Epidemiology and Factors Associated with Treatment Success of Invasive Fungal Infections Among Newly Hematologic Malignancy Patients Receiving Chemotherapy or Hematopoietic Stem Cell Transplant in Thailand

Purpose

Invasive fungal infection (IFI) causes disability/death in patients with hematologic malignancy (HM) receiving chemotherapy or hematopoietic stem cell transplant (HSCT). There is limited epidemiological data, treatment outcomes, and factors associated with IFI treatment success in Thailand. This study aimed to identify factors associated with IFI treatment success among new HM patients receiving chemotherapy or HSCT, determine IFI incidence among HM patients receiving chemotherapy or HSCT, and the IFI incidence of a breakthrough in patients receiving primary antifungal prophylaxis, and identify antifungal drugs susceptibility.

Patients and Methods

This study reviewed the charts of patients aged ≥ 15 years with newly HM who received chemotherapy or HSCT between January 2016 and June 2021 at King Chulalongkorn Memorial Hospital, Bangkok, Thailand. The 2020 EORTC/MSG criteria were used to diagnose IFI. IFI treatment success factors were evaluated using logistic regression.

Results

Ninety-two patients with 107 episodes of IFI met the inclusion criteria. IFI incidence on proven and probable cases among newly HM patients receiving chemotherapy or HSCT was 7%. Most infections (38.3%) occurred during the induction-phase chemotherapy. Aspergillosis (35.5%) was the commonest IFI, followed by candidiasis (11.2%), Pneumocystis jirovecii pneumonia (8.4%), mucormycosis (3.7%), and others, respectively. The 12-week IFI treatment success rate was 67.3%. It was associated with age < 60 years, absence of coinfection, and the receipt of appropriate empirical therapy on the first day of IFI diagnosis. The incidence of breakthrough IFI from proven and probable cases in patients receiving primary antifungal prophylaxis was 6.1%. Most fungal pathogen isolates were still highly susceptible to antifungal drugs.

Conclusion

The IFI treatment success in patients with HM or HSCT in our study was high. Close monitoring of coinfected patients aged ≥ 60 is recommended. Appropriate antifungal drugs are essential for clinical outcomes.

1453. Clinical Manifestation and Risk Factors Associated with Mortality of Cytomegalovirus Infection in Immunocompetent Patients in King Chulalongkorn Memorial Hospital, Bangkok, Thailand: a 3-year experience

Background

Cytomegalovirus (CMV) infection usually occurs in organ transplant or HIV-infected patients. Recently, we found CMV infection was increased in non-transplant and non-HIV infected patients. Our study aimed to determine the epidemiology, clinical manifestation, clinical outcome, and risk factors associated mortality of CMV infection in this population.

Methods

The retrospective study was conducted in King Chulalongkorn Memorial Hospital. Patients aged above 18 years with diagnosis of CMV infection from January 2017 to September 2019 were collected and identified by ICD-10 code. Patients with HIV infection, solid organ transplant and hematopoietic stem cell transplant were excluded.

Results

A total of 51 patients, including 28 males (54.9%) were identified. The median age was 61 years (range 48-73 years). 46 patients (90.2%) had underlying disease which were 19 cases (37.3%) of autoimmune disease, 13 cases (25.5%) of hematologic disease (mostly hematologic malignancy), 4 cases (7.8%) of chronic kidney disease, and 10 cases (21.6%) of others. CMV viremia was found in 31.4%. Regarding CMV end-organ disease, there were 20 cases of gastrointestinal tract CMV infection, 10 cases were CMV retinitis, 5 cases were CMV pneumonitis and 1 case was CMV hepatitis and CMV transverse myelitis. The all-cause mortality was 25.5% and significantly in age over 70-year-old (p=0.037). The end-organ disease and CMV viral load were not different in survived and death group (p=0.445 and p=0.838, respectively).

Factors associated with mortality of CMV infection

Conclusion

CMV infection was an emerging problem in non-transplant and non-HIV infected adult patients, especially in age over 70-year-old in our Institute. The study showed infections predominated in rheumatologic and hematologic malignant patients who were received chemotherapy or immunosuppressive agent. Viremia and gastrointestinal tract were organs that mainly involved. CMV infection will become an important complication in the era of treatment with immuno-chemotherapy. Clinician should be aware of this potentially life-threatening infection.

Disclosures

All Authors: No reported disclosures.

The first report of kidney transplantation in a human immunodeficiency virus-positive recipient in Thailand and literature review: Encouragement for developing countries in Southeast Asia

Patients with human immunodeficiency virus infection are at risk of chronic kidney disease and end-stage renal disease. Human immunodeficiency virus infection impedes patients' accessibility to transplantation in Thailand and other developing countries in Southeast Asia, where the burdens of human immunodeficiency virus infection and chronic kidney disease are rapidly increasing. We report the successful kidney transplantation in a human immunodeficiency virus-positive recipient in Thailand and provide brief information about the current knowledge of human immunodeficiency virus medicine and transplantation that are needed for conducting kidney transplantations in such patients. Patient selection and evaluation, the choice of antiretroviral therapy, immunosuppressive regimens, and infectious complications are reviewed and discussed. The aim is to encourage kidney transplantation in end-stage renal disease patients with well-controlled human immunodeficiency virus infection, especially in countries where the prevalence of human immunodeficiency virus infection is high and the accessibility to transplantation is still limited.

Risk factors and clinical outcomes of tuberculosis among kidney transplant recipients in high endemic country

BACKGROUND

Tuberculosis (TB) is considered as a challenge issue in solid organ transplant recipients because of high morbidity and mortality. Active TB after transplant mostly occurs from reactivation of latent infection. Understanding risk factors and clinical information of TB may provide an appropriate prevention and treatment strategies in this specific patient population, however data from high endemic area is scarce.

METHODS

A matched single-center, case-control study was conducted in our institute. Cases were defined as newly diagnosed confirmed or clinical active TB in patients who underwent kidney transplant (KT) between April 1992 and October 2018. For each case, 5 controls were matched by age and sex. Risk factor associated with TB was determined using univariate and multivariate conditional logistic regression.

RESULTS

Between study period, KT was performed in 787 patients. Twenty-seven patients (3.43%) were diagnosed with active TB including 20 confirmed and 7 clinical diagnosed cases. The global incidence of TB in our population was 315 cases per 100 000 patients per year. Among 27 cases, pulmonary involvement was the most common (48.1%) followed by disseminated (18.5%), extrapulmonary (14.8%), pleura (11.1%) and pleuropulmonary (7.4%) TB. Allograft rejection was significantly associated with active TB (P < .001). The median onset duration of infection was 17 months (IQR, 4-59 months) after KT. Twenty-four (88.9%) patients received rifampicin containing regimen for treatment with median duration of 10 months (IQR, 6-12 months). All patients were cured after complete treatment, however those with TB remained having unfavorable outcomes including higher all-cause mortality and graft loss.

CONCLUSIONS

Incidence rate of TB in KT recipients is higher than normal population. Allograft rejection was identified as a significant risk factor. Increase unfavorable outcomes including graft loss and mortality were also observed among patients with TB.

A randomized controlled trial of comparative effectiveness between the 2 dose and 3 dose regimens of hepatitis a vaccine in kidney transplant recipients

Hepatitis A virus (HAV) is able to cause a spectrum of illnesses ranging from no symptom to fulminant hepatitis which may lead to acute kidney injury. Although hepatitis A vaccine is recommended in non-immune solid organ transplant recipients who live in or travel to endemic areas, the standard 2-dose vaccination regimen demonstrated less favorable immunogenicity among these population. The 3-dose regimen showed higher response rate and immune durability in patients with human immunodeficiency virus. However, this strategy has never been studied in solid organ transplant recipients. A single-center, open-labeled, computer-based randomized controlled trial (RCT) with a 2:1 allocation ratio was conducted from August 2017 to December 2018. The study compared the seroconversion rate after receiving 2- or 3-dose regimen of hepatitis A vaccine at 0, 6 and 0, 1, 6 months, respectively, in non-immune kidney transplant recipients. A total of 401 adult kidney transplant recipients were screened for anti-HAV IgG and 285 subjects had positive results so the seroprevalence was 71.1%. Of 116 seronegative recipients, 93 (80.2%) completed vaccination; 60 and 33 participants completed 2- and 3-dose vaccination, respectively. The baseline characteristics were comparable between both groups. The seroconversion rate at 1 month after vaccination was 51.7% in the standard 2-dose regimen and 48.5% in the 3-dose regimen (p = 0.769). Overall, the seroconversion rate appeared to be associated with high estimated glomerular infiltration rate, high serum albumin, and low intensity immunosuppressive regimen. Seroconversion rate after hepatitis A vaccination in kidney transplant recipients was less favorable than healthy population. Three-dose regimen did not show superior benefit over the standard 2-dose regimen. Other strategies of immunization may increase immunogenicity among kidney transplant recipients.

1165. Epidemiology, management and outcomes of fungal keratitis: A single center study from tertiary hospital in Thailand

Background

Fungal keratitis is known as an important cause of sight threatening infection worldwide. Variation of clinical characteristics and treatment have been observed among different geographic regions. Currently, clinical data of fungal keratitis in South East Asia remain scarce.

Methods

A retrospective single study was conducted at King Chulalongkorn Memorial Hospital in Thailand. Medical records of patient with diagnosis of fungal keratitis between January 2016 and December 2018 were reviewed. Cases were identified using ICD-10 code. Data on demographics, clinical presentations, investigations and outcomes were collected. Mycological diagnosis was made in patients who had clinical presentation compatible with fungal keratitis and positive fungal detection in clinical specimen.

Results

During study period, fungal keratitis was diagnosed in 59 pts including 31 by mycological and 28 by clinical diagnosis. KOH preparation of corneal scraping was positive in 19 of 53 pts (35.8%). Culture from cornea, aqueous and vitreous yielded positive result in 18 of 53 (33.9%), 2 of 14 (14.3%), respectively. ITS sequence analysis was positive in 7 of 15 (46.7%) from cornea, 1 of 6 (16.7%) from aqueous and 2 of 2 (100%) from vitreous. Culture and molecular detection from clinical specimens provided additional mycological diagnosis in 8 and 5 cases with negative KOH preparation. Fusarium was the most common pathogen (33%) followed by Paecilomyces (9.7%), Aspergillus (6.4%), Candida (6.4%). Ten patients (32.2%) had only positive KOH preparation. All patients received treatment with topical antifungal agent, while 38 pts (64%) required systemic, 24 pts (40.7%) received intrastromal, 22 pts (37.2%) received intracameral and 3 pts (5.1%) received intravitreal antifungal therapy. Operation was performed in 21 pts (35.6%) which 6 (28.5%) required evisceration. Twenty-three patients (39%) had visual improvement after complete treatment.

Conclusion

Fungal keratitis is not an uncommon disease. Fusarium was the most common etiologic agent similar to study from other region. Unfavorable outcomes were observed in majority of cases. Appropriate fungal culture and molecular detection from clinical specimens can be considered as they may increase diagnostic yield in some patients.

Disclosures

All Authors: No reported disclosures

A case of successful treatment of severe COVID-19 pneumonia with favipiravir and tocilizumab in post-kidney transplant recipient

We report a case of COVID‐19 in kidney transplant patient in Thailand. A 58‐year‐old 2 years post–kidney transplant recipient, with maintenance immunosuppression of tacrolimus, mycophenolate mofetil (MMF), and prednisolone, presented with acute diarrhea which followed by fever on day 12. Symptoms of pneumonia together with lymphopenia from complete blood count were developed on day 7 after onset of fever with the x‐ray finding of bilateral multifocal patchy infiltration. COVID‐19 infection has been confirmed by reverse real‐time polymerase chain reaction (PCR) in nasal swab as well as found in stool. Darunavir together with ritonavir, hydroxychloroquine, azithromycin, and favipiravir was initiated on the first day of admission at primary hospital. Patient has been transferred to our hospital on day 2 of admission in which tacrolimus together with MMF was discontinued. High‐flow nasal cannula oxygen therapy was required on days 4‐5 of hospitalization. Tocilizumab was administered after rising of serum IL‐6 level. Symptoms of pneumonia were improved in which no oxygen treatment required from day 10 of hospitalization. Drug interaction between tacrolimus and anti‐viral treatment leads to severely high level of tacrolimus which caused reversible acute kidney injury (AKI) after supportive treatment.

Post-transplant Lymphoproliferative Disorder of Naso-orbital Region in Adult Renal Transplant Recipients: A Case Report and Literature Review

Post-transplant lymphoproliferative disorder (PTLD) is an uncommon but fatal complication following both solid organ and hematologic stem cell transplantations. Epstein-Barr virus (EBV) has been considered a main etiologic agent causing PTLD, especially in the first year after transplantation. Extranodal manifestations are frequently found in PTLD; however, naso-orbital involvement in adults is rare. We report a case of EBV-associated PTLD of the naso-orbital region in a 72-year-old patient that occurred 10 years after kidney transplant. Six additional adults with naso-orbital PTLD were identified after completing this literature review, including 2 cases with eyelid swelling, 3 cases with proptosis, and 1 case with facial numbness. The majority of cases occurred after 1 year of transplantation and were associated with EBV. This report emphasizes recognizing PTLD as differential diagnosis in transplant recipients who present with naso-orbital symptoms.

1693. Risk Factors Associated with Mortality of Invasive Aspergillosis in King Chulalongkorn Memorial Hospital

Background

Invasive aspergillosis is the serious fungal infection that often found in the immunocompromised host such as hematologic malignancy, bone marrow transplantation, organ transplantation, and patient who received chemotherapy. Nowadays the patient who diagnosed with invasive aspergillosis has a high mortality rate of 50–60%. There were some studies about the risk factor of mortality of invasive aspergillosis but most of them were not in Thailand. The objective of this study was to identify risk factors related to mortality and the mortality rate of invasive aspergillosis in King Chulalongkorn Memorial Hospital.

Methods

The retrospective study by collected and analyzed the data from medical record by ICD 10, between 1 January 2012 and 30 October 2017.

Results

Total patients were 176 patients; the mortality rate of invasive aspergillosis patient was 46%. The most common underlying condition was AML (27.8%). The risk of invasive aspergillosis was prolonged neutropenia (31.3%), prolonged corticosteroid therapy 27.8% and induction phase chemotherapy 22.7%. The most infection site was the pulmonary system at 80.1%, sinus 13.6%, and CNS 5.7%. The significant factor which affect the mortality rate was cirrhosis [HR 4.21, 95% CI 1.46–11.69, P = 0.008], HIV infection/AIDS [HR 3.24, 95% CI 1.03–10.24, P = 0.045], tracheal infection [HR 21.81, 95% CI 1.48–320.41, P = 0.025] and empirical treatment with itraconazole [HR 11.65, 95% CI 3.14–43.17, P ≤ 0.001]

Conclusion

The Risk factors associated with mortality of invasive aspergillosis in King Chulalongkorn Memorial Hospital was cirrhosis, HIV infection/AIDS, tracheal infection, and the empirical treatment with itraconazole. The overall mortality rate of invasive aspergillosis was 46%.

Disclosures

All authors: No reported disclosures.

1389. Risk Factors and Clinical Outcomes of Tuberculosis Among Kidney Transplant Recipients in High Endemic Country: A Case–Control Study

Background

Tuberculosis (TB) is considered as a challenging issue in solid-organ transplant recipients because of high morbidity and mortality. Active TB after transplant can occur from reactivation of latent infection or newly acquired from community. Understanding risk factors and clinical information of TB may provide an appropriate prevention and treatment strategies in this specific patient population; however, most of data were from non-endemic countries.

Methods

A single-center, matched case–control study was conducted in our institute. Cases were defined as newly diagnosed proven or probable active TB in patients who underwent kidney transplant between April 1992 and October 2018. For each case, 5 controls were matched by age and sex. Risk factor associated with TB was determined using univariate and multivariate conditional logistic regression.

Results

Between study period, kidney transplant was performed in 787 patients. None of the recipients was screened or treated for latent tuberculosis. Twenty-seven patients (3.43%) were diagnosed with active TB including 20 proven and 7 probable cases. The overall incidence of TB in our population was 315 cases per 100,000 patients per year. Allograft rejection was significantly associated with active TB (P < 0.001). The median onset of infection was 17 months (IQR, 4–59 months) after transplantation and 3.4 months (IQR, 2.7–16.3 months) after episode of allograft rejection. Majority of patients (96.3%) were cured after complete treatment; however, those with TB remained having significant unfavorable outcomes including higher all-cause mortality and graft loss.

Conclusion

Incidence of TB in kidney transplant recipients is higher than normal population. Increasing risk of active TB after allograft rejection is probably due to mycobacterial reactivation following high-dose immunosuppression. Since TB is associated with poor post-transplant outcomes, screening, and treatment of latent infection may be beneficial even in endemic country.

Disclosures

All authors: No reported disclosures.

2709. Immune Response After Diphtheria and Tetanus Toxoid Booster in Patients with Adult-Onset Immunodeficiency with Anti-interferon-γ Autoantibody

Background

Immunization were the key of prevention in tetanus and diphtherial disease. Nevertheless, in previous observational study, low seroprotection rate of both diphtheria and tetanus were observed in Thai healthy population. Reduced-dose diphtheria and tetanus toxoid vaccine (dT) was recommended to all adult patients regardless of immunologic status. However, data on vaccine efficacy in interferon gamma (IFN-γ) autoantibody were limited. We therefore conducted clinical study to evaluate efficacy and safety of one dose of dT in IFN-γ autoantibody patient compared with healthy individuals at 4 weeks after vaccination.

Methods

Study was conducted from February to April 2019. Total 18 patients with confirmed IFN-γ autoantibody were enrolled. Baseline tetanus and diphtheria serologic study and 4 weeks after vaccination were examined. Antibody levels were measured with a solid-phase IgG-specific ELISAs (EUROIMMUN, Germany). Geometric mean titers (GMTs) were calculated using the log transformation of serological titers and from taking the antilog mean of the transformed values.

Results

Seroprevalence of tetanus was 94.5% in healthy population compared with 60.1% in IFN-γ autoantibody patients. While, seroprevalence of diphtheria was 27.8% and 77.8%, respectively. After vaccination, all healthy adults had reached seroprotection level in both diphtheria and tetanus. For patients with IFN-γ autoantibody, 88.9% and 94.4% had anti-tetanus toxin IgG and anti-diphtheria toxin IgG level above 0.1 IU/mL, respectively. These results indicated seroconversion rate of 71% for tetanus and 75% for diphtheria after dT vaccination. (Table 2). In the subgroup analysis, unboosted IFN-γ autoantibody patient had lower tetanus seroconversion rate compared with previously boosted patient (50% vs 100%). Active infection was also associated with lower immune response after tetanus vaccination. There was no severe adverse event in both group.

Conclusion

This is the first study on immune response after dT vaccination in IFN-γ autoantibody patient. Seroconversion rate of dT vaccine in IFN-γ autoantibody patient were slightly lower than healthy adults. Active infection and previously unboosted patient provided lower immune response of tetanus.

Disclosures

All authors: No reported disclosures.

2679. Factors Associated with Multidrug-resistant Gram-Negative Bacteremia in Acute Leukemia Patients with Neutropenic Fever, a Retrospective Study

Background

Gram--negative bacteremia in acute leukemia patients with neutropenia is associated with high morbidity and mortality rate. Appropriate antibiotic for empirical treatment is crucial; however, antibiotic selection is challenging especially in setting with high prevalence of infections with multidrug-resistant (MDR) organisms. Data on associated factors of MDR Gram-negative bacteremia in this population is limited.

Methods

A retrospective study was conducted in King Chulalongkorn Hospital, Bangkok, Thailand. Medical records of patients aged ≥15 years with acute leukemia who were hospitalized in our institute and had neutropenic fever between 1 January 2001 and 31 December 2016 were reviewed. Demographic data, causative organisms, treatment and outcomes were documented. Episodes of MDR Gram-negative bacteremia were compared with non-MDR group. Associated risk factor was assessed by multivariate logistic regression

Results

From total 405 admission records of 227 acute leukemia patients, 587 episodes of neutropenic fever occurred with 131 episodes of Gram-negative bacteremia. Majority (81.68%) were bacteremia without source of infection. Most common causative pathogens were E. coli, P. aeruginosa and K. pneumoniae, respectively. Sixty episodes of Gram-negative bacteremia (53.57%) were caused by MDR pathogen. Associated factor for MDR Gram-negative bacteremia was prior colonization or infection with MDR Gram-negative bacteria within 3 months (P = 0.049). Subgroup analysis in patients with non-lactose fermenter bacteremia showed higher rate of intensive care unit (ICU) admission and in-hospital death in MDR group (P = 0.03 and P = 0.004).

Conclusion

Prior colonization or infection by MDR Gram-negative bacteria within 3 months was associated with MDR Gram-negative bacteremia in acute leukemia patients with neutropenic fever. Thoroughly review of previous culture data and active screening for colonization may increase chance of appropriate empirical antibiotics.

Disclosures

All authors: No reported disclosures.

Common viral infections in kidney transplant recipients

Infectious complications have been considered as a major cause of morbidity and mortality after kidney transplantation, especially in the Asian population. Therefore, prevention, early detection, and prompt treatment of such infections are crucial in kidney transplant recipients. Among all infectious complications, viruses are considered to be the most common agents because of their abundance, infectivity, and latency ability. Herpes simplex virus, varicella zoster virus, Epstein-Barr virus, cytomegalovirus, hepatitis B virus, BK polyomavirus, and adenovirus are well-known etiologic agents of viral infections in kidney transplant patients worldwide because of their wide range of distribution. As DNA viruses, they are able to reactivate after affected patients receive immunosuppressive agents. These DNA viruses can cause systemic diseases or allograft dysfunction, especially in the first six months after transplantation. Pretransplant evaluation and immunization as well as appropriate prophylaxis and preemptive approaches after transplant have been established in the guidelines and are used effectively to reduce the incidence of these viral infections. This review will describe the etiology, diagnosis, prevention, and treatment of viral infections that commonly affect kidney transplant recipients.

1546. Incidence of Carbapenemase-Producing Klebsiella pneumoniae Colonization in Hematopoietic Stem Cell Transplant Recipients in King Chulalongkorn Memorial Hospital (KCMH), Thailand

Background

Carbapenemase-producing Klebsiella pneumoniae (CPKP) is an emerging pathogen which had the serious clinical infections, high mortality and difficult to control. Hematopoietic stem cell transplantation (HSCT) patients are particularly susceptible to multidrug-resistant bacteria especially carbapenemase-producing Enterobacteriacae. CPKP infections are an emerging cause of death after HSCT and the mortality rate was reported up to 60%. The major risk factors of CPKP infections were colonization these organism before transplantation. However, in Thailand, the incidence rate of CPKP colonization and clinical outcome in HSCT was limited.

Objectives. To determine the incidence rate of CPKP colonizationand risk factors of 30-day-hospital mortality in HSCT patients at King Chulalongkorn Memorial Hospital.

Methods

A prospective study was conducted in total of 96 consecutive HSCT patients at King Chulalongkorn Memorial Hospital, Bangkok, Thailand, from July 2016 to March 31, 2018.

Results

Incidence rate of CPKP colonizationin HSCT patients was 22.2% (18/96 patients) and incidence rate of CPKP infections was 5.2% (5/96 patients). Both bla_OXA-48 and bla_NDM were the most common carbapenemase gene (50%). Patients with CPKP infection were more likely in ICU setting than colonization group. CPKP colonization was more significantly found in urinary specimens (P = 0.029) whereas CPKP infections were common found in respiratory tract, but not significantly (P = 0.583). In CPKP infection group, the 30-day mortality rate was significantly higher than colonization group; 80% (4/5) vs. 23% (3/13), P = 0.047). Using univariable analysis, ICU setting was associated with CPKP infection (RR = 6.27 95% CI, 0.87–45.34) and had a worse outcome.The risk factor associated with 30-day mortality was CPKP infection (RR = 3.47 95% CI 1.17–10.26).

Conclusion

In our study, the incidence of CPKP colonization in HSCT patients was 22.2%. The incidence of CPKP infections found only 5.2% in HSCT patients, but there was significantly associated with increased 30-day-hospital mortality.

Disclosures

All authors: No reported disclosures.

Skin Manifestations in Patients with Adult-onset Immunodeficiency due to Anti-interferon-gamma Autoantibody: A Relationship with Systemic Infections

Adult-onset immunodeficiency due to anti-interferon-γ autoantibody is an emerging acquired immunodeficiency with frequent skin manifestations. A retrospective chart review was conducted and identified 41 patients with the syndrome. Skin involvement was detected in 33 (80%) patients, 15 (45%) with infective skin diseases and 27 (82%) with reactive skin disorders. Reactive lesions were mostly neutrophilic dermatoses, e.g. Sweet syndrome. Of note, the presence of neutrophilic dermatoses was highly associated with infections of other sites. An adjusted odds ratio for the existence of infections in patients with neutrophilic dermatoses was 14.79 (95% CI: 5.13, 42.70; p < 0.001). Moreover, neutrophilic dermatoses were significantly correlated with opportunistic infections observed in those with defects in cell-mediated immunity including non-tuberculous mycobacterium and disseminated fungal infection. The odds ratio for opportunistic infections in the presence of neutrophilic dermatoses was 12.35 (95% CI: 5.00, 30.55; p <0.001). Thus, the presence of neutrophilic dermatoses in patients with the syndrome can signal opportunistic infections that warrant physician attention.

B-cell activating factor, a predictor of antibody mediated rejection in kidney transplantation recipients

AIM

Donor-specific antibody (DSA) is a widely-used biomarker for antibody-mediated rejection (ABMR) but correctly indicates only 30-40% of patients with ABMR. Additional biomarkers of ABMR in kidney transplant recipients are needed.

METHODS

All 68 kidney transplanted-recipients enrolled in this study were negative for graft rejection as determined by surveillance-biopsy ELISA at day 7 post-transplantation. Allograft biopsy was then performed at 6 months post-transplantation for subclinical-ABMR detection. Recipients were stratified by pre-transplant DSA and BAFF at day 7 into four groups.

RESULTS

During the study period, 13.2% of the recipients demonstrated subclinical-ABMR at 6 months, without patient with clinical ABMR presentations. Overall mean BAFF at day 7 was 393 pg/mL (95% CI = 316-471 pg/mL). The optimal cut-off value for low vs. high BAFF level was 573 pg/mL, with sensitivity and specificity at 77.8% and 88.1%, respectively. Fifty percent of recipients with high BAFF at day 7 (14 patients) and only 3.7% of patients with low BAFF demonstrated ABMR (P < 0.05). Indeed, ABMR was more common in patients high BAFF level (hazard ratio = 7.30; 95% CI = 3.77-14.15). The prevalence of ABMR among negative pre-transplant DSA/low BAFF, positive DSA/low BAFF, negative DSA/high BAFF, and positive DSA/ high BAFF recipients were 4.4, 0, 37.5 and 66.7%, respectively (P < 0.05).

CONCLUSIONS

Post-transplant ABMR can be predicted by perioperative serum BAFF level. Together with DSA testing, BAFF provides additional predictive value for ABMR.

Anti-GM-CSF autoantibodies in patients with cryptococcal meningitis

Cryptococcal meningitis has been described in immunocompromised patients, as well as in those for whom no immune defect has been identified. GM-CSF regulates the function of phagocytes and pulmonary alveolar macrophages, critical elements in cryptococcal control. We performed clinical histories, immunological evaluation, and anticytokine autoantibody screening in four current patients with cryptococcal meningitis and identified and tested 103 archived plasma/cerebrospinal fluid samples from patients with cryptococcal meningitis. We assessed the ability of anti-GM-CSF autoantibody-containing plasmas to inhibit GM-CSF signaling. We recognized anti-GM-CSF autoantibodies in an otherwise healthy female with cryptococcal meningitis who later developed pulmonary alveolar proteinosis (PAP). Her diagnosis prompted screening of patients with cryptococcal meningitis for anticytokine autoantibodies. We identified seven HIV-negative patients with cryptococcal meningitis who tested positive for high-titer anti-GM-CSF autoantibodies. Two of the seven later developed evidence of PAP. Plasma from all patients prevented GM-CSF-induced STAT5 phosphorylation and MIP-1α production in normal PBMCs. This effect was limited to their IgG fraction. Anti-GM-CSF autoantibodies are associated with some cases of cryptococcal meningitis in otherwise immunocompetent patients. These cases need not have associated PAP.

Adult-onset immunodeficiency in Thailand and Taiwan

BACKGROUND

Autoantibodies against interferon-γ are associated with severe disseminated opportunistic infection, but their importance and prevalence are unknown.

METHODS

We enrolled 203 persons from sites in Thailand and Taiwan in five groups: 52 patients with disseminated, rapidly or slowly growing, nontuberculous mycobacterial infection (group 1); 45 patients with another opportunistic infection, with or without nontuberculous mycobacterial infection (group 2); 9 patients with disseminated tuberculosis (group 3); 49 patients with pulmonary tuberculosis (group 4); and 48 healthy controls (group 5). Clinical histories were recorded, and blood specimens were obtained.

RESULTS

Patients in groups 1 and 2 had CD4+ T-lymphocyte counts that were similar to those in patients in groups 4 and 5, and they were not infected with the human immunodeficiency virus (HIV). Washed cells obtained from patients in groups 1 and 2 had intact cytokine production and a response to cytokine stimulation. In contrast, plasma obtained from these patients inhibited the activity of interferon-γ in normal cells. High-titer anti-interferon-γ autoantibodies were detected in 81% of patients in group 1, 96% of patients in group 2, 11% of patients in group 3, 2% of patients in group 4, and 2% of controls (group 5). Forty other anticytokine autoantibodies were assayed. One patient with cryptococcal meningitis had autoantibodies only against granulocyte-macrophage colony-stimulating factor. No other anticytokine autoantibodies or genetic defects correlated with infections. There was no familial clustering.

CONCLUSIONS

Neutralizing anti-interferon-γ autoantibodies were detected in 88% of Asian adults with multiple opportunistic infections and were associated with an adult-onset immunodeficiency akin to that of advanced HIV infection. (Funded by the National Institute of Allergy and Infectious Diseases and the National Institute of Dental and Craniofacial Research; ClinicalTrials.gov number, NCT00814827.).

Determination of human anticytokine autoantibody profiles using a particle-based approach

BACKGROUND

Anticytokine autoantibodies cause numerous human diseases, ranging from pure red cell aplasia to acquired immunodeficiencies. Rapid, simple, and affordable detection and monitoring of these antibodies is essential. We sought to develop a standardizable assay that is rapid, sensitive, and specific and able to simultaneously detect multiple anticytokine autoantibodies in small volumes (<10 μl).

METHODS

We conjugated purified human cytokines to commercially available fluorescently labeled microspheres and tested them against sera from well-characterized subjects with at least one high-titer, disease-associated anticytokine autoantibody.

RESULTS

Cytokine-conjugated microspheres efficiently and rapidly determined plasma concentration and IgG subclass of anticytokine autoantibodies in single or multiplex formats.

CONCLUSION

This particle-based multiplex assay can reproducibly characterize anticytokine autoantibodies. This efficient and inexpensive approach to diagnosing and monitoring anticytokine autoantibodies has clinical applications.

Therapeutic effectiveness of a generic versus original meropenem in serious infections

BACKGROUND

Meropenem plays a significant role in the current antimicrobial treatment of serious infections. Recently, generic meropenems have become widely available in Thailand.

OBJECTIVE

Compare the effectiveness and safety ofa generic meropenem (Mapenem) with the original meropenem (Meronem) in clinical practice.

MATERIAL AND METHOD

A retrospective cohort study was conducted in hospitalized patients with serious infections that had been treated with either the generic or the original meropenem in nine secondary- and tertiary-care hospitals nationwide. The treatment outcomes at days 3, 7, and 14 after the use ofmeropenem between the two groups were compared.

RESULTS

Three hundred ninety seven patients with a mean (SD) age of 66.4 +/- 16.9 years were included. There were 228 (57.4%) males and 169 (42.6%) females. Two hundred and seven (52.1%) and 190 (47.9%) cases fell into the generic and original groups respectively. There were no significant differences regarding age, gender history of underlying disease, body weight, and ward of admission between the two groups. The majority ofpatients had presented with the respiratory tract (48.6%) and bloodstream infections (29.5%). The three most common causative bacteria were Pseudomonas aeruginosa, Acinetobacter baumannii, and extended-spectrum beta-lactamase (ESBL) producing Escherichia coli. The distribution ofthe sites of infection, causative microorganisms, the dosage ofmeropenem, and duration oftreatment were similar between the two groups. The distribution of patients with complete resolution, improvement, stable, worse, diedfrom infection, and died from other causes were similar between the two groups at day 3, 7, and 14 ofmeropenem use (p > 0.05). The drugs were well-tolerated, and less than 2% of patients in both groups discontinued meropenem due to the adverse drug effects.

CONCLUSION

The generic meropenem has a similar effectiveness in the treatment of serious bacterial infections when compared with original meropenem. Both formulations are well tolerated among patients with substantial comorbidities. Adverse drug effects that lead to drug discontinuation are uncommon.

A prospective study of ceftriaxone treatment in acute pyelonephritis caused by extended-spectrum beta-lactamase-producing bacteria

BACKGROUND

Much controversy exists as to whether cephalosporin treatment is appropriate for infections caused by ESBL-producing organisms because no randomized controlled studies have been performed.

OBJECTIVE

Evaluate the therapeutic outcomes of ceftriaxone treatment in acute pyelonephritis caused by ESBL-producing Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis.

MATERIAL AND METHOD

The authors performed a prospective study in female patients hospitalized with acute pyelonephritis caused by ESBL-producing or ESBL-nonproducing E. coli, K. pneumoniae, or P. mirabilis in four hospitals in Thailand from 2004 to 2006. The clinical and microbiological outcomes were evaluated at 72 hours after empirical ceftriaxone treatment.

RESULTS

One hundred eleven patients with the mean age of 65.29 years participated in this study. There were no differences in demographic and clinical characteristics and laboratory data between the ESBL-producing and ESBL-nonproducing groups except the higher rates of previous antibiotic use and urinary tract infection; and the lower frequency of costovertebral angle tenderness in the ESBL-producing group. Both clinical (65% and 93%) and microbiological (67.5% and 100%) responses at 72 hours after ceftriaxone treatment were poorer in the ESBL-producing group than in the ESBL-nonproducing group (p < 0.0002).

CONCLUSION

To the authors' knowledge, this is the first prospective study to evaluate the outcomes of ceftriaxone treatment in acute pyelonephritis caused by ESBL-producing Enterobacteriaceae. The present study confirms that acute pyelonephritis in the female patients caused by ESBL-producing strains could not be treated with ceftriaxone.

Basal ganglia and brainstem encephalitis, optic neuritis, and radiculomyelitis in Epstein–Barr virus infection

The neurologic complications of Epstein-Barr virus (EBV) infection are rare. We describe a healthy adult with acute EBV meningoencephalomyeloradiculitis. The clinical manifestations, a serologic study, and a dynamic change of EBV DNA in the cerebrospinal fluid with spontaneous recovery confirmed the diagnosis of EBV infection of the nervous system. In addition, we provide other clinical clues for suspicion of EBV infection in patients with encephalitis. These include bilateral basal ganglia and brainstem lesions on magnetic resonance imaging, optic neuritis, or involvement of all levels of the nervous system.