Laparoscopic surgery during the COVID-19 pandemic: detection of SARS-COV-2 in abdominal tissues, fluids, and surgical smoke.

BACKGROUND: There are still concerns over the safety of laparoscopic surgery in coronavirus disease 2019 (COVID-19) patients due to the potential risk of viral transmission through surgical smoke/laparoscopic pneumoperitoneum. METHODS: We performed a systematic review of currently available literature to determine the presence of severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) in abdominal tissues or fluids and in surgical smoke. RESULTS: A total of 19 studies (15 case reports and 4 case series) comprising 29 COVID-19 patients were included. The viral RNA was positively identified in 11 patients (37.9%). The samples that tested positive include the peritoneal fluid, bile, ascitic fluid, peritoneal dialysate, duodenal wall, and appendix. Similar samples, together with the omentum and abdominal subcutaneous fat, tested negative in the other patients. Only one study investigated SARS-COV-2 RNA in surgical smoke generated during laparoscopy, reporting negative findings. CONCLUSIONS: There are conflicting results regarding the presence of SARS-COV-2 in abdominal tissues and fluids. No currently available evidence supports the hypothesis that SARS-COV-2 can be aerosolized and transmitted through surgical smoke. Larger studies are urgently needed to corroborate these findings.

Duodenal perforation in a SARS-CoV-2-positive patient with negative PCR results for SARS-CoV-2 in the peritoneal fluid.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has significantly affected health care organizations globally. Many aspects of this disease, as well as the risks for patients treated with multiple drug regimens to control severe COVID-19, are unclear. During emergency surgery for SARS-CoV-2-positive patients, the risk of SARS-CoV-2 exposure and transmission to the surgical staff has yet to be determined. PATIENTS AND METHODS: In this report, we describe a SARS-CoV-2-positive patient with severe respiratory syndrome treated with multiple doses of IL-6 inhibitors who presented with a perforated duodenal ulcer and underwent emergency surgery. During and after surgery, we tested for SARS-CoV-2 at the ulcer site and in the peritoneal fluid. RESULTS: The history of the patient allows for two possible interpretations of the pathogenesis of the duodenal ulcer, which could have been a stress ulcer, or a gastrointestinal ulcer associated to the use of IL-6 inhibitors. We also noticed that the ulcer site and peritoneal fluid repeatedly tested negative for SARS-CoV-2. Therefore, we reviewed the pertinent literature on gastrointestinal bleeding in patients with COVID-19 and on SARS-CoV-2 detection in the peritoneal fluid of surgical patients and discussed possible prevention strategies for bleeding and the actual risk of infection for the surgical staff. CONCLUSIONS: The first implication of this case is that the relation between repeated administration of IL-6 inhibitors and upper gastrointestinal bleeding and perforation must be investigated, and that the threshold for administering prophylactic proton pump inhibitors therapy should be carefully considered for patients with severe COVID-19. The second implication is that further testing should be performed on the peritoneal fluid of COVID-19 patients undergoing emergency surgical procedures to clarify the discordant results for the presence of SARS-CoV-2 in the peritoneal cavity and the possible risk of transmission to the surgical staff.

Risks of COVID-19 transmission in blood and serum during surgery A prospective cross-sectional study from a single dedicated COVID-19 center.

The present pandemic caused by the SARS COV-2 coronavirus is still ongoing, although it is registered a slowdown in the spread for new cases. The main environmental route of transmission of SARS-CoV-2 is through droplets and fomites or surfaces, but there is a potential risk of virus spread also in smaller aerosols during various medical procedures causing airborne transmission. To date, no information is available on the risk of contagion from the peritoneal fluid with which surgeons can come into contact during the abdominal surgery on COVID-19 patients. We have investigated the presence of SARS-CoV-2 RNA in the peritoneal cavity of patients affected by COVID-19, intraoperatively and postoperatively. KEY WORDS: Covid-19, Laparotomy, Surgery.

SARS-Cov-2 Was Not Found in the Peritoneal Fluid of an Asymptomatic Patient Undergoing Laparoscopic Appendectomy.

BACKGROUND: The safety of laparoscopic surgery in SARS-CoV-2 positive patients remains unclear. The presence of the virus within peritoneal fluid and the peritoneal tissues is not known. We report an asymptomatic COVID-19 positive patient who underwent laparoscopic appendectomy with negative peritoneal sampling for SARS-CoV-2. MATERIALS AND METHODS: During a standard 3 port laparoscopic surgery samples peritoneal fluid, peritoneal brushings, and surgical smoke plum were collected. Specific real-time reverse transcriptase-polymerase chain reaction targeting SARS-CoV-2 were used to detect the presence of the virus in the samples. RESULTS: SARS-CoV-2 was not detected on multiple samples of the peritoneum in an asymptomatic patient. CONCLUSIONS: SARS-CoV-2 was not found in the peritoneum of a single patient with asymptomatic infection. Further studies comparing SARS-CoV-2 surgical candidates are needed to address safety concerns.

COVID-19 not detected in peritoneal fluid: a case of laparoscopic appendicectomy for acute appendicitis in a COVID-19-infected patient.

PURPOSE: COVID-19 greatly affected millions and affected the way we practice with heightened posture in the way we treat surgical patients. Surgical consensus guidelines are recommending caution in the use of laparoscopy for the theoretical possibility of viral transmission from aerosolization of tissue and peritoneal fluid during surgery. However, there has yet to be proof of COVID-19 being present in peritoneal fluid, justifying the consensus statements. We aim to assess the presence of COVID-19 in peritoneal fluid. METHODS: We performed a laparoscopic appendicectomy for a COVID-19-infected patient with acute appendicitis. Peritoneal fluid and peritoneal washings were collected and sent for COVID-19 PCR. RESULTS: The peritoneal fluid sample collected on entry and at the end of the operation was negative for COVID-19 on PCR. The patient had an uneventful recovery from surgery. CONCLUSIONS: This case revealed that COVID-19 was not detected in peritoneal fluid and peritoneal washings in a patient infected with COVID-19. This study provides novel preliminary data in the investigation of COVID-19 transmission from laparoscopy-related aerosolization.

SARS-CoV-2 Is Present in Peritoneal Fluid in COVID-19 Patients.

BACKGROUND: The excretion pathomechanisms of SARS-CoV-2 are actually unknown. No certain data exist about viral load in the different body compartments and fluids during the different disease phases. MATERIAL AND METHODS: Specific real-time reverse transcriptase-polymerase chain reaction targeting 3 SARS-CoV-e genes were used to detect the presence of the virus. RESULTS: SARS-CoV-2 was detected in peritoneal fluid at a higher concentration than in respiratory tract. CONCLUSION: Detection of SARS-CoV-2 in peritoneal fluid has never been reported. The present article represents the very first positive result describing the presence of the virus in peritoneal fluid during an emergency surgical procedure in a COVID-19 sick patient. This article thus represents a warning for increasing the level of awareness and protection for surgeon especially in emergency surgical setting.

Phase I Study of Oncolytic Vaccinia Virus GL-ONC1 in Patients with Peritoneal Carcinomatosis.

Purpose: Peritoneal carcinomatosis is common in advanced tumor stages or disease recurrence arising from gastrointestinal cancers, gynecologic malignancies, or primary peritoneal carcinoma. Because current therapies are mostly ineffective, new therapeutic approaches are needed. Here, we report on a phase I study designed to assess safety, MTD, and antitumor activity of intraperitoneal administration of oncolytic vaccinia virus GL-ONC1 in advanced stage peritoneal carcinomatosis patients.Patients and Methods: GL-ONC1 was administered intraperitoneally every 4 weeks for up to four cycles at three different dose levels (107-109 pfu) following a standard 3+3 dose escalation design. GL-ONC1 was infused via an indwelling catheter that enabled repetitive analyses of peritoneal fluid biopsies. The primary study objective was safety of GL-ONC1 according to Common Terminology Criteria for Adverse Events, version 4.0 (CTCAEv4.0).Results: Patients with advanced-stage peritoneal carcinomatosis (n = 7) or advanced peritoneal mesothelioma (n = 2) received 24 doses of GL-ONC1. Adverse events were limited to grades 1-3, including transient flu-like symptoms and increased abdominal pain, resulting from treatment-induced peritonitis. No DLT was reported, and the MTD was not reached. Furthermore, no signs of viral shedding were observed. Importantly, in 8 of 9 study patients, effective intraperitoneal infections, in-patient replication of GL-ONC1, and subsequent oncolysis were demonstrated in cycle 1. All patients developed neutralizing activities against GL-ONC1.Conclusions: GL-ONC1 was well tolerated when administered into the peritoneal cavity of patients with advanced stage peritoneal carcinomatosis. Efficient tumor cell infection, in-patient virus replication, and oncolysis were limited to treatment cycle 1 (ClinicalTrials.gov number, NCT01443260). Clin Cancer Res; 24(18); 4388-98. ©2018 AACR.

The nucleoside analog GS-441524 strongly inhibits feline infectious peritonitis (FIP) virus in tissue culture and experimental cat infection studies.

Feline infectious peritonitis (FIP) is a common and highly lethal coronavirus disease of domestic cats. Recent studies of diseases caused by several RNA viruses in people and other species indicate that antiviral therapy may be effective against FIP in cats. The small molecule nucleoside analog GS-441524 is a molecular precursor to a pharmacologically active nucleoside triphosphate molecule. These analogs act as an alternative substrate and RNA-chain terminator of viral RNA dependent RNA polymerase. We determined that GS-441524 was non-toxic in feline cells at concentrations as high as 100 uM and effectively inhibited FIPV replication in cultured CRFK cells and in naturally infected feline peritoneal macrophages at concentrations as low as 1 uM. We determined the pharmacokinetics of GS-441524 in cats in vivo and established a dosage that would sustain effective blood levels for 24 h. In an experimental FIPV infection of cats, GS-441524 treatment caused a rapid reversal of disease signs and return to normality with as little as two weeks of treatment in 10/10 cats and with no apparent toxicity.

Babesia spp. no líquido peritoneal em cão com ascite - relato de caso / Babesia spp. in the peritoneal fluid in dog with ascites - case report

Babesia canis é um protozoário cosmopolita que parasita eritrócitos de cães domésticos e selvagens. O diagnóstico é realizado mediante a observação direta do microrganismo em hemácias no esfregaço de sangue periférico, métodos sorológicos e técnicas moleculares. O objetivo deste trabalho é relatar pela primeira vez a presença de merozoítos de Babesia spp. no líquido peritoneal de um cão com ascite. No Hospital Veterinário da Universidade Federal de Viçosa, foi atendido um cão, macho, sem raça definida, de sete meses de idade, com histórico de emaciação, apatia e abaulamento abdominal. No exame físico, foram evidenciadas mucosas hipocoradas, ascite, sopro sistólico grau IV/V e taquipneia. Nos exames laboratoriais, evidenciou-se anemia normocítica/normocrômica, trombocitopenia e hipoproteinemia. No esfregaço sanguíneo, foram observadas estruturas intraeritrocitárias compatíveis com Babesia spp. A avaliação do líquido ascítico foi compatível com transudato modificado e observaram-se inúmeras estruturas intra e extracelulares compatíveis com merozoítas de Babesia spp. A presença de microrganismos intra e extracelular poderia estar relacionada a uma lesão no baço com extravasamento do conteúdo para a cavidade abdominal. A coleta do líquido peritoneal pode ser uma alternativa para o diagnóstico de babesiose quando o animal com suspeita da infecção apresentar ascite.(AU)

Babesia canis is a cosmopolitan protozoan that parasites erythrocytes of domestic and wild dogs. The diagnosis is performed by direct observation of the microorganism in red blood cells in the peripheral blood smear, serological methods and molecular techniques. The aim of this work is to report for the first time the presence of merozoites of Babesia spp. in the peritoneal fluid of a dog with ascites. At the Veterinary Hospital of the Federal University of Viçosa was attended a Mixed-breed seven month old dog, male, with history of emaciation, apathy and abdominal bulging. Pale mucous membranes, ascites, grade IV/V systolic murmur and tachypnea were evidenced in the physical examination. Laboratory tests revealed normocytic/normochromic anemia, thrombocytopenia, and hypoproteinemia. Intra-erythrocyte structures compatible with Babesia spp. were observed in the blood smear. The evaluation of the ascites fluid was compatible with modified transudate where numerous intra and extracellular structures compatible with Babesia spp. merozoites were observed. The presence of intra and extracellular microorganisms could be related to an injury of the spleen with extravasation of the contents into the abdominal cavity. Collection of the peritoneal fluid may be an alternative for the diagnosis of babesiosis when the animal with suspected infection has ascites.(AU)

HCV-RNA quantification in liver bioptic samples and extrahepatic compartments, using the abbott RealTime HCV assay.

BACKGROUND & AIMS: We evaluated the performance of a rapid method to quantify HCV-RNA in the hepatic and extrahepatic compartments, by using for the first time the Abbott RealTime HCV-assay. METHODS: Non-tumoral (NT), tumoral (TT) liver samples, lymph nodes and ascitic fluid from patients undergoing orthotopic-liver-transplantation (N=18) or liver resection (N=4) were used for the HCV-RNA quantification; 5/22 patients were tested after or during direct acting antivirals (DAA) treatment. Total RNA and DNA quantification from tissue-biopsies allowed normalization of HCV-RNA concentrations in IU/µg of total RNA and IU/106 liver-cells, respectively. RESULTS: HCV-RNA was successfully quantified with high reliability in liver biopsies, lymph nodes and ascitic fluid samples. Among the 17 untreated patients, a positive and significant HCV-RNA correlation between serum and NT liver-samples was observed (Pearson: rho=0.544, p=0.024). Three DAA-treated patients were HCV-RNA "undetectable" in serum, but still "detectable" in all tested liver-tissues. Differently, only one DAA-treated patient, tested after sustained-virological-response, showed HCV-RNA "undetectability" in liver-tissue. CONCLUSIONS: HCV-RNA was successfully quantified with high reliability in liver bioptic samples and extrahepatic compartments, even when HCV-RNA was "undetectable" in serum. Abbott RealTime HCV-assay is a good diagnostic tool for HCV quantification in intra- and extra-hepatic compartments, whenever a bioptic sample is available.

Human herpesvirus type 8 in tuberculosis patients with effusion.

BACKGROUND: Many patients with tuberculosis (TB) are seropositive for human herpesvirus type 8 (HHV-8), and many patients with primary effusion lymphoma have high levels of HHV-8 DNA in their effusions. However, the status of HHV-8 in the effusions of patients with TB remains unclear. METHODS: Blood samples were collected from 129 patients with pulmonary TB and 129 age- and sex-matched healthy controls. Forty of the TB patients had pleural or peritoneal effusions, and 38 of these effusions were available. Both blood and effusion samples were analyzed for lymphocyte and monocyte counts and/or HHV-8 antibodies and DNA. RESULTS: TB patients with or without effusions had significantly greater HHV-8 seropositivity (p = 0.009) and titers of HHV-8 antibodies (p = 0.005) than healthy controls. The seropositivity and blood titers of HHV-8 antibodies were similar in TB patients with and without effusions. Among TB patients with effusions, similar percentages had seropositive plasma and seropositive effusions. Plasma samples of 6 TB patients, but none of the healthy controls, were positive for HHV-8 DNA (p = 0.03). TB patients with or without effusions had lower blood lymphocyte counts and higher blood monocyte counts than healthy controls (p < 0.0001 for both). TB patients with effusions had significantly lower blood lymphocyte counts than those without effusions (p = 0.035). CONCLUSIONS: HHV-8 had similar seroprevalence in TB patients with and without effusions. However, TB patients with effusions had lower blood lymphocyte counts than those without effusions.

Characterization of a variant virus from ascitic fluid of subacute granulomatous serositis in interferon-gamma-deficient C57BL/6 mice persistently infected with murine coronavirus strain JHM.

Previously, we showed that intraperitoneal infection with murine coronavirus strain JHM (JHMV) established a persistent infection with subacute granulomatous serositis in interferon-gamma-deficient C57BL/6 (B6-GKO) mice. Herein, we characterize a variant virus from B6-GKO mice persistently infected with JHMV. Viruses were isolated from ascites at 25 d post-infection and cloned by limiting dilution on DBT cells; one variant was named 25V16G. To compare pathogenicity in vivo, we inoculated 25V16G and JHMV intraperitoneally into 8- to 12-week-old B6-GKO mice. Whereas nearly all of the B6-GKO mice infected with JHMV survived over 14 d, all of those infected with 25V16G died by 9 d post-infection. Histopathological examination revealed that 25V16G induced acute fulminant hepatitis in B6-GKO mice, whereas JHMV caused severe but focal hepatitis. The virus titer of 25V16G in the liver was 50- and 250-fold higher than that of JHMV at 5 and 7 d post-infection, respectively. However, there was no significant difference in viral growth between 25V16G and JHMV in cell lines cultured in vitro. Nucleotide sequencing of the S gene of 25V16G and JHMV revealed a deletion of 29 amino acids encompassing S(511-539), which covers a major cytotoxic T lymphocyte (CTL) epitope in C57BL/6 mice, and two point mutations resulting in amino acid changes in the S protein of 25V16G. One explanation for the greater pathogenicity of 25V16G is that 25V16G escapes CTL-mediated protection in B6-GKO mice. This experimental model may be used to assess the role of IFN-gamma in viral persistence in vivo.

Cytologic diagnosis of hemophagocytic lymphohistiocytosis in ascitic fluid: a case report.

BACKGROUND: Hemophagocytic lymphohistiocytosis (HLH), also known as macrophage activation syndrome, is a rare, fatal hematopoietic disease. Its cytologic features may be subtle because the abnormal histiocytes may not be recognized if one is not aware of this entity. We report a case of HLH involving the ascitic fluid. CASE REPORT: A 73-year-old man developed weakness, lethargy, decreased appetite and progressive shortness of breath after a cholecystectomy. Physical examination revealed hypotension, tachycardia and chest dullness with decreased breath sounds bilaterally. Radiologic examination revealed bilateral pleural effusions. The patient accumulated fluid in the peritoneal cavity, lungs, retroperitoneum and mediastinum. Bone marrow biopsy showed abundant histiocytes infiltrating the marrow cavity, and many of these histiocytes contained cellular debris. A diagnosis of HLH was therefore made. The abdominal paracentesis specimen contained many similar histiocytes exhibiting erythrophagocytosis and lymphophagocytosis. These abnormal histiocytes were positive for CD68 and negative for AE1/AE3, confirming the diagnosis of HLH. The patient died soon after from disseminated aspergillosis. CONCLUSION: HLH is cytologically characterized by the presence of abnormal histiocytes with ingested cellular debris. In serous effusions they should not be confused with mesothelial cells. Immunohistochemical studies may help confirm the diagnosis.

Relationship between the quantity of Kaposi sarcoma-associated herpesvirus (KSHV) in peripheral blood and effusion fluid samples and KSHV-associated disease.

The Kaposi sarcoma-associated herpesvirus (KSHV)-DNA level was determined in samples from 71 patients with Kaposi sarcoma (KS), 28 patients with multicentric Castleman disease (MCD), and 8 patients with primary effusion lymphoma (PEL). KSHV-DNA levels were higher in patients with active KS or MCD than in those with KS or MCD in remission. Among patients with active disease, the highest KSHV-DNA levels were observed in effusion fluid samples from patients with PEL (7.2 log(10) copies/150,000 cells), followed by blood samples from patients with MCD and PEL (4.86 and 3.83 log(10) copies/150,000 cells, respectively), and the lowest levels were observed in blood samples from patients with KS (2.63 log(10) copies/150,000 cells). Determining the KSHV-DNA level may be useful in diagnosing KSHV-associated disease and for following up patients with KS when the development of MCD or PEL is suspected.

Primary effusion lymphoma.

Primary effusion lymphoma (PEL) is a rare HIV-associated non-Hodgkin's lymphoma (NHL) that accounts for approximately 4% of all HIV-associated NHL. PEL has a unique clinical presentation in having a predilection for arising in body cavities such as the pleural space, pericardium, and peritoneum. PEL cells are morphologically variable with a null lymphocyte immunophenotype and evidence of human herpesvirus (HHV)-8 infection. The exact oncogenic mechanisms of HHV-8 have not been clearly defined. Treatment is usually with combination CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) chemotherapy and antiretroviral therapy (if HIV positive). The prognosis for PEL is poor, with a median survival time of around 6 months. As the exact molecular steps in HHV-8-driven oncogenesis are unraveled, it is hoped that more specific therapeutic targets will be revealed.

Transfusion-transmitted cytomegalovirus (CMV) infections in a murine model: characterization of CMV-infected donor mice.

BACKGROUND: Donor and recipient mechanisms that modulate the incidence and severity of transfusion-transmitted cytomegalovirus (TT-CMV) are unclear. The kinetics of murine CMV (MCMV) infection in the peripheral blood of donor mice were investigated to determine the utility of this model for studying TT-CMV. STUDY DESIGN AND METHODS: BALB/cByJ mice, experimentally infected with Smith strain MCMV, were killed at serial time points up to 28 days after infection. Peritoneal exudate cells (PECs), peripheral blood white blood cells (WBCs), plasma, and marrow were tested for MCMV DNA with quantitative polymerase chain reaction (PCR), replication-competent virus with quantitative culture, and transcription of viral genes with reverse transcription (RT)-PCR targeted at the immediate-early 1 (ie1) gene. RESULTS: PECs, macrophages infected by MCMV shortly after intraperitoneal inoculation, demonstrated high mean levels of MCMV DNA (10(5)-10(7) genome equivalents [geqs]/10(5) PECs), virus production (10(1)-10(4) infectious virions/10(5) PECs), and ie1 gene transcription, demonstrating productive infection. In contrast, while MCMV loads averaged 10(4) to 10(6) geqs per 10(5) peripheral WBCs, all WBC samples were uniformly negative for MCMV ie1 expression by RT-PCR and for culturable virus, consistent with latent MCMV infection. Plasma and marrow showed lower viral loads than WBCs and PECs and were all negative by culture and RT-PCR analysis. CONCLUSIONS: Following experimental MCMV infection, murine peripheral blood WBCs appear to be latently infected with virus (MCMV DNA-positive; MCMV RNA-negative; MCMV culture-negative), similar to the latently infected human monocytes in peripheral blood of CMV-seropositive donors. These donor kinetics suggest that the experimental MCMV system can be used to effectively model the mechanisms of TT-CMV infections in humans.

Primary effusion lymphoma: cytopathologic diagnosis using in situ molecular genetic analysis for human herpesvirus 8.

Primary effusion lymphoma is a form of diffuse large B-cell lymphoma with neoplastic cells largely limited to proliferation within major body cavities. Human herpes virus-8 is both integral to and required for an unequivocal diagnosis of primary effusion lymphoma. Prior methods for virus identification include DNA extraction with Southern blot analysis or in situ hybridization from paraffin-embedded samples. Our aim is to examine the utility of human herpesvirus-8 identification performed directly on smears from effusion samples by reverse transcriptase in situ polymerase chain reaction in patients with primary effusion lymphoma. Smears and cell block of body cavity fluids from five patients with effusions (three pleural, one peritoneal, and one both pleural and peritoneal) were examined microscopically by conventional Papanicolaou and Romanowsky (Diff-Quik) staining, and by reverse transcriptase in situ polymerase chain reaction for human herpesvirus-8 detection. In situ hybridization was performed also for Epstein-Barr virus (EBER-1, -2), T-cell receptor-beta, and kappa (kappa) and lambda (lambda) mRNA in all cases. Five adults ranged from 40-81 years of age. Three adults were HIV positive, one was a renal transplant recipient, and the oldest patient (Case 3) had the unusual distinction of a normal immune status. Two of three HIV-seropositive patients had concurrent Kaposi sarcoma. All samples were cytologically similar with lymphocytes having large-cell, plasmablastic, and immunoblastic morphology. Malignant cells from effusions were as follows: human herpesvirus-8 positive (all five cases), exhibited kappa monoclonal light chain (five cases), Epstein-Barr virus positive (three cases), and T-cell beta-gene receptor positive (two cases). Diffuse large B-cell lymphoma was evident in one peritoneal nodule (< 10% human herpesvirus-8 positive cells in contrast to > 90% positive in effusions, all kappa positive). Six other tissue specimens (lung, bone marrow, spleen, lymph node) were human herpesvirus-8 negative, and showed no evidence of lymphoma. Reverse transcriptase in situ polymerase chain reaction demonstrated near-complete restriction of human herpesvirus-8-infected malignant lymphoid cells to those in body cavities. Definitive diagnosis of primary effusion lymphoma is possible directly from cytologic smears/cell block by combining cytologic morphology with reverse transcriptase in situ polymerase chain reaction detection of human herpesvirus-8.