COVID-19 and MIS-C
Jason Liebowitz, Philip Seo, David Hellmann, Michael Zeide in Clinical Innovation in Rheumatology, 2023
Laboratory findings reported in MIS-C include elevated inflammatory markers (as required by most diagnostic criteria), elevated D-dimer, high neutrophil-to-lymphocyte ratio, and relative or absolute thrombocytopenia. Cardiac enzyme abnormalities, including elevated troponin T and B-type natriuretic peptide (BNP), are common in those with cardiac involvement (Dufort, Whittaker, Feldstein NEJM). Ferritin is typically elevated, though not as dramatically as in macrophage-activation syndrome (Lee). Transaminitis may occur late in the illness after other laboratory features have begun to normalize. Although procalcitonin has been reported as a marker of bacterial infection and is also observed in patients with critical illness due to viruses, elevated procalcitonin appears to be a feature of MIS-C and, therefore, should not be relied upon as a marker of bacterial infection in this setting (Memar, Gautman, Roberts, Kelly).
Treatment of Ventilator-Associated Pneumonia
Stephen M. Cohn, Alan Lisbon, Stephen Heard in 50 Landmark Papers, 2021
One of the most important advancements in VAP treatment in recent years has been the systematic shortening of treatment durations. Guided by results from several randomized controlled trials, patients receiving shorter courses of VAP therapy have demonstrated fewer days of antibiotic therapy as well as reductions in recurrent pneumonias due to multidrug resistant organisms without adverse effects on mortality. Less drug resistance and fewer antibiotic-related complications are the obvious advantages of shorter treatment courses, but some patients may remain undertreated with the currently recommended seven days of therapy. Serum procalcitonin has been used as a biomarker to guide the discontinuation of therapy, and may be particularly useful in patients who remain clinically unwell at the end of their treatment course. Use of procalcitonin in conjunction with clinical criteria to guide antibiotic discontinuation is currently recommended. This is particularly important considering the nearly 30% failure rate of initial treatment reported by Chastre et al. In their landmark study. Deciding who to treat, and for how long is certainly one of the great challenges in VAP management. The available evidence suggests we have erred on the side of overtreatment. Identifying ways to limit antibiotic therapy and detect treatment failure early will be instrumental to ensuring we have effective drugs for our future patients [5].
Severe Influenza Pneumonia and Its Mimics in the Critical Care Unit
Cheston B. Cunha, Burke A. Cunha in Infectious Diseases and Antimicrobial Stewardship in Critical Care Medicine, 2020
The measurement of non-specific inflammation markers, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), procalcitonin, and fibrinogen may assist in excluding a bacterial coinfection from primary influenza A pneumonia. The CRP and ESR concentrations in serum usually peak during days 2–4 and 4–5 after influenza illness, respectively. Concentrations of procalcitonin greater than 0.5 μg/L support bacterial infection, whereas repeatedly low amounts suggest that bacterial infection is unlikely [32]. Fibrinogen concentrations are mostly low to normal. Measurement of serum ferritin may strongly assist as a diagnostic eliminator toward influenza A and suggests the possibility of an alternate diagnosis (high elevated ferritin levels are identified in Legionella infection) [33].
RSV induced rhabdomyolysis: a case report
Published in Acta Clinica Belgica, 2023
Stijn Arnaert, Thomas Malfait, Astrid Deruyck, Farah Desoete, Maria Nersisjan, Inge Matthijs, Bart Maes
We present the case of an 18-year-old male patient without relevant medical history who was admitted to the emergency department referred by the primary physician with nearly asymptomatic rhabdomyolysis. He consulted his primary physician because of a cough with purulent sputa, he did not mention muscle pain or fever. The patient had a lean constitution and performed sports several times per week, he did not recall any traumatic injury. He did not take any medication or drugs. Routine blood sample showed a creatine kinase level of 40.400 U/L, a normal renal function and electrolytes and a mildly elevated CRP of 20.7 mg/L. Leucocytes were slightly elevated without neutrophilia (Table 1). Transaminases were elevated (AST 946 U/L, ALT 423 U/L). Troponins and CK-MB were normal, myoglobin was elevated (237 µg/L). Procalcitonin was low, suggesting the unlikeliness of a bacterial infection. A nasopharyngeal swab for respiratory viral PCR detected RSV, but was negative for COVID-19, Influenza A and B. Urine toxicology was negative. Urine sediment was normal. Radiography of the thorax did not show any consolidations.
Internal evaluation of risk stratification tool using serial procalcitonin and clinical risk factors in pediatric febrile neutropenia: The non-interventional, single institution experience prior to clinical implementation
Published in Pediatric Hematology and Oncology, 2023
C. N. Nessle, T. Braun, S. W. Choi, R. Mody
Risk stratification was assigned based on initial presentation using a modified version of a clinical risk tool initially published by Alexander, et al. validated in similar populations and recommended by COG to assign episodes as clinical standard-risk or clinical high-risk.10,14,21,23 Expanded high-risk clinical factors were added to reflect our institution’s local population and acuity similar to prior studies, such as age less than 1 year and diagnosis of Down Syndrome.16 The evaluated risk tool, termed study decision rules (SDR), is the combination of the modified clinical risk tool with two serial procalcitonin values, one at presentation and after one night of inpatient observation to aid in BSI screening19 [Table 1]. Serial procalcitonin was incorporated into routine lab assessments to avoid accessing the central venous line for extra occurrences. Additionally, we determined this lab schedule would be most feasible to incorporate into clinical practice, and this rationale was reflected in the internal assessment.
Risk factors of intensive care admission and mortality in a cohort of 111 Egyptian COVID-19 patients
Published in Egyptian Journal of Anaesthesia, 2022
Enas R Mohamed, Dina Ragab, Mohamed Taeimah, Heba Shaltoot
Procalcitonin is generally synthesized by parafollicular thyroid cells and is mainly induced by endotoxins; therefore, it is considered as a marker of sepsis in clinical practice. Endotoxins indirectly induce the production of procalcitonin by inducing the production of inflammatory cytokines [35]. However, these inflammatory cytokines are reported to be increased during COVID-19 infection, resulting in a cytokine storm. Thus, elevated levels of procalcitonin in COVID-19 might directly result from the cytokine storm that can occur during COVID-19 or could be due to a secondary bacterial infection [36]. In the present study, procalcitonin positivity was significantly higher among the non-survivors and in patients admitted to the ICU. Zhao et al. [19] also reported higher procalcitonin levels in non-survivors and in patients admitted to ICU. Moreover, Wang et al. [12] reported higher proportion of patients with positive procalcitonin among ICU patients compared to ward patients. Furthermore, Zhou et al. [14] and Ayed et al. [33] reported higher procalcitonin levels in non-survivors with a procalcitonin level of >0.2 ng/mL being an independent predictor of mortality.