Clinical management of sepsis resulting from infections including COVID-19

Sepsis is an important disorder in intensive care medicine, and the emphasis is not on infections but the imbalance in body reactions and life-threatening organ dysfunction. The infection, the imbalance in the body's reaction, and the deadly organ dysfunction are three aspects of sepsis. Currently, there is still a debate on suitable criteria for the diagnosis of patients with sepsis with continuing changes in the guidelines on sepsis management. Here we summarize recent advances on the definitions, diagnosis, and treatment in the clinical practice of sepsis management in the emergency department. We also highlight future research directions on sepsis. In particular, given the global outbreak of coronavirus disease 2019 (COVID-19), we briefly describe the relationship between COVID-19 and sepsis. How to manage sepsis caused by emerging pathogens such as COVID-19 is a new challenge for care professionals in the emergency department.

Prevalence and risk factors associated with Leishmania infection in Trang Province, southern Thailand

BACKGROUND

Autochthonous cutaneous and visceral leishmaniasis (VL) caused by Leishmania martiniquensis and Leishmania siamensis have been considered emerging infectious diseases in Thailand. The disease burden is significantly underestimated, especially the prevalence of Leishmania infection among HIV-positive patients.

METHODS

A cross-sectional study was conducted to determine the prevalence and risk factors associated with Leishmania infection among patients with HIV/AIDS living in Trang province, southern Thailand, between 2015 and 2016. Antibodies against Leishmania infection were assayed using the direct agglutination test (DAT). DNA of Leishmania was detected by ITS1-PCR using the buffy coat. Species of Leishmania were also identified.

RESULTS

Of 724 participants, the prevalence of Leishmania infection was 25.1% (182/724) using either DAT or PCR assays. Seroprevalence of Leishmania infection was 18.5% (134/724), while Leishmania DNA detected by the PCR method was 8.4% (61/724). Of these, 24.9% (180/724) were asymptomatic, whereas 0.3% (2/724) were symptomatic VL and VL/CL (cutaneous leishmaniasis). At least five species were identified: L. siamensis, L. martiniquensis, L. donovani complex, L. lainsoni, and L. major. Multivariate analysis showed that CD4+ levels <500 cells/μL and living in stilt houses were independently associated with Leishmania infection. Those who were PCR positive for Leishmania DNA were significantly associated with a detectable viral load, whereas non-injection drug use (NIDU) and CD4+ levels <500 cells/μL were potential risk factors of Leishmania seropositivity.

CONCLUSIONS

A magnitude of the prevalence of underreporting Leishmania infection among Thai patients with HIV was revealed in this study. Effective public health policy to prevent and control disease transmission is urgently needed.

The Emerging Zika Virus Threat: A Guide for Dermatologists

We provide a guide for dermatologists to follow if they encounter patients with a rash and clinical history suspicious of Zika virus infection, including diagnostic testing and management options. We also provide an illustrative case report of a patient from Brazil who was diagnosed with Zika virus infection after presenting with a generalized pruritic rash. One of the most prominent symptoms of Zika virus infection is a cutaneous eruption. As such, it is especially necessary for dermatologists to understand this virus so that they may appropriately recognize this entity as a diagnostic consideration in the clinic. The rash associated with Zika virus infection is most commonly an erythematous maculopapular eruption that presents after an initial 3-4 days of fever, headache, and arthralgia or myalgia. The rash typically lasts for an average of 6 days, and can spread to involve any part of the body, including the face, torso, extremities, palms, and soles.

Zika virus infection: Past and present of another emerging vector-borne disease

Zika virus infection is an emerging mosquito-borne disease, first identified in Uganda in 1947. It is caused by the Zika arbovirus, and transmitted by the bites of infected mosquitoes of the genus Aedes. For almost half a century, the Zika virus was reported as the causative agent of sporadic human infections. In 2007, the Zika virus emerged outside Asia and Africa causing an epidemic on the Island of Yap in Micronesia. The manifestation of the newly acquired human infection varies from asymptomatic to self-limiting acute febrile illness with symptoms and clinical features similar to those caused by the Dengue virus ('Dengue-like syndrome'). The real-time PCR and serological methods have been successfully applied for the diagnosis of the disease. The treatment is symptomatic, since there is no specific antiviral treatment or a vaccine. During the recent outbreaks in French Polynesia and Brazil, incidents of Guillain-Barrι syndrome and microcephaly were associated with Zika virus infection, giving rise to fears of further global spread of the virus. Prevention and vector control strategies have to be urgently implemented by national health authorities in order to contain future outbreaks in vulnerable populations. This review summarizes the existing information on Zika virus characteristics, pathogenesis and epidemiology, the available methods for the diagnosis of Zika virus infection and recent approaches for prevention and control.

Severe pulmonary manifestation of leptospirosis

Based on increasing incidence and the occurrence of worldwide outbreaks, leptospirosis is recognised as an emerging zoonosis. Severe manifestations are associated with high morbidity and mortality rates and may therefore pose an important risk to public health, especially in certain high prevalence areas. A considerable number of infections progress to a severe form, which can present as the well-known triad of jaundice, impaired renal function and haemorrhage, known as Weil's disease. The severe pulmonary form of leptospirosis (SPFL) is a less known entity and is characterised by intra-alveolar haemorrhage and can lead to acute respiratory failure and death when adequate treatment fails. Prognostic factors correlating with severity and survival of leptospirosis include indicators of renal failure, pulmonary involvement and electrolyte imbalances. We report an imported case of SPFL in a returning traveller, and review the literature discussing epidemiology, clinical manifestations, prognostic factors and treatment of this resurgent disease.

Chikungunya: a re-emerging virus

In the past decade, chikungunya--a virus transmitted by Aedes spp mosquitoes--has re-emerged in Africa, southern and southeastern Asia, and the Indian Ocean Islands as the cause of large outbreaks of human disease. The disease is characterised by fever, headache, myalgia, rash, and both acute and persistent arthralgia. The disease can cause severe morbidity and, since 2005, fatality. The virus is endemic to tropical regions, but the spread of Aedes albopictus into Europe and the Americas coupled with high viraemia in infected travellers returning from endemic areas increases the risk that this virus could establish itself in new endemic regions. This Seminar focuses on the re-emergence of this disease, the clinical manifestations, pathogenesis of virus-induced arthralgia, diagnostic techniques, and various treatment modalities.

Chikungunya: a re-emerging virus

In the past decade, chikungunya--a virus transmitted by Aedes spp mosquitoes--has re-emerged in Africa, southern and southeastern Asia, and the Indian Ocean Islands as the cause of large outbreaks of human disease. The disease is characterised by fever, headache, myalgia, rash, and both acute and persistent arthralgia. The disease can cause severe morbidity and, since 2005, fatality. The virus is endemic to tropical regions, but the spread of Aedes albopictus into Europe and the Americas coupled with high viraemia in infected travellers returning from endemic areas increases the risk that this virus could establish itself in new endemic regions. This Seminar focuses on the re-emergence of this disease, the clinical manifestations, pathogenesis of virus-induced arthralgia, diagnostic techniques, and various treatment modalities.

Recurrent Helicobacter cinaedi cellulitis and bacteremia in a patient with systemic lupus erythematosus

A 31-year-old woman who had developed systemic lupus erythematosus at 17 years of age was admitted to the hospital for suspected cellulitis in the lower extremities. A blood culture performed upon admission to the hospital detected Helicobacter cinaedi (H. cinaedi), which was also isolated in blood and fecal cultures obtained on the 42nd hospital day. Bacterial translocation of H. cinaedi present in the intestines may have led to the development of recurrent bacteremia and cellulitis. In cases such as this, appropriate antibiotics therapy might be needed for more than one month. Moreover, H. cinaedi, a cause of emerging infections, requires a long period of time to grow; therefore it is important to extend the culture duration when the presence of this bacterium is suspected.

Geosmithia argillacea: an emerging pathogen in patients with cystic fibrosis

We report eight cases of airway colonization by Geosmithia argillacea in patients with cystic fibrosis. This filamentous fungus, resembling members of the genera Penicillium and Paecilomyces, was identified by molecular analysis. All patients carried a mutation on each CFTR (cystic fibrosis transmembrane conductance regulator) allele, with at least one copy of the F508del mutation. The first isolation of this fungus occurred from F508del-homozygous patients at a younger age than in F508del-heterozygous patients. Before recovery of G. argillacea, all patients were treated with itraconazole; two of them had also received voriconazole for an Aspergillus fumigatus infection. However, antifungal susceptibility patterns showed high MICs of voriconazole for all isolates, and high MICs of amphotericin B and itraconazole for the majority of them, but mostly low minimum effective concentrations (MECs) of caspofungin. The appearance and persistence of G. argillacea in the airways were not associated with exacerbation of the disease. However, the clinical implications of G. argillacea, particularly in immunocompromised patients, remain a concern, particularly given recent observations suggesting that this fungus may also cause disseminated infections.

Dual infection by chikungunya virus and other imported infectious agent in a traveller returning from India

Chikungunya virus infection is a vector-borne self-limiting disease. Recent outbreaks in the Indian Ocean islands have drawn attention to the condition. Nevertheless, only a few reports of co-infection with other communicable agents have been reported. The case described now is of a traveller returning from India with concomitant documented chikungunya virus infection associated with systemic amoebiasis. This report highlights the multifaceted pathology that can be encountered with tropical infections.

Emerging and Unusual Gram-Negative Infections in Cystic Fibrosis

People with cystic fibrosis (CF) have chronic airway infection and frequent exposure to antibiotics, which often leads to the emergence of resistant organisms. In addition to the development of multiresistance in common CF pathogens such as Pseudomonas aeruginosa, several newer, inherently resistant gram-negative species are becoming more common, including Burkholderia cepacia complex, Stenotrophomonas maltophilia, Achromobacter (Alcaligenes) xylosoxidans, certain Ralstonia species, and those within the new genus Pandoraea. Many of these are closely related and have similar phenotypes, making accurate laboratory identification challenging. Although their role in contributing to pulmonary disease in CF is not clear, some, such as those of the B. cepacia complex, are clearly linked to an adverse prognosis, and both treatment and infection control issues can pose a real challenge.

Emerging infectious determinants of chronic diseases

Infectious agents, often through complex systems, likely determine more chronic diseases than is currently appreciated.

Evidence now confirms that noncommunicable chronic diseases can stem from infectious agents. Furthermore, at least 13 of 39 recently described infectious agents induce chronic syndromes. Identifying the relationships can affect health across populations, creating opportunities to reduce the impact of chronic disease by preventing or treating infection. As the concept is progressively accepted, advances in laboratory technology and epidemiology facilitate the detection of noncultivable, novel, and even recognized microbial origins. A spectrum of diverse pathogens and chronic syndromes emerges, with a range of pathways from exposure to chronic illness or disability. Complex systems of changing human behavioral traits superimposed on human, microbial, and environmental factors often determine risk for exposure and chronic outcome. Yet the strength of causal evidence varies widely, and detecting a microbe does not prove causality. Nevertheless, infectious agents likely determine more cancers, immune-mediated syndromes, neurodevelopmental disorders, and other chronic conditions than currently appreciated.

Acute hearing loss due to scrub typhus: a forgotten complication of a reemerging disease

We describe 6 patients with scrub typhus who presented with acute hearing loss, a forgotten complication of this reemerging disease. They were admitted with fever of 10-14 days' duration and had clinical evidence of deafness and pneumonitis. Five patients had eschars, which prompted the diagnosis of typhus fever and led to early institution of treatment. Deafness has been described as a clue to the diagnosis of scrub typhus; awareness of this symptom facilitated early diagnosis in 4 of 5 patients who recovered. Acute hearing loss or hearing impairment in a febrile patient should arouse strong suspicion of scrub typhus.

Emerging acute Chagas disease in Amazonian Brazil: case reports with serious cardiac involvement

Four cases of serious cardiac attacks by autochthonous Trypanosoma cruzi infection from the Brazilian Amazon are reported; three of them occurred in micro-epidemic episodes. The manifestations included sudden fever, myalgia, dyspnea and signs of heart failure. Diagnosis was confirmed by specific exams, especially QBC (Quantitative Buffy Coat) and natural xenodiagnosis. Despite treatment with benznidazol, three patients died with serious myocarditis, renal failure and cardiac tamponade. The authors call attention to the emergence of this disease and reveal a previously unknown pathogenicity of T. cruzi strains in this area, added to a non-usual transmission form.

Is Q fever an emerging infection in Turkey?

Between 4 May and 8 August 2002,46 cases of acute fever were reported near the Black Sea region in northern Turkey. The infection was treated rapidly and successfully with tetracyclines, so clinical diagnosis of rickettsial or ehrlichial infection was considered. Analysis of serum and blood samples taken from 19 patients identified the causative organism as Coxiella burnetii; 7 cases were reported as acute Q fever and 8 as seropositive for past infection. The most common clinical symptoms among the acute cases were vomiting (100.0%), nausea (85.7%), diarrhoea (57.1%), fever (42.9%), abdominal pain (42.9%) and headache (42.9%). Liver enzymes were elevated in all patients. It is considered that epidemiological investigation for Q fever will be essential in the affected region in future.

[Changing patterns of communicable diseases in Korea]

Before twentieth centuries and during early twentieth centuries, communicable diseases were the major cause of morbidity and mortality in Korea. But reliable data are not available. After 1975, the overall morbidity and mortality from communicable diseases, rapidly declined. Recently many new pathogenic microbes were recognized: L. monocytogenes, Hantaan virus, Y. pseudotuberculosis, P. multocida, L. pneumophilia, Human immunodeficiency virus (HIV), G. seoi, H. capsulatum, C. burnetii, V. cholerae 0139, C. parvum, F. tularensis, E. coli 0157:H7, B. burgdorferi, S. Typhimurium DT104, Rotavirus, hepatitis C virus and so on. Since the first HIV infection recognized in 1985, the reported cases of infection and deaths from HIV/AIDS have been steady increased each year. Legionnaire's disease, E. coli 0157:H7 colitis, listeriosis and crytosporidiasis have been occurring just sporadically among immunocompromized cases. Many re-emerging communicable diseases were occurred in Korea: leptospirosis, malaria, endemic typhus, cholera, tsutsugamushi disease, salmonellosis, hepatitis A, shigellosis, mumps, measles, acute hemorrhagic conjunctivitis, brucellosis and so on. Leptospirosis and tsutsugamushi diseases have been noticed as major public health problems since 1980s. The malaria that had been virtually disappeared for a decade has reappeared from 1993 with striking increase of patients in recent 3-4 years. The distributions of salmonella and shigella serotypes have been changed a lot in recent few decades. Furthermore rapid emergence of antibiotic-resistant bacterial strains induces more difficult and complex problems in control of communicable diseases. We must recognize on the importance of environment and ecosystem conservation and careful prescription of anti-microbial agent in order to prevent communicable diseases.

Invasive amebiasis as an emerging parasitic disease in patients with human immunodeficiency virus type 1 infection in Taiwan

BACKGROUND

Whether risk of invasive amebiasis due to Entamoeba histolytica is higher among human immunodeficiency virus (HIV)-infected persons than uninfected persons remains unclear, although intestinal colonization by Entamoeba dispar is common among men who have sex with men. Our objective was to determine the prevalence of invasive amebiasis and intestinal colonization by E histolytica and E dispar in HIV-infected persons and uninfected controls.

METHODS

We assessed the prevalence of invasive amebiasis by case review of 951 HIV-infected persons and by serologic studies of 634 of the 951 HIV-infected persons, 429 uninfected controls with gastrointestinal symptoms, and 178 uninfected healthy controls using indirect hemagglutination antibody assay. We assessed the rate of intestinal colonization by E histolytica and E dispar by fecal antigen and polymerase chain reaction tests in 332 asymptomatic HIV-infected persons and 144 of the 178 uninfected healthy controls.

RESULTS

Forty-nine (5.2%) of 951 HIV-infected persons had 51 episodes of invasive amebiasis. A high indirect hemagglutination antibody titer was detected in 39 (6.2%) of 634 HIV-infected persons compared with 10 (2.3%) of 429 uninfected controls with gastrointestinal symptoms and 0 of 178 uninfected healthy controls (P<.001). Stool specimens from 40 (12.1%) of 332 HIV-infected persons and 2 (1.4%) of 144 uninfected healthy controls were positive for E histolytica or E dispar antigen (P<.001). Ten (25.0%) of the 40 antigen-positive stool specimens from HIV-infected persons contained E histolytica.

CONCLUSION

Persons infected with HIV in Taiwan are at increased risk for invasive amebiasis and exhibit a relatively high frequency of elevated antibody titers and intestinal colonization with E histolytica.

Clinical characteristics, management and prognostic factors in patients with probable severe acute respiratory syndrome (SARS) in a SARS center in Taiwan

BACKGROUND

Severe acute respiratory syndrome (SARS) is an emerging viral infectious disease. We report our experience in treating SARS patients.

METHODS

From April 27 to May 24, 2003, a total of 36 patients with probable SARS were admitted and treated in a hospital rearranged as a special center for the management of SARS patients. Medical records for the patients were retrospectively reviewed. Univariate and multivariate analyses were performed to determine factors associated with respiratory failure and intubation.

RESULTS

Of the 36 patients with probable SARS (median age, 37 years; range, 22-66 years), 9 were male and 27 were female. Thirty-two patients (88.9%) were infected in the hospital setting. All patients presented with fever, and 33 eventually developed lymphopenia during hospitalization. Chest radiography showed no unique pattern, but pleural effusion was not seen. All patients initially received empiric antibacterial therapy against common causative pathogens of atypical pneumonia. Ribavirin was given to all except 1 patient. Twenty-two patients received immunoglobulin therapy, and 32 were given corticosteroids. A total of 20 patients (55.6%) required supplemental oxygen, and 8 (22.2%) were intubated with mechanical ventilatory support. Two of these patients died. A higher body temperature at presentation (median 39.5 vs 38.6 degrees C), and higher peak values of lactate dehydrogenase (410 vs 282 U/L) and C-reactive protein (10.2 vs 2.5 mg/dL), were associated with subsequent respiratory failure. Multivariate analysis showed that peak level of C-reactive protein was the only independent predictor of respiratory failure and intubation (odds ratio for every increment of 1 mg/dL = 1.45; 95% confidence interval = 1.003, 2.097; p = 0.048).

CONCLUSION

All patients with probable SARS who were admitted to hospital presented with fever and lymphopenia. While the efficacy of different treatments could not be evaluated from this retrospective study, a higher value of C-reactive protein was associated with the development of respiratory failure and subsequent intubation.

Emerging diseases: Measles

High vaccination coverage rates and the administration of a second dose of measles vaccine have resulted in a significant decline in the incidence of measles and neurologic diseases due to measles in many countries. However, intermittent outbreaks of measles still occur even in countries with excellent vaccination coverage, suggesting the existence of high rates of measles virus introduction from endemic regions and/or waning of vaccine-induced immunity. Strategies to sustain high levels of global immunity to measles virus by increasing vaccine coverage with routine and supplementary vaccination campaigns must be supported.

Severe acute respiratory syndrome complicated by spontaneous pneumothorax

Severe acute respiratory syndrome (SARS) presents an unprecedented diagnostic and therapeutic challenge to clinicians. Despite recent progress in identifying and analyzing the coronavirus that is responsible for it, few reports have addressed the clinical complications of SARS. The present study was a two-center retrospective cohort study. All patients in the study had SARS, were managed in the two major Hong Kong hospitals (ie, Prince of Wales Hospital and United Christian Hospital), and had developed spontaneous pneumothorax during their hospitalization between March 10, 2003, and April 28, 2003. Spontaneous pneumothorax was reported in 6 of 356 SARS patients who were treated at the two hospitals during the period. This represents an incidence of 1.7%. None of the six patients had a history of smoking or pulmonary disease. The rate of admission to the ICU was 66.7% and the crude mortality rate was 33.3% in this group of patients. There was a trend for the mean neutrophil count in these patients to be higher than in previously reported cohorts of comparable SARS patients (14.5 × 10⁹ vs 4.6 × 10⁹ neutrophils per liter, respectively). Conservative measures like tube thoracostomy or observation alone offered satisfactory initial symptomatic management in five of six patients. Spontaneous pneumothorax is a specific and potentially life-threatening complication in SARS patients. Patients with extensive lung injury, as indicated by severe clinical courses, and in particular high neutrophil counts, appear to be most at risk. The benefits of surgical management must be balanced against the potential risks to health-care workers.

Severe acute respiratory syndrome: another challenge for critical care nurses

Severe acute respiratory syndrome (SARS) is a viral disease that may be contracted by exposure to a newly recognized form of the coronavirus. It often manifests through a set of common respiratory symptoms that include fever and nonproductive cough. To date, SARS has no vaccine or definitive treatment. Approximately 20% of SARS patients develop respiratory failure, which requires mechanical ventilation and close cardiopulmonary monitoring. Intensive care unit (ICU) nurses and other healthcare workers who care for SARS patients are at risk of contracting the disease. Thus, it is important that ICU nurses be familiar with the disease and its implications for critical care. This article provides critical care nurses with an update on the first SARS outbreak, its origin, case definition, clinical manifestations, diagnosis, relevant infection control practices, management, and recommendations for the role of ICU nurses in dealing with future outbreaks.

Severe acute respiratory syndrome: clinical outcome and prognostic correlates

Severe acute respiratory syndrome (SARS) poses a major threat to the health of people worldwide. We performed a retrospective case series analysis to assess clinical outcome and identify pretreatment prognostic correlates of SARS, managed under a standardized treatment protocol. We studied 127 male and 196 female patients with a mean age of 41±14 (range 18–83). All patients, except two, received ribavirin and steroid combination therapy. In 115 (36%) patients, the course of disease was limited. Pneumonitis progressed rapidly in the remaining patients. Sixty-seven (21%) patients required intensive care, and 42 (13%) required ventilator support. Advanced age, high admission neutrophil count, and high initial lactate dehydrogenase level were independent correlates of an adverse clinical outcome. SARS-associated coronavirus caused severe illnesses in most patients, despite early treatment with ribavirin and steroid. This study has identified three independent pretreatment prognostic correlates.

Neurocysticercosis: regional status, epidemiology, impact and control measures in the Americas

The analysis of epidemiological data concerning human cysticercosis point to important advances in understanding the magnitude and distribution of this parasitic disease in Latin America, as well as the relationship of the elements that conform the life cycle of Taenia solium. The data indicate that the main risk factor for acquiring human neurocysticercosis and swine cysticercosis is the presence of the tapeworm carrier in the household. Therefore, several intervention measures for the control of cysticercosis have been evaluated: mass treatment in order to cure tapeworm carriers, health education towards understanding the risk factors, pig control by restraining them, experimental vaccination of pigs and treatment of swine cysticercosis. In this paper, we review the information obtained in these areas. We hope it will be useful in other endemic countries that wish to elaborate an action plan for the control and ultimate eradication of T. solium.