ABSTRACT
SESSION TITLE: Critical Care in Chest Infections Case Report Posters 1 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: The "common cold” is a syndrome defined by upper respiratory symptoms in addition to: rhinorrhea, fever, chills, headache, and/or malaise. Classically "colds” are thought of as a mild, self-limiting disease;however, they can cause severe respiratory symptoms in immunocompetent individuals. We present a case of severe acute respiratory distress syndrome (ARDS) caused by the Human Rhinovirus in an immunocompetent host. CASE PRESENTATION: 61-year-old gentleman with a past medical history significant for hypertension presented to an outside hospital for worsening shortness of breath, fatigue, and cough with production x 3 weeks. Social history is notable that he had a 12-pack-year history and quit smoking tobacco approximately 10 years ago. On arrival, the patient was noted to be hypoxic with percent saturation of 88% on 2 L nasal cannula. He rapidly deteriorated and required intubation 5 days after admission. The patient subsequently transferred to a tertiary care intensive care unit for further workup and management. Upon arrival at the tertiary care center, he was found to have a PaO2/FiO2 ratio of 71 and ARDS protocol was initiated. Despite pronation, paralyzation, dexamethasone, and nitric oxide, the patient continued to deteriorate. Three COVID-19 PCR's and COVID-19 antibody resulted negative. Extensive work-up including fungal, autoimmune, viral, and bacterial were negative with the exception of a positive rhinovirus PCR. MRI brain was completed due to patient's unequal pupils which demonstrated numerous recent infarcts of the bilateral cerebral and cerebellar hemispheres with mass-effect with mild leftward shift. The family ultimately decided to pursue comfort measures and the patient died. DISCUSSION: Human Rhinovirus is responsible for ? to ½ of common colds in adults making it the most common cause of "colds.” Due to its more than 100 serotypes, an average adult has approximately 2-3 Rhinovirus infections per year. Rhinovirus infections are classically thought to be self-resolving and mild, particularly in the immunocompetent. However, several recent studies have shown coinfection of the rhinovirus in patients with community acquired pneumonia;although these studies have been unable to tease out how clinically significant the rhinovirus infection was in these patients. The patient case above is an example that the Rhinovirus may be a more important culprit in community-acquired pneumonia than previously suspected. In addition to its possible respiratory conditions, studies have demonstrated an increase in risk of stroke. Currently, there are no FDA-approved antivirals for the Human Rhinovirus, treatment largely aimed to reduce symptomatology. CONCLUSIONS: The medical community, in large, thinks of the Rhinovirus as a relatively benign disease process. Though this may be the case in most patients, even immunocompetent individuals can suffer from serious complications of the virus. Reference #1: Chu HY;Englund JA;Strelitz B;Lacombe K;Jones C;Follmer K;Martin EK;Bradford M;Qin X;Kuypers J;Klein EJ;"Rhinovirus Disease in Children Seeking Care in a Tertiary Pediatric Emergency Department.” Journal of the Pediatric Infectious Diseases Society, U.S. National Library of Medicine, https://pubmed.ncbi.nlm.nih.gov/26908489/. Reference #2: JO;, Proud D;Naclerio RM;Gwaltney JM;Hendley. "Kinins Are Generated in Nasal Secretions during Natural Rhinovirus Colds.” The Journal of Infectious Diseases, U.S. National Library of Medicine, https://pubmed.ncbi.nlm.nih.gov/2295843/. Reference #3: Subramanian, A., et al. "Stroke Following Positive Biomarker for Viral Respiratory Illnesses.” B47. CRITICAL CARE: NON-PULMONARY CRITICAL CARE, 2020, https://doi.org/10.1164/ajrccm-conference.2020.201.1_meetings.a3566. DISCLOSURES: No relevant relationships by Philip Forys No relevant relationships by Brandon Pearce
ABSTRACT
Introduction Echinacea purpurea has been shown to broadly inhibit coronaviruses and SARS-CoV-2 in vitro [1]. Aim To assess the available clinical evidence for Echinacea preparations in the infection prevention against coronaviruses. Method In a systematic literature search on MEDLINE and EMBASE articles were selected for clinical trials with Echinacea studying RT-PCR-confirmed viral respiratory tract infections in humans. Results Jawad collected nasopharyngeal swabs from N=755 adults over 4 months of prevention. Overall, 24 and 47 enveloped virus infections occurred, including 21 and 33 coronavirus detections [229E;HKU1;OC43] with Echinaforce® (2400 mg/d) and placebo, respectively (p=0.0114) [2]. Ogal administered Echinaforce® extract (1'200 mg) or control for 4 months to N=203 children (4-12 years). The incidence of enveloped virus infections was reduced from 47 to 29 (p=0.0038). Viral loads in nasal secretions were significantly diminished by 98.5%, with Ct-values 31.1 [95%CI 26.3;35.9] versus 25.0 [95%CI 20.5;29.5] (p=0.0479) ([Fig.1]) [3]. Kolev applied Echinaforce® extract (2'400 mg/d) vs. no treatment over 5 months to N = 120 adults and reported 10 vs. 20 coronavirus infections (p=0.046) of which 5 vs. 14 samples tested SARS-CoV-2 positive (p=0.03) [4]. Conclusion Echinacea's broad antiviral spectrum was confirmed in clinical trials suggesting its potential for prevention of infections by respiratory pathogens, including coronavirus and SARS-CoV-2.
ABSTRACT
Introduction In the light of the ongoing corona and influenza virus public health crisis, traditional East Asian herbal medicines with anti-viral activities might be an option in therapy. Methods Literature research on anti-viral effects of traditional East Asian medicine was performed. Results In patients with uncomplicated upper respiratory tract infection, treatment with Andrographis paniculata (Jap. Senshinren) extract resulted in 53% of improvement compared with placebo. When 158 common cold patients took 1.2 g of dried extract of A. paniculata for 5 days, nasal secretion, sore throat and sleep disorder were improved [1]. Ding Y et al. [2] demonstrated that mice infected with influenza A and treated with extract of A. paniculata improved body weight, lung function and showed reduced inflammation. In Japan, Kampo prescriptions like Maoto as well as its variant Maoto-ka-senshinren ([Tab. 1]), were examined for anti-viral activity [3] [4]. Nabeshima et al. [5] investigated Maoto for the treatment of influenza in a randomized trial in comparison with oseltamivir and zanamivir. No significant differences for total symptom score and no severe adverse events were found. In A549 cells infected with influenza A virus that were treated with Maoto, the virus titre in the supernatant, intracellular viral proteins and viral RNA were significantly reduced. Maoto also inhibited the uncoating of the influenza virus [6]. Conclusion In Japan, Maoto is regarded as a suitable medication for influenza. Maoto-ka-senshinren ([Tab. 1]) may present a promising therapy option for influenza and potentially COVID-19.
ABSTRACT
Background: Molnupiravir, a prodrug of the broadly active, direct-acting antiviral, ribonucleoside analogue EIDD-1931, is a promising COVID-19 drug. Given the primary route of SARS-CoV-2 transmission through respiratory droplets we evaluated EIDD-1931 PK in saliva, nasal secretions and tears of patients with mild-to-moderate COVID-19 through the phase Ib/IIa AGILE platform (NCT04746183). Methods: Patients with PCR-confirmed SARS-CoV-2 infection, within 5 days of symptom onset with mild-to-moderate disease were randomised to oral molnupiravir 300, 600 or 800 mg twice daily. Plasma and non-plasma (saliva, nasal and tear swabs) samples were collected pre-dose, 0.5, 1, 2, and 4 hours post-dose on study days 1 and 5 and molnupiravir and EIDD-1931 measured by LC/MS (lower limit of quantification, 2.5 ng/mL). PK parameters were determined (Phoenix 64, WinNonlin, v. 8.3) and non-plasma:plasma (NP:P) ratios (based on AUC0-4) calculated. Relationships between paired non-plasma and plasma samples were evaluated by linear regression. Results: Twelve participants (n=4 per dose;75% female) completed the study contributing 111, 112 and 97 saliva, nasal and tear samples, respectively. Molnupiravir was detected in 11% of saliva samples [median (range) 4.86 ng/mL (2.63-31.44)] and not evaluated in swabs. Quantifiable EIDD-1931, following molnupiravir 300, 600 and 800 mg twice daily were i) saliva: 17.7 (2.8-133), 16.6 (2.9-469), 25.8 (4.0-230) ng/mL, ii) nasal swabs: 182 (18-1700), 136 (18-917), 295 (24-1879) ng/mL and iii) tears: 297 (24-1650), 176 (16-1260), 307 (32-2760) ng/mL. PK parameters are shown (Table 1). Median (range, CV%) pooled NP:P ratio for saliva was 0.03 (0.01-0.11, 60%;n=16). Nasal and tear ratios were 6-fold higher with values of 0.21 (0.05-0.73, 70%;n=17) and 0.22 (0.09-1.05, 92%;n=12), respectively. Non-plasma and plasma concentrations were significantly correlated (r2: 0.360-0.677;p<0.0001). Of measured saliva, nasal and tear samples, 6, 50 and 61%, respectively were within or above the EIDD-1931 EC90 against SARS-CoV-2 in primary human airway epithelia cultures (approximately 0.5-1 μ M ≈ 130-260 ng/mL). Conclusion: This is the first report of EIDD-1931 PK at sites of initial SARS-CoV-2 exposure in patients with COVID-19. Investigations of PK/PD relationships are warranted;however, these data suggest therapeutic concentrations are potentially achieved in nasal and tear compartments, but not saliva and have important implications for prophylactic coverage.
ABSTRACT
Case Report A male infant is born at 37w to a 34-year-old G3P2 mother by vaginal delivery after an uncomplicated pregnancy. Prenatal screens are negative. The patient had a birth weight of 2,620 g, with Apgar scores of 9 and 9. On day 2 after birth, had increased work of breathing which prompted transfer to a level II NICU for further management. On arrival to the unit, the infant is tachypneic with mild chest wall retractions and thick nasal secretions. A CBC and blood culture were collected and empiric antibiotic therapy was started. Respiratory viral panel and COVID test are negative. A chest radiograph shows a middle lobe opacity concerning for pneumonia (figure 1). His clinical status failed to improve and on day 4 after birth, supplemental oxygen was provided. The primary team consulted ENT and Pulmonology services. Flexible laryngoscopy showed a normal anatomy. Pulmonology recommended transferring to our NICU for a chest CT with bronchoscopy. Our differential diagnosis for this neonate with respiratory distress that fails to improve over time or with antibiotics was broad, but further testing revealed this infant's condition. A CBC, CRP and a blood gas were collected on admission and were normal. ID service was consulted. A Chest CT showed bilateral atelectasis. Bronchoscopy showed a normal anatomy. Bronchoalveolar lavage was sent. Umbilicus swab was positive for MRSA, nasal wash/sputum culture/bronchoalveolar fluid also grew moderate S. aureus. Nasal ciliary biopsy sent for electron microscopy. Positive umbilicus and nasal swab, and subsequently BAL for MRSA led to a diagnosis of MRSA neonatal rhinitis. Therapy with IV vancomycin was initiated and later changed to oral clindamycin to complete a total of 14 days of therapy. The neonate was weaned off oxygen support on day 11. His clinical symptoms improved. He was discharged on oral clindamycin with follow up appointments with pulmonology and ID clinics. His ciliary biopsy showed absence of outer and inner dynein arms, compatible with the diagnosis of primary ciliary dyskinesia (PCD) (figure 2). Genetic testing for PCD showed mutations in the DNAAF1 and CCDC40 genes. This neonate was diagnosed with primary ciliary dyskinesia (PCD) but his presentation at birth was nonspecific and the differential diagnosis was broad. There is no gold standard diagnostic test for PCD and high clinical suspicion is important. Since it is most likely an AR inheritance, screening of family members is essential. Initial management of neonates may include measures that manage the respiratory distress, airway clearance to prevent respiratory infections and treat bacterial infections. Chest physiotherapy may help if recurrent atelectasis. Flexible bronchoscopy and bronchoalveolar lavage may help both to diagnose and treat the underlying infection. Antibiotic therapy based on organism growth for exacerbations may prevent development of bronchiectasis. (Figure Presented).
ABSTRACT
Objective: This study aimed to investigate the nasal findings in patients who tested positive for the coronavirus disease 2019 (COVID-19) and objectively evaluate the amount of nasal secretion and nasal clearance. Methods: The study included 40 patients who tested positive and 40 volunteers who tested negative for COVID-19 infection. The self-administered Turkish version of the sinonasal outcome test -22 (SNOT-22) questionnaire was used to evaluate the sinonasal findings, the nasal Schirmer test was used to evaluate the amount of nasal secretion, and the saccharin test was used to evaluate nasal clearance. The results of both groups were compared. Results: The SNOT-22 score averages were 23.3±14.5 and 11.2±11.7 for the COVID-19-positive group and COVID-19-negative controls, respectively. In the COVID-19 positive group, SNOT-22 results were statistically significantly higher than those of the controls (p≤0.001). The nasal Schirmer and nasal saccharin test results in the COVID-19-positive group were statistically significantly higher than those of the controls (p≤0.002 and p≤0.001). Conclusion: In patients who tested positive for COVID-19 infection, increased amounts of nasal secretion and prolonged nasal clearance time were observed. They also had higher SNOT-22 scores than those of the negative controls. Although these findings demonstrate that there may be changes in nasal functions in patients positive for COVID-19 infection, new studies are needed to elucidate the nasal effects in detail.
ABSTRACT
Background: Respiratory syncytial virus (RSV) is the main cause of acute bronchiolitis. The peak of the infection is historically described in the autumn/winter season. The 2020 COVID-19 pandemic seems to have modified the seasonality of some respiratory viruses. The first case of SARS-CoV-2 infection diagnosed in Portugal was in March 2020. School closure and the use of masks are some of the pointed reasons for a decreased number of RSV infections observed in the autumn/winter season post the beginning of the pandemic. Interestingly, there are now a few studies from around the globe showing the resurgence of RSV infections in the spring/summer season that followed. Aim: To characterize the population of RSV infected infants admitted to a tertiary hospital before and after the beginning of the COVID-19 pandemic. Methods: A retrospective, descriptive, study was performed. All the RSV infected infants who were admitted to a Portuguese tertiary hospital from January 2017 to August 2021 were evaluated. The diagnosis of RSV infection was made through polymerase chain reaction of nasal secretions. Data such as age, gender, reason for admission, comorbidities, viral coinfection, bacterial superinfection, oxygen therapy, admission at Intensive Care Unit, ventilatory support and length of hospital stay were analyzed. Results: The data of a total of 354 patients was analyzed. The median age was 4 months (min 9 days, max 4 years), 50% were male. Before the COVID-19 pandemics (between 2017 and 2019), the peak of RSV infections used to occur in the months of December and January (medium of 25 and 28 cases per month, respectively). However, in December 2020 and January 2021 there was no detection of RSV. Nonetheless, a peak of RSV infection was verified in July and August 2021 (18 and 15 cases per month, respectively). The number of patients admitted for non-respiratory motifs, but in whom RSV was detected during the course of hospital stay, increased in 2021 (39%), comparing to 2017 (0%), 2018 (3%), 2019 (8%) or 2020 (3%), p<0,05. The number of viral coinfections was higher in 2021 (50%) comparing to 2017 (29%), 2019 (19%) or 2020 (18%), p<0,05. The patients admitted in 2021 were older (12 months average) than patients admitted in 2017 (5 months average) or 2018 (6 months average), p<0,05. Conclusions: RSV seasonality was modified by the COVID-19 pandemic, with an increase of the hospital admissions being registered in the summer of 2021. Our tertiary hospital's numbers reproduce what is being described in other places of the world. Subsequent studies are needed to verify the behavior of RSV infections in the next seasons, to understand if RSV infections are becoming more or less severe and to analyze the impact of SARS-CoV-2 virus on the virulence of RSV.