Model-interpreted outcomes of artificial neural networks classifying immune biomarkers associated with severe infections in ICU.

Introduction: Millions of deaths worldwide are a result of sepsis (viral and bacterial) and septic shock syndromes which originate from microbial infections and cause a dysregulated host immune response. These diseases share both clinical and immunological patterns that involve a plethora of biomarkers that can be quantified and used to explain the severity level of the disease. Therefore, we hypothesize that the severity of sepsis and septic shock in patients is a function of the concentration of biomarkers of patients. Methods: In our work, we quantified data from 30 biomarkers with direct immune function. We used distinct Feature Selection algorithms to isolate biomarkers to be fed into machine learning algorithms, whose mapping of the decision process would allow us to propose an early diagnostic tool. Results: We isolated two biomarkers, i.e., Programmed Death Ligand-1 and Myeloperoxidase, that were flagged by the interpretation of an Artificial Neural Network. The upregulation of both biomarkers was indicated as contributing to increase the severity level in sepsis (viral and bacterial induced) and septic shock patients. Discussion: In conclusion, we built a function considering biomarker concentrations to explain severity among sepsis, sepsis COVID, and septic shock patients. The rules of this function include biomarkers with known medical, biological, and immunological activity, favoring the development of an early diagnosis system based in knowledge extracted from artificial intelligence.

Two cases of multisystem inflammatory syndrome in adults: experience at a single centre in Sydney.

We report two cases of middle-aged men who presented with clinical features that satisfied the diagnostic criteria for multisystem inflammatory syndrome in adults (MIS-A). Both patients were treated for toxic shock syndrome and MIS-A and have recovered. The purpose of this article is to communicate our experience and challenges of assessing and treating this condition and to raise awareness of the condition.

Could presepsin be an alternative marker in the early diagnosis of sepsis in COVID-19?

In critical patients with Coronavirus Disease (COVID-19), we investigated the diagnostic value of presepsin in the early diagnosis of superinfection with sepsis, and the effect of antibiotic treatment (AT) in the levels of presepsin and procalcitonin and C-reactive protein. A total of 68 critical patients with sepsis and septic shock in the intensive care unit and 20 outpatients (control group) with COVID-19 were taken. ICU patients (n = 68) were further divided into three groups. C(-)AT(-) had negative blood or tracheal aspirate cultures (C) and not AT on admission to ICU (n = 18), C(-)AT(+) had negative C and AT on admission to intensive care unit (n = 31) and C(+) had positive C (n = 19). Presepsin, procalcitonin, C-reactive protein results were compared between the groups. There were no significant relationships between presepsin levels with sepsis, septic shock, mortality, or length of stay in ICU in patients with COVID-19. For procalcitonin and C-reactive protein levels in C(-)AT(+) and C(+) groups were significantly higher than in control and C(-)AT(-) groups (p < .001). C-reactive protein levels in C(-)AT(-) group were significantly higher than in the control group (p < .001). PCT and CRP, there was no difference between C(-)AT(+) and C(+) groups, and procalcitonin there was no difference between control and C(-)AT(-) groups. Presepsin was not found as a useful biomarker for the prediction of sepsis in COVID-19 patients. These study findings indicate that procalcitonin and C-reactive protein may be an indicator of an early diagnostic marker for superinfection in critical COVID-19 patients.

Fatal septic shock due to Capnocytophaga canimorsus bacteremia masquerading as COVID-19 pneumonia - a case report.

BACKGROUND: Capnocytophaga canimorsus (C. canimorsus) infections are rare and usually present with unspecific symptoms, which can eventually end in fatal septic shock and multiorgan failure. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) related coronavirus disease 2019 (COVID-19), on the other hand, is predominantly characterized by acute respiratory failure, although other organ complications can occur. Both infectious diseases have in common that hyperinflammation with a cytokine storm can occur. While microbial detection of C. canimorsus in blood cultures can take over 48 h, diagnosis of SARS-CoV-2 is facilitated by a widely available rapid antigen diagnostic test (Ag-RDT) the results of which are available within half an hour. These Ag-RDT results are commonly verified by a nucleic acid amplification test (NAAT), whose results are only available after a further 24 h. CASE PRESENTATION: A 68-year-old male patient with the diagnosis of COVID-19 pneumonia was referred to our Intensive Care Unit (ICU) from another hospital after testing positive on an Ag-RDT. While the initial therapy was focused on COVID-19, the patient developed a fulminant septic shock within a few hours after admission to the ICU, unresponsive to maximum treatment. SARS-CoV-2 NAATs were negative, but bacteremia of C. canimorsus was diagnosed post-mortem. Further anamnestic information suggest that a small skin injury caused by a dog leash or the subsequent contact of this injury with the patient's dog could be the possible point of entry for these bacteria. CONCLUSION: During the acute phase of hyperinflammation and cytokine storm, laboratory results can resemble both, sepsis of bacterial origin or SARS-CoV-2. This means that even in the light of a global SARS-CoV-2 pandemic, where this diagnosis provides the most salient train of thoughts, differential diagnoses must be considered. Ag-RDT can contribute to early detection of a SARS-CoV-2 infection, but false-positive results may cause fixation errors with severe consequences for patient outcome.

Nursing Care for the Initial Resuscitation of Severe Sepsis Patients.

Sepsis is recognized as a major health care problem worldwide. In the United States, mortality from severe sepsis and septic shock remains a serious health problem; yet, the early recognition of sepsis by nurses reduces can reduce mortality, morbidity, and long-term consequences of sepsis for patients. Improving the knowledge of nurses to first recognize the early signs of sepsis and then how to apply the most up-to-date evidence-based treatments can improve outcomes. Enhanced monitoring includes the use of computerized early warning systems to alert nurses of worrisome clinical patterns and promote the early recognition of sepsis.

Severe acute respiratory syndrome coronavirus 2-related multisystem inflammatory syndrome in children mimicking Kawasaki disease.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has been characterized by high transmission rates and high mortality in adults with predisposing factors, including age>70 years, obesity, diabetes, systemic hypertension and other underlying diseases. During the second week of viral pneumonia, acute respiratory distress syndrome can occur and carries high mortality. Unlike most common respiratory viruses, children seem to be less susceptible to SARS-CoV-2 infection, and generally develop mild disease with low mortality. However, clusters of severe shock associated with high levels of cardiac biomarkers and unusual vasoplegia requiring inotropes, vasopressors and volume loading have recently been described. Both the clinical symptoms (i.e. high and persistent fever, gastrointestinal disorders, skin rash, conjunctival injection and dry cracked lips) and the biological signs (e.g. elevated C-reactive protein/procalcitonin and high levels of ferritinaemia) mimicked Kawasaki disease. In most cases, intravenous immunoglobin therapy improved cardiac function and led to full recovery within a few days. Adjunctive steroid therapy and sometimes biotherapy (e.g. anti-interleukin 1Ra and anti-interleukin 6 monoclonal antibodies) were often necessary. Although almost all children fully recovered within a week, some of them later developed coronary artery dilation or aneurysm. Thus, a new "multisystem inflammatory syndrome in children" related to SARS-CoV-2 has recently been described. Similarities with Kawasaki disease and the physiopathology of this syndrome still need further exploration.

[39-Year-Old Woman with Severe COVID-19 Pneumonia: Successful Weaning after Septic Shock and Forefoot Amputation after Microvascular Complications]. / 39-jährige Frau mit schwerer COVID-19-Pneumonie: Erfolgreiches Weaning nach septischem Schock und Vorfußamputation wegen mikrovaskulärer Komplikationen.

We present the case of a slightly obese 39-year-old patient with a severe course of COVID-19 pneumonia. The patient was referred from a hospital to regular care with suspected COVID-19 pneumonia. The initial clinical symptoms consisted of dysuria and fever. A bilateral infiltrate was seen in the chest x-ray. In the CT thorax, advanced COVID-19 typical changes were found on both sides. The COVID-19 infection was confirmed by a positive SARS-CoV-2 PCR from the nasopharynx smear. In the case of progressive ARDS with respiratory exhaustion, the patient was intubated and invasively ventilated. When a bacterial superinfection was suspected, we initiated empirical antibiotic therapy. In addition, a therapy with dexamethasone was applied. Therapy with ASA and weight-adapted semi-therapeutic low molecular weight heparin was also carried out. During the intensive care treatment the patient developed a fulminant septic shock with consecutive severe thrombocytopenia. A dilated tracheotomy was performed. The weaning progress was hampered by recurrent septic attacks. Necrosis in the area of ​​the right foot was identified as the cause of the septic relapses. As there was no alternative focus, surgical rehabilitation with partial amputation was carried out. The patient then remained infection-free and could be weaned from the respirator.

Complicated Monochorionic-Diamniotic Twins in a Pregnant Woman with COVID-19 in the Second Trimester.

OBJECTIVE: A majority of studies evaluating the risk of vertical transmission and adverse outcomes in pregnancies with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are mostly based on third-trimester infections. There is limited data available on pregnancy sequelae of maternal infection in the first or second trimester. STUDY DESIGN: We present a patient with monochorionic-diamniotic twins that develops coronavirus disease 2019 infection at 15 weeks of gestation. The pregnancy is further complicated by stage II twin-twin transfusion syndrome. She undergoes laser ablation, which is complicated by development of a subchorionic hematoma. The patient then develops Escherichia coli bacteremia, resulting in septic shock and preterm labor followed by previable delivery at 21 weeks of gestation. Amniotic fluid and placenta were negative for SARS-CoV-2 by real-time polymerase chain reaction. CONCLUSION: This case of SARS-CoV-2 argues against transplacental transmission after a second-trimester infection but brings attention to the possible downstream complications that may arise following early infection. KEY POINTS: · Vertical transmission of SARS-CoV-2 is not evident after a second-trimester infection.. · Antepartum coronavirus disease 2019 may cause vascular placental changes and placental insufficiency.. · SARS-CoV-2 is associated with a maternal hypercoagulable state with adverse perinatal outcomes..

Clinical aspects for differential diagnosis of Kawasaki disease shock syndrome: a case control study.

BACKGROUND: Because of the absence of a specific diagnostic test and pathognomonic clinical features, physicians must rely on the presence of specific clinical criteria and laboratory data that support the diagnosis of KD. To help clinicians distinguish KD, KDSS, septic shock, and TSS earlier, we suggest differential diagnosis and treatment guideline. METHODS: Medical records of immunocompetent patients who were admitted to the pediatric department with a diagnosis of KDSS, septic shock or TSS (SS group) were retrospectively reviewed. In addition, KD patients were selected by seasonal matching to each case of KDSS patient by date of admission (± 2 weeks). RESULTS: There were 13 patients with KDSS, 35 patients with SS group, and 91 patients with KD. In comparison between KDSS and septic shock group, KDSS group had significantly higher rate of coronary aneurysm incidence, and higher left ventricle dysfunction rate. In comparison between KDSS and TSS, patients with KDSS had a significantly higher erythrocyte sedimentation rate (ESR) and significantly lower creatinine. Receiver operation characteristic curve revealed that the optimal ESR cut off value for determining the KDSS was 56.0 (sensitivity 75.0%, specificity of 100.0%) and the optimal creatinine cut off value for determining the TSS was 0.695 (sensitivity 76.9%, specificity 84.6%). CONCLUSIONS: Clinical symptoms, laboratory finding, echocardiography, and culture studies can be used to differentiate KD, KDSS, septic shock and TSS.

[Risk factors for the early development of septic shock in patients with severe COVID-19].

AIM: In a retrospective study, we evaluated factors associated with the early development of septic shock in patients with severe COVID-19. MATERIALS AND METHODS: We collected medical records of the intensive care unit patients submitted by the local COVID-19 hospitals across Russia to the Federal Center for the Critical Care at the Sechenov First Moscow State Medical University (Sechenov University). Septic shock in crticially ill patients requiring mechanical ventilation was defined as a need in vasopressors to maintain blood pressure. RESULTS: We studied 1078 patients with severe COVID-19 who were admitted to the intensive care units for respiratory support. There were 611 males and 467 females. The mean age was 61.013.7 years. Five hundred twenty five medical records (48.7%) were received from the Moscow hospitals, 159 (14.7%) from the Moscow region, and 394 (36.5%) from the hospitals located in 58 regions of the Russian Federation. In 613 (56.9%) patients, diagnosis of SARS-CoV-2 infection was confirmed by PCR, and in the other cases it was established on the basis of the clinical picture and the results of the chest CT scan. Septic shock developed in 214 (19.9%) of 1078 patients. In the logistic regression model, the risk of septic shock in patients older than 50 years was higher than in patients of a younger age (OR 2.34; 95% CI 1.533.67; p0.0001). In patients with more severe SARS-CoV-2 infection, there was an increase in the prevalence of cardiovascular diseases, including coronary heart disease and atrial fibrillation, type 2 diabetes and malignant tumors. The risk of septic shock in patients with three or more concomitant diseases was higher than in patients without any concomitant chronic diseases (OR 1.76; 95% CI 1.762.70). CONCLUSION: The risk of septic shock in patients with acute respiratory distress syndrome induced by SARS-CoV-2 is higher in patients older than 50 years with concomitant diseases, although a severe course of the disease is also possible in younger patients without any concomitant disorders.

Respiratory viral sepsis: epidemiology, pathophysiology, diagnosis and treatment.

According to the Third International Consensus Definition for Sepsis and Septic Shock, sepsis is a life-threatening organ dysfunction resulting from dysregulated host responses to infection. Epidemiological data about sepsis from the 2017 Global Burden of Diseases, Injuries and Risk Factor Study showed that the global burden of sepsis was greater than previously estimated. Bacteria have been shown to be the predominant pathogen of sepsis among patients with pathogens detected, while sepsis caused by viruses is underdiagnosed worldwide. The coronavirus disease that emerged in 2019 in China and now in many other countries has brought viral sepsis back into the vision of physicians and researchers worldwide. Although the current understanding of the pathophysiology of sepsis has improved, the differences between viral and bacterial sepsis at the level of pathophysiology are not well understood. Diagnosis methods that can broadly differentiate between bacterial and viral sepsis at the initial stage after the development of sepsis are limited. New treatments that can be applied at clinics for sepsis are scarce and this situation is not consistent with the growing understanding of pathophysiology. This review aims to give a brief summary of current knowledge of the epidemiology, pathophysiology, diagnosis and treatment of viral sepsis.