Laparoscopic surgery during the COVID-19 pandemic: detection of SARS-COV-2 in abdominal tissues, fluids, and surgical smoke.

BACKGROUND: There are still concerns over the safety of laparoscopic surgery in coronavirus disease 2019 (COVID-19) patients due to the potential risk of viral transmission through surgical smoke/laparoscopic pneumoperitoneum. METHODS: We performed a systematic review of currently available literature to determine the presence of severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) in abdominal tissues or fluids and in surgical smoke. RESULTS: A total of 19 studies (15 case reports and 4 case series) comprising 29 COVID-19 patients were included. The viral RNA was positively identified in 11 patients (37.9%). The samples that tested positive include the peritoneal fluid, bile, ascitic fluid, peritoneal dialysate, duodenal wall, and appendix. Similar samples, together with the omentum and abdominal subcutaneous fat, tested negative in the other patients. Only one study investigated SARS-COV-2 RNA in surgical smoke generated during laparoscopy, reporting negative findings. CONCLUSIONS: There are conflicting results regarding the presence of SARS-COV-2 in abdominal tissues and fluids. No currently available evidence supports the hypothesis that SARS-COV-2 can be aerosolized and transmitted through surgical smoke. Larger studies are urgently needed to corroborate these findings.

Peritoneal Dialysis Is an Option for Acute Kidney Injury Management in Patients with COVID-19.

In December 2019, cases of acute respiratory illness of unknown origin were reported in Wuhan, China. The disease is caused by "severe acute respiratory syndrome coronavirus 2". After identifying severe lung damage, injury to other organs, such as the kidney, has been identified. Peritoneal dialysis is a renal replacement therapy (RRT) and is at least as effective as other extracorporeal therapy options, with significant cost-effective advantages. However, this strategy is rarely used for the management of acute kidney injury in severe lung disease. In this review, we explore PD as an RRT strategy that may be a key instrument in countries and hospitals with limited access to all RRTs.

Duodenal perforation in a SARS-CoV-2-positive patient with negative PCR results for SARS-CoV-2 in the peritoneal fluid.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has significantly affected health care organizations globally. Many aspects of this disease, as well as the risks for patients treated with multiple drug regimens to control severe COVID-19, are unclear. During emergency surgery for SARS-CoV-2-positive patients, the risk of SARS-CoV-2 exposure and transmission to the surgical staff has yet to be determined. PATIENTS AND METHODS: In this report, we describe a SARS-CoV-2-positive patient with severe respiratory syndrome treated with multiple doses of IL-6 inhibitors who presented with a perforated duodenal ulcer and underwent emergency surgery. During and after surgery, we tested for SARS-CoV-2 at the ulcer site and in the peritoneal fluid. RESULTS: The history of the patient allows for two possible interpretations of the pathogenesis of the duodenal ulcer, which could have been a stress ulcer, or a gastrointestinal ulcer associated to the use of IL-6 inhibitors. We also noticed that the ulcer site and peritoneal fluid repeatedly tested negative for SARS-CoV-2. Therefore, we reviewed the pertinent literature on gastrointestinal bleeding in patients with COVID-19 and on SARS-CoV-2 detection in the peritoneal fluid of surgical patients and discussed possible prevention strategies for bleeding and the actual risk of infection for the surgical staff. CONCLUSIONS: The first implication of this case is that the relation between repeated administration of IL-6 inhibitors and upper gastrointestinal bleeding and perforation must be investigated, and that the threshold for administering prophylactic proton pump inhibitors therapy should be carefully considered for patients with severe COVID-19. The second implication is that further testing should be performed on the peritoneal fluid of COVID-19 patients undergoing emergency surgical procedures to clarify the discordant results for the presence of SARS-CoV-2 in the peritoneal cavity and the possible risk of transmission to the surgical staff.

Risks of COVID-19 transmission in blood and serum during surgery A prospective cross-sectional study from a single dedicated COVID-19 center.

The present pandemic caused by the SARS COV-2 coronavirus is still ongoing, although it is registered a slowdown in the spread for new cases. The main environmental route of transmission of SARS-CoV-2 is through droplets and fomites or surfaces, but there is a potential risk of virus spread also in smaller aerosols during various medical procedures causing airborne transmission. To date, no information is available on the risk of contagion from the peritoneal fluid with which surgeons can come into contact during the abdominal surgery on COVID-19 patients. We have investigated the presence of SARS-CoV-2 RNA in the peritoneal cavity of patients affected by COVID-19, intraoperatively and postoperatively. KEY WORDS: Covid-19, Laparotomy, Surgery.

Absence of SARS-CoV-2 in the effluent of peritoneal dialysis patients.

The pandemic of respiratory disease (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is life-threatening in peritoneal dialysis (PD) patients. In PD patients with systemic viral infections, peritoneal effluent may be theoretically contaminated. We searched for the presence of SARS-CoV-2 genetic material by real-time reverse transcriptase-polymerase chain reaction assays in serial PD effluents of three PD infected patients. Nasopharyngeal swabs obtained at admission showed high viral load in all three patients, whereas none of the PD effluent specimen tested positive, even after dialysate concentration. Those results support at most a very low SARS-CoV-2 dissemination risk by the peritoneal effluent of PD patients. Imposing special disposal procedures, such as the instillation of hypochlorite in the drainage bags to prevent viral spread to health-care workers, are probably not required.

SARS-Cov-2 Was Not Found in the Peritoneal Fluid of an Asymptomatic Patient Undergoing Laparoscopic Appendectomy.

BACKGROUND: The safety of laparoscopic surgery in SARS-CoV-2 positive patients remains unclear. The presence of the virus within peritoneal fluid and the peritoneal tissues is not known. We report an asymptomatic COVID-19 positive patient who underwent laparoscopic appendectomy with negative peritoneal sampling for SARS-CoV-2. MATERIALS AND METHODS: During a standard 3 port laparoscopic surgery samples peritoneal fluid, peritoneal brushings, and surgical smoke plum were collected. Specific real-time reverse transcriptase-polymerase chain reaction targeting SARS-CoV-2 were used to detect the presence of the virus in the samples. RESULTS: SARS-CoV-2 was not detected on multiple samples of the peritoneum in an asymptomatic patient. CONCLUSIONS: SARS-CoV-2 was not found in the peritoneum of a single patient with asymptomatic infection. Further studies comparing SARS-CoV-2 surgical candidates are needed to address safety concerns.

COVID-19 not detected in peritoneal fluid: a case of laparoscopic appendicectomy for acute appendicitis in a COVID-19-infected patient.

PURPOSE: COVID-19 greatly affected millions and affected the way we practice with heightened posture in the way we treat surgical patients. Surgical consensus guidelines are recommending caution in the use of laparoscopy for the theoretical possibility of viral transmission from aerosolization of tissue and peritoneal fluid during surgery. However, there has yet to be proof of COVID-19 being present in peritoneal fluid, justifying the consensus statements. We aim to assess the presence of COVID-19 in peritoneal fluid. METHODS: We performed a laparoscopic appendicectomy for a COVID-19-infected patient with acute appendicitis. Peritoneal fluid and peritoneal washings were collected and sent for COVID-19 PCR. RESULTS: The peritoneal fluid sample collected on entry and at the end of the operation was negative for COVID-19 on PCR. The patient had an uneventful recovery from surgery. CONCLUSIONS: This case revealed that COVID-19 was not detected in peritoneal fluid and peritoneal washings in a patient infected with COVID-19. This study provides novel preliminary data in the investigation of COVID-19 transmission from laparoscopy-related aerosolization.

Unravelling the consequences of the bacteriophages in human samples.

Bacteriophages are abundant in human biomes and therefore in human clinical samples. Although this is usually not considered, they might interfere with the recovery of bacterial pathogens at two levels: 1) by propagating in the enrichment cultures used to isolate the infectious agent, causing the lysis of the bacterial host and 2) by the detection of bacterial genes inside the phage capsids that mislead the presence of the bacterial pathogen. To unravel these interferences, human samples (n = 271) were analyzed and infectious phages were observed in 11% of blood culture, 28% of serum, 45% of ascitic fluid, 14% of cerebrospinal fluid and 23% of urine samples. The genetic content of phage particles from a pool of urine and ascitic fluid samples corresponded to bacteriophages infecting different bacterial genera. In addition, many bacterial genes packaged in the phage capsids, including antibiotic resistance genes and 16S rRNA genes, were detected in the viromes. Phage interference can be minimized applying a simple procedure that reduced the content of phages up to 3 logs while maintaining the bacterial load. This method reduced the detection of phage genes avoiding the interference with molecular detection of bacteria and reduced the phage propagation in the cultures, enhancing the recovery of bacteria up to 6 logs.

SARS-CoV-2 Is Present in Peritoneal Fluid in COVID-19 Patients.

BACKGROUND: The excretion pathomechanisms of SARS-CoV-2 are actually unknown. No certain data exist about viral load in the different body compartments and fluids during the different disease phases. MATERIAL AND METHODS: Specific real-time reverse transcriptase-polymerase chain reaction targeting 3 SARS-CoV-e genes were used to detect the presence of the virus. RESULTS: SARS-CoV-2 was detected in peritoneal fluid at a higher concentration than in respiratory tract. CONCLUSION: Detection of SARS-CoV-2 in peritoneal fluid has never been reported. The present article represents the very first positive result describing the presence of the virus in peritoneal fluid during an emergency surgical procedure in a COVID-19 sick patient. This article thus represents a warning for increasing the level of awareness and protection for surgeon especially in emergency surgical setting.

Discrepancies between feline coronavirus antibody and nucleic acid detection in effusions of cats with suspected feline infectious peritonitis.

Intra-vitam diagnosis of feline infectious peritonitis (FIP) is a challenge for veterinary diagnosticians, since there are no highly specific and sensitive assays currently available. With the aim to contribute to fill this diagnostic gap, a total of 61 effusions from cats with suspected effusive FIP were collected intra-vitam for detection of feline coronavirus (FCoV) antibodies and RNA by means of indirect immunofluorescence (IIF) assay and real-time RT-PCR (qRT-PCR), respectively. In 5 effusions there was no evidence for either FCoV RNA or antibodies, 51 and 52 specimens tested positive by IIF and qRT-PCR, respectively, although antibody titres≥1:1600, which are considered highly suggestive of FIP, were detected only in 37 effusions. Three samples with high antibody levels tested negative by qRT-PCR, whereas 18 qRT-PCR positive effusions contained no or low-titre antibodies. qRT-PCR positive samples with low antibody titres mostly contained low FCoV RNA loads, although the highest antibody titres were detected in effusions with CT values>30. In conclusion, combining the two methods, i.e., antibody and RNA detection would help improving the intra-vitam diagnosis of effusive FIP.

Phase I Study of Oncolytic Vaccinia Virus GL-ONC1 in Patients with Peritoneal Carcinomatosis.

Purpose: Peritoneal carcinomatosis is common in advanced tumor stages or disease recurrence arising from gastrointestinal cancers, gynecologic malignancies, or primary peritoneal carcinoma. Because current therapies are mostly ineffective, new therapeutic approaches are needed. Here, we report on a phase I study designed to assess safety, MTD, and antitumor activity of intraperitoneal administration of oncolytic vaccinia virus GL-ONC1 in advanced stage peritoneal carcinomatosis patients.Patients and Methods: GL-ONC1 was administered intraperitoneally every 4 weeks for up to four cycles at three different dose levels (107-109 pfu) following a standard 3+3 dose escalation design. GL-ONC1 was infused via an indwelling catheter that enabled repetitive analyses of peritoneal fluid biopsies. The primary study objective was safety of GL-ONC1 according to Common Terminology Criteria for Adverse Events, version 4.0 (CTCAEv4.0).Results: Patients with advanced-stage peritoneal carcinomatosis (n = 7) or advanced peritoneal mesothelioma (n = 2) received 24 doses of GL-ONC1. Adverse events were limited to grades 1-3, including transient flu-like symptoms and increased abdominal pain, resulting from treatment-induced peritonitis. No DLT was reported, and the MTD was not reached. Furthermore, no signs of viral shedding were observed. Importantly, in 8 of 9 study patients, effective intraperitoneal infections, in-patient replication of GL-ONC1, and subsequent oncolysis were demonstrated in cycle 1. All patients developed neutralizing activities against GL-ONC1.Conclusions: GL-ONC1 was well tolerated when administered into the peritoneal cavity of patients with advanced stage peritoneal carcinomatosis. Efficient tumor cell infection, in-patient virus replication, and oncolysis were limited to treatment cycle 1 (ClinicalTrials.gov number, NCT01443260). Clin Cancer Res; 24(18); 4388-98. ©2018 AACR.

The nucleoside analog GS-441524 strongly inhibits feline infectious peritonitis (FIP) virus in tissue culture and experimental cat infection studies.

Feline infectious peritonitis (FIP) is a common and highly lethal coronavirus disease of domestic cats. Recent studies of diseases caused by several RNA viruses in people and other species indicate that antiviral therapy may be effective against FIP in cats. The small molecule nucleoside analog GS-441524 is a molecular precursor to a pharmacologically active nucleoside triphosphate molecule. These analogs act as an alternative substrate and RNA-chain terminator of viral RNA dependent RNA polymerase. We determined that GS-441524 was non-toxic in feline cells at concentrations as high as 100 uM and effectively inhibited FIPV replication in cultured CRFK cells and in naturally infected feline peritoneal macrophages at concentrations as low as 1 uM. We determined the pharmacokinetics of GS-441524 in cats in vivo and established a dosage that would sustain effective blood levels for 24 h. In an experimental FIPV infection of cats, GS-441524 treatment caused a rapid reversal of disease signs and return to normality with as little as two weeks of treatment in 10/10 cats and with no apparent toxicity.

Babesia spp. no líquido peritoneal em cão com ascite - relato de caso / Babesia spp. in the peritoneal fluid in dog with ascites - case report

Babesia canis é um protozoário cosmopolita que parasita eritrócitos de cães domésticos e selvagens. O diagnóstico é realizado mediante a observação direta do microrganismo em hemácias no esfregaço de sangue periférico, métodos sorológicos e técnicas moleculares. O objetivo deste trabalho é relatar pela primeira vez a presença de merozoítos de Babesia spp. no líquido peritoneal de um cão com ascite. No Hospital Veterinário da Universidade Federal de Viçosa, foi atendido um cão, macho, sem raça definida, de sete meses de idade, com histórico de emaciação, apatia e abaulamento abdominal. No exame físico, foram evidenciadas mucosas hipocoradas, ascite, sopro sistólico grau IV/V e taquipneia. Nos exames laboratoriais, evidenciou-se anemia normocítica/normocrômica, trombocitopenia e hipoproteinemia. No esfregaço sanguíneo, foram observadas estruturas intraeritrocitárias compatíveis com Babesia spp. A avaliação do líquido ascítico foi compatível com transudato modificado e observaram-se inúmeras estruturas intra e extracelulares compatíveis com merozoítas de Babesia spp. A presença de microrganismos intra e extracelular poderia estar relacionada a uma lesão no baço com extravasamento do conteúdo para a cavidade abdominal. A coleta do líquido peritoneal pode ser uma alternativa para o diagnóstico de babesiose quando o animal com suspeita da infecção apresentar ascite.(AU)

Babesia canis is a cosmopolitan protozoan that parasites erythrocytes of domestic and wild dogs. The diagnosis is performed by direct observation of the microorganism in red blood cells in the peripheral blood smear, serological methods and molecular techniques. The aim of this work is to report for the first time the presence of merozoites of Babesia spp. in the peritoneal fluid of a dog with ascites. At the Veterinary Hospital of the Federal University of Viçosa was attended a Mixed-breed seven month old dog, male, with history of emaciation, apathy and abdominal bulging. Pale mucous membranes, ascites, grade IV/V systolic murmur and tachypnea were evidenced in the physical examination. Laboratory tests revealed normocytic/normochromic anemia, thrombocytopenia, and hypoproteinemia. Intra-erythrocyte structures compatible with Babesia spp. were observed in the blood smear. The evaluation of the ascites fluid was compatible with modified transudate where numerous intra and extracellular structures compatible with Babesia spp. merozoites were observed. The presence of intra and extracellular microorganisms could be related to an injury of the spleen with extravasation of the contents into the abdominal cavity. Collection of the peritoneal fluid may be an alternative for the diagnosis of babesiosis when the animal with suspected infection has ascites.(AU)

Sensitivity and specificity of a real-time reverse transcriptase polymerase chain reaction detecting feline coronavirus mutations in effusion and serum/plasma of cats to diagnose feline infectious peritonitis.

BACKGROUND: Feline coronavirus (FCoV) exists as two pathotypes, and FCoV spike gene mutations are considered responsible for the pathotypic switch in feline infectious peritonitis (FIP) pathogenesis. The aim of this study was to evaluate sensitivity and specificity of a real-time reverse transcriptase polymerase chain reaction (RT-PCR) specifically designed to detect FCoV spike gene mutations at two nucleotide positions. It was hypothesized that this test would correctly discriminate feline infectious peritonitis virus (FIPV) and feline enteric coronavirus (FECV). METHODS: The study included 63 cats with signs consistent with FIP. FIP was confirmed in 38 cats. Twenty-five control cats were definitively diagnosed with a disease other than FIP. Effusion and/or serum/plasma samples were examined by real-time RT-PCR targeting the two FCoV spike gene fusion peptide mutations M1058 L and S1060A using an allelic discrimination approach. Sensitivity, specificity, negative and positive predictive values including 95% confidence intervals (95% CI) were calculated. RESULTS: FIPV was detected in the effusion of 25/59 cats, one of them being a control cat with chronic kidney disease. A mixed population of FIPV/FECV was detected in the effusion of 2/59 cats; all of them had FIP. RT-PCR was negative or the pathotype could not be determined in 34/59 effusion samples. In effusion, sensitivity was 68.6% (95% CI 50.7-83.2), specificity was 95.8% (95% CI 78.9-99.9). No serum/plasma samples were positive for FIPV. CONCLUSIONS: Although specificity of the test in effusions was high, one false positive result occurred. The use of serum/plasma cannot be recommended due to a low viral load in blood.

HCV-RNA quantification in liver bioptic samples and extrahepatic compartments, using the abbott RealTime HCV assay.

BACKGROUND & AIMS: We evaluated the performance of a rapid method to quantify HCV-RNA in the hepatic and extrahepatic compartments, by using for the first time the Abbott RealTime HCV-assay. METHODS: Non-tumoral (NT), tumoral (TT) liver samples, lymph nodes and ascitic fluid from patients undergoing orthotopic-liver-transplantation (N=18) or liver resection (N=4) were used for the HCV-RNA quantification; 5/22 patients were tested after or during direct acting antivirals (DAA) treatment. Total RNA and DNA quantification from tissue-biopsies allowed normalization of HCV-RNA concentrations in IU/µg of total RNA and IU/106 liver-cells, respectively. RESULTS: HCV-RNA was successfully quantified with high reliability in liver biopsies, lymph nodes and ascitic fluid samples. Among the 17 untreated patients, a positive and significant HCV-RNA correlation between serum and NT liver-samples was observed (Pearson: rho=0.544, p=0.024). Three DAA-treated patients were HCV-RNA "undetectable" in serum, but still "detectable" in all tested liver-tissues. Differently, only one DAA-treated patient, tested after sustained-virological-response, showed HCV-RNA "undetectability" in liver-tissue. CONCLUSIONS: HCV-RNA was successfully quantified with high reliability in liver bioptic samples and extrahepatic compartments, even when HCV-RNA was "undetectable" in serum. Abbott RealTime HCV-assay is a good diagnostic tool for HCV quantification in intra- and extra-hepatic compartments, whenever a bioptic sample is available.

Expression profiles of immune mediators in feline Coronavirus-infected cells and clinical samples of feline Coronavirus-positive cats.

BACKGROUND: There are two biotypes of feline coronavirus (FCoV): the self-limiting feline enteric coronavirus (FECV) and the feline infectious peritonitis virus (FIPV), which causes feline infectious peritonitis (FIP), a fatal disease associated with cats living in multi-cat environments. This study provides an insight on the various immune mediators detected in FCoV-positive cats which may be responsible for the development of FIP. RESULTS: In this study, using real-time PCR and multiplex bead-based immunoassay, the expression profiles of several immune mediators were examined in Crandell-Reese feline kidney (CRFK) cells infected with the feline coronavirus (FCoV) strain FIPV 79-1146 and in samples obtained from FCoV-positive cats. CRFK cells infected with FIPV 79-1146 showed an increase in the expression of interferon-related genes and pro-inflammatory cytokines such as MX1, viperin, CXCL10, CCL8, RANTES, KC, MCP1, and IL8. In addition, an increase in the expression of the above cytokines as well as GM-CSF and IFNγ was also detected in the PBMC, serum, and peritoneal effusions of FCoV-positive cats. Although the expression of MX1 and viperin genes was variable between cats, the expression of these two genes was relatively higher in cats having peritoneal effusion compared to cats without clinically obvious effusion. Higher viral load was also detected in the supernatant of peritoneal effusions compared to in the plasma of FCoV-positive cats. As expected, the secretion of IL1ß, IL6 and TNFα was readily detected in the supernatant of peritoneal effusions of the FCoV-positive cats. CONCLUSIONS: This study has identified various pro-inflammatory cytokines and interferon-related genes such as MX1, viperin, CXCL10, CCL8, RANTES, KC, MCP1, IL8, GM-CSF and IFNγ in FCoV-positive cats. With the exception of MX1 and viperin, no distinct pattern of immune mediators was observed that distinguished between FCoV-positive cats with and without peritoneal effusion. Further studies based on definitive diagnosis of FIP need to be performed to confirm the clinical importance of this study.

Human herpesvirus type 8 in tuberculosis patients with effusion.

BACKGROUND: Many patients with tuberculosis (TB) are seropositive for human herpesvirus type 8 (HHV-8), and many patients with primary effusion lymphoma have high levels of HHV-8 DNA in their effusions. However, the status of HHV-8 in the effusions of patients with TB remains unclear. METHODS: Blood samples were collected from 129 patients with pulmonary TB and 129 age- and sex-matched healthy controls. Forty of the TB patients had pleural or peritoneal effusions, and 38 of these effusions were available. Both blood and effusion samples were analyzed for lymphocyte and monocyte counts and/or HHV-8 antibodies and DNA. RESULTS: TB patients with or without effusions had significantly greater HHV-8 seropositivity (p = 0.009) and titers of HHV-8 antibodies (p = 0.005) than healthy controls. The seropositivity and blood titers of HHV-8 antibodies were similar in TB patients with and without effusions. Among TB patients with effusions, similar percentages had seropositive plasma and seropositive effusions. Plasma samples of 6 TB patients, but none of the healthy controls, were positive for HHV-8 DNA (p = 0.03). TB patients with or without effusions had lower blood lymphocyte counts and higher blood monocyte counts than healthy controls (p < 0.0001 for both). TB patients with effusions had significantly lower blood lymphocyte counts than those without effusions (p = 0.035). CONCLUSIONS: HHV-8 had similar seroprevalence in TB patients with and without effusions. However, TB patients with effusions had lower blood lymphocyte counts than those without effusions.