Respiratory virus infections, such as influenza A, cause significant morbidity in hematopoietic stem cell transplantation (HSCT) recipients. The clinical characteristics and impact of infection with the novel H1N1 virus in this patient population is not yet well defined, however. HSCT recipients diagnosed with proven or probable H1N1 during the 2009 pandemic were identified and charts were retrospectively reviewed with analysis of clinical descriptions, risk factors, diagnosis, treatments, and outcomes. Twenty-seven patients from two medical centers were identified. Fever and cough were the most common presenting symptoms. The incidence of influenza lower respiratory tract infection (LRTI) was 52% (14/27). Compared with patients with LRTI, those with influenza upper respiratory tract infection (URTI) were more likely to have a classic influenza-like syndrome. Compared to patients with URTI, those with LRTI were started on antiviral therapy significantly later after symptom onset (3.0 days vs 6.58 days after onset of symptoms; P = .03; 95% confidence interval [CI], 0.29-6.8). Overall influenza-related 30-day mortality was 22% (6/27), and that in patients with LRTI was 43% (6/14). Chronic steroid use (≥20 mg/day of prednisone equivalent) at the time of presentation was associated with LRTI (P = .006) and mortality (P = .003) on univariate analysis. Five cases were hospital-acquired. In this first season of the novel H1N1 pandemic, infection in HSCT often presented as an atypical severe illness with a high incidence of LRTI and high mortality.
A 56 year-old woman presented with new onset focal seizure with a history of bronchiectasis. Brain abscess was diagnosed by magnetic resonance. She was confirmed to be immunocompetent and had histoplasmosis, tuberculosis, and infective endocarditis ruled out. Nocardia sp. was isolated from the brain abscess and identified as Nocardia abscessus complex by 16S rRNA sequencing. She was discharged on trimethoprim/sulfamethoxazole. Nocardia sp. is a cause of brain abscesses in patients with underlying pulmonary structural disease like bronchiectasis. Nocardia identification is of paramount importance as it is not treated with empiric antimicrobial therapy.
Background
COVID-19, caused by SARS-CoV-2, has emerged as a global public health emergency and has been the main cause of intensive care admission during the pandemic. Invasive pulmonary aspergillosis (IPA) superinfection has been reported in case series of critically ill patients. Mexico has been widely affected by SARS-CoV-2. We present a case series of COVID-19-associated IPA at a teaching hospital in Mexico City.
Methods
We performed a retrospective analysis of COVID-19 patients admitted to the ABC Medical Center from March 13 to June 1, 2020. Only those with severe or critical COVID-19 were hospitalized. Patients with a diagnosis of putative IPA were analyzed. SARS-CoV-2 was diagnosed by Real-Time PCR from nasopharyngeal swabs. Aspergillus antigen testing in tracheal aspirate and serum was done with Aspergillus-specific galactomannoprotein (GP) ELISA (Euroimmun Medizinische Labordiagnostika).The study was approved by the hospital ethics committee.
Results
Among the 47 admitted patients who required invasive mechanical ventilation (IMV), we identified seven (14.9%) cases of IPA. The mean age was 59.7 ± 17.8 years and five were male. All our patients had comorbidities, but none were under previous immunosuppressive treatment. All had critical COVID-19 pneumonia requiring IMV. All but one patient received corticosteroids, and five patients were treated with tocilizumab before IPA diagnosis. Putative IPA was diagnosed in six cases (86%) by a positive GP in tracheal aspirate, additionally in one of these, the tracheal aspirate culture also grew Aspergillus niger. The remaining one (14%) had a positive serum GP. The median time from COVID-19 to IPA diagnosis was 10 days. There were five bacterial co-infections, three with Pseudomonas aeruginosa, one with Stenotrophomonas maltophilia, and one with Mycobacterium tuberculosis. Six patients were treated with isavuconazole and one voriconazole. As of June 17, 2020, three patients had died, two patients had been discharged, and two were still in the intensive care unit receiving IMV.
Aspergillus niger isolated from a tracheal aspirate of a critically-ill COVID-19 patient
Conclusion
COVID-19-associated IPA had a lower prevalence than previously reported in other series. However, it appears to be linked to high mortality and could be associated with other bacterial coinfections.
Disclosures
All Authors: No reported disclosures
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