Dual anti-viral treatment for persistent COVID-19 in immunocompromised hemato-oncological patients is associated with a favorable prognosis and minor side effects.

In hemato-oncological patients, COVID-19 can present as a persistent infection with ongoing symptoms and viral replication over a prolonged period of time. Data are scarce on the preferred treatment options for these patients. We describe our experience with a five-day course of dual anti-viral treatment with remdesivir and nirmatrelvir/ritonavir for hemato-oncological immunocompromised patients with persistent COVID-19. Fifteen patients with a history of lymphoma, CLL, and MM were included. Eight were male, median age was 74. All patients had an immediate clinical and virological response. In 73 % of patients, PCR for SARS-CoV-2 became negative at the end of treatment and the rest had an increase in PCR cycle threshold (CT) values, with a median increase of 6 cycles. After a follow-up of three months, 60 % of patients remained in full clinical and virological remission. None required invasive mechanical ventilation or died. The side effects we observed, neutropenia, lactatemia and elevated transaminases, were mild and almost all transient in nature. We conclude that dual anti-viral treatment appears to be a valid treatment option for persistent COVID-19.

Mpox Presenting as Proctitis in Men Who Have Sex With Men.

In our cohort of 70 patients of men who have sex with men (MSM) with mpox, more than one-third presented with proctitis. In two-thirds of proctitis patients, there was no typical rash upon presentation, and in one-fifth, there was no rash at all, making the diagnosis a challenge. A rectal swab for mpox polymerase chain reaction (PCR) can be diagnostic.

Mpox proctitis as a likely predisposing factor for chlamydial perihepatitis in a male patient.

Perihepatitis (Fitz-Hugh-Curtis syndrome) is a rare complication of sexually transmitted infections, mostly seen in women. Only 12 male cases have been reported to date, of which Chlamydia trachomatis was confirmed in 2. We report a case of chlamydial perihepatitis in a male patient, occurring 1 month after Mpox and associated with the unusual LGV ST23 strain. Our case suggests that rectal Mpox lesions may facilitate chlamydial dissemination.

CT findings in temporal bone sites in skull base osteomyelitis from malignant otitis externa.

OBJECTIVES: To identify the earliest sites and spread patterns of bony erosions on high-resolution temporal bone computerized tomographic (HRTBCT) scans and conjugate the radiological findings with clinical/laboratory data for guiding the interpretation of CT images of skull base osteomyelitis (SBOM) from malignant otitis externa (MOE). STUDY DESIGN: Retrospective and prospective medical records analysis. METHODS: The medical records of all patients who presented to a referral medical center during 2015-2022 and initially diagnosed with SBOM. Radiological assessment of each sub-site was performed by 2 qualified neuro-radiologist, who were blind to the clinical data. RESULTS: 33 patients were enrolled. All patients suffered edema and exudates of the external auditory canal (EAC). The most common osseous markers for SBOM were dehiscence or irregularity of the anterior EAC wall and temporomandibular joint (TMJ) medial wall (21/33, 64% patients, each), followed by a fistula from the TMJ to the EAC (20/33, 61% patients). Eustachian tube bony walls and condylar irregularity and/or dehiscence were as prevalent as 16/33, 48% of patients, each. EAC inferior and posterior walls of the EACs were irregular or dehiscent in patients with more advanced disease. CONCLUSIONS: The high symptomatologic overlap between SBOM and other aural pathologies might cause diagnostic (and subsequent treatment) delay and result in dire complications. EAC edema and irregularity or dehiscence of the anterior EAC wall are the most common early CT findings associated with SBOM caused by MOE.

Effect of composite resin containing antibacterial filler on sugar-induced pH drop caused by whole saliva bacteria.

STATEMENT OF PROBLEM: Secondary caries around restorations is a major problem and can be attributed to bacteria invading microgaps formed at the tooth-restoration interface. An antibacterial composite resin containing quaternary ammonium silica (QASi) filler has been reported to inhibit enamel demineralization in situ. However, whether the prevention of enamel demineralization by QASi-containing composite resin is because of the reduced metabolic activity of acid-producing saliva bacteria is unclear. PURPOSE: The purpose of this study was to compare the effects of QASi-containing composite resin and 2 other restorative materials on the viability of salivary bacteria and sugar-induced acid production. MATERIAL AND METHODS: Whole saliva from each of the 30 study participants, 14 at high risk and 16 at low risk for caries, was brought into contact with quadruplicate specimens of 3 restorative materials, Infinix Flowable Composite, an anti-bacterial composite resin containing 1.5% QASi filler (Nobio), Filtek Supreme Flowable Restorative (3M), a conventional flowable composite resin, and dental amalgam (Silmet). Bacterial growth and sugar-induced acid production on each restorative material were measured every 20 minutes for 18 hours. Caries risk groups were compared using the t test and repeated measures analysis of variance (α=.05). When significant, Bonferroni multiple comparisons were used. RESULTS: On average, the saliva with the QASi-containing composite resin specimens maintained a near-neutral pH, not dropping below pH 6.0. The saliva associated with both conventional restorative materials exhibited a pH drop below 5.5 (P<.001), the critical threshold for tooth demineralization according to the Stephan curve. Virtually no growth was measured on the surface of the antibacterial composite resin, whereas bacteria grew on the conventional composite resin and dental amalgam (P<.001). No differences were observed between participants at high and low risk of caries. CONCLUSIONS: Unlike amalgam and conventional composite resin, the QASi-containing composite resin showed a near-complete shutdown of the metabolic activity of salivary bacteria upon contact and virtually no bacterial viability. This suggests that the prevention of tooth demineralization by QASi-containing restoratives is associated with a significant reduction in bacterial metabolic activity.

B-cell non-Hodgkin lymphoma linked to Coxiella burnetii.

Bacteria can induce human lymphomas, whereas lymphoproliferative disorders have been described in patients with Q fever. We observed a lymphoma in a patient with Q fever that prompted us to investigate the association between the 2 diseases. We screened 1468 consecutive patients of the 2004 to 2014 French National Referral Center for Q fever database. The standardized incidence ratios (SIRs) of diffuse large B-cell lymphoma (DLBCL) and follicular lymphoma (FL) were calculated comparatively to the 2012 Francim Registry. The presence of Coxiella burnetii was tested using immunofluorescence and fluorescence in situ hybridization using a specific 16S ribosomal RNA probe and genomic DNA probe. Seven patients (0.48%) presented mature B-cell lymphoma consisting of 6 DLBCL and 1 FL. An excess risk of DLBCL and FL was found in Q fever patients compared with the general population (SIR [95% confidence interval], 25.4 [11.4-56.4] and 6.7 [0.9-47.9], respectively). C burnetii was detected in CD68(+) macrophages within both lymphoma and lymphadenitis tissues but localization in CD123(+) plasmacytoid dendritic cells (pDCs) was found only in lymphoma tissues. Q fever patients with persistent focalized infection were found more at risk of lymphoma (hazard ratio, 9.35 [1.10-79.4]). Interleukin-10 (IL10) overproduction (P = .0003) was found in patients developing lymphoma. These results suggest that C burnetii should be added to the list of bacteria that promote human B-cell non-Hodgkin lymphoma, possibly by the infection of pDCs and IL10 overproduction. Screening for early lymphoma diagnosis should be considered in the management of patients with Q fever, especially those with persistent focalized infections.

Epidemiology of autoimmune encephalitis and comparison to infectious causes-Experience from a tertiary center.

OBJECTIVES: The incidence of autoimmune encephalitis (AIE) has risen in the last decade, yet recent studies are lacking. We compared the epidemiology of autoimmune and infectious encephalitis cases in Tel-Aviv Sourasky Medical Center (TASMC) between 2010 and 2020. METHODS: All encephalitis cases, aged 18 and above, admitted to TASMC between the years 2010 and 2020 were reviewed for demographic, clinical, laboratory, and imaging data and categorized based on etiology. RESULTS: Two hundred and twenty-five patients with encephalitis were identified. The most common identifiable cause was viral (42%), followed by autoimmune encephalitis (35%), bacterial (18%), and fungal/parasitic (5%). The incidence of AIE cases out of the yearly admitted cases increased substantially, from 3.8/100 K in 2010 to 18.8/100 K in 2020. The incidence of viral cases also increased while those of bacterial and fungal/parasitic infections remained stable. Patients with AIE were younger compared to infectious patients (p-value <0.001) and had lower markers of systemic and cerebrospinal fluid inflammation (p-value for all <0.001). Seizures were more common among AIE patients (p-value <0.001), yet one-year mortality rates were higher among infectious patients (p-value <0.001). INTERPRETATION: AIE incidence has risen significantly in our institution during the past decade, with current rates comparable to those of all infectious causes combined. Based on this cohort, clinical clues for an autoimmune etiology include a non-inflammatory cerebrospinal fluid profile, the presence of seizures, and temporal lobe imaging abnormalities (also common in herpetic encephalitis). In light of its rising incidence and the importance of early treatment, AIE should be considered in the differential diagnosis of all encephalitis cases.

Outcomes of Enterobacter cloacae-Associated Periprosthetic Joint Infection Following Hip Arthroplasties.

Background: Periprosthetic joint infections (PJIs) represent a serious complication following total hip arthroplasty (THA) and are associated with significant morbidity. While recent data suggest that Enterobacter cloacae is an emerging source of PJI, characteristics and outcomes of E. cloacae-associated infections are rarely described. The study aimed to present and describe the findings and outcomes of E. cloacae-associated PJI in our department. Methods: This is a retrospective descriptive study of patients who underwent revision THA for E. cloacae-associated PJI between 2011 and 2020 and has a minimum follow-up of 2 years. Outcomes included organism characteristics as well as clinical outcomes, represented by the number of reoperations needed for PJI eradication and the Musculoskeletal Infection Society (MSIS) outcome reporting tool score. Of 108 revision THAs, 12 patients (11.1%) were diagnosed with E. cloacae-associated PJI. Results: The majority of cases had a polymicrobial PJI (n=8, 66.7%). Five E. cloacae strains (41.7%) were gentamicin-resistant. Six patients (50.0%) underwent 2 or more revisions, while 3 of them (25.0%) required 4 or more revisions until their PJI was resolved. When utilizing the MSIS outcome score, the first surgical intervention was considered successful (MSIS score tiers 1 and 2) for 5 patients (41.7%) and failed (tiers 3 and 4) for 7 patients (58.3%). Conclusions: E. cloacae is emerging as a common source of PJI following hip arthroplasty procedures. The findings of our study suggest that this pathogen is primarily of polymicrobial nature and represents high virulence and poor postoperative outcomes, as represented by both an increased number of required revision procedures and high rates of patients with MSIS outcome scores of 3 and 4. When managing patients with E. cloacae-associated PJI, surgeons should consider these characteristics and inform patients regarding predicted outcomes.

Nosocomial transmission of MPOX virus to health care workers -an emerging occupational hazard: A case report and review of the literature.

We present an unusual case of monkeypox (MPOX) virus transmission to a dermatology resident during examination of affected patients. Viral DNA sequencing led to the identification of the most likely contact. This case, along with a review of all published cases so far, emphasizes the possible hazard of MPOX transmission to health care personnel, even when wearing personal protective equipment. It also emphasizes the need for maintaining high index of suspicion when examining patients with new dermatological lesions and strict compliance with the revised Centers for Disease Control and Prevention recommendations for specimen collection from such patients.

Regional Antibiotic Delivery for Implanted Cardiovascular Electronic Device Infections.

BACKGROUND: Present guidelines endorse complete removal of cardiovascular implantable electronic devices (pacemakers/defibrillators), including extraction of all intracardiac electrodes, not only for systemic infections, but also for localized pocket infections. OBJECTIVES: The authors evaluated the efficacy of delivering continuous, in situ-targeted, ultrahigh concentration of antibiotics (CITA) into the infected subcutaneous device pocket, obviating the need for device/lead extraction. METHODS: The CITA group consisted of 80 patients with pocket infection who were treated with CITA during 2007-2021. Of them, 9 patients declined lead extraction because of prohibitive operative risk, and 6 patients had questionable indications for extraction. The remaining 65 patients with pocket infection, who were eligible for extraction, but opted for CITA treatment, were compared with 81 patients with pocket infection and similar characteristics who underwent device/lead extraction as primary therapy. RESULTS: A total of 80 patients with pocket infection were treated with CITA during 2007-2021. CITA was curative in 85% (n = 68 of 80) of patients, who remained free of infection (median follow-up 3 years [IQR: 1.0-6.8 years]). In the case-control study of CITA vs device/lead extraction, cure rates were higher after device/lead extraction than after CITA (96.2% [n = 78 of 81] vs 84.6% [n = 55 of 65]; P = 0.027). However, rates of serious complications were also higher after extraction (n = 12 [14.8%] vs n = 1 [1.5%]; P = 0.005). All-cause 1-month and 1-year mortality were similar for CITA and device/lead extraction (0.0% vs 3.7%; P = 0.25 and 12.3% vs 13.6%; P = 1.00, respectively). Extraction was avoided in 90.8% (n = 59 of 65) of extraction-eligible patients treated with CITA. CONCLUSIONS: CITA is a safe and effective alternative for patients with pocket infection who are unsuitable or unwilling to undergo extraction. (Salvage of Infected Cardiovascular Implantable Electronic Devices [CIED] by Localized High-Dose Antibiotics; NCT01770067).