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Kasule SN, Grant LM, Apolinario MA, Speiser LJ, Saling CF, Blair JE, Vikram HR. Endemic Fungal Infective Endocarditis Caused by Coccidioides, Blastomyces and Histoplasma Species in the United States. Cureus 2024; 16:e60285. [PMID: 38746483 PMCID: PMC11093152 DOI: 10.7759/cureus.60285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2024] [Indexed: 05/16/2024] Open
Abstract
We describe a recent case of Coccidioides bioprosthetic aortic valve infective endocarditis successfully managed at our institution. This led us to perform a literature review of endemic fungal infective endocarditis in the United States caused by Coccidioides, Blastomyces, and Histoplasma. Symptoms preceded infective endocarditis diagnosis by several months. Patients with Coccidioides and Blastomyces infective endocarditis were younger with fewer comorbid conditions. Valvular involvement was relatively uncommon in Blastomyces infective endocarditis (27%). Fungemia was noted in patients with infective endocarditis due to Histoplasma (30%) and Coccidioides (18%). Mortality rates for infective endocarditis were high (Histoplasma, 46%; Coccidioides, 58%; Blastomyces, 80%); infective endocarditis was commonly diagnosed post-mortem (Coccidioides, 58%; Blastomyces, 89%). Most surviving patients with infective endocarditis (Histoplasma, 79%; Coccidioides, 80%) underwent valve surgery along with prolonged antifungal therapy. The two surviving patients with Blastomyces infective endocarditis received antifungal therapy without surgery.
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Mbonde AA, Gritsch D, Harahsheh EY, Kasule SN, Hasan S, Parsons AM, Zhang N, Butterfield R, Shiue H, Norville KA, Reynolds JL, Vikram HR, Chong B, Grill MF. Neuroinvasive West Nile Virus Infection in Immunosuppressed and Immunocompetent Adults. JAMA Netw Open 2024; 7:e244294. [PMID: 38546642 PMCID: PMC10979308 DOI: 10.1001/jamanetworkopen.2024.4294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 02/02/2024] [Indexed: 04/01/2024] Open
Abstract
Importance West Nile virus (WNV) is the leading cause of human arboviral disease in the US, peaking during summer. The incidence of WNV, including its neuroinvasive form (NWNV), is increasing, largely due to the expanding distribution of its vector, the Culex mosquito, and climatic changes causing heavy monsoon rains. However, the distinct characteristics and outcomes of NWNV in individuals who are immunosuppressed (IS) and individuals who are not IS remain underexplored. Objective To describe and compare clinical and radiographic features, treatment responses, and outcomes of NWNV infection in individuals who are IS and those who are not IS. Design, Setting, and Participants This retrospective cohort study used data from the Mayo Clinic Hospital system collected from July 2006 to December 2021. Participants were adult patients (age ≥18 years) with established diagnosis of NWNV infection. Data were analyzed from May 12, 2020, to July 20, 2023. Exposure Immunosuppresion. Main Outcomes and Measures Outcomes of interest were clinical and radiographic features and 90-day mortality among patients with and without IS. Results Of 115 participants with NWNV infection (mean [SD] age, 64 [16] years; 75 [66%] male) enrolled, 72 (63%) were not IS and 43 (37%) were IS. Neurologic manifestations were meningoencephalitis (98 patients [85%]), encephalitis (10 patients [9%]), and myeloradiculitis (7 patients [6%]). Patients without IS, compared with those with IS, more frequently reported headache (45 patients [63%] vs 18 patients [42%]) and myalgias (32 patients [44%] vs 9 patients [21%]). In contrast, patients with IS, compared with those without, had higher rates of altered mental status (33 patients [77%] vs 41 patients [57%]) and myoclonus (8 patients [19%] vs 8 patients [4%]). Magnetic resonance imaging revealed more frequent thalamic T2 fluid-attenuated inversion recovery hyperintensities in individuals with IS than those without (4 patients [11%] vs 0 patients). Individuals with IS had more severe disease requiring higher rates of intensive care unit admission (26 patients [61%] vs 24 patients [33%]) and mechanical ventilation (24 patients [56%] vs 22 patients [31%]). The 90-day all-cause mortality rate was higher in the patients with IS compared with patients without IS (12 patients [28%] vs 5 patients [7%]), and this difference in mortality persisted after adjusting for Glasgow Coma Scale score (adjusted hazard ratio, 2.22; 95% CI, 1.07-4.27; P = .03). Individuals with IS were more likely to receive intravenous immunoglobulin than individuals without IS (12 individuals [17%] vs 24 individuals [56%]), but its use was not associated with survival (hazard ratio, 1.24; 95% CI, 0.50-3.09; P = .64). Conclusions and Relevance In this cohort study of individuals with NWNV infection, individuals with IS had a higher risk of disease complications and poor outcomes than individuals without IS, highlighting the need for innovative and effective therapies to improve outcomes in this high-risk population.
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Affiliation(s)
- Amir A. Mbonde
- Department of Neurology, Mayo Clinic College of Medicine and Science, Phoenix, Arizona
| | - David Gritsch
- Department of Neurology, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Ehab Y. Harahsheh
- Department of Neurology, Mayo Clinic College of Medicine and Science, Phoenix, Arizona
| | - Sabirah N. Kasule
- Division of Infectious Diseases, Mayo Clinic College of Medicine and Science, Phoenix, Arizona
| | - Shemonti Hasan
- Department of Neurology, Mayo Clinic College of Medicine and Science, Phoenix, Arizona
| | | | - Nan Zhang
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Phoenix, Arizona
| | - Richard Butterfield
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Phoenix, Arizona
| | - Harn Shiue
- Department of Pharmacy, Mayo Clinic College of Medicine and Science, Phoenix, Arizona
| | - Kathryn A. Norville
- Department of Pharmacy, Mayo Clinic College of Medicine and Science, Phoenix, Arizona
| | - Jenna L. Reynolds
- Department of Pharmacy, Mayo Clinic College of Medicine and Science, Phoenix, Arizona
| | - Holenarasipur R. Vikram
- Division of Infectious Diseases, Mayo Clinic College of Medicine and Science, Phoenix, Arizona
| | - Brian Chong
- Department of Neuroradiology, Mayo Clinic College of Medicine and Science, Phoenix, Arizona
| | - Marie F. Grill
- Department of Neurology, Mayo Clinic College of Medicine and Science, Phoenix, Arizona
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Chandok T, Kasule SN, Kelly PJ, Gonzalez E, Chilimuri SS, Zeana CB. A Rare Case of Septic Ovarian Thrombophlebitis Caused by Tissierella praeacuta. Cureus 2023; 15:e42385. [PMID: 37621834 PMCID: PMC10446103 DOI: 10.7759/cureus.42385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2023] [Indexed: 08/26/2023] Open
Abstract
We report a case of Tissierella praeacuta bacteremia and septic thrombophlebitis of the ovarian vein as a rare puerperal complication in a young patient. She was successfully managed with subcutaneous low molecular weight heparin (LMWH) and intravenous (IV) antibiotics before transitioning to a prolonged course of oral antibiotics at discharge.
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Affiliation(s)
| | | | - Paul J Kelly
- Infectious Disease, BronxCare Health System, Bronx, USA
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4
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Kasule SN, Gupta S, Patron RL, Grill MF, Vikram HR. Neuroinvasive West Nile virus infection in solid organ transplant recipients. Transpl Infect Dis 2023; 25:e14004. [PMID: 36573623 DOI: 10.1111/tid.14004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 12/06/2022] [Accepted: 12/11/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Literature on the natural course of neuroinvasive West Nile virus (WNV) infection in solid organ transplant (SOT) recipients is sparse. In the setting of a 2021 WNV outbreak in Arizona, we reviewed our institution's experience with neuroinvasive WNV infection in patients with SOT. METHODS We retrospectively identified SOT recipients treated for neuroinvasive WNV at Mayo Clinic in Arizona from 2007 through 2021. Clinical manifestations, disease course, and outcomes were analyzed. RESULTS Among 24 SOT recipients with WNV infection identified during the study period, 13 infections occurred in 2021. Most patients had gastrointestinal tract symptoms and fever at disease presentation. Five patients had cognitive impairment, and 14 initially or eventually had acute flaccid paralysis. Clinically significant deterioration occurred at a median of 4 (range, 1-11) days after hospital admission. Seventeen patients (71%) were transferred to the intensive care unit, with 15 requiring mechanical ventilation. Initial cerebrospinal fluid analysis mainly demonstrated a neutrophil-predominant pleocytosis. Almost all patients (n = 23) were treated with intravenous immunoglobulin alone or in combination with interferon alfa-2b. Sixteen patients had clinical improvement, 4 of whom recovered completely. Six patients died during hospitalization due to complications of neuroinvasive WNV infection. Two patients were discharged to hospice without clinical recovery. The overall 30-day mortality rate was 36%. CONCLUSION Despite advances in supportive care, neuroinvasive WNV infection is associated with substantial morbidity and mortality in SOT recipients. Flaccid paralysis is an indicator of poor prognosis.
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Affiliation(s)
- Sabirah N Kasule
- Division of Infectious Diseases, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Simran Gupta
- Department of Internal Medicine, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Roberto L Patron
- Division of Infectious Diseases, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Marie F Grill
- Department of Neurology, Mayo Clinic Hospital, Phoenix, Arizona, USA
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Chan L, Gupta S, Sacco AJ, Kasule SN, Chaffin H, Feller FF, Mi L, Lim ES, Seville MT. Infections and antimicrobial prescribing in patients hospitalized with coronavirus disease 2019 (COVID-19) during the first pandemic wave. Antimicrob Steward Healthc Epidemiol 2023; 3:e75. [PMID: 37113207 PMCID: PMC10127243 DOI: 10.1017/ash.2023.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/10/2023] [Accepted: 02/14/2023] [Indexed: 04/29/2023]
Abstract
Objective To evaluate the rate of coinfections and secondary infections seen in hospitalized patients with COVID-19 and antimicrobial prescribing patterns. Methods This single-center, retrospective study included all patients aged ≥18 years admitted with COVID-19 for at least 24 hours to a 280-bed, academic, tertiary-care hospital between March 1, 2020, and August 31, 2020. Coinfections, secondary infections, and antimicrobials prescribed for these patients were collected. Results In total, 331 patients with a confirmed diagnosis of COVID-19 were evaluated. No additional cases were identified in 281 (84.9%) patients, whereas 50 (15.1%) had at least 1 infection. In total, of 50 patients (15.1%) who were diagnosed with coinfection or secondary infection had bacteremia, pneumonia, and/or urinary tract infections. Patients who had positive cultures, who were admitted to the ICU, who required supplemental oxygen, or who were transferred from another hospital for higher level of care were more likely to have infections. The most commonly used antimicrobials were azithromycin (75.2%) and ceftriaxone (64.9%). Antimicrobials were prescribed appropriately for 55% of patients. Conclusions Coinfection and secondary infections are common in patients who are critically ill with COVID-19 at hospital admission. Clinicians should consider starting antimicrobial therapy in critically ill patients while limiting antimicrobial use in patients who are not critically ill.
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Affiliation(s)
- Lynn Chan
- Department of Pharmacy, Ronald Reagan UCLA Medical Center, Los Angeles, California
- Author for correspondence: Lynn Chan, Department of Pharmacy, Ronald Reagan UCLA Medical Center, 757 Westwood Plaza, Ste B140. Los Angeles, CA90095. E-mail:
| | - Simran Gupta
- Department of Internal Medicine, Mayo Clinic Hospital, Phoenix, Arizona
| | - Alicia J. Sacco
- Department of Pharmacy, Mayo Clinic Hospital, Phoenix, Arizona
| | - Sabirah N. Kasule
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Hally Chaffin
- Department of Internal Medicine, Mayo Clinic Hospital, Phoenix, Arizona
| | - Fionna F. Feller
- Division of Infectious Diseases, Yale New Haven Hospital, New Haven, Connecticut
| | - Lanyu Mi
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Elisabeth S. Lim
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic Arizona, Scottsdale, Arizona
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Thet AK, Kelly PJ, Kasule SN, Shah AK, Chawala A, Latif A, Chilimuri SS, Zeana CB. The use of vaccinia immune globulin in the treatment of severe mpox virus infection in HIV/AIDS. Clin Infect Dis 2022; 76:1671-1673. [PMID: 36571287 DOI: 10.1093/cid/ciac971] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/08/2022] [Accepted: 12/22/2022] [Indexed: 12/27/2022] Open
Abstract
We report a case of progressive, severe mpox virus (MPXV) infection in a patient with acquired immune deficiency syndrome (AIDS) despite a standard course of tecovirimat. He significantly improved after administration of intravenous vaccinia immune globulin (VIGIV) highlighting its use as an adjunct for severe disease in immunocompromised hosts.
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Affiliation(s)
- Andrea K Thet
- Division of Infectious Diseases, Department of Internal Medicine, BronxCare Health System, Bronx, NY, USA
| | - Paul J Kelly
- Division of Infectious Diseases, Department of Internal Medicine, BronxCare Health System, Bronx, NY, USA
| | - Sabirah N Kasule
- Division of Infectious Diseases, Department of Internal Medicine, BronxCare Health System, Bronx, NY, USA
| | - Anish K Shah
- Internal Medicine Residency, Department of Internal Medicine, BronxCare Health System affiliated with Icahn School of Medicine at Mt Sinai, Bronx, NY, USA
| | - Arpan Chawala
- Internal Medicine Residency, Department of Internal Medicine, BronxCare Health System affiliated with Icahn School of Medicine at Mt Sinai, Bronx, NY, USA
| | - Amber Latif
- American University of the Caribbean School of Medicine, Cupecoy, St Marteen, USA
| | | | - Cosmina B Zeana
- Division of Infectious Diseases, Department of Internal Medicine, BronxCare Health System, Bronx, NY, USA
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Mbonde A, David G, Harahsheh E, Kasule SN, Vikram HR, Hasan S, Butterfield R, Grill M. 1029. Clinical Characteristics and Outcomes of Neuroinvasive West Nile Virus Infection in Immunocompromised and Immunocompetent Individuals. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
Despite the increasing incidence of neuroinvasive West Nile virus (NiWNV) infection in the US, the spectrum of disease characteristics and neuroimaging findings in immunosuppressed (IS) individuals are not adequately described. We aimed to compare the clinical characteristics and outcomes of NiWNV infection in IS and immunocompetent (IC) patients.
Methods
We extracted relevant data from all NiWNV patients hospitalized 7/2003-10/2021 at Mayo Clinic hospitals. Cohort was inclusive of patients from the recent historic WNV outbreak in Arizona in 2021. Chi-Square or Kruskal-Wallis and logistic regression were used to compare relevant variables and determine predictors of mortality respectively.
Results
We included 115 patients (72 IC and 43 IS), mean age 63.5 years; neurologic syndromes included meningoencephalitis (85.2%), encephalomyelitis (8.7%) and myeloradiculitis (6.1%). Presenting symptoms were malaise (72%), fever (66%), altered mentation (64%), gastrointestinal (47%) and myalgia (35.7%). MRI brain was abnormal in 62.8% (49/78), demonstrating T2/FLAIR hyperintensities in 47.4% (brainstem, thalamus, temporal lobes), leptomeningeal enhancement (16.7%) and diffusion restriction (20.5%). Altered mental status (76.7% vs 56.9%), myalgia (44.4% vs. 20.9%), myoclonus (18.6% vs. 4.2%) and thalamic MRI T2 FLAIR abnormalities (11.4% vs 0%) were more common in IS patients. Higher CSF WBC counts were observed in IC vs IS patients (P< 0.05). Immunosuppressed patients were more likely to be treated with intravenous immunoglobulin (44.2% vs 8.3% p=< 0.001) and/or interferon therapy (32.6% vs 6.9%, p=0.0003) and had increased odds of 90-day mortality on multivariable analysis (Adjusted Odds Ratio, AOR 2.22; 95% CI 1.065-4.627, p=0.0334). In the IS subgroup, ICU admission, mechanical ventilation, and Glasgow coma scale of < 8 were associated with reduced overall survival/increased 90-day mortality (p< 0.005).
Conclusion
Individuals presenting in summer/fall months with the aforementioned symptoms and/or MRI abnormalities should be evaluated for NiWNV infection. Compared to the immunocompetent, immunosuppressed patients with NiWNV are at a significantly greater mortality risk. Novel and effective antiviral therapies aimed at improving outcomes are warranted.
Disclosures
All Authors: No reported disclosures.
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Affiliation(s)
| | | | | | - Sabirah N Kasule
- Bronx Healthcare Network , Bronx, NY, Long Island City, New York
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Kasule SN, Gupta S, Klyver J, Chan L, Seville T. 1804. Quality Improvement Project to improve empiric antibiotic therapy for skin and soft tissue infections using the nasal MRSA PCR. Open Forum Infect Dis 2022. [PMCID: PMC9752679 DOI: 10.1093/ofid/ofac492.1434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Large cohort studies from the Veteran’s Administration support the negative predictive value of the methicillin resistant Staphylococcus aureus (MRSA) nasal polymerase chain reaction (PCR) swabs for skin and soft tissue infection (SSTI). We investigated the use of the nasal MRSA PCR swab to reduce the inappropriate empiric use of vancomycin and piperacillin-tazobactam for SSTI at our institution. Methods Between July and August 2021, we educated Hospital Internal Medicine (HIM) and Internal Medicine Residents (IMR) on the basics of SSTI management and the utility of a negative nasal MRSA PCR swab. Data on empiric use of vancomycin and piperacillin-tazobactam for SSTIs were collected 3/1/2021 to 7/1/2021 (pre-intervention) and 8/30/2021 to 12/29/2021 (post-intervention). We excluded patients who didn’t have an SSTI, weren’t managed by IMR or HIM, and whose empiric antibiotics were for another indication. To account for antibiotics started in the emergency department (ED), a patient was regarded as having received appropriate empiric antibiotics if they were de-escalated in the first 24 hours of being admitted to IMR or HIM.
![]() Example of education material. These fliers were distributed to resident rooms following a series of noon conferences Results Pre-intervention there were 106 patient encounters. In 56 of these (52.8%), patients were placed on inappropriate empiric antibiotics. Post-intervention, there were 72 patient encounters. In 23of these (31.9%), patients were placed on inappropriate empiric antibiotic for an absolute risk reduction (ARR) of 20.9% with a statistically significant 95% CI (6.522 - 35.249) and a number needed to treat (NNT) of 4.78. Nasal MRSA PCR testing increased from 40.6% to 56.9%. The ARR among the HIM teams was 21.3% and was statistically significant with a 95% CI (4.24 - 38.394). Their proportion of MRSA testing increased from 41.5% to 50%. The IMR teams had an ARR of 14.8%, which was not statistically significant (95% CI, -11.339 to 40.884). Their MRSA nasal PCR testing increased from 37.5% to 72%.
![]() ![]() Conclusion Education on SSTI treatment coupled with use of the MRSA nares PCR appeared to improve empiric antibiotic choices. Residents stated that the nasal MRSA PCR facilitated empiric antibiotic choice. Positive ARR was seen in whole and sub-group analyses of physician teams. We theorize that the lack of statistical significance in the IMR group was related to a small sample size. Disclosures All Authors: No reported disclosures.
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Affiliation(s)
| | - Simran Gupta
- Mayo Clinic Hospital in Phoenix, AZ, Phoenix, Arizona
| | - John Klyver
- Mayo Clinic Hospital in Phoenix, AZ, Phoenix, Arizona
| | - Lynn Chan
- Ronald Reagan UCLA Medical Center, Los Angeles, California
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Murphy CB, Kasule SN, Vikram HR. 1935. Cardiac Tamponade Following COVID-19 Vaccination. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.1562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
While numerous, most described cases of myocarditis and pericarditis following COVID-19 vaccination are mild and self-limited. We present two cases of life-threatening cardiac tamponade following COVID-19 vaccination.
Methods
Two cases of cardiac tamponade in temporal association with COVID-19 vaccination were reviewed
Results
Case 1 : 75-year-old male with rheumatoid arthritis admitted with chest pressure and hypotension 2 days after his 1st dose of Pfizer-BioNTech COVID-19 vaccine. Pericardiocentesis removed 275 ml of exudative effusion with 14,140 nucleated cells/ml. Fluid bacterial and fungal cultures were negative; cytology was inconsistent with malignancy. He had no Epstein-Barr virus (EBV) or cytomegalovirus (CMV) viremia. Symptoms resolved on prednisone and colchicine. A week later, he had an uneventful second COVID-19 vaccine. He went on to have 3 recurrences of pericarditis starting two months after his first. One was within 48 hours of his COVID-19 booster. He is on long term prednisone. Case 2: 66-year-old male with non-Hodgkin’s lymphoma in remission. He developed chest pain a day after his 2nd dose of Pfizer-BioNTech COVID-19 vaccine. Admitted 4 days later with pericardial effusion and managed medically. Readmitted a week later with fever and chest pain. Echocardiogram now showed cardiac tamponade. Pericardiocentesis removed 400 ml of exudative fluid with 1,191 nucleated cells/mL. Cultures for bacteria, fungi, and mycobacteria were negative. Cytology didn't show malignancy. Serologies for CMV, EBV and parvovirus represented past infection. He was discharged with a pericardial drain, colchicine, and NSAIDs. He was later readmitted with fevers. Echocardiogram only showed small pericardial effusion, which did not require drainage. Figure 1Circumferential pericardial effusion seen on trans-thoracic echocardiography from patient in case 1.
Conclusion
Given the proximity to COVID-19 vaccination and lack of alternative explanations, we believe that tamponade was a direct result of post-vaccine inflammatory pericarditis. Neither patient had a prior history of pericardial effusion. Both tested negative for SARS-CoV-2 by nasopharyngeal swab excluding active infection. Healthcare providers should consider the possibility of pericardial effusion and tamponade in patients with chest pain, shortness of breath, or hypotension following COVID-19 vaccination.
Disclosures
All Authors: No reported disclosures.
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Affiliation(s)
| | - Sabirah N Kasule
- Bronx Healthcare Network, Bronx , NY, Long Island City, New York
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Grant LM, Kasule SN, Singer ML, Speiser LJ, Vikram HR. Superimposed Neuroinvasive Coccidioidomycosis and West Nile Virus Infection. Cureus 2022; 14:e29783. [DOI: 10.7759/cureus.29783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2022] [Indexed: 11/05/2022] Open
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Gupta S, Kasule SN, Seville MT. Cerebral abscess with Streptococcus intermedius as a complication of pelvic inflammatory disease in the setting of intrauterine device use. IDCases 2022; 27:e01454. [PMID: 35242560 PMCID: PMC8861415 DOI: 10.1016/j.idcr.2022.e01454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 02/15/2022] [Accepted: 02/16/2022] [Indexed: 10/25/2022] Open
Abstract
A 43-year-old healthy female with no significant medical problems except for recently diagnosed pelvic inflammatory disease presented to our hospital with acute onset, severe head and neck pain. Brain imaging revealed a rim-enhancing lesion consistent with an abscess. The patient underwent successful surgical removal of the abscess and its capsule. Intraoperative cultures grew Streptococcus intermedius and she was discharged with a plan for four weeks of intravenous ceftriaxone.
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Affiliation(s)
- Simran Gupta
- Department of Internal Medicine, Mayo Clinic, Phoenix, AZ, USA
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12
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Saling C, Kasule SN, Vikram HR. 1233. Serious Toxicities During Antimicrobial Therapy for Disseminated Nocardia Infection in Solid Organ Transplant Recipients. Open Forum Infect Dis 2021. [PMCID: PMC8644005 DOI: 10.1093/ofid/ofab466.1425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Management of disseminated Nocardia (NC) infection in transplant recipients requires prolonged antimicrobial therapy. Treatment can be particularly challenging if NC is resistant to standard agents. Drug toxicities can further limit options. We present a series of transplant patients with multi-drug resistant, disseminated NC infection complicated by serious adverse reactions to sequential antimicrobials.
Methods
This is a prospective review monitoring response to treatment of disseminated NC as well as adverse events to therapies.
Results
The first case is a 66-year old heart transplant patient who presented with fever and cough. Investigations revealed N. otitidiscaviarum lung lesion and multiple brain abscesses. Trimethoprim-sulfamethoxazole (TMP-SMX) and linezolid were started empirically. NC was fully susceptible to linezolid only, and intermediate to quinolones and tobramycin. Linezolid was switched to ciprofloxacin due to ongoing cytopenia, and dose of TMP-SMX was reduced due to renal insufficiency. Repeat brain MRI showed enlarging abscesses; regimen was changed to linezolid and moxifloxacin. Severe peripheral neuropathy led to linezolid discontinuation and initiation of high-dose doxycycline plus moxifloxacin. One year into therapy, he presented with a large aortic dissection. His long-term quinolone therapy was felt to be contributory. He underwent aortic stent placement and remains on doxycycline monotherapy. The second case is a 74-year old female renal transplant patient who presented with fevers. A perinephric abscess was found which grew N. farcinica resistant to floroquinolones and clarithromycin, and intermediate to doxycycline. Further imaging also revealed pulmonary and brain involvement. TMP-SMX was started but soon switched to linezolid due to acute kidney injury. One month later she presented with severe thrombocytopenia and subdural hematoma thought to be secondary to linezolid. She died despite surgery.
Conclusion
This series illustrates challenges encountered in the treatment of disseminated NC infection in transplant recipients. Multidrug resistant NC coupled with serious toxicities of therapies often severely limits treatment options. Counseling patients and closely monitoring for adverse events is essential.
Disclosures
All Authors: No reported disclosures
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Kasule SN, Apolinario M, Saling C, Blair JE, Speiser L, Vikram HR. 692. Coccidioides sp. Infective Endocarditis: A Review of the Literature. Open Forum Infect Dis 2021. [PMCID: PMC8644323 DOI: 10.1093/ofid/ofab466.889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Despite the endemic nature of Coccidioides sp. to the American Southwest, the incidence Coccidioides sp. infective endocarditis (CIE) is rare. Following successful treatment of a patient with CIE at our institution, we reviewed the literature to identify trends in disease presentation, patient characteristics, and outcomes. Methods We reviewed all cases of CIE reported since 1938. Details including patient demographics, underlying immunodeficiency, time to diagnosis, treatment, and outcome were collected for analysis of diagnostic challenges and survival. Results Including ours, we identified 11 published cases of CIE. The majority (7) occurred in men. 5 patients were of either African American or Hispanic descent. Of the 10 patients with reported ages, the median age was 35.5 years (range 3 weeks – 61 years). 5 patients had a previous diagnosis of coccidioidomycosis and only 3 had an immunocompromising condition. These comprised pregnancy, heart transplant, and juvenile inflammatory arthritis. Three cases had multi-valvular involvement, but the majority affected the mitral (5) and the aortic (4) valves. Only 2 of the 11 cases involved a prosthetic valve. Of the 8 cases with reported blood cultures, only 2 were positive. Ten of the 11 cases had extra-cardiac disease. Complement fixation (CF) titers were heterogenous with a median of 1:32 and a range of 1:1 to 1:2048. There was no obvious correlation between a patient’s CF titer and their survival. Average time to diagnosis was 3.5 months (range 2.5 – 36 months). Diagnosis was made post-mortem in 4 of the 11 cases. 6 patients (54%) did not survive. Notably, 2 of the fatal cases preceded the discovery of amphotericin B (1969) and 4 occurred prior to the discovery of fluconazole (1990). Of the five patients that survived, four required surgical intervention in addition to azole therapy. Conclusion CIE is a diagnostic and therapeutic challenge. The diagnosis itself is rare, culture incubation times are long, and the symptoms are often non-specific thus delaying definitive therapy. The introduction of azole therapy appears to have had significant impact on rates of survival. Despite this, successful management of CIE still requires concurrent surgical intervention with aggressive, indefinite anti-fungal therapy. Disclosures All Authors: No reported disclosures
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Saling C, Kasule SN, Vikram HR. 336. COVID-19 and Pneumocystis jiroveci Pneumonia. Open Forum Infect Dis 2021. [PMCID: PMC8643773 DOI: 10.1093/ofid/ofab466.537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background More accounts of opportunistic infection in COVID-19 patients are emerging. At our institution, we identified 2 COVID-19 patients with Pneumocystis jiroveci pneumonia (PJP) opportunistic infection. This prompted a review of the literature to identify trends in patient characteristics, risk factors, and outcomes in this population. Methods A literature review was conducted using PubMed that identified 13 other patients with both COVID-19 and PJP infection. Age, gender, human immunodeficiency virus (HIV) status, other immunocompromised states, time between COVID-19 and PJP diagnosis, and clinical outcomes were captured for analysis. Results Eleven patients were male. The average age was 56 years. All but 2 patients were immunocompromised. At time of PJP diagnosis, seven patients had newly diagnosed HIV and one had known, well-controlled HIV. One patient had rheumatoid arthritis receiving leflunomide, 1 had ulcerative colitis receiving budesonide and sulfasalazine, 2 patients had multiple myeloma whereby both were on lenalidomide, 1 patient was a renal transplant recipient immunosuppressed on tacrolimus, mycophenolate, and methylprednisolone, and 1 patient had chronic lymphocytic leukemia getting fludarabine, cyclophosphamide, and rituximab. Nine patients had positive COVID-19 and PJP tests performed within 7 days of one another. One patient tested positive for PJP 54 days into admission for COVID-19. This patient received high dose steroids and tocilizumab for initial COVID-19 infection. Three patients were re-hospitalized with PJP after a recent admission for COVID-19 pneumonia, with a mean time to readmission of 25 days. One of these 3 patients had no treatment for COVID-19, while 2 received steroids. Five of the total 15 patients (33%) died. Conclusion COVID-19 treatments with high dose steroids and tocilizumab can make patients vulnerable for opportunistic infection with PJP. Furthermore, COVID-19 is known to cause lymphopenia which may further increase this risk. A diagnosis of concomitant PJP can be especially challenging due to nearly identical radiographical findings. Serum beta-D glucan and HIV testing can be especially helpful in this situation, and there should be a low threshold for performing bronchoalveolar lavage. Disclosures All Authors: No reported disclosures
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Abstract
Coccidioidomycosis is an infection caused by the geographically restricted dimorphic fungus, Coccidioides. Coccidioidomycosis occurs endemically in the southwestern and western United States, mainly in focused regions of Arizona and California where the incidence is highest, and in Central and South America. Patients with impaired immunity, especially those with impaired cellular immunity, are at higher risk of severe and disseminated disease. In this review, we describe the fungal ecology and mycology, epidemiology, pathophysiology, and normal immune defenses to Coccidioides as well as address current concepts in diagnosis, treatment, and continued care of patients with pulmonary coccidioidomycosis. We also present and answer our most frequently asked questions regarding patients with primary pulmonary coccidioidomycosis.
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Affiliation(s)
- Kathryn E Kimes
- Division of Infectious Diseases, Mayo Clinic Hospital, Phoenix, Arizona
| | - Sabirah N Kasule
- Department of Internal Medicine, Mayo Clinic, Scottsdale, Arizona
| | - Janis E Blair
- Division of Infectious Diseases, Mayo Clinic Hospital, Phoenix, Arizona
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Tseng AS, Kasule SN, Rice F, Mi L, Chan L, Seville MT, Grys TE. Is It Actionable? An Evaluation of the Rapid PCR-Based Blood Culture Identification Panel on the Management of Gram-Positive and Gram-Negative Blood Stream Infections. Open Forum Infect Dis 2018; 5:ofy308. [PMID: 30555850 PMCID: PMC6288766 DOI: 10.1093/ofid/ofy308] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 12/03/2018] [Indexed: 01/02/2023] Open
Abstract
Background There is growing interest in the use of rapid blood culture identification (BCID) in antimicrobial stewardship programs (ASPs). Although many studies have looked at its clinical and economic utility, its comparative utility in gram-positive and gram-negative blood stream infections (BSIs) has not been as well characterized. Methods The study was a quasi-experimental retrospective study at the Mayo Clinic in Phoenix, Arizona. All adult patients with positive blood cultures before BCID implementation (June 2015 to December 2015) and after BCID implementation (June 2016 to December 2016) were included. The outcomes of interest included time to first appropriate antibiotic escalation, time to first appropriate antibiotic de-escalation, time to organism identification, length of stay, infectious diseases consultation, discharge disposition, and in-hospital mortality. Results In total, 203 patients were included in this study. There was a significant difference in the time to organism identification between the pre- and post-BCID cohorts (27.1 hours vs 3.3 hours, P < .0001). BCID did not significantly reduce the time to first appropriate antimicrobial escalation or de-escalation for either gram-positive BSIs (GP-BSIs) or gram-negative BSIs (GN-BSIs). Providers were more likely to escalate antimicrobial therapy in GP-BSIs after gram stain and more likely to de-escalate therapy in GN-BSIs after susceptibilities. Although there were no significant differences in changes in antimicrobial therapy for organism identification by BCID vs traditional methods, more than one-quarter of providers (28.1%) made changes after organism identification. There were no differences in hospital length of stay or in-hospital mortality comparing pre- vs post-BCID. Conclusions Although BCID significantly reduced the time to identification for both GP-BSIs and GN-BSIs, BCID did not reduce the time to first appropriate antimicrobial escalation and de-escalation.
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Affiliation(s)
- Andrew S Tseng
- Department of Internal Medicine, Mayo Clinic, Scottsdale, Arizona
| | - Sabirah N Kasule
- Department of Internal Medicine, Mayo Clinic, Scottsdale, Arizona
| | - Felicia Rice
- Division of Laboratory Medicine, Mayo Clinic, Phoenix, Arizona
| | - Lanyu Mi
- Division of Health Sciences Research, Department of Biomedical Statistics and Informatics, Mayo Clinic, Scottsdale, Arizona
| | - Lynn Chan
- Division of Infectious Diseases, Mayo Clinic, Phoenix, Arizona
| | - Maria T Seville
- Division of Infectious Diseases, Mayo Clinic, Phoenix, Arizona
| | - Thomas E Grys
- Division of Laboratory Medicine, Mayo Clinic, Phoenix, Arizona
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Abstract
Objectives: To study the knowledge, attitudes, and practices with regard to human immunodeficiency virus infection / acquired immune deficiency syndrome (HIV/AIDS) in illegal residents, in the Kingdom of Saudi Arabia (KSA). Materials and Methods: A questionnaire study was conducted among the illegal residents from four regions in Saudi Arabia: Jeddah, Makkah, Riyadh, and Jazan. Results: The survey enrolled 5,000 participants, 79%male (39.6% from Jeddah; 20% from Riyadh; and 20% from Jazan), aged between 15 and 45 years. Of the total, 1288 (25.8%) had not heard about HIV/AIDS. Knowledge of HIV transmission was poor in 90% of the respondents. Of the total, 737 had read about HIV/AIDS materials and 649 participants had been previously tested for HIV. The majority of participants (85%) held a negative attitude toward people living with HIV/AIDS. Those who were knowledgeable about HIV/AIDS expressed more a positive attitude. One-fifth (968, majority were men; single 55%, married 45%) had engaged in non-marital sexual activity. The largest proportion of the individuals who had engaged in non-marital sex were single (54.9%) followed by the married ones (40.4%). Men cited pleasure as the main reason for such activity (84.6%), whereas women (73.4%) cited financial gain. Of the respondents, 53.9 and 32.1% believed that TV and schools were the best media through which information with regard to HIV/AIDS could be imparted. Conclusions: Knowledge of HIV/AIDS, its mode of transmission, and prevention measures was poor. Educational programs specifically targeted toward this group were required.
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Affiliation(s)
- Ziad A Memish
- Ministry of Health, Riyadh, Saudi Arabia ; College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | | | | | - Jaffar A Al-Tawfiq
- Speciality Mediicne, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia ; Indiana University School of Medicine, Indianapolis, Indiana, USA
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