Risk Factors for Nontuberculous Mycobacteria Infections in Solid Organ Transplant Recipients: A Multinational Case-Control Study

BACKGROUND

Risk factors for nontuberculous mycobacteria (NTM) infections after solid organ transplant (SOT) are not well characterized. Here we aimed to describe these factors.

METHODS

Retrospective, multinational, 1:2 matched case-control study that included SOT recipients ≥12 years old diagnosed with NTM infection from 1 January 2008 to 31 December 2018. Controls were matched on transplanted organ, NTM treatment center, and post-transplant survival greater than or equal to the time to NTM diagnosis. Logistic regression on matched pairs was used to assess associations between risk factors and NTM infections.

RESULTS

Analyses included 85 cases and 169 controls (59% male, 88% White, median age at time of SOT of 54 years [interquartile range {IQR} 40-62]). NTM infection occurred in kidney (42%), lung (35%), heart and liver (11% each), and pancreas transplant recipients (1%). Median time from transplant to infection was 21.6 months (IQR 5.3-55.2). Most underlying comorbidities were evenly distributed between groups; however, cases were older at the time of NTM diagnosis, more frequently on systemic corticosteroids and had a lower lymphocyte count (all P < .05). In the multivariable model, older age at transplant (adjusted odds ratio [aOR] 1.04; 95 confidence interval [CI], 1.01-1.07), hospital admission within 90 days (aOR, 3.14; 95% CI, 1.41-6.98), receipt of antifungals (aOR, 5.35; 95% CI, 1.7-16.91), and lymphocyte-specific antibodies (aOR, 7.73; 95% CI, 1.07-56.14), were associated with NTM infection.

CONCLUSIONS

Risk of NTM infection in SOT recipients was associated with older age at SOT, prior hospital admission, receipt of antifungals or lymphocyte-specific antibodies. NTM infection should be considered in SOT patients with these risk factors.

Inhaled and intranasal ciclesonide for the treatment of covid-19 in adult outpatients: CONTAIN phase II randomised controlled trial

OBJECTIVE

To determine if inhaled and intranasal ciclesonide are superior to placebo at decreasing respiratory symptoms in adult outpatients with covid-19.

DESIGN

Randomised, double blind, placebo controlled trial.

SETTING

Three Canadian provinces (Quebec, Ontario, and British Columbia).

PARTICIPANTS

203 adults aged 18 years and older with polymerase chain reaction confirmed covid-19, presenting with fever, cough, or dyspnoea.

INTERVENTION

Participants were randomised to receive either inhaled ciclesonide (600 μg twice daily) and intranasal ciclesonide (200 μg daily) or metered dose inhaler and nasal saline placebos for 14 days.

MAIN OUTCOME MEASURES

The primary outcome was symptom resolution at day 7. Analyses were conducted on the modified intention-to-treat population (participants who took at least one dose of study drug and completed one follow-up survey) and adjusted for stratified randomisation by sex.

RESULTS

The modified intention-to-treat population included 203 participants: 105 were randomly assigned to ciclesonide (excluding two dropouts and one loss to follow-up) and 98 to placebo (excluding three dropouts and six losses to follow-up). The median age was 35 years (interquartile range 27-47 years) and 54% were women. The proportion of participants with resolution of symptoms by day 7 did not differ significantly between the intervention group (42/105, 40%) and control group (34/98, 35%); absolute adjusted risk difference 5.5% (95% confidence interval -7.8% to 18.8%). Results might be limited to the population studied, which mainly included younger adults without comorbidities. The trial was stopped early, therefore could have been underpowered.

CONCLUSION

Compared with placebo, the combination of inhaled and intranasal ciclesonide did not show a statistically significant increase in resolution of symptoms among healthier young adults with covid-19 presenting with prominent respiratory symptoms. As evidence is insufficient to determine the benefit of inhaled and intranasal corticosteroids in the treatment of covid-19, further research is needed.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04435795.

Rabies virus infection in a 21-year-old male presenting with ascending paralysis after a bat scratch

A 21-year-old, previously healthy male presented to hospital following 1 week of bilateral asymmetric ascending paralysis, odynophagia, and dysphagia. Initial magnetic resonance imaging (MRI) of the spine revealed an abnormal increased T2 signal with predominant dorsal column involvement and sparing of white matter throughout the cervical cord and extending to T5. The initial presumptive diagnosis was an acute infectious, versus inflammatory, myelitis. On reviewing the history, family members recalled a bat scratch on the left hand, sustained months prior, for which the patient did not seek or receive post-exposure prophylaxis (PEP). Rabies virus (RABV) RNA was detected by quantitative reverse transcription polymerase chain reaction (RT-qPCR) in two saliva samples, while nuchal skin biopsy and cerebrospinal fluid (CSF) were negative. Serum was negative for RABV neutralizing antibody. Sequencing and phylogenetic analyses identified the infecting RABV as a variant associated with silver-haired bats. Following risk assessment of exposure, 67 health care workers and several family members were offered PEP.

458. Diagnostic Accuracy and Management of Suspected Moderate to Severe Cellulitis Referred to an Infectious Diseases Outpatient Parenteral Antibiotic Clinic: A Prospective Cross-Sectional Study

Background

Moderate to severe cellulitis is a common reason for presentation to the emergency department and administration of intravenous antibiotics. Misdiagnosis of cellulitis occurs frequently as the disease can masquerade as a wide variety of noninfectious and infectious problems. There are currently no studies evaluating the impact of infectious diseases physicians on the diagnostic accuracy and management of cellulitis referred to an outpatient parenteral antibiotic clinic from the emergency department. The objective of this study was to quantify the prevalence of misdiagnosed moderate to severe cellulitis through an evaluation by an infectious diseases specialist, characterize the alternative diagnoses, and assess variables associated with misdiagnosis.

Methods

A prospective cross-sectional study of adults referred from emergency departments with presumed moderate to severe cellulitis to an outpatient parenteral antibiotic clinic staffed by infectious diseases specialists.

Results

301 consecutive patients with presumed cellulitis were evaluated over a 6-month period. A concurring diagnosis of cellulitis was found in 170 patients (56.5%), for a misdiagnosis rate of 43.5% (131/301). Table 1 summarizes the alternative diagnoses. Infectious conditions other than cellulitis were the most common (63/301; 20.9%), with abscess being present in 23 (7.6%) of patients. Fifty-two of 301 (17.3%) of the diagnoses were noninfectious and 16/301 (5.3%) patients had a dual diagnosis where minor cellulitis was present, but secondary to another, predomintating condition. The presence of stasis dermatitis (OR 6.62, P = 0.013) and a history of physical trauma (OR 1.76, P = 0.046) were associated with a misdiagnosis. 31.9% (107/335) of antibiotic regimens prescribed by emergency physicians were inappropriate or sub-optimal compared with 7.9% (22/280) of those ordered by infectious disease doctors.

Conclusion

Moderate to severe cellulitis was incorrectly diagnosed in nearly half of the patients referred for intravenous antibiotics and resulted in a high rate of unstewardly antimicrobial use. Infectious diseases physicians at an outpatient antibiotic clinic improved the diagnostic accuracy and management of this complicated condition.

Disclosures

All authors: No reported disclosures.

egl-4 acts through a transforming growth factor-beta/SMAD pathway in Caenorhabditis elegans to regulate multiple neuronal circuits in response to sensory cues

Sensory cues regulate several aspects of behavior and development in Caenorhabditis elegans, including entry into and exit from an alternative developmental stage called the dauer larva. Three parallel pathways, including a TGF-beta-like pathway, regulate dauer formation. The mechanisms by which the activities of these pathways are regulated by sensory signals are largely unknown. The gene egl-4 was initially identified based on its egg-laying defects. We show here that egl-4 has many pleiotropies, including defects in chemosensory behavior, body size, synaptic transmission, and dauer formation. Our results are consistent with a role for egl-4 in relaying sensory cues to multiple behavioral and developmental circuits in C. elegans. By epistasis analysis, we also place egl-4 in the TGF-beta-like branch and show that a SMAD gene functions downstream of egl-4 in multiple egl-4-regulated pathways, including chemosensation.

Taxol treatment of experimental proliferative vitreoretinopathy

Taxol is a potent stabilizer of microtubules, and inhibitor of in vitro replication, migration, and contraction of fibroblasts. It has been found to limit the development of experimental tractional retinal detachments in nonvitrectomized rabbit eyes. We used taxol in vitrectomized, phakic rabbit eyes with experimentally induced proliferative vitreoretinopathy and tractional retinal detachments. Taxol was dissolved in 30% DMSO because of poor aqueous solubility. A single 0.1 ml intravitreal dose of 2 x 10(-4) M taxol in 30% DMSO was injected immediately after 250,000 heterologous corneal fibroblasts had been injected; 0.1 ml of 30% DMSO was injected into control eyes. Taxol reduced the incidence of tractional retinal detachments seen 3-4 weeks later. When taxol injection was delayed for 3 days after the initial intravitreal injection of fibroblasts into nonvitrectomized eyes, the extent of retinal detachments was reduced, but the incidence of retinal detachment was unchanged from the untreated eyes at the end of 4 weeks. These data indicate that taxol may be most useful when given early in the course of proliferative vitreoretinopathy.

Ocular toxoplasmosis in patients with the acquired immunodeficiency syndrome

In seven of eight cases of presumed ocular toxoplasmosis in patients with AIDS, the diagnosis was supported by a reduction or resolution of intraocular inflammation and healing of necrotic retinal lesions after initiation of antiparasitic drug therapy including one or more of the following medications: pyrimethamine, sulfadiazine, clindamycin, tetracycline, or spiramycin. In two cases the diagnosis was confirmed histologically. The cases differed clinically and histopathologically from those in immunocompetent patients. There was no evidence that disease originated in preexisting retinochoroidal scars. Lesions frequently were bilateral and multifocal. Vitreous inflammatory reaction was a common clinical finding, but histopathologic examination demonstrated scant retinal inflammation in areas of necrosis. Ocular toxoplasmosis in these patients with AIDS probably resulted from newly acquired infection or dissemination of organisms from nonocular sites of disease. Infections became clinically inactive with drug therapy in all treated patients, but reactivation and progression of disease occurred when therapy was stopped in two of three patients. Severe retinal necrosis led to retinal tears or detachment in three cases. Ocular lesions were the first manifestation of Toxoplasma gondii infection in four of five patients with evidence of multisystem infection.

Incidence, risk factors, and morphology in operating microscope light retinopathy

A review of 135 consecutive cataract operations identified ten cases (7.4%) of operating microscope light retinopathy. Ophthalmoscopically, these light retinopathy lesions appeared as a focal pigment epithelial change with varying degrees of pigment clumping in the center. Fluorescein angiography accentuated the lesion by demonstrating a sharply demarcated transmission defect, occasionally with multiple satellite lesions. The shape of the lesion matched the shape of the illuminating source of the particular operating microscope used during the surgery. The most significant risk factor associated with the production of these light retinopathy lesions was prolonged operating time. Mean total operating time for the ten patients with light retinopathy was 51 minutes longer than for those without (P less than .0001). Other significant associated factors were the presence of diabetes mellitus (P less than .03), younger age (P less than .05), and the use of hydrochlorothiazide (P less than .04).

Effects of an optokinetic background on pursuit eye movements

The effects of an optokinetic background on pursuit eye movements was studied in four normal human subjects and seven patients with impaired pursuit and/or optokinetic nystagmus (OKN). Eye movements were recorded by DC electro-oculography and eye movement velocity was analyzed by a digital, microprocessor system. Tracking of a small laser target was performed against a featureless, white screen, a stationary OKN background that filled the entire visual field and an OKN background moving at constant velocity. The OKN background significantly affected pursuit in all subjects. The stationary background or background moving in the direction opposite to that of the laser target impaired pursuit; whereas, the background moving in the same direction as that of the target improved pursuit. The effects of the background on pursuit were greater in subjects with lower pursuit gains during tracking against the screen. An algebraic summation of independently induced pursuit and OKN eye movements could not account for all of the experimental observations.