Acute ischaemic stroke associated with SARS-CoV-2 infection in North America.

BACKGROUND: To analyse the clinical characteristics of COVID-19 with acute ischaemic stroke (AIS) and identify factors predicting functional outcome. METHODS: Multicentre retrospective cohort study of COVID-19 patients with AIS who presented to 30 stroke centres in the USA and Canada between 14 March and 30 August 2020. The primary endpoint was poor functional outcome, defined as a modified Rankin Scale (mRS) of 5 or 6 at discharge. Secondary endpoints include favourable outcome (mRS ≤2) and mortality at discharge, ordinal mRS (shift analysis), symptomatic intracranial haemorrhage (sICH) and occurrence of in-hospital complications. RESULTS: A total of 216 COVID-19 patients with AIS were included. 68.1% (147/216) were older than 60 years, while 31.9% (69/216) were younger. Median [IQR] National Institutes of Health Stroke Scale (NIHSS) at presentation was 12.5 (15.8), and 44.2% (87/197) presented with large vessel occlusion (LVO). Approximately 51.3% (98/191) of the patients had poor outcomes with an observed mortality rate of 39.1% (81/207). Age >60 years (aOR: 5.11, 95% CI 2.08 to 12.56, p<0.001), diabetes mellitus (aOR: 2.66, 95% CI 1.16 to 6.09, p=0.021), higher NIHSS at admission (aOR: 1.08, 95% CI 1.02 to 1.14, p=0.006), LVO (aOR: 2.45, 95% CI 1.04 to 5.78, p=0.042), and higher NLR level (aOR: 1.06, 95% CI 1.01 to 1.11, p=0.028) were significantly associated with poor functional outcome. CONCLUSION: There is relationship between COVID-19-associated AIS and severe disability or death. We identified several factors which predict worse outcomes, and these outcomes were more frequent compared to global averages. We found that elevated neutrophil-to-lymphocyte ratio, rather than D-Dimer, predicted both morbidity and mortality.

Utilizing the Promise of Omadacycline in a Resistant, Non-tubercular Mycobacterial Pulmonary Infection.

The non-tubercular mycobacterium, Mycobacterium abscessus (M. abscessus), is a resistant, opportunistic pathogen that causes lung infections that are not curable, but which can be controlled with appropriate antibiotic regimens. A new broad-spectrum tetracycline analog called omadacycline was approved in 2018 in the United States for the treatment of bacterial, community-acquired pneumonia and acute skin infections. We discuss a case to assess the effect of this novel antibiotic in the management of a nefariously resistant M. abscessus infection. Our patient had underlying chronic bronchiectasis and a long-standing M.abscessus infection, along with numerous drug allergies and previously failed antibiotic regimens. All of these factors entailed a disease process that was difficult to manage and a worsening morbidity. The utilization of omadacycline in this case addressed a multitude of problems by improving ease of administration and circumventing the patient's allergic reaction to antibiotics; on follow-up, the patient demonstrated an improved clinical status including well-controlled symptoms and weight gain.

Acute Respiratory Distress Syndrome Requiring Extracorporeal Membrane Oxygenation as the Initial Presentation of Anti-neutrophillic Cytoplasmic Auto-antibody Positive Vasculitis.

Acute respiratory distress syndrome (ARDS) is a life-threatening inflammatory state of lung injury that can require acute interventions including mechanical ventilation as well as emergent veno-venous extracorporeal membrane oxygenation (VV-ECMO) for management. Etiologies of ARDS are not clearly discernible in certain cases and can vary from sepsis, pneumonia, trauma and intoxication. Anti-nuclear cytoplasmic auto-antibody (ANCA)-associated vasculitis (AAV) is a group of several conditions that can have pulmonary complications including ARDS. We present a case where the primary manifestation of myeloperoxidase (MPO)-ANCA positive vasculitis was ARDS, in order to highlight the importance of investigating rare vasculitides as the underlying cause of ARDS and the importance of ECMO as an early life-saving intervention for the management of ARDS.