Inflammatory Response Assessment in Patients with COVID-19 Under Extracorporeal Membrane Oxygenation Support.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO), could be extremely helpful in the management of COVID-19 patients with refractory hypoxemic respiratory failure; however, to date, evidence on the true effecttiveness of ECMO in the COVID19 setting still hangs in the balance. METHODS: This was a prospective cohort study of 39 COVID-19 patients admitted to the intensive care unit (ICU) in an experienced ECMO center at a tertiary hospital during March/April 2020. Among the recruited participants, 10 (25.6%) required ECMO (ICU-ECMO group) and 29 (74.4%) did not have ECMO support (ICU group). Immunological parameters were assessed both at ICU admission and on a daily basis for 7 consecutive days. RESULTS: The absolute lymphocyte count increased significantly in the ICU-ECMO group compared to the ICU group in which it remained relatively stable: ß for the time variable was 127.1 [95% CI 68.9 - 185.3], p < 0.001 and for the interaction term -141.36 [-208.95 - -73.77], p < 0.001. On the other hand, globally, no significant differences were observed over time for the lymphocyte percentage, although it was higher in the ICU patients. Neutrophil counts were overall higher in the ICU-ECMO group (ß -4,275.38 [-6,845.21 - 1,705.55], p = 0.001). In regard to neutrophil percentage, a significant decrease over time was reported (ß -1.76 [-3.16 - -0.36], p = 0.014), namely in the ICU-ECMO group (ß for the interaction 2.09 [0.45 - 3.73], p = 0.013). CONCLUSIONS: Herein, we found ECMO support seems to provide a less aggressive immune response in COVID-19 patients with severe and refractory respiratory dysfunction.

Vitek® MS v3.0 System in the Identification of Filamentous Fungi.

Infections caused by filamentous fungi are rising in incidence and became a serious health concern. Their rapid and reliable identification in the clinical laboratory is essential for an early and accurate diagnosis to guide timely therapy. Matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) has been reported as a rapid and reliable method for identification of bacteria and yeasts isolated from clinical samples. However, it has less used for molds identification. The aim of this study was to evaluate Vitek® MS (a MALDI-TOF MS system) ability to identify molds and differentiate species within a complex. A collection of 90 filamentous fungi, 70 clinical and 20 environmental isolates, was studied by morphological and molecular methods and by Vitek® MS. Seventy-four isolates (82.2%) were identified using Vitek® MS v3.0 at Genus/Complex/Species group level; within these, 47/74 (63.5%) were correctly identified at species level and only one was misidentified. In contrast, 16/90 isolates (17.8%) were not identified, of which 13 were not present in the database. Results here expressed favor Vitek® MS v3.0 as a very useful system for identification of most common clinical isolates of filamentous fungi. Accordingly, it may be an important tool for clinical microbiology laboratories in their task to answer to clinicians, adequately and rapidly, helping in proper patient's management.

Vibrio cholerae non-O1 and non-O139 bacteremia in a non-traveler Portuguese cirrhotic patient: first case report.

Bacteremia due to Vibrio cholerae non-O1 and non-O139 is a rare condition and potentially fatal. We report a case of bacteremia due to V. cholerae non-O1 and non-O139 in a Portuguese male with Hepatitis C cirrhosis, admitted due to acute diarrhea, after consuming shrimp. He had no recent travels. To our knowledge, this is the first reported case of bacteremia due to V. cholerae non-O1 and non-O139 in Portugal.

A 10-Year Retrospective Clinical Analysis of Fungal Keratitis in a Portuguese Tertiary Centre.

PURPOSE: To determine the microbiological profile, risk factors, treatment and surgical intervention rates of fungal keratitis at a tertiary referral centre. METHODS: A retrospective review of microbiological and medical records from hospitalised patients treated for fungal keratitis at Centro Hospitalar Universitário de São João from 2009 to 2019 was conducted. RESULTS: Overall, 43 patients were included in our study. The mean age of patients was 63.7 years and 46.5% were men. In culture were isolated 22 (51.2%) filamentous fungi and 21 (48.8%) yeast. Candida species (n = 20, 46.5%), Fusarium species (n = 10, 23.4%) and Aspergillus species (n = 4, 9.3%) were the most common isolated species. Important risk factors were contact lens use (n = 24, 55.8%), long-term users of topical corticosteroids (n = 19, 44.2%) and previous keratitis (n = 19, 44.2%). Yeast isolates had a statistically significant higher prevalence in long-term users of topical corticosteroids compared to filamentous ones (p = 0.043). Twenty-four cases (55.8%) required surgical intervention, of which 23 cases underwent therapeutic penetrating keratoplasty. Ocular complications, such as evisceration was noted in 12 patients (27.9%) and endophthalmitis in 5 (11.6%). No statistically significant changes of best corrected visual acuity (BCVA) were found after treatment (p = 0.687). CONCLUSION: Most patients with fungal keratitis have associated risk factors. Filamentous and yeast species have equally prevalent etiologies. In general, our results mirror how difficult and challenging the approach and treatment of fungal keratitis could be.

Aspergillus Species and Antifungals Susceptibility in Clinical Setting in the North of Portugal: Cryptic Species and Emerging Azoles Resistance in A. fumigatus.

Aspergillus spp. are agents of a broad-spectrum of diseases among humans. Their growing resistance to azoles, the cornerstone in the management of human aspergillosis, is a worrisome problem around the world. Considering lack of data from Portugal on this topic, particularly from the northern region, a retrospective surveillance study was planned to assess frequency of cryptic Aspergillus species and azoles resistance. A total of 227 clinical isolates, mainly from the respiratory tract (92.1%), collected from three hospitals serving a population of about three million people, were studied for their epidemiology and antifungal susceptibility patterns determined by the E.DEF.9.3 protocol of EUCAST. Employing molecular methods, seven Aspergillus complexes were identified; Aspergillus fumigatus sensu stricto was the most frequent isolate (86.7%). A 7.5% prevalence of cryptic species was found; A. welwitschiae (A. niger complex-3.1%) and A. lentulus (A. fumigatus complex-2.2%) were the most frequent. Amongst cryptic species, it was found a percentage of resistance to voriconazole, posaconazole and isavuconazole of 47.1, 82.4, and 100%, respectively. Five A. fumigatus sensu stricto showed pan-azole resistance. Sequencing their cyp51A gene revealed the presence of one isolate with TR46/Y121F/T289A mutation and two isolates with TR34/L98H mutation. This study emphasizes the need to identify strains to the species level and to evaluate their antifungal susceptibility in all human originated Aspergillus spp. isolates, particularly those from invasive aspergillosis.

Beauveria bassiana keratitis in bullous keratopathy: antifungal sensitivity testing and management.

PURPOSE: Beauveria bassiana is a ubiquitous fungus available as an insecticide. In humans, it has limited virulence; to our knowledge, only 3 cases of invasive disease and 10 cases of keratitis have been documented. METHODS AND RESULTS: We report the first case of B bassiana keratitis in a patient with aphakic bullous keratopathy. The fungal keratitis proved to be highly resistant to topical clotrimazole. Molecular identification was based on DNA sequence analysis. The minimal inhibitory concentrations (MIC) obtained were 2 µg/mL for voriconazole, 0.250 µg/mL for posaconazole, and >128 µg/mL for fluconazole; amphotericin B MIC was >16 µg/mL. In the absence of clinical improvement, a penetrating keratoplasty (PK) was performed. The patient was discharged on topical and systemic voriconazole and prednisolone 40 mg PO/day. The eye remained calm with a transparent cornea and clear anterior chamber. CONCLUSIONS: B bassiana keratitis is extremely rare, with only a few cases reported. Its risk factors are unknown. We report the first case in a patient with aphakic bullous keratopathy, which proved highly resistant to antifungal therapy (antifungal susceptibility results are presented). A PK was necessary for clinical improvement. A review of the literature is performed in an effort to define therapeutic strategies.