Incidencia y factores de riesgo de tuberculosis en el trasplante de pulmón: importancia de la profilaxis

Introducción. Justificación de la hipótesis y los objetivos: La tuberculosis presenta una prevalencia y tasa de incidencia muy altas entre los trasplantados de órganos sólido, especialmente en el trasplante pulmonar. Esta infección se presenta en dos tercios de los casos en el primer año postrasplante pero puede ocurrir también pasado este período. En la mayoría de los casos se produce por una reactivación de una infección tuberculosa latente adquirida previamente al trasplante. Se han definido una serie de factores de riesgo generales y para algunos órganos específicos pero no para el trasplante pulmonar en concreto. Se suele presentar con sintomatología clínica habitual, pero puede también llegarse al diagnóstico en pacientes asintomáticos. La presentación extrapulmonar y diseminada es más frecuente que en población no trasplantada. La tuberculosis conlleva para estos pacientes altas tasas de mortalidad y morbilidad. Las guías actuales recomiendan realizar despistaje de una infección tuberculosa latente pretrasplante con el objetivo de disminuir las reactivaciones en el período postrasplante. El tratamiento de la infección tuberculosa latente recomendado es mediante una pauta de isoniazida durante 9 meses. Hipótesis: La pauta corta 3HR es eficaz y segura para el tratamiento de la infección tuberculosa latente en pacientes candidatos a trasplante pulmonar. Es posible determinar una serie de factores de riesgo para el desarrollo de tuberculosis en el postrasplante pulmonar que nos ayude a diferenciar aquellos pacientes de alto riesgo en los que es necesario priorizar medidas preventivas. Objetivos: 1. Evaluar la eficacia de una pauta corta 3HR para el tratamiento de la infección tuberculosa latente en pacientes candidatos a trasplante pulmonar. 2. Evaluar la seguridad de una pauta corta 3HR como tratamiento de la infección tuberculosa latente en pacientes candidatos a trasplante pulmonar. 3. Realizar un análisis de factores de riesgo de tuberculosis en pacientes receptores de un trasplante pulmonar.Material y métodos: Análisis retrospectivo de una cohorte de 398 trasplantados pulmonares del Hospital Reina Sofía de Córdoba. Se recogieron una serie de variables pre y postrasplante así como datos relativos al tratamiento de la infección tuberculosa latente, efectos adversos y cumplimentación de la pauta. Se calcularon la prevalencia e incidencia de tuberculosis postrasplante. Se realizó un análisis uni y multivariante de factores de riesgo de tuberculosis postrasplante. Resultados: 23 pacientes realizaron tratamiento de la infección tuberculosa latente mediante la pauta 3HR. 20 de ellos completaron la pauta (86.9%) y sólo 2 pacientes no completaron el tratamiento debido a efectos adversos (8.7%). Se diagnosticaron 6 casos de tuberculosis postrasplante (1.5%) lo que supuso una tasa de incidencia de 406.3 casos/105 pacientes-año. Ninguno de los pacientes que realizó tratamiento de la infección tuberculosa latente con 3HR desarrolló tuberculosis. En el análisis multivariante se identificaron como factores de riesgo independientes de tuberculosis postrasplante a la presencia de alteraciones en la TAC pretrasplante sugestivas de tuberculosis residual (OR 11.5, IC 95% 1.9-69.1, p=0.008), el tratamiento postrasplante con azatioprina (OR 10.6, IC 95% 1.1-99.1, p=0.038) y el tratamiento postrasplante con everolimus (OR 6.7, IC 95% 1.1- 39.8, p=0.036). Conclusiones: 1. La pauta de tratamiento de la infección tuberculosa latente mediante 3HR es eficaz en la prevención de la tuberculosis postrasplante en candidatos a un trasplante pulmonar. 2. La pauta de tratamiento de la infección tuberculosa latente mediante 3HR ofrece un buen perfil de seguridad en pacientes candidatos a un trasplante pulmonar. 3. Se han establecido una serie de factores de riesgo independientes para el desarrollo de tuberculosis en el postrasplante pulmonar, como son la presencia de alteraciones sugestivas de tuberculosis residual en la TAC de tórax pretrasplante, el tratamiento postrasplante con azatioprina y el tratamiento postrasplante con everolimus.Introduction. Justification of the hypothesis and objectives: Tuberculosis has high prevalence and incidence rate among solid organ transplant recipients, especially in lung transplantation. This infection occurs in two thirds of cases in the first year after transplantation but can also develop after this period. Most of the cases are reactivation of a latent tuberculosis infection acquired in the pretransplant period. Some risk factors have previously been identified for general solid organ transplant recipients and for some specific organs, but not for lung transplantation specifically. Tuberculosis usually presents with common clinical symptoms, but asymptomatic patients are also frequent. Disseminated and extrapulmonary presentation is more common than in non-transplant population. Tuberculosis results in high mortality and morbidity rates for these patients. Current guidelines advocate performing pretransplant screening of latent tuberculosis infection in order to reduce reactivation in the post-transplant period. Treatment of latent tuberculosis infection is recommended with a course of isoniazid for nine months. Hypothesis: The short course 3HR is effective and safe for the treatment of latent tuberculosis infection in candidates to a lung transplantation. It is possible to identify a number of risk factors for the development of tuberculosis in the lung transplant, in order to differentiate those patients at high risk in whom it is necessary to prioritize preventive measures. Objectives: 1. Evaluate the effectiveness of a short 3HR course for the treatment of latent tuberculosis infection in candidates to lung transplantation. 2. Assess the safety of a short 3HR course as a treatment for latent tuberculosis infection in candidates to lung transplantation. 3. Perform an analysis of risk factors for tuberculosis in patients receiving lung transplantation.Methods: Retrospective analysis of a cohort of 398 lung transplant recipients at the Reina Sofía Hospital in Córdoba. Pre and post-transplant parameters were collected as well as data concerning the treatment of latent tuberculosis infection, adverse effects and completion of the course. Prevalence and incidence rate of postransplant tuberculosis were calculated. Univariate and multivariate risk factors analysis for postransplant tuberculosis were performed. Results: 23 patients underwent treatment for latent tuberculosis infection with 3HR course. 20 of them completed the pattern (86.9%) and only 2 patients did not complete treatment due to adverse events (8.7%). 6 cases of tuberculosis after transplantation were diagnosed (1.5%) which represents an incidence rate of 406.3 cases / 105 patient-years. None of the patients who performed treatment of latent tuberculosis infection with 3HR developed postransplant tuberculosis. In multivariate analysis, several risk factors for postransplant tuberculosis were identified: lesions in the pretransplant CT suggestive of residual tuberculosis (OR 11.5, 95% CI 1.9- 69.1, p = 0.008), post-transplant treatment with azathioprine (OR 10.6, 95% CI 1.1-99.1, p = 0.038) and post-transplant treatment with everolimus (OR 6.7, 95% CI 1.1-39.8, p = 0.036). Conclusions: 1. Short 3HR course is effective in preventing postransplant tuberculosis in lung transplant candidates. 2. Short 3HR course provides a good safety profile in lung transplant candidates. 3. Several independent risk factors for postransplant tuberculosis in lung transplantation, such as the presence of residual lesions in the pretransplant CT, postranspant treatment with azathioprine and everolimus

Lung Ultrasound, Clinical and Analytic Scoring Systems as Prognostic Tools in SARS-CoV-2 Pneumonia: A Validating Cohort

At the moment, several COVID-19 scoring systems have been developed. It is necessary to determine which one better predicts a poor outcome of the disease. We conducted a single-center prospective cohort study to validate four COVID-19 prognosis scores in adult patients with confirmed infection at ward. These are National Early Warning Score (NEWS) 2, Lung Ultrasound Score (LUS), COVID-19 Worsening Score (COWS), and Spanish Society of Infectious Diseases and Clinical Microbiology score (SEIMC Score). Our outcomes were the combined variable “poor outcome” (noninvasive mechanical ventilation, intubation, intensive care unit admission, and death at 28 days) and death at 28 days. Scores were analysed using univariate logistic regression models, receiver operating characteristic curves, and areas under the curve. Eighty-one patients were included, from which 21 had a poor outcome, and 9 died. We found a statistically significant correlation between poor outcome and NEWS2, LUS > 15, and COWS. Death at 28 days was statistically correlated with NEWS2 and SEIMC Score although COWS also performs well. NEWS2, LUS, and COWS accurately predict poor outcome; and NEWS2, SEIMC Score, and COWS are useful for anticipating death at 28 days. Lung ultrasound is a diagnostic tool that should be included in COVID-19 patients evaluation

Nocardia paucivorans brain abscess. Clinical and microbiological characteristics

Nocardia paucivorans brain abscesses are unusual in humans. Sixteen cases of this infection have been reported in the world medical literature. There is precise clinical information available from nine patients. All of these patients recovered or were cured from their brain disease with long-term antimicrobial treatment. Surgical drainage was performed in four patients. Keywords: Nocardia, Nocardiosis, Nocardia paucivorans, Nocardia brain abscess, Nocardia infection

Fracturas patológicas como forma de presentación de un mieloma múltiple no secretor: un dilema diagnóstico

We present the clinical case of a 60 year-old woman who was admitted to our hospital referring a precordial pleuromechanic pain and was diagnosed with multiple bone fractures. A bone marrow biopsy gave the diagnosis of multiple myeloma and no monoclonal peak was detected, neither light chains in blood nor urine. The final diagnosis was non-secretory multiple myeloma and secondary spontaneous fractures. Non-secretory multiple myeloma represents only 3% of all multiple myelomas and has several characteristics that make it important to distinguish from other myelomas.Presentamos el caso de una mujer de 60 años de edad que acudió a nuestro hospital por dolor precordial pleuromecánico y fue diagnosticada de fracturas óseas multiples. La biopsia de médula ósea dio el diagnóstico de mieloma multiple y no se detectó pico monoclonal, ni tampoco cadenas ligeras en sangre ni orina. El diagnóstico final fue de mieloma múltiple no secretor y fracturas espontáneas secundarias. El mieloma múltiple no secretor representa solo el 3% del total de mielomas múltiples y tiene características peculiares que hacen necesaria su distinction del resto de mielomas

Eficacia de los pulsos de corticoides en pacientes con síndrome de liberación de citocinas inducido por infección por SARS-CoV-2.

Cytokine storm syndrome (CSS) is a serious complication of COVID-19 patients. Treatment is tocilizumab. The use of glucocorticoids (GC) is controversial. In other very similar CSS, such as macrophage activation syndrome (MAS) and hemophagocytic syndrome (HFS), the main treatment are corticosteroids. Our objective is to evaluate the efficacy of GC in the CSS by COVID-19. We included 92 patients with CSS associated to COVID-19 who received GC, GC, and tocilizumab and only tocilizumab. We determine CSS markers. We evaluated mortality, intubation, and a combined variable. In all cases the percentages of events were lower in the group of patients with GC was administered. The hazard ratio of the final variables with GC versus the group in which only tocilizumab was administered was lower as CGs were considered, with statistical significance for survival. The early use of GC pulses could control SLC, with a lower requirement to use tocilizumab and a decrease in events such as intubation and death

Ultrasound findings of lung ultrasonography in COVID-19: A systematic review.

To identify the defining lung ultrasound (LUS) findings of COVID-19, and establish its association to the initial severity of the disease and prognostic outcomes. Systematic review was conducted according to the PRISMA guidelines. We queried PubMed, Embase, Web of Science, Cochrane Database and Scopus using the terms ((coronavirus) OR (covid-19) OR (sars AND cov AND 2) OR (2019-nCoV)) AND (("lung ultrasound") OR (LUS)), from 31st of December 2019 to 31st of January 2021. PCR-confirmed cases of SARS-CoV-2 infection, obtained from original studies with at least 10 participants 18 years old or older, were included. Risk of bias and applicability was evaluated with QUADAS-2. We found 1333 articles, from which 66 articles were included, with a pooled population of 4687 patients. The most examined findings were at least 3 B-lines, confluent B-lines, subpleural consolidation, pleural effusion and bilateral or unilateral distribution. B-lines, its confluent presentation and pleural abnormalities are the most frequent findings. LUS score was higher in intensive care unit (ICU) patients and emergency department (ED), and it was associated with a higher risk of developing unfavorable outcomes (death, ICU admission or need for mechanical ventilation). LUS findings and/or the LUS score had a good negative predictive value in the diagnosis of COVID-19 compared to RT-PCR. The most frequent ultrasound findings of COVID-19 are B-lines and pleural abnormalities. High LUS score is associated with developing unfavorable outcomes. The inclusion of pleural effusion in the LUS score and the standardisation of the imaging protocol in COVID-19 LUS remains to be defined