Post-COVID-19 Multisystem Inflammatory Syndrome in Children and Adults: What Happens After Discharge?

Introduction Classification criteria and practice guidelines for inpatient management of multisystem inflammatory syndrome (MIS) exist, but reports on outpatient management and clinical outcomes are lacking. Here we describe the management and clinical outcomes of four children and four adults with MIS seen at Walter Reed National Military Medical Center (WRNMMC) from diagnosis to six months follow-up. Methods This retrospective, case-series describes the initial presentation and management of MIS in four children and four adults seen at WRNMMC from March 2020 to September 2021. Data on each patient was collected from the time of exposure to the SARS-CoV-2 virus to six months post-diagnosis with MIS. Extracted data includes: demographics, comorbidities, initial MIS presentation, inpatient treatment, outpatient treatment, and clinical outcomes. Results A total of 62.5% of patients presented in shock. All pediatric patients received IVIG, methylprednisolone, and anakinra; no adult received this combination. Steroids and immunomodulatory medications were discontinued in 1-2 months outpatient. Three children and two adults had full symptomatic resolution. One child and two adults had persistent deconditioning at six months follow-up. One adult had persistent dyspnea. Conclusions MIS appears to be monophasic with no recurrences at six months follow-up in our patients who only required 1-2 months of glucocorticoid or immunomodulatory medications. The better outcomes in children raise the question of how much of this difference can be attributed to early combination therapy versus physiologic differences in children and adults.

Infective endocarditis due to Haemophilus sputorum.

Introduction: Haemophilus species are gram-negative, non-motile, facultative anaerobic coccobacilli in the larger family of Pasteurellaceae . Implicated in a variety of human diseases, Haemophilus species are also included in the 'HACEK' group of organisms, which are fastidious gram-negative bacteria, a well-described but uncommon cause of endocarditis. Among the Haemophilus species responsible for endocarditis, Haemophilus parainfluenzae is the most frequently isolated. However, novel species of Haemophilus have recently been described, and their clinical significance remains uncertain. Case presentation: A 35-year-old man was admitted to the hospital after presenting with a 3 month history of nightly fevers, night sweats and unintentional weight loss, with a new murmur detected on cardiac auscultation. Blood cultures returned positive for Haemophilus sputorum identified by matrix assisted laser desorption ionization - time of flight MS, and confirmed with whole genome sequencing. Echocardiography revealed the presence of an aortic valve vegetation, with aortic and mitral valve leaflet perforations. He was successfully treated with surgical bioprosthetic valve replacements and pathogen-directed antibiotics without complications. Conclusion: We describe a case of infective endocarditis due to H. sputorum , a newly identified Haemophilus species, which to the best of our knowledge has yet to be reported, and discuss the available literature regarding this organism.

The Current State of Coronary Revascularization: Percutaneous Coronary Intervention versus Coronary Artery Bypass Graft Surgery.

The question of percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery remains among the most important questions in the treatment of coronary artery disease. The leading North American and European societies largely agree on the current guidelines for the revascularization of unprotected left-main disease (ULMD) and multivessel disease (MVD) which are largely supported by the outcomes of several large randomized trials including SYNTAX, PRECOMBAT, NOBLE, and EXCEL. While these trials are of the highest quality, currently available, they suffer several limitations, including the use of bare metal and/or first-generation drug-eluting stents in early trials and lack of updated surgical outcomes data. The objective of this review is to briefly discuss these key early trials, as well as explore contemporary studies, to provide insight on the current state of coronary revascularization. Evidence suggests that in ULMD and MVD, there are similar mortality rates for CABG and PCI but PCI is associated with fewer "early" strokes, whereas CABG is associated with fewer "late" strokes, myocardial infarctions, and lower need for repeat revascularization. Additionally, studies suggest that CABG remains superior to PCI in patients with intermediate/high SYNTAX scores and in MVD with concomitant proximal left anterior descending (pLAD) artery stenosis. Despite the preceding research and its basis for our current guidelines, there remains significant variation in care that has yet to be quantified. Emerging studies evaluating second-generation drug-eluting stents, specific lesion anatomy, and minimally invasive and hybrid approaches to CABG may lend itself to more individualized patient care.

Correction to: Long-Term Prognostic Value of Coronary Computed Tomography Angiography.

The authors would like to note that this article published in Current Treatment Options in Cardiovascular Medicine journal is not showing Open Access on the website. Thus, the paper is still not available for free online.

Long-Term Prognostic Value of Coronary Computed Tomography Angiography.

OPINION STATEMENT: Coronary CT angiography (CTA) is a highly accurate test for the diagnosis of coronary artery disease (CAD), with its use guided by numerous contemporary appropriate use criteria and clinical guidelines. Unique among non-invasive tests for CAD, coronary CTA provides direct visualization of coronary atherosclerosis for the assessment of angiographic stenosis, as well as validated measures of plaque vulnerability. Long-term studies now clearly demonstrate that the absence of CAD on coronary CTA identifies a patient that is at very low risk for future cardiovascular events. Conversely, the presence, location, and severity of CAD as measured on coronary CTA provide powerful prognostic information that is superior to traditional risk factors and other clinical variables. Observational studies and data obtained from clinical trials suggest that the anatomic information derived from coronary CTA significantly increases the utilization of statins and aspirin. Furthermore, these changes are associated with reductions in the risk for mortality, revascularizations, and incident myocardial infarctions among subjects with coronary atherosclerosis. As a result, current societal consensus statements have attempted to standardize coronary CTA reporting, to include incorporation of vulnerable plaque features and recommendations on the use of preventive therapies, such as statins, so to more consistently link important prognostic findings on coronary CTA to appropriate preventive and therapeutic interventions. Automated measures of total coronary plaque volume, machine learning, and CT-derived fractional flow reserve may further refine the prognostic accuracy of coronary CTA. Herein, we summarize recently published literature that reports the long-term (≥ 5 years of follow-up) prognostic usefulness of coronary CTA.

Everolimus Implicated in Case of Severe Gastrointestinal Hemorrhage.

Breast cancer remains the leading cause of cancer and the third leading cause of cancer related deaths among our population with an estimated number of 246,660 new cases and 40,450 deaths in 2016. With treatment advancements, including targeted agents such as Everolimus, a mammalian target of rapamycin (mTOR) inhibitor, survivability and quality of life continue to improve. However, with the use of these agents come adverse effects, some of which are still being characterized. Our case demonstrates recurrent episodes of gastrointestinal bleeding in a 60-year-old woman being treated with Everolimus for progressive metastatic breast cancer. On endoscopy, bleeding was secondary to erosive gastritis. Previous case reports have described bleeding due to gastric antral vascular ectasia (GAVE), which was described in two prior reported cases. In our case, bleeding also occurred on a reduced dose of Everolimus compared to what is previously reported (5 mg versus 10 mg). As a result of her gastrointestinal bleeding, she required multiple endoscopic interventions including argon plasma coagulation and multipolar heater probe to achieve hemostasis. This is the first case reported of gastrointestinal bleeding not consistent with GAVE and occurring while being on a reduced dose of Everolimus. It is important to document our case so that the Gastroenterology and Hematology communities can be educated and made aware for their patient populations on Everolimus.