RESUMO
The present paper reports, to the best of our knowledge for the first time, the efficacy and tolerability of the combination of interferon (IFN)α-2a in pegylated formulation and rituximab after a "priming" phase with IFN in the frontline treatment of hairy cell leukemia (HCL) in a profoundly immunosuppressed patient with a Mycobacterium abscessus infection at onset. This immunotherapy combination may represent a potential therapeutic option in patients with active severe infection and for whom the use of purine nucleoside analogues (PNA) is contraindicated. The benefits and drawbacks of remarkably rapid immune reconstitution in the context of opportunistic infections are highlighted as well, as the potentially paradoxical effects of immune recovery as a result of effective immunotherapy strategies, known as immune reconstitution inflammatory syndrome (IRIS), have to be taken into account when dealing with patients with opportunistic infections.
RESUMO
B cell-targeting strategies such as rituximab are widely used in B cell hematologic malignancies, rheumatologic and musculoskeletal diseases and a variety of autoimmune disorders. The purpose of this paper is to illustrate how exposure to anti-CD20 treatment profoundly affects B cell functions involved in anti-SARS-CoV-2 immunity and significantly impacts on the clinical and serological course of SARS-CoV-2 infection, long term immunity and vaccine responses. The data presented here suggest that the effects of B cell-depleting agents on adaptive immunity should be taken into account for the proper selection and interpretation of SARS-CoV-2 diagnostics and to guide appropriate therapeutic approaches and protective measures. Combination therapeutic strategies including immunotherapy in association with prolonged antiviral treatment may play a decisive role in the setting of B cell immune deficiencies.
Assuntos
Antígenos CD20/imunologia , Linfócitos B/imunologia , Tratamento Farmacológico da COVID-19 , COVID-19 , Fatores Imunológicos/uso terapêutico , Rituximab/uso terapêutico , SARS-CoV-2 , COVID-19/diagnóstico , COVID-19/imunologia , COVID-19/prevenção & controle , Vacinas contra COVID-19 , HumanosAssuntos
Monofosfato de Adenosina/análogos & derivados , Alanina/análogos & derivados , COVID-19/terapia , Linfoma não Hodgkin/terapia , Rituximab/uso terapêutico , Monofosfato de Adenosina/administração & dosagem , Alanina/administração & dosagem , Linfócitos B/patologia , COVID-19/complicações , Terapia Combinada , Esquema de Medicação , Humanos , Imunização Passiva/métodos , Hospedeiro Imunocomprometido , Imunossupressores/efeitos adversos , Imunossupressores/uso terapêutico , Itália , Linfoma não Hodgkin/complicações , Linfoma não Hodgkin/patologia , Linfopenia/etiologia , Linfopenia/patologia , Linfopenia/terapia , Masculino , Pessoa de Meia-Idade , Pneumonia Viral/complicações , Pneumonia Viral/terapia , Rituximab/efeitos adversos , SARS-CoV-2/fisiologia , Resultado do Tratamento , Tratamento Farmacológico da COVID-19 , Soroterapia para COVID-19Assuntos
Endocardite Bacteriana/diagnóstico por imagem , Próteses Valvulares Cardíacas/microbiologia , Imagem Multimodal , Infecções Estreptocócicas/diagnóstico por imagem , Idoso , Antibacterianos/uso terapêutico , Terapia Combinada , Ecocardiografia Transesofagiana , Endocardite Bacteriana/microbiologia , Endocardite Bacteriana/terapia , Fluordesoxiglucose F18 , Humanos , Masculino , Tomografia por Emissão de Pósitrons , Compostos Radiofarmacêuticos , Esplenectomia , Infecções Estreptocócicas/microbiologia , Infecções Estreptocócicas/terapia , Streptococcus anginosus/isolamento & purificação , Neoplasias da Glândula Tireoide/diagnóstico , Neoplasias da Glândula Tireoide/cirurgia , Tireoidectomia , Tomografia Computadorizada por Raios X , Tonsilite/microbiologiaRESUMO
Even in the modern era of advanced diagnostic imaging, improved antibiotic therapy and potentially curative surgery, infective endocarditis remains a serious disease with high rates of morbidity and mortality. Reasons for such a persistently poor outcome may be represented by the changing epidemiology and microbiology, with new groups of patients at risk and new and more aggressive microorganisms. However, the inadequate use of both diagnostic (blood cultures and echocardiography) and therapeutic (antibiotics and surgery) means can influence the generally delayed diagnosis and poor prognosis seen in patients with infective endocarditis. We tried to identify the critical points in the management of patients with infective endocarditis and to elaborate a formal multidisciplinary approach based on the strict collaboration of specialists in infectious diseases, microbiology, cardiology and cardiac surgery. We hypothesized that this approach could increase the adherence to the published guidelines, and could represent a means to improve the outcome of patients with infective endocarditis.
Assuntos
Protocolos Clínicos , Endocardite/terapia , Equipe de Assistência ao Paciente/organização & administração , Antibacterianos/uso terapêutico , Proteína C-Reativa/análise , Continuidade da Assistência ao Paciente , Tomada de Decisões , Ecocardiografia , Endocardite/sangue , Endocardite/diagnóstico , Fidelidade a Diretrizes , Mortalidade Hospitalar , Humanos , Itália , Pessoa de Meia-Idade , Alta do Paciente , Seleção de Pacientes , Guias de Prática Clínica como Assunto , Medição de Risco , Tempo para o TratamentoRESUMO
The aim of this study was to assess the impact of an operative protocol with a multidisciplinary approach on the outcome of patients with prosthetic valve endocarditis (PVE). A formal policy for the care of PVE was introduced at our hospital in 2003 in which patients were referred to and managed by a preexisting team involving a cardiologist, a specialist in infectious diseases, and a cardiac surgeon. All patients underwent transesophageal echocardiography as soon as clinical suspicion of PVE arose. If high-risk conditions such as heart failure, ring abscess, conditions associated with impending malfunctioning of the prosthesis, or vegetations at high risk for systemic embolization were found during the initial multidisciplinary evaluation (performed within 12 hours of admission), patients were operated on within 48 hours. Stable patients were evaluated weekly by the multidisciplinary team, and on-treatment surgery was performed whenever high-risk conditions developed or when there was persistent fever/bacteremia after 1 week of adequate antibiotic therapy. Comparing the period 2003 through 2009 with 1996 through 2002 (when a multidisciplinary policy was not followed), patients with PVE were more numerous (61 vs 38), older (mean age 68.3 vs 63.1, p = 0.01), and had more co-morbidities (mean Charlson index 3.15 vs 2.42, p = 0.03). The most frequent causative organisms were Staphylococci in both periods. In the second period, fewer patients had delayed diagnosis (39% vs 71%, p = 0.03), heart failure (20% vs 45%, p = 0.01), abscess (20% vs 39%, p = 0.04), culture-negative infective endocarditis (11% vs 29%, p = 0.03), and worsened renal function (21% vs 42%, p = 0.04). A significant reduction in in-hospital mortality (53% to 23%, p = 0.04) and 3-year mortality (60% to 28%, p = 0.001) was observed, driven by the increased number of patients successfully treated with medical therapy alone (44% vs 16%, p = 0.04). In conclusion, formalized, collaborative management led to significant improvement in PVE-related mortality.
Assuntos
Antibacterianos/uso terapêutico , Gerenciamento Clínico , Endocardite Bacteriana/terapia , Guias de Prática Clínica como Assunto , Infecções Relacionadas à Prótese/terapia , Infecções Estafilocócicas/terapia , Idoso , Ecocardiografia Transesofagiana , Endocardite Bacteriana/etiologia , Endocardite Bacteriana/mortalidade , Feminino , Seguimentos , Mortalidade Hospitalar/tendências , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Infecções Relacionadas à Prótese/complicações , Infecções Relacionadas à Prótese/mortalidade , Reoperação , Infecções Estafilocócicas/complicações , Infecções Estafilocócicas/mortalidadeRESUMO
Strategies to improve management of patients with native valve endocarditis (NVE) are needed because of persistently high morbidity and mortality. We sought to assess the impact of an operative protocol of multidisciplinary approach on the outcome of patients with NVE. A formal policy for the care of infective endocarditis was introduced at our hospital in 2003 in which patients were referred to and managed by a preexisting team involving a cardiologist, a specialist in infectious diseases, and a cardiac surgeon. The initial multidisciplinary evaluation was performed within 12 hours of admission. Whenever conditions associated with impending hemodynamic impairment, high-risk for systemic embolization, or unsuccessful medical therapy were found, patients were operated on within 48 hours. Stable patients were evaluated weekly by the multidisciplinary team, and on-treatment surgery was performed whenever the above high-risk conditions had developed. Comparing the period 2003 through 2009 with 1996 through 2002 (when a multidisciplinary policy was not followed), patients were more numerous (190 vs 102), older (mean age 59.1 vs 54.2, p = 0.01), and had more co-morbidities (mean Charlson index 3.01 vs 2.31, p = 0.02). The pattern of infection did not change in terms of valve infected or paravalvular complications. In the second period, fewer patients had culture-negative NVE (8% vs 21%, p = 0.01) and worsened renal function (37% vs 58%, p = 0.001). A significant reduction in overall in-hospital mortality (28% to 13%, p = 0.02), mortality for surgery during the active phase (47% to 13%, p ≤0.001), and 3-year mortality (34% vs 16%, p = 0.0007) was observed. In conclusion, formalized, collaborative management led to significant improvement in NVE-related mortality, notwithstanding the less favorable patients' baseline characteristics.
Assuntos
Valva Aórtica , Gerenciamento Clínico , Ecocardiografia/métodos , Endocardite/terapia , Doenças das Valvas Cardíacas/terapia , Guias de Prática Clínica como Assunto , Infecções Estafilocócicas/terapia , Idoso , Endocardite/complicações , Endocardite/mortalidade , Feminino , Seguimentos , Doenças das Valvas Cardíacas/diagnóstico , Doenças das Valvas Cardíacas/etiologia , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Infecções Estafilocócicas/complicações , Infecções Estafilocócicas/diagnóstico , Taxa de Sobrevida/tendênciasRESUMO
We report four imported cases of progressive disseminated histoplasmosis (PDH) due to Histoplasma capsulatum variety capsulatum in Human Immunodeficiency Virus-infected patients from West Africa. This report highlights the need to consider diagnosis of PDH among patients with acquired immunodeficiency syndrome who originate from West Africa and present with a prolonged febrile illness and very low CD4 count.
Assuntos
Infecções Oportunistas Relacionadas com a AIDS/epidemiologia , Emigrantes e Imigrantes , HIV-1 , HIV-2 , Histoplasma/isolamento & purificação , Histoplasmose/epidemiologia , Infecções Oportunistas Relacionadas com a AIDS/diagnóstico , Adulto , Medula Óssea/microbiologia , Medula Óssea/patologia , Comorbidade , Côte d'Ivoire/etnologia , Infecções por Citomegalovirus/complicações , Doenças Endêmicas , Feminino , Gana/etnologia , Infecções por HIV/diagnóstico , Histoplasmose/diagnóstico , Humanos , Itália/epidemiologia , Libéria/etnologia , Masculino , Senegal/etnologia , Estrongiloidíase/complicações , Tuberculose Pulmonar/complicaçõesRESUMO
BACKGROUND AND AIM OF THE STUDY: Numerous studies have been conducted to investigate the conditions associated with poor outcome among patients with infective endocarditis (IE). Yet, diabetes mellitus alone has rarely been analyzed as participating in the prognosis, and few data are available relating to the clinical characteristics of IE in diabetics. The study aim was to assess the influence of diabetes mellitus on the characteristics and prognosis of IE, and to identify predictors of poor outcome among diabetic patients with this condition. METHODS: The study included consecutive patients with IE who had presented to a tertiary center between 1990 and 2006. All patients underwent transthoracic and transesophageal echocardiography. Three or more blood cultures were collected from each patient. Records of all patients were collected prospectively into a computerized database. RESULTS: Among 309 patients with definitive IE (according to modified Duke criteria), 38 (12%) had diabetes mellitus. Typically, diabetic patients were older than non-diabetics (67.1 +/- 10.4 versus 60.7 +/- 15.8 years; p < 0.001), had more serious comorbidities (Charlson index 2.8 +/- 0.7 versus 1.2 +/- 0.5; p = 0.005), and a higher frequency of enterococcal endocarditis. No differences were noted between patients with or without diabetes mellitus for the valve involved, nor for the subvalvular involvement. In a multivariate analysis, diabetes mellitus was identified as an independent predictor of mortality (OR 2.49; 95% CI 1.15-5.62). Surgery was performed in the active phase in 139 patients: surgical mortality was higher for diabetic patients (29% versus 10% p = 0.049). In-hospital mortality was significantly higher among diabetic patients (34%) than in non-diabetics (20%) (p = 0.002). Enterococcal endocarditis, left ventricular ejection fraction < 0.45, multi-organ failure, heart failure, persistent fever after one week of antibiotic therapy, and a Charlson index > 3 were associated with an increased mortality among diabetic patients. CONCLUSION: Diabetes mellitus represents a relevant risk factor for a worse clinical course and outcome of IE.