A unique presentation of Cryptococcus neoformans and Pneumocystis jirovecii PJP ) co infection in a newly diagnosed HIV patient

One week prior to demise, a 30 years old smoker male with a past medical history significant for intermittent asthma presented to emergency with shortness of breath, wheezing, productive cough, and generalized fatigue for 1 week. He was afebrile, normotensive, tachycardic and had O2 saturation of 96% on room air. Physical examination showed cachexia, audible wheezes and oropharyngeal erythema. Labs showed WBC 3600/uL with lymphocyte count of 700/uL and mild thrombocytopenia. Chest X ray was clear. Serology was reactive for HIV, pending viral load. Working diagnosis was asthma exacerbation in the setting of a possible viral infection for which he was discharged home to complete a 5-day course of high dose prednisone, with follow up with infectious diseases as an outpatient. Subsequent, HIV viral load after discharge was 194,643 copies/mL. One week later, he presented to the ED with worsening respiratory symptoms, new onset chest pain and vomiting. He was hypotensive, tachycardic, tachypneic, and afebrile. He had leukocytosis of 12,700/uL with neutrophilia, lactate of 6.6, BNP 841. Influenza A, B and RSV, and urine histoplasma antigen were negative. EKG showed abnormal ST segment elevation with concerns for STEMI. Chest CT revealed multifocal, bilateral ground glass and nodular opacities with cystic cavities. Mediastinal and hilar lymphadenopathy was also noted. Pulmonary embolism and pneumothorax were ruled out. Blood gases reflected acute hypoxemic respiratory failure. Vancomycin and Piperacillin/tazobactam were started. A bed side ultrasound showed significantly dilated right ventricle with severely reduced function and hence concerns for cardiogenic component of shock. He was intubated and shortly after developed asystole and expired after prolonged cardiopulmonary resuscitation within twelve hours of admission. At autopsy, gross exam showed bilateral pulmonary congestion, bilateral hilar adenopathy and matted lymph nodes in the mediastinum. Microscopy revealed cryptococcus (mucicarmine positive encapsulated yeast forms) involving intraalveolar and alveolar septal parts of all lobes of the lungs, effacing lymph nodes, and involving microscopic foci in bilateral myocardial ventricles. Modified GMS-positive cup shaped Pneumocystis organisms involved the alveoli of all lung lobes. The lung parenchyma showed minimal inflammatory response. Our case is of an HIV patient with respiratory symptoms found to have pulmonary co-infection with PJP and Cryptococcus neoformans, confirmed on pathology report. This is uncommon in literature. Additionally, this case is unique in reporting the presentation of Cryptococcus neoformans as involving the mediastinal lymph nodes and myocardium.https://scholarlycommons.henryford.com/merf2020caserpt/1122/thumbnail.jp

Respiratory culture nudge improves antibiotic prescribing for Moraxella catarrhalis and Haemophilus influenzae lower respiratory tract infections

We compared optimal antibiotic prescribing before and after implementing an interpretive β-lactamase microbiology comment for Haemophilus influenzae and Moraxella catarrhalis in lower respiratory-tract infections. The postintervention group was associated with 5-fold increased odds of optimal de-escalation (adjusted odds ratio, 5.03; 95% confidence interval, 2.57-9.87)

Comparison of bacterial maxillary sinus cultures between odontogenic sinusitis and chronic rhinosinusitis

BACKGROUND: Bacterial odontogenic sinusitis (ODS) is distinct from other forms of rhinosinusitis. Diagnosing ODS can be challenging because of nonspecific clinical presentations and underrepresentation in the literature. The purpose of this study was to compare maxillary sinus bacterial cultures between patients with ODS and chronic rhinosinusitis (CRS), to determine whether certain bacteria are associated with ODS. METHODS: This was a retrospective case-control study of 276 consecutive patients from August 2015 to August 2019 who underwent endoscopic sinus surgery (ESS) for bacterial ODS, CRS without nasal polyps (CRSsNP), or CRS with nasal polyps (CRSwNP). When present, pus was sterilely cultured from maxillary sinuses after maxillary antrostomy, and aerobic and anaerobic cultures were immediately sent for processing. Demographics and culture results were compared between ODS and CRS patients, and then separately between ODS and CRSsNP, and ODS and CRSwNP. ODS culture results were also compared between different dental pathologies (endodontic vs oroantral fistula). RESULTS: The following bacteria were significantly more likely in ODS compared to CRS: mixed anaerobes, Fusobacterium spp., Eikenella corrodens, Streptococcus intermedius, Streptococcus anginosus, and Streptococcus constellatus. Staphylococcus aureus and Pseudomonas aeruginosa were inversely related to ODS. There were no significant differences in cultures between the different dental pathologies. CONCLUSION: Certain bacteria were more likely to be associated with ODS compared to CRS when purulence was cultured from the maxillary sinus. Physicians should evaluate for an odontogenic source of sinusitis when these ODS-associated bacteria are identified in maxillary sinus cultures

The long-term sustainability of a respiratory culture nudge

Resource-intensive interventions and education are susceptible to a lack of long-term sustainability and regression to the mean. The respiratory culture nudge changed reporting to Commensal Respiratory Flora only: No S. aureus/MRSA or P. aeruginosa. This study demonstrated sustained reduction in broad-spectrum antibiotic duration and long-term sustainability 3 years after implementation

The effect of ultraviolet C radiation against different N95 respirators inoculated with SARS-CoV-2

OBJECTIVES: There are currently no studies that have examined whether one dosage can be uniformly applied to different respirator types to effectively decontaminate SARS-CoV-2 on N95 filtering facepiece respirators (FFRs). Health care workers have been using this disinfection method during the pandemic. Our objective was to determine the effect of UVC on SARS-CoV-2 inoculated N95 respirators and whether this was respirator material/model type dependent. METHODS: Four different locations (facepiece and strap) on five different N95 FFR models (3M 1860, 8210, 8511, 9211; Moldex 1511) were inoculated with a 10 μL drop of SARS-CoV-2 viral stock (8 × 10 RESULTS: UVC delivered using a dose of 1.5 J/cm(2), to each side, was an effective method of decontamination for the facepieces of 3 M 1860 and Moldex 1511, and for the straps of 3 M 8210 and the Moldex 1511. CONCLUSION: This dose is an appropriate decontamination method to facilitate the reuse of respirators for healthcare personnel when applied to specific models/materials. Also, some straps may require additional disinfection to maximize the safety of frontline workers. Implementation of widespread UVC decontamination methods requires careful consideration of model, material type, design, and fit-testing following irradiation

Risk Factors Associated With Hospitalization and Death in COVID-19 Breakthrough Infections

BACKGROUND: Characterizations of coronavirus disease 2019 (COVID-19) vaccine breakthrough infections are limited. We aim to characterize breakthrough infections and identify risk factors associated with outcomes. METHODS: This was a retrospective case series of consecutive fully vaccinated patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a multicenter academic center in Southeast Michigan, between December 30, 2020, and September 15, 2021. RESULTS: A total of 982 patients were identified; the mean age was 57.9 years, 565 (59%) were female, 774 (79%) were White, and 255 (26%) were health care workers (HCWs). The median number of comorbidities was 2; 225 (23%) were immunocompromised. BNT162b2 was administered to 737 (75%) individuals. The mean time to SARS-CoV-2 detection was 135 days. The majority were asymptomatic or exhibited mild to moderate disease, 154 (16%) required hospitalization, 127 (13%) had severe-critical illness, and 19 (2%) died. Age (odds ratio [OR], 1.14; 95% CI, 1.04-1.07; P \u3c .001), cardiovascular disease (OR, 3.02; 95% CI, 1.55-5.89; P = .001), and immunocompromised status (OR, 2.57; 95% CI, 1.70-3.90; P \u3c .001) were independent risk factors for hospitalization. Additionally, age (OR, 1.06; 95% CI, 1.02-1.11; P = .006) was significantly associated with mortality. HCWs (OR, 0.15; 95% CI, 0.05-0.50; P = .002) were less likely to be hospitalized, and prior receipt of BNT162b2 was associated with lower odds of hospitalization (OR, 0.436; 95% CI, 0.303-0.626; P \u3c .001) and/or death (OR, 0.360; 95% CI, 0.145-0.898; P = .029). CONCLUSIONS: COVID-19 vaccines remain effective at attenuating disease severity. However, patients with breakthrough infections necessitating hospitalization may benefit from early treatment modalities and COVID-19-mitigating strategies, especially in areas with substantial or high transmission rates

Involvement of circulating CEA in liver metastases from colorectal cancers re-examined in a new experimental model

Both experimental and clinical data show evidence of a correlation between elevated blood levels of carcinoembryonic antigen (CEA) and the development of liver metastases from colorectal carcinomas. However, a cause-effect relationship between these two observations has not been demonstrated. For this reason, we developed a new experimental model to evaluate the possible role of circulating CEA in the facilitation of liver metastases. A CEA-negative subclone from the human colon carcinoma cell line CO115 was transfected either with CEA-cDNA truncated at its 3' end by the deletion of 78 base pairs leading to the synthesis of a secreted form of CEA or with a full-length CEA-cDNA leading to the synthesis of the entire CEA molecule linked to the cell surface by a GPI anchor. Transfectants were selected either for their high CEA secretion (clone CO115-2C2 secreting up to 13 microg CEA per 10(6) cells within 72 h) or for their high CEA membrane expression (clone CO115-5F12 expressing up to 1 x 10(6) CEA molecules per cell). When grafted subcutaneously, CO115-2C2 cells gave rise to circulating CEA levels that were directly related to the tumour volume (from 100 to 1000 ng ml(-1) for tumours ranging from 100 to 1000 mm3), whereas no circulating CEA was detectable in CO115 and CO115-5F12 tumour-bearing mice. Three series of nude mice bearing a subcutaneous xenograft from either clone CO115-2C2 or the CO115-5F12 transfectant, or an untransfected CO115 xenograft, were further challenged for induction of experimental liver metastases by intrasplenic injection of three different CEA-expressing human colorectal carcinoma cell lines (LoVo, LS174T or CO112). The number and size of the liver metastases were shown to be independent of the circulating CEA levels induced by the subcutaneous CEA secreting clone (CO115-2C2), but they were directly related to the metastatic properties of the intrasplenically injected tumour cells

Project #37: Management Guidelines for Patients with COVID-19: Rapid Cycle Improvement

Project’s purpose is to rapidly devise, continually improve, educate, and implement a live and changing COVID-19 management guideline based upon emerging best available evidence. This project also aims to optimize the care of patients with COVID-19 and improve patient outcomes.https://scholarlycommons.henryford.com/qualityexpo2022/1004/thumbnail.jp