RESUMO
BACKGROUND: Lung transplant recipients (LTRs) are at risk for Mycobacterium avium complex (MAC) infections, in part due to the presence of structural lung disease pre-transplant and relatively higher levels of immunosuppression post-transplant. There is a lack of data regarding outcomes of LTR with MAC infections pre-transplant. METHODS: This is a single-center retrospective analysis of patients who received lung transplants (LTs) from 2013 to 2020 with 1) evidence of MAC on culture or polymerase chain reaction before or at the time of transplant or 2) granulomas on explant pathology and positive acid-fast bacillus stains with no other mycobacteria identified. Patients were deemed to have MAC pulmonary disease (MAC-PD) if they met the American Thoracic Society/Infectious Disease Society of America criteria. RESULTS: Fourteen patients (14/882, 2%) met inclusion criteria. Seven patients (7/14, 50%) had pre-transplant MAC-PD, four of whom had cavitary disease. None of the 14 patients had smear-positive cultures at the time of transplant. Two patients in our cohort received treatment for MAC before transplant. Thirteen patients were bilateral LTR (13/14, 93%). One single LTR was the sole patient to receive MAC treatment post-transplant. No patients developed MAC-PD after transplant. CONCLUSION: The bilateral LTR in our cohort did not develop MAC-PD despite not receiving MAC treatment post-transplant. It is possible source control was achieved with native lung explantation. Our observations suggest patients may not uniformly require pre- or post-transplant MAC treatment if they are smear-negative and undergo bilateral LT.
Assuntos
Reação em Cadeia da Polimerase , Humanos , Reações Falso-Negativas , Pneumocystis/genética , Pneumocystis/isolamento & purificação , Pneumocystis/classificação , Pneumocystis carinii/genética , Pneumocystis carinii/isolamento & purificação , Pneumonia por Pneumocystis/diagnóstico , Pneumonia por Pneumocystis/microbiologia , Reação em Cadeia da Polimerase/métodosRESUMO
SARS-CoV2, first described in December 2019, was declared a pandemic by the World Health Organization in March 2020. Various surgical and medical societies promptly published guidelines, based on expert opinion, on managing patients with COVID-19, with a consensus to postpone elective surgeries and procedures. We describe the case of an orthotopic liver transplantation (OLT) in a young female who presented with acute liver failure secondary to acetaminophen toxicity to manage abdominal pain and in the setting of a positive SARS-CoV2 test. Despite a positive test, she had no respiratory symptoms at time of presentation. The positive test was thought to be residual viral load. The patient had a very favorable outcome, likely related to multiple factors including her young age, lack of respiratory COVID-19 manifestations and plasma exchange peri-operatively. We recommend a full work-up for OLT in COVID-19 patients with uncomplicated disease according to standard of care, with careful interpretation of COVID-19 testing in patients presenting with conditions requiring urgent or emergent surgery as well as repeat testing even a few days after initial testing, as this could alter management.
Assuntos
Acetaminofen/intoxicação , COVID-19/virologia , Overdose de Drogas/complicações , Falência Hepática Aguda/induzido quimicamente , Transplante de Fígado/métodos , Pandemias , SARS-CoV-2/genética , Adulto , Analgésicos não Narcóticos/intoxicação , COVID-19/epidemiologia , Feminino , Humanos , Falência Hepática Aguda/cirurgia , RNA Viral , Resultado do Tratamento , Tratamento Farmacológico da COVID-19Assuntos
Alemtuzumab/efeitos adversos , Fatores Imunológicos/efeitos adversos , Legionella pneumophila/isolamento & purificação , Doença dos Legionários/etiologia , Esclerose Múltipla/tratamento farmacológico , Adulto , Humanos , Doença dos Legionários/diagnóstico por imagem , Masculino , Radiografia Torácica , Tomografia Computadorizada por Raios XRESUMO
Background: Centers for Disease Control and Prevention recommends 3 months of once-weekly rifapentine/isoniazid (3HP) for latent tuberculosis infection (LTBI) treatment given by directly observed therapy (DOT) or self-administered therapy (SAT) in patients ≥2 years old. 3HP has been associated with increased incidence of hepatic, gastrointestinal, flu-like, and cutaneous adverse drug reactions (ADRs) compared with isoniazid monotherapy. Objective: This study evaluated 3HP completion rates and tolerability for LTBI treatment in a real-world setting. Methods: A single-center retrospective cohort with a nested case-control study, comparing patients experiencing ADRs with those who did not, evaluated patients ≥18 years old receiving 3HP by DOT or SAT for LTBI at Cleveland Clinic from October 2011 through July 2018. Information on baseline characteristics, 3HP administrations, and ADRs were collected. Results: Of 199 patients screened, 144 were included (111 DOT, 33 SAT). 3HP completion rates were high at 82.6% and similar between DOT and SAT groups. During treatment, 92/144 (63.9%) patients experienced any ADR. The most common ADR included flu-like symptoms (38.2%) and gastrointestinal (31.9%) and hepatic (2.1%) reactions. Despite high rate of overall ADRs, rates of significant ADRs (grade 2 or higher) were 4.2%. Overall, 9% of patients discontinued 3HP because of ADRs. After adjusting for other factors associated with ADRs at baseline, SAT was not associated with increased incidence of ADRs, but female sex was a significant predictor (odds ratio = 2.61 [95% CI, 1.23 to 5.56]). Conclusion and Relevance: This study observed high 3HP treatment completion rates, low incidence of significant ADRs, and low discontinuation rates resulting from ADRs.
Assuntos
Antituberculosos/uso terapêutico , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/etiologia , Isoniazida/uso terapêutico , Tuberculose Latente/tratamento farmacológico , Rifampina/análogos & derivados , Adulto , Antituberculosos/administração & dosagem , Antituberculosos/efeitos adversos , Estudos de Casos e Controles , Terapia Diretamente Observada/métodos , Esquema de Medicação , Quimioterapia Combinada , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/epidemiologia , Feminino , Trato Gastrointestinal/efeitos dos fármacos , Humanos , Isoniazida/administração & dosagem , Isoniazida/efeitos adversos , Tuberculose Latente/epidemiologia , Fígado/efeitos dos fármacos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Rifampina/administração & dosagem , Rifampina/efeitos adversos , Rifampina/uso terapêutico , AutoadministraçãoRESUMO
Tuberculosis (TB) in the health care worker demands orchestrated efforts from health care institutions to promptly identify cases and address community risk. We describe a pediatric intensive care unit nurse with latent TB infection who developed hemoptysis and a lung infiltrate concerning for active TB. Her evaluation and contact investigation were facilitated by our institution's command center. Although TB was ultimately ruled out, this case tested our team-based care in response to a suspected high-consequence pathogen.
Assuntos
Busca de Comunicante/métodos , Transmissão de Doença Infecciosa do Profissional para o Paciente/prevenção & controle , Tuberculose Latente/transmissão , Infecções por Mycobacterium não Tuberculosas/transmissão , Micobactérias não Tuberculosas , Diagnóstico Diferencial , Feminino , Pessoal de Saúde , Humanos , Tuberculose Latente/diagnóstico , Pessoa de Meia-Idade , Infecções por Mycobacterium não Tuberculosas/diagnósticoRESUMO
Selection of the appropriate donor is essential to a successful allograft recipient outcome for solid organ transplantation. Multiple infectious diseases have been transmitted from the donor to the recipient via transplantation. Donor-transmitted infections cause increased morbidity and mortality to the recipient. In recent years, a series of high-profile transmissions of infections have occurred in organ recipients prompting increased attention on the process of improving the selection of an appropriate donor that balances the shortage of needed allografts with an approach that mitigates the risk of donor-transmitted infection to the recipient. Important advances focused on improving donor screening diagnostics, using previously excluded high-risk donors, and individualizing the selection of allografts to recipients based on their prior infection history are serving to increase the donor pool and improve outcomes after transplant. This article serves to review the relevant literature surrounding this topic and to provide a suggested approach to the selection of an appropriate solid organ transplant donor.
RESUMO
Cutaneous fistula as a clinical presentation of intracardiac abscess of the right side is such an unusual occurrence that it has not until now been reported in the English-language medical literature. We present a rare case of right-sided infective endocarditis caused by Achromobacter xylosoxidans in which recurrent infection presented as sternal wound discharge. The infection was found to have an intracardiac origin and was successfully managed by radical débridement on cardiopulmonary bypass.
Assuntos
Abscesso/microbiologia , Achromobacter denitrificans/isolamento & purificação , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Fístula Cutânea/microbiologia , Endocardite Bacteriana/microbiologia , Infecções por Bactérias Gram-Negativas/microbiologia , Comunicação Interventricular/cirurgia , Infecção da Ferida Cirúrgica/microbiologia , Abscesso/diagnóstico , Antibacterianos/uso terapêutico , Ponte Cardiopulmonar , Fístula Cutânea/diagnóstico , Fístula Cutânea/cirurgia , Desbridamento , Diagnóstico Diferencial , Endocardite Bacteriana/diagnóstico , Feminino , Infecções por Bactérias Gram-Negativas/diagnóstico , Infecções por Bactérias Gram-Negativas/cirurgia , Humanos , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Recidiva , Reoperação , Infecção da Ferida Cirúrgica/diagnóstico , Fatores de Tempo , Resultado do Tratamento , CicatrizaçãoRESUMO
On June 13, 2012, a group of key stakeholders, leaders, and national experts on tuberculosis (TB), occupational health, and laboratory science met in Atlanta, Georgia, to focus national discussion on the higher than expected positive results occurring among low-risk, unexposed healthcare workers undergoing serial testing with interferon-γ release assays (IGRAs). The objectives of the meeting were to present the latest clinical and operational research findings on the topic, to discuss evaluation and treatment algorithms that are emerging in the absence of national guidance, and to develop a consensus on the action steps needed to assist programs and physicians in the interpretation of serial testing IGRA results. This report summarizes its proceedings.
Assuntos
Testes de Liberação de Interferon-gama/normas , Saúde Ocupacional , Guias de Prática Clínica como Assunto , Tuberculose/diagnóstico , Setor de Assistência à Saúde , Humanos , Curva ROC , Tuberculose/tratamento farmacológico , Tuberculose/prevenção & controle , Estados UnidosRESUMO
BACKGROUND: Clinical data with use of serial interferon-γ release assay (IGRA) testing in US health-care workers (HCWs) are limited. METHODS: A single-center, retrospective chart review was done from 2007 to 2010 of HCWs who underwent preemployment QuantiFERON-TB Gold In-Tube testing. Demographic data, bacille Calmette-Guérin history, prior tuberculin skin test result if done, and baseline and serial IGRA values were obtained. The number of IGRA converters and reverters and their subsequent management by infectious disease physicians were reviewed. Quantitative IGRA-negative values were not available. RESULTS: A total of 7,374 IGRAs were performed on newly hired HCWs. Of these tests, 486 (6.6%) were positive at baseline, 305 (4.1%) were indeterminate, and 6,583 (89.3%) were negative. From 2007 to 2010, 52 of 1,857 HCWs (2.8%) with serial IGRA tests were identified as converters, with a serial IGRA median value of 0.63 IU/mL. Seventy-one percent of HCWs with IGRA conversion had values ≤ 1 IU/mL. None of the converters had active TB or were part of an outbreak investigation. CONCLUSIONS: Clinical significance of most QuantiFERON-TB Gold In-Tube conversions in serial testing remains a challenging task for clinicians. The use of a single cutoff point criterion for IGRA may lead to overdiagnosis of new TB infections. Clinical assessment and evaluation may help to prevent unnecessary therapy in these cases. The criteria for defining conversions and reversions by establishing new cutoffs needs to be evaluated further, especially in HCWs.
Assuntos
Pessoal de Saúde , Testes de Liberação de Interferon-gama/normas , Programas de Rastreamento/métodos , Tuberculose/diagnóstico , Adolescente , Adulto , Feminino , Humanos , Transmissão de Doença Infecciosa do Profissional para o Paciente/prevenção & controle , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Teste Tuberculínico , Tuberculose/epidemiologia , Adulto JovemAssuntos
Anticorpos Monoclonais/uso terapêutico , Antivirais/uso terapêutico , Infecções por Citomegalovirus , Citomegalovirus/fisiologia , Pneumonia , Viremia , Adulto , Anticorpos Monoclonais/efeitos adversos , Anticorpos Monoclonais Humanizados , Antivirais/efeitos adversos , Infecções por Citomegalovirus/complicações , Infecções por Citomegalovirus/tratamento farmacológico , Infecções por Citomegalovirus/virologia , Ganciclovir/uso terapêutico , Humanos , Masculino , Pneumonia/complicações , Pneumonia/tratamento farmacológico , Resultado do Tratamento , Viremia/tratamento farmacológico , Viremia/virologiaRESUMO
Although the tuberculin skin test has long been the standard for detecting latent tuberculosis infection, it has many limitations. Interferon-gamma-release assays are gaining acceptance as an alternative. In this paper we present cases to illustrate how these new tests can be used and how to interpret the results.
Assuntos
Testes Imunológicos/métodos , Interferon gama/análise , Interferon gama/biossíntese , Tuberculose/diagnóstico , Tuberculose/imunologia , Adulto , Idoso , Sangue/imunologia , Células Sanguíneas/imunologia , Células Cultivadas/imunologia , Feminino , Humanos , Tuberculose Latente/diagnóstico , Masculino , Pessoa de Meia-Idade , Sensibilidade e EspecificidadeRESUMO
We implemented the QuantiFERON-TB Gold (QFT-G) In-Tube test to identify latent tuberculosis infection among potential employees prior to employment. The rates of indeterminate QFT-G In-Tube test results were higher than expected and prompted an investigation that led to successful interventions (eg, manual vortexing before incubation and the use of a modified in-tube method). The tracking of indeterminate results is suggested as an important quality control measure.