Hospital Resources May Be an Important Aspect of Mortality Rate among Critically Ill Patients with COVID-19: The Paradigm of Greece.

For critically ill patients with coronavirus disease 2019 (COVID-19) who require intensive care unit (ICU) admission, extremely high mortality rates (even 97%) have been reported. We hypothesized that overburdened hospital resources by the extent of the pandemic rather than the disease per se might play an important role on unfavorable prognosis. We sought to determine the outcome of such patients admitted to the general ICUs of a hospital with sufficient resources. We performed a prospective observational study of adult patients with COVID-19 consecutively admitted to COVID-designated ICUs at Evangelismos Hospital, Athens, Greece. Among 50 patients, ICU and hospital mortality was 32% (16/50). Median PaO2/FiO2 was 121 mmHg (interquartile range (IQR), 86-171 mmHg) and most patients had moderate or severe acute respiratory distress syndrome (ARDS). Hospital resources may be an important aspect of mortality rates, since severely ill COVID-19 patients with moderate and severe ARDS may have understandable mortality, provided that they are admitted to general ICUs without limitations on hospital resources.

Fulminant pancytopenia due to cytomegalovirus infection in an immunocompetent adult.

A case of severe and irreversible pancytopenia secondary to acute primary cytomegalovirus infection in an immunocompetent woman is described. The patient presented with thrombocytopenia, lymphopenia, anemia, and abnormal liver function tests. Treatment with corticosteroids and intravenous immunoglobulin was ineffective in reconstituting hemopoiesis. The patient developed severe sepsis and eventually expired.

Fulminant pancytopenia due to cytomegalovirus infection in an immunocompetent adult

A case of severe and irreversible pancytopenia secondary to acute primary cytomegalovirus infection in an immunocompetent woman is described. The patient presented with thrombocytopenia, lymphopenia, anemia, and abnormal liver function tests. Treatment with corticosteroids and intravenous immunoglobulin was ineffective in reconstituting hemopoiesis. The patient developed severe sepsis and eventually expired.

An outbreak of hemodialysis catheter-related bacteremia with sepsis caused by Streptococcus agalactiae in a hemodialysis unit.

BACKGROUND: Rates of invasive group B Streptococcus (GBS; Streptococcus agalactiae) disease in adults are on the rise. Invasive GBS disease can be community- or healthcare-associated. We report an outbreak of GBS catheter-related bacteremia in a hemodialysis (HD) unit. MATERIALS AND METHODS: Two patients undergoing HD at the same outpatient HD unit were admitted on the same day (within a few hours of each other) with catheter-related GBS bacteremia. A retrospective study was undertaken at the HD unit to address risk factors for febrile illness on the last HD session day. A detailed questionnaire was completed by all HD patients treated on the same day as the two GBS patients and by all members of the nursing and medical staff. Medical and nursing records of the HD unit were reviewed, as well as infection control and catheter care practices. Patients and staff members submitted swabs for culture. RESULTS: No rectal or vaginal culture of any HD patient or staff member was positive for GBS. The development of recent febrile disease was significantly associated with the presence of a hemodialysis catheter (p=0.028) and care for more than 30min by a specific nurse during the last two HD sessions (p=0.007). CONCLUSIONS: We speculate that the GBS strain was transmitted from one patient to the other through the hands of medical personnel. No such outbreak has ever been reported in HD patients. The importance of strict infection control practices in HD units and the avoidance of catheters for long-term HD should be emphasized.

Course of inflammatory bowel disease in patients infected with human immunodeficiency virus.

BACKGROUND: Human immunodeficiency virus (HIV) infection depletes CD4+ lymphocytes, which may benefit patients with inflammatory bowel disease (IBD). The aim was to compare the course of IBD in HIV patients with a matched group of IBD seronegative patients. METHODS: A total of 20 IBD (14 Crohn's disease, 6 ulcerative colitis) HIV infected patients and 40 matched control seronegative IBD patients (2 controls per case) were compared regarding relapse of their disease. The CD4+ count was followed every 6 months and a value of < or =500 cells/microL was used to define patients with immunosuppression. Relapse rates per year of follow-up were compared among the 2 groups and survival curves for cumulative remission rates were compared with a log-rank test. Multivariate analysis was used to discriminate among the impact of different variables on the risk of IBD relapse. RESULTS: The median duration of follow-up was 8.4 years (range 0.6-18 years). The mean relapse rate for the HIV+IBD group was 0.016/year of follow-up as compared to 0.053/year of follow-up for the IBD-matched control group (P = 0.032). Regarding the HIV-positive/IBD group, 14 patients were immunosuppressed at any given time during the follow-up period. None of these patients experienced an IBD relapse, whereas 3 out of the 6 without immunosuppression relapsed (P = 0.017). According to the multivariate analysis, HIV status was the only risk factor independently associated with a lower probability of IBD relapse. CONCLUSIONS: HIV infection reduces the relapse rates in IBD patients and this may be attributed to the lower CD4+ counts seen in these patients.

Poststernotomy sternal osteomyelitis and mediastinitis by Trichosporon asahii: a rare occurrence with a grave prognosis.

Post-sternotomy infectious complications, including superficial and deep wound infections, sternal osteomyelitis and mediastinitis, are rarely caused by fungi. Trichosporon asahii is the main Trichosporon species that causes systemic infection in humans. Most cases involved neutropenic patients with hematologic malignancies. We report a unique case of a non-cancer, non-neutropenic but severely ill patient who developed an ultimately lethal T. asahii infection after sternotomy. We speculate that our patient had been colonized with the fungus and his surgical site infection may have been related to his emergency revascularization surgery. Therapy with liposomal amphotericin failed to sterilize the bloodstream despite in vitro susceptibility results. The addition of voriconazole helped sterilizing the bloodstream without changing the outcome. Physicians must be aware of the continuously expanding spectrum of infections with this emerging difficult-to-treat fungal pathogen.

Community-acquired methicillin-resistant Staphylococcus aureus as a cause of rapidly progressing pyelonephritis with pyonephrosis, necessitating emergent nephrectomy.

In this article, we describe the first, to our knowledge, reported case of severe bacteremic upper urinary tract infection with pyonephrosis-in the context of prior chronic urinary tract disease-caused by community-acquired methicillin-resistant Staphylococcus aureus (MRSA). The patient presented with fever and constitutional symptoms, and computed tomography revealed extensive renal parenchymal infection along with a staghorn calculus and dilatation of the pyelocalyceal system. His clinical condition rapidly deteriorated, and he developed uncontrollable sepsis, necessitating an emergent nephrectomy. Significant pyonephrosis was noted during surgery. Blood cultures yielded MRSA, and molecular analysis (by polymerase chain reaction) of the MRSA strains from blood and wound fluid showed that they were Panton-Valentine leukocidin positive and they also possessed SCCmecA type IV. Postoperatively, the patient was treated with intravenous vancomycin for 3 weeks and had a favorable outcome.

First-time use of bevacizumab for aggressive, metastatic hepatocellular carcinoma in an HIV/hepatitis B virus coinfected patient: a case report.

We present a case of an HIV-1 infected patient with history of chronic hepatitis B and chronic alcohol use without cirrhosis, who presented with aggressive hepatocellular carcinoma with multiple metastases. Systemic chemotherapy combined with use of bevacizumab (anti-vascular endothelium growth factor monoclonal antibody) was without effect and the patient succumbed to his disease within few weeks. To our knowledge, this is the first report in the English literature of bevacizumab use for metastatic hepatocellular carcinoma in HIV-infected patients.

Revertant multiresistant HIV in chronically infected drug naïve patients: when baseline resistance testing is not enough.

We present a patient with chronic HIV-1 infection and primary multi-drug resistance, the magnitude of which was underestimated by the baseline genotypic resistance testing (GRT) due to reversion of some of the mutations of the transmitted strain. This resulted in complete failure of his first antiretroviral regimen with rapid appearance of presumably archived mutations to more than one antiretroviral classes. Interestingly, his viral load remained high even in the presence of the M184V mutation. Baseline GRT in chronic HIV infection may not give adequate information in the presence of acquired multi-drug-resistant HIV strains, which have one or more of their mutations reverted. The presence of 215 codon polymorphisms should alert physicians to the possible coexistence of archived nucleoside and non-nucleoside reverse transcriptase inhibitor mutations. In such a case, initiation of a regimen with a low genetic barrier to resistance may not be the best choice and, if done, should be done cautiously and with more frequent monitoring of treatment response than usual.