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Two cases of Rhinocladiella mackenziei have been noted in our institute, the first case in 2015 (post-renal transplant) and the second case in 2021 (post-COVID infection). Both the patients had received immunosuppressants for varying dura-tion. Both the cases presented to the hospital with neurological deficit secondary to brain abscess. On initial assessment, the melanized fungus was noted which was later identified as Rhinocladiella on culture and further confirmed with molecular meth-ods. Both the cases were treated with injection of L AmB, voriconazole and 5FC for a prolonged duration and later discharged when the condition improved. The renal transplant patient was advised lifelong voriconazole since he would continue to be on immunosuppressants. To our knowledge, the second patient diagnosed post-COVID could be the first case report of invasive dematiaceous fungal infection in an apparently immunocompetent individual. Both cases also highlight the challenges in man-agement such as designing an appropriate regimen, deciding the optimum duration of antifungal therapy, and managing the toxicities associated with long-term antifungal use. R. mackenziei is a frequently fatal melanized neurotropic fungus known to carry almost 100% mortality despite the combination of antifungal agents and surgery. Central nervous system infections due to R. mackenziei have been exclusively reported from the Middle East, except for cases recently reported from India.
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This report describes the case of a man affected by Myosin Heavy Chain 9 (MYH9)-related platelet disorder, with a recent history of SARS-CoV-2 pneumonia, who developed pulmonary embolism (PE). At the admittance the patient presented a marked thrombocytopenia. The rotational thromboelastometry (ROTEM) showed a reduction in maximum clot firmness. The CT scan showed a lobar PE while and no sign of superficial or deep venous thrombosis was found. Given the contraindication of anticoagulant therapy due to severe thrombocytopenia, after collegial evaluation of the case, an inferior vena cava filter was applied. The patient was discharged after 5 days of hospitalization, and fondaparinux 2.5 mg subcutaneously was prescribed for two months. Could MYH9 mutation contribute to thrombotic predisposition? Or rather the endothelial dysfunction induced by SARS-CoV-2 infection? The report presents a dissertation on the possible causes for the PE and describes the therapeutic strategy adopted. (www.actabiomedica.it).
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Background and Aims: Subclinical atrial fibrillation (SCAF) is an asymptomatic, short and fast atrial arrhythmia observed during long-term monitoring. SCAF incidence ranges between 5-15% in critical illness and is associated to an increased risk of one-yeardeath, while its role in thromboembolism is debated. With this pilot study, we assessed SCAF incidence in a longitudinal cohort of moderate-to-severe CoViD-19, evaluating its association with inhospital death, major bleeding or thromboembolism. Methods: We considered all the subjects admitted to our subintensive medicine department for moderate-to-severe CoViD-19 undergoing to continuous ECG monitoring for at least seven consecutive days, evaluating the occurrence of SCAF daily. We also collected history, ECG, age, sex, occurrence of in-hospital death, thromboembolism and major bleeding. Results: Of 34 consecutive patients, 4 were excluded for pre-existing atrial fibrillation. We analysed 30 subjects who completed ECG monitoring: mean age was 66±14.8 years, 47% were females. SCAF incidence was 20% in 7 days. During the admission we observed 6(20%) deaths, 2(6%) thromboembolic events and 2(6%) major bleedings, with no relationship with SCAF occurrence. SCAF was more frequently observed in severe than in moderate CoViD-19 (p=0.0001). Conclusions: SCAF shows high incidence in CoViD-19, especially within a severe disease. This pilot study did not underline an association with short-term events: we are expanding our cohort and performing a longer follow-up to validate our data and to assess associations with post-CoViD events.
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Background and Aims: Subclinical atrial fibrillation (SCAF) is defined as a fast, asymptomatic and self-terminating arrhythmic event, often diagnosed by long-term monitoring. We observed a high SCAF prevalence in moderate-to-severe CoViD-19. We aimed to assess the determinants of SCAF in this cohort. Methods: All the consecutive patients affected by moderate-tosevere CoViD-19 admitted in a subintensive CoViD-19 unit were enrolled;each patient was submitted to continuous ECG monitoring for 7 days;for each subject, we collected - at the admission - age, sex, BMI, history of heart failure, history of hypertension, history of COPD, LUSS score, 12-leads ECG (calculating intervals and assessing the most common alterations), BNP, Troponin I and PaO2/FiO2. Results: We obtained 34 consecutive patients;4 patients were excluded for pre-existing atrial fibrillation;SCAF was observed in 20% of the sample;age, sex, BMI, history of heart failure, hypertension and COPD, all the ECG intervals (PR, QRS and ST), ECG alterations (atrioventricular blocks, intraventricular blocks, hypertrophy or ischemia), BNP, Troponin I and PaO2/FiO2 did not result statistically associated with SCAF. Patient developing SCAF had a higher LUSS score resulted significantly associated to SCAF (LUSS in no-SCAF: 15.36±5,38;LUSS in SCAF: 20,0±4,27;p=0,027), even after Bonferroni correction. Conclusions: SCAF has a high prevalence in CoViD-19 and seems to be correlated more to the disease severity than to the classical risk factors for atrial fibrillation. Larger cohorts are required to validate our observations.
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BACKGROUND: Published reports on tocilizumab in COVID-19 pneumonitis show conflicting results due to weak designs or heterogeneity in critical methodological issues. METHODS: This open-label trial, structured according to Simon's optimal design, aims to identify factors predicting which patients could benefit from anti-IL6 strategies and to enhance the design of unequivocal and reliable future randomized trials. A total of 46 patients with COVID-19 pneumonia needing of oxygen therapy to maintain SO2 > 93% and with recent worsening of lung function received a single infusion of tocilizumab. Clinical and biological markers were measured to test their predictive values. Primary end point was early and sustained clinical response. RESULTS: Twenty-one patients fulfilled pre-defined response criteria. Lower levels of IL-6 at 24 h after tocilizumab infusion (P = 0.049) and higher baseline values of PaO2/FiO2 (P = 0.008) predicted a favourable response. CONCLUSIONS: Objective clinical response rate overcame the pre-defined threshold of 30%. Efficacy of tocilizumab to improve respiratory function in patients selected according to our inclusion criteria warrants investigations in randomized trials.