Aspergillus hip arthritis in COVID-19 era: Two case reports

Corticosteroids have been a mainstay in the treatment protocols and guidelines of COVID-19. However, its use in high dosage or for extended duration renders patients immunocompromised after COVID-19 recovery, and thus, susceptible to secondary opportunistic infections. We report the two cases of septic hip arthritis due to Aspergillus species in corticosteroid immunosuppressed post-COVID-19 patients. One patient recovered successfully from the arthritis and subsequently underwent total hip arthroplasty with good outcome. The second patient presented late to us in a critical condition and had two comorbid conditions along with, due to which, in spite of all measures, could not be revived and succumbed to death. We highlight the issue of the rare cause of fungal hip arthritis in immunosuppressed post-COVID-19 patients and stress the necessity to remain vigilant and identify the causative organisms correctly, especially fungal pathogens in such susceptible populations in the present COVID-19 era.

Knowledge and Perceptions of Reactive Arthritis Diagnosis and Management Among Healthcare Workers During the COVID-19 Pandemic: Online Survey.

BACKGROUND: Reactive arthritis (ReA) is an often neglected disease that received some attention during the coronavirus disease 2019 (COVID-19) pandemic. There is some evidence that infection with severe acute respiratory syndrome coronavirus 2 can lead to "reactive" arthritis. However, this does not follow the classical definition of ReA that limits the organisms leading to this condition. Also, there is no recommendation by any international society on the management of ReA during the current pandemic. Thus, a survey was conducted to gather information about how modern clinicians across the world approach ReA. METHODS: An e-survey was carried out based on convenient sampling via social media platforms. Twenty questions were validated on the pathogenesis, clinical presentation, and management of ReA. These also included information on post-COVID-19 arthritis. Duplicate entries were prevented and standard guidelines were followed for reporting internet-based surveys. RESULTS: There were 193 respondents from 24 countries. Around one-fifth knew the classical definition of ReA. Nearly half considered the triad of conjunctivitis, urethritis and asymmetric oligoarthritis a "must" for diagnosis of ReA. Other common manifestations reported include enthesitis, dermatitis, dactylitis, uveitis, and oral or genital ulcers. Three-fourths opined that no test was specific for ReA. Drugs for ReA were non-steroidal anti-inflammatory drugs, intra-articular injections, and conventional disease-modifying agents with less than 10% supporting biological use. CONCLUSION: The survey brought out the gap in existing concepts of ReA. The current definition needs to be updated. There is an unmet need for consensus recommendations for the management of ReA, including the use of biologicals.

A UNIQUE CASE: ACUTE EOSINOPHILIC PNEUMONIA SECONDARY TO DAPTOMYCIN: A COVID-19 PNEUMONIA MIMIC

SESSION TITLE: Drug-Induced Lung Injury Pathology Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Acute eosinophilic pneumonia (AEP) is an atypical cause of acute hypoxic respiratory failure in adults, however if not identified can prove to be fatal. It can all be a COVID19 mimic during the pandemic. AEP has several causes, such as inhalational drugs, infections and various pharmaceuticals. Often, patients will have an acute respiratory syndrome for less than one-month, pulmonary infiltrates on chest computed tomography (CT) or radiography (CXR), in addition to bronchoalveolar lavage (BAL) with more than 25% of eosinophils. CASE PRESENTATION: A 79 y/o man underwent an elective total knee replacement complicated by acute lower limb ischemia from an occluded bypass graft. He developed methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycin-resistant Enterococcus (VRE) joint and soft tissue infection of the lower extremity. He was prescribed a 6-week course of Daptomycin. He presented about 3 weeks into treatment with shortness of breath. He was initially diagnosed with acute on chronic congestive heart failure (CHF) exacerbation and COVID negative. He was initially treated with diuretics. He developed acute renal failure requiring dialysis and acute hypoxic respiratory failure requiring intubation. CXR revealed bilateral lung infiltrates with BAL having 80% eosinophils, eosinophilia and urinalysis positive for eosinophils. Daptomycin was discontinued and he was started on systemic steroids for a two-week course. He was successfully extubated 5 days after diagnosis of AEP and was subsequently discharged to a rehabilitation facility on lifelong Doxycycline for MRSA prosthetic joint infection prophylaxis. DISCUSSION: AEP related to Daptomycin was first reported in 2007, in a patient that developed the condition after receiving treatment for endocarditis. Daptomycin caused an inflammatory reaction within the lungs, due to an accumulation of the drug within the pulmonary surfactant. Our case report patient met all components for AEP diagnosis, in addition to symptom onset being approximately 3 weeks into treatment. The ultimate treatment for AEP is to stop the reversible cause, if identifiable, along with glucocorticoids and symptomatic support. Prognosis for patients with AEP is excellent when diagnosis is prompt, and usually infiltrates are resolved within 1 month without long term adverse pulmonary effects. Our patient was discharged to an acute rehab facility without supplemental oxygen therapy and continues to improve from functional standpoint. This case a definite cause of AEP from Daptomycin presented as COVID19 pneumonia mimic. It highlights the importance of rapid diagnosis to prevent morbidity and mortality. CONCLUSIONS: The differential in a patient with acute hypoxic respiratory failure is numerous, especially during the COVID19 pandemic. During these challenging times, it is important to think of atypical causes, such as AEP to improve the patient's clinical status. Reference #1: Allen JN, Pacht ER, Gadek JE, Davis WB. Acute Eosinophilic Pneumonia as a Reversible Cause of Noninfectious Respiratory Failure. N Engl J Med. 1989;321:569-574 Reference #2: Hayes Jr. D, Anstead MI, Kuhn RJ. Eosinophilic pneumonia induced by daptomycin. J Infect. 2007;54(4):e211-213. Reference #3: Rachid M, Ahmad K, Saunders-Kurban M, Fatima A, Shah A, Nahhas A. Daptomycin-Induced Acute Eosinophilic Pneumonia: Late Onset and Quick Recovery. Case Reports in Pulmonology. 2017. DISCLOSURES: No relevant relationships by Moses Bachan No relevant relationships by Zinobia Khan No relevant relationships by Kaitlyn Mehern

Septic Arthritis With Superimposed Acute Gouty Arthritis in a Rheumatoid Arthritis Patient.

Septic arthritis is a rare but serious complication of both rheumatoid and gouty arthritis and can lead to significant morbidity and even mortality. Here, we report a case of septic arthritis with bacteremia, monosodium urate crystals, and hyperuricemia in a 75-year-old male with long-standing rheumatoid arthritis. Arthrocentesis revealed gram-positive cocci representing group B streptococcus (Streptococcus agalactiae) infection and monosodium urate crystals. A diagnosis of septic arthritis with superimposed acute gouty arthritis was made and the patient was treated accordingly. Management included surgical irrigation and debridement, antibiotic therapy, and systemic glucocorticoids which resulted in a significant improvement in the patient's clinical status.

The ID Physician Is Out: Are Remote ID E-Consults an Effective Substitute?

Background. Telemedicine (TM) can provide specialty ID care for remote and underserved areas;however, the need for dedicated audio-visual equipment, secure and stable internet connectivity, and local staff to assist with the consultation has limited wider implementation of synchronous TM. ID e-consults (ID electronic consultations or asynchronous™) are an alternative but data are limited on their effectiveness, especially patient outcomes. Methods. In the setting of the COVID-19 pandemic and ID physician outage, we were asked to perform ID e-consults at a 380-bed tertiary care hospital located in Blair County, PA. We performed retrospective chart reviews of 121 patients initially evaluated by ID e-consults between April 2020 and July 2020. Follow-up visits were also conducted via e-consults with or without direct phone calls with the patient. Key patient outcomes assessed were length of stay (LOS), disposition after hospitalization, 30-day mortality from initial ID e-consult and 30-day readmission post-discharge. Results. The majority of patients were white males and non-ICU (Table 1). The most common ID diagnosis was bacteremia (27.3%, 33/121), followed by skin and soft tissue infections (15.7%, 19/121) and bone/joint infections (14.9%, 18/121) (Figure 1). Table 2 shows patient outcomes. Average total LOS was 11 days and 7 days post-initial ID e-consult. 48.7% (59/121) of patients were discharged home and 37.2% (45/121) to a post-acute rehabilitation facility. 2.5% (3/121) of patients required transfer to a higher level of care facility;none of which were to obtain in-person ID care. The index mortality rate was 3.3% (4/121), which appears to be lower than published data for in-person ID care. The 30-day mortality rate was 4.1% (5/121), which is also comparable to previously reported for ID e-consults. 25.6% (31/121) of patients required readmission within 30 days but only 14.0% (17/121) were related to the initial infection. Conclusion. We believe that this is the first report of the implementation of ID e-consults at a tertiary care hospital. Mortality rates appear to be comparable to in-person ID care. In the absence of in-person ID physicians, ID e-consults can be a reasonable substitute. Further study is required to compare performance of ID e-consults to in-person ID consults.

Long Acting Lipoglycopeptide Use in Veterans for Serious Gram-Positive Infections in the COVID Era

Background. Dalbavancin and Oritavancin are semisynthetic lipoglycopeptides (LGP) that are FDA-approved for treatment of skin and soft tissue infections, but emerging data supports LGP use for other serious gram positive (GP) infections. We describe our experience with LGP during the COVID-19 pandemic. Methods. We initiated a quality improvement project to assess the use of LGP for label and off-label indications at the Atlanta Veterans Affairs Health Care System. We define serious GP infections as infective endocarditis, osteomyelitis, joint infections, or bacteremia. Patients with serious GP infections that receivedLGP were selected at the treating physician's discretion. We reviewed medical records of all patients receiving at least one dose of long-acting LGP from March 1, 2020 - May 31, 2021. We described patient demographics, clinical information,and outcomes (90-day readmission). Results. Nineteen patients with GP infections received LGP (table). Overall, the most common infection was cellulitis 7 (35%);14 patients received LGPs for serious GP infections. All patients received at least one other non-LGP antibiotic for at least 2 days, majority vancomycin (60%) and cefazolin (30%). Overall, the median hospital stay among patients who received LGP was 8.5 days (range: 2-45 days), for those with serious GP infections the median hospital stay was 15 days (range: 4-45). 90% of patientswho received LGP were discharged home. Number of LGP doses ranged from 1 to 6 doses total, based on type of infection. Sixteen veterans (80%) followed up in outpatient clinicfollowing discharge within 2 weeks, two patients were discharged to home hospice due to complications of underlying malignancies and two patients were lost to follow up. Noadverse drug events were reported, and none with serious GP infections required rehospitalization at 90 days. Conclusion. Our experience suggests that long-acting LGP may be valuable tools to treat serious gram-positive infections by optimizing theduration of hospitalization and preventing unnecessary admissions to acute care and nursing facilities for daily antibiotic infusions. These aspects of LGP use are especially important during the COVID-19 pandemic where nosocomial transmission has been documented.

Perceptions of Telemedicine among Infectious Disease Outpatient Providers during the COVID-19 Pandemic

Background. Access to infectious disease (ID) providers has been heavily impacted by COVID-19. Telemedicine (TM) has been viewed as a promising solution to the challenges in care delivery posed by this pandemic. However, perceptions of TM among ID providers remain unclear. This study investigated the impact of TM on outpatient ID during the COVID-19 pandemic, efficacy of TM in ID clinics, which clinical conditions within ID that TM may be best suited for, and influences on provider attitudes toward TM. Methods. We conducted online surveys of outpatient ID providers via the IDSA Idea Exchange and by reaching out to large ID private practices via email. Data was collected October 2020 - April 2021 and recorded through REDCap (Research and Electronic Data Capture). Associations were calculated using Hmisc in R and p-values adjusted using B-H. Missing values were imputed by median. Results. 108 respondents completed the survey. 70.4% were attendings, 63% were under age 50, and 65.7% practiced in academic centers. 55.7% somewhat or strongly agreed there was a decline in outpatient visits. A median of 40% of outpatient visits during COVID were reported to be conducted via TM, divided equally between telephone and televideo (TV). 71.9% of providers somewhat or strongly agreed that TV visits were more effective than telephone visits. Reasons cited for TM as less effective than in person visits included lessened ability to examine the patient, diminished rapport, and inability to perform labwork. 85.2% somewhat or strongly agreed that patients responded favorably to TM. 89.8% of providers somewhat or strongly agreed they will continue to conduct TM visits when appropriate after COVID-19. Plans to continue TM after COVID were significantly associated with perceptions of patient response to TM. Respondents mentioned specific problems less suited to TM: new HIV patients, skin, soft tissue, and joint infections, fever, abdominal pain, transplant evaluations, rash, and wounds. Conclusion. The majority of providers felt their patients responded favorably to TM. Most providers plan to conduct TM visits after COVID-19. These plans are associated with views of patient response and comparability to other visit types. Specific diagnoses were cited as better suited for TM.