Prolonged Course Research Articles

COVID-19 in children with somatic pathology

The coronavirus infection is a pressing issue in modern healthcare, yet the characteristics of the SARS-CoV-2 infection course in children with comorbidities remain insufficiently studied. The aim of this study was to evaluate the clinical form, severity, and duration of SARS-CoV-2 virus shedding in pediatric patients with somatic diseases, depending on the comorbid pathology. Materials and Methods. A comprehensive single-center retrospective study was conducted, analyzing 314 medical records of patients hospitalized in the infectious diseases department of the Russian Children’s Clinical Hospital in Moscow over 11 months in 2022. The inclusion criterion was the presence of a laboratory-confirmed COVID-19 diagnosis. Results. Children with comorbidities were found to be predisposed to a more severe course of SARS-CoV-2 infection compared to the pediatric population in general. Children with hematological diseases were at the highest risk of adverse outcomes from COVID-19. Patients with oncological and hematological diseases and primary immunodeficiencies shed the SARS-CoV-2 virus significantly longer than patients with other somatic pathologies. The duration of SARS-CoV-2 RNA detection in patients with severe COVID-19 was significantly longer, which also correlated with the severity of the underlying somatic disease. Conclusion. Children with comorbidities are at risk for a more severe and prolonged course of SARS-CoV-2 infection.

A CASE OF THE FORMATION OF A ROUGH CYCLITIC MEMBRANE IN A CHILD AGAINST THE BACKGROUND OF INTERMEDIATE UVEITIS

Intermediate uveitis often occurs asymptomatically, and children tend to underestimate changes in vision until the first complications appear, leading to a prolonged course of the disease without treatment. The formation of opacities in the lens is one of the most common complications of uveitis in children that require surgical intervention. However, lens opacification is often considered in isolation from other changes in the eye, which in turn defines the goal of the surgery as achieving a quick functional result. At the same time, one of the complications of intermediate chronic uveitis, existing alongside cataract, is the cyclitic membrane, which is an important factor in determining the strategy for surgical treatment. This article presents a clinical case of treating complications of uveitis in a child, where the intervention strategy aimed to minimize the number of complications in the future despite the delayed functional outcome.

Abstract 4119908: Outcomes for heart failure patients with reduced ejection fraction attending emergency department and discharged within 24 hours versus those admitted patients in heart failure unit.

Introduction: Heart failure (HF) is a clinical syndrome with increasing prevalence. Currently, there are extensive evidence-based therapies targeted at managing patients with heart failure and reduced ejection fraction (HFrEF) to improve outcomes. The National Heart Failure Audit shows the quality of inpatient care (specialist review, discharge medication etc) is related to outcome. This study aimed to evaluate the current practice at a London tertiary centre hospital in managing patients with heart failure and compared outcomes in patients who had a short course of admission (less than 1 day) with those who had a more prolonged course of admission. Method: Retrospective data was collected from a London tertiary centre hospital database for consecutive patients from Sep/2022 till Sep/2023. Statistical analysis was performed using Chi-Square test. The eligibility criteria included a new or previous diagnosis of HF with left ventricular ejection fraction (LVEF) < 40%. Patients were divided into two groups: Group A included 40 eligible patients who were admitted and discharged from the emergency department (ED) within 24 hours. Group B included 37 eligible patients who were admitted and discharged from the dedicated heart failure unit after 10-15 days of hospital admission. Results: In Group A, prescribing guideline-directed medical therapy (GDMT) was lower compared to Group B; Renin-Angiotensin-Aldosterone Inhibitors (47.50% vs. 94.59%), beta blockers (55% vs. 91.89%), mineralocorticoid receptor antagonists (12.50 %vs. 94.59%), and sodium-glucose co-transporter 2 inhibitors (15% vs. 89.19%). More patients in Group B received all four pillars of GDMT (86.49%) compared to Group A (5%). At 6-month follow-up,18.75% were on 4 GDMT in Group A versus 92% in group Group B. Re-admission within 6 months was higher in Group A (30%) compared to Group B (16.22%); however, the difference was not statistically significant (P value: 0.153). Higher mortality rates were observed in Group A (mortality rate: 20%) compared to Group B (mortality rate: 2.70%), with statistical significance (P value: 0.018). Conclusion: This study showed that HFrEF patients admitted to a specialist heart failure unit achieve higher rates of GDMT and have significantly improved outcomes compared to those who had a shorter inpatient stay and discharged from the emergency department. These findings underscore the high risks associated with rapid discharge from hospital on incomplete medical therapy.

NCMP-29. BRAIN LESIONS IN A TEEN WITH NEWLY DIAGNOSED T-CELL ALL AND SARS-COV-2 INFECTION

Abstract T-cell Lymphoblastic Leukemia (T-cell ALL) accounts for up to 15% of all newly diagnosed cases of acute lymphoblastic leukemia in pediatric patients (0-18 years old). Patients are at risk of opportunistic infections during induction therapy with up to 2% developing blood stream infections when their absolute neutrophil count is above 1,500. We report a case of a 15-year-old female with High-Risk T-cell ALL, CNS1 (negative CNS disease), presenting with three days of headaches, photophobia, and non-neutropenic fever. She completed induction chemotherapy one week earlier with vincristine, daunorubicin, calaspargase and a 28-day course of dexamethasone. On physical exam, she had no focal deficits or changes in sensation or strength. CBC was notable for a white blood cell count: 7500, hemoglobin: 8.6, platelets: 328,000 and ANC (Absolute Neutrophil Count): 4700. The patient was also COVID positive on admission. A contrast enhanced MRI brain demonstrated multiple diffusion restricting and peripherally enhancing lesions, concerning for intracranial abscesses. Neurosurgery performed a burr hole craniotomy and aspirated 5 mL of purulent drainage, the culture of which grew Aspergillus fumigatus complex. The patient was started empirically on Voriconazole, in addition to broad spectrum antibiotic coverage pending culture results, due to excellent CNS penetration and proven superiority to amphotericin-based therapy for invasive aspergillosis. Micafungin was added due to CT chest demonstrating nodular infiltrates, suggesting primary pulmonary aspergillosis with CNS dissemination. The patient improved symptomatically without further sequelae. Patients with COVID-19 on prolonged courses of corticosteroids are at higher risk of developing fungal co-infections regardless of neutrophil count. While pulmonary aspergillosis is the most common location of a COVID-19 aspergillus coinfection, there have been documented reports of intracranial micro-abscesses. Contrast-enhanced brain MRI should be obtained in any patient with a recent history of COVID-19 presenting with new neurological symptoms, especially in a patient with a recent history of corticosteroids.

Case Report and Literature Review of Exophiala dermatitidis Fungal Endocarditis in a Prosthetic Aortic Valve

Abstract Prosthetic valve endocarditis is a rare complication following surgical aortic valve replacement, accounting for a small fraction of all endocarditis cases. This complication is typically caused by bacterial pathogens and carries a high mortality rate. In rare cases, prosthetic valve endocarditis may be attributed to fungal organisms. We present the case of a 47-year-old woman who developed prosthetic valve endocarditis from a fungus known as Exophiala dermatitidis. Prosthetic valve endocarditis caused by this pathogen is extremely rare, with only 3 previously reported cases of prosthetic valve endocarditis attributed to this fungus since 1969. Review of the previous literature revealed an additional 3 cases originating in native aortic valves. These cases tended to occur in relatively young patients and those with risk factors for infective endocarditis such as immunosuppression and intravenous drug use. Septic emboli to various organs, particularly the brain and spleen, appear to be a complication of fungal endocarditis caused by this organism. Management can be difficult due to the lack of guidelines to treat such rare infective complications, but replacement of the infected valve and a prolonged course of antifungal therapy appear to be effective in some cases.

CCR8/CCL1 and CXCR3/CXCL10 axis mediated memory T cell activations in recalcitrant drug-induced hypersensitivity patients.

As a drug-induced hypersensitivity syndrome, drug reaction with eosinophilia and systemic symptoms (DRESS) is potentially fatal. Most patients with DRESS recover within a few weeks; however, some patients may suffer from a prolonged disease course and develop autoimmune sequelae. We investigated the immune mechanism and therapeutic targets of patients with recalcitrant DRESS with a prolonged disease course. A total of 32 patients with recalcitrant DRESS with a prolonged treatment course ≥8 weeks, 28 patients with short-duration DRESS with a treatment course <2 weeks, and 26 healthy individuals were enrolled in the study for analysis. Bulk transcriptome results demonstrated that mRNA expression levels of CCR8 and CXCR3 were significantly increased in the blood samples from patients in the acute stage of prolonged DRESS (adjusted p-values: CCR8=1.50×10-9 and CXCR3=2.60×10-4, respectively, for comparison of patients with prolonged DRESS to the healthy donor group). Serum and skin lesional concentrations of CCL1 and CXCL10, as the ligands of CCR8 and CXCR3, respectively, were significantly elevated in patients with prolonged DRESS as compared to those patients with short-duration DRESS. The results from high-parameter flow cytometry and autoantibody screening also identified significant escalations of CD8+ GNLY+CXCR3+effector memory T cells, CD8+central memory T cells, CD4+CCR8+Th2 cells, and IgG-anti-HES6 autoantibodies in patients with prolonged DRESS. Furthermore, in vitro blocking assays revealed that JAK inhibitors (mainly tofacitinib and upadacitinib) significantly decreased the release of CCL1 and CXCL10, and some patients with prolonged DRESS were successfully treated with JAK inhibitors. JAK inhibitors (tofacitinib and upadacitinib) were associated with decreased concentrations of CCL1 and CXCL10, suggesting that they may attenuate CCR8/CCL1- and CXCR3/CXCL10-axis-mediated memory T cell activation, which contribute to disease pathogenesis for patients with recalcitrant DRESS and a long-term treatment course.

Development of Nanocomposite Microspheres for Nasal Administration of Deferiprone in Neurodegenerative Disorders

Elevated brain iron levels are characteristic of many neurodegenerative diseases. As an iron chelator with short biological half-life, deferiprone leads to agranulocytosis and neutropenia with a prolonged therapeutic course. Its inclusion in sustained-release dosage forms may reduce the frequency of administration. On the other hand, when administered by an alternative route of administration, such as the nasal route, systemic exposure to deferiprone will be reduced, thereby reducing the occurrence of adverse effects. Direct nose-to-brain delivery has been raised as a non-invasive strategy to deliver drugs to the brain, bypassing the blood–brain barrier. The aim of the study was to develop and characterize nanocomposite microspheres suitable for intranasal administration by combining nano- and microparticle-based approaches. Nanoparticles with an average particle size of 213 ± 56 nm based on the biodegradable polymer poly-ε-caprolactone were developed using the solvent evaporation method. To ensure the deposition of the particles in the nasal cavity and avoid exhalation or deposition into the small airways, the nanoparticles were incorporated into composite structures of sodium alginate obtained by spray drying. Deferiprone demonstrated sustained release from the nanocomposite microspheres and high iron-chelating activity.

Anogenital psoriasis - clinical picture and therapy

Psoriasis presenting with anogenital lesions is an important medical and social problem that is not sufficiently covered in the literature. The genitals and perianal area are involved in severe plaque and inverse psoriasis. Occasionally, the disease can be localized only in the anogenital zone. Diagnosis of psoriasis with localization on the genitals and/or perianal area is difficult, which is associated with the anatomical and physiological characteristics of the affected area. The manifestations of psoriasis become exudative, infiltration of papules and plaques is expressed little, the borders of rashes lose clarity, peeling on the skin is expressed weakly, in the depth of the folds due to maceration and friction is absent. Subjectively significant localization of the process, its prolonged course, pruritus lead to significant violations of the quality of life of patients and serve as prerequisites for the formation of anxiety-depressive disorders and sexual dysfunction Diagnosis and treatment of anogenital psoriasis presents significant challenges. Clinical guidelines tend to emphasize external therapy with topical corticosteroids and calcineurin inhibitors; in recent years, the efficacy of genetically engineered biological agents, including interleukin-17 inhibitors and phosphodiesterase-4 inhibitors, has been considered. The presented review systematizes information about anogenital psoriasis, peculiarities of its epidemiology, clinical picture, diagnosis and approaches to therapy.

Antibiotic-associated neutropenia is marked by the depletion of intestinal Lachnospiraceae and associated metabolites in pediatric patients.

Prolonged antibiotic exposure causes dangerous hematologic side effects, including neutropenia, in up to 34% of patients. Murine studies established a link between the intestinal microbiota and hematopoiesis. To identify factors that predispose to neutropenia in pediatric patients, we evaluated changes in microbiota-derived metabolites and intestinal microbiota composition after prolonged courses of antibiotics. In this multi-center study, patients with infections requiring anticipated antibiotic treatment of two or more weeks were enrolled. Stool samples were obtained at the start and completion of antibiotics or at neutropenia onset (prospective arm). Some patients were enrolled in a retrospective arm in which a stool sample was collected at the time of neutropenia during antibiotic therapy and 2-4 weeks after completion of antibiotics with recovery of blood counts. We identified 10 patients who developed neutropenia on antibiotics and 29 controls matched for age, sex, race, and ethnicity. Clinical data demonstrated no association between neutropenia and the type of infection or antibiotic used; however, patients with neutropenia were admitted to the intensive care unit more often and received longer courses of antibiotics. Reduced intestinal microbiome richness and, specifically, decreased abundance of Lachnospiraceae family members correlated with neutropenia. Untargeted stool metabolomic profiling revealed several metabolites that were depleted exclusively in patients with neutropenia, including members of the urea cycle pathway, pyrimidine metabolism, and fatty acid metabolism that are known to be produced by Lachnospiraceae. Our study shows a relationship between intestinal microbiota disruption and abnormal hematopoiesis and identifies taxa and metabolites likely to contribute to microbiota-sustained hematopoiesis.

Erysipelothrix rhusiopathiae-associated bloodstream infection in a patient with systemic lupus erythematosus: a case report and literature review

Introduction. Systemic human infections caused by Erysipelothrix rhusiopathiae have been increasingly reported especially within immunocompromised hosts and those with significant occupational exposure to livestock and aquatic animals. We report a case of E. rhusiopathiae bacteraemia in a patient with systemic lupus erythematosus (SLE) and present a literature review on clinical outcomes and microbiologic diagnosis for this organism. Case presentation. A 43-year-old female patient was reporting a 1-month history of intermittent fevers. She recently increased her immunosuppression medication for her underlying SLE on the advice of her rheumatologist. The patient sustained a finger laceration from butchering cattle meat 2 weeks after the onset of her initial symptoms, with worsening index finger swelling and increased febrile episodes. Two weeks post-injury, multiple blood cultures were drawn, and each isolated Gram-positive bacilli. Given her recurrent intermittent fevers, there was a concern for ongoing infection, and therefore, intravenous vancomycin was started with prompt referral to an outpatient parenteral antibiotic therapy clinic. The Gram-positive bacillus was confirmed as E. rhusiopathiae via matrix-assisted laser desorption/ionization-time of flight analysis. Given intrinsic resistance to vancomycin, vancomycin was switched to intravenous ceftriaxone as targeted antimicrobial therapy for 2 weeks. Reassuringly, there was no echocardiographic evidence of infective endocarditis, warranting the prolonged treatment course. Post-treatment, she remained symptom-free with the resolution of joint symptoms and fevers. Conclusion. Our report illustrates a case of E. rhusiopathiae bacteraemia from an immunodeficient host, with prompt microbiologic diagnosis and intervention with appropriate antimicrobial coverage. Literature reflects the rarity of this infection, predilections to specific susceptible hosts and the importance of raising awareness of zoonotic infections.

COVID-19 and COVID-19 Vaccine-Related Skin Ulcerations in the Lower Extremities: A Case Report and Literature Review

Several associations have been made between COVID-19 and vasculitis. Recent data also shows the prevalence and association of de novo vasculitis with either COVID-19 infection or COVID-19 post vaccination. In this article, we present the case of new-onset leukocytoclastic vasculitis, secondary to COVID-19 vaccination, that was complicated by severe infected and nonhealing ulcers in the lower extremities. Case A 53-year-old male patient presented to the dermatology clinics with a three-week history of painful necrotic patches coalescent of the lateral malleolus of the right and left ankles. History goes back to when the patient reported developing pruritic papules two weeks after receiving his second shot of the Pfizer BioNTech COVID-19 vaccine (BNT162b2). Punch biopsy was consistent with leukocytoclastic vasculitis. He was prescribed a four-week course of systemic corticosteroids and antibiotics as per cultures. Vascular assessment confirmed normal peripheral arterial and venous system. Two months later, the patient re-presented with fever and worsening of his lower extremity ulcers. He underwent debridement of his wounds. Intra-operative cultures revealed multidrug resistant bacteria. He required an additional debridement session a few days later and a 14-day course of Piperacillin-Tazobactam. The patient was subsequently discharged on corticosteroids and Azathioprine and followed up in the vascular surgery and rheumatology clinics. At four months follow-up, the patient's wounds were almost completely healed. Conclusion This article highlights a case of severe new-onset COVID-19 vaccine-associated leukocytoclastic vasculitis complicated with infected ulcers that required debridement twice in addition to a prolonged course of antibiotics and immunosuppression therapy. To our knowledge, none of the cases reported in the literature were this severe in nature. In this post-pandemic era, it must remain high on the differential list, and healthcare specialists should maintain a high index of suspicion when evaluating sudden new-onset skin lesions that do not have an immediately apparent etiology.

Acute appendicitis due to extrapulmonary tuberculosis

Introduction and ImportanceTuberculous appendicitis is very infrequent, estimated to occur in only 0.1% of all appendectomies. Appendicular tuberculosis can manifest as either a primary or secondary infection. Primary appendicular tuberculosis is even more uncommon and occurs in the absence of any detectable primary focus elsewhere in the body. Case presentationIn this report, we present a challenging case of primary tuberculous appendicitis that does not appear to have originated from the lungs. This case highlights the importance of considering tuberculosis in the differential diagnosis of appendicitis, especially in regions where tuberculosis is endemic or in patients with a history of tuberculosis exposure. Clinical DiscussionDiagnosing tuberculous appendicitis can be challenging due to its rarity and the non-specific nature of its symptoms, which often mimic those of more common conditions such as acute appendicitis and because of these non-specific symptoms, tuberculous appendicitis is mostly diagnosed only after surgical intervention. ConclusionThis case underscores the need for a high index of suspicion and thorough diagnostic evaluation in patients with atypical presentations of appendicitis specifically in patients with chronic complaints. Treatment typically involves a combination of surgical intervention to remove the affected appendix and a prolonged course of anti-tuberculous medication to eradicate the infection and prevent recurrence.

Prolonged transcranial magnetic stimulation in a pregnant patient with treatment-resistant depression: a case report

IntroductionPerinatal depression is a serious and highly prevalent medical condition in the USA. Nearly 85% of individuals with perinatal depression go untreated, leading to significant morbidity and mortality. There is an urgent need to develop and advance safe and effective treatments for perinatal depression. Transcranial magnetic stimulation is an established intervention for depression in non-pregnant individuals yet is not well studied in perinatal depression.Case presentationA 33-year-old pregnant Latina female presented with severe, recurrent, treatment-resistant depression and suicidal ideation. The patient had previously trialed psychotherapy, multiple antidepressants, and mood stabilizers and had achieved remission with lithium prior to pregnancy. Due to pregnancy and fetal safety concerns, the patient discontinued lithium and consequently suffered progressive worsening of perinatal depression. At 24 weeks gestation and after additional failed medication trials, a prolonged course of transcranial magnetic stimulation was initiated. Following 46 transcranial magnetic stimulation treatments over 9 weeks using two protocol types (repetitive transcranial magnetic stimulation and intermittent theta burst stimulation), she achieved near-remission of perinatal depression and resolution of suicidal ideation. There were no identified maternal or fetal adverse events at 6 weeks post-delivery.ConclusionTo our knowledge, this is the first published case of a pregnant individual with perinatal depression who received and tolerated a prolonged transcranial magnetic stimulation course with two distinct protocols (repetitive transcranial magnetic stimulation and intermittent theta burst stimulation) with clinically significant response. Transcranial magnetic stimulation is a well-tolerated and effective intervention that warrants further investigation for use in treatment-resistant perinatal depression.

Results of surgical treatment for drug-resistant temporal epilepsy and related predictors of negative post-surgery outcome

Objective: to evaluate the results of surgical treatment and identify related predictors of unfavorable outcome in patients with temporal drug-resistant epilepsy (DRE) in long-term postoperative period.Material and methods. Fifty-one patients with temporal lobe DRE were examined using clinical, neuroimaging, electro- physiological, and laboratory research methods from June 2020 to June 2023. Anteromedial temporal lobectomy (AMLE) and selective amygdalohippocampectomy (SAHE) were performed in 38 (74.5%) and 13 (25.5%) cases, respectively. Postsurgery outcomes were evaluated in 51 patients 6 months later, continued in 43 and 20 patients 1 year and 2 years, respectively, afterwards.Results. The percentage of patients with significant improvement (Engel I/II) 6 months, 1 year and 2 years post-surgery was 82.4%, 72.1%, and 55.0%, respectively. After AMLE vs. SAHE, patients had a more favorable outcome while assessing seizure control. The predictors of unfavorable post-surgery outcome included a prolonged epilepsy course before surgery, the presence of electroencephalography-verified epileptiform activity in postoperative period, and repeated surgical intervention. Patient age, the presence of focal seizures evolving into bilateral tonic-clonic seizures as well as more frequent seizures before surgery were considered as potential predictors.Conclusion. The study results show that quite high effectiveness of seizure control in postoperative period in temporal DRE is quite high that may be accounted for by probability of removing epileptogenic foci and suppression of the mechanisms ensuring emergence and irritation of epileptic discharges. Nevertheless, effectiveness of surgical treatment fades off with time, which requires to further investigate the negative factors countering long-term post-surgery effect. In connection with this, a special attention should be paid to factors such as the presence of electroencephalography-verified epileptiform activity in postoperative period, repeated surgical intervention as well as prolonged epilepsy before surgery.

A novel variant BCL11B mutation in a pediatric patient with difficult‐to‐treat eosinophilic esophagitis

AbstractEosinophilic esophagitis (EoE) is an immunoinflammatory disease of the esophagus attributable to a complex interaction between genetic and environmental factors. While several genetic risk variants have been linked with EoE, we report a novel association between B‐cell lymphoma/leukemia 11B genetic mutation in a child with dysmorphic facies, developmental delays, atopic comorbidities, and difficult‐to‐treat EoE. After a prolonged course of EoE and multiple esophagogastroduodenoscopies with biopsies, this patient achieved clinical and histologic remission on a combination of swallowed topical steroids and high‐dose proton pump inhibitor (PPI) therapy. However, her EoE relapsed when we attempted to wean her off PPI, and it was finally controlled after adding PPI back to her regimen. This report underscores the importance of genetic testing in patients with unusual clinical features and difficult‐to‐treat EoE. Relevant to real‐world clinical practice, this case also raises the question of the treatment goals in children with EoE and underlying genetic mutation(s).

Effect of Age and Gender on Categorical Perception of Vocal Emotion Under Tonal Language Background.

Categorical perception (CP) manifests in various aspects of human cognition. While there is mounting evidence for CP in facial emotions, CP in vocal emotions remains understudied. The current study attempted to test whether individuals with a tonal language background perceive vocal emotions categorically and to examine how factors such as gender and age influence the plasticity of these perceptual categories. This study examined the identification and discrimination performance of 24 Mandarin-speaking children (14 boys and 10 girls) and 32 adults (16 males and 16 females) when they were presented with three vocal emotion continua. Speech stimuli in each continuum consisted of 11 resynthesized Mandarin disyllabic words. CP phenomena were detected when Mandarin participants perceived vocal emotions. We further found the modulating effect of age and gender in vocal emotion categorization. Our results demonstrate for the first time that a categorical strategy is used by Mandarin speakers when perceiving vocal emotions. Furthermore, our findings reveal that the categorization ability of vocal emotions follows a prolonged course of development and the maturation patterns differ across genders. This study opens a promising line of research for investigating how sensory features are mapped to higher order perception and provides implications for our understanding of clinical populations characterized by altered emotional processing. https://doi.org/10.23641/asha.27204057.

Clinical features and prognosis of children with fungal bloodstream infection following chemotherapy for acute leukemia

To investigate the clinical features and prognosis of children with fungal bloodstream infection (BSI) following chemotherapy for acute leukemia (AL). A retrospective analysis was performed on 23 children with fungal BSI following chemotherapy for AL in three hospitals in Fujian Province, China, from January 2015 to December 2023. Their clinical features and prognosis were analyzed. Among all children following chemotherapy for AL, the incidence rate of fungal BSI was 1.38% (23/1 668). At the time of fungal BSI, 87% (20/23) of the children had neutrophil deficiency for more than one week, and all the children presented with fever, while 22% (5/23) of them experienced septic shock. All 23 children exhibited significant increases in C-reactive protein and procalcitonin levels. A total of 23 fungal isolates were detected in peripheral blood cultures, with Candida tropicalis being the most common isolate (52%, 12/23). Caspofungin or micafungin combined with liposomal amphotericin B had a relatively high response rate (75%, 12/16), and the median duration of antifungal therapy was 3.0 months. The overall mortality rate in the patients with fungal BSI was 35% (8/23), and the attributable death rate was 22% (5/23). Fungal BSI following chemotherapy in children with AL often occurs in children with persistent neutrophil deficiency and lacks specific clinical manifestations. The children with fungal BSI following chemotherapy for AL experience a prolonged course of antifungal therapy and have a high mortality rate, with Candida tropicalis being the most common pathogen.

Persistent Serous Choroidal and Retinal Detachment After Ab Interno Trabeculotomy for Glaucoma.

We describe a case of serous retinal detachment (SRD) with ciliochoroidal detachment (CCD) that persisted for 2 years and 7 months after minimally invasive glaucoma surgery (MIGS). A 71-year-old woman with primary open-angle glaucoma and cataracts had a central corneal thickness of 489 μm/492 μm and an ocular axis length of 24.05 mm/24.30 mm. She underwent phacoemulsification and intraocular lens implantation in the right eye (OD), along with goniosynechialysis and microhook ab interno trabeculotomy. Postoperative intraocular pressure was 4-6 mmHg in the OD. Five months later, SRD was observed temporally and inferiorly to the macula, with increased choroidal thickness. Best-corrected visual acuity at 5 months was (1.2)/(1.2) (right eye [OD]/left eye [OS]), and intraocular pressure was 6 mmHg/13 mmHg. CCD in the OD was accompanied by choroidal vessel dilation and choroidal vascular hyperpermeability. Two years and 7 months post-surgery, intraocular pressure spiked to 50-54 mmHg but settled at 12 mmHg 1 week later. CCD resolved, and choroidal folds and SRD disappeared, with decreased choroid thickness. Two years and 10 months postoperatively, there was no SRD recurrence at 10 mmHg on two antiglaucoma eye drops, and best-corrected visual acuity remained stable at (1.0)/(1.0). This case suggests that SRD may result from increased choroidal vessel permeability and retinal pigment epithelium dysfunction secondary to prolonged CCD/low IOP after MIGS. The prolonged disease course may be attributed to the balance between aqueous humor excretion and absorption, influenced by the limited size of the cyclodialysis cleft caused by MIGS.

Notes from the Field: Mpox Cluster Caused by Tecovirimat-Resistant Monkeypox Virus - Five States, October 2023-February 2024.

The antiviral drug tecovirimat* has been used extensively to treat U.S. mpox cases since the start of a global outbreak in 2022. Mutations in the mpox viral protein target (F13 or VP37) that occur during treatment can result in resistance to tecovirimat† (1,2). CDC and public health partners have conducted genetic surveillance of monkeypox virus (MPXV) for F13 mutations through sequencing and monitoring of public databases. MPXV F13 mutations associated with resistance have been reported since 2022, typically among severely immunocompromised mpox patients who required prolonged courses of tecovirimat (3-5). A majority of patients with infections caused by MPXV with resistant mutations had a history of tecovirimat treatment; however, spread of tecovirimat-resistant MPXV was reported in California during late 2022 to early 2023 among persons with no previous tecovirimat treatment (3). This report describes a second, unrelated cluster of tecovirimat-resistant MPXV among 18 persons with no previous history of tecovirimat treatment in multiple states.

Antibiotic Appropriateness for Urinary Tract Infections in Children.

We examined local prescribing patterns across the entire treatment course for children treated for uncomplicated urinary tract infection (UTI) to determine opportunities for antibiotic stewardship initiatives. We conducted a retrospective review of emergency department and inpatient encounters for febrile and afebrile UTI in a children's hospital from 2021 to 2022. An antibiotic spectrum ranking was established, and providers' choices were assessed for appropriateness on the basis of the individuals' urine culture (UCx). Groups were stratified by fever presence and compared using χ2, Fisher's exact, and Mann-Whitney U tests. Of 172 encounters (83% emergency department), 99 (58%) had a positive UCx. Eighty (80%) grew Escherichia coli, with 67 (84%) being susceptible to cefazolin (minimum inhibitory concentration ≤16 mg/L). There were 229 antibiotic regimens and 39 (17%) were appropriate. Inappropriate antibiotic choices included unnecessary use of broad-spectrum antibiotics and misdiagnosed UTI. Grouping by encounter, at least 1 dose of a third cephalosporin was given in 51% of encounters, and 80% of these received it unnecessarily because of UTI misdiagnosis or suitability of a narrower-spectrum antibiotic. The median prescribed antibiotic duration was 7 days (interquartile range 7-10). Of 73 encounters with UCx growing mixed flora or a nonuropathogen, only 29 (40%) had antibiotics discontinued. Confirmed UTI was associated with fever and nitrite positivity. Our study revealed high prevalence of inappropriate antibiotics, particularly unnecessary prescribing of third cephalosporin, prescriptions not supported by laboratory data, and prolonged treatment courses. Our results identify factors that can be used to support UTI treatment pathways and ensure antibiotic stewardship.