A 67-year-old female presents with worsening shortness of breath, fever, and hypoxemia requiring mechanical ventilation. She was transferred from a Long-Term Acute Care Facility with a chronic tracheostomy.
CRAB (Carbapenem-Resistant Acinetobacter baumannii) Treatment Options Read More »
The role of viral infections as precipitants for autoimmune hepatitis (AIH) has been previously suggested, yet the direct link between acute hepatitis E virus (HEV) infection and the onset of AIH remains to be elucidated.
Concomitant Acute Hepatitis E Infection and Autoimmune Hepatitis Read More »
Necrotizing soft tissue infections (NSTIs) are surgical emergencies often presenting with concomitant sepsis. The use of intravenous hydrocortisone, vitamin C (ascorbic acid), and thiamine (HAT) has been proposed as beneficial in treating sepsis. To our knowledge, no study has focused exclusively on its use in NSTIs. This study aimed to evaluate use of HAT among patients with NSTIs and included patients from a single Midwestern regional burn center. Patients diagnosed with sepsis or septic shock secondary to an NSTI were randomized and received either intravenous HAT or placebo. The primary outcome was hospital survival. Secondary outcomes included vasopressor therapy duration, renal replacement therapy need, intensive care unit length of stay, serum procalcitonin and sequential organ failure assessment (SOFA) change in the first 72 h, number of wound-related surgeries, and wound classification at hospital discharge. While our study started as a randomized controlled trial, due to low enrollment it was transitioned to a case series. Of the 10 patients enrolled, half received HAT therapy. No significant difference was found between the treatment and placebo groups. Future larger, multicenter studies may help better elucidate the role of intravenous HAT therapy in patients with NSTIs.
As immune checkpoint inhibitor (ICI) therapy becomes increasingly popular for the treatment of cancer, there is a growing body of literature on opportunistic infections associated with ICI therapy. Pembrolizumab binds specifically to the PD-1 receptor on T cells, preventing PD-1’s interaction with PD-L1 and PD-L2. This blockade interrupts the inhibitory signal and restores a T cell’s ability to recognize and attack tumor cells. We present a case of invasive Listeria infection associated with ICI therapy. The case also suggests treating patients undergoing active ICI therapy as potential immunocompromised hosts due to possible immune dysregulation related to ICI therapy.
Abstract: Background: The surge of COVID-19 hospitalizations in January 2022, at the onset of the Omicron period and before widespread population immunity, was a window in which to study the impact of vaccination status and other factors on disease severity in Omicron infections. Methods: This was a case-control study of adults hospitalized with COVID-19 during January 2022 that evaluated risk factors for severe disease. Cases were patients with severe COVID-19, defined in three ways: (1) requiring supplemental oxygen > 24 hours if not on home oxygen, (2) requiring high-level oxygen: either high flow of > 15 L/min, noninvasive ventilation, or mechanical ventilation (MV), and (3) the composite of MV or hospital death. Controls were patients hospitalized with COVID-19 who did not meet the respective case definition. Results: Among the 379 patients not on home oxygen before admission, 133 required supplemental oxygen. Among all 393 patients meeting the study criteria, 58 required high-level oxygen, 22 required MV, and 28 died. Factors associated with all case definitions were (1) absence of full vaccination compared to booster vaccination: requiring oxygen, odds ratio [OR], 7.86 [95% CI, 3.78-16.4]; high-level oxygen, OR, 5.17 [95% CI, 2.01-13.3]; MV or hospital death, OR, 5.21 [ 95% CI, 1.63-16.6]; (2) immunocompromised status: requiring oxygen, OR, 2.79 [95% CI, 1.38-5.63]; high-level oxygen, OR, 3.79 [95% CI 1.66-8.67]; MV or hospital death, OR 4.63 [95% CI 1.72-12.5], and (3) age > 75 years compared to 50 to 64 years: requiring oxygen, OR 2.85, [95% CI 1.43-6.07]; high-level oxygen, OR 4.02 [95% CI 1.47-11.0]; MV or hospital death, OR 5.68 [95% CI 1.49-21.7]. Other factors associated with requiring oxygen were obesity: body mass index (BMI) 35.0-39.9 kg/m2, OR, 2.4 [95% CI 1.09-5.26]; BMI > 40.0 kg/m2, OR, 3.29 [95% CI 1.34-8.10] compared to BMI < 24.9 kg/m2; and age 65-74 years compared to 50-64 years, OR, 2.13 [ 95% CI 1.03-4.38]. Factors associated with requiring high-level oxygen were cardiomyopathy, OR, 2.11 [95% CI 1.04-4.32], and male gender, OR 1.93 [95% CI 1.01-3.7]. Factors associated with MV or hospital death were cardiomyopathy, OR, 2.67 [ 95% CI 1.11-6.42], and chronic kidney disease, OR, 3.17 [95% CI 1.27-7.96]. Factors not associated with any case definitions were full vaccination without compared to with a booster: requiring oxygen, OR, 1.07 [95% CI 0.522-2.21], high-level oxygen, OR, 1.08 [0.415-2.81], MV or hospital death, OR 0.992 [0.328-3.0]; age 18-49 years compared to 50-64 years: requiring oxygen, OR, 1.04 [95% CI 0.495-2.2]; high-level oxygen, OR, 1.2 [95% CI 0.418-3.43]; MV or hospital death, OR, 0.355 [95% CI 0.034-3.75]; and other medical conditions. Conclusions: In patients hospitalized with COVID-19 during the Omicron surge of January 2022, factors associated with requiring oxygen were the absence of full vaccination, immunosuppression, age > 65 years, and body mass index > 35 kg/m2, but not the absence of a booster if fully vaccinated. This is further evidence that immune memory mitigates disease severity in Omicron infections.
Immunoglobulin G subclass deficiency has been diagnosed in 25% of patients presenting with recurrent infections. Similar to other primary immunodeficiencies, it is commonly overlooked or misdiagnosed. The diagnosis includes documentation of a decreased level of one or more subclasses in conjunction with an inadequate response to a vaccine challenge. Understanding the specific actions of the four subclasses allows the clinician to direct the evaluation and define a treatment program. Several subclass deficiencies are also associated with other disease states. Diagnosis of this entity will limit patient morbidity and allow for more rapid identification of other potentially life-altering illnesses.
IgG Subclass Deficiency Read More »
A middle-aged man presented with sternal pain that progressed to the development of a sternal mass over the next few months. The subsequent workup and treatment are outlined, and the differential diagnosis is discussed.
A Man with Chest Pain and an Abnormal Sternal CT Read More »
Systemic lupus erythematosus is an autoimmune disease affecting all organs of the body. It has a higher incidence in women and can affect the central nervous system (CNS) in 10% to 20% of cases. Any structure in the CNS can be involved, resulting in a varied and often complex symptomatology. CNS lupus vasculitis is an even rarer manifestation characterized by small vessel inflammation that can result in vessel thrombosis and necrosis. We present the case of a 31-year-old woman with a history of systemic lupus erythematosus and Sjögren’s syndrome who was treated at our institution for an acute exacerbation of lupus complicated by CNS lupus vasculitis. This case was particularly challenging due to concurrent bacteremia and a travel history that broadened the differential diagnosis widely, thus requiring our input as infectious disease consultants. CNS lupus vasculitis is a diagnosis of exclusion that requires a high level of clinical suspicion to arrive at a prompt diagnosis paired with aggressive management to guarantee good outcomes. In this report, we share our stepwise approach to this challenging case in a didactic manner to benefit trainees and independent infectious diseases providers who may encounter similar clinical scenarios in their practice.
Enigmatic CNS Lupus Vasculitis: A Heuristic Approach Read More »
Despite the stimulating nature of infectious diseases (ID), fellowship programs have failed, on a yearly basis, to fill multiple positions. In addition, numerous entities have published information showing that infectious disease physicians are poorly reimbursed compared to their colleagues in other specialties and are likely to feel overwhelmed. To assess the status of our ID group and define opportunities for improvement, Metro Infectious Disease Consultants (MIDC) conducted an internal audit. Eighty-nine percent of physician employees and 94% of partners were satisfied or very satisfied with MIDC. In addition, based on a Medscape survey, MIDC employees received financial compensation that was 18% greater and partners 235% greater than the average for all ID physicians. A private practice model of infectious diseases is a viable, lucrative, and professionally stimulating option to other ID models. This allows for enhanced lifestyle flexibility and should be viewed by potential ID applicants as a realistic and widely available option to practice this dynamic specialty.
Private Practice Infectious Disease: Metro Infectious Disease Consultants Read More »
In 1978, Robert G. Petersdorf, MD, made the statement that the war against infectious diseases had been won and that additional ID specialists were no longer necessary. He went on to say that if additional specialists were trained, they would end up culturing one another. He continued that: Infectious disease is destined to function best as an academic specialty whose trainees should pursue careers primarily as investigators. The number of clinicians leaving training should be reduced and not further glut the marketplace; they should be based in academic divisions and devote their clinical time and effort to the care of complex referral and to indigent patients.
Town or Gown? ID Needs Both Read More »
