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Introduction This study aimed to determine the prevalence of multidrug-resistant Gram-negative bacteria (GNB) from blood cultures in a tertiary-care hospital and the multiplex PCR assay's ability to detect resistance genes. Methods A total of 388 GNB isolates obtained from hospitalized patients between November 2019 and November 2021 were included in the study. Antimicrobial susceptibility testing was done by VITEK 2 system and broth microdilution method. Beta-lactamase-encoding genes were detected by multiplex PCR assays, BioFire-Blood Culture Identification 2 (BCID2) panel (bioMerieux, France). Extended-spectrum beta-lactamases (ESBLs) were detected phenotypically with VITEK AST-GN71 card (bioMerieux, France). The isolates of GNB were classified into multidrug-resistant, extensively-drug-resistant, and pandrug-resistant categories, and their prevalence and distribution in different wards, including coronavirus diseases 2019 (COVID-19) intensive care units (ICU), were calculated. Results Results revealed that all isolates of Acinetobacter baumannii and Pseudomonas aeruginosa were multidrug-resistant as well as 91.6% of Enterobacter cloacae, 80.6% of Proteus mirabilis, and 76.1% of Klebsiella pneumoniae, respectively. In fermentative bacteria, blaOXA-48-like (58.1%), blaNDM (16.1%), blaKPC (9.7%) and blaVIM (6.5%) genes were detected. More than half of Enterobacter cloacae (58.3%) and Klebsiella pneumoniae (53.7%) produced ESBLs. Among non-fermenters, the blaNDM gene was carried by 55% of Pseudomonas aeruginosa and 19.5% of Acinetobacter baumannii. In the COVID-19 ICU, Acinetobacter baumannii was the most common isolate (86.1%). Conclusions This study revealed high proportions of multidrug-resistant blood isolates and various underlying resistance genes in Gram-negative strains. The BCID2 panel seems to be helpful for the detection of the most prevalent resistance genes of fermentative bacteria.Copyright © GERMS 2022.
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Burkholderia pseudomallei is soil saprophytic Gram-negative bacilli that cause a fatal disease called melioidosis. Melioidosis is capable of causing cutaneous infection and systemic infections in the respiratory tract, cardiovascular, gastrointestinal, urinary, skin and soft tissue, and musculoskeletal and central nervous systems. Here, we report rare forms of pulmonary, cerebral, and splenic abscess case series of melioidosis caused by B. pseudomallei. Imported cases have been reported among tourists, immigrants, and soldiers who returned from endemic areas. The acquisition of infection is through percutaneous, inhalation, and ingestion of contaminated water;person-to-person transmission is very rare. Melioidosis cases are primarily found in the rainfall season and are usually associated with risk factors such as diabetes, alcoholism, and chronic renal diseases. However, 20-26% of cases were not associated with predisposing conditions. The identification is based on colony morphology, Gram stain, antibiotic susceptibility testing, and other supportive automated and molecular assays when we suspect B. pseudomallei. There are two phases, the intensive and eradication phases, in managing melioidosis. In the intensive phase, ceftazidime for 2 weeks showed efficacy in almost 50% of cases, and the eradication phase treatment with co-trimoxazole and doxycycline or amoxicillin/clavulanic acid for 3-6 months showed an excellent response. The improper clinical diagnosis and management of B. pseudomallei can lead to complications. Hence, early diagnosis with microbiological approaches such as culture, biochemical reactions, or automated systems available and antimicrobial sensitivity testing will cure the patient quickly without mortality.Copyright © 2023 The Authors.
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Carbapenem administration is an important therapy for nosocomial infections due to MDRO, especially Acinetobacter baumannii. The global increase in carbapenem-resistant A. baumannii (CRAB) that causes this pathogen has significantly threatened public health due to the lack of adequate treatment options due to the very few currently available antimicrobial agents that actively fight CRAB. Antimicrobial resistance is a major negative impact of inappropriate antimicrobial prescribing. Ineffective empiric treatment (initial antibiotic regimen not sensitive to identified pathogens based on in vitro sensitivity test results) is associated with a higher rate of deaths compared to effective empiric treatment. In this study, we analyzed the correlation between the suitability of empiric and definitive antibiotics and the clinical outcomes of patients with bacteremia due to CRAB treated in the inpatient ward of Dr. Soetomo Tertiary Referral Hospital, Surabaya. There were 227 isolates of bacteremia due to CRAB, consisting of 156 carbapenem-resistant A. baumanni and 71 carbapenem-sensitive A. baumannii. There were 88 isolates that met the inclusion and exclusion criteria, and all of them were resistant to ceftriaxone, cefepime, and ciprofloxacin. A total of 29.5% of the isolates were sensitive to cotrimoxazole, 3.4% of the isolates were sensitive to tigecycline, and 2.3% of the isolates were sensitive to amikacin, levofloxacin, and cefoperazone sulbactam. Adequate empirical antibiotics and definitive antibiotics (sensitive based on culture sensitivity test) amounted to 12.5% and 27.3%, respectively. There is no significant correlation between the suitability of empiric and definitive therapies with the patients' clinical outcomes (death and length of stay).Copyright © 2022 Phcogj.Com.
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Background: Sepsis is a life-threatening condition that needs immediate diagnosis and treatment to maximize the chances of survival. Bacterial superinfection is a severe and frequent complication among COVID-19 patients and its diagnosis is challenging. Previous reports suggested that Pancreatic Stone Protein (PSP) may be a predictive biomarker for sepsis in critically ill patients. We report a case series of three COVID- 19 patients admitted to our intensive care unit (ICU) with risk of sepsis. Method(s): We daily monitored PSP, procalcitonin (PCT), and C-reactive protein (CRP) levels in three COVID- 19 patients admitted to our ICU. Microbiological sampling and antibiotic treatment were performed according to the ward organization and in case of clinical suspects for infection. Positive cultures and antibiotic treatment were retrieved from clinical charts and patients were followed from ICU admission up to a maximum of 20 days. Result(s): Patient 1 (male, 55 years-old, overweight, no other comorbidity) was admitted to the ICU in treatment with Ceftriaxone then interrupted on day 7. On day 2 he was intubated and piperacillin/tazobactam was started on day 12 for suspected hospital acquired pneumonia. PSP levels markedly increased on day 10 with no significant changes in CRP and PCT levels. On day 13 a positive bronchospirate for Klebsiella pneumoniae was found. Similarly, patient 2 (male, 70 years-old, mild emphysema and diabetes) was admitted to ICU without antibiotic and with a PSP level of 287 ng/ml. His conditions rapidly worsened in severe septic shock requiring intubation. CRP markedly raised 48-72 hours after PSP with only mild increase of PCT. Patient 3 (male, 78 years-old, no comorbidities) was admitted to ICU with high levels of PSP and piperacillin/tazobactam therapy was started. After 48-72 hours CRP levels increased with no significant changes of PCT. A positive bronchospirate for Ps. aeruginosa was collected on day 3. Conclusion(s): Our findings suggest a potential role of PSP as early biomarker of sepsis in critically ill COVID-19 patients. Daily PSP monitoring may anticipate an appropriate treatment of COVID-19 patients with a septic complication in comparison with the actual laboratory markers. Further studies are needed to confirm our hypothesis.
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Background: Only recently studies have been able to demonstrate the safety and efficacy of purification therapies in inflammatory diseases. Here we present the management of a young (21y) male patient in severe cardiogenic shock due to COVID-19 perymyocarditis admitted to the ICU at Bolzano Central Hospital. November 30th 2020 the patient developed high fever (>40 C) and diarrhea. After unsuccessfully being treated orally with a macrolide he was admitted to a peripheral hospital the 4th of December. The day after he deteriorated, required transfer to the ICU, endotracheal intubation and pharmacological cardiovascular support (Norepinephrine, Levosimendan). Antimicrobial treatment was started with piperacillin/tazobactam, linezolid and metronidazole. Despite multiple radiological and microbiological diagnostic attempts the origin of this severe septic shock remained unclear. December 6th the patient was transferred to Bolzano Central Hospital for VA-ECMO evaluation. Method(s): The transesophageal echocardiography revealed 15-20% of EF, lactate (5,2 mmol/l), cardiac enzymes (TropT 1400 mcg/l) and inflammatory parameters (PCT 35 ng/ml, IL-6 685 pg/ml) were elevated. We performed cardiac monitoring via Swan-Ganz catheter. The cardiac index was 1,6 l/min/m2. The peak dosage for Norepinephrine reached 7,5mg/h (1,47 mcg/kg/min). At Bolzano ICU we facilitate the pharmacological therapy with milrinone, vasopressin and low dose epinephrine. Furthermore, we impost continuous hemodiafiltration with CytoSorb filter. Result(s): Only hours after the start of filtration therapy the patient improved and we were able to gradually reduce catecholamine therapy, lactate values decreased. A VA-ECMO implantation was no more necessary. December 10th, we saw a stable patient without ventilatory or cardiovascular support, at echocardiography we revealed a normal EF. Conclusion(s): Clinically we saw a young patient in severe septic/cardiogenic shock due to perimyocarditis. Yet diagnostic attempts (CT-scan, multiple blood/urinary/liquor cultures) remained negative. Despite multiple negative PCR tests for SARS-CoV2 infection we performed specific immunoglobulin analysis and received a positive result for IgM. We therefore conclude on a COVID-19 associated perymyocarditis. Furthermore, this case illustrates the potential benefit of cytokine filtration and elimination in COVID-19 patients with altered IL6 levels.
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Lymphangitis carcinomatosa refers to pulmonary interstitial involvement by cancer and is a dreaded clinical finding in oncology because it is a late manifestation indicative of metastatic malignancy, from either a lung or a nonlung primary cancer, and is associated with poor prognosis. Its presentation is nonspecific, often with subacute dyspnoea and a nonproductive cough in a person with a known history of malignancy, but in some cases is the first manifestation of cancer. CT imaging can be suggestive, typically demonstrating thickening of the peribronchovascular interstitium, interlobular septa and fissures. However, a biopsy may be required to confirm the pathological diagnosis as these changes can also be due to concurrent disease such as heart failure, ILD, infection, radiation pneumonitis and drug reactions. Diagnosis allows symptomatic treatment, with personalised treatment directed towards the primary cancer most likely to provide a meaningful benefit. Future research should focus on prospective clinical trials to identify new interventions to improve both diagnosis and treatment of lymphangitis carcinomatosa.Copyright © ERS 2021.
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Hepatitis A is a common viral infection worldwide that is transmitted via the fecal-oral route. Since the introduction of an efficient vaccine, the incidence of infection has decreased but the number of cases has risen due to widespread community outbreaks among unimmunized individuals. Classic symptoms include fever, malaise, dark urine, and jaundice, and are more common in older children and adults. People are often most infectious 14 days prior to and 7 days following the onset of jaundice. We will discuss the case of a young male patient, diagnosed with acute hepatitis A, leading to fulminant hepatitis refractory to conventional therapy and the development of subsequent kidney injury. The medical treatment through the course of hospitalization was challenging and included the use of L-ornithine-L-aspartate and prolonged intermittent hemodialysis, leading to a remarkable outcome. Hepatitis A is usually self-limited and vaccine-preventable;supportive care is often sufficient for treatment, and chronic infection or chronic liver disease rarely develops. However, fulminant hepatitis, although rare, can be very challenging to manage as in the case of our patient.Copyright © 2023 The Author(s).
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Antibiotics play an essential role in antimicrobial therapy. Among all the medications in children, the most commonly prescribed therapy is antibiotics and is currently the indispensable means to cure transmissible diseases. Several categories of antibiotics have been introduced into clinical practice to treat microbial infections. Reducing the unnecessary use of antibiotics is a global need and priority. This article aims to provide better knowledge and understanding of the impact of the early use of antibiotics. This article highlights the proper use of antibiotics in chil-dren, detailing how early and inappropriate use of antibiotics affect the gut microbiome during normal body development and consequently affect the metabolism due to diabetes mellitus, obe-sity, and recurrence of infections, such as UTI. Several new antibiotics in their development stage, newly marketed antibiotics, and some recalled and withdrawn from the market are also briefly discussed in this article. This study will help future researchers in exploring the latest information about antibiotics used in paediatrics.Copyright © 2023 Bentham Science Publishers.
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Description of case: We report a case of Tropheryma whipplei endocarditis, a rare cause of bloodculture-negative infective endocarditis (BCNIE). Due to its rarity and lack of availability of diagnostic tests in district hospitals, the diagnosis remains challenging. The objective of this case report is to increase physician awareness of this pathogen. A 61-year-old man presented to the Emergency Department with central chest pain at rest. A 12-lead ECG demonstrated ST- segment depression in V4-V6 leads, and his serial troponin levels were raised. He was commenced on treatment for acute coronary syndrome and transferred to the Coronary Care Unit. An echocardiogram showed a 15mm x 15mm vegetation in the aortic valve with mild aortic regurgitation. His initial microbiology workup, which included two sets of blood cultures (pre-antibiotics), MRSA screen & COVID-19 PCR, was negative. He was transferred to a cardiothoracic centre four days later. Pre-operative CT coronary angiogram showed severe three vessel coronary artery disease. He underwent triple coronary artery by-pass grafts and tissue aortic valve replacement. During early post-op recovery, he had fever episodes and an elevated C-reactive protein of 280 mg/L but normal white cell counts. He was treated with intravenous Tazocin for hospital-acquired pneumonia and discharged on doxycycline. Two weeks post-discharge, he had a positive 16S/18S PCR for Tropheryma whipplei on molecular analysis of the aortic valve. He was treated for Whipples endocarditis with a 4-week course of IV Ceftriaxone, followed by a 12-month course of oral Cotrimoxazole. The patient has reported doing well since the surgery. Discussion(s): Molecular assay with PCR of the heart valve is the mainstay of diagnosing Whipple's endocarditis. There have been 5 previously reported cases of Whipple's endocarditis in the United Kingdom in our knowledge. It is likely under-reported because of a reliance on tissue diagnosis. Preceding intestinal manifestations and arthralgia should raise its clinical suspicion for timely workup. Physician awareness of Whipple's Endocarditis is paramount in investigating for this pathogen.
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Objectives: The COVID-19 pandemic has had a major impact on the healthcare system, which has been forced to manage large num-bers of patients, including those with respiratory insufficiency and in need of oxygen therapy. Due to concerns about bacterial co-in-fection, antibiotic therapy was administered to many patients. The aim of the present study was to compare antimicrobial resistance in intensive care patients in the pre-pandemic and pandemic periods. Material(s) and Method(s): Patients hospitalized at the Department of Anesthesiology, Resuscitation and Intensive Care Medicine of the University Hospital Olomouc in the pre-COVID-19 period (2018-2019) and during the pandemic (2020-2021) were enrolled in the stu-dy. Clinical samples from the lower respiratory tract were routinely collected twice a week, with one strain of a given species first isolated from each patient being included in the study. Result(s): While several bacterial species (Escherichia coli, Proteus mirabilis and Haemophilus influenzae) were found to occur less fre-quently, an increased occurrence was documented for Enterococcus faecium, Serratia marcescens and Klebsiella variicola. Overall, ho-wever, it can be concluded that there was no major change in the frequency of bacterial pathogens isolated from the lower respiratory tract during the COVID-19 period. Similarly, with only a few exceptions, antimicrobial resistance did not change significantly. More significant increases in resistance to piperacillin/tazobactam, cefotaxime, ciprofloxacin and gentamicin have been demonstrated for Serratia marcescens. However, a decrease in the resistance of Pseudomonas aeruginosa and Burkholderia cepacia complex to mero-penem was also observed. Conclusion(s): There was no significant change in the frequency of bacterial pathogens and their resistance to antibiotics during the COVID-19 pandemic. However, there was an increase or decrease in the percentage of some species and in their resistance.Copyright © 2022, Trios spol. s.r.o.. All rights reserved.
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Background: Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a life-threatening drug-induced condition presenting with skin rash, fever, lymphadenopathy, systemic involvement and hematological (eosinophilia, atypical lymphocytes) findings. Although DRESS syndrome is frequently associated with reactivation of herpesviruses, the link between DRESS and COVID-19 has not been systematically analyzed. Method(s): A systematic search using PubMed and Google Scholar was conducted following the PRISMA guidelines to identify all reported DRESS cases associated with COVID-19 published between January 2020 and January 2022 using the keywords "COVID-19" AND "DRESS syndrome" OR "drug reaction with eosinophilia and systemic symptoms" OR "drug-induced hypersensitivity syndrome" OR "eosinophilia" AND "SARS-CoV- 2" OR "coronavirus". The identified DRESS cases were evaluated using the Registry of Severe Cutaneous Adverse Reactions (RegiSCAR) scoring system [Kardaun et al, 2007]. Result(s): We identified twelve published DRESS cases associated with COVID-19 (Table 1). Eleven patients presented with severe COVID-19 disease complicated by DRESS syndrome that developed several days after initial COVID-19 clinical presentation (ARDS n5;multiorgan failure n1;pneumonia requiring mechanical ventilation, n4), one patient was asymptomatic. The culprit drugs included piperacillin-tazobactam (n4), hydroxychloroquine (n5), vancomycin (n2), ceftriaxone (n1), midazolam (n1), sulphasalazine (n1), azithromycin (n1), esomeprazole (n1), cefepime (n1), levofloxacin (n1), and meropenem (n1). The latency between the onset of treatment with culprit drug(s) and the onset of symptoms ranged from 9 to 42 days. All patients presented with widespread maculopapular rash, affecting > 50% of body surface area;five patients also had facial edema. Systemic involvement included liver (n8), renal abnormalities (n8), and heart involvement (n4). All patients had elevated body temperature (fever > = 38.5degreeC, n6) and blood eosinophilia, five patients had lymphadenopathy. Atypical lymphocytes were a rare laboratory finding (n2). Systemic corticosteroids were used in all patients;three patients received benralizumab for DRESS syndrome. Nine patients recovered, two patients died and the outcome was not reported in one case Conclusion(s): DRESS syndrome in COVID-19 patients is associated with multiple drugs, most notably with hydroxychloroquine and a variety of antibiotics. An early recognition may improve management of DRESS syndrome in COVID-19 patients.
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Background: Bloodstream Infections (BSIs) that arise secondary to urinary tract infections (UTIs) are frequently encountered in both community and hospital settings and are associated with significant morbidity, mortality, high healthcare costs and prolonged hospital stays Objective: This descriptive review aims to evaluate available information on the relationship of urinary tract infections with healthcare-associated and community-onset bloodstream infections to get a deeper understanding of improved public health interventions and suggest possibilities for future research. Material andMethods: A literature search was conducted using PubMed and Embase. Articles published during the last 10 years (2010 and 2020) were imported into covidence for the initial title and screening. All study s were reviewed by two independent reviewers and were eligible for full-text review if they mentioned urinary tract infection as a source of bloodstream infection. The data obtained were analyzed in Microsoft Excel. Result(s): Out of 65 articles reviewed for full text, 10 studies were selected. In total 6763 BSI cases were reported. We observed 2075 (30.6%) community-acquired (CA) BSIs compared to 1102 (16.2%) healthcare-associated (HCA) BSIs, and 1484 (21.9%) hospital-acquired (HA) BSIs. UTI was a major source of BSIs in community settings followed by HCA BSIs in most studies. Escherichia. coli was the most common pathogen isolated in patients with CA-BSIs. Hospital Acquired and HCA bacterial infections have the most antimicrobial resistance, compared to CA-infections. Conclusion(s): Urinary tract Infections are a major source of developing secondary BSIs. Escherichia. coli is a major pathogen in CA-BSIs. Multidrug-resistant organisms accounted for most of the BSIs, especially in hospital settings and among patients receiving health care.Copyright © 2023, Khyber Medical College. All rights reserved.
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Case report We present the case of a 63-year- old man with two consecutive admissions, due to COVID19 infection and subsequent bacterial superinfection. Three days after the second admission (04/28), and 43 days from the beginning of the infection an assessment by dermatology and allergology is then requested. The patient had generalized erythematous maculopapular rash in the trunk, back, groin and limbs. On the left side and back, pustular lesions not focused on follicles were also added, with a fever of 37.7degreeC. There were no oral and genital lesions. No psoriasis. The drugs used during the present and previous admissions were reviewed. Previous admission (04/04-22/ 20): Linezolid, ciprofloxacin, meropenem 04/13-22, piperacillin/tazobactam, hydroxychloroquine, azithromycin, ceftriaxone. Upon discharge amoxicillin/acid clavulanic. Present admission (04/25) Cutaneous reaction 04/28. 04/25: meropenem, paracetamol, enoxaparin, insulin, omeprazole, venlafaxine. 04/26: Darbepoetin, furosemide, mycophenolate in single dose. 04/27: Linezolid, macrogol, Clopidogrel, Magnesium, Calcitriol. Medical records: DM type 2, liver transplantation due to HCV cirrhosis, HCV recurrence, uninodular hepatocarcinoma, advanced CKD, secondary hyperparathyroidism, multiple neurological antecedents. We performed a detailed study. We hypothesized with a pharmagological/ drug reaction with several drugs possibly involved and our main suspicion was an allergic reaction to beta-lactams. Biopsy: Subcorneal pustules, basal spongiosis and presence in the superficial dermis of edema and an inflammatory infiltrate with abundant neutrophils. No fungi. Findings compatible with clinical diagnosis of generalized acute exanthematic pustulosis (PEGA). Immunohistochemical study Covid19. (Jimenez Diaz Foundation) Finely granular positivity in endothelium and more coarse in sweaty epithelium. Neutrophilic superficial inflammatory component with presumably spure staining. ACe-2 (positive external control) is not detected. The patient presents a EuroSCAR score of 9, sum of the clinic and the pathological anatomy, and therefore defined diagnosis. Clinical diagnosis: PEGA secondary to meropenem. Conclusion(s): We present the case of a PEGA by meropenem, not very often described in the literature. We highlight the importance of differential diagnosis with viral infections. Skin tests, especially epicutaneous tests, are key to the diagnosis. (Figure Presented).
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Background: Currently, the present world is facing a new deadly challenge from a pandemic disease called COVID-19, which is caused by a coronavirus named SARS-CoV-2. To date, no drug or vaccine can treat COVID-19 completely, but some drugs have been used primarily, and they are in different stages of clinical trials. This review article discussed and compared those drugs which are running ahead in COVID-19 treatments. Method(s): We have explored PUBMED, SCOPUS, WEB OF SCIENCE, as well as press releases of WHO, NIH and FDA for articles related to COVID-19 and reviewed them. Result(s): Drugs like favipiravir, remdesivir, lopinavir/ritonavir, hydroxychloroquine, azithromycin, ivermectin, corticosteroids and interferons have been found effective to some extent, and partially approved by FDA and WHO to treat COVID-19 at different levels. However, some of these drugs have been disapproved later, although clinical trials are going on. In parallel, plasma therapy has been found fruitful to some extent too, and a number of vaccine trials are going on. Conclusion(s): This review article discussed the epidemiologic and mechanistic characteristics of SARS-CoV-2, and how drugs could act on this virus with the comparative discussion on progress and drawbacks of major drugs used till date, which might be beneficial for choosing therapies against COVID-19 in different countries.Copyright © 2022 Bentham Science Publishers.
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Background: 47-year Emirati female, has history of T2DM since age of 39. Her overall diabetes poorly controlled with HbA1C of 8.6% (69 mmol/mol IFCC) on Empagliflozin 10 mg OD over the last 2 years well tolerated. NO micro- or macrovascular complications of her diabetes. No other significant medical history apart from hypertension she is taking Amlodipine 10 mg OD for it with good control. She has presented twice to the hospital 24 hours apart. 1st Visit to ER in our Hospital with fever epigastric pain discharged on Ciprofloxacin suspected gastroenteritis with PPI and sent home. Approximately, 24 hours later she presented again with same symptoms namely fever and epigastric pain but this time associated with diarrhea and nausea for last 20 hours. There was no shortness of Breath or cough. This time she has been admitted to isolating room giving suspicion of COVID-19. Vital signs as following: Temp 38.5 HR 105, BP 135/65 mmHg O2 Sats 96%. on RA. On examination, she was conscious, oriented to time place person. No signs of dehydration. abdomen soft non tender, Chest good air entry no added sound. Hear S1-S2 no murmurs. HRCT has been done at ER. HRCT shows wide spread area of multifocal ground glass opacification are seen in both lungs most of them shows peripheral sub-pleural distribution Around small size consolidation are seen within the ground glass opacification, CT findings are in favour of possibility of COVID-19. Result(s): Blood test as following On admission, FBC was normal, with Hb 13.2, WBC 8.0, Plt 388 cellX 10/ul, U/Es: S.NA 132, s.K 4.2 mmo/l, s. Creatinine normal (58 umol/L -NR 49-90 umol/L) LFTs, Amylase and lipase normal, LDH mild elevation 304 U/L (NR 81-234), Very low Phosphate 03 mmol/L (NR 0.87-1.45), D-Dimer 0.6 mg/L (NR 0.0- 0.5), Corrected Calcium normal, S. Ferritin was 242 ug/L (NR 8.00- 388.00 ug/L), Urinalysis Protein =1 and 4+ ketones, CRP was normal 1 mg/dl ( increased to 214 mg/ l 3rd day) before it goes done 41 mg/L on 7th day of admission. Giving the pandemic of COVID 19 and according to MOHAP Criteria for presenting symptoms. This lady underwent HRCT and COVID19 test by Nasal Swab. Meanwhile, Her Venous Blood gas shows sever metabolic acidosis pH 7.107, PCO2 12.90, PCO2 69.10 On RA, BC 8.9, BE -25.5. Blood sugar 13.2 mmol/L with Urinary Ketones of 4+. Patient has put on DKA Protocol according to our Hospital DKA protocol in addition Stopped her SGLT2 and start on Lantus as a basal. She has put on Scale C (which is the higher scale with infusion about 10 units per hour, for about 96 hours (i.e. 4 days till the blood sugar back to normal for Ketones to disappear, her acidosis didn't improve 1st 24 hours till we give her 1.26% of 500 ml of Sodium Bicarbonate over 6 hours. COVID 19 Test back after 72 hours with positive results. Once out of DKA Diabetes team has stopped her Lantus a stared-on Humalog mix 50% 25 unit TDS. Meanwhile, she has received the following medications waiting for COVID 19 test. Treated with Favipiravir 1600 mg BD for 1 day and 600 mg BD, Start Tazocin 4.5 (stopped after 3 days) Metronidazole, and with prophylactic dose of Clexane. The Hydroxychloroquine hasn't started as Prolong QTC has been notice). Discussion(s): This patient presentation with DKA is another example how COVID- 19 could be a reason for DKA, though SGLT2 could be another cause of her presentation, however the huge insulin requirement and unusual prolong DKA status even with sever acidosis is making COVID-19 more likely causing her presentation It. Conclusion(s): We report this case to highlight the fact DKA - and in fact sever resistant DKA need prolong treatment can happen to Patient with T2DM and COVID 19 positive, and special attention to be paid (with early referral to the diabetes team) if the patient already on SGLT2. And we recommend that to have low threshold to start investigation and treatment as early as possible, regardless the type of Diabetes these patient might have.
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Methicillin-resistant Staphylococcus aureus (MRSA) infections are a primary health concern. They are commonly differentiated as hospital-acquired methicillin-resistant Staphylococcus aureus (HA-MRSA) and community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections, based on their epidemiology, susceptibility findings, and molecular typing patterns. Therefore, appropriate contact precautions and isolation measures should be implemented. CA-MRSA mostly causes skin and soft-tissue infections, but the probability and incidence of it causing sepsis and invasive infections have increased dramatically in recent years. In this study, we report a case of CA-MRSA pneumonia with pan-pneumonic effusion in a 59-year-old male diabetic patient with preexisting comorbidities such as diabetic ketoacidosis and non-ST elevated myocardial infarction. The early reporting of the organism's identity and its antimicrobial susceptibility, as well as timely initiation of antibiotic therapy, aided in the successful management and cure of the patient.
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Rationale: The impact of COVID-19 in patients with autoimmune liver disease treated with immunosuppressive therapy has not been described so far. This case report describes the clinical course of a patient with autoimmune hepatitis (AIH) who developed COVID-19 and the features of cytokine syndrome leading to its deterioration in our intensive care unit. Patient's Concern: A 28-year-old male presented with generalized anasarca for two weeks and chronic liver disease for 8 months. Diagnosis: AIH and Covid-19 with features of cytokine storm syndrome. Interventions: Intravenous furosemide, mannitol, syrup lactulose, steroids (prednisolone 40 mg), azathioprine 1 mg/kg body weight, rifaximin, vitamin K, and blood products. Outcomes: The patient had hepatic encephalopathy and AIH and died on the 10th day after admission despite ventilatory support, sustained low-efficiency hemodialysis, and resuscition. Lessons: The dramatic release of cytokines and the inflammatory-immune responses not only alter the pathophysiology but also affects the onset and severity of disease progression in patients with AIH.
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SESSION TITLE: Systemic Diseases with Deceptive Pulmonary Manifestations SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Pulmonary cavitary lesions can have varying etiologies. Among these, Lemierre syndrome is an uncommon disease which usually presents with symptoms of upper respiratory tract infection with unilateral neck pain, tenderness or swelling. In recent years, antibiotic stewardship for upper respiratory illnesses has led to its delayed diagnosis resulting in possible increased morbidity and mortality. There have been few reported cases of pulmonary cavitary lesions as the initial presentation of Lemierre syndrome. Our patient presented with incidental bilateral pulmonary cavitary lesions, which led to a diagnosis of Lemierre syndrome. CASE PRESENTATION: A 30-year-old gentleman with no significant past medical history visited urgent care for reproducible chest pain following motor vehicle accident. Chest x ray obtained for suspected rib fracture showed bilateral patchy and rounded opacities, confirmed by CT as bilateral cavitary nodules and consolidation. He was referred to our hospital for further care. Two weeks prior, following administration of COVID booster vaccine, he had developed fever, sore throat, tender lump behind left ear, left jaw and anterior left neck. Most symptoms self resolved in 3-5 days except persistent fever. On arrival, patient was febrile to 102F and hemodynamically stable. Physical examination revealed dry mucous membranes and erythematous pharynx. Labs were significant for leukocytosis of 24.5uL with bandemia and elevated inflammatory markers. Three sets of blood cultures were drawn and empirically started on vancomycin and piperacillin/tazobactam. Echocardiogram ruled out heart valve vegetations. CT angiography of neck showed intraluminal thrombi in left internal jugular vein. Blood cultures finalized to Fusobacterium nucleatum and antibiotics were tapered to metronidazole. Due to persistent fever, anticoagulation was initiated with apixaban 5mg twice daily. Pan CT showed improvement in size of many pulmonary septic emboli. After 48 hours of patient being afebrile, he was discharged on antibiotics and apixaban for at least 4 weeks until surveillance CT angiography showed non progression of thrombus. DISCUSSION: Lemierre syndrome is septic thrombophlebitis of internal jugular vein which presents within 1-3 weeks following upper respiratory tract infections with multi-system complications. Management involves prolonged antibiotic course with use of anticoagulation and vein stripping still being debated. Our patient came to the hospital with an incidental finding of bilateral cavitary pulmonary lesions which went on to be diagnosed as Lemierre syndrome from positive blood cultures and CT angiography findings. CONCLUSIONS: Lemierre syndrome is an uncommon disease with mortality up to 18%. A call out to health care providers to keep a low threshold for its diagnosis in patients with initial presentation of bilateral pulmonary cavitary lesions, warranting prompt management. Reference #1: Sinave CP, Hardy GJ, Fardy PW. The Lemierre syndrome: suppurative thrombophlebitis of the internal jugular vein secondary to oropharyngeal infection. Medicine (Baltimore). 1989 Mar;68(2):85-94. PMID: 2646510. Reference #2: Golpe R, Marín B, Alonso M. Lemierre's syndrome (necrobacillosis). Postgrad Med J. 1999 Mar;75(881):141-4. doi: 10.1136/pgmj.75.881.141. PMID: 10448489;PMCID: PMC1741175. Reference #3: Lee WS, Jean SS, Chen FL, Hsieh SM, Hsueh PR. Lemierre's syndrome: A forgotten and re-emerging infection. J Microbiol Immunol Infect. 2020 Aug;53(4):513-517. doi: 10.1016/j.jmii.2020.03.027. Epub 2020 Apr 4. PMID: 32303484. DISCLOSURES: No relevant relationships by Sumukh Arun Kumar No relevant relationships by Megna Machado No relevant relationships by Sushmita Prabhu No relevant relationships by PAWINA SUBEDI No relevant relationships by Mithil Gowda Suresh No relevant relationships by Bradley Switzer
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SESSION TITLE: Invasion of the Pleura SESSION TYPE: Case Reports PRESENTED ON: 10/18/2022 11:15 am - 12:15 pm INTRODUCTION: Schwannoma is a well circumscribed encapsulated solitary neoplasm arising from myelin producing cells of peripheral nerve sheaths. Pleural schwannomas represent only 1-2% of thoracic tumors and rarely present with pleural effusion. To our knowledge only six cases of benign pleural schwannoma have presented with a pleural effusion to date. We present a rare case of a pleural schwannoma with bilateral serosanguinous pleural effusions complicated by necrotizing pneumonia. CASE PRESENTATION: 54 year old smoking male with no past medical history was transferred from an outside hospital after two weeks of worsening acute hypoxemic respiratory failure while being treated for necrotizing pneumonia, right sided loculated pleural effusion, and a right paramediastinal mass. His only presenting symptom was worsening dyspnea for three days. Upon arrival to our hospital, the patient was on maximal ventilator settings with two right sided chest tubes draining blood tinged pleural fluid. CTA of the chest showed a large cavitary consolidation in the right upper lobe with destruction of the lung parenchyma. Additionally, there was an intrapleural heterogenous mass in the posterior aspect of the right lung apex which abut the mediastinum measuring 9.7 x 7.5 x 10.3 cm. He was treated with zosyn for positive sputum cultures growing beta hemolytic strep group F. Patient underwent a flexible bronchoscopy with EBUS-TBNA of mediastinal lymphnodes and lung mass which was non-diagnostic. A CT guided biopsy revealed a spindle cell neoplasm with a Ki-67 of 10-20%. Immunohistochemical analysis demonstrated positive staining of the tumor cells for S-100 protein. The final pathological diagnosis was benign schwannoma. He underwent a tracheostomy and PEG and was sent to a rehab center with outpatient follow-up with cardiothoracic surgery for tumor removal. DISCUSSION: Pleural schwannomas are slow growing, rarely progress to malignancy, and are often located in the posterior mediastinum. Patients are usually asymptomatic but can present with symptoms associated with obstructive pneumonia. It is very rare for a benign pleural schwannoma to present with a pleural effusion. Literature review has revealed only six cases of benign schwannoma presenting with a pleural effusion, all of which were blood stained. Spontaneous tumor hemorrhage or cyst rupture has been a theory of etiology for the effusions. Prognostically, once the pleural schwannomas are surgically resected there is minimal chance of recurrence. CONCLUSIONS: Our case represents a benign pleural schwannoma that caused extrinsic compression on the right upper lobe bronchus leading to a necrotizing pneumonia along with bilateral serosanguinous pleural effusions. A pleural schwannoma should be considered in the differential diagnosis of intrathoracic tumors even when presenting with pleural effusions. Reference #1: Shoaib D, Zahir M, Khan S, et al. Difficulty Breathing or Just a Case of the Nerves? Incidental Finding of Primary Pleural Schwannoma in a Covid-19 Survivor. Cureus. 2021. 13(8): e17511. Reference #2: Bibby A, Daly R, Internullo E, et al. Benign Pleural Schwannoma Presenting with a Large, Blood Stained Pleural Effusion. Thorax. 2018. 73:497-498. Reference #3: Nosrati R, Annissian D, Ramezani F, et al. Benign schwannoma of posterior mediastinum accompanied by blood pleural effusion misdiagnosed as solitary fibrous tumor: A Case report. Casplan J Intern Med. 2019. 10:468-471. DISCLOSURES: No relevant relationships by Brittany Bass No relevant relationships by Oleg Epelbaum No relevant relationships by Theresa Henson No relevant relationships by Yasmin Leigh No relevant relationships by Ester Sherman No relevant relationships by Sally Ziatabar
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SESSION TITLE: Critical Thinking SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 09:15 am - 10:15 am INTRODUCTION: We describe a case of severe thrombocytopenia due to reaction with an electron-beam sterilized polysulfone (PS) membrane in a patient with a previous diagnosis of reported chronic immune thrombocytopenic purpura (ITP). This phenomenon has been previously described but is rarely reported. Electron-beam (e-beam) sterilized PS membranes are classically more biocompatible than cellulose-based membranes but adverse reactions may occur as demonstrated in our case. CASE PRESENTATION: An 84-year-old woman with ESRD on hemodialysis (HD) and reported chronic ITP refractory to glucocorticoids with severe thrombocytopenia at baseline presented for evaluation of chest pain. She was incidentally found to have severe thrombocytopenia and treated with high dose glucocorticoids with minimal improvement in her thrombocytopenia and transitioned to chronic glucocorticoid taper. She had a severe chronic thrombocytopenia despite glucocorticoids which was suspected to be chronic ITP and diagnosed after initiation of outpatient HD. HD was held the first few days of her admission. She was found to have multifocal pneumonia due to SARS-CoV-2 infection. She developed progressive hypoxemic respiratory failure requiring intubation with sepsis treated with vancomycin & piperacillin-tazobactam. BAL revealed ESBL Escherichia coli & transitioned to ertapenem. She developed recurrent thrombocytopenia following HD and her PLT would improve between HD sessions. Evaluation of usual culprits of thrombocytopenia was unrevealing. Reaction to the PS membrane was suspected and a cellulose-based dialyzer membrane was used instead for subsequent sessions of HD with recovery of the platelet counts to normal. The remainder of her course was significant for tracheostomy with ventilator dependence and surrogate pursued compassionate care. DISCUSSION: We describe an interesting case of severe thrombocytopenia due to PS membrane reaction which was previously labeled as chronic ITP. Usual culprits such as pseudothrombocytopenia, HIT, HIV, HCV, hypersplenism, alcohol use, nutritional deficiencies, and rheumatologic disease were excluded. Synthetic membranes like PS-membranes are traditionally regarded as more biocompatible but filter reactions are described [1]. It is hypothesized that e-beam radiation may affect dialyzer membrane integrity or structure, or produce intermediary products which may cause platelet activation, aggregation, and adsorption, and therefore thrombocytopenia [2]. There is a high prevalence of thrombocytopenia among critically ill patients undergoing HD [3]. CONCLUSIONS: Thrombocytopenia due to PS dialyzer membrane is a rarely reported phenomenon and may be underrecognized in critically ill patients. This entity should be considered in the differential diagnosis of patients undergoing HD who develop thrombocytopenia. Early recognition may reduce incidence of bleeding and need for blood products in these patients. Reference #1: Golli-Bennour EE, Kouidhi B, Dey M et al. Cytotoxic effects exerted by polyarylsulfone dialyser membranes depend on different sterilization processes. Int Urol Nephrol 2011;43: 483–490. Reference #2: Batalini F, Aleixo GF, Maoz A, Sarosiek S. Haemodialysis-associated thrombocytopenia: interactions among the immune system, membranes and sterilisation methods. BMJ Case Rep. 2019 Sep 4;12(9):e229594. doi: 10.1136/bcr-2019-229594. PMID: 31488440;PMCID: PMC6731774. Reference #3: Griffin BR, Jovanovich A, You Z, Palevsky P, Faubel S, Jalal D. Effects of Baseline Thrombocytopenia and Platelet Decrease Following Renal Replacement Therapy Initiation in Patients With Severe Acute Kidney Injury. Crit Care Med. 2019;47(4):e325-e331. doi:10.1097/CCM.0000000000003598 DISCLOSURES: No relevant relationships by Adefemi Adeyemo No relevant relationships by Zachary Chandler No relevant relationships by Bijal Patel No relevant relationships by Vandana Seeram