A retrospective comparison between influenza and COVID-19-associated ARDS in a Croatian tertiary care center.

BACKGROUND: Since the beginning of the Corona virus disease 2019 (COVID-19) pandemic the new Severe acute respiratory syndrome coronoavirus 2 (SARS-CoV­2) virus has been repeatedly compared to the influenza virus; however, the comparison of invasively mechanically ventilated patients with acute respiratory distress syndrome (ARDS) caused by these viruses is very scarce. The purpose of this study was to compare clinical course and laboratory parameters between the most severely ill flu and COVID 19 patients treated with invasive mechanical ventilation (IMV). METHODS: The study was conducted at the intensive care unit (ICU) of the tertiary care hospital in Zagreb, Croatia in the period between November 2018 and July 2020. Investigation included 72 adult patients requiring IMV due to influenza or SARS-CoV­2 virus infection and 42 patients had influenza and 30 had SARS-CoV­2 virus infection and the comparison between two etiological groups was conducted. RESULTS: Invasively mechanically ventilated patients with COVID 19 and influenza differ in certain aspects. COVID 19 patients are older, male, have lower C-reactive protein (CRP) levels and have less need for extracorporeal membrane oxygenation (ECMO) support. In other measured variables, including mortality, the difference between influenza or SARS-CoV­2 etiology was not significant. CONCLUSION: High mortality of IMV patients with influenza and COVID 19 with 55% and 63%, respectively, challenges and urges medical and especially ICU community to expand our quest for further treatments, especially since ECMO use that is scarcely required in COVID 19 patients probably has limited impact in reducing mortality in COVID 19 patients.

Presepsin values as markers of severity of sepsis.

OBJECTIVES: Biomarkers are widely used for rapid diagnosis of sepsis. This study evaluated the diagnostic accuracy of presepsin, procalcitonin (PCT), and C-reactive protein (CRP) in differentiating sepsis severity as well as their association with Sepsis-related Organ Failure Assessment (SOFA) score. METHODS: One hundred septic patients from two university clinical centers were enrolled in the study during two time periods. New Sepsis-3 definitions were used for sepsis stratification. Biomarkers and SOFA score were evaluated four times during the illness. A sandwich ELISA kit was used for presepsin measurement. Generalized linear mixed effects model was used to test the changes in biomarkers concentrations and SOFA score values during the illness and to estimate the differences between severity groups. Multivariate analysis was used to test the association of biomarkers with SOFA score. RESULTS: Presepsin concentrations were significantly higher on admission in patients with septic shock (n = 34) compared to patients with sepsis (n = 66), mean ± SD: 128.5 ± 47.6 ng/mL vs. 88.6 ± 65.6 ng/mL, respectively (p < 0.001). The same was not observed for PCT and CRP; their concentrations did not differ significantly between severity groups. A strong correlation of presepsin with SOFA score was also found (p < 0.0001). CONCLUSIONS: Presepsin had a good diagnostic ability to differentiate septic shock from sepsis in the study groups. PCT and CRP failed in differentiating sepsis severity.

A case report of severe recurrent varicella in an ankylosing spondylitis patient treated with adalimumab - a new side effect after 15 years of usage.

BACKGROUND: Tumor necrosis factor-α (TNF-α) antagonists, most of which are monoclonal antibodies, became a widespread treatment for autoimmune diseases such as rheumatoid arthritis, ankylosing spondylitis, inflammatory bowel diseases, psoriasis, psoriatic arthritis, hidradenitis suppurativa and uveitis. Their use is based on the blockage of TNF-α, which plays an important role in granulomas formation, development of phagosomes, activation and differentiation of macrophages, immune response against viral pathogens. The multiple adverse effects of TNF-α inhibition have been identified, including a two-to four-fold increased risk of active tuberculosis and other granulomatous conditions and an increased occurrence of some other serious bacterial, fungal and certain viral infections. CASE PRESENTATION: A 34-year-old male patient with disseminated varicella and pneumonitis was admitted to our hospital. The diagnosis of varicella was established serologically by enzyme immunoassay (EIA) and by polymerase chain reaction confirmation of the virus in vesicular fluid. The patient has been receiving adalimumab and methotrexate for the last 3 years due to ankylosing spondylitis and was seropositive to varicella zoster virus prior to the introduction of TNF-α antagonists. Acyclovir was administered for 10 days with the resolution of clinical illness and radiological signs of pneumonitis. CONCLUSION: Due to the use of biological agents, particularly TNF-α inhibitors, as a well-established therapy for some autoimmune diseases, new potential adverse events can be expected in the future and we wanted to point out one of them. To our knowledge this is the first case of recurrent disseminated varicella in a patient taking TNF-α antagonists.