Immunocompetent Patients Research Articles

Reassessing Halm's clinical stability criteria in community-acquired pneumonia management.

Halm's clinical stability criteria have long guided antibiotic treatment and hospital discharge decisions for patients hospitalised with community-acquired pneumonia (CAP). Originally introduced in 1998, these criteria were established based on a relatively small and select patient population. Consequently, our study aims to reassess their applicability in management of CAP in a contemporary real-world setting. This cohort study included 2918 immunocompetent patients hospitalised with CAP from three hospitals in Denmark between 2017-2020. The primary outcome was time to achieve clinical stability as defined by Halm's criteria. Additionally, we examined recurrence of clinical instability and severe complications. Cumulative incidence function or Kaplan-Meier survival curves were used to analyse these outcomes, considering competing risks. The study population primarily comprised elderly individuals (median age: 75 years) with significant comorbidities. The median time to clinical stability according to Halm's criteria was 4 days, with one-fifth experiencing recurrence of instability after early clinical response (stability within 3 days). Severe complications within 30 days mainly comprised mortality, with rates of 5.1% (64/1257) overall in those with early clinical response, 1.7% (18/1045) in the subgroup without do-not-resuscitate orders, and 17.3% (276/1595) among the rest. Halm's clinical stability criteria effectively classify CAP patients with different disease courses, yet achieving stability required more time in this aging population with substantial comorbidities and more severe disease. Early clinical response indicates reduced risk of complications, especially in those without do-not-resuscitate orders.

Seasonal Patterns of Common Respiratory Viral Infections in Immunocompetent and Immunosuppressed Patients.

Several respiratory viruses have been shown to have seasonal patterns. The aim of our study was to evaluate and compare these patterns in immunocompetent and immunosuppressed patients for five different respiratory viruses. We performed a retrospective analysis of results for 13,591 respiratory tract samples for human metapneumovirus (HMPV), influenza virus, parainfluenza virus (PIV) and respiratory syncytial virus (RSV) in immunocompetent and immunosuppressed patients. A seasonal pattern was aligned to the data of immunocompetent patients through a logistic regression model of positive and negative test results. A narrow seasonal pattern (January to March) was documented for HMPV. Most RSV infections were detected in the winter and early spring months, from December to March, but occasional cases of RSV could be found throughout the year. The peak season for PIV-3 was during the summer months, and that for PIV-4 was mostly in autumn. A narrow seasonal pattern emerged for influenza virus as most infections were detected in the winter, in January and February. The seasonal patterns of HMPV, RSV, PIV, and influenza virus were similar for both immunocompetent and immunocompromised patients. We found no difference in the seasonality of HMPV, RSV, PIV, and influenza virus infections between immunosuppressed and immunocompetent hosts.

Bilateral Uveopapillitis Revealing a Herpes - Hepatitis B - Cytomegalovirus Viral Coinfection in an Immunocompetent Patient: Case Report from the Thiès Regional Hospital Center

Co-infection in immunocompetent patients is not a common occurrence in everyday practice, especially in the case of uveitis. The type G immunoglobulins found in the chronic carriage of the three germs raised serious questions about their virulent potential in the chronic phase. The corticosteroid therapy administered considerably reduced the inflammatory cascade that had already begun.

A challenging coexistence: community-acquired methicillin-resistant Staphylococcus aureus and Mycobacterium tuberculosis

BackgroundCommunity-acquired Methicillin-resistant Staphylococcus aureus (CA-MRSA) usually emerges after a viral infection and causes severe disease in immunocompetent individuals. Concurrent infection with tuberculosis (TB) is generally very rare in immunocompetent patients. Our case is the first report of the coexistence of CA-MRSA and TB in an immunocompetent patient.Case presentationA 24-year-old male patient of African origin, who has been living in Turkey for a year, was admitted to our hospital 3 months ago with fever, cough, and sputum complaints, which developed following symptoms of influenza infection. More intense bilateral infiltration and cavitary appearance were observed on the left in the chest radiography of the patient who did not respond to amoxicillin and gemifloxacin treatments. The patient’s sputum culture showed MRSA growth, and his sputum acid-resistant bacteria (ARB) was reported as three positive. Vancomycin, isoniazid, rifampicin, pyrazinamide, and ethambutol treatments were started. Subsequently, Mycobacterium Tuberculosis growth was also detected in the mycobacteria culture. Vancomycin treatment was completed in 14 days. There was no growth in the control sputum culture. When the patient, who gave clinical and laboratory response, was admitted with increased shortness of breath complaint two months after discharge, it was observed that minimal spontaneous pneumothorax developed in the left lung, and it was decided to follow up without intervention. In the second month of tuberculosis treatment, sputum ARB and mycobacteria culture became negative, and the patient was switched to dual antituberculosis treatment (isoniazid, rifampicin), and his treatment is still ongoing.ConclusionsMixed infections should be considered in case of non-response to treatment in patients with pneumonia. Mixed infections should also be followed closely as they may be more complicated.

Indocyanine green angiography reveals choroidal hypoperfusion in subacute sclerosing panencephalitis (SSPE).

We report the choroidal findings on indocyanine green angiography (ICGA) in two cases of subacute sclerosing panencephalitis (SSPE). The two immunocompetent patients (31-year-old and 30-year-old Asian Indian males) presented with acute-onset rapidly progressing vision loss with findings of necrotizing retinitis involving the central macula. Both patients tested negative for serological evidence of herpes or varicella, and toxoplasma antibodies. The patients demonstrated high serum and cerebrospinal fluid titers of anti-measles antibody (and abnormal electroencephalogram in one patient) leading to the diagnosis of SSPE. ICGA of both patients revealed distinct "dark dots" which showed hypofluorescence in the early and late phases suggestive of choroidal involvement/hypoperfusion. Choroidal involvement in SSPE has not been evaluated before and must be considered in the pathological manifestations of the disease.

Risk factors for prolonged infection and secondary infection in pediatric severe sepsis.

Sepsis causes significant worldwide morbidity and mortality. Inability to clear an infection and secondary infections are known complications in severe sepsis and likely result in worsened outcomes. We sought to characterize risk factors of these complications. We performed a secondary analysis of clinical data from 401 subjects enrolled in the PHENOtyping sepsis-induced Multiple organ failure Study. We examined factors associated with prolonged infection, defined as infection that continued to be identified 7days or more from initial identification, and secondary infection, defined as new infections identified ≥ 3days from presentation. Multivariable adjustment was performed to examine laboratory markers of immune depression, with immunocompromised and immunocompetent subjects analyzed separately. Illness severity, immunocompromised status, invasive procedures, and site of infection were associated with secondary infection and/or prolonged infection. Persistent lymphopenia, defined as an absolute lymphocyte count (ALC) < 1000 cells/µL twice in the first five days, and persistent neutropenia, defined as absolute neutrophil count (ANC) < 1000 cells/µL twice in the first five days, were associated with secondary and prolonged infections. When adjusted in multivariable analysis, persistent lymphopenia remained associated with secondary infection in both immunocompromised (aOR = 14.19, 95% CI [2.69, 262.22] and immunocompetent subjects (aOR = 2.09, 95% CI [1.03, 4.17]). Persistent neutropenia was independently associated with secondary infection in immunocompromised subjects (aOR = 5.34, 95% CI [1.92, 15.84]). Secondary and prolonged infections were associated with worse outcomes, including death. Laboratory markers of immune suppression can be used to predict secondary infection. Lymphopenia is an independent risk factor in immunocompromised and immunocompetent patients for secondary infection.

The Wide Spectrum of Presentations of Cytomegalovirus Infection in Immunocompetent Hosts: An Exhaustive Narrative Review.

CMV is a ubiquitous DNA virus that establishes infection and results in 40-100% seropositivity. Viral replication occurs following an acquired primary infection (or reinfection) or by the reactivation of life-long latency. In immunocompetent patients, CMV infection is mostly asymptomatic or mild and self-limited. However, an extensive review of the literature published up to April 2024 reveals that despite immunocompetence, CMV can cause a very large variety of clinical syndromes in any part of the gastrointestinal tract (the most common pattern), the central or peripheral nervous system, and the eyes, as well as hematological, pulmonary, cardiac, and cutaneous disease. Not uncommonly, more than one system is involved, and though the disease is often self-limited, treatment with intravenous ganciclovir or oral valganciclovir may be required, and in isolated cases, fatalities may occur. Thus, a potential CMV infection should be considered in the differential of myriad syndromes in non-immunocompromised patients. Associated systemic symptoms (fever, sweats, and weight loss), lymphocytosis, and hepatitis are not uncommon and can be a useful clue. Some populations, such as critically ill patients in intensive care, pregnant women, elderly patients, and those with inflammatory bowel disease, may be more susceptible. Moreover, the potential of past, latent CMV infection (i.e., CMV seropositivity) to be associated with significant cardiovascular morbidity and all-cause mortality years later is intriguing and requires further study. All these data indicate the outstanding importance of developing a vaccine against CMV, which hopefully will become available in the foreseeable future. Meanwhile, a solid diagnosis of active CMV infection can be quickly established (or ruled out) by widely available serology tests and PCR amplification, and clinicians in all disciplines need to be more aware of the diverse guises of CMV infection and remember to consider it in any host, including an immunocompetent one.

Application of metagenomic next-generation sequencing and targeted metagenomic next-generation sequencing in diagnosing pulmonary infections in immunocompetent and immunocompromised patients.

Metagenomic next-generation sequencing (mNGS) technology has been widely used to diagnose various infections. Based on the most common pathogen profiles, targeted mNGS (tNGS) using multiplex PCR has been developed to detect pathogens with predesigned primers in the panel, significantly improving sensitivity and reducing economic burden on patients. However, there are few studies on summarizing pathogen profiles of pulmonary infections in immunocompetent and immunocompromised patients in Jilin Province of China on large scale. From January 2021 to December 2023, bronchoalveolar lavage fluid (BALF) or sputum samples from 546 immunocompetent and immunocompromised patients with suspected community-acquired pneumonia were collected. Pathogen profiles in those patients on whom mNGS was performed were summarized. Additionally, we also evaluated the performance of tNGS in diagnosing pulmonary infections. Combined with results of mNGS and culture, we found that the most common bacterial pathogens were Pseudomonas aeruginosa, Klebsiella pneumoniae, and Acinetobacter baumannii in both immunocompromised and immunocompetent patients with high detection rates of Staphylococcus aureus and Enterococcus faecium, respectively. For fungal pathogens, Pneumocystis jirovecii was commonly detected in patients, while fungal infections in immunocompetent patients were mainly caused by Candida albicans. Most of viral infections in patients were caused by Human betaherpesvirus 5 and Human gammaherpesvirus 4. It is worth noting that, compared with immunocompetent patients (34.9%, 76/218), more mixed infections were found in immunocompromised patients (37.8%, 14/37). Additionally, taking final comprehensive clinical diagnoses as reference standard, total coincidence rate of BALF tNGS (81.4%, 48/59) was much higher than that of BALF mNGS (40.0%, 112/280). Our findings supplemented and classified the pathogen profiles of pulmonary infections in immunocompetent and immunocompromised patients in Jilin Province of China. Most importantly, our findings can accelerate the development and design of tNGS specifically used for regional pulmonary infections.

An immunocompetent lady with invasive aspergillosis presenting as disseminated lesions: a case report

BackgroundInvasive Aspergillosis is a fungal infection caused by Aspergillus species, typically posing life-threatening risks to immunocompromised individuals. While occurrences in immunocompetent hosts are rare, a recent case report documented fulminant pulmonary aspergillosis in an immunocompetent patient during autopsy. Here, we present a case of invasive aspergillosis in an immunocompetent woman, manifesting with disseminated lesions.Case presentationA 29-year-old Asian woman presented to our hospital in March 2022, reporting chest pain and shortness of breath persisting for two months. Upon examination, she appeared thin and unwell, with no notable abnormalities otherwise. Radiographic imaging revealed an ill-defined lesion in her left lung. Subsequent bronchoscopy and lavage were performed, followed by initiation of empirical antibiotic therapy. Lavage results were negative for gram staining, culture, and ZN staining for AFB, but revealed numerous septate hyphae on fungal smear. Histopathological examination indicated chronic granulomatous inflammation with septal fungal hyphae, indicative of aspergillosis. Subsequent culture confirmed Aspergillus species, prompting initiation of voriconazole therapy. Remarkably, the patient exhibited significant improvement, with weight gain and restored appetite observed within a short period. Within 2 months of treatment, her symptoms resolved, and she resumed near-normal daily activities.ConclusionThis case highlights the diagnosis of aspergillosis in an immunocompetent individual presenting with disseminated nodular lesions across the lungs, mediastinum, and abdomen. Clinicians should maintain a high index of suspicion for aspergillosis in cases of non-resolving pneumonia and disseminated nodular lesions, even in patients lacking traditional predisposing factors.

Analysis of the Diagnostic Yield of Nucleic Acid Amplification Tests in Immunocompetent Patients with Tuberculous Cervical Lymphadenitis

Analysis of the Diagnostic Yield of Nucleic Acid Amplification Tests in Immunocompetent Patients with Tuberculous Cervical Lymphadenitis

Candida parapsilosis in Late Prosthetic Joint Infections Among Immunocompetent Patients: A Case Series.

Fungal prosthetic joint infections (PJIs) are very rare in immunocompetent patients. PJI can present either early, delayed, or as late chronic infections. Diagnosis of fungal PJI presenting late is challenging due to the difficulty in isolation as well as the clinical presentation very similar to an aseptic loosening. There are no clear guidelines regarding the management of these patients. We present five cases of Candida parapsilosis PJI presenting as late chronic infections. All five patients were culture-negative preoperatively, immunocompetent, and with good soft-tissue condition. There were three infected knee prostheses and two infected hip hemiarthroplasty. All of them were treated with extensive debridement, meticulous sampling, and extended culture. We treated all of them with long-term antifungals without any disease reactivation or recurrence till the last follow-up. Fungal infection should be suspected in immunocompetent patients presenting early with features of aseptic loosening but without typical signs of periprosthetic infection. Revision with long-term suppressive therapy can give good results in these patients.

Pneumonia With Empyema: A Rare Clinical Presentation of Bartonella henselae Infection in a 10-Year-Old Boy.

Cat-scratch disease is a common zoonosis in children. However, atypical clinical presentation of cat-scratch disease is less common, and lung involvement is particularly rare. The usual presentation of lung disease in bartonellosis includes other organ involvement and is more common in immunocompromised patients. We present a 10-year-old immunocompetent patient with pneumonia and inoculated empyema caused by Bartonella henselae, without any other organ involvement, which occurred 2 weeks after lymphadenopathy. The definite diagnosis was established using the polymerase chain reaction of the empyema obtained from thoracocentesis. The boy was treated with several antibiotics (ceftriaxone, azithromycin, amoxicillin with clavulanic acid, meropenem and vancomycin) and completely recovered after the 3-month follow-up period. This is a unique case of the difficult-to-treat pneumonia with inoculated empyema, caused by B. henselae, in an immunocompetent child, without any other organ involvement. The clinical course was favorable. A high level of clinical suspicion is mandatory for the diagnosis.

Macrophagic activation syndrome complicating miliary tuberculosis: A case report

Macrophage activation syndrome (MAS), also known as hemophagocytic syndrome or lymphohistiocytic activation syndrome, is a rare but potentially fatal disease. It results from inappropriate stimulation of macrophages in the bone marrow and lymphoid organs. The diagnosis of MAS is based on a combination of clinical, biological, and histological or cytological signs. MAS is categorized into primary forms, which mainly affect newborns and infants with a family history, and secondary forms, which occur in the context of neoplastic, autoimmune, or infectious diseases. Treatment involves addressing the specific causative agent of MAS and, in certain cases, early administration of corticosteroids and immunoglobulins. MAS is rarely associated with tuberculosis. We report the case of an immunocompetent patient presenting with miliary tuberculosis complicated by macrophage activation syndrome.

Common Practice Patterns in the Diagnosis and Management of Acute Retinal Necrosis: A Survey Study of Uveitis Specialists

ABSTRACT Purpose Due to lack of large randomized clinical trials to determine best practices in treating acute retinal necrosis (ARN), there is not a clear consensus amongst ophthalmologists on how to best manage this potentially blinding condition. The aim of this study is to survey common practice patterns and analyze the factors that affect ophthalmologists’ management of ARN. Methods An anonymous survey was distributed to uveitis and retina specialists who are members of the American Uveitis Society (AUS) via email to query practice patterns regarding ARN. The survey included 22 questions with an additional 10 questions based on response. Survey question topics included demographic information, diagnostic testing, antiviral therapy, corticosteroids, and surgical procedures. Results 67 surveys were included for analysis. Most respondents (87%) always or frequently obtain intraocular aqueous fluid for diagnostic PCR testing. The majority of respondents would administer intravitreal antiviral injections to a unilateral immunocompetent ARN patient (67%), but would be even more likely to do so for a bilateral immunosuppressed ARN patient (87%). Respondents tend to treat ARN with systemic rather than local corticosteroids, with the majority (63%) of respondents initiating corticosteroid treatment 48 hours after treatment. Most respondents (79%) never perform a vitrectomy to manage ARN unless the patient has a retinal detachment or tear. The majority (63%) rarely or never perform prophylactic laser barricade, but may consider laser treatment if there is extensive retinal involvement. Conclusion Current practice patterns for diagnosis and management of ARN among AUS members generally align with the suggested practices outlined by the American Academy of Ophthalmology.

An amplicon-based sequencing approach for Usutu virus characterization

Usutu virus (USUV), an arbovirus from the Flaviviridae family, genus Flavivirus, has recently gained increasing attention because of its potential for emergence. After his discovery in South Africa, USUV spread to other African countries, then emerged in Europe where it was responsible for epizootics. The virus has recently been found in Asia. USUV infection in humans is considered to be most often asymptomatic or to cause mild clinical signs. However, a few cases of neurological complications such as encephalitis or meningo-encephalitis have been reported in both immunocompromised and immunocompetent patients. USUV natural life cycle involves Culex mosquitoes as its main vector, and multiple bird species as natural viral reservoirs or amplifying hosts, humans and horses can be incidental hosts. Phylogenetic studies carried out showed eight lineages, showing an increasing genetic diversity for USUV. This work describes the development and validation of a novel whole-genome amplicon-based sequencing approach to Usutu virus. This study was carried out on different strains from Senegal and Italy. The new approach showed good coverage using samples derived from several vertebrate hosts and may be valuable for Usutu virus genomic surveillance to better understand the dynamics of evolution and transmission of the virus.

Frequency and clinical significance of Herpes simplex virus type 1/2 reactivation in adult patients with mild to moderately severe community-acquired pneumonia: a multicentre cohort study.

This study assessed the frequency, clinical significance, and risk factors for Herpes simplex virus (HSV) reactivation in immunocompetent patients with community-acquired pneumonia (CAP). The study included adult CAP-patients who were enrolled in the CAPNETZ study between 2007 and 2017 and had a residual sputum sample available for analysis. In addition to routine diagnostics, sputum and blood samples were tested for HSV-1/2 using PCR. Demographics, comorbidities, and CRB-65 score were compared between HSV-positive and negative patients using Fisher exact or Mann Whitney test. Logistic regression analyses investigated the influence of HSV reactivation on a modified hospital recovery scale (HRS) until day 7, divided into 3 categories (no oxygen therapy, oxygen therapy, ICU admission or death). Among 245 patients, HSV-1 and HSV-2 were detected in 30 patients (12.2%, 95%CI 8.7-16.9) and 0 patients, respectively. All HSV-positive patients were hospitalized, had a CRB-65 severity score of 0-2 and survived the first 28day. In the HSV-positive group, patients had a non-significantly higher median age (70.5 versus 66years) and a higher rate of oncological comorbidities (16.7% versus 8.8%) compared to the HSV-negative group. Distribution of co-pathogens and outcome parameters did not significantly differ between both groups. In a multivariate logistic regression model, age (AOR 1.029, p = 0.012) and CRB-65 score (AOR 1.709, p = 0.048), but not HSV-1 as single or co-pathogen were independently associated with higher HRS. Our study suggests that HSV-1 reactivation is common in CAP but might not be associated with specific risk factors or a complicated disease course.

Histoplasmosis misdiagnosed as malignancies in immunocompetent and immunocompromised patients: A global perspective on clinical presentation, radiological and pathological findings

The clinical presentation of histoplasmosis is non-specific and has several mimics as documented in the literature. Regarding cancers, previous reviews emphasized mainly the clinical and radiological similarities between histoplasmosis and pulmonary malignancies. Besides lung cancers, histoplasmosis also masquerades as other malignancies. We identified one hundred and twenty-four cases of histoplasmosis clinically mistaken for malignancies. Of the 124,84 (67.7%) were included in the analyses of demographics, immune status, clinical features, diagnosis, and treatment outcomes. The remainder were excluded as the available data was mainly on diagnosis. Of the eighty-four, histoplasmosis was predominantly misdiagnosed as lung cancers (n = 16, 19.0%), gastrointestinal tumors (n = 15, 17.9%), and lymphomas/hematological malignancies (n = 15, 17.9%). Fifty-four (64.3%) were immunocompromised including 16 (29.6%) who were living with HIV, while the remainder were immunocompetent. We conclude that infective aetiologies like histoplasmosis should be considered or ruled out in patients clinically suspected of malignancy regardless of their immune status.

COVID-19 as a critical risk factor for osteonecrosis of the jaw: diagnostic challenge and surgical treatment

This case report describes a unique and complex presentation of osteonecrosis of the maxilla, complicated by Aspergillosis and Mucormycosis, developed in an immunocompetent patient recovering from COVID-19. The patient presented with a range of clinical symptoms, including facial pain, rhinorrhea, cacosmia, cough, and radiographic evidence of jaw involvement. Cytological and histological examinations revealed the presence of Aspergillus niger and mucormycosis-like fungal elements. Our report discusses the main diagnostic challenges, the different potential etiopathological hypotheses, and the alternative therapeutic and rehabilitative approaches. This atypical surgical case definitely highlights the need for heightened awareness among healthcare professionals, regarding the potential risk to discover severe opportunistic fungal infections also in COVID-19 patients; this case further sheds light on the importance of a multidisciplinary approach for an effective management of such intricate post-COVID-19 complications.

Delayed Presentation of Intradural Extramedullary Tuberculoma of Spine in an Immunocompetent MDR-TB Patient

Abstract Intradural spinal tuberculoma is a rare entity, constituting &lt;5% of CNS tuberculoma, whereas intradural extramedullary tuberculoma of spinal cord (IETSC) is even less frequently encountered. Here, we report a case of IETSC at two noncontiguous levels in spinal cord presenting with compressive myelopathy in a patient on multidrug-resistant tuberculosis (MDR-TB) treatment. Surgical decompression and appropriate ATT regimen resulted in gradual return to near-normal neurological function with no functional disability. To our knowledge, this is the first case report of IETSC developing in an immunocompetent patient on MDR regimen for drug resistant sputum-positive pulmonary tuberculosis.

A retrospective observational study on disseminated herpes zoster in immunocompetent patients

IntroductionDisseminated herpes zoster (DHZ) is a severe infection associated with high incidences and mortality rates in immunocompromised patients. Although studies have shown its occurrence in immunocompetent patients, its epidemiology, clinical presentation, and treatment outcomes in this cohort remain unknown. Thus, this study aimed to examine the clinical presentation, treatment, complications, and outcomes of DHZ in immunocompetent patients and compare these findings with previous studies. MethodsWe included 20 immunocompetent patients of DHZ at our institution and reviewed 42 previously published cases. We then investigated the clinical features, predisposing factors, laboratory findings, treatment, and outcomes of all cases including in-hospital mortality, neurological dysfunction at discharge, and postherpetic neuralgia. We compared DHZ-immunocompetent patients to DHZ-immunocompromised patients. ResultsPatients had a median age of 71.5 years and were predominantly male. The trigeminal area was the most common site of initial rash, with a mean dissemination time of 6.5 days. Pain was the most common symptom, followed by fever (approximately 40 % of cases); acyclovir was the most used treatment. Additionally, the in-hospital mortality was 0 %, neuropathy at discharge was observed in approximately 10 % of patients, and postherpetic neuralgia was present in approximately 40 % of patients. In the immunocompromised cases, the mortality rate was 12 %, which was higher than in our cases; however, the rates of neuropathy and postherpetic neuralgia were lower. ConclusionsThis study provides new insights into the clinical presentation, treatment, and outcomes of DHZ cases in immunocompetent patients, highlighting its tendency for residual neurological damage despite having low mortality rates.