Multiple Infectious Complications Research Articles

Oligoclonal T-cell expansion in a patient with bone marrow failure after CD19 CAR-T therapy for Richter-transformed DLBCL

The advent of chimeric antigen receptor (CAR) T-cell therapy has revolutionized the treatment landscape of refractory B-cell malignancies. Real-world evidence has highlighted the high incidence of hematological toxicity, including prolonged and profound cytopenia. Here, we present a case of bone marrow (BM) failure in a 57-year old man with DLBCL-type Richter transformation receiving tisagenlecleucel in a standard-of-care setting. His clinical course was notable for underlying BM infiltration, severe cytokine release syndrome, and multiple infectious complications in the setting of prolonged, profound neutropenia. Cytokine profiling revealed a signature consistent with acquired aplastic anemia - including downregulation of CD40-L and EGF. Flow cytometric analyses demonstrated migration of CAR T-cells to the BM, as well as peripheral blood expansion of both CAR and non-CAR bearing CD8+CD57+ T-cells, an immunophenotype linked to oligoclonality in aplastic anemia. From single-cell level transcriptomics, this cytotoxic T-cell population was characterized by T-cell receptor Vβ oligoclonal expansion and post-CAR clonal drift. Gene expression profiling revealed upregulation of exhaustion markers on (CAR) T-cells and decreased expression of genes involved in STAT signalling and inflammatory response. In conclusion, this case highlights the complex nature of CAR-T-related hematological toxicity and introduces oligoclonal (CAR) T-cell expansion as a potential contributing pathophysiologic mechanism.

Robotic vs. Laparoscopic Metabolic and Bariatric Surgery, Outcomes over 5 Years in Nearly 800,000 Patients.

Studies assessing outcomes between laparoscopic and robotic bariatric metabolic surgery (BMS) have been limited by the relatively small percentage of robotic cases. However, in recent years, the number of robotic BMS cases has doubled. We report the largest US study comparing robotic versus laparoscopic outcomes in BMS over the longest time period (5years). Analysis of the MBSAQIP database was undertaken. This included information on 791,423 patients from 2015-2019 in the USA. Within this retrospective case-control study, 13.7% of SG and 16.6% of RYGB cases were done robotically. USA, MBSAQIP database. Robotic BMS increased mean operative time by 26min for SG and 40min for RYGB. However, this did not increase the 30-day venous thromboembolism (VTE) or organ dysfunction complications between the 2 groups. Robotic SG had slightly higher risks of multiple infectious complications (OR 1.26 to 1.76). Robotic RYGB had slightly lower infectious complications and transfusion requirements. Robotic BMS had higher 30-day readmission rates and 30-day reoperative rates for both SG and RYGB. Both robotic SG and RYGB were found to have significantly longer operative times than laparoscopic SG and RYGB. Potential outcome benefits from robotic BMS can include a reduction in infectious complications and transfusion requirements with robotic RYGB cases. SGs were found to have slightly higher infectious complications.

Rituximab in glomerular diseases: a case series and narrative review.

Introduction:The use of Rituximab (RTX) in glomerular diseases (GD) has increased in the past years, although it is still only used in a small fraction of patients.Methods:A single center retrospective study of adult patients with membranous nephropathy (MN), focal segmental glomerulosclerosis (FSGS), lupus nephritis (LN), and vasculitis treated with RTX as first or second-line therapy was conducted at our center from 2010 to 2020.Results:We identified 19 patients; 36.8% had MN and 25.0% each had FSGS, LN, and vasculitis. RTX was first-line therapy in 26.3% of patients and in 73.7% it was second-line therapy. Mean follow-up time was 7.7 ± 7.2 years. In MN, 2 patients (28.6%) had complete remission (CR), 2 patients (28.6%) had partial remission (PR), and 3 patients (42.9%) had no response (NR). In FSGS, 2 patients (50.0%) presented CR, 1 patient (25.0%) had no response, and 1 patient had renal deterioration. Two patients (50.0%) had a LN class IV with a CR after RTX, 1 patient with LN class IIIC/V had no response, and 1 patient with LN class II had renal deterioration. In vasculitis, 3 patients (75.0%) presented CR and 1 patient had PR. Infusion reactions were present in 2 patients (10.5%) and one patient had multiple infectious complications.Conclusions:The efficacy of RTX in treating different types of immune-mediated GD has been demonstrated with different response rates, but an overall safe profile. In our case series, the results are also encouraging. Longitudinal studies are needed to better understand the effect of RTX in GD.

Dueling Malignancies: A Rare Instance of Both Kaposi Sarcoma and Cardiac Plasmacytoma in a Patient Post OHT

<h3>Introduction</h3> Judicious immunosuppressive therapy is important to balance immune tolerance of the donor organ, while minimizing the risk of infection and malignancy. This case highlights the development of two unusual malignancies post orthotopic heart transplant (OHT). <h3>Case Report</h3> A 69 year old male, with a history of ischemic cardiomyopathy and no prior history of hematological malignancies underwent OHT. His post-transplant course was complicated by multiple infectious complications, leading to discontinuation of mycophenalate mofetil and he was maintained on an immunosuppressive regimen of tacrolimus and low-dose prednisone. Two years post OHT he noticed the development of a nodule on his 2nd right toe. Biopsy revealed Kaposi Sarcoma (KS). The patient underwent a total body PET scan and was found to have bilateral hypermetabolic inguinal lymph node involvement confirmed as KS by biopsy. His tacrolimus goal was lowered and he was treated with 8 cycles of paclitaxel, which resulted in complete PET resolution. One year later as part of a routine endomyocardial biopsy the patient was found to have a population of plasma cells with kappa restriction that were EBV negative. A TTE showed a structurally normal heart without evidence of mass/tumor. Magnetic resonance imaging showed late gadolinium enhancement in the inferior, basal inferolateral and anterolateral segments. Workup for MGUS/Multiple Myeloma was unrevealing. The diagnosis was thought to be a solitary cardiac plasmacytoma. The decision was made to further minimize immunosuppression to single agent tacrolimus with a goal tac level of 4-6. <h3>Summary</h3> Kaposi Sarcoma and cardiac plasmacyotoma are infrequent to rare tumors encountered in the transplant population. The literature on treatment for patients who develop malignancy post transplantation is sparse, with the majority of anecdotal evidence suggesting that reducing the level of baseline transplant immunosuppression is adequate for resolution of the underlying malignancy.

Rectal culture-directed antibiotic prophylaxis before transrectal prostate biopsy: Reduced infectious complications and healthcare costs

BackgroundTransrectal ultrasound-guided prostate biopsy (TUPB) is associated with infectious complications (ICs), which are related to a greater prevalence of ciprofloxacin-resistant bacteria (CRB) in rectal flora. We examined the ICs that occurred in 2 groups: A guided antibiotic prophylaxis (GP) group and an empiric prophylaxis (EP) group. We assessed the financial impact of GP. Material and methodsThe GP group was studied prospectively (June 2013 to July 2014). We collected rectal cultures (RCs) before the TUPB, which were seeded on selective media with ciprofloxacin to determine the presence of CRB. The patients with sensitive bacteria were administered ciprofloxacin. Patients with resistant bacteria were administered GP according to the RC antibiogram.The EP group was studied retrospectively (January 2011 to June 2009). RCs were not performed, and all patients were treated with ciprofloxacin as prophylaxis.The ICs in both groups were recorded during a period no longer than 30 days following TUPB (electronic medical history). ResultsThree hundred patients underwent TUPB, 145 underwent GP, and 155 underwent EP. In the GP group, 23 patients (15.86%) presented CRB in the RCs. Only one patient (0.7%) experienced a UTI. In the EP group, 26 patients (16.8%) experienced multiple ICs (including 2 cases of sepsis) (p<.005). The estimated total cost, including the management of the ICs, was €57,076 with EP versus €4802.33 with GP. The average cost per patient with EP was €368.23 versus €33.11 with GP. GP achieved an estimated total savings of €52,273.67. Six patients had to undergo GP to prevent an IC. ConclusionsGP is associated with a marked decrease in the incidence of ICs caused by CRB and reduced healthcare costs.

Profilaxis antibiótica «dirigida» por cultivos rectales antes de la biopsia prostática transrectal: reducción de complicaciones infecciosas y costes de atención sanitaria

BackgroundTransrectal ultrasound-guided prostate biopsy (TUPB) is associated with infectious complications (ICs), which are related to a greater prevalence of ciprofloxacin-resistant bacteria (CRB) in rectal flora. We examined the ICs that occurred in 2 groups: A guided antibiotic prophylaxis (GP) group and an empiric prophylaxis (EP) group. We assessed the financial impact of GP. Material and methodsThe GP group was studied prospectively (June 2013 to July 2014). We collected rectal cultures (RCs) before the TUPB, which were seeded on selective media with ciprofloxacin to determine the presence of CRB. The patients with sensitive bacteria were administered ciprofloxacin. Patients with resistant bacteria were administered GP according to the RC antibiogram.The EP group was studied retrospectively (January 2011 to June 2009). RCs were not performed, and all patients were treated with ciprofloxacin as prophylaxis.The ICs in both groups were recorded during a period no longer than 30 days following TUPB (electronic medical history). ResultsThree hundred patients underwent TUPB, 145 underwent GP, and 155 underwent EP. In the GP group, 23 patients (15.86%) presented CRB in the RCs. Only one patient (0.7%) experienced a UTI. In the EP group, 26 patients (16.8%) experienced multiple ICs (including 2 cases of sepsis) (P<.005). The estimated total cost, including the management of the ICs, was €57,076 with EP versus €4802.33 with GP. The average cost per patient with EP was €368.23 versus €33.11 with GP. GP achieved an estimated total savings of €52,273.67. Six patients had to undergo GP to prevent an IC. ConclusionsGP is associated with a marked decrease in the incidence of ICs caused by CRB and reduced healthcare costs.

TREATMENT CHALLENGES IN ENTEROCOCCUS FAECIUM SEPSIS AND CLOSTRIDIUM DIFFICILE DIARRHEA IN A PATIENT WITH B-CELL NON-HODGKIN LYMPHOMA – CASE REPORT

The risk of developing secondary infections in immunocompromised patients due to hematological malignancies and the treatments for such conditions is very well known. Fever can be the only manifestation of a serious infection among this category of patients. The degree and duration of neutropenia is directly related to the risk of multiple infectious complications. When we are dealing with severely impaired host defenses virtually any microorganism can become invasive, bacteria (gram-positive pathogens, but gram-negative as well), being the greatest immediate threat. Multiple pathogens isolated from an immunocompromised host can represent a major challenge for the clinician, especially when we have to face multidrug resistant (MDR) microorganisms, also called “superbugs”. Besides, when we confront such a patient with many comorbidities and a high risk for MDR pathogens infection, we also confront with a lot of limitations in terms of treatment options. We present a complicated case of glycopeptide-resistant Enterococcus faecium sepsis secondary to Clostridium difficile colitis in a 63 years old female patient with B-cell non-Hodgkin Lymphoma (NHL) during the R-CHOP therapy.

Multiple Infectious Complications in a Severely Injured Patient with Single Nucleotide Polymorphisms in Important Innate Immune Response Genes.

Trauma is a major public health problem worldwide. Infectious complications, sepsis, and multiple organ dysfunction syndrome (MODS) remain important causes for morbidity and mortality in patients who survive the initial trauma. There is increasing evidence for the role of genetic variation in the innate immune system on infectious complications in severe trauma patients. We describe a trauma patient with multiple infectious complications caused by multiple micro-organisms leading to prolonged hospital stay with numerous treatments. This patient had multiple single nucleotide polymorphisms (SNPs) in the MBL2, MASP2, FCN2 and TLR2 genes, most likely contributing to increased susceptibility and severity of infectious disease.

Drug-resistant tuberculosis in two children in Greece: Report of the first extensively drug-resistant case

Extensively drug-resistant (XDR) tuberculosis (TB) represents a serious and growing problem in both endemic and non-endemic countries. We describe a 2.5-year-old girl with XDR-pulmonary TB and an 18-month-old boy with pre-XDR-central nervous system TB. Patients received individualized treatment with second-line anti-TB agents based on genotypic and phenotypic drug susceptibility testing results. Both children achieved culture conversion 3 months and 1 month after treatment initiation, respectively. The child with XDR-pulmonary TB showed evidence of cure while treatment adverse events were managed without treatment interruption. The child with pre-XDR-central nervous system TB after 6-month hospitalization with multiple infectious complications had a dismal end due to hepatic insufficiency possibly related to anti-TB treatment. This is the first report of children with pre-XDR and XDR TB in Greece, emphasizing the public health dimensions and management complexity of XDR TB.

Rhodococcus erythropolisEncephalitis in Patient Receiving Rituximab

<i>Rhodococcus erythropolis</i>Encephalitis in Patient Receiving Rituximab

Infección asociada a catéter central por Cryptococcus laurentii en niño críticamente enfermo: a propósito de un caso y revisión del tema

Cryptococcosis is a fungal infection that predominantly affects patients with compromised cellular immunity. Cryptococcus neoformans is the most common pathogen of this class. Endovascular catheter-related infection is a rare entity described for Cryptococcus laurentii and, in exceptional cases, for C. neoformans. A case of a 3-month-old child with adenovirus acute bronchiolitis which lead to respiratory failure requiring inotropy and developing multiple infectious complications is presented. Cryptococcus laurentii was isolated in the culture from the tip of the central catheter, which could not be obtained in blood cultures. He was treated with amphotericin B in a cumulative dose of 10 mg/kg with negative control cultures. From a respiratory point of view, evolution was not good, with a failure from mechanical ventilation and posterior death.

Anesthetic management of a patient diagnosed with CADASIL (cerebral arteriopathy, autosomal dominant, with subcortical infarcts and leukoencephalopathy)

CADASIL (cerebral arteriopathy, autosomal dominant, with subcortical infarcts and leu–koencephalopathy) is an infrequent inherited disease that could have anesthetic implica–tions. However these have rarely been reported. We present a male patient previously diagnosed with CADASIL, who had suffered an ischemic vascular cerebral accident with a MRI compatible with leukoencephalopathy, and who was dependent for daily activities, and sustained dementia, mood alterations, apathy, and urine incontinence. He had famil–ial antecedents of psychiatric symptoms and ischemic stroke events in several relatives including his father, two brothers and one sister. He was scheduled for arthrodesis of the left knee because of multiple infectious complications of prosthetic knee surgery. He was under clopidogrel treatment which was withdrawn seven days before surgery. The pro–cedure was performed under combined spinal-epidural anesthesia, intraoperative seda–tion with midazolam, and postoperative multimodal analgesia including epidural patient controlled analgesia. The perioperative management was uneventful and we outline the adequacy of managing these patients under regional anesthesia and analgesia, as these permit to maintain hemodynamic stability leading to adequate cerebral perfusion, key to avoid an increase in the effects of the chronic arteriopathy patients with CADASIL sustain

A Longitudinal Case Series Description of Meningitis Due to Streptococcus gallolyticus subsp. pasteurianus in Infants

Streptococcus gallolyticus subsp. pasteurianus, previously known as Streptococcus bovis biotype II.2, is known to cause multiple infectious complications, including bacterial meningitis, in adults. Only sporadic individual case reports have identified this pathogen as a cause of meningitis in infants. This study is the first to longitudinally document S. gallolyticus subsp. pasteurianus as a cause of meningitis in four epidemiologically unrelated infants less than 2 weeks of age. The 16S rRNA gene sequences of all 4 isolates were identical, and further were identical to 3 central nervous system (CNS) strains (two adults and one child) reported in existing literature. S. gallolyticus subsp. pasteurianus is an increasingly recognized cause of meningitis and bacteremia in the newborn period, and it merits further study with respect to etiology of infection.

Pseudallescheria boydii infection after liver retransplantation

Pseudallescheria boydii infection after liver retransplantation

Creutzfeldt-Jakob’s disease: case report with emphasis on the electroencephalographic features

Creuzfeldt-Jakob’s Disease is a rare neurodegenerative disorder that is included among the transmissible spongiform encephalopathies. The clinical features are those of a rapid progressive dementia with mioclonic jerks, which progresses to death in less than one year. We report the case of a 79 years old woman, with initial complaints of vertigo, visual and gait compromise, with an initial brain MRI, EEG and CSF that had no specific features of CJD. After 12 days she was again admitted to the hospital with a worsening of her symptoms, along with global spasticity, inability to walk and a further deterioration of speech and swallowing. A new EEG disclosed periodic triphasic complexes, typical of the disease. CSF had a positive 14-3-3 protein. She later evolved with mioclonic jerks, coma, multiple infectious complications and, ultimately, death 45 days after her second admission. We focus on the role of the EEG as an adjuctive eletrophysiological tool for the presumptive in vivo diagnosis of the disease.

The effect of lidocaine on bacterial growth in propofol.

Extrinsically contaminated propofol has been associated with multiple infectious complications. Injection of propofol is associated with pain that is diminished by the addition of lidocaine. Lidocaine has antibacterial properties at high concentrations, but low concentrations of lidocaine (0.1%) have not been studied. We examined the growth rates of Staphylococcus aureus, Serratia marcescens, Pseudomonas aeruginosa, and Candida albicans in propofol containing disodium edeteate with and without added lidocaine 0.1% 2, 5, and 24 h after inoculation. There was no significant difference in the number of colony-forming units between propofol with and without added lidocaine at any time after inoculation. The addition of lidocaine to propofol in concentrations clinically effective in reducing pain on injection had no effect on microbial growth. Adherence to strict aseptic technique is further emphasized.