•We explore cardiac/inflammatory biomarkers to predict in-hospital mortality in endocarditis.•Troponin concentration measured at admission showed the highest accuracy for mortality ...prediction.•Inflammatory biomarkers had better accuracy at the 7th day than at admission.
Evidence regarding biomarkers for risk prediction in patients with infective endocarditis (IE) is limited. We aimed to investigate the value of a panel of biomarkers for the prediction of in-hospital mortality in patients with IE.
Between 2016 and 2018, consecutive IE patients admitted to the emergency department were prospectively included. Blood concentrations of nine biomarkers were measured at admission (D0) and on the seventh day (D7) of antibiotic therapy: C-reactive protein (CRP), sensitive troponin I (s-cTnI), procalcitonin, B-type natriuretic peptide (BNP), neutrophil gelatinase-associated lipocalin (NGAL), interleukin 6 (IL6), tumor necrosis factor α (TNF-α), proadrenomedullin, alpha-1-acid glycoprotein, and galectin 3. The primary endpoint was in-hospital mortality.
Among 97 patients, 56% underwent cardiac surgery, and in-hospital mortality was 27%. At admission, six biomarkers were independent predictors of in-hospital mortality: s-cTnI (OR 3.4; 95%CI 1.8–6.4; P<0.001), BNP (OR 2.7; 95%CI 1.4–5.1; P=0.002), IL-6 (OR 2.06; 95%CI 1.3–3.7; P=0.019), procalcitonin (OR 1.9; 95%CI 1.1–3.2; P=0.018), TNF-α (OR 1.8; 95%CI 1.1–2.9; P=0.019), and CRP (OR 1.8; 95%CI 1.0–3.3; P=0.037). At admission, S-cTnI provided the highest accuracy for predicting mortality (area under the ROC curve: s-cTnI 0.812, BNP 0.727, IL-6 0.734, procalcitonin 0.684, TNF-α 0.675, CRP 0.670). After 7 days of antibiotic therapy, BNP and inflammatory biomarkers improved their performance (s-cTnI 0.814, BNP 0.823, IL-6 0.695, procalcitonin 0.802, TNF-α 0.554, CRP 0.759).
S-cTnI concentration measured at admission had the highest accuracy for mortality prediction in patients with IE.
Heart transplant (HT) recipients may be at higher risk of acquiring SARS-CoV-2 infection and developing critical illness. The aim of this study is to describe characteristics and outcomes of HT ...recipients infected by SARS-COV-2, from a high-volume transplant center.
We have described data of all adult HT recipients with confirmed coronavirus disease 2019 by RT-PCR in nasopharyngeal samples from April 5, 2020, to January 5, 2021. Outcomes and follow-up were recorded until February 5, 2021.
Forty patients were included. Twenty-four patients (60%) were men; the median age was 53 (40-60) y old; median HT time was 34 mo; and median follow-up time 162 d. The majority needed hospitalization (83%). Immunosuppressive therapy was reduced/withdrawn in the majority of patients, except from steroids, which were maintained. Seventeen patients (42.5%) were classified as having severe disease according to the ordinal scale developed by the World Health Organization Committee. They tended to have lower absolute lymphocyte count (P < 0.001) during follow-up when compared with patients with mild disease. Thirty-day mortality was 12.5%. However, a longer follow-up revealed increased later mortality (27.5%), with median time to death around 35 d. Bacterial nosocomial infections were a leading cause of death. Cardiac allograft rejection (10%) and ventricular dysfunction (12.5%) were also not negligible.
Major findings of this study corroborate other cohorts' results, but it also reports significant rate of later events, suggesting that a strict midterm surveillance is advisable to HT recipients with coronavirus disease 2019.
Horizontal transmission of fluconazole-resistant
(FRCP) through healthcare workers' hands has contributed to the occurrence of candidemia outbreaks worldwide. Since the first COVID-19 case in Brazil ...was detected in early 2020, hospitals have reinforced hand hygiene and disinfection practices to minimize SARS-CoV-2 contamination. However, a Brazilian cardiology center, which shares ICU patients with a cancer center under a FRCP outbreak since 2019, reported an increased FRCP candidemia incidence in May 2020. Therefore, the purpose of this study was to investigate an inter-hospital candidemia outbreak caused by FRCP isolates during the first year of the COVID-19 pandemic in Brazil.
bloodstream isolates obtained from the cancer (
= 35) and cardiology (
= 30) centers in 2020 were submitted to microsatellite genotyping and fluconazole susceptibility testing. The
gene of all isolates from the cardiology center was sequenced and compared to the corresponding sequences of the FRCP genotype responsible for the cancer center outbreak in 2019. Unprecedentedly, most of the FRCP isolates from the cardiology center presented the same genetic profile and Erg11-Y132F mutation detected in the strain that has been causing the persistent outbreak in the cancer center, highlighting the uninterrupted horizontal transmission of clonal isolates in our hospitals during the COVID-19 pandemic.
Introdution
COVID-19 is associated with an increased risk of thrombotic events. However, the contribution of platelet reactivity (PR) to the aetiology of the increased thrombotic risk associated with ...COVID-19 remains unclear. Our aim was to evaluate PR in stable patients diagnosed with COVID-19 and hospitalized with respiratory symptoms (mainly dyspnoea and dry cough), in comparison with a control group comprised of non-hospitalized healthy controls.
Methods
Observational, case control study that included patients with confirmed COVID-19 (COVID-19 group,
n
= 60) and healthy individuals matched by age and sex (control group,
n
= 60). Multiplate electrode aggregometry (MEA) tests were used to assess PR with adenosine diphosphate (MEA-ADP, low PR defined as < 53 AUC), arachidonic acid (MEA-ASPI, low PR < 86 AUC) and thrombin receptor-activating peptide 6 (MEA-TRAP, low PR < 97 AUC) in both groups.
Results
The rates of low PR with MEA-ADP were 27.5% in the COVID-19 group and 21.7% in the control group (OR = 1.60,
p
= 0.20); with MEA-ASPI, the rates were, respectively, 37.5% and 22.5% (OR = 3.67,
p
< 0.001); and with MEA-TRAP, the incidences were 48.5% and 18.8%, respectively (OR = 9.58,
p
< 0.001). Levels of
d
-dimer, fibrinogen, and plasminogen activator inhibitor 1 (PAI-1) were higher in the COVID-19 group in comparison with the control group (all
p
< 0.05). Thromboelastometry was utilized in a subgroup of patients and showed a hypercoagulable state in the COVID-19 group.
Conclusion
Patients hospitalized with non-severe COVID-19 had lower PR compared to healthy controls, despite having higher levels of
d
-dimer, fibrinogen, and PAI-1, and hypercoagulability by thromboelastometry.
Trial Registration
ClinicalTrials.gov identifier, NCT04447131.
Summary Objectives Cytomegalovirus (CMV) is a ubiquitous virus and its reactivation may lead to CMV end-organ disease (CMV EOD) in immunocompromised patients and also in immunocompetent patients when ...they are critically ill. We aimed to investigate the frequency and the clinical features of proven CMV EOD in previously non-immunosuppressed patients admitted to our institution. Methods From January 2000 to March 2013, the records of all patients with a histopathological diagnosis of CMV EOD at our teaching hospital were reviewed retrospectively. CMV EOD was diagnosed histologically by the identification of true cytomegalic viral inclusion involving endothelial, stromal, and/or epithelial cells on hematoxylin and eosin staining, and was subsequently confirmed by immunohistochemistry using specific antibody against CMV antigens. Immunocompromised patients were excluded. Results CMV EOD manifesting as colitis was diagnosed in 14 previously immunocompetent intensive care unit (ICU) patients. The mean age of the patients was 64 years. All had co-morbidities and developed shock before CMV EOD. The major manifestation was gastrointestinal bleeding. The in-hospital mortality rate was 71.4% despite specific treatment with ganciclovir. Conclusions Despite being a rare condition, lower gastrointestinal bleeding in this profile of ICU patients could be the clinical manifestation of CMV colitis, and intensivists should be alert to this condition.
On 12 June 2020, Brazil reached the second position worldwide in the number of COVID-19 cases. Authorities increased the number of tests performed, including the identification of antibodies to ...SARS-CoV-2 (IgG, IgA, and IgM). There was an overflooding of the market with several tests, and the presence of possible false-positive results became a challenge. The purpose of this study was to describe the seroprevalence and immunoglobulin blood levels in a group of asymptomatic individuals using the reference levels provided by the manufacturer.
Levels of IgG and IgA antibodies to SARS-CoV-2 were determined in blood serum by the same ELISA (enzyme-linked immunoassay) test. Patients must be free of symptoms.
From 20 to 22 May 2020, 938 individuals were tested. There were 441 (47%) men, age 53 years (interquartile range (IQR) = 39-63.2). The sample included 335 (35.7%) subjects aged ≥60 years old. Subjects with a positive test were 54 (5.8%) for IgG and 96 (10.2%) for IgA and 42 (4.5%) for both IgG and IgA. The prevalence of IgG and IgA positive test was not different in men and women and not different in individuals under 60 and over 60 years of age. Conversely, analysing only individuals with positive tests, the levels of IgG in positive subjects were significantly higher than those with an IgA positive test, 3.00 (IQR = 1.68-5.65), and 1.95 (IQR = 1.40-3.38), respectively;
= 0.017. Additionally, individuals with isolated IgA positive tests had significantly lower levels of IgA than those with both IgA and IgG positive tests: 1.95 (IQR = 1.60-2.40) and 3.15 (IQR = 2.20-3.90), respectively,
= 0.005. These latter data suggest that IgA shows a deviation of the distribution to the left in comparison to IgG distribution data. Indeed, many subjects reported as IgA positive had immunoglobulin levels slightly elevated.
In conclusion, we strongly suggest caution in the interpretation of IgA test results. This recommendation is more important for those with positive IgA just above the reference level.
IntroductionInfective endocarditis (IE) is a disease with high in-hospital and longer term mortality.HypothesisA validated risk model of prognostic variables may improve clinical risk ...stratification.MethodsUsing a large, multinational, prospective registry of definite IE (International Collaboration on Endocarditis-Prospective Cohort Study, 2000-2006, n=4066), a model to predict 6-month survival was developed by Cox proportional hazard modeling with inverse probability weighting for surgery treatment and internally validated by bootstrapping method. This model was externally validated in an independent prospective registry (ICE-PLUS, 2008-2012, n=1582).ResultsSix-month mortality was 964/4066 (23.7%) in ICE-PCS and 346/1582 (21.9%) in ICE-PLUS cohorts. Surgery during the index hospitalization was performed in 49.5% and 56.0% of the cohorts, respectively. In the derivation model, variables related to host factors (age, dialysis), IE characteristics (prosthetic or nosocomial IE, causative organism, left-sided valve vegetation), and IE complications (severe heart failure, stroke, paravalvular complication, and persistent bacteremia) were independently associated with 6-month mortality, and surgery was associated with a lower risk of mortality (Harrell’s C statistic=0.715). In the validation model, these variables had similar hazard ratios (Harrell’s C statistic=0.682), with a similar, independent benefit of surgery (HR=0.74 95% CI, 0.62-0.89). Both models differentiated quintiles of risk for 6-month mortality. A simplified risk model was developed by weight-adjustment of these variables.ConclusionsSix-month mortality after IE is approximately 25% and predicted by host factors, IE characteristics, and IE complications. Surgery during the index hospitalization is associated with lower mortality. A simplified risk model may be used to identify specific risk sub-groups in IE.
Neutropenic patients are at risk of the development of hyalohyphomycosis and mucormycosis. Correct identification is essential for the initiation of the specific treatment, but concomitant mold ...infections are rarely reported. We report one unprecedented case of concomitant mucormycosis and fusariosis in a neutropenic patient with acute myeloid leukemia. The patient developed rhino-orbital infection by
Rhizopus arrhizus
and disseminated infection by
Fusarium solani
. The first culture from a sinus biopsy grew
Rhizopus
, which was consistent with the histopathology report of mucormycosis. A second sinus biopsy collected later during the patient’s clinical deterioration was reported as hyalohyphomycosis, and the culture yielded
F.
solani
. Due to the discordant reports, the second biopsy was reviewed and two hyphae types suggestive of both hyalohyphomycetes and mucormycetes were found. The dual mold infection was confirmed by PCR assays from paraffinized tissue sections. Increased awareness of the existence of dual mold infections in at-risk patients is necessary. PCR methods in tissue sections may increase the diagnosis of dual mold infections. In case of sequential biopsies showing discrepant results, mixed infections have to be suspected.
We report a case of a 67 year-old-male patient admitted to the intensive care unit in the post-coronary bypass surgery period who presented cardiogenic shock, acute renal failure and three episodes ...of sepsis, the latter with pulmonary distress at the 30th post-operative day. The patient expired within five days in spite of treatment with vancomycin, imipenem, colistimethate and amphotericin B. At autopsy severe adenovirus pneumonia was found. Viral pulmonary infections following cardiovascular surgery are uncommon. We highlight the importance of etiological diagnosis to a correct treatment approach.
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