Graded Dalbavancin Challenge in a Patient With Severe Vancomycin Hypersensitivity Reaction

Cross-reactivity should be considered when treating patients with a previous hypersensitivity reaction within the same class of antibiotics that share similar chemical structures. This case report describes a patient with severe hypersensitivity reaction to vancomycin who successfully tolerated a dalbavancin graded challenge.

The Longitudinal Immune Response to Coronavirus Disease 2019: Chasing the Cytokine Storm

The clinical progression of the severe acute respiratory syndrome coronavirus 2 infection, coronavirus 2019 (COVID-19), to critical illness is associated with an exaggerated immune response, leading to magnified inflammation termed the "cytokine storm." This response is thought to contribute to the pathogenicity of severe COVID-19. There is an initial weak interferon response and macrophage activation that results in delayed neutrophil recruitment leading to impeded viral clearance. This causes prolonged immune stimulation and the release of proinflammatory cytokines. Elevated inflammatory markers in COVID-19 (e.g., d-dimer, C-reactive protein, lactate dehydrogenase, ferritin, and interleukin-6) are reminiscent of the cytokine storm seen in severe hyperinflammatory macrophage disorders. The dysfunctional immune response in COVID-19 also includes lymphopenia, reduced T cells, reduced natural killer cell maturation, and unmitigated plasmablast proliferation causing aberrant IgG levels. The progression to severe disease is accompanied by endotheliopathy, immunothrombosis, and hypercoagulability. Thus, both parts of the immune system-innate and adaptive-play a significant role in the cytokine storm, multiorgan dysfunction, and coagulopathy. This review highlights the importance of understanding the immunologic mechanisms of COVID-19 as they inform the clinical presentation and advise potential therapeutic targets.

Comparative Survival Analysis of Immunomodulatory Therapy for Coronavirus Disease 2019 Cytokine Storm

Background

Cytokine storm is a marker of coronavirus disease 2019 (COVID-19) illness severity and increased mortality. Immunomodulatory treatments have been repurposed to improve mortality outcomes.

Research Question

Do immunomodulatory therapies improve survival in patients with COVID-19 cytokine storm (CCS)?

Study Design and Methods

We conducted a retrospective analysis of electronic health records across the Northwell Health system. COVID-19 patients hospitalized between March 1, 2020, and April 24, 2020, were included. CCS was defined by inflammatory markers: ferritin, > 700 ng/mL; C-reactive protein (CRP), > 30 mg/dL; or lactate dehydrogenase (LDH), > 300 U/L. Patients were subdivided into six groups: no immunomodulatory treatment (standard of care) and five groups that received either corticosteroids, anti-IL-6 antibody (tocilizumab), or anti-IL-1 therapy (anakinra) alone or in combination with corticosteroids. The primary outcome was hospital mortality.

Results

Five thousand seven hundred seventy-six patients met the inclusion criteria. The most common comorbidities were hypertension (44%-59%), diabetes (32%-46%), and cardiovascular disease (5%-14%). Patients most frequently met criteria with high LDH (76.2%) alone or in combination, followed by ferritin (63.2%) and CRP (8.4%). More than 80% of patients showed an elevated D-dimer. Patients treated with corticosteroids and tocilizumab combination showed lower mortality compared with patients receiving standard-of-care (SoC) treatment (hazard ratio [HR], 0.44; 95% CI, 0.35-0.55; P < .0001) and with patients treated with corticosteroids alone (HR, 0.66; 95% CI, 0.53-0.83; P = .004) or in combination with anakinra (HR, 0.64; 95% CI, 0.50-0.81; P = .003). Corticosteroids when administered alone (HR, 0.66; 95% CI, 0.57-0.76; P < .0001) or in combination with tocilizumab (HR, 0.43; 95% CI, 0.35-0.55; P < .0001) or anakinra (HR, 0.68; 95% CI, 0.57-0.81; P < .0001) improved hospital survival compared with SoC treatment.

Interpretation

The combination of corticosteroids with tocilizumab showed superior survival outcome when compared with SoC treatment as well as treatment with corticosteroids alone or in combination with anakinra. Furthermore, corticosteroid use either alone or in combination with tocilizumab or anakinra was associated with reduced hospital mortality for patients with CCS compared with patients receiving SoC treatment.

Heme oxygenase-1 deficiency presenting with interstitial lung disease and hemophagocytic flares

BACKGROUND

Heme oxygenase-1 (HMOX1) catalyzes the metabolism of heme into carbon monoxide, ferrous iron, and biliverdin. Through biliverdin reductase, biliverdin becomes bilirubin. HMOX1-deficiency is a rare autosomal recessive disorder with hallmark features of direct antibody negative hemolytic anemia with normal bilirubin, hyperinflammation and features similar to macrophage activation syndrome. Clinical findings have included asplenia, nephritis, hepatitis, and vasculitis. Pulmonary features and evaluation of the immune response have been limited.

CASE PRESENTATION

We present a young boy who presented with chronic respiratory failure due to nonspecific interstitial pneumonia following a chronic history of infection-triggered recurrent hyperinflammatory flares. Episodes included hemolysis without hyperbilirubinemia, immunodeficiency, hepatomegaly with mild transaminitis, asplenia, leukocytosis, thrombocytosis, joint pain and features of macrophage activation with negative autoimmune serologies. Lung biopsy revealed cholesterol granulomas. He was found post-mortem by whole exome sequencing to have a compound heterozygous paternal frame shift a paternal frame shift HMOX1 c.264_269delCTGG (p.L89Sfs*24) and maternal splice donor HMOX1 (c.636 + 2 T > A) consistent with HMOX1 deficiency. Western blot analysis confirmed lack of HMOX1 protein upon oxidant stimulation of the patient cells.

CONCLUSIONS

Here, we describe a phenotype expansion for HMOX1-deficiency to include not only asplenia and hepatomegaly, but also interstitial lung disease with cholesterol granulomas and inflammatory flares with hemophagocytosis present in the bone marrow.

Nebulized in-line endotracheal dornase alfa and albuterol administered to mechanically ventilated COVID-19 patients: A case series

Background

Mechanically ventilated patients with coronavirus disease 2019 (COVID-19) have a mortality of 24–53%, in part due to distal mucopurulent secretions interfering with ventilation. Dornase alfa is recombinant human DNase 1 and digests DNA in mucoid sputum. Nebulized dornase alfa is FDA-approved for cystic fibrosis treatment. DNA from neutrophil extracellular traps (NETs) contributes to the viscosity of mucopurulent secretions. NETs are found in the serum of patients with severe COVID-19, and targeting NETs reduces mortality in animal models of acute respiratory distress syndrome (ARDS). Thus, dornase alfa may be beneficial to patients with severe COVID-19—acting as a mucolytic and targeting NETs. However, delivery of nebulized drugs can aerosolize SARS-CoV-2, which causes COVID-19, increasing the infection risk for staff. Here, we report a single center case series where dornase alfa was administered through an in-line nebulizer system to minimize risk of virus aerosolization.

Methods

Demographic, clinical data, and outcomes were collected from the electronic medical records of five mechanically ventilated patients with COVID-19—including three requiring veno-venous extracorporeal membrane oxygenation (VV-ECMO)—treated with nebulized in-line endotracheal dornase alfa co-administered with albuterol (used to increase delivery to the alveoli), between March 31 and April 24, 2020. Data on tolerability and responses, including longitudinal values capturing respiratory function and inflammatory status, were analyzed.

Results

Following nebulized in-line administration of dornase alfa with albuterol, the fraction of inspired oxygen requirements was reduced for all five patients. All patients remain alive and two patients have been discharged from the intensive care unit. No drug associated toxicities were identified.

Conclusions

The results presented in this case series suggest that dornase alfa will be well-tolerated by critically ill patients with COVID-19. Clinical trials are required to formally test the dosing, safety, and efficacy of dornase alfa in COVID-19, and two have recently been registered (NCT04359654 and NCT04355364). With this case series, we hope to contribute to the development of management approaches for critically ill patients with COVID-19.

EmtA, a rRNA methyltransferase conferring high-level evernimicin resistance

Enterococcus faecium strain 9631355 was isolated from animal sources on the basis of its resistance to the growth promotant avilamycin. The strain also exhibited high-level resistance to evernimicin, a drug undergoing evaluation as a therapeutic agent in humans. Ribosomes from strain 9631355 exhibited a dramatic reduction in evernimicin binding, shown by both cell-free translation assays and direct-binding assays. The resistance determinant was cloned from strain 9631355; sequence alignments suggested it was a methyltransferase and therefore it was designated emtA for evernimicin methyltransferase. Evernimicin resistance was transmissible and emtA was localized to a plasmid-borne insertion element. Purified EmtA methylated 50S subunits from an evernimicin-sensitive strain 30-fold more efficiently than those from a resistant strain. Reverse transcription identified a pause site that was unique to the 23S rRNA extracted from resistant ribosomes. The pause corresponded to methylation of residue G2470 (Escherichia coli numbering). RNA footprinting revealed that G2470 is located within the evernimicin-binding site on the ribosome, thus providing an explanation for the reduced binding of the drug to methylated ribosomes.

Inactivation of p42 mitogen-activated protein kinase is required for exit from M-phase after cyclin destruction

By using cycling Xenopus egg extracts, we have previously found that if mitogen-activated protein kinase (p42 MAPK) is activated on entry into mitosis (M-phase), the extract is arrested with condensed chromosomes and spindle microtubules. Here we show that these arrested extracts have high levels of M-phase promoting factor (MPF, Cyclin B/Cdc2) activity, stabilized levels of Cyclin B, and sustained M-phase-specific phosphorylations. We also examined the role of p42 MAPK in DNA damage checkpoint-arrested extracts that were induced to enter M-phase by the addition of Cdc25C protein. In these extracts, Cdc25C protein triggers the abrupt, premature activation of MPF and entry into M-phase. MPF activity then drops suddenly due to Cyclin B proteolysis, just as p42 MAPK is activated. Unexpectedly, however, M-phase is sustained, as judged by maintenance of M-phase-specific phosphorylations and condensed chromosomes. To determine if this M-phase arrest depended on p42 MAPK activation, we added PD98059 (PD), an inhibitor of p42 MAPK activation, to egg extracts with exogenous Cdc25. Both untreated and PD-treated extracts entered M-phase simultaneously, with a sharp peak of MPF activity. However, only PD-treated extracts subsequently exited from M-phase and entered interphase. In PD-treated extracts, p42 MAPK was not activated, and the transition to interphase was accompanied by the formation of decondensed nuclei and the disappearance of M-phase-specific phosphorylation of proteins. These results show that although entry into M-phase requires the activation of MPF, exit from M-phase even after cyclin destruction, is dependent on the inactivation of p42 MAPK.

Mos-induced p42 mitogen-activated protein kinase activation stabilizes M-phase in Xenopus egg extracts after cyclin destruction

Previously, we have shown that the addition of a constitutively-active mitogen-activated protein kinase kinase protein (MAPKK = MEK) to cycling Xenopus egg extracts activates the p42MAPK pathway, leading to a G2 or M-phase cell cycle arrest. The stage of the arrest depends on the timing of p42MAPK activation. If p42MAPK is activated prior to M-phase, or after exit from M-phase, the extract is arrested in G2. If p42MAPK is activated during entry into M-phase, the extract is arrested in M-phase. In this study, we show that the addition of recombinant Mos protein (which directly phosphorylates and activates MEK) to cycling egg extracts has the same effect as those described for MEK. The addition of Mos to the extract at the start of incubation leads to a G2 arrest with large interphase nuclei with intact nuclear envelopes. If Mos is added at later times, however, the activation of p42MAPK leads to an M-phase arrest with condensed chromosomes and mitotic arrays of microtubules. Moreover, the extent of M-phase specific phosphorylations is shown by the sustained presence of phosphoproteins that are detected by the monoclonal antibody MPM-2. Unexpectedly, in certain M-phase arrested extracts, histone H1 kinase activity levels reach a peak on entry into M-phase but then fall abruptly to interphase levels. When these extracts are analyzed by immunoblotting, Cyclin B2 is destroyed in those samples containing low maturation promoting factor activity (MPF, cyclin B/Cdc2), yet chromosomes remain condensed with associated mitotic arrays of microtubules and M-phase-specific phosphorylations are sustained. These results suggest that although MPF is required for entry into M-phase, once established, M-phase can be maintained by the p42MAPK pathway after the proteolysis of mitotic cyclins.

Activation of the p42 mitogen-activated protein kinase pathway inhibits Cdc2 activation and entry into M-phase in cycling Xenopus egg extracts

We have added constitutively active MAP kinase/ERK kinase (MEK), an activator of the mitogen-activated protein kinase (MAPK) signaling pathway, to cycling Xenopus egg extracts at various times during the cell cycle. p42MAPK activation during entry into M-phase arrested the cell cycle in metaphase, as has been shown previously. Unexpectedly, p42MAPK activation during interphase inhibited entry into M-phase. In these interphase-arrested extracts, H1 kinase activity remained low, Cdc2 was tyrosine phosphorylated, and nuclei continued to enlarge. The interphase arrest was overcome by recombinant cyclin B. In other experiments, p42MAPK activation by MEK or by Mos inhibited Cdc2 activation by cyclin B. PD098059, a specific inhibitor of MEK, blocked the effects of MEK(QP) and Mos. Mos-induced activation of p42MAPK did not inhibit DNA replication. These results indicate that, in addition to the established role of p42MAPK activation in M-phase arrest, the inappropriate activation of p42MAPK during interphase prevents normal entry into M-phase.

Cloning and nucleotide sequence of the gyrA gene from Campylobacter fetus subsp. fetus ATCC 27374 and characterization of ciprofloxacin-resistant laboratory and clinical isolates

The gyrA gene of Campylobacter fetus subsp. fetus, which encodes the A subunit of DNA gyrase, was cloned, and its nucleotide sequence was determined. An open reading frame of 2,586 nucleotides which encodes a polypeptide of 862 amino acids with an Mr of 96,782 was identified. C. fetus subsp. fetus GyrA is most closely related to Campylobacter jejuni GyrA, with 73% homology at the nucleotide level and 78% identity between polypeptides. The next most closely related GyrA was that from Helicobacter pylori, with both DNA homology and amino acid identity of 63%. The gyrA and gyrB (DNA gyrase B subunit) genes were located on the genomic map of C. fetus subsp. fetus ATCC 27374 and shown to be separate. A clinical isolate of C. fetus subsp. fetus and a laboratory-derived mutant of ATCC 27374, both resistant to ciprofloxacin, had identical mutations within the quinolone resistance determining region. In both mutants a G-->T transversion, corresponding to a substitution of Asp-91 to Tyr in GyrA, was linked to ciprofloxacin resistance, giving MICs of 8 to 16 micrograms/ml.

Effect of naturally occurring visual acuity differences between two eyes in stereoacuity

Stereoacuity was measured in 30 subjects with a naturally occurring visual acuity (VA) difference between the eyes. The stereoacuity was measured by a modified Howard's apparatus using the staircase method and VA was measured with log MAR charts. Stereoacuity was worse in subjects with a large VA difference between the two eyes; the correlation between stereoacuity and VA difference was significant (r = 0.76, P < 0.001). Neither the VA of the worse eye nor of the better eye contributed to the reduction in stereoacuity. The deterioration was more obvious if VA difference between the two eyes was one line or more (correlation coefficient, r= 0.88, P < 0.001). This study also reinforces the use of a > or = 70% stereothreshold when attempt stereoacuity results to compare with other studies.

An analysis of multiple congenital anomaly syndromes in a Chinese population

During an eight-year period, 4,890 index patients and their families were referred to the Clinical Genetic Service. Of the probands, 2,096 were diagnosed as suffering from multiple congenital anomaly syndromes. These represented 42.9% of the total. Ten commonest conditions accounted for 50% of patients suffering from this category of genetic diseases. A multidisciplinary approach was emphasized in the diagnosis and management.

Solvent effects on response factors for polynuclear aromatic hydrocarbons determined by capillary gas chromatography using splitless injections

When standard solutions of polynuclear aromatic hydrocarbons (PAHs) were analyzed by capillary column gas chromatography using splitless injections, response factors were observed to be dependent on the solvent used to prepare the standard. This report presents the response factors for 16 individual PAHs in 5 commonly used solvents: acetonitrile, methanol, toluene, isooctane, and cyclohexane. To minimize quantitation errors due to differences in transfer efficiency, samples and standards of PAHs should be prepared in the same solvent.

Chemical derivatization analysis of pesticide residues. IX. Analysis of phenol and 21 chlorinated phenols in natural waters by formation of pentafluorobenzyl ether derivatives

A sensitive, isomer-specific method is described for the simultaneous and quantitative analysis of 22 phenols (phenol, 18 chlorophenols, and 3 chloroalkylphenols) in natural waters. The sample was acidified to pH less than or equal to 2, extracted with dichloromethane, evaporated, and dissolved in acetone. The phenol extract was then reacted with pentafluorobenzyl bromide (PFBBr) to give the PFB ether derivatives. After silica gel column cleanup, the ethers were chromatographed on a 12 m OV-1 fused silica capillary column attached to an electron capture detector (ECD). The detection limit was 0.1 ppb for 1 L samples. Recoveries of phenols from pH 2 water samples fortified at 10, 1, and 0.1 ppb were greater than or equal to 80% in most cases except for phenol which was only 30 to 35% recovered. Coefficients of variation were between 2 and 10% for all phenols. However, phenol recovery was quantitative when the sample volume was reduced to 100 mL. Because ECD sensitivities to the 22 phenol PFB ethers were similar, this method is most suitable for simultaneous screening of nonchlorinated and monochlorinated phenols as well as other higher chlorophenols at trace levels.

Chemical derivatization analysis of pesticide residues. VIII. Analysis of 15 chlorophenols in natural water by in situ acetylation

A rapid analytical method is presented for quantitative analysis of 15 chlorophenols in natural waters by in situ acetylation. In the presence of KHCO3, phenols in water are acetylated by acetic anhydride directly without pre-extraction. The resultant acetates are extracted by petroleum ether and analyzed by electron capture gas chromatography. The investigation to optimize the conditions for in situ acetylation of these phenols is also described. This method has been validated and shown to be applicable over a range from 100 to 0.01 ppb with a 1 L water sample.

Interlaboratory quality study of the analysis of water for pesticides

An interlaboratory quality control study was conducted to provide information to 5 participating Canadian laboratories on their capability in analyzing natural waters for 10 pesticides. The study was designed to identify the quality of each laboratory's working standards for 15 organochlorine pesticides, and the accuracy and precision of each laboratory's analytical procedures. Fifteen samples were provided, of which 3 were standards prepared for direct injection into an electron capture gas chromatograph. Instructions were provided to use these 3 standards for quantitating the pesticide content (8-150 ng/L) in 5 pairs of 1 L water samples. These paired samples contained 10 organochlorine pesticides approaching natural levels. Results of the study indicated that participants were fairly precise and achieved the designed ratio 1.5 for concentrations in the paired samples.

Analysis pesticides by chemical derivatization. III. Gas chromatographic characteristics and conditions for the formation of pentafluorobenzyl derivatives of ten herbicidal acids

The reaction conditions to form pentafluorobenzyl derivatives of 10 herbicidal acids, at pesticide residue levels, were studied. The optimum conditions were reaction at room temperature for at least 5 hr (or overnight), using potassium carbonate solution as catalyst. The gas chromatographic characteristics of these derivatives were also studied. Nine of 10 of these derivatives can be separated on an OV-101/OV-210 gas chromatographic column.

Analysis of pesticide residues by chemical derivatization. II. N-methylcarbamates in natural water and soils

A method for the quantitative determination of several N-methylcarbamates in natural waters and the applicability of the derivative to soil samples using a previously published extraction procedure are described. After extraction of the carbamates from the substrate, the carbamates are hydrolyzed in a 10% methanol-potassium hydroxide solution to form the phenolic hydrolysis products, which are isolated and derivatized with pentafluorobenzyl (PFB) bromide to produce the PFB ether derivatives. The PFB derivatives are cleaned up and fractionated on a silica gel microcolumn and determined by electron capture gas-liquid chromatography (GLC). Eight organophosphate pesticides and 2 phthalate acid esters that hydrolyze to phenols or phthalic acid were evaluated as potential interferences and were found not to interfere with any of the carbamates tested. Quantitative determinations of 0.1 mug carbofuran and 3-ketocarbofuran and 0.5 mug carbaryl, metmercapturon, and Mobam in a 1 L water sample are possible. Propoxur was not determined at levels less than 1 mug/L due to the short GLC retention time of the derivative and interferences from the reagents at the lower levels.

Analysis of pesticides by chemical derivatization. I. a new procedure for the formation of 2-chloroethyl esters of ten herbicidal acids

A new esterification procedure was developed to form 2-chloroethyl esters for 10 common herbicidal acids, using dicyclohexyl carbodiimide and 2-chloroethanol. This reagent was found to be more desirable than the commonly used boron trichloride/2-chloroethanol reagent. Maximum esterification was given for picloram at a lower reaction temperature with a shorter reaction time. Also, maximum esterification of dicamba and 2,3,6-TBA was achieved. The boron trichloride/2-chlorethanol gave poor or little esterification with these 2 acids under the various conditions investigated. The effect of solvents on esterification with the 2 reagents was also explored.

Electron capture gas chromatographic methodology for the quantitation of polychlorinated biphenyls: survey and compromise

A uniform approach to quantitation of environmental PCB residues was sought. There exists a requirement for a reasonable compromise between accurate analysis and the ability to handle large numbers of samples. An international survey of electron-capture gas chromatographic methods utilized by laboratories currently analyzing for PCB was conducted from the Canada Centre for Inland Waters. Subsequent evaluation of the methods received has led to adoption of a uniform basic procedure which fulfils the objectives and demonstrates a wide general applicability.

Confirmation of pesticide residue identity: part IX. Organophosphorus pesticides

This paper describes a confirmation procedure for residue levels of dyfonate, dichlorofenthion and cyanox. After extraction and quantitation by flame photometric detector (FPD)-gas liquid chromatography (GLC), the organophosphorus pesticides are hydrolyzed in a 10% methanolic-potassium hydroxide solution. The phenolic hydrolysis products are then extracted from this solution and reacted with pentafluorobenzyl bromide to produce the pentafluorobenzyl (PFB) ether derivatives. These PFB ethers are subsequently cleaned-up and fractionated on a silica gel micro-column and analyzed by electron capture (EC)- GLC.