Pneumocystis jirovecii pneumonia complicated a case of SARS-CoV-2 infection and multiple sclerosis after treatment with rituximab.

Although immunodeficient patients are less prone to develop Coronavirus disease 2019 (COVID-19)-mediated cytokine storm, secondary infections can cause serious complications in this vulnerable population. They are more likely to develop opportunistic infections that can mimic the symptoms of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Herein, we presented a 27-year-old male patient of SARS-CoV-2 infection, who was complicated with Pneumocystis jirovecii pneumonia (PJP), following treatment with rituximab. First, he was hospitalized for 5 days with fever, cough, and dyspnea due to COVID-19 infection, and treated with remdesivir and glucocorticoid. Then, he has been referred to our center with cough, dyspnea, body pain, and fever. Due to persistent fever, the progression of pulmonary lesions, and reduced oxygen saturation, we began treatment with piperacillin + tazobactam, vancomycin, and levofloxacin. Nevertheless, the patient's fever did not stop after the aforementioned empiric treatment and his condition got worse and he was admitted to the intensive care unit. The result of BAL fluid, tested for P. jirovecii by RT-PCR, turned out to be positive. Therefore, we started trimethoprim-sulfamethoxazole and dexamethasone, which improved his condition. We hope this article helps clinicians consider causes other than COVID-19, especially opportunistic infections such as PJP, in patients with respiratory symptoms and fever.

Vaccination status and outcomes of COVID-19 patients admitted to a tertiary hospital in Iran during the dominant Delta variant period.

BACKGROUND: This study aimed to determine the characteristics, vaccination status, and outcomes of confidence interval (COVID-19) patients, admitted to a tertiary hospital in Iran during the predominant severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) Delta variant period. METHODS: This retrospective study assessed the medical records of all hospitalized COVID-19 patients, who were admitted to a tertiary hospital from July 10 to September 15, 2021. Adjusted binary logistic regression analyses were conducted to determine factors associated with poor outcomes. RESULTS: More than 25% of hospitalized patients received at least one vaccine dose of SARS-CoV-2. The Sinopharm BIBP vaccine (China) was the most commonly received vaccine (73.3%). After adjusting for age and comorbidities, the adjusted odds ratio (AOR) for poor outcomes was significantly lower in hospitalized patients who received Remdesivir compared to those not receiving Remdesivir (AOR: 0.35; 95% confidence interval [CI]: 0.15, 0.78; p < .010). Besides, age ≥50 years (AOR: 2.51; 95% CI: 1.38, 4.59; p < .003), low educational level (AOR: 3.99; 95% CI: 1.17, 13.53; p < .027), work outside in the past year (AOR: 1.75; 95% CI: 1.02, 3.00; p < .041), and diabetes mellitus (AOR: 1.95; 95% CI: 1.66, 3.26; p = .011) were associated with more poor outcomes. CONCLUSION: Based on the present results, the risk of mortality and the risk of poor outcomes were lower in patients who received Remdesivir compared to those not receiving Remdesivir. The number of vaccinated patients was smaller than the unvaccinated among hospitalized patients. It is important to emphasize that vaccination reduced the need for hospitalization and that only vaccinated patients with comorbidities required hospitalization.

One-year prevalence and the association between SARS-CoV-2 cycle threshold, comorbidity and outcomes in population of Babol, North of Iran (2020-2021)

Background: The present study aimed to investigate the one-year prevalence of SARS-CoV-2, common comorbidities and demographic information among negative- and positive rRT-PCR in health care workers (HCW), hospitalized and outpatients. Also, the association between SARS-CoV-2 cycle threshold (Ct) and the outcomes of patients were analyzed in Babol, northern Iran. Methods: This large retrospective cross-sectional study was performed between March 2020 and March 2021. The records of 19232 hospitalized, outpatients and HCW suspected to COVID-19 were collected from teaching hospitals in the North of Iran. Results: Out of the 19232 suspected to COVID-19 patients, 7251 (37.7%) had a positive rRT-PCR result;652 (9%), 4599 (63.4%) and 2000 (27.6%) of those were categorized as HCW, hospitalized and outpatients, respectively. Moreover, between the hospitalized and the outpatient group, 10.2 and 0.8% cases died, whereas no death cases were reported in the HCW. Furthermore, it seems that death rate was significantly different between the three groups of Ct value, the highest mortality in those with Ct between 21 and 30 (group B=7.6%) and the lowest in the group with the highest Ct (between 31 and 40 = 5.5%) (p<0.001). Conclusion: In summary, 37.7% of cases were positive for SARS-CoV-2;of which, 63.4, 27.6 and 9% were hospitalized, outpatients and HCW, respectively. With regard to the mortality rate in hospitalized patients and the significant association with Ct under 20 and 30, it seems that the early detection and the initial quantification of SARS-CoV-2 in the first week of the conflict and therapeutic considerations to reduce the relative load can reduce the mortality rate.

Thrombotic thrombocytopenia After Sinopharm BBIBP-CorV COVID-19 vaccination.

Background: Severe side effects after vaccination with coronavirus disease 2019 (COVID-19) vaccines are rare but can be fatal. To date, vaccine-induced immune thrombotic thrombocytopenia (VITT) cases have been reported after injection of mRNA and adenoviral vectors COVID-19 vaccines. Here, we report the second suspected case of VITT after vaccination with the Sinopharm vaccine, an inactive vaccine. Key Clinical Question: The Key Clinical Question was to determine whether inactivated COVID-19 vaccines could induce VITT and how to diagnose and treat such cases. Clinical Approach and Conclusions: Our patient developed deteriorating symptoms the day after vaccination and was admitted to the emergency department on day 5 after vaccination. After performing laboratory analysis, thrombosis with thrombocytopenia was suggested, further confirmed by highly positive anti-heparin-platelet factor 4 antibodies assay and color Doppler ultrasonography. He was then treated with high-dose intravenous immunoglobulin, corticosteroid, and nonheparin anticoagulant.

A Large Retrospective Study of Epidemiological Characteristics of COVID-19 Patients in the North of Iran: Association between SARS-CoV-2 RT-PCR Ct Values with Demographic Data

Objectives To avoid worsening from mild, moderate, and severe diseases and to reduce mortality, it is necessary to identify the subpopulation that is more vulnerable to the development of COVID-19 unfavorable consequences. This study aims to investigate the demographic information, prevalence rates of common comorbidities among negative and positive real-time reverse-transcriptase polymerase chain reaction (rRT-PCR) patients, and the association between SARS-CoV-2 cycle threshold (Ct) at hospital admission, demographic data, and outcomes of the patients in a large population in Northern Iran. Methods This large retrospective cross-sectional study was performed from 7 March to 20 December 2020. Demographic data, including gender, age, underlying diseases, clinical outcomes, and Ct values, were obtained from 8,318 cases suspected of COVID-19, who were admitted to four teaching hospitals affiliated to Babol University of Medical Sciences (MUBABOL), in the north of Iran. Results Since 7 March 2020, the data were collected from 8,318 cases suspected of COVID-19 (48.5% female and 51.5% male) with a mean age of 53 ± 25.3 years. Among 8,318 suspected COVID-19 patients, 3,250 (39.1%) had a positive rRT-PCR result;1,632 (50.2%) patients were male and 335 (10.3%) patients died during their hospital stay. The distribution of positive rRT-PCR revealed that most patients (464 (75.7%)) had a Ct between 21 and 30 (Group B). Conclusion Elderly patients, lower Ct, patients having at least one comorbidity, and male cases were significantly associated with increased risk for COVID-19-related mortality. Moreover, mortality was significantly higher in patients with diabetes, kidney disease, and respiratory disease.

Reduced frequency of T helper 17 and T helper 1 cells and their association with critical coronavirus disease 2019.

There is very little knowledge about the immune responses, particularly cellular immunity to coronavirus disease 2019 (COVID-19). The main objective of this study was to evaluate the frequency of T helper (Th) cell subtypes, including Th1, Th17, and Treg cells, in moderate-to-severe and critical COVID-19 patients compared to healthy controls. Twenty-nine moderate-to-severe and 13 critical patients confirmed for COVID-19, and 15 healthy subjects were included in this study. Interferon-γ (IFN-γ)-producing Th1 and interleukin-17A-producing Th17 and Treg cells in peripheral blood were measured with flow cytometry. The frequency of Th1 and Th17 was significantly decreased in critical patients compared to healthy subjects (aMD: -2.76 and - 2.34) and moderate-to-severe patients (aMD: -1.89 and - 1.89), respectively (p < 0.05). Differences were not significant between moderate-to-severe patients and healthy subjects for both Th1 (p = 0.358) and Th17 (p = 0.535), respectively. In contrast, significant difference was not observed between study subjects regarding the frequency of Treg cells. Patients with critical COVID-19 had a markedly lower Th1/Treg and Th17/Treg ratios compared with the controls and moderate-to-severe cases. Our study showed a dysregulated balance of Th1 and Th17 cells and its relation to the severity of COVID-19.

Effectiveness of extracorporeal blood purification (hemoadsorption) in patients with severe coronavirus disease 2019 (COVID-19).

BACKGROUND: Extracorporeal blood purification has been proposed as one of the therapeutic approaches in patients with coronavirus infection, because of its beneficial impact on elimination of inflammatory cytokines. METHODS: This controlled trial has been conducted on critically ill COVID-19 patients admitted in the state hospital affiliated to Babol University of Medical Sciences, Iran who received different antiviral and antibacterial drugs, and different modalities of respiratory treatments and did not have positive clinical improvement. No randomization and blindness was considered. All of the participants underwent three sessions of resin-directed hemoperfusion using continuous renal replacement therapy with a mode of continuous venovenous hemofiltration (CVVH). RESULTS: Five men and five women with a mean age of 57.30 ± 18.07 years have been enrolled in the study; and six of them have improved after the intervention. Peripheral capillary oxygen saturation (SpO2) changed after each session. Mean SpO2 before the three sessions of hemoperfusion was 89.60% ± 3.94% and increased to 92.13% ± 3.28% after them (p < 0.001). Serum IL-6 showed a reduction from 139.70 ± 105.62 to 72.06 ± 65.87 pg/mL (p = 0.073); and c-reactive protein decreased from 136.25 ± 84.39 to 78.25 ± 38.67 mg/L (P = 0.016). CONCLUSIONS: Extracorporeal hemoadsorption could improve the general condition in most of recruited patients with severe coronavirus disease; however, large prospective multicenter trials in carefully selected patients are needed to definitely evaluate the efficacy of hemoperfusion in COVID-19 patients. TRIAL REGISTRATION: The research protocol has been registered in the website of Iranian Registry of Clinical Trials with the reference number IRCT20150704023055N2 .