Concurrent Coronavirus Disease 2019 Research Articles

Clinical characteristics, outcome, and factors associated with mortality of pulmonary mucormycosis: a retrospective single-center study from Pakistan.

Pulmonary mucormycosis is a rare but rapidly progressive fatal disease. Limited data exist on the outcomes and factors associated with poor prognosis of pulmonary mucormycosis. The objective of this study was to evaluate clinical characteristics, factors associated with mortality, and outcomes of pulmonary mucormycosis at a tertiary care hospital in Pakistan. This was a retrospective observational study conducted at a tertiary care hospital in Karachi, Pakistan. Medical records of hospitalized patients diagnosed with proven or probable pulmonary mucormycosis between January 2018 and December 2022 were reviewed. Univariate and regression analyses were performed to identify factors associated with mortality. Fifty-three pulmonary mucormycosis patients (69.8% male) were included, with mean age of 51.19 ± 21.65 years. Diabetes mellitus was the most common comorbidity [n = 26 (49.1%)]. Chronic lung diseases were present in [n = 5 (9.4%)], and [n = 16 (30.2%)] had concurrent coronavirus disease 2019 (COVID-19) pneumonia. The predominant isolated Mucorales were Rhizopus [n = 32 (60.3%)] and Mucor species [n = 9 (17%)]. Main radiological findings included consolidation [n = 39 (73.6%)] and nodules [n = 14 (26.4%)]. Amphotericin B deoxycholate was prescribed in [n = 38 (71.7%)], and [n = 14 (26.4%)] of patients received combined medical and surgical treatment. The median [interquartile range (IQR)] hospital stay was 15.0 (10.0-21.5) days. Intensive care unit (ICU) care was required in [n = 30 (56.6%)] patients, with 26 (49.1%) needing mechanical ventilation. Overall mortality was seen in 29 (54.7%) patients. Significantly higher mortality was found among patients requiring mechanical ventilation 20/29 (69%, p = 0.002). Immunosuppression (p = 0.042), thrombocytopenia (p = 0.004), and mechanical ventilation (p = 0.018) were identified as risk factors for mortality on multivariable analysis. This study provides essential insights into the clinical characteristics, outcomes, and mortality factors associated with pulmonary mucormycosis. The mortality rate was high (54.7%), particularly in patients with immunosuppression, thrombocytopenia, and those who required mechanical ventilation.

Successful management of concurrent COVID-19 and Pneumocystis Jirovecii Pneumonia in kidney transplant recipients: a case series

BackgroundPneumocystis pneumonia (PCP) is a life-threatening pulmonary fungal infection that predominantly affects immunocompromised individuals, including kidney transplant recipients. Recent years have witnessed a rising incidence of PCP in this vulnerable population, leading to graft loss and increased mortality. Immunosuppression, which is essential in transplant recipients, heightens susceptibility to viral and opportunistic infections, magnifying the clinical challenge. Concurrently, the global impact of coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been profound. Kidney transplant recipients have faced severe outcomes when infected with SARS-CoV-2, often requiring intensive care. Co-infection with COVID-19 and PCP in this context represents a complex clinical scenario that requires precise management strategies, involving a delicate balance between immunosuppression and immune activation. Although there have been case reports on management of COVID-19 and PCP in kidney transplant recipients, guidance on how to tackle these infections when they occur concurrently remains limited.Case presentationsWe have encountered four kidney transplant recipients with concurrent COVID-19 and PCP infection. These patients received comprehensive treatment that included adjustment of their maintenance immunosuppressive regimen, anti-pneumocystis therapy, treatment for COVID-19 and other infections, and symptomatic and supportive care. After this multifaceted treatment strategy, all of these patients improved significantly and had favorable outcomes.ConclusionsWe have successfully managed four kidney transplant recipients co-infected with COVID-19 and PCP. While PCP is a known complication of immunosuppressive therapy, its incidence in patients with COVID-19 highlights the complexity of dual infections. Our findings suggest that tailored immunosuppressive regimens, coupled with antiviral and antimicrobial therapies, can lead to clinical improvement in such cases. Further research is needed to refine risk assessment and therapeutic strategies, which will ultimately enhance the care of this vulnerable population.

Abstract 14246: Impact of Coronavirus Disease 2019 Infection on Non-ST Elevation Myocardial Infarction Outcomes

Introduction: In this study, we explore the in-hospital outcomes of non-ST elevation myocardial infarction (NSTEMI) patients with and without concurrent coronavirus disease 2019 (COVID-19) infection. Methods: We utilized the National Inpatient Sample database (2016-2020) to identify patients who were admitted with a principal diagnosis of NSTEMI and a secondary diagnosis of COVID-19 infection. We conducted propensity score matching. Multivariable logistic regression, adjusted for age, sex and comorbidities, was used to compare mortality. Results: 1340 patients met our inclusion criteria. NSTEMI patients with concomitant COVID-19 infection had 3.24 times higher odds of suffering in-hospital mortality compared to NSTEMI admissions without COVID-19 (aOR 3.24, 95% CI: 1.93-5.43; p < 0.001). When separated by race, NSTEMI patients with COVID-19 had higher mortality rates amongst White (8.2% vs 4.7%, p = 0.04) and Black patients (14.2% vs 0.9%, p < 0.001, Figure 1). NSTEMI patients with COVID-19 infection were more likely to have acute respiratory distress syndrome (1.6% vs 0.1%, p = 0.004), myocarditis (1.3% vs 0%, p = 0.003) and severe sepsis (2.8% vs 0.9%, p = 0.01, Table 1). These patients were less likely to undergo percutaneous coronary intervention (PCI) (22.7% vs 28.4%, p = 0.02), but there was no significant difference in mean time to PCI (1.7 days vs 1.3 days, p = 0.12). Conclusion: Patients with NSTEMI and concurrent COVID-19 infection had higher odds of suffering in-hospital mortality compared to NSTEMI patients without COVID-19 infection. Further research should examine the impact of COVID-19 vaccination on the outcomes of this high-risk patient population.

Clinical Features of COVID-19 in Pediatric Rheumatic Diseases: 2020-2022 Survey of the Pediatric Rheumatology Association of Japan.

Coronavirus disease 2019 (COVID-19) in children can be compounded by concurrent diseases and immunosuppressants. For the first time, we aimed to report the clinical features of concurrent COVID-19 and pediatric rheumatic disease (PRD) in Japan. Pediatric Rheumatology Association of Japan members were surveyed between 1 April 2020 and 31 August 2022. Outcome measurements included the clinical features of concurrent PRD and COVID-19. Questionnaire responses were obtained from 38 hospitals. Thirty-one hospitals (82%) had children with PRD and COVID-19. The female-to-male ratio in these children (n = 156) was 7:3, with half aged 11-15 years. The highest proportion of children with PRD and COVID-19 was accounted for by juvenile idiopathic arthritis (52%), followed by systemic lupus erythematosus (24%), juvenile dermatomyositis (5%), scleroderma (4%), and Takayasu arteritis (3%). Of children with PRD, a significant majority (97%) were found to be asymptomatic (10%) or presented with mild symptoms (87%) of the COVID-19 infection. No severe cases or deaths were observed. Regarding the use of glucocorticoids, immunosuppressants, or biologics for PRD treatment before COVID-19, no significant difference was found between asymptomatic/mild and moderate COVID-19 in children with PRD. Therefore, COVID-19 is not a threat to children with PRD in Japan.

COVID-19-induced Dyslipidemia and Disease Severity: Perspectives from Southern Nigeria

Background: The relationship between dyslipidemia and the severity of coronavirus disease 2019 (COVID-19) has extensively been characterized in the Western population with a dearth of data among Nigerians. Hence, the current study evaluated the lipid/lipoprotein disorders inherent in COVID-19 and its relationship with disease severity among Nigerians. Methods: This was a retrospective study conducted among 600 patients with RT-PCR-confirmed COVID-19 at the Eleme COVID-19 treatment facility in Port Harcourt, Southern Nigeria. Data were obtained from medical records using validated acquisition templates and analyzed based on lipid/lipoprotein abnormalities and disease severity status. Results: Among those studied, 54.7% had dyslipidemia while others were normolipidemic. HDL-C dyslipidemia was the most common with a preponderance of hypoalphalipoproteinemia (84.4%). Dyslipidemia afflicted mostly middle-aged, males, urban dwellers, the overweight, and those with classic COVID-19-induced respiratory symptoms. Dyslipidemic cohorts had higher pro-calcitonin, C-reactive protein, D-dimer, total white cell count, and neutrophils, but lower albumin, lymphocyte, and platelet counts compared to the normolipidemic cohorts. Dyslipidemic cohorts with concurrent severe COVID-19 had lower levels of TChol, Tg, HDL-C, and LDL-C levels compared to patients with the less-severe disease. HDL-C was the only lipid/lipoprotein parameter that was associated with severe COVID-19 on crude (OR:8.65; CI:5.96-11.44; p<0.001) and adjusted (OR:8.11; CI:5.65-10.87; p<0.001) regression models compared to other lipid/lipoprotein indices. At 96.77% sensitivity and 89.20% specificity, HDL-C had robust predictive potentials (AUC:0.97; CI:0.84-1.00; p<0.001) over COVID-19 severity. Conclusion: Dyslipidemia is frequent among those presenting with COVID-19 in association with disease severity, especially among the HDL-C dyslipidemic cohorts. Hence, these findings should be factored in during COVID-19 treatment among Nigerians with the disease.

Clinical and biochemical predictors of intensive care unit admission among patients with diabetic ketoacidosis.

Diabetic ketoacidosis (DKA) contributes to 94% of diabetes-related hospital admissions, and its incidence is rising. Due to the complexity of its management and the need for rigorous monitoring, many DKA patients are managed in the intensive care unit (ICU). However, studies comparing DKA patients managed in ICU to non-ICU settings show an increase in healthcare costs without significantly affecting patient outcomes. It is, therefore, essential to identify suitable candidates for ICU care in DKA patients. To evaluate factors that predict the requirement for ICU care in DKA patients. This retrospective study included consecutive patients with index DKA episodes who presented to the emergency department of four general hospitals of Hamad Medical Corporation, Doha, Qatar, between January 2015 and March 2021. All adult patients (> 14 years) fulfilling the American Diabetes Association criteria for DKA diagnosis were included. We included 922 patients with DKA in the final analysis, of which 229 (25%) were managed in the ICU. Compared to non-ICU patients, patients admitted to ICU were older [mean (SD) age of 40.4 ± 13.7 years vs 34.5 ± 14.6 years; P < 0.001], had a higher body mass index [median (IQR) of 24.6 (21.5-28.4) kg/m2 vs 23.7 (20.3-27.9) kg/m2; P < 0.030], had T2DM (61.6%) and were predominantly males (69% vs 31%; P < 0.020). ICU patients had a higher white blood cell count [median (IQR) of 15.1 (10.2-21.2) × 103/uL vs 11.2 (7.9-15.7) × 103/uL, P < 0.001], urea [median (IQR) of 6.5 (4.6-10.3) mmol/L vs 5.6 (4.0-8.0) mmol/L; P < 0.001], creatinine [median (IQR) of 99 (75-144) mmol/L vs 82 (63-144) mmol/L; P < 0.001], C-reactive protein [median (IQR) of 27 (9-83) mg/L vs 14 (5-33) mg/L; P < 0.001] and anion gap [median (IQR) of 24.0 (19.2-29.0) mEq/L vs 22 (17-27) mEq/L; P < 0.001]; while a lower venous pH [mean (SD) of 7.10 ± 0.15 vs 7.20 ± 0.13; P < 0.001] and bicarbonate level [mean (SD) of 9.2 ± 4.1 mmol/L vs 11.6 ± 4.3 mmol/L; P < 0.001] at admission than those not requiring ICU management of DKA (P < 0.001). Patients in the ICU group had a longer LOS [median (IQR) of 4.2 (2.7-7.1) d vs 2.0 (1.0-3.9) d; P < 0.001] and DKA duration [median (IQR) of 24 (13-37) h vs 15 (19-24) h, P < 0.001] than those not requiring ICU admission. In the multivariate logistic regression analysis model, age, Asian ethnicity, concurrent coronavirus disease 2019 (COVID-19) infection, DKA severity, DKA trigger, and NSTEMI were the main predicting factors for ICU admission. In the largest tertiary center in Qatar, 25% of all DKA patients required ICU admission. Older age, T2DM, newly onset DM, an infectious trigger of DKA, moderate-severe DKA, concurrent NSTEMI, and COVID-19 infection are some factors that predict ICU requirement in a DKA patient.

Post-COVID-19 Pneumocystis pneumonia cases from Pakistan: an observational study.

Background. Concurrent coronavirus disease 2019 (COVID-19) and Pneumocystis jirovecii pneumonia (PJP) has been described in various reports, with a recent study describing a 9.3 % P. jirovecii detection rate in critically ill COVID-19 patients. Methods. Patients with PCR-confirmed PJP following COVID-19 infection who were admitted to Aga Khan University Hospital, Karachi, Pakistan from March 2020-June 2021 were identified through a laboratory database. Detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus was performed by RT-PCR Cobas SARS-CoV-2 qualitative assay. P. jirovecii PCR was performed using the RealStar Pneumocystis jirovecii PCR kit. Clinical, radiological and laboratory data for PJP patients were recorded. Results. During the study period, 3707 patients were admitted with COVID-19 at our hospital. P. jirovecii PCR was requested for 90 patients and was positive in 10 (11 %). Five out of 10 patients were discharged from the hospital and later developed cough and dyspnoea. Five patients remained hospitalized with severe COVID-19 and developed PJP. Eight patients in our study received systemic steroids. The trends of lymphocyte counts of all patients showed a lymphocyte count of <1000 mm-3 (<1.0×106 cells µl-1) in the week of PJP diagnosis. Four patients did not survive; one of these patients did not receive co-trimoxazole due to late diagnosis, one patient had concomitant nosocomial pneumonia and bacteraemia with multidrug-resistant Acinetobacter species, and two patients had concomitant aspergillosis. Conclusion. In summary, invasive fungal infections such as PJP should be considered as a complication in COVID-19 patients, with prompt evaluation and management.

Impact of the Severe acute respiratory syndrome coronavirus 2 pandemic on mortality associated with healthcare-associated infections.

To determine the relationship between severe acute respiratory syndrome coronavirus 2 infection, hospital-acquired infections (HAIs), and mortality. Retrospective cohort. Three St. Louis, MO hospitals. Adults admitted ≥48 hours from January 1, 2017 to August 31, 2020. Hospital-acquired infections were defined as those occurring ≥48 hours after admission and were based on positive urine, respiratory, and blood cultures. Poisson interrupted time series compared mortality trajectory before (beginning January 1, 2017) and during the first 6 months of the pandemic. Multivariable logistic regression models were fitted to identify risk factors for mortality in patients with an HAI before and during the pandemic. A time-to-event analysis considered time to death and discharge by fitting Cox proportional hazards models. Among 6,447 admissions with subsequent HAIs, patients were predominantly White (67.9%), with more females (50.9% vs 46.1%, P=.02), having slightly lower body mass index (28 vs 29, P=.001), and more having private insurance (50.6% vs 45.7%, P=.01) in the pre-pandemic period. In the pre-pandemic era, there were 1,000 (17.6%) patient deaths, whereas there were 160 deaths (21.3%, P=.01) during the pandemic. A total of 53 (42.1%) coronavirus disease 2019 (COVID-19) patients died having an HAI. Age and comorbidities increased the risk of death in patients with COVID-19 and an HAI. During the pandemic, Black patients with an HAI and COVID-19 were more likely to die than White patients with an HAI and COVID-19. In three Midwestern hospitals, patients with concurrent HAIs and COVID-19 were more likely to die if they were Black, elderly, and had certain chronic comorbidities.

COVID-associated acute limb ischemia during the Delta surge and the effect of vaccines

ObjectiveHypercoagulability is common in severe acute respiratory syndrome coronavirus 2 and has been associated with arterial thrombosis leading to acute limb ischemia (ALI). Our objective was to determine the outcomes of concurrent coronavirus disease 2019 (COVID-19) infection and ALI, particularly during the Delta variant surge and the impact of vaccination status. MethodsA retrospective review was performed of patients treated at a single health care system between March 2020 and December 2021 for ALI and recent (<14 days) COVID-19 infection or who developed ALI during hospitalization for the same disease. Patients were grouped by year as well as by pre and post Delta variant emergence in 2021 based on the World Health Organization timeline (January to May vs June to December). Baseline demographics, imaging, interventions, and outcomes were evaluated. A control cohort of all patients with ALI requiring surgical intervention for a 2-year period prior to the pandemic was used for comparison. Primary outcomes were in-hospital mortality and amputation-free survival. Kaplan-Meier survival and Cox proportional hazards analysis were performed. ResultsForty acutely ischemic limbs were identified in 36 patients with COVID-19, the majority during the Delta surge (52.8%) and after the wide availability of vaccines. The rate of COVID-19-associated ALI, although low overall, nearly doubled during the Delta surge (0.37% vs 0.20%; P = .09). Intervention (open or endovascular revascularization vs primary amputation) was performed on 31 limbs in 28 individuals, with the remaining eight treated with systemic anti-coagulation. Postoperative mortality was 48%, and overall mortality was 50%. Major amputation following revascularization was significantly higher with COVID-19 ALI (25% vs 3%; P = .006) compared with the pre-pandemic group. Thirty-day amputation-free survival was significantly lower (log-rank P < .001). COVID-19 infection (adjusted hazard ratio, 6.2; P < .001) and age (hazard ratio, 1.1; P = .006) were associated with 30-day amputation in multivariate analysis. Severity of COVID-19 infection, defined as vasopressor usage, was not associated with post-revascularization amputation. There was a higher incidence of re-thrombosis in the latter half of 2021 with the Delta surge, as reintervention for recurrent ischemia of the same limb was more common than our previous experience (21% vs 0%; P = .55). COVID-19-associated limb ischemia occurred almost exclusively in non-vaccinated patients (92%). ConclusionsALI observed with Delta appears more resistant to standard therapy. Unvaccinated status correlated highly with ALI occurrence in the setting of COVID-19 infection. Information of limb loss as a COVID-19 complication among non-vaccinated patients may help to increase compliance.

Clinicoradiological profile and outcome of cavernous sinus syndrome with coronavirus disease-2019-associated rhino-orbito-cerebral mucormycosis.

With coronavirus disease 2019 (COVID-19) pandemic across the world, there had been an exponential increase in rhino-orbito-cerebral mucormycosis (ROCM). Extension of infection to cavernous sinus leads to cavernous sinus syndrome (CSS). This study aims to describe incidence, clinicoradiological profile, and outcome of CSS positive along with comparative analysis of CSS negative COVID-19-associated ROCM. This was a prospective and observational study conducted from May 1, 2021, to July 31, 2021. Subjects included ROCM with active or recovered COVID-19 (past 6 weeks) and were categorized and staged. CSS was defined as involvement of two or more of third, fourth, fifth, or sixth cranial nerve with one each direct and indirect qualitative neuroradiological features. Clinicoradiological features of CSS-positive and negative COVID-19-associated ROCM groups were compared. Incidence of CSS with COVID-19-associated ROCM was 28%. Mean age of subjects was 44 ± 15 years with 60% being males and 73% were proven ROCM. Significant differences seen across the CSS-positive and negative groups were ocular, nasal, and cerebral findings including eyelid and periocular discoloration, ptosis, proptosis, ophthalmoplegia, nasal discharge, mucosal inflammation, and fever. Oculomotor, trochlear, and abducens nerves were significantly involved more in CSS-positive group. Significant radiological findings across two groups included indirect features in orbit, nose, and paranasal sinuses along with direct features in cavernous sinus. Surgical intervention was more common in CSS-positive group. Mortality in CSS-positive group at 8-24 weeks was 13 and 27%, respectively. Extension of ROCM to CSS was more common in young males in advanced stages of proven ROCM with concurrent COVID-19. CSS-positive group had significant difference in clinicoradiological features involving orbit, nose, paranasal sinuses, and central nervous system as compared to CSS-negative group. This study highlights the need to develop an objective scoring system considering clinical and radiological features for diagnosis of CSS with COVID-19-associated ROCM.

Correlation Between HbA1c Levels and Mortality Rates in Hospitalized COVID-19 Patients.

Objective Throughout the coronavirus disease 2019 (COVID-19) pandemic, multiple factors have been associated with poor prognosis for those infected by thesevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. Age, obesity, and medical comorbidities have been linked to poor outcomes, including admission to the intensive care unit (ICU), acute renal failure, stroke, myocardial infarction (MI), mechanical ventilation, and even death for hospitalized COVID-19 patients. Although diabetes mellitus (DM) has also been included in this set of medical comorbidities, there have been inconsistencies in the currently available body of literature, suggesting that mortality rates may or may not be correlated to elevated glycosylated hemoglobin (HbA1c) levels. This study aims to determine whether there is a correlation or trend between a range of HbA1c values and in-hospital mortality amongpatients admitted to the hospital with a COVID-19 diagnosis. Materials and methods This study was a retrospective review of electronic medical records at Arrowhead Regional Medical Center in Colton, CA. Any patient above the age of 18admitted to the hospital during a predetermined time frame, with either a positive COVID-19 PCR test on admission or during their hospital stay, was included in the study. These medical charts were reviewed for HbA1c values during admission or within three months prior to admission. In-hospital mortality was then recorded for each medical record with an available HbA1c value. Hospital discharge summaries were used to delineate comorbidities, including chronic kidney disease, cerebrovascular disease, coronary artery disease, congestive heart failure, cancer history, or history of deep vein thrombosis/pulmonary embolism amongthe patients included in the study. Average HbA1c values were recorded for the mortality and non-mortality groups, and their statistical significance was calculated. Results In this retrospective study, HbA1c levels were compared to mortality rates amongadult patients admitted to the hospital with a concurrent COVID-19 diagnosis. From the analysis conducted, those with higher HbA1c levels did not have an increased rate of in-hospital mortality, and those with lower HbA1c levels did not have a decreased rate of in-hospital mortality. Comorbidity data as a confounding factor was also reviewed and excluded from the final analysis. The SARS-CoV-2 vaccine was also excluded as a confounder in this study by selecting a specific time frame for data collection. Based on our results, we propose that HbA1c levels likely have little to minimal correlation with mortality rates amonghospitalized COVID-19 patients. Conclusion In this study, we show that HbA1c levels, regardless of concurrent comorbidities, are unlikely to be correlated to mortality rates among hospitalized COVID-19 patients. HbA1c levels should not be used as a marker for whether these patients should be admitted to the hospital for further inpatient management or discharged from the emergency department.

Boarding for Youth Mental Health Conditions: How Can Hospitalists Be Part of the Solution?

Boarding for Youth Mental Health Conditions: How Can Hospitalists Be Part of the Solution?

Concurrent Infection with SARS-CoV-2 and Pneumocystis jirovecii in Immunocompromised and Immunocompetent Individuals.

Coronavirus disease 2019 (COVID-19) may occur with concurrent infections caused by bacterial and fungal microorganisms. This systematic review evaluated studies reporting concomitant COVID-19 and Pneumocystis jirovecii pneumonia (PJP). We found 39 patients (74% male, median age: 56.8 (range: 11–83) years), including 66% immunosuppressed individuals (23% HIV-infected and 41% on long-term corticosteroid therapy). Patients were characteristically severely ill (mechanical ventilation: 70%), associated with 41% mortality. The median lymphocyte count was 527 cells/mm3 (range: 110–2200), and the median CD4+ T cell count was 206 cells/mm3 (range: 8–1021). We identified three patterns of concurrent COVID-19 and P. jirovecii infection. The first pattern (airway colonization with a low burden of P. jirovecii) does not seem to modify the COVID-19 course of illness. However, P. jirovecii superinfection, typically occurring weeks after COVID-19 diagnosis as a biphasic illness, and P. jirovecii coinfection characteristically results in progressive multilobar pneumonia, which is associated with poor outcomes. To support this categorization, we reported three patients with concurrent PJP and COVID-19 identified in our institution, presenting these clinical scenarios. The diagnosis of PJP requires a high index of suspicion, since clinical and radiological characteristics overlap with COVID-19. Observational studies are necessary to determine the PJP burden in patients with COVID-19 requiring hospitalization.

COVID-19–Associated Acute Limb Ischemia During the Delta Surge and Effect of Vaccines

Hypercoagulability is common in SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) and has been associated with arterial thrombosis leading to acute limb ischemia (ALI). Our objective was to determine the outcomes of concurrent COVID-19 (coronavirus disease 2019) infection and ALI, particularly during the Delta variant surge, and the impact of vaccination status.

Evan syndrome as initial presentation of COVID-19 infection

BackgroundEvans’ syndrome (ES) is a rare and chronic autoimmune disease characterized by the concomitant or sequential association of auto-immune hemolytic anemia (AIHA) with immune thrombocytopenia (ITP), and less frequently autoimmune neutropenia with a positive direct anti-human globulin test. ES represents up to 7% of AIHA and around 2% of ITP. Studies have found that coronavirus disease 2019 (COVID-19) may be associated with various hematological complications, i.e., coagulopathies; however, finding of Evans syndrome is a novel case.Case reportA 54-year-old diabetic man complaining of fever (high grade), arthralgia and myalgia, fatigue, and dark color of urine. He was admitted to isolation sector at Sohag General Hospital on day 6 because of fever with cough, dyspnea, and progressive fatigue, and at admission, he was tachypneic, tachycardiac, jaundiced, febrile (38 °C), and hypoxemic (O2 saturations on room air was 80%). Laboratory studies showed hemoglobin (Hb) 5.43 g/dL, high reticulocyte (12.5%), ↓ed platelet count (54 × 103/μl), hyperbilirubinemia and elevated C-reactive protein (CRP), D-dimer, ferritin, and lactate dehydrogenase. Markers of autoimmune diseases and screening for malignant diseases were negative. HRCT chest showed bilateral small-sized peripheral ground glass opacities in both lungs, with positive reverse transcriptase-polymerase chain reaction (RT-PCR) for SARS-CoV-2 RNA in the nasopharyngeal swab. Direct Coombs test was positive for immunoglobulin (IgG) and C3d. Evans syndrome secondary to COVID-19 was diagnosed and treatment with packed red cell (PRC) transfusions, favipiravir, dexamethasone, prednisone, ceftriaxone, enoxaparin, oral hypoglycemic, and oxygen using face mask, and then Hb value increased to 10.3 g/dL and he was discharged home without any complications.ConclusionThere are few reports of patients with concurrent COVID-19 and Evans syndrome. So, SARS-CoV-2 infection should be considered in any patient presenting with new-onset ES of unclear etiology.

SARS-Cov-2 Infection Uncovering Latent Mycobacterium Leprae Infection

Leprosy is a chronic granulomatous infection caused by the bacteria Mycobacterium leprae. It can remain dormant in a patient without any symptoms until triggered by a stressor on the body. During the coronavirus disease 2019 (COVID-19) pandemic, a significant amount of emotional and psychological stress was endured by patients. In addition, many patients experienced exacerbations of their preexisting conditions. Few reports have described cases of leprosy with concurrent COVID-19. This brief article presents a case of newly diagnosed leprosy in a middle-aged male following a COVID-19 infection. To our knowledge, this is the first reported case of its kind in the United States.

Ipsilateral Lymphadenopathy After COVID-19 Vaccination in Patients With Newly Diagnosed Breast Cancer.

This study aimed to evaluate the imaging and pathological findings in axillary lymph nodes in patients with breast cancer who received concurrent ipsilateral coronavirus disease 2019 (COVID-19) vaccination. Of the 19 women with breast cancer who received concurrent COVID-19 vaccination shot in the arm ipsilateral to breast cancer, axillary lymphadenopathy was observed in 84.2% (16 of 19) of patients on ultrasound (US) and 71.4% (10 of 14) of patients on magnetic resonance imaging (MRI), and 21.0% (4 of 19) of patients were diagnosed with metastasis. Abnormal US and MRI findings of cortical thickening, effacement of the fatty hilum, round shape, and asymmetry in the number or size relative to the contralateral side were noted in more than half of the non-metastatic and metastatic lymph nodes; however, statistical significance was not noted. Axillary lymphadenopathy is commonly observed in patients with breast cancer who receive concurrent ipsilateral COVID-19 vaccination without specific differential imaging features. Thus, understanding the limitations of axillary imaging and cautious interpretation is necessary to avoid overestimation or underestimation of the axillary disease burden.

Characteristics and Outcomes of a Series of COVID-Associated Mucormycosis Patients in Two Different Settings in Egypt Through the Third Pandemic Wave.

PurposeTo report on the underlying risk factors, clinical characteristics, presentation, and survival of coronavirus disease 2019 (COVID-19) associated mucormycosis (CAM) cases referred for ophthalmological consultation in two different Egyptian settings during the third viral pandemic wave (April to August of 2021).MethodsA multicentric, retrospective analysis involving one public and two private hospitals in metropolitan Cairo, and two university hospitals in upper Egypt (Aswan and Assuit). Cases that fulfilled the diagnostic criteria of mucormycosis, with a prior or concurrent COVID-19 infection, were included.ResultsOf the 26 patients included in the final analysis, 15 (57.7%) were from Cairo and 11 (42.3%) were from upper Egypt. Twenty-five patients (96.2%) had poorly controlled diabetes mellitus and 20 (76.9%) had received corticosteroid treatment for COVID-19, of which 30.8% had mild or moderate disease. The median duration from COVID-19 till the onset of CAM was 20.5 days. No visual function could be detected in the affected eye of 16 patients (61.6%) on presentation. The mortality rate was 46.2% despite surgical debridement in half of the cases that died.ConclusionCAM continues to be a concrete threat throughout Egypt, especially in patients with poorly controlled diabetes mellitus and those who inadvertently receive steroid therapy. It remains to be seen if increased vaccination coverage and early detection due to increased awareness would result in declining rates and adverse sequelae of CAM. A national registry would allow for better monitoring of the disease trends.

MASSIVE SPONTANEOUS PLEURAL EFFUSION IN END-STAGE RENAL DISEASE PATIENT WITH VANCOMYCIN RESISTANT ENTEROCOCCUS EMPYEMA AND COVID-19 INFECTION

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pleural effusion is one of the most common complications seen in end-stage renal disease (ESRD) patients [1]. Here we report a case of massive spontaneous pleural effusion in an ESRD patient, who tested positive for coronavirus disease 2019 (COVID-19) on hospital admission, and later grew vancomycin resistant enterococcus (VRE) from the pleural space. CASE PRESENTATION: 79-year-old male with past medical history of ESRD on hemodialysis, hypertension, diabetes mellitus and history of prostate cancer presented with abdominal discomfort and progressive nausea and vomiting. COVID-19 test was positive on screening, although vital signs and review of systems were negative except as above. Labs were remarkable for leukocytosis, elevated blood urea nitrogen and creatinine. Chest X-ray showed nearly complete opacification of the left hemithorax associated with dense consolidation of the left lower lobe and the lingula. Computerized tomography scan showed a large complex fluid attenuating lesion involving the left hemithorax, which may represent a large loculated left-sided effusion versus a large left-sided empyema, resulting in mediastinal shift to the right and inferior displacement of the left hemidiaphragm. Pleural fluid was drained via pigtail catheter, and on analysis was found to be exudative with few leukocytes and no microorganisms. Due to septations of the hemithorax and development of hydropneumothorax, chest tube was placed and eventually video-assisted thoracoscopic surgery was performed for further drainage and decortication. Biopsy obtained during surgery showed no malignant cells; tissue culture and subsequent pleural fluid cultures were positive for VRE. DISCUSSION: Pleural effusion is a pathological finding that is often seen in ESRD patients with heart failure, pneumonia, pulmonary embolism, cancer and uremia [1]. Interestingly, our patient received regular hemodialysis, and presented with no signs of heart failure or fluid overload, making ESRD less likely to be a major or direct cause of the massive pleural effusion. Studies show VRE is prevalent in dialysis centers and frequently colonizes ESRD patients [2]. Rarely, VRE can cause empyema, as illustrated by Cotton in an asplenic patient with multiple co-morbidities who presented with pneumonia [3]. Our patient might have VRE colonized in his airway, so pleural cultures were positive after decortication. Additionally, COVID-19 infection has been associated with pleural effusion [4]. Hussein reported an acute accumulation of moderate exudative pleural effusion in a patient with no past medical history except for concurrent COVID-19 infection. As a result, the positive COVID-19 test in our patient might also contribute to his massive effusion. CONCLUSIONS: Factors like ESRD on hemodialysis, positive VRE in pleural tissue culture, as well as COVID-19 infection, may all contribute to the rare massive pleural effusion in our case. REFERENCE #1: Uzan, G. and H. Ikitimur, Pleural Effusion in End Stage Renal Failure Patients. Sisli Etfal Hastan Tip Bul, 2019. 53(1): p. 54-57. REFERENCE #2: Zacharioudakis, I.M., et al., Vancomycin-resistant enterococci colonization among dialysis patients: a meta-analysis of prevalence, risk factors, and significance. Am J Kidney Dis, 2015. 65(1): p. 88-97.Cotton, M.J. and C.D. Packer, Vancomycin-resistant Enterococcus faecium Empyema in an Asplenic Patient. Cureus, 2018. 10(8): p. e3227. REFERENCE #3: Hussein, M., et al., Pleural effusion as an isolated finding in COVID-19 infection. Respir Med Case Rep, 2020. 31: p. 101269. DISCLOSURES: No relevant relationships by Aram Hambardzumyan, source=Web Response No relevant relationships by Stephen Jesmajian, source=Web Response No relevant relationships by Liyun Liu, source=Web Response Speaker/Speaker's Bureau relationship with GSK Please note: approx 2016 to now Added 05/02/2021 by Michael Mandel, source=Web Response, value=Consulting fee No relevant relationships by Corina Nava, source=Web Response No relevant relationships by ABHISHEK NIMKAR, source=Web Response No relevant relationships by Carlos Romano, source=Web Response

Acyclovir as a Potential Adjuvant Therapy in COVID-19 Treatment Regimens

Introduction: There are successful reports of the concomitant management of herpes infection and coronavirus disease 2019 (COVID-19), using both acyclovir (ACV) and COVID-19 treatment regimens. Furthermore, ACV has been proposed to effectively treat COVID-19, through various mechanisms, such as inhibition of viral proteases, multiple viral gene expressions, and RNA-dependent RNA polymerase (RdRP). Therefore, this study aimed to review the reported cases of patients with concomitant herpes infection and COVID-19, receiving concurrent antiviral drugs for herpetic lesions. Methods: A search was done to find the relevant articles, published between December 2019 and December 2020, with no language limitations, in the PubMed database, using the Medical Subject Headings (MeSH) terms related to herpes simplex virus or herpes zoster (namely, shingles) combined with COVID-19. Accordingly, the reports of the concomitant herpes infection and COVID-19, receiving concurrent antiviral drugs for herpetic lesions were included. Results: Out of 90 articles, 11 records reporting the cases of herpes infection and concurrent laboratory-confirmed COVID-19, receiving antiherpetic therapies, were reviewed. There were 28 patients (age range of 7-82 years) with laboratory-confirmed COVID-19, concomitant with reactivation of herpes infection, receiving antiviral drugs alongside candidate COVID-19 treatment regimens, but no mortality. The mean (standard deviation [SD] range) age of these 28 patients during treatment was 56.4 (18.6 [7-82]) years, and the majority were male (n=18, 64.3%). A total number of 20 patients had also received ACV and eight cases had been administered with other two antiviral compounds, including seven cases with valacyclovir, and one case with famciclovir, with no mortality. Conclusion: The potential use of ACV, as an add-on therapy, along with candidate COVID-19 treatment regimens was proposed in this study. However, further clinical trials are recommended to test this hypothetical adjuvant therapy.