The intestinal commensal fungus Wallemia mellicola enhances asthma in mice through Dectin-2

Overgrowth of the fungus Wallemia mellicola in the intestines of mice enhances the severity of asthma. Wallemia mellicola interacts with the immune system through Dectin-2 expressed on the surface of myeloid and intestinal epithelial cells. Using Dectin-2-deficient mice, we show that the interaction of W. mellicola with Dectin-2 is essential for the gut-lung pathways, enhancing the severity of asthma in mice with W. mellicola intestinal dysbiosis. These findings offer better insight into dysbiosis-associated inflammation and highlight the role pattern recognition receptors have in immune recognition of commensal fungi in the gut, leading to alterations in immune function in the lungs.

Pulmonary artery pseudoaneurysm arising from primary lung neoplasm: A proposed mechanism

Pulmonary artery pseudoaneurysms (PAPs) are rare and life-threatening occurrences. We present a 57-year-old male patient with squamous cell lung cancer, who presented with hemoptysis. Bronchoscopy did not reveal ongoing bleeding. Imaging showed a left lower lobe tumor, a cavitary lesion communicating with the bronchus, and a pulmonary artery pseudoaneurysm. Successful embolization of the originating segmental branch of the pulmonary artery was performed. The pathogenesis of PAPs associated with primary lung malignancies remains poorly understood. We propose a four-step mechanism involving primary tumor expansion, central cavitary necrosis, direct arterial invasion, inflammatory response, vessel wall damage, pseudoaneurysm formation, and subsequent filling of the former cavitary lesion. This case emphasizes the importance of considering PAPs in primary lung malignancies, particularly in male patients with squamous cell pathology. Understanding the proposed pathogenic mechanism could lead to early detection, prompt intervention, and improved outcomes.

Clinical Characteristics and Outcomes of Patients with SARS-CoV-2 Reinfection

Objective

To examine the clinical characteristics, risk of hospitalization and mortality of patients diagnosed with SARS-CoV-2 reinfection.

Patients and Methods

We retrospectively reviewed all patients with SARS-CoV-2 reinfection all Mayo Clinic sites between May 23, 2020, and June 30, 2021 (the period before emergence of delta variant in United States). The reinfection was defined as positive SARS-CoV-2 test ≥ 90 days after initial infection or 45-89 days after with symptomatic second episode. Vaccination status was classified as fully vaccinated, first dose and unvaccinated. Comparative analysis of baseline characteristics and comorbidities was performed by hospitalization and vaccination status. The survival analysis of hospitalized patients was performed using cox-proportional hazard regression.

Results

Among 554 reinfected patients, 59 (10.6%) were pediatric, and 495 (89.4%) were adults. The median age was 13.9 years (interquartile range [IQR], 8.5-16.5) for pediatric and 50.2 years (IQR, 28.4-65.6) for adult population. Among adult patients, majority were unvaccinated (83.4%, n=413) and duration to reinfection from initial infection was longest in fully vaccinated group (p < .001). 42 (75%) out of 56 patients were seropositive within seven days of reinfection. In hospitalized adult patients, Charlson Comorbidity Index (CCI) was an independent risk factor for mortality (adjusted hazard ratio [aHR], 0.35; 95% CI, 0.19 to 0.51).

Conclusion

In this study, majority of adult patients with SARS-CoV-2 reinfection were unvaccinated. Furthermore, the duration to reinfection was longest in fully vaccinated individuals. Seropositivity was common among adult patients.

Ischemic brain infarcts and vasculitis in histoplasmosis of the central nervous system: A case report and review of the literature

Histoplasmosis is one of the most common endemic mycoses affecting immunocompromised individuals in the United States and Latin America. Involvement of the central nervous system carries higher mortality rates and worse prognosis, given its resemblance to stroke, vasculitis, and meningitis of other etiologies. The diagnosis is challenging, due to its subtle clinical presentation and the poor sensitivity of the cerebrospinal fluid culture. Herein the authors present a case of a middle-aged man with HIV, who presented with intermittent headaches exacerbated by an oculomotor nerve palsy, concerning for acute stroke. A diagnosis of central nervous system histoplasmosis was made, and his neurological deficits subsided after initiation of treatment. The stroke-like syndrome in this scenario may be secondary to granulomatous vasculitis of small caliber cerebral blood vessels. Histoplasmosis of the central nervous system remains a challenging diagnosis, which requires a high index of suspicion by the clinician for an early institution of therapy in order to improve outcomes.

452. Correlation of Charleston Comorbidity Index Score as the COVID-19 Pandemic Surged Throughout HCA Healthcare Facilities and Patient Outcomes

Background

As the COVID-19 pandemic raged throughout the United States, the healthcare system was strained due to a sudden increase in demand. Testing was initially limited, and the perception was that patients with high comorbidity burden were at higher risk for poor outcomes. The Charleston Comorbidity Index (CCI) is widely used as a predictor of prognosis and one-year mortality for a wide range of pathologies. This study aims to assess whether a correlation exists between CCI score, COVID-19 incidence throughout the pandemic and patient outcomes.

Charleston Comorbidity Index Score

Scoring system for Charleston Comorbidity Index (CCI). Plus 1 point for every decade age 50 years and over, maximum 4 points. Higher scores indicate a more severe condition and consequently, a worse prognosis.

Methods

Multicenter, retrospective review of patients diagnosed with COVID-19 from January 2020 to September 2020 throughout the HCA Healthcare system. The percent of total encounters that were COVID-19 positive by state was calculated along with the average CCI score for COVID-19 patients in 2-month increments. Patient outcomes were obtained across the entire population.

Results

A clear surge of infected patients was seen in almost all states in the dataset from May 2020 onward except in Colorado and Louisiana where the percentage of COVID-19 positive encounters decreased until July 2020. As summer 2020 progressed, the highest percentage of COVID-19 positive encounters among HCA Healthcare facilities was in Florida and Texas. However, despite the fact that more patients were COVID-19 positive in these states, the CCI score was the lowest (Figure 1). The highest average CCI throughout the 9-month period was 7.66 in Colorado. In the first two months of the pandemic, patients who tested positive for COVID-19 had higher CCI scores on average than those who became COVID-19 positive later in the pandemic. Missouri had the lowest CCI average but the highest ICU admissions and in-hospital mortality. Indiana had the lowest average CCI score, and lowest admission rate (Figure 2).

COVID-19 Encounters and Average CCI score by State from January 2020 to September 2020

Graph 1: Percentage of COVID-19 Encounters in 9 Months at an HCA Healthcare Facility by State: Graph presents data obtained for the total of 92,800 patient encounters from January to September 2020 and recorded in 2-month increments. The rate of positive encounters throughout 18 states increased on average from May to September. From January to March 2020, the facilities with the highest rate of COVID-19 encounters were in Colorado, Louisiana and Texas. The states with the highest increment increase of COVID-19 positive patients were Texas, Florida and South Carolina and were trending up as the pandemic wore on through the summer of 2020. Graph 2: Average Charleston Comorbidity Index of COVID-19 Patient Seen at an HCA Healthcare Facility by State in 9 Months: In winter 2020 (January to March 2020) the average CCI score for patients seen with COVDI-19 was higher than in the Spring and Summer 2020 in all states except in Montana and Kentucky. Summer 2020 (May to July 2020) demonstrated some of the lowest average CCI scores for COVID-19 positive patients seen at an HCA Healthcare Facility.

Rate of Positive COVID-19, Patient Outcomes and Average Charleston Comorbidity Index Score by State

Graph 3: Outcomes of COVID-19 Positive Patients Seen at an HCA Healthcare Facility: Mortality and ICU admission was the highest in Missouri, however, the state had the least COVID-19 patients admitted. The rate of positive test per encounter was the highest in Florida and Texas. Texas had a higher mortality among admitted COVID-19 patients than Florida, however, Florida had a higher percentage of COVID-19 patients admitted. Graph 4: Average Charleston Comorbidity Index Score of COVID-19 Positive Patients Seen at an HCA Healthcare Facility: Average CCI was the lowest in Missouri. The states with the highest CCI score were Indiana, California, New Hampshire and Nevada.

Conclusion

We observed an inverse correlation between CCI score and COVID-19 incidence while seeing that, on average, COVID-19 positive patients had higher CCI score in the first few months of the pandemic when incidence rate was lower. CCI score did not correlate to ICU admission, but a higher CCI score correlated to higher admission rate.

Disclosures

All Authors: No reported disclosures

28. Utilizing the Charleston Comorbidity Index as an Independent Predictor for Outcomes in SARS-Cov-2 Positive Patients

Background

Since COVID-19 was declared a pandemic, it has seemed that the virus is nondiscriminatory causing 3.73 million deaths worldwide. The Charleston Comorbidity Index (CCI) is a scoring system predicting the one-year mortality for patients with a range of comorbid conditions and is widely used as a predictor of prognosis and survival for a range of pathologies. This study aims to assess if there is an impact of comorbidity burden on COVID-19 patients by utilizing their CCI score.

Charleston Comorbidity Index Score

Scoring system for Charleston Comorbidity Index (CCI). Plus 1 point for every decade age 50 years and over, maximum 4 points. Higher scores indicate a more severe condition and consequently, a worse prognosis.

Methods

Multicenter, retrospective review of patients diagnosed with COVID-19 from January 2020 to September 2020 throughout the HCA Healthcare system. CCI scores for all COVID-19 positive patients were calculated and logistic regression analysis was performed to predict hospitalization and ICU admission by CCI controlling for age, sex and race. A multinomial regression model was also performed to predict discharge status by CCI controlling for age, sex and race. ROC curves to indicate the CCI cut-off point for each outcome (hospitalization, ICU admission and mortality) was performed, and Youden’s Index was used to identify the optimal point.

Results

In the study timeframe, 92,800 patients were diagnosed with COVID-19 and of those, 48,270 were hospitalized. A one-point increase in CCI was associated with higher odds of hospitalization [OR 1.718; 95% CI 1.696-1.74]. The threshold for significance to predict hospitalization was a CCI of 1.5 (AUC 0.804, Youden Index 0.48) with a specificity (73%) and sensitivity (75%). A one-point increase in CCI was associated with 1.444 higher odds of an ICU admission (95% CI 1.134-1.155). A one-point increase in CCI significantly increased the odds of discharge to hospice compared to any discharge other than hospice [OR 1.162; 95% CI 1.142-1.182]). A one-point increase in CCI score was associated with 1.188 higher odds of in-hospital mortality (95% CI, 1.173-1.203) with a CCI threshold of 3.5 having the highest specificity (50.9%) and sensitivity (79.9%) to predict mortality outcome (AUC 0.704, Youden Index 0.31).

Conclusion

In conclusion CCI score is an adequate predictor of hospitalization and in-hospital mortality but less so in predicting ICU admission in COVID-19 positive patients.

Disclosures

All Authors: No reported disclosures