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1.
Antibiotics ; 11(4), 2022.
Article in English | EMBASE | ID: covidwho-1822410

ABSTRACT

The containment measures following COVID-19 pandemic drastically reduced airway infections, but they also limited the access of patients to healthcare services. We aimed to assess the antibiotic prescription patterns in the Italian paediatric primary care setting before and after the containment measures implementation. For this retrospective analysis, we used a population database, Pedianet, collecting data of patients aged 0–14 years enrolled with family paediatricians (FP) from March 2019 to March 2021. Antibiotic prescriptions were classified according to WHO AWaRe classification. An interrupted time series evaluating the impact of the containment measures implementation on the monthly antibiotic index, on the access to watch index, and on the amoxicillin to co-amoxiclav index stratified by diagnosis was performed. Overall, 121,304 antibiotic prescriptions were retrieved from 134 FP, for a total of 162,260 children. From March 2020, the antibiotic index dropped by more than 80% for respiratory infections. The Access to Watch trend did not change after the containment measures, reflecting the propensity to prescribe more broad-spectrum antibiotics for respiratory infections even during the pandemic. Similarly, co-amoxiclav was prescribed more often than amoxicillin alone for all the diagnoses, with a significant variation in the trend slope for upper respiratory tract infections prescriptions.

2.
Journal of Personalized Medicine ; 12(3), 2022.
Article in English | EMBASE | ID: covidwho-1818175

ABSTRACT

There is a lack of data on patient and diagnostic factors for prognostication of complete recovery in patients with peripheral facial palsy. Thus, the aim of this study was to evaluate the role of a telerehabilitave enhancement through the description of a case report with the use of short-wave diathermy and neuromuscular electrical stimulation combined to facial proprioceptive neuromuscular facilitation (PNF) rehabilitation in unrecovered facial palsy, in a COVID-19 pandemic scenario describing a paradigmatic telerehabilitation report. A 43-year-old woman underwent a facial rehabilitation plan consisting of a synergistic treatment with facial PNF rehabilitation, short-wave diathermy, and neuromuscular electrical stimulation (12 sessions lasting 45 min, three sessions/week for 4 weeks). Concerning the surface electromyography evaluation of frontal and orbicularis oris muscles, the calculated ratio between amplitude of the palsy side and normal side showed an improvement in terms of movement symmetry. At the end of the outpatient treatment, a daily telere-habilitation protocol with video and teleconsultation was provided, showing a further improvement in the functioning of a woman suffering from unresolved facial paralysis. Therefore, an adequate telerehabilitation follow-up seems to play a fundamental role in the management of patients with facial palsy.

3.
Infectious Diseases in Clinical Practice ; 30(2), 2022.
Article in English | EMBASE | ID: covidwho-1769446

ABSTRACT

Curvularia species are dematiaceous filamentous fungi that can cause a variety of infections in both immunocompetent and immunocompromised hosts. We present 2 cases of severely immunosuppressed patients with acute invasive fungal sinusitis due to Curvularia species. Both patients had a history of hematologic malignancy with refractory disease and prolonged neutropenia. They presented with facial and sinus pain, which prompted maxillofacial computed tomography that showed acute sinusitis. Subsequently, they underwent nasal endoscopy with a biopsy that revealed a definitive diagnosis of invasive fungal sinusitis. Dematiaceous fungi are responsible for most fungal sinusitis cases, with Curvularia being one of the most common species isolated. Generally, invasive fungal rhinosinusitis may follow a relatively innocuous and nonspecific course. In addition, fungal infections may complicate chronic allergic sinusitis. Computed tomography scan is the first imaging modality of choice, and magnetic resonance imaging has a role in prognostication in acute invasive fungal rhinosinusitis. Endoscopic sinus surgery with biopsy yields a definitive diagnosis and is therapeutic. Management typically includes a combination of surgery and antifungal agents. Severe neutropenia is a significant risk factor for infection and is associated with poor outcomes. Aggressive surgical debridement, combined with antifungal therapy, should be emphasized in leukemic patients despite their prolonged neutropenia and bleeding tendency.

4.
Open Forum Infectious Diseases ; 8(SUPPL 1):S139, 2021.
Article in English | EMBASE | ID: covidwho-1746748

ABSTRACT

Background. In early months of COVID-19 pandemic, SGH recorded a year-on-year increase in antibiotic (ABx) use for community acquired acute respiratory infection (CA ARI) from Feb-Apr 2019 (48.7 defined daily doses (DDD)/100 bed-days) to 2020 (50.8 DDD/100 bed-days). To address concerns of misuse, the antibiotic stewardship unit (ASU) expanded prospective audit feedback (PAF) to CA ARI patients admitted to ARI wards, with low procalcitonin (PCT). PAF was conducted on day 2-3 of ABx, on weekdays. Doctors received feedback to stop/ modify when ABx was deemed inappropriate. Here, we describe the impact of ASU's adaptive approach to curb rising ABx use in patients admitted for ARI during COVID-19 pandemic. Methods. A Pre- & Post-intervention study was conducted. All patients started on ABx (ceftriaxone/co-amoxiclav/piptazo/carbapenems/levofloxacin) for CA ARI & PCT < 0.5μg/L were analysed. Those who died ≤48h of admission;admitted to intensive care;required ABx escalation;>1 infective sites;complex lung infection were excluded. Primary objective was to compare the proportion of ABx stopped ≤4 days (time to final infection diagnosis) Pre (22/3-18/4/20) & Post (21/4-13/7/20). Results. 184 (Pre) & 528 (Post) ABx courses were analysed. ASU audited 51 (Pre) & 380 (Post) courses with the rest discontinued/discharged before review. Patients were largely similar in both periods;a third had low likelihood of bacterial infection (C reactive protein < 30mg/L). In Post, 73 feedback was given to stop ABx (often because symptoms suggested viral/fluid overload) & 18 to switch to oral ABx. 82 (90%) feedback was accepted. No ABx was restarted ≤48h or deaths ≤30 days due to ARI. 1 patient had C. difficile diarrhoea a day after ABx cessation as per ASU feedback. Proportion of all ABx stopped ≤4 days was higher in Post than Pre [27/184 (15%) vs 152/528 (29%), p< 0.01]. Median duration of therapy of IV ABx was reduced (6.5 vs 3 days, p< 0.01), with corresponding shorter median length of stay (10.5 vs 6 days, p< 0.01). Conclusion. PAF directly and indirectly reduced ABx duration in patients treated for CA ARI as prescribers become more conscious about stopping ABx when investigations show low likelihood of bacterial infection. ASU must remain agile during pandemics to detect emerging problems and adapt processes to counter early.

5.
Open Forum Infectious Diseases ; 8(SUPPL 1):S162-S163, 2021.
Article in English | EMBASE | ID: covidwho-1746742

ABSTRACT

Background. Ten percent of adult, outpatient visits result in an antibiotic prescription (Rx). At the start of our intervention, our VA healthcare system consisted of 13 community-based outpatient clinics (CBOCs), 9 of which did not have an onsite pharmacy but utilized automated dispensing cabinets (ADCs) for prepackaged outpatient Rxs. ADC antibiotic orders are generated from electronic medical record (EMR) order sets. The stewardship team shortened the durations of 5 antibiotics in the ADC order sets to make them consistent with current literature and guidelines. We assessed the impact of these changes on antibiotic prescribing habits. Methods. We compared outpatient antibiotic Rx data between 10/1/2018-9/30/2019 (pre-intervention) and 10/1/19-9/30/20 (post-intervention) from 8 CBOCs with ADCs (1 closed during the pandemic). Amoxicillin-clavulanate 875/125mg (AMC), cephalexin 500mg (CPH), levofloxacin 500mg and 750mg (LEV 500 and LEV 750), and sulfamethoxazole-trimethoprim 800/160mg (SXT) prescription durations were all reduced by 3 days. Process metrics included days supplied/1000 prescriptions (DS/1000 Rx), median DS, and ADC utilization rates. We used Mann-Whitney U and correlation statistical analyses to assess differences and associations. Results. The DS/1000 Rx of antibiotics with a default duration change decreased in the post-intervention phase for CBOCs with ADCs (AMC, -25.4%;CPH, -21.1%;LEV 500, -18.9%;LEV 750, -28.0%;SXT, -27.4%). The median DS for these antibiotics all reduced by 3 days in concordance with new ADC prescriptions defaults (AMC, 10 vs 7 days, P< 0.001;CPH, 10 vs 7 days, P< 0.001;LEV 500, 8 vs 5 days, P< 0.001;LEV 750, 8 vs 5 days, P< 0.001;SXT 10 vs 7 days, P< 0.001). Due to COVID-19, 7/8 ADC CBOCs closed for in-person visits from 3/20/20-5/4/20. ADC utilization was inversely proportional to DS/1000 Rx for most antibiotics (R: -0.51 to -0.77) except SXT. Conclusion. EMR-driven reductions in ADC default Rx durations led to a corresponding decrease in overall outpatient antibiotic prescribing. Higher DS/1000 Rx were often associated with lower ADC utilization. Informatics-driven antibiotic interventions may be potential outpatient stewardship tools to increase guideline-concordant prescribing across multisite healthcare systems.

6.
Open Forum Infectious Diseases ; 8(SUPPL 1):S655-S656, 2021.
Article in English | EMBASE | ID: covidwho-1746325

ABSTRACT

Background. The Joint Commission requires ambulatory healthcare systems to collect, analyze and report antimicrobial prescribing data. Duke University Health System (DUHS) piloted a dashboard to capture outpatient prescribing for pediatric patients with URI. Implementation in 2020 allowed for an assessment of antibiotic prescribing during the pandemic. Methods. We included patients 0 - < 19 years seen at DUHS for URI and pharyngitis from 1/1/2019 -2/21/2021. Patient characteristics included: age, sex, race, ethnicity, Pediatric Medical Complexity Algorithm (PMCA) score and insurance status (public versus private). Provider characteristics included: type (physician, NP, PA) and specialty (pediatrics, family medicine, internal medicine, other). We compared pre- and post-COVID ( March 1, 2020) prescribing and prescribing during telehealth versus in-person visits. A logistic regression model was used to identify factors independently associated with antibiotic prescribing. Results. 62,447 children were seen during the study period, 29% of whom received an antibiotic. Amoxicillin was the most commonly prescribed antibiotic (64.4%), followed by cefdinir (11%) amoxicillin-clavulanic acid (10%) and azithromycin (8%). Factors associated with antibiotic prescribing are shown in Table 1. White race, private insurance, visits with nurse practitioners and visits with non-pediatric providers were associated with high prescribing. Higher PMCA scores, indicating greater medical complexity, were associated with decreased likelihood of prescribing. Although the total number of outpatient visits plummeted during the COVID period, rates of prescribing only decreased mildly from 31% to 25% (Figure 1). Conclusion. Outpatient prescribing was associated with multiple patient and provider characteristics. Similar to other studies, white race, private insurance, and visits with non-physician, non-pediatric providers were associated with antibiotic prescription. Despite a large decrease in the number of outpatient visits during the pandemic, rates of prescribing for URI decreased minimally. A better understanding of factors associated with antibiotic prescribing during the pandemic may identify priority targets for outpatient stewardship as mitigation strategies are relaxed.

7.
Indian Journal of Medical Microbiology ; 39:S40-S41, 2021.
Article in English | EMBASE | ID: covidwho-1734455

ABSTRACT

Background:During the ongoing COVID19 pandemic period, any new cases of acute-onset respiratory illness are likely to be treated as suspected COVID-19 by default. Methods:A 42year-old lady was admitted with a 4-week history of fever and cough, followed by a 4-days history of increasing short- ness of breath. Fever was intermittent, high grade and was associated with chills and rigor. The patient had a history of uncontrolled type II diabetes mellitus and on admission HbA1C was 15.5%. On examination she had a temperature of 102° F, blood pressure (BP) of 101/67mm Hg, heart rate of 130 beats per minute, respiratory rate (RR) of 24 breaths per minute and O2 saturations of 92% in room air. On respiratory examination, there were crackles in the left infrascapular and infraaxillary area. The patient was admitted in the COVID suspect ward with an impression of moderate COVID-19 infection and nasopharyngeal swab was sent for SARS-CoV-2 on RT-PCR. The patient underwent a CECT scan of thorax, abdomen and pelvis that revealed consolidation in bilateral lung fields with a cavity in lingular lobe with presence of air-fluid level. Mediastinal and hilar lymphadenopathy were present. [Formula presented] Results: SARS-CoV-2 RT-PCR was negative. The patient’s sputum sample revealed pure growth of purple, flat, dry, wrinkled colonies on Ashdown agar after 48 hours which was identified as Burkholderia pseudomallei. The Isolate was susceptible to ceftazidime, mero- penem, co-trimoxazole, amox-clav and chloramphenicol. The patient was started on I.V Meropenem 500mg every 8hourly for 21 days and was discharged on co-trimoxazole tablet. Conclusions: The case definitions of COVID-19 such as fever, cough and shortness of breath can be associated with other infectious etiologies. The role of the microbiology laboratory is thus very crucial in COVID-19 from overshadowing other infec- tious diseases, particularly in endemic areas, hence preventing misdiagnosis and consequent adverse outcomes for patients.

8.
Journal of Investigative Medicine ; 70(2):726-727, 2022.
Article in English | EMBASE | ID: covidwho-1708849

ABSTRACT

Case Report Multisystem inflammatory syndrome in children (MIS-C) typically presents with fever and multisystem dysfunction following infection with SARS-CoV-2. Per CDC guidelines, MIS-C can be diagnosed when an individual less than 21 years of age presents with fever, laboratory evidence of inflammation, and multisystem organ involvement requiring hospitalization with no alternative diagnosis and evidence of current or prior COVID-19 infection. Systems are categorized as either cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic, or neurological. Otolaryngologic is not a designated system. However, atypical presentations of MIS-C involving the deep neck have been reported. Specifically, cases of children with retropharyngeal pathology, including edema and phlegmon, have been described. Our report highlights a case of deep neck infection as the initial presentation of MIS-C. A 12-year-old male was admitted to the pediatric hospital medicine service for medical management of a moderately large retropharyngeal phlegmon/ abscess confirmed by computed tomography (CT) scan. Otolaryngology team was consulted, and surgical intervention was not recommended. The patient was started on empiric intravenous (IV) antibiotic treatment with ceftriaxone and vancomycin. After two days of antibiotics, he showed minimal improvement. On physical exam, he continued to have neck pain, tenderness to palpation on the left neck inferior/posterior to the left ear, mild edema, and limited lateral range of motion due to pain. Repeat CT scan of his neck also showed minimal improvement of phlegmon. During admission, he developed bilateral non-exudative conjunctivitis, erythematous lips, mild erythema over his palms, abdominal pain, and cough, with a worsening fever curve while on broad spectrum antibiotics. At this time, differential diagnosis was broadened to include viral syndrome, MIS-C, and atypical Kawasaki Disease. Respiratory viral panel (including COVID-19) was negative. Inflammatory markers were elevated, including CRP of 26.6 mg/dL, ESR of 64 mm/hr, and Pro-BNP of 1,908 pg/mL. Ultimately, the patient met criteria for MIS-C: less than 21 years old, presence of fever, elevated inflammatory markers, multisystem involvement, and positive COVID-19 antibody. Treatment was initiated for moderate-severe MIS-C with IV immunoglobulin (IVIG) infusion, aspirin, IV methylprednisolone, and omeprazole prophylaxis. The patient clinically improved after IVIG infusion, and antibiotics were de-escalated to oral Augmentin for a total duration of 14 days of antibiotic therapy. He was discharged on aspirin, a prednisone wean, and omeprazole with Cardiology outpatient follow-up established. MIS-C is a novel syndrome that can have unique presentations. Clinicians should consider MIS-C when a febrile patient being treated for infection does not improve with standard therapies and have a low threshold to initiate MIS-C evaluation if new symptoms involving other organ systems develop.

9.
Journal of Investigative Medicine ; 70(2):599-600, 2022.
Article in English | EMBASE | ID: covidwho-1703210

ABSTRACT

Case Report We present a case of a 4-year-old male who presented to the ED for persistent fever associated with abdominal pain, diarrhea and new onset of left neck swelling. The patient was reported to have URI symptoms 3 weeks prior to his presentation along with intermittent fever that was not resolving. He was taken to urgent care for his persistent fever and neck swelling for which he was prescribed Augmentin that did not seem to improve the patient's condition despite adherence. Upon presentation to our ED 3 days later, the patient was found to be febrile to 39.5 C with tachycardia, vital signs were otherwise normal. On physical exam, mild abdominal distension was appreciated and multiple large lymph nodes were palpable in the left cervical chain. A CT of the neck with contrast revealed pharyngitis with left cervical chain reactive lymphadenopathy. He was admitted for management of cervical lymphadenitis via IV antibiotic therapy as well as to ensure adequate hydration. Despite IV antibiotics there was little improvement in his clinical status. Due to the patient's history of URI symptoms with fever that had reappeared within the previous few days, a COVID IgG was obtained to rule out multisystem inflammatory syndrome in children(MIS-C), which came back positive. SARS-CoV-2 by RT-PCR was negative. MIS-C labs were obtained that revealed anemia, elevated fibrinogen to 470 mg/dL , D-dimer 2.61 mcg/mL, CRP 7 mg/dL, ESR 53 mm/hr, BNP 200 pg/mL, absolute lymphocyte count of 730/mcL, PTT 40.6 seconds and troponin 0.104 ng/mL. Echocardiogram was unremarkable. Treatment was then modified to IVIG and steroids, as he met criteria for MIS-C. Upon initiation of IVIG, the patient's fever as well as lymphadenopathy started resolving and the patient continued to improve clinically. Discussion MIS-C is a rare complication of COVID-19 but it can be devastating. This case highlights the importance of considering MIS-C in patients who present with nonspecific symptoms with a suggestive history of previous COVID -19 infection. It is also important to recognize that isolated lymphadenitis could be a manifestation of MIS-C especially if it is not responding to appropriate antibiotic therapy. Conclusion It is important to have a high index of suspicion for MIS-C in a child who has a history of COVID-19 as timely treatment with IVIG and steroids can help decrease the deleterious effects especially on the heart.

10.
Journal of Investigative Medicine ; 70(2):557-558, 2022.
Article in French | EMBASE | ID: covidwho-1698858

ABSTRACT

Case Report Hemophagocytic Lymphohistiocytosis (HLH) is an hyperinflammatory state due to hyperactivation of macrophages and T-cells which rarely affects adults. It can be familial or sporadic. Triggers are infections, auto-immune diseases, malignancies, and immune checkpoint inhibitors. HLH diagnostic criteria are fever, splenomegaly, bicytopenia, hypertriglyceridemia, hemophagocytosis, low/absent NK-cellactivity, elevated ferritin, and high-soluble interleukin-2-receptor (IL-2R). Five out of eight criteria are required for diagnosis. A 54-year-old female was noted to have leukopenia during a routine visit with her family physician. Follow up labs revealed worsening leukopenia, anemia and a normal platelet count. She received Amoxicillin/Clavulanic acid for a presumed upper respiratory infection and developed nausea, diarrhea and decreased appetite. She was referred to Hematology Oncology for leukopenia. During workup she developed fatigue, night sweats and high fevers. Workup revealed WBC 2400 mcL, microcytic anemia, transaminitis with lactate dehydrogenase of 1725 U/L and ferritin of >15000 ng/ mL . Peripheral blood smear showed leukopenia without immature cells or blasts and mild microcytic erythrocytes. Further tests detected CXCL-9 of 125050 pg/mL, D-dimer of >5000 ng/mL and interleukin-2-receptor of 20604 pg/ mL. EBV, CMV, HSV, HHV-6, parvovirus, bartonella, leishmaniasis, bacteria and COVID-19 were negative. Computed tomography of the chest, abdomen and pelvis did not reveal lymphadenopathy. Brain imaging showed no abnormalities. Cerebrospinal fluid cytology was unremarkable. Bone marrow biopsy (BMBX) showed prominent histiocytic phagocytosis of erythroid precursors and platelets. HLH-94 treatment protocol including weekly steroid and etoposide initiated. Patient's fever, night sweats and leukopenia resolved during hospitalization, with subsequent down trending of ferritin to 103 ng/ml, CXCL-2 to 2663 pg/mL and interleukin-2-receptor to 2,265 pg/mL. Repeat BMBX revealed significant improvement. HLH is a rare life-threatening diagnosis. This patient with nonspecific symptoms was diagnosed with HLH (fever, bicytopenia, elevated ferritin, high-soluble IL-2R and hemophagocytic lymphohistiocytosis on BMBX). Several HLH gene mutations were tested including PRF1, UNC13D, STXBP2, although none was mutated. No infectious, rheumatologic or oncologic triggers were detected. Early diagnosis and treatment are critical. Without treatment, survival is measured in months due to multiorgan failure. This syndrome rarely presents in the absence of triggers which may cause delay in diagnosis and successful treatment. 5-year overall survival with HLH 94 protocol is 54% as opposed to 0% prior to the advent of this protocol. Etoposide and steroids are the mainstay of HLH-94. Cyclosporine can be added in the maintenance phase and hematopoietic stem cell transplant is reserved for familial or relapsed HLH.

11.
Journal of Medicine (Bangladesh) ; 22(2):139-145, 2021.
Article in English | EMBASE | ID: covidwho-1666968

ABSTRACT

Bangladesh is an example of a highly populous, agricultural country where melioidosis may be a significantly under diagnosed cause of infection and death. A recent regression model predicted 16,931 cases annually in Bangladesh with a mortality rate of 56%. However, we only manage to confirm (culture) around 80 cases in last 60 years. A lack of awareness among microbiologists and clinicians and a lack of diagnostic microbiology infrastructure are factors that are likely to lead to the underreporting of melioidosis. Melioidosis transmits through inoculation, inhalation and ingestion. Diabetes mellitus is the most common risk factor (12 times higher chance of getting the infection) predisposing individuals to melioidosis and is present in >50% of all patients. The clinical presentation is widely varied and can be mistaken for other diseases such as tuberculosis or more common forms of pneumonia giving rise to its nickname as the “great mimicker”. Disease manifestations vary from pneumonia or localized abscess to acute septicemias, or may present as a chronic infection. Culture is considered the current gold-standard for diagnosis and culture-confirmation should always be sought in patients where disease is suspected. It is strongly recommended that any non–Pseudomonas aeruginosa, oxidase-positive, Gram-negative bacillus isolated from any clinical specimen from a patient in an endemic area should be suspected to be Burkholderia pseudomallei (BP). In addition, based on antibiogram, any Gramnegative bacilli that are oxidase-positive, typically resistant to aminoglycosides (e.g., gentamicin), colistin, and polymyxin but sensitive to amoxicillin/clavulanic acid should be considered as BP. This bacteria is inherently resistant to penicillin, ampicillin, first generation and second-generation cephalosporins, gentamicin, tobramycin, streptomycin, and polymyxin. For intensive phase (10 to 14 days), ceftazidime or carbapenem is the drug of choice. For eradication phase (3 to 6 months), oral trimethoprim/ sulfamethoxazole is the drug of choice. Surgery (drainage of abscess) has an important role in the management of melioidosis. Preventive measures through protective gears could be useful particularly for the risk groups.

12.
Cogent Medicine ; 8, 2021.
Article in English | EMBASE | ID: covidwho-1617059

ABSTRACT

Background: Coronavirus disease 19 (COVID-19) tends to be milder in children, but severe cases have been reported. We described a case report of a toddler admitted to our department with additional findings, highlighting the importance of assessing the patient as a whole. Case Presentation: A previously healthy, 15-month-year-old girl presented with fever and dry cough for 10 days, respiratory distress and PCR SARS-CoV-2 was positive. At admission, she presented with hypoxemia (SpO2 89-90% in room air), global retraction and bilateral bronchospasm. She was treated with bronchodilators, methylprednisolone, remdesivir and also amoxicillin/clavulanic acid. Her complete blood count revealed leucocytosis 16,160x109/L, 41% lymphocytes, C-reactive protein 57,9 mg/L, procalcitonin 0,13 ng/mL, sedimentation rate 44 mm/h, ferritin 218,4 ng/mL. Chest computed tomography (CT) scan revealed bilateral peripheral areas of ground glass, coexisting consolidation areas at inferior lobes but also revealed a 6 cm supra-renal mass. Abdominal ultrasound and CT confirmed an heterogeneous right supra-renal gland mass of 5,5cm along the greatest diameter with diffuse calcifications, evolving the inferior vena cava and the renal vascular pedicle, no signs of liver, bone, cutaneous or ganglionic metastization. These features were suggestive of neuroblastoma in stage L2. Vanillylmandelic acid, normetanephrine/creatinine ratio and metanephrine/creatinine ratio were elevated. The metaiodobenzylguanidine (Mibg) scan showed a localized disease. The total excision of the tumour mass was performed, and the histology confirmed neuroblastoma with no N-myc oncogene amplification, nor other bad prognosis chromosomal abnormalities. She is currently under oncological surveillance, with no signs of recurrence. Learning Points Discussion: Neuroblastoma is the most common extracranial solid tumour of childhood. It is known for its broad spectrum of clinical behaviour and outcome. In this case, although this toddler was admitted due to COVID-19 pneumonia, it allowed to identify a localized tumour, perform excision and due to the favourable biology tumour, she has a very good chances of being cured and free of disease.

13.
Allergy: European Journal of Allergy and Clinical Immunology ; 76(SUPPL 110):515-516, 2021.
Article in English | EMBASE | ID: covidwho-1570425

ABSTRACT

Background: In our setting,it is common for patients to be “labelled” as allergic in the presence of doubtful clinical signs of intolerance or allergic reaction. Moreover,it is not uncommon that patients who have been ruled out allergy to beta-lactam antibiotics (BL-ATB) continue to be mislabelled allergologically in the electronic medical records.Unfortunately,this mistake means that they are sometimes deprived of the first therapeutic option. Objective: The main objective of the study was to assess the correct labelling of patients(p) from an allergological point of view in Primary Care,in the Emergency Department and in visits to other specialists. The secondary objectives were:to determine the percentage of patients who received BL-ATB, the reason for the prescription and the drugs used. Method: Prospective review of the medical records of 92 patients who have been ruled out allergy to BL-ATB in our department during the months of August 1st,2019, to March 31st,2020.All patients have been followed for at least 12 months.Data were collected by reviewing the electronic medical records. Results: Of the 92 patients, only 64%(54p) were well identified in primary care. Only 36%(33p) had attended the Emergency Department,of which 76%(25p) were correctly identified and the remaining 24%(8p) were not. 38%(35p) were visited by an specialist, in a total of 42 visits(v). In 74% of the visits (31v) the patients were correctly identified and in the remaining 26% they were not.Table 1 summarises the number of visits to each specialist and the correct or incorrect allergological identification. Only 17%(16p) received BL-ATB, on a total of 20 occasions.Urinary tract infections were the most frequent reason for prescribing BL-ATB (4p), followed by H.Pilory infection(3p),skin infections(3p),respiratory infections(3p),sepsis (2p),acute otitis media(1p),pharyngitis(1p),sinusit is(1p),oral infections(1p) and bone fractures(1p). Amoxicillin was the most commonly used drug(8p),followed by Amoxicillin/Clavulanic acid(5p),Cefuroxime(2p),Meropenem(2p),Cef triaxone (1p) and Piperacillin/Tazobactam(1p). Conclusion: Despite the efforts being made by Allergology services to correctly label patients with HS to BL, a high percentage remain misidentified. In relation to the consumption of BL-ATB, we believe that the data are underestimated,given that during the months of follow-up of the study (year 2020) the use of masks and hand washing recommended by the COVID-19 pandemic have reduced both infections and access to health care. (Table Presented).

14.
American Journal of Translational Research ; 13(11):12897-12904, 2021.
Article in English | EMBASE | ID: covidwho-1567773

ABSTRACT

Objective: To compare the differences between two groups of patients with confirmed and suspected CO-VID-19. Methods: We retrospectively collected and analyzed the data of confirmed and suspected patients, including demographic, epidemic, laboratory, clinical, radiologic, and treatment data, at the fever clinic and isolation ward of our hospital from December 1, 2019 to December 30, 2019. Results: The study included 73 patients with confirmed or suspected COVID-19. The median age was 43.6 years old, and 41 patients (56.2%) were male. Patients in the suspected group (SG) (n=47) were significantly older than those in the confirmed group (CG) (n=26). Among 73 patients, 18 (24.6%) had comorbidities. Most laboratory test results in this study were normal, except for total lymphocyte counts and C-reactive protein levels. Patients in the CG had fewer lymphocyte count abnormalities than those of the SG. More patients in the CG (13 cases, 50%) displayed involvement of three or more lobes than those in the SG (8 cases, 17%). More patients in the SG (36 cases, 76.6%) displayed involvement of 1-2 lobes than those in the CG (12 cases, 46.2%). In the CG, computed tomography (CT) lung lesions were mainly distributed in the left lower lung lobe (65.4%) and left upper lung lobe (80.8%). Conclusion: The reference standard for detecting COVID-19 is still RT-PCR. However, characteristic chest CT results and a history of close contact strongly suggest COVID-19 infection.

15.
Rheumatology Advances in Practice ; 4(SUPPL 1):i18-i19, 2020.
Article in English | EMBASE | ID: covidwho-1554732

ABSTRACT

Case report-IntroductionCOVID-19, the infectious disease caused by the novel coronavirus SARS-CoV-2, and first described in Wuhan, China in December 2019, has affected more than 19 million patients worldwide and resulted in more than 700,000 deaths at the time of writing1. Patients with rheumatic diseases and those receiving immunosuppressive treatment are felt to be at greater risk of complications from this illness, though registry and trial data should help refine our understanding of these risks. We hereby describe a case of COVID-19 complicating an unusual rheumatic illness, resulting in severe multi-system disease and premature death.Case report-Case descriptionA 69 year-old male presented to rheumatology and haematology with symmetrical polyarthritis, thrombocytopenia (18 x 109/L), eosinophilia (25.4 x 109/L), raised C-reactive protein (CRP, 43 mg/L), positive rheumatoid factor (>200), antinuclear antibody (ANA) and anti-Ro. Bone marrow biopsy did not demonstrate evidence of haematological malignancy.Seropositive rheumatoid arthritis and connective tissue disease overlap were diagnosed, and treatment with Prednisolone 60mg daily was initiated. Despite rituximab and intravenous immunoglobulins, thrombocytopenia deteriorated on reducing corticosteroids, however the addition of mycophenolate mofetil (MMF) allowed gradual prednisolone tapering to 3mg daily. Hydroxychloroquine was briefly added but discontinued due to headaches. MMF was discontinued after he developed fungal pneumonia followed by jaundice. Liver biopsy was consistent with drug-induced cholestasis, attributed to co-amoxiclav, and his liver function tests (LFTs) improved on ursodeoxycholic acid. Following a further deterioration in thrombocytopenia, hyperferritinaemia and new onset erythema nodosum, he had a repeat bone marrow examination. This demonstrated large areas of fibrosis and granulomatous inflammation with a dense, pleomorphic T-cell infiltrate, but no haemophagocytosis. Haematologists felt this was reactive and prednisolone dose was increased to 10mg daily.Six months later he developed cholangitis. Magnetic resonance cholangiopancreatography (MRCP) demonstrated a tight 4cm stricture of the distal common bile duct (CBD) within the head of pancreas, which was diffusely swollen without any clear focal mass. Serum amylase was mildly elevated (316 units/L). Concurrent CT thorax, abdomen and pelvis demonstrated bilateral ground-glass changes within the lungs, and a SARS-CoV-2 nasopharyngeal PCR test was positive, though he had no respiratory symptoms or oxygen requirement at that stage.Sadly, four days after the CT scan and before a planned endoscopic retrograde cholangiopancreatography (ERCP) could be performed, he became markedly hypoxic with plain chest X-ray features suggestive of COVID-19 pneumonia. Despite medical management, including doubling of his prednisolone dose, he rapidly deteriorated and died.Case report-DiscussionThis case highlights an unusual presentation of COVID-19 in a patient with a complex background of inflammatory arthritis with immune-mediated thrombocytopenia. At the time of his final illness, these conditions were managed with steroid monotherapy. Based on the COVID-19 risk matrix recommended by the British Society for Rheumatology, he was not identified as a patient requiring shielding.Cholangitis was the major problem precipitating his final admission to hospital, and at the time of admission he had no respiratory symptoms. One week prior to this admission, his father-in-law had died of COVID-19 pneumonia, though they had not been in recent direct contact. Interstitial lung changes were incidentally noted on a CT performed to identify the cause of cholangitis, which prompted the nasopharyngeal PCR that detected SARS-CoV-2. This occurred prior to widespread routine testing of hospital inpatients for SARS-CoV-2 by PCR. Unfortunately he then rapidly developed COVID-19 pneumonia and died before the underlying cause of cholangitis could be definitively identified, though an MRCP demonstrated an obstructed CBD within a diffusely swollen pancreas, where a differential diagnosis of pancreatic malignancy or autoimmune pancreatitis was suggested by the reporting radiologist.There are emerging case reports of COVID-19 resulting in significant pancreatic injuryand a further recent laboratory analysis has suggested that ACE2 receptors, which are utilised by SARS-CoV-2 to gain entry to host cells, are highly expressed on cholangiocytes at a comparable level to type II alveolar cells. Whilst the ultimate cause of cholangitis will remain unknown in this patient, this case highlights the potential for atypical presentations and extra-pulmonary manifestations of COVID-19.Case report-Key learning points COVID-19 is a multi-system illness which can cause significant extra-pulmonary as well as pulmonary pathology, with emerging reports that the biliary tract and pancreas are frequently affected.Evidence to inform accurate prediction of which patients with rheumatic diseases are at highest risk of acquiring severe COVID-19 disease remains insufficient, with current shielding guidelines based on expert consensus.This case highlights the importance of widespread testing for COVID-19 in hospital patients, as not all patients carrying the SARS-CoV-2 virus will demonstrate classical respiratory features of the disease at the point of admission.

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