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The COVID-19 pandemic has altered people's lifestyles around the world. Prevention of recurrent episodes of the disease and mitigation of its consequences are especially associated with effective post-COVID-19 rehabilitation in patients. The aim of the study was to evaluate the effects of the drug Likopid (glucosaminylmuramyl dipeptide, GMDP) for post-COVID-19 rehabilitation in patients. Material and methods. Patients who recovered from mild to moderate COVID-19 (n=60, mean age 54+/- 11.7 years) were randomized into the observation group (n=30, 15 men and 15 women) who received 2 courses of Licopid (1 mg twice a day) and the comparison group (n=30, 15 men and 15 women). Analysis of the phenotypic and functional characteristics of the innate immune cellular factors was carried out before the start of immunomodulatory therapy, immediately after the end of the course, and also after 6 months observations. In order to assess the quality of life of all patients, we used the SF-36 Health Status Survey and the Hospital Anxiety and Depression Scale questionnaires. Results. During assessing the effect of immunomodulatory therapy on the parameters of innate immunity of patients at the stage of rehabilitation after COVID-19, an increase in the protective cytolytic activity of CD16+ and CD8+Gr+ cells, as well as a persistent increase in TLR2, TLR4 and TLR9 expression was found, which indicates the antigen recognition recovery and presentation at the level of the monocytic link of the immune system. The use of GMDP as an immunomodulatory agent resulted in an 8-fold reduction in the frequency and severity of respiratory infections due to an increase in the total monocyte count. As a result of assessing patients' quality of life against the background of the therapy, a positive dynamic in role functioning was revealed in patients. In the general assessment of their health status, an increase in physical and mental well-being was noted during 6 months of observation. The comparison group showed no improvement in the psychoemotional state. Discussion. The study demonstrated the effectiveness of GMDP immunomodulatory therapy in correcting immunological parameters for post-COVID-19 rehabilitation in patients. The data obtained are consistent with the previously discovered ability of GMDP to restore impaired functions of phagocytic cells and induce the expression of their surface activation markers, which in turn contributes to an adequate response to pathogens. Conclusion. The study revealed that the correction of immunological parameters with the use of GMDP in COVID-19 convalescents contributed not only to a decrease in the frequency and severity of respiratory infections, but also to an improvement in the psycho-emotional state of patients, and a decrease in anxiety and depression.Copyright © Eco-Vector, 2023. All rights reserved.
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The COVID-19 pandemic has left millions of cases and deaths worldwide, in children the infection is less severe and has low mortality. A post-infectious entity called Systemic Multiinflammatory Syndrome (MIS-C) associated with COVID-19 infection is described, which has a mortality rate ten times higher than acute infection in children. MIS-C is characterized by sustained systemic inflammatory manifestations associated with fever and multiple system involvement. We present the case of a schoolgirl who presented a diagnosis of MIS-C with a good response to management and 11 months later, she presented a second episode that also responded to treatment. To date, we have not found in the literature the report of recurrence of MIS-C in children, such as the case presented by us, it marks an important precedent, inviting us to consider recurrence as a possibility in the case of a similar clinical presentation.Copyright © 2023 Asociacion Colombiana de Infectologia. All rights reserved.
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Objectives: To provide an overview of trends in the current evidence landscape of products and services in development that support remote patient monitoring (RPM) and remote therapeutic monitoring (RTM), given the release of new billing codes for RPM and RTM by Centers for Medicare and Medicaid Services (CMS) in 2019. Method(s): A focused literature review was conducted in PubMed. Articles published between January 1, 2013 and January 1, 2023 were eligible for inclusion if reported technologies were classified as RPM (defined as the collection and interpretation of physiologic data digitally stored and/or transmitted by patients and/or caregivers to qualified health care professionals) or RTM (defined as the use of medical devices to monitor a patient's health or response to treatment using non-physiological data), following CMS definitions. RPM and RTM technologies included hardware, software, telehealth, and blockchain applications. Articles were then categorized using a semi-automated software platform (AutoLit, Nested Knowledge, St. Paul, MN) based on disease area, study design, intervention, and outcomes studied. Result(s): Of the 673 records screened, 245 articles were included. Observational studies (19.6%) were the most common study design, followed by systematic or focused literature reviews (11.0%) and narrative reviews (10.6%). The most common disease areas included cardiology (25.7%), coronavirus disease of 2019 (COVID-19;13.9%), and diabetes (9.4%). The most frequent clinical, non-clinical, and patient-reported outcomes were symptom monitoring (20.8%), all cause readmission and hospitalization rates (both 7.3%), and patient experience (7.8%), respectively. Conclusion(s): CMS policy and coding practices for RPM and RTM are evolving, and this trend is likely to continue into the future. This review provides details on the current evidence trends associated with RPM/RTM technologies. Evidence development of RPM and RTM should be assessed as evidence needs for coverage and reimbursement may receive increased payer management.Copyright © 2023
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Objectives: The objective of this study is to assess the clinical benefits and potential risks of using venovenous extracorporeal membrane oxygenation (VV ECMO) as a treatment for COVID-19 patients with severe respiratory failure. Method(s): Relevant studies were identified through searches of electronic databases, including PubMed, EMBASE, and the Cochrane Library, from January 2020 to December 2022. We included observational studies on adult patients who received venovenous (VV) ECMO support for COVID-19-induced ARDS. The primary outcome was in-hospital mortality, 3-month mortality, and complications associated with VV ECMO. Statistical analysis was performed using R version 4.0.3 and the metafor and meta packages. Result(s): The final analysis included 39 studies comprising 10,702 patients. In-hospital mortality for adults receiving ECMO was 34.2% (95% CI: 28.5% - 40.3%;I2 = 93%), while the 3-month mortality rate was 50.2% (95% CI: 44.4% - 56.0%;I2 = 51%). Bleeding requiring transfusion occurred in 33.7% of patients (95% CI, 23.9 - 45.1;I2 = 96%). The pooled estimates for other complications were as follows: overall thromboembolic events 40.9% (95% CI, 24.8 - 59.3;I2 = 97%), stroke 8.7% (95% CI, 5.7 - 13.2;I2 = 72%), deep vein thrombosis 15.4% (95% CI, 9.7 - 23.6;I2 = 80%), pulmonary embolism 15.6% (95% CI, 9.3 - 25.1;I2 = 92%), gastrointestinal haemorrhage 8.1% (95% CI, 5.5 - 11.8;I2 = 56%), and the need for any renal replacement therapy in 38.0% of patients (95% CI, 31.6 - 44.8;I2 = 84%). Bacterial pneumonia occurred in 46.4% of patients (95% CI, 32.5 - 61.0;I2 = 96%). Conclusion(s): Venovenous extracorporeal membrane oxygenation (VV ECMO) may be an effective treatment option for COVID-19 patients with severe respiratory failure. The use of VV ECMO was associated with reduced in-hospital and 3-month mortality. However, bleeding is a common complication that should be closely monitored. Further research is needed to determine the optimal use of VV ECMO in this patient population and to identify factors that may predict a favourable response to treatment.
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Introduction: Despite several studies, the impact of coronavirus disease 2019 on patients with multiple myeloma remains uncertain. Material(s) and Method(s): We performed a survey that covered the period of the first and second waves of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic in 23 centers inseven countries. Out of 352 patients with myeloma and SARS-CoV-2, 23% died. Results/Conclusions: Logistic regression showed a lower risk of death among patients treated with proteasome inhibitor and a higher risk of death for those who had a severe or a very severe course of disease.Copyright © 2023 Sciendo. All rights reserved.
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According to the literature, exudative pleurisy and pericarditis are considered rare complications of the new coronavirus infection. This estimation can be explained by the fact that statistical studies cover mainly the hospital treatment of this disease. The true frequency of these complications and their consequences are not fully understood. Aim. The study of late complications of the new coronavirus infection in the form of pleurisy and pericarditis. Conclusion. In our case, a 62-year-old patient with the new coronavirus infection confirmed by polymerase chain reaction, severe bilateral polysegmental viral pneumonia, CT3, 60% on day 43 after the onset of clinical symptoms, was found to have manifestations of pleurisy and pericarditis during outpatient treatment. Cardiac MRI is the most informative method for detecting small pericardial and pleural effusions. The diagnostic capabilities of this method are superior to ultrasounography of the heart and pleural cavities and computed tomography of the lungs. Administration of colchicine 1.0 g per day for 1 month allowed not only to the elimination of pericarditis and pleurisy, but also the reduction of pressure in the right ventricle, probably by reducing the damage to the pulmonary parenchyma.Copyright © Chepurnenko S.A. et al., 2023.
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Background: Guillain-Barre Syndrome (GBS) is an autoimmune disease that may occur after infections.As Coronavirus Disease 2019 (COVID-19) may bring about GBS, it is important to assess the effect of the COVID-19 pandemic on this diseaseObjectives: This study aimed to compare the distribution and characteristics of GBS during and before theCOVID-19 pandemic in an academic referral hospital in the north of Iran.Materials & Methods: This retrospective study assessed GBS distribution and characteristics during theCOVID-19 pandemic period (from March 2020 to the end of February 2021) and before the pandemic(from March 2019 to the end of February 2020) on 5340 patients referred to the Neurology Ward ofPoursina Hospital of Guilan Province, in Iran. Result(s): There was no significant difference between GBS distribution during (0.03%) and before (0.04%)the COVID-19 pandemic (P=0.413). There were also no differences between the two periods regardingthe gender (P=0.659) and age (P=0.417) of the patients. The most common subtype of GBS during theCOVID-19 pandemic was Acute Motor and Sensory Axonal Neuropathy (AMSAN) (71.4%). In bothperiods, the most common type of treatment was intravenous administration of immune globulin. Therewas no significant difference between the two periods (P=0.838) regarding the patients' treatment response. Conclusion(s): The distribution of GBS, its subtypes, type of treatment, and response to treatment were notdifferent between the two study periodsCopyright © 2018 The Authors. This is an open access article under the CC-By-NC license
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Background/Aims When the COVID-19 pandemic began, steps were taken to minimise risk to those vulnerable to severe outcomes. For immunosuppressed patients with rheumatoid arthritis (RA), consideration was given to reducing risk whilst mindful of compromising control of their underlying condition. At Leeds Teaching Hospitals NHS Trust, patients receiving rituximab (RTX) were considered for a reduced dose regimen. A retrospective study, using real-world data, was undertaken to assess the impact of lower doses of RTX on response to treatment. Methods The clinical records of all patients with RA who had received RTX between March 2020 and March 2021 were reviewed. Demographics and previous RTX exposure were recorded. The dose of RTX given during the specified period was noted. Response to treatment was recorded pragmatically by physicians as good, partial or none, based on patient reported VAS for disease activity and swollen and tender joint counts, given the limitations placed on face-to-face patient review due to the pandemic. The time to subsequent RTX treatment and the need for steroid treatment for flares was also studied. Results The number of patients treated with RTX was 282, of whom 89 patients received full dose (1g x 2 infusions), 192 patients received half dose (500mg x 2 infusions). The mean age was 61 years. 77% were female. 9% were RTX-naive, 80% had previously had full dose. Follow-up data were available for 185/192 of the group receiving 1g and 88/89 of the group receiving 2g. Clinical outcomes were as follows for the two groups (1g RTX vs 2g RTX): no response 10.3% vs 9.1%;partial response:34.9% vs 20% %;good response: 54.8% vs 70.9%. The mean length of response was 7.5 months in the patients receiving 1g of RTX compared to 8.6 months in the group receiving 2g of RTX. Similar number of patients required steroid for a flare after receiving Ig of RTX (23.9%) compare to those receiving 2g of RTX (25.8%). Conclusion A majority of patients receiving RTX for RA at either standard or reduced dose reported clinical response. Those receiving lower dose RTX were more likely to report a partial response whilst those receiving full dose were more likely to report a good response. Duration of response and need for steroid therapy for flare of RA between treatments did not significantly differ between groups. Further analysis of factors that may influence clinical response to lower dose RTX is ongoing, which could guide tailored therapy regimens should the need arise again.
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Autoimmune pulmonary alveolar proteinosis (PAP) is a rare disease, especially in pediatrics, but important to consider, as it may avoid unnecessary and/or invasive investigations and delayed diagnosis. This case report highlights an adolescent girl with rapid onset dyspnea but an unremarkable physical exam and initial testing. However, due to a high index of suspicion, a chest computed tomography (CT) scan was done, revealing a "crazy paving" pattern, which then prompted expedited assessment. This finding, however, is not as specific as often discussed and has a broad differential diagnosis, which will be reviewed in detail as part of this case. Furthermore, this report demonstrates a diagnostic approach for PAP that avoids lung biopsy, previously considered to be required for diagnosis of PAP, but is increasingly becoming unnecessary with more advanced blood tests and understanding of their sensitivity and specificity. Additionally, management strategies for PAP will be briefly discussed.Copyright © 2022 Canadian Thoracic Society.
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Introduction: Gastrointestinal tract involvement from herpes simplex virus is commonly associated with esophagitis. However, herpes simplex infection of the stomach is very rare with only a handful of cases being reported in immunocompromised patients. We present a case of herpes gastritis causing gastric outlet obstruction in an otherwise healthy, immunocompetent individual. Case Description/Methods: A 37-year-old male with a recent past medical history of COVID-19 infection, presented to the hospital with intractable nausea, vomiting, bloating, and early satiety for two days. Upon evaluation, CBC and CMP were remarkable for a WBC of 12.5 k/mm3 and ALT and AST of 124 U/L and 129 U/L, respectively. Lipase was 373 U/L. A CT abdomen/pelvis w/contrast showed circumferential wall thickening with edematous changes in the antrum consistent with localized inflammatory response. There was suspicion for gastric lymphoma and patient was admitted for further workup. An EGD was performed which showed exudative esophagitis and antral wall edema with luminal narrowing of gastric antrum. Endoscopic ultrasound (EUS) showed a 2.5 x 3 cm antral wall lesion worrisome for linitis plastica. Esophageal biopsies showed focal cytologic changes consistent with herpes esophagitis. The FNA of the gastric antral wall showed multinucleation of the basal cell layer with classic ground glass nuclei, consistent with herpes infection. No dysplasia or malignancy was seen. Both HSV1 and HSV2 IgG were elevated. HSV IgM was normal. A HSV PCR was ordered but never resulted. Patient was started on Valacyclovir 1 g PO BID for 10 days. He underwent a follow-up EGD 3 months later which showed complete resolution of the gastric antral changes (Figure). Discussion(s): Herpes gastritis is extremely rare. Literature review has revealed only 3 case reports of herpes gastritis;and all involved immunocompromised patients. To the best of our knowledge, this is the first case of herpes gastritis in an immunocompetent patient. Our patient presented with symptoms of gastric outlet obstruction which was caused by local inflammation from herpes simplex. It is unclear if having a COVID 19 infection altered patient's immunity and lead to herpes gastritis. This may need further investigation. No established guideline exists for treatment duration. Our patient received 10-day course of Valacyclovir, and his symptoms improved. Furthermore, patient had complete resolution of the herpes infection on follow-up EGD, indicating adequate treatment response.
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The proceedings contain 35 papers. The topics discussed include: germline variants and prognostic factors for cutaneous melanoma in children and adolescents;association between polygenic risk score and multiple primary melanoma;Porocarcinoma: an epidemiological, clinical, and dermoscopic 20-year study;primary cutaneous melanoma and COVID-19: a hospital-based study;atypical spitz tumors: an epidemiological, clinical and dermoscopic multicenter study with 16 years of follow-up;pediatric melanoma: an epidemiological, clinical and dermoscopic multicenter study;recurrence-free survival prediction in melanoma patients by exploiting artificial intelligence techniques on melanoma whole slide images;ultra-high frequency ultrasound and machine learning approaches for the differential diagnosis of melanocytic lesions;and genetic determinants of response to therapy in a real-world setting of advanced/metastatic melanoma patients: whole-exome sequencing and CFDNA analysis.
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Remdesivir (GS-5734) is a new direct-acting antiviral drug in the nucleotide analogue class with antiviral activity against SARS-CoV-2 and the ability to inhibit RNA-dependent RNA polymerase. Preliminary results from phase III randomized clinical trials of remdesivir are inconsistent. Understanding the fact of the limited world experience with the use of remdesivir in COVID-19 required further study of its efficacy and safety in real clinical practice. The aim of the study is to evaluate the efficacy and safety of remdesivir in the treatment of patients with COVID-19. Material and methods. The study included 1422 patients with a novel coronavirus infection (COVID-19) who received remdesivir as part of complex therapy in a hospital setting at medical organizations of the Moscow public health system. Additionally, standard therapy was carried out, regulated by the Interim Guidelines "Prevention, Diagnosis and Treatment of Novel Coronavirus Infection (COVID-19)" of the Ministry of Healthcare of the Russian Federation, the current version. The efficacy of the drug was assessed based on primary and secondary efficacy points. Primary variable: 1) cumulative incidence of clinical outcomes in patients with COVID-19 treated with remdesivir as part of complex therapy;2) median time to clinical improvement according to the World Health Organization ordinal categorical scale (under clinical improvement, the patient is assumed to move >2 categories towards improvement in clinical condition). Secondary variables: 1) median time to achieve <2 NEWS scores lasting at least 24 hours or hospital discharge;2) mortality from all causes;3) duration of fever (>38 degreeC), days;4) duration of hospitalization, days;5) time to achieve elimination of the pathogen from the upper respiratory tract (no SARS-CoV-2 RNA), days. The safety of remdesivir was assessed based on the registration of adverse events using the method of spontaneous reports. Results. The analysis of clinical outcomes of treatment showed that 1195 (84.1%) patients recovered, death from all causes occurred in 227 (15.9%) patients. The median improvement in clinical status on the World Health Organization ordinal categorical scale was 6 days. The median time to reach a NEWS score of <2, lasting at least 24 hours, or hospital discharge was 4 days. The median duration of fever was 3 days from the start of remdesivir administration. The median length of hospital stays for patients included in the Register was 9 days. Adverse reactions associated with the use of remdesivir were recorded in 11 (0.7%) patients. Serious adverse reactions were not registered. During hospitalization, all adverse reactions were resolved. Conclusion. A retrospective analysis of data from the Registry of 1422 patients with COVID-19 who received remdesivir as part of complex therapy in medical organizations of the state healthcare system of Moscow in routine clinical practice showed clinical efficacy and a favorable safety profile of remdesivir (Remdeform, lyophilizate for solution for intravenous administration 100 mg, manufactured by JSC Pharmasyntez, Russia). The data obtained are consistent with previous randomized clinical trials of remdesivir and allow us to recommend its further use in patients with COVID-19 as part of complex therapy.Copyright © The Author(s), 2022.
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Intro: Background: Obesity affects drug delivery and clearance owing to the patient's altered pharmacokinetics. In treating infection, this presents as a conundrum antibiotic dosing to achieve optimal antibiotic concentration at the same time avoiding drug toxicity. Particularly in the case of antimicrobial agents, underdosing may lead to antibiotic resistance. Method(s): Case description: We report a case of a morbidly obese (BMI=58) COVID-19 patient infected with carbapenem-sensitive multi-drug resistant (MDR) Enterobacter cloacae bacteremia, treated with ertapenem 1g twice daily and intravenous polymyxin E 9MU stat and 4.5MU twice daily for MDR Acinetobacter baumanii co-infection. He had infected huge grade IV sacral sore one month later in which intraoperative tissue culture grew phenotypically heterogeneous colonies of MDR Enterobacter cloacae with carbapenem-sensitive and carbapenem-intermediate-resistant non-carbapenemase producing colonies. He responded well clinically and biochemically with an increased dose of intravenous ciprofloxacin 800mg BD based on his actual body weight. He was discharged with oral ciprofloxacin 750mg BD for a total of six weeks. Finding(s): Discussion: Obesity is a public health crisis that has reached epidemic proportions. Obesity affects the volume distribution and renal clearance of many drugs including antibiotics. Obese patients are shown to have higher drug clearance than normal-weighted patients resulting in inadequate systemic exposure. This puts patients at risk of developing antibiotic resistant organisms. Our patient, weighing 162kg was given three different beta-lactam antibiotics to treat his infection including ertapenem in which a standard adult dose was given without body weight consideration. Possible underdosing contributed to the conversion of carbapenem susceptibility from sensitive to resistant strain. Conclusion(s): Obese individuals may need a larger ertapenem dose than their non-obese counterparts. Clinical and laboratory assessment may help in monitoring treatment response in this group of patients.Copyright © 2023
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Objectives: In the Covid-19 era, there was a surge in the cases of a life-threatening infection of rhinosinonasal mucormycosis. Mucormycosis, popularly known as black fungus, is an infection caused by mycetes mucorales, an aseptate hyphae. Presently, computed tomography (CT) and magnetic resonance imaging (MRI) are commonly used imaging modalities for the management of patients with rhinosinonasal mucormycosis. The present study was aimed to evaluate the role of 18F- FDG PET/CT in the detection of recurrent or residual disease in post-surgical or post antifungal therapy in these patients for further management. Method(s): A total of 10 patients were included in this pilot study of Covid-19 positive patients and histologically proven mucormycosis (by KOH mount). 18F- FDG PET/CT was performed to assess the disease status in 6 postoperative/ post debridement patients and response to antifungal therapy in 4 patients, at an interval of 40 (range = 27-66) days post intervention. Result(s): The mean age of the patients was 45.0 +/- 11.65 years. The male: female ratio was 9:1. The common clinical presentation was ipsilateral facial or orbital pain and swelling. Covid-19 infection was positive in all the patients except one who had CT finding with HRCT score of 10/25 and hence was considered as post Covid-19 infection. Six out of 10 patients were diabetic on oral hypoglycaemic agents or insulin. All patients had a baseline CT/MRI for staging the initial extent of the disease. Surgical debridement was done in 6 out of the 10 patients followed by antifungal therapy (Liposomal Amphotericin B and Pozaconazole). Remaining four patients were treated with antifungal therapy. PET/CTwas performed after an average of 40 days of surgical/medical intervention, in whom clinical symptoms persisted or worsened even on antifungal therapy. 18F-FDG PET/CT showed metabolically active residual disease in all the patients with a mean SUVmax of 9.78 +/- 4.03. Conclusion(s): In the era of ongoing Covid-19 infection, black fungus has been a debilitating disease with high mortality and morbidity. Present study demonstrated that 18F-FDG PET/CT can be an efficient imaging tool for an early surgical/ medical treatment response assessment and restaging.
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Background/Aims We report the features of chronic chilblain-like digital lesions newly presenting since the start of the covid-19 pandemic. Comparison with primary perniosis and acrocyanosis, reveals a unique phenotype which appears to be a long-covid phenomenon. Methods The case records of 26 patients with new onset persistent chilblain-like lesions presenting to the Rheumatology service of St George's University Hospital, London between Autumn 2020 and Spring 2022 were reviewed. Demographic and clinical features, serology, imaging, treatment response and outcome up to Summer 2022 were collated retrospectively. Results Chilblain-like lesions first occurred between September and March;2019/ 2020 6 cases, 2020/2021 18 cases and 2021/2022 2 cases. Mean age 35.4 (17-60) years, 88% female, 85% white, all non-smokers. Median body mass index (BMI) 20.2, range 17.0 - 33.2. BMI underweight (<18.5) in 27%. All cases reported new red-purple-blue colour changes of the fingers, some with pain, swelling and pruritis, affecting both hands in 12, one hand in 6, and both hands and feet in 8 cases. There was a past history of cold sensitivity or primary Raynaud's in 54%. Covid was confirmed in 3 cases, 2 - 8 months prior to onset of chilblain-like symptoms. Possible covid, unconfirmed, was suspected in 5 cases, 1 - 11 months earlier. Affected digits appeared diffusely erythro-cyanotic in 81%, with blotchy discrete maculo-papular erythematous lesions in 42%, some with both features. Involvement was asymmetric in 54%, thumbs spared in 69%. Complement was low in 50% (8/16), ANA positive in 26% (6/23). MRI of hands showed phalangeal bone marrow oedema in keeping with osteitis in 4 of 7 cases. More severe signs and symptoms were associated with low BMI, low C3/4 and a past history of cold sensitivity or Raynauds. Cold avoidance strategies were sufficient for 58%. Pain prompted a trial of NSAIDs, aspirin, nitrates, calcium channel blockers, hydroxychloroquine, oral or topical corticosteroid or topical tacrolimus in 42%. In general, these were minimally effective or not tolerated. 4 severe cases received sildenafil or tadalafil, effective in 2. In 27% complete remission occurred during the first summer season after symptoms commenced, median duration 6 (range 2 - 10) months. In the remaining 19 cases, chilblain-like symptoms returned or worsened in the subsequent second winter period, with 6 of 19 entering remission the following summer. For the remaining 13 persistent cases the total duration of symptoms spans more than a year, and in four cases more than 2 years. Conclusion This series illustrates a distinct chronic chilblain-like condition. Features similar to primary perniosis include female predominance, middle age, pruritic painful blotchy lesions, asymmetry and low BMI. Features in keeping with acrocyanosis include chronicity, extensive diffuse erythro-cyanotic discoloration, relative improvement in warm weather and lack of association with smoking.
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Purpose of Study: In February 2022, the American College of Rheumatology (ACR) updated its guidance for multisystem inflammatory syndrome in children (MIS-C). The treatment recommendation is to use intravenous immunoglobulin (IVIG) at 2 grams/kg with a maximum dose of 100 grams based on a moderate level of consensus among the task force members. To date, there are no studies comparing the response to doses of more than 100 grams in MIS-C. Methods Used: A retrospective review was conducted of patients admitted to Loma Linda University Children's Hospital for MIS-C from May 2020 to March 2021. Demographic, symptom, laboratory, and treatment data were systematically collected from the electronic medical record. The PRISM III score was calculated for all patients admitted to the PICU and used to control for severity of illness. Patients were designated non-responders if anakinra, or a second IVIG dose was given. A binomial logistic regression was used to model response to the IVIG dose in univariate and multivariate analysis with and without the PRISM III score and PICU length of stay. A Fisher's exact test was used to compare categorical variables. Summary of Results: There were 77 children treated for MIS-C. The median age was 118.5 months with a range of 3 to 254 months. There was a total of 30 patients who initially received at least 100 grams of IVIG of which 20 were in the PICU. All patients given at least 100 grams of IVIG received steroids concurrently. A univariate binomial regression using IVIG dose for patients admitted to the PICU showed an odds ratio of non-response was 0.98 (CI 0.94 - 1.02). The analysis is the same for all patients who received greater than 100 grams of IVIG. In a multivariate binomial regression, which included the PRISM III score, length of PICU stay and days of symptoms prior to admission, the odds ratio of non-response to IVIG was 0.98 (CI 0.92 - 1.03). Of the 10 patients who were not admitted to the PICU, only 1 failed to respond to IVIG and required anakinra. None of the patients who received more than 100 grams of IVIG were tested for hemolytic anemia but only 1 patient who received more than 1 dose of IVIG had a decline in hemoglobin. There was a median decline of 2.75 g/dL (range 1.6 - 6.7 g/dL) in all patients who had a decline in hemoglobin and received more than 100 grams of IVIG. Conclusion(s): In this single center cohort of patients who were admitted to the PICU for MIS-C who received more than 100 grams of IVIG initially, there was no relationship between higher doses of IVIG and halting inflammation. This study agrees with the ACR guidance regarding the dose of IVIG in MIS-C and adds evidence to give no more than 100 grams of IVIG.
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Purpose of study A 32-years old male with known multi-system sarcoidosis in remission for 5 years off treatment presented to the emergency room with complaints of generalized weakness, hematemesis, epistaxis, and bruises. Physical examination was notable for petechiae, ecchymosis along with papules and plaques suggestive of active sarcoid skin lesions on his extremities. Laboratory workup was significant for thrombocytopenia 3000/uL, acute kidney injury with sub-nephrotic proteinuria. Peripheral blood smear did not show evidence of hemolysis and direct Coombs test was negative. Infectious workup including COVID-19, HIV, and hepatitis serologies were negative. Computed Tomography (CT) of chest, abdomen, and pelvis showed mild splenomegaly and an increased number of sub-centimeter hilar and mediastinal lymph nodes. The patient was treated with dexamethasone 40 mg daily for 4 days and intravenousimmunoglobulins (IVIG-2 gm/kg) for possible Immune Thrombocytopenic Purpura (ITP) with improvement in platelet count to 42000/uL by day 3. His workup for AKI and sub-nephrotic proteinuria was negative apart from a positive ANA (1: 160) with low complements. The anti-phospholipid antibody panel was negative. The ACE level was markedly elevated (>80U/L). The patient could not get a renal biopsy due to severe thrombocytopenia. He was discharged but was re-admitted in 15 days for severe thrombocytopenia of 1000/uL, epistaxis, and bruising. We continued high dose steroids along with IVIG 1 gm/kg for refractory ITP with minimal response and started anti-CD20 agent (Rituximab) 375 mg/m2 weekly with thrombopoietin-receptor agonist (Eltrombopag). His platelets count improved in response to treatment and subsequent renal biopsy showed focal and segmental glomerulosclerosis along with mild interstitial fibrosis, tubular atrophy thought to be from long standing sarcoidosis. There was also evidence of focal arteriosclerosis with no evidence of granulomas, immune complex, complement, or IgG4 deposition. Given skin lesions, thrombocytopenia, extensive lymphadenopathy, and renal involvement with markedly elevated ACE levels the overall picture was consistent with active multi-system sarcoidosis. His platelet count increased to 177,000/uL at the time of discharge. Currently, the patient is on slow steroid taper along with Eltrombopag 25 mg every other day without any recurrence of his symptoms so far. Methods used We described one case of sarcoidosis with hematologic and renal involvement. Summary of results Our patient developed hematologic and renal complications approximately 6 years after being diagnosed with sarcoidosis. Initially, he did not demonstrate sufficient clinical response to IVIG and high dose steroids. However, after a course of anti-CD20 agent (Rituximab) and with the addition of thrombopoietin-receptor agonist (Eltrombopag) he showed improvement of platelet count and stabilization of the renal function. Currently, the patient is receiving maintenance therapy with Prednisone 7.5 mg daily along with Eltrombopag 25 mg twice weekly with no recurrence of ITP and stable renal function. A further decision on whether the patient needs another cycle of Rituximab will be determined by the patient's clinical course. Conclusions Highly variable manifestations of Sarcoidosis can pose a significant diagnostic and therapeutic challenge as can be seen from our case. ITP is a rare hematological manifestation of sarcoidosis and addition of anti-CD20 agents should be considered in refractory cases.
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Purpose of study The COVID-19 pandemic led to an unprecedented rapid transmission of healthcare information. This information was critical to enact frequently changing patient care protocols and to inform staff about redistribution of hospital resources at New York University Langone Hospital- Long Island. In this investigation, we analyze our hospital clinicians' methods of mass communication to front-line health care workers, with particular interest in assessing how communication was informed by real-time clinical findings. At the height of the pandemic (March 25th- April 15th), a mass broadcast email disseminated daily from the Director of Pulmonary and Critical Care was effective in informing treatment protocols that were clinically observed to improve patient outcomes. We analyzed over thirty broadcast emails and identified three major categories of information that were routinely addressed and/or updated: (i) reallocation of resources, (ii) clinical protocol changes, (iii) recommended lab tests for monitoring patient clinical course. We also interviewed key hospital clinicians and administrators on their experience working during the height of the pandemic. We found treatment protocols in these emails included information regarding the use of steroids and monoclonal antibody therapy, ventilators, and patient repositioning. In addition, the hospital's first autopsy results on COVID related deaths gave further insight into the disease process and manner of death for many patients (diffuse alveolar damage and evidence of hypercoagulability). So, too, did clinical findings around this time support what was seen grossly on autopsy-patients with more severe disease often presented with serial d-dimer levels >6x the normal limit. The information through these different conduits was synthesized and subsequently communicated in the aforementioned mass emails as an anticoagulation treatment protocol. Through continuous input of data, this protocol was updated and adjusted over the course of three weeks. We found that real-time communication amongst hospital staff regarding patient treatment protocols was a dynamic process that required synthesis of lab values, autopsy findings, and observed response to treatments. Successful treatment of patients depended on continuous review and communication of this information. Methods used The COVID-19 pandemic led to an unprecedented rapid transmission of healthcare information. This information was critical to enact frequently changing patient care protocols and to inform staff about redistribution of hospital resources at New York University Langone Hospital-- Long Island. In this investigation, we analyze our hospital clinicians' methods of mass communication to front-line health care workers, with particular interest in assessing how communication was informed by real-time clinical findings. At the height of the pandemic (March 25th- April 15th), a mass broadcast email disseminated daily from the Director of Pulmonary and Critical Care was effective in informing treatment protocols that were clinically observed to improve patient outcomes. Summary of results We analyzed over thirty broadcast emails and identified three major categories of information that were routinely addressed and/or updated: (i) reallocation of resources, (ii) clinical protocol changes, (iii) recommended lab tests for monitoring patient clinical course. We also interviewed key hospital clinicians and administrators on their experience working during the height of the pandemic. We found treatment protocols in these emails included information regarding the use of steroids and monoclonal antibody therapy, ventilators, and patient repositioning. In addition, the hospital's first autopsy results on COVID related deaths gave further insight into the disease process and manner of death for many patients (diffuse alveolar damage and evidence of hypercoagulability). So, too, did clinical findings around this time support what was seen grossly on autopsy- patients with more severe disease often presented with seri l d-dimer levels >6x the normal limit. The information through these different conduits was synthesized and subsequently communicated in the aforementioned mass emails as an anticoagulation treatment protocol. Through continuous input of data, this protocol was updated and adjusted over the course of three weeks. Conclusions We found that real-time communication amongst hospital staff regarding patient treatment protocols was a dynamic process that required synthesis of lab values, autopsy findings, and observed response to treatments. Successful treatment of patients depended on continuous review and communication of this information.
ABSTRACT
BACKGROUND: Multisystemic inflammatory syndrome of the adult, a new condition associated with an irregular immune response similar to that of children, is characterized by shock, heart failure or persistent hypotension, dyspnea on exertion, mild-moderate hypoxemia, gastric symptoms and elevated markers of systemic inflammation after severe COVID-19 pneumonia. CLINICAL CASE: A 56-year-old patient, uncontrolled diabetic, who presented symptoms associated with dyspnea, desaturation, chest pain and persistent fever, previously with severe pneumonia after one month of treatment. He was treated with oxygen, steroids and antibiotics for 3 weeks, but his symptoms worsened and he developed severe orthopnea, hypotension, chest pain, dyspnea at rest and severe desaturation, as well as elevation of inflammation markers (C-reactive protein, ESR, D-dimer, ferritin). Tomography of the chest showed residual pneumonia based on consolidation and ground glass. Echocardiogram evidenced diastolic dysfunction, myopericarditis and secondary endocarditis. Multisystemic inflammatory syndrome of the adult was diagnosed and patient was treated with IV immunoglobulin and steroid with a favorable response to treatment. CONCLUSION(S): This case shows that the adult systemic inflammatory syndrome is a differential diagnosis in a patient with shock of unknown etiology, heart failure and severe dyspnea previously infected by SARS-CoV-2. Immunoglobulin and steroid are the effective first-line treatment with excellent clinical response.Copyright © 2022 Comunicaciones Cientificas Mexicanas S.A. de C.V.. All rights reserved.
ABSTRACT
Introduction: COVID-19 presents a complex pathophysiology and evidence collected points towards an intricated interaction of viraldependent and individual immunological mechanisms. The identification of phenotypes, through clinical and biological markers, may provide a better understanding of the subjacent mechanisms and an early patient-tailored characterization of illness severity. Method(s): Multicenter prospective cohort study performed in 5 hospitals of Portugal and Brazil, during one year, between 2020-2021. All adult patients with an Intensive Care Unit admission with SARS-CoV-2 pneumonia were eligible. COVID-19 was diagnosed using clinical and radiologic criteria with a SARS-CoV-2 positive RT-PCR test. A two-step hierarchical cluster analysis was made using several class-defining variables. Result(s): 814 patients were included. The cluster analysis revealed a three-class model, allowing for the definition of three distinct COVID- 19 phenotypes: 244 patients in phenotype A, 163 patients in phenotype B, and 407 patients in phenotype C. Patients included in the phenotype C were significantly older, with higher baseline inflammatory biomarkers profile, and significantly higher requirement of organ support and mortality rate (Table 1 ( P062)). Phenotypes A and B demonstrated some overlapping clinical characteristics but different outcomes. Phenotype B patients presented a lower mortality rate, with consistently lower C-reactive protein, but higher procalcitonin and interleukin-6 serum levels, describing an immunological profile significantly different from phenotype A (Table 1). Conclusion(s): Severe COVID-19 patients exhibit three different clinical phenotypes with distinct profiles and outcomes. Their identification could have an impact in patients' care, justifying different therapy responses and inconsistencies identified across different randomized control trials results.