Endocavitary Right Ventricular Cardiac Metastasis of a Lung Adenocarcinoma Treated by Surgery: A Case Report About a Novel Multimodal Therapeutic Approach.

Introduction: Cardiac metastasis (CM) is a rare lung cancer location. It often remains clinically silent but may cause life-threatening complications. Better survival rates thanks to the immunotherapy revolution and the improving performance of imaging lead to an increasing number of CM diagnosis. Case Presentation: We report a case of a 54-year-old woman who was diagnosed with a stage IIIa non-small cell lung cancer. She developed a right ventricular CM without symptoms during treatment by immunotherapy after concurrent chemoradiotherapy. Cardiac magnetic resonance imaging confirmed the presence of an endocavitary lesion in the right ventricle apex. Complete surgical resection through a right ventriculotomy was performed. Conclusion: The diagnosis of similar cases has become more frequent due to immunotherapy and more advanced imaging technology. Our case report also highlights the fact that CM surgery has to be considered as a successful therapeutic option in those oligo-progression situations. Guidelines on the management and treatment of lung cancer CM are needed as well as larger studies to evaluate the survival benefit from surgical treatment.

Efficacy and safety of anakinra in adults presenting deteriorating respiratory symptoms from COVID-19: A randomized controlled trial.

OBJECTIVE: We aimed to investigate whether anakinra, an interleukin-1receptor inhibitor, could improve outcome in moderate COVID-19 patients. METHODS: In this controlled, open-label trial, we enrolled adults with COVID-19 requiring oxygen. We randomly assigned patients to receive intravenous anakinra plus optimized standard of care (oSOC) vs. oSOC alone. The primary outcome was treatment success at day 14 defined as patient alive and not requiring mechanical ventilation or extracorporeal membrane oxygenation. RESULTS: Between 27th April and 6th October 2020, we enrolled 71 patients (240 patients planned to been enrolled): 37 were assigned to the anakinra group and 34 to oSOC group. The study ended prematurely by recommendation of the data and safety monitoring board due to safety concerns. On day 14, the proportion of treatment success was significantly lower in the anakinra group 70% (n = 26) vs. 91% (n = 31) in the oSOC group: risk difference-21 percentage points (95% CI, -39 to -2), odds ratio 0.23 (95% CI, 0.06 to 0.91), p = 0.027. After a 28-day follow-up, 9 patients in the anakinra group and 3 in the oSOC group had died. Overall survival at day 28 was 75% (95% CI, 62% to 91%) in the anakinra group versus 91% (95% CI, 82% to 100%) (p = 0.06) in the oSOC group. Serious adverse events occurred in 19 (51%) patients in the anakinra group and 18 (53%) in the oSOC group (p = 0·89). CONCLUSION: This trial did not show efficacy of anakinra in patients with COVID-19. Furthermore, contrary to our hypothesis, we found that anakinra was inferior to oSOC in patients with moderate COVID-19 pneumonia.

Primary meningococcal arthritis in a COVID-19 18-year-old man: a case report and review of the literature.

BACKGROUND: SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infection is associated with various complications. PMA (primary meningococcal arthritis) is a rare meningococcus-associated disease causing arthritis of the knee usually, without any signs of invasive meningococcal disease. No case of PMA in a COVID-19 (coronavirus disease, 2019) patient has yet been described. PMA mainly strikes young adults. PMA is not associated with any immunocompromising condition. It has a better outcome than usual septic arthritis CASE PRESENTATION: Herein, we report an 18-year-old man diagnosed with COVID-19, later admitted with persistent fever, right knee arthralgia and maculopapular rash. Due to family history, psoriasis and Henoch-Schönlein purpura were hypothesized and ruled out. Finally, synovial fluid culture confirmed Neisseria meningitidis serogroup B arthritis without any other symptoms of invasive meningococcal disease. Healing was achieved quickly with surgery and antibiotics. We concluded in a PMA. CONCLUSION: We describe here the first primary meningococcal arthritis in a COVID-19 patient and we hope to shine a light on this rare but serious complication.

Decreased Cerebrospinal Fluid Flow Is Associated With Cognitive Deficit in Elderly Patients.

Background: Disruptions in cerebrospinal fluid (CSF) flow during aging could compromise protein clearance from the brain and contribute to the etiology of Alzheimer's Disease (AD). Objective: To determine whether CSF flow is associated with cognitive deficit in elderly patients (>70 years). Methods: We studied 92 patients admitted to our geriatric unit for non-acute reasons using phase-contrast magnetic resonance imaging (PC-MRI) to calculate their ventricular and spinal CSF flow, and assessed their global cognitive status, memory, executive functions, and praxis. Multivariable regressions with backward selection (criterion p < 0.15) were performed to determine associations between cognitive tests and ventricular and spinal CSF flow, adjusting for depression, anxiety, and cardiovascular risk factors. Results: The cohort comprised 71 women (77%) and 21 (33%) men, aged 84.1 ± 5.2 years (range, 73-96). Net ventricular CSF flow was 52 ± 40 µL/cc (range, 0-210), and net spinal CSF flow was 500 ± 295 µL/cc (range, 0-1420). Ventricular CSF flow was associated with the number of BEC96 figures recognized (ß = 0.18, CI, 0.02-0.33; p = 0.025). Spinal CSF flow was associated with the WAIS Digit Span Backward test (ß = 0.06, CI, 0.01-0.12; p = 0.034), and categoric verbal fluency (ß = 0.53, CI, 0.07-0.98; p = 0.024) and semantic verbal fluency (ß = 0.55, CI, 0.07-1.02; p = 0.024). Conclusion: Patients with lower CSF flow had significantly worse memory, visuo-constructive capacities, and verbal fluency. Alterations in CSF flow could contribute to some of the cognitive deficit observed in patients with AD. Diagnosis and treatment of CSF flow alterations in geriatric patients with neurocognitive disorders could contribute to the prevention of their cognitive decline.

Sleep Apnea Syndrome in an Elderly Population Admitted to a Geriatric Unit: Prevalence and Effect on Cognitive Function.

BACKGROUND: Sleep apnea leads to cognitive impairment in older patients, but its association with neurodegeneration remains controversial, and most studies do not distinguish between the more common obstructive form (OSAS) and the rarer central form (CSAS). OBJECTIVE: The purpose of this study was to assess the prevalence of the different forms of sleep apnea in a cohort of cognitively impaired elderly patients (>70 years) and to investigate their associations with cognitive deficit, weighted against known risk factors for neurodegeneration. METHODS: Overnight polygraphy was performed for 76 consecutive patients admitted to our geriatric unit. Their cognitive function was assessed using the Mini Mental-State Exam (MMSE), Mattis Dementia Rating Scale (MDRS) and Stroop test. Multivariable analyses were performed to determine associations between cognitive function and independent variables describing demographics, sleep apnea measures, and cardiovascular risk factors. RESULTS: The cohort comprised 58 women and 18 men aged a mean of 84 years (range, 73-96). Sleep apnea syndrome (SAS) was diagnosed in 48 patients (63%), of which 31 (41%) with OSAS and 17 (22%) with CSAS. Multivariable regression analysis revealed that MDRS was lower in patients with OSAS (ß = -10.03, p = 0.018), that Stroop Colors and Words delays increased with AHI (ß = 0.17, p = 0.030 and ß = 0.31, p = 0.047) and that that Stroop Interference delay was higher in patients with CSAS (ß = 24.45, p = 0.002). CONCLUSION: Sleep apnea is thus highly prevalent in elderly patients with cognitive impairment. OSAS was associated with lower general cognitive function, while CSAS was only associated with increased Stroop Interference delays. Elderly patients with cognitive deficit could benefit from sleep apnea screening and treatment.

X4 Tropic Virus Prediction Is Associated with a Nadir CD4 T-Cell Count below 100 Cells/mm.

OBJECTIVE: The aim of this study was to evaluate tropism prediction performances of three algorithms [geno2pheno false-positive rate 10% (G2P10), position-specific scoring matrix (PSSM) and a combination of the 11/25 and net charge rules] and to investigate the viral and host factors potentially involved in the X4 or R5 prediction in human immunodeficiency virus-1 (HIV-1) patients. METHODS: Viral tropism was determined in 179 HIV-1-infected patients eligible for CCR5 antagonist therapy. HIV-1 RNA or DNA was extracted and amplified for env gp120 sequencing. In parallel, demographic, viral, immunological and clinical determinants were analyzed. RESULTS: According to the G2P10 algorithm, 48 patients harbored X4 or X4R5 virus. The tropism prediction was concordant for 87.7 and 88.2% of samples when comparing G2P10 with PSSM or with a combination of the 11/25 and net charge rules, respectively. X4 prediction was significantly associated with more than 35 amino acids in the V3 domain (p < 0.0001) and loss of an N-linked glycosylation site (p < 0.0001). Of the factors studied, only the nadir CD4 T-cell count was significantly associated with X4 tropism (p = 0.01). CONCLUSION: We determined that the X4 virus detection is closely linked to the nadir CD4 T-cell count below 100 cells/mm(3) that must be taken into account when considering a CCR5 antagonist therapy switch.

Assessing urine human papillomavirus polymerase chain reaction testing as a tool for screening anal HPV infection in HIV-positive MSM.

Multiple types of human papillomavirus (HPV) are responsible for most cervical cancers but also cause anal cancers-especially in HIV-positive patients. Furthermore, men who have sex with men (MSM) are twice as likely to develop anal cancers as non-MSM. A simple screening test for HPV infection would be useful in these patients. The aim of our study was to evaluate the detection of HPV by real-time polymerase chain reaction (PCR) in urine as a marker of anal infection in MSM. The study included 52 HIV-positive MSM treated at Amiens University Hospital (Amiens, France). After obtaining informed consent, we performed an anal swab and gathered 10 mL of first-void urine. Samples were extracted and amplified in a real-time PCR. Genotypes were determined with a PapilloCheck(®) system (Greiner Bio-One, Frickenhausen, Germany). The anal test was the gold standard for calculating the characteristics of the urine test. The sensitivity of the urine test for diagnosing anal HPV infection was 15%, the specificity was 66%, the positive predictive value was 87.5%, and negative predictive value was 4.5%. The prevalence of anal HPV infection in the study population was 94%. Genotype 42 was the most common. The anal HPV viral load was significantly lower in men in a stable relationship than in single men. However, there was no statistically significant relationship between anal viral load and anal intraepithelial lesions. We conclude that urine-based HPV is a poor predictor of anal HPV infection in HIV-positive MSM.

Bacterial lung sepsis in patients with febrile neutropenia.

PURPOSE OF REVIEW: This review provides an update on microbiological and therapeutic data in febrile neutropenic patients in general and those with bacterial lung sepsis in particular. Although the Infectious Diseases Society of America updated its guidelines on febrile neutropenia in 2010, changing epidemiological factors and the spread of new drug resistance constitutes challenges for initial treatment of this condition. RECENT FINDINGS: Lung sepsis stands out because of the frequent absence of microbiological identification. We review the use of newly available, novel, broad-spectrum antibiotics (linezolid, tigecycline, daptomycin, etc.) in this indication. SUMMARY: Although the incidence of Gram-negative infections in neutropenic fever is leveling off, there is a worrying increase in resistance. New drugs are available but not well studied in febrile neutropenia; daptomycin and tigecycline should not be used in suspected lung sepsis in these patients. New diagnostic tools (such as the procalcitonin assay and the LightCycler SeptiFast assay, Roche Molecular Systems) appear to be unhelpful in febrile neutropenia, although more data on fungal sepsis are required. There are no specific features of the treatment of pneumonia or septic shock in neutropenic fever, but both conditions increase the mortality rate.

Bacterial infection profiles in lung cancer patients with febrile neutropenia.

BACKGROUND: The chemotherapy used to treat lung cancer causes febrile neutropenia in 10 to 40% of patients. Although most episodes are of undetermined origin, an infectious etiology can be suspected in 30% of cases. In view of the scarcity of data on lung cancer patients with febrile neutropenia, we performed a retrospective study of the microbiological characteristics of cases recorded in three medical centers in the Picardy region of northern France. METHODS: We analyzed the medical records of lung cancer patients with neutropenia (neutrophil count < 500/mm(3)) and fever (temperature > 38.3°C). RESULTS: The study included 87 lung cancer patients with febrile neutropenia (mean age: 64.2). Two thirds of the patients had metastases and half had poor performance status. Thirty-three of the 87 cases were microbiologically documented. Gram-negative bacteria (mainly enterobacteriaceae from the urinary and digestive tracts) were identified in 59% of these cases. Staphylococcus species (mainly S. aureus) accounted for a high proportion of the identified Gram-positive bacteria. Bacteremia accounted for 60% of the microbiologically documented cases of fever. 23% of the blood cultures were positive. 14% of the infections were probably hospital-acquired and 14% were caused by multidrug-resistant strains. The overall mortality rate at day 30 was 33% and the infection-related mortality rate was 16.1%. Treatment with antibiotics was successful in 82.8% of cases. In a multivariate analysis, predictive factors for treatment failure were age >60 and thrombocytopenia < 20000/mm(3). CONCLUSION: Gram-negative species were the most frequently identified bacteria in lung cancer patients with febrile neutropenia. Despite the success of antibiotic treatment and a low-risk neutropenic patient group, mortality is high in this particular population.

Aortic endostent followed by extended pneumonectomy for T4 lung cancer.

Pulmonary and aortic en bloc resection may be performed with cardiopulmonary bypass support, but is associated with high surgical morbidity and mortality. A 59-year-old man with left lower lobe cancer invading the aorta was considered to be unsuitable for such an extended operation because of previous myocardial infarction, coronary bypass grafts, and subsequent multiple coronary artery stenting. Pneumonectomy with en bloc resection of aortic adventitia and media was accomplished after thoracic aorta endovascular stent graft placement. The aortic defect was reinforced with an extrathoracic muscle flap. The postoperative course was uneventful, and the patient was faring well at the 23-month follow-up. An endovascular stent may be an alternative in selected patients with aortic involvement, avoiding the need for cardiopulmonary bypass.

Bronchial fistula associated with sunitinib in a patient previously treated with radiation therapy.

OBJECTIVE: To report a case of bronchial fistula associated with sunitinib in a patient previously treated with radiation therapy. CASE SUMMARY: A 40-year-old man with renal cell cancer diagnosed in 2005 and initially treated by radical nephrectomy presented in March 2007 with a recurrence with cerebral, mediastinal, and lung metastases. A thoracic computed tomography (CT) scan showed a subcarinal tumor obstructing the bronchus intermedius. The patient was initially treated with cerebral and thoracic radiotherapy and then with sunitinib 50 mg/day (4 weeks on, 2 weeks off). Two months after the beginning of treatment, a CT scan revealed a dramatic reduction in the size of the tumor, associated with a bronchial fistula. This was confirmed by flexible bronchoscopy, which showed complete necrosis of the tumor and a large perforation of the bronchus intermedius. Sunitinib was immediately withdrawn and antibiotic prophylaxis was instituted. It was not possible to place an endobronchial stent. Two weeks later, flexible bronchoscopy revealed the reappearance of a yellowish mass protruding into the bronchus intermedius (40% obstruction). A few months later, the obstruction of the bronchus intermedius progressed to 90% and was associated with a contralateral obstruction of the left mainstem bronchus (20%). A rigid bronchoscopy was then performed to clear the obstruction and an endobronchial stent was placed, with satisfactory initial results. In February 2008, the patient presented with new bronchial obstruction under the endobronchial stent but refused a rigid bronchoscopy and died in March 2008. DISCUSSION: Sunitinib, a multitarget tyrosine kinase inhibitor with antiangiogenic and antitumoral activities, has been approved for the treatment of advanced renal cell carcinoma. This treatment is generally well tolerated. Serious complications may occur, however. According to the Naranjo probability scale, the bronchial fistula was possibly related to sunitinib treatment. CONCLUSIONS: This is a rare case of a bronchial perforation leading to a fistula associated with sunitinib treatment after mediastinal radiation therapy. Clinicians may consider strict follow-up of patients with proximal lung metastases treated with sunitinib (CT scan and, if appropriate, placement of an endobronchial stent).

Non-tuberculous mycobacteria pulmonary infection: management and follow-up of 31 infected patients.

BACKGROUND: The global number of non-tuberculous mycobacteria (NTM) pulmonary infections is increasing. Treatment decisions and management are difficult and the prognosis of these infections has been rarely evaluated. METHODS: The aim of this study was to evaluate management and prognosis of patients with NTM pulmonary infection in a French teaching hospital. In this study, we evaluated management of patients satisfying the ATS (American Thoracic Society) criteria for NTM pulmonary infection in Amiens hospital from 1992 to 2002 and retrospectively compared this management to ATS guidelines. Short-term and long-term survival was also described. RESULTS: Thirty-one patients satisfying the ATS criteria for NTM pulmonary infection were included: 15 patients were infected with Mycobacterium xenopi, nine with Mycobacterium avium intracellulare, four with Mycobacterium kansasii and three patients were infected with rapidly growing mycobacteria. Twenty-seven patients had past or concomitant diseases responsible for local or systemic immunosuppression. Eleven patients were not treated. In the 20 treated patients, 13 different antibiotic combinations were used, often comprising three or more drugs. The median survival was 15 months. Twenty-one patients (67%) died before 5 years of follow-up. Thirty per cent of deaths were attributed to NTM pulmonary infection. Adjusting treatment to the results of susceptibility tests or ATS guidelines was not associated with any significant difference in survival. CONCLUSION: As the high mortality rate may be related to concomitant diseases, management of NTM pulmonary infection also depends on comorbidities, and should be defined according to the severity of underlying diseases.

Nocardia nova as the causative agent in spondylodiscitis and psoas abscess.

We describe here the first case of Nocardia nova spondylodiscitis accompanied by a psoas abscess due to spreading from pulmonary nocardiosis. Nocardia was cultured from all affected sites. After 1 year of an appropriate antimicrobial therapy and a surgical drainage of the abscess that was required, the patient's clinical condition had improved.

community-acquired infection with healthcare-associated methicillin-resistant Staphylococcus aureus: the role of home nursing care.

OBJECTIVE: To better understand the role of indirect transmission in community-acquired infection with methicillin-resistant Staphylococcus aureus (MRSA). DESIGN: Prospective case-control study. SETTING: A French teaching hospital. PATIENTS: A total of 198 case patients and 198 control patients with MRSA or methicillin-susceptible S. aureus infection diagnosed between April 2002 and July 2003. RESULTS: Multivariate analysis showed a highly significant independent link between MRSA infection at admission and prior receipt of home nursing care (odds ratio [OR], 3.7; P<.001). Other independent risk factors were prior hospitalization (OR, 3.8; P<.001), transfer from another institution (OR, 2.3; P=.008), and age older than 65 years (OR, 1.6; P=.04). Prior home nursing care showed a frequency dose-response relationship. Eleven MRSA-infected patients had had home nursing procedures but no hospital stay in the previous 3 years. These patients' MRSA strains were related to the prevalent MRSA clone currently spreading in French hospitals. CONCLUSION: Home nursing care appears to be an independent risk factor for MRSA acquisition in the community. The reservoir probably consists of MRSA carriers discharged from the hospital. Community nurses seem to be a potential vector.

Paecilomyces variotii fungemia in a patient with multiple myeloma: case report and literature review.

Infectious complications are common in patient with multiple myeloma. However, Paecilomyces variotii, a common saprophytic fungus, rarely causes human infection. We report the first case of P. variotii fungemia in this illness with good response with adapted anti-mycotic treatment.

Increased prevalence of hypothyroidism among human immunodeficiency virus-infected patients: a need for screening.

The aim of this cross-sectional multicenter study was to determine the prevalence of and risk factors for hypothyroidism in human immunodeficiency virus (HIV)-infected patients. Free T4, free T3, and thyroid-stimulating hormone levels were determined. Data on age, sex, weight variation, smoking status, duration of HIV infection, Centers for Disease Control and Prevention disease stage, CD4 cell count, HIV RNA load, lipodystrophy, HIV-hepatitis C virus coinfection, and antiretroviral treatment (type of drugs and total cumulative dose) were collected. The prevalence study included 350 HIV-infected patients. Sixteen percent of patients had hypothyroidism: 2.6% had overt hypothyroidism, 6.6% had subclinical hypothyroidism, and 6.8% had a low free T4 level. The prevalence of subclinical hypothyroidism was higher among HIV-infected men than among HIV-infected women. A case-control study was conducted that compared hypothyroid (n=56) and euthyroid (n=287) patients. In the multivariate analysis, receipt of stavudine and low CD4 cell count were associated with hypothyroidism. Therefore, screening may be indicated for patients, especially men, who have received stavudine or have decreased CD4 cell counts.

A phase I study of a six-week cycle of immunotherapy with Murabutide in HIV-1 patients naive to antiretrovirals.

BACKGROUND: Limitations in the use of antiretroviral therapy suggest the need for additional approaches to enhance immune restoration and the control of HIV-1 replication. Therefore, we evaluated the clinical tolerance and biological effects of immunotherapy with the synthetic immunomodulator Murabutide in 9 treatment-naive HIV-1 patients presenting with CD4+ lymphocyte counts >500 cells/mm3 and plasma viral loads <30.000 copies/ml. MATERIAL/METHODS: Murabutide was administered at a daily dose of 7 mg on 5 consecutive days per week, for a period of 6 weeks. The study duration extended over 22 weeks, and clinical, virological, and immunological evaluations were carried out on 2 occasions before, during, and after immunotherapy. RESULTS: With acceptable clinical tolerance and only 2 reversible grade III adverse events, clinical and virological parameters remained highly stable throughout the study period. However, maintained or improved lymphoproliferative responses to several recall and HIV-1 antigens, as well as modest but significant increases in the percentages of naive cells were noted during or/and after immunotherapy. These changes could not be demonstrated in an observation group of 9 additional patients who were identically followed for a 22-week period. CONCLUSIONS: Our results suggest that non-specific immunotherapy targeting dysfunctions in innate immunity could bring about restoration of immune responses in HIV disease.