An immunosuppressed woman in her sixties with a high fever. / En immunsupprimert kvinne i 60-årene med høy feber.

Investigation of fever in immunosuppressed patients can be challenging. Rapid and correct microbiological test results are essential for steering the investigation in the right direction. Our patient was eventually diagnosed with a condition that was initially suspected, but the time to reach a laboratory-confirmed diagnosis was unusually long.

Respiratory dysfunction three months after severe COVID-19 is associated with gut microbiota alterations.

BACKGROUND: Although coronavirus disease 2019 (COVID-19) is primarily a respiratory infection, mounting evidence suggests that the gastrointestinal tract is involved in the disease, with gut barrier dysfunction and gut microbiota alterations being related to disease severity. Whether these alterations persist and are related to long-term respiratory dysfunction remains unknown. METHODS: Plasma was collected during hospital admission and after 3 months from the NOR-Solidarity trial (n = 181) and analyzed for markers of gut barrier dysfunction and inflammation. At the 3-month follow-up, pulmonary function was assessed by measuring the diffusing capacity of the lungs for carbon monoxide (DLCO ). Rectal swabs for gut microbiota analyses were collected (n = 97) and analyzed by sequencing the 16S rRNA gene. RESULTS: Gut microbiota diversity was reduced in COVID-19 patients with respiratory dysfunction, defined as DLCO below the lower limit of normal 3 months after hospitalization. These patients also had an altered global gut microbiota composition, with reduced relative abundance of 20 bacterial taxa and increased abundance of five taxa, including Veillonella, potentially linked to fibrosis. During hospitalization, increased plasma levels of lipopolysaccharide-binding protein (LBP) were strongly associated with respiratory failure, defined as pO2 /fiO2 (P/F ratio) <26.6 kPa. LBP levels remained elevated during and after hospitalization and were associated with low-grade inflammation and respiratory dysfunction after 3 months. CONCLUSION: Respiratory dysfunction after COVID-19 is associated with altered gut microbiota and persistently elevated LBP levels. Our results should be regarded as hypothesis generating, pointing to a potential gut-lung axis that should be further investigated in relation to long-term pulmonary dysfunction and long COVID.

Evaluation of the Effects of Remdesivir and Hydroxychloroquine on Viral Clearance in COVID-19 : A Randomized Trial.

BACKGROUND: New treatment modalities are urgently needed for patients with COVID-19. The World Health Organization (WHO) Solidarity trial showed no effect of remdesivir or hydroxychloroquine (HCQ) on mortality, but the antiviral effects of these drugs are not known. OBJECTIVE: To evaluate the effects of remdesivir and HCQ on all-cause, in-hospital mortality; the degree of respiratory failure and inflammation; and viral clearance in the oropharynx. DESIGN: NOR-Solidarity is an independent, add-on, randomized controlled trial to the WHO Solidarity trial that included biobanking and 3 months of clinical follow-up (ClinicalTrials.gov: NCT04321616). SETTING: 23 hospitals in Norway. PATIENTS: Eligible patients were adults hospitalized with confirmed SARS-CoV-2 infection. INTERVENTION: Between 28 March and 4 October 2020, a total of 185 patients were randomly assigned and 181 were included in the full analysis set. Patients received remdesivir (n = 42), HCQ (n = 52), or standard of care (SoC) (n = 87). MEASUREMENTS: In addition to the primary end point of WHO Solidarity, study-specific outcomes were viral clearance in oropharyngeal specimens, the degree of respiratory failure, and inflammatory variables. RESULTS: No significant differences were seen between treatment groups in mortality during hospitalization. There was a marked decrease in SARS-CoV-2 load in the oropharynx during the first week overall, with similar decreases and 10-day viral loads among the remdesivir, HCQ, and SoC groups. Remdesivir and HCQ did not affect the degree of respiratory failure or inflammatory variables in plasma or serum. The lack of antiviral effect was not associated with symptom duration, level of viral load, degree of inflammation, or presence of antibodies against SARS-CoV-2 at hospital admittance. LIMITATION: The trial had no placebo group. CONCLUSION: Neither remdesivir nor HCQ affected viral clearance in hospitalized patients with COVID-19. PRIMARY FUNDING SOURCE: National Clinical Therapy Research in the Specialist Health Services, Norway.

[A man in his thirties with icterus and itching]. / En mann i 30-årene med icterus og kløe.

BACKGROUND: We present a patient from South-East Asia who has been living in Norway for five years. He was referred to our department with jaundice caused by opisthorchiasis/clonorchiasis. This reason for jaundice is highly unusual in Europe. Worldwide, however about 35,000,000 people are infected. CASE PRESENTATION: A male in his thirties, originally from South-East Asia, experienced diffuse itching for five weeks and painless jaundice for two weeks. Blood samples showed increasing cholestasis. Abdominal ultrasound, MRCP and computed tomography showed no sign of bile duct obstruction or liver tumour. Serological tests and liver biopsy revealed no infectious or autoimmune liver disease. ERCP showed normal bile ducts, but large quantities of typical hookworms in the duodenum. Stool samples showed at least one egg typical of Opisthorchis/Clonorchis and a large quantity of hookworm eggs. We interpreted these findings as parasite-induced obstruction of some of the small bile ducts. The patient recovered completely after treatment with Praziquantel. INTERPRETATION: Jaundice due to bile duct obstruction by opisthorchiasis/clonorchiasis is a well-known problem in South-East Asia. It may become more common in Europe as well as a result of increasing migration. Treatment with Praziquantel is simple and effective.

[A man with persisting fever, night sweats and high sedimentation rate]. / En mann med vedvarende feber, nattesvette og høy senkningsreaksjon.

BACKGROUND: Fever of unknown origin and high sedimentation rate are common clinical problems. MATERIAL AND METHODS: A middle-aged man with fever of unknown origin, night sweats and high sedimentation rate was referred to our hospital for investigation. RESULTS AND INTERPRETATION: The patient was suspected to have mononucleosis or reactivation of infectious mononucleosis because of mild anaemia and thrombocytopenia, a weakly positive IgM antibody test for Epstein-Barr virus and monocytosis (in peripheral blood). Because monocytosis, elevated sedimentation rate and fever persisted, bone marrow smears were prepared and biopsies taken.The third biopsy showed that morphology was consistent with chronic myelomonocytic leukemia (CMML), which was confirmed by two later biopsies. However, a malignant cell population (consisting of blasts in peripheral blood) was only found in one of several flow cytometry assessments of peripheral blood and bone marrow aspirate and cytogenetic analyses of bone marrow cells were normal. The patient's clinical situation has been stable for some years and treatment has not been necessary.

[Increasing antibiotic resistance in urinary tract infections]. / Økende forekomst av antibiotikaresistens ved urinveisinfeksjoner.

BACKGROUND: There is increasing focus on the development of bacterial antibiotic resistance. MATERIALS AND METHODS: We conducted a retrospective study of urine samples from patients resident in a Norwegian county, comparing 9121 samples culture-positive in 2003-04 with 28 066 samples in 1997-99. Determination of resistance was done with the MAST automatic multipoint inoculator system. RESULTS: Escherichia coli was found in 68% and 56% of out-patient and in-patient isolates respectively. Significant declines in mecillinam sensitivity (from 96% to 94%), nitrofurantoin sensitivity (from 97% to 95%) and sulfonamide sensitivity (from 73% to 71%) in in-patient E. coli isolates were found. In out-patients we found significant reductions in sensitivity to ampicillin (from 78% to 76%) and trimethoprim (from 83% to 82%). For urinary tract infection isolates as a whole, the greatest sensitivity was observed for nitrofurantoin: 85% in in-patient isolates and 75% in out-patient isolates, but there was a significant decline in resistance to several antibiotics. INTERPRETATION: Increasing antibiotic resistance may be related to increasing antibiotic use. Mecillinam and nitrofurantoin may be considered first-choice preparations as E. coli is the dominant etiological agent and shows the greatest sensitivity to these two antibiotics.