A 58-year-old female with a 15-year history of rheumatoid arthritis (RA) and a history of treatment consisting of methotrexate, hydroxychloroquine, leflunomide, and chronic prednisolone therapy, presented with fever, productive cough, dyspnea, and left leg cellulitis. She developed septic shock complicated by tension pneumothorax requiring emergency thoracostomy and non-ST-elevation myocardial infarction (NSTEMI). Pleural fluid culture grew Cupriavidus pauculus, a rare environmental gram-negative bacillus, alongside Burkholderia cepacia and Candida parapsilosis, indicating polymicrobial infection which was most likely predisposed by patient's immunosuppressed state from RA and prolonged steroid use. Treatment consisted of trimethoprim/sulfamethoxazole, meropenem, fluconazole, and cardiopulmonary support, and culminated in recovery after three weeks. This first reported C. pauculus case from Pakistan highlights diagnostic challenges in immunocompromised hosts and underscores the importance of rapid microbiological characterization and multidisciplinary care when managing sepsis caused by rare pathogens amidst complex comorbidities.
Background: Respiratory syncytial virus (RSV) is a negative sense single-stranded RNA virus (ssRNA) that primarily causes respiratory infections in both children and older adults. We examined clinical characteristics and outcomes of hospitalized adult patients who tested positive for RSV. Methods: This was a multicenter, retrospective, descriptive study that examined adult patients admitted with a positive RSV test over two years across eight hospitals in Orlando, Florida. Results: A total of 120 patients were included, of which 88 (73%) were 60 years old and older. Overall, patients with RSV infection were caucasian (62%) with a median age of 70 years and had diabetes mellitus (42%), cardiovascular disease (38%), or chronic respiratory illnesses (36%). Median body mass index (BMI) was 27.8 kg/m2 and median Charlson Comorbidity Index (CCI) was 5. Median hospital and intensive care unit (ICU) length of stay were 4 and 3 days, respectively. Median hospital length of stay for patients under and above 60 years old was 4 days. Median hospital length of stay for those admitted to the ICU was 10 days. Only one patient received ribavirin; the rest received supportive care. Inpatient mortality rate was 4% (5 patients), 67 (57%) were treated with supplemental oxygen, and 7 (6%) were treated with mechanical ventilation. Overall, there was a 30-day readmission rate of 18% (21 patients). Symptomatic RSV infection was present in 102 patients. The clinical characteristics of patients admitted to non-ICU settings and symptomatic patients overall were similar to the total 120 patients. Patients admitted to the ICU were a median age of 77 years of age, females (58%), caucasians (67%), and had a history of chronic kidney disease (CKD) (42%). Conclusions: RSV infection in adult hospitalized patients was predominantly seen among caucasian patients aged 60 years and older. Diabetes mellitus, cardiovascular disease, and chronic respiratory disease were the predominant comorbidities in this cohort. Of the 120 hospitalizations included in our study, 102 were considered to be symptomatic for RSV. Mortality in our population was low; however, RSV alone still accounts for significant morbidity and consumption of healthcare resources.
Introduction: Bronchiectasis, currently being recognized worldwide, is an abnormal dilatation of the bronchi and bronchioles brought on by recurrent cycles of inflammation and airway infection. Impaired pulmonary function has a predictive significance in bronchiectasis. When treating patients with suspected or confirmed respiratory diseases, pulmonary function tests (PFT) are useful examinations. Very few studies have been done on PFTs in bronchiectasis. The main aim of this study is to study PFTs in bronchiectasis. Method: This is a retrospective observational study done on 50 patients over two years at the tertiary care center. The previous records of patients were collected from the Pulmonary Function Lab. The spectrum of lung functions in patients with bronchiectasis was studied with the parameters in pulmonary function tests to see pre- and post-bronchodilator changes in the study population. Results: After post-bronchodilator use, flow volume curve parameters were significantly increased. The mean responses were significant for both FEV1 (increased from 1.29 to 1.53) and FEV1/FVC (increased from 70.9 to 78.4) criteria. However, there was no significant change for the mean MMEF 25/75 (increased from 1.09 to 1.45) criteria after bronchodilator use. The most common pattern was an obstructive defect 24 (48%). Conclusion: When diagnosing and treating bronchiectasis, lung function tests are a crucial evaluation tool. Objective information regarding the kind and severity of respiratory impairment is provided by lung function testing. An airflow obstruction is the most frequent ventilatory pattern associated with bronchiectasis. There is improvement in FEV1 and FVC following bronchodilator use in bronchiectasis.
Background: During 2019, México’s total public spending on health was 5.43% of the national gross domestic product, making it one of the countries of the Organisation for Economic Co-operation and Development that invested the least in developing public health systems. This study analyzes hospital mortality among intubated patients with laboratory-confirmed COVID-19 according to type of institution in San Luis Potosí, México, from March 18, 2020, to April 7, 2022. Methods: This is a secondary data analysis of publicly available information about mortality among intubated patients with a laboratory-confirmed diagnosis of COVID-19 with respect to the type of hospitalization institution. Results: Multivariate logistic regression models showed that patients admitted to public healthcare institutions had 2.4 times the risk of death compared to those admitted to private healthcare institutions. Conclusion: In public sector institutions, COVID-19 mortality among intubated patients was moderately higher. Further studies are needed to clarify whether or not factors such as decreased availability of infrastructure (such as ventilators, intensive care unit beds, and oxygen reserves), decreased human resources, and high demand for public health services might account for the observed mortality differences.
Introduction: Pleural effusions in patients with community-acquired pneumonia have been associated with worse outcomes in emergency department and hospital inpatient populations, but the incidence of effusions and their outcomes in outpatient urgent care clinics is unknown. This observational cohort study describes patients diagnosed with pneumonia and pleural effusions on upright 2-view chest X-rays performed in urgent care clinics. Methods: We extracted electronic health record data from January 2019 through December 2020 on all patients over 12 years old with an International Statistical Classification of Diseases 10th revision diagnosis of pneumonia entered by the treating clinician, plus “possible” or “likely” radiographic pneumonia identified in the clinical radiologist report. We excluded patients without recorded vital signs and those with a prior episode of pneumonia in the prior 30 days. Results: Of 5211 patients with documented vital signs, 93 (1.8%) had clinically significant effusions: 64 unilateral and 29 bilateral. Multiple logistic regression showed that older age and higher Charlson comorbidity index scores were associated with pleural effusions (AUC 0.78). Patients with effusions had higher Pneumonia Severity Index scores, lower SpO2, and higher Shock Index scores than patients without effusions. A greater percentage of pneumonia patients with clinically significant pleural effusion 33 (35%) were admitted to the ED or hospital within 7 days compared to those who had pneumonia but no effusion 575 (11%, P Conclusions: Fewer urgent care clinic patients diagnosed with community-acquired pneumonia have pleural effusions compared with emergency department and hospital cohorts, but the association with higher illness severity and downstream medical care remain.
Background: Individuals face stigma associated with numerous health conditions. Stigma can arise rapidly during the early spread of a new disease, adding to the burden felt by those affected. COVID-19 can be used as an example to study stigma during the early phases of a pandemic. This narrative review is a descriptive analysis that tracks the ways in which COVID-19 stigma was discussed in the scholarly literature during the first year of the pandemic to understand how stigma was viewed in the context of a rapidly spreading pandemic. Methods: PubMed was used as a non-exhaustive sample of the literature. Searches for stigma and COVID-19 or SARS-CoV-2 were carried out in January 2021. To be included for review, articles had to be accessible in English, published on PubMed in 2019 or later, and focused on COVID-19/SARS-CoV-2, with at least a mention of stigma related to COVID-19. The included articles were then reviewed for chronological time, depth of emphasis on stigma, definition and interpretation of stigma, type of publication, and recommendations. Demographic features of the authors and studied populations were also tracked. Results: This review identified 321 articles on PubMed discussing stigma and COVID-19. Of these, 180 articles met inclusion criteria and were reviewed. The earliest publication included in the review was from April 2020. Authors from India, the USA, and China published the most articles related to COVID-19 and stigma. The most frequent forms of publication were cross-sectional studies, commentaries, and letters to the editor. In nearly half of the publications, stigma was one of several factors studied. All of the included publications described the negative impact stigma has on the community. Five major types of recommendations were noted: need for further research, dissemination of accurate health information, expansion of resources, policy and protocol changes, and community engagement. Conclusions: Stigma can have a profound impact on individuals affected by a disease, causing barriers to both treatment and attempts to stop disease spread. The stigma seen during the early days of COVID-19 provides useful information on pandemic-related stigma. The recommendations gleaned from this review can be helpful in the mitigation of disease-related stigma and used to slow the spread of stigma during the early stages of future pandemics.
See editorial commentary on this article Respiratory syncytial virus (RSV) is one of many etiologies for acute respiratory tract illness among all age groups. Clinical presentation differs depending on age, health status, and whether the infection is primary or secondary. RSV is the most common cause of lower respiratory tract infection in children under the age of one.[1] Adults, especially those who are older and/or have predisposing conditions, also have high susceptibility. Many viruses cause upper respiratory tract illnesses and induce severe manifestations when affecting the lower respiratory tract.[1] The annual rate of RSV hospitalization is just over 4 per 1,000 among children under the age of five years and is highest among those under six months at 20 per 1,000.[2]
Background: The COVID-19 pandemic has evolved dramatically over the past two years, and literature on COVID-19 coagulopathy has been overwhelming, which complicates the process of understanding the literature or assessing the quality of the data available. The objective of this narrative review was to highlight and analyze data reported on COVID-19-induced coagulopathy and its outcomes in patients with severe or critical disease over two years of the pandemic. Methods: Studies published in high-impact journals reporting on hospitalized adult COVID-19 patients, their coagulation parameters, and their thrombotic complications were included. We searched MEDLINE, Embase, and Ovid between Dec 1, 2019 and July 18, 2021. We abstracted the following data: country; date of publication; total number, age, and sex of patients; detailed coagulation parameters; thrombotic complications; and anticoagulation data. Descriptive statistics, including percentages and averages, were used where applicable; otherwise, individual study data were presented. We used the New Ottawa Scale (NOS) to assess risk of bias in the included studies. Results: A total of 18,581 patients (9,255 males) reported in 62 studies from 16 different countries published between March 2020 and July 2021 were included this review. The highest number of studies was reported in July–August 2020, with additional peaks in February and May 2021. Coagulation laboratory parameters were reported in most studies, with considerable heterogeneity. A key finding is a more pronounced pro-coagulant profile in intensive care unit (ICU) patients. Controversy existed around thrombocytopenia and other platelet abnormalities in association with severe or late disease. Elevated D-dimer was consistently reported and was predictive of thrombosis and poor outcomes. Thrombosis occurred despite guideline-recommended thromboprophylaxis. Anticoagulation was reported in all studies, but practices were diverse, with 83% and 88% of studies in 2020 and 2021 respectively reporting thromboprophylaxis or thromboprophylaxis alongside treatment. Conclusion: This narrative review provided highlights of the literature regarding coagulation impairments, thrombotic complications, and anticoagulation use in COVID-19 patients over two years of the pandemic. We hope this analysis contributes to better understanding of COVID-19-induced coagulopathy and supports investigators designing future studies.
Background Even though the proportional burden of COPD among never-smokers is significant in both developing and developed nations, accounting for around 30% of all COPD in the community, there is little awareness of the prevalence of COPD in this population. Understanding the molecular processes that underlie COPD in nonsmokers is essential. Methods Dataset (GSE146560) was acquired from the Gene Expression Omnibus (GEO). The limma and clusterProfiler software tools were used to identify differentially expressed genes (DEGs) and conduct a functional enrichment analysis respectively. Results In all, 10,583 DEGs were found, of which 1,065 were up-regulated and 9,518 were down-regulated. The KEGG pathways such as Neuroactive ligand-receptor interaction, taste transduction, maturity onset diabetes of the young, Hippo signaling pathway, insulin secretion, dilated cardiomyopathy, morphine addiction, and calcium signaling pathway were mainly enriched in the DEGs, along with pathways for the Byzantine Arch palate, inflammation, infection, and feeding difficulties. Conclusion Particularly downregulated COPD genes such FBXL19-AS1, KRTAP5-AS1, and HAGLR antisense are identified as COPD biomarkers and may play a role in the pathogenesis of the illness. However, more investigation is required to support this study's conclusions.
Background: COVID-19 infection is associated with neurologic and psychiatric morbidity that suggests a direct effect of the virus or secondary effect of an inflammatory process. These neuropsychiatric consequences may increase the likelihood of schizophrenia in the offspring of women who become infected with COVID-19 during their pregnancy. Methods: We performed a directed narrative review of the literature focusing on the proposed pathophysiological processes that lead to schizophrenia and known pathological consequences of COVID-19 infection. Results: Schizophrenia in adult offspring has been associated with maternal infections during pregnancy by a wide range of respiratory and neurotropic pathogens. Spikes in the incidence of schizophrenia approximately 20 years after several influenza pandemics have been documented. There are multiple lines of evidence suggesting that a similar pattern may be seen due to the recent COVID-19 pandemic. These include the nonspecific consequences of acute illness and hyperpyrexia, as well as more specific derangements of brain development related to direct effects of the virus or secondary effects of the inflammatory response on the developing brain. There is the potential to prospectively test this hypothesis by following the offspring of women who are known to have developed COVID-19 during their pregnancy. Conclusion: The COVID-19 pandemic is likely associated with a range of future neuropsychiatric consequences in people whose mothers suffered the infection during their fetal development. It is important to try to follow these offspring to determine the full range of consequences of COVID-19 infection.
Just when we were celebrating some attenuation of COVID-19 contagion, there are resurgent, new outbreaks of respiratory syncytial virus (RSV) and influenza infections.Our previous coronavirus precautions might have predisposed our population to a higher incidence of illness now.These three respiratory ailments initially present in a similar fashion, and each of them might, via lowered immunity, augment the chances of contracting the other infections.RSV is a single-stranded RNA virus belonging to the Paramyxoviridae family.It was discovered in chimpanzees in 1955 and was later confirmed to be a human pathogen.The RSV structure is that of a bilipid layer envelope surrounding a ribonucleoprotein core, with several membrane proteins that aid attachment and fusion to host cells.[1] Serious illness associated with RSV infection occurs mainly in young children.Symptoms of infection most commonly appear around four to six days after exposure to the virus and may include dry cough, congested runny nose, sneezing, sore throat, headache, and fever.[2]
During the first two years of the coronavirus disease 2019 (COVID-19) pandemic, nasopharyngeal (NP) specimens were the gold standard for clinical diagnostic testing. As information about the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing the pandemic continued to be shared, it was clear that the virus could be detected in other specimen types during an active infection. The University of Louisville Infectious Diseases Laboratory accepted non-traditional specimen types, most without a paired, positive NP result, for research purposes only to support local epidemiology efforts. A real-time reverse transcription-polymerase chain reaction (RT-PCR) assay originally validated for NP specimens was used for non-traditional specimen types using a variety of specimen preparation methods. Limit of detection (LOD) studies allowed for direct comparison between NP, sputum, and breast milk specimen types. The primary aim of the study was to determine whether SARS-CoV-2 RNA could be detected in different human specimen types. The results showed that the non-traditional specimens were not inherently inhibitory since SARS-CoV-2 RNA was detected in 36 (14.5%) out of 249 non-traditional specimens, and the limit of detection for SARS-CoV-2 in breast milk and sputum was the same as for NP specimens. SARS-CoV-2 was not detected in 15 breast milk specimens from mothers with positive SARS-CoV-2 NP results. In addition, a direct comparison study showed that NP specimens performed better than paired nasal specimens. In conclusion, by analyzing real-time RT-PCR test results for these non-traditional specimen types, two benefits were realized. Health care providers gained additional epidemiologic information (since information was not to be used for managing or treating patients), and the laboratory gathered important information about specimen types for which complete method validation studies could be pursued in the future.
Hepatic hydrothorax (HH) is a complication of decompensated liver cirrhosis that only occurs in about 5–6% of cirrhosis patients, defined as a pleural fluid in the setting of known liver disease, with the absence of any other cardiopulmonary etiology. Infected HH is a rare complication, designated as spontaneous bacterial empyema (SBEM), found in only 13–16% of patients with HH. This case follows a patient with SBEM who developed a recurrent pleural effusion minutes after thoracentesis. Our patient is a 56-year-old female with a history of alcoholic cirrhosis with pleuritic pain found to have right-sided pleural effusion with decompensation. She had no ascites. She was initiated on antibiotics due to leukocytosis and underwent thoracentesis, revealing a sterile but exudative pleural effusion with high neutrophil count, confirming the diagnosis of SBEM. Despite initial symptom relief, her respiratory symptoms recurred within mere minutes of thoracentesis. Imaging showed reaccumulated right-sided effusion, and repeat thoracentesis showed a transudative effusion, suggesting HH. While she was in our care, we pursued expert consultation with gastroenterology and thoracic surgery; based on our shared clinical decision making, we agreed that definitive intervention with either indwelling catheter or intrapleural surgical options would cause more harm than good to our patient given her decompensated alcoholic cirrhosis. The patient was discharged with instructions for serial thoracentesis and close follow-up with gastroenterology to discuss next steps regarding her advanced and uncontrolled cirrhosis. We refer to this case to discuss HH and its rare complication of SBEM, as well as the management options for patients with these conditions.
During the COVID-19 pandemic, laboratories experienced periods of shortages for certain critical materials required to meet the high demand for SARS-CoV-2 testing. The U.S. Food & Drug Administration provided a template for molecular diagnostic testing, including guidance for a specimen pooling process in order to evaluate performance of the SARS-CoV-2 nucleic acid amplification assay. This study aimed to evaluate the testing of pooled specimens consisting of four nasopharyngeal swab specimens using the Luminex ARIES ® nucleic acid amplification platform. Results indicated that there was a loss of analytic sensitivity with pooled nasopharyngeal swab samples, demonstrating that this approach should be bal- anced against material shortages and the clinical utility of a less sensitive assay.
Introduction: Hospital-based antimicrobial stewardship efforts have traditionally focused on inpatient settings. Antibiotic prescribing at discharge is often an overlooked area of focus for antimicrobial stewardship programs. Discharge prescribing optimization is necessary to combat antibiotic overuse. Methods: This was an observational, retrospective cohort study at a four–adult community hospital system. Four hundred adult patients admitted with community-acquired pneumonia and discharged with antibiotics were included. The primary outcome was overall (inpatient and discharge) antibiotic length of therapy. The secondary outcome was percentage of patients discharged on a fluoroquinolone who had not received one in the hospital. Descriptive statistics were utilized. Results: The median total antibiotic length of therapy was 9.5 days (IQR 8, 11). The median inpatient and discharge antibiotic lengths of therapy were 4 days (IQR 3, 5) and 5 days (IQR 5, 7), respectively. Of the 108 patients prescribed a fluoroquinolone at discharge, 43% (46/108) had not previously received a fluoroquinolone while hospitalized. Conclusion: Both length of therapy and fluoroquinolone stewardship at discharge may represent possible antimicrobial stewardship targets in community-acquired pneumonia patients.
Vaccine hesitancy is an issue that should be addressed to maximize protection from serious COVID-19.SARS-CoV-2 vaccination hesitancy in the United States ranges from 21 to 42%.[1] Fear of adverse effects and concerns about safety are some of the main reasons for refusing to be immunized.[2,3] Vaccinations can induce adverse reactions, such as injection site tenderness, headache, myalgia, and arthralgia.Fever is occasionally a systemic side effect.[4]People often self-treat these problems with antipyretic and/or analgesic drugs; physicians sometimes recommend these as well.
Diffuse alveolar hemorrhage (DAH) syndrome has a mortality rate of 30 to 60%. A 15-year-old male patient presented with a seven-day abdominal pain, vomiting, non-dysenteric diarrhea, conjunctival injection, and fever. Chest radiography revealed bilateral interstitial infiltrates predominating in the lower left lobe. The patient’s condition worsened within hours, with the development of massive hemoptysis, acute respiratory distress syndrome (ARDS), arterial hypotension, and hematocrit decline requiring mechanical ventilation. A chest computed tomography (CT) showed ground-glass opacities with consolidation areas in lower lobes, diffuse tree-in-bud opacities, and centrilobular nodules. A bronchoscopy was conducted without endoluminal lesions and bronchoalveolar lavage (BAL) consistent with alveolar hemorrhage. DAH was diagnosed, and the patient received therapy with intravenous methylprednisolone. The outcome of treatment was successful after eight days of mechanical ventilation. Leptospirosis was diagnosed by serology after discharge. The laboratory findings were normal, and a chest CT scan showed the resolution of the infiltrates. Early recognition of severe hemorrhagic pulmonary syndrome, which has a high mortality rate, is crucial. Therefore, leptospirosis should be suspected as a differential diagnosis in every patient with alveolar hemorrhage, ARDS manifestations, and epidemiological factors.
