Never too old: A case of fatal epstein barr virus pneumonia in an immunocompetent adult.

A 67-year-old immunocompetent male with COPD on supplemental oxygen presented with shortness of breath and was initially treated for bronchitis exacerbation with initial suspicion of bacterial pneumonia. He was later found to have EBV pneumonia diagnosed via positive EBV on bronchoalveolar lavage PCR. Severe lung involvement has been rarely reported in context of acute EBV infection. Treatment for this entity has not yet been established, with few reports of acyclovir and steroid use. This report describes the presentation, diagnosis, and treatment of acute EBV pneumonia.

Cavitary lung lesion as sequelae of mild COVID-19 in a patient with HIV.

Cavitary lung lesions involve a large spectrum of acute to chronic infections, chronic systemic diseases, and malignancies. During the COVID-19 pandemic, we have seen an increase in lung cavitation, mainly secondary to bacterial infection however, there have been limited reports of these lesions with mild COVID-19 disease. There has been an association between severe COVID-19 infection and secondary bacterial/fungal infections and cavitary lung lesions. We report the first case of a 32-year-old man with well-controlled HIV who presented with cough and fever from what appeared to be a cavitary lesion as a sequela of his recent COVID-19 infection.

Spontaneous coronary artery dissection of ramus intermedius in an elderly woman.

Spontaneous coronary artery dissection (SCAD) is a rare cause of myocardial ischemia commonly seen in younger patients, particularly women. Patients often present similar to those with acute coronary syndrome (ACS); however, they often are missing the classic risk factors that are typically associated with coronary artery disease. Differentiating between SCAD and ACS is vital as they are managed differently with up to 80% of SCAD being managed conservatively. We present a case of 61-year-old woman with no previous cardiac history presenting with chest pain and was found to have spontaneous coronary artery dissection on coronary angiography.

Plasma Cell-Free DNA Predicts Survival and Maps Specific Sources of Injury in Pulmonary Arterial Hypertension.

BACKGROUND: Cell-free DNA (cfDNA) is a noninvasive marker of cellular injury. Its significance in pulmonary arterial hypertension (PAH) is unknown. METHODS: Plasma cfDNA was measured in 2 PAH cohorts (A, n=48; B, n=161) and controls (n=48). Data were collected for REVEAL 2.0 (Registry to Evaluate Early and Long-Term PAH Disease Management) scores and outcome determinations. Patients were divided into the following REVEAL risk groups: low (≤6), medium (7-8), and high (≥9). Total cfDNA concentrations were compared among controls and PAH risk groups by 1-way analysis of variance. Log-rank tests compared survival between cfDNA tertiles and REVEAL risk groups. Areas under the receiver operating characteristic curve were estimated from logistic regression models. A sample subset from cohort B (n=96) and controls (n=16) underwent bisulfite sequencing followed by a deconvolution algorithm to map cell-specific cfDNA methylation patterns, with concentrations compared using t tests. RESULTS: In cohort A, median (interquartile range) age was 62 years (47-71), with 75% female, and median (interquartile range) REVEAL 2.0 was 6 (4-9). In cohort B, median (interquartile range) age was 59 years (49-71), with 69% female, and median (interquartile range) REVEAL 2.0 was 7 (6-9). In both cohorts, cfDNA concentrations differed among patients with PAH of varying REVEAL risk and controls (analysis of variance P≤0.002) and were greater in the high-risk compared with the low-risk category (P≤0.002). In cohort B, death or lung transplant occurred in 14 of 54, 23 of 53, and 35 of 54 patients in the lowest, middle, and highest cfDNA tertiles, respectively. cfDNA levels stratified as tertiles (log-rank: P=0.0001) and REVEAL risk groups (log-rank: P<0.0001) each predicted transplant-free survival. The addition of cfDNA to REVEAL improved discrimination (area under the receiver operating characteristic curve, 0.72-0.78; P=0.02). Compared with controls, methylation analysis in patients with PAH revealed increased cfDNA originating from erythrocyte progenitors, neutrophils, monocytes, adipocytes, natural killer cells, vascular endothelium, and cardiac myocytes (Bonferroni adjusted P<0.05). cfDNA concentrations derived from erythrocyte progenitor cells, cardiac myocytes, and vascular endothelium were greater in patients with PAH with high-risk versus low-risk REVEAL scores (P≤0.02). CONCLUSIONS: Circulating cfDNA is elevated in patients with PAH, correlates with disease severity, and predicts worse survival. Results from cfDNA methylation analyses in patients with PAH are consistent with prevailing paradigms of disease pathogenesis.

Fungal Peritonitis Secondary to Aspergillosis in a Peritoneal Dialysis Patient.

Fungal peritonitis remains a serious complication of peritoneal dialysis that carries a high morbidity and mortality. Most cases of fungal infections are due to Candida species; however few cases are seen in the setting of non-Candida such Aspergillus, Fusarium, and Mucor. Prompt peritoneal dialysis catheter removal and early anti-fungal treatment have been considered as best strategies to improve survival. We present a rare case of a 27-year-old male with focal segmental glomerulosclerosis on peritoneal dialysis (PD) presented to the hospital recurrent episodes of abdominal pain, diarrhea, and cloudy output from his peritoneal catheter. He was found to have fungal peritonitis secondary to Aspergillosis Fumigatus. This report highlights that fungal peritonitis should be considered in the differential diagnosis of patients with prolonged antibiotic use, recent bacterial peritonitis, and recent hospitalization. The speciation of Aspergillosis Fumigatus carries a rare incidence in this population and voriconazole is the mainstay treatment.

Fecal carriage of MDROs in a population of Lebanese elderly: Dynamics and impact on bacterial fitness.

Muti-Drug Resistant Organisms (MDROs) are problematic all over the world, especially in Lebanon. High fecal carriage rates of MDR Enterobacteriaceae were reported from Lebanese nursing homes. Some studies show that MDROs have a fitness cost as compared to sensitive isolates. In this study, the competitive growth of MDR Escherichia coli obtained from fecal samples from elderly is assessed. Fecal swabs from ten elderly patients from a Lebanese nursing home were obtained between June and December, 2015. Isolates were identified by API 20E and antimicrobial susceptibilities were determined. Production of ESBL (extended spectrum ß lactamase), MBL (metallo ß lactamse), AmpC and KPC (Klebsiella pneumonia carbapenemase) was detected phenotypically by the use of EDTA, PBA, cloxacillin, and DDSTs. In-vitro competition assays were performed using E. coli isolates with different combinations of bacterial resistance. A total of 117 isolates was obtained with 71.8% E. coli, 7.7% of which were ESBL and 5.1% AmpC producers. Sensitive E. coli isolates out-competed all other isolates when in competition, followed sequentially by ESBL, AmpC, and OXA-48 (oxacillin) producers. This study shows an advantage of sensitive E. coli strains obtained from fecal samples to out-compete resistant strains in specific in-vitro conditions. This ability could be exploited in the elimination of MDR organisms from the gut flora, after further investigation.