COVID-19 Outbreak at a Geriatric Rehabilitation Facility: The Silent Threat of Asymptomatic Patients with High Viral Loads

Data about outbreaks of nosocomial COVID-19 disease within geriatric rehabilitation facilities are scarce. In this retrospective case series analysis, we describe such an outbreak, determine the proportion of a-/presymptomatic patients, the median time before symptom onset among presymptomatic patients and investigate whether the viral load differs between patients with and without symptoms. Typical and atypical symptoms were retrieved from the electronic medical records of patients who tested positive for COVID-19 disease during their stay at a 95-bed geriatric rehabilitation facility. The viral load at the time of diagnosis was estimated on cycle threshold values of the rRT-PCR test. Overall, 34 patients (median age, 87 years; range, 66–98; 67% female) tested positive for SARS-CoV-2. During the same period, 19 health care workers were also diagnosed with COVID-19. Among the 27 patients who provided consent, 20 (74%) were symptomatic at the time of testing. Among the remaining seven patients, six developed symptoms after a median of 2 days. A viral load > 106 copies/mL was observed in 20 out of the 27 patients, including five out of the seven initially asymptomatic patients. The rapid transmission of SARS-CoV-2 and the prevalence of initially asymptomatic patients with high viral loads support an extended screening strategy at such facilities.

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Clinical importance of reporting SARS-CoV-2 viral loads across the different stages of the COVID-19 pandemic

10.1101/2020.07.10.20149773 ◽

2020 ◽

Author(s):

Milo Moraz ◽

Damien Jacot ◽

Matthaios Papadimitriou-Olivgeris ◽

Laurence Senn ◽

Gilbert Greub ◽

...

Keyword(s):

Viral Load ◽

Universal Screening ◽

Clinical Importance ◽

Screening Strategy ◽

Rt Pcr ◽

Chain Reaction ◽

Viral Loads ◽

Asymptomatic Patients ◽

Admission Screening ◽

Polymerase Chain

On April 25th, corresponding to the first deconfinement phase after the end of the lockdown in Switzerland, a universal admission screening strategy for COVID-19 was introduced in our hospital. All patients, including asymptomatic patients were tested for SARS-CoV-2 by quantitative reverse transcription polymerase chain reaction (RT-PCR). In addition to a qualitative answer, providing viral load values to the RT-PCR results not only helped the clinician to evaluate the stage of the infection but addressed patient contagiousness and guided infection control decisions. Here, we discuss the importance of reporting viral load values when a shift from a symptomatic to a universal screening strategy was performed.

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Differential Kinetics of Cycle Threshold Values during Admission by Symptoms among Patients with Mild COVID-19: A Prospective Cohort Study

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph18158181 ◽

2021 ◽

Vol 18 (15) ◽

pp. 8181

Author(s):

Teppei Sakano ◽

Mitsuyoshi Urashima ◽

Hiroyuki Takao ◽

Kohei Takeshita ◽

Hiroe Kobashi ◽

...

Keyword(s):

Cohort Study ◽

Viral Load ◽

Prospective Cohort Study ◽

Prospective Cohort ◽

Polymerase Chain Reaction Test ◽

Cycle Threshold ◽

Viral Loads ◽

Asymptomatic Patients ◽

Asymptomatic Individuals ◽

Chain Reaction Test

In the coronavirus disease 2019 (COVID-19) pandemic, more than half of the cases of transmission may occur via asymptomatic individuals, which makes it difficult to contain. However, whether viral load in the throat during admission is different between asymptomatic and symptomatic patients is not well known. By conducting a prospective cohort study of patients with asymptomatic or mild COVID-19, cycle threshold (Ct) values of the polymerase chain reaction test for COVID-19 were examined every other day during admission. The Ct values during admission increased more steadily in symptomatic patients and febrile patients than in asymptomatic patients, with significance (p = 0.01 and p = 0.004, respectively), although the Ct values as a whole were not significantly different between the two groups. Moreover, the Ct values as a whole were higher in patients with dysosmia/dysgeusia than in those without it (p = 0.02), whereas they were lower in patients with a headache than those without (p = 0.01). Patients who were IgG-positive at discharge maintained higher Ct values, e.g., more than 35, during admission than those with IgG-negative (p = 0.03). Assuming that viral load and Ct values are negatively associated, the viral loads as a whole and their changes by time may be different by symptoms and immune reaction, i.e., IgG-positive at discharge.

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Viral Load of SARS-CoV-2 in Respiratory Aerosols Emitted by COVID-19 Patients while Breathing, Talking, and Singing

10.1101/2021.07.15.21260561 ◽

2021 ◽

Author(s):

Kristen K. Coleman ◽

Douglas Jie Wen Tay ◽

Kai Sen Tan ◽

Sean Wei Xiang Ong ◽

Than The Son ◽

...

Keyword(s):

Viral Load ◽

Significant Role ◽

N Gene ◽

Exhaled Breath ◽

Indoor Environments ◽

Future Studies ◽

Viral Loads ◽

Asymptomatic Patients ◽

Gene Copies ◽

Study Participants

Background: Multiple SARS-CoV-2 superspreading events suggest that aerosols play an important role in driving the COVID-19 pandemic. However, the detailed roles of coarse (>5μm) and fine (≤5μm) respiratory aerosols produced when breathing, talking, and singing are not well-understood. Methods: Using a G-II exhaled breath collector, we measured viral RNA in coarse and fine respiratory aerosols emitted by COVID-19 patients during 30 minutes of breathing, 15 minutes of talking, and 15 minutes of singing. Results: Among the 22 study participants, 13 (59%) emitted detectable levels of SARS-CoV-2 RNA in respiratory aerosols, including 3 asymptomatic patients and 1 presymptomatic patient. Viral loads ranged from 63 - 5,821 N gene copies per expiratory activity. Patients earlier in illness were more likely to emit detectable RNA, and loads differed significantly between breathing, talking, and singing. The largest proportion of SARS-CoV-2 RNA copies was emitted by singing (53%), followed by talking (41%) and breathing (6%). Overall, fine aerosols constituted 85% of the viral load detected in our study. Virus cultures were negative. Conclusions: Fine aerosols produced by talking and singing contain more SARS-CoV-2 copies than coarse aerosols and may play a significant role in the transmission of SARS-CoV-2. Exposure to fine aerosols should be mitigated, especially in indoor environments where airborne transmission of SARS-CoV-2 is likely to occur. Isolating viable SARS-CoV-2 from respiratory aerosol samples remains challenging, and whether this can be more easily accomplished for emerging SARS-CoV-2 variants is an important enquiry for future studies.

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Initial experience in Mexico with convalescent plasma in COVID-19 patients with severe respiratory failure, a retrospective case series

10.1101/2020.07.14.20144469 ◽

2020 ◽

Cited By ~ 3

Author(s):

Michel F. Martinez-Resendez ◽

Fernando Castilleja-Leal ◽

Alejandro Torres-Quintanilla ◽

Augusto Rojas-Martinez ◽

Gerardo Garcia-Rivas ◽

...

Keyword(s):

Viral Load ◽

Respiratory Failure ◽

Troponin I ◽

Therapeutic Option ◽

Treatment Options ◽

Case Series ◽

High Sensitivity ◽

Retrospective Case ◽

X Ray ◽

Chest X Ray

Introduction: Hospital mortality due to COVID-19 in Mexico is high (32%) and as of today, effective treatment options are limited. More effective treatments that shorten hospital stay and reduce mortality are needed. Initial reports for the use of convalescent plasma (CP) therapy for COVID-19 appear promising. We describe a case series of eight patients with impending respiratory failure, who underwent CP therapy. Methods: Six male and two female (ages 31 to 79) patients that were admitted to the intensive-care unit for severe COVID-19 were transfused with two doses of CP (250 mL per dose, anti-SARS-CoV-2 IgG titers > 1:100). Donors were six SARS-CoV-2 infected males who remained asymptomatic for > 7 days and were negative for two nasopharyngeal RT-PCR tests. Clinical characteristics, inflammatory and cellular injury markers, chest X-ray findings and viral loads were analyzed before and after CP administration. Viral load association to disease severity was further analyzed on a separate cohort of asymptomatic vs hospitalized patients with COVID-19. Results: Eight patients with respiratory failure were successfully discharged with a median length of stay of 22.5 (IQR 18.25-29.00). After CP therapy, we observed a reduction of C-reactive protein (CRP) (median, 22.80 mg/dL vs. 1.63 mg/dL), and of procalcitonin (median, 0.27 ng/mL vs. 0.13 ng/mL). High-Sensitivity Cardiac Troponin I (hs-cTnI), Brain Natriuretic Peptide (BNP) and Lactate Dehydrogenase (LDH) were lower, and a mild reduction of pulmonary infiltrates by chest X-ray was observed. Lastly, a reduction of viral load was after CP therapy was found. (log, median [IQR], 1.2 [0.70-2.20] vs. 0.25 [0.00-1.78]). We observed no adverse effects. Conclusions: CP could potentially be an effective therapeutic option for patients with severe COVID-19. Clinical benefit needs to be studied further through randomized controlled trials.

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Systematic review and patient-level meta-analysis of SARS-CoV-2 viral dynamics to model response to antiviral therapies

10.1101/2020.08.20.20178699 ◽

2020 ◽

Author(s):

Silke Gastine ◽

Juanita Pang ◽

Florencia A.T. Boshier ◽

Simon J Carter ◽

Dagan O. Lonsdale ◽

...

Keyword(s):

Systematic Review ◽

Viral Load ◽

Case Reports ◽

Meta Analysis ◽

Severe Disease ◽

Case Series ◽

Viral Clearance ◽

Viral Dynamics ◽

Viral Loads ◽

Patient Level

Background: SARS-CoV-2 viral loads change rapidly following symptom onset so to assess antivirals it is important to understand the natural history and patient factors influencing this. We undertook an individual patient-level meta-analysis of SARS-CoV-2 viral dynamics in humans to describe viral dynamics and estimate the effects of antivirals used to-date. Methods: This systematic review identified case reports, case series and clinical trial data from publications between 1/1/2020 and 31/5/2020 following PRISMA guidelines. A multivariable Cox proportional hazards regression model (Cox-PH) of time to viral clearance was fitted to respiratory and stool samples. A simplified four parameter nonlinear mixed-effects (NLME) model was fitted to viral load trajectories in all sampling sites and covariate modelling of respiratory viral dynamics was performed to quantify time dependent drug effects. Findings: Patient-level data from 645 individuals (age 1 month-100 years) with 6316 viral loads were extracted. Model-based simulations of viral load trajectories in samples from the upper and lower respiratory tract, stool, blood, urine, ocular secretions and breast milk were generated. Cox-PH modelling showed longer time to viral clearance in older patients, males and those with more severe disease. Remdesivir was associated with faster viral clearance (adjusted hazard ratio (AHR) = 9.19, p<0.001), as well as interferon, particularly when combined with ribavirin (AHR = 2.2, p=0.015; AHR = 6.04, p = 0.006). Interpretation: Combination therapy including interferons should be further investigated. A NLME model for designing and analysing viral pharmacodynamics in trials has been established.

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A Retrospective 10-Year Analysis of Water Absorbent Bead Ingestion in Children

Emergency Medicine International ◽

10.1155/2018/5910527 ◽

2018 ◽

Vol 2018 ◽

pp. 1-4 ◽

Cited By ~ 1

Author(s):

Feride Mehmetoğlu

Keyword(s):

Emergency Service ◽

Relevant Literature ◽

Case Series ◽

Medical Procedures ◽

Retrospective Case ◽

Small Children ◽

X Ray ◽

Asymptomatic Patients ◽

Laboratory Investigations

Aim. This retrospective case series was designed to evaluate the clinical experience of pediatric patients who had ingested water absorbent beads (WABs) and review the relevant literature.Materials and Methods. A retrospective chart analysis of 21 children who were admitted to the emergency service or outpatient clinic with complaints of swallowing WABs during a 10-year period was performed. The patients were divided into two groups: 6 patients who were hospitalized and 15 patients who were observed as outpatients for groups 1 and 2, respectively. All data were screened with respect to presentation, age, gender, clinical and radiological findings, modalities of treatment, and follow-up.Results. All patients were asymptomatic with uneventful outcomes. Laboratory studies, X-ray, and ultrasound examinations revealed normal results. None of the patients underwent surgery or other medical procedures. Gastrointestinal system obstruction or any other pathological findings were not detected after WAB ingestion. No complications were identified during follow-up.Discussion. This first clinical study showed that asymptomatic patients do not require inpatient observation and laboratory investigations, X-ray, and ultrasound. However, results of the present study cannot be generalized to children of all ages due to the few cases of bowel obstruction reported to date in small children.

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Evaluation of the SARS-CoV-2 positivity ratio and upper respiratory tract viral load among asymptomatic individuals screened before hospitalization or surgery in Flanders, Belgium

PLoS ONE ◽

10.1371/journal.pone.0259908 ◽

2021 ◽

Vol 16 (11) ◽

pp. e0259908

Author(s):

Laura Heireman ◽

Steven Abrams ◽

Peggy Bruynseels ◽

Reinoud Cartuyvels ◽

Lize Cuypers ◽

...

Keyword(s):

Viral Load ◽

Respiratory Tract ◽

Age Group ◽

Test Results ◽

Rt Pcr ◽

Median Viral Load ◽

Viral Loads ◽

Asymptomatic Patients ◽

Positivity Ratio ◽

Second Wave

Introduction The incidence of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infections in the Belgian community is mainly estimated based on test results of patients with coronavirus disease (COVID-19)-like symptoms. The aim of this study was to investigate the evolution of the SARS-CoV-2 reverse transcriptase polymerase chain reaction (RT-PCR) positivity ratio and distribution of viral loads within a cohort of asymptomatic patients screened prior hospitalization or surgery, stratified by age category. Materials/Methods We retrospectively studied data on SARS-CoV-2 real-time RT-PCR detection in respiratory tract samples of asymptomatic patients screened pre-hospitalization or pre-surgery in nine Belgian hospitals located in Flanders over a 12-month period (1 April 2020–31 March 2021). Results In total, 255925 SARS-CoV-2 RT-PCR test results and 2421 positive results for which a viral load was reported, were included in this study. An unweighted overall SARS-CoV-2 real-time RT-PCR positivity ratio of 1.27% was observed with strong spatiotemporal differences. SARS-CoV-2 circulated predominantly in 80+ year old individuals across all time periods except between the first and second COVID-19 wave and in 20–30 year old individuals before the second COVID-19 wave. In contrast to the first wave, a significantly higher positivity ratio was observed for the 20–40 age group in addition to the 80+ age group compared to the other age groups during the second wave. The median viral load follows a similar temporal evolution as the positivity rate with an increase ahead of the second wave and highest viral loads observed for 80+ year old individuals. Conclusion There was a high SARS-CoV-2 circulation among asymptomatic patients with a predominance and highest viral loads observed in the elderly. Moreover, ahead of the second COVID-19 wave an increase in median viral load was noted with the highest overall positivity ratio observed in 20–30 year old individuals, indicating they could have been the hidden drivers of this wave.

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Relationships between Viral Load and the Clinical Course of COVID-19

Viruses ◽

10.3390/v13020304 ◽

2021 ◽

Vol 13 (2) ◽

pp. 304

Author(s):

Hiroyuki Tsukagoshi ◽

Daisuke Shinoda ◽

Mariko Saito ◽

Kaori Okayama ◽

Mitsuru Sada ◽

...

Keyword(s):

Viral Load ◽

Early Stage ◽

Fatal Case ◽

Epidemiological Data ◽

High Viral Load ◽

Viral Loads ◽

Severe Stage ◽

Asymptomatic Patients ◽

Positive Rate

To predict the clinical outcome of coronavirus disease-2019 (COVID-19), we examined relationships among epidemiological data, viral load, and disease severity. We examined viral loads of severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) in fatal (15 cases), symptomatic/survived (133 cases), and asymptomatic cases (138 cases) using reverse transcription quantitative real-time PCR (RT-qPCR). We examined 5768 nasopharyngeal swabs (NPS) and attempted to detect the SARS-CoV-2 genome using RT-qPCR. Among them, the viral genome was detected using the method for the 370 NPS samples with a positive rate of 6.4%. A comparison of each age showed that the fatal case was higher than the survived case and asymptomatic patients. Survived cases were older than asymptomatic patients. Notably, the viral load in the fatal cases was significantly higher than in symptomatic or asymptomatic cases (p < 0.05). These results suggested that a high viral load of the SARS-CoV-2 in elderly patients at an early stage of the disease results in a poor outcome. We should, therefore, intervene early to prevent a severe stage of the disease in such cases.

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Early Outcomes of Carotid Revascularization in Retrospective Case Series

Journal of Clinical Medicine ◽

10.3390/jcm10050935 ◽

2021 ◽

Vol 10 (5) ◽

pp. 935

Author(s):

Petroula Nana ◽

George Kouvelos ◽

Alexandros Brotis ◽

Konstantinos Spanos ◽

Efthimios Dardiotis ◽

...

Keyword(s):

Real World ◽

English Literature ◽

Meta Analysis ◽

Case Series ◽

Cardiac Events ◽

Retrospective Case ◽

Stroke Incidence ◽

Carotid Revascularization ◽

Asymptomatic Patients ◽

Ischemic Events

Background: Most data in carotid stenosis treatment arise from randomized control trials (RCTs) and cohort studies. The aim of this meta-analysis was to compare 30-day outcomes in real-world practice from centers providing both modalities. Methods: A data search of the English literature was conducted, using PubMed, EMBASE and CENTRAL databases, until December 2019, using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement (PRISMA) guidelines. Only studies reporting on 30-day outcomes from centers, where both techniques were performed, were eligible for this analysis. Results: In total, 15 articles were included (16,043 patients). Of the patients, 68.1% were asymptomatic. Carotid artery stenting (CAS) did not differ from carotid endarterectomy (CEA) in terms of stroke (odds ratio (OR) 0.98; 0.77–1.25; I2 = 0%), myocardial ischemic events (OR 1.03; 0.72–1.48; I2 = 0%) and all events (OR 1.0; 0.82–1.21; I2 = 0%). Pooled stroke incidence in asymptomatic patients was 1% (95% CI: 0–2%) for CEA and 1% for CAS (95% CI: 0–2%). Pooled stroke rate in symptomatic patients was 3% (95% CI: 1–4%) for CEA and 3% (95% CI: 1–4%) for CAS. The two techniques did not differ in either outcome both in asymptomatic and symptomatic patients. Conclusion: Carotid revascularization, performed in centers providing both CAS and CEA, is safe and effective. Both techniques did not differ in terms of post-procedural neurological and cardiac events, both in asymptomatic and symptomatic patients. These findings reiterate the importance of a tailored therapeutic strategy and that “real-world” outcomes may only be valid from centers providing both treatments.

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Atypical presentations and treatment variations of pelvic congestion syndrome: A four patient case series

F1000Research ◽

10.12688/f1000research.10477.1 ◽

2016 ◽

Vol 5 ◽

pp. 2906

Author(s):

David Greuner ◽

Andrew Amorosso ◽

Arno Rotgans ◽

Chris Hollingsworth ◽

Adam Tonis

Keyword(s):

Case Series ◽

Duplex Ultrasound ◽

Chronic Lower Back Pain ◽

Case Review ◽

Retrospective Case ◽

Pelvic Congestion Syndrome ◽

Atypical Symptoms ◽

Gonadal Vein ◽

Atypical Presentations ◽

Pelvic Congestion

This is a retrospective case review of four patients randomly selected from a pool of 43 patients who presented to our practice with historically atypical symptoms for pelvic congestion syndrome, and the treatment they received. These 43 patients were treated between June and December of 2016. Each patient presented with various atypical symptoms including chronic lower back pain, urinary frequency and incontinence, hip pain, tenesmus, and uncontrollable flatulence. Diagnostic abdominal and pelvic duplex ultrasound and fluoroscopic venography was performed on all patients with informed consent. The four selected patients for this study were all positive for pelvic venous reflux, pelvic venous insufficiency and ovarian/gonadal vein reflux and varicosities. All four of the patients selected in this retrospective study were examined at 1 week from date of intervention and again at 1 month from date of intervention. At the 1 week postoperative exam all four patients had experienced significant resolution of their symptoms, although all had residual congestion present on their right side. After re-intervention to treat right sided congestion via the right gonadal vein, at the 1 month postoperative exam all four patients had experienced an almost complete resolution of symptoms.

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