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1.
Frontiers in Medicine ; 9, 2022.
Article in English | EMBASE | ID: covidwho-1822377

ABSTRACT

Background: The COVID-19 pandemic has major implications on kidney transplant recipients (KTRs) since they show increased mortality due to impaired immune responses to SARS-CoV-2 infection and a reduced efficacy of SARS-CoV-2 vaccination. Surprisingly, dialysis patients have shown superior seroconversion rates after vaccination compared to KTRs. Therefore, we investigated peripheral blood B cell (BC) composition before and after kidney transplantation (KT) and aimed to screen the BC compartment to explain impaired antibody generation. Methods: A total of 105 patients were recruited, and multicolor flow cytometric phenotyping of peripheral venous blood BC subpopulations was performed before and 1 year after KT. Complete follow-up was available for 71 individuals. Anti-SARS-CoV-2 antibodies were collected retrospectively and were available for 40 subjects, who had received two doses of an mRNA-based vaccine (BNT162b2 or mRNA-1273). Results: Overall, relative BC frequencies within lymphocytes decreased, and their absolute counts trended in the same direction 1 year after KT as compared to CKD G5 patients. Frequencies and absolute numbers of naïve BCs remained stable. Frequencies of double negative BCs, a heterogeneous subpopulation of antigen experienced BCs lacking CD27 expression, were increased after KT, yet their absolute counts were similar at both time points. Transitional BCs (TrBCs) and plasmablasts were significantly reduced after KT in absolute and relative terms. Memory BCs were affected differently since class-switched and IgM-only subsets decreased after KT, but unswitched and IgD-only memory BCs remained unchanged. CD86+ and CD5+ expression on BCs was downregulated after KT. Correlational analysis revealed that TrBCs were the only subset to correlate with titer levels after SARS-CoV-2 vaccination. Responders showed higher TrBCs, both absolute and relative, than non-responders. Conclusion: Together, after 1 year, KTRs showed persistent and profound compositional changes within the BC compartment. Low TrBCs, 1 year after KT, may account for the low serological response to SARS-CoV-2 vaccination in KTRs compared to dialysis patients. Our findings need confirmation in further studies as they may guide vaccination strategies.

2.
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.

3.
Open Forum Infectious Diseases ; 8(SUPPL 1):S237-S238, 2021.
Article in English | EMBASE | ID: covidwho-1746719

ABSTRACT

Background. Listeria monocytogenes is a gram-positive, facultative anaerobic bacillus common in the intestinal flora of many animals and humans. We describe an unusual case of meningitis by Listeria monocytogenes (LM) complicated by hydrocephalus in a child with dermatomyositis. Methods. A 15-year-old girl presented to an outside hospital (OH) after a threeday history of headache, fever and was hospitalized with a diagnosis of meningitis and lumbar puncture performed. CSF sample could not be evaluated clearly due to its hemorrhagic nature. Her past medical history was significant for dermatomyositis for five years. She had received induction of IVIG five days prior. She was also taking cyclosporin A and hydroxychloroquine. She was empirically treated with intravenous cefotaxime, vancomycin, and acyclovir. She was urgently transferred to the theatre for an external shunt placement in the right lateral ventricle. The interval between the first symptoms and the diagnosis of hydrocephalus was around 4 days. CSF from this catheter showed growth of LM with sensitivity to meropenem and resistance to erythromycin, ampicillin, and sulfamethoxazole-trimethoprim. Gram staining of CSF resulted negative for bacteria. Cefotaxime was switched to intravenous meropenem. Immunological screening of cellular and humoral immunity, complement, and blood iron levels were normal. SARS-Cov2 PCR and HIV tests were negative. Herpes virus, mycobacterium tuberculosis real-time PCR, respiratory viral panel studied in the CSF sample were negative. MRI and Angio of the brain showed no abnormality. She is being followed in the pediatric intensive care unit as intubated. Results. In patients who received immunosuppressive medication, L. monocytogenes should be evaluated in the differential diagnosis of central nervous system infections. Even if effective antibiotic therapy has been initiated, this case highlights the need of recognizing early hydrocephalus as a consequence of Listeria meningitis in children with neurological deterioration a few days after initial presentation. Conclusion. The literature on the management and outcome of Listeria meningitis-related hydrocephalus in children is limited.

4.
Open Forum Infectious Diseases ; 8(SUPPL 1):S554-S555, 2021.
Article in English | EMBASE | ID: covidwho-1746351

ABSTRACT

Background. Chimeric antigen receptor (CAR-T) T-cell therapy is a novel immunotherapy for cancer treatment in which patients are treated with targeted, genetically-modified T-cells. Common side effects include cytokine release syndrome, neurotoxicity, hypogammaglobulinemia, and increased susceptibility to infections. Long-term infectious outcomes are poorly characterized. Methods. We retrospectively examined patients who received CAR-T therapy at BIDMC & MGH from July 2016 to March 2020 and evaluated bacterial, fungal, viral, and parasitic infections at 3 months intervals to 1 year following cell infusion. The incidence, timing, and outcomes of the infectious complications were evaluated. Results. In total, there were 47 patients;averaging 61.4 years of age (±12 years). Primary indications for CAR-T therapy included diffuse large b-cell lymphoma (65%) and multiple myeloma (25%), chronic lymphocytic leukemia (2%) and mantle cell lymphoma (2%). Patients had received an average 4 ± 2.9 lines of chemotherapy prior to CAR-T infusion;19 subjects (40%) had a history of prior autologous stem cell transplant. All patients received acyclovir for antiviral prophylaxis and most received either trimethoprim-sulfamethoxazole (24/47;51%) or atovaquone (16/47;34%) for pneumocystis prophylaxis. In the first year, 35/47 (74.5%) of subjects experienced at least one infection with an infection rate of 84.4/10,000 person days. Median time to first infection was 59 days (range 1-338 patient days). 31/47 (66.0%) subjects had at least one bacterial infection, with pulmonary (42/113;37.2%) sources being the most common site of infection. 13/47 (27.7%) of patients had a viral infection (predominantly respiratory viral infections) and 6/47 (12.8%) had a proven or probable fungal infection. Death attributed to infection was noted in 2 subjects (4.3%), both related to COVID-19. Baseline IgG levels were significantly lower in the group with infections (p=0.028), while white blood cell count and absolute neutrophil counts were comparable. Conclusion. Infectious complications, particularly of bacterial etiology, are common in the first year following CAR-T therapy. These data may inform future prophylactic strategies in this patient population.

5.
Open Forum Infectious Diseases ; 8(SUPPL 1):S566, 2021.
Article in English | EMBASE | ID: covidwho-1746348

ABSTRACT

Background. The renal transplant population is at increased risk of Nocardiosis due to impaired T-cell mediated immunity with immunosuppression. Pneumocystis jirovecii (PJP) prophylaxis with trimethoprim/sulfamethoxazole (TMP/SMX) provides coverage against Nocardia spp. unlike alternative agents such as atovaquone (ATQ), aerosolized pentamidine (AP), and dapsone. During the COVID-19 pandemic, patients receiving AP were transitioned to ATQ to avoid the use of nebulized medication. This, in turn, led to decreased use of TMP/SMX as patients on oral ATQ were not reassessed for the use of TMP/SMX as would have occurred while on AP. Additionally, an increased incidence of Nocardia infections was observed during this time. The objective of this study was to determine the association between the incidence of Nocardia infections and number of TMP/SMX prophylaxis-days in preversus COVID-19 cohorts. Methods. This was a single center retrospective chart review of all renal transplant recipients between September 2018 - August 2019 (pre-COVID-19 cohort) and April 2020 - March 2021 (COVID-19 cohort). Patients were included if they were at least 18 years of age and a recipient of a cadaveric or living donor kidney transplant. Exclusion criteria included multi-organ transplant, pediatric patients, and repeat transplants. The primary outcome was incidence of Nocardiosis within the first 6 months post-transplant in the pre- and COVID-19 cohorts. Results. A total of 218 patients were included (Table 1). Induction therapy and initial immunosuppression did not differ significantly between groups, nor did rates of rejection within 180 days of transplant (Table 2). Although the pre-COVID-19 cohort had a higher rate of neutropenia, there was no difference in median absolute lymphocyte count between the two groups. The COVID-19 cohort had a decreased percentage of TMP/SMX prophylaxis-days (59.2% vs. 72.5%, p < 0.0001) and an increased incidence of Nocardia infections in the first 6 months post-transplant (4% vs. 0%, p=0.0292). All 4 cases of Nocardia infections occurred in patients receiving ATQ. Conclusion. The increased incidence of Nocardiosis was associated with a decreased use of TMP/SMX for PJP prophylaxis which may have been an unintended consequence of increased use of ATQ in lieu of AP during COVID-19.

6.
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.

7.
Journal of the Association of Physicians of India ; 69(May):78-79, 2021.
Article in English | CAB Abstracts | ID: covidwho-1716893

ABSTRACT

This is a case of 75-year-old doctor known diabetic and hypertensive who is diagnosed as having COVID-19 based upon HRCT scan, which revealed CORADS-4 but, RT-PCR negative and clinically asymptomatic except for mild hypoxemia on pulseoximeter. Treated as per COVID 19 protocol. Saturation improved gradually. Ten days later, cytokine storm was diagnosed based upon gradual fall in the saturation along with the supporting biochemical and radiological data. Pulse dose steroid therapy started with Inj. methyl prednisolone 500 mg 0D for 4 days along with broad spectrum antibiotic cover. Theuraptic dose of SEPSIVAC vacccine was administered Later after two weeks of hospital stay including 1 week of ICU stay, patient was discharged on oral anticoagulants, oral steroids and oral antibiotics. Since then he was on tapering dose of steroid from methyl prednisolone 32 mg to 2mg over a month. Treated with broad spectrum antibiotics along with coverage for PJP Pneumonia in view of long term steroid usage. Biochemical markers and clinical status were worsened over the next 48 hrs and PJP pneumonia was suspected. Trimethoprim/sulfamethaxazole 15 mg / kg, fluconazole along with broad spectrum antibiotic cover administered. Pulse dose steroid of 500 mg given for 3 days along with regular standard of care. Meanwhile serum Beta-D-Glucan level was obtained which is 678 pg/ ml (normal being < 70 pg/ml). Gradually patient dyspnoea resolved and resting saturation improved from 91% to 96 % on room air.

8.
Kidney International Reports ; 7(2):S328, 2022.
Article in English | EMBASE | ID: covidwho-1707023

ABSTRACT

Introduction: Angioinvasive aspergillosis is a rare opportunistic infection. its occurrence increases the mortality and morbidity of organ transplant recipients. Methods: It is about a 27-year-old patient with a history of end-stage renal failure due to an apparent mineralocorticoid deficiency, hemodialysis for 10 months until he received a kidney transplant from a related living donor sharing 4 HLA identities. He received induction therapy with globulin antithymocyte and methylprednisolone followed by maintenance therapy with Mycophenolate Mofetil, prednisolone, tacrolimus. Since the recipient was not immune to cytomegalovirus (CMV), he received ganciclovir prophylaxis immediately after transplant. Post-transplant evolution was marked by the immediate resumption of diuresis, creatinine figures stagnating between 200 and 250 µmol/l. The remainder of her usual treatment consists of a proton pump inhibitor, β-blocker, cotrimoxazole. Our patient presented 2 months post transplant with febrile neutropenia. Clinically, apart from a fever of 38 °, the examination was without abnormalities. Biologically, pancytopenia, inflammatory syndrome (high CRP and procalcitonin), hypokalaemia, hypophosphatemia and hypomagnesemia, hyperferritinemia and hypertriglyceridemia were noted. A post-infectious macrophagic activation syndrome was suspected, confirmed by a sternal puncture. An etiological investigation has been launched;viral serologies (HBV, HCV, HIV, EBV, CMV, COVID 19, HSV) were negative, a cardiac ultrasound ruled out infective endocarditis, a thoracoabdominal CT scan showed multifocal sub-segmental parenchymal condensations of the right lung surrounded by a halo, an appearance suggesting angio-invasive pulmonary aspergillosis and intracortical graft hematomas. Sputum bacteriological examination did not show pneumocystis but isolated two types of candida crucei and tropicalis. A weakly positive aspergillus antigenemia (index : 0.53) was noticed. Our patient received triple antibiotic therapy (vancomycin / imipenem / levofloxacin) and an antifungal (voriconazole) after adaptation according to the antibiogram for a total duration of 15 days with daily dosage of tacrolimus. In addition, he received venoglobulins for 5 days at a dose of (0.4 mg / kg / day). The clinical and biological course was favorable with apyrexia and improvement in the blood count from the third day of treatment. Aspergillus antigenemia and a follow-up chest CT scan were scheduled after the end of treatment. Results: Initially, In view of the intensity of the induction treatment received, leuconeutropenia and in order of frequency, the 2 most evoked causes were CMV et covid19 but the CT aspect straightened the diagnosis, which was supported by aspergillary antigenemia. The emerging interest of this case report is the clinical and computed tomography discordance and the unusual rapidly favorable outcome to an aspect of angioinvasive pulmonary aspergillosis which usually show respiratory signs such as cough, hemoptysis or even respiratory distress. Conclusions: Invasive mycoses, associated with significant morbidity and mortality, are a frequent difficulty in solid organ transplantation. The clinical pictures differ and we could be faced with an atypical presentation which affects the therapeutic management. No conflict of interest

9.
Kidney International Reports ; 7(2):S298, 2022.
Article in English | EMBASE | ID: covidwho-1704613

ABSTRACT

Introduction: Peritonitis is a major complication of Peritoneal Dialysis (PD), inadequate response to treatment, and the inflammatory state inherent in PD patients may result in hospitalization time and mortality. This Study aims to observe prognosis patients who Peritoneal Dialysis-Associated Peritonitis (PDAP) by Neutrophil-to-Lymphocyte Ratio (NLR). Methods: We have performed observation the incidences of peritonitis, causative organisms, clinical outcomes and mortality between patients undergoing Continuous Ambulatory Peritoneal Dialysis (CAPD) during pandemic era from January 2020-September 2021 in Central General Hospital Dr. Sardjito. Outcomes and clinical course of treatment in the selected patients were reviewed. Results: The Latest case, Male, 22 years old,the Peritoneal Equilibration Test (PET) results are Low. Since the end of August 2021 felt pain in the abdomen accompanied by cloudy dialysis fluid and sometimes there is fibrin. From routine blood examination, the results NLR is 2. The patient received Ceftriaxone and Gentamicin with the results of dialysate fluid culture obtained Klebsiella Pneumonia. The symptoms of peritonitis improved but on the 14th day the symptoms started to reappear, the antibiotics were continued and a re-culture was performed on the 15th day, Burkholderia Cepacia bacteria were sensitive to Meropenem, Trimethoprim/Sulfamethoxazole, and Ceftazidime. Next case, male, 71 years old, since 2014 using CAPD with the last evaluation of PET was High Average. Complaints were felt in early October 2020 with same symptoms. The NLR is 21 and the results of culture Staphylococcus Capitis. Patients receiving therapy with Vancomycin and evaluation of culture results negative. But in December 2020 the signs and symptoms appeared again with NLR 25. Because of the weakness condition, the patient was hospitalized with the culture results Pseudomonas Aeruginosa, sensitive to Ciprofloxacin, because of improvement, the patient was allowed outpatient. The results of the culture evaluation showed the bacteria were the same as sensitive to the same antibiotic group as well, but was replaced with Ceftazidim and Fluconazole. After 14 days of administration antibiotics, the complaints improved and the culture results were negative. In March 2021 the patient came back with the same complaints again related to recurrent peritonitis, with culture results showing Pseudomonas Aeruginosa infection and only sensitive to Ciprofloxacin and Gentamicin. The patient received both antibiotic therapy in an outpatient condition but in the course of his illness the patient died because COVID-19 in other hospital. For last case, the patient was 51 years old with PET Low Average results and NLR 6. The patient presented with persistent symptoms peritonitis 3 times continously after the evaluation but the culture results were always negative. In the treatment of the first infection, the patient had received therapy Ceftazidime and Gentamicin, but because the symptoms did not improve, the patient's antibiotics were then replaced with Ciprofloxacin, and the third evaluation was given Vancomycin even though the bacteria did not grow. Due to the condition of recurrent peritonitis infection in this patient, access to CAPD was then withdrawn and back to HD. Conclusions: According to our findings, the incidence of symptomatic PDAP maybe related with NLR, it can be a prognostic factor but still unclear. No conflict of interest

10.
Journal of Investigative Medicine ; 70(2):573, 2022.
Article in English | EMBASE | ID: covidwho-1700487

ABSTRACT

Background West Nile Virus is the most common cause of arboviral diseases and is endemic in the US. It can cause clinical presentation ranging from asymptomatic infection to neuroinvasive disease. Factors like old age, hematologic malignancies, and organ transplantation result in more severe disease. Case presentation An 85-year-old male farmer with coronary artery disease, congestive heart failure (CHF) and diabetes presented with sore throat, cough and shortness of breath. He was treated for CHF exacerbation and discharged but returned with fatigue, headache, Nausea, and vomiting. Imaging of the head and chest, inflammatory markers, COVID-19 PCR,and metabolic panel were all negative, . Then he became febrile, lethargic, and had altered mentation. He exhibited asymmetric weakness, bilateral positive Babinski and neck rigidity. Intravenous ceftriaxone, vancomycin, bactrim, and acyclovir were all initiated for meningoencephalitis of unclear etiology. CSF analysis showed 51 WBC, 0 RBC, 49% granulocytes, 55 glucose and 74 proteins. He was transferred to ICU with a glasgow coma score of 6-7 but was on a 'DO NOT INTUBATE' status. He developed acute anuric kidney injury which prompted emergent hemodialysis and vasopressor support had to be initiated. Family elected for palliative care, and he passed away shortly after. A day later, West Nile serology was reported positive as IGM in CSF. Also, both IgG and IgM were positive in serum Discussion This case demonstrates a rare, severe presentation of West Nile infection. Most persons infected with West Nile (WNV) virus are asymptomatic;symptoms are seen in only about 20 to 40 percent of infected patients [1] Serologic surveys and extrapolations from blood donor screening data indicate that neuroinvasive disease following infection is infrequent, with estimates ranging from 1 in 140 to 1 in 256 infections resulting in meningitis or encephalitis [2] The patient's risk factors for severe infection include elderly age and male sex. Age in particular is the most important risk factor for neurologic progression of disease.[3] The diagnosis can be suspected in patients who have altered mental status, signs of meningitis, unexplained fever, and focal neurologic deficit, especially when it presents in late summer months and has no obvious etiology. The CSF West Nile IgM antibody detection via ELISA is diagnostic as was in our case. The treatment is mainly supportive. The preventive measures including mosquito control, personal protective devices are of substantial importance. Vaccines are not available. [4 5 6] Conclusion The high index of suspicion is necessary to diagnose WNV neuroinvasive diseases especially in patients with atypical presentation. Seasonal clues must be considered.

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.
Chest ; 161(1):A164, 2022.
Article in English | EMBASE | ID: covidwho-1633429

ABSTRACT

TYPE: Case Report TOPIC: Chest Infections INTRODUCTION: Cytomegalovirus is an important cause of morbidity and mortality in immunocompromised patients.CMV is an important cause of pneumoina in lung transplant patients too. Pneumocytis Jiroveci (PCP) can casue a potentially life-threatening infection in immunocompromised individuals, especially HIV patients or transplant patients. In our we are presenting a rare case of an immunocompromised patient with penumonia who was infected concurrently with CMV and PCP. CASE PRESENTATION: A 53 year-old female patient with history of Rheumatoid Arthritis treated with methotrexate, prednisone and rituximab presented to the emergency room with fatigue and tiredness but no fever. She was tested for COVID-19 and influenza infections (PCR) and both were negative. At presentation, her WBC was 9900. CT with contrast of the chest showed no embolism but multi-focal ground glass opacities. Pulmonary and infectious disease teams were consulted. Blood culture was negative, MRSA screen was negative, Fungitell was positive, LDH test was elevated to 382. CMV quantitaive PCR of 10,000 copies. CMV PCR BAL is detected at 650 copies/ ml, and EBV PCR tests was negative. Pneumocystis Jiroveci pneumonia was detected on BAL DFA. Fungitell waqs more than 500. CMV retinitis has been ruled out by ophthalmology exam. Patient was diagnosed with concurrent infections. Pt was started on Bactrim, valganciclovir PO and intravenous ganciclovir with improvement in her condition. DISCUSSION: It is rare to have a concurrent pneumonia infection caused by Pneumocytis Jiroveci and CMV except in immunocompromised patients. CONCLUSIONS: A concurrent Pneumocystis Jiroveci and CMV pneumonia is a rare infection but could occur in immunocompromised patients. DISCLOSURE: Nothing to declare.

13.
Cogent Medicine ; 8, 2021.
Article in English | EMBASE | ID: covidwho-1617062

ABSTRACT

Background: COVID-19 has changed the perspective through which medical staff look at dyspnea and hypoxemia cases. Epidemiological links are frequently missing, and clinical and imagological findings are often unspecific, overlapping substantially with other respiratory infections. Case summary: We report the case of an 11-year-old girl with a known history of asthma who had recently moved from Guinea-Bissau with her mother. Although the mother reported being Ag HBs positive, no serologic studies had ever been performed on the child. The patient was admitted to the Emergency Room after 4 days of cough and the feeling of thoracic oppression, without fever. No contact with suspected or confirmed individuals infected with SARS-CoV-2 or other respiratory viruses was reported. She presented with peripheral oxygen saturation of 90%, costal retractions and a prolonged expiratory phase. After an unsuccessful course of bronchodilators and prednisolone, she was admitted to the Pediatric Intermediate Care Unit because of a sustained need for oxygen therapy. Polymerase chain reaction analysis for SARS CoV-2 came back negative. A chest radiograph displayed a bilateral reticular infiltrate, and therapy with azithromycin was started. Due to a deterioration of the dyspnea, a chest tomography was eventually performed, revealing an exuberant and bilateral ground glass-like densification suggestive of alveolar injury. Echocardiogram and e electrocardiogram were both normal. After a positive serologic result for HIV, the patient was transferred to a Level III hospital, and Pneumocystis jirovecii was identified in bronchoalveolar lavage. T cell count was 12/mm3. Highly active antiretroviral therapy and cotrimoxazole were started, prompting clinical and analytical recovery. Discussion: Pneumocystis jirovecii can cause fatal pneumonia in immunocompromised children. Even though an asthma exacerbation and atypical bacterial or viral infections, namely COVID-19, present as more usual causes of dyspnea, a low suspicion index is warranted in children coming from HIV-endemic countries, particularly those who are unresponsive to conventional bronchodilator and antibiotic therapy.

14.
Allergy: European Journal of Allergy and Clinical Immunology ; 76(SUPPL 110):468-469, 2021.
Article in English | EMBASE | ID: covidwho-1570395

ABSTRACT

In 2012 a 25-year-old man presented to our outpatient clinic for severe atopic dermatitis (AD) and severe allergic eosinophilic asthma in polisensitivity (house dust mite, cat, gramineous plants, birch, milk protein and, in particular, Alternaria). His clinical history was also characterized by gastro-esophageal reflux disease and chronic rhinitis without polyposis, with septal deviation and turbinate hypertrophy, worthy of surgical intervention. History taking revealed egg and cow milk protein allergy and severe asthma since the first months of life, with frequent hospital admissions due to exacerbations. AD was severe and diffuse, involving especially face, neck, back and superior limbs, often complicated by impetigo. The esthetic, social and psychological impact led him to quit his job as a barman. At presentation, the Eczema Area and Severity Index (EASI) score was 72/72. Laboratory tests showed eosinophilic count ranging between 1.060 and 2.140/mm3, and high serum levels of total Immunoglobulin E (5.939 kUI/L). Tryptase levels were normal and autoantibody analysis was negative. Parasite stool examination was negative. Nasal swab tested positive for Staphylococcus aureus, which was treated with Sulfamethoxazole-Trimethoprim. Asthma Control Test was 15/25, pulmonary function tests (PFTs) showed mild obstruction (FEV1 4.43 L, 103%, FEV1/FVC 69%), with positive bronchodilator testing (FEV1 5.12 L, + 670 mL, + 16%). Firstly, he was treated with topical steroids and sometimes with oral corticosteroids, with poor response. Then, in July 2019, he initiated therapy with cyclosporine 3-5 mg/kg. Soon, the drug had to be discontinued due to adverse effects (gastrointestinal symptoms and infections). In November 2019, at the age of 32 years, he started therapy with monoclonal antibody anti-IL-5 receptor alpha (benralizumab 30 mg 1 subcutaneous vial every 4 weeks for the first three administrations and then every 8 weeks), with a terrific clinical improvement of AD since the first administrations and with benefit on asthma control (ACT after the first administration increased up to 25/25;PFTs could not be performed, due to SARS-CoV-2 pandemic). This therapy has always been well tolerated. The eosinophilic count decreased to 0/mm3 after the first administration. At the moment, after one year of therapy, AD is almost fully disappeared (EASI SCORE 4/72), despite being in free diet, and the quality of life of the patient has definitely improved.

15.
Italian Journal of Medicine ; 15(3):36, 2021.
Article in English | EMBASE | ID: covidwho-1567464

ABSTRACT

Background: SARS-CoV-2 infection, in the most severe cases, can cause bilateral pneumonia and respiratory failure. In these cases, therapy is based on the use of antiviral drugs, immunosuppressants (in order to reduce the cytokine-mediated inflammatory response),oxygen and sometimes non-invasive mechanical ventilation (NIV).We describe 2 cases of severe bacterial infections probably favored by the immunosuppressive therapy. Description of the cases: A 63-year-old man with no history of significant medical conditions and an 86-year-old man with history of ischemic heart disease treated with PTCA+DES, were both hospitalized for severe bilateral SARS-CoV-2 pneumonia and treated with NIV associated with high-dose steroids (Dexamethasone 8 mg IV per day). After the resolution of the pulmonary infection, the first one developed a Pneumocystis jirovecii pneumonia with the need for re-hospitalization and treatment with trimethoprim-sulfamethoxazole;the second one developed a methicillin-resistant Staphylococcus aureus (MRSA) endocarditis with infarct lesions caused by septic emboli in brain and splenic area, with subsequent clinical aggravation and death. Conclusions: The SARS-CoV-2 pneumonia treatment is based on combined use of NIV and anti-inflammatory, antiviral and immunosuppresive drugs: it is important to minimize duration of treatment because it may lead to the development of serious complications like septic states (even by opportunistic pathogens) that are lifethreatening for the patients.

16.
U.S. Pharm. ; 46:6-13, 2021.
Article in English | EMBASE | ID: covidwho-1553161

ABSTRACT

Bacterial meningitis is a serious infection that requires immediate treatment. Recommended empiric antimicrobial therapy is based upon the most likely pathogen, according to a patient’s age and immune status. Antimicrobial therapy should be modified after identification of the causative microorganism and results of susceptibility tests. Preventive measures include the use of vaccines that target Neisseria meningitidis, Haemophilus influenzae, and Streptococcus pneumoniae, as well as the use of chemoprophylaxis in selected situations. Pharmacists are in a key position to recommend appropriate antimicrobial therapy for the treatment and prophylaxis of bacterial meningitis and to ensure that patients are receiving recommended vaccinations.

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