Serum Polymerase Chain Reaction Research Articles

A baby girl with TBX1 haploinsufficiency who died after elective cardiac repair surgery due to suspected enteroviral meningitis

IntroductionTBX1 haploinsufficiency is an inborn error of immunity with the phenotype of DiGeorge Syndrome. DiGeorge Syndrome has variable immunodeficiency associated with grade of thymic hypoplasia ranging from mild with no infections to severe requiring thymus implant. Enterovirus is an example of an opportunistic infection that can be fatal in these patients. Case PresentationA 1 year old girl with TBX1 haploinsufficiency complicated by Tetralogy of Fallot, pulmonary atresia, high arched palate, and vesicovaginal fistula presented for elective cardiac repair surgery from another country due to failure to thrive and cyanosis. She had no prior infectious history but was on sulfamethoxazole-trimethoprim for prophylaxis. She was asymptomatic with a negative COVID test but no other infectious studies performed. Immediately postoperatively, she was febrile and nasal respiratory viral panel was positive for rhinovirus/enterovirus with increased procalcitonin and leukocytosis with left shift. She decompensated with multi-organ failure and cardiac arrest on postoperative day two. She was cannulated to veno-arterial extracorporeal membrane oxygenation (ECMO). Pre-operatively, she had a normal absolute lymphocyte count. No thymus tissue was observed in surgery. She had profound CD3 lymphopenia to 130 cells/cmm when critically ill. Enteroviral meningitis was suspected as no infectious, cardiac, or other pathology could be identified causing decompensation. Enteroviral serum polymerase chain reaction (PCR) test was negative while lumbar puncture deferred due to clinical status. She was treated with immunoglobulin. Offlabel investigational drug pocapavir was considered but deferred to patient’s irreversible neurological status. The patient was disconnected from ECMO and expired. DiscussionThough we cannot confirm that this patient had enteroviral meningitis, invasive enteroviral infections are associated with elevated transaminases, coagulopathy, and seizures all present in our patient. There has also been reported negative serum enteroviral PCR but positive CSF enteroviral PCR in an immunodeficient patient. Additionally, this case highlights the importance of immunologic evaluation in patients with DiGeorge Syndrome and questions if asymptomatic viral screening for viruses like enterovirus should be considered pre-operatively in patients with inborn errors of immunity. This case highlights potential treatment options for invasive enteroviral infections in patients with inborn errors of immunity: high dose immunoglobulin, fluoxetine, and pocapavir.

BK virus nephropathy in renal transplantation and the effect of intravenous immunoglobulin: A prospective longitudinal single-center study in South Asia

Aims and Objectives: The aim was to assess the prevalence and treatment of BK virus nephropathy (BKVN) in patients who underwent renal transplantation at a single center in South India with a 1-year follow-up analysis. To assess the efficacy of treatment with intravenous immunoglobulin (IvIg) in cases of proven BKVN. Materials and Methods: Three hundred and seventy-one patients underwent renal transplantation from 2018 to 2020. All were screened for BKVN with quantitative serum polymerase chain reaction (PCR) every 3 months for 1 year after transplant. Patients with positive tests underwent renal allograft biopsy. In all patients, antimetabolite was stopped, tacrolimus dose was reduced, and leflunomide was started. All patients with biopsy-proven BKVN were administered IvIg 2 grams/kg over 5 days and had a 1-year follow-up. Results: Fourteen patients had BK viremia; 12 had biopsy-proven BKVN. All were male with a mean age of mean age: 45.3 years ± 14.8 standard deviation (SD). Induction: basiliximab (7) and antithymocyte globulin (ATG) (7). Maintenance immunosuppression: tacrolimus, enteric-coated mycophenolate mofetil, and prednisolone. The median presentation time was 12 months. Mean graft function: baseline S. Creatinine of 1.32 mg/dL changed to 2.01 mg/dL at diagnosis. The mean presenting BKV PCR (copies/ml) was 44912 ± 56285 SD. No significant differences were observed in time of presentation, severity, mean tacrolimus level, and graft failure between patients receiving basiliximab or ATG. There were two relapses; two grafts failed. Class I BKVN had a better prognosis. Graft survival at 1 year was 85.71%. Conclusions: This is the first South Asian follow-up study of BKVN in kidney transplant recipients treated with IvIg. BKVN was documented in the first 15 months after transplant. There was no increased prevalence of BKVN in patients with ATG. Histopathological class has prognostic relevance with Class I having a better prognosis. Multipronged treatment, including IvIg, leads to 1-year graft survival of 85.71%. Long-term outcomes need follow-up.

A case report of severe systemic herpes simplex virus-1 (HSV-1) infection with multi-organ involvement after a course of oral corticosteroid treatment

BackgroundHerpes simplex virus (HSV) rarely causes organ-invasive infection. Diagnosis and treatment for such infections are often delayed, and mortality is high. We present the first reported case of disseminated HSV-1 infection in an adult causing liver failure, myocarditis, and encephalitis in a patient who recovered after receiving parenteral acyclovir treatment.Case presentationA 46-year-old female presented with fever, chills, and malaise after 2 weeks of oral corticosteroid treatment for uveitis. She was diagnosed with disseminated HSV-1 infection with multi-organ involvement causing hepatitis, encephalitis, and myocarditis. Diagnosis was made timely using serum polymerase chain reaction (PCR) for HSV DNA and the patient was given intravenous acyclovir treatment promptly, which led to her survival without significant morbidity.ConclusionsClinicians should have a low threshold for suspecting HSV infection and ordering HSV PCR to decrease morbidity and mortality when there is a high clinical suspicion of systemic HSV infection with multi-organ involvement. Serum PCR for HSV DNA is an excellent modality for an initial diagnostic approach. Further research is warranted to elucidate causality between a course of corticosteroid therapy and systemic HSV-1 infection without major immunosuppressive comorbidities or treatments.

Major evidence of nutrological regulation in obese patients with meta-inflammation: a systematic review

Introduction: Obesity stands out as a multifactorial disease that can cause several public health problems. There are 2.0 billion overweight and obese people in the world, and Brazil ranks fifth in the world. A healthy nutritional status promotes immune function and can prevent the onset of a serious inflammatory process and severe infections, especially in times of a pandemic such as COVID-19. Objective: It was to highlight the main clinical considerations of nutrological and dietary regulation in obese patients with marked inflammatory processes and meta-inflammation through a systematic review. Methods: The systematic review rules of the PRISMA Platform were followed. The research was carried out from August to September 2022 in Scopus, PubMed, Science Direct, Scielo, and Google Scholar databases. The quality of the studies was based on the GRADE instrument and the risk of bias was analyzed according to the Cochrane instrument. Results and Conclusion: A total of 127 articles were found. A total of 74 articles were fully evaluated and 29 were included and developed in the present systematic review study. Considering the Cochrane tool for risk of bias, the overall assessment resulted in 32 studies at high risk of bias and 25 studies that did not meet the GRADE. Research has shown that unbalanced dietary patterns, such as the Western diet, rich in simple sugars, refined carbohydrates, and saturated and trans fatty acids, lead to chronic inflammatory responses, increased fat deposits, and future comorbidities associated with overweight and obesity. Caloric restriction decreased polymerase chain reaction (PCR) in obese patients and diet administration over 12 weeks had a beneficial effect. Furthermore, obese patients with antioxidant supplementation had lower values of BMI, waist circumference, fasting blood glucose level, and insulin resistance homeostasis model assessment when compared to the placebo group, as well as lower total cholesterol levels, triglycerides, LDL, malondialdehyde and tumor necrosis factor-alpha. Supplementation of n-3 PUFA can significantly reduce serum PCR, tumor necrosis factor α (TNFα), and interleukin 6 (IL-6) concentrations.

Expression analysis of miRNA-155 level in Helicobacter pylori related inflammation and chronic gastritis.

Helicobacter pylori, is a major etiologic agent associated with gastritis. There is more evidence of noncoding microRNAs (miRs) dysregulation in gastrointestinal diseases, including inflammation caused by Helicobacter pylori. Also, the classification of gastrointestinal malignancies using the miRs profile is better than the protein profile. MiRNA-155(miRNA-155) among other miRs plays an important role in control of inflammation and gastric malignancy, so it can be remarkable prognosis marker of gastric cancer in the phase of chronic gastritis. The aim of this study was to compare the expression of miRNA-155 in gastric biopsy and serum samples of adult patients with chronic gastritis. Biopsy and blood samples were collected from endoscopy candidates at Taleghani hospital, Tehran, during 2019. H. pylori infection was detected using histology, culture and molecular PCR methods. Based on cagA and vacA genotyping, the toxicity of H. pylori isolates were determined. After RNA extraction, the expression rate of miRNA-155 was evaluated by real-time polymerase chain reaction (RT-PCR) in gastric tissue and serum of adults infected by H. pylori (n = 30) compared with control group without infection (n = 20). RNU6 housekeeping miRNA were used as endogenous control and statistical analyses were performed using SPSS, ANOVA and Student's t-test. miRNA-155 expression in H. pylori infected adult patients increased significantly by 5.61 and 10.11 fold in serum and tissue respectively, compared to that observed in the control group. Evaluation of miRNA-155 expression pattern in relation to bacterial virulence factors showed that the increase in miRNA-155 expression is independent of CagA and VacA toxins. According to the differential expression patterns of miRNA-155 in serum samples of the infected adult patients, miRNA-155 has the potential to evaluate as chronic gastritis marker.

Serum Cytomegalovirus Polymerase Chain Reaction Test Is a Valuable Negative Predictor of Infection in Acute Severe Ulcerative Colitis.

Diagnosis of cytomegalovirus (CMV) colitis in the setting of severe ulcerative colitis (UC) remains a clinical challenge. This study aimed to determine the utility of serum CMV polymerase chain reaction (PCR) as a non-invasive test for the diagnosis of CMV superinfection in patients hospitalized with UC. This retrospective study included consecutive admitted patients with UC who had serum testing for CMV completed as part of standard hospital procedure and CMV colitis diagnosed by expert pathologists. Two hundred and six patients with UC were included; 13 patients (6%) had histologically confirmed CMV colitis. Eleven of 13 patients with CMV colitis (84%) and 3 of 193 (1.5%) patients without CMV colitis had a positive serum PCR test (p < 0.0001). ROC analysis showed that a CMV PCR level of 259IU/mL had a sensitivity and specificity of 77% and 99%, respectively, for diagnosis of CMV colitis with an AUC of 0.9 (p < 0.0001). Serum CMV PCR level significantly correlated to the number of inclusion bodies on biopsy specimens with data available (n = 8) (r = 0.8, p = 0.02). CMV positivity did not predict the need for salvage therapy, admission or 1-year colectomy rates. Serum CMV PCR has an excellent negative predictive value and demonstrates a strong correlation with CMV positivity on histology. This work supports a rationale for serum CMV PCR testing on admission to assess the risk of CMV colitis in patients with severe UC.

Association des manifestations neurologiques rares à West Nile virus chez un patient immunocompétent

BackgroundNeuro-invasive disease is the most dreaded complication of West Nile virus infection. We report the case of an immunocompetent patient who developed a meningeal syndrome associated with cerebellar ataxia, facial diplegia and hemiparesis caused by West Nile virus infection with a favourable outcome. ObservationA 42-year-old man was admitted for a febrile meningeal syndrome and confusion associated with cerebellar ataxia. The patient had developed facial diplegia, left hemiparesis with worsening cerebellar syndrome. He was diagnosed with neuro-invasive West Nile virus infection given the positive West Nile virus serologies in serum and cerebrospinal fluid as well as West Nile virus polymerase chain reaction in serum and urine. The outcome was favourable. ConclusionBecause of the increasing prevalence of West Nile virus, this infection should be suspected in the event of atypical neurological manifestations even in immunocompetent patients.

Clinical value of lncRNA SOX2-OT in pulmonary arterial hypertension and its role in pulmonary artery smooth muscle cell proliferation, migration, apoptosis, and inflammatory

BackgroundNon-coding RNA is confirmed to be involved in pulmonary arterial hypertension (PAH). ObjectivesThis study investigated the clinical value and potential mechanisms of the long noncoding RNA (lncRNA) SRY-box transcription factor 2 overlapping transcript (SOX2-OT) in PAH. MethodsSOX2-OT levels were measured by quantitative real-time polymerase chain reaction (qRT-PCR) in serum of 82 patients with PAH and 76 healthy controls. Receiver operating characteristic (ROC) analysis was performed to assess the diagnostic value of SOX2-OT. Human pulmonary arterial smooth muscle cells (hPASMCs) were treated by hypoxia to construct PAH cell models. Proliferation, migration, apoptosis, and inflammatory cytokines levels of hPASMCs were examined by CCK-8, Transwell, flow cytometry, and ELISA assay. Dual-luciferase reporter gene assays were performed to verify the target relationships between miR-455-3p and SOX2-OT, as well as small ubiquitin-related modifier 1 (SUMO1). ResultsSerum SOX2-OT was highly expressed in patients with PAH (P < 0.05). And elevated SOX2-OT levels significantly differentiated PAH patients from healthy controls, confirming high diagnostic feasibility. What's more, SOX2-OT was increased in hypoxia-induced hPASMCs in a time-dependent manner. Silencing SOX2-OT could reverse hypoxia-induced proliferation, migration, anti-apoptosis, and inflammation of hPASMCs (P < 0.05). However, rescue experiments showed that this reversal effect of silencing SOX2-OT was attenuated by suppressed miR-455-3p, which was presumably achieved by SUMO1 (P < 0.05). ConclusionsElevated SOX2-OT is a feasible diagnostic marker for PAH, and its silencing may attenuated hypoxia-induced hPASMCs proliferation, migration, anti-apoptosis, and inflammation by modulating the miR-455-3p/SUMO1 axis, preventing vascular remodeling and PAH progression. Our research provided new insights for PAH treatment.

Comparative Evaluation of Three Diagnostic Tools for the Detection of Hepatitis C Virus among High-risk Individuals in a Tertiary Care Centre of Northeast India

Introduction: Hepatitis C virus (HCV) has posed a major public health problem globally. Since majority of HCV infected patients are asymptomatic, diagnosis of HCV infection is mainly based on the detection of anti-HCV antibodies by the Enzyme Linked Immunosorbent Assay (ELISA) or Rapid Diagnostic Tests (RDTs) and HCV Ribonucleic Acid (RNA) by real time Polymerase Chain Reaction (PCR) of serum or plasma samples. Aim: To assess the performance of RDT and 4th generation ELISA against real time reverse transcriptase PCR for the detection of HCV. Materials and Methods: A hospital-based cross-sectional study was carried out in the Virology Section, Department of Microbiology, Jawaharlal Nehru Institute of Medical Sciences (JNIMS), Imphal, Manipur, India, for a period of two years from June 2019 to May 2021. The study included 3,254 plasma samples from suspected cases of HCV monoinfection, and HCV/HIV co-infection. The plasma samples were subjected to anti-HCV antibodies by RDT (SD BIOLINE, South Korea) and 4th generation ELISA (Monolisa™ HCV Ag-Ab ULTRA, BioRad, France), and HCV RNA by real time PCR. Data analysis was done using descriptive statistics, and performance of the assays was evaluated by using Cohen kappa test (κ) and Receiver Operating Characteristic (ROC) curve. Results: PCR is considered as the gold standard test. HCV was detected by RDT in 453 (13.92%), ELISA in 413 (12.69%) and RT-PCR in 367 (11.28%) samples. The present study demonstrated sensitivity of 97.55% and specificity of 96.71% with Positive Predictive Value (PPV) of 79.03% by HCV-RDT. The 4th generation ELISA showed high sensitivity of 99.46% and specificity of 98.34%. Using ROC curve, the area under the curve was 81% for ELISA with diagnostic accuracy of 98.46%. Conclusion: 4th generation ELISA is more sensitive and specific than RDT for the detection of HCV infection. Confirmatory HCV-RNA assay could be performed to clear doubts related to false-positive and false-negative findings of the primary screening assays.

Polyomavirus exerts detrimental effects on renal function in patients after lung transplantation.

Chronic kidney disease (CKD) is associated with significant morbidity and mortality after lung transplantation (LTX). Calcineurin inhibitor (CNI) nephrotoxicity is the leading cause of CKD. After kidney transplantation, polyomavirus-associated nephropathy (PyVAN) is a well-recognized problem. This study aims to evaluate the role of polyomavirus in patients after LTX. From January 2017 to January 2020, all lung transplant recipients who performed follow-up visits in our center were included in the study and retrospectively assessed. We measured renal function (creatinine levels before and after transplantation), JCPyV, and BKPyV load by polymerase chain reaction (PCR) in serum and urine samples after transplantation. In total, 104 consecutive patients (59 males, 56.7%) with a mean age of 49.6±11.1 years were identified. JCPyV was found in urine of 36 patients (34.6%) and serum of 3 patients (2.9%). BKPyV was found in urine of 40 patients (38.5%) and serum of 4 patients (3.8%), respectively. Urine evidence for JCPyV (p<0.001, coefficient: +21.44) and BKPyV (p<0.001, coefficient: +29.65) correlated highly with further kidney function decline. Kidney function deterioration is associated with JCPyV and BKPyV viruria in patients after LTX. This might indicate a role of PyVAN in lung transplant recipients.

Skin Erosions in a Newborn.

Skin Erosions in a Newborn.

&lt;i&gt;Ehrlichia chaffeensis&lt;/i&gt;&lt;i&gt;-&lt;/i&gt;associated Hemophagocytic Lymphohistiocytosis: A Case Series and Literature Review

Introduction: Hemophagocytic lymphohistiocytosis (HLH) is an uncommon condition characterized by abnormal, excessive immune activation resulting in severe cytopenias from an uncontrolled inflammatory response. It can be primary/ familial or secondary/sporadic. Infections, particularly viral infections are a common cause of secondary HLH. HLH due to Human monocytic ehrlichiosis (HME) is very rare, hence we are reporting our cases. Objective: To review cases of Ehrlichia-associated HLH at our institution and perform a literature review regarding this entity. Methods: We reviewed cases of Ehrlichia-associated HLH for the previous two years at our institution (Carilion Clinic). We then performed a review of the published literature on it, using Pubmed. Results: Over the past two years, five cases of Ehrlichia-associated HLH were diagnosed at our hospital. The average age of the patients was 67 years with predominantly males. All the patients were pancytopenic, and a majority had abnormal liver function tests. Diagnosis of ehrlichiosis was made by serum polymerase chain reaction (PCR) assay on blood. Patients had further testing done because of lack of clinical improvement. All patients had significantly elevated ferritin levels. Bone marrow biopsy samples of all patients showed findings of hemophagocytosis. All, but one, patients were treated with doxycycline and a combination of etoposide and dexamethasone. Three patients recovered while two died. On review of medical literature, we found a total of only 36 cases of Ehrlichia-associated HLH, including our five cases. There were 19 adults and 17 children. Both population groups showed varying degrees of pancytopenia. Splenomegaly was relatively uncommon, seen in less than one-third of the patients. Ferritin and triglyceride levels were routinely elevated. Bone marrow biopsy showing hemophagocytosis was the confirmatory test in all patients. A significant number of patients, both adults and children, required a combination of doxycycline and chemotherapy (etoposide and dexamethasone) to achieve clinical cure. Children had a better prognosis than adults, with one child and four adults succumbing to their illness. Conclusions: Ehrlichia-associated HLH is a rare but emerging disease entity. In endemic areas, a high degree of suspicion is required to diagnose ehrlichiosis and HLH resulting from it. Early diagnosis and prompt initiation of treatment for HLH is key to a favorable outcome.

Acute kidney injury with partial Fanconi syndrome in a patient with leptospirosis: a case report

BackgroundLeptospirosis is an underdiagnosed bacterial infection with nonspecific symptoms, hence, a diagnostic challenge. Identifying a case of leptospirosis in Switzerland is uncommon. Although kidney complications are frequent in severe forms, including tubular dysfunction, observing this complication is rare in our country. We report the case of a patient with leptospirosis and kidney dysfunction, which was notable for proximal tubulopathy. This case report describes the diagnosis and management of this patient’s tubular dysfunction.Case presentationA 34-year-old Caucasian male known for alcohol and drug abuse presented to our emergency department suffering from severe pain in the lower limbs, jaundice, and fever with flu-like symptoms. Physical examination was not contributory. Blood tests showed cytopenia, elevated inflammatory markers, acute kidney injury, and altered liver function tests with predominant cholestasis. Urinalysis showed proteinuria and significant glycosuria without concomitant hyperglycemia. Leptospirosis was suspected and confirmed by both positive serum polymerase chain reaction and elevated immunoglobulin M for Leptospira interrogans. The patient was treated with intravenous amoxicillin–clavulanate and doxycycline for 7 days. After antibiotic treatment, symptoms disappeared, and kidney dysfunction completely resolved.ConclusionOur case focuses on the description of leptospirosis-related acute kidney injury with proximal tubular dysfunction, which is a rare finding in Switzerland.

Patients with Central Nervous System Lymphoma Undergoing Thiotepa, Busulfan, and Cyclophosphamide-Conditioned Autologous Stem Cell Transplantation Are at a Higher Risk for DNA Virus Infections Than Patients with Systemic Non-Hodgkin Lymphoma Receiving Traditional Conditioning

Background: Consolidative high-dose therapy and autologous stem cell transplantation (ASCT) with thiotepa, busulfan, and cyclophosphamide (TBC)-conditioning results in highly favorable outcomes in patients with central nervous system lymphoma (CNSL), but it is met with regimen-related toxicity. In a recent analysis, we noted a higher than expected incidence of DNA virus reactivations and several cases of serious viral organ disease (Scordo et al., BBMT 2017). We aimed to compare the incidence of DNA virus infections between patients with CNSL undergoing TBC-conditioned ASCT and those with systemic non-Hodgkin lymphoma (NHL) undergoing carmustine, etoposide, cytarabine, and melphalan (BEAM)-conditioned ASCT. We hypothesized that patients receiving TBC are at a higher risk for viral infections, and may require unique post-ASCT surveillance and follow-up.Methods: We retrospectively evaluated adults with chemosensitive CNSL undergoing TBC-conditioned ASCT and those with systemic, chemosensitive diffuse large B-cell lymphoma undergoing BEAM-conditioned ASCT between 2013 and 2016. We recorded all positive DNA virus reactivations infections by serum polymerase chain reaction (PCR) from the start of conditioning until 6 months post-ASCT, and then assessed for evidence of clinically relevant viral infection. We used a combined viral infection endpoint that included: cytomegalovirus (CMV), adenovirus (ADV), Epstein-Barr virus (EBV), and human herpesvirus-6 (HHV-6). The cumulative incidences (CI) of combined viral PCR reactivation and clinically relevant viral infection were compared by the log rank test. Cox proportional hazard analysis was used to compare the risk of viral infection between both groups. Variables with p-values of < 0.2 in the univariate analysis were included in the multivariate analysis.Results: We evaluated 67 patients that underwent BEAM-conditioned and 54 patients that underwent TBC-conditioned ASCT. Baseline patient characteristics including age, gender, disease status, pre-ASCT absolute lymphocyte count (ALC), day +30 ALC, and steroid use during the first 30 days post-ASCT (prednisone 40 mg equivalent or higher) were similar between groups, and are shown in Table 1. There were 6 viral reactivations (5 HHV-6 and 1 CMV) among the BEAM patients (CI 9.1%), and 19 (1 ADV, 5 CMV, 13 HHV-6) among TBC patients (CI 35.2%), p=0.0003, as shown in Figure 1. No BEAM patients had a clinically significant viral infection, while there were 7 clinically significant viral infections (2 CMV, 1 ADV, 4 HHV-6) among TBC patients, p=0.0003, as shown in Figure 2. Among all patients in the univariate analysis, receiving TBC conditioning was the only characteristic that was associated with a higher risk of viral reactivation/infection, hazard-ratio (HR) 4.78 (1.91-12.0), p<0.001. In the multivariate analysis, receiving TBC conditioning was associated with an increased risk of viral reactivation [HR 5.43 (2.1-13.8), p<0.001], and advanced age [HR 0.97, (0.94-0.99), p=0.03] was associated with a slightly reduced risk of viral reactivation as shown in Table 2.Conclusions: Patients with CNSL undergoing TBC-conditioned ASCT are at an increased risk for DNA virus reactivation and clinically relevant DNA virus infections when compared to patients receiving BEAM. This may reflect the higher myeloablative intensity of TBC compared to BEAM, and possibly inherent differences in immune function in patients with CNSL compared to systemic NHL. These data highlight the need to implement early post-ASCT viral serum PCR monitoring for patients undergoing TBC-conditioned ASCT, with the goal of pre-emptive treatment of clinically relevant infections. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Results of a Protocol for Targeted Testing of Congenital Cytomegalovirus Infection in Babies who Fail the Newborn Hearing Screen

<strong>Background and objectives:</strong> Cytomegalovirus (CMV) is a major cause of sensorineural hearing loss in children [1]. Universal screening is controversial due to the low risk of CMV-related hearing loss [2]. The prevalence of CMV related hearing loss is 0.5 in 1000 children and is thought to be responsible for 15% to 20% of moderate-to-severe hearing loss in children [3, 4]. Since 2018, New York state law requires targeted CMV testing for newborns who “refer” on the Newborn Hearing Screen (NBHS) prior to discharge from the hospital at birth [5]. This is a report of a CMV testing protocol implemented at a community hospital for newborns who “refer” on the NBHS. <strong>Methods:</strong> Clinical records of all neonates born at BronxCare Health System (BCHS) who did not pass the NBHS between March 2019 and September 2020 were retrospectively reviewed. All newborns are screened using Auditory Brainstem Response (ABR) and those who do not pass are referred for audiology evaluation. Newborns who failed NBHS were tested for CMV prior to hospital discharge using Salivary Real-time Polymerase Chain Reaction (PCR) (Quest Diagnostics). Positive results were confirmed with serum PCR. We analyzed NBHS, audiology evaluation and CMV testing results. <strong>Results:</strong> A total of 3555 newborns had NBHS performed; 44 did not pass and were referred for audiology evaluation within 2 weeks of hospital discharge. Of these 44, CMV testing was done for 37 (84%) while 7 (16%) were not tested for CMV. Of those tested, salivary PCR detected CMV in two patients: the first had negative confirmatory serum PCR test; the second was confirmed positive and treated with ganciclovir. This patient, who is confirmed positive, had inconclusive results on follow-up audiology evaluation and was referred for Early Intervention services. Of the original cohort of 44 patients who were referred to audiology; thirty-three (75%) passed audiology evaluation and eleven did not. Of these eleven, two cases were followed successfully and have confirmed hearing loss, while 9 were lost to subsequent audiology follow-up. Of the two hearing loss cases; one was the confirmed CMV positive baby who started treatment with valganciclovir, while the other was CMV negative. Of the nine newborns who were lost to audiology follow up, 8 were tested negative for CMV while one baby was not tested for CMV. <strong>Conclusion:</strong> At BCHS, the prevalence of CMV related hearing loss is 0.28/1000 as compared to the reported prevalence of 0.5/1000. Eighteen months of targeted CMV testing in newborns who did not pass the NBHS found only one confirmed case of congenital CMV infection. This suggests that targeted CMV screening based on NBHS results misses some cases of congenital CMV infection. Of the eligible newborns who failed NBHS; seven were not tested for CMV. The testing protocol will need further refinement to avoid missing patients in the future.

Blood Culture-negative Endocarditis Caused by Tropheryma whipplei: Whipple's endocarditis.

A 67-year-old man was admitted with progressive heart failure due to blood culture-negative endocarditis of the aortic valve. Urgent aortic valve replacement was needed. Polymerase chain reaction (PCR) testing of samples of the explanted aortic valve revealed Tropheryma whipplei. The patient received ceftriaxone, followed by long-term co-trimoxazole. Recent arthralgia may have been a diagnostic clue. Whipple's endocarditis should be considered in patients with arthralgia and blood culture-negative endocarditis (BCNIE). Whipple's endocarditis should be considered in patients with symptoms of arthralgia and blood culture-negative endocarditis (BCNIE).Serum polymerase chain reaction is the main diagnostic test.Both physician awareness and multidisciplinary management by regional endocarditis teams are recommended strategies to provide optimal patient care.

Ehrlichia Meningoencephalitis: A Case Series

Objective: We present the distinct clinical and laboratory findings in two cases of Ehrlichia meningoencephalitis, along with one suspected case. Background: The number of cases of Ehrlichia chaffeensis reported to the CDC has more than doubled from 2007-2017. A PubMed literature search using the words “Ehrlichiosis and meningoencephalitis” revealed five case reports with neurologic manifestations. Design/Methods: This is a retrospective observational study. Two elderly patients presented with encephalopathy, fever, transaminitis, thrombocytopenia, a positive E. chaffeensis Polymerase Chain Reaction (PCR) in Serum, and Cerebrospinal Fluid (CSF) with a lymphocytic or neutrophilic pleocytosis and elevated protein. One patient had similar symptoms and a positive E. chaffeensis PCR, but lumbar puncture was unable to be performed due to severe thrombocytopenia. They presented in May or June. Doxycycline was started within 2-3 days after presentation to the hospital. Follow up five months later revealed all patients were close, or back to baseline. Results and Conclusions: Suspicion of Ehrlichia meningoencephalitis should be raised in elderly patients presenting with fever and encephalopathy in the summer season with history of tick bite or residence in wooded areas. Thrombocytopenia and transaminitis should raise further suspicion. CSF studies typically show a lymphocytic pleocytosis and elevated protein. PCR technique allows for direct detection of pathogen-specific DNA and is the preferred method of detection during the acute phase of illness. Prompt treatment with doxycycline results in good outcomes. Doxycycline is not included in the typical meningitis regimen, therefore, this disease is important to quickly identify as delay in Doxycycline can result in worse outcomes.

SARS-CoV-2 Leakage From the Gas Outlet Port During Extracorporeal Membrane Oxygenation for COVID-19.

Patients with the coronavirus disease 2019 (COVID-19) sometimes develop refractory respiratory failure and may require venovenous extracorporeal membrane oxygenation (VV-ECMO). It is known that the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is sometimes present in the blood of COVID-19 patients. VV-ECMO is often used for several weeks, and plasma leaks can occur, albeit rarely. Hence, in terms of infection control, a concern is that SARS-CoV-2 may leak from the gas outlet port of the oxygenator during ECMO support of critically ill COVID-19 patients. The aim of this study was to clarify whether SARS-CoV-2 leaks from the oxygenator during ECMO support. Five patients with critical COVID-19 pneumonia were placed on VV-ECMO. Silicone-coated polypropylene membrane oxygenators were used in the ECMO circuits for these patients. SARS-CoV-2 ribonucleic acid (RNA) was measured by quantitative reverse transcription polymerase chain reaction in serum and at the gas outlet port of the ECMO circuit at the time of circuit replacement or liberation from ECMO. SARS-CoV-2 RNA was detected in the gas outlet port of the ECMO circuit for three of the five patients. None of the medical staff involved in the care of these five patients has been infected with COVID-19. In conclusion, SARS-CoV-2 could leak to the gas outlet port of the ECMO circuit through silicone-coated polypropylene membranes during ECMO support of critically ill COVID-19 patients.

Fatal primary dengue-induced Haemophagocytic Lymphohistiocytosis (HLH) in a returning traveller from India treated with anakinra for the first time

Abstract Background Dengue fever is an arthropod-borne flavivirus infection that is highly prevalent in the tropics. A proportion of clinical cases develop severe dengue, defined by life-threatening complications including haemorrhage, capillary leak and multi-organ failure. Recently there has been increasing recognition that some cases of severe dengue may be a consequence of HLH. To our knowledge, this is the first report of treatment with Anakinra for dengue-induced HLH. Case report We report a case of Dengue fever triggering HLH in an eighteen-year-old female returning traveller from India, diagnosed with systemic lupus erythematosus (SLE) two months prior to presentation. The patient initially presented to a district general hospital emergency department (ED) with a three-day history of flu-like symptoms, fever, erythematous rash, widespread joint pain, nausea and chills. Acute Dengue virus infection was confirmed with serum polymerase chain reaction (PCR) testing. On day two, she was admitted to intensive care for multi-organ support necessitated by refractory hypotension, oligo-anuric severe acute kidney injury (AKI), acute liver failure with lactataemia and type one respiratory failure. The possibility of Dengue-induced HLH was considered early with multiple criteria for diagnosis met including hyperferritinaemia, pancytopenia, lipaemia and a marked transaminitis. HLH-directed therapy was commenced with intravenous immunoglobulins (IVIG), intravenous methylprednisolone (IVMP) and Anakinra. Subsequent bone marrow biopsy analysis demonstrated clear evidence of HLH, in the context of a persistent and marked Dengue viraemia. We observed resolution of HLH markers as well as reducing requirements for multi-organ support after initiation of Anakinra therapy. During her recovery, the patient unexpectedly developed focal neurology; intracranial imaging demonstrated widespread, discreet parenchymal lesions thought to be haemorrhagic in nature, which were deemed too severe an insult to recover from. On day 19, the difficult decision of withdrawing care after deep discussion with the family was reached, soon after which the patient passed away. A post-mortem examination was not arranged.

TNNC1 Reduced Gemcitabine Sensitivity of Nonsmall-Cell Lung Cancer by Increasing Autophagy.

BackgroundAs we know, chemotherapy resistance is a critical factor leading to recurrence and metastasis of nonsmall-cell lung cancer (NSCLC). To clarify the key target and potential mechanism of resistance to gemcitabine (GEM) in NSCLC, we selected Gene Expression Omnibus Data Set and statistically analyzed a parent cell group and a GEM-resistant cell group. Results showed that the expression of troponin C1, slow skeletal and cardiac type (TNNC1) in GEM-resistant cells was higher than in parent cells, which implies that TNNC1 was associated with GEM resistance in lung cancer cells.Material/MethodsTNNC1 expression level was detected by reverse transcription-quantitative polymerase chain reaction or western blot in GEM-resistant patient serum and cell lines. It could reduce or increase autophagy response and GEM resistance accordingly by inhibition of the short interfering ribonucleic acid or by forced overexpression of TNNC1 viruses in A549 cell line and GEM-resistant cell line (A549/GemR) respectively. Blocking autophagy with 3-methyladenine increased the sensitivity of chemotherapy confirmed by flow cytometry and microtubule-associated protein 1A/1B – light chain 3 punctate assay. What’s more, in a loss-of-function model, silencing of forkhead box 03 (FOXO3) in A549/GemR cells could rescue the autophagy weakened by TNNC1.ResultsTNNC1 promoted GEM chemoresistance of NSCLC by activating cytoprotective autophagy, regulated negatively by FOXO3. This research may provide a completely new strategy for NSCLC treatment.ConclusionsTargeting the TNNC1/FOXO3 signaling pathway in NSCLC may be a novel strategy to combat GEM resistance.