Cutaneous Manifestations of Disseminated Histoplasmosis in a Patient with AIDS

Introduction: Disseminated histoplasmosis is often seen in immunocompromised individuals, such those with acquired immunodeficiency syndrome (AIDS). The initial infection mainly involves the lungs but it may develop into a disseminated form especially in immunocompromised patients. Since it can be a systemic disease with cutaneous manifestations, dermatologists must be able to recognize its clinical presentation to ensure prompt management.Case: We present a man in his 50s with past medical history of AIDS who developed disseminated histoplasmosis with skin and gastrointestinal involvement over a one-month period of time. Despite receiving induction therapy with intravenous amphotericin B followed by oral itraconazole, the patient expired. His death was attributed to his persistently low CD4 T-cell count and secondary bacteremia.Discussion: This condition should be recognized early and treated aggressively. However, patients with multiple comorbidities are at increased risk of mortality even despite adequate treatment. This case highlights the significant mortality risk of disseminated histoplasmosis in patients with AIDS.

Download Full-text

THE EMERGENCE OF FRAILTY MAY LEAD TO A STATE OF BURNT OUT TYPE 2 DIABETES

Journal of Frailty & Aging ◽

10.14283/jfa.2016.98 ◽

2016 ◽

pp. 1-6

Author(s):

A.H. ABDELHAFIZ ◽

L. KOAY ◽

A.J. SINCLAIR

Keyword(s):

Type 2 Diabetes ◽

Β Cells ◽

Risk Of Mortality ◽

Vulnerable Patients ◽

Increased Risk ◽

History Of ◽

The One ◽

And Function ◽

Glucose Dynamics

Ageing is associated with hyperglycaemic tendency due to the change in body composition leading to accumulation of visceral fat and increased insulin resistance on the one hand and reduced insulin secretion due to decreased number and function of the β-cells of the pancreas on the other. However, with the emergence of frailty there may be a tendency towards normoglycaemia or even hypoglycaemia due to malnutrition, weight loss and reduced physiologic reserve. This shift in glucose metabolism induced by frailty may change the natural history of type 2 diabetes from a progressive to a regressive course. Studies which showed increased risk of mortality with low HbA1c included frail patients in the lower HbA1c categories and healthier patients in the higher HbA1c categories suggesting that frailty is a possible confounding factor. Therefore, hypoglycemia may be a prognostic tool to identify vulnerable patients who may be at increased risk of mortality. The metabolic changes of insulin/glucose dynamics associated with frailty need further research.

Download Full-text

An immigrant with acquired immunodeficiency syndrome presenting with a rash: A case report

SAGE Open Medical Case Reports ◽

10.1177/2050313x19829616 ◽

2019 ◽

Vol 7 ◽

pp. 2050313X1982961

Author(s):

Connie Zhang ◽

Megan A Sander

Keyword(s):

Human Immunodeficiency Virus ◽

Acquired Immunodeficiency Syndrome ◽

Systemic Disease ◽

Immunodeficiency Virus ◽

History Of ◽

Acquired Immunodeficiency ◽

Laboratory Investigations ◽

Polymerase Chain ◽

Immunodeficiency Syndrome ◽

Work Up

A 58-year-old woman from Zimbabwe, with a history of untreated human immunodeficiency virus, presented with leonine facies and a diffuse rash. The rash occurred in the context of a 1-year history of constitutional symptoms and cognitive decline. Laboratory investigations confirmed that her human immunodeficiency virus had progressed to acquired immunodeficiency syndrome. Through imaging, tissue biopsies, and polymerase chain reaction, a diagnosis of disseminated histoplasmosis was made. Since there was no history of travel and histoplasmosis is not locally endemic, the patient likely contracted this fungal infection more than 7 years ago, while living in Africa. We speculate that the histoplasmosis remained latent until her immune system began to decline. The work-up and management of this rare cutaneous presentation of a systemic disease, which should be added to the list of “great mimickers” in dermatology, are discussed.

Download Full-text

Thrombosis and Risk of Mortality in Newly Diagnosed High-Risk Polycythemia Vera: An Analysis of the Medicare Claims Database in the United States

Blood ◽

10.1182/blood-2020-141370 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 9-10

Author(s):

Naveen Pemmaraju ◽

Aaron T. Gerds ◽

Shreekant Parasuraman ◽

Jingbo Yu ◽

Anne Shah ◽

...

Keyword(s):

High Risk ◽

Median Time ◽

Research Funding ◽

Index Date ◽

Newly Diagnosed ◽

Publicly Traded ◽

Risk Of Mortality ◽

Increased Risk ◽

History Of

Background Polycythemia vera (PV) is a myeloproliferative neoplasm (MPN) associated with an increased risk of thrombotic events (TEs), a major cause of morbidity and mortality. Patients aged ≥60 years and/or with a history of thrombosis are considered to have high-risk PV. There is limited contemporary, real-world evidence exploring the effect of TEs on mortality in patients with PV. The aim of this analysis was to compare the risk of mortality in patients newly diagnosed with high-risk PV who experienced a TE vs those who did not experience a TE. Study Design and Methods All data from the Medicare Fee-for-Service (FFS) claims database (Parts A/B/D) from January 2010-December 2017 were used to identify patients with a PV diagnosis (all high risk based on cohort being ≥65 years of age) with ≥1 inpatient or ≥2 outpatient claims. The index date was the date of the first qualifying PV claim. Patients with a PV diagnosis or use of cytoreductive therapy within 12 months before the index date (pre-index period) were excluded; ≥12-months continuous medical and pharmacy enrollment pre-index dates was required. The study sample was categorized into TE and non-TE groups based on the occurrence of any of the following events during follow-up: deep vein thrombosis, pulmonary embolism, ischemic stroke, acute myocardial infarction, transient ischemic attack, peripheral arterial thrombosis, or superficial thrombophlebitis. TEs were evaluated from the index date to the end of follow-up. Cox regression analyses with time-varying effects were used to assess mortality risk among patients with PV, with post-index TE as a time-dependent variable, stratified by pre-index TE, and adjusting for patient demographic characteristics and comorbid conditions. Results A total of 56,176 Medicare FFS beneficiaries with PV diagnoses met inclusion criteria. The median age was 73 years, 51.9% were men, and 90.7% were white; 10,110 patients (18.0%) had a history of TE before diagnosis (ie, pre-index). In the follow-up period, 20,105 patients (35.8%) had a TE and 36,071 patients (64.2%) did not have a TE. In the comparison between the TE vs non-TE groups, the median (range) age (75.0 [65-104] vs 73.0 [65-106] years, respectively), mean (SD) Charlson comorbidity index score (3.1 [2.6] vs 2.2 [2.3]), and percentage of patients with a history of cardiovascular events (34.1% vs 23.8%), bleeding (13.3% vs 10.4%), or anemia (28.6% vs 23.4%) were higher (Table 1). Among all patients with PV, the median time from diagnosis to first post-index TE was 7.5 months. Among those with pre-index TE (n=10,093), median time from index to first post-index TE was 0.6 months, whereas patients without pre-index TE (n=46,083) had a median time to first post-index TE of 14.2 months. Among all patients with TE during follow-up, the most common TEs were ischemic stroke (47.5%), transient ischemic attack (30.9%), and acute myocardial infarction (30.5%). The risk of mortality was increased for patients who experienced a TE compared with those who did not (hazard ratio [HR; 95% CI], 9.3 [8.4-10.2]; P<0.0001). For patients who experienced a pre-index TE, the risk of mortality was increased for patients who experienced a subsequent TE during follow-up compared with patients who did not (HR [95% CI], 6.7 [5.8-7.8]; P<0.0001). Likewise, for patients who did not experience a pre-index TE, the risk of mortality was increased for patients who experienced a TE during follow-up compared with patients who did not (HR [95% CI], 13.1 [11.4-15.0]; P<0.0001). Conclusions In this real-world study, approximately one-third of patients with newly diagnosed high-risk PV experienced a TE during follow-up and had a 9-fold increased risk of mortality vs those who did not experience a TE. TE risk mitigation remains an important management goal in patients with PV, particularly in those with prior TE. Disclosures Pemmaraju: Samus Therapeutics: Research Funding; Celgene: Honoraria; SagerStrong Foundation: Other: Grant Support; Affymetrix: Other: Grant Support, Research Funding; MustangBio: Honoraria; Blueprint Medicines: Honoraria; LFB Biotechnologies: Honoraria; Plexxikon: Research Funding; Novartis: Honoraria, Research Funding; AbbVie: Honoraria, Research Funding; Stemline Therapeutics: Honoraria, Research Funding; Pacylex Pharmaceuticals: Consultancy; Daiichi Sankyo: Research Funding; Incyte Corporation: Honoraria; Roche Diagnostics: Honoraria; Cellectis: Research Funding; DAVA Oncology: Honoraria. Gerds:Sierra Oncology: Research Funding; Celgene: Consultancy, Research Funding; Gilead Sciences: Research Funding; Imago Biosciences: Research Funding; Pfizer: Research Funding; CTI Biopharma: Consultancy, Research Funding; Roche/Genentech: Research Funding; Apexx Oncology: Consultancy; AstraZeneca/MedImmune: Consultancy; Incyte Corporation: Consultancy, Research Funding. Parasuraman:Incyte Corporation: Current Employment, Current equity holder in publicly-traded company. Yu:Incyte Corporation: Current Employment, Current equity holder in publicly-traded company. Shah:Avalere Health: Current Employment. Xi:Incyte Corporation: Other: Avalere Health is a paid consultant of Incyte Corporation; Avalere Health: Current Employment. Kumar:Avalere Health: Current Employment; Incyte Corporation: Other: Avalere Health is a paid consultant of Incyte Corporation. Scherber:Incyte Corporation: Current Employment, Current equity holder in publicly-traded company. Verstovsek:Gilead: Research Funding; Incyte Corporation: Consultancy, Research Funding; Novartis: Consultancy, Research Funding; CTI Biopharma Corp: Research Funding; Promedior: Research Funding; Roche: Research Funding; AstraZeneca: Research Funding; Blueprint Medicines Corp: Research Funding; Genentech: Research Funding; Sierra Oncology: Consultancy, Research Funding; Protagonist Therapeutics: Research Funding; ItalPharma: Research Funding; PharmaEssentia: Research Funding; NS Pharma: Research Funding; Celgene: Consultancy, Research Funding.

Download Full-text

Intubated COVID-19 predictive (ICOP) score for early mortality after intubation in patients with COVID-19

Scientific Reports ◽

10.1038/s41598-021-00591-1 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Mitsuaki Nishikimi ◽

Rehana Rasul ◽

Cristina P. Sison ◽

Daniel Jafari ◽

Muhammad Shoaib ◽

...

Keyword(s):

New York ◽

Operating Characteristic ◽

Characteristic Curve ◽

Early Mortality ◽

Predictive Score ◽

Derivation Cohort ◽

Risk Of Mortality ◽

Increased Risk ◽

Failure Assessment ◽

History Of

AbstractPatients with coronavirus disease 2019 (COVID-19) can have increased risk of mortality shortly after intubation. The aim of this study is to develop a model using predictors of early mortality after intubation from COVID-19. A retrospective study of 1945 intubated patients with COVID-19 admitted to 12 Northwell hospitals in the greater New York City area was performed. Logistic regression model using backward selection was applied. This study evaluated predictors of 14-day mortality after intubation for COVID-19 patients. The predictors of mortality within 14 days after intubation included older age, history of chronic kidney disease, lower mean arterial pressure or increased dose of required vasopressors, higher urea nitrogen level, higher ferritin, higher oxygen index, and abnormal pH levels. We developed and externally validated an intubated COVID-19 predictive score (ICOP). The area under the receiver operating characteristic curve was 0.75 (95% CI 0.73–0.78) in the derivation cohort and 0.71 (95% CI 0.67–0.75) in the validation cohort; both were significantly greater than corresponding values for sequential organ failure assessment (SOFA) or CURB-65 scores. The externally validated predictive score may help clinicians estimate early mortality risk after intubation and provide guidance for deciding the most effective patient therapies.

Download Full-text

Abstract T MP104: The Role of Antithrombotics Therapy in Recent Ischaemic Stroke Patients with Atrial Fibrillation: Analysis from VISTA

Stroke ◽

10.1161/str.45.suppl_1.tmp104 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Azmil H Abdul-Rahim ◽

Rachael L Fulton ◽

Frank Benedikt ◽

Turgut Tatlisumak ◽

Maurizio Paciaroni ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischaemic Stroke ◽

Recurrent Stroke ◽

Previous History ◽

Neurological Impairment ◽

Antithrombotic Treatment ◽

Risk Of Mortality ◽

Natural Progression ◽

Increased Risk ◽

History Of

Background and Purpose: There is uncertainty on the optimal latency after acute ischaemic stroke at which antithrombotic treatment should commence for atrial fibrillation (AF) patients, in order to prevent recurrent stroke (RS) without provoking symptomatic intracranial haemorrhage (SICH). We sought to describe the risk factors and patterns of RS and SICH in a cohort of patients with AF and recent stroke. Methods: We assessed the association of antihrombotic treatment (i.e. anticoagulants and antiplatelets) with the distribution of the modified Rankin Scale (mRS) at day 90, and the occurrence of RS and SICH. We developed statistical models for the prediction of RS and SICH in the first 90 days after stroke, using univariate and multivariate analysis. Results: Data were available for 1,644 patients. Combined antithrombotic therapy with both anticoagulation and antiplatelet (n=782) was associated with more favourable functional outcome across full scale mRS OR=1.785 (95% CI: 1.316, 2.421; P=0.0002), and significantly lower risk of mortality by day 90, SICH by day 90 and RS by day 90: Mortality day 90 OR=0.344 (95% CI: 0.235, 0.502; P<0.0001), SICH day 90 OR=0.18 (95% CI: 0.086, 0.37; P<0.0001) and RS day 90 OR=0.33 (95% CI: 0.21, 0.53; P<0.0001). Patients with ischaemic stroke who had high baseline glucose had a high risk of both RS and SICH events after stroke. Additionally, patients who had increased neurological impairment, previous history of TIA and received no antithrombotic treatment were at increased risk of RS. The relative risk of RS versus SICH appeared constant over time. Conclusions: It seems justified to initiate anticoagulation immediately the patient attains medical and neurological stability, taking into account the potential of haemorrhagic transformation as part of the natural progression in stroke and the increasing risk of recurrent stroke with time if left untreated. Antiplatelet treatment pending introduction of anticoagulation is reasonable.

Download Full-text

Pulmonary Complications of Sickle Cell Anemia

Chest Imaging ◽

10.1093/med/9780199858064.003.0025 ◽

2019 ◽

pp. 141-145

Author(s):

Constantine Raptis

Keyword(s):

Sickle Cell Disease ◽

Sickle Cell ◽

Community Acquired Pneumonia ◽

Pulmonary Complications ◽

Acute Chest Syndrome ◽

Globin Chain ◽

Cell Disease ◽

Risk Of Mortality ◽

Increased Risk ◽

History Of

“Sickle cell disease” describes the spectrum of pathology in patients with at least one HbS chain and one other abnormal β‎ globin chain. Although patients with sickle cell disease often present with a simple community acquired pneumonia, acute chest syndrome must be considered in patients presenting with chest pain and fever, as it carries an increased risk of mortality, especially in adults. A few other entities, including rib infarction and subdiaphragmatic pathologies, can mimic the symptoms of acute chest syndrome. Finally, the findings of sickle cell disease on chest radiography will be discussed. Radiologists must be familiar with these findings in order to accurately interpret imaging studies, especially when the history of sickle cell is not provided.

Download Full-text

Severe varicose veins and the risk of mortality: a nationwide population-based cohort study

BMJ Open ◽

10.1136/bmjopen-2019-034245 ◽

2020 ◽

Vol 10 (6) ◽

pp. e034245

Author(s):

Nan-Chun Wu ◽

Zhih-Cherng Chen ◽

I-Jung Feng ◽

Chung-Han Ho ◽

Chun-Yen Chiang ◽

...

Keyword(s):

Cohort Study ◽

Cardiovascular Events ◽

Proportional Hazards ◽

Varicose Veins ◽

Systemic Disease ◽

Cox Proportional Hazards ◽

Major Adverse Cardiovascular Events ◽

Coronary Syndrome ◽

Risk Of Mortality ◽

Increased Risk

ObjectiveVaricose veins (VVs) are common and although considered benign may cause morbidity. However, the association between VV severity and cardiovascular and mortality risks remains unknown. The aim of this study was to investigate the factors associated with overall mortality in patients with VV.MethodsA total of 4644 patients with newly diagnosed VV between 1999 and 2013 were identified from Taiwan’s National Health Insurance Database. VV severity was classified from grade 1 to 3 according to the presentation of ulcers or inflammation. Moreover, 9497, 2541 and 5722 age-matched, sex-matched and chronic cardiovascular risk factor-matched controls, as assessed based on propensity score, were separately selected for three grading VV groups. Enrolled patients were analysed using conditional Cox proportional hazards regression analysis to estimate risk of mortality and major adverse cardiovascular events (MACEs) in the VV and control groups.ResultsMost patients with VV were free from systemic disease. However, compared with matched controls, patients with VV showed a 1.37 times increased risk of mortality (95% CI 1.19 to 1.57; p<0.0001). Compared with matched controls, older (age ≧65 years) (adjusted HR: 1.38; 95% CI 1.17 to 1.62; p=0.0001) and male patients with VV (adjusted HR 1.41; 95% CI 1.18 to 1.68; p=0.0001) showed increased risk of mortality. Furthermore, compared with controls, patients with VV showed 2.05 times greater risk of MACE. Compared with matched controls, population at grade 3 increased 1.83 times risk of mortality and 2.04 to 38.42 times risk of heart failure, acute coronary syndrome, ischaemic stroke and venous thromboembolism.ConclusionsThis nationwide cohort study demonstrated that patients with VV are at a risk of cardiovascular events and mortality. Our findings suggest that presence of VV warrants close attention in terms of prognosis and treatment.

Download Full-text

P681Acute Myocardial Infarction in patients with Leukaemia: A national analysis of prevalence, predictors and outcomes in United States hospitalisations (2004 to 2014)

European Heart Journal ◽

10.1093/eurheartj/ehz747.0287 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

M O Mohamed ◽

J C Lopez-Mattei ◽

C A Iliescu ◽

P Purwani ◽

A Bharadwaj ◽

...

Keyword(s):

Myocardial Infarction ◽

Clinical Outcomes ◽

Coronary Intervention ◽

Cardiac Complications ◽

Risk Of Mortality ◽

Cerebrovascular Events ◽

Increased Risk ◽

Percutaneous Coronary ◽

History Of ◽

National Analysis

Abstract Background Patients with leukaemia are at increased risk of cardiovascular events. There is limited outcomes data for patients with a history of leukaemia who present with an acute myocardial infarction (AMI). Purpose To examine the prevalence and clinical characteristics of patients with leukaemia presenting with AMI, and evaluate differences in clinical outcomes according to the subtype of leukaemia in comparison to patients without leukaemia. Methods We analysed the Nationwide Inpatient Sample (2004–2014) for patients with a primary discharge diagnosis of AMI and concomitant leukaemia, and further stratified according to the subtype of leukaemia into 4 groups; AML; ALL; CML; and CLL. Multiple logistic regression was conducted to identify the association between leukaemia and major acute cardiovascular and cerebrovascular events (MACCE; composite of mortality, stroke and cardiac complications) and bleeding. Results Out of 6,750,927 AMI admissions, a total of 21,694 patients had a leukaemia diagnosis. The leukaemia group experienced higher rates of MACCE (11.8% vs. 7.8%), mortality (10.3% vs. 5.8%) and bleeding (5.6% vs. 5.3%). Following adjustments, leukaemia was independently associated with increased odds of MACCE (OR 1.26 [1.20,1.31]) and mortality (OR 1.43 [1.37,1.50]) without an increased risk of bleeding (OR 0.86 [0.81,0.92]). Acute myeloid leukaemia (AML) was associated with approximately three-fold risk of MACCE (RR 2.81 [2.51, 3.13]) and a four-fold risk of mortality (RR 3.75 [3.34, 4.22]) (Figure 1). Patients with leukaemia were less likely to undergo coronary angiography (CA) (48.5% vs. 64.5%) and percutaneous coronary intervention (PCI) (28.2% vs. 42.9%) compared to those without leukaemia. Figure 1.Relative risk of adverse events Conclusion Patients with leukaemia, especially those with AML, are associated with poor clinical outcomes after AMI, and are less likely to receive CA and PCI compared to those without leukaemia. A multi-disciplinary approach between cardiologists and haematology oncologists may improve the outcomes of patients with leukaemia after AMI.

Download Full-text

History of premorbid depression is a risk factor for COVID-related mortality: Analysis of a retrospective cohort of 1,387 COVID+ patients

10.1101/2020.12.17.20248362 ◽

2020 ◽

Author(s):

Sean Clouston ◽

Benjamin J Luft ◽

Edward Sun

Keyword(s):

Risk Factors ◽

Risk Factor ◽

Proportional Hazards ◽

Cox Proportional Hazards ◽

Cox Proportional Hazards Models ◽

Risk Of Mortality ◽

Increased Risk ◽

History Of ◽

History Of Depression ◽

Related Mortality

Background: The goal of the present work was to examine risk factors for mortality in a 1,387 COVID+ patients admitted to a hospital in Suffolk County, NY. Methods: Data were collated by the hospital epidemiological service for patients admitted from 3/7/2020-9/1/2020. Time until final discharge or death was the outcome. Cox proportional hazards models were used to estimate time until death among admitted patients. Findings: In total, 99.06% of cases had resolved leading to 1,179 discharges and 211 deaths. Length of stay was significantly longer in those who died as compared to those who did not p=0.007). Of patients who had been discharged (n=1,179), 54 were readmitted and 9 subsequently died. Multivariable-adjusted Cox proportional hazards regression revealed that in addition to older age, male sex, and heart failure, a history of premorbid depression was a risk factor for COVI-19 mortality. Interpretation: While an increasing number of studies have shown effects linking cardiovascular risk factors with increased risk of mortality in COVID+ patients, this study reports that history of depression is a risk factor for COVID mortality.

Download Full-text

Predictors of mortality for patients with COVID-19 and large vessel occlusion

Interventional Neuroradiology ◽

10.1177/1591019920954603 ◽

2020 ◽

Vol 26 (5) ◽

pp. 623-628 ◽

Cited By ~ 3

Author(s):

David J Altschul ◽

Charles Esenwa ◽

Neil Haranhalli ◽

Santiago R Unda ◽

Rafael de La Garza Ramos ◽

...

Keyword(s):

Cigarette Smoking ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Old Patients ◽

Risk Of Mortality ◽

Increased Risk ◽

History Of ◽

Radiographic Data ◽

D Dimer

Background This study evaluates the mortality risk of patients with emergent large vessel occlusion (ELVO) and COVID-19 during the pandemic. Methods We performed a retrospective cohort study of two cohorts of consecutive patients with ELVO admitted to a quaternary hospital from March 1 to April 17, 2020. We abstracted data from electronic health records on baseline, biomarker profiles, key time points, quality measures and radiographic data. Results Of 179 patients admitted with ischemic stroke, 36 had ELVO. Patients with COVID-19 and ELVO had a higher risk of mortality during the pandemic versus patients without COVID-19 (OR 16.63, p = 0.004). An age-based sub-analysis showed in-hospital mortality in 60% of COVID-19 positive patients between 61-70 years-old, 66.7% in between 51-60 years-old, 50% in between 41-50 years-old and 33.3% in between 31-40 years old. Patients that presented with pulmonary symptoms at time of stroke presentation had 71.4% mortality rate. 27.3% of COVID-19 patients presenting with ELVO had a good outcome at discharge (mRS 0-2). Patients with a history of cigarette smoking (p = 0.003), elevated d-dimer (p = 0.007), failure to recanalize (p = 0.007), and elevated ferritin levels (p = 0.006) had an increased risk of mortality. Conclusion Patients with COVID-19 and ELVO had a significantly higher risk for mortality compared to COVID-19 negative patients with ELVO. A small percentage of COVID-19 ELVO patients had good outcomes. Age greater than 60 and pulmonary symptoms at presentation have higher risk for mortality. Other risk factors for mortality were a history of cigarette smoking, elevated, failure to recanalize, elevated d-dimer and ferritin levels.

Download Full-text