1
|
Cari EV, Siddiqui Z, Leedy N, Fenwick A, Myint T. 352. Evaluation of Serial Serum (1-- >3)-b-D-glucan Assay in Patients with Invasive candidiasis, Pneumocystis Jiroveci Pneumonia and Aspergillosis. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
Serum (1-- >3)-b-D-glucan (BDG) assay is a noninvasive serological marker that can be used as an adjunct to the diagnosis of invasive candida infections, Pneumocystis jiroveci pneumonia (PJP) as well as aspergillosis. There is limited data in serial monitoring of serum BDG in those fungal infections after treatment was initiated. Figure 1:Serial serum BDG levels of each subject after treatment initiation
Methods
This is a cross-sectional study of subjects with proven fungal infection (invasive candidiasis, aspergillosis or PJP) and with increased serum BDG >500 pg/ml who were admitted to University of Kentucky (UK) hospitals or clinics from 01/2012 to 01/2021. It was approved by institutional IRB. We compared at least two measures of the serum β-D-glucan levels obtained within two to eight weeks after initial diagnosis to evaluate the levels of β-D-glucan during and post-treatment. A decrease in BDG level is defined as any value below 500 pg/ml; normal serum BDG level as < 80 pg/ml.
Results
Of 26 subjects included in this cohort, 14 (51.8%) subjects had invasive candidiasis, six (22.2%) subjects had PJP, and six (22.2%) subjects had invasive aspergillosis. Twelve patients did not have a repeat BDG level after at least two separate levels with >500 pg/ml. Ten (38.5%) subjects had a decline in BDG level 2-3 weeks after starting treatment. Serum BDG level did not return to within normal limits at week 4 of treatment except one patient.
A repeat serum BDG level was seen decline at three weeks of treatment in four of six (66.6%) subjects with PJP, six weeks of treatment in three of six (50.0%) subjects with invasive aspergillosis and 8 weeks of treatment in six of 14 (42.8%) patients with invasive candidiasis. Two subjects had persistent elevation of BDG 8 weeks after treatment. (Figure 1)
Conclusion
Serial serum BDG level was not routinely done for monitoring the treatment response in this cohort. There was no linear decline in serum BDG level even after appropriate treatment in invasive fungal infections. A decline in serum BDG level was best observed among subjects with PJP pneumonia. It appears that the duration of a decline in serum BDG level was shorter in patients with PJP and longer in patients with invasive candidiasis.
Disclosures
All Authors: No reported disclosures.
Collapse
Affiliation(s)
| | | | | | | | - Thein Myint
- University of Kentucky , Lexington, Kentucky
| |
Collapse
|
2
|
Kyaw MT, Myint T, Lwin TZ. Acute myocarditis in a young male after gastroenteritis: A case report and literature review. Clin Case Rep 2022; 10:e6699. [PMID: 36483859 PMCID: PMC9723471 DOI: 10.1002/ccr3.6699] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/08/2022] [Accepted: 11/18/2022] [Indexed: 12/12/2022] Open
Abstract
A 16-year-old patient presented with acute myocarditis after gastroenteritis. His ECGs showed STEMI-like evolutionary changes. Serial troponin measurement was maximum on 3rd day. Echocardiography showed a mildly reduced ejection fraction (45%). He made an uneventful recovery after appropriate treatment. After one-month follow-up, his ECG and echo returned to normal.
Collapse
Affiliation(s)
- May Thu Kyaw
- Heart and Vascular CenterVictoria HospitalYangonMyanmar
| | - Thein Myint
- Department of MedicineUniversity of Medicine (1)YangonMyanmar
| | - Thant Zaw Lwin
- Department of CardiologyUniversity of Medicine (2)YangonMyanmar
| |
Collapse
|
3
|
Sim MM, Banerjee M, Myint T, Garvy BA, Whiteheart SW, Wood JP. Total Plasma Protein S Is a Prothrombotic Marker in People Living With HIV. J Acquir Immune Defic Syndr 2022; 90:463-471. [PMID: 35616596 PMCID: PMC9246910 DOI: 10.1097/qai.0000000000002994] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 03/21/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND HIV-1 infection is associated with multiple procoagulant changes and increased thrombotic risk. Possible mechanisms for this risk include heigthened expression of procoagulant tissue factor (TF) on circulating monocytes, extracellular vesicles, and viral particles and/or acquired deficiency of protein S (PS), a critical cofactor for the anticoagulant protein C (PC). PS deficiency occurs in up to 76% of people living with HIV-1 (PLWH). As increased ex vivo plasma thrombin generation is a strong predictor of mortality, we investigated whether PS and plasma TF are associated with plasma thrombin generation. METHODS We analyzed plasma samples from 9 healthy controls, 17 PLWH on first diagnosis (naive), and 13 PLWH on antiretroviral therapy (ART). Plasma thrombin generation, total and free PS, PC, C4b-binding protein, and TF activity were measured. RESULTS We determined that the plasma thrombin generation assay is insensitive to PS, because of a lack of PC activation, and developed a modified PS-sensitive assay. Total plasma PS was reduced in 58% of the naive and 38% of the ART-treated PLWH samples and correlated with increased thrombin generation in the modified assay. Conversely, plasma TF was not increased in our patient population, suggesting that it does not significantly contribute to ex vivo plasma thrombin generation. CONCLUSION These data suggest that reduced total plasma PS contributes to the thrombotic risk associated with HIV-1 infection and can serve as a prothrombotic biomarker. In addition, our refined thrombin generation assay offers a more sensitive tool to assess the functional consequences of acquired PS deficiency in PLWH.
Collapse
Affiliation(s)
- Martha M.S. Sim
- Department of Molecular and Cellular Biochemistry, University of Kentucky, Lexington, KY
| | - Meenakshi Banerjee
- Department of Molecular and Cellular Biochemistry, University of Kentucky, Lexington, KY
| | - Thein Myint
- Division of Infectious Diseases, Department of Internal Medicine, University of Kentucky, Lexington, KY
- Bluegrass Care Clinic, Kentucky Clinic, University of Kentucky, Lexington, KY
| | - Beth A. Garvy
- Department of Microbiology, Immunology and Molecular Genetics, University of Kentucky, Lexington, KY
| | - Sidney W. Whiteheart
- Department of Molecular and Cellular Biochemistry, University of Kentucky, Lexington, KY
- Lexington Veterans’ Affairs Healthcare System, Lexington, KY
| | - Jeremy P. Wood
- Department of Molecular and Cellular Biochemistry, University of Kentucky, Lexington, KY
- Gill Heart and Vascular Institute, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Kentucky, Lexington, KY
- Saha Cardiovascular Research Center, University of Kentucky, Lexington, KY
| |
Collapse
|
4
|
Villacorta Cari E, Leedy N, Ribes JA, Soria J, Myint T. Risk factors of severe blastomycosis and comparison of diagnosis and outcomes between immunocompetent and immunocompromised patients. Mycoses 2021; 65:239-246. [PMID: 34874582 DOI: 10.1111/myc.13409] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 11/15/2021] [Accepted: 11/29/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Blastomycosis is an endemic fungal infection that causes pulmonary and systemic disease. It can occur irrespective of the patient's immune status. The risk factors associated with the severity of the disease are not well studied. METHODS This is a retrospective study of patients admitted with blastomycosis at the University of Kentucky Hospital from 2004 to 2019. Logistic regression was used to identify variables associated with severe blastomycosis. RESULTS A total of 76 patients were identified; 22 (28.9%) had at least one immunosuppressive condition. Pulmonary blastomycosis was reported in 49/76 (65%) of the patients and disseminated infection in 27/76 (35.5%). All diagnostic tests were not significantly different in diagnostic results in immunocompromised vs immunocompetent patients. Cultures and histopathology were positive in 56/61 (91.8%) and 54/63 (85.7%) respectively. Blastomyces or Histoplasma antigen test was positive in 13/17 (76.4%) in immunocompromised patients compared to 26/42 (61.9%) in immunocompetent patients. Immunocompromised patients were more likely to be admitted to the hospital and ICU compared to immunocompetent patients. In the multivariate analysis, pulmonary multilobar disease (RR 5.68; 95% CI 2.13-15.15), obesity (RR 2.39; 95% CI 1.26-4.51), diabetes mellitus (RR 3.50; 95% CI 1.38-8.90) and immunosuppression (RR 2.28; 95% CI 1.14-4.56) were significant independent risk factors for severe blastomycosis. Inpatient mortality proportion was higher in immunocompromised patients but not statistically significant. CONCLUSION Pulmonary multilobar disease, obesity, diabetes mellitus and immunosuppression were risk factors associated with severe blastomycosis. Immunocompromised patients required more frequent hospitalisations compared to immunocompetent patients.
Collapse
Affiliation(s)
- Evelyn Villacorta Cari
- Division of Infectious Diseases, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Nicole Leedy
- Division of Infectious Diseases, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Julie A Ribes
- Department of Pathology and Laboratory Medicine, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Jaime Soria
- Division of Infectious Diseases, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Thein Myint
- Division of Infectious Diseases, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| |
Collapse
|
5
|
Abdallah W, Myint T, LaRue RW, Minderman M, Gunn S, Wheat LJ, Hage CA. 721. Diagnosis of Histoplasmosis Using the MVista Histoplasma Galactomannan Antigen Qualitative Lateral Flow-Based Immunoassay; A Multicenter Study. Open Forum Infect Dis 2021. [DOI: 10.1093/ofid/ofab466.918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Accurate and timely methods for the diagnosis of histoplasmosis in endemic resource-limited settings are largely lacking. Histoplasma galactomannan antigen detection by enzyme immunoassay (EIA) is the most widely used method for the diagnosis of acute pulmonary and disseminated histoplasmosis in the United States (USA). EIA methods have constraints in resource-limited settings including cost, turnaround time, and the need for large reference laboratories, leading to missed or delayed diagnoses and poor outcomes. Lateral flow assays (LFA) are practical methods that can be used in this setting for Histoplasma antigen detection.
Methods
Frozen urine specimens were submitted to MiraVista (MVista) for Histoplasma antigen EIA testing from three academic medical centers in highly endemic areas of the USA. They were also blinded and tested for the MVista Histoplasma LFA by skilled MVista technologists. Medical records were reviewed for clinical information. Patients were classified as controls or cases of histoplasmosis. Cases were divided into proven or probable, pulmonary, or disseminated, immune competent or immune suppressed, and mild, moderate, or severe.
Results
352 subjects were enrolled, including 66 cases of histoplasmosis (44 proven, 22 probable) and 286 controls. Most of the cases were immunocompromised (68%). 76% had disseminated histoplasmosis. 6% were mild, 66% moderate, and 28% severe. A high degree of concordance was found between LFA and EIA results (kappa 0.837, OR 372.7, LR 204, p< 0.001). Overall, the sensitivity and specificity of the LFA were 78.8% and 99.3% respectively (kappa 0.84, p< 0.001). The sensitivity was higher in proven cases (93.2%), in patient with disseminated (94.7%), moderate (80%) and severe disease (94%), and those with galactomannan levels ≥ 2 ng/mL (97.7%). Specificity was 99.3% in proven cases, 99.3% in patient with moderate and severe disease, and 96.4% in those with galactomannan levels ≥ 2 ng/mL.
Table 1. Statistical characteristics of the LFA test for histoplasmosis in different categories. PPV: Positive Predictive Value. NPV: Negative Predictive Value. EIA: Enzyme Immunoassay.
The LFA test for histoplasmosis is more accurate in patients with high burden of infection.
Conclusion
The MVista Histoplasma galactomannan LFA may meet the need for accurate rapid diagnosis of histoplasmosis in resource-limited settings, especially in patients with relatively high disease burden, potentially reducing morbidity and mortality.
Disclosures
Melissa Minderman, Bachelor's Degree, Molecular Biology, MiraVista Diagnostics (Employee) Suphansa Gunn, Bachelor's Degree, psychology, MiraVista Diagnostics (Employee) Lawrence J. Wheat, MD, MiraVista Diagnostics (Employee)
Collapse
Affiliation(s)
- Wassim Abdallah
- Indiana University School of Medicine, Indianapolis, Indiana
| | | | | | | | | | | | | |
Collapse
|
6
|
Abdallah W, Myint T, LaRue R, Minderman M, Gunn S, Wheat LJ, Hage CA. Diagnosis of Histoplasmosis Using the MVista Histoplasma Galactomannan Antigen Qualitative Lateral Flow-Based Immunoassay: A Multicenter Study. Open Forum Infect Dis 2021; 8:ofab454. [PMID: 34557565 PMCID: PMC8454512 DOI: 10.1093/ofid/ofab454] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 08/30/2021] [Indexed: 02/06/2023] Open
Abstract
Background Accurate and timely methods for the diagnosis of histoplasmosis in resource-limited countries are lacking. Histoplasma antigen detection by enzyme immunoassay (EIA) is widely used in the United States (US) but not in resource-limited countries, leading to missed or delayed diagnoses and poor outcomes. Lateral flow assays (LFAs) can be used in this setting. Methods Frozen urine specimens were submitted to MiraVista diagnostics for antigen testing from 3 medical centers in endemic areas of the US. They were blinded and tested for the MVista Histoplasma LFA. Patients were classified as controls or cases of histoplasmosis. Cases were divided into proven or probable; pulmonary or disseminated; immunocompetent or immunosuppressed; and mild, moderate, or severe. Results Three hundred fifty-two subjects were enrolled, including 66 cases (44 proven, 22 probable) and 286 controls. Most of the cases were immunocompromised (71%), and 46 had disseminated and 20 had pulmonary histoplasmosis. Four cases were mild, 42 moderate, and 20 severe. LFA and EIA were highly concordant (κ = 0.84). Sensitivity and specificity of the LFA were 78.8% and 99.3%, respectively. LFA sensitivity was higher in proven cases (93.2%), patients with disseminated (91.3%), moderate (78.6%), and severe disease (80%), and those with galactomannan levels >1.8 ng/mL (97.8%). Specificity was 99.3% in proven cases, 99.3% in patients with moderate or severe disease, and 96.8% in those with galactomannan levels >1.8 ng/mL. Cross-reactivity was noted with other endemic mycoses. Conclusions The MVista Histoplasma LFA meets the need for accurate rapid diagnosis of histoplasmosis in resource-limited countries, especially in patients with high disease burden, potentially reducing morbidity and mortality.
Collapse
Affiliation(s)
- Wassim Abdallah
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Thein Myint
- Department of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Richard LaRue
- Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | | | | | | | - Chadi A Hage
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| |
Collapse
|
7
|
Bhatt M, Porterfield JZ, Ribes JA, Arora V, Myint T. Changing demographics and risk factors for cryptococcosis: A 12-year review at a tertiary care centre. Mycoses 2021; 64:1073-1082. [PMID: 34033158 DOI: 10.1111/myc.13323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 05/11/2021] [Accepted: 05/18/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cryptococcosis is classically associated with the immunocompromised patients but there is a rising appreciation for its impact on the immunocompetent hosts. We sought to analyse the trends, diagnosis, treatment of different hosts and the effect of immunodeficiency and chronic liver disease on relapse and in-house mortality. METHODS This is a retrospective study of 12 years of patients with cryptococcosis, divided into three different groups: HIV-infected, transplant and non-HIV non-transplant (NHNT). Data were analysed with Chi-square, unpaired parametric t test, simple and multivariate logistic regression analysis. RESULTS Of 114 identified patients, 23 (20.2%) had HIV infection, 11 (9.6%) had transplant, 80 (70.2%) were NHNT patients. Overall, mortality was 28.1% (32/114) and relapse occurred in 10.5% (12/114) of patients. The mortality trend was higher (OR = 2.346, p = .287) in the transplant group (45.5%, 5/11) than in HIV (26.1%, 6/23) and NHNT groups (26.3%, 21/80). HIV was associated with relapse; 30.4% (7/23) for HIV-positive patients and 5.5% (5/91) for HIV-negative patients (OR = 7.525, p = .002). Chronic liver disease had a large and statistically significant association with mortality on multivariate analysis (OR = 3.583, p = .013) which was more pronounced than the HIV or transplant groups. It was independently associated with mortality by chi-square analysis (OR 3.137, p = .012). CONCLUSION Chronic liver disease represented 30.7% (35/114) of all studied patients. It was a risk factor for in-hospital mortality. HIV infection and transplant were not statistically significant for mortality. Relapse was highest in the HIV-infected patients at 30.4% (7/23). These data highlight the effect of type and degree of immunocompromise on cryptococcosis.
Collapse
Affiliation(s)
- Mahesh Bhatt
- Division of Infectious Diseases, Department of Internal Medicine, North Mississippi Medical Center, Tupelo, MS, USA
| | - J Zachary Porterfield
- Division of Infectious Diseases, Department of Internal Medicine, University of Kentucky, Lexington, KY, USA.,Department of Microbiology, Immunology, and Molecular Genetics, University of Kentucky, Lexington, KY, USA
| | - Julie A Ribes
- Department of Pathology and Laboratory Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Vaneet Arora
- Department of Pathology and Laboratory Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Thein Myint
- Division of Infectious Diseases, Department of Internal Medicine, University of Kentucky, Lexington, KY, USA
| |
Collapse
|
8
|
Park SK, Wong Z, Park SH, Vu KV, Bang KB, Piyachaturawat P, Myint T, Hilmi I, Park DI. Extraintestinal manifestation of inflammatory bowel disease in Asian patients: A multinational study. Dig Liver Dis 2021; 53:196-201. [PMID: 32736897 DOI: 10.1016/j.dld.2020.06.046] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/29/2020] [Accepted: 06/29/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIM Although inflammatory bowel disease (IBD) incidence has increased over the past two decades in Asia, data on extraintestinal manifestations (EIMs) of IBD in Asian patients are limited. We aimed to evaluate the prevalence and clinical characteristics of EIMs in Asian IBD patients. METHODS In total, 1,764 patients (1,130 with ulcerative colitis [UC] and 634 with Crohn's disease [CD]) were recruited from 10 tertiary centers in Asia. The medical records of IBD patients were retrospectively reviewed for the presence, clinical characteristics, chronological order, and therapeutic management of EIMs. RESULTS EIMs were reported in 199 (11.3%) patients, of which 17 (1.0%) patients had multiple EIMs. EIMs were more prevalent in CD patients (P = 0.02). Multiple logistic regression analysis revealed that female sex (odds ratio [OR] 2.02, 95% confidence interval [CI] 1.15-3.55), stricture (OR 2.49, 95% CI 1.41-4.39) and female sex (OR 2.57, 95% CI 1.52-4.34), extensive colitis (OR 2.63, 95% CI 1.57-4.41) were associated with EIMs in CD and UC patients respectively. EIMs appeared in 8% of patients before IBD diagnosis; 95% of cases with EIM could be managed via first-line therapy. CONCLUSION EIM prevalence is lower among Asian IBD patients than among patients from Western countries; however, the risk factors for EIM were similar between both populations.
Collapse
Affiliation(s)
- Soo-Kyung Park
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University, 29 Saemunan-ro, Jongno-gu, Seoul, Republic of Korea
| | - Zhiqin Wong
- Gastroenterology Unit, Department of Medicine, Faculty of Medicine, National University Of Malaysia, Kuala Lumpur, Malaysia
| | - Sang Hyoung Park
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Khien Van Vu
- Department of GI Endoscopy, 108 Military Central Hospital, Hanoi, Vietnam
| | - Ki Bae Bang
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Republic of Korea
| | - Panida Piyachaturawat
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross, Bangkok, Thailand
| | - Thein Myint
- Department of Gastroenterology, Yangon General Hospital, Yangon, Myanmar
| | - Ida Hilmi
- Division of Gastroenterology and Hepatology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Dong-Il Park
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University, 29 Saemunan-ro, Jongno-gu, Seoul, Republic of Korea.
| |
Collapse
|
9
|
Xhemali X, Forster DW, Clemons B, Cotner S, VanHoose J, Burgess DR, Burgess D, Myint T, Maskey M, Wallace K. 58. Evaluation of a Disease State Stewardship Intervention for Urinary Tract Infections at an Academic Medical Center. Open Forum Infect Dis 2020. [PMCID: PMC7776418 DOI: 10.1093/ofid/ofaa439.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Urinary tract infections (UTIs) are often misdiagnosed and mismanaged. Disease state stewardship initiatives targeting UTIs may have a significant impact on the overuse of antimicrobials (ABX). The purpose of our study is to evaluate the effectiveness of a UTI focused disease state stewardship intervention. Methods This retrospective study was conducted at a tertiary care academic medical center. Patients > 18 years of age with a collected urinalysis (UA) and receiving ABX for a UTI were included. Retrospective review of UTI management from 9–11/2017 was performed and used as the baseline. In the post-intervention period, 9–11/2018, the UTI management guideline had been published and service lines educated. A prospective audit and feedback (PAAF) initiative was started 6/2019, whereby the antimicrobial stewardship team performed daily reviews of patients on ABX for UTIs. Patients reviewed 9–11/2019 were included in the PAAF cohort. Exclusion criteria included: pregnancy, undergoing a urologic procedure, treatment of a concomitant infection, receiving therapy based on outside recommendations, or left AMA/expired during treatment. The primary outcome of this study was to evaluate overall guideline adherence. Results 600 patients (200 in each group) were included, with 419 (69.8%) female and an overall median age of 61.4 years. Altered mental status (24.8%) and dysuria (21.5%) were the two main diagnostic testing indications. Treatment of asymptomatic presentations decreased between the three periods, 74.0% vs 48.5% vs 36.0%. Appropriate ordering of UA (33.5% vs 55.0% vs 68.5%, p< 0.001) and urine cultures (29.0% vs 57.1% vs 64.8%, p< 0.001) improved following guideline implementation and PAAF. Interventions by the stewardship team were made in 21% of patients during PAAF, namely therapy discontinuation (78.6%). Overall guideline adherence significantly improved over time, 13.0% vs 27.0% vs 36.5%, p< 0.001. Conclusion UTI disease state intervention was associated with a reduction in the treatment of asymptomatic presentations, increase in appropriate diagnostic ordering, and improvement in overall guideline adherence. PAAF can be a powerful stewardship strategy for promoting consistency in UTI treatment and decreasing unnecessary ABX use. Disclosures All Authors: No reported disclosures
Collapse
Affiliation(s)
- Xhilda Xhemali
- University of Kentucky HealthCare, Farmington Hills, Michigan
| | | | - Bryant Clemons
- University of Kentucky HealthCare, Farmington Hills, Michigan
| | | | | | | | | | | | | | - Katie Wallace
- University of Kentucky HealthCare, Farmington Hills, Michigan
| |
Collapse
|
10
|
Cari EV, Leedy N, Ribes JA, Soria J, Myint T. 1156. Clinical and epidemiological features and outcomes of Blastomycosis in a tertiary hospital in Kentucky. Open Forum Infect Dis 2020. [PMCID: PMC7777301 DOI: 10.1093/ofid/ofaa439.1342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Blastomycosis is an endemic dimorphic fungal infection caused by Blastomyces dermatitidis. The risk factors associated with severe presentation are not well defined.
Methods
Retrospective study of patients treated for blastomycosis at the University of Kentucky Hospital from 2004-2019. Statistical analyses were performed with STATA version 12.0 (College Station, Texas). Logistic regression was used to identify variables associated with severe infections.
Results
Among 82 patients, median age was 48 years old (range: 16 - 89); 66 (80.5%) were male and 71 (92.2%) were white, 25/77 (32.4%) were obese, 24 (29.2%) were diabetic, 21 (25.6%) had COPD, 26 (31.7%) had at least one immunosuppressive condition. The median duration of illness was 86 (3-365) days. 37 (45.1%) had cough and 35 (42.6%) had dyspnea 19 (23.1%) patients were treated in the ICU, 42 (51.3%) in non-ICU inpatient wards, and 21 (25.6%) in an outpatient setting. Cultures were obtained in 69 cases, 59 (85.5%) reported as positive, KOH stain positive in 30/61 (49.1%). Histopathology was positive in 48/66 (72.7%) samples. Urine Histoplasma or Blastomyces antigen was positive in 41/58 (70.6%), and Serum Histoplasma or Blastomyces antigen was positive in 22/34 (64.7%). Among 64 (78.0%) patients with pulmonary blastomycosis, acute and chronic pneumonia were 16 (25.0%) and 12 (18.7%) cases respectively, and nodular lung lesions were reported in 36 (56.2%). Initial antifungal treatment was amphotericin B liposomal in 38/80 (47.5%), overall mortality was 11 (13.4%). A multivariable analysis was performed to find predictors of severe blastomycosis infection, no association was seen with factors as male sex (IRR 1.96; 95%CI 0.84 – 4.55), and was confirmed that significant independent associated risk factors for severe infection were age older than 50 (IRR 3.5; 95%CI 1.42-8.83), obesity (IRR 3.1; 95% CI 1.41-6.87), diabetes (IRR 2.5; 95% CI 1.16-5.50), leukocytosis (IRR 1.03; 95%CI 1.00-1.07) and anemia (IRR 3.0; 95% CI 1.55-5.85).
Conclusion
Pulmonary Blastomycosis is the most common presentation. Culture and histopathology are more sensitive than antigen assay. Independent factors associated to severe disease were older age, obesity, diabetes, and anemia at admission.
Disclosures
All Authors: No reported disclosures
Collapse
|
11
|
lin J, Myint T, Arora V, Ribes JA. 653. Comparison of Yeasts identification by Biofire, Culture and ePlex for Quality Assurance purpose. Open Forum Infect Dis 2020. [PMCID: PMC7776130 DOI: 10.1093/ofid/ofaa439.847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background At the University of Kentucky Medical center (UKMC), positive fungal blood cultures are concurrently run through the Biofire Blood Culture Identification (BCID) panel which detects 5 Candida species. The newer platform, the GenMarkDx ePlex BCID-FP (fungal panel) is designed to detect 16 fungal targets. Our study compares the performance of the Biofire BCID panel’s with culture as the gold standard method. We examine the percentage of agreement by both testing methods and predict the performance of the GenMarkDx ePlex BCID-FP panel based on culture results. We also look at the number of other yeasts not included in Biofire BCID panel that could be picked up by the GenMarkDx ePlex BCID-FP panel. Methods Positive fungal blood cultures from July 1, 2018 to June 30, 2019 were run through the Biofire BCID panel. Culture results were used to extrapolate whether the GenMarkDx ePlex FP would provide any additional diagnostic benefit. Results were categorized as true or false positives and negatives as compared to culture as the gold standard. Results A total of 141 blood cultures were tested via the Biofire BCID panel for the identification of yeasts. Of these, 123 (87%) yielded Biofire results in concordance with culture results. We would expect these also to be positive on the GenMarkDx ePlex BCID-FP panel. In addition, 18 specimens (13%) would have tested positive on the GenMarkDx ePlex BCID-FP panel and not the Biofire BCID panel. These organisms were noted to be Candida lusitaniae (n=6), Cryptococcus neoformans (n=3), Candida dublinensis (n=2), and Candida keyfr (n=1). Organisms that were found on culture that were not detected by both GenMarkDx ePlex BCID-FP panel and Biofire BCID panel were Candida nivariensis (n=2), Pichia ohmeri (n=1), Trichospon species (n=2). Conclusion Based on these data, we expect that the ePlex would have correctly identified 95.9% of the yeasts in this patient population. This represents an additional 18 (13%) of specimens that could be detected rapidly from the positive blood culture if the GenMarkDx ePlex BCID-FP panel were used instead of the Biofire BCID panel. Early identification can influence the choice of antifungal agent. Less than 5 % of the yeasts would have remained unidentified by ePLex compared to 13% for Biofire. Disclosures All Authors: No reported disclosures
Collapse
|
12
|
Banerjee M, Huang Y, Joshi S, Popa GJ, Mendenhall MD, Wang QJ, Garvy BA, Myint T, Whiteheart SW. Platelets Endocytose Viral Particles and Are Activated via TLR (Toll-Like Receptor) Signaling. Arterioscler Thromb Vasc Biol 2020; 40:1635-1650. [PMID: 32434410 DOI: 10.1161/atvbaha.120.314180] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Thrombocytopenia is associated with many viral infections suggesting virions interact with and affect platelets. Consistently, viral particles are seen inside platelets, and platelet activation markers are detected in viremic patients. In this article, we sought mechanistic insights into these virion/platelet interactions by examining how platelets endocytose, traffic, and are activated by a model virion. Approach and Results: Using fluorescently tagged HIV-1 pseudovirions, 3-dimensional structured illumination microscopy, and transgenic mouse models, we probed the interactions between platelets and virions. Mouse platelets used known endocytic machinery, that is, dynamin, VAMP (vesicle-associated membrane protein)-3, and Arf6 (ADP-ribosylation factor 6), to take up and traffic HIV-1 pseudovirions. Endocytosed HIV-1 pseudovirions trafficked through early (Rab4+) and late endosomes (Rab7+), and then to an LC3+ (microtubule-associated protein 1A/1B-light chain 3) compartment. Incubation with virions induced IRAK4 (interleukin 1 receptor-associated kinase 4), Akt (protein kinase B), and IKK (IκB kinase) activation, granule secretion, and platelet-leukocyte aggregate formation. This activation required TLRs (Toll-like receptors) and MyD88 (myeloid differentiation primary response protein 88) but was less extensive and slower than activation with thrombin. In vivo, HIV-1 pseudovirions injection led to virion uptake and platelet activation, as measured by IKK activation, platelet-leukocyte aggregate formation, and mild thrombocytopenia. All were decreased in VAMP-3-/- and, megakaryocyte/platelet-specific, Arf6-/- mice. Similar platelet activation profiles (increased platelet-leukocyte aggregates, plasma platelet factor 4, and phospho-IκBα) were detected in newly diagnosed and antiretroviral therapy-controlled HIV-1+ patients. CONCLUSIONS Collectively, our data provide mechanistic insights into the cell biology of how platelets endocytose and process virions. We propose a mechanism by which platelets sample the circulation and respond to potential pathogens that they take up.
Collapse
Affiliation(s)
- Meenakshi Banerjee
- Department of Molecular and Cellular Biochemistry (M.B., S.J., G.J.P., M.D.M., S.W.W.), University of Kentucky, Lexington
| | - Yunjie Huang
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, OH (Y.H.)
| | - Smita Joshi
- Department of Molecular and Cellular Biochemistry (M.B., S.J., G.J.P., M.D.M., S.W.W.), University of Kentucky, Lexington.,Lexington VA Health Care System, KY (S.J., S.W.W.)
| | - Gabriel J Popa
- Department of Molecular and Cellular Biochemistry (M.B., S.J., G.J.P., M.D.M., S.W.W.), University of Kentucky, Lexington
| | - Michael D Mendenhall
- Department of Molecular and Cellular Biochemistry (M.B., S.J., G.J.P., M.D.M., S.W.W.), University of Kentucky, Lexington
| | - Qing Jun Wang
- Department of Ophthalmology and Visual Sciences (Q.J.W.), University of Kentucky, Lexington
| | - Beth A Garvy
- Department of Microbiology, Immunology and Molecular Genetics (B.A.G.), University of Kentucky, Lexington
| | - Thein Myint
- Department of Infectious Diseases, Bluegrass Care Clinic, Kentucky Clinic (T.M.), University of Kentucky, Lexington
| | - Sidney W Whiteheart
- Department of Molecular and Cellular Biochemistry (M.B., S.J., G.J.P., M.D.M., S.W.W.), University of Kentucky, Lexington.,Lexington VA Health Care System, KY (S.J., S.W.W.)
| |
Collapse
|
13
|
Pyone ZC, Aung MW, Myint T, Khin TS, Hlaing TT. SUN-386 Treatment Outcomes of Intravenous Zoledronic Acid vs Oral Alendronate in Postmenopausal Women with Osteoporosis. J Endocr Soc 2020. [PMCID: PMC7208430 DOI: 10.1210/jendso/bvaa046.850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
In real practice, many patients with osteoporosis are poorly compliant with oral bisphosphonate, partly due to gastrointestinal side effects and partly due to medication procedure leading to premature termination of treatment. Once yearly intravenous zoledronic acid is well tolerated; little or no gastrointestinal effects and effective drug in treatment of postmenopausal osteoporosis with favourable dosing regimen to improve compliance of patients. So this study aims to study treatment outcomes of intravenous zoledronic acid vs oral alendronate in postmenopausal women with osteoporosis. This study was a randomized open label comparative study and included 94 postmenopausal women with osteoporosis. In this study, once yearly zoledronic acid (ZOL) infusion provided a greater reduction of serum procollagen type 1 N propeptide (P1NP) at 3 months than once weekly oral alendronate (ALN). Percentages of P1NP change in ZOL group was -70.25±17.51% and ALN group was -60.61±18.87% (P= 0.012). A decrease of P1NP ≥40% was observed in the majority of patients in both groups (89.4% in ZOL group and 85.1% in ALN group) (P= 0.536). ZOL was non-inferior to ALN in terms of BMD change at lumbar spine (4.8±5.5% in ZOL versus 4.9±4.5% in ALN treated patients) with P value of 0.922 and also at total hip (3.8±8.0% in ZOL versus 3.8±7.5% in ALN group) (P= 0.970). Two cases (4.3%) of new fractures was observed in ZOL group whereas 4 cases (8.5%) of new fractures occurred in ALN group over one year of study. The overall frequencies of treatment related adverse effects were similar between ZOL group (57.4%) and ALN group (42.6%) (P= 0.149). ZOL group showed significantly increased frequencies of musculoskeletal pain (57.4%) and acute phase reaction (12.8%) and 12.8% of participants in ALN group complained of heartburn. The overall preference to continue current medication was higher in ZOL group than ALN group (P= 0.002). The participants treated with ZOL were tend to have more satisfaction (P= 0.026) and willing to receive it longer period (P< 0.001).Compared to weekly oral alendronate therapy in treatment of postmenopausal osteoporosis, yearly infusion of 5 mg zoledronic acid infusion produced a significant greater response in serum P1NP at 3 months and similar change in BMD at one year of treatment and overall frequencies of adverse effects were similar between two treatment groups with excellent patient preference and satisfaction after zoledronate treatment. Reference: (1) Al-Bogami et al (2015) Favorable therapeutic response of osteoporotic patients to treatment with intravenous zoledronate compared with oral alendronate. Saudi Med J. 36(11):1305-1311. (2) Saag et al (2007) A single zoledronic acid infusion reduces bone resorption markers more rapidly than weekly oral alendronate in postmenopausal women with low bone mineral density. Bone. 40:1238-1243.
Collapse
Affiliation(s)
| | | | - Thein Myint
- University of Medicine (Magway), Magway, Myanmar
| | | | | |
Collapse
|
14
|
Sim MM, Li X, Bidarian SJ, Song X, Banerjee M, Myint T, Whiteheart SW, Wood JP. A Refined Plasma Thrombin Generation Assay Identifies Functional Importance of the First Two EGF‐like Domains of the Anticoagulant Protein S. FASEB J 2020. [DOI: 10.1096/fasebj.2020.34.s1.06196] [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: 11/11/2022]
|
15
|
Myint T, Leedy N, Villacorta Cari E, Wheat LJ. HIV-Associated Histoplasmosis: Current Perspectives. HIV AIDS (Auckl) 2020; 12:113-125. [PMID: 32256121 PMCID: PMC7090190 DOI: 10.2147/hiv.s185631] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 02/27/2020] [Indexed: 12/12/2022]
Abstract
Histoplasmosis is an endemic mycosis caused by Histoplasma capsulatum. Infection develops by inhalation of microconidia from environmental sites inhabited by birds and bats. Disseminated disease is the usual presentation due to impaired cellular immunity. Common clinical manifestations include fever, fatigue, malaise, anorexia, weight loss, and respiratory symptoms. Histoplasma antigen detection is the most sensitive method for diagnosis. The sensitivity of the MVista® Quantitative Histoplasma antigen enzyme immunoassay is 95-100% in urine, over 90% in serum and bronchoalveolar lavage (BAL) antigen and 78% in cerebral spinal fluid (CSF). A proven diagnosis can be established by culture or pathology with sensitivities between 70% and 80%. The sensitivity of antibody detection by immunodiffusion or complement fixation was between 60% and 70%. Diagnosis using molecular methods has not been adequately validated for implementation and FDA cleared assays are unavailable. Liposomal amphotericin B should be used for 1-2 weeks followed by itraconazole for at least one year until CD4 counts are above 150 cells/mm3, HIV viral load is below 400 copies/mL and Histoplasma urine antigen is negative. Serum itraconazole level should be monitored to avoid drug toxicity. Antigen should be measured periodically to establish that treatment is effective and to assist in identifying relapse. The incidence of immune reconstitution inflammatory syndrome is low but it must be considered in patients who are thought to be failing antifungal treatment as it does not respond to changing antifungal agents but rather to initiation of corticosteroid therapy. In this review, we discuss pathogenesis, clinical manifestations, diagnosis and treatment based on personal experience and relevant publications.
Collapse
Affiliation(s)
- Thein Myint
- Division of Infectious Diseases, Department of Internal Medicine, University of Kentucky, Lexington, KY, USA
| | - Nicole Leedy
- Division of Infectious Diseases, Department of Internal Medicine, University of Kentucky, Lexington, KY, USA
| | - Evelyn Villacorta Cari
- Division of Infectious Diseases, Department of Internal Medicine, University of Kentucky, Lexington, KY, USA
| | | |
Collapse
|
16
|
Ahmad O, Crawford TN, Myint T. Comparing the Outcomes of Ceftaroline Plus Vancomycin or Daptomycin Combination Therapy Versus Monotherapy in Adults with Complicated and Prolonged Methicillin-Resistant Staphylococcus Aureus Bacteremia Initially Treated with Supplemental Ceftaroline. Infect Dis Ther 2019; 9:77-87. [PMID: 31776844 PMCID: PMC7054513 DOI: 10.1007/s40121-019-00277-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia confers considerable morbidity and mortality. Although vancomycin or daptomycin monotherapy is usually curative, prolonged bacteremia necessitating supplemental ceftaroline has occurred. The practice has led to the question of whether to continue with ceftaroline following bacteremia resolution. METHODS Adult patients hospitalized with MRSA bacteremia at the University of Kentucky Medical Center between January 2015 and December 2017 were retrospectively reviewed. Study subjects required supplemental ceftaroline due to 4 or more days of bacteremia despite vancomycin or daptomycin. They additionally had accompanying native valve infective endocarditis, osteomyelitis, or brain abscess. Patients were divided into two cohorts. One group continued with ceftaroline plus vancomycin or daptomycin following bacteremia resolution (combination therapy group). The other group received vancomycin or daptomycin alone (monotherapy group). All involved received 6-8 weeks of therapy. Patients' Pitt bacteremia score (PBS) and Charlson comorbidity index (CCI) values were calculated. Treatment outcomes of inpatient mortality, recurrence of bacteremia, 30-day readmission, acute kidney injury, and leukopenia were recorded and compared. RESULTS A total of 30 patients comprised the study population. 15 patients were assigned to each cohort. The median PBS value of the combination therapy group was 2, compared with 1 among the monotherapy group. The median CCI score of both groups was 0. No statistically significant difference in the aforementioned treatment outcomes was seen between the two groups. CONCLUSION In subjects with complicated and prolonged MRSA bacteremia requiring supplemental ceftaroline, clinical outcomes did not differ among patients prescribed vancomycin or daptomycin alone following bacteremia resolution versus patients who continued combination therapy.
Collapse
Affiliation(s)
- Omar Ahmad
- Division of Infectious Diseases, University of Kentucky, Lexington, KY, USA.
| | - Timothy N Crawford
- Department of Population and Public Health Sciences, Wright State University, Dayton, OH, USA
| | - Thein Myint
- Division of Infectious Diseases, University of Kentucky, Lexington, KY, USA
| |
Collapse
|
17
|
Villacorta E, Acosta L, Myint T, Leedy N, Lia Castellanos A, Gedaly R. 2661. Sarcopenia Increases Risk of Post-Surgical Infections in Kidney Transplant Recipients. Open Forum Infect Dis 2019. [PMCID: PMC6810160 DOI: 10.1093/ofid/ofz360.2339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Sarcopenia (reduced skeletal muscle mass) has been associated with serious infection in liver transplant recipients. We analyzed the association of sarcopenia and early post-surgical infections in kidney transplant recipients.
Methods
Retrospective cohort study of 125 patients underwent kidney transplantation from 2010 to 2014 at University of Kentucky Medical Center. Sarcopenia was diagnosed by measuring the skeletal muscle mass on computed tomography imaging obtained during the pre-transplant evaluation using SliceOmatic 5.0 software at L3 level (≤ 52.4 cm2/m2 in males and ≤ 38.5 cm2/m2 in females). Early post-transplant infections were confirmed by positive culture from blood, urine, and/or peritoneal fluid within 30 days after kidney transplantation. A generalized linear model (GLM) was used to identify variables predictive of post- surgical infection and Risk Ratio (RR) was obtained, with a P-value of < 0.05. The statistical analysis was performed with STATA version 12.0 (College Station, Texas).
Results
Among 125 patients, 52 (41.6%) were identified with sarcopenia, 110 (88.0%) patients were white, 76 (60.8%) male, with a median age of 56 (range 20–72) at the time of transplant. Diabetes was reported in 50 (40.0%) patients, obesity in 64 (51.6%) patients and smoking in 43 (34.6%) patients. Six (4.8%) patients had graft failure. Infections were identified in 22 (17.6%) patients, more than one source of infection was reported in 4 (3.2%) cases. The most common infections were urinary tract infection in 13 (10.4%) patients and bacteremia in 5 (4.0%) patients. The median time to development of infection was 9 days (range 1–27). In the bivariate analysis, sarcopenia was associated with high risk of post-surgical infections (RR 2.45; 95% CI 1.10–5.44). In multivariable analysis, sarcopenia was a significant independent predictor of infection (RR 2.58; 95% CI 1.20–5.52). None associations were found with other variables; age over 40 years, male sex, smoking, obesity and diabetes.
Conclusion
Our study suggested that sarcopenia was associated with an increased risk of early post-surgical infection in kidney transplant recipients.
Disclosures
All authors: No reported disclosures.
Collapse
|
18
|
Abstract
Background At University of Kentucky (UK) HealthCare, the transition from latex agglutination testing (Remel, Lenexa, KS) to IMMY Cryptococcal Antigen Lateral Flow Assay (CrAg LFA) occurred in September 2016. A few months later, it was noticed that several cryptococcal cases were diagnosed with weak positive test results where the diagnosis could not be confirmed by additional testing. The purpose of this study was to analyze the characteristics of these patients, and to assess the interventions they received based on positive results. Methods This was a retrospective study of the patients with positive CrAg LFA treated at UK HealthCare from November to December 2016. Low antigen titers (≤ 1:20) were considered to be false positive if repeat testing with the Remel Cryptococcal Latex assay, IMMY latex and IMMY microwell EIA were negative, cultures and histopathology were negative and there was no clear clinical evidence of infection. Results During this 2-month period, CrAg LFA was positive in 12 patients. The diagnosis of cryptococcosis could not be confirmed by additional testing in 9 (75%) individuals. Cirrhosis/liver disease was present in 3 (33.3%) patients, 5 (55.6%) underwent lumber puncture and antifungal therapy was administered in 8 (88.9%) patients (Table 1). CrAg LFA was false positive in 1/2 (50%) HIV, 3/3 (100%) transplant, and 5/7 (71.4%) non-HIV/non-transplant patients (Figure 1). Among the false positives, 4 (44.4%) patients had titer of 1:5, two (22.2%) had 1:20, and the original positive screen was not detected upon titration in 3 (33.3%) other patients. One HIV patient received a complete treatment course for unconfirmed cryptococcal meningitis because an LP could not be performed. Conclusion False-positive low CrAg LFA titers led to unnecessary tests, antifungal treatments and prolonged hospitalization in some patients. One-third of these individuals had cirrhosis/liver disease. Other institutions also reported false-positive low CrAg LFA titers. As a result, the company staged a recall of the specific lot and corrected the problem in reagent manufacturing. Low-positive titers using CrAg LFA should be interpreted carefully and further testing should be considered as determined by the clinical situation. ![]()
![]()
Disclosures All authors: No reported disclosures.
Collapse
|
19
|
Moss J, Forster DW, Arora V, Burgess D, Wallace K, Cotner S, Burgess DR, Ribes JA, Suder T, Myint T, VanHoose J, Jones CR. 1982. A Diagnostic Stewardship Intervention for Clostridioides difficile: Impact of Stool Toxin Testing on Treatment of Adult Inpatients. Open Forum Infect Dis 2019. [PMCID: PMC6808651 DOI: 10.1093/ofid/ofz360.1662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Testing for Clostridioides difficile infection has been the subject of recent debate. Guidelines from the Infectious Diseases Society of America now support the addition of a stool toxin test to a positive nucleic acid amplification test (NAAT) as part of a multi-step testing algorithm. In November 2017, the University of Kentucky HealthCare system added stool toxin testing to any specimen positive for C. difficile by NAAT. This change was accompanied by face to face education with provider groups and clinical decision support in the form of interpretive verbiage added to the results that are reported into the electronic record. The objective of this study was to assess whether this diagnostic stewardship intervention made an impact on C. difficile treatment Methods We performed a retrospective review of adult patients admitted to UK HealthCare from November 1, 2017 through October 31, 2018 who tested positive by NAAT but negative by stool toxin test to determine whether or not they were treated. We also assessed treatment by service line to see whether there were treatment differences among these groups. A cost analysis was also performed. Results A total of 300 adult inpatients were positive for C. difficile by NAAT during the study period with 71% (213 patients) having a negative stool toxin test. Of those, 58% (123) were never started on C. difficile therapy and an additional 14% (30) had their therapy stopped after 48 hours. Only 28% (60) of these patients received a full course of therapy. Hospital medicine had the highest rate of non-treatment at 82%. Conversely, our solid-organ and bone marrow transplant services had the lowest rate of non-treatment at 31%. Overall, this approach was associated with an estimated 1470 oral vancomycin days avoided (5,880 doses) and a cost savings of $6,278. Conclusion The addition of stool toxin testing to NAAT combined with education and clinical decision support lead to a dramatic reduction of treatment for NAAT positive but toxin-negative patients. This form of diagnostic stewardship had a significant impact on therapy decisions and can be a powerful antimicrobial stewardship approach to decrease unnecessary treatment of C. difficile colonization. Disclosures All authors: No reported disclosures.
Collapse
Affiliation(s)
| | | | | | | | - Katie Wallace
- University of Kentucky HealthCare, Lexington, Kentucky
| | | | | | | | | | | | | | | |
Collapse
|
20
|
Bhatt M, Ribes JA, Arora V, Myint T. 1705. Clinical Characteristics and Outcomes of Cryptococcosis in a Tertiary Care Center in Kentucky, 2005 to 2017. Open Forum Infect Dis 2019. [PMCID: PMC6810739 DOI: 10.1093/ofid/ofz360.1569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Cryptococcosis is an invasive fungal infection that causes pneumonia and extrapulmonary infection. This study explores its presentations, diagnostic tests, and outcome in different groups over a 12-year period at an academic medical center. Methods This was a retrospective study of the patients treated at University of Kentucky HealthCare from October 16, 2005 to October 15, 2017. Inclusion criteria were positive cryptococcal antigen (Ag), positive culture, or presence of yeast morphologically consistent with Cryptococcus on cyto- or histopathology. Patients were divided into HIV-infected, solid-organ transplant (SOT) recipients, and non-HIV/non-transplant groups. Cryptococcal meningitis comprised of either positive CSF Ag, culture, cytology or histopathology. Results A total of 114 patients were identified; 23 HIV-infected, 11 SOT recipients and 80 non-HIV/non-transplant patients (Table 1). Cryptococcus neoformans was the most common yeast isolated (91.8%). Cryptococcal meningitis was seen in 56% of total patients whereas 27% had isolated cryptococcal pneumonia (P < 0.01). Blood cultures and serum Ag were positive in 34% and 70%, respectively. Only 8.7% of HIV-infected patients had isolated pulmonary cryptococcosis compared with 36.4% in SOT recipients (P < 0.01). In patients with cryptococcal meningitis, abnormal CSF cell count, protein, or glucose was noted in 85.3%; India ink was positive in 61.3% and CSF culture was positive in 73.4% (Table 2, Figure 1). CSF cryptococcal Ag was detected in 95.6% cases if CSF cultures were positive, whereas serum Ag was positive in only 85.1% of meningitis cases. Mortality was seen in 48.6% (17/35) of patients with cirrhosis/liver disease, compared with 21.5% (17/79) of non-cirrhosis/liver disease (P = 0.003). Transplant group had 54.5% mortality compared with 26.1% in HIV group (P = 0.016). Conclusion Cryptococcal meningitis was the most common presentation for cryptococcal disease in all three groups. Isolated pulmonary disease was least common in the HIV-infected group. Inpatient mortality rate was higher in patients with cirrhosis/liver disease and transplant group compared with those without cirrhosis/liver disease and HIV group, respectively. It is imperative to rule out meningitis in immunosuppressed patients with cryptococcal pneumonia. ![]()
![]()
![]()
Disclosures All authors: No reported disclosures.
Collapse
|
21
|
Bloch KC, Myint T, Raymond-Guillen L, Hage CA, Davis TE, Wright PW, Chow FC, Woc-Colburn L, Khairy RN, Street AC, Yamamoto T, Albers A, Wheat LJ. Improvement in Diagnosis of Histoplasma Meningitis by Combined Testing for Histoplasma Antigen and Immunoglobulin G and Immunoglobulin M Anti-Histoplasma Antibody in Cerebrospinal Fluid. Clin Infect Dis 2019; 66:89-94. [PMID: 29020213 PMCID: PMC5850023 DOI: 10.1093/cid/cix706] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 08/07/2017] [Indexed: 01/29/2023] Open
Abstract
Background Central nervous system (CNS) histoplasmosis is a life-threatening condition and represents a diagnostic and therapeutic challenge. Isolation of Histoplasma capsulatum from cerebrospinal fluid (CSF) or brain tissue is diagnostic; however, culture is insensitive and slow growth may result in significant treatment delay. We performed a retrospective multicenter study to evaluate the sensitivity and specificity of a new anti-Histoplasma antibody enzyme immunoassay (EIA) for the detection of IgG and IgM antibody in the CSF for diagnosis of CNS histoplasmosis, the primary objective of the study. The secondary objective was to determine the effect of improvements in the Histoplasma galactomannan antigen detection EIA on the diagnosis of Histoplasma meningitis. Methods Residual CSF specimens from patients with Histoplasma meningitis and controls were tested for Histoplasma antigen and anti-Histoplasma immunoglobulin G (IgG) and immunoglobulin M (IgM) antibody using assays developed at MiraVista Diagnostics. Results A total of 50 cases and 157 controls were evaluated. Fifty percent of patients with CNS histoplasmosis were immunocompromised, 14% had other medical conditions, and 36% were healthy. Histoplasma antigen was detected in CSF in 78% of cases and the specificity was 97%. Anti-Histoplasma IgG or IgM antibody was detected in 82% of cases and the specificity was 93%. The sensitivity of detection of antibody by currently available serologic testing including immunodiffusion and complement fixation was 51% and the specificity was 96%. Testing for both CSF antigen and antibody by EIA was the most sensitive approach, detecting 98% of cases. Conclusions Testing CSF for anti-Histoplasma IgG and IgM antibody complements antigen detection and improves the sensitivity for diagnosis of Histoplasma meningitis.
Collapse
Affiliation(s)
- Karen C Bloch
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Thein Myint
- University of Kentucky School of Medicine, Lexington
| | | | - Chadi A Hage
- Indiana University School of Medicine, Indianapolis
| | | | - Patty W Wright
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Felicia C Chow
- School of Medicine, University of California, San Francisco
| | | | - Raed N Khairy
- Sparks Center for Infectious Diseases, Fort Smith, Arkansas
| | - Alan C Street
- Royal Melbourne Hospital, Parkville, Victoria, Australia
| | | | | | | |
Collapse
|
22
|
Bhatt M, Burgess DR, Wallace KL, Gregory E, Myint T. 1804. Impact of Susceptibility Testing Method on Antibiotic Selection for Methicillin-Resistant Staphylococcus Aureus (MRSA) Bacteremia. Open Forum Infect Dis 2018. [PMCID: PMC6254558 DOI: 10.1093/ofid/ofy210.1460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background The selection of intravenous (IV) antibiotics for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia can be influenced by the vancomycin minimum inhibitory concentration (MIC). This study explores the changes in antibiotic use and inpatient mortality for patients with MRSA bacteremia after switching the MIC testing methods. Methods At University of Kentucky Medical Center, Etest™ was implemented in November 2013 for all Staphylococcus aureus blood isolates. In April 2016, this was changed to Phoenix™ automated system. Data regarding antibiotic usage for patients with MRSA bacteremia were collected from July 2014 to December 2015 (Etest™) and September 2016 to March 2017 (Phoenix™). Only patients started on IV vancomycin were included. Daptomycin and ceftaroline use was monitored by the antimicrobial stewardship team with focus on guideline adherence. Results A total of 119 and 62 patients were identified before and after switching to Phoenix™. MICs of 2 μg/mL were significantly decreased (P < 0.001) after changing to Phoenix™ (Table 1). Daptomycin use (alone or in combination) decreased from 37% (44/119) to 21% (13/62) (P = 0.013). Ceftaroline use (alone or in combination) decreased from 32% (38/119) to 19% (12/62) (P = 0.036). The reason for escalation in 13 of 44 (30%) patients with daptomycin and 6 of 38 (16%) patients with ceftaroline was an MIC of 2 μg/mL. Overall, IV vancomycin use (alone or in combination) increased from 50% (60/119) to 69% (43/62) (P = 0.007). All-cause inpatient mortality was 16% (19/119) before and 10% (6/62) (P = 0.24) after switching to Phoenix. Conclusion A switch in vancomycin susceptibility testing from Etest™ to Phoenix™ automated system was associated with a significant decrease in daptomycin and ceftaroline use and an increase in IV vancomycin use without any change in all-cause inpatient mortality. Disclosures All authors: No reported disclosures.
Collapse
Affiliation(s)
- Mahesh Bhatt
- Division of Infectious Diseases, University of Kentucky, Lexington, Kentucky
| | - Donna R Burgess
- University of Kentucky, College of Pharmacy, Lexington, Kentucky
- University of Kentucky HealthCare, Lexington, Kentucky
| | - Katie L Wallace
- University of Kentucky, College of Pharmacy, Lexington, Kentucky
- University of Kentucky HealthCare, Lexington, Kentucky
| | - Eric Gregory
- University of Kentucky HealthCare, Lexington, Kentucky
| | - Thein Myint
- Division of Infectious Diseases, University of Kentucky, Lexington, Kentucky
| |
Collapse
|
23
|
Burgess DR, Hile G, Reynolds J, Cotner S, Baum R, Bailey AM, Myint T, Wallace KL. 1878. Expanding Kentucky’s “One and Done” Tradition: Lipoglycopeptide Administration in the Emergency Department at a Tertiary, Academic Medical Center. Open Forum Infect Dis 2018. [PMCID: PMC6253951 DOI: 10.1093/ofid/ofy210.1534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background Acute bacterial skin and skin structure infection (ABSSSI) incidence continues to rise, accounting for around 3.5 million emergency department (ED) visits per year in the United States. Dalbavancin and oritavancin are lipoglycopeptides with long half-lives allowing for single dose treatment options for eligible patients presenting with ABSSSIs in the ED, avoiding an inpatient admission. The objective of this study was to investigate the financial outcomes of utilizing these agents in the ED. Methods This was a single-center, retrospective study in adult patients with ABSSSIs that received a lipoglycopeptide in the ED at an academic medical center from April 2016 to February 2018. A multidisciplinary institutional guideline was developed and implemented in April 2016. Data were documented in the electronic medical record and/or REDCap™ database. A comparator group was identified by utilizing similar ICD-10 codes for patients that were admitted for ABSSSI. Variable direct cost-avoidance was examined to explore the financial implication of lipoglycopeptide treatment in this population. Results The average length of stay in the comparator group who were admitted for ABSSSIs during the predefined time period was 4.3 days. Because patients receiving a lipoglycopeptide did not require admission for intravenous antibiotics, 94.6 patient-days were avoided increasing the capacity by 14.1 patients. Overall, 22 patients received either dalbavancin (n = 18) or oritavancin (n = 4). The age was 40.8 ± 13.2 years for the study group with 55% male. The age of the comparator group was 40.5 ± 19.7 years. All patients were discharged home from the ED without being admitted. Two patients were readmitted for treatment failure requiring IV antibiotics. Despite 2 of 22 patients receiving a lipoglycopeptide without insurance, the variable direct cost avoidance was $4,560 per case, or $1,060 per day. Conclusion The use of lipoglycopeptides offers patient convenience and financial benefits, warranting its consideration for use in the ED at tertiary academic medical centers. Disclosures All authors: No reported disclosures.
Collapse
Affiliation(s)
- Donna R Burgess
- University of Kentucky HealthCare, Lexington, Kentucky
- University of Kentucky, College of Pharmacy, Lexington, Kentucky
| | - Garrett Hile
- University of Kentucky HealthCare, Lexington, Kentucky
| | | | - Sarah Cotner
- University of Kentucky, College of Pharmacy, Lexington, Kentucky
| | - Regan Baum
- University of Kentucky HealthCare, Lexington, Kentucky
- University of Kentucky, College of Pharmacy, Lexington, Kentucky
| | - Abby M Bailey
- University of Kentucky HealthCare, Lexington, Kentucky
- University of Kentucky, College of Pharmacy, Lexington, Kentucky
| | - Thein Myint
- Division of Infectious Diseases, University of Kentucky, Lexington, Kentucky
| | - Katie L Wallace
- University of Kentucky HealthCare, Lexington, Kentucky
- University of Kentucky, College of Pharmacy, Lexington, Kentucky
| |
Collapse
|
24
|
Wheat J, Myint T, Guo Y, Kemmer P, Hage C, Terry C, Azar MM, Riddell J, Ender P, Chen S, Shehab K, Cleveland K, Esguerra E, Johnson J, Wright P, Douglas V, Vergidis P, Ooi W, Baddley J, Bamberger D, Khairy R, Vikram H, Jenny-Avital E, Sivasubramanian G, Bowlware K, Pahud B, Sarria J, Tsai T, Assi M, Mocherla S, Prakash V, Allen D, Passaretti C, Huprikar S, Anderson A. Central nervous system histoplasmosis: Multicenter retrospective study on clinical features, diagnostic approach and outcome of treatment. Medicine (Baltimore) 2018; 97:e0245. [PMID: 29595679 PMCID: PMC5895412 DOI: 10.1097/md.0000000000010245] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Central nervous system (CNS) involvement occurs in 5 to 10% of individuals with disseminated histoplasmosis. Most experience has been derived from small single center case series, or case report literature reviews. Therefore, a larger study of central nervous system (CNS) histoplasmosis is needed in order to guide the approach to diagnosis, and treatment.A convenience sample of 77 patients with histoplasmosis infection of the CNS was evaluated. Data was collected that focused on recognition of infection, diagnostic techniques, and outcomes of treatment.Twenty nine percent of patients were not immunosuppressed. Histoplasma antigen, or anti-Histoplasma antibodies were detected in the cerebrospinal fluid (CSF) in 75% of patients. One year survival was 75% among patients treated initially with amphotericin B, and was highest with liposomal, or deoxycholate formulations. Mortality was higher in immunocompromised patients, and patients 54 years of age, or older. Six percent of patients relapsed, all of whom had the acquired immunodeficiency syndrome (AIDS), and were poorly adherent with treatment.While CNS histoplasmosis occurred most often in immunocompromised individuals, a significant proportion of patients were previously, healthy. The diagnosis can be established by antigen, and antibody testing of the CSF, and serum, and antigen testing of the urine in most patients. Treatment with liposomal amphotericin B (AMB-L) for at least 1 month; followed by itraconazole for at least 1 year, results in survival among the majority of individuals. Patients should be followed for relapse for at least 1 year, after stopping therapy.
Collapse
Affiliation(s)
| | - Thein Myint
- University of Kentucky School of Medicine, Lexington, Kentucky
| | - Ying Guo
- Emory University Rollins School of Public Health
| | - Phebe Kemmer
- Emory University Rollins School of Public Health
| | | | - Colin Terry
- Indiana University Health, Indianapolis, Indiana
| | - Marwan M. Azar
- Yale University School of Medicine, New Haven, Connecticut
| | - James Riddell
- University of Michigan Health System, Ann Arbor, Michigan
| | - Peter Ender
- St. Luke's University Hospital and Health Network, Bethlehem
| | - Sharon Chen
- Stanford University School of Medicine, Stanford
| | | | | | | | - James Johnson
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Patty Wright
- University of California at San Francisco School of Medicine, San Francisco
| | - Vanja Douglas
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Winnie Ooi
- Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - John Baddley
- University of Alabama- Birmingham, Birmingham, Alabama
| | | | - Raed Khairy
- Sparks Center for Infectious Diseases, Fort Smith, Arkansas
| | | | | | | | - Karen Bowlware
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | | | - Juan Sarria
- University of Texas Medical Branch, Galveston
| | | | - Maha Assi
- Infectious Disease Consultants, Wichita, Kansas
| | | | - Vidhya Prakash
- Southern Illinois University School of Medicine, Springfield, Illinois
| | - David Allen
- Courage Fund, National University of Singapore, Singapore
| | | | | | | |
Collapse
|
25
|
Myint T, Miftahussurur M, Vilaichone RK, Ni N, Aye TT, Subsomwong P, Uchida T, Mahachai V, Yamaoka Y. Characterizing Helicobacter pylori cagA in Myanmar. Gut Liver 2018; 12:51-57. [PMID: 29069889 PMCID: PMC5753684 DOI: 10.5009/gnl17053] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 04/21/2017] [Accepted: 04/29/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND/AIMS Differences in the Helicobacter pylori infection rate are not sufficient to clarify the dissimilarity of gastric cancer incidence between Myanmar and its neighboring countries. To better understand this trend, the H. pylori virulence gene cagA was characterized in Myanmar. METHODS Glutamate-proline-isoleucine-tyrosine-alanine (EPIYA) patterns and CagA multimerization (CM) motifs of cagA genotypes were examined by performing polymerase chain reactions and DNA sequencing. RESULTS Of 69 tested H. pylori strains, cagA-positive patients had significantly more severe histological scores in their antrum than cagA-negative patients. Sequence analysis revealed that 94.1% of strains had Western-type cagA containing an EPIYA motif (92.6%) or EPIYT motif (6.4%). The intestinal metaplasia scores in the antral of patients infected with the ABC and ABCC types of cagA were significantly higher than those of patients with AB-type cagA. Interestingly, in patients infected with H. pylori, 46.3% of strains with three EPIYA motifs contained two identical Western-typical CM motifs, and these patients showed significantly higher antrum inflammation scores than patients infected with two identical nontypical-CM motif strains (p=0.02). CONCLUSIONS In Myanmarese strains, Western-type cagA was predominant. The presence of CM motifs and the proportion of multiple EPIYA-C segments might partially explain the intermediate gastric cancer risk found in Myanmar.
Collapse
Affiliation(s)
- Thein Myint
- Department of Gastroenterology, Yangon General Hospital, University of Medicine (1), Yangon,
Myanmar
| | - Muhammad Miftahussurur
- Department of Environmental and Preventive Medicine, Oita University Faculty of Medicine, Yufu,
Japan
- Department of Medicine, Gastroenterology and Hepatology Section, Baylor College of Medicine, Houston, TX,
USA
- Gastroentero-Hepatology Division, Department of Internal Medicine, Dr. Soetomo Teaching Hospital-Faculty of Medicine-Institute of Tropical Disease, Universitas Airlangga, Surabaya,
Indonesia
| | - Ratha-korn Vilaichone
- Gastroenterology Unit, Department of Medicine, Thammasat University Hospital, Pathumthani,
Thailand
| | - New Ni
- Department of Gastroenterology, Mandalay General Hospital, University of Medicine (Mandalay), Mandalay,
Myanmar
| | - Than Than Aye
- Department of Gastroenterology, Thingangyun Sanpya General Hospital, University of Medicine (2), Thingangyun,
Myanmar
| | - Phawinee Subsomwong
- Department of Environmental and Preventive Medicine, Oita University Faculty of Medicine, Yufu,
Japan
| | - Tomohisa Uchida
- Department of Molecular Pathology, Oita University Faculty of Medicine, Yufu,
Japan
| | | | - Yoshio Yamaoka
- Department of Environmental and Preventive Medicine, Oita University Faculty of Medicine, Yufu,
Japan
- Department of Medicine, Gastroenterology and Hepatology Section, Baylor College of Medicine, Houston, TX,
USA
| |
Collapse
|
26
|
Ansari S, Kabamba ET, Shrestha PK, Aftab H, Myint T, Tshering L, Sharma RP, Ni N, Aye TT, Subsomwong P, Uchida T, Ratanachu-ek T, Vilaichone RK, Mahachai V, Matsumoto T, Akada J, Yamaoka Y. Helicobacter pylori bab characterization in clinical isolates from Bhutan, Myanmar, Nepal and Bangladesh. PLoS One 2017; 12:e0187225. [PMID: 29107979 PMCID: PMC5673166 DOI: 10.1371/journal.pone.0187225] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Accepted: 10/16/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Helicobacter pylori BabA is an important outer membrane protein that involves in the attachment to the gastric mucosa and enhances the virulence property of the bacterium. This study was aimed to characterize the bab genotypes, to evaluate its association with cagA, vacA and clinical diseases as well as degree of gastric inflammation. METHODS H. pylori isolates from four countries were subjected for the characterization of bab. The locus specific forward and bab specific reverse primers were used to get the specific products by PCR, which could distinguish the three locus (A, B and C). The histological activities were evaluated according to the Updated Sydney system. RESULT In patients from high risk countries (Bhutan and Myanmar) relatively higher frequencies of strains with babA-positivity (91.8% and 90.7%, respectively), babA at locus A (98% and 91.2%, respectively) and with single babA (96.8% and 91.2%, respectively) were found. Strains with two loci occupied were the most prevalent in Bhutan (84.6%), Myanmar (74.7%), Nepal (58.3%) and Bangladesh (56.9%). The genotype babA at locus A/babB at locus B/bab-negative at locus C (babA/babB/-) was the most common genotype isolated from Bhutan (82.7%), Myanmar (58.7%), Nepal (32%) and Bangladesh (31.4%) among all genotypes assessed. This genotype was also associated with the peptic ulcer disease (P = 0.013) when compared to gastritis. babA-positive characteristics and the genotype babA/babB/- exhibited the enhanced histological activities. CONCLUSIONS The higher prevalence of virulence associated babA-positive characteristics and enhanced histological activities in Bhutan than in Myanmar, Nepal and Bangladesh might partly explain why the peoples in Bhutan are at higher risk for developing severe gastric complications.
Collapse
Affiliation(s)
- Shamshul Ansari
- Department of Environmental and Preventive Medicine, Oita University Faculty of Medicine, Yufu, Japan
| | | | - Pradeep Krishna Shrestha
- Gastroenterology Department, Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Hafeza Aftab
- Department of Gastroenterology, Dhaka Medical College and Hospital, Dhaka, Bangladesh
| | - Thein Myint
- Department of Gastroenterology, Yangon General Hospital, Yangon, Myanmar
| | - Lotay Tshering
- Department of Surgery, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Rabi Prakash Sharma
- Gastroenterology Department, Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Nwe Ni
- Department of Gastroenterology, Mandalay General Hospital and University of Medicine (Mandalay), Mandalay, Myanmar
| | - Than Than Aye
- Department of Gastroenterology, Thingangyun Sanpya General Hospital and University of Medicine (2), Thingangyun, Myanmar
| | - Phawinee Subsomwong
- Department of Environmental and Preventive Medicine, Oita University Faculty of Medicine, Yufu, Japan
| | - Tomohisa Uchida
- Department of Molecular Pathology, Faculty of Medicine, Oita University, Hasama-machi, Yufu-City, Oita, Japan
| | | | - Ratha-korn Vilaichone
- Gastroenterology Unit, Department of Medicine, Thammasat University Hospital, Pathum Thani, Thailand
| | | | - Takashi Matsumoto
- Department of Environmental and Preventive Medicine, Oita University Faculty of Medicine, Yufu, Japan
| | - Junko Akada
- Department of Environmental and Preventive Medicine, Oita University Faculty of Medicine, Yufu, Japan
| | - Yoshio Yamaoka
- Department of Environmental and Preventive Medicine, Oita University Faculty of Medicine, Yufu, Japan
- Department of Medicine-Gastroenterology, Baylor College of Medicine, Houston, TX, United States of America
| |
Collapse
|
27
|
Yu I, Greenberg RN, Crawford TN, Thornton AC, Myint T. Persistence of Macrocytosis after Discontinuation of Zidovudine in HIV-Infected Patients. J Int Assoc Provid AIDS Care 2017; 16:512-515. [PMID: 28393661 DOI: 10.1177/2325957417702486] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The duration of macrocytosis after stopping zidovudine (ZDV) is unknown. Among 104 HIV-infected patients treated with ZDV for more than 1 year, 84 patients had macrocytosis at ZDV discontinuation. The median mean corpuscular volume (MCV) was 114.6 fL (range 100-128 fL). Patients were divided into 2 groups: those who did (resolved macrocytosis, n = 36) and did not (persistent macrocytosis, n = 48) normalize MCV at 3 to 6 months after ZDV discontinuation. Alcohol use ( P = .02), smoking ( P = .03), and lower (but within normal range) folic acid levels ( P = .05) were related to the persistence of macrocytosis. A persistence of macrocytosis was observed in 57% at 3 to 6 months, 38% at 1 year and 37% at 2 years after ZDV therapy had stopped. Duration of ZDV therapy did not have an effect on the persistence of macrocytosis ( P = .73). The median time for the MCV to normalize after stopping ZDV was 12.5 months.
Collapse
Affiliation(s)
- Inski Yu
- 1 Division of Infectious Diseases, Department of Internal Medicine, St Joseph Medical Center, Lewiston, ID, USA
| | - Richard N Greenberg
- 2 Division of Infectious Diseases, Department of Internal Medicine, University of Kentucky, Lexington, KY, USA
| | | | - Alice C Thornton
- 2 Division of Infectious Diseases, Department of Internal Medicine, University of Kentucky, Lexington, KY, USA
| | - Thein Myint
- 2 Division of Infectious Diseases, Department of Internal Medicine, University of Kentucky, Lexington, KY, USA
| |
Collapse
|
28
|
Tennant SJ, Burgess DR, Myint T, Kincaid S, Burgess DS. Using Pharmacist-Driven Recommendations to Optimize Management of Staphylococcal Bacteremia. Open Forum Infect Dis 2016. [DOI: 10.1093/ofid/ofw172.1486] [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: 11/12/2022] Open
Affiliation(s)
- Sarah J. Tennant
- University of Kentucky HealthCare, Lexington, Kentucky
- University of Kentucky, College of Pharmacy, Lexington, Kentucky
| | - Donna R. Burgess
- University of Kentucky HealthCare, Lexington, Kentucky
- University of Kentucky, College of Pharmacy, Lexington, Kentucky
| | - Thein Myint
- Division of Infectious Diseases, University of Kentucky, Lexington, Kentucky
| | - Scott Kincaid
- University of Kentucky HealthCare, Lexington, Kentucky
- University of Kentucky, College of Pharmacy, Lexington, Kentucky
| | - David S. Burgess
- University of Kentucky, College of Pharmacy, Lexington, Kentucky
| |
Collapse
|
29
|
Bloch K, Myint T, Guillen L, Albers A, Wheat LJ. Diagnosis of Central Nervous System Histoplasmosis by Cerebrospinal Fluid EIA Antibody Detection. Open Forum Infect Dis 2016. [DOI: 10.1093/ofid/ofw172.1253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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] Open
Affiliation(s)
- Karen Bloch
- Medicine and Health Policy, Vanderbilt University Medical Center, Nashville, TN
| | - Thein Myint
- Division of Infectious Diseases, University of Kentucky, Lexington, KY
| | - Luke Guillen
- Medicine, Indiana University School of Medicine, Indianapolis, IN
| | | | | |
Collapse
|
30
|
Myint T, Evans ME, Burgess DR, Greenberg RN. Respiratory Muscle Paralysis Associated With Colistin, Polymyxin B, and Muscle Relaxants Drugs: A Case Report. J Investig Med High Impact Case Rep 2016; 4:2324709616638362. [PMID: 27047979 PMCID: PMC4797228 DOI: 10.1177/2324709616638362] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Revised: 02/02/2016] [Accepted: 02/16/2016] [Indexed: 11/16/2022] Open
Abstract
Polymyxins B and E (colistin) exert a bactericidal effect on the gram-negative bacterial cell wall, causing permeability changes in the cytoplasmic membrane, leading to cell death. Their use was substantially decreased in clinical practice from the 1970s to 2000s due to their significant nephrotoxicity and neurotoxicity compared to the newly introduced antibiotics. The increasing prevalence of multidrug-resistant gram-negative bacteria infections in this century has led to an upsurge in the use of these "older" drugs. Respiratory paralysis caused by neuromuscular blockage associated with the use of polymyxin B and E was reported mostly in literature published in the 1960s to 1970s with a few reports after 2000. In addition, such a reaction might be enhanced by the presence of other classes of drugs. We report a case of polymyxin B and E-induced apnea in a patient receiving "muscle relaxants."
Collapse
Affiliation(s)
- Thein Myint
- University of Kentucky Medical Center, Lexington, KY, USA
| | - Martin E Evans
- University of Kentucky Medical Center, Lexington, KY, USA
| | | | | |
Collapse
|
31
|
Myint T, Dykhuizen MJ, McDonald CH, Ribes JA. Post operative fungal endopthalmitis due to Geotrichum candidum. Med Mycol Case Rep 2015; 10:4-6. [PMID: 26779419 PMCID: PMC4685175 DOI: 10.1016/j.mmcr.2015.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 10/30/2015] [Accepted: 11/19/2015] [Indexed: 11/04/2022] Open
Abstract
Geotrichum species have been rarely reported as the cause of sepsis, disseminated infection in immunosuppressed patients. The patient we describe developed indolent endophthalmitis four months after her routine right eye cataract surgery. The intraoperative sample from right vitreous fluid grew Geotrichum candidum. The patient underwent vitrectomy, artificial lens explantation and intravitreal injection of amphotericin B followed by oral voriconazole. Despite these interventions, she underwent enucleation. This is the first published case of Geotrichum candidum endophthalmitis.
Collapse
Affiliation(s)
- Thein Myint
- Division of Infectious Diseases, University of Kentucky, KY, USA
| | | | | | - Julie A Ribes
- Department of Microbiology, University of Kentucky, KY, USA; Department of Pathology and Laboratory Medicine, University of Kentucky, KY, USA
| |
Collapse
|
32
|
Taniguchi N, Kaneto H, Islam KN, Hoshi S, Myint T. Glycation of metal-containing proteins such as Cu,Zn-superoxide dismutase, ceruloplasmin, and ferritin: possible implication for DNA damage in vivo. Contrib Nephrol 2015; 112:18-23. [PMID: 7554989 DOI: 10.1159/000424088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- N Taniguchi
- Department of Biochemistry, Osaka University Medical School, Japan
| | | | | | | | | |
Collapse
|
33
|
Vergidis P, Avery RK, Wheat LJ, Dotson JL, Assi MA, Antoun SA, Hamoud KA, Burdette SD, Freifeld AG, McKinsey DS, Money ME, Myint T, Andes DR, Hoey CA, Kaul DA, Dickter JK, Liebers DE, Miller RA, Muth WE, Prakash V, Steiner FT, Walker RC, Hage CA. Histoplasmosis complicating tumor necrosis factor-α blocker therapy: a retrospective analysis of 98 cases. Clin Infect Dis 2015; 61:409-17. [PMID: 25870331 DOI: 10.1093/cid/civ299] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 04/05/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Histoplasmosis may complicate tumor necrosis factor (TNF)-α blocker therapy. Published case series provide limited guidance on disease management. We sought to determine the need for long-term antifungal therapy and the safety of resuming TNF-α blocker therapy after successful treatment of histoplasmosis. METHODS We conducted a multicenter retrospective review of 98 patients diagnosed with histoplasmosis between January 2000 and June 2011. Multivariate logistic regression was used to evaluate risk factors for severe disease. RESULTS The most commonly used biologic agent was infliximab (67.3%). Concomitant corticosteroid use (odds ratio [OR], 3.94 [95% confidence interval {CI}, 1.06-14.60]) and higher urine Histoplasma antigen levels (OR, 1.14 [95% CI, 1.03-1.25]) were found to be independent predictors of severe disease. Forty-six (47.4%) patients were initially treated with an amphotericin B formulation for a median duration of 2 weeks. Azole treatment was given for a median of 12 months. TNF-α blocker therapy was initially discontinued in 95 of 98 (96.9%) patients and later resumed in 25 of 74 (33.8%) patients at a median of 12 months (range, 1-69 months). The recurrence rate was 3.2% at a median follow-up period of 32 months. Of the 3 patients with recurrence, 2 had restarted TNF-α blocker therapy, 1 of whom died. Mortality rate was 3.2%. CONCLUSIONS In this study, disease outcomes were generally favorable. Discontinuation of antifungal treatment after clinical response and an appropriate duration of therapy, probably at least 12 months, appears safe if pharmacologic immunosuppression has been held. Resumption of TNF-α blocker therapy also appears safe, assuming that the initial antifungal therapy was administered for 12 months.
Collapse
Affiliation(s)
- Paschalis Vergidis
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pennsylvania
| | - Robin K Avery
- Division of Infectious Disease, Johns Hopkins Hospital, Baltimore, Maryland
| | - L Joseph Wheat
- MiraVista Diagnostics and Mirabella Technologies, Indianapolis, Indiana
| | - Jennifer L Dotson
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, and Center for Innovation in Pediatric Practice, The Research Institute, Nationwide Children's Hospital, Columbus, Ohio
| | - Maha A Assi
- Department of Internal Medicine, University of Kansas School of Medicine, Wichita
| | - Smyrna A Antoun
- Department of Internal Medicine, University of Kansas School of Medicine, Wichita
| | - Kassem A Hamoud
- Division of Infectious Diseases, University of Kansas Medical Center, Kansas City
| | - Steven D Burdette
- Division of Infectious Disease, Wright State University Boonshoft School of Medicine, Dayton, Ohio
| | - Alison G Freifeld
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha
| | | | - Mary E Money
- Department of Medicine, Meritus Medical Center, Hagerstown, Maryland
| | - Thein Myint
- Division of Infectious Disease, University of Kentucky, Lexington
| | - David R Andes
- Department of Medicine and Medical Microbiology and Immunology, University of Wisconsin, Madison
| | - Cynthia A Hoey
- Long Island Infectious Disease Associates, Huntington, New York
| | - Daniel A Kaul
- Division of Infectious Disease, University of Michigan Medical School, Ann Arbor
| | - Jana K Dickter
- Division of Infectious Diseases, Kaiser Permanente, Fontana, California
| | | | - Rachel A Miller
- Division of Infectious Diseases, University of Iowa, Iowa City
| | | | - Vidhya Prakash
- Division of Infectious Diseases, Southern Illinois University School of Medicine, Springfield
| | | | - Randall C Walker
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota
| | - Chadi A Hage
- Pulmonary-Critical Care Medicine, Indiana University, Indianapolis
| |
Collapse
|
34
|
Myint T, Shiota S, Vilaichone RK, Ni N, Aye TT, Matsuda M, Tran TTH, Uchida T, Mahachai V, Yamaoka Y. Prevalence of Helicobacter pylori infection and atrophic gastritis in patients with dyspeptic symptoms in Myanmar. World J Gastroenterol 2015; 21:629-636. [PMID: 25605987 PMCID: PMC4296025 DOI: 10.3748/wjg.v21.i2.629] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 05/12/2014] [Accepted: 07/22/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To survey the detailed analyses for Helicobacter pylori (H. pylori) infection and gastric mucosal status in Myanmar.
METHODS: A total of 252 volunteers with dyspeptic symptoms (155 female and 97 male; mean age of 43.6 ± 14.2 years) was participated in Yangon and Mandalay. The status of H. pylori infection was determined based on 5 different tests including rapid urease test, culture, histology, immunohistochemistry and serology. Histological scores were evaluated according to the update Sydney system and the Operative Link for Gastritis Assessment system. Pepsinogen (PG) I and PG II were measured using enzyme-linked immunosorbent assays.
RESULTS: The overall prevalence of H. pylori infection was 48.0%. There was no relationship between age and infection rate. Even in young group (less than 29 years old), the H. pylori infection rate was relatively high (41.9%). The prevalence of H. pylori infection was significantly higher in Yangon than that of Mandalay. H. pylori infection was significantly associated with the presence of gastric mucosal atrophy. All 7 subjects with peptic ulcer were infected with H. pylori. Although H. pylori-positive subjects showed stronger gastritis than H. pylori-negative subjects, most cases had mild gastritis.
CONCLUSION: We revealed the prevalence of H. pylori infection in patients with dyspeptic symptoms in Myanmar. The H. pylori infection was a risk factor for peptic ulcer and stronger gastritis.
Collapse
|
35
|
Mathur A, Awin N, Adisasmita A, Jayaratne K, Francis S, Sharma S, Myint T. Maternal death review in selected countries of South East Asia Region. BJOG 2014; 121 Suppl 4:67-70. [PMID: 25236636 DOI: 10.1111/1471-0528.13001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2014] [Indexed: 11/27/2022]
Abstract
Understanding the underlying factors that led to maternal deaths through a maternal death review (MDR) throws light on the causes, characteristics and circumstances of the death. We reviewed and report on the implementation of MDR in India, Indonesia, Myanmar, Nepal and Sri Lanka, capturing the experiences of MDR initiatives, follow-up actions and lessons learnet. Overall, while the findings from MDRs have been used to design or change policies and strategies for improvement of services provided, there are still challenges in scaling up these initiatives, particularly in the larger countries.
Collapse
Affiliation(s)
- A Mathur
- Department of Family Health and Research, WHO South East Asia Regional Office (SEARO), New Delhi, India
| | | | | | | | | | | | | |
Collapse
|
36
|
Gundelly P, Thornton A, Greenberg RN, McCormick M, Myint T. Rhodococcus equi pericarditis in a patient living with HIV/AIDS. J Int Assoc Provid AIDS Care 2014; 13:309-312. [PMID: 25513024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023] Open
Abstract
INTRODUCTION Rhodococcus equi, previously called Corynebacterium equi, is known to cause pneumonia in foals and swine. Although it was known to cause infection rarely in humans, R equi infection in humans has increased with the advent of HIV and increased use of immunosuppressants. CASE We report a case of a 48-year-old male patient with newly diagnosed HIV/AIDS presenting with recurrent R equi bacteremia, pericardial effusion, and pericardial cyst. The infection was treated with drainage of the pericardial effusion and cyst and 2 weeks of intravenous vancomycin and 6 months of oral azithromycin and levofloxacin. DISCUSSION Rhodococcus equi causes pericarditis and pericardial effusion. It can be effectively treated with debridement, drainage, and a prolonged course of antibiotics. In vitro antibiotic susceptibility should be checked as resistance to antibiotics can develop, especially if drainage is inadequate.
Collapse
|
37
|
Abstract
Introduction: Rhodococcus equi, previously called Corynebacterium equi, is known to cause pneumonia in foals and swine. Although it was known to cause infection rarely in humans, R equi infection in humans has increased with the advent of HIV and increased use of immunosuppressants. Case: We report a case of a 48-year-old male patient with newly diagnosed HIV/AIDS presenting with recurrent R equi bacteremia, pericardial effusion, and pericardial cyst. The infection was treated with drainage of the pericardial effusion and cyst and 2 weeks of intravenous vancomycin and 6 months of oral azithromycin and levofloxacin. Discussion: Rhodococcus equi causes pericarditis and pericardial effusion. It can be effectively treated with debridement, drainage, and a prolonged course of antibiotics. In vitro antibiotic susceptibility should be checked as resistance to antibiotics can develop, especially if drainage is inadequate.
Collapse
Affiliation(s)
- Praveen Gundelly
- Department of Infectious Diseases, University of Kentucky, Lexington, KY, USA
| | - Alice Thornton
- Department of Infectious Diseases, University of Kentucky, Lexington, KY, USA
| | | | | | - Thein Myint
- Department of Infectious Diseases, University of Kentucky, Lexington, KY, USA
| |
Collapse
|
38
|
Myint T, Anderson AM, Sanchez A, Farabi A, Hage C, Baddley JW, Jhaveri M, Greenberg RN, Bamberger DM, Rodgers M, Crawford TN, Wheat LJ. Histoplasmosis in patients with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS): multicenter study of outcomes and factors associated with relapse. Medicine (Baltimore) 2014; 93:11-18. [PMID: 24378739 PMCID: PMC4616326 DOI: 10.1097/md.0000000000000016] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Although discontinuation of suppressive antifungal therapy for acquired immunodeficiency syndrome (AIDS)-associated histoplasmosis is accepted for patients with immunologic recovery, there have been no published studies of this approach in clinical practice, and minimal characterization of individuals who relapse with this disease. We performed a multicenter retrospective cohort study to determine the outcome in AIDS patients following discontinuation of suppressive antifungal therapy for histoplasmosis. Ninety-seven patients were divided into a physician-discontinued suppressive therapy group (PD) (38 patients) and a physician-continued suppressive therapy group (PC) (59 patients). The 2 groups were not statistically different at baseline, but at discontinuation of therapy and at the most recent follow-up there were significant differences in adherence to therapy, human immunodeficiency virus (HIV) RNA, and urinary Histoplasma antigen concentration. There was no relapse or death attributed to histoplasmosis in the PD group compared with 36% relapse (p < 0.0001) and 5% death (p = 0.28) in the PC group. Relapse occurred in 53% of the nonadherent patients but not in the adherent patients (p < 0.0001). Sixty-seven percent of patients with initial central nervous system (CNS) histoplasmosis relapsed compared to 15% of patients without CNS involvement (p = 0.0004), which may be accounted for by nonadherence. In addition, patients with antigenuria above 2.0 ng/mL at 1-year follow-up were 12.82 times (95% confidence interval, 2.91-55.56) more likely to relapse compared to those with antigenuria below 2.0 ng/mL. Discontinuation of antifungal therapy was safe in adherent patients who completed at least 1 year of antifungal treatment, and had CD4 counts >150 cells/mL, HIV RNA <400 c/mL, Histoplasma antigenuria <2 ng/mL (equivalent to <4.0 units in second-generation method), and no CNS histoplasmosis.
Collapse
Affiliation(s)
- Thein Myint
- From Division of Infectious Diseases (TM, RNG), Department of Internal Medicine, and Department of Public Health (TNC), University of Kentucky, Lexington, Kentucky; Division of Infectious Diseases (AMA), Department of Internal Medicine, Emory University, Atlanta, Georgia; Division of Infectious Diseases (AS), Department of Internal Medicine, University of Southern California, Los Angeles, California; Division of Infectious Diseases (AF), Department of Internal Medicine, University Medical Center of Southern Nevada, Las Vegas, Nevada; Department of Pulmonary and Critical Care Medicine, Thoracic Transplantation (CH), Indiana University Health, Indianapolis, Indiana; Division of Infectious Disease (JWB), Department of Internal Medicine, University of Alabama, Birmingham, Alabama; Departmentof Epidemiology (MJ), College of Public Health, University of Louisville, Louisville, Kentucky; Division of Infectious Disease (DMB), Department of Internal Medicine, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri; and MiraVista Diagnostics (MR, LJW), Indianapolis, Indiana
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Assi M, Martin S, Wheat LJ, Hage C, Freifeld A, Avery R, Baddley JW, Vergidis P, Miller R, Andes D, Young JAH, Hammoud K, Huprikar S, McKinsey D, Myint T, Garcia-Diaz J, Esguerra E, Kwak EJ, Morris M, Mullane KM, Prakash V, Burdette SD, Sandid M, Dickter J, Ostrander D, Antoun SA, Kaul DR. Histoplasmosis after solid organ transplant. Clin Infect Dis 2013; 57:1542-9. [PMID: 24046304 DOI: 10.1093/cid/cit593] [Citation(s) in RCA: 113] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND To improve our understanding of risk factors, management, diagnosis, and outcomes associated with histoplasmosis after solid organ transplant (SOT), we report a large series of histoplasmosis occurring after SOT. METHODS All cases of histoplasmosis in SOT recipients diagnosed between 1 January 2003 and 31 December 2010 at 24 institutions were identified. Demographic, clinical, and laboratory data were collected. RESULTS One hundred fifty-two cases were identified: kidney (51%), liver (16%), kidney/pancreas (14%), heart (9%), lung (5%), pancreas (2%), and other (2%). The median time from transplant to diagnosis was 27 months, but 34% were diagnosed in the first year after transplant. Twenty-eight percent of patients had severe disease (requiring intensive care unit admission); 81% had disseminated disease. Urine Histoplasma antigen detection was the most sensitive diagnostic method, positive in 132 of 142 patients (93%). An amphotericin formulation was administered initially to 73% of patients for a median duration of 2 weeks; step-down therapy with an azole was continued for a median duration of 12 months. Ten percent of patients died due to histoplasmosis with 72% of deaths occurring in the first month after diagnosis; older age and severe disease were risk factors for death from histoplasmosis. Relapse occurred in 6% of patients. CONCLUSIONS Although late cases occur, the first year after SOT is the period of highest risk for histoplasmosis. In patients who survive the first month after diagnosis, treatment with an amphotericin formulation followed by an azole for 12 months is usually successful, with only rare relapse.
Collapse
Affiliation(s)
- Maha Assi
- Department of Internal Medicine, University of Kansas School of Medicine, Wichita
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Myint T, Al-Hasan MN, Ribes JA, Murphy BS, Greenberg RN. Temporal trends, clinical characteristics, and outcomes of histoplasmosis in a tertiary care center in Kentucky, 2000 to 2009. J Int Assoc Provid AIDS Care 2013; 13:100-5. [PMID: 24029651 DOI: 10.1177/2325957413500535] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The impact of highly active antiretroviral therapy (HAART) on the epidemiology of AIDS-associated histoplasmosis in the past decade is poorly defined. Among 100 patients with histoplasmosis in an endemic region between 2000 and 2009, 42 patients were immunocompetent, 32 were infected with HIV, and 26 were non-HIV-immunocompromised patients. The percentage with HIV decreased 67% in 2000-2001 to 18% in 2008-2009 (P = .004), while the proportion of non-HIV immunocompromised patients increased, 8% to 41% (P = .14). Histoplasma antigen was the most sensitive test (73%), whereas potassium hydroxide examination of clinical specimens was the least sensitive test (33%) in all 3 groups. Bronchoalveloar fluid culture (74%) had the highest yield among the cultures. The relapse rate was higher in HIV-infected patients compared to the other 2 groups (P = .04). The epidemiology of histoplasmosis in our endemic area has changed during the era of HAART. Organ transplantation and increasing use of immunosuppressive agents for chronic inflammatory conditions in non-HIV patients now account for most of the cases of histoplasmosis.
Collapse
Affiliation(s)
- Thein Myint
- Department of Internal Medicine, Division of Infectious Diseases, University of Kentucky, Lexington, KY, USA
| | | | | | | | | |
Collapse
|
41
|
Affiliation(s)
- Thein Myint
- Division of Infectious Diseases, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky, USA
| | | | | |
Collapse
|
42
|
|
43
|
Rajaram S, Burke K, Connell B, Myint T, Sabaté J. A monounsaturated fatty acid-rich pecan-enriched diet favorably alters the serum lipid profile of healthy men and women. J Nutr 2001; 131:2275-9. [PMID: 11533266 DOI: 10.1093/jn/131.9.2275] [Citation(s) in RCA: 105] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Frequent consumption of nuts is associated with decreased risk of cardiovascular disease. We investigated the effect of pecans rich in monounsaturated fat as an alternative to the Step 1 diet in modifying serum lipids and lipoproteins in men and women with normal to moderately high serum cholesterol. In a single-blind, randomized, controlled, crossover feeding study, we assigned 23 subjects (mean age: 38 y; 9 women, 14 men) to follow two diets, each for 4 wk: a Step I diet and a pecan-enriched diet (accomplished by proportionately reducing all food items in a Step I diet by one fifth for a 20% isoenergetic replacement with pecans). The percentage of energy from fat in the two diets was 28.3 and 39.6%, respectively. Both diets improved the lipid profile; however, the pecan-enriched diet decreased both serum total and LDL cholesterol by 0.32 mmol/L (6.7 and 10.4%, respectively) and triglyceride by 0.14 mmol/L (11.1%) beyond the Step I diet, while increasing HDL cholesterol by 0.06 mmol/L (2.5 mg/dL). Serum apolipoprotein B and lipoprotein(a) decreased by 11.6 and 11.1%, respectively, and apolipoprotein A1 increased by 2.2% when subjects consumed the pecan compared with the Step I diet. These differences were all significant (P < 0.05). A 20% isoenergetic replacement of a Step I diet with pecans favorably altered the serum lipid profile beyond the Step I diet, without increasing body weight. Nuts such as pecans that are rich in monounsaturated fat may therefore be recommended as part of prescribed cholesterol-lowering diet of patients or habitual diet of healthy individuals.
Collapse
Affiliation(s)
- S Rajaram
- Department of Nutrition, School of Public Health, Loma Linda University, Loma Linda, California, USA
| | | | | | | | | |
Collapse
|
44
|
Sakata N, Uesugi N, Takebayashi S, Nagai R, Jono T, Horiuchi S, Takeya M, Itabe H, Takano T, Myint T, Taniguchi N. Glycoxidation and lipid peroxidation of low-density lipoprotein can synergistically enhance atherogenesis. Cardiovasc Res 2001; 49:466-75. [PMID: 11164857 DOI: 10.1016/s0008-6363(00)00262-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE The purpose of this study was to clarify the role of glycoxidation and lipid peroxidation of low-density lipoprotein (LDL) in atherogenesis. METHODS AND RESULTS We examined the formation of N(epsilon)-(carboxymethyl) lysine (CML), a glycoxidation product, and malondialdehyde (MDA), a lipid peroxidation product, in vitro and their co-localization in human atherosclerotic lesions. Immunochemical analysis revealed that CML was formed in a time-dependent manner by human LDL incubated with copper ions and glucose, i.e. an in vitro model of glycoxidation of LDL. When LDL was exposed to copper ions alone, a small amount of CML was formed, however this was significantly less in oxidized LDL than glycoxidative LDL. In contrast, MDA formation was observed in both oxidation and glycoxidation of LDL, but not in glycation of LDL. Hexitol-lysine (HL), an Amadori product, was formed by both glycation and glycoxidation of LDL, but not by oxidation of LDL. Immunohistochemical analysis showed that CML and MDA accumulated mainly in macrophage/foam cells, while pyrraline, a non-oxidative product of glycation, and apolipoprotein B were localized in the extracellular matrix in atherosclerotic lesions. Atheromas were positive for CML and MDA, but negative for pyrraline. Macrophage/foam cells in atherosclerotic lesions exhibited co-localization of macrophage scavenger receptor-A with CML and MDA, but not with pyrraline. CONCLUSION Our results suggest that glycoxidation and lipid peroxidation of LDL synergistically promote the development of atherosclerotic lesions through interaction with macrophage scavenger receptor-A.
Collapse
Affiliation(s)
- N Sakata
- Department of Pathology, School of Medicine, Fukuoka University, 814-0180, Fukuoka, Japan.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Myint T, Fraser GE, Lindsted KD, Knutsen SF, Hubbard RW, Bennett HW. Urinary 1-methylhistidine is a marker of meat consumption in Black and in White California Seventh-day Adventists. Am J Epidemiol 2000; 152:752-5. [PMID: 11052553 DOI: 10.1093/aje/152.8.752] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Meat consumption predicts risk of several chronic diseases. The authors validate the accuracy of meat consumption reported by food frequency questionnaires and the mean of eight 24-hour recalls, using urinary methylhistidine excretion, in 55 Black and 71 White Adventist subjects in Los Angeles and San Diego, California, in 1994-1997. 1-Methylhistidine excretion predicts vegetarian status in Black (p = 0.02) and in White (p = 0.005) subjects. Spearman's correlation coefficients between 1-methylhistidine and estimated meat consumption were usually between 0.4 and 0.6 for both food frequency questionnaires and 24-hour recall data. This is despite the chance collection of dietary recalls and urines from omnivores on meatless days.
Collapse
Affiliation(s)
- T Myint
- Department of Epidemiology and Biostatistics, Loma Linda University, CA 92350, USA
| | | | | | | | | | | |
Collapse
|
46
|
Okado-Matsumoto A, Myint T, Fujii J, Taniguchi N. Gain in functions of mutant Cu,Zn-superoxide dismutases as a causative factor in familial amyotrophic lateral sclerosis: less reactive oxidant formation but high spontaneous aggregation and precipitation. Free Radic Res 2000; 33:65-73. [PMID: 10826922 DOI: 10.1080/10715760000300621] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Eight mutant Cu,Zn-superoxide dismutases (SODs) related to familial amyotrophic lateral sclerosis (FALS) were produced in a baculovirus/insect cell expression system and their molecular properties in terms of hydroxyl radical formation and aggregation were compared with the wild-type enzyme. Treatment of the enzymes with Chelex 100 resin decreased Cu contents as well as SOD activities in all mutant Cu,Zn-SODs, indicating that the affinities of the enzymes for copper ion were decreased. Contrary to previous reports, all the mutant Cu,Zn-SODs exhibited less reactive oxidant producing ability in the presence of hydrogen peroxide than the wild-type enzyme. Both SOD activities and their reactive oxidant forming correlated well with the copper ion content of the molecules. In addition, the proteins spontaneously aggregated and were precipitated by simple centrifugation at 12,000g for 20 min in keeping their enzyme activities. Since hyaline inclusions found in FALS patients with SOD1 mutations contained components which were reactive to anti-Cu,Zn-SOD antibody, a primary reaction caused by mutant SOD1 may be attributed to their propensity to form aggregates. Aggregated but still active mutant SOD1 would be expected to mediate the formation of reactive oxygen species and nitrosylation in a more condensed state.
Collapse
Affiliation(s)
- A Okado-Matsumoto
- Department of Biochemistry, Osaka University Medical School, Suita, Japan
| | | | | | | |
Collapse
|
47
|
Meng J, Sakata N, Takebayashi S, Asano T, Futata T, Nagai R, Ikeda K, Horiuchi S, Myint T, Taniguchi N. Glycoxidation in aortic collagen from STZ-induced diabetic rats and its relevance to vascular damage. Atherosclerosis 1998; 136:355-65. [PMID: 9543107 DOI: 10.1016/s0021-9150(97)00238-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Glycoxidation reactions lead to the formation of permanent, irreversible chemical modifications and cross-links in protein, such as the glycoxidation products carboxymethyllysine (CML) and pentosidine. It has been implicated that CML as well as Amadori products play a role in the formation of superoxidative products, such as H2O2 and advanced glycosylation endproducts in trapping LDL. Therefore, a possible relationship between glycoxidation and lipoperoxidation might exist because oxidized lipoprotein, which has been directly linked to atheroma formation, could be produced by the superoxidative products released from the pathway of CML formation. Using a CML-specific monoclonal antibody (6D12) and a specific antiserum against hexitol-lysine (HL), an Amadori product, we studied the relationship between glycoxidation and lipoperoxidation by determining the aortic CML contents with ELISA and the fluorescence levels of lipoperoxidation side products, malondialdehyde (MDA) and hydroxynonenal (HNE) from STZ-induced diabetic rats and age-matched control rats. The immunohistochemical and ultrastructural changes relevant to glycoxidation and lipoperoxidation were also studied. The CML content measured by ELISA in DM rats was significantly higher than that in the control rats at 28 weeks (n = 11, P < 0.01). The levels of MDA-linked and HNE-linked fluorescence in the DM rats increased in a similar way and were significantly higher than the levels in control rats at 28 weeks (n = 11, both P < 0.01 at 28 weeks). The CML contents correlated with the fluorescence levels of both MDA-linked (n = 19, r = 0.638, P < 0.01) and HNE-linked fluorescence (n = 19, r = 0.629, P < 0.01) only in the DM rats, but not in the control rats. Our immunohistochemical study thus demonstrated that CML was initially formed in the aortic media of diabetic rats in the 16th week of diabetes, localized primarily in the extracellular matrix surrounding the aortic smooth muscle cells after HL occurred early in the 2nd week of diabetes. Consequently, a significant increase in the extracellular matrix and decrease in the area of the SMCs were observed in the aortic media in the DM rats by a morphometrical study. The in vivo results of this study provided the first evidence that CML correlated with fluorescence levels of MDA and HNE, and thus suggested the existence of a close relationship between glycoxidation and lipoperoxidation in vivo. This information is thus considered to shed some new light on the etiology of atherogenesis in diabetes.
Collapse
Affiliation(s)
- J Meng
- The Second Department of Pathology, Fukuoka University Medical School, Japan
| | | | | | | | | | | | | | | | | | | |
Collapse
|
48
|
Abstract
The majority of patients with MELAS syndrome (mitochondrial myopathy, encephalopathy, lactic acidosis, and strokelike episodes) have an A-->G mutation at nucleotide 3243 in mitochondrial transfer (t)RNA. To date there have only been 10 reported cases of MELAS syndrome in patients with a T-->C mutation at position 3271 of mitochondrial tRNA. Although many of the clinical features are similar between patients with these different mutations, it appears that the age at onset is later for the 3271 mutation. This report provides information from a North American kindred with the 3271 mutation (n = 6 proven; n = 2 probable; n = 3 possible) that adds clinical, physiological, histological, and molecular information to the pool of information on this rare disorder. Many of these features were similar to previous reports of both 3243 and 3271 patients. We conclude that the phenotypic expression of these different mutations are similar, but the age of onset for 3271 patients is later than for 3243 patients.
Collapse
Affiliation(s)
- M A Tarnopolsky
- Department of Neurology, McMaster University Medical Center, Hamilton, Ontario, Canada
| | | | | | | | | |
Collapse
|
49
|
Pe T, Myint T, Htut A, Htut T, Myint AA, Aung NN. Envenoming by Chinese krait (Bungarus multicinctus) and banded krait (B. fasciatus) in Myanmar. Trans R Soc Trop Med Hyg 1997; 91:686-8. [PMID: 9509180 DOI: 10.1016/s0035-9203(97)90524-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
A retrospective study of 8 cases of envenoming by Chinese krait (Bungarus multicinctus) and one banded krait (B. fasciatus) in southern Myanmar is reported. Chinese krait bite produced minimal local reactions, except in one person bitten on the lip which resulted in local swelling. Onset of neurotoxic symptoms occurred 2.5-6 h after the bite, and the interval between bite and death ranged from 12-30 h. Three deaths were due to respiratory failure. Four mildly envenomed cases recovered spontaneously without assisted ventilation. One severely envenomed patient recovered after 8 d intensive respiratory care. Cobra (Naja kaouthia) antivenom had no value in reversing neurotoxic symptoms. Anticholinesterase injection given to one patient failed to improve neurotoxic symptoms. The bite of banded krait (B. fasciatus) resulted in neurotoxic envenoming within 2 h after the bite, with minimal local reactions. The victim died of respiratory failure 14 h after the bite.
Collapse
Affiliation(s)
- T Pe
- Intensive Care Unit, Yangon General Hospital, Myanmar
| | | | | | | | | | | |
Collapse
|
50
|
Kaneto H, Fujii J, Myint T, Miyazawa N, Islam KN, Kawasaki Y, Suzuki K, Nakamura M, Tatsumi H, Yamasaki Y, Taniguchi N. Reducing sugars trigger oxidative modification and apoptosis in pancreatic beta-cells by provoking oxidative stress through the glycation reaction. Biochem J 1996; 320 ( Pt 3):855-63. [PMID: 9003372 PMCID: PMC1218007 DOI: 10.1042/bj3200855] [Citation(s) in RCA: 180] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Several reducing sugars brought about apoptosis in isolated rat pancreatic islet cells and in the pancreatic beta-cell-derived cell line HIT. This apoptosis was characterized biochemically by inter-nucleosomal DNA cleavage and morphologically by nuclear shrinkage, chromatin condensation and apoptotic body formation. N-Acetyl-L-cysteine, an antioxidant, and aminoguanidine, an inhibitor of the glycation reaction, inhibited this apoptosis. We also showed directly that proteins in beta-cells were actually glycated by using an antibody which can specifically recognize proteins glycated by fructose, but not by glucose. Furthermore, fluorescence-activated cell sorting analysis using dichlorofluorescein diacetate showed that reducing sugars increased intracellular peroxide levels prior to the induction of apoptosis. Levels of carbonyl, an index of oxidative modification, and of malondialdehyde, a lipid peroxidation product, were also increased. Taken together, these results suggest that reducing sugars trigger oxidative modification and apoptosis in pancreatic beta-cells by provoking oxidative stress mainly through the glycation reaction, which may explain the deterioration of beta-cells under conditions of diabetes.
Collapse
Affiliation(s)
- H Kaneto
- Department of Biochemistry, Osaka University Medical School, Japan
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|