ABSTRACT
Background: Increasing availability of highly effective cystic fibrosis (CF) transmembrane conductance regulator (CFTR) modulator therapy (HEMT) has improved the quality of life and long-term prognosis for many people with CF. Thus, more people with CF are considering parenthood. Almost all menwith CF (MwCF) are infertile because of congenital bilateral absence of the vas deferens (CBAVD). Based on CF animal models, CBAVD occurs early in gestation and is unlikely to be reversible using HEMT, but assisted reproductive techniques (ARTs) can enable MwCF to father children using the sperm in their testes. Animal reproductive models suggest no HEMT teratogenicity, and the amount of exposure of the fetus to HEMT via absorption of seminal fluid through the vaginal wall is predicted to be negligible, although to ensure no sperm exposure to HEMT, the life span of sperm would require MwCF to discontinue CFTR modulators for approximately 3 months before ART. Because abrupt discontinuation of CFTR modulators may result in health decline, MwCF and their providers must consider all potential risks. There are no published data in MwCF regarding use of HEMT during conception and partner pregnancy. Method(s): Beginning in August 2021, CF center staff in the United States, United Kingdom, and Australia completed a two-page anonymous questionnaire regarding MwCF who used CFTR modulators during ART (sperm retrieval and in vitro fertilization) or natural conception with subsequent partner pregnancy. Result(s): Providers have submitted 34 surveys for MwCF on CFTR modulators whose partner became pregnant after use of ART (n = 32) or natural conception (n = 2). The median age of the samplewas 32 (range 24- 43). Fifteen were homozygous for F508del, median percentage predicted forced expiratory volume in 1 second was 76% (range (22-111%), and median body mass index was 24 kg/m2 (range 18.5-32.1). Twenty-three were taking elexacaftor/tezacaftor/ivacaftor. The median time that MwCF were taking CFTR modulators before partner conception was 18 months (range 0-82). One newly diagnosed man initiated HEMT after sperm retrieval. Four MwCF stopped CFTR modulators before sperm retrieval, one of whom experienced pulmonary decline. None of the 19 MwCF whose condom use during pregnancy was known used condoms. Fetal complications in partners of MwCF included three first-trimester miscarriages, two* COVID, two breech presentation, two* vaginal bleeding, and one vasa previa. None of the complications were deemed definitively related to use of CFTR modulators. One MwCF experienced testicular infection after sperm retrieval#. Postpartum complications included three# infants with hypoxemia requiring neonatal intensive care unit stay, three maternal blood loss, one forceps delivery, and one caesarean section. No congenital anomalies were reported for any infant. (*/# overlap). Conclusion(s): Use of CFTR modulator therapy during partner conception and pregnancy in 34 MwCF has not resulted in higher-than-expected miscarriage rates or congenital anomalies. Providers should consider the risk to the health of MwCF combined with the lack of teratogenicity in animal reproductive models and limited safety data in the human fetus before discontinuing CFTR modulators before ART or natural partner conception. Survey collection is ongoing;results will be updated for presentationCopyright © 2022, European Cystic Fibrosis Society. All rights reserved
ABSTRACT
Background: As a quality service improvement response since elexacaftor/ tezacaftor/ivacaftor (ELX/TEZ/IVA) became available and the yearly average number of cystic fibrosis (CF) pregnancies (n = 7 pre-2020, n = 33 in 2021) increased significantly at an adult CF center (~600 people with CF), a monthly multidisciplinary CF-maternal health virtual clinic was established with antenatal virtual CF exercise classes dedicated to providing adaptive, specialist support to this cohort, aswell as outreach guidance and education to local obstetric teams. Method(s): This was a single-center retrospective reviewof Royal Brompton Hospital CF-Maternal Health multidisciplinary team clinic records and a patient survey from March 2020 to March 2022. Result(s): Of 47 pregnancies in 41 women (median age 30;) eligible for ELX/ TEZ/IVA at start of pregnancy, 40% (n = 19) were unplanned, and 19% (n = 9) used assisted conception. Three women with a history of infertility conceived naturally, having required assisted conception for previous pregnancies, and five women had multiple pregnancies during the study period. ELX/TEZ/IVA was continued in 60% (n = 28), delayed in 28% (n = 13), and stopped in 13% (n = 6) of pregnancies through maternal choice and careful clinical counselling. Pre-pregnancy pulmonary status was poorer in women who continued than in those who delayed or stopped (Table 1). Of those who stopped, 85% (n = 5) restarted because of pulmonary deterioration by the third trimester. Prenatal CF complications included at least one episode of minor hemoptysis in 21% (n = 9/41) of women, at least one infective exacerbation in 55% of pregnancies (n = 26/47), and noninvasive ventilation in one woman. Other pregnancy-associated complications included one case of ovarian hyperstimulation syndrome, one case of sub-segmental pulmonary embolism, and two cases of pregnancy-induced hypertension. Excluding 10 first trimester terminations, 10 current pregnancies, and one patient relocation, obstetric outcomes available for 26 pregnancies confirmed a live birth rate of 85% (n = 22/26) and a 15% first-trimester miscarriage rate (n = 4). Obstetric complications included preterm delivery rate of 23% (n = 6/26), including two cases of COVID infection resulting in two neonatal intensive care unit admissions, one case of endometritis after cesarean section, and a fourthdegree perineal tear. There were no ectopic pregnancies, maternal or neonatal deaths, or reports of infant cataracts or congenital malformations. Median gestational age was 37/40 weeks (range 29-40). Mode of delivery was via cesarean section in 45% (n = 10/22, of which twowere emergency) and vaginal in 55% (n = 12/22), of which 83% (n = 10/12) were via induction of labor for diabetes (CF or gestational) indication. Deliveries were supported and occurred equally at local obstetric units and in tertiarycare obstetric hospital settings (50%, n = 11/22). Patient-experience survey responses cited high levels of confidence in health optimization and prioritization during pregnancy and praised excellent inter-health care provider communication and peer-to-peer emotional support provided among expectant mothers in the virtual prenatal exercise groups. Table 1. Baseline demographic and clinical characteristics of elexacaftor/tezacaftor/ivacaftoreligible expectant mothers according to therapeutic decision (Table Presented) Conclusion(s): In the absence of clinical trial safety data, the novel approach of a dedicated CF-maternal health multidisciplinary team clinic with local obstetric outreach support has ensured regular specialist clinical and emotional peer-to-peer support for this cohort of women eligible for ELX/ TEZ/IVA to ensure optimal outcomes and experiences of their pregnancies, where appropriate, close to home.Copyright © 2022, European Cystic Fibrosis Society. All rights reserved
ABSTRACT
Plasmid-mediated quinolone resistance (PMQR) genes confer low resistance to Fluoroquinolones (FQs). This study aims to detect five PMQR genes among FQs-resistant Klebsiella pneumoniae isolated from various clinical specimens. Out of 120 K. pneumoniae isolates, 68 FQs-resistance K. pneumoniae were included in a molecular study. Standard microbiological tests were used for identification and antimicrobial susceptibility. For the detection of PMQR genes, conventional polymerase chain reaction was used. A molecular study revealed that (73.5%) of samples harbored PMQR genes, and among them, 58% were co-carriages of PMQR gene variants. Aac (6')-Ib-cr gene was predominant (47.1%) among samples, and qepA had the lowest percentage (11.8%), qnr genes were (32.4%) (29.4%) (20.6%) qnrS, qnrB, and qnrA respectively. Overall, high percentages of PMQR genes were detected, and almost all of samples were phenotypically resistant to ciprofloxacin. As well, there was a significant statistical relationship between phenotypically ESBL-producers and qnrB and qepA genes.Copyright © Abdulkareem MM et al. This is an open access article distributed under the terms of the Creative Commons Attribution License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
ABSTRACT
A nasal monoclonal antibody Investigations following a pilot trial of foralumab, the nasal monoclonal antibody a monoclonal antibody develop for inflammatory conditions and now repurposed for COVID-19, revealed decreased inflammatory markers and the same gene expression modulation seen in patients with multiple sclerosis. A subsequent gene expression analysis found changes in gene expression patterns (including NKG7, TGF beB1 and GIMAP7) involved with the anti-inflammatory effects of the drug, not only in COVID-19 patients, but also in a patient with multiple sclerosis, meaning the drug may be used for several diseases. For more on COVID-19 drug resistance see Sci Adv 2023;published online March 29. https://www.science.org/doi/10.1126/sciadv.ade8778 For more on the new target for COVID-19 drugs see eLife 2023;published online March 21. https://doi.org/10.7554/eLife.83710 For more on the nasal monoclonal antibody see Proc Natl Acad Sci USA 2023;published online March 7. https://doi.org/10.1073/pnas.2220272120 For more on antibodies for yellow fever see Sci Transl Med 2023;published online March 29. https://doi.org/10.1126/scitranslmed.ade5795 For more on a new drug for mpox see J Med Virol 2023;published online March 10. https://doi.org/10.1002/jmv.28652 For more on the transmission of bacterial vaginosis see Cell Rep Med 2023;published online March 21. https://doi.org/10.1016/j.xcrm.2023.100981 For more on endolysin see J Invest Dermatol 2023;published online March 6. https://doi.org/10.1016/j.jid.2023.01.039
ABSTRACT
Background Vaginal bleeding is a common complication that may occur at any time during pregnancy. Up to 22% of women asked at delivery reported that vaginal bleeding occurred at some time during pregnancy. Preterm delivery is the delivery before 37 weeks of gestation, which involves approximately 12% of all pregnancies. If vaginal bleeding happens during pregnancy, some adverse outcomes including mortality before and after birth, low birth weight and preterm delivery will be increased. Vaginal bleeding is associated with two-fold increased risk of preterm delivery. Methods This prospective cohort study included 60 cases of pregnant female with first or second trimester vaginal bleeding at Obstetrics& Gynecology Department, Faculty of Medicine, of Damanhur Medical National Institute. The duration of the study was from April 2021 to April 2022. In the study 4 cases refused to complete the study and other 56 completed. Results There was significant decrease in birth weight and Apgar score with increase severity of vaginal bleeding. There was significant increase in neonatal intensive care unit (NICU) admission, intrauterine growth restriction (IUGR) occurrence and preterm labor with increase severity of vaginal bleeding. There was significant positive correlation between vaginal bleeding and IUGR and NICU admission. There was significant negative correlation between vaginal bleeding and Birth weight and APGAR score. Conclusion It seems that previous COVID-19 infection does not affect greatly pregnancy outcomes associated with vaginal bleeding. Vaginal bleeding was the main parameter affecting pregnancy outcomes.Copyright © 2022 Authors. All rights reserved.
ABSTRACT
Introduction: Prepubertal vaginal bleeding outside the neonatal period is always abnormal and is very alarming to both parents and physicians. The variable etiologies of vulvovaginitis are the most common causes of vaginal bleeding during the prepubertal period. We report a series of three cases observed during covid" period of 2020-2022. Case report: two patients 8 and 9 year -old girls, were refered to pediatric secondary center due to of external vaginal bleeding. Hormonal levels were pre-pubertal and bone age was not advanced. Both girls were hospitalized and sellar X-ray and pelvic MRI were done during further course, not revealing the etiology of bleeding. Six months after the first bleeding, they were reffered to a pediatric gynecologist where foreign bodies (grass seed) were found during vaginoscopy. Third patient, a 3-year- old girl, was examined by her pediatrician because of heavy bleeding. Hormonal analysis and bone age were not suggestive of precocious puberty. Additional analyses revealed elevated alpha fetoprotein level (>5000 IJ,), which led to the diagnosis of yolk sac tumor in vagina wall, which was then confirmed by vagionoscopy and biopsy. It is important to perform vaginoscopy in premenarchal girls with repeated vaginal bleeding because in patients older than five years, a common reason for vaginal bleeding is foreign body but in younger patients, the primary goal is to exclude a malignant tumor.Copyright © 2023
ABSTRACT
Background: With a prevalence of 1-3 cases per million, acquired haemophilia A (AHA) is a rare autoimmune bleeding disorder caused by the presence of neutralizing antibodies against factor VIII. Even though diagnosis of this bleeding disorder is rarely established among children and adolescents, AHA may lead to severe, life-threatening hemorrhage in this age group, and therefore it requires special caution. Case report: 19 year old primigravida with confirmed SARS-CoV-2 infection was admitted to hospital due to prolonged vaginal bleeding six weeks postpartum. All gynaecological causes of uterine bleeding were excluded, Foley catheter was placed, but the bleeding still persisted. Coagulation tests revealed isolated deranged aPTT values. Further haematology evaluation demonstrated factor VIII deficiency, presence of factor VIII inhibiting factors, and the diagnosis of AHA was proposed. The anti-inhibitor coagulant complex drug was introduced and patient has responded positively to the treatment. Conclusion(s): Due to disturbance of immune system, pregnancy and postpartum period represent predilection time for AHA development. Furthermore, viral infection in pregnancy, such as COVID-19, might be considered as an additional risk factor for AHA development and several reported cases of AHA after COVID-19 infection support this hypothesis. Even though AHA is a rare disease, due to its high mortality rate of more than 20%, it should be considered in all cases of unusual bleeding of unknown cause in all age groups. Publication of this case report is approved by Institutional Review Board.Copyright © 2023
ABSTRACT
Acquired hemophilia (AH) is a potentially life-threatening hemorrhagic disorder. We report the second confirmed case of COVID-19-associated AH in a 45-year-old female which, unfortunately, expired as her treatment failed. She presented to the emergency department with abnormal bleeding and spontaneous hemoptysis about ten days after a removal surgery of her epiglottis tumor. Aggregation tests, such as partial thromboplastin time (PTT), are recommended in patients with COVID-19 infection that have bleeding episodes.Copyright © 2022 The Author(s);Published by Society of Diabetic Nephropathy Prevention.
ABSTRACT
At the 2022 Conference on Retroviruses and Opportunistic Infections, several speakers discussed disparities in HIV and COVID-19 infections and outcomes. Although the lifetime risk of HIV infection in the United States is higher overall in males than females, Black females have higher risk than White males. In 12 countries in sub-Saharan Africa, women aged 15 to 34 years accounted for more than half of all infections. Because knowledge of HIV serostatus is important for treatment and for prevention, several novel strategies were evaluated in the distribution of HIV self-test kits to undertested populations in the United States and sub-Saharan Africa. Data were presented on new products in the pre-exposure prophylaxis (PrEP) pipeline, including long-acting injectable cabotegravir, islatravir, vaginal rings, and in-situ forming implants. Challenges remain in the roll-out of oral PrEP, and a number of innovative strategies to address barriers were discussed. Models suggest that the greatest impact of novel PrEP agents would be to increase the pool of persons using PrEP, rather than through improved efficacy. COVID-19 caused substantial declines in HIV and sexually transmitted infection prevention and treatment services, which have started to rebound, but are not yet at prepandemic levels in several settings.Copyright © 2022, IAS-USA. All rights reserved.
ABSTRACT
The human body is inhabited by trillions of diverse microorganisms collectively called "microbiome" or "microbiota". Microbiota consists of bacteria, viruses, fungi, protozoa, and archaea. Microbiome demonstrates multi-faceted effects on human physical and mental health. Per evidence there is a multi-functional interplay between the whole-body microbiome composition on the epithelial surfaces including skin, nasal and oral cavities, airway, gastro-intestinal and urogenital tracts on one hand and on the other hand, the individual health status. Microbiota composition as well as an option to modulate it - together create a highly attractive operation area for the translational bio/medical research with multi-professional expertise and healthcare-relevant output in the framework of predictive, preventive and personalised medicine (PPPM/3 PM). Advanced PPPM strategies implemented in the microbiome area are expected to significantly improve individual outcomes and overall cost-efficacy of healthcare. According to the accumulated research data, corresponding diagnostic and treatment approaches are applicable to primary care (health risk assessment in individuals with sub-optimal health conditions and prevention of a disease development), secondary care (personalised treatment of clinically manifested disorders preventing a disease progression) and tertiary care (making palliation to an optimal management of non-curable diseases). In the current book, we do highlight the implementation potential of the microbiome-relevant research in the framework of predictive diagnostics, targeted prevention and treatments tailored to the individualised patient profile.Copyright © 2023, The Author(s), under exclusive license to Springer Nature Switzerland AG.
ABSTRACT
Background: The present study aims to understand the perceptions, apprehensions, and fears of peripartum COVID-positive women in low-resource settings. Study design: Cross-sectional observational study. Methodology: All COVID-positive postpartum women who delivered in the institution (vaginal delivery and cesarean section) were included in the study. Exclusion criteria included ICU admission and known mental illness. Results: A total of 61 COVID-positive women delivered in the facility during the study period. About 33 out of 61 women were nulliparous, while 28 were multigravida. Two babies tested positive for COVID-19 within 24 hours of birth. Majority of the patients were anxious prior to coming to hospital (51/61, i.e., 83.6%). The most common perceived fear reported by patients was fear of not receiving support from partner and provider (80%). Due to restrictions imposed on birth companion, 80% (49/61) women feared loneliness during labor. Apprehension of not receiving respectful maternity care was experienced by 75.4% (46/61) of women. Only 16 (26.2%) patients feared progression of disease, and 32 women (52%) were afraid of infection being transmitted to baby. However, 85% of the women reported a positive birthing experience. Good support from the family was observed in 76% of women. Despite regular visits by the doctors, eight patients (13%) felt a lack of connect due to the prevailing situation. Inability to celebrate joyful moments with family, neonatal separation, and delay in discharge were the major causes of discontent among the postpartum women. Conclusion: The study shows that the excitement and joy of pregnancy and delivery in pre-COVID times has been replaced by fear, anxiety, and uncertainty in this COVID era. Strategies, like good communication and provision of adequate support, may be particularly useful to help these women have a positive birthing experience.
ABSTRACT
An article in this issue of American Family Physician describes the importance of spirometry in making an accurate diagnosis of obstructive lung disease and in distinguishing between asthma and chronic obstructive pulmonary disease.1 An analysis of the Multi-Ethnic Study of Atherosclerosis (MESA) Lung Study—a prospective cohort study of more than 3,000 participants—found that the use of race corrections in spirometry interpretation did not help to predict chronic lower respiratory disease events any more accurately than the use of race-neutral calculations.2 This analysis demonstrated how a 65-year-old man with a specific height, forced expiratory volume in one second (FEV1), and forced vital capacity (FVC) would receive a percentage-predicted FEV1 result of 70% (i.e., moderate lung disease) using a White race correction as opposed to a result of 82% (i.e., normal lung function) using a Black race correction because of assumptions that Black patients have a smaller lung capacity.2 Thus, a Black patient could receive a false-negative interpretation of results and be deprived of symptomatic treatment or more targeted counseling for underlying asthma or chronic obstructive pulmonary disease. Others have raised concerns about the use of race-based spirometry in assessing recovery following COVID-19 infection, which could result in missing the diagnosis of restrictive ventilatory dysfunction.3
ABSTRACT
Purpose: Exacerbated by the COVID-19 pandemic, adolescents from structurally marginalized communities face barriers to accessing sexual and reproductive health (SRH) care. Mobile health units (MHUs) may be effective in reaching these adolescents but few studies have assessed their feasibility in this population. Methods: We assessed the feasibility of an MHU to provide SRH care to adolescents in community settings. Adolescents were invited to community demonstrations of hypothetical MHU care ("Demonstration events”). Adolescents completed surveys (demographics, likelihood of future MHU-based care, and access to health care) and staff documented field notes. We then partnered with adolescents, health care providers, and community leaders to create adolescent-centered SRH care for MHU delivery ("Clinical events”). Free and confidential services provided on the MHU included contraceptive care, condoms, testing for pregnancy, Neisseria gonorrhea (GC), Chlamydia trachomatis (CT), Syphilis, and Human Immunodeficiency virus (HIV). Initially, we provided electronic prescriptions for contraception during MHU visits. We later designed a system to dispense contraception [I.e., emergency contraception (EC) for future use, combined hormonal oral contraceptives (CHOCs), patches and Medroxyprogesterone] in the MHU. After MHU care, adolescents completed surveys to report satisfaction while staff documented feedback through field notes. Results: At 8 community "Demonstration events”, 98 teens (mean age 15.8 years, 67% female at birth, 17% Genderfluid/Non-Binary/Trans, 49% heterosexual, 24% Hispanic, 49% Black, 40% White) were enrolled. Most (70%) reported no previous vaginal/penile sex. Many (46%) had forgone needed health care in the previous year. Most (77%) said they were very/somewhat likely to get care on the MHU if available in the future and 82% would recommend it to friends. Most thought the MHU would be a great way to increase access to SRH care because it eliminated transportation obstacles and appointment delays. Many felt the MHU would provide adequate privacy and advised bringing the MHU to school or community events. Teens recommended collecting urine specimens in nearby restrooms and using a brown bag to transport them to the MHU. Utilizing their feedback, we partnered with teen-serving community organizations and schools to host the MHU. At two "Clinical events”, we provided care for five patients (4 biologic females, 1 biologic male). Accepted health services included condom provision (n=5) and, pregnancy (n=3), GC/CT (n=4), and Syphilis/HIV (n=2) testing. Two MHU patients received contraceptive prescriptions, one received contraception onsite (EC and CHOCs), and one with a positive CT test was contacted and treated. Four adolescents completed a post-care survey. All (100%) were very satisfied with MHU care and said they would recommend it to a friend. All (100%) agreed/strongly agreed they learned something new about SRH and reported the information was helpful. Field notes revealed patients communicated appreciation for the care, felt comfortable on the MHU, and found school-based SRH care acceptable. We plan to host five additional MHU "Clinical events” (Fall 2022). Conclusions: As COVID-19 continues to negatively impact adolescent SRH care-seeking, our work offers key insights to customizing MHU-based SRH care to meet the unique needs of adolescents from structurally marginalized communities. Sources of Support: Institutional expansion of NIH-funded KL2 program (RB), 3R21HD098086-02S1 (MM), K23HD098299 (KM).
ABSTRACT
Objective: Non-puerperal uterine inversion is a rare occurrence. The common etiology for this condition is uterine sarcoma, endometrial carcinoma, and myoma. Case Presentation: This case is a 44-year-old woman with a protruding malodorous vaginal mass, abdominal pain, and urinary retention. Total hysterectomy with bilateral salpingectomy was per-formed. Conclusion: Diagnosis of uterine inversion might be difficult and requires a high index of suspicion. © 2023 Bentham Science Publishers.
ABSTRACT
Background: COVID-19 can infect anyone, but for some groups of people who have a higher risk of exposure to COVID-19, it can lead to death. Providing health services during a pandemic is a challenge for health workers. Midwives are one of the health workers who are at the forefront when serving pregnant and giving birth women during this pandemic so that midwives have a high risk of contracting the COVID-19 virus. Purpose: The purpose of the phenomenological study in this study was to identify and explore the experiences of midwives in providing delivery assistance to mothers with suspected and confirmed COVID-19 at Bhakti Dharma Husada Hospital, Surabaya. Method: This study uses a qualitative research design with a phenomenological approach, namely a study that describes or describes experiences or phenomena that occur or are experienced by someone who aims to understand a phenomenon in a natural social context by prioritizing a process of in-depth communication interaction between researchers and phenomenon under study. Results: From the results of research that has been conducted on midwives' experiences in providing delivery assistance to mothers with suspected and confirmed COVID-19, there are several things according to informants that need to be evaluated, namely PONEK service rooms, use of delivery chambers, transition rooms, less strategic service rooms and interprofessional communication. Conclusion: The conclusions obtained from qualitative research on "Midwives' Experience in Providing Birth Assistance to Mothers with suspected and confirmed COVID-19: Qualitative Phenomenological Studies" are midwives' perceptions, preparations in carrying out delivery assistance, delivery assistance by midwives, adaptation changes, support systems in services, expectations of midwives and evaluation of services. (English) [ FROM AUTHOR]
ABSTRACT
Objetivos: Relatar o caso clinico de um paciente com Purpura Trombocitopenica Trombotica (PTT) associado a COVID-19. Material e Metodos: trata-se de um trabalho retrospectivo com analise de prontuario. Relato do caso: Mulher, 44 anos, branca em acompanhamento no ambulatorio de Oncohematologia do Complexo Hospitalar de Sorocaba desde 2019, devido a um Linfoma Nao Hodgkin (LNH) MALT de parotida, tratado em 2020 com Radioterapia (RT) e em remissao completa desde entao. Deu entrada no servico em 03/2022 pela clinica cirurgica com historico de hematomas em abdome e membros inferiores associados a sangramento vaginal e gengival ha uma semana. Na origem, realizou exames laboratoriais que evidenciaram Hemoglobina (Hb) 7,6 g/dL plaquetas (PLT) de 83.000/mm3, reticulocitose, Desidrogenase Lactica de 821 U/L e Bilirrubina Indireta de 1,96 mg/dL. Foi realizado esfregaco de sangue periferico, que mostrou a presenca de numerosos esquizocitos e coombs direto negativo, evidenciando o diagnostico de PTT. O tratamento de escolha foi a plasmaferese, que foi interrompida apos oito sessoes devido a multiplas reacoes de anafilaxia, optando-se, entao, pela realizacao de pulsoterapia com metilprednisolona (1000 mg por 3 dias). Durante a internacao, a paciente relatou historico previo de COVID-19 duas semanas antes do quadro, sendo aventada a hipotese de PTT relacionada a COVID-19. Com o tratamento, apresentou melhora clinica e laboratorial com Hb 14 g/dL e PLT 223.000/mm3 e recebeu alta para acompanhamento ambulatorial em uso de Prednisona 60 mg/dia. Atualmente, esta em seguimento ambulatorial com esquema de desmame de prednisona e sem queixas. Discussao: A PTT e uma microangiopatia trombotica caracterizada pela formacao de trombos que ocluem, difusamente, a microcirculacao arterial. Os pacientes frequentemente apresentam anemia hemolitica microangiopatica, trombocitopenia, insuficiencia renal e isquemia tecidual. Infeccoes agudas sao gatilhos para o desenvolvimento de PTT, principalmente infeccoes que alterem a hemostasia como no caso da COVID-19. O papel da atividade da protease ADAMTS13 na PTT ja e bem conhecido, uma vez que a reducao da sua atividade causa a formacao dos trombos pela associacao do fator de Von Willebrand com as plaquetas. Entretanto, sua relacao com a COVID-19 ainda nao e bem estabelecida. Acredita-se que a reacao imunologica desregulada contra o SARS-COV-2, com a liberacao de citocinas inflamatorias, acarreta no surgimento de Anti-ADAMTS13. Alem disso, e sabido que o tropismo do SARS-COV-2 pela Enzima Conversora de Angiotensina 2 afeta, diretamente, fatores vasoconstritores e teciduais, levando a uma disfuncao endotelial e, consequentemente, Eventos Tomboembolicos (TE). Somado a esses fatores, a liberacao exacerbada de citocinas inflamatorias, por si so, ja tem a capacidade de inducao de um estado pro-trombotico. Desta forma, o tratamento com utilizacao de plasmaferese e a primeira escolha na PTT e o uso de corticosteroides reduz os anticorpos anti-ADAMTS13. Conclusao: A PTT e uma doenca de instalacao abrupta que demanda um diagnostico assertivo para inicio precoce do tratamento. Pode apresentar gatilhos virais como o SARS-COV-2, devido ao estado pro inflamatorio e trombotico induzido pelo virus, alem da interacao entre o sistema imunologico e a protease ADAMTS13. Porem, sua relacao ainda nao esta totalmente elucidada. Copyright © 2022
ABSTRACT
Background: The SARS-CoV-2 pandemic has resulted in the implementation of recommendations to reduce interpersonal contact. From March 2020, rules were applied also in Italian Obstetrics units. Recent data report reduced rates of nosocomial and surgical site infections during the pandemic period. We wonder whether measures for containment of SARS-CoV-2 transmission would affect Group B streptococcus (GBS) maternal recto-vaginal colonization rates, usually screened at 36-37 weeks' gestation. The primary endpoint of this study was to evaluate the rate of maternal GBS colonization at antenatal screening. Method(s): This is a retrospective observational study (carried out in district of Modena), comparing maternal GBS colonization rates in the pre-COVID-19 (2018-2019) and during the pandemic period (2020-2021). Rates of rectovaginal colonization were retrieved from the laboratory database. The total number of deliveries was collected. Data were analyzed by using the Chi-Squared test, also evaluating the adherence to the GBS screening. A p-value < 0.05 was considered significant. Result(s): A total of 10968 and 10802 deliveries occurred in the pre-COVID-19 and the Pandemic period respectively (overall reduction in deliveries of 1.5%). The adherence to the antenatal GBS screening declined from 96.6% (pre-COVID-19 era) to 91.6% (pandemic era, p<0.001). Notably, the proportion of positive GBS screening remained stable (18.3% in 2018-2019 and 18.2% in 2020-2021, p=0.80). Conclusion(s): During the SARS-CoV-2 pandemic, we reported a reduced adherence to antenatal GBS screening. SARS-CoV-2 containment measures adopted by both the population and hospital professionals did not affect GBS colonization rates.
ABSTRACT
SESSION TITLE: Autoimmune Diseases Gone Wild: Rare Cases of Pulmonary Manifestations SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Post-Covid-19 Multisystem Inflammatory Syndrome (MIS) is a severe hyperinflammatory syndrome associated with either the acute or recovery phase of covid-19 infection affecting multiple organ systems requiring hospitalization. This syndrome has been described in both children (MIS-C) and adults (MIS-A). Several case reports and systematic reviews have reported an association between post-covid-19 MIS-A and several autoimmune diseases. CASE PRESENTATION: We herein report a case of a 27-year-old female with no known chronic medical condition and a non-contributory family history who was diagnosed with post-covid-19 multisystem inflammatory syndrome in adults (MIS-A). She presented with generalized partial thickness erythematous skin ulcerations with tender blistering and painful erosion of her mucus membranes (oral and vaginal mucosa). This was diagnosed as Steven Johnsons syndrome. She was pulsed with intravenous methylprednisone. During this therapy, she progressed to severe acute respiratory distress syndrome (ARDS) requiring mechanical ventilation (fig 1). Bronchoscopy revealed mild pulmonary hemorrhage fig 2a&b). Serological testing heralded a new onset systemic lupus erythematosus in light of positive antinuclear antibodies, anti Ds DNA and anti Smith antibodies. Her course was complicated by significant proteinuria and an active renal cast suggestive of lupus nephritis. This necessitated further treatment for active lupus. She was successfully extubated and discharged home. DISCUSSION: We arrived at the diagnosis of post-covid-19 multisystem inflammatory syndrome in adults (MIS-A) in light of her presenting with fever, hypotension, persistent sinus tachycardia and new onset atrial fibrillation), acute pancreatitis, acute kidney injury, elevation in transaminases, new onset skin rash, elevated inflammatory markers and a recent history of positive SARS-CoV-2 infection. Covid-19 has been reported to induce wide spread vasculitis resulting in MIS-A or MIS-C by triggering type 3 hypersensitivity (1). Also, multiple case reports and systemic reviews have reported a direct association between MIS-A and several autoimmune diseases including SLE, SJS (2). The patient recovered with high dose corticosteroid and supportive therapy indicating her severe ARDS was most likely due associated to SJS, SLE and MIS-A. Clinicians should also keep in mind that SARS-CoV-2 PCR swab may be negative at the time patient presents with symptoms of MIS-A as the infection might have occurred about 4-5weeks prior just as in our patient(3) CONCLUSIONS: We cannot underscore enough the importance of clinicians having a high index of suspicion for this syndrome in patients with acute or recent covid-19 infection, with or without a positive PCR covid-19 test. Early involvement of a multidisciplinary approach and appropriate management is essential to mitigate morbidity and mortality in these patients. Reference #1: Roncati L, Ligabue G, Fabbiani L, Malagoli C, Gallo G, Lusenti B, et al. Type 3 hypersensitivity in COVID-19 vasculitis. Clin Immunol Orlando Fla. 2020 Aug;217:108487. Reference #2: Gracia-Ramos AE, Martin-Nares E, Hernández-Molina G. New Onset of Autoimmune Diseases Following COVID-19 Diagnosis. Cells [Internet]. 2021 Dec 20 [cited 2022 Mar 22];10(12):3592. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8700122/ Reference #3: Morris SB. Case Series of Multisystem Inflammatory Syndrome in Adults Associated with SARS-CoV-2 Infection — United Kingdom and United States, March–August 2020. MMWR Morb Mortal Wkly Rep [Internet]. 2020 [cited 2022 Mar 22];69. Available from: https://www.cdc.gov/mmwr/volumes/69/wr/mm6940e1.htm DISCLOSURES: No relevant relationships by Isaac Ikwu No relevant relationships by Anthony Lyonga Ngonge No relevant relationships by Alem Mehari No relevant relationships by Noordeep Panesar no disclosure on file for Vis al Poddar;No relevant relationships by Emnet Yibeltal
ABSTRACT
SESSION TITLE: Critical Systemic Disease Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Granulomatosis with polyangiitis(GPA) is an autoimmune small vessel vasculitis that is included in the group of anti-neutrophilic cytoplasmic antibody(ANCA)- associated small vessel vasculitides (AAVs). GPA is a systemic disease, however acronym ELK is used to describe the most common involvement of Ear, nose, throat, Lungs, and Kidneys. We report a case of GPA, highlighting its presentation. CASE PRESENTATION: 59-year old female presented with vaginal bleeding, malaise, blurry vision, non productive cough and shortness of breath few days after receiving COVID-19 vaccine. Physical exam was remarkable for bilateral conjunctival injection with right sided ptosis and inguinal lymphadenopathy. Laboratory findings were significant for acute kidney injury and anemia. Computed tomography (CT) of chest revealed bilateral bronchovascular nodules and masses with interlobular septal thickening and enlarged mediastinal lymph nodes. Fine needle aspiration of left inguinal lymph node was negative for malignancy. Bronchoscopy with bronchial brush revealed alveolar hemorrhage with capillaritis;bronchoalveolar lavage(BAL) showed hemosiderin laden macrophages. Tissue biopsy was negative for malignancy. Testing for pulmonary renal syndrome was positive for C-ANCA and proteinase-3 (PR-3) antibodies. Anti-GBM antibody and anti-MPO antibody was negative. Plasmapheresis (PLEX) and pulse dose steroids were initiated however the patient was unable to tolerate the treatment. Her clinical condition continued to decline requiring multiple pressors, broad spectrum antibiotics and continuous renal replacement therapy. She was transitioned to comfort care per family's wishes and passed away. DISCUSSION: GPA is a rare necrotizing granulomatous vasculitis of small to medium sized vessels that can affect any organ but mainly involves the upper and lower respiratory tract. Necrotizing glomerulonephritis is common. Pulmonary involvement can include consolidation, tracheal or subglottic stenosis, diffuse alveolar hemorrhage, pleural effusion and interstitial lung disease. Lymphadenopathy, as seen in our patient is a rare presentation. Tissue biopsy is crucial for the diagnosis. Association with PR-3 ANCA is seen in more than 80% of GPA patients. Cases of AAVs after administration of COVID vaccine have been reported in the literature, although it is difficult to demonstrate causal relationship. Treatment of GPA with immunosuppression, usually corticosteroids, rituximab or cyclophosphamide, is recommended. The role of PLEX continues to evolve with emerging data, but use of this therapy is reasonable for patients with severe kidney injury and DAH secondary to active vasculitis refractory to immunosuppressive therapy. CONCLUSIONS: Early diagnosis of GPA is challenging as it can mimic metastatic lung malignancy. It should be considered in a broad range of differentials when evaluating patients presenting with pulmonary nodules. Reference #1: Greco A, Marinelli C, Fusconi M, Macri GF, Gallo A, De Virgilio A, Zambetti G, de Vincentiis M. Clinic manifestations in granulomatosis with polyangiitis. Int J Immunopathol Pharmacol. 2016 Jun;29(2):151-9. doi: 10.1177/0394632015617063. Epub 2015 Dec 18. PMID: 26684637;PMCID: PMC5806708. Reference #2: Kitching, A. R., Anders, H. J., Basu, N., Brouwer, E., Gordon, J., Jayne, D. R., Kullman, J., Lyons, P. A., Merkel, P. A., Savage, C., Specks, U., & Kain, R. (2020). ANCA-associated vasculitis. Nature reviews. Disease primers, 6(1), 71. https://doi.org/10.1038/s41572-020-0204-y Reference #3: Szymanowska-Narloch, A., Gawryluk, D., Błasińska-Przerwa, K., & Siemińska, A. (2019). Atypical manifestations of granulomatosis with polyangiitis: the diagnostic challenge for pulmonologists. Advances in respiratory medicine, 87(6), 244–253. https://doi.org/10.5603/ARM.2019.0062 DISCLOSURES: No relevant relationships by Sean Davidson No relevant relationships by Eric Flenaugh No relevant relationships by Marilyn Foreman No relevant relationships by KOMAL KAUR No relevant relationships by Gabriela Oprea-Ilies
ABSTRACT
SESSION TITLE: COVID-19 Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Fusobacterium (FB) are anaerobic, Gram-negative bacilli found in the normal flora of the oral, gastrointestinal, vaginal and upper respiratory tract mucosa. It can cause soft tissue infections and rarely causes bacteremia, yet Fusobacterium bacteremia is associated with high rate of ICU admission, extended hospitalization and significant mortality. Pyogenic liver abscess is a rare indolent disease and is mostly secondary to bacterial infection. CASE PRESENTATION: A 39-year-old female with no comorbidities presented with nausea, vomiting, fatigue, diarrhea, fatigue, heavy menstrual bleed, and high-grade fever. Symptoms started four days before the presentation. She reported a positive COVID-test two weeks earlier and a new IUD placement five weeks before presentation. She is sexually active with one male partner and does not use a contact barrier. On presentation, she was hypotensive, tachycardic, ill-looking with rapid shallow breathing, and fever of 100.7. EKG showed sinus tachycardia, CXR showed no pulmonary disease. Blood tests were significant for leukocytosis, elevated serum lactic acid, and elevated D-dimer. CTA chest was remarkable for two 2x3 cm liver cysts. Patient was admitted to the MICU and started on IV fluids Boluses, Norepinephrine drip, Ceftriaxone and Azithromycin. Gynecology was consulted and recommended against removing the IUD as patient had no signs of IUD infection. Patient continued to be critically sick. Gynecology team was recontacted and removed the IUD and was uninfected on culture. Antibiotics were switched to Vancomycin and Piperacillin-Tazobactam. MRI liver with contrast confirmed the diagnosis liver abscess. Patient received bedside US-guided aspiration, it was remarkable for 16 cc of frank pus. Patient showed significant improvement after procedure and was transferred to the medical floor within 24 hours. Blood culture grew F. Necrophorum and antibiotics were switched to Clindamycin. DISCUSSION: FB is part of the vaginal flora. Mucosal disruption during IUD placement can precipitate disseminated infection with liver abscesses and/or sepsis. Absence of signs of GU tract infection or a non-infective IUD doesn't rule out FB sepsis. Patient Presented five weeks after IUD placement which fits the indolent nature of pyogenic liver abscess. Four cases of F. Nucleatum bacteremia were reported recently in Belgium in COVID patients. One of the cases was healthy young female. Our similar scenario raises a question about a potential association between COVID and risk of floral septicemia. Our patient has F. necrophorum. CONCLUSIONS: Patient presenting with sepsis and liver cyst should be evaluated for liver abscess as appropriate. Recent procedures and mucosal instrumentation can precipitate liver abscess and should be considered if the timing suggest an indolent course. Further studies are needed to evaluate a potential link between COVID infection and FB bacteremia. Reference #1: Goldberg EA, Venkat-Ramani T, Hewit M, Bonilla HF. Epidemiology and clinical outcomes of patients with Fusobacterium bacteraemia. Epidemiol Infect. 2013 Feb;141(2):325-9. doi: 10.1017/S0950268812000660. Epub 2012 Apr 17. PMID: 22717143. Reference #2: Garcia-Carretero R. Bacteraemia and multiple liver abscesses due to Fusobacterium nucleatum in a patient with oropharyngeal malignancy. BMJ Case Rep. 2019 Jan 29;12(1):e228237. doi: 10.1136/bcr-2018-228237. PMID: 30700472;PMCID: PMC6352811. Reference #3: Wolff L, Martiny D, Deyi VYM, Maillart E, Clevenbergh P, Dauby N. COVID-19-Associated Fusobacterium nucleatum Bacteremia, Belgium. Emerg Infect Dis. 2021 Mar;27(3):975-977. doi: 10.3201/eid2703.202284. Epub 2020 Dec 8. PMID: 33292922;PMCID: PMC7920680. DISCLOSURES: No relevant relationships by Zainab Abdulsada No relevant relationships by Ahmed Abomhya No relevant relationships by Richard Fremont