Mortality and Morbidity of Human Metapneumovirus Infection in the Pre-COVID-19 Era: The Value of the Charlson Comorbidity Index on Outcome Prediction.

INTRODUCTION: Human metapneumovirus (HMPV) is an important cause of seasonal respiratory tract infections, mainly in children and immunocompromised adults. The use of the Charlson Comorbidity Index (CCI) to predict outcomes in hospitalized patients has been validated in several settings. OBJECTIVE: This study aims to describe the clinical characteristics of adult patients with HMPV infection and evaluate the value of the CCI in predicting outcomes in patients with acute HMPV infections requiring hospitalization. METHOD: This is a single-center case-series study of hospitalized patients with HMPV infection in 2017. RESULTS: Twenty-two adult patients with a mean age of 65 years were reviewed. The mean CCI was 4.6±2.6. The overall mortality was 22%. An abnormal chest X-ray (CXR) was reported in 15 patients. CCI was not different between survivors and non-survivors. Non-survivors were more likely to have abnormal CXR and a higher fever at the time of diagnosis, required mechanical ventilation, or had other concomitant infections. CONCLUSION: The average CCI was 4.5, which was not significantly different between survivors and non-survivors. The mortality rate was elevated by 22% and was likely associated with admission to the ICU as well as the presence of another concomitant infection.

Re-purposed drive-through vaccination set-up for Mpox, New York Metropolitan Area.

Background: This report details how one large medical center in the Metropolitan New York area re-purposed a drive-through COVID-19 vaccination structure to handle a surge in Mpox cases in July 2022.Methods/Results: Simultaneous to on-going COVID -19 vaccination and testing, Mpox vaccination was rolled out in the same drive through structure. More than 1,820 Jynneos (Smallpox and Monkeypox Vaccine, Live, Non-replicating) vaccine dosages were delivered subcutaneously and then intradermally to 1,123 individuals through the open window of their vehicles, averaging 8-10 patients an hour. Five vaccine recipients suffered Mpox rash; there was no exposure among healthcare providers. Conclusion: Drive-through vaccination is an efficient model to be redeployed for future unexpected vaccine initiatives.

The Impact of Post-COVID-19 Syndrome in Adolescents: A Pilot Study.

BACKGROUND:  Post-COVID-19 syndrome has emerged as a long-term complication in adults and children; its effect on adolescents' performance in school is not well studied. OBJECTIVES: To study the physical/psychological impact of prolonged post-COVID-19 symptoms on school performance. METHODS:  This is a cross-sectional study using Google Forms, a web-based fully anonymized survey of children in grades 10-12. RESULTS:  The study included 54 students with a mean age of 16 years of whom 32 had COVID-19. Two were hospitalized and 10 had symptoms lasting more than four weeks. Commonly reported chronic symptoms were fatigue and cough. Seven students quit sports; eight had a decrease in their academic performance. Adolescents being infected more than once or not being fully vaccinated were more likely to develop prolonged symptoms and quit sports while academic performance in school was not affected. Three out of 10 (30%) students who had COVID-19 and responded to the questionnaire reported not seeking help. CONCLUSION: Post-COVID-19 syndrome is associated with a decline in physical but not mental performance in school. Being infected more than once with SARS-CoV-2 seems to play an important role in the persistence of post-COVID-19 symptoms despite the fact that some adolescents are hesitant to seek medical or psychological care.

Significant increase in mortality and risk of acute ischemic stroke in infective endocarditis patients with subarachnoid hemorrhage secondary to mycotic aneurysms.

Infective Endocarditis (IE) patients are known to have a variety of complications with one of the rarest, but serious being cerebral mycotic aneurysm, which can result in subarachnoid hemorrhage (SAH). Using the National In-Patient Sample database, we sought to determine the rate of acute ischemic stroke (AIS) and outcomes in IE- patients with and without SAH. In total, we identified 82,844 IE-patients from 2010 to 2016, of which 641 had a concurrent diagnosis of SAH. IE patients with SAH had a more complicated course, higher mortality rate (OR 4.65 CI 95% 3.9-5.5, P < 0.001), and worse outcomes. This patient population also had a significantly higher rate of AIS (OR 6.3 CI 95% 5.4-7.4, P < 0.001). Overall, 41.5% of IE-patients with SAH had AIS during their hospitalization as compared to 10.1% of IE only patients. IE-patients with SAH were more likely to undergo endovascular treatment (3.6%) with 0.8% of the IE patients with AIS undergoing mechanical thrombectomy. While IE-patients are at risk for various complications, our study suggests a significant increase in the mortality and risk of AIS in those with SAH.

Acute myopericarditis due to human granulocytic anaplasmosis.

We present a case of a 54-year-old gentleman with a history of hypertension and chronic HIV who presented with fever and epigastric pain, found to have elevated troponin-I levels and diffuse ST-segement elevations on ECG without clinical evidence of ischemia concerning for myopericarditis. Initial laboratory findings also included thrombocytopenia and elevated aminotransferases as well as computed tomography imaging revealing splenic infarcts. Given plausible exposure to ticks, this led to the eventual diagnosis of anaplasmosis confirmed on PCR assay. Cardiac MRI images confirmed myocardial involvement, which resolved with antibiotic treatment. While rare, cardiac involvement is possible sequelae of anaplasmosis infection as illustrated by this case.

Personalised therapeutic approaches to glioblastoma: A systematic review.

Introduction: Glioblastoma is the most common and malignant primary brain tumour with median survival of 14.6 months. Personalised medicine aims to improve survival by targeting individualised patient characteristics. However, a major limitation has been application of targeted therapies in a non-personalised manner without biomarker enrichment. This has risked therapies being discounted without fair and rigorous evaluation. The objective was therefore to synthesise the current evidence on survival efficacy of personalised therapies in glioblastoma. Methods: Studies reporting a survival outcome in human adults with supratentorial glioblastoma were eligible. PRISMA guidelines were followed. MEDLINE, Embase, Scopus, Web of Science and the Cochrane Library were searched to 5th May 2022. Clinicaltrials.gov was searched to 25th May 2022. Reference lists were hand-searched. Duplicate title/abstract screening, data extraction and risk of bias assessments were conducted. A quantitative synthesis is presented. Results: A total of 102 trials were included: 16 were randomised and 41 studied newly diagnosed patients. Of 5,527 included patients, 59.4% were male and mean age was 53.7 years. More than 20 types of personalised therapy were included: targeted molecular therapies were the most studied (33.3%, 34/102), followed by autologous dendritic cell vaccines (32.4%, 33/102) and autologous tumour vaccines (10.8%, 11/102). There was no consistent evidence for survival efficacy of any personalised therapy. Conclusion: Personalised glioblastoma therapies remain of unproven survival benefit. Evidence is inconsistent with high risk of bias. Nonetheless, encouraging results in some trials provide reason for optimism. Future focus should address target-enriched trials, combination therapies, longitudinal biomarker monitoring and standardised reporting.

Mpox in the New York metropolitan area, Summer 2022.

Early in the 2022 Mpox (MPX) global outbreak, caseloads in the New York Metropolitan area climbed rapidly before other US urban areas. This case series summarizes the authors' clinical experience detecting and treating MPX, during a quickly evolving outbreak. Clinical outcomes were recorded with a focus on varied clinical presentation and outcomes such as complications and response to experimental tecovirimat therapy. A focal or multifocal rash was the most common presenting symptom in 91% of patients. Almost two-thirds (62%) of patients had anogenital involvement. Proctitis was one of the most painful presentations with 75% requiring antiviral treatment and three patients needing hospitalization for pain management. Most patients responded promptly to antiviral treatment with tecovirimat. Five out of 10 patients treated with tecovirimat reported symptom resolution within 48-72 h of therapy and another three saw resolution within first 96 h. Two patients had poor response to tecovirimat. This series includes the only reported case of an HIV positive, immunocompetent patient who experienced recurrent anal ulcers due to Mpox and required a second course of tecovirimat. Other unique presentations included urethritis, abscess formation and MPX infection postvaccination. Control of this current Mpox outbreak was possible due to timely diagnosis and the availability of both a licensed vaccine and an investigational drug.

Tremor as a symptom of degenerative cervical myelopathy: a systematic review.

BACKGROUND: AO Spine RECODE-DCM (Research objectives and common data elements for degenerative cervical myelopathy) has highlighted that the subjective disability reported by people living with DCM is much broader than routinely considered today by most professionals. This includes a description of tremor. The objective of this review was to study the incidence and possible aetiology of tremor in degenerative cervical myelopathy (DCM). METHODS: A systematic review registered in PROSPERO (CRD42020176905) was conducted in Embase and MEDLINE for papers studying tremor and DCM published on or before the 20th of July 2020. All manuscripts describing an association between tremor and DCM in humans were included. Articles relating to non-human animals, and those not available in English were excluded. An analysis was conducted in accordance with PRISMA and SWiM guidelines for systematic reviews. RESULTS: Out of a total of 4402 screened abstracts, we identified 7 case reports and series describing tremor in 9 DCM patients. Papers were divided into three groups for the discussion. The first group includes DCM correctly identified on presentation, with tremor as a described symptom. The second group includes cases where DCM was misdiagnosed, often as Parkinson's disease. The third group includes a single case with a previous history of DCM, presenting with an otherwise unexplained tremor. This grouping allows for the clustering of cases supporting various arguments for the association between tremor and DCM. CONCLUSION: DCM can be associated with tremor. The current evidence is restricted to case series. Further study is warranted to establish tremor prevalence, and its significance to assessment and management.

Hypothermia is Associated With Poor Prognosis in Hospitalized Patients With Severe COVID-19 Symptoms.

Rationale Hypothermia forms a part of the diagnostic criteria for Systemic Inflammatory Response Syndrome (SIRS), National Early Warning Score (NEWS) and has repeatedly been shown to be associated with worse outcomes when compared to normothermic and hyperthermic patients with sepsis. We evaluate whether this is the case in COVID-19 patients. Objective To determine whether there is an association between hypothermia and worse prognosis in COVID-19 patients in the intensive care unit. Methods Retrospective study of a cohort of patients (n = 57) admitted to the intensive care unit of a community hospital with a positive test for COVID-19. Measurements Data relating to mortality, comorbidities and length of stay was recorded from electronic medical records for each patient. Hypothermia was defined as ≥2 recorded body temperatures of less than 96.5℉ (35.83℃) at the time of admission. Main results Of the 57 patients enrolled in the study, 21 developed hypothermia during their stay and 36 did not. Our results show that patients who have hypothermia at the time of admission spend a longer time intubated (p < 0.01) and go through longer ICU stays (p < 0.01). These patients are also 2.18 times more likely to suffer a fatal outcome compared to patients that did not develop hypothermia while in the intensive care unit (Chi-squared = 8.6209, p < 0.01, RR = 2.18). Conclusions Hypothermia in patients with severe COVID-19 at the time of admission to the ICU is associated with poorer outcomes for patients. This manifests as a longer period of intubation, longer ICU stay, and increased risk of mortality.

Corynebacterium Jeikeium Endocarditis: A Review of the Literature.

Corynebacterium jeikeium is a gram-positive, aerobic, pleomorphic, nonspore forming bacillus, commonly present on the skin surface. Infective endocarditis secondary to C. jeikeium most commonly affects left-sided heart valves and has a higher likelihood to require valve replacement compared to other Corynebacterium endocarditis. C. jeikeium endocarditis is extremely difficult to treat as it is characteristically resistant to penicillin, cephalosporins and aminoglycosides, and sensitivity to quinolones, macrolides, tetracyclines and rifampin is variable. Despite treatment, mortality rates as high as 33% have been reported. We hereby review the literature regarding the epidemiology, diagnosis and treatment of this deadly microorganism.

Clostridium septicum aortitis: A kiss of the devil.

BACKGROUND: Clostridium septicum aortitis is a lethal infection. C. septicum has a strong association with an underlying malignancy, most commonly in the colon. AIM: Early identification methods and management strategies of C. Septicum infection. MATERIALS AND METHODS: We present a 64-year-old man with aortic aneurysm and C. septicum bacteremia with unknown malignancy who passed away on the fourth day of hospitalization despite emergent endovascular intervention. Computed tomography showed periaortic gas which is the hallmark of infection. DISCUSSION: This case report highlights the need of prompt surgical treatment and its different modalities along with the early use of appropriate antibiotics due to the rapid spread of infection associated with high fatality. The authors also discuss the association of C. septicum aortitis with underlying occult malignancies. CONCLUSION: Delay in identification and treatment of C. Septicum is associated with very high mortality rates.

Co-infections in Persons with Early Lyme Disease, New York, USA.

In certain regions of New York state, USA, Ixodes scapularis ticks can potentially transmit 4 pathogens in addition to Borrelia burgdorferi: Anaplasma phagocytophilum, Babesia microti, Borrelia miyamotoi, and the deer tick virus subtype of Powassan virus. In a prospective study, we systematically evaluated 52 adult patients with erythema migrans, the most common clinical manifestation of B. burgdorferi infection (Lyme disease), who had not received treatment for Lyme disease. We used serologic testing to evaluate these patients for evidence of co-infection with any of the 4 other tickborne pathogens. Evidence of co-infection was found for B. microti only; 4-6 patients were co-infected with Babesia microti. Nearly 90% of the patients evaluated had no evidence of co-infection. Our finding of B. microti co-infection documents the increasing clinical relevance of this emerging infection.

Babesiosis as a cause of acute respiratory distress syndrome: a series of eight cases.

OBJECTIVES: The characteristics of patients with Acute Respiratory Distress Syndrome (ARDS) as a complication of Babesia microti infection have not been systematically described. METHODS: Adult patients admitted to the medical intensive care unit (MICU) of a tertiary care hospital in the Lower Hudson Valley of New York from 1/1/2008 to 8/1/2016 were evaluated for ARDS complicating babesiosis. RESULTS: Of 22 patients with babesiosis in the MICU, eight (36.4%; 95% CI: 19.7-57.0%) had ARDS. Six patients (75%) developed ARDS following initiation of anti-babesia drug therapy; however, the mean duration of symptoms in these patients exceeded that of patients who developed ARDS prior to initiation of treatment (7.50 ± 3.83d vs. 4.50 ± 0.71d, p = 0.34). Three patients (37.5%; 95% CI: 13.7-69.4%) expired without recovery from ARDS. In comparison, the mortality rate for the 14 MICU babesiosis patients without ARDS was 14.3% (p = 0.31). There was a trend toward younger age in survivors relative to non-survivors (mean age 54.6 ± 13.8y vs. 74.0 ± 6.24y, p = 0.07). Three of the five survivors did not require mechanical ventilation. The mean sequential organ failure assessment score of non-survivors was significantly higher than that of survivors (12.3 ± 1.15 vs. 6.0 ± 1.4, p = 0.0006). CONCLUSION: Among 22 critically ill adult patients with B. microti infection, ARDS developed in eight (35.4%), and three (37.5%) expired without resolution of the ARDS. ARDS often followed the initiation of anti-babesia drug therapy, raising the question of whether the death of the parasite per se contributed to its development. However, this observation was confounded by the longer duration of symptoms preceding initiation of drug therapy.

Primary Klebsiella pneumoniae Osteomyelitis with Bacteremia and Sepsis in a Patient with Cirrhosis.

Osteomyelitis is commonly caused by Staphylococci, Streptococci, Escherichia coli, and anaerobes. There have been cases of rare organisms like Klebsiella pneumoniae (Kp) being initially overlooked as causes of osteomyelitis. We report a case of an elderly cirrhotic adult male transferred for further management of liver failure, who was subsequently diagnosed with Kp osteomyelitis and sepsis. He had a history of blunt leg trauma, and MRI of the leg revealed osteomyelitis, with a negative workup for other sources of infection. Kp osteomyelitis is reported in less than 100 cases, mainly in pediatric and sickle-cell patients. There are no pathognomonic imaging findings. Lesions may be metastatic, with rapid widespread destruction and exuberant periosteal reaction. Kp is a rare, under recognized cause of osteomyelitis in immune-suppressed adults. Given its pathogenicity, early identification is critical.

Potential role of deer tick virus in Powassan encephalitis cases in Lyme disease-endemic areas of New York, U.S.A.

Powassan virus, a member of the tick-borne encephalitis group of flaviviruses, encompasses 2 lineages with separate enzootic cycles. The prototype lineage of Powassan virus (POWV) is principally maintained between Ixodes cookei ticks and the groundhog (Marmota momax) or striped skunk (Mephitis mephitis), whereas the deer tick virus (DTV) lineage is believed to be maintained between Ixodes scapularis ticks and the white-footed mouse (Peromyscus leucopus). We report 14 cases of Powassan encephalitis from New York during 2004-2012. Ten (72%) of the patients were residents of the Lower Hudson Valley, a Lyme disease-endemic area in which I. scapularis ticks account for most human tick bites. This finding suggests that many of these cases were caused by DTV rather than POWV. In 2 patients, DTV infection was confirmed by genetic sequencing. As molecular testing becomes increasingly available, more cases of Powassan encephalitis may be determined to be attributable to the DTV lineage.

Diagnostic challenges in Balamuthia mandrillaris infections.

Balamuthia mandrillaris is an emerging cause of subacute granulomatous amebic encephalitis (GAE). The diagnosis of this infection has proven to be difficult and is usually made postmortem. Early recognition and treatment may offer some benefit. This report describes a previously healthy woman who died from GAE due to B. mandrillaris.

Diagnosis of acute deer tick virus encephalitis.

BACKGROUND: Deer tick virus (DTV) is a tick-borne flavivirus that has only recently been appreciated as a cause of viral encephalitis. We describe the clinical presentation of a patient who had DTV encephalitis diagnosed before death and survived for 8 months despite severe neurologic dysfunction. METHODS: Diagnosis was made from a cerebrospinal fluid specimen, using a flavivirus-specific polymerase chain-reaction assay followed by sequence confirmation, and the phylogeny was analyzed. Serologic testing, including plaque reduction neutralization testing, was also performed. RESULTS: Molecular analysis indicated that the virus was closely related to 2 strains of DTV that had been detected in Ixodes scapularis ticks from Massachusetts in 1996 and in the brain of a patient from New York in 2007. CONCLUSIONS: DTV encephalitis should be considered in the differential diagnosis of encephalitis in geographic areas that are endemic for Lyme disease.

Aspergillus osteomyelitis of the lumbar spine complicated with orbital apex syndrome: A potential role of the Batson's plexus in disease propagation.

We report a rare case of orbital apex syndrome following epidural steroid injections of the lumbar spine in an immunocompetent individual with osteomyelitis and discitis caused by Aspergillus fumigatus. We suspect that the craniospinal venous system, also known as the Batson's plexus, was the main route for steroid-facilitated disease propagation from the spine to intracranial structures.

Non-surgical management of spontaneous splenic rupture due to Babesia microti infection.

Babesiosis is an emerging tick-borne infection. We describe 2 hospitalized patients from the United States with spontaneous splenic rupture attributable to Babesia microti infection. The first patient was a 36-year-old previously healthy man with a low-grade splenic rupture not requiring surgical intervention. The second was a 70-year-old healthy man whose splenic rupture required proximal splenic artery embolization. Since the spleen is an important organ involved in controlling Babesia infection, management of splenic rupture in an infected patient using an organ preserving approach when appropriate may be preferred.