Secondary organizing pneumonia associated with protracted COVID: A case series.

OBJECTIVES: Immunocompromised B-cell-depleted patients are at risk of developing protracted COVID-19, a clinical syndrome characterized by prolonged viral shedding and respiratory symptoms that can lead to hypoxemic pneumonia. Our aim is to describe this unusual condition and its treatment. PATIENTS AND METHODS: This monocentric retrospective study reports six cases of severe organizing pneumonia that developed during the clinical course of protracted COVID-19. RESULTS: All patients developed organizing pneumonia (OP) in the setting of protracted COVID. Clinical improvement was obtained after several treatment lines including specific antiviral agents and occurred simultaneously with control of the viral load. CONCLUSION: As it was the most frequent presentation of protracted COVID-19 in our survey, we believe that this specific form of organizing pneumonia warrants increased awareness. Furthermore, specific antiviral therapy seems to control this condition.

Clinical characteristics and humoral immune response in healthcare workers with COVID-19 in a teaching hospital in Belgium.

BACKGROUND: Healthcare workers (HCWs) are at high risk of acquiring COVID-19 and could play a role in nosocomial transmission. Since 4th February 2020, Belgian Health authorities reported more than 90,568 cases, of which 8.3% were HCWs. Data on clinical characteristics, sources of infection and humoral immune response of HCWs with COVID-19 remain scarce. AIM: To analyse the clinical characteristics, humoral immune response, sources of contamination, and outcomes among HCWs with COVID-19. METHODS: This retrospective study included 176 HCWs with laboratory-confirmed COVID-19 in a teaching hospital in Belgium. Between 1st March and 31st May 2020, all HCWs with symptoms suspected of COVID-19 were tested by reverse transcription polymerase chain reaction on a nasopharyngeal swab. Serological testing was performed between 55 and 137 days after the onset of symptoms. FINDINGS: Median age was 40.8 years and 75% were female. Median delay between onset of symptoms and diagnosis was 4.39 days. Most frequent symptoms were cough and headache (both 75%). Fever accounted for 68.7%. Most represented professions were nurses (42%). HCWs were mainly infected by patient contact (32.9%); 7.6% required hospitalization and 1.7% were admitted to the intensive care unit. Unfortunately, one HCW died (0.5%). Total antibodies were positive in 109/126 (86.5%). CONCLUSIONS: Clinical presentation of COVID-19 in HCWs does not differ from the general population. However, outcomes were more favourable with a mortality rate lower than that reported in Belgian COVID-19 patients in general (16%). The main source of infection was the hospital setting. Our positive antibodies rate was high but lower than previously reported.

Fatal thoracic empyema involving Campylobacter rectus: A case report.

We report the case of a 69-year-old man admitted for septic shock secondary to necrotic pneumoniae complicated by thoracic empyema of fatal issue. Microbiological examination of pleural liquid revealed a mixed anaerobic flora involving Campylobacter rectus and Actinomyces meyeri. Campylobacter rectus is an infrequent anaerobic pathogen of oral origin To our knowledge, this is the first case report of fatal C. rectus - associated thoracic empyema, and only the second reported case in which identification was successfully performed by MALDI-TOF MS.

First Robinsoniella peoriensis aortic cross homograft mycotic pseudoaneurysm: A case report and review of the literature.

Mycotic aortic aneurysm is a rare and challenging complication of aortic homografts caused by an infection and is associated with high morbidity and mortality. We report the first case of an aortic cross homograft mycotic pseudoaneurysm caused by Robinsoniella peoriensis in a 70-year-old man. Our patient underwent surgery for a recurrence of aortic cross mycotic pseudoaneurysm at the level of the aortic homograft he had had 7 years before. A clot-removal of the pseudoaneurysm was surgically carried out and the homograft was completely removed. Anaerobic culture from tissue samples yielded pure growth of a spore-forming Gram-positive rod, identified later as Robinsoniella peoriensis by 16S rRNA gene sequencing. The patient was then discharged with oral clindamycin according to the in vitro susceptibility testing. Identification of R. peoriensis might be challenging in clinical laboratories with no access to molecular methods.

Ruptured aortic aneurysm due to Mycobacterium bovis BCG with a delayed bacteriological diagnosis due to false negative result of the MPB 64 immunochromatographic assay.

BACKGROUND: Adjuvant therapy with bacillus Calmette-Guerin (BCG), a live attenuated strain of Mycobacterium bovis, has become the treatment of choice for low-risk superficial bladder carcinoma following transurethral resection of the bladder. Complications following vesical BCG instillations are uncommon but, in some cases, severe side-effects can occur such as sepsis or mycotic aneurysm. Besides usual laboratory techniques used for the diagnosis of Mycobacterium tuberculosis complex (MTBC) infections (smear microscopy and cultures), commercial immunochromatographic assays detecting MBP64, a 24 kDa M. tuberculosis complex-specific secretory protein, can rapidly distinguish MTBC and non-tuberculosis mycobacteria (NTM). MPB64 is found in M. tuberculosis, M. bovis and some but not all substrains of M.bovis BCG. Therefore, these immunochromatographic tests can lead to false negative results and delayed bacteriological diagnosis depending on the presence or absence of MPB64 protein in BCG substrains used for intravesical therapy. CASE PRESENTATION: We report the case of a 78-year-old male patient who was admitted to the hospital because of a 1-month history of unexplained fever, thrill, weight-loss and general malaise. His past medical history was marked by a non-muscle-invasive bladder carcinoma treated by transurethral resection followed by BCG instillations (Oncotice, Merck, USA). The patient was initially treated for a urinary tract infection but as fever persists after 72 h of antibiotherapy, urinary tract ultrasound was performed and revealed a large abdominal aortic aneurysm confirmed by computed tomography. Surgery was performed after multidisciplinary discussion. Direct smear of perioperative samples revealed acid-fast bacilli and both solid and liquid cultures were massively positive. Rapid identification of the positive mycobacterial culture was performed using an immunochromatographic assay based on the detection of the Mycobacterium tuberculosis MPB 64 antigen. The result was negative for Mycobacterium tuberculosis complex. After review of the medical record, a polymerase chain reaction (PCR) was performed and gave a positive result for M. tuberculosis complex. Anti-tuberculosis therapy was started immediately and the patient evolved favorably. CONCLUSIONS: Through this case, we showed how the utilisation of MPB64 immunochromatographic assays can provide misleading information due to the variable presence of this protein among the different BCG strains. This case further illustrates the utility of rapid TB complex-specific PCR assays which provide a more reliable identification of all MTBC species.

Pneumococcal septic arthritis in adults: clinical analysis and review.

BACKGROUND: Septic arthritis (SA) is a rheumatological emergency that can lead to rapid joint destruction and irreversible loss of function. The most common pathogen causing SA is Staphylococcus aureus which is responsible for 37-65% of cases. Streptococcus pneumoniae is traditionally described as an uncommon cause of SA of a native joint. The objective of our study was to analyse clinical characteristics, treatment, and outcome of all cases of pneumococcal septic arthritis treated in our institution, and to compare them with other series published in the literature. MATERIALS AND METHODS: We conducted a retrospective study of pneumococcal SA identified among all cases of SA diagnosed in a teaching hospital of one thousand beds between 2004 and 2009. Diagnosis was based on culture of joint liquid or by the presence of pneumococcal bacteraemia and purulent (more than 50 000/mm(3) white blood cells with more than 90% neutrophils) joint fluid aspiration. RESULTS: Among 266 cases of SA, nine patients (3·3%) were diagnosed as having pneumococcal SA. The median age was 75 years. The main affected joint was the knee (7/9). No patient had more than one joint involved. Four patients suffered from concomitant pneumonia. Joint culture and blood cultures were positive in 7/9 and 5/9, respectively. Median (range) length of stay was 18 days (3-47 days). One patient with associated pneumococcal bacteraemia died 19 days after admission. Seven patients recovered completely. CONCLUSIONS: Streptococcus pneumoniae is now being increasingly recognized as a common agent of SA. This organism is frequently associated with pneumococcal pneumonia or bacteraemia, particularly in patients with advanced age and comorbidities. Direct inoculation of joint fluid into blood culture medium BACTEC system increases the probability of microbiological diagnosis. The prognosis is usually favourable if the disease is promptly recognized and treated (antibiotic therapy combined with joint drainage).

Late presentation for human immunodeficiency virus HIV diagnosis results of a Belgian single centre.

BACKGROUND: Antiretroviral therapy reduces mortality and morbidity in HIVinfected individuals, most markedly when initiated early, before advanced immunodeficiency has developed. Although the international guidelines recommend starting antiretroviral therapy ART with a high CD4 cell count level, in the practice, this is particularly challenging to achieve, especially in late presentation of HIV diagnosis. The aim of this study was to determine the frequency and the demographic features associated with late presentation for HIV diagnosis in our Centre. METHODS: All newly diagnosed patients with HIV between January 2007 and December 2011 in our AIDS Reference Centre, were included. Late presenter patient was defined as patient with CD4 count 350/mm(3) at the time of diagnosis. Demographic age, sex, ethnicity, migration and clinical characteristics transmission mode, CD4 cell count, viral load were collected. We also collected data on outcome median day of hospitalization, mortality, virological response to ART and lost to followup LTFU. LTFU was defined as patient without any medical contact and viral load measurements during two consecutive years in our centre. RESULTS: From 2007 to 2011, 154 429 out of 359 patients newly diagnosed with HIV were late presenters. According to univariate analysis, age 50, female gender, migrant from subSaharan Africa and heterosexual contact were associated with late presentation for HIV diagnosis. In the multivariate analysis, age 50, heterosexual contact and migrant status particularly women were the only independent risk factors for late presentation. Late presenters tend to have a worse outcome than nonlate presenters. CONCLUSION: A considerable proportion of patients continue to be diagnosed with advanced HIV disease, despite the fact that risk factors for late presentation have been clearly identified. Despite high testing rate for HIV in Belgium, highrisk population like migrant, heterosexual contact, remain under tested. In order to be able to detect and treat all patients with high CD4 cell count as recommended by all international guidelines, we recommend developing testing policies specifically focused on these categories at high risk for late presentation.

Imported malaria in a tertiary hospital in Belgium: epidemiological and clinical analysis.

BACKGROUND AND OBJECTIVE: There has been a marked increase in tourism, immigration, and business travel to malaria-endemic areas. Non-immune individuals (western travellers) or immigrants living for more than one year in non-endemic areas who visit friends and relatives (VFR) are particularly susceptible to developing severe malaria when travelling to areas with high levels of transmission. In this study, epidemiological, clinical and biological features of malaria in travellers returning from endemic areas were analysed. This may help clinicians unfamiliar with malaria not to overlook this disease in its early stage, and to initiate prompt treatment. PATIENTS AND METHODS: We retrospectively analysed all cases of patients who presented with malaria in our institution between 2003 and 2008. RESULTS: Eighty patients were included. Most patients visited Africa (93.6%). Accordingly, P. falciparum was the main species identified (67/77 patients i.e. 87%). Sixty-five patients (65/78 i.e. 83.3%) had not taken any prophylaxis and 13 (16.7%) had taken it inadequately. Common clinical features were fever (80/80, 100%), influenza-like symptoms (16/80, 20.1%), respiratory symptoms (5/80, 6.3%), neurological symptoms (2/80, 2.5%) or digestive symptoms (15/80, 18.8%). Digestive symptoms were predominant in children < 16 y.o. (60% of these patients). CONCLUSION: Imported malaria cases are mostly related to the lack of adequate use of chemoprophylaxis. Plasmodium falciparum is the main species responsible for imported cases of malaria in our institution. Clinical features vary, but fever is universally present at presentation. As such, all cases of fever upon return from a malaria-endemic area must be considered as malaria until proven otherwise, at least during the first three months after the return.

Tigecycline-induced acute pancreatitis: about two cases and review of the literature.

Tigecycline (formerly CAR-936, Tygacyl) is the first glycylcycline antibiotic available for clinical use. It has an expanded broad-spectrum antibiotic activity. Phase III studies have identified gastrointestinal side-effects, especially nausea and vomiting, as the most common adverse events. Few cases of acute pancreatitis (AP) have been described in the literature. We report two new cases of mild tigecycline-induced pancreatitis. Tigecycline was given for soft-tissue infection in both cases. Symptoms such as nausea, vomiting and mostly abdominal pain occurred within 5 days after starting Tigecycline. Pancreatic enzymes elevation occurred five to six days after initiation of treatment, and resolved within a week after drug-discontinuation. Diagnosis of mild pancreatitis was confirmed after performing CT-Scan of the abdomen in both cases. We take this opportunity to review the literature about this potentially serious side-effect induced by tigecycline.

High FDG uptake on FDG-PET scan in HIV-1 infected patient with advanced disease.

UNLABELLED: We report the case of a 48-year-old Caucasian male positive for HIV-1 who was admitted in our clinic for a fever of unknown origin with weight loss. The CD4 cell count was 99/mm3 and the viral load (VL) was 836500 copies/ml. A first FDG-PET-CT showed abnormal hypermetabolism of multiple lymp nodes, of the bone marrow and of the spleen. Tuberculosis and lymphoma were excluded by a lymph node biopsy and a culture. Six months after the start of a highly active anti-retroviral therapy (HAART) containing lamuvidine, tenofovir, atazanavir boosted by ritonavir, a new FDG-PET-CT showed a complete normalisation of the metabolism in the regions previously described as having a high FDG uptake. The VL was < 37 copies/ml and his CD4 cell count was 399/mm3. IN CONCLUSION: in patients with advanced HIV infections presenting with FUO, high uptake in 18FDG-PET-CT can be the marker of advanced disease reflecting the areas of viral replication.

Low-molecular-weight heparin-induced skin necrosis: about 2 cases.

Heparin-induced skin necrosis is an infrequent condition, complicating unfractionated heparin and more rarely low-molecular-weight heparin administration. Like heparin-induced thrombocytopenia, it is associated with the presence of anti-PF4 antibodies. After reporting 2 observations, we briefly review the clinical features and management of this condition. Early recognition is of the utmost importance since heparin-induced skin necrosis can be associated with HIT, a potentially lethal disorder.

Iatrogenic Cushing's syndrome and secondary adrenal insufficiency after a single intra-articular administration of triamcinolone acetonide in HIV-infected patients treated with ritonavir.

The development of an iatrogenic Cushing's syndrome (ICS) followed by secondary adrenal failure remains an exceptional event after a single dose administration of a synthetic glucocorticoid. Medical attention has been drawn recently on the possible impact of ritonavir-based antiretroviral regimens on the systemic deleterious effects of a chronic administration of corticosteroids in HIV-infected patients. Three HIV-infected patients treated by a ritonavir-boosted protease inhibitor (PI) regimen received a single intra-articular injection of 40 mg triamcinolone acetonide in our university hospital. The three patients rapidly developed signs and symptoms of ICS followed by secondary adrenal insufficiency. Special attention must be paid when a single administration of corticosteroids has to be given in HIV-positive patients under ritonavir-boosted antiretroviral treatment, as these patients are at risk of developing early cushingoid features and a prolonged suppression of their hypothalamic-pituitary-adrenal axis.