First Sign Of Infection Research Articles

A dermatologic assessment of 101 mpox (monkeypox) cases from 13 countries during the 2022 outbreak: Skin lesion morphology, clinical course, and scarring

In the 2022 mpox (monkeypox) outbreak, 79,000 global cases have been reported. Yet, limited dermatologic data have been published regarding lesion morphology and progression. The objective of this study was to characterize skin lesion morphology, symptomatology, and outcomes of mpox infection over time. The American Academy of Dermatology/International League of Dermatological Societies Dermatology COVID-19, Mpox, and Emerging Infections Registry captured deidentified patient cases of mpox entered by health care professionals. From August 4 to November 13, 2022, 101 cases from 13 countries were entered, primarily by dermatologists (92%). Thirty-nine percent had fewer than 5 lesions. In 54% of cases, skin lesions were the first sign of infection. In the first 1-5days of infection, papules (36%), vesicles (17%), and pustules (20%) predominated. By days 6-10, pustules (36%) were most common, followed by erosions/ulcers (27%) and crusts/scabs (24%). Crusts/scabs were the predominant morphology after day 11. Ten cases of morbilliform rash were reported. Scarring occurred in 13% of the cases. Registry-reported data cannot address incidence. There is a potential reporting bias from the predilection to report cases with greater clinical severity. These findings highlight differences in skin findings compared to historical outbreaks, notably the presence of skin lesions prior to systemic symptoms and low overall lesion counts. Scarring emerged as a major possible sequela.

COVID-19 Infection and Risk for Neuropsychiatric Symptoms

COVID-19 Infection and Risk for Neuropsychiatric Symptoms

Ulcer at Corner of Mouth as First Sign of Infection With Monkeypox Virus.

Ulcer at Corner of Mouth as First Sign of Infection With Monkeypox Virus.

First Report of Fusarium lateritium Causing Shoot Dieback of Acer negundo in Europe.

Box elder (Acer negundo) is a tree native to North America. In Europe it is considered a dangerous invasive species, and assigned to the highest (4th) category of environmental hazard (Tokarska-Guzik et al. 2012). The tree can threaten a wide range of ecosystems and compete with the native flora. The shoot dieback was observed on 20% of boxelder in July 2018 and 2019 in Bryzgiel (N53°59.963' E23°04.324') in NE Poland (Europe). Young trees (10-15 yr. old) with visible symptoms were observed in a small group on the rural roadside. Infected shoots were chlorotic. There were visible shallow cracks on the bark and brown discoloration in sapwood inside infected branches. Symptomatic shoots were collected in sterile envelopes, surface disinfected with 95% ethanol. Twelve fragments of wood were cut from the border of living and dead tissue, and then divided into 3-5 mm pieces, placed on PDA medium and incubated at 21°C. After 10 days ten Fusarium spp. strains were obtained. Pure cultures were derived by monosporic isolation. The identification of the isolates was initially based on morphology and molecular genotyping (Leslie & Summerell 2006). On PDA, strains produced white, dense, floccose aerial mycelium with a pink surface. The underside of the petri dish was brown. Growth of the colony was relatively slow and reached Ø 3.5 cm after two weeks. Microscopic observation revealed the presence of macroconidia located in a few orange sporodochia. Macroconidia were slightly curved, with dimensions of 38-45 µm × 3.2-3,5 µm, 4-5 septate, with well-formed foot cell and beak on the apex. On aerial hyphae, single intercalary chlamydospores were present. Microconidia were not found. Morphological identification was confirmed by sequencing the ITS regions, the TEF-1α and β-tubulin genes for representative isolates. Mycelia were grown on PDB and freeze dried prior to genomic DNA extraction using the CTAB method. Sequences of two isolates were deposited in GenBank as MN186748 and MN588156 for ITS; MZ191070 and MZ191072 for TEF-1α; and MZ191069 and MZ191071 for TEF-1α. BLASTn search in the NCBI database revealed 100, 98 and >99% similarities of ITS, TEF-1α and β-tubulin with F. lateritium isolates LC171689, KT350607 and FN554618 respectively. A pathogenicity test was conducted on five first year Ø 0.6-0.8cm shoots from a 10-year-old tree. Before inoculation their surface was disinfected with 95% ethanol. Then, bark of the twigs was split longitudinally with a sterile blade and pieces of 10-day-old aerial mycelium grown on PDA were applied on the wound sites. Control samples were inoculated with sterile distilled water only. Inoculated areas were covered with parafilm. First sign of infection was observed after three weeks, as a dark lesion in the place of inoculation and chlorosis. Three weeks later the brown ring on the sapwood was marked in the shoot cross-section. Morphologically identical to the original, F. lateritium isolate was reisolated from the infected tissues, thus fulfilling Koch's postulates. F. lateritium is a species closely associated with trees and shrubs (Leslie & Summerell 2006). However, it has not been recorded on boxelder and this is the first report of F. lateritium causing dieback of boxelder maple. According to the Enemy Release Hypothesis (Elton 1958), new pathogens appearing on alien species can be an indicator of developing environmental resistance to the outlander, which indicate the grade of their domestication. This kind of notification poses a crucial role in invasion monitoring and the search for new biocontrol methods of invasive plant species.

The effect of Echinacea spp. on the prevention or treatment of COVID-19 and other respiratory tract infections in humans: A rapid review

Brief overviewCurrent evidence suggests that Echinacea supplementation may decrease the duration and severity of acute respiratory tract infections; however, no studies using Echinacea in the prevention or treatment of conditions similar to COVID-19 have been identified. Few adverse events were reported, suggesting that this herbal therapy is reasonably safe. Because Echinacea can increase immune function, there is a concern that it could worsen over-activation of the immune system in cytokine storm; however, clinical trials show that Echinacea decreases levels of immune molecules involved in cytokine storm. VerdictEchinacea supplementation may assist with the symptoms of acute respiratory infections (ARI) and the common cold, particularly when administered at the first sign of infection; however, no studies using Echinacea in the prevention or treatment of conditions similar to COVID-19 have been identified. Previous studies have reported that Echinacea may decrease the severity and/or duration of ARI when taken at the onset of symptoms. The studies reporting benefit used E. purpurea or a combination of E. purpurea and E. angustifolia containing standardized amounts of active constituents.Few adverse events from the use of Echinacea were reported, suggesting that this herbal therapy is reasonably safe. No human trials could be located reporting evidence of cytokine storm when Echinacea was used for up to 4 months.When assessing all human trials which reported changes in cytokine levels in response to Echinacea supplementation, the results were largely consistent with a decrease in the pro-inflammatory cytokines that play a role in the progression of cytokine storm and Acute Respiratory Distress Syndrome (ARDS), factors that play a significant role in the death of COVID-19 patients. While there is currently no research on the therapeutic effects of Echinacea in the management of cytokine storm, this evidence suggests that further research is warranted.

Azithromycin and COVID-19: Prompt early use at first signs of this infection in adults and children, an approach worthy of consideration.

The devastating effects of the coronavirus designated severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) have led to urgent attempts to find effective therapeutic agents for inpatient and outpatient treatment of COVID‐19. Initial enthusiasm for the combination of hydroxychloroquine and azithromycin has abated. However, as a result of positive clinical experience with azithromycin used alone during the first few days of the flu‐like illness caused by this coronavirus, we recommend formal clinical trials using azithromycin early in the course of a COVID‐19 infection. There is one clinical trial initiated, the individually randomized, telemedicine‐based, “Azithromycin for COVID‐19 Treatment in Outpatients Nationwide” based at the University of California San Francisco. This placebo‐controlled trial is designed to determine the efficacy of a single 1.2‐g dose of oral azithromycin to prevent COVID‐19 patient progression to hospitalization. We recommend formal clinical trials of azithromycin in its prepackaged form at the first sign of COVID‐19 infection in adults and children, using an initial adult dose of 500 mg followed by 250 mg per day for 4 days, a total cumulative dose of 1.5 g, and for children 5 to 18 years of age, 10 mg/kg on the first day followed by 5 mg/kg for 4 days.

Monitoring Temperature: Knowledge and Skills of Outpatients With Cancer.

Elevated temperature can be the first sign of infection; obtaining an accurate temperature in patients undergoing chemotherapy is critical. This study sought to determine outpatients' temperature-monitoring knowledge and skills; whether an educational DVD could increase knowledge; and the level of agreement between a home thermometer and a calibrated hospital thermometer. The intervention was an educational DVD. Patients completed a survey and were observed taking their temperature. Investigators rated whether the correct steps were taken and then obtained the temperature. The bias and precision of the patient's thermometer were determined. Knowledge scores averaged 68%. Most participants correctly identified elevated temperatures for fever (91%); less than 50% correctly identified other signs of infection, and less than 25% correctly identified activities that could falsely elevate or depress temperature readings.

Structure of dinitrogen fixing nodules in Erythrina poeppigiana

The development and anatomy of root nodules induced in seedlings of Erythrina poeppigiana by a strain of Bradyrhizobium spp (CR 751) is described. Infection apparently occurred via injuries where lateral roots (devoid of root hairs) emerged. The first sign of infection was a group of epidermal cells (fluffy) on the secondary (emerging) root that covered the nodule primordium. Here, thin-walled cells with plastids and in active division were observed but not infection threads. Infection appears to have occurred via protoxylem which was preceded by a dissolution of the vessels' cell wall. A peribacteroid, membrane-generating organelle in infected cells is described. The adjacent noninfected cells showed electron dense depositions (phenolics 2). Developed nodules were spherical 0.5 to 2 cm in diameter. The surface was corky, with lenticels. The peridermis showed several layers of suberized dead cells. The cortex consisted of external, medium and internal layers. Vascular bundles ran in the medium cortex in a centripetal way to join the root vascular system at the base of the nodule. In these vascular bundles, baciliar bacteria were observed which were confirmed to be Bradyrhizobium sp (results of a separate study using immunocitochemistry). Bacteroids densely filled infected cells of the nodule medulla within peribacteroid membranes. Among infected cells non-infected auxiliary cells were seen loaded with starch granules. During later stages of root development few root hairs appeared on tertiary and secondary roots. Infection also occurred via root hairs, resulting in oblong nodules caused by a tumefaction of the root cortex .

Improving Antimicrobial Regimens for the Treatment of Breast Tissue Expander-Related Infections.

Background:Infectious complications in tissue expander (TE) breast reconstruction can be devastating and costly. Therefore, to optimize care, we examined patient’s demographics, microbiology of TE infections, and the efficacy of empiric antimicrobial regimens and thereafter generated an algorithm for the treatment of these complex infections.Methods:We retrospectively reviewed all patients who underwent TE breast reconstruction between 2003 and 2012 and analyzed those patients who developed a “definite” device-related infection leading to TE explantation and had a positive intraoperative culture.Results:A total of 3,082 patients underwent immediate breast reconstruction with TE. Of these, 378 patients (12.3%) developed an infection, 189 (6.1%) eventually proceed with explantation, and 118 (3.8%) had a positive intraoperative culture. Gram-positive organisms caused 73% of infections, and Gram-negative organisms caused 27% of infections. Narrow-spectrum empiric antimicrobials with predominantly Gram-positive coverage were deemed appropriate in only 62% of cases, and those with Gram-negative coverage were appropriate in 46%. Broad-spectrum antimicrobials were used in 47% of cases, mainly recommended by infectious disease specialists, and were considered appropriate in >90% of the occasions.Conclusions:Current empiric antibiotic regimens do not cover the vast spectrum of organisms causing TE infections. To increase the salvage rate of an infected TE, at the first sign of infection, in addition to benefiting with an infectious diseases consultation, empiric coverage with broad-spectrum antibiotics active against biofilm-embedded organisms should be administered.

Study of ocular candidiasis during nine-year period.

To determine the clinical features, fungal profiles, treatment outcomes, and factors that are significantly associated with the visual outcomes of eyes with endogenous fungal endophthalmitis (EFE). The medical records of 17 eyes of 9 patients diagnosed with EFE during January 2005 to December 2013 were reviewed. The collected data included patient characteristics, visual acuities (VAs), length between appearance of the first sign of infection and the first ophthalmic examinations, fungal profiles, and treatment regimen. The main outcome measure was the VA. Statistical analyses were done to detect the factors significantly associated with the visual prognosis. The median age at presentation was 67 years. Seven patients had Candida albicans, and 2 had Candida tropicalis. Eight patients received intravenous fosfluconazole, 4 systemic micafungin, 4 oral itraconazole, and 2 intravenous voriconazole. The minimum inhibitory concentrations of fluconazole against Candida albicans isolated from 5 patients ranged from 0.25 to 1.0μg/mL. A final VA of ≥20/200 was achieved in 69.2% of the eyes. Multiple regression analysis (r(2)=0.695) detected both initial logMAR (the Logarithm of the minimum angle of resolution) VA (P=0.0067) and longer length between onset of symptoms and the first ophthalmic examinations (P=0.0491) as significant worsen factors for final logMAR VA. Early ophthalmic consultation, better initial visual acuity, and use of effective systemic antifungal treatment might lead to relatively good visual outcomes in EFE.

Studies on the Histopathological Responses of Vigna Mungo towards Meloidogyne Incognita at Different Time Intervals

The pot experiments on Vigna mungo with five replicates for each treatment were set up in the Department of Botany, Aligarh Muslim University, Aligarh, Uttar Pradesh (27°52’59” N to 78°04’59” E; 180 m above sea level), India. Histological studies of the roots of infected plants were carried out after 24 h, 48 h, 72 h, 5 days, 10 days, 15 days, 21 days, 25 days and 30 days of inoculation. The second-stage juveniles penetrated into the roots and moved intercellularly by separating the cell walls after 24 h. The first sign of infection observed after 48 h of inoculation was hypertrophy in the cells, around the head of the juvenile. The cytological changes in the hypertrophied cells became more prominent after 72 h of inoculation, and the cells transformed into discrete giant cells. The giant cell cytoplasm became dense and stained darkly, the size of the nuclei and the nucleoli increased after five days of inoculation. Ten days after inoculation, the width of vessel elements was also increased. The second-stage juveniles moulted into the third stage. After 21 days of nematode exposure, the hypertrophied and hyperplastied parenchyma cells were observed adjacent to the giant cells. At several occasions, the giant cell complexes appeared to be surrounded by abnormal xylem comprising of abnormal vessel elements, which were transformed from the hypertrophic and hyperplastic parenchymatous tissue. The head region of the nematode was in contact with the giant cells while remaining part of the body expanded and caused disruptions in the arrangement of vascular and cortical tissues, as was observed after 25 days of inoculation. After 30 days of nematode inoculation, egg masses were found associated with all the mature females. The tissues were disrupted as the egg masses were pushed out to the surface of the root. Several eggs enclosed first stage juveniles.

Infections in acute leukemia in Indian Children

Aims: In the present study acute leukemic children were studied to determine the incidence and principal site of infection, correlation with absolute neutrophil count, causative organisms and to standardize the initial empirical anti microbial therapy. Materials and methods: A total 40 children in the age group 6 month to 12 year with acute leukemia relapse were included in this study. A total 82 infectious episodes including 61 febrile episodes were investigated for infectious etiology. Results: We found that the frequency of infections increased significantly with the degree of immunocompromisation specially neutropenia (ANC < 500/cmm). The skin and soft tissue was the commonest site of infection (26.83%), followed by respiratory tract (21.95%). Staphylococcus nonhemolytic coagulase-negative (34%), followed by Klebsiella (17%) were the most common organisms isolated from blood. Staphylococcus non-hemolytic coagulase-negative was also the commonest isolate (26%) from other sites of infection. Most strains were sensitive to Cloxacillin, cephalosporin and aminoglycosides. Conclusion: For the treatment of febrile episodes, empirical use of beta-lactamase resistant penicillin e.g. Cloxacillin or cephalosporin combined with an aminoglycosides with a broad spectrum antifungal like fluconazole in selective cases at the first sign of infection is recommended. Journal of College of Medical Sciences-Nepal, 2013, Vol-9, No-1, 40-47 DOI: http://dx.doi.org/10.3126/jcmsn.v9i1.9672

Legal Briefs: Devastating Consequences From Prolonged Use of an Umbilical Arterial Catheter

A 960-g, 26-3/7 weeks’ gestation male twin B was delivered by normal vaginal spontaneous delivery in the breech position to 31-year-old, healthy, gravida 3 para 1 mother whose pregnancy was complicated by preterm labor and diamniotic dichorionic twins. The mother received antibiotics, a partial course of betamethasone, and magnesium sulfate for tocolysis. At delivery, the infant had a heart rate (HR) less than 100 beats per minute, no respiratory effort, and was blue. The infant was intubated and required resuscitation, including chest compressions for 15 seconds, and 2 doses of epinephrine via an endotracheal tube (ETT). Apgar scores were 2 at 1 minute, 4 at 5 minutes, and 7 at 10 minutes. The infant was then admitted to the NICU, where an umbilical venous catheter (UVC) and an umbilical arterial catheter (UAC) were placed. The UVC was placed in the right atrium, where it remained until its removal several days later, and his UAC was placed appropriately at the seventh thoracic vertebrae and removed on day 13. The infant’s vital signs and blood pressure were normal. He had respiratory distress syndrome, for which he was given 3 doses of surfactant. Initially, the infant required 100% oxygen, but after several hours, the inspired oxygen was weaned to 30%, and the ventilator settings were low. His initial complete blood cell count revealed a white blood cell count (WBC) of 3.1 × 103/uL, a platelet count of 185 × 103/uL, and a hematocrit reading of 51% (0.51). The infant was given ampicillin and gentamicin after blood culture results were obtained, and he was started on low-dose indomethacin for intraventricular hemorrhage prophylaxis. On day 1, the fraction of inspired oxygen (Fio2) and ventilatory settings were low. The blood gas values were normal, with some permissive hypercarbia in the …

Hepatobiliary Quiz-7 (2013)

1.Regarding the molecular virology of hepatitis E virus (HEV) the following are TRUE:1.HEV genome consists of three open reading frames (ORF)2.ORF1 codes for structural proteins3.The 5′ untranslated region is important for viral encapsidation4.The 3′ untranslated region is important for initiation of viral replication5.Unlike other positive strand ribonucleic acid (RNA) viruses, replication of HEV does not require a negative sense RNA intermediary2.Regarding the immunology of HEV the following are TRUE:1.First sign of infection is the detection of IgM antibodies2.Shedding of virus in feces commonly persists after onset of clinical disease3.IgG antibodies persist for years after infection and may protect from future infection4.Liver damage is immune mediated rather than due to direct cytotoxic effect of HEV5.Antibody mediated liver injury is more important than cellular mechanisms3.Regarding chronic HEV infection the following are TRUE:1.Chronic HEV infection is exclusively seen with genotype 3 in immunocompromised individuals2.HEV RNA positivity in solid organ transplant recipients is about 30%3.HEV infection in immunocompromised patients is severe with higher bilirubin and aminotransferase levels4.Chronic HEV infection can progress to cirrhosis5.Risk factors for chronic HEV infection include use of tacrolimus, higher degree of immunosuppression and large heterogeneity of quasispecies of HEV4.Regarding immunosuppressive agents used after liver transplantation the following are TRUE EXCEPT:1.Tacrolimus is more likely to cause diabetes than cyclosporine2.Gingival hyperplasia and hypertrichosis are common with tacrolimus3.Main advantage of using mycophenolate is absence of haematological side effects4.Sirolimus is has additional anti-tumour effects making it useful in cases of transplantation for hepatocellular carcinoma5.Basiliximab and daclizumab are IL-2receptor blocking antibodies5.Regarding involvement of the liver in sarcoidosis the following are TRUE EXCEPT:1.Majority of patients of sarcoidosis will have liver involvement on investigation2.Symptomatic liver disease is common in sarcoidosis3.Pulmonary involvement is absent in about 25% of hepatic sarcoidosis4.Portal hypertension is a common finding in hepatic sarcoidosis5.Sarcoidosis is not a cause for cirrhosis of the liver6.Regarding non-alcoholic fatty liver disease (NAFLD) in Asia the following are TRUE:1.South Asians like Indians are at a higher risk of insulin resistance than their Western counterparts2.India has a low prevalence of NAFLD3.Prevalence of NAFLD is increasing in Asian countries4.PNPLA3 gene polymorphisms are not associated with NAFLD in Asians5.APO C3 gene polymorphisms are associated with NAFLD predominantly in Caucasians7.Regarding liver transplantation for cirrhosis due to non-alcoholic steatohepatitis (NASH) the following are TRUE EXCEPT:1.Recurrence of NAFLD is very common2.Overall survival after transplantation is poorer compared to other etiologies of cirrhosis3.Renal dysfunction after transplantation is less common compared to other etiologies of cirrhosis4.Cardiovascular events are a more common cause of death after transplantation in NASH patients5.Pre-transplant diagnosis of NASH related cirrhosis is an independent predictor of development of metabolic syndrome after transplantation8.Regarding nutritional management of patients with cirrhosis the following are TRUE:1.Resting energy expenditure is lower in patients with cirrhosis2.Late evening snack of complex carbohydrates may improve quality of life and survival3.Protein restriction is not advisable even in patients with hepatic encephalopathy4.Animal protein is preferred to vegetable protein5.Branched chain amino acids improve event free survival9.Regarding management of ascites in cirrhosis the following are TRUE:1.Mean arterial pressure is a predictor of survival in patients of cirrhosis with ascites2.Angiotensin converting enzyme inhibitors are good anti-hypertensive drugs in patients with ascites3.Standard medical therapy consisting of sodium restriction and diuretics is successful in controlling ascites in 90% of cases4.Midodrine is a treatment option for patients with refractory ascites5.Peritoneovenous shunts are a favoured treatment option for refractory ascites10.Regarding spontaneous bacterial peritonitis (SBP) the following are TRUE:1.Culture-negative neutrocytic ascites has better outcome than culture positive SBP2.Monomicrobial non-neutrocytic bacterascites frequently resolves spontaneously3.Albumin infusions decrease mortality in patients with SBP4.Primary prophylaxis for SBP is indicated if Child score is ≥9 and serum bilirubin is ≥3 mg/dl5.Short-term prophylaxis for SBP in patients with gastrointestinal bleeding reduces infection rate but does not affect mortality

P04.61. Do infectious disease (ID) physicians use cranberry for prevention of urinary tract infections (UTI)?

Methods In a 2010 survey of 1000 ID physicians, we presented a case vignette about prevention of uncomplicated UTIs. “Ms. Smith is a 23 y.o. female who presents with a history of recurrent bacterial UTIs. In the past, she has self-treated with antibiotics at the first sign of infection; however she is now interested in preventing future occurrences. Previous work up has revealed no predisposing factors.”We also presented a research summary of an article demonstrating evidence of efficacy of cranberry extract for UTI prevention.

Thrombin Generation in Pediatric Patients Treated with L-asparaginase.

Abstract 3983Poster Board III-919 IntroductionTreatment with L-asparaginase is associated with an disturbance of coagulation cascade. Increased thrombin generation is the most frequently cited coagulation anomaly associated with L-asparaginase treatment. Until now, almost all studies aimed on estimation of thrombin generation, have used circulating procoagulant markers such are thrombin/antithrombin complexes(TAT),D dimers(DD),prothrombin fragments (F1,F2).Calibrated automated thrombogram (CAT) allows the precise estimation of the whole amount of thrombin generated in vivo at present time. We show the first data on thrombin generation measured by CAT among pediatric patients with acute lymphoblastic leukemia treated with L-asparaginase. Patients and methodsThrombin generation was measured in platelet poor plasma of 18 patients (age 7-17years) by means of CAT. Samples were obtained at pre-defined time points during the induction and reinduction phase of protocol ALL-IC BFM 2000. We simultaneously checked the APTT,PT,AT III,fibrinogen and DD from each blood sample. Detailed patientsx data were collected prospectively. ResultsWe collected 22 series of CAT measurements from 18 patients. The average endogenous thrombin potential (ETP) value was 1237,64±334,49nM/min during protocol I(PI) and 892,31±405,03 during protocol II resp.III(PII/III) (p .000013). Maximum ETP was reached on day 24 in PI (1310,15±256,3nM/min) and on day 15 in PII/III (978,20±262,30 nM/ min). The average ETP value in 20 healthy controls was 1218,12±129,00 nM/min. Three patients developed deep venous thrombosis (DVT) during the study period, all of them on PI. Their average ETP value on the last measurement before thrombosis was 1510,54±78,6 nM/min. Four patient had an infection gr. III/IV, according WHO, during the study period. Their average ETP value after the infection was 1711,43±106,0 nM/min. Two of those four patient developed DVT within 5 resp.8 days after the first sign of infection. Fibrinogen level <1g/l was detected in 19 samples out of 104. From those 19 samples with fibrinogen < 1,0,the ETP value from the same sample was normal in 14 cases and low in 5 cases. There were no bleeding episodes in that time. ConclusionsThrombin generation is preserved in majority of patients treated with L-asparaginase in accordance with ALL-IC BFM 2000 protocol, despite the associated hypofibrinogenemia. Patients on induction treatment generate significantly more thrombin than patients on reinduction treatment. Our results show the sharp increase in ETP right after the infection with risk of DVT. Our data should be proved on larger group of patients. Disclosures:No relevant conflicts of interest to declare.

Prophylactic and Preemptive Anti-Fungal Therapy after Cord Blood Transplantation: A Retrospective Analyses of 188 Adult Patients.

Background: Therapeutic outcomes for hematological diseases have recently been markedly improved due to the introduction of hematopoietic stem cell transplantation (HSCT), improvement of therapeutic regimens, and advancement of support therapy. Although invasive fungal infections have been one of the major causes of morbidity and mortality after cord blood transplantation(CBT), proper prophylactic and therapeutic approach to them has not been clearly established yet. To address this, we performed retrospective analysis to assess the effectiveness and safety of various antifungal agents for prevention and treatment of invasive fungal infections.Patients and Methods: Medical records of a total of 188 patients who underwent umbilical CBT at Toranomon hospital between March 2002 and December 2005 were reviewed. The diagnosis included AML (n=53), ML (n=32), MDS (n=25), ALL (n=24), ATL (n=22), CML (n=7), AA (n=5), MM (n=3), and others (n=17). The median age was 54 (range; 17–79). The conditioning regimen consisted of fludarabine (125mg/m2), melphalan (80 mg/m2) and 4 Gy TBI for most of the patients. The incidence of breakthrough invasive fungal infection within 50 days after transplant was analysed.Results: Forty-eight of the 188 were administered prophylactic anti-fungal agents other than fluconazole (FLCZ) due to prior mold infection, intorelant to FLCZ, and so on, were excluded. Remaining 140 patients who received FLCZ categolized into 2 groups; those who had empirically switched FLCZ to micafungin (MCFG) and/or amphotericin B (AMPH) and/or itraconazole (ITCZ) capsule at the first sign of infection (group A, n=69), and those who had continued FLCZ (group B, n=71). Four breakthrough invasive fungal infections were observed, 3 of them were invasive pulmonary aspergillosis (IPA), and 1 of them was tricosporon sepsis. Interestingly, all of these 4 were in group B, whereas no breakthrough infections were observed in those who were in group A. All 3 diagnosed IPA died of its exacerbation despite MCFG and/or AMPH treatment.Conclusion: Proper administration of prophylactic anti-fungal agents can reduce the incidence of invasive fungal infection early after CBT. Although FLCZ has less activity to aspergillus, prophylactic FLCZ is effective enough to prevent breakthrough fungal infection. Immediate switch to other agents at the first sign of infection, such as MCFG, AMPH, ITCZ which are active against aspergillus could be recommended to prevent breakthrough infections.

Treatment of Infected Total Knee Arthroplasty

The primary aim of treating infected knee joints after total knee arthroplasty is to eradicate the infection, but this is difficult to achieve. In patients with rheumatoid arthritis affecting multiple joints and active patients with osteoarthritis, revision achieves the best functional outcome. If there is no loosening, preservation of the implant should be attempted. However, if preservation is not possible, revision should be performed when feasible. We believe that patient education is needed to encourage early attendance at the first sign of infection, as well as a hospital system that allows treatment to be started immediately after infection is detected.

Early diagnosis of invasive candidiasis with mannan antigenemia and antimannan antibodies

Late treatment of invasive candidiasis (IC) results in severe complications and high mortality. New tools are needed for early diagnosis. We conducted a retrospective study to assess the diagnostic utility of mannan antigenemia (Mn) and antimannan antibodies (anti-Mn) in neutropenic cancer patients at high risk for candidiasis. Twenty-eight patients with IC (based on European Organization for Research and Treatment of Cancer and Mycoses Study Group definitions) and 25 controls were studied. Mn and anti-Mn were positive (≥0.25 ng/mL and ≥5 AU/mL, respectively) in 25/28 (89%) patients with candidiasis and in 4/25 (16%) controls: sensitivity, 89%; specificity, 84%; positive predictive value, 86%; negative predictive value, 88%. In patients with hepatosplenic lesions, assessing Mn/anti-Mn shortened the median time of diagnosis of candidiasis when compared with imaging (9 versus 25 days after fever onset as first sign of infection; P < 0.001). Candidiasis was diagnosed before neutrophil recovery in 78% and 11% of cases with Mn/anti-Mn and radiology, respectively ( P < 0.001). Mn and anti-Mn may be useful for early noninvasive diagnosis of IC.

Fever in neutropenic cancer patients: A structured approach

Infectious complications related to acquired neutropenia have become a major medical issue, often requiring intensive care management. These infections may be lethal if empirical broad-spectrum treatment is not rapidly started at the first sign of infection (i.e., fever), and this concept is now widely recognized a standard practice. However, the choice of antibiotics has generated considerable controversy for nearly 25 years. After reviewing some particularities of infection in neutropenic patients, this paper will discuss the options and present comprehensive algorithm for non-infectious diseases specialist, including recent advances about early IV-oral switch and the selection of low risk patients for outpatient management.