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Background: Data are limited regarding the safety of and antibody response to the BNT162b2 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) messenger ribonucleic acid vaccine in adolescents and young adults with underlying disease. Methods: This prospective observational study enrolled patients age 12–25 years with chronic underlying disease who received 2 doses of BNT162b2. A 18-item questionnaire was used to assess adverse events within 7 days post-vaccination, and data regarding severe adverse events were collected from electronic medical records. An antibody titer for the receptor-binding domain of the spike protein in SARS-CoV-2 was used to assess antibody response after the second vaccine dose. Results: Study participants were 429 patients (241 [56.2%] age 12–15 years;188 [43.8%] age 16–25 years). The most common underlying diseases were genetic or chromosomal abnormalities and/or congenital anomalies, followed by endocrine or metabolic diseases;32% of participants were immunocompromised. Severe adverse events were observed after the second dose in 1 (0.4%) patient age 12–15 years and in 2 (1.1%) patients age 16–25 years;all patients recovered. Seropositivity after the second vaccine dose was 99.0%. The geometric mean antibody titer was higher in patients age 12–15 years versus 16–25 years (1603.3 [1321.8–1944.7] U/mL vs. 949.4 [744.2–1211.0] U/mL). Compared with immunocompetent patients, immunocompromised patients had a lower antibody titer (2106.8 [1917.5–2314.7] U/mL vs. 467.9 [324.4–674.8] U/mL). Conclusions: Vaccination with BNT162b2 was acceptably safe and immunogenic for adolescents and young adults with underlying disease. © 2022 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases
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Purpose of Study: In areas endemic for murine typhus, it can be difficult to distinguish from other febrile syndromes. During COVID-19 surges, we identified several cases of typhus. Presenting symptoms and quantitative lab values at and during admission were compared between patients who were diagnosed with murine typhus or multisystem-inflammatory syndrome in children (MIS-C). Methods Used: Retrospective data was collected at a tertiary care center from July 2020 to March 2022. Inclusion criteria were patients under 21 years of age diagnosed at discharge with murine typhus or MIS-C based on clinical and laboratory evidence, serologic data, and expert consultation. Patients found to have an alternate diagnosis, and those without serologic testing were excluded. Subjects were grouped as either MIS-C or typhus based final diagnosis. Categorical data included headache, fatigue, mucocutaneous changes, rash, con-junctival injection, sore throat, rhinorrhea, palpitations, shortness of breath, chest pain, abdominal pain, nausea/vomiting, diarrhea, myalgia, and appetite change at initial presentation. The categorical data were compared using chi-square test. Quantitative data included age, maximum temperature in first 24 hours of hospitalization, duration of symptoms prior to admission, C-reactive protein, erythrocyte sedimentation rate, platelet count, white blood cell count (WBC), absolute neutrophil count (ANC), absolute lymphocyte count, serum sodium, alanine aminotransferase, hemoglobin (Hgb), and albumin (Alb). Means of the quantitative data were compared with a one-tailed 2- Sample T-Test. The maximum and minimum laboratory values during admission were also compared. Additional demographic data including gender and date of initial presentation was also collected. Summary of Results: There were 7 patients in the MIS-C group and 19 in the typhus group. The average age of MIS-C patients, 6.5 years of age vs. 11.5,was significantly lower (p < 0.5) than the typhus group. Initial mean WBC (cells x 103/mm3) was higher in MIS-C than typhus (12.21, SD = 3.52, vs. 7.85, SD = 3.52, p < 0.05), as was ANC (8.9, SD = 3.7vs. 5.12, SD = 2.05, p < 0.05). During hospitalization, minimum Hgb (g/dL) was 9.3, SD = 2.07, and11.49, SD = 1.67, in MIS-C and typhus respectively (p < 0.05). Minimum albumin (g/dL) was also lower in MIS-C than typhus (2.32, SD = 0.86 vs. 2.8, SD = 0.45, p < 0.05). There were no other statistically significant differences in categorical or quantitative data. Typhus cases typically occurred in the summer and fall months. There was no clear seasonality of MIS-C, but occurred during local COVID-19 surges. Conclusion(s): The initial presenting symptoms of typhus and MIS-C were similar. WBC and ANC were higher in MIS-C, while age, Hgb and Alb were lower. These parameters may aid in distinguishing the diseases. A high clinical suspicion for both typhus and MIS-C in endemic areas for typhus is crucial. A rapid detection for typhus would aid in distinguishing these diseases and allow prompt treatment interventions. Copyright © 2023 Southern Society for Clinical Investigation.
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Case report - Introduction: Catastrophic antiphospholipid syndrome (CAPS) is a rare, life-threatening disease occurring in up to 1% of antiphospholipid syndrome (APS) cases. It was first defined in 1992 and remains a difficult to treat entity with a mortality rate of 37%. We describe a patient with systemic lupus erythematosus (SLE) and CAPS presenting with simultaneous multi-organ injuries who was successfully managed with 'triple' therapy including cyclophosphamide. Case report - Case description: A 42-year-old female presented to her local hospital with chest pain and worsening vision. She had a background of SLE, triple antibody-positive APS (previous DVT, pregnancy loss and strokes), hypertension, a metallic mitral valve, a previous myocardial infarction and pre-existing visual impairment due to a prior intra-cerebral bleed related to anticoagulation. Examination revealed a faint malar rash, cortical blindness and long tract neurological signs. Her ECG showed ischaemic changes and the admission troponin was significantly raised (3773ng/L). An echocardiogram showed new left ventricular dysfunction and a subsequent cardiac MRI was in keeping with coronary artery disease. Investigations showed an acute kidney injury, newly deranged liver function tests and a raised INR (>11, with no bleeding). Complement was normal with a low dsDNA titre. Urinalysis revealed proteinuria and a protein creatinine ratio measured 176mg/mmol. MRI diffusion weighted brain imaging showed acute bilateral occipital and left fronto-parietal infarcts. She had symptoms of a lupus flare with arthralgia and a butterfly facial rash. COVID-19 PCR tests were negative and she had not been recently vaccinated. She was diagnosed with CAPS and transferred to St Thomas' hospital intensive care. On arrival, she received 1mg intravenous vitamin K followed by triple therapy for CAPS: an unfractionated heparin infusion, oral prednisolone 40mg daily, 5 days of plasma exchange and, given her background of SLE, she was treated with intravenous cyclophosphamide (according to the EUROLUPUS regimen). Intravenous methylprednisolone was avoided due to a previous hypertensive encephalopathy reaction. She responded rapidly. Her troponin fell from a peak of 5054 to 294ng/ L, her creatinine settled at a new baseline (232umol/L) and her liver function normalised. She was switched back to warfarin due to her metallic valve and started on aspirin for cardiovascular secondary prevention. She required physical and occupational therapy due to her strokes but recovered well. Case report - Discussion: According to the 2003 criteria, CAPS can be classified as definite when there is evidence of: -3 organs involved, development of manifestations simultaneously or within a week, confirmation by imaging and/or histopathology of small vessel occlusion and positive antiphospholipid antibodies. Probable CAPS is when 3 out of the 4 criteria are present. In this case, three organs were confirmed to be involved with imaging showing cerebral and cardiac ischaemia. Her creatinine rose from a base of 190 to 289umol/L coupled with a high protein creatinine ratio confirming renal involvement. A Budd-Chiari syndrome was also suspected due to deranged liver function tests and INR, though imaging performed after therapy did not confirm this. A biopsy of any of these four organs was not feasible given the severity of her presentation and coagulopathy. There are no randomised controlled trials but data from the CAPS registry guides treatment and management follows a logical approach: anticoagulation to treat thrombosis, glucocorticoids for inflammation and plasma exchange (or IVIG) to remove the circulating autoantibodies. Triple therapy was associated with a reduced mortality compared to no treatment (28.6% versus 75%, respectively). Following analyses from the CAPS registry we also chose to treat with cyclophosphamide, which is associated with improved survival in patients with SLE. This decision was based on the clinical features of an SLE flare as opposed to serological grounds. There have b en reports of rituximab and eculizumab being used successfully in CAPS, though generally as a last resort. As complement activation is seen in animal models of antiphospholipid syndrome thrombosis and rituximab is often used in refractory SLE, they may prove to be promising agents for refractory CAPS. Case report - Key learning points: 1. Prompt recognition and early treatment is vital in managing CAPS 2. Triple therapy with anticoagulation, glucocorticoids and plasma exchange / IVIG is associated with better survival in CAPS 3. Cyclophosphamide is associated with better survival in patients with CAPS and concomitant SLE.
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The outbreak of coronavirus disease 2019 (COVID-19) in December 2019 has rapidly spread globally with significant negative impact on health. There is an urgent need for a drug or vaccine certified for treating and preventing COVID-19 respectively. Tocilizumab, an interleukin-6 monoclonal receptor antibody, has been used in some centers for mitigating the severe inflammatory response seen in patients with severe COVID-19 with encouraging results. To the best of our knowledge, reports detailing the outcomes of patients with severe COVID-19 undergoing treatment with tocilizumab are sparse in sub-Saharan Africa. We describe the clinical and laboratory profile, chest Computed Tomography (CT) scan findings and clinical outcome in a Ghanaian patient with severe COVID-19 pneumonia treated with tocilizumab. A 54-year old hypertensive male presented with fever, productive cough, pleuritic chest pain and breathlessness. He tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by polymerase chain reaction analysis done on a nasopharyngeal swab sample. His respiratory symptoms worsened while on admission despite receiving standard of care. His C-reactive protein (CRP) was elevated to 80.59mg/L and chest CT scan findings were indicative of severe COVID-19 pneumonia. He was treated with a single 400mg dose of intravenous tocilizumab with a positive clinical outcome, rapid decline in CRP and improvement in chest CT findings. Our experience shows that tocilizumab shows great promise as drug therapy for COVID-19 pneumonia. Copyright © 2020, African Field Epidemiology Network. All rights reserved.