Analysis of clinical characteristics and risk factors between elderly patients with severe and nonsevere Omicron variant infection

BACKGROUND

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has led to millions of confirmed cases and deaths worldwide. Elderly patients are at high risk of developing and dying from COVID-19 due to advanced age, decreased immune function, intense inflammatory response, and comorbidities. Shanghai has experienced a wave of infection with Omicron, a new variant of SARS-CoV-2, since March 2022. There is a pressing need to identify clinical features and risk factors for disease progression among elderly patients with Omicron infection to provide solid evidence for clinical policy-makers, public health officials, researchers, and the general public.

AIM

To investigate clinical characteristic differences and risk factors between elderly patients with severe and nonsevere Omicron SARS-CoV-2 variant infection.

METHODS

A total of 328 elderly patients with COVID-19 admitted to the Ninth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine from April 2022 to June 2022 were enrolled and divided into a severe group (82 patients) and a nonsevere group (246 patients) according to the diagnosis and treatment protocol of COVID-19 (version 7). The clinical data and laboratory results of both groups were collected and compared. A chi-square test, t test, Mann-Whitney U test, hierarchical log-rank test, univariate and multivariate logistic regression, and hierarchical analyses were used to determine significant differences.

RESULTS

The severe group was older (84 vs 74 years, P < 0.001), included more males (57.3% vs 43.9%, P = 0.037), had a lower vaccination rate (P < 0.001), and had a higher proportion of comorbidities, including chronic respiratory disease (P = 0.001), cerebral infarction (P < 0.001), chronic kidney disease (P = 0.002), and neurodegenerative disease (P < 0.001), than the nonsevere group. In addition, severe disease patients had a higher inflammatory index (P < 0.001), greater need for symptomatic treatment (P < 0.001), longer hospital stay (P = 0.011), extended viral shedding time (P = 0.014), and higher mortality than nonsevere disease patients (P < 0.001). No difference was observed in the application of Paxlovid in the severe and nonsevere groups (P = 0.817). Oxygen saturation, cerebral infarction, and D-dimer were predictive factors for developing severe disease in patients with COVID-19, with D-dimer having an excellent role (area under the curve: 90.1%, 95%CI: 86.1-94.0%). In addition, D-dimer was a risk factor for developing severe COVID-19 according to multivariate stratified analysis.

CONCLUSION

The clinical course of severe COVID-19 is complex, with a higher need for symptomatic treatment. D-dimer is a suitable biomarker for identifying patients at risk for developing severe COVID-19.

Monkeypox in humans: Transmission, pathophysiology, diagnosis, treatment, prevention, and all recent updates

The Centers for Disease Control and Prevention (CDC) is monitoring an epidemic of monkeypox infection in the United States. The outbreak is now global and more than 6900 cases have already been reported. There are 83 confirmed cases among children and adolescents, as shown in the report published on November 3, 2022, in the USA. However, monkeypox in pediatric patients is still infrequent (< 0.3% of total cases). Among cases in the United States, 16 cases were in children < 5 years, 12 in the age group 5-12 years, and 55 cases in adolescents 13-17 years old. In the adolescent age group, 89% were male. For children < 12 years of age, close physical contact with an adult household with monkeypox was the primary exposure, but for adolescents, male-to-male sexual contact was found more frequently. The CDC advised United States healthcare providers to remain vigilant for patients with a rash resembling monkeypox, even if there is no history of travel to a country with high risk. This article summarizes the history and epidemiology of monkeypox with a specific emphasis on clinical features and management in pediatric patients.

Brucellosis, a diagnostic dilemma, presenting atypically in a child with terminal ileitis: A case report

BACKGROUND

Brucellosis is endemic in India with seropositivity rates as high as 10% in children in the eastern states, yet the disease is not on the radar when a differential diagnosis of pyrexia of unknown origin (PUO) is being considered, especially in children in urban set-up. This may be because of the non-specific multitude of systemic symptoms seen in this disease and the lack of awareness among clinicians.

CASE SUMMARY

We present a case of a 13-year-old boy, who came with a history of undulating fever for the past three and a half months, loss of appetite, and abdominal pain. The child had visited several pediatricians and was even admitted to a tertiary care hospital for PUO evaluation, but to no avail. He presented to us after three and half months of suffering and weight loss of more than 10% of body weight. His ultrasonography revealed thickening of the terminal ileum. His blood culture grew Brucella melitensis. A diagnosis of Brucellosis with terminal ileitis was made. Brucella serology by enzyme-linked immunoassay (ELISA) was positive for both IgG and IgM. He was treated with doxycycline and Rifampicin along with syrup multivitamin and zinc, for 6 wk. There was remarkable improvement with gain in 4 kg body weight within 2 mo of completing treatment. History revealed consumption of unpasteurized milk and contact with cattle.

CONCLUSION

Clinical suspicion, detailed history, appropriate laboratory investigations are the three pillars for diagnosing Brucellosis in patients presenting with vague symptoms.

Emerging leishmaniasis in southern Himalayas: A mini-review

Leishmaniasis is a vector-borne parasitic disease affecting millions of people worldwide. However, in the last decade, the number of cases has been reduced from well-documented endemic parts, but sporadic cases have been reported widely from various non-endemic areas, especially from the southern Himalayan zone. This raises concerns about the emergence of new ecological niches. This warrants a critical evaluation of key factors causing this rapid spread and possibly indigenous transmission. This mini-review article is aimed to briefly address the parasite, the vector, and the environmental aspects in the transmission of leishmaniasis in these new foci against a background of worldwide endemic leishmaniasis with a special focus on the southern Himalayan zone. As the lack of knowledge about the causative parasites, vectors, reservoir hosts, atypical presentations, and their management make the problem serious and may lead to the emergence of public health issues. The present works also reviewed the existing information regarding clinical variations, diagnostic methods, treatment, its outcome, and ignite for further research in these aspects of the disease.

Three-dimensional models of antigens with serodiagnostic potential for leprosy: An in silico study

BACKGROUND

Leprosy is a disease caused by Mycobacterium leprae (M. leprae), an intracellular pathogen that has tropism and affects skin and nervous system cells. The disease has two forms of presentation: Paucibacillary and multibacillary, with different clinical and immunological manifestations. Unlike what occurs in the multibacillary form , the diagnostic tests for the paucibacillary form are nonspecific and not very sensitive, allowing the existence of infected individuals without treatment, which contributes to the spread of the pathogen in the population. To mitigate this contamination, more sensitive diagnostic tests capable of detecting paucibacillary patients are needed.

AIM

To predict the three-dimensional structure models of M. leprae antigens with serodiagnostic potential for leprosy.

METHODS

In this in silico study, satisfactory templates were selected in the Protein Data Bank (PDB) using Basic Local Alignment Search Tool to predict the structural templates of ML2038, ML0286, ML0050, and 85B antigens by comparative modeling. The templates were selected according to general criteria such as sequence identity, coverage, X-ray resolution, Global Model Quality Estimate value and phylogenetic relationship; Clustal X 2.1 software was used in this analysis. Molecular modeling was completed using the software Modeller 9v13. Visualization of the models was made using ViewerLite 4.2 and PyMol software, and analysis of the quality of the predicted models was performed using the QMEAN score and Z-score. Finally, the three-dimensional moels were validated using the MolProbity and Verify 3D platforms.

RESULTS

The three-dimensional structure models of ML2038, ML0286, ML0050, and 85B antigens of M. leprae were predicted using the templates PDB: 3UOI (90.51% identity), PDB: 3EKL (87.46% identity), PDB: 3FAV (40.00% identity), and PDB: 1F0N (85.21% identity), respectively. The QMEAN and Z-score values indicated the good quality of the structure models. These data refer to the monomeric units of antigens, since some of these antigens have quaternary structure. The validation of the models was performed with the final three-dimensional structure - monomer (ML0050 and 85B antigens) and quaternary structures (ML2038 and ML0286). The majority of amino acid residues were observed in favorable and allowed regions in the Ramachandran plot, indicating correct positioning of the side chain and absence of steric impediment. The MolProbity score value and Verify 3D results of all models indicated a satisfactory prediction.

CONCLUSION

The polarized immune response against M. leprae creates a problem in leprosy detection. The selection of immunodominant epitopes is essential for the development of more sensitive serodiagnostic tests, for this it is important to know the three-dimensional structure of the antigens, which can be predicted with bioinformatics tools.

Steps taken to fight the COVID-19 pandemic at the grassroots level of rural India: Experience of a community physician

Coronavirus disease (COVID-19) was first identified in Wuhan, China and then rapidly spread all over the world. The World Health Organization declared a pandemic on March 11, 2020 as a result of COVID-19. As it has caused substantial morbidity and mortality, most countries took several measures to control its spread, including India. As of now, India has witnessed three major waves of COVID-19. Several measures like nationwide lockdown, active case finding, contact tracing, home isolation, and vaccination were taken. There was involvement of multiple sectors (including private and government) and community participation. During the pandemic, I was posted at a primary health centre in a rural setting in India. A rural primary care setting has its own limitations. All the steps taken had several challenges at the grassroots level. Therefore, through this article, I highlighted the challenges faced during the implementation of steps taken to battle the pandemic and the outcome.

Clinical significance of anti-nucleocapsid-IgG sero-positivity in SARS-CoV-2 infection in hospitalized patients in North Dakota

BACKGROUND

During the peak of the coronavirus diseases 2019 (COVID-19) pandemic, clinicians actively studied the utility of various epidemiologic-clinical parameters to determine the prognosis for patients hospitalized with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Serum IgG antibody level, D-Dimer, C-reactive protein and neutrophil to lymphocyte ratio, etc. were studied to assess their association with the clinical course in hospitalized patients and predict who may be at increased risk for poor clinical outcome. However, the influence of SARS-CoV-2-anti-nucleocapsid-IgG antibody (IgG-N) sero-positivity on the clinical outcome of patients with COVID-19 is largely unknown.

AIM

To study the influence of SARS-CoV-2 anti-nucleocapsid-IgG seropositivity on clinical course and diseases severity in hospitalized COVID-19 patients.

METHODS

We conducted a retrospective study of adults admitted to a tertiary care community hospital in North Dakota with COVID-19. Included patients had severe COVID-19 disease or worse and so required supplemental oxygen on admission. They were serologically tested for SARS-CoV-2-anti-nuceocapsid-IgG (IgG-N). The IgG-N positive group were 26 patients and the IgG-N negative group had 33 patients. The groups received similar treatment for COVID-19 as approved by our healthcare system from Day 1 of admission until discharge or death. Measurable parameters for monitoring the patients’ clinical course included the following: Length of hospitalization (LOS), use of high flow nasal canula (HFNC), use of noninvasive bilevel positive pressure ventilation (BiPAP), admission into the intensive care unit, need for mechanical ventilation (VENT); and the patient outcome/discharge or death. Other variables included were age, gender and body-mass-index, and duration of symptoms before presentation. For each variable, the outcome was modeled as a function of SARS-CoV-2-IgG-N status (positive or negative) using a generalized linear model. For LOS-days, a negative binomial distribution was used as it had a better fit than a Poisson or Gaussian distribution as evidenced by a Pearson chi-square/df value closer to 1.0. All other outcomes utilized a binary logistic regression model.

RESULTS

After a thorough examination of patient data, it was found that admission rates to the Intensive Care Unit, as well as the usage of BiPAP, HFNC and VENT support, in conjunction with patient outcomes, were not significantly different across IgG-N status. However, the LOS variable when assessed by IgG-N status was found to be significant (t value = 2.16, P value = 0.0349). IgG-N negative patients had higher than average LOS in comparison to IgG-N positive patients (15.12 vs 9.35 d). Even when removing the extreme value (an LOS of 158 d), IgG-N negative patients still had slightly higher than average stays (10.66 vs 9.35 d) but the relationship was no longer significant. For patient outcome/death, only age (numerical) was a significant predictor (F value = 4.66, P value = 0.0352). No other variables for any of the outcomes were significant predictors of clinical course or disease severity.

CONCLUSION

Our study demonstrated that IgG-N seroconversion had no significant association with clinical outcomes in hospitalized COVID-19 patients.

Five-year retrospective hospital-based study on epidemiological data regarding human leishmaniasis in West Kordofan state, Sudan

BACKGROUND

Leishmaniasis is a neglected zoonotic disease, endemic in Sudan. Estimating this disease is very important to inform the health care policymakers and the governments to apply proper health and economic policies.

AIM

To find out the frequency and distribution of human leishmaniasis based on sex and age for 5 years in the West Kordofan state, Sudan.

METHODS

A 5-year retrospective study from 2016 through 2020 was carried out using local hospital records of leishmaniasis patients. The positive results were recorded after performing at least one of the following leishmaniasis standard tests: direct agglutination test, enzyme-linked immunosorbent assay and leishmania skin test. The sex and age of each patient were recorded. The collected data were analyzed using STATA package version 16.

RESULTS

A total of 162443 patient records from 2016 to 2020 were retrieved. Of these, 4.39% were found to be positive for leishmaniasis. The disease has been more common in males (65.3%) than in females (34.7%). The highest reported prevalence (6.58%) was in patients 15-44 years, and the lowest prevalence (1.95%) was among patients ≥ 65 years.

CONCLUSION

The results of the current study indicate that leishmaniasis is endemic in the study area even though the numbers of patients in the 5 consecutive years were varying. In addition, the disease was common in males and adults. The interpretation of these findings should take into consideration the absence of information about some important confounding factors.

Incidental diagnosis of intestinal spirochetosis in a patient with chronic hepatitis B: A case report

BACKGROUND

Intestinal spirochetosis (IS) is caused by Brachyspira colonization of the gastrointestinal tract. Some patients are asymptomatic, while others present with gastrointestinal complaints such as abdominal pain, diarrhea, or gastrointestinal bleeding. However, the clinical significance of asymptomatic IS is unclear, and guidelines are lacking regarding decision to treat.

CASE SUMMARY

A 73-year-old male with peptic ulcer disease and gastroesophageal reflux was evaluated for elevated liver enzymes. He was diagnosed with chronic hepatitis B virus and prescribed entecavir. Additionally, he was leukopenic and had stage 4 liver fibrosis on transient elastography. After 5 mo, the patient returned for esophagogastroduodenoscopy and screening colonoscopy. He denied any gastrointestinal symptoms at that time. Findings included grade I distal esophageal varices, mild portal hypertensive gastropathy, and patchy nodular gastric antral mucosa. On colonoscopy, several polyps were removed. Hematoxylin and eosin stain of mucosa adjacent to the polyps revealed a “false brush border,” and Steiner stain identified spirochetes adherent to the mucosa. These pathology findings confirmed the diagnosis of IS. He was managed conservatively with careful observation and without antibiotic therapy via a multidisciplinary approach between gastroenterology and infectious disease. He remained asymptomatic at the 7-wk follow-up.

CONCLUSION

This case reports the finding of incidental, asymptomatic IS in a leukopenic patient with hepatitis B virus. Conservative management was appropriate.

Pericarditis following COVID-19 vaccination: Two case reports

BACKGROUND

Coronavirus disease 2019 (COVID-19) is a highly contagious viral illness which conventionally manifests with primarily respiratory symptoms and less commonly with cardiac involvement in various forms, such as pericarditis. Myocarditis and pericarditis have been reported in a variety of live and attenuated vaccines, such as smallpox and influenza. As of October 2021, no cases of pericarditis associated with COVID-19 vaccination have been published. We present two healthy male patients who present post COVID-19 vaccination with pericarditis diagnoses.

CASE SUMMARY

A 21-year-old male with no significant past medical history presented with myalgia, chills, mild headache, and chest pain for two days. Patient received the Moderna COVID-19 vaccine the day prior to symptom onset. On presentation, electrocardiogram (ECG) revealed sinus rhythm with ST elevation, and troponin was elevated. Emergent cardiac catheterization was not significant for abnormalities. The primary diagnosis was acute pericarditis, and the patient was discharged on colchicine and indomethacin. Additionally, a 35-year-old male with no pertinent past medical history presented with fever, chills, weakness, nausea, vomiting, diarrhea, and retrosternal chest pain for three days. He received the Moderna COVID-19 vaccine four days prior to symptom onset. On presentation, troponin was elevated, and ECG revealed mild ST elevation. Left ventricular dysfunction with ejection fraction of 41% was reported on transthoracic echocardiogram. Patient was started on ibuprofen and colchicine for diagnosis of myopericarditis.

CONCLUSION

These case reports highlight a potential unintended consequence, pericarditis, associated with COVID-19 vaccination that may not warrant invasive cardiac intervention.

Unusual cause of hemorrhagic pleural effusion: A case report

BACKGROUND

Infected aortic aneurysms are uncommon and difficult to treat. We present a case of infected aortic aneurysm with recurrent nontyphoidal Salmonella bacteremia.

CASE SUMMARY

A 68-year-old gentleman presented with non-specific symptoms and was found to have nontyphoidal Salmonella bacteremia and was treated with intravenous ceftriaxone. However his condition did not improve, and he developed a multiloculated right pleural effusion. Thoracocentesis was done to drain hemorrhagic pleural fluid. Chest computed tomography demonstrated descending thoracic aorta saccular aneurysm with periaortic hematoma likely due to recent bleed and extending to the right pleural cavity. He was referred to cardiothoracic surgery team and was planned for medical therapy in view of hemodynamic stability and no evidence of active leakage. He completed intravenous antibiotic for 5 wk and refused surgical intervention. Unfortunately, he was admitted twice for recurrent nontyphoidal Salmonella bacteremia. Finally, he agreed for surgical intervention and underwent endovascular aortic repair 3 mo later. Postoperatively, his condition remained stable with no recurrence of infection.

CONCLUSION

Our case highlights the importance of high index of suspicion of infected aortic aneurysm in patients with Salmonella bacteremia with high-risk factors such as atherosclerosis.

COVID-19, stigma, and people with disabilities: A mental health perspective

Discrimination is an age-old ‘illness’ irrespective of its context. Stigma is a common factor that has been associated with disability and coronavirus disease 2019. The public health impact of stigma on differently-abled people during this pandemic is not known and it is a poorly investigated and neglected area. It is important to address the current research need in the concerned area and its implications for public health policymaking and changes in practices that it requires. Together we can win the war against pandemics if we reduce the mental distancing in all perspectives.

Imaging related to underlying immunological and pathological processes in COVID-19

The introduction of coronavirus disease-2019 (COVID-19) as a global pandemic has contributed to overall morbidity and mortality. With a focus on understanding the immunology and pathophysiology of the disease, these features can be linked with the respective findings of imaging studies. Thus, the constellation between clinical presentation, histological, laboratory, immunological, and imaging results is crucial for the proper management of patients. The purpose of this article is to examine the role of imaging during the particular stages of severe acute respiratory syndrome coronavirus 2 infection – asymptomatic stage, typical and atypical COVID-19 pneumonia, acute respiratory distress syndrome, multiorgan failure, and thrombosis. The use of imaging methods to assess the severity and duration of changes is crucial in patients with COVID-19. Radiography and computed tomography are among the methods that allow accurate characterization of changes.

Mutations of the brpR and brpS genes affect biofilm formation in Staphylococcus aureus

BACKGROUND

In the United States, Staphylococcus aureus (S. aureus) kills tens of thousands of individuals each year and the formation of a biofilm contributes to lethality. Biofilm-associated infections are hard to treat once the biofilm has formed. A new stilbene drug, labeled SK-03-92, was shown to kill S. aureus and affected transcription of two genes tied to a putative two-component system (TCS) we have named brpR (biofilm regulating protein regulator) and brpS (biofilm regulating protein sensor).

AIM

To determine if BrpR and BrpS regulate biofilm formation, brpR and brpS mutants were assessed using biofilm assays compared to wild-type S. aureus.

METHODS

A combination of biofilm and quantitative real-time-polymerase chain reaction assays were used. In addition, bioinformatic software tools were also utilized.

RESULTS

Significantly more biofilm was created in the brpR and brpS mutants vs wild-type cells. Quantitative real-time polymerase chain reactions showed the brpS mutant had differences in transcription of biofilm associated genes that were eight-fold higher for srtA, two-fold lower for lrgA, and 1.6-fold higher for cidA compared to wild-type. Bioinformatic analysis demonstrated that the S. aureus brpR/brpS TCS had homology to streptococcal late-stage competence proteins involved in cell-death, increased biofilm production, and the development of persister cells.

CONCLUSION

Our study suggests that brpR/brpS is a TCS that may repress S. aureus biofilm production and be linked to late-stage competence in S. aureus.

Can a radioimmunoassay kit be developed for accurate detection of the S protein of severe acute respiratory syndrome coronavirus 2?

The coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) at the end of 2019 spread worldwide within only a few months. The screening and timely isolation of infected individuals have been regarded as an effective means of epidemic prevention and control. Therefore, effective screening of infected individuals plays a vital role in epidemic prevention and control. At present, reverse transcription-polymerase chain reaction (RT–PCR) is the main method for the in vitro detection of SARS-CoV-2. However, RT–PCR requires certified laboratories, expensive equipment, and trained technicians. Therefore, it is necessary to develop simpler and more convenient methods. Some studies have shown that the PepKAA peptide has a high affinity for the S protein of SARS-CoV-2. The tyrosine in PepKAA is labeled with ¹²⁵I and used to design a radioimmunoassay kit for the detection of the S protein of SARS-CoV-2, which is of great significance for the early diagnosis of COVID-19.

Lymphocyte count predicts the severity of COVID-19: Evidence from a meta-analysis

BACKGROUND

In December 2019, coronavirus disease 2019 (COVID-19) was reported firstly in Wuhan, China. COVID-19 is currently a global pandemic.

AIM

To assess the suitability of lymphocyte count as a biomarker of COVID-19 severity.

METHODS

Five literature databases (PubMed/MEDLINE, Web of Science, Google Scholar, Embase, and Scopus) were searched to identify eligible articles. A meta-analysis was performed to calculate the standard mean difference (SMD) and 95% confidence interval (CI) of lymphocyte counts in coronaviral pneumonia cases.

RESULTS

Eight studies, including 1057 patients, were integrated in the meta-analysis. Lymphocyte counts were associated with severe coronavirus (CoV) infection (SMD = 1.35, 95%CI: 1.97 to 0.37, P < 0.001, I² = 92.6%). In the subgroup analysis stratified by prognosis, lymphocytes were associated with CoV infection mortality (n = 2, SMD = 0.42, 95%CI: 0.66 to 0.19, P < 0.001, I² = 0.0%), severity (n = 2, SMD = 0.93, 95%CI: 1.20 to 0.67, P < 0.001, I² = 0.0%), and diagnostic rate (n = 4, SMD = 2.32, 95%CI: 3.60 to 1.04, P < 0.001, I² = 91.2%).

CONCLUSION

Lymphocyte count may represent a simple, rapid, and commonly available laboratory index with which to diagnosis infection and predict the severity of CoV infections, including COVID-19.

Prevalence of anal human papillomavirus infection in patients with human immunodeficiency virus infection: A systematic review

BACKGROUND

Human papillomavirus (HPV) is one of the most common sexually transmitted viruses nowadays.

AIM

To analyze the prevalence of HPV infection in human immunodeficiency virus (HIV)-positive patients and the risk factors associated with this infection through a review of studies published in the period from January 2010 to April 2020.

METHODS

A total of 384 articles were initially identified in our searches, of which ten were selected according to previously defined eligibility criteria.

RESULTS

Anal intercourse, absence of condom use, multiple partners, other specific sexual and life habits, and HIV infection are among the risk factors associated with anal HPV infection.

CONCLUSION

In general, there is a higher prevalence of anal HPV infection among HIV-positive patients, mostly in individuals over 30 years old, those with multiple partners, those who had an early homosexual debut, and cigarette, alcohol, and drug users.

COVID-19 mortality and gross domestic product loss: A wake-up call for government leaders

Government leaders have struggled to reduce the infection and deaths due to coronavirus disease 2019 (COVID-19) as well as to keep the economy and businesses open. There is a large variation of mortality and damage to economy among countries. One possible cause leading to the large variation is the manner in which countries have delt with COVID-19. Some countries or regions such as China, New Zealand, and Taiwan, acted quickly and aggressively by implementing border closures, lockdown, school closures, mass testing, etc. On the other hand, many European countries, United States, and Brazil delayed their decisions to implement these restrictions and measures. No study has assessed the correlation between gross domestic product (GDP) and COVID-19 mortality. In the present study, there was a negative correlation between GDP and COVID-19 mortality suggesting that countries that failed to control the virus (larger COVID-19 mortality) would see a larger decline in GDP. Governmental leaders should act fast and aggressively when making decisions because data shows that countries who have run after two hares have caught neither. Furthermore, citizens of each country need to do their own part by following guidelines and practicing social distancing and mask wearing, which are considered the most effective, easiest, and cheapest measures that can be taken, so that repeated lockdowns can be avoided.

Cutaneous leishmaniasis in Louisiana - one-year follow-up: A case report

BACKGROUND

Reports of leishmaniasis are scarce in North America. It is considered to be one of the neglected tropical diseases. It is seen in immigrants from endemic areas to United States. Treatments are not readily available in the United States. Untreated or inadequately treated cutaneous leishmaniasis not only causes localized disfigurement but can advance to more permanent and devastating mucosal disfigurement and perforation, if caused by a species that can also cause mucocutaneous leishmaniasis.

CASE SUMMARY

A 42-year-old human immunodeficiency virus negative male immigrant from Honduras presented to the emergency department of our facility in Louisiana with a 2-mo history of a left lower extremity ulcer. It started as a painless blister that progressed in size and developed into other smaller lesions tracking up the thigh and became tender and erythematous. Clinically looked nontoxic and healthy. He was afebrile. Blood tests, except inflammatory markers, were within normal limits. The cellulitis of the leg was treated with 6 d of vancomycin that also relieved the pain. Skin biopsy was obtained, and histopathology was suspicious for leishmania. Polymerase chain reaction/deoxyribonucleic acid sequencing done by centers for disease control and prevention confirmed the diagnosis as Leishmania panamensis. There was no involvement of naso-oropharyngeal mucosa, confirmed by otolaryngology. The patient was treated with miltefosine for 28 d. Clinic follow-up after approximately 11 mo revealed a healed skin ulcer.

CONCLUSION

Cutaneous leishmaniasis should be in the differential diagnosis of skin ulcers of travelers from endemic areas. Awareness regarding diagnosis and treatment of leishmaniasis needs to be enhanced.

Liver transplantation in patients with SARS-CoV-2: Two case reports

BACKGROUND

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19). This disease was declared a worldwide health problem with the characteristics of a pandemic. Most patients have mild symptoms and a good prognosis. Information on the evolution and prognosis of COVID-19 in solid organ recipients is scarce.

CASE SUMMARY

We describe two patients who underwent liver transplantation with a positive test result for detection of the viral sequence for COVID-19, using reverse-transcription polymerase chain reaction (RT-PCR), immediately before transplantation. The patients showed good evolution in the postoperative period, without signs of graft dysfunction. The immunosuppressive therapy was not modified. Both patients were discharged for subsequent outpatient follow-up.

CONCLUSION

In conclusion, it is expected that the experience at this center can be used as an example, aimed at the continuation of transplantations by other services and, thus, the morbidity and mortality of patients with liver disease on the transplantation waiting list can be reduced. Transplant centers must be able to readjust daily to the evolution of the COVID-19 pandemic.

Life after recovery from SARS, influenza, and Middle East respiratory syndrome: An insight into possible long-term consequences of COVID-19

Viral infectious diseases have become an increased public health issue in the past 20 years. The outbreaks of severe acute respiratory syndrome coronavirus (SARS-CoV-1) in 2002, influenza H1N1 in 2009, Middle East respiratory syndrome-CoV in 2012, and the current new coronavirus SARS-CoV-2 have shown that viral infectious diseases are a major concern in the 21^st century. As the world lives under the pandemic of a new coronavirus (COVID-19), knowing the clinical characteristics from those past diseases and their long-term outcomes is important to understand the current coronavirus pandemic and its complications and consequences better and plan for possible future outbreaks. Several long-term complications have been described with these respiratory viral diseases, such as decreased pulmonary function, pulmonary fibrosis, chronic fatigue syndrome, avascular necrosis of bone, polyneuropathy, encephalitis, posttraumatic stress disorder, depression, and anxiety. This article summarizes several studies describing chronic complications and long-term outcomes of patients recovered from these viral syndromes.

Stenotrophomonas maltophilia, an emerging pathogen in newborns: Three case reports and a review of the literature

BACKGROUND

Stenotrophomonas maltophilia (S. maltophilia) is a rare cause of neonatal sepsis with significant morbidity and mortality and has extensive resistance to several antibiotics leaving few options for antimicrobial therapy. Only a few cases have been reported in neonates from developing countries. We report three cases of critically ill, extramural babies with neonatal S. maltophilia sepsis. All three babies recovered and were discharged.

CASE SUMMARY

All three cases were term extramural babies, who were critically ill at the time of presentation at our neonatal intensive care unit. They had features of multiorgan dysfunction at admission. Blood culture was positive for S. maltophilia in two babies and one had a positive tracheal aspirate culture. The babies were treated according to the antibiogram available. They recovered and were subsequently discharged.

CONCLUSION

Although various authors have reported S. maltophilia in pediatric and adult populations, only a few cases have been reported in the newborn period and this infection is even rarer in developing countries. Although S. maltophilia infection has a grave outcome, our three babies were successfully treated and subsequently discharged.

Top ten tips for perfect corona-2 prophylaxis

The current corona-2 pandemic has stimulated wide research for hydroxychloroquine (Quine) therapy and lately, prophylaxis. To optimize prophylaxis proper methods of use are explained. The focus is on tools of assessment and robust comparison; defining infection objectively; loading and maintenance dose designing based on pharmaco-viro-kinetics; confirming Quine threshold-levels and its sufficiency; and Quine side-effects vigilance/ amelioration. Attention to statistics to study valid endpoints of goals in appropriately-sized population is essential. Mass interactive quine dose auto designer software is built to simplify, optimize and help collaboration of complex Quine dosing system. A similar chloroquine software can be built.

COVID-19 and dengue coinfection in Brazil

The case we present here is a man who lives in a dengue-endemic area. Initially, the patient was diagnosed with dengue fever by clinical evaluation and laboratorial confirmation. Subsequently, he presented respiratory symptoms, and a concomitant severe acute respiratory syndrome coronavirus 2 infection was confirmed. He was hospitalized for 17 d and had a satisfactory recovery.

COVID-19 risk comorbidities: Time to reappraise our physical inactivity habits (again!)

Infection and mortality rates of coronavirus disease 2019 (COVID-19) are astonishing. As of September 7, 2020, more than 27 million people around the world have already been infected, with more than 890 thousand deaths. Hypertension, diabetes, and obesity are among the most reported comorbidities associated with mortality by this disease. All these comorbidities are also strongly associated with physical inactivity and sedentary behavior. On the other hand, it is known that aerobic and resistive exercises are excellent tools to prevent and manage these comorbidities. Hence, physically active people may have a better prognosis if infected by COVID-19. Also, science tried to warn about mortality and morbidity associated to physical inactivity more than 80 years ago. However, physical inactivity habits are getting more prevalent around the world. Reasons for that include social, technology, and economic development that led to large industrialization and urbanization. Along with these changes, both professional and domestic activities became less active. Consequently, health care costs related to hypokinesis are estimated to increase exponentially in various regions of the planet. Now, while facing COVID-19 pandemic, it is time to reinforce the physiological, social, and economic relevance of regular physical exercise. Therefore, urgent reappraisal of our physical inactivity habits should be done, again!

Abdominal aortic thrombosis as initial presentation of COVID-19 infection: A case report

BACKGROUND

The hypercoagulable state associated with coronavirus disease 2019 (COVID-19) has been shown to complicate the course of this viral illness with both venous and arterial clots. Often presenting after hospitalization and known COVID-19 diagnosis, the etiology of thrombosis has been attributed to the hyperinflammatory state and endothelial dysfunction associated with COVID-19. This report portrays a patient who experienced an aortic thrombosis resulting in back and leg pain with subsequent loss of motor function of his legs as his initial presentation of COVID-19.

CASE SUMMARY

Patient is a 60-year-old Caucasian male with no medical history who presented with sudden onset pain in his lower back and lower extremities. He went on to experience complete motor loss of the lower extremities two hours after admission. Chest pain and shortness of breath developed one day later but were not present at time of presentation. Computed tomography angiography of the chest, abdomen, and pelvis revealed occlusion by thrombosis of the abdominal aorta in addition to multifocal pulmonary ground-glass opacities prompting COVID-19 PCR, which was positive. He was taken to surgery for attempted thrombectomy and the thrombus was retrieved starting from the right common femoral artery, but a second thrombus had immediately reformed in place of the prior thrombectomy site resulting in conclusion of the procedure. He was continued on unfractionated heparin and received a dose of tocilizumab 400 mg, but rapidly developed hemodynamic compromise and expired from cardiac arrest.

CONCLUSION

This presentation emphasizes the importance of evaluating patients for COVID-19 who experience unusual thromboses without superior explanation.

Antibiotics for complicated urinary tract infection and acute pyelonephritis: A systematic review

BACKGROUND

The increasing rates of antibiotic-resistance in recent years have supported emergence of multiple drug-resistant bacteria. Therefore, antibiotics that are recommended by the current clinical guidelines may not be effective for the treatment of complicated urinary tract infection (UTI) and acute pyelonephritis.

AIM

To determine the clinical efficacy and safety of antibiotics for the treatment of complicated UTI and acute pyelonephritis.

METHOD

A search of PubMed, EMBASE, and Google Scholar was conducted for eligible articles describing the use of antibiotics in managing complicated UTI and acute pyelonephritis. The following keywords were used to perform the literature search: “urinary tract infection”, “complicated UTI”, “pyelonephritis”, “treatment”, and “antibiotics”. Additional articles of interest were retrieved from the reference lists of selected papers. Eligibility criteria for this systematic review were diagnosis of either complicated UTI or acute pyelonephritis and use of antibiotics in management. Clinical trials and observational studies were included, while case reports and reviews were excluded. The methodological quality of clinical trials and observational studies was assessed. A descriptive approach was adopted to analyze the data, due to the variation of methodology and interventions.

RESULT

A total of 183 studies were screened, and 8 matched all the eligibility criteria and were included in this review. The antibiotics used included ceftazidime-avibactam, doripenem, levofloxacin, meropenem-vaborbactam, piperacillin-tazobactam, plazomicin, tazobactam-ceftolozane, and gentamicin. Two clinical trials reported that shorter-duration levofloxacin or non-fluoroquinolone antibiotic treatment was as effective as the duration of antibiotic therapy recommended by the current guidelines in treating complicated UTI and pyelonephritis. Besides that, ceftazidime-avibactam, piperacillin-tazobactam and tazobactam-ceftolozane can be used as alternatives to carbapenem in treating extended-spectrum -lactamase-producing Escherichia coli. The cure rates of complicated UTI and pyelonephritis by meropenem-vaborbactam, piperacillin-tazobactam and tazobactam-ceftolozane was comparable (95.6%-98.4%). Furthermore, levofloxacin had a relatively high rate of adverse events (33.1% and 47.7% in two clinical trials respectively), while tazobactam-ceftolozane had a relatively low rate of adverse events (17.5%). All studies have limitations and a potential for bias.

CONCLUSION

N

Predictors of severe and critical COVID-19: A systematic review

BACKGROUND

Coronavirus disease 2019 (COVID-19) has emerged as a public health crisis that was declared as a global pandemic by the World Health Organization. Although most cases have no or mild symptoms, around 10% of patients develop severe or critical illness that necessitates hospitalization and intensive care unit admission.

AIM

To assess the literature for the predictive factors that can identify patients having severe/critical COVID-19 disease.

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic search of the literature was conducted. Electronic databases including PubMed/MEDLINE, Scopus, and Cochrane Library were queried. The main outcome measures were the predictors of severe/critical COVID-19 and mortality.

RESULTS

Five studies including 583 patients of a median age of 50.5 years were reviewed. Patients were 346 (59.4%) male and 237 (40.6%) female. Of 583 hospitalized patients, 242 (41.5%) had critical illness. Acute respiratory distress disease occurred in 291 patients, accounting for 46.7% of total complications. One-hundred (17.1%) mortalities were recorded. The most commonly reported predictors of severe COVID-19 were older age, medical comorbidities, lymphopenia, elevated C-reactive protein, increased D-dimer, and increased neutrophil ratio. Findings on computed tomography (CT) scanning predictive of severe disease were bronchial wall thickening, CT score > 7, linear opacities, consolidation, right upper lobe affection, and crazy paving pattern.

CONCLUSION

Several demographic, clinical, laboratory, and radiologic factors can help predict severe and critical COVID-19 along with the potential need for mechanical ventilation. Factors that were more commonly reported were older age, medical comorbidities, lymphopenia, increased neutrophil ratio, elevated C-reactive protein, and increased D-dimer.

COVID-19 compared to other epidemic coronavirus diseases and the flu

Coronaviruses are among the largest group of known positive - sense RNA viruses with a wide range of animal hosts as reservoir. In the last two decades, newly evolved coronaviruses such as the severe acute respiratory syndrome coronavirus (SARS-CoV) which caused the infamous 2002 outbreak, the Middle East respiratory syndrome coronavirus (MERS-CoV) which caused an outbreak in 2012, and now the SARS-CoV-2 [responsible for the current coronavirus disease 2019 (COVID-19)] have all posed notable threats to global public health. But, how does the current COVID-19 outbreak compare with previous coronaviruses diseases? In this review, we look at the key differences between SARS-CoV, MERS-CoV, and SARS-CoV-2, and examine challenges in determining accurate estimates of the severity of COVID-19. We discuss coronavirus outbreaks in light of key outbreak severity indicators including, disease fatality, pathogen novelty, ease of transmission, geographical range, and outbreak preparedness. Finally, we review clinical trials of emerging treatment modalities and provide recommendations on the control of COVID-19 based on the mode of transmission of the coronaviruses. We also recommend the development and use of a standardized predictive epidemic severity models to inform future epidemic response.

GadE regulates fliC gene transcription and motility in Escherichia coli

BACKGROUND

Escherichia coli (E. coli) express flagella to ascend human urinary tracts. To survive in the acidic pH of human urine, E. coli uses the glutamate decarboxylase acid response system, which is regulated by the GadE protein.

AIM

To determine if growth in an acidic pH environment affected fliC transcription and whether GadE regulated that transcription.

METHODS

A fliC-lacZ reporter fusion was created on a single copy number plasmid to assess the effects of acidic pH on fliC transcription. Further, a ΔgadE mutant strain of a uropathogenic E. coli was created and tested for motility compared to the wild-type strain.

RESULTS

Escherichia coli cells carrying the fliC-lacZ fusion displayed significantly less fliC transcription when grown in an acidic pH medium compared to when grown in a neutral pH medium. Transcription of fliC fell further when the E. coli was grown in an acidic pH/high osmolarity environment. Since GadE is a critical regulator of one acid response system, fliC transcription was tested in a gadE mutant strain grown under acidic conditions. Expression of fliC was derepressed in the E. coli gadE mutant strain grown under acidic conditions compared to that in wild-type bacteria under the same conditions. Furthermore, a gadE mutation in a uropathogenic E. coli background exhibited significantly greater motility than the wild-type strain following growth in an acidic medium.

CONCLUSION

Together, our results suggest that GadE may down-regulate fliC transcription and motility in E. coli grown under acidic conditions.

Serratia marcescens and other non-AACEK GNB endocarditis: A case report and review of literature

BACKGROUND

Non-Aggregatibacter aphrophilus, Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella spp. (non-AACEK) gram-negative bacilli (GNBs) are an infrequent and challenging cause of endocarditis associated previously with mainly intravenous drug use. Currently, this pathology has increasingly become a healthcare-associated issue. Current guidelines do not clearly define the management of non-AACEK GNB endocarditis due to a lack of prospective trials. We review characteristics, outcomes and treatment of non-AACEK GNB endocarditis, in particular Serratia marcescens endocarditis.

CASE SUMMARY

We describe the case report of a 46-year-old man who presented to the emergency department with high-grade fever and a purulent exudate on an intracardiac device site. Serratia marcescens mitral valve endocarditis as a consequence of complicated generator pocket infection was diagnosed. The patient was treated with complete device removal and a long course of broad-spectrum antibiotics for 6 wk after surgery with intravenous piperacillin-tazobactam and ciprofloxacin, which was later switched to oral ciprofloxacin and sulfamethoxazole-trimethoprim. The patient had complete resolution of symptoms and inflammatory parameters at the end of the treatment and at follow-up.

CONCLUSION

Long-term dual-antibiotic therapy containing a beta-lactam is indicated for most non-AACEK GNB endocarditis, whereas valve surgery may not be necessary in all patients.

Towards the worldwide eradication of hepatitis B virus infection: A combination of prophylactic and therapeutic factors

Hepatitis B virus (HBV) is still a global health problem, mostly because of the intermediate/high rates of HBV chronic carriers living in most Asian, African and eastern European countries. The universal HBV vaccination of new-borns undertaken in most nations over the last 3 decades and effective HBV antiviral treatments (nucleos(t)ide analogue with high genetic barrier to viral resistance) introduced in the last decade have shown their beneficial effects in inducing a clear reduction of HBV endemicity in the countries where they have been extensively applied. Great hopes are now placed on new antiviral and immunotherapeutic drugs that are now at an advanced stage of study. It is in fact already conceivable that the synergistic use of new drugs targeting more than one HBV-lifecycle steps (covalent closed circular DNA destruction/silencing, HBV entry inhibitors, nucleocapsid assembly modulators targeting viral transcripts) and of some new immunotherapeutic agents might eliminate the intrahepatic covalent closed circular DNA and achieve the eradication of HBV infection. In spite of this, a strong effort should be given to extensive educational and screening programs for the at-risk population and to the implementation of HBV vaccination in developing countries.

Treatments and limitations for methicillin-resistant Staphylococcus aureus: A review of current literature

Methicillin-resistant Staphylococcus aureus (MRSA) has remained a major threat to healthcare; in both hospital and community settings over the past five decades. With the current use of antibiotics for a variety of infections, including MRSA, emerging resistance is a major concern. Currently available treatments have restrictions limiting their use. These issues include, but are not limited to, side effects, cross-resistance, lack of understanding of pharmacokinetics and clinical pharmacodynamics, gradual increment in minimal inhibitory concentration over the period (MIC creep) and ineffectiveness in dealing with bacterial biofilms. Despite availability of various therapeutic options for MRSA, the clinical cure rates remain low with high morbidity and mortality. Given these challenges with existing treatments, there is a need for development of novel agents for MRSA. Along with prompt infection control strategies and strict implementation of antibiotic stewardship, cautious use of newer anti-MRSA agents will be of utmost importance. This article reviews the treatments and limitations of MRSA management and highlights the future path.

Gastric mucormycosis: A case report

Mucormycosis is a rare fungal infection which is largely diagnosed in immune-compromised patients. The infection can cause pulmonary, rhinocerebral, skin and soft tissue, central nervous system and gastrointestinal system. The gastrointestinal involvement is the rarest presentation, especially the stomach. We present a 38 years old HIV positive female seen in Steve Biko Academic Hospital with 2 wk history of cough, shortness of breath and lethargy. She was clinically found to be pale, pyrexial, dyspnoea and had severe oral thrush. Blood tests revealed hemoglobin of 6 g/dL CD4 count of 63 cells/uL. Chest X-ray showed multi-lobe pneumonia and gastroscopy confirmed esophageal candidiasis and nodular gastritis. She continued to deteriorate despite antibiotics, antifungal and antituberculous treatment. She developed upper gastrointestinal bleed on day 34, and gastroscopy showed a plaque like lesion in the stomach, histology of which confirmed mucormycosis. She improved on Amphotericin B but subsequently deteriorated and demised a few days later. These cases illustrate the occurrence of a rare fungal infection of the stomach and the poor mortality when diagnosis is delayed. Mucormycosis can co-exist with candidiasis and clinicians should have a high index of suspicion especially in patients not responding to appropriate treatment.

Autoimmune hepatitis in human immunodeficiency virus infection: Case report and literature review

The infection due to human immunodeficiency virus (HIV) is characterized by the progressive reduction of CD4⁺ T lymphocytes and the compromise of other cell lines of the immune system, resulting in immunosuppression. In this context, autoimmune diseases could be considered contradictory, however, cases of autoimmune diseases during this infection have been described, including autoimmune hepatitis (AIH), which is uncommon and has few case reports within medical literature, none of them from Latin America. In this case report where a patient with an HIV infection on combined antiretroviral treatment developed acute elevation of transaminases, hyperbilirubinemia, and deterioration in hepatic synthetic function. Although initially an antiretroviral drug-induced liver injury was suspected, during the study a diagnosis of autoimmune hepatitis was proven, which required treatment with corticosteroid and azathioprine, obtaining a satisfactory response and managing to continue the antiretroviral therapy. Autoimmune diseases in HIV infection must be taken into account. In the case of hepatitis in patients with HIV on antiretroviral treatment, the differentiation between viral hepatitis caused by autoimmune diseases or medications is essential to establish an adequate treatment, and avoid the suspension of the antiretroviral therapy.

Atypical manifestation of herpes esophagitis in an immunocompetent patient: Case report and literature review

Herpes simplex virus (HSV) is known to cause esophagitis in immunosuppressed patients; however, it is rarely seen in immunocompetent patients. We present a unique case of HSV esophagitis in a healthy male, without any immunocompromising conditions or significant comorbidities. The patient presented with a two-week history of dysphagia, odynophagia and epigastric pain. Physical exam revealed oral hyperemia without any visible ulcers or vesicles. He underwent esophagogastroduodenoscopy which noted severe esophagitis with ulceration. Esophageal biopsies were positive for HSV. Serology was positive for HSV as well. After initiating treatment with Famciclovir 250 mg 3 times/d, high dose proton pump inhibitor and sucralfate, patient had complete resolution of symptoms at his 2.5 wk follow up appointment. Subsequent workup did not reveal any underlying immune disorders. While HSV is a known causative of esophagitis in the immunocompromised, its presentation in healthy patients without any significant comorbidity is uncommon. Presentation with a systemic viral prodrome further makes this case unique.

Healthcare seeking trends in acute respiratory infections among children of Pakistan

AIM

To assess healthcare seeking trends among Pakistani children with acute respiratory infections through comparative analysis between demographic health surveys (DHS) 2006-2007 and 2012-2013.

METHODS

Data of the last born children 0-24 mo of age of the sampled households from both the DHS was analyzed after seeking permission from the DHS open access website. These were children who had suffered from cough and/or breathing difficulty in the past two weeks and sought health care thereafter. The trends of health care seeking were determined separately for the individual, household and community level according to the study parameters. χ² test was applied to compare these trends. A P-value of < 0.05 was considered significant.

RESULTS

Out of 2508 children in 2006-2007 there were 1590 with acute respiratory infections (ARI) according to case definition along with 2142 out of 3419 children in 2012-2013 DHS, whose data was analyzed. During 2006-2007, 69% cases sought healthcare for ARI which improved to 79% in 2012-2013. Additionally, it was revealed that when compared between 2006-2007 and 2012-2013, improvement in care seeking practices was observed among illiterate mothers (64% vs 77%) although there was minimal change in those literate. Similarly, those women working also showed an increase in healthcare seeking from 67% to 79%. Additionally, those belonging to low and middle socioeconomic class showed a marked increase as compared to those in the higher class where there was no significant change. Whereas those living in rural communities also showed an increase from 66% to 78%.

CONCLUSION

Increasing health budget, improving maternal education and strengthening multi-sectoral coordination are among the effective strategies to improve outcomes associated with healthcare seeking in ARI.