Background: Stenotrophomonas maltophilia infections represent a clinical challenge in treating frail and immunocompromised patients. Alternatives to trimethoprim-sulfamethoxazole (SXT) are needed, with cefiderocol (FDC) representing a promising option, but clinical evidence is limited; moreover, data to support the superiority of mono or combination therapy are lacking. Case presentation: We describe the case of a 55-year-old female patient with a tunneled hemodialysis central venous catheter (HD-CVC)-associated bloodstream infection caused by S. maltophilia that, after failure of a prolonged SXT monotherapy, was successfully treated by HD-CVC replacement followed by intravenous cefiderocol (FDC) and levofloxacin (LVX). Conclusions: FDC represents an interesting option for complex cases of S. maltophilia bloodstream infections, and the combination with LVX might add benefit in cases associated with biofilm formation on intravascular devices.

BackgroundNew Delhi metallo-beta-lactamase (NDM)-producing Klebsiella pneumoniae (NDM-Kp) represents a growing challenge for modern medicine.ObjectivesTo assess real-life clinical outcomes in patients adequately treated in Internal medicine units (IMUs) for bloodstream infections (BSI) caused by NDM-Kp.MethodsA two-years retrospective study was conducted recruiting 30 consecutive adult patients with NDM-Kp BSI treated with an adequate definitive antibiotic therapy (27 aztreonam plus ceftazidime/avibactam; 3 cefiderocol) in three Italian IMUs located in a highly endemic area.ResultsMean age of patients was 75.3 years, mean Charlson Comorbidity Index (CCI) 7.5. All the patients had rectal colonization. Thirty-day mortality rate was 46.7%; 78.6% of patients who died received an adequate empiric therapy. Non-survivors had mean age, CCI and SOFA score significantly higher compared to survivors (80.1 vs. 71.2, p = 0.036; 8.6 vs. 6.6, p = 0.047; 5.9 vs. 4, p = 0.043, respectively). The percentage of survivors was significantly higher among the 13 cases with community-acquired than in the 17 with hospital-acquired BSI (76.9% vs. 35.3%, p = 0.024). In the multivariate penalized logistic regression analysis, age, CCI, SOFA score and hospital-acquired BSI onset were identified as independent predictors of mortality.ConclusionThis study provides real-life data on clinical outcomes regarding old and highly multimorbid patients hospitalized in IMU for BSI caused by NDM-Kp, showing a very high 30-day mortality even in case of adequate treatment.

New Delhi metallo-beta-lactamase (NDM)-producing Klebsiella pneumoniae (NDM-Kp) represents a growing challenge for modern medicine. To assess real-life clinical outcomes in patients adequately treated in Internal medicine units (IMUs) for bloodstream infections (BSI) caused by NDM-Kp. A two-years retrospective study was conducted recruiting 30 consecutive adult patients with NDM-Kp BSI treated with an adequate definitive antibiotic therapy (27 aztreonam plus ceftazidime/avibactam; 3 cefiderocol) in three Italian IMUs located in a highly endemic area. Mean age of patients was 75.3 years, mean Charlson Comorbidity Index (CCI) 7.5. All the patients had rectal colonization. Thirty-day mortality rate was 46.7

BACKGROUND: Coagulation plays a crucial role in innate immune response to invasive infections. Coagulative biomarkers might predict clinical outcomes differently, depending on etiology. METHODS: A retrospective study was conducted during a 79-month period, recruiting 90 patients with meningitis or bloodstream infection caused by Neisseria meningitidis (n = 47) or Streptococcus pneumoniae (n = 43), median age 19 and 58 years, respectively. Biomarkers were assessed within 24 hours. RESULTS: For N. meningitidis: in univariate analysis, increasing D-dimer was associated with in-hospital mortality (odds ratio [OR] 1.360; 95% confidence interval [CI], 1.063-1.889); in multivariate regression, increasing Ddimer was predictive (OR 1.037; 95% CI, 1.001-1.074) of the composite outcome (in-hospital mortality or amputations or hearing loss or neurological sequelae); protein C showed a clear trend toward lower levels in nonsurvivors (26% vs 48%) and in patients with the composite outcome (32% vs 51%); activated partial thromboplastin time (aPTT) was significantly prolonged in nonsurvivors (51.3 vs 35.3 seconds, P = .003), confirmed in univariate analysis (OR 1.122; 95% CI, 1.031-1.253). For S. pneumoniae: antithrombin was significantly lower in non- survivors (70% vs 81%, P = .038), confirmed in univariate analysis (OR 0.961; 95% CI, 0.921-0.997). For overall population: in multivariate regression, increasing age was associated with mortality (OR 1.043; 95% CI, 1.010-1.077), and S. pneumoniae etiology with the composite outcome (OR 6.024; 95% CI, 1.798-20.180). CONCLUSIONS: For invasive infections caused by N. meningitidis, D-dimer is a biomarker capable of predicting unfavorable clinical outcomes; a potential role is suggested for aPTT prolongation and protein C decrease, and, in case of S. pneumoniae infections, for antithrombin decrease. (c) 2024 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) center dot The American Journal of Medicine (2025) 138:504-512

Calciphylaxis is a rare but highly disabling disease, occurring both in chronic kidney disease (CKD) with renal replacement therapy (RRT) and in normal renal function. Given the frequent coexistence of atrial fibrillation (AF) and CKD, anticoagulation is often required. Warfarin, as a promoter of vascular calcification, is frequently reported as a triggering factor of calciphylaxis. Here, we present the case of a 71-year old male patient with a history of AF and a previous ischaemic stroke, on RRT for three years and warfarin therapy. The patient presented with two painful necrotic skin ulcers over the right leg and a skin biopsy confirmed calciphylaxis. After discontinuation of warfarin, the lesions completely healed with sodium thiosulfate intravenous infusion and local wound treatment. A literature search was performed up to 1 September 2022 through PubMed. The following terms were searched in different combinations: ‘calciphylaxis’; ‘VKA’ [vitamin K antagonist]; ‘warfarin’; ‘haemodialysis’; ‘end-stage renal disease’; and ‘ulcer’. In our opinion, in patients requiring anticoagulant therapy, the introduction or continuation of vitamin K antagonists (VKAs) should be carefully balanced when calciphylaxis develops, and other options, such as enoxaparin or apixaban, should be considered. Clinical decisions for patients requiring haemodialysis and requiring anticoagulant therapy should take into account the possible risk of warfarin-induced calciphylaxis. Further studies are needed to clarify the safety, tolerability profile and outcomes of each currently available treatment in this patient population.

Real-life outcomes data for elderly patients with infections caused by Klebsiella pneumoniae producing New Delhi metallo-beta-lactamase (NDM-Kp) are lacking. We conducted a retrospective cohort study enrolling 33 consecutive adult patients (mean age 77.4 years; 48.5% males; mean Charlson Comorbidity Index—CCI 5.9) hospitalized for NDM-Kp infections during a 24-month period in an Italian highly endemic area. 78.8% were admitted to Internal Medicine ward. 45.4% of patients had bloodstream infections (BSI), 39.4% urinary tract infections (UTI) without BSI, 9.1% respiratory tract infections and 6.1% intra-abdominal infections. 93.9% had rectal colonization. Adequate definitive antibiotic therapy (mainly represented by aztreonam plus ceftazidime/avibactam) was provided to 36.4% of cases. Mean age and CCI of patients adequately treated were significantly lower than those inadequately treated (71.2 vs 80.9 years, p = 0.041, and 4.6 vs 6.7, p = 0.040, respectively). Patients adequately treated had a mean hospitalization length significantly higher (28 vs 15 days, p = 0.016). The overall 30-day survival rate of patients adequately and inadequately treated was 83.3% and 57.1%, respectively: this difference was not statistically significant. Mean age and CCI of 22 patients who survived at 30 days were lower than those of 11 patients who died (73.7 vs 84.8 years, p = 0.003, and 5.3 vs 7.2, p = 0.049, respectively). Twelve survivors received an inadequate therapy: 8/12 had UTI. Six of nine patients inadequately treated who died within 30 days, died before microbiological diagnosis. Our study provides real-life data on outcomes of elderly and multimorbid patients hospitalized for infections caused by NDM-Kp. Further studies with larger sample size are warranted.

This study retrospectively analyzes all consecutive patients who underwent during a year hospital readmissions, defined as an admission to a hospital within 30 days of discharge, to an Italian Internal Medicine ward. All these data were compared with those from patients who underwent only 1 hospital admission in the same period. The aim of this study was to identify potential novel risk factors for hospital readmissions. In 2018, a total of 3012 patients were hospitalized. Among these, 14.1% (n = 426; mean age, 79.7 ± 11.9; range, 23-100) were defined as readmissions; data were compared with controls (n = 420; 13.9%; mean age, 75.9 ± 14.7; range, 22-99) who had only 1 hospitalization. Cases showed a significantly higher prevalence than controls regarding cerebrovascular disease (77.2% vs 48.1%), cognitive impairment (51.8% vs 26.9%), congestive heart failure (47.6% vs 20.2%), chronic kidney disease (31.7% vs 13.1%), and chronic obstructive pulmonary disease (23.0% vs 14.5%). Skin ulcers were significantly more prevalent among cases (45.1% vs 17.6%). Diagnosis-related group (DRG) analysis showed a higher proportion of "infectious disease" (24.4% vs 15.0%) among the cases than in controls. Despite skin ulcers were very frequent among cases and controls (45.1% vs 17.6%), they were codified as "skin wound" DRG only in 1.4% and 0.2%, respectively. At the DRGs analysis, sepsis (31.6% vs 19.1%), pneumonia (17.1% vs 7.6%), and kidney failure (9.6% vs 3.8%) represented the main significant cause of death in cases compared to controls. Our study confirms that readmissions to Internal Medicine departments are related to the severity of chronic diseases affecting patients. Skin ulcers are present in about half of patients who will be early readmitted within 30 days, but they are almost never reported in DRGs, so more accurate coding is needed. Key challenges for the future are sepsis prevention measures and investing resources in chronic disease assistance, including skin ulcer chronic management.

BACKGROUND:The risk of barotrauma associated with different types of ventilatory support is unclear in COVID-19 patients. The primary aim of this study was to evaluate the effect of the different respiratory support strategies on barotrauma occurrence; we also sought to determine the frequency of barotrauma and the clinical characteristics of the patients who experienced this complication. METHODS:This multicentre retrospective case-control study from 1 March 2020 to 28 February 2021 included COVID-19 patients who experienced barotrauma during hospital stay. They were matched with controls in a 1:1 ratio for the same admission period in the same ward of treatment. Univariable and multivariable logistic regression (OR) were performed to explore which factors were associated with barotrauma and in-hospital death. RESULTS:We included 200 cases and 200 controls. Invasive mechanical ventilation was used in 39.3% of patients in the barotrauma group, and in 20.1% of controls (p<0.001). Receiving non-invasive ventilation (C-PAP/PSV) instead of conventional oxygen therapy (COT) increased the risk of barotrauma (OR 5.04, 95% CI 2.30 - 11.08, p<0.001), similarly for invasive mechanical ventilation (OR 6.24, 95% CI 2.86-13.60, p<0.001). High Flow Nasal Oxygen (HFNO), compared with COT, did not significantly increase the risk of barotrauma. Barotrauma frequency occurred in 1.00% [95% CI 0.88-1.16] of patients; these were older (p=0.022) and more frequently immunosuppressed (p=0.013). Barotrauma was shown to be an independent risk for death (OR 5.32, 95% CI 2.82-10.03, p<0.001). CONCLUSIONS:C-PAP/PSV compared with COT or HFNO increased the risk of barotrauma; otherwise HFNO did not. Barotrauma was recorded in 1.00% of patients, affecting mainly patients with more severe COVID-19 disease. Barotrauma was independently associated with mortality. TRIAL REGISTRATION:this case-control study was prospectively registered in clinicaltrial.gov as NCT04897152 (on 21 May 2021).

Chronic limb-threatening ischemia (CLTI) represents an unfavorable evolution of peripheral artery disease, characterized by pain at rest, ulceration, and gangrene and also by an increased risk of cardiovascular events, amputations, and death. According to scientific literature, in almost one third of cases affected by CLTI, defined as no-option CLTI patients, revascularization strategies are not feasible. In the past decade, several studies investigated the role of therapeutic angiogenesis through cell autologous therapy, administered through intramuscular injections or multiple local intralesional and perilesional injections. In this article, we report the case of a necrotizing inflammatory reaction in a patient affected by CLTI and chronic leg wounds that occurred on the multiple injection sites after autologous peripheral blood-derived mononuclear cells (PB-TNCs) transplantation. Since the patient was affected by corticosteroid-induced skin atrophy and rheumatoid arthritis, we hypothesize that an increased skin fragility and a mechanism of immune-mediated pathergy could have been main factors leading to worsening of wounds. This case report strongly suggests the urgent need to better define the indications and contraindications of cell therapy, and further studies of adequate methodology are required to definitively assess the efficacy and safety of autologous cell therapy by local injections of PB-TNCs in patients with chronic inflammatory disorder, such as rheumatoid arthritis, especially in case of concomitant marked skin atrophy. Pending definitive evidence from literature, a strong caution is needed in patients affected by chronic systemic inflammatory diseases, since multiple injections, acting as mechanical stimulus and pathergy trigger, might exacerbate a severe and uncontrolled inflammatory response.

Transcranial color-coded duplex sonography (TCCS) allows to study intracranial vessels through the intact skull, but the visualization of normal and pathologic brain structures in adults is often suboptimal due to inadequate acoustic window. The full potential of TCCS for clinical practice remains unfulfilled. Here, we describe the ability of TCCS to detect a non-functioning pituitary macroadenoma in a 58-year-old man affected by headache. The macroadenoma was visualized as a roundish, well-defined mass, mildly hyperechogenic compared to the hypoechogenic mesencephalic brainstem but mainly hypoechogenic compared to the surrounding intracranial structures. Intracranial vessels represented useful landmarks. Using tissue harmonic imaging mode, the borders of the macroadenoma were visualized more clearly. Macroadenoma characteristics were confirmed by magnetic resonance imaging. Neurosonologists should be aware of the possibility to incidentally find, during routinary TCCS, pituitary macroadenomas or other brain tumors (as incidentalomas), worthy to be recognized and referred for further investigations.

In multimorbid, unvaccinated and non-hospitalized patients, early administration of remdesivir, nirmatrelvir/ritonavir and molnupiravir was effective in reducing the risk of hospitalization or death from any cause. Similar data are lacking with regard to patients already hospitalized and who acquire in-hospital SARS-CoV-2 infection. We conducted a retrospective study during two outbreaks of SARS-CoV-2 infections involving 90 inpatients already hospitalized for medical or surgical conditions, in order to assess the effectiveness of early administration of remdesivir. Forty-seven cases were treated with a 3-day course of remdesivir (200 mg on day 1 and 100 mg on days 2 and 3) within a median time of 1.4 day from testing positive, and were compared to a matched case-control cohort of 43 untreated patients; matching was based on age, sex, vaccination status, previous symptomatic infections by SARS-CoV-2, reasons for hospitalization (no significant differences). No case presented adverse events to remdesivir or death from COVID-19. No significant difference in overall in-hospital mortality was observed in cases compared to controls (17% vs 16.3%, p=0.925), but progression to severe pneumonia, although the difference was still not significant, showed an evident trend of a better outcome (8.5% vs 16.3%, p=0.261). Moreover, cases had a median discharge delay of 3 days (p=0.008).

Primary meningococcal arthritis (PMA) represents an uncommon clinical presentation of meningococcal infection, mainly reported among young people. Herein, a case of PMA of the knee in an elderly patient is described.On January 2022, an 87-year-old patient arrived at hospital with continuous fever persisting for three days and a picture of pain, swelling, redness, and warmth of her left knee. An arthrocentesis was promptly performed and the inoculated synovial fluid turned positive with numerous Gram-negative diplococci at the microscopic examination. The identification of bacteria was done in 48 h using matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF) MS systems (VITEK®MS-bioMérieux) and standard microbiological procedures (VITEK®2 NH ID card-bioMérieux). Both methods identified the strain as N. meningitidis. The meningococcal isolate belonged to the serogroup B (MenB), Sequence type (ST)-162/clonal complex (cc)162. Two grams of ceftriaxone twice a day were administered for 21 days; than cefditoren pivoxil 400 mg twice a day for further 6 weeks after discharge. In Italy, from 2018 to January 2022, among 135 MenB, 31 MenB/cc162 were identified, of which only the case here reported was associated with an atypical clinical presentation.A total of 41 cases of PMA caused by N. meningitidis was reported in the literature, but only four occurred in elderly. To our knowledgements, no cases of PMA caused by MenB were previously reported among patients of more than 65 years of age.

Computed tomography (CT) and magnetic resonance (MR) represent the gold standard for evaluating intracranial tumours, such as meningiomas; most meningiomas can be managed by surveillance and clinical follow-up, therefore, the ideal technology should be cheap, non-invasive, safe and able to reduce radiation exposure. Transcranial colour-coded duplex sonography (TCCS) can detect space-occupying lesions, but its full potential for clinical practice is still unexpressed.We describe the ability of TCCS to directly and accurately image, in a 77-year-old woman hospitalised for septic shock and coma, a suprasellar meningioma with a spatial resolution very similar to CT.The meningioma was clearly visualised as a roundish mass, with well-defined borders, heterogeneously hyperechogenic compared with the surrounding brain structures; multiple intralesional calcifications were detectable as highly echogenic spots. Latero-lateral and antero-posterior diameters were well measurable.TCCS should not be considered as an alternative to CT and MR imaging, but it might have a complementary role, useful for use at the bedside in uncooperative or non-transportable patients and for follow-up, when an adequate acoustic window is guaranteed. Neurologists and neuroradiologists should further explore the full potential of this technology.

Persisting limitations in respiratory function and gas exchange, cognitive impairment, and mental health deterioration have been observed weeks and months after acute SARS-CoV-2 (COVID-19). The present study aims at assessing the impairment at three-months in patients who successfully recovered from acute COVID-19. We collected data from May to July 2020. Patients underwent a multidimensional extensive assessment including pulmonary function test, psychological tests, thoracic echo scan, and functional exercise capacity. A total of 21 patients (M:13; Age 57.05 ± 11.02) completed the global assessment. A considerable proportion of patients showed symptoms of post-traumatic stress disorder (28.6%), moderate depressive symptoms (9.5%), and clinical insomnia (9.5%); 14.3% of patients exhibited moderate anxiety. A total of eleven patients (52.4%) showed impaired respiratory gas exchange capacity (P-DLCO, DLCO ≤ 79% pred). Compared to patients with normal gas exchange, the P-DLCO subgroup perceived a significant worsening in quality of life (QoL) after COVID-19 (p = 0.024), higher fatigue (p = 0.005), and higher impact of lung disease (p = 0.013). In P-DLCO subgroup, higher echo score was positively associated with hospitalization length of stay (p = 0.047), depressive symptoms (p = 0.042), fatigue (p = 0.035), impairment in mental health (p = 0.035), and impact of lung disease in health status (p = 0.020). Pulmonary function and echo scan lung changes were associated to worsened QoL, fatigue, and psychological distress symptoms.

The injury caused by the intramuscular injection of a single dose of Bothrops jararaca venom (0.24 mg/kg body weight) to mice on day 8 of pregnancy and examined on day 9 was investigated. Macroscopic and histological examination showed that the bothropic venom caused an increase in the incidence of fetal resorptions. Histologically, a characteristic involution of mature decidua was noticed in saline-treated mice; however, necrotic trophoblast giant cells and decidual cells were also present in this region of mice treated with B. jararaca venom, mainly close to the embryo. Hemorrhagic areas were also observed at maternal–fetal interface, which contained maternal erythrocytes and polymorphonuclears. Plasma fibrinogen levels were lower in envenomed group (p≤0.0001), but prothrombin time and activated partial thromboplastin time remained unaltered. Total and differential white blood cell counts were not statistically different between groups. Thus, B. jararaca venom causes injuries not only to the fetus, but also to decidual tissue and blood coagulation of pregnant mice. It is not clear, nonetheless, whether disturbances during the development of pregnancy are due to a direct effect of venom on uterus/fetus or to homeostatic changes in dams, such as clotting disturbances, or to both of them.

Background Few data are available on the validity of "Sepsis-3" criteria in identifying patients with sepsis in internal medicine wards (IMWs). Real-life data about this topic and on the prevalence of sepsis in IMWs could be useful for improving hospital organization. Objectives To assess the validity of "Sepsis-3" criteria in identifying patients with community-onset sepsis in IMWs. Secondary objectives: to evaluate the prevalence of these patients in IMWs and to compare "Sepsis-3" and "Sepsis-1" criteria. Methods Multicenter, prospective, observational, cohort study, carried out in 22 IMWs of Tuscany (Italy). All patients admitted to each of the study centers over a period of 21-31 days were evaluated within 48 hours; those with clinical signs of infection were enrolled. The main outcome was in-hospital mortality. Results 2,839 patients were evaluated and 938 (33%) met the inclusion criteria. Patients with sepsis diagnosed according to "Sepsis-3" were 522, representing 55.6% of patients with infection and 18.4% of all patients hospitalized; they were older than those without sepsis (79.4±12.5 vs 74.6±15.2 years, p<0.001). In-hospital mortality was significantly higher in patients with sepsis compared to others (13.8% vs 4.6%; p<0.001). "Sepsis-3" criteria showed greater predictive validity for in-hospital mortality than "Sepsis-1" criteria (AUROC=0.71; 95%CI, 0.66-0.77 vs 0.60; 95%CI 0.54-0.66; p=0.0038). Conclusions "Sepsis-3" criteria are able to identify patients with community-onset sepsis in IMWs, whose prevalence and in-hospital mortality are remarkably high. Medical departments should adapt their organization to the needs for care of these complex patients.

Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection; no current clinical measure adequately reflects the concept of dysregulated response. Coagulation plays a pivotal role in the normal response to pathogens (immunothrombosis), thus the evolution toward sepsis-induced coagulopathy could be individuate through coagulation/fibrinolysis-related biomarkers. We focused on the role of D-dimer assessed within 24 h after admission in predicting clinical outcomes in a cohort of 270 patients hospitalized in a 79 months period for meningitis and/or bloodstream infections due to Streptococcus pneumoniae ( n = 162) or Neisseria meningitidis ( n = 108). Comparisons were performed with unpaired t -test, Mann-Whitney-test or chi-squared-test with continuity correction, as appropriate, and multivariable logistic regression analysis was performed with Bayesian model averaging. In-hospital mortality was 14.8% for the overall population, significantly higher in S. pneumoniae than in N. meningitidis patients: 19.1 vs. 8.3%, respectively ( p = 0.014). At univariable logistic regression analysis the following variables were significantly associated with in-hospital mortality: pneumococcal etiology, female sex, age, ICU admission, SOFA score, septic shock, MODS, and D-dimer levels. At multivariable analysis D-dimer showed an effect only in N. meningitidis subgroup: as 500 ng/mL of D-dimer increased, the probability of unfavorable outcome increased on average by 4%. Median D-dimer was significantly higher in N. meningitidis than in S. pneumoniae patients (1,314 vs. 1,055 ng/mL, p = 0.009). For N. meningitidis in-hospital mortality was 0% for D-dimer <500 ng/mL, very low (3.5%) for D-dimer <7,000 ng/mL, and increased to 26.1% for D-dimer >7,000 ng/mL. Kaplan-Meier analysis of in-hospital mortality showed for N. meningitidis infections a statistically significant difference for D-dimer >7,000 ng/mL compared to values <500 ng/mL ( p = 0.021) and 500–3,000 ng/mL ( p = 0.002). For S. pneumoniae the mortality risk resulted always high, over 10%, irrespective by D-dimer values. In conclusion, D-dimer is rapid to be obtained, at low cost and available everywhere, and can help stratify the risk of in-hospital mortality and complications in patients with invasive infections due to N. meningitidis : D-dimer <500 ng/mL excludes any further complications, and a cut-off of 7,000 ng/mL seems able to predict a significantly increased mortality risk from much <10% to over 25%.

INTRODUCTION:The duration of immunity after infection from SARS-CoV-2 conferring protection from subsequent COVID-19 episodes is not yet fully understood. We reviewed the literature for cases of documented reinfection. MATERIALS AND METHODS:A comprehensive computerized search in PubMed, through 15 December 2020, using the following terms in combination: COVID-19, SARS-CoV-2, reinfection, reactivation, recurrence. To exclude cases due to prolonged viral shedding or protracted infection, only cases occurring at least 12 weeks apart or confirmed as being sustained by genetically different viruses by viral genome analysis were included. RESULTS:We identified 23 cases globally, for which viral genome analysis was performed in 10 cases and serology in 19 cases. The mean interval between the two episodes was 15 weeks. Mean age of cases was 44.5 years, and 10 (43.5%) were women. In 17/23 cases, no comorbidity was observed. In 10 cases, the first episode was more severe than the ensuing episode, whereas in seven cases the ensuing episode was more severe. In four cases, there was no difference in severity and in two cases both episodes were asymptomatic. CONCLUSIONS:From this sample of 23 cases, a clear pattern of the second episode being less or more severe did not emerge. A better understanding of immunity to SARS-CoV-2, necessary to assess the probability of a second infection and the durability of protection conferred by vaccination, is warranted.

A correction to this paper has been published: https://doi.org/10.1007/s15010-021-01596-8