Disseminated herpes zoster as a result of immunomodulation by Adalimumab

"The patient is a 75-year-old Caucasian male who was admitted in May for management of a penile ulceration and a generalized rash. He has a medical history of Type II Diabetes Mellitus, tobacco abuse, and Rheumatoid Arthritis (RA) on adalimumab. One week prior to his presentation, the patient noted an ulcer proximal to the glans penis (Figure 1). Upon further questioning, he reported noticing a small tick attached to his thigh one week prior. He has no history of sexually transmitted illnesses, incarceration, animal exposures, or meningeal signs. Two days prior to admission, the patient developed a large, dark, vesicular lesion on the anterior scalp, followed by smaller lesions over the rest of his body including the hard palate (Figures 2-6). Laboratory studies demonstrated a mildly elevated Erythrocyte Sedimentary Rate, C-Reactive Protein, and transaminitis. The patient was started on empiric doxycycline and intravenous acyclovir. Infectious work-up was negative for gonorrhea, chlamydia, syphilis, HIV, Ehrlichia, and Rocky Mountain Spotted Fever. Shave biopsies were obtained of the penile lesion and a lesion from the patient's upper back. Dermatopathology evaluation demonstrated herpetic dermatitis in both sites, and a penile swab polymerase chain reaction for Varicella Zoster Virus was positive. Treatment for disseminated Herpes Zoster was initiated with marked improvement of the lesions noted at follow-up."Tarang Patel (1), Ethan Karle (1), Taylor Nelson (2), Dima Dandachi (2); 1. Department of Medicine, University of Missouri. 2. Department of Medicine, Division of Infectious Diseases, University of Missouri.Includes bibliographical reference

Long-acting antiretroviral injectable : who would benefit?

"People with HIV (PWH) face many challenges in obtaining HIV care: transportation issues, travel distance, competing life events, etc. Long-acting (LA)-injectable antiretrovirals (ART) could help curb some of these barriers. This project aimed to determine which patients seen at the MU outpatient HIV clinic would be candidates to receive the LA-injectable ART Cabotegravir/Rilpivirine (Cabenuva) as an alternative to a standard oral daily regimen in order to promote further HIV medication adherence."--Introduction

From Baghdad through Beirut: the role of social support in Iraqi refugees’ coping with estrangement and insecurity in transit

Submitted to The International Journal of Refugee StudiesThis paper contributes to the literature on displacement and forced migration by presenting the findings of an exploratory study on Iraqi refugees in Lebanon from in-depth interviews and group discussions with Iraqi families in two suburbs of Beirut. The findings reveal that the absence of clear policies on war affected refugees in Lebanon have resulted in discriminatory legal actions against them which are implemented and felt differently in the two suburbs of Beirut. The Iraqi refugees who fare better are those who have stronger social support from different sources, and have clearer understanding of the processing of their resettlement paperwork

Primary cutaneous cryptococcal infection due to fingolimod – Induced lymphopenia with literature review

Cryptococcus. Neoformans (C. neoformans) is an encapsulated heterobasidiomycetous fungus responsible for opportunistic infections worldwide in immunocompromised patients. Clinical presentation ranges from asymptomatic respiratory tract colonization to disseminated infection in any human body part. The central nervous system (CNS) and pulmonary diseases garner most of the clinical attention. Secondary cutaneous cryptococcosis is an uncommon manifestation seen as a sentinel sign commonly in disseminated cryptococcal infection. Primary cutaneous cryptococcosis (PCC) is a rare manifestation seen in both immunocompromised and immunocompetent patients. It is a discrete infection with different epidemiological trends. Immunosuppressive therapy (corticosteroids, tacrolimus) predisposes a patient to acquire this clinical entity. We present a case of an elderly Caucasian male on fingolimod for relapsing-remitting multiple sclerosis with nonhealing scalp lesions for four years. He was a referral to our healthcare center for the presence of fungal elements seen on a scalp biopsy fungal stains. Final cultures returned positive for C. neoformans susceptible to fluconazole (MIC = 8 μg/mL). The CD4 count was 13 cells/uL, and workup for CNS and disseminated cryptococcal infection were negative. Fingolimod is an immunomodulator that acts on sphingosine 1-phosphate receptors, affecting the lymphocytes. Pubmed literature review revealed few case reports (< 5) with PCC in patients on fingolimod. To our knowledge, ours is the first case with scalp cryptococcosis, with the lowest CD4 count while being on fingolimod. No randomized controlled trial data exist for the treatment of PCC. Therapy initiated with oral luconazole for six months with significant improvement at three months

Whole Tumor Histogram Analysis Using DW MRI in Primary Central Nervous System Lymphoma Correlates with Tumor Biomarkers and Outcome

The ability to non-invasively predict outcomes and monitor treatment response in primary central nervous system lymphoma (PCNSL) is important as treatment regimens are constantly being trialed. The aim of this study was to assess the validity of using apparent diffusion coefficient (ADC) histogram values to predict Ki-67 expression, a tumor proliferation marker, and patient outcomes in PCNSL in both immunocompetent patients and patients living with HIV (PLWH). Qualitative PCNSL magnetic resonance imaging (MRI) characteristics from 93 patients (23 PLWH and 70 immunocompetent) were analyzed, and whole tumor segmentation was performed on the ADC maps. Quantitative histogram analyses of the segmentations were calculated. These measures were compared to PCNSL Ki-67 expression. Progression-free survival (PFS) and overall survival (OS) were analyzed via comparison to the International Primary Central Nervous System Lymphoma Collaboration Group Response Criteria. Associations between ADC measures and clinical outcomes were assessed using univariate and multivariate Cox proportional hazards models. Normalized ADC (nADC)Min, nADCMean, nADC1, nADC5, and nADC15 values were significantly associated with a poorer OS. nADCMax, nADCMean, nADC5, nADC15, nADC75, nADC95, nADC99 inversely correlated with Ki-67 expression. OS was also significantly associated with lesion hemorrhage. PFS was not significantly associated with ADC values but with lesion hemorrhage. ADC histogram values and related parameters can predict the degree of tumor proliferation and patient outcomes for primary central nervous system lymphoma patients and in both immunocompetent patients and patients living with HIV

Electronic Vaping-Induced Methicillin-Sensitive Staphylococcus Aureus Pneumonia and Empyema

Pneumonia is a severe acute inflammation of the lower respiratory tract due to infectious pathogens. Pathogens responsible include bacteria, viruses, fungi, and parasites. Pneumonia categorizations include community-acquired pneumonia (CAP), hospital-acquired pneumonia, and ventilator-associated pneumonia. It is the single most common cause of infection-related mortality in the United States. Among the typical bacterial CAP causes, Staphylococcus aureus (S. aureus) is responsible for less than 5% of all cases. Among the S. aureus, methicillin-susceptible S. aureus (MSSA) is slightly more common than the methicillin-resistant S. aureus (MRSA). CAP caused by S. aureus is associated with worse clinical outcomes compared to streptococcal pneumoniae. Although S. aureus CAP occurs throughout the year, it is less common except during the influenza season when there is a spike. Multiple studies have stratified risk factors for MRSA infection. MSSA pneumonia in immunocompetent young patients is uncommon due to healthy host defense mechanisms. However, certain individual risk factors promote infection, such as intravenous drug abuse. Recent multiple research studies implicate increased virulence of S. aureus in colonized patients after exposure to electronic cigarette vapor exposure (ECVE), resulting in pneumonia. A PubMed search revealed no MSSA community-acquired bacterial pneumonia due to ECVE. We report a 38-year-old female who developed acute MSSA pneumonia, which was complicated by left empyema due to ECVE from JUUL device with third-party compatible cannabidiol pods. The patient completed treatment successfully with a chest tube placement followed by fibrinolysis and intravenous antibiotics

COVID-19 Associated Myocarditis Clinical Outcomes among Hospitalized Patients in the United States: A Propensity Matched Analysis of National Inpatient Sample

Coronavirus-19 (COVID-19), preliminarily a respiratory virus, can affect multiple organs, including the heart. Myocarditis is a well-known complication among COVID-19 infections, with limited large-scale studies evaluating outcomes associated with COVID-19-related Myocarditis. We used the National Inpatient Sample (NIS) database to compare COVID-19 patients with and without Myocarditis. A total of 1,659,040 patients were included in the study: COVID-19 with Myocarditis (n = 6,455, 0.4%) and COVID-19 without Myocarditis (n = 1,652,585, 99.6%). The primary outcome was in-hospital mortality. Secondary outcomes included mechanical ventilation, vasopressor use, sudden cardiac arrest, cardiogenic shock, acute kidney injury requiring hemodialysis, length of stay, health care utilization costs, and disposition. We conducted a secondary analysis with propensity matching to confirm results obtained by traditional multivariate analysis. COVID-19 patients with Myocarditis had significantly higher in-hospital mortality compared to COVID-19 patients without Myocarditis (30.5% vs. 13.1%, adjusted OR: 3 [95% CI 2.1&ndash;4.2], p &lt; 0.001). This cohort also had significantly increased cardiogenic shock, acute kidney injury requiring hemodialysis, sudden cardiac death, required more mechanical ventilation and vasopressor support and higher hospitalization cost. Vaccination and more research for treatment strategies will be critical for reducing worse outcomes in patients with COVID-19-related Myocarditis

Risk of COVID-19 after natural infection or vaccinationResearch in context

Summary: Background: While vaccines have established utility against COVID-19, phase 3 efficacy studies have generally not comprehensively evaluated protection provided by previous infection or hybrid immunity (previous infection plus vaccination). Individual patient data from US government-supported harmonized vaccine trials provide an unprecedented sample population to address this issue. We characterized the protective efficacy of previous SARS-CoV-2 infection and hybrid immunity against COVID-19 early in the pandemic over three-to six-month follow-up and compared with vaccine-associated protection. Methods: In this post-hoc cross-protocol analysis of the Moderna, AstraZeneca, Janssen, and Novavax COVID-19 vaccine clinical trials, we allocated participants into four groups based on previous-infection status at enrolment and treatment: no previous infection/placebo; previous infection/placebo; no previous infection/vaccine; and previous infection/vaccine. The main outcome was RT-PCR-confirmed COVID-19 >7–15 days (per original protocols) after final study injection. We calculated crude and adjusted efficacy measures. Findings: Previous infection/placebo participants had a 92% decreased risk of future COVID-19 compared to no previous infection/placebo participants (overall hazard ratio [HR] ratio: 0.08; 95% CI: 0.05–0.13). Among single-dose Janssen participants, hybrid immunity conferred greater protection than vaccine alone (HR: 0.03; 95% CI: 0.01–0.10). Too few infections were observed to draw statistical inferences comparing hybrid immunity to vaccine alone for other trials. Vaccination, previous infection, and hybrid immunity all provided near-complete protection against severe disease. Interpretation: Previous infection, any hybrid immunity, and two-dose vaccination all provided substantial protection against symptomatic and severe COVID-19 through the early Delta period. Thus, as a surrogate for natural infection, vaccination remains the safest approach to protection. Funding: National Institutes of Health