Surgical Resections of Superinfected Pneumatoceles in a COVID-19 Patient.

Emerging studies on radiologic findings in patients with coronavirus disease 2019 (COVID-19) report a high incidence of bilateral lung involvement, with ground-glass opacities imaging being the most common pattern on computed tomography. Cystic lesions, such as pneumatoceles, are rare, although they may occur in 10% of cases. Cyst formation may be explained by a focal pulmonary trauma caused by mechanical ventilation or infection-related damage to the alveolar walls leading to pneumatoceles. The superinfection of pneumatoceles is a potential life-threatening condition for which no standardized therapeutic algorithm has been accepted. We report a case of a COVID-19 patient successfully treated by lung resections for infected pneumatoceles.

Brèves.

TITLE: Brèves. ABSTRACT: L'unité d'enseignement « Immunopathologie ¼ qui propose les brèves de ce numéro est suivie par des étudiants des sept parcours recherche du Master Biologie Santé de l'Université de Montpellier. On y étudie les bases physiopathologiques des maladies immunologiques, les cibles thérapeutiques et les mécanismes d'échappement des microorganismes et des tumeurs. Ce Master rassemble des étudiants issus du domaine des sciences et technologies et de celui de la santé. Les articles présentés ont été choisis par les étudiants selon leur domaine de prédilection.

Outcomes of donor-derived superinfection screening in HIV-positive to HIV-positive kidney and liver transplantation: a multicentre, prospective, observational study.

BACKGROUND: One of the primary risks of HIV-positive to HIV-positive organ transplantation is loss of virological control because of donor-derived HIV superinfection, which occurs when an HIV-positive individual becomes infected with a new distinct HIV strain. In this study, as part of the larger HIV Organ Policy Equity pilot study, HIV-positive to HIV-positive kidney and liver transplant recipients in the USA were examined for evidence of sustained donor-derived HIV superinfection. METHODS: In this multicentre, prospective, observational study, HIV-positive to HIV-positive kidney and liver transplant recipients were followed in three hospitals in the USA. Candidates with well controlled HIV infection on ART, no active opportunistic infections, and minimum CD4 T-cell counts (>100 cells per µL for liver and >200 cells per µL for kidney per federal guidelines) were eligible to receive a kidney or liver from deceased HIV-positive donors without active infections or neoplasm. Peripheral blood mononuclear cells were collected from donor-recipient pairs at the time of transplantation, and from recipients at several timepoints up to 3 years after transplantation. Donor samples were assessed for HIV RNA viral load, CD4 cell count, and antiretroviral drug-resistant mutations. Donor and recipient HIV proviral DNA, and viral RNA from the viraemic timepoint were sequenced using a site-directed next-generation sequencing assay for the reverse transcriptase and gp41 genes. Neighbour-joining phylogenetic trees and direct sequence comparison were used to detect the presence of HIV superinfection. This study is registered with ClinicalTrials.gov, NCT02602262. FINDINGS: 14 HIV-positive to HIV-positive kidney and eight liver transplant recipients were followed from March, 2016, to July, 2019. 17 recipients had adequate viral sequences allowing for HIV superinfection assessment. Eight donors were suppressed (viral load <400 copies per mL), and none had multiclass drug-resistant mutations detected. None of the recipients examined had evidence of HIV superinfection. One recipient had a viraemic episode (viral load of 2 080 000 copies per mL) 3 years after transplantation as a result of non-adherence to ART. Only recipient viral sequences were detected during the viraemic episode, suggesting that the donor virus, if present, was not reactivated despite temporary withdrawal of ART. INTERPRETATION: These findings suggest that loss of HIV suppression due to donor-derived HIV superinfection might not be a significant clinical concern in carefully monitored ART suppressed HIV-positive organ recipients. FUNDING: US National Institute of Allergy and Infectious Diseases and National Cancer Institute.

The influenza replication blocking inhibitor LASAG does not sensitize human epithelial cells for bacterial infections.

Severe influenza virus (IV) infections still represent a major challenge to public health. To combat IV infections, vaccines and antiviral compounds are available. However, vaccine efficacies vary with very limited to no protection against newly emerging zoonotic IV introductions. In addition, the development of resistant virus variants against currently available antivirals can be rapidly detected, in consequence demanding the design of novel antiviral strategies. Virus supportive cellular signaling cascades, such as the NF-κB pathway, have been identified to be promising antiviral targets against IV in in vitro and in vivo studies and clinical trials. While administration of NF-κB pathway inhibiting agents, such as LASAG results in decreased IV replication, it remained unclear whether blocking of NF-κB might sensitize cells to secondary bacterial infections, which often come along with viral infections. Thus, we examined IV and Staphylococcus aureus growth during LASAG treatment. Interestingly, our data reveal that the presence of LASAG during superinfection still leads to reduced IV titers. Furthermore, the inhibition of the NF-κB pathway resulted in decreased intracellular Staphylococcus aureus loads within epithelial cells, indicating a dependency on the pathway for bacterial uptake. Unfortunately, so far it is not entirely clear if this phenomenon might be a drawback in bacterial clearance during infection.

Bacterial Superinfection of Amoebic Liver Abscess.

A 78-year-old male, originally from China, was brought to the hospital for weakness, urinary incontinence, confusion, and poor oral intake. He was started on empiric antibiotics, which were narrowed when blood cultures produced gram-negative bacteremia speciating to Klebsiella pneumoniae, sensitive to ceftriaxone. Computed tomography scan of the abdomen and pelvis demonstrated a large cystic region with air-fluid level in the left lobe of the liver. Suspecting this to be the source of the patient's bacteremia, the lesion was percutaneously drained and the fluid cultured, which also revealed ceftriaxone-sensitive Klebsiella pneumoniae. While a stool ova and parasite examination on the patient was negative, further workup was positive for Entamoeba histolytica antibody in the serum, detected via enzyme-linked immunosorbent assay and indicative of either current or past infection. This suggested possible prolonged subclinical infection with bacterial superinfection, especially given that Klebsiella pneumoniae is one of the most common organisms cultured from these abscesses. In patients with liver abscesses who immigrated from developing and/or endemic regions or have a relevant recent travel history, an underlying amoebic etiology of an abscess should be considered.

Interferon Lambda Inhibits Bacterial Uptake during Influenza Superinfection.

Influenza kills 30,000 to 40,000 people each year in the United States and causes 10 times as many hospitalizations. A common complication of influenza is bacterial superinfection, which exacerbates morbidity and mortality from the viral illness. Recently, methicillin-resistant Staphylococcus aureus (MRSA) has emerged as the dominant pathogen found in bacterial superinfection, with Streptococcus pneumoniae a close second. However, clinicians have few tools to treat bacterial superinfection. Current therapy for influenza/bacterial superinfection consists of treating the underlying influenza infection and adding various antibiotics, which are increasingly rendered ineffective by rising bacterial multidrug resistance. Several groups have recently proposed the use of the antiviral cytokine interferon lambda (IFN-λ) as a therapeutic for influenza, as administration of pegylated IFN-λ improves lung function and survival during influenza by reducing the overabundance of neutrophils in the lung. However, our data suggest that therapeutic IFN-λ impairs bacterial clearance during influenza superinfection. Specifically, mice treated with an adenoviral vector to overexpress IFN-λ during influenza infection exhibited increased bacterial burdens upon superinfection with either MRSA or S. pneumoniae Surprisingly, adhesion molecule expression, antimicrobial peptide production, and reactive oxygen species activity were not altered by IFN-λ treatment. However, neutrophil uptake of MRSA and S. pneumoniae was significantly reduced upon IFN-λ treatment during influenza superinfection in vivo Together, these data support the theory that IFN-λ decreases neutrophil motility and function in the influenza-infected lung, which increases the bacterial burden during superinfection. Thus, we believe that caution should be exercised in the possible future use of IFN-λ as therapy for influenza.

Photodynamic Therapy With Methylene Blue for Skin Ulcers Infected With Pseudomonas aeruginosa and Fusarium spp. / Terapia fotodinámica con azul de metileno en úlceras cutáneas infectadas con Pseudomonas aeruginosa y Fusarium spp.

Photodynamic therapy (PDT) is a therapeutic modality with significant antimicrobial activity. We present 2 cases of chronic lower limb ulcers in which fungal and bacterial superinfection complicated management. PDT with methylene blue as the photosensitizer led to clinical and microbiological cure with no significant adverse effects. PDT with methylene blue is a valid option for the management of superinfected chronic ulcers, reducing the use of antibiotics and the induction of resistance.

A case report of crusted scabies in an adult patient with Down syndrome.

IMPORTANCE: Crusted (Norwegian) scabies is a severe manifestation of the contagious skin infection caused by Sarcoptes scabiei. Crusted scabies has been well described in patients with known immunocompromised states. Treatment may be complicated by delayed diagnosis and/or inadequate treatment. This infection may not rank highly on one's differential diagnosis in the absence of an immunocompromised state, highlighting the uniqueness of the case being presented. Several papers describe immunocompromised children with Down syndrome who are infected with crusted scabies. We present a case of infection in an adult with Down syndrome without evidence of an immunocompromised state. OBSERVATIONS: Our patient came to us with a 13-month history of progressively worsening symptoms, the last 4-6 weeks of that time period being most dramatic, despite various treatments. We performed tissue biopsy, culture, and laboratory evaluations, which revealed numerous mites and bacterial superinfection. CONCLUSIONS AND RELEVANCE: Crusted scabies infection may occur in adult age individuals with Down syndrome regardless of immune status, leading us to encourage practitioners to consider this condition when presented with patients of this population. We also highlight the need for further exploration of disease prevalence in this patient population.

Multifocal bacterial osteomyelitis after varicella infection: a rare but dreaded complication of chickenpox.

Chickenpox is an infectious disease common in children, which in most cases is benign toward the self-limited resolution. There are, however, serious systemic and musculoskeletal complications, especially in patients with immunosuppression. We report a case of multifocal skeletal muscle involvement, as a complication of chickenpox by Streptococcus pyogenes.

[High risk of strongyloïdes hyperinfection in a patient with sarcoidosis]. / Risque d'anguillulose maligne chez un patient présentant une sarcoïdose.

Strongyloïdes stercoralis infection is a polymorphic and non specific clinical presentation. Often asymptomatic, it can be not seen. However, in patients with immunodeficiency, high parasite load can be observed, consequence of self-infestation cycle, and can spread throughout the body. This presentation of malignant strongyloidiasis presents a mortality rate of 70%. The case report presents a 45 years old patient of Caribbean origin, long time treated with corticosteroids for sarcoidosis, and hospitalized for Strongyloïdes stercoralis colitis with high parasite load, raising fears an evolution to hyperinfection. His last visit to endemic area was in 2002. In conclusion, the potential severity of strongyloidiasis is strongly increased by immunosuppression, including corticosteroids. This risk should be notified prior to initiation of any treatment with corticosteroids, firstly by looking at a stay in endemic areas. The case of our patient illustrates the fact that a long time between risk of contamination and clinical manifestations is not a sufficient criterion for excluding an asymptomatic chronic infection with Strongyloïdes stercoralis. It is therefore recommended for patients who have lived in endemic areas to search the parasite in stool by a sensitive method.

Endoscopic ultrasound-guided transmural drainage of infected pancreatic fluid collections with placement of covered self-expanding metal stents: a case series.

Endoscopic ultrasound-guided transmural drainage (EUS-GTD) has become the standard procedure for treating symptomatic pancreatic fluid collections. The aim of this series was to evaluate the efficacy and safety of covered self-expanding metal stent (CSEMS) placement for treating infected pancreatic fluid collections. From January 2007 to May 2010, 22 patients (18 M/4F; mean age 56.9) with infected pancreatic fluid collections (mean size, 13.2 cm) at two Italian centers were evaluated for EUS-GTD. In 20 of the 22 patients, EUS-GTD with CSEMS placement was indicated. Early complications occurred in two patients: one patient developed a superinfection, which was managed conservatively, and one experienced stent migration and superinfection, and was managed surgically. The CSEMSs were removed without difficulty in 18 patients after a median of 26 days, while stent removal failed in one patient due to inflammatory tissue ingrowth; instead it was removed during surgery performed for renal cancer. Clinical success was achieved without additional intervention in 17 patients during a mean follow-up of 610 days; only one symptomatic recurrence was observed. In our experience, EUS-GTD with CSEMS placement appears safe for the treatment of infected pancreatic fluid collections.

[Maxillary sinusitis of odontogenic origin: surgical treatment]. / Sinusites maxillaires d'origine dentaire : traitement chirurgical.

PURPOSE: The frequency of maxillary sinusitis of dental origin (MSDO) is under estimated. The medical and surgical treatment has improved thanks to endoscopic guidance. We report our experience and strategy in the treatment of MSDO. PATIENTS AND METHODS: Twenty-two patients presenting with MSDO were treated between 1998 and 2008. The results were evaluated on clinical, functional, sinusal, and odontologic signs. RESULTS: MSDO accounted for 16% of surgically managed sinusitis. CT was performed in 95% of cases. The etiologies were apical leakage in seven patients, migration of a tooth or root during extraction, or presence of ectopic tooth in the sinus in nine patients, a cyst in three patients, and oroantral communication in three patients. Surgery was performed after antibiotic and NSAID treatment. The first surgical step was the treatment of the odontogenic source. The second step was sinus drainage by endoscopic treatment in 64%, Caldwell-Luc in 23%, and drainage by oroantral communication enlarged then closed in the same operative time in 13%. The follow up ranged from 3 months to 10 years. Early postoperative superinfection was observed in two patients. Two patients presented with recurrent sinusitis. The postoperative sequels were hyposmia in three patients, dental pulpotomy, and trigeminal neuralgia in five patients treated by Caldwell-Luc surgery. DISCUSSION: Nasal endoscopy has improved the surgical management of MSDO. It makes curettage and exclusion of sinus cavities obsolete. It is reliable and has a low rate of complications. The best treatment remains prevention.

[Diaper dermatitis]. / Windeldermatitis.

Diaper dermatitis is one of the most common skin diseases during infancy and childhood. It is a type of irritant contact eczema resulting from a complex interaction between urine and feces under occlusive conditions in combination with the hyperhydration of the stratum corneum, pressure and friction under the diaper. These conditions pave the way for Candida albicans infection, which is often associated with diaper dermatitis. The anogenital region can be involved by a variety of dermatoses, so a precise skin examination, detailed history and sometimes histologic examination are needed for a precise diagnosis. Therapeutically, frequent diaper changes and adequate skin care are most important.

Novel influenza A (H1N1) viral infection in pediatric patients with sickle-cell disease.

BACKGROUND: The 2009 novel influenza A (H1N1) pandemic has had profound public health implications all over the world. The majority of patients infected with the novel strain have recovered uneventfully. However, certain populations have been defined who appear to be at increased risk of complications due to H1N1 infections. This review summarizes the clinical course of five patients with sickle cell, four of whom had confirmed H1N1 infection, and one whom had a presumed H1N1 infection. PROCEDURE: The clinical presentation, hospital course, and treatment of five pediatric patients with sickle-cell disease and H1N1 infection were reviewed retrospectively. RESULTS: In this case series, our patients experienced complications such as the acute chest syndrome, acute marrow suppression of red cell production, pain crisis, and hematuria. CONCLUSIONS: In this population, who are at increased risk for bacterial superinfection as well as complications from the influenza virus itself, vigilance toward diagnosis and aggressive treatment will continue to be important as long as the novel virus is in circulation.