Clinical Efficacy of Intravenous Immunoglobulin Therapy in Critical Patients with COVID-19: A multicenter retrospective cohort study

ImportanceCoronavirus disease 2019 (COVID-19) has become pandemic, causing more than 1.5 million infections and over ten-thousands of deaths in a short period of time worldwide. However, little is known about its pathological mechanism, and reports on clinical study on specific treatment are few. ObjectiveThe purpose of this study is to determine the clinical efficacy of intravenous immunoglobulin (IVIG) therapy in COVID-19 patients. Design, setting and participantsThis multicenter retrospective cohort study enrolled 325 adult critical COVID-19 patients, including severe type and critical type, according to the clinical classification defined by National Health Commission of China, in 8 government designated treatment centers in China from Dec 23, 2019 to Mar 31, 2020. Demographic, clinical, treatment, and laboratory data as well as prognosis were extracted from electronic medical records. ExposureIVIG was exposure factor. Main outcomes and measuresPrimary outcomes were the 28-day and 60-day mortality, and secondary outcomes were the total length of in-hospital and the total duration of the disease. Meanwhile, the parameters of inflammation responses and organ functions were measured. The risk factors were determined by COX proportional hazards model. The subgroup analysis was carried out according to clinical classification of COVID-19, IVIG dosage, and timing. ResultsIn the enrolled 325 patients, 222 (68%) were severe type and 103 (32%) were critical type; 42 (13%) died in 28-day within hospitalization, and 54 (17%) died within 60-day; The death in 60-day includes 6 (3%) severe type patients and 48 (47%) critical type patients. 174 cases were used IVIG, and 151 cases were not. Compared with the baseline characteristics between two groups, the results showed that the patients in IVIG group presented higher Acute Physiology and Chronic Health Evaluation (APACHII) score and Sequential Organ Failure Assessment (SOFA) score, higher plasm levels of IL-6 and lactate, and lower lymphocyte count and oxygenation index (all P<0.05). The 28-day and 60-day mortality were not improved with IVIG in overall cohort. The in-hospital stay and the total duration of disease were longer in IVIG group (P<0.001). Risk factors were clinical classifications (hazards ratio 0.126, 95% confidence interval 0.039-0.413, P=0.001), and using IVIG (hazards ratio 0.252, 95% confidence interval 0.107-0.591, P=0.002) with COX proportional hazards model. Subgroup analysis showed that only in patients with critical type, IVIG could significantly reduce the 28-day mortality, decrease the inflammatory response, and improve some organ functions (all P<0.05); and application of IVIG in the early stage (admission[≤]7 days) with a high dose (>15 g/d) exhibited significant reduction of 60-day mortality in the critical type patients. Conclusions and RelevanceEarly administration of IVIG with high dose improves the prognosis of critical type patients with COVID-19. This study provides important information on clinical application of the IVIG in treatment of SARS-CoV-2 infection, including patient selection and administration timing and dosage. Key pointsO_ST_ABSQuestionC_ST_ABSIntravenous immunoglobulin (IVIG) was recommended to treat critical Coronavirus disease 2019 (COVID-19) patients in a few reviews, but the clinical study evidence on its efficacy in COVID-19 patients was lacked. FindingIn this multicenter cohort study that included 325 adult critical patients from 8 treatment centers, the results showed that early administration (admission [≤] 7 days) of IVIG with high dose (> 15 g/d) improves the prognosis of critical type patients with COVID-19. MeaningThis study provides important information on clinical application of IVIG in treatment of SARS-CoV-2 infection, including patient selection, administration timing and dosage.

Clinical features and outcomes of 2019 novel coronavirus-infected patients with high plasma BNP levels

AimsTo explore clinical features and outcome of 2019 novel coronavirus(2019-nCoV)-infected patients with high BNP levels Methods and resultsData were collected from patients medical records, and we defined high BNP according to the plasma BNP was above > 100 pg/mL. In total,34 patients with corona virus disease 2019(COVID-19)were included in the analysis. Ten patients had high plasma BNP level. The median age for these patients was 60.5 years(interquartile range, 40-80y), and 6/10 (60%) were men. Underlying comorbidities in some patients were coronary heart disease (n=2, 20%), hypertesion (n=3,30%), heart failure (n=1,10%)and diabetes (n=2, 20%). Six (60%) patients had a history of Wuhan exposure. The most common symptoms at illness onset in patients were fever (n=7, 70%), cough (n=3, 30%), headache or fatigue(n=4,40%). These patients had higher aspartate aminotransferase(AST), troponin I, C reactive protein and lower hemoglobin, and platelet count,compared with patients with normal BNP, respectively. Compared with patients with normal BNP, patients with high BNP were more likely to develop severe pneumonia, and receive tracheal cannula, invasive mechanical ventilation, continuous renal replacement therapy, extracorporeal membrane oxygenation, and be admitted to the intensive care unit. One patient with high BNP died during the study. ConclusionHigh BNP is a common condition among patients infected with 2019-nCoV. Patients with high BNP showed poor clinical outcomes

Clinical features and outcomes of 2019 novel coronavirus-infected patients with cardiac injury

AimsTo explore the epidemiological and clinical features of 2019 novel coronavirus(2019-nCoV)-infected patients with cardiac injury. Methods and resultsData were collected from patients medical records, and we defined cardiac injury according to cardiac biomarker troponin I level > 0.03 g/L. Among the 291 patients, 15 (5.2%) showed evidence of cardiac injury. Of 15 hospitalized patients with cardiac injury, the median age was 65 years, and 11/15 (73.3%) were men. Underlying cardiovascular diseases in some patients were hypertension (n=7, 46.7%), coronary heart disease (n=3, 20%) and diabetes (n=3, 20%). The most common symptoms at illness onset in patients with cardiac injury were fever (n=11, 73.3%), cough (n=7, 46.7%), headache or fatigue (n=5, 33.3%) and dyspnea (n=4, 26.7%). These patients had higher systolic pressures, white blood cell count, neutrophil count, troponin I, brain natriuretic peptide, D-dimer and lower lymphocyte count, and platelet count, compared with patients without cardiac injury, respectively. Bilateral infiltrates on chest X-ray and elevated C-reactive protein occurred in all patients with cardiac injury. Compared with patients without cardiac injury, patients with cardiac injury were more likely to develop acute respiratory distress syndrome, and receive mechanical ventilation, continuous renal replacement therapy, extracorporeal membrane oxygenation and vasopressor therapy and be admitted to the intensive care unit. ConclusionCardiac injury is a common condition among patients infected with 2019-nCoV. Compared with patients without cardiac injury, the clinical outcomes of patients with cardiac injury are relatively worse.

Clinical and pathological features of intestinal Talaromycosis marneffei infection in patients with acquired immunodeficiency syndrome / 中华传染病杂志

Objective:To investigate the clinical and pathological characteristics of acquired immunodeficiency syndrome (AIDS) patients with intestinal Talaromycosis marneffei (TM) infection. Methods:A total of 64 AIDS patients who underwent colonoscopy in Guangzhou Eighth People′s Hospital from January, 2010 to December, 2018 were retrospectively collected. Among them, 32 patients were co-infected with TM (AIDS with intestinal TM infection group) and 32 patients were not (AIDS without intestinal TM infection group) according to the colonic mucosa pathology. The clinical manifestations and pathological differences were compared between the two groups. Nonparametric rank sum test and Fisher exact probability method were used for statistical analysis.Results:The proportions of patients presented with fever, cough, retroperitoneal lymph nodes tume faction, nausea and vomiting, abdominal muscle tension, abdominal tenderness and rebound pain in AIDS with intestinal TM infection group were 28 (87.5%), 16 (50.0%), 13 (40.6%), 9 (28.1%), 8 (25.0%), 20 (62.5%) and 12 (37.5%), respectively, which were all significantly higher than those in AIDS without intestinal TM infection group 11 (34.4%), 6 (18.8%), 3 (9.4%), 2 (6.2%), 1 (3.1%), 8 (25.0%) and 1 (3.1%), respectively, the differences were statistically significant (Fisher exact test, all P<0.05). The median counts of peripheral blood CD4 + T lymphocyte, lymphocytes, monocytes, hemoglobin, platelet and albumin in AIDS with intestinal TM infection group were 13.5/μL, 0.30×10 9/L, 0.16×10 9/L, 88 g/L, 122×10 9/L and 23.5 g/L, respectively, which were all significantly lower than those in AIDS without intestinal TM infection group 207.0/ μL, 1.35×10 9/L, 0.35×10 9/L, 128 g/L, 201×10 9/L and 37.5 g/L, respectively, the differences were all statistically significant ( Z=-6.111, -6.191, -4.273, -5.353, -2.974 and-6.666, respectively, all P<0.05). Multivariate logistic regression analysis showed that CD4 + T lymphocytes <50/μL, hemoglobin <90 g/L and fecal occult blood positive were independent risk factors for AIDS with intestinal TM infection. The main manifestations of colonoscopy in AIDS with intestinal TM infection group were discontinuous ulcers (31.2%(10/32)), erosion (31.2%(10/32)) or co-exitance of ulcer and erosion (21.9%(7/32)), while suspected tumor-like eminence lesions were less common (15.6%(5/32)). The pathological features of colon mucosa were ulcer and/or erosion (53.1%(17/32)), chronic inflammation (46.9%(15/32)) and inflammatory granuloma (43.8%(14/32)). Oval or round spore with apparent septum could be seen by special staining. In AIDS with intestinal TM infection group, 27 patients were cured or improved, five patients died or deteriorated, while all patients in the AIDS without intestinal TM infection group improved after treatment without death. Conclusions:There are no specific gastrointestinal symptoms in AIDS patients with intestinal TM infection, while the patients present with decreased immunological cells and multiple colony pathological features. Specific fungal spores can be seen.

Study on Helicobacter Pylori infection in patients with liver-cirrhosis / 中华消化内镜杂志

0. 1). The incidence of peptic ulcer, incidence and severity of portal hypertensive gastropathy (PHG) and the incidence of upper gastrointestinal hemorrhage in Hp positive patients were higher than those in Hp negative . Conclusion Hp infection in patients with liver - cirrhosis may be related to incidences of peptic ulcer, PHG and upper gastrointestinal hemorrhage.