A 27-year-old woman, who had emigrated from Sierra Leone 5 years prior, presented with worsening headaches of 3-month duration. Magnetic resonance imaging of the brain revealed a lobulated mass lesion with central necrosis in the right parietal and occipital lobes. Biopsy was performed, and histopathology revealed multiple granulomas. Although acid-fast stain of the tissue was negative, gene probe showed Mycobacterium tuberculosis complex, and culture revealed Mycobacterium africanum. This species is rare in the United States, and to the best of our knowledge, this is the first reported case of M. africanum causing a brain mass.
We describe here the first case of Moraxella lacunata causing septicemia and acute tubular necrosis in an immunocompetent patient. A 34-year-old white man presented with fever, chills, and rigors for 5 days. Physical examination was significant for bibasilar lung crackles. His blood urea nitrogen and creatinine were significantly elevated at 72 and 8.7 mg/dL, respectively. His white blood cell count was 18,000/μL with 26% bands, and urine sediment showed muddy brown casts, coarse granular casts, 5 to 10 white blood cells, and 10 to 20 red blood cells. Echocardiogram was within normal limits with no evidence of endocarditis. Stool cultures grew normal enteric flora, and no ova and parasites were identified. Hepatitis serologies and autoimmune workup for renal failure were negative. A blood culture grew M. lacunata and was appropriately treated. Subsequently, renal failure resolved at the time of discharge.
Abstract Background Antibiotic-resistant infections are one of the greatest public health issues with more than 2 million infections and 23,000 deaths per year in the United States. Reducing inappropriate antibiotic use is essential to reduce both antibiotic resistance and adverse events. The most important modifiable risk factor for antibiotic resistance is inappropriate prescribing of antibiotics. At least 30% of outpatient antibiotic prescriptions in the United States are unnecessary. We aimed to pilot our outpatient antimicrobial stewardship initiative to track and reduce antibiotic prescriptions among adult patients presenting with common acute respiratory infections in our hospital’s outpatient primary care settings. Methods A retrospective and prospective cohort study from October, 2017 to March, 2019. Implemented a robust outpatient antimicrobial stewardship initiative with a dedicated team and data analyst based on CDC core elements for outpatient antimicrobial stewardship and a prior UHF initiative. Data of common respiratory tract infections and the respective rates of antibiotic prescriptions from 3 adult primary care sites were collected from the EHR. Serials of educational interventions were performed between June, 2018 to September, 2018. We disseminated resources from the CDC and DOH like brochures, posters, viral prescription pads, pocket guidelines, grand rounds and electronic lectures for providers and periodic provider feedback reports. Results Our findings revealed that the physician compliance rate of antibiotics not prescribed for common respiratory tract infections remarkably improved from 72% to 85% after implementing our interventions (Figure 1). The chi-square test showed 40, and P value is 0.000034 which is less than 0.05. Thus, we are 95% confident that there is a significant association between our interventions and reduction of inappropriate antibiotic use (Figure 2). Conclusion Introduction of a robust and multifaceted Outpatient Antimicrobial Stewardship initiative with a dedicated team can substantially decrease outpatient antibiotic prescription rates for respiratory tract infections in metropolitan community hospital-based primary care settings. Disclosures All authors: No reported disclosures.
Abstract Background New York City emerged as the Epicenter for Covid-19 due to novel Coronavirus SARS-CoV-2 soon after it was declared a Global Pandemic in early 2020 by the WHO. Covid-19 presents with a wide spectrum of illness from asymptomatic to severe respiratory failure, shock, multiorgan failure and death. Although the overall fatality rate is low, there is significant mortality among hospitalized patients. There is limited information exploring the impact of Covid-19 in community hospital settings in ethnically diverse populations. We aimed to identify risk factors for Covid-19 mortality in our institution. Methods We conducted a retrospective cohort study of hospitalized in our institution for Covid 19 from March 1st to June 21st 2020. It comprised of 425 discharged patients and 245 expired patients. Information was extracted from our EMR which included demographics, presenting symptoms, and laboratory data. We propensity matched 245 expired patients with a concurrent cohort of discharged patients. Statistically significant covariates were applied in matching, which included age, gender, race, body mass index (BMI), diabetes mellitus, and hypertension. The admission clinical attributes and laboratory parameters and outcomes were analyzed. Results The mean age of the matched cohort was 66.9 years. Expired patients had a higher incidence of dyspnea (P < 0.001) and headache (0.031). In addition, expired patients had elevated CRP- hs (mg/dl) ≥ 123 (< .0001), SGOT or AST (IU/L) ≥ 54 (p < 0.001), SGPT or ALT (IU/L) ≥ 41 (p < 0.001), and creatinine (mg/dl) ≥ 1.135 (0.001), lower WBC counts (k/ul) ≥ 8.42 (0.009). Furthermore, on multivariate logistic regression, dyspnea (OR = 2.56, P < 0.001), creatinine ≥ 1.135 (OR = 1.79, P = 0.007), LDH(U/L) > 465 (OR = 2.18, P = 0.001), systolic blood pressure < 90 mm Hg (OR = 4.28, p = .02), respiratory rate > 24 (OR = 2.88, p = .001), absolute lymphocyte percent (≤ 12%) (OR = 1.68, p = .001) and procalcitonin (ng/ml) ≥ 0.305 (OR = 1.71, P = .027) predicted in- hospital mortality in all matched patients. Conclusion Our case series provides admission clinical characteristics and laboratory parameters that predict in- hospital mortality in propensity Covid 19 matched patients with a large Hispanic population. These risk factors will require further validation. Disclosures All Authors: No reported disclosures
Abstract Background As part of our outpatient Antimicrobial Stewardship Program, we do surveillance of diagnoses and antibiotic use for common upper respiratory tract infections such as acute upper respiratory tract infection, acute bronchitis, sinusitis, and pharyngitis. We sought to evaluate the impact of the Covid-19 pandemic on the incidence rate of upper respiratory tract infection diagnoses per clinic visit during October 2020 to March 2021 season compared to the three prior respiratory seasons. We also sought to reflect of impact of increase in televisits and overlapping symptoms of COVID 19 and upper respiratory tract infections. Methods Our cohort study extending from October 2017 to March 2021. We collected number of diagnoses of upper respiratory infections and number of unique clinic visits during four consecutive respiratory seasons at our primary care sites via electronic health records. Results During the recent October 2020 to March 2021 respiratory season which coincided with the second NYC Covid-19 wave, we had 11569 unique clinic visits and 39 diagnoses of an upper respiratory tract infection - incident rate of 1.29. In the three prior respiratory seasons combined, we had 40939 unique clinic visits and 833 diagnoses of an upper respiratory tract infection – incident rate of 1.49. The incident rates showed a dramatic decline using the test based method and the chi square-statistic p< 0.0001 with an incident rate ratio using a poisson exact method of 6.0359. Statistical comparisons of the current season to each prior individual season yielded similar results. The percentage of Tele-visits during the current season was 19% compared to 0% in the 3 prior seasons. Conclusion During the first respiratory season from October 2020 to March 2021 in midst of the Covid-19 pandemic which also coincided with the second Covid-19 wave in New York, we saw a statistically significant decrease in incidence of common upper respiratory tract infection diagnoses per clinic visit compared to the three prior respiratory seasons. Overlapping signs and symptoms of upper respiratory tract infections and Covid-19 with the added percentage in Tele-visits did not cause an increase in incidence rates of upper respiratory tract infection diagnoses. Covid-19 related mitigation efforts may have played a role. Disclosures All Authors: No reported disclosures
Purpose: Introduction: Hyperkalemia is a commonly encountered condition in patients with CKD and usually the first treatment opted by most physicians is with Sodium polystyrene sulfonate or Kayexalate in sorbitol. We report a case of Kayexalate induced ileo-colonic necrosis complicated by hemodynamic shock and Campylobacter-induced bacteremia/sepsis. Case: A 80 year old man with history of CKD, severe COPD was admitted with acute on chronic kidney failure, a complicated UTI and developed hyperkalemia during his course of hospitalization (serum Potassium of 6.3 mmol/L). The patient received multiple doses of Kayexalate orally as the Potassium levels remained persistently elevated despite repeated administration of Sodium polystyrene sulfonate in 33% sorbitol, Insulin and D5W. After three days of treatment his levels decreased to 5.5 mmol/Liter. Ten days later the patient was noted to have maroon colored stools and the Hgb/Hct dropped to 8.1 g/dl/23.4%. The patient had multiple episodes of bleeding per rectum, became hemodynamically unstable and was transferred to the ICU. The patient was emergently taken to the OR and a subtotal colectomy with terminal ileostomy was performed and samples from the resected colon and terminal ileum were sent for pathology. The results showed Kayexalate related mucosal injury with focal ulceration, intraluminal and mucosal Kayexalate resin fragments. The patient further developed Campylobacter gracilis in his blood cultures, the source was described as translocation from the necrosed gut and was treated with Azithromycin, Tigecycline and Imipenem. Discussion: Kayexalate induced colonic mucosal necrosis and perforation has been reported commonly in patients receiving enemas, in the setting of recent abdominal surgery, bowel injury or intestinal dysfunction. It is rarely seen, about 0.2-0.3% almost exclusively in patients at risk including patients with uremia, hypovolemia, hypotension, coagulation disorders and immunosuppression. There is very little data to suggest that oral SPS given with 33% sorbitol causes colonic necrosis. Physicians prescribing Kayexalate should be aware of the potential for fatal side effects. The definite diagnosis is with pathological examination showing Kayexalate crystals in necrotic gastrointestinal tissue. In patients who had developed gastrointestinal necrosis associated with Kayexalate, cessation of medication is necessary. As compared to upper intestinal injury, which may recover spontaneously without sequelae, potentially lethal ileonecrosis requires timely surgical intervention. Another complication to be aware of is bacterial translocation from the gut leading to bacteremia and sepsis.
In HIV-infected individuals, macrophages, the key defense effector cells, manifest defective activity in their interactions with a wide variety of opportunistic pathogens, including fungi and protozoa. Understanding the morphological characteristics of intracellular opportunistic pathogens in addition to their pathogenesis is of critical importance to provide optimal therapy, thereby decreasing morbidity and mortality in HIV-infected patients. We herein present a case of disseminated histoplasmosis confused with disseminated visceral leishmaniasis in an HIV-infected individual from Guyana who developed intracellular organisms within alveolar macrophages
Purpose: Introduction: Chilaiditi syndrome is the interposition of the right colon between the liver and right hemi- diaphragm. Findings of the chest radiograph are called Chilaiditi sign in which bowels containing air can be seen interposed between the liver and diaphragm. This rare syndrome has been reported only sporadically. Because of its rarity, Chilaiditi syndrome is often misdiagnosed as pneumoperitoneum. The treatment of Chilaiditi syndrome is generally conservative. Therefore, this clinical entity should be kept in mind to avoid unnecessary invasive intervention. Case Presentation: A 46-year-old man presented with progressive abdominal pain, nausea, vomiting and distention for 2 days. His past medical history was significant for schizophrenia well controlled by antipsychotics. On physical exam, he appeared dehydrated and his skin turgor was poor. His vital signs were T 97.5 °F, BP 133/95 mmHg, HR 108 beats/min, RR 22 breaths/min, SpO2 97% on ambient air. His heart sounds were regular and lungs were clear to auscultation. The abdomen was diffusely tender and distended, bowel sounds were sluggish, but there was no guarding or rigidity. Erect/supine and chest radiographs revealed distended bowel loops and air under the right hemidiaphragm. Subsequent abdominal/pelvic CT disclosed transposition of the colon between the diaphragm and liver without evidence of obstruction. Laboratory studies showed WBC 17,300/μL with 91% neutrophils, HGB 11.4 g/dL, PLT 244 K/μL, Na 145 mEq/L, K 4.0 mEq/L, BUN 17 mg/dL, Cr 0.9 mg/dL and HCO-3 32 mEq/L. His liver function tests as well as amylase and lipase levels were normal. The patient was kept NPO and given intravenous fluids and metoclopramide with significant clinical improvement. Discussion: Hepato-diaphragmatic interposition of the bowel is a rare cause of air under the diaphragm and is called Chilaiditi sign or Chilaiditi syndrome when it results in symptoms. According to the literature, the incidence of this syndrome in the general population ranges from 0.025% to 0.28%. Because of its rarity, it is often confused with free air. However, the presence of haustra in the hepato-diaphragmatic space aids the distinction between intraluminal gas and free air. An abdominal/pelvic CT showing the bowel between the liver and diaphragm confirms the diagnosis. Unless suspected of volvulus, patients with this syndrome often respond to conservative treatments such as bed-rest and nasogastric decompression. Our patient showed considerable improvement without any invasive procedures. This rare entity should be kept in mind not only by radiologists but also by gastroenterologists.
PURPOSE:Covid-19 caused by the novel SARS-CoV-2 has emerged as a global health crisis with various clinical complications.Covid-19 related respiratory manifestations have been reported as mild, moderate to severe including acute lung injury and acute respiratory distress syndrome necessitating non-invasive forms of oxygenation to mechanical ventilation (MV).MV patients frequently undergo prolonged hospitalizations with substantial morbidity and mortality.We sought to evaluate risk factors for MV in our cohort. METHODS:We conducted a retrospective cohort study of patients admitted in our institution from March 1 st to June 21 st 2020, to assess risk factors for Covid-19 related respiratory failure requiring MV.The original cohort encompassed 166 MV and 503 non MV patients.Information from our hospital medical records was extracted, which included demographics, presenting symptoms, past medical history, vital signals, and laboratory data and need for MV.We propensity matched 166 MV with a concurrent cohort of non MV patients in our institution.Covariates applied in matching included age, gender, race, and body mass index (BMI).The admission clinical attributes and laboratory parameters were analyzed, along with outcomes. RESULTS:The mean age of our matched cohort was 63.8 years.Mechanically Ventilated patients had a higher incidence of tachycardia (heart rate > 125) (p <.001), elevated respiratory rate > 24 cycles per minute (p <.001), fever > 97.8 F (Temperature > (p = .037),shortness of breath (p = .001),and headaches (p = .005).In addition, mechanically ventilated patients had a lower serum albumin (g/dl) # 3 units (p <. 001), elevated serum creatinine (mg/dl) $ 1.135 units (p = .02),elevated serum CRP-HS $ 123 units (p = .005),HbA1C (%) > 6.6 units (p = .004),serum lactic acid (mmol/L) > 1.7 units (p = .003),serum LDH U/L > 465 U/L (p <.001), Procalcitonin (ng/ml) > .305units (p <0.001), SGOT IU/L or AST IU/L $ 54 units (p < 0.001), SGPT or ALT IU/L $ 41 units (p = .021),and WBC count > 8.4 k/ul (p <.001).Furthermore, tachycardia (OR = 3.98, p = .001),HbA1C (OR = 2.36, p = .008),serum LDH (OR = 1.9, p = .041),and absolute lymphocyte percent # 12 (OR = 1.98, p = .022)predicted mechanical ventilation in all matched patients in our institutional cohort. CONCLUSIONS:Our case series provides clinical characteristics, laboratory parameters, and predictors for mechanical ventilation in matched patients with Covid-19.Elevated heart rate, HbA1C, serum LDH and decreased lymphocyte percentage were predictors for mechanical ventilation.Tachycardia had the highest odds of 3.98.CLINICAL IMPLICATIONS: Several clinical and laboratory parameters can be utilized for evaluating and stratifying Covid-19 patients' risk for mechanical ventilation.These risk factors will need further validation in other similar cohorts.
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