Meifang Yang

Clinical findings of 40 patients with nocardiosis: A retrospective analysis in a tertiary hospital

To the best of our knowledge, no Chinese case studies concerning Nocardia infection have been published to date. Therefore, the present study aimed to retrospectively evaluate the risk factors, clinical features, imaging results, laboratory abnormalities, treatments and outcomes of nocardiosis in a Chinese tertiary hospital. Data collected from patients with laboratory-confirmed nocardiosis were retrospectively analyzed. A total of 40 patients who had a positive culture of Nocardia were included. The median time between the onset of symptoms and diagnosis was 42 days. Underlying diseases were identified in 72.5% of the patients of which diabetes was the most common (32.5%). The most important risk factor was corticosteroid administration. Fever and cough were common clinical symptoms. The pleuropulmonary (85%) were the most frequently involved sites and the disseminated disease rate was 30.0%. Frequent chest computed tomography scans revealed the presence of airspace opacities, nodules and masses, in addition to cavitary lesions that were particularly common among the study group. Brain images revealed lesions associated with abscesses. The majority of the patients (71.1%) were treated with trimethoprim sulfamethoxazole alone or in combination with other drugs. The in-hospital mortality rate was 15.0%. Disseminated disease, immunocompromised patients, an older age, brain involvement and concomitant infections were associated with a poor prognosis. Nocardiosis is an uncommon but emerging disease. The present study reports the first case series on nocardiosis from China and provides important information on the clinical features and risk factors of nocardiosis. Early recognition of the disease and the initiation of appropriate treatment are essential for a good prognosis.

Monitoring of human cytomegalovirus glycoprotein B genotypes using real-time quantitative PCR in immunocompromised Chinese patients

Based on sequence variation in the N-terminus of glycoprotein B (gB), human cytomegalovirus (HCMV) can be classified into four gBn genotypes, and these genotypes are associated with different clinical outcomes. The distribution of gBn genotypes and the level of gBn DNA load were examined in immunocompromised Chinese patients using real-time quantitative PCR. In addition, the PCR and pp65 antigenemia results were compared. In 1480 specimens, 81.4% were antigen-positive, 12.6% were PCR-positive. The gB genotype distribution was as follows among PCR-positive samples: gBn1, 63.1%; gBn2, 13.4%; gBn3, 8.6%; gBn4, not detected; mixed genotypes, 14.9% (gBn1 and gBn3, 14.4%; gBn2 and gBn3, 0.5%). The gBn3 and gBn1 genotypes had the highest and lowest copy numbers, respectively (p<0.05). The quantity of gBn DNA found in PCR-positive, pp65-negative samples was significantly lower than that found in PCR-positive, pp65-positive samples (p<0.05). The PCR and antigenemia results did not differ among bone marrow transplant patients, solid organ transplant patients, and immunocompromised patients without transplantation (p>0.05). HCMV gBn genotyping using real-time quantitative PCR was established successfully, and the distribution of gBn genotypes in immunocompromised Chinese patients was investigated. This method may help to understand better the relationship between gBn genotype and clinical outcome and aid in clinical detection.

Bacterial coinfection is associated with severity of avian influenza A (H7N9), and procalcitonin is a useful marker for early diagnosis

Patients contracting avian influenza A (H7N9) often develop severe disease. However, information on the contribution of bacterial coinfection to the severity of H7N9 is limited. We retrospectively studied 83 patients with confirmed H7N9 infection from April 2013 to February 2014. The severity of patients with bacterial coinfection and markers for early diagnosis of bacterial coinfection in H7N9 were analyzed. We found Staphylococcus aureus was the most prevalent pathogen. Higher Acute Physiology and Chronic Health Evaluation II score, shock, renal replacement treatment, mechanical ventilation, and extracorporeal membrane oxygenation treatment were more frequently observed in patients with bacterial coinfection. Procalcitonin is more sensitive than C-reactive protein in determining bacterial coinfection in H7N9 patients. In conclusion, H7N9 infection patients with bacterial coinfection had a more severe condition. Elevated procalcitonin is an accurate marker for diagnosing bacterial coinfection in H7N9 patients, thus enabling earlier antibiotic therapy.

Correlations between Clinical Features and Mortality in Patients with Vibrio vulnificus Infection.

Vibrio vulnificus is a common gram-negative bacterium, which might cause morbidity and mortality in patients following consumption of seafood or exposure to seawater in Southeast China. We retrospectively analyzed clinical data of patients with laboratory confirmed V. vulnificus infection. Twenty one patients were divided into a survival group and a non-surviving (or death) group according to their clinical outcome. Clinical data and measurements were statistically analyzed. Four patients (19.05%) died and five patients gave positive cultures from bile fluid, and 16 other patients gave positive culture from blood or blisters. Ten patients (47.62%) had an underlying liver disease and marine-related events were found in sixteen patients (76.2%). Patients with heavy drinking habits might be at increased mortality (p = 0.028). Clinical manifestations of cellulitis (47.6%), septic shock (42.9%) and multiple organ failure (28.6%) were statistically significant when comparing survivors and non-survivors (p = 0.035, p = 0.021 and p = 0.003, respectively). The laboratory results, including hemoglobin < 9.0 g/L (p = 0.012), platelets < 2.0×109 /L, prothrombin time activity (PTA) <20%, decreased serum creatinine and increased urea nitrogen were statistically significant (p = 0.012, p = 0.003, p = 0.028 and p = 0.028, respectively). Patients may be at a higher risk of mortality under situations where they have a history of habitual heavy alcoholic drink consumption (p = 0.028, OR = 22.5, 95%CI 1.5–335.3), accompanied with cellulitis, shock, multiple organ failure, and laboratory examinations that are complicated by decreased platelets, hemoglobin and significantly prolonged prothrombin time (PT).

a fatal case of Trichosporon asahii fungemia and pneumonia in a kidney transplant recipient during caspofungin treatment

Trichosporon asahii is an emerging opportunistic pathogen that is life-threatening particularly for immunosuppressed patients. Only a few studies have described Trichosporon infection in kidney transplant recipients. This study reports a 67-year-old male kidney transplant recipient who developed fatal fungemia and pneumonia caused by T. asahii during caspofungin treatment. Although funguria is benign, kidney transplant recipients are still at risk of T. asahii fungemia and invasive T. asahii infection even if they are under antifungal therapy, particularly echinocandins.

Opportunistic Posttransplantation Virus Infections in Renal Transplant Recipients

BACKGROUND Opportunistic virus infection is one of the most common complications in renal transplant (RT) recipients. Cytomegalovirus (CMV) and BK virus (BKV) are important pathogens and each of these infections affects the other. In contrast, there is only limited information on JC virus (JCV) infection and its relation to CMV infection in RT recipients. This prospective study investigated the rates of JCV and CMV infections and their risk factors and correlations. METHODS We studied 52 RT recipients. JCV and CMV were detected using nested qualitative polymerase chain reaction assays of urine. The clinical characteristics of JCV and CMV infection were compared and risk factors analyzed with the use of binary logistic regression. RESULTS JCV and CMV were detected in 40.4% and 34.6% of the RT recipients, respectively. Cyclosporine (CsA) was a risk factor for both JCV and CMV infection (odds ratio [OR] 7.187; P=.002; OR 4.182; P=.021); CMV infection was a risk factor for JCV infection (OR 3.900; P=.039). CONCLUSIONS JCV and CMV infections are common in RT recipients. CsA is a risk factor for both JCV and CMV infection. JCV infection is related to CMV infection.

Diagnostic delay and mortality of active tuberculosis in patients after kidney transplantation in a tertiary care hospital in China

TB infection in patients after kidney transplantation remains a concern in a successful long-term outcome. This retrospective, descriptive study was performed on tuberculosis infection after kidney transplantation in the Department of Infectious Disease of the First Affiliated Hospital of Zhejiang University, a tertiary care hospital in China, from January 2011 to April 2017, with the aim to explain the clinical features of active tuberculosis after kidney transplantation and explore the correlated factors for diagnostic delay and mortality. It included 48 cases. All these cases were followed up for at least 12 months after anti-tuberculosis therapy, except the ones who died during this period. The median time of transplantation to active tuberculosis of these 48 patients was about 5.4 years. The time from a first hospital visit to the diagnosis (diagnostic delay) of 12 (25%) cases was more than 30 days. The correlated factors for the diagnostic delay more than 30 days were a fever for more than 2 weeks and antibiotic use for more than 2 weeks. Nine (18.8%) cases died during the anti-tuberculosis therapy or following-up period due to TB relapse. The risk factors for mortality were severe complications, such as encephaledema, severe pneumonia, intestinal perforation, liver function failure, and the following multiple-organ failure. In conclusion, the possibility of tuberculosis infection should be carefully assessed and sometimes diagnostic anti-tuberculosis therapy may be required for patients who had a fever for more than 2 weeks or used antibiotics for more than 2 weeks after kidney transplantation. Severe complications and the following multiple-organ failure might increase the mortality among these patients.

Community- or Healthcare-Associated Bacterial Infections Increase Long-Term Mortality in Patients With Acute Decompensation of Cirrhosis

Background: The aim of the present study was to determine the specific role of different types of bacterial infections (BIs) on the prognosis of cirrhotic patients with acute decompensation (AD). Methods: We performed a prospective, observational cohort study consisting of 492 cirrhotic patients with AD at our center from February 2014 to March 2015. Clinical, laboratory and survival data were collected. The relationship between BIs and mortality was analyzed. Results: BIs were identified in 157 of 492 patients at the time of admission or during the hospital stay. Among the patients, 65 had community‐acquired (CA) or healthcare‐associated (HCA) BIs, 54 developed hospital‐acquired (HA) BIs, and 38 had CA/HCA with HA BIs. Patients with CA/HCA BIs had higher 90‐day, 1‐year and 2‐year mortality rates (29.2%, 44.6% and 52.3%, respectively) and CA/HCA BIs remained an independent risk factor for long‐term mortality on multivariate analysis (1 year: hazard ratio = 1.60; 95% CI: 1.07‐2.41; P = 0.023 and 2 year: hazard ratio = 1.54; 95% CI: 1.05‐2.25; P = 0.026). In contrast, patients with HA BIs had a higher 28‐day mortality rate than patients with CA/HCA BIs. Logistic regression analysis showed previous ascites and prior BIs within 3 months were independent risk factors for CA/HCA BIs, whereas invasive minor surgical procedures with acute‐on‐chronic liver failure throughout the hospital stay and high chronic liver failure‐sequential organ failure assessment scores were associated with nosocomial BIs. Conclusions: CA/HCA BIs were associated with increased long‐term mortality in cirrhotic patients with AD, whereas nosocomial BIs may be related to poor short‐term prognosis.

Nocardiosis in ectopic ACTH syndrome: A case report and review of 11 cases from the literature

Ectopic adrenocorticotropic hormone (ACTH) syndrome (EAS) associated with nocardiosis is rare, and little information is available regarding its clinical characteristics. In this study, the case of a 35-year-old male patient who showed significant cushingoid features and had a cough with yellow phlegm for 1 month is described. Pulmonary computed tomography (CT) scanning and 18F-fluorodeoxyglucose positron emission tomography combined with CT identified two different lesions in the mediastinum and pulmonary region, respectively. The lesion in the mediastinum was finally diagnosed as an ACTH-secreting mediastinal paraganglioma via biopsy. The sputum culture confirmed pulmonary nocardiosis. The patient was effectively treated with complete tumor resection following the treatment of nocardiosis using trimethoprim-sulfamethoxazole. Following the present case, 11 additional cases of nocardiosis in EAS were identified in the literature and their clinical characteristics were compared and evaluated. It may be concluded that, although Nocardia remains a rare opportunistic infection pathogen in EAS, it is necessary to consider nocardiosis as a diagnosis for patients with pulmonary imaging findings of cavity, consolidation or nodule, particularly when there are brain and extra-pulmonary lesions as well as a poor response to regular treatment.

Monitoring of Human Cytomegalovirus Infection in Bone Marrow and Liver Transplant Recipients by Antigenaemia Assay and Enzyme-Linked Immunosorbent Assay

Human cytomegalovirus (HCMV) infection is a common complication in transplant recipients. Sensitive, specific and timely diagnostic tests for the detection of HCMV infection remain essential for successful therapy. The results of three tests to detect HCMV in bone marrow and liver transplant recipients were compared: a pp65 antigenaemia assay, an immediate-early (IE) antigenaemia assay and an anti-HCMV immunoglobulin M (IgM) antibody enzyme-linked immunosorbent assay (ELISA). Of 1344 samples, 911 (67.8%) and 917 (68.2%) samples were positive for pp65 and IE, respectively. The coincidence level was 85.1%. There was no statistical difference after transplantation to the first positive detection of HCMV (mean first checkout time) between the pp65 and IE antigenaemia assays. Moreover, the levels of HCMV detected by the pp65 and IE antigenaemia assays were significantly correlated. The HCMV-positivity rate as detected by the anti-HCMV IgM ELISA was 11.1%, which was significantly different from the IE and pp65 antigenaemia assays. We suggest that the IE antigenaemia assay could replace the pp65 antigenaemia assay for monitoring active HCMV infection and early detection of HCMV infection.