Hyperuricemia and Adverse Outcomes in Patients Hospitalized for COVID-19 Disease.

Background: Hyperuricemia is associated with several risk factors for mortality and severe coronavirus disease 2019 (COVID-19) manifestations.Objective: The objective of this research was to examine whether hyperuricemia is a risk factor for mortality and other adverse outcomes in patients hospitalized for COVID-19.Design: This is a retrospective review of patients hospitalized for COVID-19 between March 15 and November 30, 2020, with available uric acid (UA) levels.Results: Among 1566 patients who were hospitalized during the study period, 222 patients had an available UA level. The mean age ± standard deviation (SD) was 56.5 ± 19.5 years. The mean ± SD for UA (mg/dL) among the total cohort was 5.65 ± 2.18, and 21.2% of the total study population had hyperuricemia (UA > 7 mg/dL) on admission. The mortality rate was 14.4%, and mortality was associated with higher UA levels on admission (6.9 ± 2.6 mg/dL vs. 5.5 ± 2 mg/dL in patients who survived, P < 0.05). Patients who needed intensive oxygen support (high-flow nasal cannula or mechanical ventilation) and those who required longer-than-average hospitalization (> 7 days) had more hyperuricemia (intensive oxygen support: 30% vs. 18%, P = 0.07; long hospitalization 29% vs. 16.2%, P < 0.05).Conclusion: Our findings show that high UA levels are associated with adverse outcomes in patients hospitalized for COVID-19. We suggest evaluating hyperuricemia as a marker that integrates and reflects both poor prognostic baseline characteristics and acute components such as inflammatory state, hypovolemic state, and renal failure.

A deep look into the storm: Israeli multi-center experience of coronavirus disease 2019 (COVID-19) in patients with autoimmune inflammatory rheumatic diseases before and after vaccinations.

Objective: We aimed to characterize the course of COVID-19 in autoimmune inflammatory rheumatic disease (AIIRD) patients in Israel, taking into consideration several remarkable aspects, including the outcomes of the different outbreaks, the effect of vaccination campaigns, and AIIRD activity post-recovery. Methods: We established a national registry of AIIRD patients diagnosed with COVID-19, including demographic data, AIIRD diagnosis, duration and systemic involvement, comorbidities, date of COVID-19 diagnosis, clinical course, and dates of vaccinations. COVID-19 was diagnosed by a positive SARS-CoV-2 polymerase chain reaction. Results: Israel experienced 4 outbreaks of COVID-19 until 30.11.2021. The first three outbreaks (1.3.2020 - 30.4.2021) comprised 298 AIIRD patients. 64.9% had a mild disease and 24.2% had a severe course; 161 (53.3%) patients were hospitalized, 27 (8.9%) died. The 4th outbreak (delta variant), starting 6 months after the beginning of the vaccination campaign comprised 110 patients. Despite similar demographic and clinical characteristics, a smaller proportion of AIIRD patients had negative outcomes as compared to the first 3 outbreaks, with regards to severity (16 patients,14.5%), hospitalization (29 patients, 26.4%) and death (7 patients, 6.4%). COVID-19 did not seem to influence the AIIRD activity 1-3 months post-recovery. Conclusions: COVID-19 is more severe and has an increased mortality in active AIIRD patients with systemic involvement, older age and comorbidities. Vaccination with 3 doses of the mRNA vaccine against SARS-CoV-2 protected from severe COVID-19, hospitalization and death during the 4th outbreak. The pattern of spread of COVID-19 in AIIRD patients was similar to the general population.

Social distancing and bacteraemia in the time of COVID-19.

BACKGROUND: Social distancing was the predominant strategy used to mitigate the spread of Coronavirus disease 2019 (COVID-19) at the start of the COVID-19 pandemic. AIMS: To study the impact of social distancing on the incidence of bacteraemia. The number of admitted patients with positive blood cultures in April-May 2020 in one tertiary medical centre was compared with the number during the same period in the previous 3 years (April-May 2017-2019). METHODS: Retrospective review of all positive blood cultures from January to July in the years 2017-2020. RESULTS: There were fewer cases of Streptococcus bacteraemia as well as coagulase-negative Staphylococcus bacteraemia and other possible contaminated blood cultures in April-May 2020. Compared with the previous 3 years, the incidence of Streptococcus pneumoniae bacteraemia among all bacteraemias was lower in April-May 2020 (5%) than in 2017-2019 (12.0%; 95% confidence interval 10.3-14.1%). In general, fewer cases of bacteraemia caused by oropharynx organisms were observed in April-May 2020; only 6 cases versus 31 (95% confidence interval 10-53) during the same period in 2017-2019. Only one case of S. pneumoniae bacteraemia was observed in April-May 2020 and its percentage among all bacteraemias was lower in April-May 2020 (0.4%) than during the same period in 2017-2019 (3.3%). CONCLUSION: The incidences of streptococcal bacteraemia and bacteraemia of organisms transmitted through respiratory secretions were lower when there were social distancing restrictions. Adopting measures of social distancing may decrease the morbidity from bacteraemia caused by oropharynx and respiratory bacteria.

Clinical implications of ANCA positivity in a hospital setting: a tertiary center experience.

ANCA testing plays an established critical role in the diagnosis of ANCA Associated vasculitis (AAV). The spectrum of diseases associated with positive ANCA has recently broadened, thus calling into question the diagnostic implications of ANCA positivity in a hospital setting. We retrospectively studied all adult patients who had a positive ANCA test (by Indirect Immunofluorescence (IIF), ELISA or both) performed over the span of 19 years. Subjects were then divided into discordant (positive on one assay) and concordant ANCA (positive on both assays) groups based on their ANCA positivity status. The two groups were then compared with regards to their demographic, clinical and laboratory characteristics, the indication for ANCA testing in both groups and their final diagnoses. Of the 9189 ANCA tests ordered during the 19-year span of the study, 389 (4.2%) were positive. Two hundred and forty subjects met the exclusion criteria (patients aged less than 18 years or the lack of clinical and laboratory data in the medical file) thus resulting in a final cohort of 149 subjects. Of them, 122 subjects had discrepant ANCA results and 27 had matching ANCA results. Most cases in the discrepancy group were IIF positive and ELISA negative (86.8%). The diagnosis of AAV was highly unlikely in cases with discrepant IIF and ELISA serologies compared to cases with matching IIF and ELISA serologies (4.1% versus 44.4%, p value < 0.001). The diagnosis of AAV in unlikely in subjects with discrepancies between IIF and ELISA, particularly with only positive IIF.

Bilateral Adrenal Hemorrhage in Coronavirus Disease 2019 Patient: A Case Report.

CONTEXT: Bilateral adrenal hemorrhage is a rare condition with potentially life-threatening consequences such as acute adrenal insufficiency. Early adrenal axis testing, as well as directed imaging, is crucial for immediate diagnosis and treatment. Coronavirus disease 2019 (COVID-19) has been associated with coagulopathy and thromboembolic events. CASE DESCRIPTION: A 66-year-old woman presented with acute COVID-19 infection and primary adrenal insufficiency due to bilateral adrenal hemorrhage (BAH). She also had a renal vein thrombosis. Her past medical history revealed primary antiphospholipid syndrome (APLS). Four weeks after discharge she had no signs of COVID-19 infection and her polymerase chain reaction test for COVID-19 was negative, but she still needed glucocorticoid and mineralocorticoid replacement therapy. The combination of APLS and COVID-19 was probably responsible of the adrenal event as a "two-hit" mechanism. CONCLUSIONS: COVID-19 infection is associated with coagulopathy and thromboembolic events, including BAH. Adrenal insufficiency is life threatening; therefore, we suggest that early adrenal axis testing for COVID-19 patients with clinical suspicion of adrenal insufficiency should be carried out.

Ruptured hemorrhagic corpus luteum as a presenting symptom of systemic lupus erythematous.

A young female presented to the emergency room with ruptured hemorrhagic corpus luteum (RHCL). Her workup revealed a new diagnosis of SLE with nephritis and positive lupus anticoagulant (LAC) test without thrombocytopenia. We reviewed the literature and found one similar case of a 23-year-old subject who presented with a RHCL that was found to be the presenting symptom of SLE; unlike the current case, the patient presented with severe anemia (Hg 6.7 g/dl) and thrombocytopenia (10,000/ml). Possible mechanisms are discussed.

Survival of patients with giant cell arteritis: a controversial issue.

OBJECTIVES: Epidemiologic studies differ regarding overall survival in giant cell arteritis (GCA). In this review we evaluated longevity and the impact of several disease parameters on survival of GCA patients. METHODS: Review of the medical literature during the period 1975-2018, using PubMed database. RESULTS: Epidemiologic studies addressing the issue of survival in GCA patients used variable methods of calculating mortality rates in relation to background population or in relation to selected controls. Several epidemiologic studies found that survival of GCA patients was similar to that of the general population. Others reported increased mortality in patients with GCA, or in subgroups of GCA patients. 5-Year and 10-year survival rates differed considerably among studies: 5-year survival rates ranged between 60-90% (except for 2 extremes of 35% and 97%), and 10-year survival rates ranged between 48-81%. Reasons for these discrepancies are unclear, and may be related to differences in populations, in the period of the study, and in study methods. Several studies found that mortality was increased in female GCA patients, and some reported increased mortality early in the course of the disease (mostly within the first 2 years after diagnosis). The deleterious effect of vision loss on survival was noted in a few studies, although most studies did not address the issue of mortality in this particular subgroup of GCA patients. CONCLUSIONS: Epidemiologic studies varied considerably in the reported outcomes of GCA patients: some found that the overall survival was similar to that of the general population while others reported increased mortality in GCA or in subgroups of GCA patients.

Uric Acid Level as a Predictor of Long-Term Mortality in Advanced Age Population.

BACKGROUND: Hyperuricemia is associated with the development, progression and outcome of several diseases. The purpose of this study is to evaluate the serum uric acid (UA) levels as a predictor of long-term mortality in an older population (age 60 years and above). MATERIALS AND METHODS: Patients older than 60 years who were hospitalized in the departments of geriatrics and internal medicine in Shaare Zedek Medical Center in Jerusalem during a period of 4 months (March-June 2014) were included in this observational study. Association between hyperuricemia and long-term mortality were analyzed using multiple logistic regression, Kaplan-Meier and Cox proportional hazards regressions analysis. RESULTS: A total of 624 patients were included in our study with mean age of 77.2 ± 14.6 years. Overall, 381 patients died during the follow-up period (61.1%). Mortality rate in the hyperuricemic group (> 7 mg/dL) was higher (69.1%) than in the normouricemic group 58.4%. (P = 0.004). The median survival for hyperuricemic patients was significantly shorter compared to normouricemic patients (606 and 1018 days, respectively, P < 0.0001). High levels of UA were significantly associated with higher long-term mortality in patients with cardiovascular disease at their admission (P < 0.000). CONCLUSIONS: Elevated levels of UA in older patients in acute settings is a predictor of long-term mortality.

Synovial fluid culture: agar plates vs. blood culture bottles for microbiological identification.

OBJECTIVES: Bacteriological diagnosis of septic arthritis (SA) is complicated. Agar plates are the main culture method and yields 40-60% of positive bacterial detection. Addition of bottled culture broth (Bactec®) as a method for detecting synovial microorganisms is common. The advantages of this method and the combination of both have not been thoroughly investigated. This study evaluates an added value of the Bactec culture broth as a single method or as combined with the agar-plate culture. METHODS: All culture aspirates of SA-suspected patients were analyzed. All cases with a positive result by either method were reviewed for background data and clinical diagnosis. RESULTS: Out of 5000 synovial fluid samples, a clinical diagnosis of SA was suspected in 1024 cases. Samples processed by both culture methods were extracted during the same event. Bactec® vials were positive for significant bacterial detection in 113/148 cases (76.4%) while agar-plate cultures were positive in only 96/154 (62.3%) representing higher sensitivity of 0.5 vs. 0.42 and a positive predictive value (PPV) of 0.76 vs. 0.62. Bacterial detection by both methods combined was positive in 137/221 (62%) and did not achieve a significant increment. CONCLUSIONS: The Bactec® method has many advantages in bacteriological identification of synovial infection, including a broader identification spectrum, faster response time, and superior qualities of identification although being more expensive. This method has a better yield in detecting septic arthritis and might be considered a single method for synovial fluid culture in cases suspected for SA.Key Points• The Bactec method had improved detection rates.• Culturing by agar plates and Bactec revealed higher sensitivity and lower specificity.• The use of the blood culture bottles (Bactec system) alone will raise the detection rate of septic arthritis with lower false positive rates and at lower costs.

Segmental arterial mediolysis: a vasculitis mimicker. A single centre experience.

OBJECTIVES: Segmental arterial mediolysis (SAM) is a rare vasculopathy of unknown aetiology. It is non-atherosclerotic, non-inflammatory, non-hereditary, non-infectious, large to medium-sized arteriopathy. SAM is a condition which in some circumstances behaves as a vasculitis mimicker and should be recognised in order to provide appropriate treatment and avoid unnecessary immune-suppressive therapy. METHODS: We report a single-centre experience of 6 consecutive SAM cases (3 males and 3 females). A literature search of cases reported with SAM was performed and data summarised. RESULTS: Abdominal or flank pain was the presenting symptom in 5 of the 6 patients. CT angiography (CTA) was the method of diagnosis in all 6 patients. 3 patients underwent therapeutic angiography; 2 with angiographic embolisation because of bleeding, and one patient needed a stent insertion because of left renal infarction. 2 patients underwent FDG-PET to rule out vasculitis. Serological tests were negative in all case, but C-reactive protein was elevated in 4 of them. 2 patients were treated with angiographic embolisation due to bleeding, 2 treated with anti-platelet therapy, one with stent insertion, and one with antihypertensive treatment. A medical literature review of 160 additional cases shows that abdominal or flank pain was the chief complaint in the vast majority of the cases. Renal and abdominal medium-sized arteries were the most commonly involved. CTA was the preferred method of diagnosis. CONCLUSIONS: SAM should be suspected in cases presenting with abdominal or flank pain. Angiographic features should be carefully studied by experienced radiologists to rule out vasculitis.

Trends in antimicrobial resistance among bacteria causing septic arthritis in adults in a single center: A 15-years retrospective analysis.

Septic arthritis (SA) is commonly associated with Staphylococcal or Streptococcal infections. Overtime, there has been a global increase in the distribution of antimicrobial resistance within both Gram-positive bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) and Gram-negative bacteria such as extended-spectrum beta-lactamase (ESBL) positive Enterobacteriacea. The aim of this study was to determine whether this change in epidemiology similarly affected the distribution of resistant pathogens causing SA. The study was conducted at the Shaare Zedek Medical Center in Jerusalem, Israel. All adult patients diagnosed with SA during 2002-2016 were included in the cohort. Antimicrobial resistance trends were examined over three periods: 2002-2009, 2010-2013, and 2014-2016. Of 85 patients with SA, mean age of patients was 66.8 (± 20.3) years, with male predominance (n = 62, 66%). Most SA cases involved native knee joints and more than 85% (n = 80) were acquired in the community. The most common isolates were S. aureus (n = 38, 45%) and beta-hemolytic streptococci (n = 13, 15%). MRSA SA was diagnosed in 8% of all SA cases (n = 7). An increasing, although non-significant trend in MRSA SA was observed during the study period (p = 0.3). Gram-negative infections were uncommon (n = 14). No ESBL-positive or carbapenem-resistant Enterobacteriacea were detected. Over a 15-year study period, no significant increase in resistant pathogens causing SA was observed. In the era of antibiotic stewardship, these results strengthen our practice of administering narrow-spectrum antimicrobials empirically for SA. However, our findings cannot be generalized to regions with higher rates of MRSA in the community.

Correction: Modeling suggests that microliter volumes of contaminated blood caused an outbreak of hepatitis C during computerized tomography.

[This corrects the article DOI: 10.1371/journal.pone.0210173.].

Modeling suggests that microliter volumes of contaminated blood caused an outbreak of hepatitis C during computerized tomography.

BACKGROUND & AIMS: Acute hepatitis C (AHC) is not frequently identified because patients are usually asymptomatic, although may be recognized after iatrogenic exposures such as needle stick injuries, medical injection, and acupuncture. We describe an outbreak of AHC among 12 patients who received IV saline flush from a single multi-dose vial after intravenous contrast administration for a computerized tomography (CT) scan. The last patient to receive IV contrast with saline flush from a multi-dose vial at the clinic on the previous day was known to have chronic HCV genotype 1b (termed potential source, PS). Here we sought to confirm (via genetic analysis) the source of infection and to predict the minimal contaminating level of IV saline flush needed to transmit infectious virus to all patients. METHODS: In order to confirm the source of infection, we sequenced the HCV E1E2 region in 7 CT patients, in PS, and in 2 control samples from unrelated patients also infected with HCV genotype 1b. A transmission probabilistic model was developed to predict the contamination volume of blood that would have been sufficient to transmit infectious virus to all patients. RESULTS: Viral sequencing showed close clustering of the cases with the PS. The transmission probabilistic model predicted that contamination of the multi-dose saline vial with 0.6-8.7 microliters of blood would have been sufficient to transmit infectious virus to all patients. CONCLUSION: Analysis of this unique cohort provides a new understanding of HCV transmission with respect to contaminating volumes and viral titers.