Clinical characteristics, risk factors and antiviral treatments of influenza in immunosuppressed inpatients in Beijing during the 2015–2020 influenza seasons

Background Compared with immunocompetent patients, immunosuppressed patients have higher morbidity and mortality, a longer duration of viral shedding, more frequent complications, and more antiviral resistance during influenza infections. However, few data on this population in China have been reported. We analysed the clinical characteristics, effects of antiviral therapy, and risk factors for admission to the intensive care unit (ICU) and death in this population after influenza infections and explored the influenza vaccination situation for this population. Methods We analysed 111 immunosuppressed inpatients who were infected with influenza virus during the 2015–2020 influenza seasons. Medical data were collected through the electronic medical record system and analysed. Univariate analysis and multivariate logistics analysis were used to identify risk factors. Results The most common cause of immunosuppression was malignancies being treated with chemotherapy (64.0%, 71/111), followed by haematopoietic stem cell transplantation (HSCT) (23.4%, 26/111). The most common presenting symptoms were fever and cough. Dyspnoea, gastrointestinal symptoms and altered mental status were more common in HSCT patients than in patients with immunosuppression due to other causes. Approximately 14.4% (16/111) of patients were admitted to the ICU, and 9.9% (11/111) of patients died. Combined and double doses of neuraminidase inhibitors did not significantly reduce the risk of admission to the ICU or death. Risk factors for admission to the ICU were dyspnoea, coinfection with other pathogens and no antiviral treatment within 48 h. The presence of dyspnoea and altered mental status were independently associated with death. Only 2.7% (3/111) of patients less than 12 months old had received a seasonal influenza vaccine. Conclusion Fever and other classic symptoms of influenza may be absent in immunosuppressed recipients, especially in HSCT patients. Conducting influenza virus detection at the first presentation seems to be a good choice for early diagnosis. Clinicians should pay extra attention to immunosuppressed patients with dyspnoea, altered mental status, coinfection with other pathogens and no antiviral treatment within 48 h because these patients have a high risk of severe illness. Inactivated influenza vaccines are recommended for immunosuppressed patients.

Posterior Reversible Encephalopathy Syndrome (PRES) Associated With COVID-19 Infection—A Case Report and Review

Coronavirus disease 2019 (COVID-19) has caused a large number of systemic complications including a variety of neurological complications. Some of the neurological complications are not known. Posterior reversible encephalopathy syndrome (PRES) is a known acute neurotoxic syndrome causing a wide range of neurological symptoms. If remains untreated, it can potentially become a life-threatening condition. However, it is not a known neurological complication of COVID-19. We describe a presentation of PRES in a patient with positive COVID-19 and presented with altered mental status. A 78-year-old male with history of idiopathic epilepsy was initially admitted with respiratory illness with negative COVID-19 test. Later during his hospitalization, his respiratory condition got worse and his repeat COVID-19 test came back positive. He had continued encephalopathy and was found to have status epilepticus afterward. Magnetic Resonance Imaging brain showed extensive PRES-related changes. His blood pressure remained overall within control without significant fluctuations. No other apparent etiology was identified for PRES except for possible correlation with COVID-19. Clinicians should consider PRES early in their differential diagnoses in patients with severe COVID-19 with continued encephalopathy.

Effects of Not Intubating Non-Trauma Patients With Low Glasgow Coma Scale Scores: a Retrospective Study

Background: Endotracheal intubation (EI) is a critical life-saving procedure commonly performed on emergency department (ED) patients who present with altered mental status (AMS). Aims: We aimed to investigate the safety of observing, without EI, patients who present to the ED with decreased levels of consciousness (LOC). Methods: We reviewed the data of all adult ED patients with a Glasgow Coma Scale (GCS) score ≤ 8, during the period between 2012 and 2018, in an academic tertiary care centre. Trauma patients were excluded. The patients were divided into two groups for comparison: those who were intubated and those who were not. Data on mortality, morbidity, and baseline clinical characteristics were collected and analysed. Results: After screening 6334 electronic medical records of patients presenting to the ED with decreased LOC, only 257 patients met the inclusion criteria. 173 (67.3%) patients were intubated, while 84 (32.7%) were not. Among the intubated patients, 165 (95.4%) were intubated early (within two hours of presentation). Mortality, morbidity and length of stay for the intubated group were higher, although the baseline clinical characteristics were the same. Conclusion: It might be safe to observe non-trauma emergency patients with a GCS score ≤ 8 without intubation. However, such decision should be taken carefully, as delayed intubation can be associated with higher mortality and morbidity

The Urine Drug Screen in the Emergency Department

Urine drug screens (UDSs) are often performed in the emergency department (ED) as part of a standard ED order set in patients with significant altered mental status, trauma, or seizures usually without the patient’s knowledge or specified informed consent. In the ED the UDS has been included in the standard consent to treatment for routine testing along with blood studies, EKG, urinalysis and radiology. Many technical factors are known to effect UDS results.There is a lack of education among physicians regarding the clinical pitfalls of UDS interpretation. This article discusses the current state and issues associated with the UDS, and presents three clinical vignettes that illustrate the impact of false-positive UDS results on patient care and the potential for a patient becoming unknowingly and unfairly stigmatized. The article also offers suggestions including a requirement for either formal informed consent or an “opt out” screening process, as recommended by the CDC in HIV testing, designed to protect patient autonomy and confidentiality.

The Urine Drug Screen in the Emergency Department

Urine drug screens (UDSs) are often performed in the emergency department (ED) as part of a standard ED order set in patients with significant altered mental status, trauma, or seizures usually without the patient’s knowledge or specified informed consent. In the ED the UDS has been included in the standard consent to treatment for routine testing along with blood studies, EKG, urinalysis and radiology. Many technical factors are known to effect UDS results.There is a lack of education among physicians regarding the clinical pitfalls of UDS interpretation. This article discusses the current state and issues associated with the UDS, and presents three clinical vignettes that illustrate the impact of false-positive UDS results on patient care and the potential for a patient becoming unknowingly and unfairly stigmatized. The article also offers suggestions including a requirement for either formal informed consent or an “opt out” screening process, as recommended by the CDC in HIV testing, designed to protect patient autonomy and confidentiality.

Epstein-Barr Virus Encephalitis in a Patient with Rheumatoid Arthritis

A 53-year-old woman with a 6-year history of rheumatoid arthritis (RA) presented with pharyngeal pain, fever, and altered mental status. The patient had been treated with methotrexate (MTX) 12 mg/week, baricitinib 4 mg/day, and tacrolimus 2 mg/day. Magnetic resonance imaging of the brain revealed diffuse high-intensity lesions in the cerebral white matter, basal ganglia, brainstem, and right cerebellar hemisphere. She was diagnosed with Epstein-Barr virus (EBV) encephalitis due to elevated levels of EBV-DNA in the cerebrospinal fluid and serum. Although MTX-associated lymphoproliferative disorders are well-known complications in patients with RA, EBV encephalitis requires careful attention for such patients undergoing treatment with multiple potent immunosuppressants.

Isolated Leptomeningeal Progression in a Patient with NTRK Fusion+ Uterine Sarcoma: A Case Report

While neurotrophic tropomyosin receptor kinase (NTRK) fusions represent rare oncogenic drivers (&#x3c;1% of solid cancers), the recent approval of NTRK inhibitors (larotrectinib and entrectinib) led to dramatic responses in patients with NTRK fusion+ tumors. Both drugs have phase I data, demonstrating efficacy in the central nervous system (CNS), including both primary brain tumors and brain metastases. We present a 29-year-old woman who was diagnosed with <i>NTRK3-SPECC1L</i> fusion+ undifferentiated uterine sarcoma and underwent resection, chemotherapy, and radiotherapy. Two years later, lung metastases were discovered. She was started on larotrectinib with complete response. She remained stable on larotrectinib until she presented with altered mental status and seizures. MRI demonstrated leptomeningeal enhancement, but because leptomeningeal progression from sarcoma is exceedingly rare and her symptoms improved dramatically with antiepileptics, these findings were initially attributed to seizures. After 2 unrevealing lumbar punctures and stable systemic imaging, a brain biopsy demonstrated metastatic sarcoma, still showing NTRK positivity. She underwent whole brain radiotherapy and was switched to entrectinib, but had clinical progression 1 month later and transitioned to hospice. This case demonstrates the efficacy of NTRK inhibitors in rare and aggressive cancer but highlights that these patients can develop isolated CNS progression even in the setting of CNS-penetrant drugs. CNS progression can occur if there is incomplete CNS drug penetration, discordance in molecular profiles between CNS and systemic disease, or acquired NTRK inhibitor resistance. In this case, CNS disease maintained the NTRK fusion status, but either inadequate CNS penetration or development of a resistance gene may explain the isolated CNS progression.