Patients' Perception and Knowledge about Influenza and Pneumococcal Vaccination during the COVID-19 Pandemic: An Online Survey in Patients at Risk of Infections

INTRODUCTION

The objective of our study was to assess, in an at-risk population, perception and knowledge about influenza and pneumococcal vaccinations.

METHODS

An anonymous web-based survey was submitted to patients recruited in France, from both an Ipsos internal panel and AVNIR patient associations. The study was conducted between July and October 2020, in the context of the COVID-19 pandemic.

RESULTS

Overall, 2177 questionnaires from patients at risk of infection were analyzed. Almost all respondents (86%, 1869/2177) declared themselves to be favorable to vaccination. Nearly half of the patients (49%, 1069/2177) were aware of which vaccine was recommended for their specific situation. This percentage was significantly (p < 0.001) higher for members of a patient association and for people affected by multiple chronic conditions and varied according to the type of condition. Almost two-thirds of patients (1373/2177) declared having been vaccinated during the 2019/2020 influenza season, and 41% (894/2177) were certain about being up to date with the pneumococcal vaccination. The main barriers to vaccination for influenza are the fear of side effects, doubt regarding the efficacy of the vaccine and for pneumococcal vaccination, and the absence of suggestions by the healthcare professionals (HCPs), as 64% of respondents were not recommended to obtain pneumococcal vaccination. To improve vaccine coverage, information is of prime importance and GPs are recognized as the main HCP to inform about vaccination. Nearly two-thirds (62%, 1360/2177) of patients declared that the COVID-19 pandemic convinced them to have all the recommended vaccines.

CONCLUSION

Our study highlighted the nonoptimal vaccine coverage in at-risk populations despite a highly positive perception of vaccines and confirmed that physicians are on the front lines to suggest and recommend these vaccinations, especially in the current pandemic context, which may be used to promote other vaccines.

Epidemiology, Diagnosis, and Treatment of Clostridioides difficile Infection in Immunocompromised Children

Clostridioides difficile infection is very common in immunocompromised children. Management is confounded by frequent asymptomatic colonization, multiple alternative etiologies for gastrointestinal symptoms, and high rates of relapse. Important considerations include indications for testing, appropriate choice of diagnostic tests, antibiotic therapy for initial and subsequent episodes, and primary and secondary prevention.

Biology and Treatment Advances in Cutaneous Squamous Cell Carcinoma

Cutaneous squamous cell carcinoma (CSCC) is the second most common skin cancer diagnosed worldwide. CSCC is generally localized and managed with local therapies such as excision and/or radiotherapy. For patients with unresectable or metastatic disease, recent improvements in our understanding of the underlying biology have led to significant advancements in treatment approaches-including the use of immune checkpoint inhibition (ICI)-which have resulted in substantial gains in response and survival compared to traditional cytotoxic approaches. However, there is a lack of understanding of the biology underpinning CSCC in immunocompromised patients, in whom the risk of developing CSCC is hundreds of times higher compared to immunocompetent patients. Furthermore, current ICI approaches are associated with significant risk of graft rejection in organ transplant recipients who make up a significant proportion of immunocompromised patients. Ongoing scientific and clinical research efforts are needed in order to maintain momentum to increase our understanding and refine our therapeutic approaches for patients with CSCC.

Evolution of spike mutations following antibody treatment in two immunocompromised patients with persistent COVID-19 infection

Immunocompromised patients have an increased risk of persistent COVID‐19 disease. We report here the clinical course of two patients with hematologic malignancies hospitalized due to severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection. In both patients, viral evolution including new spike gene mutations that occurred following treatment with anti‐SARS‐CoV‐2 antibodies preparations, including convalescent plasma and bamlanivimab. These cases demonstrate the possibility of antibody‐resistant SARS‐CoV‐2 infections evolution in immunocompromised patients.

Patients with hematologic malignancies are at risk of persistent SARS‐CoV‐2 infection.

Using anti‐SRAS‐CoV‐2 antibody preparations in immunocompromised patients may lead to the evolution of antibody‐resistant SRAS‐CoV‐2 infections.

Antibody‐resistant SRAS‐CoV‐2 infections might have severe epidemiological implications.

Clinical characteristics and prognostic risk factors of mortality in patients with interstitial lung diseases and viral infection: a retrospective cohort study

Introduction. Patients with interstitial lung disease (ILD) who subsequently develop a viral infection have high rates of morbidity and mortality.Hypothesis/Gap Statement. Few large-scale epidemiological studies have investigated potential prognostic factors for morbidity and mortality in this patient group.Aim. To evaluate the risk factors for morbidity and mortality in hospitalized patients with ILD and viral infection, as well as the clinical characteristics.Methodology. This retrospective cohort study included patients with ILD who were hospitalized for a viral infection in two tertiary academic hospitals in China, between 1 January 2013 and 31 December 2019. We analysed the prevalence of comorbidities, clinical characteristics, 30 day mortality rates, and prognostic risk factors.Results. A total of 282 patients were included; 195 and 87 were immunocompromised and immunocompetent, respectively. The most common underlying interstitial diseases were idiopathic pulmonary fibrosis (42.9 %) and connective tissue disease (36.9 %). The 30 day mortality rate was 20.6 %. During the influenza season, an increase in influenza virus (IFV) (25.7 %), respiratory syncytial virus (14.9 %) and cytomegalovirus (CMV) (11.3 %) cases was observed in the immunocompromised group. The most frequently detected virus in the immunocompetent group was IFV (44.8 %), followed by respiratory syncytial virus (11.5 %), and human rhinovirus (9.2 %). During the non-influenza season, CMV (34.4 %) was the main virus detected in the immunocompromised group. The 30 day mortality rates of non-IFV patients were higher than those of IFV patients. Older age (>60 years), respiratory failure, persistent lymphocytopenia, invasive mechanical ventilation and non-IFV virus infection were significantly associated with increased 30 day mortality.Conclusion. Patients with ILD who develop viral infection have high rates of morbidity and mortality, which are associated with increased age (>60 years), respiratory failure, mechanical ventilation, persistent lymphocytopenia and non-IFV virus infection. These risk factors should be carefully considered when determining treatment strategies for this patient population.

Recommendations of the Italian society for infectious and tropical diseases (SIMIT) for adult vaccinations

Vaccination prevents 2-3 million deaths worldwide every year. Nevertheless, vaccine-preventable diseases (VPDs) still cause a considerable number of deaths especially in subjects belonging to "risk groups." These are represented by older adults, immunocompromised individuals and all subjects with underlying chronic medical conditions (cardiovascular, pulmonary, renal and liver chronic diseases, diabetes, immunodeficiency disorders). They have a weaker immune system and, if infected, are more likely to develop severe complications of their condition or of the preventable-infectious disease. This document summarizes the recommendations for vaccination of the main Global Institutional Organizations and analyses the risks of comorbidities associated with infectious disease and the benefits of vaccination for each specific group. The document provides a clear, practical and authoritative guide to adult vaccination.

The role of procalcitonin in identifying high-risk cancer patients with febrile neutropenia: A useful alternative to the multinational association for supportive care in cancer score

Background

The Multinational Association for Supportive Care in Cancer (MASCC) risk index has been utilized to determine the risk for poor clinical outcomes in patients with febrile neutropenia (FN) in an emergency center (EC). However, this index comprises subjective elements and elaborated metrics limiting its use in ECs. We sought to determine whether procalcitonin (PCT) level (biomarker of bacterial infection) with or without lactate level (marker of inadequate tissue perfusion) offers a potential alternative to MASSC score in predicting the outcomes of patients with FN presenting to an EC.

Methods

We retrospectively identified 550 cancer patients with FN who presented to our EC between April 2018, and April 2019, and had serum PCT and lactate levels measured.

Results

Compared with patients with PCT levels <0.25 ng/ml, those with levels ≥0.25 ng/ml had a significantly higher 14‐day mortality rate (5.2% vs. 0.7%; p = 0.002), a higher bloodstream infection (BSI) rate, and a longer hospital length of stay (LOS). Logistic regression analysis showed that patients with PCT levels ≥0.25 ng/ml and lactate levels >2.2 mmol/L were more likely to be admitted and have an LOS >7 days, BSI, and 14‐day mortality than patients with lower levels. PCT level was a significantly better predictor of BSI than MASSC score (p = 0.003) or lactate level (p < 0.0001).

Conclusions

Procalcitonin level is superior to MASCC index in predicting BSI. The combination of PCT and lactate levels is a good predictor of BSI, hospital admission, and 14‐day mortality and could be useful in identifying high‐risk FN patients who require hospital admission.

COVID-19 Infection in Kidney Transplant Recipients: A Single Centre Study from Northern India

INTRODUCTION

Coronavirus disease 2019 (COVID-19) has resulted in significant morbidity and mortality worldwide. The pre-immunosuppressed state along with other existing co-morbidities can influence the outcomes of COVID-19 in transplant patients.

MATERIAL AND METHODS

This was a single centre prospective cohort study done in kidney transplant recipients (KTRs), who underwent kidney transplantation (from December 2012 to November 2020), who were actively followed up at our centre and were diagnosed with COVID-19 disease between 1 April and 30 November 2020.

RESULTS

A total of 62 kidney-transplant recipients tested positive for COVID-19. Their median age was 39 (19-61). Males were predominantly infected (87.1%). Fever was the most common symptom (77.42%). Thirteen (20.9%) had mild form of disease, 32 (51.6%) had moderate form and 17 (27.4%) had severe disease. Based on initial symptom, 18 (29.03%) were given home treatment, 29 (46.7%) were treated in isolation wards and 15 (24.1%) were treated in intensive care unit. Decrease in the dose of immunosuppressant (anti-metabolites in 67.7%, calcineurin inhibitor in 22.5%) was predominantly carried out as the initial mode of treatment. Remdesivir in 64.5% and anticoagulant therapy in 54.84% were given as a modality of treatment. Mortality rate in our study was 14.5%.

CONCLUSIONS

Patients of kidney transplant are at high risk of getting infected with COVID-19, due to their immunosuppressed state. Initial symptoms in KTRs with COVID-19 are similar to that of the general population. Mortality rate is comparatively higher in KTRs as compared to general population.

Acquired epidermodysplasia verruciformis (AEV) in three children after cardiac transplantation: A case series and review of the literature

Acquired epidermodysplasia verruciformis (AEV) describes epidermodysplasia verruciformis developing in an immunocompromised host. There is limited information in the literature regarding AEV in the pediatric population; of the patients reported, most patients described had HIV, with only two reported cases of children who developed AEV post-transplantation. This case series describes three pediatric patients who developed AEV on immunosuppressant therapy following cardiac transplantation. We review risk factors, treatment options, and prognosis of AEV in the pediatric population.

Longitudinal immune profiling of a SARS-CoV-2 reinfection in a solid organ transplant recipient

BACKGROUND

The underlying immunologic deficiencies enabling SARS-CoV-2 reinfection are currently unknown. We describe deep longitudinal immune profiling of a transplant recipient hospitalized twice for COVID-19.

METHODS

A 66-year-old male renal transplant recipient was hospitalized with COVID-19 March 2020 then readmitted to the hospital with COVID-19 233 days after initial diagnosis. Virologic and immunologic investigation were performed on samples from the primary and secondary infections.

RESULTS

Whole viral genome sequencing and phylogenic analysis revealed that viruses causing both infections were caused by distinct genetic lineages without evidence of immune escape mutations. Longitudinal comparison of cellular and humoral responses during primary SARS-CoV-2 infection revealed that this patient responded to the primary infection with low neutralization titer anti-SARS-CoV-2 antibodies that were likely present at the time of reinfection.

DISCUSSION

The development of neutralizing antibodies and humoral memory responses in this patient failed to confer protection against reinfection, suggesting that they were below a neutralizing titer threshold or that additional factors may be required for efficient prevention of SARS-CoV-2 reinfection. Development of poorly neutralizing antibodies may have been due to profound and relatively specific reduction in naïve CD4 T-cell pools. Seropositivity alone may not be a perfect correlate of protection in immunocompromised patients.

COVID-19 in an Immunocompromised Host: Persistent Shedding of Viable SARS-CoV-2 and Emergence of Multiple Mutations, a Case Report

This article reports a case of a 21-year-old woman with refractory B-cell acute lymphocytic leukaemia who presented with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). She remained positive for SARS-CoV-2 by viral culture for 78 days and by polymerase chain reaction (PCR) for 97 days. Sequencing of repeat samples over time demonstrated an increasing and dynamic repertoire of mutations.

COVID-19 Vaccine Booster: To Boost or Not to Boost

Developing safe and effective vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) at a breakneck speed has been an exceptional human achievement. It remains our best hope of containing the coronavirus disease 2019 (COVID-19) pandemic. However, newer, more aggressive SARS-CoV-2 viral strains, as well as the possibility of fading immunity following vaccination, have prompted health officials to investigate the necessity for additional immunization. This has put further pressure on disregarded human life in lower-income countries that already have minimal access to COVID-19 vaccines. The Centers for Disease Control and Prevention (CDC) have recommended a third COVID-19 vaccine dose in immunocompromised individuals in a recent announcement. Governments and health care officials need to develop usage guidelines for COVID-19 vaccine booster doses while considering the dangers of potential waning immunity and new viral strains and prioritizing vulnerable populations everywhere, including those living in lower-income countries.

ECMO Support in Pre-B-Cell ALL for Disseminated Legionnaire's Disease

Legionella pneumophila is a common cause of community- and hospital-acquired pneumonia. Its increasing frequency and reemergence as a pathogen of interest in the intensive care unit is likely due to increased awareness, recognition, and diagnostic test availability (1). Extracorporeal Membrane Oxygenation (ECMO) is increasingly used in the pediatric intensive care unit (PICU) for refractory cardiopulmonary failure and acute respiratory distress syndrome (ARDS) in concert with conventional modalities or when these have failed to adequately support the patient. The breadth of applications for this technology are ever-expanding as our collective knowledge and experience grows. With a particularly high mortality rate among immunocompromised patients, Legionnaires' disease should be considered early in the differential diagnosis and appropriate antimicrobials initiated (1). We present the case of an adolescent patient with pre-B-cell acute lymphoblastic leukemia (pre-B ALL) requiring ECMO support for septic shock and ARDS due to disseminated Legionella. To our knowledge, this is the first case describing an immunocompromised pediatric patient supported with ECMO for Legionnaires' disease.

Tropheryma whipplei intestinal colonization in immunocompromised children in Iran: a preliminary study

Aim & method: Tropheryma whipplei causes Whipple's disease. Children are reservoirs of this bacterium. The aim of this study was to investigate the presence of T. whipplei in children with immunodeficiency in central Iran from July 2018 to February 2019. Stool samples were tested by SYBR Green and Taq-Man real-time PCR assays. For confirmation, the isolated DNA was sequenced. Results: One hundred and thirty children were enrolled. Acute lymphocytic leukemia was the most reported immunodeficient disease (77%), followed by non-Hodgkin lymphoma and retinoblastoma. Thirteen (10%) children had T. whipplei DNA in the stool; 11.4% of the children under 5 years old were positive. Conclusion: This is the first study showing the circulation of T. whipplei in Iran.

Interferon gamma immunotherapy in five critically ill COVID-19 patients with impaired cellular immunity: A case series

Background

Prolonged severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) shedding has been described in immunocompromised coronavirus disease 2019 (COVID-19) patients, resulting in protracted disease and poor outcome. Specific therapy to improve viral clearance and outcome for this group of patients is currently unavailable.

Methods

Five critically ill COVID-19 patients with severe defects in cellular immune responses, high SARS-CoV-2 viral RNA loads, and no respiratory improvement were treated with interferon gamma, 100 μg subcutaneously, thrice weekly. Bronchial secretion was collected every 48 h for routine diagnostic SARS-CoV-2 RT-PCR and viral culture.

Findings

Interferon gamma administration was followed by a rapid decline in SARS-CoV-2 load and a positive-to-negative viral culture conversion. Four patients recovered, and no signs of hyperinflammation were observed.

Conclusions

Interferon gamma may be considered as adjuvant immunotherapy in a subset of immunocompromised COVID-19 patients.

Funding

A.v.L. and R.v.C. are supported by National Institutes of Health (R01AI145781). G.J.O. and R.P.v.R. are supported by a VICI grant (016.VICI.170.090) from the Dutch Research Council (NWO). W.F.A. is supported by a clinical fellowship grant (9071561) of Netherlands Organization for Health Research and Development. M.G.N. is supported by an ERC advanced grant (833247) and a Spinoza grant of the Netherlands Organization for Scientific Research.

SARS-CoV-2 Neutralization Resistance Mutations in Patient with HIV/AIDS, California, USA

We report persistent severe acute respiratory syndrome coronavirus 2 infection in a patient with HIV/AIDS; the virus developed spike N terminal domain and receptor binding domain neutralization resistance mutations. Our findings suggest that immunocompromised patients can harbor emerging variants of severe acute respiratory syndrome coronavirus 2.

Cryptococcal meningitis in an immunocompetent individual: A case report

Cryptococcal meningitis (CM) is mostly seen in immune-compromised patients and rarely occurs in immune-competent individuals. Immunocompetent individuals with CM present with indolent neurological disease and have better clinical outcomes after treatment. However, misdiagnosis is common and these patients may suffer from serious complications with high mortality.

COVID-19 in Immunocompromised Cancer Patients: A Case Series and Review of the Literature

The global pandemic of the novel coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has presented newfound challenges to the oncology community regarding management of disease progression in immunocompromised and cancer patients. Further, the large influx of COVID-19 patients has overwhelmed healthcare facilities, limited access to intensive care unit beds and ventilators, and canceled elective surgeries causing disruptions to the cancer care continuum and re-organization of oncological care. While it is known that the potential threat of infection is greatest in elderly patients (>60 years of age) and patients with underlying comorbidities, there is still insufficient data to determine the risk of COVID-19 in cancer patients. Given the immunosuppressive status in cancer patients arising from chemotherapy and other comorbidities, management of COVID-19 in this patient population carries a unique set of challenges. We report three cases of COVID-19 in immunocompromised cancer patients and discuss the challenges in preventing, diagnosing, and treating this vulnerable group.

Invasive Fusariosis in Patients with Hematologic Diseases

Fusarium species are filamentous fungi widely encountered in nature, and may cause invasive disease in patients with hematologic conditions. Patients at higher risk are those with acute leukemia receiving induction remission chemotherapy or allogeneic hematopoietic cell transplant recipients. In these hosts, invasive fusariosis presents typically with disseminated disease, fever, metastatic skin lesions, pneumonia, and positive blood cultures. The prognosis is poor and the outcome is largely dependent on the immune status of the host, with virtually a 100% death rate in persistently neutropenic patients, despite monotherapy or combination antifungal therapy. In this paper, we will review the epidemiology, clinical manifestations, diagnosis, and management of invasive fusariosis affecting patients with hematologic diseases.

Emergomyces orientalis Emergomycosis Diagnosed by Metagenomic Next-Generation Sequencing

Emergomyces is a newly described dimorphic fungus genus; it may cause fatal infections in immunocompromised patients, but diagnosis is often delayed. We report a case of disseminated emergomycosis caused by the novel species Emergomyces orientalis in a kidney transplant recipient from Tibet. Infection was diagnosed early by metagenomic next-generation sequencing.

Nocardiosis in Immunocompromised Patients on Alternative Pneumocystis Prophylaxis

Prophylactic trimethoprim/sulfamethoxazole (TMP/SMX) prevents Pneumocystis jirovecii pneumonia and nocardiosis in immunocompromised patients but sometimes is avoided because of purported allergies or side effects. Of 25 immunocompromised patients receiving alternative prophylaxis in whom nocardiosis developed, 16 subsequently tolerated TMP/SMX treatment. Clinicians should consider TMP/SMX allergy evaluation and rechallenging to assess patient tolerance.

Rat Hepatitis E Virus: Presence in Humans in South-Western France?

Background: Hepatitis E Virus (HEV) is one of the most common causes of hepatitis worldwide, and South-Western France is a high HEV seroprevalence area. While most cases of HEV infection are associated with the species Orthohepevirus-A, several studies have reported a few cases of HEV infections due to Orthohepevirus-C (HEV-C) that usually infects rats. Most of these human cases have occurred in immunocompromised patients. We have screened for the presence of HEV-C in our region. Methods and Results: We tested 224 sera, mostly from immunocompromised patients, for HEV-C RNA using an in-house real time RT-PCR. Liver function tests gave elevated results in 63% of patients: mean ALT was 159 IU/L (normal < 40 IU/L). Anti-HEV IgG (49%) and anti-HEV IgM (9.4%) were frequently present but none of the samples tested positive for HEV-C RNA. Conclusion: HEV-C does not circulate in the human population of South-Western France, despite the high seroprevalence of anti-HEV IgG.

Sirolimus in a Renal Transplant Recipient Infected With COVID-19: A Blessing in Disguise?

Immunocompromised status Is often associated with severe coronavirus infection given the inability of the immune system to combat the deadly severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Patients with multiple comorbidities such as diabetes mellitus, hypertension, and chronic kidney disease along with patients on immunosuppressants or chemotherapy are at higher risk of getting infected during the ongoing pandemic with more probability of adverse outcomes. However, we report a rare case of a renal transplant recipient who was on sirolimus and contracted coronavirus disease (COVID-19). His immunosuppressants were continued and he was managed with antiviral, steroids and low molecular weight heparin and the patient responded well to the treatment and recovered completely after a span of one week. Use of sirolimus in a patient with renal transplant recipient helped in preventing intensification of the severity in COVID-19 attributing to its inhibiting effect on mammalian target of rapamycin (mTOR) which he was using post his renal transplant, therefore, proving to be a blessing in disguise.

Improving the Outcomes of Immunocompromised Patients With Coronavirus Disease 2019

Recent case studies have highlighted the fact that certain immunocompromised individuals are at risk for prolonged SARS-CoV-2 replication, intrahost viral evolution of multiply-mutated variants, and poor clinical outcomes. The immunologic determinants of this risk, the duration of infectiousness, and optimal treatment and prevention strategies in immunocompromised hosts are ill defined. Of additional concern is the widespread use of immunosuppressive medications to treat COVID-19, which may enhance and prolong viral replication in the context of immunodeficiency. We outline the rationale for 4 interrelated approaches to usher in an era of evidence-based medicine for optimal management of immunocompromised patients with COVID-19: multicenter pathogenesis and outcomes studies to relate the risk of severe disease to the type and degree of immunodeficiency, studies to evaluate immunologic responses to SARS-CoV-2 vaccines, studies to evaluate the efficacy of monoclonal antibodies for primary prophylaxis, and clinical trials of novel antiviral agents for the treatment of COVID-19.