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Raj K, Yeruva K, Jyotheeswara Pillai K, Kumar P, Agrawal A, Chandna S, Khuttan A, Tripathi S, Akella R, Gudi TR, Watts A, Toquica Gahona CC, Bhagat U, Aedma SK, Jalal AT, Ganti S, Varadarajan P, Pai RG. Population Risk Factors for Severe Disease and Mortality in COVID-19 in the United States during the Pre-Vaccine Era: A Retrospective Cohort Study of National Inpatient Sample. Med Sci (Basel) 2022; 10:medsci10040067. [PMID: 36548002 PMCID: PMC9788467 DOI: 10.3390/medsci10040067] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/28/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
Background-Previous studies on coronavirus disease 2019 (COVID-19) were limited to specific geographical locations and small sample sizes. Therefore, we used the National Inpatient Sample (NIS) 2020 database to determine the risk factors for severe outcomes and mortality in COVID-19. Methods-We included adult patients with COVID-19. Univariate and multivariate logistic regression was performed to determine the predictors of severe outcomes and mortality in COVID-19. Results-1,608,980 (95% CI 1,570,803-1,647,156) hospitalizations with COVID-19 were included. Severe complications occurred in 78.3% of COVID-19 acute respiratory distress syndrome (ARDS) and 25% of COVID-19 pneumonia patients. The mortality rate for COVID-19 ARDS was 54% and for COVID-19 pneumonia was 16.6%. On multivariate analysis, age > 65 years, male sex, government insurance or no insurance, residence in low-income areas, non-white races, stroke, chronic kidney disease, heart failure, malnutrition, primary immunodeficiency, long-term steroid/immunomodulatory use, complicated diabetes mellitus, and liver disease were associated with COVID-19 related complications and mortality. Cardiac arrest, septic shock, and intubation had the highest odds of mortality. Conclusions-Socioeconomic disparities and medical comorbidities were significant determinants of mortality in the US in the pre-vaccine era. Therefore, aggressive vaccination of high-risk patients and healthcare policies to address socioeconomic disparities are necessary to reduce death rates in future pandemics.
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Affiliation(s)
- Kavin Raj
- Division of Cardiology, Department of Medicine, University of California Riverside School of Medicine, Riverside, CA 92521, USA
- Correspondence:
| | - Karthik Yeruva
- Department of Internal Medicine, Merit Health River Region Hospital, Vicksburg, MS 39183, USA
| | | | - Preetham Kumar
- Division of Cardiology, Department of Medicine, University of California Riverside School of Medicine, Riverside, CA 92521, USA
| | - Ankit Agrawal
- Department of Hospital Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Sanya Chandna
- Department of Hospital Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Akhilesh Khuttan
- Department of Cardiac Hospital Medicine, University of Iowa, Iowa City, IA 52242, USA
| | - Shalini Tripathi
- Department of Hospital Medicine, Carolina East Medical Center, New Bern, NC 28560, USA
| | - Ramya Akella
- Department of Hospital Medicine, Pikeville Medical Center, Pikeville, KY 41501, USA
| | - Thulasi Ram Gudi
- Department of Internal Medicine, Merit Health River Region Hospital, Vicksburg, MS 39183, USA
| | - Abi Watts
- Division of Cardiology, Department of Medicine, University of Texas Health Sciences Center at Houston, Houston, TX 77030, USA
| | - Christian C Toquica Gahona
- Division of Cardiology, Department of Medicine, Kansas University Medical Center, Kansas City, KS 66160, USA
| | - Umesh Bhagat
- Department of Hospital Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Surya Kiran Aedma
- Division of Cardiology, Department of Medicine, University of California Riverside School of Medicine, Riverside, CA 92521, USA
| | - Ayesha Tamkinat Jalal
- Department of Internal Medicine, Memorial Healthcare System, Hollywood, FL 33021, USA
| | - Shyam Ganti
- Department of Pulmonary Critical Care, Appalachian Regional Healthcare, Lexington, KY 40505, USA
| | - Padmini Varadarajan
- Division of Cardiology, Department of Medicine, University of California Riverside School of Medicine, Riverside, CA 92521, USA
| | - Ramdas G Pai
- Division of Cardiology, Department of Medicine, University of California Riverside School of Medicine, Riverside, CA 92521, USA
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Bangash BA, Alarmanazi F, Atlanov A, Toquica Gahona CC, Farabi B. Hemophagocytic Lymphohistiocytosis Syndrome With Hepatic Involvement and Secondary to Acute B-cell Lymphocytic Leukemia: A Case Report. Cureus 2022; 14:e28620. [PMID: 36185842 PMCID: PMC9523978 DOI: 10.7759/cureus.28620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2022] [Indexed: 11/10/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a hyperactivation syndrome associated with the overactivation of macrophages, which produce enormous amounts of tumor necrosis factor-alpha and interferon-gamma. HLH often presents with diminished T-cell and natural killer (NK) cell regulation, which can develop due to underlying genetic causes, infections, autoimmune diseases, and/or secondary to malignancies. Here, we describe the case of a 39-year-old man who presented with subjective fevers and fatigue. Further workup revealed hyperferritinemia, hypertriglyceridemia, and absent NK-cell activity, which raised a strong suspicion for HLH. The workup also revealed elevated aminotransferases signaling hepatic involvement that was attributed to HLH. Bone marrow biopsy revealed hypercellularity instead of the hemophagocytosis usually seen in HLH. Flow cytometry revealed acute B-cell lymphocytic leukemia, which was identified as the cause of HLH in our patient. This case highlights the rare presentation of HLH secondary to a B-cell malignancy. It addresses the importance of high clinical suspicion in patients with high fevers despite the use of broad-spectrum antibiotics. There is limited information on the treatment of HLH secondary to malignancies specifically, and further research in this area is needed to increase the survival rate.
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Watts A, Toquica Gahona CC, Raj K. Multifocal Pneumonia Amidst the Global COVID-19 Pandemic: A Case of Daptomycin-Induced Eosinophilic Pneumonia. Cureus 2021; 13:e16002. [PMID: 34336493 PMCID: PMC8318610 DOI: 10.7759/cureus.16002] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2021] [Indexed: 12/02/2022] Open
Abstract
Multifocal pneumonia amidst this global pandemic is often attributed to COVID-19, resulting in missed diagnosis of other potentially fatal illnesses such as eosinophilic pneumonia. Eosinophilic pneumonia is often associated with antibiotics and non-steroidal anti-inflammatory drugs. A 65-year-old male presented to the emergency department for a four-day history of fatigue, cough, and worsening dyspnea; CT thorax showed extensive multifocal pneumonia, and COVID-19 was suspected. COVID-19 testing using reverse transcription polymerase chain reaction was negative, and complete blood count revealed peripheral eosinophilia, which is not expected in COVID-19. The patient was being treated concomitantly with daptomycin and ceftaroline for septic arthritis and methicillin-resistant Staphylococcus aureus bacteremia. We reconsidered our initial diagnosis and held daptomycin, after which the patient started to improve. Due to hypoxia, steroids were added, which resulted in a dramatic improvement of the patient's symptoms. Daptomycin can have toxic effects, resulting in the accumulation of eosinophils in the lung parenchyma. Symptoms usually arise by the third week and include dyspnea, peripheral eosinophilia, and infiltrates involving the outer one-third of the lung fields. FDA drug safety guidance helped to establish this diagnosis. The treatment options include the removal of offending agents and steroids in severe cases.
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Affiliation(s)
- Abi Watts
- Internal Medicine, Saint Peter's University Hospital, New Brunswick, USA
| | | | - Kavin Raj
- Internal Medicine, Saint Peter's University Hospital, New Brunswick, USA
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Abstract
Multiple infectious causes have been implicated with the development of secondary immune thrombocytopenic purpura (ITP). Nevertheless, new pathogens, including coronavirus disease 2019 (COVID-19), are recently being described in its development. A 41-year-old Hispanic male presented to the Emergency Department with a two-day history of bleeding gums and blood-tinged sputum. A severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) test was positive on admission. Initial laboratory studies showed severe thrombocytopenia of 3x109/L (150-400x109/L) with no abnormal platelets or schistocytes seen on peripheral blood smear, with normal prothrombin time/international normalized ratio (PT/INR), partial thromboplastin time (PTT) and fibrinogen levels. Secondary causes of thrombocytopenia were ruled out. One unit of single donor platelets was transfused and the patient was treated with intravenous dexamethasone for a total of five days and intravenous immunoglobulin (IVIG) for two days. One week after discharge the patient had a recurrence of epistaxis and hematuria requiring a second course of steroids and IVIG and the decision was made to start the patient on eltrombopag 50mg daily, which maintained his platelet counts within normal limits. COVID-19-associated ITP can be severe and life-threatening and hence warrants rapid and prompt management with steroids and IVIG. In refractory cases, thrombopoietin receptor agonists should be used.
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Affiliation(s)
- Abi Watts
- Internal Medicine, Saint Peter's University Hospital, New Brunswick, USA
| | - Kavin Raj
- Internal Medicine, Saint Peter's University Hospital, New Brunswick, USA
| | - Pooja Gogia
- Internal Medicine, Saint Peter's University Hospital, New Brunswick, USA
| | | | - Marcus Porcelli
- Hematology and Oncology, Saint Peter's University Hospital, New Brunswick, USA
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Abstract
Subcutaneous emphysema is a rare complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia that should prompt immediate attention to find its cause. Herein, we describe three patients with SARS-CoV-2 pneumonia who were admitted to the ICU and developed subcutaneous emphysema and one with a concomitant pneumothorax. Three patients with diagnosis of SARS-CoV-2 pneumonia admitted to the ICU developed subcutaneous emphysema during the hospital admission. One of them who had concomitant pneumothorax required thoracostomy tube for treatment and the other two were monitored clinically without additional interventions. Two patients died during the first two to three weeks of their hospital course. One patient survived and was discharged after 63 days in the hospital. Subcutaneous emphysema is considered a non-life-threatening condition and is usually self-limited requiring supportive treatment in mild cases. For such cases, observation is appropriate. Patients with newly discovered SE life-threatening pathology, such as pneumothorax, esophageal rupture, and necrotizing infections, should be investigated depending on the clinical setting. This is one of the first paper that shows the development of subcutaneous emphysema in patients with SARS-CoV-2 pneumonia. This may represent a rare complication of the infection as well as may be attributable to other factors such as increased cough and mechanical ventilation. There is a need for studies on the clinical characteristics of a disease with still many unknown features and a wide clinical spectrum that is still being defined.
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Affiliation(s)
| | - Kavin Raj
- Internal Medicine, Saint Peter's University Hospital, New Brunswick, USA
| | - Keshav Bhandari
- Internal Medicine, Saint Peter's University Hospital, New Brunswick, USA
| | - Shashank Nuguru
- Pulmonology, Saint Peter's University Hospital, New Brunswick, USA
| | - Amar Bukhari
- Pulmonary Critical Care, Saint Peter's University Hospital, New Brunswick, USA
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