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Ashcherkin N, Pisipati S, Athale J, Carey EJ, Chascsa D, Adamski J, Shah S. Solid organ graft-versus-host disease in a recipient of a COVID-19 positive liver graft. J Liver Transpl 2023; 10:100154. [PMID: 38013675 PMCID: PMC10114352 DOI: 10.1016/j.liver.2023.100154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/17/2023] [Accepted: 04/18/2023] [Indexed: 11/29/2023] Open
Abstract
A 66-year-old male with end-stage liver disease (ESLD) secondary to non-alcoholic fatty liver disease (NAFLD), complicated by hepatocellular carcinoma (HCC), underwent deceased donor liver transplantation from a Coronavirus disease 2019 (COVID-19) positive donor. He presented a month later with fever, diarrhea and pancytopenia which led to hospitalization. The hospital course was notable for respiratory failure, attributed to invasive aspergillosis, as well as a diffuse rash. A bone marrow biopsy revealed hypocellular marrow without specific findings. In the following days, laboratory parameters raised concern for secondary hemophagocytic lymphohistiocytosis (HLH). Clinical concern also grew for solid organ transplant graft-versus-host-disease (SOT-GVHD) based on repeat marrow biopsy with elevated donor-derived CD3+ T cells on chimerism. After, a multidisciplinary discussion, the patient was started on ruxolitinib, in addition to high dose steroids, to address both SOT-GVHD and secondary HLH. Patient developed symptoms concerning for hemorrhagic stroke and was transitioned to comfort care. Although GVHD has been studied extensively in hematopoietic stem cell transplant (HSCT) patients, it is a rare entity in SOT with a lack of guidelines for management. Additionally, whether COVID-19 may play a role in development of SOT-GVDH has not been explored.
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Affiliation(s)
- N Ashcherkin
- Department of Internal Medicine, Mayo Clinic, AZ, USA
| | - S Pisipati
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, USA
| | - J Athale
- Department of Critical Care, Mayo Clinic Arizona, USA
- Division of Hematology and Medical Oncology, Mayo Clinic Arizona, USA
| | - E J Carey
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, USA
- Transplant Center, Mayo Clinic Arizona, USA
| | - D Chascsa
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, USA
- Transplant Center, Mayo Clinic Arizona, USA
| | - J Adamski
- Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, USA
| | - S Shah
- Division of Hematology and Medical Oncology, Mayo Clinic Arizona, USA
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Ashcherkin N, Patel AA, Algeciras-Schimnich A, Doshi KB. Bone turnover markers to monitor oral bisphosphonate therapy. Cleve Clin J Med 2023; 90:26-31. [PMID: 36596600 DOI: 10.3949/ccjm.90a.22002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Bisphosphonates are widely used as first-line therapy to slow bone loss and decrease fracture risk in postmenopausal women with osteoporosis. Nonadherence to oral bisphosphonates diminishes the benefit of reduced bone loss and fracture risk of these medications. Strategies to enhance osteoporosis monitoring and adherence to therapy are crucial to improve outcomes. Dual-energy x-ray absorptiometry (DXA) is the gold standard for monitoring bone mineral density but is slow to detect change after initiation of oral bisphosphonate therapy. Bone turnover markers (BTMs) are by-products released during bone remodeling and are measurable in blood and urine. We review how the rapid change in BTMs can be a useful short-term tool to monitor the effectiveness of oral bisphosphonate therapy, which may ultimately improve adherence to therapy and outcomes.
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Affiliation(s)
| | | | - Alicia Algeciras-Schimnich
- Professor of Laboratory Medicine and Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Krupa B Doshi
- Assistant Professor of Medicine, Division of Endocrinology, Department of Medicine, Mayo Clinic, Scottsdale, AZ
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Ashcherkin N, Gupta S, Huff DA, Vikram HR, Ampel NM, Fischer KM, Blair JE. Impact of COVID-19 on diagnosis of primary pulmonary coccidioidomycosis. Medicine (Baltimore) 2022; 101:e30361. [PMID: 36107584 PMCID: PMC9439624 DOI: 10.1097/md.0000000000030361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
The COVID-19 pandemic has disrupted medical care worldwide and caused delays in care for many illnesses and procedures unrelated to COVID-19; however, less clear is how it may have affected diagnosis of conditions that present with similar symptoms, such as primary pulmonary coccidioidomycosis (PPC). We conducted an observational cohort study of patients diagnosed with PPC between March 1 and December 1 in 2 years: 2019 (before COVID-19) and in 2020 (after COVID-19) to compare the time from symptom onset to PPC diagnosis. Relevant demographic and clinical variables were collected, and statistical analyses were performed with the χ2 test, Wilcoxon rank sum test, and Cox proportional hazards regression analysis. During 2019, 83 patients were diagnosed with PPC. During 2020, 113 patients were diagnosed with PPC. For both groups, the median time from symptom onset to diagnosis of PPC was 14 days (P = .13). No significant differences in time to diagnosis existed between the 2 years for location of diagnosis (outpatient clinic, emergency department, or in hospital), for computed tomographic imaging performed before diagnosis, or for number of COVID-19 tests received before PPC diagnosis. In addition, there were no differences in the 2 years between the total number of clinical visits before diagnosis. However, patients in the post-COVID-19 group who had fever were diagnosed with PPC earlier than those without fever (hazard ratio, 1.77; 95% confidence interval, 1.15-2.73; P = .01). Contrary to what we expected, no significant delay in diagnosis of PPC occurred during the COVID-19 pandemic.
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Affiliation(s)
- Nikita Ashcherkin
- Department of Internal Medicine, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Scottsdale, Arizona, USA
| | - Simran Gupta
- Department of Internal Medicine, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Scottsdale, Arizona, USA
| | - Daniel A. Huff
- Department of Internal Medicine, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Scottsdale, Arizona, USA
| | | | - Neil M. Ampel
- Division of Infectious Diseases, Mayo Clinic, Phoenix, Arizona, USA
| | - Karen M. Fischer
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Janis E. Blair
- Division of Infectious Diseases, Mayo Clinic, Phoenix, Arizona, USA
- *Correspondence: Janis E. Blair, Division of Infectious Diseases, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA (e-mail: )
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Gupta S, Ashcherkin N, Blair JE. Do all patients with primary pulmonary coccidioidomycosis need antifungal therapy? Cleve Clin J Med 2022; 89:451-455. [PMID: 35914937 DOI: 10.3949/ccjm.89a.21125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Simran Gupta
- Department of Internal Medicine, Mayo Clinic, Phoenix, AZ
| | | | - Janis E Blair
- Division of Infectious Diseases, Mayo Clinic, Phoenix, AZ
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Ammari Z, Hasnie AA, Ruzieh M, Dasa O, Al-Sarie M, Shastri P, Ashcherkin N, Brewster PS, Cooper CJ, Gupta R. Prognostic Value of Computed Tomography Versus Echocardiography Derived Right to Left Ventricular Diameter Ratio in Acute Pulmonary Embolism. Am J Med Sci 2021; 361:445-450. [DOI: 10.1016/j.amjms.2020.07.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 06/02/2020] [Accepted: 07/07/2020] [Indexed: 01/14/2023]
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Gupta R, Liu L, Zhang X, Fan X, Krishnamurthy P, Verma S, Tongers J, Misener S, Ashcherkin N, Sun H, Tian J, Kishore R. IL-10 provides cardioprotection in diabetic myocardial infarction via upregulation of Heme clearance pathways. JCI Insight 2020; 5:133050. [PMID: 32879134 PMCID: PMC7526458 DOI: 10.1172/jci.insight.133050] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 07/29/2020] [Indexed: 01/10/2023] Open
Abstract
Diabetes is a risk factor for myocardial infarction, and outcomes after myocardial infarction are worse among diabetics compared with nondiabetics. Diabetes is associated with impaired Heme clearance. Here, we determined whether heme toxicity and impaired heme clearance contribute to diabetic myocardial infarction injury and assessed IL-10 as a therapeutic agent for diabetic myocardial infarction. Plasma-free hemoglobin was significantly elevated in diabetic mice compared with nondiabetic mice after myocardial infarction. Infarct size had strong correlation to the level of plasma-free hemoglobin. Hemoglobin and reactive iron deposition within the infarct zone were also demonstrated in diabetic MI. IL-10 significantly reduced infarct size and improved cardiac function in diabetic mice. Moreover, IL-10 improved capillary density, reduced apoptosis, and decreased inflammation in the border zone of the infarcted hearts, findings that were partially inhibited by Tin protoporphyrin (a heme oxygenase-1 inhibitor). IL-10 upregulated CD163, the hemoglobin:haptoglobin scavenger receptor, and heme oxygenase-1 in THP-1-derived and primary human CD14+ macrophages. IL-10 significantly protected against ischemic injury when HL-1 cardiomyocytes were cotreated with hemoglobin. Together, our findings indicate that IL-10 is cardioprotective in diabetic myocardial infarction via upregulation of heme clearance pathways. These findings implicate heme clearance as a potentially novel therapeutic direction for diabetic myocardial infarction.
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Affiliation(s)
- Rajesh Gupta
- Division of Cardiovascular Medicine, Department of Medicine, University of Toledo College of Medicine, Toledo, Ohio, USA
- Feinberg Cardiovascular Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lijun Liu
- Division of Cardiovascular Medicine, Department of Medicine, University of Toledo College of Medicine, Toledo, Ohio, USA
| | - Xiaolu Zhang
- Division of Cardiovascular Medicine, Department of Medicine, University of Toledo College of Medicine, Toledo, Ohio, USA
| | - Xiaoming Fan
- Division of Cardiovascular Medicine, Department of Medicine, University of Toledo College of Medicine, Toledo, Ohio, USA
| | - Prasanna Krishnamurthy
- Feinberg Cardiovascular Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Biomedical Engineering and
| | - Suresh Verma
- Feinberg Cardiovascular Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jörn Tongers
- Feinberg Cardiovascular Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Mid-German Heart Center, Department of Internal Medicine III, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University, Halle (Saale), Germany
| | - Sol Misener
- Feinberg Cardiovascular Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Nikita Ashcherkin
- Division of Cardiovascular Medicine, Department of Medicine, University of Toledo College of Medicine, Toledo, Ohio, USA
| | - Hongliu Sun
- Department of Pathology, University of Toledo College of Medicine, Toledo, Ohio, USA
| | - Jiang Tian
- Division of Cardiovascular Medicine, Department of Medicine, University of Toledo College of Medicine, Toledo, Ohio, USA
| | - Raj Kishore
- Feinberg Cardiovascular Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Center for Translational Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
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Abstract
Infective endocarditis is typically caused by Staphylococcus aureus (S. aureus), coagulase-negative staphylococci and streptococci but infection with Corynebacterium striatum (C. striatum) is also becoming prominent. We present the case of a 65-year-old female with a recent history of the coronary artery bypass graft with bioprosthetic aortic valve replacement. The surgery was complicated by sternal wound dehiscence with methicillin-sensitive S. aureus (MSSA) for which she was treated for six weeks with intravenous antibiotics. Two months later, she was found to have C. striatum which was treated. A transesophageal echocardiogram was done as well which did not show any vegetation. She presented to the hospital with vomiting, cough, fever, and shortness of breath. She had pyuria on urinalysis and was started on empiric antibiotics after taking blood cultures. She decompensated soon after admission and was transferred to the intensive care unit where she had a pulseless ventricular tachycardia and was resuscitated but required vasopressor support. The blood cultures from admission started growing C. striatum again. Daptomycin was added to the empiric antibiotics and supportive care was continued, but the family decided to make her 'do not resuscitate - comfort care only'. The support was withdrawn and she passed away.
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Affiliation(s)
| | | | - Murtaza Sundhu
- Internal Medicine, Order of St. Francis - St. Francis Medical Center, Peoria, USA
| | - Laila Hakam
- Internal Medicine, Cleveland Clinic, Fairview Hospital, Cleveland, USA
| | - Sajjad Gul
- Internal Medicine, Order of St. Francis - St. Francis Medical Center, Peoria, USA
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