Immunocompetent Adult Patients Research Articles

High-dose chemotherapy with autologous haematopoietic stem cell transplantation in patients with isolated vitreoretinal lymphoma: a LOC network study.

Despite its indolent evolution, vitreoretinal lymphoma (VRL) has a poor prognosis due to a major risk of relapse in the central nervous system (CNS) and may necessitate aggressive therapy. However, the use of high-dose chemotherapy with autologous stem cell transplantation (HCT-ASCT) is poorly documented. We retrospectively analysed from the French LOC network database the adult immunocompetent patients treated with HCT-ASCT for isolated VRL. Thirty-eight patients underwent consolidation with HCT-ASCT for isolated VRL between 2008 and 2019 after induction chemotherapy. Twenty patients had primary VRL, and 18 had an isolated VRL relapse of a primary CNS lymphoma. Three patients underwent HCT-ASCT in first-line treatment, 24 in second-line treatment, and 11 in subsequent lines. At HCT-ASCT, the median age was 61 years, and the median KPS was 90. Thirty-two patients (84%) received high-dose thiotepa-based HCT. One patient (3%) died from HCT-ASCT toxicity. Nineteen (50%) patients relapsed after HCT-ASCT, including 17 cases occurring in the brain. The median progression-free survival, brain-free survival and overall survival from HCT-ASCT were 96, 113 and 92 months, respectively. HCT-ASCT represents an effective therapeutic strategy for select VRL patients, with a tolerable safety profile. However, the risk of subsequent brain relapse remains significant.

Severe Clinical Outcomes Due to Human Adenoviral Respiratory Infections in Hospitalized Immunocompetent Adults

Background Human adenoviral infections typically result in upper respiratory tract infections, conjunctivitis, and gastroenteritis that is classically self-limiting but can be life-threatening in immunocompromised individuals. In relatively rare cases, adenovirus infections in immunocompetent patients can result in hospitalizations and severe outcomes that include need for critical care or death. The risk factors that are associated with severe adenoviral infections in immunocompetent hosts have not been thoroughly investigated and are currently poorly understood. Methods Retrospective cohort of 78 patients with ages ranging from 18–85 years who were admitted to Yale New Haven-affiliated hospitals over a period of 2 years with positive adenovirus tests on a nasopharyngeal respiratory viral panel. Immunocompromised patients were excluded from the study. Patient charts were reviewed to obtain demographic information, comorbid conditions, smoking history, and clinical outcomes. Results Of the 78 patients admitted, 15 (19.2%) were admitted as observation, 44 (56.4%) were admitted to the hospital for over 48 hours, 15 (19.2%) required critical care, and 4 (5.1%) expired during hospitalization. Pulmonary disease as a comorbidity in the form of asthma (33.3%) or chronic obstructive pulmonary disease (12.8%), and smoking history (59.0%) were more common in those with severe adenoviral infections. With severe disease, 13 (16.7%) required mechanical ventilation, 10 (12.8%) required pressor support, and 2 (2.6%) required extracorporeal membrane oxygenation. Conclusions This retrospective study characterizes severity of adenoviral infections in adult immunocompetent patients, highlights the lack of treatment available, and identifies potential risk factors for severe disease, including asthma, smoking, absence of fever, and presence of coinfection.

Clinical characteristics and outcomes of respiratory syncytial virus-associated ARF in immunocompetent patients: A seven-year experience at a tertiary hospital in France

Respiratory syncytial virus (RSV) is widely recognized as a cause of acute respiratory failure in infants and immunocompromised patients. However, RSV can also contribute to acute respiratory failure in adults, particularly among the elderly population. The objective of this study was to analyze the clinical characteristics and outcomes of immunocompetent adults hospitalized for RSV infection. This retrospective study included all immunocompetent adult patients consecutively admitted to a tertiary care hospital with RSV-related acute respiratory failure over a seven-year period (2016-2023). Diagnosis of RSV infection was made through nasal swabs or pulmonary samples, with multiplex reverse transcription polymerase chain reaction (RT-PCR). Patients were eligible for inclusion if they required supplemental oxygen therapy for at least 48h. One hundred and four patients met the inclusion criteria. Median age [IQR] was 77 years [67-85]. Ninety-seven patients had at least one comorbidity (97/104, 93%). At the time of RSV diagnosis, 67 patients (67/104, 64%) experienced acute decompensation of a pre-existing chronic comorbidity. Antibiotics were started in 80% (77/104) of patients; however, only 16 patients had a confirmed diagnosis of bacterial superinfection. Twenty-six patients needed ventilatory support (26/104, 25%) and 21 were admitted to the intensive care unit (21/104, 20%). The median duration of oxygen therapy [IQR] was 6 days [3-9], while the median hospital length of stay [IQR] was 11 days [6-15]. The overall mortality rate within 1 month of hospital admission was 13% (14/104). The sole variables associated with one-month mortality were age and maximum oxygen flow during hospitalization. RSV-associated acute respiratory failure affected elderly individuals with multiple comorbidities and was associated with prolonged hospitalization and a high mortality rate.

AB156. SOH24AB_273. Primary splenic abscess in an immunocompetent adult female patient: a case report

AB156. SOH24AB_273. Primary splenic abscess in an immunocompetent adult female patient: a case report

Immunocompetent isolated cerebral mucormycosis presenting with obstructive hydrocephalus: illustrative case.

Isolated cerebral mucormycosis is rare in immunocompetent adults and is only sparsely reported to be associated with obstructive hydrocephalus. Here, the authors report a case of obstructive hydrocephalus secondary to central nervous system mucormycosis without other systems or rhino-orbital involvement and its technical surgical management. A 23-year-old, incarcerated, immunocompetent patient with history of intravenous (IV) drug use presented with syncope. Although clinical and radiographic findings failed to elucidate an infectious pathology, endoscopy revealed an obstructive mass lesion at the level of the third ventricle, which, on microbiological testing, was confirmed to be Rhizopus fungal ventriculitis. Perioperative cerebrospinal fluid diversion, endoscopic third ventriculostomy, endoscopic biopsy technique, patient outcomes, and the literature are reviewed here. The patient received intrathecal and IV amphotericin B followed by a course of oral antifungal treatment and currently remains in remission. The patient's unique presentation and diagnosis of isolated cerebral mucormycosis reveal this pathogen as a cause of ventriculitis and obstructive hydrocephalus in immunocompetent adult patients, even in the absence of infectious sequelae on neuroimaging.

Imaging in pulmonary infections of immunocompetent adult patients.

Pneumonia is a clinical syndrome characterised by fever, cough and alveolar infiltration of purulent fluid, caused by infection with a microbial pathogen. It can be caused by infections with bacteria, viruses or fungi, but a causative organism is identified in less than half of cases. The most common type of pneumonia is community-acquired pneumonia, which is caused by infections acquired outside the hospital. Current guidelines for pneumonia diagnosis require imaging to confirm the clinical suspicion of pneumonia. Thus, imaging plays an important role in both the diagnosis and management of pneumonia, with each modality having specific advantages and limitations. Chest radiographs are commonly used but have limitations in terms of sensitivity and specificity. Lung ultrasound shows high sensitivity and specificity. Computed tomography scans offer higher diagnostic accuracy but involve higher radiation doses. Radiological patterns, including lobar, lobular and interstitial pneumonia, provide valuable insights into causative pathogens and treatment decisions. Understanding these radiological patterns is crucial for accurate diagnosis. In this review, we will summarise the most important aspects pertaining to the role of imaging in pneumonia and will highlight the imaging characteristics of the most common causative organisms.

Immunological features of acute cytomegalovirus infection in immunocompetent patients

Objective. To identify and evaluate immunological features in immunocompetent patients with acute cytomegalovirus infection (CMVI).Materials and methods. Thirty-three immunocompetent adult patients with acute cytomegalovirus infection were included in the study; 4 of them had thrombotic complications. The control group consisted of 10 healthy donors. All 33 blood samples were tested by flow cytometry. The content of antigen-specific cells was checked in all patients. Results. All patients had positive cytomegalovirus DNA PCR tests. The content of activated T cells in patients with acute CMV infection and thrombotic complications is 7.7 times higher (p < 0.001) than in conditionally healthy patients (median values: 36.02% (31.01; 47.92) and 4.68% (3.39; 5.25), respectively). The content of granulocytic myeloid suppressor cells (G-MLSC) in patients with acute CMV infection and thrombosis exceeds the same indicator in the group of healthy volunteers by 8.3 times (p < 0.001) (median values were 0.38% (0.24; 0.54) and 0.05% (0.03; 0.07) respectively). The number of regulatory T cells in patients with acute CMV infection and thrombosis was reduced by 3.1 times (p < 0.001) compared to the same indicator in the group of healthy volunteers (median indicators: 0.79% (0.57; 1.09) and 2.45% (2.01; 3.86), respectively). Immunophenotyping of CD3+ cells showed a tendency to increase the proportion of more mature cells, namely effector memory cells (TEM) and terminally differentiated memory cells (TEM RA) with a decrease in the percentage of “naive” cells.Conclusion. A high level of antigen-specific T-cell response and a low content of T-regulatory cells may indicate insufficient control of the proliferation of T-cytotoxic lymphocytes, which may contribute to the long-term persistence of the virus and the development of chronic inflammation of the vessel wall, which requires further study. Thus, in patients with acute CMV infection, an additional risk factor for thrombosis appears, which must be taken into account when carrying out therapeutic and diagnostic measures.

PCV13 vaccine prevents pneumococcal biofilms without affecting Staphylococcus aureus population within the polymicrobial biofilm.

In respiratory pathogens such as Streptococcus pneumoniae, biofilm formation is associated with the colonization of the nasopharynx and chronic respiratory infection. Previous data have shown that pneumococcal conjugate vaccines (PCVs) had an impact on S. pneumoniae colonization and a potential replacement by other respiratory pathogens such as Staphylococcus aureus. The objective of this work was to evaluate the evasion of the immune system by monospecific biofilms and by S. aureus-S. pneumoniae mixed biofilms. We performed opsonophagocytosis assays (OPA) using human HL-60 against previously disaggregated monospecific biofilms of MSSA, MRSA and S. aureus-S. pneumoniae mixed biofilms. We used pre-immune and post-immune serum from immunocompetent adult patients vaccinated with PCV13. Immune sera had a clear effect in reducing pneumococcal biofilms of serotypes 3, 14, 18C, 19F and 19A, whereas had no effect in non-PCV13 serotypes such as 8, 11A and 24F. Our study confirmed that serum from vaccinated patients with PCV13 did not have any effect in reducing S. aureus population in monospecific biofilms, regardless the methicillin resistance phenotype. Moreover, immunized sera from vaccinated patients with PCV13 did not have any effect in S. aureus population in the mixed biofilm, whereas significantly reduced the population of pneumococcal serotype 19A strain in the mixed biofilm which is of great interest because this serotype is included in PCV13, and it is associated with vaccine failures.

КЛИНИЧЕСКИЕ ОСОБЕННОСТИ ОСТРОЙ ЦИТОМЕГАЛОВИРУСНОЙ ИНФЕКЦИИ, СОПРОВОЖДАЮЩЕЙСЯ ТРОМБОТИЧЕСКИМИ ОСЛОЖНЕНИЯМИ, У ИММУНОКОМПЕТЕНТНЫХ ПАЦИЕНТОВ

Objective of the study. To identify and analyse clinical and laboratory features in immunocompetent patients with thrombotic complications in acute cytomegalovirus infection. Development of the algorithm of prognosis and early diagnosis of thrombotic complications in order to reduce the risk of severe course of the disease and lethal outcome. Materials and Methods. The study included 100 immunocompetent adult patients undergoing inpatient observation and treatment with laboratory-proven acute cytomegalovirus infection. All patients had a detailed clinical and epidemiological history for the possible presence of modifiable and/or non-modifiable prothrombotic risk factors; a multifaceted laboratory and instrumental examination was performed. Results. Out of one hundred patients with acute cytomegalovirus infection selected in the study, thrombotic diseases were observed in 7% of cases (in 7 patients). The mean age of the patients was 41 (38; 42) years. Patients were hospitalised on average on 12 (10; 14) days from the onset of the disease. The main complaints on admission were: prolonged fever up to 38°C and marked general weakness. The patients had elevated ALT and AST in 88% and 80% of cases, respectively. The presence of reactive lymphocytes was registered in 57% of cases. Enlargement of liver and spleen was observed in 67% and 70% of cases, respectively. Compared to patients with uncomplicated course of acute cytomegalovirus infection, statistically significant laboratory differences were observed in SRB (p<0.001) and D-dimers (p<0.05) in patients who had thrombotic complications. All patients who had genetic material (DNA) to CMV in the blood had positive tests for rr65 antigenemia. The polymorphism of factor V gene G1691A (FVLeiden) was detected in only one patient, who was a carrier of heterozygous GA allele. Conclusion. Acute cytomegalovirus infection in immunocompetent patients includes a symptom complex consisting of a typical clinical picture (prolonged febrile intoxication, hepatosplenomegaly, elevated hepatic transaminases, CRP and D-dimer levels) and obligatory laboratory detection of the virus (positive PCR and/or Ag pp65 tests for CMV). Cytomegalovirus is an independent and reliable prothrombotic risk factor, with thrombotic complications occurring in 7% of cases. Patients with risk factors for thrombotic complications with verified acute cytomegalovirus infection are recommended to be prescribed anticoagulant therapy at prophylactic doses. Also, patients with a proven case of thrombotic process on the background of acute cytomegalovirus infection are recommended a course of etiotropic antiviral therapy.

Abstract 18155: A Rare Case of Acute Purulent Pericarditis Secondary to Invasive Streptococcal Infection (S. Pyogenes) With Cardiac Tamponade in an Immunocompetent 37-Year Old Female: A Case Report

BACKGROUND: Purulent pericarditis is a rare occurrence in the era of modern antibiotics. It is most often caused by organisms such as Staphylococcus aureus, Streptococcus pneumoniae, viridans streptococci, Haemophilus influenzae, and anaerobic bacteria with Streptococcus pyogenes (S. pyogenes) being a possible, though very uncommon etiology. It is usually associated with an underlying infection or compromised immune system. Purulent bacterial pericarditis is a high mortality entity and represents only 1% of the causes of pericarditis, among these only a few cases have been reported of Streptococcus pyogenes pericarditis. This is an extremely rare case of acute purulent bacterial pericarditis caused by S. pyogenes in an immunocompetent adult patient with no underlying chronic medical conditions. CASE PRESENTATION: A 37-year-old healthy female with no known comorbidities came in for chills, dyspnea, chest pain radiating to the upper back aggravated by deep breathing and relieved with leaning forward. She initially presented with unstable vital signs (hypotension and tachycardia). Electrocardiography demonstrated diffuse ST-segment elevation and PR segment depression, while chest Xray and CT scan showed lobar pneumonia. Blood tests showed leukocytosis with neutrophilic predominance indication infection and workup for autoimmune disease was done which was negative. 2D echo showed large pericardial effusion with tamponade physiology. An urgent pericardiocentesis was done with drainage of 350cc nonclotting purulent serous fluid. Cultures grew Streptococcus pyogenes (S. pyogenes) confirming the diagnosis of acute purulent bacterial pericarditis. Management for pericarditis including daily drainage of pericardial effusion, colchicine, ibuprofen was initiated together with antibiotics for the pneumonia and the patient had resolution of the pericardial effusion as documented by repeat 2DED upon follow up.

Acute disseminated toxoplasmosis in an immunocompetent adult patient. Case report

Abstract Introduction: Toxoplasmosis is a disease of global distribution caused by the parasite Toxoplasma gondii, which develops differently depending on the immunologic status of the patient. In immunocompetent patients, it is usually asymptomatic and complications such as pneumonitis, encephalitis, or multiple organ dysfunction are rare. The following is the case of an immunocompetent patient with acute disseminated toxoplasmosis. Case report: A 42-year-old man, with no history of immunocompromise, or relevant medical, family or personal history, was transferred to the emergency department of a tertiary care institution in the city of Bogotá D.C. (Colombia) due to a fever that had lasted for a month, headache, and progressive neurological deterioration. Studies looking for other infectious etiologies, as well as for autoimmunity, neoplasms, and metabolic disorders, were negative. Computed tomography (CT) of the skull showed findings of meningoencephalitis. He was considered as a possible case of toxoplasmosis and treatment with trimethoprim/sulfamethoxazole was initiated. During his stay in the intensive care unit (ICU), he developed multiple organ dysfunction syndrome (MODS) and ultimately died. The post-mortem histopathological study of tissues reported the presence of Toxoplasma gondii bradyzoites, which confirmed the diagnosis of acute toxoplasmosis. Conclusions: Acute disseminated toxoplasmosis is a diagnostic challenge because it can mimic other etiologies. A timely diagnosis may prevent medical complications and increase the patient's chances of recovery. Knowledge about this disease in immunocompetent patients is a subject being developed.

AUTOLOGOUS HEMATOPOIETIC CELL TRANSPLANTATION FOR PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA (PCNSL). REAL‐WORLD REPORT OF POLISH LYMPHOMA RESEARCH GROUP.

Introduction: High-dose chemotherapy with autologous stem-cell transplantation (HDC-ASCT) is now the preferred consolidation strategy for young PCNSL patients. The optimal conditioning regimen is unknown. The data suggests that BEAM (carmustine, etoposide, cytarabine, melphalan) is ineffective, BCNU/TT (carmustine/thiotepa) is well-tolerated with treatment related mortality (TRM) 1%–3%, but late relapses are common, and TBC (thiotepa, busulfan, cyclophosphamide) is highly effective but with higher TRM 11%. Methods: The aim of the study was to analyze the safety and efficacy of consolidation based on conditioning regimen consisted of carmustine, etoposide and thiotepa (BET)1 followed by ASCT. We evaluated the outcome of 45 immunocompetent adult patients with PCNSL treated in 4 Polish centers between Feb. 2015 and Oct. 2022. Six cycles of induction with rituximab, methotrexate (3.5 g/m2), ifosfamide and vincristine (R-MIV) and one cycle of cytarabine with thiotepa (AT)2 were given. Patients with a complete or partial response (CR/PR) proceeded to consolidation with carmustine 400 mg/m2 on day -5, etoposide 150 mg/m2 on day -5,-4, -3, and thiotepa 5 mg/kg every 12 h on days -4 and -3 (total 4 doses), followed by ASCT. Results: Median age (range) of 45 transplanted patients was 57 years (19-66) with 15 (33%) patients ≥60 years old. At the end of induction 29 (64.5%) patients obtained CR/CRun (19/10 respectively), with additional 5 (11%) patients with no evidence of disease at baseline, and 11 (24.5%) in PR, based on standard CT/MRI assessment. For 32 (71%) patients with 18FDG PET/CT done before ASCT, metabolic-CR was confirmed. Mean (range) number of 584.4 (187–2642) × 106 CD34+ peripheral blood stem cells were collected, corresponding to 7.2 × 106 cells/kg (2.55–34.7 × 106 cells/kg). Mean hospitalization time from the day of ASCT was 15 days. Mean time to hematologic recovery with PLT > 25 G/L and NEU > 0.5/ > 1.0 G/L was 9 and 9/10 days, respectively. The most common grade 3–4 non-haematological toxicities were diarrhea (12 patients, mean 4 days) and mucositis (18 patients, mean 5 days). Febrile neutropenia occurred in 21 patients (mean 2.5 days). Blood cultures did not reveal any relevant pathogens except one patient with confirmed Enterobacter cloacae-ESBL and Klebsiella oxytoca. Two patients (TRM 4.4%) died of transplant-related complications: septic shock and neurotoxicity. At a median (range) follow-up of 41 (13-92) months, 3-year progression free survival (PFS) and overall survival (OS) was 78% (95% CI: 65-91) and 81% (95% CI: 68-93). Relapse occurred in 9 patients, in all but one within first 11 months after ASCT. Causes of death were: lymphoma progression (n = 6), TRM (n = 2), accident (n = 1) and concomitant diseases (n = 2). Keywords: aggressive B-cell non-Hodgkin lymphoma, stem cell transplant No conflicts of interests pertinent to the abstract.

Meningo encephalitis with Epstein-Barr virus in an immunocompetent adult patient: case report

Epstein-Barr virus is a rare ethology of the neurological infections, expressed as encephalitis, aseptic meningitis, Guillain-Barre syndrome or acute demyelinating encephalomyelitis. Most common cases were reported in children, while this infection is rarely described in immunocompetent adults. We present the case of an elderly immunocompetent patient with hypertension and hypothyroidism under treatment who has presented to the emergency department for unusual headache, confusion, sudden loss of consciousness with retrograde amnesia, suddenly onset for 2 hours associated with febrile respiratory symptoms. Traumatic neurological events, cerebral ischemia or metabolic encephalopathies were ruled out, while examination of the cerebrospinal fluid was positive for Epstein-Barr virus. The course of the meningoencephalitis was favorable, although an episode of diarrhea with Clostridioides difficile with binary positive toxin A+B was notified. The primary infection or the reactivation of a previous infection, is a questionable mechanism of meningoencephalitis with Epstein Barr Virus in an old immunocompetent patient. According to the reported studies, the antiviral treatment with Acyclovir is controversial. The long-term prognosis of acute meningoencephalitis with Epstein-Barr virus is unpredictable and involves careful neurological and onco-hematological monitoring.

Liver abscess due to Granulicatella adiacens in an immunocompetent patient: Case report

Pyogenic liver abscesses due to Granulicatella adiacens are infections associated with high mortality, mainly in immunocompromised patients. The main microorganisms associated with liver abscesses are Klebsiella pneumoniae, and Escherichia coli, though it may also be polymicrobial. However, case reports describing liver infection by Granulicatella adiacens are scarce.We present the case of an immunocompetent adult patient who presented 15 days of evolution consisting of quantified fever peaks associated with asthenia, adynamia, chills, jaundice and coluria. The initial clinical examination revealed a generalized icteric tint without abdominal pain, and blood pressure with a tendency to hypotension. Biliopancreatic confluent neoplasia, secondary cholangitis and sepsis of biliary origin were suspected, initiating fluid resuscitation and antibiotic therapy; blood cultures and complementary diagnostic studies were taken. Hepatobiliary ultrasound with evidence of an abscess of 73 x 62 mm in segment IV; the bile duct and pancreas were within normal limits. To better characterize the lesion evidenced in the liver, a contrast-enhanced computed tomography of the abdomen was performed. The patient completed antibiotic management with ciprofloxacin, vancomycin, and metronidazole in good condition and was successfully discharged.This is the first pyogenic liver abscess reported caused by Granulicatella adiacens in an immunocompetent patient, in whom early microbiological diagnosis in conjunction with targeted antibiotic treatment and percutaneous drainage of the lesion was decisive in the clinical outcome.

Clinical characteristics and severity prediction score of Adenovirus pneumonia in immunocompetent adult.

Compared with children and immunocompromised patients, Adenovirus pneumonia in immunocompetent adults is less common. Evaluation of the applicability of severity score in predicting intensive care unit (ICU) admission of Adenovirus pneumonia is limited. We retrospectively reviewed 50 Adenovirus pneumonia inpatients in Xiangtan Central Hospital from 2018 to 2020. Hospitalized patients with no pneumonia or immunosuppression were excluded. Clinical characteristics and chest image at the admission of all patients were collected. Severity scores, including Pneumonia severity index (PSI), CURB-65, SMART-COP, and PaO2/FiO2 combined lymphocyte were evaluated to compare the performance of ICU admission. Fifty inpatients with Adenovirus pneumonia were selected, 27 (54%) non-ICU and 23 (46%) ICU. Most patients were men (40 [80.00%]). Age median was 46.0 (IQR 31.0-56.0). Patients who required ICU care (n = 23) were more likely to report dyspnea (13[56.52%] vs 6[22.22%]; P = 0.002) and have lower transcutaneous oxygen saturation ([90% (IQR, 90-96), 95% (IQR, 93-96)]; P = 0.032). 76% (38/50) of patients had bilateral parenchymal abnormalities, including 91.30% (21/23) of ICU patients and 62.96% (17/27) of non-ICU patients. 23 Adenovirus pneumonia patients had bacterial infections, 17 had other viruses, and 5 had fungi. Coinfection with virus was more common in non-ICU patients than ICU patients (13[48.15%]VS 4[17.39%], P = 0.024), while bacteria and fungi not. SMART-COP exhibited the best ICU admission evaluation performance in Adenovirus pneumonia patients (AUC = 0.873, p < 0.001) and distributed similar in coinfections and no coinfections (p = 0.26). In summary, Adenovirus pneumonia is not uncommon in immunocompetent adult patients who are susceptible to coinfection with other etiological illnesses. The initial SMART-COP score is still a reliable and valuable predictor of ICU admission in non-immunocompromised adult inpatients with adenovirus pneumonia.

Evaluating outpatient diagnostic stewardship of comprehensive polymerase chain reaction Clostridioides difficile testing in a regional health system.

We examined the use of comprehensive and targeted polymerase chain reaction (PCR) of Clostridioides difficile infection (CDI) among immunocompetent patients with and without CDI risk factors across different outpatient settings. A priori, we expected patients with higher CDI risk to be associated with targeted testing to reflect providers incorporating pretest risk factors in their choice of test assay. Retrospective analysis of adult patients from clinic, emergency room, and non-medically acute inpatient settings. A tertiary academic medical center offering inpatient and outpatient medical, surgical, mental health, and rehabilitation services to Veterans across the Puget Sound region. Immunocompetent adult patients with ≥1 stool PCR assay performed between January 2016 and December 2019. Patients were tested with either a specific tcdB PCR assay or a comprehensive gastrointestinal PCR panel that tests for 22 pathogens. A total of 2,717 tests (74% targeted, 26% comprehensive) were obtained from 2,156 patients, among which 13% detected C. difficile and 7% detected other organisms. The proportion of comprehensive PCR tests increased nearly four-fold from 2016 to 2019 in clinic and emergency room settings, independent of CDI risk factors. Only two CDI risk factors (prior history of CDI and antibiotic use within three months before testing) were associated with increased targeted testing. The use of comprehensive GI PCR among immunocompetent adults with diarrhea is increasing in the outpatient setting. There may be an opportunity for diagnostic stewardship by nudging providers to consider all CDI risk factors at the time of test selection.

Acute Coxsackievirus B3-induced meningo-cerebellitis in an immunocompetent adult patient.

We report an acute Coxsackievirus B3 (CVB3)-induced meningo-cerebellitis in an immunocompetent adult patient. CVB3 has a global distribution and is the most common Enteroviruses cause of myocarditis and sudden cardiac death. To our knowledge, CVB3 is exceedingly rare as causes of meningo-encephalitis in immunocompetent adults, whereas some cases have been reported in neonates due to perinatal acquired infections or in immunocompromised patients.

Voriconazole in the treatment of invasive aspergillosis of orbit

BackgroundThe aim of the study was to evaluate the outcomes of voriconazole in terms of functional recovery and response on imaging in the management of invasive aspergillosis of orbit. MethodsThis was a prospective non-comparative interventional study. Diagnosed cases of invasive orbital aspergillosis were studied in a tertiary care hospital. Intravenous voriconazole followed by oral treatment was given. Sinus debridement was done, where needed. The response to treatment was assessed clinically and on radiology. ResultsA total of 10 diagnosed cases of invasive orbital aspergillosis were studied. Nine cases (90%) occurred in immunocompetent patients. Predisposing sinus infection was seen in 8 patients (80%). The most common presenting complaint was the protrusion of eye. On voriconazole treatment, there was a statistically significant improvement in vision and extraocular movements from first week onwards (p = 0.01 and p = 0.02, respectively) and reduction in proptosis from second week onwards (p = 0.003). Imaging was done at three months follow-up which revealed a good response to treatment in 90% of patients. All patients tolerated the drug well except one who had transient hepatic dysfunction. The mean follow-up was 5.8 months (range: 3–12 months). There was no recurrence of disease till the last follow-up. ConclusionInvasive orbital aspergillosis commonly presents as sino-orbital disease, mostly in immunocompetent adult patients. Voriconazole is a safe and effective drug with good short-term clinical outcome.

Single-Dose, Patient-Initiated Amenamevir Therapy for Recurrent Genital Herpes: A Phase 3, Randomized, Double-Blind, Placebo-Controlled Study.

BackgroundAmenamevir is a helicase-primase inhibitor with novel mechanisms of antiherpetic action. A patient-initiated single-dose regimen showed clinical efficacy for genital herpes in a phase 2 study.MethodsIn this phase 3 study, adult immunocompetent patients with recurrent genital herpes and able to accurately recognize prodromal symptoms were randomly assigned to administer amenamevir 1200 mg or placebo as a patient-initiated therapy within 6 hours after onset of prodromal symptoms. The primary efficacy endpoint was time to healing of all genital herpes lesions.ResultsIn the modified intention-to-treat population, which excluded patients with aborted lesions (amenamevir, n = 89; placebo, n = 97), the median time to all lesion healing was 4.0 days for amenamevir versus 5.1 days for placebo (hazard ratio, 1.60 [95% confidence interval, 1.19–2.15]; P = .0018), indicating superiority of amenamevir. All treatment-emergent adverse events in both groups were mild in severity.ConclusionsPatient-initiated single-dose amenamevir reduced the time to all lesion healing of recurrent genital herpes versus placebo, with no safety concerns, suggesting it could be an effective treatment option for patients with recurrent genital herpes. Clinical Trials Registration. JapicCTI-194955.

Analysis of medical and economic efficiency of vaccine prevention of respiratory diseases among builders of the Amur Gas Processing Plant using expert assessments and methods of predictive modeling

Introduction. Acute respiratory viral and pneumococcal infections, the incidence of which is associated with high economic costs, are one of the most important problems in epidemiology and pulmonology. Preventive vaccination is a tool for managing the incidence of acute respiratory viral infection (ARVI) and pneumococcal infections. The issues of medical and economic efficiency of preventive vaccination are constantly in the field of epidemiological surveillance, and the estimates obtained in this case are a necessary condition for making decisions on the viability of investing in its organization.Aim. Expert assessment and predictive modeling of the potential cost-effectiveness of vaccination with pneumococcal and influenza vaccines in immunocompetent adult patients with different levels of risk of acute and chronic respiratory diseases among the builders of the Amur Gas Processing Plant (GPP).Materials and methods. A complex of studies was carried out using the methods of statistics, epidemiological analysis and monitoring, comparative and economic analysis. Determination of the economic profitability of vaccination was carried out on the basis of methods of comparing “costs” and “benefits”. The surveyed cohort is represented by adults working on the construction of the Amur GPP (Svobodny, Amur Region). The main risk factors and inclusion criteria were the conditions of adverse effects of occupational, social and biological factors on human respiratory health. A set of preventive measures was carried out using methods and means of specific prevention of acute and chronic respiratory diseases: anti-influenza (Ultrix Quadri) and pneumococcal (Prevenar-13) vaccines. Efficacy analysis was carried out for 20-, 40- and 60-year-old patients with 1, 2 and 3 risk factors in accordance with the methods of its medical, social and economic evaluation. A retrospective determination of the cases of diseases (deaths) and economic damage prevented as a result of vaccination was carried out on the basis of the difference in morbidity (mortality) rates for the period preceding vaccination and for the period following vaccination. When constructing a predictive model for evaluating the effectiveness of vaccine prevention of respiratory infections, expert assessments, legal documents and the methodology of individual researchers were used.Results. The predicted incidence of pneumonia among the builders of the Amur GPP, taking into account all risk factors, can be 32.3‰. At the same time, the total volume of prevented predictive incidence of pneumonia in the post-vaccination period only with the use of pneumococcal vaccine can be 26.5‰, reducing the initial incidence rate by 5.5 times. As a result of the calculations and economic assessment, it was found that the total (direct and indirect) economic costs of the state and the plant (economic damage) with the incidence of community-acquired pneumonia in the working-age population (20-60 years) on the territory of this construction site is 112,811 rubles. per person per year. Consequently, the prevented economic damage among the employees and builders of the Amur GPP only as a result of the use of the pneumococcal vaccine “Prevenar-13” is 13,537,411 rubles. In addition, immunoprophylaxis with the use of influenza vaccines can reduce the incidence of influenza, ARVI, pneumonia and chronic forms of respiratory diseases, which corresponds to additional prevented economic damage to the plant in the amount of 103,786,764 rubles. Thus, the predicted total prevented economic damage for this plant as a result of vaccination may amount to 117,324,175 rubles.Conclusion. The results of the studies indicate that the implementation of the Program for the Prevention of Acute Respiratory Diseases by means of influenza and pneumococcal vaccines among the builders of the Amur GPP has a high level of medical and socio-economic efficiency, identified on the basis of its predictive modeling and expert assessments.