but not at the other loci, was significantly higher in responders than in non-responders (p = 0.0003), independent of response-associated covariates (age, time since transplant, immunosuppression). Moreover, for both vaccines, there was a strong relationship between DQB1 HED, the diversity of the immunopeptidome and the quality of the vaccine response. In conclusion, DQB1 HED is a critical determinant of humoral response to vaccines in liver transplant recipients. This metric could guide the design of future vaccines as it predicts the magnitude of the repertoire of vaccine-derived peptides presented to CD4 helper T cells.
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Aim: Transmission of SARS-CoV-2 infection can easily occur through direct or close contact with infected people, just as with other infectious diseases. Therefore, it is important to detect it prior to the intervention for protecting the health of both the healthcare worker and the patient. In the study, it was aimed to determine the seropositivity rates of acute respiratory syndrome coronavirus 2, hepatitis A, hepatitis B, hepatitis C virus and human immune deficiency virus infections among children who underwent gastrointestinal endoscopy. Material(s) and Method(s): The study was conducted at the Department of Pediatric Gastroenterology of the Karabuk University in Turkey from December 2020 to December of 2021. A total of 175 children were included in the study. The study was divided into three age groups as follows: 1-6 years old, 7-12 years old and 13-18 years old. All children were screened for acute respiratory syndrome coronavirus 2, hepatitis A, hepatitis B, hepatitis C virus and human immune deficiency virus infections. Result(s): The median age was 12.5 years (1-18). The seroprevalence of acute respiratory syndrome coronavirus 2, Anti-HAV IgM, Anti-HAV IgG, HBsAg, Anti-HBs, Anti-HCV, Anti-HIV and were detected 0.57%, 0.57%, 42.8%, 0%, 58.8%, 1.1% and 0 % respectively. The seroprevalence of Anti-HAV IgG was significantly higher in children aged 1-6 years than in the group aged 13-18 years (95.7 vs 25.2: chi2=48.1, p=0.001). Discussion(s): Although seroprevalence rates prior to endoscopy were low in this study, viral screening, except for hepatitis A infection, is essential for the safety of both patients and healthcare.Copyright © 2022, Derman Medical Publishing. All rights reserved.
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Background: According to the recent medical literature, COVID-19 disease can lead to a constellation of clinical syndromes lasting well beyond the frst 30 days of infection. The most common post COVID sequalae includes pulmonary, nervous system and neurocognitive, mental, metabolic, cardiovascular, gastrointestinal and several other clinical manifestations. Regarding joint involvement and particularly reactive arthritis (ReA), literature data is limited and describes case reports or series of cases of patients diagnosed with this condition following COVID-19 disease. Objectives: To describe the pattern and the management of post-COVID reactive arthritis. Methods: We have conducted a descriptive study of consecutive adult patients who presented to rheumatology outpatient clinic for joint or peri-articular pain/swelling/stiffness and received a diagnosis of post-COVID 19 reactive arthritis, by excluding other types of rheumatological conditions. The assessed clinical variables were: visual analogue scale (VAS) pain, swollen joint count (SJC), tender joint count (TJC), duration of morning stiffness, presence of enthesitis/tendinitis and axial involvement. Biochemistry and serology was performed: rheumatoid factor, ACPA, ANA, HLA B27, antiChlamydia Trachomatis, Ureaplasma Urealyticum and Mycoplasma Hominis Ab, anti HBs and HBc Ab, and anti HCV. COVID-19 disease prior to diagnosis of ReA was confrmed by PCR test. Results: In the study were included 16 patients with confrmed post COVID-19 ReA. The mean age of the study group was 43.5±10.8 (range 21-60), the female: male ratio was 4:1 and the duration of joint symptoms was 10.4±11.8 (range 1-42) weeks. The severity of COVID-19 disease was mild in 68.7% cases, moderate in 18.7% and severe in only 6.2% of the cases. The duration between COVID-19 diagnosis and ReA varied between cases, with a mean value of 4.3±4.2 (range 1-12) weeks. In 43.7% of the cases patients had peripheral joint involvement (synovitis), in 37.5%-periarticular involvement (enthesitis), 6.25%-isolate axial involvement (sacroiliac joints), 6.25% enthesitis and axial involvement (cervical spine) and 6.25% synovitis and enthesitis. In patients with peripheral joint pattern, the distribution of pain was symmetric (71.4%). The pattern of synovitis was determined by a TJC of 6.25±5.2 (range 1-16) joints and SJC 1.6±2.4 (range 0-7) joints. Both TJC and SJC correlated positively with the duration of morning stiffness (r=0.9 and r=0.6), but did not correlate with the VAS pain scale. In most of the cases synovitis affected the hand (wrist, MCP and PIP) 62.5% and the knee, feet and ankles-50%. Two patients presented with monoarthritis, 1 with oligoarthritis and 5 with polyarthritis, in the majority of cases, involvement being symmetric (75%). Periarticular pattern was determined by enthesi-tis, affecting the elbow and shoulder (50%), costo-sternal enthesitis (25%) and trochanteritis (25%). From the entire study group, 31.2% had elevated serum infammatory markers (ESR and/or CRP). Patients responded well to NSAIDs alone in 68.7% cases, local (intra-articular or peri-articular infltrations) or and systemic corticoids (5 mg Prednisolone equivalent) were administered in 5.3% and 12.5% cases respectively, in 12.5% cases (two patients) Methotrexate was administered. Conclusion: Reactive arthritis represents a post COVID-19 sequelae. The time of onset of ReA varied between 1 and 12 weeks after COVID-19 diagnosis. The clinical pattern of the disease was expressed by joint or periarticular involvement, mainly affecting the hand, feet and knee symmetrically. Cases of axial manifestations were less common. Most of the patients responded well to NSAIDs, only in a few particular cases, low doses of corticoids and/or Methotrexate were recommended.
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Background: Opportunistic and chronic infections can arise in the context of treatment used for Autoimmune Rheumatic Diseases (ARDs). Although it is recognized that screening procedures and prophylactic measures must be followed, clinical practice is largely heterogeneous, with relevant recommendations not currently developed or disparately located across the literature. Objectives: To conduct a systematic literature review (SLR) focusing on the screening and prophylaxis of opportunistic and chronic infections in ARDs. This is preparatory work done by members of the respective EULAR task force (TF). Methods: Following the EULAR standardised operating procedures, we conducted an SLR with the following 5 search domains;1) Infection: infectious agents identifed by a scoping review and expert opinion (TF members), 2) Rheumatic Diseases: all ARDs, 3) Immunosuppression: all immunosuppressives/immunomodulators used in rheumatology, 4) Screening: general and specifc (e.g mantoux test) terms, 5) Prophylaxis: general and specifc (e.g trimethop-rim) terms. Articles were retrieved having the terms from domains 1 AND 2 AND 3, plus terms from domains 4 OR 5. Databases searched: Pubmed, Embase, Cochrane. Exclusion criteria: post-operative infections, pediatric ARDs, not ARDs (e.g septic arthritis), not concerning screening or prophylaxis, Covid-19 studies, articles concerning vaccinations and non-Εnglish literature. Quality of studies included was assessed as follows: Newcastle Ottawa scale for non-randomized controlled trials (RCTs), RoB-Cochrane tool for RCTs, AMSTAR2 for SLRs. Results: 5641 studies were initially retrieved (Figure 1). After title and screening and removal of duplicates, 568 full-text articles were assessed for eligibility. Finally, 293 articles were included in the SLR. Most studies were of medium quality. Reasons for exclusion are shown in Figure 1. Results categorized as per type of microbe, are as follows: For Tuberculosis;evidence suggests that tuberculin skin test (TST) is affected by treatment with glucocorticoids and conventional synthetic DMARDs (csDMARDs) and its performance is inferior to interferon gamma release assay (IGRA). Agreement between TST and IGRA is moderate to low. Conversion of TST/IGRA occurs in about 10-15% of patients treated with biologic DMARDs (bDMARDs). Various prophylactic schemes have been used for latent TB, including isoniazide for 9 months, rifampicin for 4 months, isoniazide/rifampicin for 3-4 months. For hepatitis B (HBV): there is evidence that risk of reactivation is increased in patients positive for hepatitis B surface antigen. These patients should be referred for HBV treatment. Patients who are positive for anti-HBcore antibodies, are at low risk for reactivation when treated with glucocorticoids, cDMARDs and bDMARDs but should be monitored periodically with liver function tests and HBV-viral load. Patients treated with rituximab display higher risk for HBV reactivation especially when anti-HBs titers are low. Risk for reactivation in hepatitis C RNA positive patients, treated with bDMARDs is low. However, all patients should be referred for antiviral treatment and monitored periodically. For pneumocystis jirovecii: prophylaxis with trimeth-oprim/sulfamethoxazole (alternatively with atovaquone or pentamidine) should be considered in patients treated with prednisolone: 15-30mg/day for more than 4 weeks. Few data exist for screening and prophylaxis from viruses like E B V, CMV and Varicella Zoster Virus. Expert opinion supports the screening of rare bugs like histoplasma and trypanosoma in patients considered to be at high risk (e.g living in endemic areas). Conclusion: The risk of chronic and opportunistic infections should be considered in all patients prior to treatment with immunosuppressives/immunomod-ulators. Different screening and prophylaxis approaches are described in the literature, partly determined by individual patient and disease characteristics. Collaboration between different disciplines is important.
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Those affected by sickle cell disease have an increased susceptibility to infection by encapsulated bacteria and hepatitis B virus due to reduced splenic function and increased likelihood of receiving blood transfusions. Sickle cell disease patients are also more likely to suffer from complications, such as vaso-occlusive crises or acute chest syndrome, following infection with influenza or COVID-19. Standards for Clinical Care of Adults with Sickle Cell Disease in the UK (2018) outline that that those with sickle cell disease are recommended to be vaccinated against invasive pneumococcal disease, Haemophilus influenza type B, Neisseria meningitis types ACWY and type B, hepatitis B, and influenza . These patients are also recommended to have their hepatitis B immunity reviewed annually and to receive a hepatitis B vaccination booster if hepatitis B surface antibody (HBsAb) levels are less than 100 mIU/ml. According to the Standards , hospital staff is advised to remind and check with the patients' primary care teams whether these vaccinations have been administered. In this audit, we examined the records of 64 patients with sickle cell disease who receive regular care at the Cambridge University Hospitals NHS Foundation Trust. We collected data on the uptake of the pneumococcal conjugate vaccine (PCV13), pneumococcal polysaccharide vaccine (PPV23 or Pneumovax) within 5 years, two doses of Meningitis B vaccine, Meningitis ACWY vaccine (MenACWY), Haemophilus influenzae type b vaccine (Hib/MenC), influenza vaccine within 1 year, hepatitis B vaccine (HepB), whether HBsAb levels have been reviewed within 1 year, HepB booster if HBsAb levels were less than 100 mIU/ml, and two doses of COVID-19 vaccine. These records were obtained from electrical medical records provided by patients' general practitioners. Data collection took place from 23 September to 4 November 2021. The uptake of vaccinations was 67.4% for PCV13, 61.0% for PPV23 or Pneumovax within 5 years, 75.0% for Hib/MenC, 45.3% for MenACWY, 42.2% for the first dose of MenB and 29.3% for the second dose of MenB, 54.7% for influenza within 1 year, 75.0% for HepB, 71.9% for the first dose of the COVID-19 vaccine, and 68.3% for the second dose of the COVID-19 vaccine. 43.8% had their HbsAB reviewed and 20.0% received a HepB booster following HBsAb levels of less than 100mIU/ml. The uptake levels for the recommended vaccinations are lower than expected in our hospital trust. The COVID-19 pandemic has highlighted the effect of health inequalities and the uptake of the vaccination programme by patients of different ethnicities. During our patient support group, patients identified the Tuskegee syphilis experiment as one of the reasons why there is still distrust of the medical profession by those with Afro-Caribbean heritage. Beyond directed patient education, more communication is needed with the primary care teams to raise awareness of which vaccinations are required for sickle cell patients. Certain vaccinations, such as MenACWY and MenB were only introduced in 2015, meaning that some general practitioners may be still unaware of their necessity in adults with sickle cell disease..
ABSTRACT
The patient presented with fever and appetite loss. Computed tomography (CT) revealed a moderate grade 2 pneumonia. Besides, further blood examination showed his HB antigen as negative, anti-HBs/c anti-body as positive, and HBV DNA level as 1.0 LIU/mL. Therefore, he was diagnosed with COVID-19. Administered treatments comprised oxygen inhalation and steroid therapy, including pulses, remdesivir, and baricitinib, which improved pneumonia. Interestingly, one month posttreatment, his HBV DNA level in-creased to 1.4 LIU/mL, followed by a further increase to 1.7 LIU/Ml, showing an improvement. Tenofovir alafenamide fumarate was thus administered. In clinical practice, immunosuppressive therapy is used for patients with moderate-to-severe COVID-19 pneumo-nia. However, close attention should also be paid to the elevation of blood HBV DNA levels during and after treatment.
ABSTRACT
A reativação do vírus da hepatite B (VHB) pode ocorrer em pacientes com perfil sorológico atípico, incluindo aqueles anti-HBsAg+. Imunossupressões, seja por neoplasia, transplante, quimioterapia, uso de imunobiológicos ou corticoterapia prolongada são fatores de risco relevantes. Sugere-se que em doença renal crônica (DRC), níveis adequados de AntiHBsAg sejam > 100mUi/mL. Feminino, 72 anos, portadora de múltiplas comorbidades: hipertensão arterial, diabetes, doença pulmonar obstrutiva crônica (DPOC), DRC e lúpus eritematoso sem atividade. Em 07/2020 foi internada em unidade de terapia intensiva por descompensação de DPOC e diagnóstico confirmado de COVID-19, tendo feito uso de corticoterapia prolongada e antibioticoterapia de amplo espectro. Evoluiu com necessidade de terapia renal substitutiva (TRS). Em 10/2020, exames sorológicos de triagem da TRS demonstravam HIV, Anti-HCV e sífilis não reagentes (NR) e infecção prévia pelo VHB com soroconversão (HBsAg NR, AntiHBc IgG reagente (R), AntiHBc IgM NR, AntiHBsAg R [94 mUI/mL]), TGO 61 UI/mL, TGP 46 UI/mL. Durante acompanhamento, necessitou internações recorrentes por DPOC descompensado, pneumonia e infecção de corrente sanguínea relacionada a acesso vascular. Neste período, fez uso de múltiplos antimicrobianos, corticoide inalatório + broncodilatador continuamente e foi exposta a altas doses de hidrocortisona nas crises. Em 03/2021, após elevação de TGP (203), foi identificada reativação da Hepatite B, com a repositivação dos seguintes marcadores: HBsAg R (595, NR < 0,9), AntiHBc IgM R (39, VR < 0,9), HBeAG (1.464, NR < 0,9), AntiHbeAg NR (54, NR >1) e AntiHBs R (73). Os marcadores foram confirmados pelo laboratório de referência e o PCR DNA VHB foi 1.676.917 mUI/mL. Pela gravidade esperada para casos de reativação, a elevação de TGP e a DRC, foi optado por iniciar tratamento imediato com Entecavir 0,5 mg 1x semana (Clearance < 10ml/min). A paciente teve múltiplas internações nos últimos 6 meses, com uso irregular do entecavir e aguarda resultado de nova carga viral do VHB para controle. Ainda é incerto se a COVID-19 pode auxiliar na reativação do VHB, porém, pelo uso de corticoterapia, especialmente em altas doses (off label), esta doença pode se tornar um fator de risco associado a este fenômeno. A vigilância de marcadores virais em pacientes em TRS deve ser intensificada, especialmente naqueles com outros fatores para imunossupressão, como o uso de corticoterapia prolongada, sepse e choque séptico.
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Introduction: Emergency healthcare workers (HCW) are the first point of contact for patients with traumatic injuries and acute illnesses. These professionals are at increased risk for respiratory and blood borne infections, as is the case of hepatitis B virus (HBV) infection and coronavirus disease 2019 (COVID-19). Vaccination is a major tool for preventing HBV infections. The protection provided by the COVID-19 vaccines are yet under evaluation. The objective of this study is to evaluate the HBV and COVID-19 vaccination coverage and the serological hepatitis B immunity among nurse aides working in the emergency department (EM) in a secondary hospital in Portugal. Material and Methods: A descriptive cross-sectional study was conducted by analyzing the Occupational Health Service database of Centro Hospitalar do Baixo Vouga in Aveiro, considering active nurse aides working in the EM in August 2021. Results and Conclusions: Of the total 71 workers included in the study, 61 (85.9%) had completed the vaccination against HBV. From these fully vaccinated HCW, 45 (73.7%) had confirmation of protective Hepatitis B surface antibody (HBsAb) levels (>10 mIU/mL) and 11 (18.3%) had unknown HBsAb levels. Regarding COVID-19 vaccination, 68 (95.7%) of the 71 total workers, had complete vaccination. From these, 43 (63.2%) had the last shot more than 6 months ago. Overall, there is a good adherence of nurse aides working in the EM to HBV and COVID-19 vaccination. In what concerns to HBV vaccination, it is important to implement a more robust system to diminish cases of workers only partially vaccinated or with unknown immunity status.