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What was the administration route of drug 'BISOPROLOL'?	Bradycardia Shock Caused by the Combined Use of Carteolol Eye Drops and Verapamil in an Elderly Patient with Atrial Fibrillation and Chronic Kidney Disease. Ophthalmic carteolol is often used to treat glaucoma. Elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) are common among the super-elderly in Japan. Because these patients are exposed to polypharmacy, they are at a high-risk of adverse drug interactions. We herein report an elderly patient with CKD who suffered bradycardia shock after the combined use of carteolol eye drops and verapamil for glaucoma and paroxysmal AF. This case highlights the fact that eye drops have a similar systemic effect to oral drugs, and especially in elderly patients with polypharmacy, drug interactions can unwittingly lead to serious events. Introduction Ophthalmic beta blockers, represented by timolol and carteolol, are often used to treat glaucoma in the elderly (1). As the elderly population is dramatically increasing in Japan, we often encounter elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) (2). Because such patients tend to have multiple comorbidities, they often visit several medical institutions, and accordingly, they are prescribed multiple medications (i.e. polypharmacy). One clinical issue in those patients is that they may unwittingly experience drug interactions due to their polypharmacy, leading to a potential risk of adverse clinical events (3). There have been two case reports of bradycardia with the combined use of timolol eye drops and verapamil, with their combined use first reported in the 20th century (4,5). However, the interaction between carteolol eye drops and verapamil has not been reported. We herein report a case of bradycardia shock caused by the combined use of carteolol eye drops and verapamil in an elderly patient with a history of CKD and glaucoma, who suffered from paroxysmal AF (PAF). Case Report An 84-year-old woman presented with a 3-day history of shortness of breath and chest discomfort. She was determined to be frail as evaluated by a Canadian Study of Health and Aging Clinical Frailty Scale of 6 on admission. She had a history of glaucoma, hypertension, and CKD (estimated glomerular filtration rate 32.6 mL/min/1.73 m2) from over 10 years earlier and was being treated separately at ophthalmology and internal medicine outpatient clinics. She had blindness in her right eye due to glaucoma, and her left eye had been treated with ophthalmic carteolol and travoprost for the last few years. She had been taking azilsartan and doxazosin in addition to diet therapy for hypertension and CKD. As a result, she had been taking five kinds of internal medications, two kinds of external medications, and four kinds of eye drops a day, resulting in polypharmacy. Five days before admission, she had been diagnosed with symptomatic PAF, so verapamil [40 mg twice a day (b.i.d.)] had been newly initiated by her internal medicine physician. According to the information from the previous doctor, her heart rate had been about 60-80 beats/minute (bpm) before the start of verapamil. At admission, her heart rate was 29 bpm, and her blood pressure could not be obtained, although her radial artery pulse was palpable. Her respiratory rate and body temperature were 15/min and 36.0 °C, respectively. Her laboratory data on admission are shown in Table, revealing high serum potassium, high liver enzyme, and high lactate levels. A 12-lead electrocardiogram (ECG) during the initial examination showed a heart rate of 24 bpm and narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes (Fig. 1). Transthoracic echocardiography revealed a normal left ventricular function without any asynergy, D-shape, echo-free space, or valvular disease with a normal size of the left atrial diameter (32.0 mm). Chest X-ray revealed pulmonary edema and enlargement of the cardio-thoracic ratio. Table. Laboratory Data at the Time of Admission. WBC 5,900 /mm3 Na 139 mEq/L Hb 11.4 g/dL K 6.5 mEq/L Plt 14.2×104 /μL Cl 110 mEq/L BUN 35.6 mg/dL Ca 8.5 mg/dL Cre 1.21 mg/dL T-Chol 160 mg/dL eGFR 32.6 HDL-Chol 67 mg/dL CCR 21.25 LDL-Chol 66 mg/dL CRP 0.11 mg/dL TG 64 mg/dL TP 5.2 g/dL UA 6.3 mg/dL Alb 3.0 g/dL CK 66 U/L T-Bil 1.20 mg/dL CK-MB 4 U/L AST 234 U/L Troponin I 0.01 ng/mL ALT 119 U/L NT-proBNP 3,722 pg/mL LDH 421 U/L TSH 7.79 μlU/mL ALP 248 mEq/L Free T3 2.36 pg/mL BS 157 mg/dL Free T4 1.20 ng/mL HbA1c 5.3 % Lactate 2.9 mmol/L Alb: albumin, ALT: alanine aminotransferase, AST: aspartate aminotransferase, BS: blood sugar, BUN: blood urea nitrogen, Ca: serum calcium, CCR: creatinine clearance, CK: creatine kinase, Cl: serum chloride, Cre: serum creatinine, CRP: C-reactive protein, eGFR: estimated glomerular filtration rate, Free T3: free triiodothyronine, Free T4: free thyroxine, Hb: hemoglobin, HbA1c: hemoglobin A1c, HDL-Chol: high density lipoprotein cholesterol, K: serum potassium, LDH: lactate dehydrogenase, LDL-Chol: low density lipoprotein cholesterol, Na: serum sodium, NT-proBNP: N-terminal pro-Brain Natriuretic Peptide, Plt: platelets, T-Bil: total bilirubin, T-Chol: total cholesterol, TG: triglyceride, TP: total protein, TSH: thyroid-stimulating hormone, UA: serum uric acid, WBC: white blood cells Figure 1. A 12-lead electrocardiogram during the initial examination. A heart rate of 24 bpm and a narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes were noted. Her clinical course is shown in Fig. 2. Because she had bradycardia shock, represented by high serum lactate and liver enzyme levels, with hyperkalemia, a temporary pacing catheter was placed through the right internal jugular vein, and right ventricular pacing was performed at 90 bpm while administrating an intravenous injection of calcium gluconate hydrate and glucose-insulin therapy for hyperkalemia. Anticholinergics could not be used due to glaucoma. With this treatment, the shock immediately resolved, and the symptoms disappeared. The carteolol eye drops, verapamil, and azilsartan were discontinued, and the patient was treated with a pacing rhythm until the next day (Fig. 3). The morning after she was hospitalized, her heart rhythm returned to a normal sinus rhythm with a heart rate of 63 bpm (Fig. 4). The carteolol eye drops were discontinued after consultation with the ophthalmologist, and a different non-beta blocker for glaucoma (dorzolamide hydrochloride) was prescribed to protect her non-blind left eye. The bradycardia no longer appeared after normalization of the potassium level and discontinuing verapamil and the carteolol eye drops. Figure 2. Clinical course of this case. ALT: alanine aminotransferase, AST: aspartate aminotransferase, Calcicol: calcium gluconate hydrate, GI: glucose-insulin therapy, HR: heart rate, PAF: paroxysmal atrial fibrillation, PMI: pacemaker intubation Figure 3. A 12-lead electrocardiogram after initiating temporary pacing. A heart rate of 93 bpm, wide QRS rhythm with a left bundle branch block and upper axis pattern, and right ventricular apex origin were noted. Figure 4. A 12-lead electrocardiogram the day after the hospitalization. A heart rate of 63 bpm with normal sinus rhythm and T-wave flattening in leads III and aVF were observed. However, she had symptomatic PAF with a rapid ventricular response on the first hospital day. When the PAF stopped, she temporarily had a backup pacing with VVI 50 bpm due to sick sinus syndrome. Based on her clinical course, it was judged that the use of antiarrhythmic drugs alone for PAF carried a risk of bradycardia shock, so it was decided to administer antiarrhythmic drugs after pacemaker implantation. However, pulmonary vein isolation was not selected due to her age and activity of daily living. Pacemaker implantation was performed on the 14th hospital day. Finally, her arrhythmia, blood pressure, and glaucoma were controlled with the pacemaker implantation and adjustment of her medications, as shown in Fig. 2, and she was discharged in good health on the 20th hospital day. Discussion Ophthalmic carteolol, as well as timolol, is used as an eye drop beta blocker for glaucoma. Carteolol has been considered to have a lower risk of cardiovascular events than timolol because carteolol generally has a weaker effect on slowing the heart rate than timolol, depending on the characterization of the intrinsic sympathomimetic activity (ISA) (6,7). Although warning clues of cardiovascular events, such as bradycardia, heart block, and hypotension, have been reported due to the use of timolol eye drops (8), there have been no reports of severe cardiovascular events with the use of carteolol eye drops. Because timolol eye drops are absorbed via the nasal mucosa through the nasolacrimal duct, their bioavailability is approximately 50% of that after oral administration, and they have a systemic effect similar to oral administration; however, they are topically administered (9). Furthermore, because both carteolol and timolol are metabolized by cytochrome P450 2D6 (CYP2D6), their effect can be enhanced in elderly people with a weakened CYP2D6 when combined with a drug with a CYP2D6 inhibitory effect and/or verapamil (10). Verapamil is a commonly used class IV antiarrhythmic medication that blocks calcium-dependent slow channels, depresses the cardiac contractility, slows the myocardial conduction, and relaxes vascular smooth muscle. It serves to decrease sino-atrial (SA) node discharges and slow atrioventricular (AV) conduction, and the concomitant use with beta blockers can potentially cause severe bradycardia (11). Elderly patients sometimes have both AF and CKD (2). Because carteolol is mainly excreted by the kidneys, it may have a strong cardiac depressant effect in elderly patients with CKD (12). Elderly people tend to have polypharmacy (3,13), and if prescriptions are obtained from multiple medical institutions, it is possible that the same drugs may be prescribed. In addition, as in the present case, when the serum potassium level is increased due to a side effect of an angiotensin II receptor blocker (ARB) (14), a cardiac depressant effect due to hyperkalemia may exacerbate the cardiac function. In the present case, both the SA node and AV node were likely suppressed by the combination of the ophthalmic carteolol, verapamil, and hyperkalemia, resulting in serious bradycardia due to sick sinus syndrome. Of note, eye drops have a systemic effect similar to oral drugs. Drug interactions are more likely to occur in the elderly, especially when ophthalmic beta blockers are used in glaucoma patients, and careful follow-up in terms of cardiovascular events is needed; furthermore, verapamil should not be used for rate control in patients with AF. Although the mechanism may have involved the interaction between the carteolol eye drops and either verapamil or azilsaltan-related hyperkalemia, it is equally likely that the interaction was between all three drugs under the existence of CKD in this elderly patient. In conclusion, physicians should always consider the potential risk of adverse drug interactions when prescribing a new medication to a patient, especially in elderly patients with polypharmacy. Even topical medications, such as carteolol eye drops, might have significant systemic absorption, leading to serious side effects through drug interactions in elderly patients. Author's disclosure of potential Conflicts of Interest (COI). Yasuo Okumura: Research funding, Boston Scientific Japan. Acknowledgement We thank all of the doctors and medical staff who were involved in the treatment of this patient. In particular, Ph. So Iwabuchi and Ph. Takahiro Sekine provided important information about the carteolol eye drops. We also thank Mr. John Martin for his help with the English editing.	Oral	DrugAdministrationRoute	CC BY-NC-ND	32830185	18,270,051	2021-01-01
What was the administration route of drug 'BROMFENAC SODIUM'?	Bradycardia Shock Caused by the Combined Use of Carteolol Eye Drops and Verapamil in an Elderly Patient with Atrial Fibrillation and Chronic Kidney Disease. Ophthalmic carteolol is often used to treat glaucoma. Elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) are common among the super-elderly in Japan. Because these patients are exposed to polypharmacy, they are at a high-risk of adverse drug interactions. We herein report an elderly patient with CKD who suffered bradycardia shock after the combined use of carteolol eye drops and verapamil for glaucoma and paroxysmal AF. This case highlights the fact that eye drops have a similar systemic effect to oral drugs, and especially in elderly patients with polypharmacy, drug interactions can unwittingly lead to serious events. Introduction Ophthalmic beta blockers, represented by timolol and carteolol, are often used to treat glaucoma in the elderly (1). As the elderly population is dramatically increasing in Japan, we often encounter elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) (2). Because such patients tend to have multiple comorbidities, they often visit several medical institutions, and accordingly, they are prescribed multiple medications (i.e. polypharmacy). One clinical issue in those patients is that they may unwittingly experience drug interactions due to their polypharmacy, leading to a potential risk of adverse clinical events (3). There have been two case reports of bradycardia with the combined use of timolol eye drops and verapamil, with their combined use first reported in the 20th century (4,5). However, the interaction between carteolol eye drops and verapamil has not been reported. We herein report a case of bradycardia shock caused by the combined use of carteolol eye drops and verapamil in an elderly patient with a history of CKD and glaucoma, who suffered from paroxysmal AF (PAF). Case Report An 84-year-old woman presented with a 3-day history of shortness of breath and chest discomfort. She was determined to be frail as evaluated by a Canadian Study of Health and Aging Clinical Frailty Scale of 6 on admission. She had a history of glaucoma, hypertension, and CKD (estimated glomerular filtration rate 32.6 mL/min/1.73 m2) from over 10 years earlier and was being treated separately at ophthalmology and internal medicine outpatient clinics. She had blindness in her right eye due to glaucoma, and her left eye had been treated with ophthalmic carteolol and travoprost for the last few years. She had been taking azilsartan and doxazosin in addition to diet therapy for hypertension and CKD. As a result, she had been taking five kinds of internal medications, two kinds of external medications, and four kinds of eye drops a day, resulting in polypharmacy. Five days before admission, she had been diagnosed with symptomatic PAF, so verapamil [40 mg twice a day (b.i.d.)] had been newly initiated by her internal medicine physician. According to the information from the previous doctor, her heart rate had been about 60-80 beats/minute (bpm) before the start of verapamil. At admission, her heart rate was 29 bpm, and her blood pressure could not be obtained, although her radial artery pulse was palpable. Her respiratory rate and body temperature were 15/min and 36.0 °C, respectively. Her laboratory data on admission are shown in Table, revealing high serum potassium, high liver enzyme, and high lactate levels. A 12-lead electrocardiogram (ECG) during the initial examination showed a heart rate of 24 bpm and narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes (Fig. 1). Transthoracic echocardiography revealed a normal left ventricular function without any asynergy, D-shape, echo-free space, or valvular disease with a normal size of the left atrial diameter (32.0 mm). Chest X-ray revealed pulmonary edema and enlargement of the cardio-thoracic ratio. Table. Laboratory Data at the Time of Admission. WBC 5,900 /mm3 Na 139 mEq/L Hb 11.4 g/dL K 6.5 mEq/L Plt 14.2×104 /μL Cl 110 mEq/L BUN 35.6 mg/dL Ca 8.5 mg/dL Cre 1.21 mg/dL T-Chol 160 mg/dL eGFR 32.6 HDL-Chol 67 mg/dL CCR 21.25 LDL-Chol 66 mg/dL CRP 0.11 mg/dL TG 64 mg/dL TP 5.2 g/dL UA 6.3 mg/dL Alb 3.0 g/dL CK 66 U/L T-Bil 1.20 mg/dL CK-MB 4 U/L AST 234 U/L Troponin I 0.01 ng/mL ALT 119 U/L NT-proBNP 3,722 pg/mL LDH 421 U/L TSH 7.79 μlU/mL ALP 248 mEq/L Free T3 2.36 pg/mL BS 157 mg/dL Free T4 1.20 ng/mL HbA1c 5.3 % Lactate 2.9 mmol/L Alb: albumin, ALT: alanine aminotransferase, AST: aspartate aminotransferase, BS: blood sugar, BUN: blood urea nitrogen, Ca: serum calcium, CCR: creatinine clearance, CK: creatine kinase, Cl: serum chloride, Cre: serum creatinine, CRP: C-reactive protein, eGFR: estimated glomerular filtration rate, Free T3: free triiodothyronine, Free T4: free thyroxine, Hb: hemoglobin, HbA1c: hemoglobin A1c, HDL-Chol: high density lipoprotein cholesterol, K: serum potassium, LDH: lactate dehydrogenase, LDL-Chol: low density lipoprotein cholesterol, Na: serum sodium, NT-proBNP: N-terminal pro-Brain Natriuretic Peptide, Plt: platelets, T-Bil: total bilirubin, T-Chol: total cholesterol, TG: triglyceride, TP: total protein, TSH: thyroid-stimulating hormone, UA: serum uric acid, WBC: white blood cells Figure 1. A 12-lead electrocardiogram during the initial examination. A heart rate of 24 bpm and a narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes were noted. Her clinical course is shown in Fig. 2. Because she had bradycardia shock, represented by high serum lactate and liver enzyme levels, with hyperkalemia, a temporary pacing catheter was placed through the right internal jugular vein, and right ventricular pacing was performed at 90 bpm while administrating an intravenous injection of calcium gluconate hydrate and glucose-insulin therapy for hyperkalemia. Anticholinergics could not be used due to glaucoma. With this treatment, the shock immediately resolved, and the symptoms disappeared. The carteolol eye drops, verapamil, and azilsartan were discontinued, and the patient was treated with a pacing rhythm until the next day (Fig. 3). The morning after she was hospitalized, her heart rhythm returned to a normal sinus rhythm with a heart rate of 63 bpm (Fig. 4). The carteolol eye drops were discontinued after consultation with the ophthalmologist, and a different non-beta blocker for glaucoma (dorzolamide hydrochloride) was prescribed to protect her non-blind left eye. The bradycardia no longer appeared after normalization of the potassium level and discontinuing verapamil and the carteolol eye drops. Figure 2. Clinical course of this case. ALT: alanine aminotransferase, AST: aspartate aminotransferase, Calcicol: calcium gluconate hydrate, GI: glucose-insulin therapy, HR: heart rate, PAF: paroxysmal atrial fibrillation, PMI: pacemaker intubation Figure 3. A 12-lead electrocardiogram after initiating temporary pacing. A heart rate of 93 bpm, wide QRS rhythm with a left bundle branch block and upper axis pattern, and right ventricular apex origin were noted. Figure 4. A 12-lead electrocardiogram the day after the hospitalization. A heart rate of 63 bpm with normal sinus rhythm and T-wave flattening in leads III and aVF were observed. However, she had symptomatic PAF with a rapid ventricular response on the first hospital day. When the PAF stopped, she temporarily had a backup pacing with VVI 50 bpm due to sick sinus syndrome. Based on her clinical course, it was judged that the use of antiarrhythmic drugs alone for PAF carried a risk of bradycardia shock, so it was decided to administer antiarrhythmic drugs after pacemaker implantation. However, pulmonary vein isolation was not selected due to her age and activity of daily living. Pacemaker implantation was performed on the 14th hospital day. Finally, her arrhythmia, blood pressure, and glaucoma were controlled with the pacemaker implantation and adjustment of her medications, as shown in Fig. 2, and she was discharged in good health on the 20th hospital day. Discussion Ophthalmic carteolol, as well as timolol, is used as an eye drop beta blocker for glaucoma. Carteolol has been considered to have a lower risk of cardiovascular events than timolol because carteolol generally has a weaker effect on slowing the heart rate than timolol, depending on the characterization of the intrinsic sympathomimetic activity (ISA) (6,7). Although warning clues of cardiovascular events, such as bradycardia, heart block, and hypotension, have been reported due to the use of timolol eye drops (8), there have been no reports of severe cardiovascular events with the use of carteolol eye drops. Because timolol eye drops are absorbed via the nasal mucosa through the nasolacrimal duct, their bioavailability is approximately 50% of that after oral administration, and they have a systemic effect similar to oral administration; however, they are topically administered (9). Furthermore, because both carteolol and timolol are metabolized by cytochrome P450 2D6 (CYP2D6), their effect can be enhanced in elderly people with a weakened CYP2D6 when combined with a drug with a CYP2D6 inhibitory effect and/or verapamil (10). Verapamil is a commonly used class IV antiarrhythmic medication that blocks calcium-dependent slow channels, depresses the cardiac contractility, slows the myocardial conduction, and relaxes vascular smooth muscle. It serves to decrease sino-atrial (SA) node discharges and slow atrioventricular (AV) conduction, and the concomitant use with beta blockers can potentially cause severe bradycardia (11). Elderly patients sometimes have both AF and CKD (2). Because carteolol is mainly excreted by the kidneys, it may have a strong cardiac depressant effect in elderly patients with CKD (12). Elderly people tend to have polypharmacy (3,13), and if prescriptions are obtained from multiple medical institutions, it is possible that the same drugs may be prescribed. In addition, as in the present case, when the serum potassium level is increased due to a side effect of an angiotensin II receptor blocker (ARB) (14), a cardiac depressant effect due to hyperkalemia may exacerbate the cardiac function. In the present case, both the SA node and AV node were likely suppressed by the combination of the ophthalmic carteolol, verapamil, and hyperkalemia, resulting in serious bradycardia due to sick sinus syndrome. Of note, eye drops have a systemic effect similar to oral drugs. Drug interactions are more likely to occur in the elderly, especially when ophthalmic beta blockers are used in glaucoma patients, and careful follow-up in terms of cardiovascular events is needed; furthermore, verapamil should not be used for rate control in patients with AF. Although the mechanism may have involved the interaction between the carteolol eye drops and either verapamil or azilsaltan-related hyperkalemia, it is equally likely that the interaction was between all three drugs under the existence of CKD in this elderly patient. In conclusion, physicians should always consider the potential risk of adverse drug interactions when prescribing a new medication to a patient, especially in elderly patients with polypharmacy. Even topical medications, such as carteolol eye drops, might have significant systemic absorption, leading to serious side effects through drug interactions in elderly patients. Author's disclosure of potential Conflicts of Interest (COI). Yasuo Okumura: Research funding, Boston Scientific Japan. Acknowledgement We thank all of the doctors and medical staff who were involved in the treatment of this patient. In particular, Ph. So Iwabuchi and Ph. Takahiro Sekine provided important information about the carteolol eye drops. We also thank Mr. John Martin for his help with the English editing.	Ophthalmic	DrugAdministrationRoute	CC BY-NC-ND	32830185	18,270,051	2021-01-01
What was the administration route of drug 'CALCIUM GLUCONATE'?	Bradycardia Shock Caused by the Combined Use of Carteolol Eye Drops and Verapamil in an Elderly Patient with Atrial Fibrillation and Chronic Kidney Disease. Ophthalmic carteolol is often used to treat glaucoma. Elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) are common among the super-elderly in Japan. Because these patients are exposed to polypharmacy, they are at a high-risk of adverse drug interactions. We herein report an elderly patient with CKD who suffered bradycardia shock after the combined use of carteolol eye drops and verapamil for glaucoma and paroxysmal AF. This case highlights the fact that eye drops have a similar systemic effect to oral drugs, and especially in elderly patients with polypharmacy, drug interactions can unwittingly lead to serious events. Introduction Ophthalmic beta blockers, represented by timolol and carteolol, are often used to treat glaucoma in the elderly (1). As the elderly population is dramatically increasing in Japan, we often encounter elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) (2). Because such patients tend to have multiple comorbidities, they often visit several medical institutions, and accordingly, they are prescribed multiple medications (i.e. polypharmacy). One clinical issue in those patients is that they may unwittingly experience drug interactions due to their polypharmacy, leading to a potential risk of adverse clinical events (3). There have been two case reports of bradycardia with the combined use of timolol eye drops and verapamil, with their combined use first reported in the 20th century (4,5). However, the interaction between carteolol eye drops and verapamil has not been reported. We herein report a case of bradycardia shock caused by the combined use of carteolol eye drops and verapamil in an elderly patient with a history of CKD and glaucoma, who suffered from paroxysmal AF (PAF). Case Report An 84-year-old woman presented with a 3-day history of shortness of breath and chest discomfort. She was determined to be frail as evaluated by a Canadian Study of Health and Aging Clinical Frailty Scale of 6 on admission. She had a history of glaucoma, hypertension, and CKD (estimated glomerular filtration rate 32.6 mL/min/1.73 m2) from over 10 years earlier and was being treated separately at ophthalmology and internal medicine outpatient clinics. She had blindness in her right eye due to glaucoma, and her left eye had been treated with ophthalmic carteolol and travoprost for the last few years. She had been taking azilsartan and doxazosin in addition to diet therapy for hypertension and CKD. As a result, she had been taking five kinds of internal medications, two kinds of external medications, and four kinds of eye drops a day, resulting in polypharmacy. Five days before admission, she had been diagnosed with symptomatic PAF, so verapamil [40 mg twice a day (b.i.d.)] had been newly initiated by her internal medicine physician. According to the information from the previous doctor, her heart rate had been about 60-80 beats/minute (bpm) before the start of verapamil. At admission, her heart rate was 29 bpm, and her blood pressure could not be obtained, although her radial artery pulse was palpable. Her respiratory rate and body temperature were 15/min and 36.0 °C, respectively. Her laboratory data on admission are shown in Table, revealing high serum potassium, high liver enzyme, and high lactate levels. A 12-lead electrocardiogram (ECG) during the initial examination showed a heart rate of 24 bpm and narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes (Fig. 1). Transthoracic echocardiography revealed a normal left ventricular function without any asynergy, D-shape, echo-free space, or valvular disease with a normal size of the left atrial diameter (32.0 mm). Chest X-ray revealed pulmonary edema and enlargement of the cardio-thoracic ratio. Table. Laboratory Data at the Time of Admission. WBC 5,900 /mm3 Na 139 mEq/L Hb 11.4 g/dL K 6.5 mEq/L Plt 14.2×104 /μL Cl 110 mEq/L BUN 35.6 mg/dL Ca 8.5 mg/dL Cre 1.21 mg/dL T-Chol 160 mg/dL eGFR 32.6 HDL-Chol 67 mg/dL CCR 21.25 LDL-Chol 66 mg/dL CRP 0.11 mg/dL TG 64 mg/dL TP 5.2 g/dL UA 6.3 mg/dL Alb 3.0 g/dL CK 66 U/L T-Bil 1.20 mg/dL CK-MB 4 U/L AST 234 U/L Troponin I 0.01 ng/mL ALT 119 U/L NT-proBNP 3,722 pg/mL LDH 421 U/L TSH 7.79 μlU/mL ALP 248 mEq/L Free T3 2.36 pg/mL BS 157 mg/dL Free T4 1.20 ng/mL HbA1c 5.3 % Lactate 2.9 mmol/L Alb: albumin, ALT: alanine aminotransferase, AST: aspartate aminotransferase, BS: blood sugar, BUN: blood urea nitrogen, Ca: serum calcium, CCR: creatinine clearance, CK: creatine kinase, Cl: serum chloride, Cre: serum creatinine, CRP: C-reactive protein, eGFR: estimated glomerular filtration rate, Free T3: free triiodothyronine, Free T4: free thyroxine, Hb: hemoglobin, HbA1c: hemoglobin A1c, HDL-Chol: high density lipoprotein cholesterol, K: serum potassium, LDH: lactate dehydrogenase, LDL-Chol: low density lipoprotein cholesterol, Na: serum sodium, NT-proBNP: N-terminal pro-Brain Natriuretic Peptide, Plt: platelets, T-Bil: total bilirubin, T-Chol: total cholesterol, TG: triglyceride, TP: total protein, TSH: thyroid-stimulating hormone, UA: serum uric acid, WBC: white blood cells Figure 1. A 12-lead electrocardiogram during the initial examination. A heart rate of 24 bpm and a narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes were noted. Her clinical course is shown in Fig. 2. Because she had bradycardia shock, represented by high serum lactate and liver enzyme levels, with hyperkalemia, a temporary pacing catheter was placed through the right internal jugular vein, and right ventricular pacing was performed at 90 bpm while administrating an intravenous injection of calcium gluconate hydrate and glucose-insulin therapy for hyperkalemia. Anticholinergics could not be used due to glaucoma. With this treatment, the shock immediately resolved, and the symptoms disappeared. The carteolol eye drops, verapamil, and azilsartan were discontinued, and the patient was treated with a pacing rhythm until the next day (Fig. 3). The morning after she was hospitalized, her heart rhythm returned to a normal sinus rhythm with a heart rate of 63 bpm (Fig. 4). The carteolol eye drops were discontinued after consultation with the ophthalmologist, and a different non-beta blocker for glaucoma (dorzolamide hydrochloride) was prescribed to protect her non-blind left eye. The bradycardia no longer appeared after normalization of the potassium level and discontinuing verapamil and the carteolol eye drops. Figure 2. Clinical course of this case. ALT: alanine aminotransferase, AST: aspartate aminotransferase, Calcicol: calcium gluconate hydrate, GI: glucose-insulin therapy, HR: heart rate, PAF: paroxysmal atrial fibrillation, PMI: pacemaker intubation Figure 3. A 12-lead electrocardiogram after initiating temporary pacing. A heart rate of 93 bpm, wide QRS rhythm with a left bundle branch block and upper axis pattern, and right ventricular apex origin were noted. Figure 4. A 12-lead electrocardiogram the day after the hospitalization. A heart rate of 63 bpm with normal sinus rhythm and T-wave flattening in leads III and aVF were observed. However, she had symptomatic PAF with a rapid ventricular response on the first hospital day. When the PAF stopped, she temporarily had a backup pacing with VVI 50 bpm due to sick sinus syndrome. Based on her clinical course, it was judged that the use of antiarrhythmic drugs alone for PAF carried a risk of bradycardia shock, so it was decided to administer antiarrhythmic drugs after pacemaker implantation. However, pulmonary vein isolation was not selected due to her age and activity of daily living. Pacemaker implantation was performed on the 14th hospital day. Finally, her arrhythmia, blood pressure, and glaucoma were controlled with the pacemaker implantation and adjustment of her medications, as shown in Fig. 2, and she was discharged in good health on the 20th hospital day. Discussion Ophthalmic carteolol, as well as timolol, is used as an eye drop beta blocker for glaucoma. Carteolol has been considered to have a lower risk of cardiovascular events than timolol because carteolol generally has a weaker effect on slowing the heart rate than timolol, depending on the characterization of the intrinsic sympathomimetic activity (ISA) (6,7). Although warning clues of cardiovascular events, such as bradycardia, heart block, and hypotension, have been reported due to the use of timolol eye drops (8), there have been no reports of severe cardiovascular events with the use of carteolol eye drops. Because timolol eye drops are absorbed via the nasal mucosa through the nasolacrimal duct, their bioavailability is approximately 50% of that after oral administration, and they have a systemic effect similar to oral administration; however, they are topically administered (9). Furthermore, because both carteolol and timolol are metabolized by cytochrome P450 2D6 (CYP2D6), their effect can be enhanced in elderly people with a weakened CYP2D6 when combined with a drug with a CYP2D6 inhibitory effect and/or verapamil (10). Verapamil is a commonly used class IV antiarrhythmic medication that blocks calcium-dependent slow channels, depresses the cardiac contractility, slows the myocardial conduction, and relaxes vascular smooth muscle. It serves to decrease sino-atrial (SA) node discharges and slow atrioventricular (AV) conduction, and the concomitant use with beta blockers can potentially cause severe bradycardia (11). Elderly patients sometimes have both AF and CKD (2). Because carteolol is mainly excreted by the kidneys, it may have a strong cardiac depressant effect in elderly patients with CKD (12). Elderly people tend to have polypharmacy (3,13), and if prescriptions are obtained from multiple medical institutions, it is possible that the same drugs may be prescribed. In addition, as in the present case, when the serum potassium level is increased due to a side effect of an angiotensin II receptor blocker (ARB) (14), a cardiac depressant effect due to hyperkalemia may exacerbate the cardiac function. In the present case, both the SA node and AV node were likely suppressed by the combination of the ophthalmic carteolol, verapamil, and hyperkalemia, resulting in serious bradycardia due to sick sinus syndrome. Of note, eye drops have a systemic effect similar to oral drugs. Drug interactions are more likely to occur in the elderly, especially when ophthalmic beta blockers are used in glaucoma patients, and careful follow-up in terms of cardiovascular events is needed; furthermore, verapamil should not be used for rate control in patients with AF. Although the mechanism may have involved the interaction between the carteolol eye drops and either verapamil or azilsaltan-related hyperkalemia, it is equally likely that the interaction was between all three drugs under the existence of CKD in this elderly patient. In conclusion, physicians should always consider the potential risk of adverse drug interactions when prescribing a new medication to a patient, especially in elderly patients with polypharmacy. Even topical medications, such as carteolol eye drops, might have significant systemic absorption, leading to serious side effects through drug interactions in elderly patients. Author's disclosure of potential Conflicts of Interest (COI). Yasuo Okumura: Research funding, Boston Scientific Japan. Acknowledgement We thank all of the doctors and medical staff who were involved in the treatment of this patient. In particular, Ph. So Iwabuchi and Ph. Takahiro Sekine provided important information about the carteolol eye drops. We also thank Mr. John Martin for his help with the English editing.	Intravenous (not otherwise specified)	DrugAdministrationRoute	CC BY-NC-ND	32830185	18,270,051	2021-01-01
What was the administration route of drug 'CARTEOLOL HYDROCHLORIDE'?	Bradycardia Shock Caused by the Combined Use of Carteolol Eye Drops and Verapamil in an Elderly Patient with Atrial Fibrillation and Chronic Kidney Disease. Ophthalmic carteolol is often used to treat glaucoma. Elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) are common among the super-elderly in Japan. Because these patients are exposed to polypharmacy, they are at a high-risk of adverse drug interactions. We herein report an elderly patient with CKD who suffered bradycardia shock after the combined use of carteolol eye drops and verapamil for glaucoma and paroxysmal AF. This case highlights the fact that eye drops have a similar systemic effect to oral drugs, and especially in elderly patients with polypharmacy, drug interactions can unwittingly lead to serious events. Introduction Ophthalmic beta blockers, represented by timolol and carteolol, are often used to treat glaucoma in the elderly (1). As the elderly population is dramatically increasing in Japan, we often encounter elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) (2). Because such patients tend to have multiple comorbidities, they often visit several medical institutions, and accordingly, they are prescribed multiple medications (i.e. polypharmacy). One clinical issue in those patients is that they may unwittingly experience drug interactions due to their polypharmacy, leading to a potential risk of adverse clinical events (3). There have been two case reports of bradycardia with the combined use of timolol eye drops and verapamil, with their combined use first reported in the 20th century (4,5). However, the interaction between carteolol eye drops and verapamil has not been reported. We herein report a case of bradycardia shock caused by the combined use of carteolol eye drops and verapamil in an elderly patient with a history of CKD and glaucoma, who suffered from paroxysmal AF (PAF). Case Report An 84-year-old woman presented with a 3-day history of shortness of breath and chest discomfort. She was determined to be frail as evaluated by a Canadian Study of Health and Aging Clinical Frailty Scale of 6 on admission. She had a history of glaucoma, hypertension, and CKD (estimated glomerular filtration rate 32.6 mL/min/1.73 m2) from over 10 years earlier and was being treated separately at ophthalmology and internal medicine outpatient clinics. She had blindness in her right eye due to glaucoma, and her left eye had been treated with ophthalmic carteolol and travoprost for the last few years. She had been taking azilsartan and doxazosin in addition to diet therapy for hypertension and CKD. As a result, she had been taking five kinds of internal medications, two kinds of external medications, and four kinds of eye drops a day, resulting in polypharmacy. Five days before admission, she had been diagnosed with symptomatic PAF, so verapamil [40 mg twice a day (b.i.d.)] had been newly initiated by her internal medicine physician. According to the information from the previous doctor, her heart rate had been about 60-80 beats/minute (bpm) before the start of verapamil. At admission, her heart rate was 29 bpm, and her blood pressure could not be obtained, although her radial artery pulse was palpable. Her respiratory rate and body temperature were 15/min and 36.0 °C, respectively. Her laboratory data on admission are shown in Table, revealing high serum potassium, high liver enzyme, and high lactate levels. A 12-lead electrocardiogram (ECG) during the initial examination showed a heart rate of 24 bpm and narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes (Fig. 1). Transthoracic echocardiography revealed a normal left ventricular function without any asynergy, D-shape, echo-free space, or valvular disease with a normal size of the left atrial diameter (32.0 mm). Chest X-ray revealed pulmonary edema and enlargement of the cardio-thoracic ratio. Table. Laboratory Data at the Time of Admission. WBC 5,900 /mm3 Na 139 mEq/L Hb 11.4 g/dL K 6.5 mEq/L Plt 14.2×104 /μL Cl 110 mEq/L BUN 35.6 mg/dL Ca 8.5 mg/dL Cre 1.21 mg/dL T-Chol 160 mg/dL eGFR 32.6 HDL-Chol 67 mg/dL CCR 21.25 LDL-Chol 66 mg/dL CRP 0.11 mg/dL TG 64 mg/dL TP 5.2 g/dL UA 6.3 mg/dL Alb 3.0 g/dL CK 66 U/L T-Bil 1.20 mg/dL CK-MB 4 U/L AST 234 U/L Troponin I 0.01 ng/mL ALT 119 U/L NT-proBNP 3,722 pg/mL LDH 421 U/L TSH 7.79 μlU/mL ALP 248 mEq/L Free T3 2.36 pg/mL BS 157 mg/dL Free T4 1.20 ng/mL HbA1c 5.3 % Lactate 2.9 mmol/L Alb: albumin, ALT: alanine aminotransferase, AST: aspartate aminotransferase, BS: blood sugar, BUN: blood urea nitrogen, Ca: serum calcium, CCR: creatinine clearance, CK: creatine kinase, Cl: serum chloride, Cre: serum creatinine, CRP: C-reactive protein, eGFR: estimated glomerular filtration rate, Free T3: free triiodothyronine, Free T4: free thyroxine, Hb: hemoglobin, HbA1c: hemoglobin A1c, HDL-Chol: high density lipoprotein cholesterol, K: serum potassium, LDH: lactate dehydrogenase, LDL-Chol: low density lipoprotein cholesterol, Na: serum sodium, NT-proBNP: N-terminal pro-Brain Natriuretic Peptide, Plt: platelets, T-Bil: total bilirubin, T-Chol: total cholesterol, TG: triglyceride, TP: total protein, TSH: thyroid-stimulating hormone, UA: serum uric acid, WBC: white blood cells Figure 1. A 12-lead electrocardiogram during the initial examination. A heart rate of 24 bpm and a narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes were noted. Her clinical course is shown in Fig. 2. Because she had bradycardia shock, represented by high serum lactate and liver enzyme levels, with hyperkalemia, a temporary pacing catheter was placed through the right internal jugular vein, and right ventricular pacing was performed at 90 bpm while administrating an intravenous injection of calcium gluconate hydrate and glucose-insulin therapy for hyperkalemia. Anticholinergics could not be used due to glaucoma. With this treatment, the shock immediately resolved, and the symptoms disappeared. The carteolol eye drops, verapamil, and azilsartan were discontinued, and the patient was treated with a pacing rhythm until the next day (Fig. 3). The morning after she was hospitalized, her heart rhythm returned to a normal sinus rhythm with a heart rate of 63 bpm (Fig. 4). The carteolol eye drops were discontinued after consultation with the ophthalmologist, and a different non-beta blocker for glaucoma (dorzolamide hydrochloride) was prescribed to protect her non-blind left eye. The bradycardia no longer appeared after normalization of the potassium level and discontinuing verapamil and the carteolol eye drops. Figure 2. Clinical course of this case. ALT: alanine aminotransferase, AST: aspartate aminotransferase, Calcicol: calcium gluconate hydrate, GI: glucose-insulin therapy, HR: heart rate, PAF: paroxysmal atrial fibrillation, PMI: pacemaker intubation Figure 3. A 12-lead electrocardiogram after initiating temporary pacing. A heart rate of 93 bpm, wide QRS rhythm with a left bundle branch block and upper axis pattern, and right ventricular apex origin were noted. Figure 4. A 12-lead electrocardiogram the day after the hospitalization. A heart rate of 63 bpm with normal sinus rhythm and T-wave flattening in leads III and aVF were observed. However, she had symptomatic PAF with a rapid ventricular response on the first hospital day. When the PAF stopped, she temporarily had a backup pacing with VVI 50 bpm due to sick sinus syndrome. Based on her clinical course, it was judged that the use of antiarrhythmic drugs alone for PAF carried a risk of bradycardia shock, so it was decided to administer antiarrhythmic drugs after pacemaker implantation. However, pulmonary vein isolation was not selected due to her age and activity of daily living. Pacemaker implantation was performed on the 14th hospital day. Finally, her arrhythmia, blood pressure, and glaucoma were controlled with the pacemaker implantation and adjustment of her medications, as shown in Fig. 2, and she was discharged in good health on the 20th hospital day. Discussion Ophthalmic carteolol, as well as timolol, is used as an eye drop beta blocker for glaucoma. Carteolol has been considered to have a lower risk of cardiovascular events than timolol because carteolol generally has a weaker effect on slowing the heart rate than timolol, depending on the characterization of the intrinsic sympathomimetic activity (ISA) (6,7). Although warning clues of cardiovascular events, such as bradycardia, heart block, and hypotension, have been reported due to the use of timolol eye drops (8), there have been no reports of severe cardiovascular events with the use of carteolol eye drops. Because timolol eye drops are absorbed via the nasal mucosa through the nasolacrimal duct, their bioavailability is approximately 50% of that after oral administration, and they have a systemic effect similar to oral administration; however, they are topically administered (9). Furthermore, because both carteolol and timolol are metabolized by cytochrome P450 2D6 (CYP2D6), their effect can be enhanced in elderly people with a weakened CYP2D6 when combined with a drug with a CYP2D6 inhibitory effect and/or verapamil (10). Verapamil is a commonly used class IV antiarrhythmic medication that blocks calcium-dependent slow channels, depresses the cardiac contractility, slows the myocardial conduction, and relaxes vascular smooth muscle. It serves to decrease sino-atrial (SA) node discharges and slow atrioventricular (AV) conduction, and the concomitant use with beta blockers can potentially cause severe bradycardia (11). Elderly patients sometimes have both AF and CKD (2). Because carteolol is mainly excreted by the kidneys, it may have a strong cardiac depressant effect in elderly patients with CKD (12). Elderly people tend to have polypharmacy (3,13), and if prescriptions are obtained from multiple medical institutions, it is possible that the same drugs may be prescribed. In addition, as in the present case, when the serum potassium level is increased due to a side effect of an angiotensin II receptor blocker (ARB) (14), a cardiac depressant effect due to hyperkalemia may exacerbate the cardiac function. In the present case, both the SA node and AV node were likely suppressed by the combination of the ophthalmic carteolol, verapamil, and hyperkalemia, resulting in serious bradycardia due to sick sinus syndrome. Of note, eye drops have a systemic effect similar to oral drugs. Drug interactions are more likely to occur in the elderly, especially when ophthalmic beta blockers are used in glaucoma patients, and careful follow-up in terms of cardiovascular events is needed; furthermore, verapamil should not be used for rate control in patients with AF. Although the mechanism may have involved the interaction between the carteolol eye drops and either verapamil or azilsaltan-related hyperkalemia, it is equally likely that the interaction was between all three drugs under the existence of CKD in this elderly patient. In conclusion, physicians should always consider the potential risk of adverse drug interactions when prescribing a new medication to a patient, especially in elderly patients with polypharmacy. Even topical medications, such as carteolol eye drops, might have significant systemic absorption, leading to serious side effects through drug interactions in elderly patients. Author's disclosure of potential Conflicts of Interest (COI). Yasuo Okumura: Research funding, Boston Scientific Japan. Acknowledgement We thank all of the doctors and medical staff who were involved in the treatment of this patient. In particular, Ph. So Iwabuchi and Ph. Takahiro Sekine provided important information about the carteolol eye drops. We also thank Mr. John Martin for his help with the English editing.	Ophthalmic	DrugAdministrationRoute	CC BY-NC-ND	32830185	18,270,051	2021-01-01
What was the administration route of drug 'CARTEOLOL'?	Bradycardia Shock Caused by the Combined Use of Carteolol Eye Drops and Verapamil in an Elderly Patient with Atrial Fibrillation and Chronic Kidney Disease. Ophthalmic carteolol is often used to treat glaucoma. Elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) are common among the super-elderly in Japan. Because these patients are exposed to polypharmacy, they are at a high-risk of adverse drug interactions. We herein report an elderly patient with CKD who suffered bradycardia shock after the combined use of carteolol eye drops and verapamil for glaucoma and paroxysmal AF. This case highlights the fact that eye drops have a similar systemic effect to oral drugs, and especially in elderly patients with polypharmacy, drug interactions can unwittingly lead to serious events. Introduction Ophthalmic beta blockers, represented by timolol and carteolol, are often used to treat glaucoma in the elderly (1). As the elderly population is dramatically increasing in Japan, we often encounter elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) (2). Because such patients tend to have multiple comorbidities, they often visit several medical institutions, and accordingly, they are prescribed multiple medications (i.e. polypharmacy). One clinical issue in those patients is that they may unwittingly experience drug interactions due to their polypharmacy, leading to a potential risk of adverse clinical events (3). There have been two case reports of bradycardia with the combined use of timolol eye drops and verapamil, with their combined use first reported in the 20th century (4,5). However, the interaction between carteolol eye drops and verapamil has not been reported. We herein report a case of bradycardia shock caused by the combined use of carteolol eye drops and verapamil in an elderly patient with a history of CKD and glaucoma, who suffered from paroxysmal AF (PAF). Case Report An 84-year-old woman presented with a 3-day history of shortness of breath and chest discomfort. She was determined to be frail as evaluated by a Canadian Study of Health and Aging Clinical Frailty Scale of 6 on admission. She had a history of glaucoma, hypertension, and CKD (estimated glomerular filtration rate 32.6 mL/min/1.73 m2) from over 10 years earlier and was being treated separately at ophthalmology and internal medicine outpatient clinics. She had blindness in her right eye due to glaucoma, and her left eye had been treated with ophthalmic carteolol and travoprost for the last few years. She had been taking azilsartan and doxazosin in addition to diet therapy for hypertension and CKD. As a result, she had been taking five kinds of internal medications, two kinds of external medications, and four kinds of eye drops a day, resulting in polypharmacy. Five days before admission, she had been diagnosed with symptomatic PAF, so verapamil [40 mg twice a day (b.i.d.)] had been newly initiated by her internal medicine physician. According to the information from the previous doctor, her heart rate had been about 60-80 beats/minute (bpm) before the start of verapamil. At admission, her heart rate was 29 bpm, and her blood pressure could not be obtained, although her radial artery pulse was palpable. Her respiratory rate and body temperature were 15/min and 36.0 °C, respectively. Her laboratory data on admission are shown in Table, revealing high serum potassium, high liver enzyme, and high lactate levels. A 12-lead electrocardiogram (ECG) during the initial examination showed a heart rate of 24 bpm and narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes (Fig. 1). Transthoracic echocardiography revealed a normal left ventricular function without any asynergy, D-shape, echo-free space, or valvular disease with a normal size of the left atrial diameter (32.0 mm). Chest X-ray revealed pulmonary edema and enlargement of the cardio-thoracic ratio. Table. Laboratory Data at the Time of Admission. WBC 5,900 /mm3 Na 139 mEq/L Hb 11.4 g/dL K 6.5 mEq/L Plt 14.2×104 /μL Cl 110 mEq/L BUN 35.6 mg/dL Ca 8.5 mg/dL Cre 1.21 mg/dL T-Chol 160 mg/dL eGFR 32.6 HDL-Chol 67 mg/dL CCR 21.25 LDL-Chol 66 mg/dL CRP 0.11 mg/dL TG 64 mg/dL TP 5.2 g/dL UA 6.3 mg/dL Alb 3.0 g/dL CK 66 U/L T-Bil 1.20 mg/dL CK-MB 4 U/L AST 234 U/L Troponin I 0.01 ng/mL ALT 119 U/L NT-proBNP 3,722 pg/mL LDH 421 U/L TSH 7.79 μlU/mL ALP 248 mEq/L Free T3 2.36 pg/mL BS 157 mg/dL Free T4 1.20 ng/mL HbA1c 5.3 % Lactate 2.9 mmol/L Alb: albumin, ALT: alanine aminotransferase, AST: aspartate aminotransferase, BS: blood sugar, BUN: blood urea nitrogen, Ca: serum calcium, CCR: creatinine clearance, CK: creatine kinase, Cl: serum chloride, Cre: serum creatinine, CRP: C-reactive protein, eGFR: estimated glomerular filtration rate, Free T3: free triiodothyronine, Free T4: free thyroxine, Hb: hemoglobin, HbA1c: hemoglobin A1c, HDL-Chol: high density lipoprotein cholesterol, K: serum potassium, LDH: lactate dehydrogenase, LDL-Chol: low density lipoprotein cholesterol, Na: serum sodium, NT-proBNP: N-terminal pro-Brain Natriuretic Peptide, Plt: platelets, T-Bil: total bilirubin, T-Chol: total cholesterol, TG: triglyceride, TP: total protein, TSH: thyroid-stimulating hormone, UA: serum uric acid, WBC: white blood cells Figure 1. A 12-lead electrocardiogram during the initial examination. A heart rate of 24 bpm and a narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes were noted. Her clinical course is shown in Fig. 2. Because she had bradycardia shock, represented by high serum lactate and liver enzyme levels, with hyperkalemia, a temporary pacing catheter was placed through the right internal jugular vein, and right ventricular pacing was performed at 90 bpm while administrating an intravenous injection of calcium gluconate hydrate and glucose-insulin therapy for hyperkalemia. Anticholinergics could not be used due to glaucoma. With this treatment, the shock immediately resolved, and the symptoms disappeared. The carteolol eye drops, verapamil, and azilsartan were discontinued, and the patient was treated with a pacing rhythm until the next day (Fig. 3). The morning after she was hospitalized, her heart rhythm returned to a normal sinus rhythm with a heart rate of 63 bpm (Fig. 4). The carteolol eye drops were discontinued after consultation with the ophthalmologist, and a different non-beta blocker for glaucoma (dorzolamide hydrochloride) was prescribed to protect her non-blind left eye. The bradycardia no longer appeared after normalization of the potassium level and discontinuing verapamil and the carteolol eye drops. Figure 2. Clinical course of this case. ALT: alanine aminotransferase, AST: aspartate aminotransferase, Calcicol: calcium gluconate hydrate, GI: glucose-insulin therapy, HR: heart rate, PAF: paroxysmal atrial fibrillation, PMI: pacemaker intubation Figure 3. A 12-lead electrocardiogram after initiating temporary pacing. A heart rate of 93 bpm, wide QRS rhythm with a left bundle branch block and upper axis pattern, and right ventricular apex origin were noted. Figure 4. A 12-lead electrocardiogram the day after the hospitalization. A heart rate of 63 bpm with normal sinus rhythm and T-wave flattening in leads III and aVF were observed. However, she had symptomatic PAF with a rapid ventricular response on the first hospital day. When the PAF stopped, she temporarily had a backup pacing with VVI 50 bpm due to sick sinus syndrome. Based on her clinical course, it was judged that the use of antiarrhythmic drugs alone for PAF carried a risk of bradycardia shock, so it was decided to administer antiarrhythmic drugs after pacemaker implantation. However, pulmonary vein isolation was not selected due to her age and activity of daily living. Pacemaker implantation was performed on the 14th hospital day. Finally, her arrhythmia, blood pressure, and glaucoma were controlled with the pacemaker implantation and adjustment of her medications, as shown in Fig. 2, and she was discharged in good health on the 20th hospital day. Discussion Ophthalmic carteolol, as well as timolol, is used as an eye drop beta blocker for glaucoma. Carteolol has been considered to have a lower risk of cardiovascular events than timolol because carteolol generally has a weaker effect on slowing the heart rate than timolol, depending on the characterization of the intrinsic sympathomimetic activity (ISA) (6,7). Although warning clues of cardiovascular events, such as bradycardia, heart block, and hypotension, have been reported due to the use of timolol eye drops (8), there have been no reports of severe cardiovascular events with the use of carteolol eye drops. Because timolol eye drops are absorbed via the nasal mucosa through the nasolacrimal duct, their bioavailability is approximately 50% of that after oral administration, and they have a systemic effect similar to oral administration; however, they are topically administered (9). Furthermore, because both carteolol and timolol are metabolized by cytochrome P450 2D6 (CYP2D6), their effect can be enhanced in elderly people with a weakened CYP2D6 when combined with a drug with a CYP2D6 inhibitory effect and/or verapamil (10). Verapamil is a commonly used class IV antiarrhythmic medication that blocks calcium-dependent slow channels, depresses the cardiac contractility, slows the myocardial conduction, and relaxes vascular smooth muscle. It serves to decrease sino-atrial (SA) node discharges and slow atrioventricular (AV) conduction, and the concomitant use with beta blockers can potentially cause severe bradycardia (11). Elderly patients sometimes have both AF and CKD (2). Because carteolol is mainly excreted by the kidneys, it may have a strong cardiac depressant effect in elderly patients with CKD (12). Elderly people tend to have polypharmacy (3,13), and if prescriptions are obtained from multiple medical institutions, it is possible that the same drugs may be prescribed. In addition, as in the present case, when the serum potassium level is increased due to a side effect of an angiotensin II receptor blocker (ARB) (14), a cardiac depressant effect due to hyperkalemia may exacerbate the cardiac function. In the present case, both the SA node and AV node were likely suppressed by the combination of the ophthalmic carteolol, verapamil, and hyperkalemia, resulting in serious bradycardia due to sick sinus syndrome. Of note, eye drops have a systemic effect similar to oral drugs. Drug interactions are more likely to occur in the elderly, especially when ophthalmic beta blockers are used in glaucoma patients, and careful follow-up in terms of cardiovascular events is needed; furthermore, verapamil should not be used for rate control in patients with AF. Although the mechanism may have involved the interaction between the carteolol eye drops and either verapamil or azilsaltan-related hyperkalemia, it is equally likely that the interaction was between all three drugs under the existence of CKD in this elderly patient. In conclusion, physicians should always consider the potential risk of adverse drug interactions when prescribing a new medication to a patient, especially in elderly patients with polypharmacy. Even topical medications, such as carteolol eye drops, might have significant systemic absorption, leading to serious side effects through drug interactions in elderly patients. Author's disclosure of potential Conflicts of Interest (COI). Yasuo Okumura: Research funding, Boston Scientific Japan. Acknowledgement We thank all of the doctors and medical staff who were involved in the treatment of this patient. In particular, Ph. So Iwabuchi and Ph. Takahiro Sekine provided important information about the carteolol eye drops. We also thank Mr. John Martin for his help with the English editing.	Ophthalmic	DrugAdministrationRoute	CC BY-NC-ND	32830185	18,817,303	2021-01-01
What was the administration route of drug 'DORZOLAMIDE HYDROCHLORIDE'?	Bradycardia Shock Caused by the Combined Use of Carteolol Eye Drops and Verapamil in an Elderly Patient with Atrial Fibrillation and Chronic Kidney Disease. Ophthalmic carteolol is often used to treat glaucoma. Elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) are common among the super-elderly in Japan. Because these patients are exposed to polypharmacy, they are at a high-risk of adverse drug interactions. We herein report an elderly patient with CKD who suffered bradycardia shock after the combined use of carteolol eye drops and verapamil for glaucoma and paroxysmal AF. This case highlights the fact that eye drops have a similar systemic effect to oral drugs, and especially in elderly patients with polypharmacy, drug interactions can unwittingly lead to serious events. Introduction Ophthalmic beta blockers, represented by timolol and carteolol, are often used to treat glaucoma in the elderly (1). As the elderly population is dramatically increasing in Japan, we often encounter elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) (2). Because such patients tend to have multiple comorbidities, they often visit several medical institutions, and accordingly, they are prescribed multiple medications (i.e. polypharmacy). One clinical issue in those patients is that they may unwittingly experience drug interactions due to their polypharmacy, leading to a potential risk of adverse clinical events (3). There have been two case reports of bradycardia with the combined use of timolol eye drops and verapamil, with their combined use first reported in the 20th century (4,5). However, the interaction between carteolol eye drops and verapamil has not been reported. We herein report a case of bradycardia shock caused by the combined use of carteolol eye drops and verapamil in an elderly patient with a history of CKD and glaucoma, who suffered from paroxysmal AF (PAF). Case Report An 84-year-old woman presented with a 3-day history of shortness of breath and chest discomfort. She was determined to be frail as evaluated by a Canadian Study of Health and Aging Clinical Frailty Scale of 6 on admission. She had a history of glaucoma, hypertension, and CKD (estimated glomerular filtration rate 32.6 mL/min/1.73 m2) from over 10 years earlier and was being treated separately at ophthalmology and internal medicine outpatient clinics. She had blindness in her right eye due to glaucoma, and her left eye had been treated with ophthalmic carteolol and travoprost for the last few years. She had been taking azilsartan and doxazosin in addition to diet therapy for hypertension and CKD. As a result, she had been taking five kinds of internal medications, two kinds of external medications, and four kinds of eye drops a day, resulting in polypharmacy. Five days before admission, she had been diagnosed with symptomatic PAF, so verapamil [40 mg twice a day (b.i.d.)] had been newly initiated by her internal medicine physician. According to the information from the previous doctor, her heart rate had been about 60-80 beats/minute (bpm) before the start of verapamil. At admission, her heart rate was 29 bpm, and her blood pressure could not be obtained, although her radial artery pulse was palpable. Her respiratory rate and body temperature were 15/min and 36.0 °C, respectively. Her laboratory data on admission are shown in Table, revealing high serum potassium, high liver enzyme, and high lactate levels. A 12-lead electrocardiogram (ECG) during the initial examination showed a heart rate of 24 bpm and narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes (Fig. 1). Transthoracic echocardiography revealed a normal left ventricular function without any asynergy, D-shape, echo-free space, or valvular disease with a normal size of the left atrial diameter (32.0 mm). Chest X-ray revealed pulmonary edema and enlargement of the cardio-thoracic ratio. Table. Laboratory Data at the Time of Admission. WBC 5,900 /mm3 Na 139 mEq/L Hb 11.4 g/dL K 6.5 mEq/L Plt 14.2×104 /μL Cl 110 mEq/L BUN 35.6 mg/dL Ca 8.5 mg/dL Cre 1.21 mg/dL T-Chol 160 mg/dL eGFR 32.6 HDL-Chol 67 mg/dL CCR 21.25 LDL-Chol 66 mg/dL CRP 0.11 mg/dL TG 64 mg/dL TP 5.2 g/dL UA 6.3 mg/dL Alb 3.0 g/dL CK 66 U/L T-Bil 1.20 mg/dL CK-MB 4 U/L AST 234 U/L Troponin I 0.01 ng/mL ALT 119 U/L NT-proBNP 3,722 pg/mL LDH 421 U/L TSH 7.79 μlU/mL ALP 248 mEq/L Free T3 2.36 pg/mL BS 157 mg/dL Free T4 1.20 ng/mL HbA1c 5.3 % Lactate 2.9 mmol/L Alb: albumin, ALT: alanine aminotransferase, AST: aspartate aminotransferase, BS: blood sugar, BUN: blood urea nitrogen, Ca: serum calcium, CCR: creatinine clearance, CK: creatine kinase, Cl: serum chloride, Cre: serum creatinine, CRP: C-reactive protein, eGFR: estimated glomerular filtration rate, Free T3: free triiodothyronine, Free T4: free thyroxine, Hb: hemoglobin, HbA1c: hemoglobin A1c, HDL-Chol: high density lipoprotein cholesterol, K: serum potassium, LDH: lactate dehydrogenase, LDL-Chol: low density lipoprotein cholesterol, Na: serum sodium, NT-proBNP: N-terminal pro-Brain Natriuretic Peptide, Plt: platelets, T-Bil: total bilirubin, T-Chol: total cholesterol, TG: triglyceride, TP: total protein, TSH: thyroid-stimulating hormone, UA: serum uric acid, WBC: white blood cells Figure 1. A 12-lead electrocardiogram during the initial examination. A heart rate of 24 bpm and a narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes were noted. Her clinical course is shown in Fig. 2. Because she had bradycardia shock, represented by high serum lactate and liver enzyme levels, with hyperkalemia, a temporary pacing catheter was placed through the right internal jugular vein, and right ventricular pacing was performed at 90 bpm while administrating an intravenous injection of calcium gluconate hydrate and glucose-insulin therapy for hyperkalemia. Anticholinergics could not be used due to glaucoma. With this treatment, the shock immediately resolved, and the symptoms disappeared. The carteolol eye drops, verapamil, and azilsartan were discontinued, and the patient was treated with a pacing rhythm until the next day (Fig. 3). The morning after she was hospitalized, her heart rhythm returned to a normal sinus rhythm with a heart rate of 63 bpm (Fig. 4). The carteolol eye drops were discontinued after consultation with the ophthalmologist, and a different non-beta blocker for glaucoma (dorzolamide hydrochloride) was prescribed to protect her non-blind left eye. The bradycardia no longer appeared after normalization of the potassium level and discontinuing verapamil and the carteolol eye drops. Figure 2. Clinical course of this case. ALT: alanine aminotransferase, AST: aspartate aminotransferase, Calcicol: calcium gluconate hydrate, GI: glucose-insulin therapy, HR: heart rate, PAF: paroxysmal atrial fibrillation, PMI: pacemaker intubation Figure 3. A 12-lead electrocardiogram after initiating temporary pacing. A heart rate of 93 bpm, wide QRS rhythm with a left bundle branch block and upper axis pattern, and right ventricular apex origin were noted. Figure 4. A 12-lead electrocardiogram the day after the hospitalization. A heart rate of 63 bpm with normal sinus rhythm and T-wave flattening in leads III and aVF were observed. However, she had symptomatic PAF with a rapid ventricular response on the first hospital day. When the PAF stopped, she temporarily had a backup pacing with VVI 50 bpm due to sick sinus syndrome. Based on her clinical course, it was judged that the use of antiarrhythmic drugs alone for PAF carried a risk of bradycardia shock, so it was decided to administer antiarrhythmic drugs after pacemaker implantation. However, pulmonary vein isolation was not selected due to her age and activity of daily living. Pacemaker implantation was performed on the 14th hospital day. Finally, her arrhythmia, blood pressure, and glaucoma were controlled with the pacemaker implantation and adjustment of her medications, as shown in Fig. 2, and she was discharged in good health on the 20th hospital day. Discussion Ophthalmic carteolol, as well as timolol, is used as an eye drop beta blocker for glaucoma. Carteolol has been considered to have a lower risk of cardiovascular events than timolol because carteolol generally has a weaker effect on slowing the heart rate than timolol, depending on the characterization of the intrinsic sympathomimetic activity (ISA) (6,7). Although warning clues of cardiovascular events, such as bradycardia, heart block, and hypotension, have been reported due to the use of timolol eye drops (8), there have been no reports of severe cardiovascular events with the use of carteolol eye drops. Because timolol eye drops are absorbed via the nasal mucosa through the nasolacrimal duct, their bioavailability is approximately 50% of that after oral administration, and they have a systemic effect similar to oral administration; however, they are topically administered (9). Furthermore, because both carteolol and timolol are metabolized by cytochrome P450 2D6 (CYP2D6), their effect can be enhanced in elderly people with a weakened CYP2D6 when combined with a drug with a CYP2D6 inhibitory effect and/or verapamil (10). Verapamil is a commonly used class IV antiarrhythmic medication that blocks calcium-dependent slow channels, depresses the cardiac contractility, slows the myocardial conduction, and relaxes vascular smooth muscle. It serves to decrease sino-atrial (SA) node discharges and slow atrioventricular (AV) conduction, and the concomitant use with beta blockers can potentially cause severe bradycardia (11). Elderly patients sometimes have both AF and CKD (2). Because carteolol is mainly excreted by the kidneys, it may have a strong cardiac depressant effect in elderly patients with CKD (12). Elderly people tend to have polypharmacy (3,13), and if prescriptions are obtained from multiple medical institutions, it is possible that the same drugs may be prescribed. In addition, as in the present case, when the serum potassium level is increased due to a side effect of an angiotensin II receptor blocker (ARB) (14), a cardiac depressant effect due to hyperkalemia may exacerbate the cardiac function. In the present case, both the SA node and AV node were likely suppressed by the combination of the ophthalmic carteolol, verapamil, and hyperkalemia, resulting in serious bradycardia due to sick sinus syndrome. Of note, eye drops have a systemic effect similar to oral drugs. Drug interactions are more likely to occur in the elderly, especially when ophthalmic beta blockers are used in glaucoma patients, and careful follow-up in terms of cardiovascular events is needed; furthermore, verapamil should not be used for rate control in patients with AF. Although the mechanism may have involved the interaction between the carteolol eye drops and either verapamil or azilsaltan-related hyperkalemia, it is equally likely that the interaction was between all three drugs under the existence of CKD in this elderly patient. In conclusion, physicians should always consider the potential risk of adverse drug interactions when prescribing a new medication to a patient, especially in elderly patients with polypharmacy. Even topical medications, such as carteolol eye drops, might have significant systemic absorption, leading to serious side effects through drug interactions in elderly patients. Author's disclosure of potential Conflicts of Interest (COI). Yasuo Okumura: Research funding, Boston Scientific Japan. Acknowledgement We thank all of the doctors and medical staff who were involved in the treatment of this patient. In particular, Ph. So Iwabuchi and Ph. Takahiro Sekine provided important information about the carteolol eye drops. We also thank Mr. John Martin for his help with the English editing.	Ophthalmic	DrugAdministrationRoute	CC BY-NC-ND	32830185	18,270,051	2021-01-01
What was the administration route of drug 'DOXAZOSIN MESYLATE'?	Bradycardia Shock Caused by the Combined Use of Carteolol Eye Drops and Verapamil in an Elderly Patient with Atrial Fibrillation and Chronic Kidney Disease. Ophthalmic carteolol is often used to treat glaucoma. Elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) are common among the super-elderly in Japan. Because these patients are exposed to polypharmacy, they are at a high-risk of adverse drug interactions. We herein report an elderly patient with CKD who suffered bradycardia shock after the combined use of carteolol eye drops and verapamil for glaucoma and paroxysmal AF. This case highlights the fact that eye drops have a similar systemic effect to oral drugs, and especially in elderly patients with polypharmacy, drug interactions can unwittingly lead to serious events. Introduction Ophthalmic beta blockers, represented by timolol and carteolol, are often used to treat glaucoma in the elderly (1). As the elderly population is dramatically increasing in Japan, we often encounter elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) (2). Because such patients tend to have multiple comorbidities, they often visit several medical institutions, and accordingly, they are prescribed multiple medications (i.e. polypharmacy). One clinical issue in those patients is that they may unwittingly experience drug interactions due to their polypharmacy, leading to a potential risk of adverse clinical events (3). There have been two case reports of bradycardia with the combined use of timolol eye drops and verapamil, with their combined use first reported in the 20th century (4,5). However, the interaction between carteolol eye drops and verapamil has not been reported. We herein report a case of bradycardia shock caused by the combined use of carteolol eye drops and verapamil in an elderly patient with a history of CKD and glaucoma, who suffered from paroxysmal AF (PAF). Case Report An 84-year-old woman presented with a 3-day history of shortness of breath and chest discomfort. She was determined to be frail as evaluated by a Canadian Study of Health and Aging Clinical Frailty Scale of 6 on admission. She had a history of glaucoma, hypertension, and CKD (estimated glomerular filtration rate 32.6 mL/min/1.73 m2) from over 10 years earlier and was being treated separately at ophthalmology and internal medicine outpatient clinics. She had blindness in her right eye due to glaucoma, and her left eye had been treated with ophthalmic carteolol and travoprost for the last few years. She had been taking azilsartan and doxazosin in addition to diet therapy for hypertension and CKD. As a result, she had been taking five kinds of internal medications, two kinds of external medications, and four kinds of eye drops a day, resulting in polypharmacy. Five days before admission, she had been diagnosed with symptomatic PAF, so verapamil [40 mg twice a day (b.i.d.)] had been newly initiated by her internal medicine physician. According to the information from the previous doctor, her heart rate had been about 60-80 beats/minute (bpm) before the start of verapamil. At admission, her heart rate was 29 bpm, and her blood pressure could not be obtained, although her radial artery pulse was palpable. Her respiratory rate and body temperature were 15/min and 36.0 °C, respectively. Her laboratory data on admission are shown in Table, revealing high serum potassium, high liver enzyme, and high lactate levels. A 12-lead electrocardiogram (ECG) during the initial examination showed a heart rate of 24 bpm and narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes (Fig. 1). Transthoracic echocardiography revealed a normal left ventricular function without any asynergy, D-shape, echo-free space, or valvular disease with a normal size of the left atrial diameter (32.0 mm). Chest X-ray revealed pulmonary edema and enlargement of the cardio-thoracic ratio. Table. Laboratory Data at the Time of Admission. WBC 5,900 /mm3 Na 139 mEq/L Hb 11.4 g/dL K 6.5 mEq/L Plt 14.2×104 /μL Cl 110 mEq/L BUN 35.6 mg/dL Ca 8.5 mg/dL Cre 1.21 mg/dL T-Chol 160 mg/dL eGFR 32.6 HDL-Chol 67 mg/dL CCR 21.25 LDL-Chol 66 mg/dL CRP 0.11 mg/dL TG 64 mg/dL TP 5.2 g/dL UA 6.3 mg/dL Alb 3.0 g/dL CK 66 U/L T-Bil 1.20 mg/dL CK-MB 4 U/L AST 234 U/L Troponin I 0.01 ng/mL ALT 119 U/L NT-proBNP 3,722 pg/mL LDH 421 U/L TSH 7.79 μlU/mL ALP 248 mEq/L Free T3 2.36 pg/mL BS 157 mg/dL Free T4 1.20 ng/mL HbA1c 5.3 % Lactate 2.9 mmol/L Alb: albumin, ALT: alanine aminotransferase, AST: aspartate aminotransferase, BS: blood sugar, BUN: blood urea nitrogen, Ca: serum calcium, CCR: creatinine clearance, CK: creatine kinase, Cl: serum chloride, Cre: serum creatinine, CRP: C-reactive protein, eGFR: estimated glomerular filtration rate, Free T3: free triiodothyronine, Free T4: free thyroxine, Hb: hemoglobin, HbA1c: hemoglobin A1c, HDL-Chol: high density lipoprotein cholesterol, K: serum potassium, LDH: lactate dehydrogenase, LDL-Chol: low density lipoprotein cholesterol, Na: serum sodium, NT-proBNP: N-terminal pro-Brain Natriuretic Peptide, Plt: platelets, T-Bil: total bilirubin, T-Chol: total cholesterol, TG: triglyceride, TP: total protein, TSH: thyroid-stimulating hormone, UA: serum uric acid, WBC: white blood cells Figure 1. A 12-lead electrocardiogram during the initial examination. A heart rate of 24 bpm and a narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes were noted. Her clinical course is shown in Fig. 2. Because she had bradycardia shock, represented by high serum lactate and liver enzyme levels, with hyperkalemia, a temporary pacing catheter was placed through the right internal jugular vein, and right ventricular pacing was performed at 90 bpm while administrating an intravenous injection of calcium gluconate hydrate and glucose-insulin therapy for hyperkalemia. Anticholinergics could not be used due to glaucoma. With this treatment, the shock immediately resolved, and the symptoms disappeared. The carteolol eye drops, verapamil, and azilsartan were discontinued, and the patient was treated with a pacing rhythm until the next day (Fig. 3). The morning after she was hospitalized, her heart rhythm returned to a normal sinus rhythm with a heart rate of 63 bpm (Fig. 4). The carteolol eye drops were discontinued after consultation with the ophthalmologist, and a different non-beta blocker for glaucoma (dorzolamide hydrochloride) was prescribed to protect her non-blind left eye. The bradycardia no longer appeared after normalization of the potassium level and discontinuing verapamil and the carteolol eye drops. Figure 2. Clinical course of this case. ALT: alanine aminotransferase, AST: aspartate aminotransferase, Calcicol: calcium gluconate hydrate, GI: glucose-insulin therapy, HR: heart rate, PAF: paroxysmal atrial fibrillation, PMI: pacemaker intubation Figure 3. A 12-lead electrocardiogram after initiating temporary pacing. A heart rate of 93 bpm, wide QRS rhythm with a left bundle branch block and upper axis pattern, and right ventricular apex origin were noted. Figure 4. A 12-lead electrocardiogram the day after the hospitalization. A heart rate of 63 bpm with normal sinus rhythm and T-wave flattening in leads III and aVF were observed. However, she had symptomatic PAF with a rapid ventricular response on the first hospital day. When the PAF stopped, she temporarily had a backup pacing with VVI 50 bpm due to sick sinus syndrome. Based on her clinical course, it was judged that the use of antiarrhythmic drugs alone for PAF carried a risk of bradycardia shock, so it was decided to administer antiarrhythmic drugs after pacemaker implantation. However, pulmonary vein isolation was not selected due to her age and activity of daily living. Pacemaker implantation was performed on the 14th hospital day. Finally, her arrhythmia, blood pressure, and glaucoma were controlled with the pacemaker implantation and adjustment of her medications, as shown in Fig. 2, and she was discharged in good health on the 20th hospital day. Discussion Ophthalmic carteolol, as well as timolol, is used as an eye drop beta blocker for glaucoma. Carteolol has been considered to have a lower risk of cardiovascular events than timolol because carteolol generally has a weaker effect on slowing the heart rate than timolol, depending on the characterization of the intrinsic sympathomimetic activity (ISA) (6,7). Although warning clues of cardiovascular events, such as bradycardia, heart block, and hypotension, have been reported due to the use of timolol eye drops (8), there have been no reports of severe cardiovascular events with the use of carteolol eye drops. Because timolol eye drops are absorbed via the nasal mucosa through the nasolacrimal duct, their bioavailability is approximately 50% of that after oral administration, and they have a systemic effect similar to oral administration; however, they are topically administered (9). Furthermore, because both carteolol and timolol are metabolized by cytochrome P450 2D6 (CYP2D6), their effect can be enhanced in elderly people with a weakened CYP2D6 when combined with a drug with a CYP2D6 inhibitory effect and/or verapamil (10). Verapamil is a commonly used class IV antiarrhythmic medication that blocks calcium-dependent slow channels, depresses the cardiac contractility, slows the myocardial conduction, and relaxes vascular smooth muscle. It serves to decrease sino-atrial (SA) node discharges and slow atrioventricular (AV) conduction, and the concomitant use with beta blockers can potentially cause severe bradycardia (11). Elderly patients sometimes have both AF and CKD (2). Because carteolol is mainly excreted by the kidneys, it may have a strong cardiac depressant effect in elderly patients with CKD (12). Elderly people tend to have polypharmacy (3,13), and if prescriptions are obtained from multiple medical institutions, it is possible that the same drugs may be prescribed. In addition, as in the present case, when the serum potassium level is increased due to a side effect of an angiotensin II receptor blocker (ARB) (14), a cardiac depressant effect due to hyperkalemia may exacerbate the cardiac function. In the present case, both the SA node and AV node were likely suppressed by the combination of the ophthalmic carteolol, verapamil, and hyperkalemia, resulting in serious bradycardia due to sick sinus syndrome. Of note, eye drops have a systemic effect similar to oral drugs. Drug interactions are more likely to occur in the elderly, especially when ophthalmic beta blockers are used in glaucoma patients, and careful follow-up in terms of cardiovascular events is needed; furthermore, verapamil should not be used for rate control in patients with AF. Although the mechanism may have involved the interaction between the carteolol eye drops and either verapamil or azilsaltan-related hyperkalemia, it is equally likely that the interaction was between all three drugs under the existence of CKD in this elderly patient. In conclusion, physicians should always consider the potential risk of adverse drug interactions when prescribing a new medication to a patient, especially in elderly patients with polypharmacy. Even topical medications, such as carteolol eye drops, might have significant systemic absorption, leading to serious side effects through drug interactions in elderly patients. Author's disclosure of potential Conflicts of Interest (COI). Yasuo Okumura: Research funding, Boston Scientific Japan. Acknowledgement We thank all of the doctors and medical staff who were involved in the treatment of this patient. In particular, Ph. So Iwabuchi and Ph. Takahiro Sekine provided important information about the carteolol eye drops. We also thank Mr. John Martin for his help with the English editing.	Oral	DrugAdministrationRoute	CC BY-NC-ND	32830185	18,270,051	2021-01-01
What was the administration route of drug 'EDOXABAN TOSYLATE'?	Bradycardia Shock Caused by the Combined Use of Carteolol Eye Drops and Verapamil in an Elderly Patient with Atrial Fibrillation and Chronic Kidney Disease. Ophthalmic carteolol is often used to treat glaucoma. Elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) are common among the super-elderly in Japan. Because these patients are exposed to polypharmacy, they are at a high-risk of adverse drug interactions. We herein report an elderly patient with CKD who suffered bradycardia shock after the combined use of carteolol eye drops and verapamil for glaucoma and paroxysmal AF. This case highlights the fact that eye drops have a similar systemic effect to oral drugs, and especially in elderly patients with polypharmacy, drug interactions can unwittingly lead to serious events. Introduction Ophthalmic beta blockers, represented by timolol and carteolol, are often used to treat glaucoma in the elderly (1). As the elderly population is dramatically increasing in Japan, we often encounter elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) (2). Because such patients tend to have multiple comorbidities, they often visit several medical institutions, and accordingly, they are prescribed multiple medications (i.e. polypharmacy). One clinical issue in those patients is that they may unwittingly experience drug interactions due to their polypharmacy, leading to a potential risk of adverse clinical events (3). There have been two case reports of bradycardia with the combined use of timolol eye drops and verapamil, with their combined use first reported in the 20th century (4,5). However, the interaction between carteolol eye drops and verapamil has not been reported. We herein report a case of bradycardia shock caused by the combined use of carteolol eye drops and verapamil in an elderly patient with a history of CKD and glaucoma, who suffered from paroxysmal AF (PAF). Case Report An 84-year-old woman presented with a 3-day history of shortness of breath and chest discomfort. She was determined to be frail as evaluated by a Canadian Study of Health and Aging Clinical Frailty Scale of 6 on admission. She had a history of glaucoma, hypertension, and CKD (estimated glomerular filtration rate 32.6 mL/min/1.73 m2) from over 10 years earlier and was being treated separately at ophthalmology and internal medicine outpatient clinics. She had blindness in her right eye due to glaucoma, and her left eye had been treated with ophthalmic carteolol and travoprost for the last few years. She had been taking azilsartan and doxazosin in addition to diet therapy for hypertension and CKD. As a result, she had been taking five kinds of internal medications, two kinds of external medications, and four kinds of eye drops a day, resulting in polypharmacy. Five days before admission, she had been diagnosed with symptomatic PAF, so verapamil [40 mg twice a day (b.i.d.)] had been newly initiated by her internal medicine physician. According to the information from the previous doctor, her heart rate had been about 60-80 beats/minute (bpm) before the start of verapamil. At admission, her heart rate was 29 bpm, and her blood pressure could not be obtained, although her radial artery pulse was palpable. Her respiratory rate and body temperature were 15/min and 36.0 °C, respectively. Her laboratory data on admission are shown in Table, revealing high serum potassium, high liver enzyme, and high lactate levels. A 12-lead electrocardiogram (ECG) during the initial examination showed a heart rate of 24 bpm and narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes (Fig. 1). Transthoracic echocardiography revealed a normal left ventricular function without any asynergy, D-shape, echo-free space, or valvular disease with a normal size of the left atrial diameter (32.0 mm). Chest X-ray revealed pulmonary edema and enlargement of the cardio-thoracic ratio. Table. Laboratory Data at the Time of Admission. WBC 5,900 /mm3 Na 139 mEq/L Hb 11.4 g/dL K 6.5 mEq/L Plt 14.2×104 /μL Cl 110 mEq/L BUN 35.6 mg/dL Ca 8.5 mg/dL Cre 1.21 mg/dL T-Chol 160 mg/dL eGFR 32.6 HDL-Chol 67 mg/dL CCR 21.25 LDL-Chol 66 mg/dL CRP 0.11 mg/dL TG 64 mg/dL TP 5.2 g/dL UA 6.3 mg/dL Alb 3.0 g/dL CK 66 U/L T-Bil 1.20 mg/dL CK-MB 4 U/L AST 234 U/L Troponin I 0.01 ng/mL ALT 119 U/L NT-proBNP 3,722 pg/mL LDH 421 U/L TSH 7.79 μlU/mL ALP 248 mEq/L Free T3 2.36 pg/mL BS 157 mg/dL Free T4 1.20 ng/mL HbA1c 5.3 % Lactate 2.9 mmol/L Alb: albumin, ALT: alanine aminotransferase, AST: aspartate aminotransferase, BS: blood sugar, BUN: blood urea nitrogen, Ca: serum calcium, CCR: creatinine clearance, CK: creatine kinase, Cl: serum chloride, Cre: serum creatinine, CRP: C-reactive protein, eGFR: estimated glomerular filtration rate, Free T3: free triiodothyronine, Free T4: free thyroxine, Hb: hemoglobin, HbA1c: hemoglobin A1c, HDL-Chol: high density lipoprotein cholesterol, K: serum potassium, LDH: lactate dehydrogenase, LDL-Chol: low density lipoprotein cholesterol, Na: serum sodium, NT-proBNP: N-terminal pro-Brain Natriuretic Peptide, Plt: platelets, T-Bil: total bilirubin, T-Chol: total cholesterol, TG: triglyceride, TP: total protein, TSH: thyroid-stimulating hormone, UA: serum uric acid, WBC: white blood cells Figure 1. A 12-lead electrocardiogram during the initial examination. A heart rate of 24 bpm and a narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes were noted. Her clinical course is shown in Fig. 2. Because she had bradycardia shock, represented by high serum lactate and liver enzyme levels, with hyperkalemia, a temporary pacing catheter was placed through the right internal jugular vein, and right ventricular pacing was performed at 90 bpm while administrating an intravenous injection of calcium gluconate hydrate and glucose-insulin therapy for hyperkalemia. Anticholinergics could not be used due to glaucoma. With this treatment, the shock immediately resolved, and the symptoms disappeared. The carteolol eye drops, verapamil, and azilsartan were discontinued, and the patient was treated with a pacing rhythm until the next day (Fig. 3). The morning after she was hospitalized, her heart rhythm returned to a normal sinus rhythm with a heart rate of 63 bpm (Fig. 4). The carteolol eye drops were discontinued after consultation with the ophthalmologist, and a different non-beta blocker for glaucoma (dorzolamide hydrochloride) was prescribed to protect her non-blind left eye. The bradycardia no longer appeared after normalization of the potassium level and discontinuing verapamil and the carteolol eye drops. Figure 2. Clinical course of this case. ALT: alanine aminotransferase, AST: aspartate aminotransferase, Calcicol: calcium gluconate hydrate, GI: glucose-insulin therapy, HR: heart rate, PAF: paroxysmal atrial fibrillation, PMI: pacemaker intubation Figure 3. A 12-lead electrocardiogram after initiating temporary pacing. A heart rate of 93 bpm, wide QRS rhythm with a left bundle branch block and upper axis pattern, and right ventricular apex origin were noted. Figure 4. A 12-lead electrocardiogram the day after the hospitalization. A heart rate of 63 bpm with normal sinus rhythm and T-wave flattening in leads III and aVF were observed. However, she had symptomatic PAF with a rapid ventricular response on the first hospital day. When the PAF stopped, she temporarily had a backup pacing with VVI 50 bpm due to sick sinus syndrome. Based on her clinical course, it was judged that the use of antiarrhythmic drugs alone for PAF carried a risk of bradycardia shock, so it was decided to administer antiarrhythmic drugs after pacemaker implantation. However, pulmonary vein isolation was not selected due to her age and activity of daily living. Pacemaker implantation was performed on the 14th hospital day. Finally, her arrhythmia, blood pressure, and glaucoma were controlled with the pacemaker implantation and adjustment of her medications, as shown in Fig. 2, and she was discharged in good health on the 20th hospital day. Discussion Ophthalmic carteolol, as well as timolol, is used as an eye drop beta blocker for glaucoma. Carteolol has been considered to have a lower risk of cardiovascular events than timolol because carteolol generally has a weaker effect on slowing the heart rate than timolol, depending on the characterization of the intrinsic sympathomimetic activity (ISA) (6,7). Although warning clues of cardiovascular events, such as bradycardia, heart block, and hypotension, have been reported due to the use of timolol eye drops (8), there have been no reports of severe cardiovascular events with the use of carteolol eye drops. Because timolol eye drops are absorbed via the nasal mucosa through the nasolacrimal duct, their bioavailability is approximately 50% of that after oral administration, and they have a systemic effect similar to oral administration; however, they are topically administered (9). Furthermore, because both carteolol and timolol are metabolized by cytochrome P450 2D6 (CYP2D6), their effect can be enhanced in elderly people with a weakened CYP2D6 when combined with a drug with a CYP2D6 inhibitory effect and/or verapamil (10). Verapamil is a commonly used class IV antiarrhythmic medication that blocks calcium-dependent slow channels, depresses the cardiac contractility, slows the myocardial conduction, and relaxes vascular smooth muscle. It serves to decrease sino-atrial (SA) node discharges and slow atrioventricular (AV) conduction, and the concomitant use with beta blockers can potentially cause severe bradycardia (11). Elderly patients sometimes have both AF and CKD (2). Because carteolol is mainly excreted by the kidneys, it may have a strong cardiac depressant effect in elderly patients with CKD (12). Elderly people tend to have polypharmacy (3,13), and if prescriptions are obtained from multiple medical institutions, it is possible that the same drugs may be prescribed. In addition, as in the present case, when the serum potassium level is increased due to a side effect of an angiotensin II receptor blocker (ARB) (14), a cardiac depressant effect due to hyperkalemia may exacerbate the cardiac function. In the present case, both the SA node and AV node were likely suppressed by the combination of the ophthalmic carteolol, verapamil, and hyperkalemia, resulting in serious bradycardia due to sick sinus syndrome. Of note, eye drops have a systemic effect similar to oral drugs. Drug interactions are more likely to occur in the elderly, especially when ophthalmic beta blockers are used in glaucoma patients, and careful follow-up in terms of cardiovascular events is needed; furthermore, verapamil should not be used for rate control in patients with AF. Although the mechanism may have involved the interaction between the carteolol eye drops and either verapamil or azilsaltan-related hyperkalemia, it is equally likely that the interaction was between all three drugs under the existence of CKD in this elderly patient. In conclusion, physicians should always consider the potential risk of adverse drug interactions when prescribing a new medication to a patient, especially in elderly patients with polypharmacy. Even topical medications, such as carteolol eye drops, might have significant systemic absorption, leading to serious side effects through drug interactions in elderly patients. Author's disclosure of potential Conflicts of Interest (COI). Yasuo Okumura: Research funding, Boston Scientific Japan. Acknowledgement We thank all of the doctors and medical staff who were involved in the treatment of this patient. In particular, Ph. So Iwabuchi and Ph. Takahiro Sekine provided important information about the carteolol eye drops. We also thank Mr. John Martin for his help with the English editing.	Oral	DrugAdministrationRoute	CC BY-NC-ND	32830185	18,270,051	2021-01-01
What was the administration route of drug 'REBAMIPIDE'?	Bradycardia Shock Caused by the Combined Use of Carteolol Eye Drops and Verapamil in an Elderly Patient with Atrial Fibrillation and Chronic Kidney Disease. Ophthalmic carteolol is often used to treat glaucoma. Elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) are common among the super-elderly in Japan. Because these patients are exposed to polypharmacy, they are at a high-risk of adverse drug interactions. We herein report an elderly patient with CKD who suffered bradycardia shock after the combined use of carteolol eye drops and verapamil for glaucoma and paroxysmal AF. This case highlights the fact that eye drops have a similar systemic effect to oral drugs, and especially in elderly patients with polypharmacy, drug interactions can unwittingly lead to serious events. Introduction Ophthalmic beta blockers, represented by timolol and carteolol, are often used to treat glaucoma in the elderly (1). As the elderly population is dramatically increasing in Japan, we often encounter elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) (2). Because such patients tend to have multiple comorbidities, they often visit several medical institutions, and accordingly, they are prescribed multiple medications (i.e. polypharmacy). One clinical issue in those patients is that they may unwittingly experience drug interactions due to their polypharmacy, leading to a potential risk of adverse clinical events (3). There have been two case reports of bradycardia with the combined use of timolol eye drops and verapamil, with their combined use first reported in the 20th century (4,5). However, the interaction between carteolol eye drops and verapamil has not been reported. We herein report a case of bradycardia shock caused by the combined use of carteolol eye drops and verapamil in an elderly patient with a history of CKD and glaucoma, who suffered from paroxysmal AF (PAF). Case Report An 84-year-old woman presented with a 3-day history of shortness of breath and chest discomfort. She was determined to be frail as evaluated by a Canadian Study of Health and Aging Clinical Frailty Scale of 6 on admission. She had a history of glaucoma, hypertension, and CKD (estimated glomerular filtration rate 32.6 mL/min/1.73 m2) from over 10 years earlier and was being treated separately at ophthalmology and internal medicine outpatient clinics. She had blindness in her right eye due to glaucoma, and her left eye had been treated with ophthalmic carteolol and travoprost for the last few years. She had been taking azilsartan and doxazosin in addition to diet therapy for hypertension and CKD. As a result, she had been taking five kinds of internal medications, two kinds of external medications, and four kinds of eye drops a day, resulting in polypharmacy. Five days before admission, she had been diagnosed with symptomatic PAF, so verapamil [40 mg twice a day (b.i.d.)] had been newly initiated by her internal medicine physician. According to the information from the previous doctor, her heart rate had been about 60-80 beats/minute (bpm) before the start of verapamil. At admission, her heart rate was 29 bpm, and her blood pressure could not be obtained, although her radial artery pulse was palpable. Her respiratory rate and body temperature were 15/min and 36.0 °C, respectively. Her laboratory data on admission are shown in Table, revealing high serum potassium, high liver enzyme, and high lactate levels. A 12-lead electrocardiogram (ECG) during the initial examination showed a heart rate of 24 bpm and narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes (Fig. 1). Transthoracic echocardiography revealed a normal left ventricular function without any asynergy, D-shape, echo-free space, or valvular disease with a normal size of the left atrial diameter (32.0 mm). Chest X-ray revealed pulmonary edema and enlargement of the cardio-thoracic ratio. Table. Laboratory Data at the Time of Admission. WBC 5,900 /mm3 Na 139 mEq/L Hb 11.4 g/dL K 6.5 mEq/L Plt 14.2×104 /μL Cl 110 mEq/L BUN 35.6 mg/dL Ca 8.5 mg/dL Cre 1.21 mg/dL T-Chol 160 mg/dL eGFR 32.6 HDL-Chol 67 mg/dL CCR 21.25 LDL-Chol 66 mg/dL CRP 0.11 mg/dL TG 64 mg/dL TP 5.2 g/dL UA 6.3 mg/dL Alb 3.0 g/dL CK 66 U/L T-Bil 1.20 mg/dL CK-MB 4 U/L AST 234 U/L Troponin I 0.01 ng/mL ALT 119 U/L NT-proBNP 3,722 pg/mL LDH 421 U/L TSH 7.79 μlU/mL ALP 248 mEq/L Free T3 2.36 pg/mL BS 157 mg/dL Free T4 1.20 ng/mL HbA1c 5.3 % Lactate 2.9 mmol/L Alb: albumin, ALT: alanine aminotransferase, AST: aspartate aminotransferase, BS: blood sugar, BUN: blood urea nitrogen, Ca: serum calcium, CCR: creatinine clearance, CK: creatine kinase, Cl: serum chloride, Cre: serum creatinine, CRP: C-reactive protein, eGFR: estimated glomerular filtration rate, Free T3: free triiodothyronine, Free T4: free thyroxine, Hb: hemoglobin, HbA1c: hemoglobin A1c, HDL-Chol: high density lipoprotein cholesterol, K: serum potassium, LDH: lactate dehydrogenase, LDL-Chol: low density lipoprotein cholesterol, Na: serum sodium, NT-proBNP: N-terminal pro-Brain Natriuretic Peptide, Plt: platelets, T-Bil: total bilirubin, T-Chol: total cholesterol, TG: triglyceride, TP: total protein, TSH: thyroid-stimulating hormone, UA: serum uric acid, WBC: white blood cells Figure 1. A 12-lead electrocardiogram during the initial examination. A heart rate of 24 bpm and a narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes were noted. Her clinical course is shown in Fig. 2. Because she had bradycardia shock, represented by high serum lactate and liver enzyme levels, with hyperkalemia, a temporary pacing catheter was placed through the right internal jugular vein, and right ventricular pacing was performed at 90 bpm while administrating an intravenous injection of calcium gluconate hydrate and glucose-insulin therapy for hyperkalemia. Anticholinergics could not be used due to glaucoma. With this treatment, the shock immediately resolved, and the symptoms disappeared. The carteolol eye drops, verapamil, and azilsartan were discontinued, and the patient was treated with a pacing rhythm until the next day (Fig. 3). The morning after she was hospitalized, her heart rhythm returned to a normal sinus rhythm with a heart rate of 63 bpm (Fig. 4). The carteolol eye drops were discontinued after consultation with the ophthalmologist, and a different non-beta blocker for glaucoma (dorzolamide hydrochloride) was prescribed to protect her non-blind left eye. The bradycardia no longer appeared after normalization of the potassium level and discontinuing verapamil and the carteolol eye drops. Figure 2. Clinical course of this case. ALT: alanine aminotransferase, AST: aspartate aminotransferase, Calcicol: calcium gluconate hydrate, GI: glucose-insulin therapy, HR: heart rate, PAF: paroxysmal atrial fibrillation, PMI: pacemaker intubation Figure 3. A 12-lead electrocardiogram after initiating temporary pacing. A heart rate of 93 bpm, wide QRS rhythm with a left bundle branch block and upper axis pattern, and right ventricular apex origin were noted. Figure 4. A 12-lead electrocardiogram the day after the hospitalization. A heart rate of 63 bpm with normal sinus rhythm and T-wave flattening in leads III and aVF were observed. However, she had symptomatic PAF with a rapid ventricular response on the first hospital day. When the PAF stopped, she temporarily had a backup pacing with VVI 50 bpm due to sick sinus syndrome. Based on her clinical course, it was judged that the use of antiarrhythmic drugs alone for PAF carried a risk of bradycardia shock, so it was decided to administer antiarrhythmic drugs after pacemaker implantation. However, pulmonary vein isolation was not selected due to her age and activity of daily living. Pacemaker implantation was performed on the 14th hospital day. Finally, her arrhythmia, blood pressure, and glaucoma were controlled with the pacemaker implantation and adjustment of her medications, as shown in Fig. 2, and she was discharged in good health on the 20th hospital day. Discussion Ophthalmic carteolol, as well as timolol, is used as an eye drop beta blocker for glaucoma. Carteolol has been considered to have a lower risk of cardiovascular events than timolol because carteolol generally has a weaker effect on slowing the heart rate than timolol, depending on the characterization of the intrinsic sympathomimetic activity (ISA) (6,7). Although warning clues of cardiovascular events, such as bradycardia, heart block, and hypotension, have been reported due to the use of timolol eye drops (8), there have been no reports of severe cardiovascular events with the use of carteolol eye drops. Because timolol eye drops are absorbed via the nasal mucosa through the nasolacrimal duct, their bioavailability is approximately 50% of that after oral administration, and they have a systemic effect similar to oral administration; however, they are topically administered (9). Furthermore, because both carteolol and timolol are metabolized by cytochrome P450 2D6 (CYP2D6), their effect can be enhanced in elderly people with a weakened CYP2D6 when combined with a drug with a CYP2D6 inhibitory effect and/or verapamil (10). Verapamil is a commonly used class IV antiarrhythmic medication that blocks calcium-dependent slow channels, depresses the cardiac contractility, slows the myocardial conduction, and relaxes vascular smooth muscle. It serves to decrease sino-atrial (SA) node discharges and slow atrioventricular (AV) conduction, and the concomitant use with beta blockers can potentially cause severe bradycardia (11). Elderly patients sometimes have both AF and CKD (2). Because carteolol is mainly excreted by the kidneys, it may have a strong cardiac depressant effect in elderly patients with CKD (12). Elderly people tend to have polypharmacy (3,13), and if prescriptions are obtained from multiple medical institutions, it is possible that the same drugs may be prescribed. In addition, as in the present case, when the serum potassium level is increased due to a side effect of an angiotensin II receptor blocker (ARB) (14), a cardiac depressant effect due to hyperkalemia may exacerbate the cardiac function. In the present case, both the SA node and AV node were likely suppressed by the combination of the ophthalmic carteolol, verapamil, and hyperkalemia, resulting in serious bradycardia due to sick sinus syndrome. Of note, eye drops have a systemic effect similar to oral drugs. Drug interactions are more likely to occur in the elderly, especially when ophthalmic beta blockers are used in glaucoma patients, and careful follow-up in terms of cardiovascular events is needed; furthermore, verapamil should not be used for rate control in patients with AF. Although the mechanism may have involved the interaction between the carteolol eye drops and either verapamil or azilsaltan-related hyperkalemia, it is equally likely that the interaction was between all three drugs under the existence of CKD in this elderly patient. In conclusion, physicians should always consider the potential risk of adverse drug interactions when prescribing a new medication to a patient, especially in elderly patients with polypharmacy. Even topical medications, such as carteolol eye drops, might have significant systemic absorption, leading to serious side effects through drug interactions in elderly patients. Author's disclosure of potential Conflicts of Interest (COI). Yasuo Okumura: Research funding, Boston Scientific Japan. Acknowledgement We thank all of the doctors and medical staff who were involved in the treatment of this patient. In particular, Ph. So Iwabuchi and Ph. Takahiro Sekine provided important information about the carteolol eye drops. We also thank Mr. John Martin for his help with the English editing.	Ophthalmic	DrugAdministrationRoute	CC BY-NC-ND	32830185	18,270,051	2021-01-01
What was the administration route of drug 'TRAVOPROST'?	Bradycardia Shock Caused by the Combined Use of Carteolol Eye Drops and Verapamil in an Elderly Patient with Atrial Fibrillation and Chronic Kidney Disease. Ophthalmic carteolol is often used to treat glaucoma. Elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) are common among the super-elderly in Japan. Because these patients are exposed to polypharmacy, they are at a high-risk of adverse drug interactions. We herein report an elderly patient with CKD who suffered bradycardia shock after the combined use of carteolol eye drops and verapamil for glaucoma and paroxysmal AF. This case highlights the fact that eye drops have a similar systemic effect to oral drugs, and especially in elderly patients with polypharmacy, drug interactions can unwittingly lead to serious events. Introduction Ophthalmic beta blockers, represented by timolol and carteolol, are often used to treat glaucoma in the elderly (1). As the elderly population is dramatically increasing in Japan, we often encounter elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) (2). Because such patients tend to have multiple comorbidities, they often visit several medical institutions, and accordingly, they are prescribed multiple medications (i.e. polypharmacy). One clinical issue in those patients is that they may unwittingly experience drug interactions due to their polypharmacy, leading to a potential risk of adverse clinical events (3). There have been two case reports of bradycardia with the combined use of timolol eye drops and verapamil, with their combined use first reported in the 20th century (4,5). However, the interaction between carteolol eye drops and verapamil has not been reported. We herein report a case of bradycardia shock caused by the combined use of carteolol eye drops and verapamil in an elderly patient with a history of CKD and glaucoma, who suffered from paroxysmal AF (PAF). Case Report An 84-year-old woman presented with a 3-day history of shortness of breath and chest discomfort. She was determined to be frail as evaluated by a Canadian Study of Health and Aging Clinical Frailty Scale of 6 on admission. She had a history of glaucoma, hypertension, and CKD (estimated glomerular filtration rate 32.6 mL/min/1.73 m2) from over 10 years earlier and was being treated separately at ophthalmology and internal medicine outpatient clinics. She had blindness in her right eye due to glaucoma, and her left eye had been treated with ophthalmic carteolol and travoprost for the last few years. She had been taking azilsartan and doxazosin in addition to diet therapy for hypertension and CKD. As a result, she had been taking five kinds of internal medications, two kinds of external medications, and four kinds of eye drops a day, resulting in polypharmacy. Five days before admission, she had been diagnosed with symptomatic PAF, so verapamil [40 mg twice a day (b.i.d.)] had been newly initiated by her internal medicine physician. According to the information from the previous doctor, her heart rate had been about 60-80 beats/minute (bpm) before the start of verapamil. At admission, her heart rate was 29 bpm, and her blood pressure could not be obtained, although her radial artery pulse was palpable. Her respiratory rate and body temperature were 15/min and 36.0 °C, respectively. Her laboratory data on admission are shown in Table, revealing high serum potassium, high liver enzyme, and high lactate levels. A 12-lead electrocardiogram (ECG) during the initial examination showed a heart rate of 24 bpm and narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes (Fig. 1). Transthoracic echocardiography revealed a normal left ventricular function without any asynergy, D-shape, echo-free space, or valvular disease with a normal size of the left atrial diameter (32.0 mm). Chest X-ray revealed pulmonary edema and enlargement of the cardio-thoracic ratio. Table. Laboratory Data at the Time of Admission. WBC 5,900 /mm3 Na 139 mEq/L Hb 11.4 g/dL K 6.5 mEq/L Plt 14.2×104 /μL Cl 110 mEq/L BUN 35.6 mg/dL Ca 8.5 mg/dL Cre 1.21 mg/dL T-Chol 160 mg/dL eGFR 32.6 HDL-Chol 67 mg/dL CCR 21.25 LDL-Chol 66 mg/dL CRP 0.11 mg/dL TG 64 mg/dL TP 5.2 g/dL UA 6.3 mg/dL Alb 3.0 g/dL CK 66 U/L T-Bil 1.20 mg/dL CK-MB 4 U/L AST 234 U/L Troponin I 0.01 ng/mL ALT 119 U/L NT-proBNP 3,722 pg/mL LDH 421 U/L TSH 7.79 μlU/mL ALP 248 mEq/L Free T3 2.36 pg/mL BS 157 mg/dL Free T4 1.20 ng/mL HbA1c 5.3 % Lactate 2.9 mmol/L Alb: albumin, ALT: alanine aminotransferase, AST: aspartate aminotransferase, BS: blood sugar, BUN: blood urea nitrogen, Ca: serum calcium, CCR: creatinine clearance, CK: creatine kinase, Cl: serum chloride, Cre: serum creatinine, CRP: C-reactive protein, eGFR: estimated glomerular filtration rate, Free T3: free triiodothyronine, Free T4: free thyroxine, Hb: hemoglobin, HbA1c: hemoglobin A1c, HDL-Chol: high density lipoprotein cholesterol, K: serum potassium, LDH: lactate dehydrogenase, LDL-Chol: low density lipoprotein cholesterol, Na: serum sodium, NT-proBNP: N-terminal pro-Brain Natriuretic Peptide, Plt: platelets, T-Bil: total bilirubin, T-Chol: total cholesterol, TG: triglyceride, TP: total protein, TSH: thyroid-stimulating hormone, UA: serum uric acid, WBC: white blood cells Figure 1. A 12-lead electrocardiogram during the initial examination. A heart rate of 24 bpm and a narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes were noted. Her clinical course is shown in Fig. 2. Because she had bradycardia shock, represented by high serum lactate and liver enzyme levels, with hyperkalemia, a temporary pacing catheter was placed through the right internal jugular vein, and right ventricular pacing was performed at 90 bpm while administrating an intravenous injection of calcium gluconate hydrate and glucose-insulin therapy for hyperkalemia. Anticholinergics could not be used due to glaucoma. With this treatment, the shock immediately resolved, and the symptoms disappeared. The carteolol eye drops, verapamil, and azilsartan were discontinued, and the patient was treated with a pacing rhythm until the next day (Fig. 3). The morning after she was hospitalized, her heart rhythm returned to a normal sinus rhythm with a heart rate of 63 bpm (Fig. 4). The carteolol eye drops were discontinued after consultation with the ophthalmologist, and a different non-beta blocker for glaucoma (dorzolamide hydrochloride) was prescribed to protect her non-blind left eye. The bradycardia no longer appeared after normalization of the potassium level and discontinuing verapamil and the carteolol eye drops. Figure 2. Clinical course of this case. ALT: alanine aminotransferase, AST: aspartate aminotransferase, Calcicol: calcium gluconate hydrate, GI: glucose-insulin therapy, HR: heart rate, PAF: paroxysmal atrial fibrillation, PMI: pacemaker intubation Figure 3. A 12-lead electrocardiogram after initiating temporary pacing. A heart rate of 93 bpm, wide QRS rhythm with a left bundle branch block and upper axis pattern, and right ventricular apex origin were noted. Figure 4. A 12-lead electrocardiogram the day after the hospitalization. A heart rate of 63 bpm with normal sinus rhythm and T-wave flattening in leads III and aVF were observed. However, she had symptomatic PAF with a rapid ventricular response on the first hospital day. When the PAF stopped, she temporarily had a backup pacing with VVI 50 bpm due to sick sinus syndrome. Based on her clinical course, it was judged that the use of antiarrhythmic drugs alone for PAF carried a risk of bradycardia shock, so it was decided to administer antiarrhythmic drugs after pacemaker implantation. However, pulmonary vein isolation was not selected due to her age and activity of daily living. Pacemaker implantation was performed on the 14th hospital day. Finally, her arrhythmia, blood pressure, and glaucoma were controlled with the pacemaker implantation and adjustment of her medications, as shown in Fig. 2, and she was discharged in good health on the 20th hospital day. Discussion Ophthalmic carteolol, as well as timolol, is used as an eye drop beta blocker for glaucoma. Carteolol has been considered to have a lower risk of cardiovascular events than timolol because carteolol generally has a weaker effect on slowing the heart rate than timolol, depending on the characterization of the intrinsic sympathomimetic activity (ISA) (6,7). Although warning clues of cardiovascular events, such as bradycardia, heart block, and hypotension, have been reported due to the use of timolol eye drops (8), there have been no reports of severe cardiovascular events with the use of carteolol eye drops. Because timolol eye drops are absorbed via the nasal mucosa through the nasolacrimal duct, their bioavailability is approximately 50% of that after oral administration, and they have a systemic effect similar to oral administration; however, they are topically administered (9). Furthermore, because both carteolol and timolol are metabolized by cytochrome P450 2D6 (CYP2D6), their effect can be enhanced in elderly people with a weakened CYP2D6 when combined with a drug with a CYP2D6 inhibitory effect and/or verapamil (10). Verapamil is a commonly used class IV antiarrhythmic medication that blocks calcium-dependent slow channels, depresses the cardiac contractility, slows the myocardial conduction, and relaxes vascular smooth muscle. It serves to decrease sino-atrial (SA) node discharges and slow atrioventricular (AV) conduction, and the concomitant use with beta blockers can potentially cause severe bradycardia (11). Elderly patients sometimes have both AF and CKD (2). Because carteolol is mainly excreted by the kidneys, it may have a strong cardiac depressant effect in elderly patients with CKD (12). Elderly people tend to have polypharmacy (3,13), and if prescriptions are obtained from multiple medical institutions, it is possible that the same drugs may be prescribed. In addition, as in the present case, when the serum potassium level is increased due to a side effect of an angiotensin II receptor blocker (ARB) (14), a cardiac depressant effect due to hyperkalemia may exacerbate the cardiac function. In the present case, both the SA node and AV node were likely suppressed by the combination of the ophthalmic carteolol, verapamil, and hyperkalemia, resulting in serious bradycardia due to sick sinus syndrome. Of note, eye drops have a systemic effect similar to oral drugs. Drug interactions are more likely to occur in the elderly, especially when ophthalmic beta blockers are used in glaucoma patients, and careful follow-up in terms of cardiovascular events is needed; furthermore, verapamil should not be used for rate control in patients with AF. Although the mechanism may have involved the interaction between the carteolol eye drops and either verapamil or azilsaltan-related hyperkalemia, it is equally likely that the interaction was between all three drugs under the existence of CKD in this elderly patient. In conclusion, physicians should always consider the potential risk of adverse drug interactions when prescribing a new medication to a patient, especially in elderly patients with polypharmacy. Even topical medications, such as carteolol eye drops, might have significant systemic absorption, leading to serious side effects through drug interactions in elderly patients. Author's disclosure of potential Conflicts of Interest (COI). Yasuo Okumura: Research funding, Boston Scientific Japan. Acknowledgement We thank all of the doctors and medical staff who were involved in the treatment of this patient. In particular, Ph. So Iwabuchi and Ph. Takahiro Sekine provided important information about the carteolol eye drops. We also thank Mr. John Martin for his help with the English editing.	Ophthalmic	DrugAdministrationRoute	CC BY-NC-ND	32830185	18,270,051	2021-01-01
What was the administration route of drug 'VERAPAMIL HYDROCHLORIDE'?	Bradycardia Shock Caused by the Combined Use of Carteolol Eye Drops and Verapamil in an Elderly Patient with Atrial Fibrillation and Chronic Kidney Disease. Ophthalmic carteolol is often used to treat glaucoma. Elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) are common among the super-elderly in Japan. Because these patients are exposed to polypharmacy, they are at a high-risk of adverse drug interactions. We herein report an elderly patient with CKD who suffered bradycardia shock after the combined use of carteolol eye drops and verapamil for glaucoma and paroxysmal AF. This case highlights the fact that eye drops have a similar systemic effect to oral drugs, and especially in elderly patients with polypharmacy, drug interactions can unwittingly lead to serious events. Introduction Ophthalmic beta blockers, represented by timolol and carteolol, are often used to treat glaucoma in the elderly (1). As the elderly population is dramatically increasing in Japan, we often encounter elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) (2). Because such patients tend to have multiple comorbidities, they often visit several medical institutions, and accordingly, they are prescribed multiple medications (i.e. polypharmacy). One clinical issue in those patients is that they may unwittingly experience drug interactions due to their polypharmacy, leading to a potential risk of adverse clinical events (3). There have been two case reports of bradycardia with the combined use of timolol eye drops and verapamil, with their combined use first reported in the 20th century (4,5). However, the interaction between carteolol eye drops and verapamil has not been reported. We herein report a case of bradycardia shock caused by the combined use of carteolol eye drops and verapamil in an elderly patient with a history of CKD and glaucoma, who suffered from paroxysmal AF (PAF). Case Report An 84-year-old woman presented with a 3-day history of shortness of breath and chest discomfort. She was determined to be frail as evaluated by a Canadian Study of Health and Aging Clinical Frailty Scale of 6 on admission. She had a history of glaucoma, hypertension, and CKD (estimated glomerular filtration rate 32.6 mL/min/1.73 m2) from over 10 years earlier and was being treated separately at ophthalmology and internal medicine outpatient clinics. She had blindness in her right eye due to glaucoma, and her left eye had been treated with ophthalmic carteolol and travoprost for the last few years. She had been taking azilsartan and doxazosin in addition to diet therapy for hypertension and CKD. As a result, she had been taking five kinds of internal medications, two kinds of external medications, and four kinds of eye drops a day, resulting in polypharmacy. Five days before admission, she had been diagnosed with symptomatic PAF, so verapamil [40 mg twice a day (b.i.d.)] had been newly initiated by her internal medicine physician. According to the information from the previous doctor, her heart rate had been about 60-80 beats/minute (bpm) before the start of verapamil. At admission, her heart rate was 29 bpm, and her blood pressure could not be obtained, although her radial artery pulse was palpable. Her respiratory rate and body temperature were 15/min and 36.0 °C, respectively. Her laboratory data on admission are shown in Table, revealing high serum potassium, high liver enzyme, and high lactate levels. A 12-lead electrocardiogram (ECG) during the initial examination showed a heart rate of 24 bpm and narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes (Fig. 1). Transthoracic echocardiography revealed a normal left ventricular function without any asynergy, D-shape, echo-free space, or valvular disease with a normal size of the left atrial diameter (32.0 mm). Chest X-ray revealed pulmonary edema and enlargement of the cardio-thoracic ratio. Table. Laboratory Data at the Time of Admission. WBC 5,900 /mm3 Na 139 mEq/L Hb 11.4 g/dL K 6.5 mEq/L Plt 14.2×104 /μL Cl 110 mEq/L BUN 35.6 mg/dL Ca 8.5 mg/dL Cre 1.21 mg/dL T-Chol 160 mg/dL eGFR 32.6 HDL-Chol 67 mg/dL CCR 21.25 LDL-Chol 66 mg/dL CRP 0.11 mg/dL TG 64 mg/dL TP 5.2 g/dL UA 6.3 mg/dL Alb 3.0 g/dL CK 66 U/L T-Bil 1.20 mg/dL CK-MB 4 U/L AST 234 U/L Troponin I 0.01 ng/mL ALT 119 U/L NT-proBNP 3,722 pg/mL LDH 421 U/L TSH 7.79 μlU/mL ALP 248 mEq/L Free T3 2.36 pg/mL BS 157 mg/dL Free T4 1.20 ng/mL HbA1c 5.3 % Lactate 2.9 mmol/L Alb: albumin, ALT: alanine aminotransferase, AST: aspartate aminotransferase, BS: blood sugar, BUN: blood urea nitrogen, Ca: serum calcium, CCR: creatinine clearance, CK: creatine kinase, Cl: serum chloride, Cre: serum creatinine, CRP: C-reactive protein, eGFR: estimated glomerular filtration rate, Free T3: free triiodothyronine, Free T4: free thyroxine, Hb: hemoglobin, HbA1c: hemoglobin A1c, HDL-Chol: high density lipoprotein cholesterol, K: serum potassium, LDH: lactate dehydrogenase, LDL-Chol: low density lipoprotein cholesterol, Na: serum sodium, NT-proBNP: N-terminal pro-Brain Natriuretic Peptide, Plt: platelets, T-Bil: total bilirubin, T-Chol: total cholesterol, TG: triglyceride, TP: total protein, TSH: thyroid-stimulating hormone, UA: serum uric acid, WBC: white blood cells Figure 1. A 12-lead electrocardiogram during the initial examination. A heart rate of 24 bpm and a narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes were noted. Her clinical course is shown in Fig. 2. Because she had bradycardia shock, represented by high serum lactate and liver enzyme levels, with hyperkalemia, a temporary pacing catheter was placed through the right internal jugular vein, and right ventricular pacing was performed at 90 bpm while administrating an intravenous injection of calcium gluconate hydrate and glucose-insulin therapy for hyperkalemia. Anticholinergics could not be used due to glaucoma. With this treatment, the shock immediately resolved, and the symptoms disappeared. The carteolol eye drops, verapamil, and azilsartan were discontinued, and the patient was treated with a pacing rhythm until the next day (Fig. 3). The morning after she was hospitalized, her heart rhythm returned to a normal sinus rhythm with a heart rate of 63 bpm (Fig. 4). The carteolol eye drops were discontinued after consultation with the ophthalmologist, and a different non-beta blocker for glaucoma (dorzolamide hydrochloride) was prescribed to protect her non-blind left eye. The bradycardia no longer appeared after normalization of the potassium level and discontinuing verapamil and the carteolol eye drops. Figure 2. Clinical course of this case. ALT: alanine aminotransferase, AST: aspartate aminotransferase, Calcicol: calcium gluconate hydrate, GI: glucose-insulin therapy, HR: heart rate, PAF: paroxysmal atrial fibrillation, PMI: pacemaker intubation Figure 3. A 12-lead electrocardiogram after initiating temporary pacing. A heart rate of 93 bpm, wide QRS rhythm with a left bundle branch block and upper axis pattern, and right ventricular apex origin were noted. Figure 4. A 12-lead electrocardiogram the day after the hospitalization. A heart rate of 63 bpm with normal sinus rhythm and T-wave flattening in leads III and aVF were observed. However, she had symptomatic PAF with a rapid ventricular response on the first hospital day. When the PAF stopped, she temporarily had a backup pacing with VVI 50 bpm due to sick sinus syndrome. Based on her clinical course, it was judged that the use of antiarrhythmic drugs alone for PAF carried a risk of bradycardia shock, so it was decided to administer antiarrhythmic drugs after pacemaker implantation. However, pulmonary vein isolation was not selected due to her age and activity of daily living. Pacemaker implantation was performed on the 14th hospital day. Finally, her arrhythmia, blood pressure, and glaucoma were controlled with the pacemaker implantation and adjustment of her medications, as shown in Fig. 2, and she was discharged in good health on the 20th hospital day. Discussion Ophthalmic carteolol, as well as timolol, is used as an eye drop beta blocker for glaucoma. Carteolol has been considered to have a lower risk of cardiovascular events than timolol because carteolol generally has a weaker effect on slowing the heart rate than timolol, depending on the characterization of the intrinsic sympathomimetic activity (ISA) (6,7). Although warning clues of cardiovascular events, such as bradycardia, heart block, and hypotension, have been reported due to the use of timolol eye drops (8), there have been no reports of severe cardiovascular events with the use of carteolol eye drops. Because timolol eye drops are absorbed via the nasal mucosa through the nasolacrimal duct, their bioavailability is approximately 50% of that after oral administration, and they have a systemic effect similar to oral administration; however, they are topically administered (9). Furthermore, because both carteolol and timolol are metabolized by cytochrome P450 2D6 (CYP2D6), their effect can be enhanced in elderly people with a weakened CYP2D6 when combined with a drug with a CYP2D6 inhibitory effect and/or verapamil (10). Verapamil is a commonly used class IV antiarrhythmic medication that blocks calcium-dependent slow channels, depresses the cardiac contractility, slows the myocardial conduction, and relaxes vascular smooth muscle. It serves to decrease sino-atrial (SA) node discharges and slow atrioventricular (AV) conduction, and the concomitant use with beta blockers can potentially cause severe bradycardia (11). Elderly patients sometimes have both AF and CKD (2). Because carteolol is mainly excreted by the kidneys, it may have a strong cardiac depressant effect in elderly patients with CKD (12). Elderly people tend to have polypharmacy (3,13), and if prescriptions are obtained from multiple medical institutions, it is possible that the same drugs may be prescribed. In addition, as in the present case, when the serum potassium level is increased due to a side effect of an angiotensin II receptor blocker (ARB) (14), a cardiac depressant effect due to hyperkalemia may exacerbate the cardiac function. In the present case, both the SA node and AV node were likely suppressed by the combination of the ophthalmic carteolol, verapamil, and hyperkalemia, resulting in serious bradycardia due to sick sinus syndrome. Of note, eye drops have a systemic effect similar to oral drugs. Drug interactions are more likely to occur in the elderly, especially when ophthalmic beta blockers are used in glaucoma patients, and careful follow-up in terms of cardiovascular events is needed; furthermore, verapamil should not be used for rate control in patients with AF. Although the mechanism may have involved the interaction between the carteolol eye drops and either verapamil or azilsaltan-related hyperkalemia, it is equally likely that the interaction was between all three drugs under the existence of CKD in this elderly patient. In conclusion, physicians should always consider the potential risk of adverse drug interactions when prescribing a new medication to a patient, especially in elderly patients with polypharmacy. Even topical medications, such as carteolol eye drops, might have significant systemic absorption, leading to serious side effects through drug interactions in elderly patients. Author's disclosure of potential Conflicts of Interest (COI). Yasuo Okumura: Research funding, Boston Scientific Japan. Acknowledgement We thank all of the doctors and medical staff who were involved in the treatment of this patient. In particular, Ph. So Iwabuchi and Ph. Takahiro Sekine provided important information about the carteolol eye drops. We also thank Mr. John Martin for his help with the English editing.	Oral	DrugAdministrationRoute	CC BY-NC-ND	32830185	18,270,051	2021-01-01
What was the dosage of drug 'CARTEOLOL HYDROCHLORIDE'?	Bradycardia Shock Caused by the Combined Use of Carteolol Eye Drops and Verapamil in an Elderly Patient with Atrial Fibrillation and Chronic Kidney Disease. Ophthalmic carteolol is often used to treat glaucoma. Elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) are common among the super-elderly in Japan. Because these patients are exposed to polypharmacy, they are at a high-risk of adverse drug interactions. We herein report an elderly patient with CKD who suffered bradycardia shock after the combined use of carteolol eye drops and verapamil for glaucoma and paroxysmal AF. This case highlights the fact that eye drops have a similar systemic effect to oral drugs, and especially in elderly patients with polypharmacy, drug interactions can unwittingly lead to serious events. Introduction Ophthalmic beta blockers, represented by timolol and carteolol, are often used to treat glaucoma in the elderly (1). As the elderly population is dramatically increasing in Japan, we often encounter elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) (2). Because such patients tend to have multiple comorbidities, they often visit several medical institutions, and accordingly, they are prescribed multiple medications (i.e. polypharmacy). One clinical issue in those patients is that they may unwittingly experience drug interactions due to their polypharmacy, leading to a potential risk of adverse clinical events (3). There have been two case reports of bradycardia with the combined use of timolol eye drops and verapamil, with their combined use first reported in the 20th century (4,5). However, the interaction between carteolol eye drops and verapamil has not been reported. We herein report a case of bradycardia shock caused by the combined use of carteolol eye drops and verapamil in an elderly patient with a history of CKD and glaucoma, who suffered from paroxysmal AF (PAF). Case Report An 84-year-old woman presented with a 3-day history of shortness of breath and chest discomfort. She was determined to be frail as evaluated by a Canadian Study of Health and Aging Clinical Frailty Scale of 6 on admission. She had a history of glaucoma, hypertension, and CKD (estimated glomerular filtration rate 32.6 mL/min/1.73 m2) from over 10 years earlier and was being treated separately at ophthalmology and internal medicine outpatient clinics. She had blindness in her right eye due to glaucoma, and her left eye had been treated with ophthalmic carteolol and travoprost for the last few years. She had been taking azilsartan and doxazosin in addition to diet therapy for hypertension and CKD. As a result, she had been taking five kinds of internal medications, two kinds of external medications, and four kinds of eye drops a day, resulting in polypharmacy. Five days before admission, she had been diagnosed with symptomatic PAF, so verapamil [40 mg twice a day (b.i.d.)] had been newly initiated by her internal medicine physician. According to the information from the previous doctor, her heart rate had been about 60-80 beats/minute (bpm) before the start of verapamil. At admission, her heart rate was 29 bpm, and her blood pressure could not be obtained, although her radial artery pulse was palpable. Her respiratory rate and body temperature were 15/min and 36.0 °C, respectively. Her laboratory data on admission are shown in Table, revealing high serum potassium, high liver enzyme, and high lactate levels. A 12-lead electrocardiogram (ECG) during the initial examination showed a heart rate of 24 bpm and narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes (Fig. 1). Transthoracic echocardiography revealed a normal left ventricular function without any asynergy, D-shape, echo-free space, or valvular disease with a normal size of the left atrial diameter (32.0 mm). Chest X-ray revealed pulmonary edema and enlargement of the cardio-thoracic ratio. Table. Laboratory Data at the Time of Admission. WBC 5,900 /mm3 Na 139 mEq/L Hb 11.4 g/dL K 6.5 mEq/L Plt 14.2×104 /μL Cl 110 mEq/L BUN 35.6 mg/dL Ca 8.5 mg/dL Cre 1.21 mg/dL T-Chol 160 mg/dL eGFR 32.6 HDL-Chol 67 mg/dL CCR 21.25 LDL-Chol 66 mg/dL CRP 0.11 mg/dL TG 64 mg/dL TP 5.2 g/dL UA 6.3 mg/dL Alb 3.0 g/dL CK 66 U/L T-Bil 1.20 mg/dL CK-MB 4 U/L AST 234 U/L Troponin I 0.01 ng/mL ALT 119 U/L NT-proBNP 3,722 pg/mL LDH 421 U/L TSH 7.79 μlU/mL ALP 248 mEq/L Free T3 2.36 pg/mL BS 157 mg/dL Free T4 1.20 ng/mL HbA1c 5.3 % Lactate 2.9 mmol/L Alb: albumin, ALT: alanine aminotransferase, AST: aspartate aminotransferase, BS: blood sugar, BUN: blood urea nitrogen, Ca: serum calcium, CCR: creatinine clearance, CK: creatine kinase, Cl: serum chloride, Cre: serum creatinine, CRP: C-reactive protein, eGFR: estimated glomerular filtration rate, Free T3: free triiodothyronine, Free T4: free thyroxine, Hb: hemoglobin, HbA1c: hemoglobin A1c, HDL-Chol: high density lipoprotein cholesterol, K: serum potassium, LDH: lactate dehydrogenase, LDL-Chol: low density lipoprotein cholesterol, Na: serum sodium, NT-proBNP: N-terminal pro-Brain Natriuretic Peptide, Plt: platelets, T-Bil: total bilirubin, T-Chol: total cholesterol, TG: triglyceride, TP: total protein, TSH: thyroid-stimulating hormone, UA: serum uric acid, WBC: white blood cells Figure 1. A 12-lead electrocardiogram during the initial examination. A heart rate of 24 bpm and a narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes were noted. Her clinical course is shown in Fig. 2. Because she had bradycardia shock, represented by high serum lactate and liver enzyme levels, with hyperkalemia, a temporary pacing catheter was placed through the right internal jugular vein, and right ventricular pacing was performed at 90 bpm while administrating an intravenous injection of calcium gluconate hydrate and glucose-insulin therapy for hyperkalemia. Anticholinergics could not be used due to glaucoma. With this treatment, the shock immediately resolved, and the symptoms disappeared. The carteolol eye drops, verapamil, and azilsartan were discontinued, and the patient was treated with a pacing rhythm until the next day (Fig. 3). The morning after she was hospitalized, her heart rhythm returned to a normal sinus rhythm with a heart rate of 63 bpm (Fig. 4). The carteolol eye drops were discontinued after consultation with the ophthalmologist, and a different non-beta blocker for glaucoma (dorzolamide hydrochloride) was prescribed to protect her non-blind left eye. The bradycardia no longer appeared after normalization of the potassium level and discontinuing verapamil and the carteolol eye drops. Figure 2. Clinical course of this case. ALT: alanine aminotransferase, AST: aspartate aminotransferase, Calcicol: calcium gluconate hydrate, GI: glucose-insulin therapy, HR: heart rate, PAF: paroxysmal atrial fibrillation, PMI: pacemaker intubation Figure 3. A 12-lead electrocardiogram after initiating temporary pacing. A heart rate of 93 bpm, wide QRS rhythm with a left bundle branch block and upper axis pattern, and right ventricular apex origin were noted. Figure 4. A 12-lead electrocardiogram the day after the hospitalization. A heart rate of 63 bpm with normal sinus rhythm and T-wave flattening in leads III and aVF were observed. However, she had symptomatic PAF with a rapid ventricular response on the first hospital day. When the PAF stopped, she temporarily had a backup pacing with VVI 50 bpm due to sick sinus syndrome. Based on her clinical course, it was judged that the use of antiarrhythmic drugs alone for PAF carried a risk of bradycardia shock, so it was decided to administer antiarrhythmic drugs after pacemaker implantation. However, pulmonary vein isolation was not selected due to her age and activity of daily living. Pacemaker implantation was performed on the 14th hospital day. Finally, her arrhythmia, blood pressure, and glaucoma were controlled with the pacemaker implantation and adjustment of her medications, as shown in Fig. 2, and she was discharged in good health on the 20th hospital day. Discussion Ophthalmic carteolol, as well as timolol, is used as an eye drop beta blocker for glaucoma. Carteolol has been considered to have a lower risk of cardiovascular events than timolol because carteolol generally has a weaker effect on slowing the heart rate than timolol, depending on the characterization of the intrinsic sympathomimetic activity (ISA) (6,7). Although warning clues of cardiovascular events, such as bradycardia, heart block, and hypotension, have been reported due to the use of timolol eye drops (8), there have been no reports of severe cardiovascular events with the use of carteolol eye drops. Because timolol eye drops are absorbed via the nasal mucosa through the nasolacrimal duct, their bioavailability is approximately 50% of that after oral administration, and they have a systemic effect similar to oral administration; however, they are topically administered (9). Furthermore, because both carteolol and timolol are metabolized by cytochrome P450 2D6 (CYP2D6), their effect can be enhanced in elderly people with a weakened CYP2D6 when combined with a drug with a CYP2D6 inhibitory effect and/or verapamil (10). Verapamil is a commonly used class IV antiarrhythmic medication that blocks calcium-dependent slow channels, depresses the cardiac contractility, slows the myocardial conduction, and relaxes vascular smooth muscle. It serves to decrease sino-atrial (SA) node discharges and slow atrioventricular (AV) conduction, and the concomitant use with beta blockers can potentially cause severe bradycardia (11). Elderly patients sometimes have both AF and CKD (2). Because carteolol is mainly excreted by the kidneys, it may have a strong cardiac depressant effect in elderly patients with CKD (12). Elderly people tend to have polypharmacy (3,13), and if prescriptions are obtained from multiple medical institutions, it is possible that the same drugs may be prescribed. In addition, as in the present case, when the serum potassium level is increased due to a side effect of an angiotensin II receptor blocker (ARB) (14), a cardiac depressant effect due to hyperkalemia may exacerbate the cardiac function. In the present case, both the SA node and AV node were likely suppressed by the combination of the ophthalmic carteolol, verapamil, and hyperkalemia, resulting in serious bradycardia due to sick sinus syndrome. Of note, eye drops have a systemic effect similar to oral drugs. Drug interactions are more likely to occur in the elderly, especially when ophthalmic beta blockers are used in glaucoma patients, and careful follow-up in terms of cardiovascular events is needed; furthermore, verapamil should not be used for rate control in patients with AF. Although the mechanism may have involved the interaction between the carteolol eye drops and either verapamil or azilsaltan-related hyperkalemia, it is equally likely that the interaction was between all three drugs under the existence of CKD in this elderly patient. In conclusion, physicians should always consider the potential risk of adverse drug interactions when prescribing a new medication to a patient, especially in elderly patients with polypharmacy. Even topical medications, such as carteolol eye drops, might have significant systemic absorption, leading to serious side effects through drug interactions in elderly patients. Author's disclosure of potential Conflicts of Interest (COI). Yasuo Okumura: Research funding, Boston Scientific Japan. Acknowledgement We thank all of the doctors and medical staff who were involved in the treatment of this patient. In particular, Ph. So Iwabuchi and Ph. Takahiro Sekine provided important information about the carteolol eye drops. We also thank Mr. John Martin for his help with the English editing.	LEFT EYE	DrugDosageText	CC BY-NC-ND	32830185	18,270,051	2021-01-01
What was the dosage of drug 'EDOXABAN TOSYLATE'?	Bradycardia Shock Caused by the Combined Use of Carteolol Eye Drops and Verapamil in an Elderly Patient with Atrial Fibrillation and Chronic Kidney Disease. Ophthalmic carteolol is often used to treat glaucoma. Elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) are common among the super-elderly in Japan. Because these patients are exposed to polypharmacy, they are at a high-risk of adverse drug interactions. We herein report an elderly patient with CKD who suffered bradycardia shock after the combined use of carteolol eye drops and verapamil for glaucoma and paroxysmal AF. This case highlights the fact that eye drops have a similar systemic effect to oral drugs, and especially in elderly patients with polypharmacy, drug interactions can unwittingly lead to serious events. Introduction Ophthalmic beta blockers, represented by timolol and carteolol, are often used to treat glaucoma in the elderly (1). As the elderly population is dramatically increasing in Japan, we often encounter elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) (2). Because such patients tend to have multiple comorbidities, they often visit several medical institutions, and accordingly, they are prescribed multiple medications (i.e. polypharmacy). One clinical issue in those patients is that they may unwittingly experience drug interactions due to their polypharmacy, leading to a potential risk of adverse clinical events (3). There have been two case reports of bradycardia with the combined use of timolol eye drops and verapamil, with their combined use first reported in the 20th century (4,5). However, the interaction between carteolol eye drops and verapamil has not been reported. We herein report a case of bradycardia shock caused by the combined use of carteolol eye drops and verapamil in an elderly patient with a history of CKD and glaucoma, who suffered from paroxysmal AF (PAF). Case Report An 84-year-old woman presented with a 3-day history of shortness of breath and chest discomfort. She was determined to be frail as evaluated by a Canadian Study of Health and Aging Clinical Frailty Scale of 6 on admission. She had a history of glaucoma, hypertension, and CKD (estimated glomerular filtration rate 32.6 mL/min/1.73 m2) from over 10 years earlier and was being treated separately at ophthalmology and internal medicine outpatient clinics. She had blindness in her right eye due to glaucoma, and her left eye had been treated with ophthalmic carteolol and travoprost for the last few years. She had been taking azilsartan and doxazosin in addition to diet therapy for hypertension and CKD. As a result, she had been taking five kinds of internal medications, two kinds of external medications, and four kinds of eye drops a day, resulting in polypharmacy. Five days before admission, she had been diagnosed with symptomatic PAF, so verapamil [40 mg twice a day (b.i.d.)] had been newly initiated by her internal medicine physician. According to the information from the previous doctor, her heart rate had been about 60-80 beats/minute (bpm) before the start of verapamil. At admission, her heart rate was 29 bpm, and her blood pressure could not be obtained, although her radial artery pulse was palpable. Her respiratory rate and body temperature were 15/min and 36.0 °C, respectively. Her laboratory data on admission are shown in Table, revealing high serum potassium, high liver enzyme, and high lactate levels. A 12-lead electrocardiogram (ECG) during the initial examination showed a heart rate of 24 bpm and narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes (Fig. 1). Transthoracic echocardiography revealed a normal left ventricular function without any asynergy, D-shape, echo-free space, or valvular disease with a normal size of the left atrial diameter (32.0 mm). Chest X-ray revealed pulmonary edema and enlargement of the cardio-thoracic ratio. Table. Laboratory Data at the Time of Admission. WBC 5,900 /mm3 Na 139 mEq/L Hb 11.4 g/dL K 6.5 mEq/L Plt 14.2×104 /μL Cl 110 mEq/L BUN 35.6 mg/dL Ca 8.5 mg/dL Cre 1.21 mg/dL T-Chol 160 mg/dL eGFR 32.6 HDL-Chol 67 mg/dL CCR 21.25 LDL-Chol 66 mg/dL CRP 0.11 mg/dL TG 64 mg/dL TP 5.2 g/dL UA 6.3 mg/dL Alb 3.0 g/dL CK 66 U/L T-Bil 1.20 mg/dL CK-MB 4 U/L AST 234 U/L Troponin I 0.01 ng/mL ALT 119 U/L NT-proBNP 3,722 pg/mL LDH 421 U/L TSH 7.79 μlU/mL ALP 248 mEq/L Free T3 2.36 pg/mL BS 157 mg/dL Free T4 1.20 ng/mL HbA1c 5.3 % Lactate 2.9 mmol/L Alb: albumin, ALT: alanine aminotransferase, AST: aspartate aminotransferase, BS: blood sugar, BUN: blood urea nitrogen, Ca: serum calcium, CCR: creatinine clearance, CK: creatine kinase, Cl: serum chloride, Cre: serum creatinine, CRP: C-reactive protein, eGFR: estimated glomerular filtration rate, Free T3: free triiodothyronine, Free T4: free thyroxine, Hb: hemoglobin, HbA1c: hemoglobin A1c, HDL-Chol: high density lipoprotein cholesterol, K: serum potassium, LDH: lactate dehydrogenase, LDL-Chol: low density lipoprotein cholesterol, Na: serum sodium, NT-proBNP: N-terminal pro-Brain Natriuretic Peptide, Plt: platelets, T-Bil: total bilirubin, T-Chol: total cholesterol, TG: triglyceride, TP: total protein, TSH: thyroid-stimulating hormone, UA: serum uric acid, WBC: white blood cells Figure 1. A 12-lead electrocardiogram during the initial examination. A heart rate of 24 bpm and a narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes were noted. Her clinical course is shown in Fig. 2. Because she had bradycardia shock, represented by high serum lactate and liver enzyme levels, with hyperkalemia, a temporary pacing catheter was placed through the right internal jugular vein, and right ventricular pacing was performed at 90 bpm while administrating an intravenous injection of calcium gluconate hydrate and glucose-insulin therapy for hyperkalemia. Anticholinergics could not be used due to glaucoma. With this treatment, the shock immediately resolved, and the symptoms disappeared. The carteolol eye drops, verapamil, and azilsartan were discontinued, and the patient was treated with a pacing rhythm until the next day (Fig. 3). The morning after she was hospitalized, her heart rhythm returned to a normal sinus rhythm with a heart rate of 63 bpm (Fig. 4). The carteolol eye drops were discontinued after consultation with the ophthalmologist, and a different non-beta blocker for glaucoma (dorzolamide hydrochloride) was prescribed to protect her non-blind left eye. The bradycardia no longer appeared after normalization of the potassium level and discontinuing verapamil and the carteolol eye drops. Figure 2. Clinical course of this case. ALT: alanine aminotransferase, AST: aspartate aminotransferase, Calcicol: calcium gluconate hydrate, GI: glucose-insulin therapy, HR: heart rate, PAF: paroxysmal atrial fibrillation, PMI: pacemaker intubation Figure 3. A 12-lead electrocardiogram after initiating temporary pacing. A heart rate of 93 bpm, wide QRS rhythm with a left bundle branch block and upper axis pattern, and right ventricular apex origin were noted. Figure 4. A 12-lead electrocardiogram the day after the hospitalization. A heart rate of 63 bpm with normal sinus rhythm and T-wave flattening in leads III and aVF were observed. However, she had symptomatic PAF with a rapid ventricular response on the first hospital day. When the PAF stopped, she temporarily had a backup pacing with VVI 50 bpm due to sick sinus syndrome. Based on her clinical course, it was judged that the use of antiarrhythmic drugs alone for PAF carried a risk of bradycardia shock, so it was decided to administer antiarrhythmic drugs after pacemaker implantation. However, pulmonary vein isolation was not selected due to her age and activity of daily living. Pacemaker implantation was performed on the 14th hospital day. Finally, her arrhythmia, blood pressure, and glaucoma were controlled with the pacemaker implantation and adjustment of her medications, as shown in Fig. 2, and she was discharged in good health on the 20th hospital day. Discussion Ophthalmic carteolol, as well as timolol, is used as an eye drop beta blocker for glaucoma. Carteolol has been considered to have a lower risk of cardiovascular events than timolol because carteolol generally has a weaker effect on slowing the heart rate than timolol, depending on the characterization of the intrinsic sympathomimetic activity (ISA) (6,7). Although warning clues of cardiovascular events, such as bradycardia, heart block, and hypotension, have been reported due to the use of timolol eye drops (8), there have been no reports of severe cardiovascular events with the use of carteolol eye drops. Because timolol eye drops are absorbed via the nasal mucosa through the nasolacrimal duct, their bioavailability is approximately 50% of that after oral administration, and they have a systemic effect similar to oral administration; however, they are topically administered (9). Furthermore, because both carteolol and timolol are metabolized by cytochrome P450 2D6 (CYP2D6), their effect can be enhanced in elderly people with a weakened CYP2D6 when combined with a drug with a CYP2D6 inhibitory effect and/or verapamil (10). Verapamil is a commonly used class IV antiarrhythmic medication that blocks calcium-dependent slow channels, depresses the cardiac contractility, slows the myocardial conduction, and relaxes vascular smooth muscle. It serves to decrease sino-atrial (SA) node discharges and slow atrioventricular (AV) conduction, and the concomitant use with beta blockers can potentially cause severe bradycardia (11). Elderly patients sometimes have both AF and CKD (2). Because carteolol is mainly excreted by the kidneys, it may have a strong cardiac depressant effect in elderly patients with CKD (12). Elderly people tend to have polypharmacy (3,13), and if prescriptions are obtained from multiple medical institutions, it is possible that the same drugs may be prescribed. In addition, as in the present case, when the serum potassium level is increased due to a side effect of an angiotensin II receptor blocker (ARB) (14), a cardiac depressant effect due to hyperkalemia may exacerbate the cardiac function. In the present case, both the SA node and AV node were likely suppressed by the combination of the ophthalmic carteolol, verapamil, and hyperkalemia, resulting in serious bradycardia due to sick sinus syndrome. Of note, eye drops have a systemic effect similar to oral drugs. Drug interactions are more likely to occur in the elderly, especially when ophthalmic beta blockers are used in glaucoma patients, and careful follow-up in terms of cardiovascular events is needed; furthermore, verapamil should not be used for rate control in patients with AF. Although the mechanism may have involved the interaction between the carteolol eye drops and either verapamil or azilsaltan-related hyperkalemia, it is equally likely that the interaction was between all three drugs under the existence of CKD in this elderly patient. In conclusion, physicians should always consider the potential risk of adverse drug interactions when prescribing a new medication to a patient, especially in elderly patients with polypharmacy. Even topical medications, such as carteolol eye drops, might have significant systemic absorption, leading to serious side effects through drug interactions in elderly patients. Author's disclosure of potential Conflicts of Interest (COI). Yasuo Okumura: Research funding, Boston Scientific Japan. Acknowledgement We thank all of the doctors and medical staff who were involved in the treatment of this patient. In particular, Ph. So Iwabuchi and Ph. Takahiro Sekine provided important information about the carteolol eye drops. We also thank Mr. John Martin for his help with the English editing.	30MG/DAY	DrugDosageText	CC BY-NC-ND	32830185	18,817,303	2021-01-01
What was the dosage of drug 'TRAVOPROST'?	Bradycardia Shock Caused by the Combined Use of Carteolol Eye Drops and Verapamil in an Elderly Patient with Atrial Fibrillation and Chronic Kidney Disease. Ophthalmic carteolol is often used to treat glaucoma. Elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) are common among the super-elderly in Japan. Because these patients are exposed to polypharmacy, they are at a high-risk of adverse drug interactions. We herein report an elderly patient with CKD who suffered bradycardia shock after the combined use of carteolol eye drops and verapamil for glaucoma and paroxysmal AF. This case highlights the fact that eye drops have a similar systemic effect to oral drugs, and especially in elderly patients with polypharmacy, drug interactions can unwittingly lead to serious events. Introduction Ophthalmic beta blockers, represented by timolol and carteolol, are often used to treat glaucoma in the elderly (1). As the elderly population is dramatically increasing in Japan, we often encounter elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) (2). Because such patients tend to have multiple comorbidities, they often visit several medical institutions, and accordingly, they are prescribed multiple medications (i.e. polypharmacy). One clinical issue in those patients is that they may unwittingly experience drug interactions due to their polypharmacy, leading to a potential risk of adverse clinical events (3). There have been two case reports of bradycardia with the combined use of timolol eye drops and verapamil, with their combined use first reported in the 20th century (4,5). However, the interaction between carteolol eye drops and verapamil has not been reported. We herein report a case of bradycardia shock caused by the combined use of carteolol eye drops and verapamil in an elderly patient with a history of CKD and glaucoma, who suffered from paroxysmal AF (PAF). Case Report An 84-year-old woman presented with a 3-day history of shortness of breath and chest discomfort. She was determined to be frail as evaluated by a Canadian Study of Health and Aging Clinical Frailty Scale of 6 on admission. She had a history of glaucoma, hypertension, and CKD (estimated glomerular filtration rate 32.6 mL/min/1.73 m2) from over 10 years earlier and was being treated separately at ophthalmology and internal medicine outpatient clinics. She had blindness in her right eye due to glaucoma, and her left eye had been treated with ophthalmic carteolol and travoprost for the last few years. She had been taking azilsartan and doxazosin in addition to diet therapy for hypertension and CKD. As a result, she had been taking five kinds of internal medications, two kinds of external medications, and four kinds of eye drops a day, resulting in polypharmacy. Five days before admission, she had been diagnosed with symptomatic PAF, so verapamil [40 mg twice a day (b.i.d.)] had been newly initiated by her internal medicine physician. According to the information from the previous doctor, her heart rate had been about 60-80 beats/minute (bpm) before the start of verapamil. At admission, her heart rate was 29 bpm, and her blood pressure could not be obtained, although her radial artery pulse was palpable. Her respiratory rate and body temperature were 15/min and 36.0 °C, respectively. Her laboratory data on admission are shown in Table, revealing high serum potassium, high liver enzyme, and high lactate levels. A 12-lead electrocardiogram (ECG) during the initial examination showed a heart rate of 24 bpm and narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes (Fig. 1). Transthoracic echocardiography revealed a normal left ventricular function without any asynergy, D-shape, echo-free space, or valvular disease with a normal size of the left atrial diameter (32.0 mm). Chest X-ray revealed pulmonary edema and enlargement of the cardio-thoracic ratio. Table. Laboratory Data at the Time of Admission. WBC 5,900 /mm3 Na 139 mEq/L Hb 11.4 g/dL K 6.5 mEq/L Plt 14.2×104 /μL Cl 110 mEq/L BUN 35.6 mg/dL Ca 8.5 mg/dL Cre 1.21 mg/dL T-Chol 160 mg/dL eGFR 32.6 HDL-Chol 67 mg/dL CCR 21.25 LDL-Chol 66 mg/dL CRP 0.11 mg/dL TG 64 mg/dL TP 5.2 g/dL UA 6.3 mg/dL Alb 3.0 g/dL CK 66 U/L T-Bil 1.20 mg/dL CK-MB 4 U/L AST 234 U/L Troponin I 0.01 ng/mL ALT 119 U/L NT-proBNP 3,722 pg/mL LDH 421 U/L TSH 7.79 μlU/mL ALP 248 mEq/L Free T3 2.36 pg/mL BS 157 mg/dL Free T4 1.20 ng/mL HbA1c 5.3 % Lactate 2.9 mmol/L Alb: albumin, ALT: alanine aminotransferase, AST: aspartate aminotransferase, BS: blood sugar, BUN: blood urea nitrogen, Ca: serum calcium, CCR: creatinine clearance, CK: creatine kinase, Cl: serum chloride, Cre: serum creatinine, CRP: C-reactive protein, eGFR: estimated glomerular filtration rate, Free T3: free triiodothyronine, Free T4: free thyroxine, Hb: hemoglobin, HbA1c: hemoglobin A1c, HDL-Chol: high density lipoprotein cholesterol, K: serum potassium, LDH: lactate dehydrogenase, LDL-Chol: low density lipoprotein cholesterol, Na: serum sodium, NT-proBNP: N-terminal pro-Brain Natriuretic Peptide, Plt: platelets, T-Bil: total bilirubin, T-Chol: total cholesterol, TG: triglyceride, TP: total protein, TSH: thyroid-stimulating hormone, UA: serum uric acid, WBC: white blood cells Figure 1. A 12-lead electrocardiogram during the initial examination. A heart rate of 24 bpm and a narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes were noted. Her clinical course is shown in Fig. 2. Because she had bradycardia shock, represented by high serum lactate and liver enzyme levels, with hyperkalemia, a temporary pacing catheter was placed through the right internal jugular vein, and right ventricular pacing was performed at 90 bpm while administrating an intravenous injection of calcium gluconate hydrate and glucose-insulin therapy for hyperkalemia. Anticholinergics could not be used due to glaucoma. With this treatment, the shock immediately resolved, and the symptoms disappeared. The carteolol eye drops, verapamil, and azilsartan were discontinued, and the patient was treated with a pacing rhythm until the next day (Fig. 3). The morning after she was hospitalized, her heart rhythm returned to a normal sinus rhythm with a heart rate of 63 bpm (Fig. 4). The carteolol eye drops were discontinued after consultation with the ophthalmologist, and a different non-beta blocker for glaucoma (dorzolamide hydrochloride) was prescribed to protect her non-blind left eye. The bradycardia no longer appeared after normalization of the potassium level and discontinuing verapamil and the carteolol eye drops. Figure 2. Clinical course of this case. ALT: alanine aminotransferase, AST: aspartate aminotransferase, Calcicol: calcium gluconate hydrate, GI: glucose-insulin therapy, HR: heart rate, PAF: paroxysmal atrial fibrillation, PMI: pacemaker intubation Figure 3. A 12-lead electrocardiogram after initiating temporary pacing. A heart rate of 93 bpm, wide QRS rhythm with a left bundle branch block and upper axis pattern, and right ventricular apex origin were noted. Figure 4. A 12-lead electrocardiogram the day after the hospitalization. A heart rate of 63 bpm with normal sinus rhythm and T-wave flattening in leads III and aVF were observed. However, she had symptomatic PAF with a rapid ventricular response on the first hospital day. When the PAF stopped, she temporarily had a backup pacing with VVI 50 bpm due to sick sinus syndrome. Based on her clinical course, it was judged that the use of antiarrhythmic drugs alone for PAF carried a risk of bradycardia shock, so it was decided to administer antiarrhythmic drugs after pacemaker implantation. However, pulmonary vein isolation was not selected due to her age and activity of daily living. Pacemaker implantation was performed on the 14th hospital day. Finally, her arrhythmia, blood pressure, and glaucoma were controlled with the pacemaker implantation and adjustment of her medications, as shown in Fig. 2, and she was discharged in good health on the 20th hospital day. Discussion Ophthalmic carteolol, as well as timolol, is used as an eye drop beta blocker for glaucoma. Carteolol has been considered to have a lower risk of cardiovascular events than timolol because carteolol generally has a weaker effect on slowing the heart rate than timolol, depending on the characterization of the intrinsic sympathomimetic activity (ISA) (6,7). Although warning clues of cardiovascular events, such as bradycardia, heart block, and hypotension, have been reported due to the use of timolol eye drops (8), there have been no reports of severe cardiovascular events with the use of carteolol eye drops. Because timolol eye drops are absorbed via the nasal mucosa through the nasolacrimal duct, their bioavailability is approximately 50% of that after oral administration, and they have a systemic effect similar to oral administration; however, they are topically administered (9). Furthermore, because both carteolol and timolol are metabolized by cytochrome P450 2D6 (CYP2D6), their effect can be enhanced in elderly people with a weakened CYP2D6 when combined with a drug with a CYP2D6 inhibitory effect and/or verapamil (10). Verapamil is a commonly used class IV antiarrhythmic medication that blocks calcium-dependent slow channels, depresses the cardiac contractility, slows the myocardial conduction, and relaxes vascular smooth muscle. It serves to decrease sino-atrial (SA) node discharges and slow atrioventricular (AV) conduction, and the concomitant use with beta blockers can potentially cause severe bradycardia (11). Elderly patients sometimes have both AF and CKD (2). Because carteolol is mainly excreted by the kidneys, it may have a strong cardiac depressant effect in elderly patients with CKD (12). Elderly people tend to have polypharmacy (3,13), and if prescriptions are obtained from multiple medical institutions, it is possible that the same drugs may be prescribed. In addition, as in the present case, when the serum potassium level is increased due to a side effect of an angiotensin II receptor blocker (ARB) (14), a cardiac depressant effect due to hyperkalemia may exacerbate the cardiac function. In the present case, both the SA node and AV node were likely suppressed by the combination of the ophthalmic carteolol, verapamil, and hyperkalemia, resulting in serious bradycardia due to sick sinus syndrome. Of note, eye drops have a systemic effect similar to oral drugs. Drug interactions are more likely to occur in the elderly, especially when ophthalmic beta blockers are used in glaucoma patients, and careful follow-up in terms of cardiovascular events is needed; furthermore, verapamil should not be used for rate control in patients with AF. Although the mechanism may have involved the interaction between the carteolol eye drops and either verapamil or azilsaltan-related hyperkalemia, it is equally likely that the interaction was between all three drugs under the existence of CKD in this elderly patient. In conclusion, physicians should always consider the potential risk of adverse drug interactions when prescribing a new medication to a patient, especially in elderly patients with polypharmacy. Even topical medications, such as carteolol eye drops, might have significant systemic absorption, leading to serious side effects through drug interactions in elderly patients. Author's disclosure of potential Conflicts of Interest (COI). Yasuo Okumura: Research funding, Boston Scientific Japan. Acknowledgement We thank all of the doctors and medical staff who were involved in the treatment of this patient. In particular, Ph. So Iwabuchi and Ph. Takahiro Sekine provided important information about the carteolol eye drops. We also thank Mr. John Martin for his help with the English editing.	LEFT EYE	DrugDosageText	CC BY-NC-ND	32830185	18,270,051	2021-01-01
What was the outcome of reaction 'Bradycardia'?	Bradycardia Shock Caused by the Combined Use of Carteolol Eye Drops and Verapamil in an Elderly Patient with Atrial Fibrillation and Chronic Kidney Disease. Ophthalmic carteolol is often used to treat glaucoma. Elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) are common among the super-elderly in Japan. Because these patients are exposed to polypharmacy, they are at a high-risk of adverse drug interactions. We herein report an elderly patient with CKD who suffered bradycardia shock after the combined use of carteolol eye drops and verapamil for glaucoma and paroxysmal AF. This case highlights the fact that eye drops have a similar systemic effect to oral drugs, and especially in elderly patients with polypharmacy, drug interactions can unwittingly lead to serious events. Introduction Ophthalmic beta blockers, represented by timolol and carteolol, are often used to treat glaucoma in the elderly (1). As the elderly population is dramatically increasing in Japan, we often encounter elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) (2). Because such patients tend to have multiple comorbidities, they often visit several medical institutions, and accordingly, they are prescribed multiple medications (i.e. polypharmacy). One clinical issue in those patients is that they may unwittingly experience drug interactions due to their polypharmacy, leading to a potential risk of adverse clinical events (3). There have been two case reports of bradycardia with the combined use of timolol eye drops and verapamil, with their combined use first reported in the 20th century (4,5). However, the interaction between carteolol eye drops and verapamil has not been reported. We herein report a case of bradycardia shock caused by the combined use of carteolol eye drops and verapamil in an elderly patient with a history of CKD and glaucoma, who suffered from paroxysmal AF (PAF). Case Report An 84-year-old woman presented with a 3-day history of shortness of breath and chest discomfort. She was determined to be frail as evaluated by a Canadian Study of Health and Aging Clinical Frailty Scale of 6 on admission. She had a history of glaucoma, hypertension, and CKD (estimated glomerular filtration rate 32.6 mL/min/1.73 m2) from over 10 years earlier and was being treated separately at ophthalmology and internal medicine outpatient clinics. She had blindness in her right eye due to glaucoma, and her left eye had been treated with ophthalmic carteolol and travoprost for the last few years. She had been taking azilsartan and doxazosin in addition to diet therapy for hypertension and CKD. As a result, she had been taking five kinds of internal medications, two kinds of external medications, and four kinds of eye drops a day, resulting in polypharmacy. Five days before admission, she had been diagnosed with symptomatic PAF, so verapamil [40 mg twice a day (b.i.d.)] had been newly initiated by her internal medicine physician. According to the information from the previous doctor, her heart rate had been about 60-80 beats/minute (bpm) before the start of verapamil. At admission, her heart rate was 29 bpm, and her blood pressure could not be obtained, although her radial artery pulse was palpable. Her respiratory rate and body temperature were 15/min and 36.0 °C, respectively. Her laboratory data on admission are shown in Table, revealing high serum potassium, high liver enzyme, and high lactate levels. A 12-lead electrocardiogram (ECG) during the initial examination showed a heart rate of 24 bpm and narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes (Fig. 1). Transthoracic echocardiography revealed a normal left ventricular function without any asynergy, D-shape, echo-free space, or valvular disease with a normal size of the left atrial diameter (32.0 mm). Chest X-ray revealed pulmonary edema and enlargement of the cardio-thoracic ratio. Table. Laboratory Data at the Time of Admission. WBC 5,900 /mm3 Na 139 mEq/L Hb 11.4 g/dL K 6.5 mEq/L Plt 14.2×104 /μL Cl 110 mEq/L BUN 35.6 mg/dL Ca 8.5 mg/dL Cre 1.21 mg/dL T-Chol 160 mg/dL eGFR 32.6 HDL-Chol 67 mg/dL CCR 21.25 LDL-Chol 66 mg/dL CRP 0.11 mg/dL TG 64 mg/dL TP 5.2 g/dL UA 6.3 mg/dL Alb 3.0 g/dL CK 66 U/L T-Bil 1.20 mg/dL CK-MB 4 U/L AST 234 U/L Troponin I 0.01 ng/mL ALT 119 U/L NT-proBNP 3,722 pg/mL LDH 421 U/L TSH 7.79 μlU/mL ALP 248 mEq/L Free T3 2.36 pg/mL BS 157 mg/dL Free T4 1.20 ng/mL HbA1c 5.3 % Lactate 2.9 mmol/L Alb: albumin, ALT: alanine aminotransferase, AST: aspartate aminotransferase, BS: blood sugar, BUN: blood urea nitrogen, Ca: serum calcium, CCR: creatinine clearance, CK: creatine kinase, Cl: serum chloride, Cre: serum creatinine, CRP: C-reactive protein, eGFR: estimated glomerular filtration rate, Free T3: free triiodothyronine, Free T4: free thyroxine, Hb: hemoglobin, HbA1c: hemoglobin A1c, HDL-Chol: high density lipoprotein cholesterol, K: serum potassium, LDH: lactate dehydrogenase, LDL-Chol: low density lipoprotein cholesterol, Na: serum sodium, NT-proBNP: N-terminal pro-Brain Natriuretic Peptide, Plt: platelets, T-Bil: total bilirubin, T-Chol: total cholesterol, TG: triglyceride, TP: total protein, TSH: thyroid-stimulating hormone, UA: serum uric acid, WBC: white blood cells Figure 1. A 12-lead electrocardiogram during the initial examination. A heart rate of 24 bpm and a narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes were noted. Her clinical course is shown in Fig. 2. Because she had bradycardia shock, represented by high serum lactate and liver enzyme levels, with hyperkalemia, a temporary pacing catheter was placed through the right internal jugular vein, and right ventricular pacing was performed at 90 bpm while administrating an intravenous injection of calcium gluconate hydrate and glucose-insulin therapy for hyperkalemia. Anticholinergics could not be used due to glaucoma. With this treatment, the shock immediately resolved, and the symptoms disappeared. The carteolol eye drops, verapamil, and azilsartan were discontinued, and the patient was treated with a pacing rhythm until the next day (Fig. 3). The morning after she was hospitalized, her heart rhythm returned to a normal sinus rhythm with a heart rate of 63 bpm (Fig. 4). The carteolol eye drops were discontinued after consultation with the ophthalmologist, and a different non-beta blocker for glaucoma (dorzolamide hydrochloride) was prescribed to protect her non-blind left eye. The bradycardia no longer appeared after normalization of the potassium level and discontinuing verapamil and the carteolol eye drops. Figure 2. Clinical course of this case. ALT: alanine aminotransferase, AST: aspartate aminotransferase, Calcicol: calcium gluconate hydrate, GI: glucose-insulin therapy, HR: heart rate, PAF: paroxysmal atrial fibrillation, PMI: pacemaker intubation Figure 3. A 12-lead electrocardiogram after initiating temporary pacing. A heart rate of 93 bpm, wide QRS rhythm with a left bundle branch block and upper axis pattern, and right ventricular apex origin were noted. Figure 4. A 12-lead electrocardiogram the day after the hospitalization. A heart rate of 63 bpm with normal sinus rhythm and T-wave flattening in leads III and aVF were observed. However, she had symptomatic PAF with a rapid ventricular response on the first hospital day. When the PAF stopped, she temporarily had a backup pacing with VVI 50 bpm due to sick sinus syndrome. Based on her clinical course, it was judged that the use of antiarrhythmic drugs alone for PAF carried a risk of bradycardia shock, so it was decided to administer antiarrhythmic drugs after pacemaker implantation. However, pulmonary vein isolation was not selected due to her age and activity of daily living. Pacemaker implantation was performed on the 14th hospital day. Finally, her arrhythmia, blood pressure, and glaucoma were controlled with the pacemaker implantation and adjustment of her medications, as shown in Fig. 2, and she was discharged in good health on the 20th hospital day. Discussion Ophthalmic carteolol, as well as timolol, is used as an eye drop beta blocker for glaucoma. Carteolol has been considered to have a lower risk of cardiovascular events than timolol because carteolol generally has a weaker effect on slowing the heart rate than timolol, depending on the characterization of the intrinsic sympathomimetic activity (ISA) (6,7). Although warning clues of cardiovascular events, such as bradycardia, heart block, and hypotension, have been reported due to the use of timolol eye drops (8), there have been no reports of severe cardiovascular events with the use of carteolol eye drops. Because timolol eye drops are absorbed via the nasal mucosa through the nasolacrimal duct, their bioavailability is approximately 50% of that after oral administration, and they have a systemic effect similar to oral administration; however, they are topically administered (9). Furthermore, because both carteolol and timolol are metabolized by cytochrome P450 2D6 (CYP2D6), their effect can be enhanced in elderly people with a weakened CYP2D6 when combined with a drug with a CYP2D6 inhibitory effect and/or verapamil (10). Verapamil is a commonly used class IV antiarrhythmic medication that blocks calcium-dependent slow channels, depresses the cardiac contractility, slows the myocardial conduction, and relaxes vascular smooth muscle. It serves to decrease sino-atrial (SA) node discharges and slow atrioventricular (AV) conduction, and the concomitant use with beta blockers can potentially cause severe bradycardia (11). Elderly patients sometimes have both AF and CKD (2). Because carteolol is mainly excreted by the kidneys, it may have a strong cardiac depressant effect in elderly patients with CKD (12). Elderly people tend to have polypharmacy (3,13), and if prescriptions are obtained from multiple medical institutions, it is possible that the same drugs may be prescribed. In addition, as in the present case, when the serum potassium level is increased due to a side effect of an angiotensin II receptor blocker (ARB) (14), a cardiac depressant effect due to hyperkalemia may exacerbate the cardiac function. In the present case, both the SA node and AV node were likely suppressed by the combination of the ophthalmic carteolol, verapamil, and hyperkalemia, resulting in serious bradycardia due to sick sinus syndrome. Of note, eye drops have a systemic effect similar to oral drugs. Drug interactions are more likely to occur in the elderly, especially when ophthalmic beta blockers are used in glaucoma patients, and careful follow-up in terms of cardiovascular events is needed; furthermore, verapamil should not be used for rate control in patients with AF. Although the mechanism may have involved the interaction between the carteolol eye drops and either verapamil or azilsaltan-related hyperkalemia, it is equally likely that the interaction was between all three drugs under the existence of CKD in this elderly patient. In conclusion, physicians should always consider the potential risk of adverse drug interactions when prescribing a new medication to a patient, especially in elderly patients with polypharmacy. Even topical medications, such as carteolol eye drops, might have significant systemic absorption, leading to serious side effects through drug interactions in elderly patients. Author's disclosure of potential Conflicts of Interest (COI). Yasuo Okumura: Research funding, Boston Scientific Japan. Acknowledgement We thank all of the doctors and medical staff who were involved in the treatment of this patient. In particular, Ph. So Iwabuchi and Ph. Takahiro Sekine provided important information about the carteolol eye drops. We also thank Mr. John Martin for his help with the English editing.	Recovered	ReactionOutcome	CC BY-NC-ND	32830185	18,270,051	2021-01-01
What was the outcome of reaction 'Shock'?	Bradycardia Shock Caused by the Combined Use of Carteolol Eye Drops and Verapamil in an Elderly Patient with Atrial Fibrillation and Chronic Kidney Disease. Ophthalmic carteolol is often used to treat glaucoma. Elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) are common among the super-elderly in Japan. Because these patients are exposed to polypharmacy, they are at a high-risk of adverse drug interactions. We herein report an elderly patient with CKD who suffered bradycardia shock after the combined use of carteolol eye drops and verapamil for glaucoma and paroxysmal AF. This case highlights the fact that eye drops have a similar systemic effect to oral drugs, and especially in elderly patients with polypharmacy, drug interactions can unwittingly lead to serious events. Introduction Ophthalmic beta blockers, represented by timolol and carteolol, are often used to treat glaucoma in the elderly (1). As the elderly population is dramatically increasing in Japan, we often encounter elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) (2). Because such patients tend to have multiple comorbidities, they often visit several medical institutions, and accordingly, they are prescribed multiple medications (i.e. polypharmacy). One clinical issue in those patients is that they may unwittingly experience drug interactions due to their polypharmacy, leading to a potential risk of adverse clinical events (3). There have been two case reports of bradycardia with the combined use of timolol eye drops and verapamil, with their combined use first reported in the 20th century (4,5). However, the interaction between carteolol eye drops and verapamil has not been reported. We herein report a case of bradycardia shock caused by the combined use of carteolol eye drops and verapamil in an elderly patient with a history of CKD and glaucoma, who suffered from paroxysmal AF (PAF). Case Report An 84-year-old woman presented with a 3-day history of shortness of breath and chest discomfort. She was determined to be frail as evaluated by a Canadian Study of Health and Aging Clinical Frailty Scale of 6 on admission. She had a history of glaucoma, hypertension, and CKD (estimated glomerular filtration rate 32.6 mL/min/1.73 m2) from over 10 years earlier and was being treated separately at ophthalmology and internal medicine outpatient clinics. She had blindness in her right eye due to glaucoma, and her left eye had been treated with ophthalmic carteolol and travoprost for the last few years. She had been taking azilsartan and doxazosin in addition to diet therapy for hypertension and CKD. As a result, she had been taking five kinds of internal medications, two kinds of external medications, and four kinds of eye drops a day, resulting in polypharmacy. Five days before admission, she had been diagnosed with symptomatic PAF, so verapamil [40 mg twice a day (b.i.d.)] had been newly initiated by her internal medicine physician. According to the information from the previous doctor, her heart rate had been about 60-80 beats/minute (bpm) before the start of verapamil. At admission, her heart rate was 29 bpm, and her blood pressure could not be obtained, although her radial artery pulse was palpable. Her respiratory rate and body temperature were 15/min and 36.0 °C, respectively. Her laboratory data on admission are shown in Table, revealing high serum potassium, high liver enzyme, and high lactate levels. A 12-lead electrocardiogram (ECG) during the initial examination showed a heart rate of 24 bpm and narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes (Fig. 1). Transthoracic echocardiography revealed a normal left ventricular function without any asynergy, D-shape, echo-free space, or valvular disease with a normal size of the left atrial diameter (32.0 mm). Chest X-ray revealed pulmonary edema and enlargement of the cardio-thoracic ratio. Table. Laboratory Data at the Time of Admission. WBC 5,900 /mm3 Na 139 mEq/L Hb 11.4 g/dL K 6.5 mEq/L Plt 14.2×104 /μL Cl 110 mEq/L BUN 35.6 mg/dL Ca 8.5 mg/dL Cre 1.21 mg/dL T-Chol 160 mg/dL eGFR 32.6 HDL-Chol 67 mg/dL CCR 21.25 LDL-Chol 66 mg/dL CRP 0.11 mg/dL TG 64 mg/dL TP 5.2 g/dL UA 6.3 mg/dL Alb 3.0 g/dL CK 66 U/L T-Bil 1.20 mg/dL CK-MB 4 U/L AST 234 U/L Troponin I 0.01 ng/mL ALT 119 U/L NT-proBNP 3,722 pg/mL LDH 421 U/L TSH 7.79 μlU/mL ALP 248 mEq/L Free T3 2.36 pg/mL BS 157 mg/dL Free T4 1.20 ng/mL HbA1c 5.3 % Lactate 2.9 mmol/L Alb: albumin, ALT: alanine aminotransferase, AST: aspartate aminotransferase, BS: blood sugar, BUN: blood urea nitrogen, Ca: serum calcium, CCR: creatinine clearance, CK: creatine kinase, Cl: serum chloride, Cre: serum creatinine, CRP: C-reactive protein, eGFR: estimated glomerular filtration rate, Free T3: free triiodothyronine, Free T4: free thyroxine, Hb: hemoglobin, HbA1c: hemoglobin A1c, HDL-Chol: high density lipoprotein cholesterol, K: serum potassium, LDH: lactate dehydrogenase, LDL-Chol: low density lipoprotein cholesterol, Na: serum sodium, NT-proBNP: N-terminal pro-Brain Natriuretic Peptide, Plt: platelets, T-Bil: total bilirubin, T-Chol: total cholesterol, TG: triglyceride, TP: total protein, TSH: thyroid-stimulating hormone, UA: serum uric acid, WBC: white blood cells Figure 1. A 12-lead electrocardiogram during the initial examination. A heart rate of 24 bpm and a narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes were noted. Her clinical course is shown in Fig. 2. Because she had bradycardia shock, represented by high serum lactate and liver enzyme levels, with hyperkalemia, a temporary pacing catheter was placed through the right internal jugular vein, and right ventricular pacing was performed at 90 bpm while administrating an intravenous injection of calcium gluconate hydrate and glucose-insulin therapy for hyperkalemia. Anticholinergics could not be used due to glaucoma. With this treatment, the shock immediately resolved, and the symptoms disappeared. The carteolol eye drops, verapamil, and azilsartan were discontinued, and the patient was treated with a pacing rhythm until the next day (Fig. 3). The morning after she was hospitalized, her heart rhythm returned to a normal sinus rhythm with a heart rate of 63 bpm (Fig. 4). The carteolol eye drops were discontinued after consultation with the ophthalmologist, and a different non-beta blocker for glaucoma (dorzolamide hydrochloride) was prescribed to protect her non-blind left eye. The bradycardia no longer appeared after normalization of the potassium level and discontinuing verapamil and the carteolol eye drops. Figure 2. Clinical course of this case. ALT: alanine aminotransferase, AST: aspartate aminotransferase, Calcicol: calcium gluconate hydrate, GI: glucose-insulin therapy, HR: heart rate, PAF: paroxysmal atrial fibrillation, PMI: pacemaker intubation Figure 3. A 12-lead electrocardiogram after initiating temporary pacing. A heart rate of 93 bpm, wide QRS rhythm with a left bundle branch block and upper axis pattern, and right ventricular apex origin were noted. Figure 4. A 12-lead electrocardiogram the day after the hospitalization. A heart rate of 63 bpm with normal sinus rhythm and T-wave flattening in leads III and aVF were observed. However, she had symptomatic PAF with a rapid ventricular response on the first hospital day. When the PAF stopped, she temporarily had a backup pacing with VVI 50 bpm due to sick sinus syndrome. Based on her clinical course, it was judged that the use of antiarrhythmic drugs alone for PAF carried a risk of bradycardia shock, so it was decided to administer antiarrhythmic drugs after pacemaker implantation. However, pulmonary vein isolation was not selected due to her age and activity of daily living. Pacemaker implantation was performed on the 14th hospital day. Finally, her arrhythmia, blood pressure, and glaucoma were controlled with the pacemaker implantation and adjustment of her medications, as shown in Fig. 2, and she was discharged in good health on the 20th hospital day. Discussion Ophthalmic carteolol, as well as timolol, is used as an eye drop beta blocker for glaucoma. Carteolol has been considered to have a lower risk of cardiovascular events than timolol because carteolol generally has a weaker effect on slowing the heart rate than timolol, depending on the characterization of the intrinsic sympathomimetic activity (ISA) (6,7). Although warning clues of cardiovascular events, such as bradycardia, heart block, and hypotension, have been reported due to the use of timolol eye drops (8), there have been no reports of severe cardiovascular events with the use of carteolol eye drops. Because timolol eye drops are absorbed via the nasal mucosa through the nasolacrimal duct, their bioavailability is approximately 50% of that after oral administration, and they have a systemic effect similar to oral administration; however, they are topically administered (9). Furthermore, because both carteolol and timolol are metabolized by cytochrome P450 2D6 (CYP2D6), their effect can be enhanced in elderly people with a weakened CYP2D6 when combined with a drug with a CYP2D6 inhibitory effect and/or verapamil (10). Verapamil is a commonly used class IV antiarrhythmic medication that blocks calcium-dependent slow channels, depresses the cardiac contractility, slows the myocardial conduction, and relaxes vascular smooth muscle. It serves to decrease sino-atrial (SA) node discharges and slow atrioventricular (AV) conduction, and the concomitant use with beta blockers can potentially cause severe bradycardia (11). Elderly patients sometimes have both AF and CKD (2). Because carteolol is mainly excreted by the kidneys, it may have a strong cardiac depressant effect in elderly patients with CKD (12). Elderly people tend to have polypharmacy (3,13), and if prescriptions are obtained from multiple medical institutions, it is possible that the same drugs may be prescribed. In addition, as in the present case, when the serum potassium level is increased due to a side effect of an angiotensin II receptor blocker (ARB) (14), a cardiac depressant effect due to hyperkalemia may exacerbate the cardiac function. In the present case, both the SA node and AV node were likely suppressed by the combination of the ophthalmic carteolol, verapamil, and hyperkalemia, resulting in serious bradycardia due to sick sinus syndrome. Of note, eye drops have a systemic effect similar to oral drugs. Drug interactions are more likely to occur in the elderly, especially when ophthalmic beta blockers are used in glaucoma patients, and careful follow-up in terms of cardiovascular events is needed; furthermore, verapamil should not be used for rate control in patients with AF. Although the mechanism may have involved the interaction between the carteolol eye drops and either verapamil or azilsaltan-related hyperkalemia, it is equally likely that the interaction was between all three drugs under the existence of CKD in this elderly patient. In conclusion, physicians should always consider the potential risk of adverse drug interactions when prescribing a new medication to a patient, especially in elderly patients with polypharmacy. Even topical medications, such as carteolol eye drops, might have significant systemic absorption, leading to serious side effects through drug interactions in elderly patients. Author's disclosure of potential Conflicts of Interest (COI). Yasuo Okumura: Research funding, Boston Scientific Japan. Acknowledgement We thank all of the doctors and medical staff who were involved in the treatment of this patient. In particular, Ph. So Iwabuchi and Ph. Takahiro Sekine provided important information about the carteolol eye drops. We also thank Mr. John Martin for his help with the English editing.	Recovered	ReactionOutcome	CC BY-NC-ND	32830185	18,270,051	2021-01-01
What was the outcome of reaction 'Sinus node dysfunction'?	Bradycardia Shock Caused by the Combined Use of Carteolol Eye Drops and Verapamil in an Elderly Patient with Atrial Fibrillation and Chronic Kidney Disease. Ophthalmic carteolol is often used to treat glaucoma. Elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) are common among the super-elderly in Japan. Because these patients are exposed to polypharmacy, they are at a high-risk of adverse drug interactions. We herein report an elderly patient with CKD who suffered bradycardia shock after the combined use of carteolol eye drops and verapamil for glaucoma and paroxysmal AF. This case highlights the fact that eye drops have a similar systemic effect to oral drugs, and especially in elderly patients with polypharmacy, drug interactions can unwittingly lead to serious events. Introduction Ophthalmic beta blockers, represented by timolol and carteolol, are often used to treat glaucoma in the elderly (1). As the elderly population is dramatically increasing in Japan, we often encounter elderly patients with atrial fibrillation (AF) and chronic kidney disease (CKD) (2). Because such patients tend to have multiple comorbidities, they often visit several medical institutions, and accordingly, they are prescribed multiple medications (i.e. polypharmacy). One clinical issue in those patients is that they may unwittingly experience drug interactions due to their polypharmacy, leading to a potential risk of adverse clinical events (3). There have been two case reports of bradycardia with the combined use of timolol eye drops and verapamil, with their combined use first reported in the 20th century (4,5). However, the interaction between carteolol eye drops and verapamil has not been reported. We herein report a case of bradycardia shock caused by the combined use of carteolol eye drops and verapamil in an elderly patient with a history of CKD and glaucoma, who suffered from paroxysmal AF (PAF). Case Report An 84-year-old woman presented with a 3-day history of shortness of breath and chest discomfort. She was determined to be frail as evaluated by a Canadian Study of Health and Aging Clinical Frailty Scale of 6 on admission. She had a history of glaucoma, hypertension, and CKD (estimated glomerular filtration rate 32.6 mL/min/1.73 m2) from over 10 years earlier and was being treated separately at ophthalmology and internal medicine outpatient clinics. She had blindness in her right eye due to glaucoma, and her left eye had been treated with ophthalmic carteolol and travoprost for the last few years. She had been taking azilsartan and doxazosin in addition to diet therapy for hypertension and CKD. As a result, she had been taking five kinds of internal medications, two kinds of external medications, and four kinds of eye drops a day, resulting in polypharmacy. Five days before admission, she had been diagnosed with symptomatic PAF, so verapamil [40 mg twice a day (b.i.d.)] had been newly initiated by her internal medicine physician. According to the information from the previous doctor, her heart rate had been about 60-80 beats/minute (bpm) before the start of verapamil. At admission, her heart rate was 29 bpm, and her blood pressure could not be obtained, although her radial artery pulse was palpable. Her respiratory rate and body temperature were 15/min and 36.0 °C, respectively. Her laboratory data on admission are shown in Table, revealing high serum potassium, high liver enzyme, and high lactate levels. A 12-lead electrocardiogram (ECG) during the initial examination showed a heart rate of 24 bpm and narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes (Fig. 1). Transthoracic echocardiography revealed a normal left ventricular function without any asynergy, D-shape, echo-free space, or valvular disease with a normal size of the left atrial diameter (32.0 mm). Chest X-ray revealed pulmonary edema and enlargement of the cardio-thoracic ratio. Table. Laboratory Data at the Time of Admission. WBC 5,900 /mm3 Na 139 mEq/L Hb 11.4 g/dL K 6.5 mEq/L Plt 14.2×104 /μL Cl 110 mEq/L BUN 35.6 mg/dL Ca 8.5 mg/dL Cre 1.21 mg/dL T-Chol 160 mg/dL eGFR 32.6 HDL-Chol 67 mg/dL CCR 21.25 LDL-Chol 66 mg/dL CRP 0.11 mg/dL TG 64 mg/dL TP 5.2 g/dL UA 6.3 mg/dL Alb 3.0 g/dL CK 66 U/L T-Bil 1.20 mg/dL CK-MB 4 U/L AST 234 U/L Troponin I 0.01 ng/mL ALT 119 U/L NT-proBNP 3,722 pg/mL LDH 421 U/L TSH 7.79 μlU/mL ALP 248 mEq/L Free T3 2.36 pg/mL BS 157 mg/dL Free T4 1.20 ng/mL HbA1c 5.3 % Lactate 2.9 mmol/L Alb: albumin, ALT: alanine aminotransferase, AST: aspartate aminotransferase, BS: blood sugar, BUN: blood urea nitrogen, Ca: serum calcium, CCR: creatinine clearance, CK: creatine kinase, Cl: serum chloride, Cre: serum creatinine, CRP: C-reactive protein, eGFR: estimated glomerular filtration rate, Free T3: free triiodothyronine, Free T4: free thyroxine, Hb: hemoglobin, HbA1c: hemoglobin A1c, HDL-Chol: high density lipoprotein cholesterol, K: serum potassium, LDH: lactate dehydrogenase, LDL-Chol: low density lipoprotein cholesterol, Na: serum sodium, NT-proBNP: N-terminal pro-Brain Natriuretic Peptide, Plt: platelets, T-Bil: total bilirubin, T-Chol: total cholesterol, TG: triglyceride, TP: total protein, TSH: thyroid-stimulating hormone, UA: serum uric acid, WBC: white blood cells Figure 1. A 12-lead electrocardiogram during the initial examination. A heart rate of 24 bpm and a narrow QRS rhythm followed by retrograde P-waves with a Wenckebach phenomenon without significant ST-segment changes were noted. Her clinical course is shown in Fig. 2. Because she had bradycardia shock, represented by high serum lactate and liver enzyme levels, with hyperkalemia, a temporary pacing catheter was placed through the right internal jugular vein, and right ventricular pacing was performed at 90 bpm while administrating an intravenous injection of calcium gluconate hydrate and glucose-insulin therapy for hyperkalemia. Anticholinergics could not be used due to glaucoma. With this treatment, the shock immediately resolved, and the symptoms disappeared. The carteolol eye drops, verapamil, and azilsartan were discontinued, and the patient was treated with a pacing rhythm until the next day (Fig. 3). The morning after she was hospitalized, her heart rhythm returned to a normal sinus rhythm with a heart rate of 63 bpm (Fig. 4). The carteolol eye drops were discontinued after consultation with the ophthalmologist, and a different non-beta blocker for glaucoma (dorzolamide hydrochloride) was prescribed to protect her non-blind left eye. The bradycardia no longer appeared after normalization of the potassium level and discontinuing verapamil and the carteolol eye drops. Figure 2. Clinical course of this case. ALT: alanine aminotransferase, AST: aspartate aminotransferase, Calcicol: calcium gluconate hydrate, GI: glucose-insulin therapy, HR: heart rate, PAF: paroxysmal atrial fibrillation, PMI: pacemaker intubation Figure 3. A 12-lead electrocardiogram after initiating temporary pacing. A heart rate of 93 bpm, wide QRS rhythm with a left bundle branch block and upper axis pattern, and right ventricular apex origin were noted. Figure 4. A 12-lead electrocardiogram the day after the hospitalization. A heart rate of 63 bpm with normal sinus rhythm and T-wave flattening in leads III and aVF were observed. However, she had symptomatic PAF with a rapid ventricular response on the first hospital day. When the PAF stopped, she temporarily had a backup pacing with VVI 50 bpm due to sick sinus syndrome. Based on her clinical course, it was judged that the use of antiarrhythmic drugs alone for PAF carried a risk of bradycardia shock, so it was decided to administer antiarrhythmic drugs after pacemaker implantation. However, pulmonary vein isolation was not selected due to her age and activity of daily living. Pacemaker implantation was performed on the 14th hospital day. Finally, her arrhythmia, blood pressure, and glaucoma were controlled with the pacemaker implantation and adjustment of her medications, as shown in Fig. 2, and she was discharged in good health on the 20th hospital day. Discussion Ophthalmic carteolol, as well as timolol, is used as an eye drop beta blocker for glaucoma. Carteolol has been considered to have a lower risk of cardiovascular events than timolol because carteolol generally has a weaker effect on slowing the heart rate than timolol, depending on the characterization of the intrinsic sympathomimetic activity (ISA) (6,7). Although warning clues of cardiovascular events, such as bradycardia, heart block, and hypotension, have been reported due to the use of timolol eye drops (8), there have been no reports of severe cardiovascular events with the use of carteolol eye drops. Because timolol eye drops are absorbed via the nasal mucosa through the nasolacrimal duct, their bioavailability is approximately 50% of that after oral administration, and they have a systemic effect similar to oral administration; however, they are topically administered (9). Furthermore, because both carteolol and timolol are metabolized by cytochrome P450 2D6 (CYP2D6), their effect can be enhanced in elderly people with a weakened CYP2D6 when combined with a drug with a CYP2D6 inhibitory effect and/or verapamil (10). Verapamil is a commonly used class IV antiarrhythmic medication that blocks calcium-dependent slow channels, depresses the cardiac contractility, slows the myocardial conduction, and relaxes vascular smooth muscle. It serves to decrease sino-atrial (SA) node discharges and slow atrioventricular (AV) conduction, and the concomitant use with beta blockers can potentially cause severe bradycardia (11). Elderly patients sometimes have both AF and CKD (2). Because carteolol is mainly excreted by the kidneys, it may have a strong cardiac depressant effect in elderly patients with CKD (12). Elderly people tend to have polypharmacy (3,13), and if prescriptions are obtained from multiple medical institutions, it is possible that the same drugs may be prescribed. In addition, as in the present case, when the serum potassium level is increased due to a side effect of an angiotensin II receptor blocker (ARB) (14), a cardiac depressant effect due to hyperkalemia may exacerbate the cardiac function. In the present case, both the SA node and AV node were likely suppressed by the combination of the ophthalmic carteolol, verapamil, and hyperkalemia, resulting in serious bradycardia due to sick sinus syndrome. Of note, eye drops have a systemic effect similar to oral drugs. Drug interactions are more likely to occur in the elderly, especially when ophthalmic beta blockers are used in glaucoma patients, and careful follow-up in terms of cardiovascular events is needed; furthermore, verapamil should not be used for rate control in patients with AF. Although the mechanism may have involved the interaction between the carteolol eye drops and either verapamil or azilsaltan-related hyperkalemia, it is equally likely that the interaction was between all three drugs under the existence of CKD in this elderly patient. In conclusion, physicians should always consider the potential risk of adverse drug interactions when prescribing a new medication to a patient, especially in elderly patients with polypharmacy. Even topical medications, such as carteolol eye drops, might have significant systemic absorption, leading to serious side effects through drug interactions in elderly patients. Author's disclosure of potential Conflicts of Interest (COI). Yasuo Okumura: Research funding, Boston Scientific Japan. Acknowledgement We thank all of the doctors and medical staff who were involved in the treatment of this patient. In particular, Ph. So Iwabuchi and Ph. Takahiro Sekine provided important information about the carteolol eye drops. We also thank Mr. John Martin for his help with the English editing.	Recovered	ReactionOutcome	CC BY-NC-ND	32830185	18,270,051	2021-01-01
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Drug ineffective for unapproved indication'.	Multi-triazole-resistant Aspergillus fumigatus and SARS-CoV-2 co-infection: A lethal combination. We report a case of severe COVID-19 pneumonia complicated by fatal co-infection with a multi-triazole resistant Aspergillus fumigatus and highlight the importance of recognising the significance of Aspergillus sp. isolation from respiratory samples. Early diagnosis and detection of triazole resistance are essential for appropriate antifungal therapy to improve outcome in patients with coronavirus associated invasive aspergillosis. 1 Introduction Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causing COVID-19 infection, is a newly recognised pathogen that has been traced to Wuhan (Hubei province) in China [1]. The clinical spectrum of COVID-19 varies from asymptomatic infection to severe pneumonia requiring mechanical ventilation. The overall case fatality rate is estimated to be 2.7%, which increases to 4.5% in those ≥ 60 years old [2]. Secondary infections with bacterial and fungal pathogens have been reported in patients with COVID-19 pneumonia which may be due to virus induced mucosal damage and/or the dysregulated immune response seen in patients with acute respiratory distress syndrome [3,4]. We report severe COVID-19 pneumonia with multi-triazole-resistant Aspergillus fumigatus co-infection in a patient not known to be immunocompromised to highlight the importance of early diagnosis and detection of triazole resistance. 2 Case A 66-year-old male presented to the emergency department with a history of progressive shortness of breath (SOB), myalgia, headaches, non-productive cough and fever. Two days previously, he had contacted his general practitioner (GP) describing a seven-day history of fever and cough. He had returned from the United Kingdom eight days earlier after visiting a relative who was subsequently diagnosed with COVID-19. He was advised to self-isolate and monitor his symptoms. Due to progressive SOB, he re-presented to his GP who referred him to the hospital for further management. The patient had Type 2 diabetes mellitus, hypertension, hyperlipidaemia and obesity with a body mass index of 35.5 (weight 90kg) with no hospital admissions in the past eight years. His medications included metformin, aspirin, simvastatin and ramipril. He had no history of prior triazole antifungal therapy. He was an ex-smoker but had not been previously diagnosed to have chronic lung disease. He works as a ground maintenance personnel where he is exposed to fungicides daily. On presentation, a portable chest radiograph was performed which showed unilateral peripheral left basal airspace shadowing (Fig. 1A). In view of the clinical presentation, radiographic findings and the recent exposure history, the patient was admitted under contact and droplet precautions.Fig. 1 A. Portable chest radiograph taken on day of admission showing unilateral peripheral left basal airspace shadowing. B. Portable chest radiograph taken on Day 12 of hospitalization (Day 20 of COVID-19 infection). The endotracheal tube and bilateral central lines are in satisfactory position. There has been interval progression of the left peripheral airspace shadowing with additional right upper and lower zone peripheral airspace shadowing with no evidence of cavitation. Fig. 1 On admission (Day 7 of COVID-19 illness), the patient was noted to be pyrexial (temperature of 38.6 °C), tachycardic (pulse rate of 174 beats per minute) with new onset atrial fibrillation, normotensive (BP 117/69 mmHg), tachypnic (24 breaths per minute) with oxygen saturation of 84% on room air. He was commenced on a trial of continuous positive airway pressure with oxygen therapy. Preliminary laboratory results revealed white cell count of 4.7 × 109/L (reference range 4.0–11.0 × 109/L), neutrophil count 3.0 × 109/L (reference range 2.0–7.0 × 109/L), lymphocyte count 0.8 × 109/L (reference range 1.0–3.0 × 109/L) and C-reactive protein of 118 mg/L (reference range < 5.0 mg/L). Nasopharyngeal and oropharyngeal swabs detected SARS-CoV-2 using real-time reverse transcriptase polymerase chain reaction on day 3. He was commenced on azithromycin (500 mg on day 1 and 250 once daily on days 2 and 3) and hydroxychloroquine (200 mg twice daily) orally as per our local protocol at that time. On day 4 (Day 11 of COVID-19 illness) he developed worsening hypoxic respiratory failure with a Sequential Organ Failure Assessment (SOFA) score of 6 necessitating intensive care unit (ICU) admission for ventilatory support. The patient was proned initially for 15 hours which did not improve his oxygenation. This, combined with significant hemodynamic instability, were contraindications for further proning. His condition continued to deteriorate progressing to multi-organ failure on day 7 (Day 14 of COVID-19 illness) which included acute respiratory failure, acute kidney injury requiring continuous renal replacement therapy and vasopressor support due to septic shock. His SOFA score increased to 12. He had continuing pyrexia and copious amounts of purulent respiratory secretions prompting a repeat septic screen which included culture of blood and endotracheal aspirate (ETA). Empiric antimicrobial therapy for hospital-acquired pneumonia with intravenous (IV) piperacillin-tazobactam (4.5g three times a day) was started. Subsequently, ETA culture grew Klebsiella varicola (susceptible to piperacillin-tazobactam), Aspergillus sp. and Candida albicans. Antifungal therapy with IV liposomal amphotericin B (3 mg per kg once daily) was commenced due to the patients rapidly deteriorating status and uncertainty of the full identification of the mould isolate which may be resistant to triazoles. The Aspergillus sp. was referred for further identification and antifungal susceptibility testing, as were serum samples for detection of 1–3, β-d-glucan (BDG) antigen and galactomannan (GM) antigen and ETA for GM antigen. His SOFA score on day 11 (Day 18 of COVID-19 illness) increased to 16. Antibiotic therapy was escalated to IV meropenem (1g twice daily) and vancomycin, with dosing based on renal function, due to ongoing pyrexia and deteriorating status. He was not prescribed systemic steroids at any time during his critical illness. A repeat portable chest radiograph on day 12 (Day 20 of COVID-19 illness) showed progression to additional right upper and lower zone peripheral airspace shadowing with no evidence of cavitation (Fig. 1B). He remained haemodynamically unstable which precluded further radiological investigations. In view of his non-responsive multi-organ failure, and after discussion with his family, the patient's life-support was withdrawn. He died on day 14 of hospitalization (Day 22 of COVID-19 illness). The Aspergillus sp. isolated from the ETA was confirmed to be A. fumigatus. Phenotypic testing utilising a 4-well triazole resistance screen (VIP check™, Mediaproducts BV, The Netherlands) (Fig. 2A and B) as well as determination of minimum inhibitory concentrations (MIC) utilising gradient strips (Liofilchem, Waltham MA, USA) were suggestive of triazole resistance (Table 1) [5]. The MIC to amphotericin was 0.125 mg/L (susceptible ≤ 1 mg/L) [5]. Genotypic testing utilising a commercial assay (Aspergenius™, Pathonostics B.V. The Netherlands) on the ETA detected A. fumigati complex with the TR34L98H resistance mutation in the cyp51A gene, the most common mutation in triazole-resistant A. fumigatus originating from an environmental source. The serum and ETA GM optical density index (ODI) were 1.1 and 5.5 respectively (Platelia™ Aspergillus Ag EIA, WA, USA). Serum BDG was 202 pg per milliliter (Fungitell™ Assay, Associates of Cape Cod, USA). These results (Table 1) were consistent with severe COVID-19 pneumonia and triazole-resistant invasive pulmonary aspergillus co-infection.Fig. 2 A and B VIPcheck™ plate, a four well triazole resistance screen plate which contains itraconazole (I) 4 mg per liter, voriconazole (V) 2 mg per liter, posaconazole. (P) 0.5 mg per liter, and growth control (GC). This is a simple phenotypic test used to screen for triazole resistance due to the common mutations in the cyp51A gene in A. fumigatus from an environmental source. The photos show a susceptible control strain AF293 (2A) where growth is only seen on GC well and the patient's isolate (2B) with growth in all wells consistent with findings seen in A. fumigatus with the cyp51A TR34/L98H mutation. Fig. 2 Table 1 Laboratory results. Table 1 Patient's Isolate A. fumigatus aClinical breakpoint > Resistant Antifungal Susceptibility Test Minimum inhibitory concentration (MIC) mg/L Voriconazole 2.0 1 Itraconazole >32 1 Posaconazole 1.0 0.25 Amphotericin B 0.125 1 Fungal antigensb Patient's results Cut-off Galactomannan Optical Density Index (ODI) Serum 1.1 ≥ 0.5 Tracheal aspirate 5.5 N/A 1,3 β-d-glucan pg/mL Serum 202 ≥ 80 a Based on the European Committee on Antimicrobial Susceptibility testing guidelines. b Fungal antigens: Galactomannan cut-off based on Platelia™ Aspergillus Ag EIA and 1–3 β-d-glucan cut-off based on Fungitell™ assay. 3 Discussion Previously known to cause infections in severely immunocompromised patients, A. fumigatus is now recognised as an emerging pathogen in critical care patients suffering chronic respiratory disorders and as a complication of severe influenza infection [6]. Aspergillus colonisation can rapidly lead to invasive aspergillosis following severe influenza infection due to multiple pathways including structural lung damage coupled with disruption of mucociliary clearance, leukopenia, Th1/Th2 imbalance and diffuse damage to the respiratory mucosa [7]. In addition, severe respiratory viral infections such as influenza have been identified as an independent risk factor for IPA with high mortality [6]. Although our patient did not receive steroids, their use in critical care patients is linked to increased risk of invasive fungal infections [6]. Like other causes of viral pneumonias, SARS-CoV-2 may impair local mucosal and systemic immune defenses [3]. Thirty-four cases of COVID-19 associated invasive aspergillosis (CAPA) have been reported to date [[8], [9], [10], [11], [12], [13], [14], [15], [16], [17]]. These were all patients with severe pneumonia with adult respiratory distress symdome, most of whom had no known history of immunocompromise. These has led to challenges in early diagnosis since most of them do not have the classical risk factors for invasive aspergillosis. Histopathology and culture from sterile site samples and biopsy remain the gold standard for proven IPA however the definition of probable or “putative” IPA has expanded but remains to be a composite of the host factors, clinical features and mycological evidence [6,18]. Although severe viral pneumonia is not considered a risk factor for IPA or other invasive mould disease according to the European Organisation for Research and Treatment of Cancer/Mycoses Study Group definitions, the structural damage to the lung parenchyma, in addition to the dysregulated immune response, can lead to IPA [6]. Recently a panel of experts proposed a case definition for influenza associated invasive aspergillosis (IAPA) which may be useful to classify COVID-19 patients with invasive aspergillosis. Following this case definition a patient with COVID-19 detected in respiratory sample by PCR, pulmonary infiltrates and a positive serum or bronchoalveolar lavage galactomannan has criteria consistent with probable CAPA [19]. Our patient had radiographic findings consistent with COVID-19 pneumonia. Unfortunately, his clinical status did not allow for computed tomography (CT) to be performed. Other mycological evidence of IPA include culture of Aspergillus sp. from non-sterile sites or detection of fungal antigens such as serum BDG. Our patient had COVID-19 pneumonia, A. fumigatus from a tracheal aspirate with elevated serum BDG and GM and elevated ETA GM, findings consistent with COVID-19 and probable IPA co-infection. Multi-triazole resistance in A. fumigatus has recently emerged and is linked to the use of triazole-containing compounds as agricultural fungicides or less commonly prolonged triazole use [20]. The former mechanism of resistance typically affects azole näive patients and is characterised by elevated MICs to itraconazole, voriconazole and posaconazole as was found in our patient. This is of serious concern since triazoles are recommended as the first-line and most effective treatment for IPA [21]. Of the 34 cases reported so far, only 7 cases had reported susceptibility results of which one was triazole resistant A. fumigatus [16] similar to our case. Our patient's exposure to fungicides daily in his work has most likely led to exposure and colonisation with triazole-resistant A. fumigatus which was further supported by detection of cyp51A TR34L98H mutation from our patient's ETA, the most prevalent triazole resistance mutation from environmental source [20]. This case highlights the importance of early evaluation of patients with COVID-19 pneumonia because of the risk of secondary or co-infection with fungal pathogens. Case definitions have been proposed for IAPA [6,19] which can be modified for early recognition of CAPA. The occurrence of multi-triazole resistance in this case emphasises the urgent need for antifungal drug susceptibility testing of Aspergillus isolates using a rapid and simple phenotypic method and/or by detection of Cyp51 gene associated triazole resistance mutations directly on respiratory samples. Funding sources This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declaration of competing interestCOI T.R.Rogers has received grants and personal fees from 10.13039/100005564 Gilead Sciences , personal fees from 10.13039/100015278 Pfizer Healthcare Ireland , personal fees from Menarini Pharma outside the submitted work, A.F.Talento has received grant and personal fees from 10.13039/100005564 Gilead Sciences and personal fees from 10.13039/100015278 Pfizer Healthcare Ireland outside the submitted work. The other authors have no conflict of interests.	AMPHOTERICIN B, ASPIRIN, AZITHROMYCIN ANHYDROUS, HYDROXYCHLOROQUINE, MEROPENEM, METFORMIN HYDROCHLORIDE, PIPERACILLIN SODIUM\TAZOBACTAM SODIUM, RAMIPRIL, SIMVASTATIN, VANCOMYCIN	DrugsGivenReaction	CC BY-NC-ND	32837879	19,468,704	2021-03
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Drug ineffective'.	Multi-triazole-resistant Aspergillus fumigatus and SARS-CoV-2 co-infection: A lethal combination. We report a case of severe COVID-19 pneumonia complicated by fatal co-infection with a multi-triazole resistant Aspergillus fumigatus and highlight the importance of recognising the significance of Aspergillus sp. isolation from respiratory samples. Early diagnosis and detection of triazole resistance are essential for appropriate antifungal therapy to improve outcome in patients with coronavirus associated invasive aspergillosis. 1 Introduction Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causing COVID-19 infection, is a newly recognised pathogen that has been traced to Wuhan (Hubei province) in China [1]. The clinical spectrum of COVID-19 varies from asymptomatic infection to severe pneumonia requiring mechanical ventilation. The overall case fatality rate is estimated to be 2.7%, which increases to 4.5% in those ≥ 60 years old [2]. Secondary infections with bacterial and fungal pathogens have been reported in patients with COVID-19 pneumonia which may be due to virus induced mucosal damage and/or the dysregulated immune response seen in patients with acute respiratory distress syndrome [3,4]. We report severe COVID-19 pneumonia with multi-triazole-resistant Aspergillus fumigatus co-infection in a patient not known to be immunocompromised to highlight the importance of early diagnosis and detection of triazole resistance. 2 Case A 66-year-old male presented to the emergency department with a history of progressive shortness of breath (SOB), myalgia, headaches, non-productive cough and fever. Two days previously, he had contacted his general practitioner (GP) describing a seven-day history of fever and cough. He had returned from the United Kingdom eight days earlier after visiting a relative who was subsequently diagnosed with COVID-19. He was advised to self-isolate and monitor his symptoms. Due to progressive SOB, he re-presented to his GP who referred him to the hospital for further management. The patient had Type 2 diabetes mellitus, hypertension, hyperlipidaemia and obesity with a body mass index of 35.5 (weight 90kg) with no hospital admissions in the past eight years. His medications included metformin, aspirin, simvastatin and ramipril. He had no history of prior triazole antifungal therapy. He was an ex-smoker but had not been previously diagnosed to have chronic lung disease. He works as a ground maintenance personnel where he is exposed to fungicides daily. On presentation, a portable chest radiograph was performed which showed unilateral peripheral left basal airspace shadowing (Fig. 1A). In view of the clinical presentation, radiographic findings and the recent exposure history, the patient was admitted under contact and droplet precautions.Fig. 1 A. Portable chest radiograph taken on day of admission showing unilateral peripheral left basal airspace shadowing. B. Portable chest radiograph taken on Day 12 of hospitalization (Day 20 of COVID-19 infection). The endotracheal tube and bilateral central lines are in satisfactory position. There has been interval progression of the left peripheral airspace shadowing with additional right upper and lower zone peripheral airspace shadowing with no evidence of cavitation. Fig. 1 On admission (Day 7 of COVID-19 illness), the patient was noted to be pyrexial (temperature of 38.6 °C), tachycardic (pulse rate of 174 beats per minute) with new onset atrial fibrillation, normotensive (BP 117/69 mmHg), tachypnic (24 breaths per minute) with oxygen saturation of 84% on room air. He was commenced on a trial of continuous positive airway pressure with oxygen therapy. Preliminary laboratory results revealed white cell count of 4.7 × 109/L (reference range 4.0–11.0 × 109/L), neutrophil count 3.0 × 109/L (reference range 2.0–7.0 × 109/L), lymphocyte count 0.8 × 109/L (reference range 1.0–3.0 × 109/L) and C-reactive protein of 118 mg/L (reference range < 5.0 mg/L). Nasopharyngeal and oropharyngeal swabs detected SARS-CoV-2 using real-time reverse transcriptase polymerase chain reaction on day 3. He was commenced on azithromycin (500 mg on day 1 and 250 once daily on days 2 and 3) and hydroxychloroquine (200 mg twice daily) orally as per our local protocol at that time. On day 4 (Day 11 of COVID-19 illness) he developed worsening hypoxic respiratory failure with a Sequential Organ Failure Assessment (SOFA) score of 6 necessitating intensive care unit (ICU) admission for ventilatory support. The patient was proned initially for 15 hours which did not improve his oxygenation. This, combined with significant hemodynamic instability, were contraindications for further proning. His condition continued to deteriorate progressing to multi-organ failure on day 7 (Day 14 of COVID-19 illness) which included acute respiratory failure, acute kidney injury requiring continuous renal replacement therapy and vasopressor support due to septic shock. His SOFA score increased to 12. He had continuing pyrexia and copious amounts of purulent respiratory secretions prompting a repeat septic screen which included culture of blood and endotracheal aspirate (ETA). Empiric antimicrobial therapy for hospital-acquired pneumonia with intravenous (IV) piperacillin-tazobactam (4.5g three times a day) was started. Subsequently, ETA culture grew Klebsiella varicola (susceptible to piperacillin-tazobactam), Aspergillus sp. and Candida albicans. Antifungal therapy with IV liposomal amphotericin B (3 mg per kg once daily) was commenced due to the patients rapidly deteriorating status and uncertainty of the full identification of the mould isolate which may be resistant to triazoles. The Aspergillus sp. was referred for further identification and antifungal susceptibility testing, as were serum samples for detection of 1–3, β-d-glucan (BDG) antigen and galactomannan (GM) antigen and ETA for GM antigen. His SOFA score on day 11 (Day 18 of COVID-19 illness) increased to 16. Antibiotic therapy was escalated to IV meropenem (1g twice daily) and vancomycin, with dosing based on renal function, due to ongoing pyrexia and deteriorating status. He was not prescribed systemic steroids at any time during his critical illness. A repeat portable chest radiograph on day 12 (Day 20 of COVID-19 illness) showed progression to additional right upper and lower zone peripheral airspace shadowing with no evidence of cavitation (Fig. 1B). He remained haemodynamically unstable which precluded further radiological investigations. In view of his non-responsive multi-organ failure, and after discussion with his family, the patient's life-support was withdrawn. He died on day 14 of hospitalization (Day 22 of COVID-19 illness). The Aspergillus sp. isolated from the ETA was confirmed to be A. fumigatus. Phenotypic testing utilising a 4-well triazole resistance screen (VIP check™, Mediaproducts BV, The Netherlands) (Fig. 2A and B) as well as determination of minimum inhibitory concentrations (MIC) utilising gradient strips (Liofilchem, Waltham MA, USA) were suggestive of triazole resistance (Table 1) [5]. The MIC to amphotericin was 0.125 mg/L (susceptible ≤ 1 mg/L) [5]. Genotypic testing utilising a commercial assay (Aspergenius™, Pathonostics B.V. The Netherlands) on the ETA detected A. fumigati complex with the TR34L98H resistance mutation in the cyp51A gene, the most common mutation in triazole-resistant A. fumigatus originating from an environmental source. The serum and ETA GM optical density index (ODI) were 1.1 and 5.5 respectively (Platelia™ Aspergillus Ag EIA, WA, USA). Serum BDG was 202 pg per milliliter (Fungitell™ Assay, Associates of Cape Cod, USA). These results (Table 1) were consistent with severe COVID-19 pneumonia and triazole-resistant invasive pulmonary aspergillus co-infection.Fig. 2 A and B VIPcheck™ plate, a four well triazole resistance screen plate which contains itraconazole (I) 4 mg per liter, voriconazole (V) 2 mg per liter, posaconazole. (P) 0.5 mg per liter, and growth control (GC). This is a simple phenotypic test used to screen for triazole resistance due to the common mutations in the cyp51A gene in A. fumigatus from an environmental source. The photos show a susceptible control strain AF293 (2A) where growth is only seen on GC well and the patient's isolate (2B) with growth in all wells consistent with findings seen in A. fumigatus with the cyp51A TR34/L98H mutation. Fig. 2 Table 1 Laboratory results. Table 1 Patient's Isolate A. fumigatus aClinical breakpoint > Resistant Antifungal Susceptibility Test Minimum inhibitory concentration (MIC) mg/L Voriconazole 2.0 1 Itraconazole >32 1 Posaconazole 1.0 0.25 Amphotericin B 0.125 1 Fungal antigensb Patient's results Cut-off Galactomannan Optical Density Index (ODI) Serum 1.1 ≥ 0.5 Tracheal aspirate 5.5 N/A 1,3 β-d-glucan pg/mL Serum 202 ≥ 80 a Based on the European Committee on Antimicrobial Susceptibility testing guidelines. b Fungal antigens: Galactomannan cut-off based on Platelia™ Aspergillus Ag EIA and 1–3 β-d-glucan cut-off based on Fungitell™ assay. 3 Discussion Previously known to cause infections in severely immunocompromised patients, A. fumigatus is now recognised as an emerging pathogen in critical care patients suffering chronic respiratory disorders and as a complication of severe influenza infection [6]. Aspergillus colonisation can rapidly lead to invasive aspergillosis following severe influenza infection due to multiple pathways including structural lung damage coupled with disruption of mucociliary clearance, leukopenia, Th1/Th2 imbalance and diffuse damage to the respiratory mucosa [7]. In addition, severe respiratory viral infections such as influenza have been identified as an independent risk factor for IPA with high mortality [6]. Although our patient did not receive steroids, their use in critical care patients is linked to increased risk of invasive fungal infections [6]. Like other causes of viral pneumonias, SARS-CoV-2 may impair local mucosal and systemic immune defenses [3]. Thirty-four cases of COVID-19 associated invasive aspergillosis (CAPA) have been reported to date [[8], [9], [10], [11], [12], [13], [14], [15], [16], [17]]. These were all patients with severe pneumonia with adult respiratory distress symdome, most of whom had no known history of immunocompromise. These has led to challenges in early diagnosis since most of them do not have the classical risk factors for invasive aspergillosis. Histopathology and culture from sterile site samples and biopsy remain the gold standard for proven IPA however the definition of probable or “putative” IPA has expanded but remains to be a composite of the host factors, clinical features and mycological evidence [6,18]. Although severe viral pneumonia is not considered a risk factor for IPA or other invasive mould disease according to the European Organisation for Research and Treatment of Cancer/Mycoses Study Group definitions, the structural damage to the lung parenchyma, in addition to the dysregulated immune response, can lead to IPA [6]. Recently a panel of experts proposed a case definition for influenza associated invasive aspergillosis (IAPA) which may be useful to classify COVID-19 patients with invasive aspergillosis. Following this case definition a patient with COVID-19 detected in respiratory sample by PCR, pulmonary infiltrates and a positive serum or bronchoalveolar lavage galactomannan has criteria consistent with probable CAPA [19]. Our patient had radiographic findings consistent with COVID-19 pneumonia. Unfortunately, his clinical status did not allow for computed tomography (CT) to be performed. Other mycological evidence of IPA include culture of Aspergillus sp. from non-sterile sites or detection of fungal antigens such as serum BDG. Our patient had COVID-19 pneumonia, A. fumigatus from a tracheal aspirate with elevated serum BDG and GM and elevated ETA GM, findings consistent with COVID-19 and probable IPA co-infection. Multi-triazole resistance in A. fumigatus has recently emerged and is linked to the use of triazole-containing compounds as agricultural fungicides or less commonly prolonged triazole use [20]. The former mechanism of resistance typically affects azole näive patients and is characterised by elevated MICs to itraconazole, voriconazole and posaconazole as was found in our patient. This is of serious concern since triazoles are recommended as the first-line and most effective treatment for IPA [21]. Of the 34 cases reported so far, only 7 cases had reported susceptibility results of which one was triazole resistant A. fumigatus [16] similar to our case. Our patient's exposure to fungicides daily in his work has most likely led to exposure and colonisation with triazole-resistant A. fumigatus which was further supported by detection of cyp51A TR34L98H mutation from our patient's ETA, the most prevalent triazole resistance mutation from environmental source [20]. This case highlights the importance of early evaluation of patients with COVID-19 pneumonia because of the risk of secondary or co-infection with fungal pathogens. Case definitions have been proposed for IAPA [6,19] which can be modified for early recognition of CAPA. The occurrence of multi-triazole resistance in this case emphasises the urgent need for antifungal drug susceptibility testing of Aspergillus isolates using a rapid and simple phenotypic method and/or by detection of Cyp51 gene associated triazole resistance mutations directly on respiratory samples. Funding sources This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declaration of competing interestCOI T.R.Rogers has received grants and personal fees from 10.13039/100005564 Gilead Sciences , personal fees from 10.13039/100015278 Pfizer Healthcare Ireland , personal fees from Menarini Pharma outside the submitted work, A.F.Talento has received grant and personal fees from 10.13039/100005564 Gilead Sciences and personal fees from 10.13039/100015278 Pfizer Healthcare Ireland outside the submitted work. The other authors have no conflict of interests.	AMPHOTERICIN B, AZITHROMYCIN ANHYDROUS, HYDROXYCHLOROQUINE, MEROPENEM, PIPERACILLIN SODIUM\TAZOBACTAM SODIUM, VANCOMYCIN	DrugsGivenReaction	CC BY-NC-ND	32837879	19,458,392	2021-03
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Therapy non-responder'.	Multi-triazole-resistant Aspergillus fumigatus and SARS-CoV-2 co-infection: A lethal combination. We report a case of severe COVID-19 pneumonia complicated by fatal co-infection with a multi-triazole resistant Aspergillus fumigatus and highlight the importance of recognising the significance of Aspergillus sp. isolation from respiratory samples. Early diagnosis and detection of triazole resistance are essential for appropriate antifungal therapy to improve outcome in patients with coronavirus associated invasive aspergillosis. 1 Introduction Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causing COVID-19 infection, is a newly recognised pathogen that has been traced to Wuhan (Hubei province) in China [1]. The clinical spectrum of COVID-19 varies from asymptomatic infection to severe pneumonia requiring mechanical ventilation. The overall case fatality rate is estimated to be 2.7%, which increases to 4.5% in those ≥ 60 years old [2]. Secondary infections with bacterial and fungal pathogens have been reported in patients with COVID-19 pneumonia which may be due to virus induced mucosal damage and/or the dysregulated immune response seen in patients with acute respiratory distress syndrome [3,4]. We report severe COVID-19 pneumonia with multi-triazole-resistant Aspergillus fumigatus co-infection in a patient not known to be immunocompromised to highlight the importance of early diagnosis and detection of triazole resistance. 2 Case A 66-year-old male presented to the emergency department with a history of progressive shortness of breath (SOB), myalgia, headaches, non-productive cough and fever. Two days previously, he had contacted his general practitioner (GP) describing a seven-day history of fever and cough. He had returned from the United Kingdom eight days earlier after visiting a relative who was subsequently diagnosed with COVID-19. He was advised to self-isolate and monitor his symptoms. Due to progressive SOB, he re-presented to his GP who referred him to the hospital for further management. The patient had Type 2 diabetes mellitus, hypertension, hyperlipidaemia and obesity with a body mass index of 35.5 (weight 90kg) with no hospital admissions in the past eight years. His medications included metformin, aspirin, simvastatin and ramipril. He had no history of prior triazole antifungal therapy. He was an ex-smoker but had not been previously diagnosed to have chronic lung disease. He works as a ground maintenance personnel where he is exposed to fungicides daily. On presentation, a portable chest radiograph was performed which showed unilateral peripheral left basal airspace shadowing (Fig. 1A). In view of the clinical presentation, radiographic findings and the recent exposure history, the patient was admitted under contact and droplet precautions.Fig. 1 A. Portable chest radiograph taken on day of admission showing unilateral peripheral left basal airspace shadowing. B. Portable chest radiograph taken on Day 12 of hospitalization (Day 20 of COVID-19 infection). The endotracheal tube and bilateral central lines are in satisfactory position. There has been interval progression of the left peripheral airspace shadowing with additional right upper and lower zone peripheral airspace shadowing with no evidence of cavitation. Fig. 1 On admission (Day 7 of COVID-19 illness), the patient was noted to be pyrexial (temperature of 38.6 °C), tachycardic (pulse rate of 174 beats per minute) with new onset atrial fibrillation, normotensive (BP 117/69 mmHg), tachypnic (24 breaths per minute) with oxygen saturation of 84% on room air. He was commenced on a trial of continuous positive airway pressure with oxygen therapy. Preliminary laboratory results revealed white cell count of 4.7 × 109/L (reference range 4.0–11.0 × 109/L), neutrophil count 3.0 × 109/L (reference range 2.0–7.0 × 109/L), lymphocyte count 0.8 × 109/L (reference range 1.0–3.0 × 109/L) and C-reactive protein of 118 mg/L (reference range < 5.0 mg/L). Nasopharyngeal and oropharyngeal swabs detected SARS-CoV-2 using real-time reverse transcriptase polymerase chain reaction on day 3. He was commenced on azithromycin (500 mg on day 1 and 250 once daily on days 2 and 3) and hydroxychloroquine (200 mg twice daily) orally as per our local protocol at that time. On day 4 (Day 11 of COVID-19 illness) he developed worsening hypoxic respiratory failure with a Sequential Organ Failure Assessment (SOFA) score of 6 necessitating intensive care unit (ICU) admission for ventilatory support. The patient was proned initially for 15 hours which did not improve his oxygenation. This, combined with significant hemodynamic instability, were contraindications for further proning. His condition continued to deteriorate progressing to multi-organ failure on day 7 (Day 14 of COVID-19 illness) which included acute respiratory failure, acute kidney injury requiring continuous renal replacement therapy and vasopressor support due to septic shock. His SOFA score increased to 12. He had continuing pyrexia and copious amounts of purulent respiratory secretions prompting a repeat septic screen which included culture of blood and endotracheal aspirate (ETA). Empiric antimicrobial therapy for hospital-acquired pneumonia with intravenous (IV) piperacillin-tazobactam (4.5g three times a day) was started. Subsequently, ETA culture grew Klebsiella varicola (susceptible to piperacillin-tazobactam), Aspergillus sp. and Candida albicans. Antifungal therapy with IV liposomal amphotericin B (3 mg per kg once daily) was commenced due to the patients rapidly deteriorating status and uncertainty of the full identification of the mould isolate which may be resistant to triazoles. The Aspergillus sp. was referred for further identification and antifungal susceptibility testing, as were serum samples for detection of 1–3, β-d-glucan (BDG) antigen and galactomannan (GM) antigen and ETA for GM antigen. His SOFA score on day 11 (Day 18 of COVID-19 illness) increased to 16. Antibiotic therapy was escalated to IV meropenem (1g twice daily) and vancomycin, with dosing based on renal function, due to ongoing pyrexia and deteriorating status. He was not prescribed systemic steroids at any time during his critical illness. A repeat portable chest radiograph on day 12 (Day 20 of COVID-19 illness) showed progression to additional right upper and lower zone peripheral airspace shadowing with no evidence of cavitation (Fig. 1B). He remained haemodynamically unstable which precluded further radiological investigations. In view of his non-responsive multi-organ failure, and after discussion with his family, the patient's life-support was withdrawn. He died on day 14 of hospitalization (Day 22 of COVID-19 illness). The Aspergillus sp. isolated from the ETA was confirmed to be A. fumigatus. Phenotypic testing utilising a 4-well triazole resistance screen (VIP check™, Mediaproducts BV, The Netherlands) (Fig. 2A and B) as well as determination of minimum inhibitory concentrations (MIC) utilising gradient strips (Liofilchem, Waltham MA, USA) were suggestive of triazole resistance (Table 1) [5]. The MIC to amphotericin was 0.125 mg/L (susceptible ≤ 1 mg/L) [5]. Genotypic testing utilising a commercial assay (Aspergenius™, Pathonostics B.V. The Netherlands) on the ETA detected A. fumigati complex with the TR34L98H resistance mutation in the cyp51A gene, the most common mutation in triazole-resistant A. fumigatus originating from an environmental source. The serum and ETA GM optical density index (ODI) were 1.1 and 5.5 respectively (Platelia™ Aspergillus Ag EIA, WA, USA). Serum BDG was 202 pg per milliliter (Fungitell™ Assay, Associates of Cape Cod, USA). These results (Table 1) were consistent with severe COVID-19 pneumonia and triazole-resistant invasive pulmonary aspergillus co-infection.Fig. 2 A and B VIPcheck™ plate, a four well triazole resistance screen plate which contains itraconazole (I) 4 mg per liter, voriconazole (V) 2 mg per liter, posaconazole. (P) 0.5 mg per liter, and growth control (GC). This is a simple phenotypic test used to screen for triazole resistance due to the common mutations in the cyp51A gene in A. fumigatus from an environmental source. The photos show a susceptible control strain AF293 (2A) where growth is only seen on GC well and the patient's isolate (2B) with growth in all wells consistent with findings seen in A. fumigatus with the cyp51A TR34/L98H mutation. Fig. 2 Table 1 Laboratory results. Table 1 Patient's Isolate A. fumigatus aClinical breakpoint > Resistant Antifungal Susceptibility Test Minimum inhibitory concentration (MIC) mg/L Voriconazole 2.0 1 Itraconazole >32 1 Posaconazole 1.0 0.25 Amphotericin B 0.125 1 Fungal antigensb Patient's results Cut-off Galactomannan Optical Density Index (ODI) Serum 1.1 ≥ 0.5 Tracheal aspirate 5.5 N/A 1,3 β-d-glucan pg/mL Serum 202 ≥ 80 a Based on the European Committee on Antimicrobial Susceptibility testing guidelines. b Fungal antigens: Galactomannan cut-off based on Platelia™ Aspergillus Ag EIA and 1–3 β-d-glucan cut-off based on Fungitell™ assay. 3 Discussion Previously known to cause infections in severely immunocompromised patients, A. fumigatus is now recognised as an emerging pathogen in critical care patients suffering chronic respiratory disorders and as a complication of severe influenza infection [6]. Aspergillus colonisation can rapidly lead to invasive aspergillosis following severe influenza infection due to multiple pathways including structural lung damage coupled with disruption of mucociliary clearance, leukopenia, Th1/Th2 imbalance and diffuse damage to the respiratory mucosa [7]. In addition, severe respiratory viral infections such as influenza have been identified as an independent risk factor for IPA with high mortality [6]. Although our patient did not receive steroids, their use in critical care patients is linked to increased risk of invasive fungal infections [6]. Like other causes of viral pneumonias, SARS-CoV-2 may impair local mucosal and systemic immune defenses [3]. Thirty-four cases of COVID-19 associated invasive aspergillosis (CAPA) have been reported to date [[8], [9], [10], [11], [12], [13], [14], [15], [16], [17]]. These were all patients with severe pneumonia with adult respiratory distress symdome, most of whom had no known history of immunocompromise. These has led to challenges in early diagnosis since most of them do not have the classical risk factors for invasive aspergillosis. Histopathology and culture from sterile site samples and biopsy remain the gold standard for proven IPA however the definition of probable or “putative” IPA has expanded but remains to be a composite of the host factors, clinical features and mycological evidence [6,18]. Although severe viral pneumonia is not considered a risk factor for IPA or other invasive mould disease according to the European Organisation for Research and Treatment of Cancer/Mycoses Study Group definitions, the structural damage to the lung parenchyma, in addition to the dysregulated immune response, can lead to IPA [6]. Recently a panel of experts proposed a case definition for influenza associated invasive aspergillosis (IAPA) which may be useful to classify COVID-19 patients with invasive aspergillosis. Following this case definition a patient with COVID-19 detected in respiratory sample by PCR, pulmonary infiltrates and a positive serum or bronchoalveolar lavage galactomannan has criteria consistent with probable CAPA [19]. Our patient had radiographic findings consistent with COVID-19 pneumonia. Unfortunately, his clinical status did not allow for computed tomography (CT) to be performed. Other mycological evidence of IPA include culture of Aspergillus sp. from non-sterile sites or detection of fungal antigens such as serum BDG. Our patient had COVID-19 pneumonia, A. fumigatus from a tracheal aspirate with elevated serum BDG and GM and elevated ETA GM, findings consistent with COVID-19 and probable IPA co-infection. Multi-triazole resistance in A. fumigatus has recently emerged and is linked to the use of triazole-containing compounds as agricultural fungicides or less commonly prolonged triazole use [20]. The former mechanism of resistance typically affects azole näive patients and is characterised by elevated MICs to itraconazole, voriconazole and posaconazole as was found in our patient. This is of serious concern since triazoles are recommended as the first-line and most effective treatment for IPA [21]. Of the 34 cases reported so far, only 7 cases had reported susceptibility results of which one was triazole resistant A. fumigatus [16] similar to our case. Our patient's exposure to fungicides daily in his work has most likely led to exposure and colonisation with triazole-resistant A. fumigatus which was further supported by detection of cyp51A TR34L98H mutation from our patient's ETA, the most prevalent triazole resistance mutation from environmental source [20]. This case highlights the importance of early evaluation of patients with COVID-19 pneumonia because of the risk of secondary or co-infection with fungal pathogens. Case definitions have been proposed for IAPA [6,19] which can be modified for early recognition of CAPA. The occurrence of multi-triazole resistance in this case emphasises the urgent need for antifungal drug susceptibility testing of Aspergillus isolates using a rapid and simple phenotypic method and/or by detection of Cyp51 gene associated triazole resistance mutations directly on respiratory samples. Funding sources This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declaration of competing interestCOI T.R.Rogers has received grants and personal fees from 10.13039/100005564 Gilead Sciences , personal fees from 10.13039/100015278 Pfizer Healthcare Ireland , personal fees from Menarini Pharma outside the submitted work, A.F.Talento has received grant and personal fees from 10.13039/100005564 Gilead Sciences and personal fees from 10.13039/100015278 Pfizer Healthcare Ireland outside the submitted work. The other authors have no conflict of interests.	AMPHOTERICIN B, ASPIRIN, AZITHROMYCIN ANHYDROUS, HYDROXYCHLOROQUINE, MEROPENEM, METFORMIN HYDROCHLORIDE, PIPERACILLIN SODIUM\TAZOBACTAM SODIUM, RAMIPRIL, SIMVASTATIN, VANCOMYCIN	DrugsGivenReaction	CC BY-NC-ND	32837879	19,468,704	2021-03
What is the weight of the patient?	Multi-triazole-resistant Aspergillus fumigatus and SARS-CoV-2 co-infection: A lethal combination. We report a case of severe COVID-19 pneumonia complicated by fatal co-infection with a multi-triazole resistant Aspergillus fumigatus and highlight the importance of recognising the significance of Aspergillus sp. isolation from respiratory samples. Early diagnosis and detection of triazole resistance are essential for appropriate antifungal therapy to improve outcome in patients with coronavirus associated invasive aspergillosis. 1 Introduction Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causing COVID-19 infection, is a newly recognised pathogen that has been traced to Wuhan (Hubei province) in China [1]. The clinical spectrum of COVID-19 varies from asymptomatic infection to severe pneumonia requiring mechanical ventilation. The overall case fatality rate is estimated to be 2.7%, which increases to 4.5% in those ≥ 60 years old [2]. Secondary infections with bacterial and fungal pathogens have been reported in patients with COVID-19 pneumonia which may be due to virus induced mucosal damage and/or the dysregulated immune response seen in patients with acute respiratory distress syndrome [3,4]. We report severe COVID-19 pneumonia with multi-triazole-resistant Aspergillus fumigatus co-infection in a patient not known to be immunocompromised to highlight the importance of early diagnosis and detection of triazole resistance. 2 Case A 66-year-old male presented to the emergency department with a history of progressive shortness of breath (SOB), myalgia, headaches, non-productive cough and fever. Two days previously, he had contacted his general practitioner (GP) describing a seven-day history of fever and cough. He had returned from the United Kingdom eight days earlier after visiting a relative who was subsequently diagnosed with COVID-19. He was advised to self-isolate and monitor his symptoms. Due to progressive SOB, he re-presented to his GP who referred him to the hospital for further management. The patient had Type 2 diabetes mellitus, hypertension, hyperlipidaemia and obesity with a body mass index of 35.5 (weight 90kg) with no hospital admissions in the past eight years. His medications included metformin, aspirin, simvastatin and ramipril. He had no history of prior triazole antifungal therapy. He was an ex-smoker but had not been previously diagnosed to have chronic lung disease. He works as a ground maintenance personnel where he is exposed to fungicides daily. On presentation, a portable chest radiograph was performed which showed unilateral peripheral left basal airspace shadowing (Fig. 1A). In view of the clinical presentation, radiographic findings and the recent exposure history, the patient was admitted under contact and droplet precautions.Fig. 1 A. Portable chest radiograph taken on day of admission showing unilateral peripheral left basal airspace shadowing. B. Portable chest radiograph taken on Day 12 of hospitalization (Day 20 of COVID-19 infection). The endotracheal tube and bilateral central lines are in satisfactory position. There has been interval progression of the left peripheral airspace shadowing with additional right upper and lower zone peripheral airspace shadowing with no evidence of cavitation. Fig. 1 On admission (Day 7 of COVID-19 illness), the patient was noted to be pyrexial (temperature of 38.6 °C), tachycardic (pulse rate of 174 beats per minute) with new onset atrial fibrillation, normotensive (BP 117/69 mmHg), tachypnic (24 breaths per minute) with oxygen saturation of 84% on room air. He was commenced on a trial of continuous positive airway pressure with oxygen therapy. Preliminary laboratory results revealed white cell count of 4.7 × 109/L (reference range 4.0–11.0 × 109/L), neutrophil count 3.0 × 109/L (reference range 2.0–7.0 × 109/L), lymphocyte count 0.8 × 109/L (reference range 1.0–3.0 × 109/L) and C-reactive protein of 118 mg/L (reference range < 5.0 mg/L). Nasopharyngeal and oropharyngeal swabs detected SARS-CoV-2 using real-time reverse transcriptase polymerase chain reaction on day 3. He was commenced on azithromycin (500 mg on day 1 and 250 once daily on days 2 and 3) and hydroxychloroquine (200 mg twice daily) orally as per our local protocol at that time. On day 4 (Day 11 of COVID-19 illness) he developed worsening hypoxic respiratory failure with a Sequential Organ Failure Assessment (SOFA) score of 6 necessitating intensive care unit (ICU) admission for ventilatory support. The patient was proned initially for 15 hours which did not improve his oxygenation. This, combined with significant hemodynamic instability, were contraindications for further proning. His condition continued to deteriorate progressing to multi-organ failure on day 7 (Day 14 of COVID-19 illness) which included acute respiratory failure, acute kidney injury requiring continuous renal replacement therapy and vasopressor support due to septic shock. His SOFA score increased to 12. He had continuing pyrexia and copious amounts of purulent respiratory secretions prompting a repeat septic screen which included culture of blood and endotracheal aspirate (ETA). Empiric antimicrobial therapy for hospital-acquired pneumonia with intravenous (IV) piperacillin-tazobactam (4.5g three times a day) was started. Subsequently, ETA culture grew Klebsiella varicola (susceptible to piperacillin-tazobactam), Aspergillus sp. and Candida albicans. Antifungal therapy with IV liposomal amphotericin B (3 mg per kg once daily) was commenced due to the patients rapidly deteriorating status and uncertainty of the full identification of the mould isolate which may be resistant to triazoles. The Aspergillus sp. was referred for further identification and antifungal susceptibility testing, as were serum samples for detection of 1–3, β-d-glucan (BDG) antigen and galactomannan (GM) antigen and ETA for GM antigen. His SOFA score on day 11 (Day 18 of COVID-19 illness) increased to 16. Antibiotic therapy was escalated to IV meropenem (1g twice daily) and vancomycin, with dosing based on renal function, due to ongoing pyrexia and deteriorating status. He was not prescribed systemic steroids at any time during his critical illness. A repeat portable chest radiograph on day 12 (Day 20 of COVID-19 illness) showed progression to additional right upper and lower zone peripheral airspace shadowing with no evidence of cavitation (Fig. 1B). He remained haemodynamically unstable which precluded further radiological investigations. In view of his non-responsive multi-organ failure, and after discussion with his family, the patient's life-support was withdrawn. He died on day 14 of hospitalization (Day 22 of COVID-19 illness). The Aspergillus sp. isolated from the ETA was confirmed to be A. fumigatus. Phenotypic testing utilising a 4-well triazole resistance screen (VIP check™, Mediaproducts BV, The Netherlands) (Fig. 2A and B) as well as determination of minimum inhibitory concentrations (MIC) utilising gradient strips (Liofilchem, Waltham MA, USA) were suggestive of triazole resistance (Table 1) [5]. The MIC to amphotericin was 0.125 mg/L (susceptible ≤ 1 mg/L) [5]. Genotypic testing utilising a commercial assay (Aspergenius™, Pathonostics B.V. The Netherlands) on the ETA detected A. fumigati complex with the TR34L98H resistance mutation in the cyp51A gene, the most common mutation in triazole-resistant A. fumigatus originating from an environmental source. The serum and ETA GM optical density index (ODI) were 1.1 and 5.5 respectively (Platelia™ Aspergillus Ag EIA, WA, USA). Serum BDG was 202 pg per milliliter (Fungitell™ Assay, Associates of Cape Cod, USA). These results (Table 1) were consistent with severe COVID-19 pneumonia and triazole-resistant invasive pulmonary aspergillus co-infection.Fig. 2 A and B VIPcheck™ plate, a four well triazole resistance screen plate which contains itraconazole (I) 4 mg per liter, voriconazole (V) 2 mg per liter, posaconazole. (P) 0.5 mg per liter, and growth control (GC). This is a simple phenotypic test used to screen for triazole resistance due to the common mutations in the cyp51A gene in A. fumigatus from an environmental source. The photos show a susceptible control strain AF293 (2A) where growth is only seen on GC well and the patient's isolate (2B) with growth in all wells consistent with findings seen in A. fumigatus with the cyp51A TR34/L98H mutation. Fig. 2 Table 1 Laboratory results. Table 1 Patient's Isolate A. fumigatus aClinical breakpoint > Resistant Antifungal Susceptibility Test Minimum inhibitory concentration (MIC) mg/L Voriconazole 2.0 1 Itraconazole >32 1 Posaconazole 1.0 0.25 Amphotericin B 0.125 1 Fungal antigensb Patient's results Cut-off Galactomannan Optical Density Index (ODI) Serum 1.1 ≥ 0.5 Tracheal aspirate 5.5 N/A 1,3 β-d-glucan pg/mL Serum 202 ≥ 80 a Based on the European Committee on Antimicrobial Susceptibility testing guidelines. b Fungal antigens: Galactomannan cut-off based on Platelia™ Aspergillus Ag EIA and 1–3 β-d-glucan cut-off based on Fungitell™ assay. 3 Discussion Previously known to cause infections in severely immunocompromised patients, A. fumigatus is now recognised as an emerging pathogen in critical care patients suffering chronic respiratory disorders and as a complication of severe influenza infection [6]. Aspergillus colonisation can rapidly lead to invasive aspergillosis following severe influenza infection due to multiple pathways including structural lung damage coupled with disruption of mucociliary clearance, leukopenia, Th1/Th2 imbalance and diffuse damage to the respiratory mucosa [7]. In addition, severe respiratory viral infections such as influenza have been identified as an independent risk factor for IPA with high mortality [6]. Although our patient did not receive steroids, their use in critical care patients is linked to increased risk of invasive fungal infections [6]. Like other causes of viral pneumonias, SARS-CoV-2 may impair local mucosal and systemic immune defenses [3]. Thirty-four cases of COVID-19 associated invasive aspergillosis (CAPA) have been reported to date [[8], [9], [10], [11], [12], [13], [14], [15], [16], [17]]. These were all patients with severe pneumonia with adult respiratory distress symdome, most of whom had no known history of immunocompromise. These has led to challenges in early diagnosis since most of them do not have the classical risk factors for invasive aspergillosis. Histopathology and culture from sterile site samples and biopsy remain the gold standard for proven IPA however the definition of probable or “putative” IPA has expanded but remains to be a composite of the host factors, clinical features and mycological evidence [6,18]. Although severe viral pneumonia is not considered a risk factor for IPA or other invasive mould disease according to the European Organisation for Research and Treatment of Cancer/Mycoses Study Group definitions, the structural damage to the lung parenchyma, in addition to the dysregulated immune response, can lead to IPA [6]. Recently a panel of experts proposed a case definition for influenza associated invasive aspergillosis (IAPA) which may be useful to classify COVID-19 patients with invasive aspergillosis. Following this case definition a patient with COVID-19 detected in respiratory sample by PCR, pulmonary infiltrates and a positive serum or bronchoalveolar lavage galactomannan has criteria consistent with probable CAPA [19]. Our patient had radiographic findings consistent with COVID-19 pneumonia. Unfortunately, his clinical status did not allow for computed tomography (CT) to be performed. Other mycological evidence of IPA include culture of Aspergillus sp. from non-sterile sites or detection of fungal antigens such as serum BDG. Our patient had COVID-19 pneumonia, A. fumigatus from a tracheal aspirate with elevated serum BDG and GM and elevated ETA GM, findings consistent with COVID-19 and probable IPA co-infection. Multi-triazole resistance in A. fumigatus has recently emerged and is linked to the use of triazole-containing compounds as agricultural fungicides or less commonly prolonged triazole use [20]. The former mechanism of resistance typically affects azole näive patients and is characterised by elevated MICs to itraconazole, voriconazole and posaconazole as was found in our patient. This is of serious concern since triazoles are recommended as the first-line and most effective treatment for IPA [21]. Of the 34 cases reported so far, only 7 cases had reported susceptibility results of which one was triazole resistant A. fumigatus [16] similar to our case. Our patient's exposure to fungicides daily in his work has most likely led to exposure and colonisation with triazole-resistant A. fumigatus which was further supported by detection of cyp51A TR34L98H mutation from our patient's ETA, the most prevalent triazole resistance mutation from environmental source [20]. This case highlights the importance of early evaluation of patients with COVID-19 pneumonia because of the risk of secondary or co-infection with fungal pathogens. Case definitions have been proposed for IAPA [6,19] which can be modified for early recognition of CAPA. The occurrence of multi-triazole resistance in this case emphasises the urgent need for antifungal drug susceptibility testing of Aspergillus isolates using a rapid and simple phenotypic method and/or by detection of Cyp51 gene associated triazole resistance mutations directly on respiratory samples. Funding sources This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declaration of competing interestCOI T.R.Rogers has received grants and personal fees from 10.13039/100005564 Gilead Sciences , personal fees from 10.13039/100015278 Pfizer Healthcare Ireland , personal fees from Menarini Pharma outside the submitted work, A.F.Talento has received grant and personal fees from 10.13039/100005564 Gilead Sciences and personal fees from 10.13039/100015278 Pfizer Healthcare Ireland outside the submitted work. The other authors have no conflict of interests.	90 kg.	Weight	CC BY-NC-ND	32837879	19,458,392	2021-03
What was the administration route of drug 'AMPHOTERICIN B'?	Multi-triazole-resistant Aspergillus fumigatus and SARS-CoV-2 co-infection: A lethal combination. We report a case of severe COVID-19 pneumonia complicated by fatal co-infection with a multi-triazole resistant Aspergillus fumigatus and highlight the importance of recognising the significance of Aspergillus sp. isolation from respiratory samples. Early diagnosis and detection of triazole resistance are essential for appropriate antifungal therapy to improve outcome in patients with coronavirus associated invasive aspergillosis. 1 Introduction Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causing COVID-19 infection, is a newly recognised pathogen that has been traced to Wuhan (Hubei province) in China [1]. The clinical spectrum of COVID-19 varies from asymptomatic infection to severe pneumonia requiring mechanical ventilation. The overall case fatality rate is estimated to be 2.7%, which increases to 4.5% in those ≥ 60 years old [2]. Secondary infections with bacterial and fungal pathogens have been reported in patients with COVID-19 pneumonia which may be due to virus induced mucosal damage and/or the dysregulated immune response seen in patients with acute respiratory distress syndrome [3,4]. We report severe COVID-19 pneumonia with multi-triazole-resistant Aspergillus fumigatus co-infection in a patient not known to be immunocompromised to highlight the importance of early diagnosis and detection of triazole resistance. 2 Case A 66-year-old male presented to the emergency department with a history of progressive shortness of breath (SOB), myalgia, headaches, non-productive cough and fever. Two days previously, he had contacted his general practitioner (GP) describing a seven-day history of fever and cough. He had returned from the United Kingdom eight days earlier after visiting a relative who was subsequently diagnosed with COVID-19. He was advised to self-isolate and monitor his symptoms. Due to progressive SOB, he re-presented to his GP who referred him to the hospital for further management. The patient had Type 2 diabetes mellitus, hypertension, hyperlipidaemia and obesity with a body mass index of 35.5 (weight 90kg) with no hospital admissions in the past eight years. His medications included metformin, aspirin, simvastatin and ramipril. He had no history of prior triazole antifungal therapy. He was an ex-smoker but had not been previously diagnosed to have chronic lung disease. He works as a ground maintenance personnel where he is exposed to fungicides daily. On presentation, a portable chest radiograph was performed which showed unilateral peripheral left basal airspace shadowing (Fig. 1A). In view of the clinical presentation, radiographic findings and the recent exposure history, the patient was admitted under contact and droplet precautions.Fig. 1 A. Portable chest radiograph taken on day of admission showing unilateral peripheral left basal airspace shadowing. B. Portable chest radiograph taken on Day 12 of hospitalization (Day 20 of COVID-19 infection). The endotracheal tube and bilateral central lines are in satisfactory position. There has been interval progression of the left peripheral airspace shadowing with additional right upper and lower zone peripheral airspace shadowing with no evidence of cavitation. Fig. 1 On admission (Day 7 of COVID-19 illness), the patient was noted to be pyrexial (temperature of 38.6 °C), tachycardic (pulse rate of 174 beats per minute) with new onset atrial fibrillation, normotensive (BP 117/69 mmHg), tachypnic (24 breaths per minute) with oxygen saturation of 84% on room air. He was commenced on a trial of continuous positive airway pressure with oxygen therapy. Preliminary laboratory results revealed white cell count of 4.7 × 109/L (reference range 4.0–11.0 × 109/L), neutrophil count 3.0 × 109/L (reference range 2.0–7.0 × 109/L), lymphocyte count 0.8 × 109/L (reference range 1.0–3.0 × 109/L) and C-reactive protein of 118 mg/L (reference range < 5.0 mg/L). Nasopharyngeal and oropharyngeal swabs detected SARS-CoV-2 using real-time reverse transcriptase polymerase chain reaction on day 3. He was commenced on azithromycin (500 mg on day 1 and 250 once daily on days 2 and 3) and hydroxychloroquine (200 mg twice daily) orally as per our local protocol at that time. On day 4 (Day 11 of COVID-19 illness) he developed worsening hypoxic respiratory failure with a Sequential Organ Failure Assessment (SOFA) score of 6 necessitating intensive care unit (ICU) admission for ventilatory support. The patient was proned initially for 15 hours which did not improve his oxygenation. This, combined with significant hemodynamic instability, were contraindications for further proning. His condition continued to deteriorate progressing to multi-organ failure on day 7 (Day 14 of COVID-19 illness) which included acute respiratory failure, acute kidney injury requiring continuous renal replacement therapy and vasopressor support due to septic shock. His SOFA score increased to 12. He had continuing pyrexia and copious amounts of purulent respiratory secretions prompting a repeat septic screen which included culture of blood and endotracheal aspirate (ETA). Empiric antimicrobial therapy for hospital-acquired pneumonia with intravenous (IV) piperacillin-tazobactam (4.5g three times a day) was started. Subsequently, ETA culture grew Klebsiella varicola (susceptible to piperacillin-tazobactam), Aspergillus sp. and Candida albicans. Antifungal therapy with IV liposomal amphotericin B (3 mg per kg once daily) was commenced due to the patients rapidly deteriorating status and uncertainty of the full identification of the mould isolate which may be resistant to triazoles. The Aspergillus sp. was referred for further identification and antifungal susceptibility testing, as were serum samples for detection of 1–3, β-d-glucan (BDG) antigen and galactomannan (GM) antigen and ETA for GM antigen. His SOFA score on day 11 (Day 18 of COVID-19 illness) increased to 16. Antibiotic therapy was escalated to IV meropenem (1g twice daily) and vancomycin, with dosing based on renal function, due to ongoing pyrexia and deteriorating status. He was not prescribed systemic steroids at any time during his critical illness. A repeat portable chest radiograph on day 12 (Day 20 of COVID-19 illness) showed progression to additional right upper and lower zone peripheral airspace shadowing with no evidence of cavitation (Fig. 1B). He remained haemodynamically unstable which precluded further radiological investigations. In view of his non-responsive multi-organ failure, and after discussion with his family, the patient's life-support was withdrawn. He died on day 14 of hospitalization (Day 22 of COVID-19 illness). The Aspergillus sp. isolated from the ETA was confirmed to be A. fumigatus. Phenotypic testing utilising a 4-well triazole resistance screen (VIP check™, Mediaproducts BV, The Netherlands) (Fig. 2A and B) as well as determination of minimum inhibitory concentrations (MIC) utilising gradient strips (Liofilchem, Waltham MA, USA) were suggestive of triazole resistance (Table 1) [5]. The MIC to amphotericin was 0.125 mg/L (susceptible ≤ 1 mg/L) [5]. Genotypic testing utilising a commercial assay (Aspergenius™, Pathonostics B.V. The Netherlands) on the ETA detected A. fumigati complex with the TR34L98H resistance mutation in the cyp51A gene, the most common mutation in triazole-resistant A. fumigatus originating from an environmental source. The serum and ETA GM optical density index (ODI) were 1.1 and 5.5 respectively (Platelia™ Aspergillus Ag EIA, WA, USA). Serum BDG was 202 pg per milliliter (Fungitell™ Assay, Associates of Cape Cod, USA). These results (Table 1) were consistent with severe COVID-19 pneumonia and triazole-resistant invasive pulmonary aspergillus co-infection.Fig. 2 A and B VIPcheck™ plate, a four well triazole resistance screen plate which contains itraconazole (I) 4 mg per liter, voriconazole (V) 2 mg per liter, posaconazole. (P) 0.5 mg per liter, and growth control (GC). This is a simple phenotypic test used to screen for triazole resistance due to the common mutations in the cyp51A gene in A. fumigatus from an environmental source. The photos show a susceptible control strain AF293 (2A) where growth is only seen on GC well and the patient's isolate (2B) with growth in all wells consistent with findings seen in A. fumigatus with the cyp51A TR34/L98H mutation. Fig. 2 Table 1 Laboratory results. Table 1 Patient's Isolate A. fumigatus aClinical breakpoint > Resistant Antifungal Susceptibility Test Minimum inhibitory concentration (MIC) mg/L Voriconazole 2.0 1 Itraconazole >32 1 Posaconazole 1.0 0.25 Amphotericin B 0.125 1 Fungal antigensb Patient's results Cut-off Galactomannan Optical Density Index (ODI) Serum 1.1 ≥ 0.5 Tracheal aspirate 5.5 N/A 1,3 β-d-glucan pg/mL Serum 202 ≥ 80 a Based on the European Committee on Antimicrobial Susceptibility testing guidelines. b Fungal antigens: Galactomannan cut-off based on Platelia™ Aspergillus Ag EIA and 1–3 β-d-glucan cut-off based on Fungitell™ assay. 3 Discussion Previously known to cause infections in severely immunocompromised patients, A. fumigatus is now recognised as an emerging pathogen in critical care patients suffering chronic respiratory disorders and as a complication of severe influenza infection [6]. Aspergillus colonisation can rapidly lead to invasive aspergillosis following severe influenza infection due to multiple pathways including structural lung damage coupled with disruption of mucociliary clearance, leukopenia, Th1/Th2 imbalance and diffuse damage to the respiratory mucosa [7]. In addition, severe respiratory viral infections such as influenza have been identified as an independent risk factor for IPA with high mortality [6]. Although our patient did not receive steroids, their use in critical care patients is linked to increased risk of invasive fungal infections [6]. Like other causes of viral pneumonias, SARS-CoV-2 may impair local mucosal and systemic immune defenses [3]. Thirty-four cases of COVID-19 associated invasive aspergillosis (CAPA) have been reported to date [[8], [9], [10], [11], [12], [13], [14], [15], [16], [17]]. These were all patients with severe pneumonia with adult respiratory distress symdome, most of whom had no known history of immunocompromise. These has led to challenges in early diagnosis since most of them do not have the classical risk factors for invasive aspergillosis. Histopathology and culture from sterile site samples and biopsy remain the gold standard for proven IPA however the definition of probable or “putative” IPA has expanded but remains to be a composite of the host factors, clinical features and mycological evidence [6,18]. Although severe viral pneumonia is not considered a risk factor for IPA or other invasive mould disease according to the European Organisation for Research and Treatment of Cancer/Mycoses Study Group definitions, the structural damage to the lung parenchyma, in addition to the dysregulated immune response, can lead to IPA [6]. Recently a panel of experts proposed a case definition for influenza associated invasive aspergillosis (IAPA) which may be useful to classify COVID-19 patients with invasive aspergillosis. Following this case definition a patient with COVID-19 detected in respiratory sample by PCR, pulmonary infiltrates and a positive serum or bronchoalveolar lavage galactomannan has criteria consistent with probable CAPA [19]. Our patient had radiographic findings consistent with COVID-19 pneumonia. Unfortunately, his clinical status did not allow for computed tomography (CT) to be performed. Other mycological evidence of IPA include culture of Aspergillus sp. from non-sterile sites or detection of fungal antigens such as serum BDG. Our patient had COVID-19 pneumonia, A. fumigatus from a tracheal aspirate with elevated serum BDG and GM and elevated ETA GM, findings consistent with COVID-19 and probable IPA co-infection. Multi-triazole resistance in A. fumigatus has recently emerged and is linked to the use of triazole-containing compounds as agricultural fungicides or less commonly prolonged triazole use [20]. The former mechanism of resistance typically affects azole näive patients and is characterised by elevated MICs to itraconazole, voriconazole and posaconazole as was found in our patient. This is of serious concern since triazoles are recommended as the first-line and most effective treatment for IPA [21]. Of the 34 cases reported so far, only 7 cases had reported susceptibility results of which one was triazole resistant A. fumigatus [16] similar to our case. Our patient's exposure to fungicides daily in his work has most likely led to exposure and colonisation with triazole-resistant A. fumigatus which was further supported by detection of cyp51A TR34L98H mutation from our patient's ETA, the most prevalent triazole resistance mutation from environmental source [20]. This case highlights the importance of early evaluation of patients with COVID-19 pneumonia because of the risk of secondary or co-infection with fungal pathogens. Case definitions have been proposed for IAPA [6,19] which can be modified for early recognition of CAPA. The occurrence of multi-triazole resistance in this case emphasises the urgent need for antifungal drug susceptibility testing of Aspergillus isolates using a rapid and simple phenotypic method and/or by detection of Cyp51 gene associated triazole resistance mutations directly on respiratory samples. Funding sources This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declaration of competing interestCOI T.R.Rogers has received grants and personal fees from 10.13039/100005564 Gilead Sciences , personal fees from 10.13039/100015278 Pfizer Healthcare Ireland , personal fees from Menarini Pharma outside the submitted work, A.F.Talento has received grant and personal fees from 10.13039/100005564 Gilead Sciences and personal fees from 10.13039/100015278 Pfizer Healthcare Ireland outside the submitted work. The other authors have no conflict of interests.	Intravenous (not otherwise specified)	DrugAdministrationRoute	CC BY-NC-ND	32837879	19,468,704	2021-03
What was the administration route of drug 'AZITHROMYCIN ANHYDROUS'?	Multi-triazole-resistant Aspergillus fumigatus and SARS-CoV-2 co-infection: A lethal combination. We report a case of severe COVID-19 pneumonia complicated by fatal co-infection with a multi-triazole resistant Aspergillus fumigatus and highlight the importance of recognising the significance of Aspergillus sp. isolation from respiratory samples. Early diagnosis and detection of triazole resistance are essential for appropriate antifungal therapy to improve outcome in patients with coronavirus associated invasive aspergillosis. 1 Introduction Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causing COVID-19 infection, is a newly recognised pathogen that has been traced to Wuhan (Hubei province) in China [1]. The clinical spectrum of COVID-19 varies from asymptomatic infection to severe pneumonia requiring mechanical ventilation. The overall case fatality rate is estimated to be 2.7%, which increases to 4.5% in those ≥ 60 years old [2]. Secondary infections with bacterial and fungal pathogens have been reported in patients with COVID-19 pneumonia which may be due to virus induced mucosal damage and/or the dysregulated immune response seen in patients with acute respiratory distress syndrome [3,4]. We report severe COVID-19 pneumonia with multi-triazole-resistant Aspergillus fumigatus co-infection in a patient not known to be immunocompromised to highlight the importance of early diagnosis and detection of triazole resistance. 2 Case A 66-year-old male presented to the emergency department with a history of progressive shortness of breath (SOB), myalgia, headaches, non-productive cough and fever. Two days previously, he had contacted his general practitioner (GP) describing a seven-day history of fever and cough. He had returned from the United Kingdom eight days earlier after visiting a relative who was subsequently diagnosed with COVID-19. He was advised to self-isolate and monitor his symptoms. Due to progressive SOB, he re-presented to his GP who referred him to the hospital for further management. The patient had Type 2 diabetes mellitus, hypertension, hyperlipidaemia and obesity with a body mass index of 35.5 (weight 90kg) with no hospital admissions in the past eight years. His medications included metformin, aspirin, simvastatin and ramipril. He had no history of prior triazole antifungal therapy. He was an ex-smoker but had not been previously diagnosed to have chronic lung disease. He works as a ground maintenance personnel where he is exposed to fungicides daily. On presentation, a portable chest radiograph was performed which showed unilateral peripheral left basal airspace shadowing (Fig. 1A). In view of the clinical presentation, radiographic findings and the recent exposure history, the patient was admitted under contact and droplet precautions.Fig. 1 A. Portable chest radiograph taken on day of admission showing unilateral peripheral left basal airspace shadowing. B. Portable chest radiograph taken on Day 12 of hospitalization (Day 20 of COVID-19 infection). The endotracheal tube and bilateral central lines are in satisfactory position. There has been interval progression of the left peripheral airspace shadowing with additional right upper and lower zone peripheral airspace shadowing with no evidence of cavitation. Fig. 1 On admission (Day 7 of COVID-19 illness), the patient was noted to be pyrexial (temperature of 38.6 °C), tachycardic (pulse rate of 174 beats per minute) with new onset atrial fibrillation, normotensive (BP 117/69 mmHg), tachypnic (24 breaths per minute) with oxygen saturation of 84% on room air. He was commenced on a trial of continuous positive airway pressure with oxygen therapy. Preliminary laboratory results revealed white cell count of 4.7 × 109/L (reference range 4.0–11.0 × 109/L), neutrophil count 3.0 × 109/L (reference range 2.0–7.0 × 109/L), lymphocyte count 0.8 × 109/L (reference range 1.0–3.0 × 109/L) and C-reactive protein of 118 mg/L (reference range < 5.0 mg/L). Nasopharyngeal and oropharyngeal swabs detected SARS-CoV-2 using real-time reverse transcriptase polymerase chain reaction on day 3. He was commenced on azithromycin (500 mg on day 1 and 250 once daily on days 2 and 3) and hydroxychloroquine (200 mg twice daily) orally as per our local protocol at that time. On day 4 (Day 11 of COVID-19 illness) he developed worsening hypoxic respiratory failure with a Sequential Organ Failure Assessment (SOFA) score of 6 necessitating intensive care unit (ICU) admission for ventilatory support. The patient was proned initially for 15 hours which did not improve his oxygenation. This, combined with significant hemodynamic instability, were contraindications for further proning. His condition continued to deteriorate progressing to multi-organ failure on day 7 (Day 14 of COVID-19 illness) which included acute respiratory failure, acute kidney injury requiring continuous renal replacement therapy and vasopressor support due to septic shock. His SOFA score increased to 12. He had continuing pyrexia and copious amounts of purulent respiratory secretions prompting a repeat septic screen which included culture of blood and endotracheal aspirate (ETA). Empiric antimicrobial therapy for hospital-acquired pneumonia with intravenous (IV) piperacillin-tazobactam (4.5g three times a day) was started. Subsequently, ETA culture grew Klebsiella varicola (susceptible to piperacillin-tazobactam), Aspergillus sp. and Candida albicans. Antifungal therapy with IV liposomal amphotericin B (3 mg per kg once daily) was commenced due to the patients rapidly deteriorating status and uncertainty of the full identification of the mould isolate which may be resistant to triazoles. The Aspergillus sp. was referred for further identification and antifungal susceptibility testing, as were serum samples for detection of 1–3, β-d-glucan (BDG) antigen and galactomannan (GM) antigen and ETA for GM antigen. His SOFA score on day 11 (Day 18 of COVID-19 illness) increased to 16. Antibiotic therapy was escalated to IV meropenem (1g twice daily) and vancomycin, with dosing based on renal function, due to ongoing pyrexia and deteriorating status. He was not prescribed systemic steroids at any time during his critical illness. A repeat portable chest radiograph on day 12 (Day 20 of COVID-19 illness) showed progression to additional right upper and lower zone peripheral airspace shadowing with no evidence of cavitation (Fig. 1B). He remained haemodynamically unstable which precluded further radiological investigations. In view of his non-responsive multi-organ failure, and after discussion with his family, the patient's life-support was withdrawn. He died on day 14 of hospitalization (Day 22 of COVID-19 illness). The Aspergillus sp. isolated from the ETA was confirmed to be A. fumigatus. Phenotypic testing utilising a 4-well triazole resistance screen (VIP check™, Mediaproducts BV, The Netherlands) (Fig. 2A and B) as well as determination of minimum inhibitory concentrations (MIC) utilising gradient strips (Liofilchem, Waltham MA, USA) were suggestive of triazole resistance (Table 1) [5]. The MIC to amphotericin was 0.125 mg/L (susceptible ≤ 1 mg/L) [5]. Genotypic testing utilising a commercial assay (Aspergenius™, Pathonostics B.V. The Netherlands) on the ETA detected A. fumigati complex with the TR34L98H resistance mutation in the cyp51A gene, the most common mutation in triazole-resistant A. fumigatus originating from an environmental source. The serum and ETA GM optical density index (ODI) were 1.1 and 5.5 respectively (Platelia™ Aspergillus Ag EIA, WA, USA). Serum BDG was 202 pg per milliliter (Fungitell™ Assay, Associates of Cape Cod, USA). These results (Table 1) were consistent with severe COVID-19 pneumonia and triazole-resistant invasive pulmonary aspergillus co-infection.Fig. 2 A and B VIPcheck™ plate, a four well triazole resistance screen plate which contains itraconazole (I) 4 mg per liter, voriconazole (V) 2 mg per liter, posaconazole. (P) 0.5 mg per liter, and growth control (GC). This is a simple phenotypic test used to screen for triazole resistance due to the common mutations in the cyp51A gene in A. fumigatus from an environmental source. The photos show a susceptible control strain AF293 (2A) where growth is only seen on GC well and the patient's isolate (2B) with growth in all wells consistent with findings seen in A. fumigatus with the cyp51A TR34/L98H mutation. Fig. 2 Table 1 Laboratory results. Table 1 Patient's Isolate A. fumigatus aClinical breakpoint > Resistant Antifungal Susceptibility Test Minimum inhibitory concentration (MIC) mg/L Voriconazole 2.0 1 Itraconazole >32 1 Posaconazole 1.0 0.25 Amphotericin B 0.125 1 Fungal antigensb Patient's results Cut-off Galactomannan Optical Density Index (ODI) Serum 1.1 ≥ 0.5 Tracheal aspirate 5.5 N/A 1,3 β-d-glucan pg/mL Serum 202 ≥ 80 a Based on the European Committee on Antimicrobial Susceptibility testing guidelines. b Fungal antigens: Galactomannan cut-off based on Platelia™ Aspergillus Ag EIA and 1–3 β-d-glucan cut-off based on Fungitell™ assay. 3 Discussion Previously known to cause infections in severely immunocompromised patients, A. fumigatus is now recognised as an emerging pathogen in critical care patients suffering chronic respiratory disorders and as a complication of severe influenza infection [6]. Aspergillus colonisation can rapidly lead to invasive aspergillosis following severe influenza infection due to multiple pathways including structural lung damage coupled with disruption of mucociliary clearance, leukopenia, Th1/Th2 imbalance and diffuse damage to the respiratory mucosa [7]. In addition, severe respiratory viral infections such as influenza have been identified as an independent risk factor for IPA with high mortality [6]. Although our patient did not receive steroids, their use in critical care patients is linked to increased risk of invasive fungal infections [6]. Like other causes of viral pneumonias, SARS-CoV-2 may impair local mucosal and systemic immune defenses [3]. Thirty-four cases of COVID-19 associated invasive aspergillosis (CAPA) have been reported to date [[8], [9], [10], [11], [12], [13], [14], [15], [16], [17]]. These were all patients with severe pneumonia with adult respiratory distress symdome, most of whom had no known history of immunocompromise. These has led to challenges in early diagnosis since most of them do not have the classical risk factors for invasive aspergillosis. Histopathology and culture from sterile site samples and biopsy remain the gold standard for proven IPA however the definition of probable or “putative” IPA has expanded but remains to be a composite of the host factors, clinical features and mycological evidence [6,18]. Although severe viral pneumonia is not considered a risk factor for IPA or other invasive mould disease according to the European Organisation for Research and Treatment of Cancer/Mycoses Study Group definitions, the structural damage to the lung parenchyma, in addition to the dysregulated immune response, can lead to IPA [6]. Recently a panel of experts proposed a case definition for influenza associated invasive aspergillosis (IAPA) which may be useful to classify COVID-19 patients with invasive aspergillosis. Following this case definition a patient with COVID-19 detected in respiratory sample by PCR, pulmonary infiltrates and a positive serum or bronchoalveolar lavage galactomannan has criteria consistent with probable CAPA [19]. Our patient had radiographic findings consistent with COVID-19 pneumonia. Unfortunately, his clinical status did not allow for computed tomography (CT) to be performed. Other mycological evidence of IPA include culture of Aspergillus sp. from non-sterile sites or detection of fungal antigens such as serum BDG. Our patient had COVID-19 pneumonia, A. fumigatus from a tracheal aspirate with elevated serum BDG and GM and elevated ETA GM, findings consistent with COVID-19 and probable IPA co-infection. Multi-triazole resistance in A. fumigatus has recently emerged and is linked to the use of triazole-containing compounds as agricultural fungicides or less commonly prolonged triazole use [20]. The former mechanism of resistance typically affects azole näive patients and is characterised by elevated MICs to itraconazole, voriconazole and posaconazole as was found in our patient. This is of serious concern since triazoles are recommended as the first-line and most effective treatment for IPA [21]. Of the 34 cases reported so far, only 7 cases had reported susceptibility results of which one was triazole resistant A. fumigatus [16] similar to our case. Our patient's exposure to fungicides daily in his work has most likely led to exposure and colonisation with triazole-resistant A. fumigatus which was further supported by detection of cyp51A TR34L98H mutation from our patient's ETA, the most prevalent triazole resistance mutation from environmental source [20]. This case highlights the importance of early evaluation of patients with COVID-19 pneumonia because of the risk of secondary or co-infection with fungal pathogens. Case definitions have been proposed for IAPA [6,19] which can be modified for early recognition of CAPA. The occurrence of multi-triazole resistance in this case emphasises the urgent need for antifungal drug susceptibility testing of Aspergillus isolates using a rapid and simple phenotypic method and/or by detection of Cyp51 gene associated triazole resistance mutations directly on respiratory samples. Funding sources This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declaration of competing interestCOI T.R.Rogers has received grants and personal fees from 10.13039/100005564 Gilead Sciences , personal fees from 10.13039/100015278 Pfizer Healthcare Ireland , personal fees from Menarini Pharma outside the submitted work, A.F.Talento has received grant and personal fees from 10.13039/100005564 Gilead Sciences and personal fees from 10.13039/100015278 Pfizer Healthcare Ireland outside the submitted work. The other authors have no conflict of interests.	Oral	DrugAdministrationRoute	CC BY-NC-ND	32837879	19,468,704	2021-03
What was the administration route of drug 'HYDROXYCHLOROQUINE'?	Multi-triazole-resistant Aspergillus fumigatus and SARS-CoV-2 co-infection: A lethal combination. We report a case of severe COVID-19 pneumonia complicated by fatal co-infection with a multi-triazole resistant Aspergillus fumigatus and highlight the importance of recognising the significance of Aspergillus sp. isolation from respiratory samples. Early diagnosis and detection of triazole resistance are essential for appropriate antifungal therapy to improve outcome in patients with coronavirus associated invasive aspergillosis. 1 Introduction Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causing COVID-19 infection, is a newly recognised pathogen that has been traced to Wuhan (Hubei province) in China [1]. The clinical spectrum of COVID-19 varies from asymptomatic infection to severe pneumonia requiring mechanical ventilation. The overall case fatality rate is estimated to be 2.7%, which increases to 4.5% in those ≥ 60 years old [2]. Secondary infections with bacterial and fungal pathogens have been reported in patients with COVID-19 pneumonia which may be due to virus induced mucosal damage and/or the dysregulated immune response seen in patients with acute respiratory distress syndrome [3,4]. We report severe COVID-19 pneumonia with multi-triazole-resistant Aspergillus fumigatus co-infection in a patient not known to be immunocompromised to highlight the importance of early diagnosis and detection of triazole resistance. 2 Case A 66-year-old male presented to the emergency department with a history of progressive shortness of breath (SOB), myalgia, headaches, non-productive cough and fever. Two days previously, he had contacted his general practitioner (GP) describing a seven-day history of fever and cough. He had returned from the United Kingdom eight days earlier after visiting a relative who was subsequently diagnosed with COVID-19. He was advised to self-isolate and monitor his symptoms. Due to progressive SOB, he re-presented to his GP who referred him to the hospital for further management. The patient had Type 2 diabetes mellitus, hypertension, hyperlipidaemia and obesity with a body mass index of 35.5 (weight 90kg) with no hospital admissions in the past eight years. His medications included metformin, aspirin, simvastatin and ramipril. He had no history of prior triazole antifungal therapy. He was an ex-smoker but had not been previously diagnosed to have chronic lung disease. He works as a ground maintenance personnel where he is exposed to fungicides daily. On presentation, a portable chest radiograph was performed which showed unilateral peripheral left basal airspace shadowing (Fig. 1A). In view of the clinical presentation, radiographic findings and the recent exposure history, the patient was admitted under contact and droplet precautions.Fig. 1 A. Portable chest radiograph taken on day of admission showing unilateral peripheral left basal airspace shadowing. B. Portable chest radiograph taken on Day 12 of hospitalization (Day 20 of COVID-19 infection). The endotracheal tube and bilateral central lines are in satisfactory position. There has been interval progression of the left peripheral airspace shadowing with additional right upper and lower zone peripheral airspace shadowing with no evidence of cavitation. Fig. 1 On admission (Day 7 of COVID-19 illness), the patient was noted to be pyrexial (temperature of 38.6 °C), tachycardic (pulse rate of 174 beats per minute) with new onset atrial fibrillation, normotensive (BP 117/69 mmHg), tachypnic (24 breaths per minute) with oxygen saturation of 84% on room air. He was commenced on a trial of continuous positive airway pressure with oxygen therapy. Preliminary laboratory results revealed white cell count of 4.7 × 109/L (reference range 4.0–11.0 × 109/L), neutrophil count 3.0 × 109/L (reference range 2.0–7.0 × 109/L), lymphocyte count 0.8 × 109/L (reference range 1.0–3.0 × 109/L) and C-reactive protein of 118 mg/L (reference range < 5.0 mg/L). Nasopharyngeal and oropharyngeal swabs detected SARS-CoV-2 using real-time reverse transcriptase polymerase chain reaction on day 3. He was commenced on azithromycin (500 mg on day 1 and 250 once daily on days 2 and 3) and hydroxychloroquine (200 mg twice daily) orally as per our local protocol at that time. On day 4 (Day 11 of COVID-19 illness) he developed worsening hypoxic respiratory failure with a Sequential Organ Failure Assessment (SOFA) score of 6 necessitating intensive care unit (ICU) admission for ventilatory support. The patient was proned initially for 15 hours which did not improve his oxygenation. This, combined with significant hemodynamic instability, were contraindications for further proning. His condition continued to deteriorate progressing to multi-organ failure on day 7 (Day 14 of COVID-19 illness) which included acute respiratory failure, acute kidney injury requiring continuous renal replacement therapy and vasopressor support due to septic shock. His SOFA score increased to 12. He had continuing pyrexia and copious amounts of purulent respiratory secretions prompting a repeat septic screen which included culture of blood and endotracheal aspirate (ETA). Empiric antimicrobial therapy for hospital-acquired pneumonia with intravenous (IV) piperacillin-tazobactam (4.5g three times a day) was started. Subsequently, ETA culture grew Klebsiella varicola (susceptible to piperacillin-tazobactam), Aspergillus sp. and Candida albicans. Antifungal therapy with IV liposomal amphotericin B (3 mg per kg once daily) was commenced due to the patients rapidly deteriorating status and uncertainty of the full identification of the mould isolate which may be resistant to triazoles. The Aspergillus sp. was referred for further identification and antifungal susceptibility testing, as were serum samples for detection of 1–3, β-d-glucan (BDG) antigen and galactomannan (GM) antigen and ETA for GM antigen. His SOFA score on day 11 (Day 18 of COVID-19 illness) increased to 16. Antibiotic therapy was escalated to IV meropenem (1g twice daily) and vancomycin, with dosing based on renal function, due to ongoing pyrexia and deteriorating status. He was not prescribed systemic steroids at any time during his critical illness. A repeat portable chest radiograph on day 12 (Day 20 of COVID-19 illness) showed progression to additional right upper and lower zone peripheral airspace shadowing with no evidence of cavitation (Fig. 1B). He remained haemodynamically unstable which precluded further radiological investigations. In view of his non-responsive multi-organ failure, and after discussion with his family, the patient's life-support was withdrawn. He died on day 14 of hospitalization (Day 22 of COVID-19 illness). The Aspergillus sp. isolated from the ETA was confirmed to be A. fumigatus. Phenotypic testing utilising a 4-well triazole resistance screen (VIP check™, Mediaproducts BV, The Netherlands) (Fig. 2A and B) as well as determination of minimum inhibitory concentrations (MIC) utilising gradient strips (Liofilchem, Waltham MA, USA) were suggestive of triazole resistance (Table 1) [5]. The MIC to amphotericin was 0.125 mg/L (susceptible ≤ 1 mg/L) [5]. Genotypic testing utilising a commercial assay (Aspergenius™, Pathonostics B.V. The Netherlands) on the ETA detected A. fumigati complex with the TR34L98H resistance mutation in the cyp51A gene, the most common mutation in triazole-resistant A. fumigatus originating from an environmental source. The serum and ETA GM optical density index (ODI) were 1.1 and 5.5 respectively (Platelia™ Aspergillus Ag EIA, WA, USA). Serum BDG was 202 pg per milliliter (Fungitell™ Assay, Associates of Cape Cod, USA). These results (Table 1) were consistent with severe COVID-19 pneumonia and triazole-resistant invasive pulmonary aspergillus co-infection.Fig. 2 A and B VIPcheck™ plate, a four well triazole resistance screen plate which contains itraconazole (I) 4 mg per liter, voriconazole (V) 2 mg per liter, posaconazole. (P) 0.5 mg per liter, and growth control (GC). This is a simple phenotypic test used to screen for triazole resistance due to the common mutations in the cyp51A gene in A. fumigatus from an environmental source. The photos show a susceptible control strain AF293 (2A) where growth is only seen on GC well and the patient's isolate (2B) with growth in all wells consistent with findings seen in A. fumigatus with the cyp51A TR34/L98H mutation. Fig. 2 Table 1 Laboratory results. Table 1 Patient's Isolate A. fumigatus aClinical breakpoint > Resistant Antifungal Susceptibility Test Minimum inhibitory concentration (MIC) mg/L Voriconazole 2.0 1 Itraconazole >32 1 Posaconazole 1.0 0.25 Amphotericin B 0.125 1 Fungal antigensb Patient's results Cut-off Galactomannan Optical Density Index (ODI) Serum 1.1 ≥ 0.5 Tracheal aspirate 5.5 N/A 1,3 β-d-glucan pg/mL Serum 202 ≥ 80 a Based on the European Committee on Antimicrobial Susceptibility testing guidelines. b Fungal antigens: Galactomannan cut-off based on Platelia™ Aspergillus Ag EIA and 1–3 β-d-glucan cut-off based on Fungitell™ assay. 3 Discussion Previously known to cause infections in severely immunocompromised patients, A. fumigatus is now recognised as an emerging pathogen in critical care patients suffering chronic respiratory disorders and as a complication of severe influenza infection [6]. Aspergillus colonisation can rapidly lead to invasive aspergillosis following severe influenza infection due to multiple pathways including structural lung damage coupled with disruption of mucociliary clearance, leukopenia, Th1/Th2 imbalance and diffuse damage to the respiratory mucosa [7]. In addition, severe respiratory viral infections such as influenza have been identified as an independent risk factor for IPA with high mortality [6]. Although our patient did not receive steroids, their use in critical care patients is linked to increased risk of invasive fungal infections [6]. Like other causes of viral pneumonias, SARS-CoV-2 may impair local mucosal and systemic immune defenses [3]. Thirty-four cases of COVID-19 associated invasive aspergillosis (CAPA) have been reported to date [[8], [9], [10], [11], [12], [13], [14], [15], [16], [17]]. These were all patients with severe pneumonia with adult respiratory distress symdome, most of whom had no known history of immunocompromise. These has led to challenges in early diagnosis since most of them do not have the classical risk factors for invasive aspergillosis. Histopathology and culture from sterile site samples and biopsy remain the gold standard for proven IPA however the definition of probable or “putative” IPA has expanded but remains to be a composite of the host factors, clinical features and mycological evidence [6,18]. Although severe viral pneumonia is not considered a risk factor for IPA or other invasive mould disease according to the European Organisation for Research and Treatment of Cancer/Mycoses Study Group definitions, the structural damage to the lung parenchyma, in addition to the dysregulated immune response, can lead to IPA [6]. Recently a panel of experts proposed a case definition for influenza associated invasive aspergillosis (IAPA) which may be useful to classify COVID-19 patients with invasive aspergillosis. Following this case definition a patient with COVID-19 detected in respiratory sample by PCR, pulmonary infiltrates and a positive serum or bronchoalveolar lavage galactomannan has criteria consistent with probable CAPA [19]. Our patient had radiographic findings consistent with COVID-19 pneumonia. Unfortunately, his clinical status did not allow for computed tomography (CT) to be performed. Other mycological evidence of IPA include culture of Aspergillus sp. from non-sterile sites or detection of fungal antigens such as serum BDG. Our patient had COVID-19 pneumonia, A. fumigatus from a tracheal aspirate with elevated serum BDG and GM and elevated ETA GM, findings consistent with COVID-19 and probable IPA co-infection. Multi-triazole resistance in A. fumigatus has recently emerged and is linked to the use of triazole-containing compounds as agricultural fungicides or less commonly prolonged triazole use [20]. The former mechanism of resistance typically affects azole näive patients and is characterised by elevated MICs to itraconazole, voriconazole and posaconazole as was found in our patient. This is of serious concern since triazoles are recommended as the first-line and most effective treatment for IPA [21]. Of the 34 cases reported so far, only 7 cases had reported susceptibility results of which one was triazole resistant A. fumigatus [16] similar to our case. Our patient's exposure to fungicides daily in his work has most likely led to exposure and colonisation with triazole-resistant A. fumigatus which was further supported by detection of cyp51A TR34L98H mutation from our patient's ETA, the most prevalent triazole resistance mutation from environmental source [20]. This case highlights the importance of early evaluation of patients with COVID-19 pneumonia because of the risk of secondary or co-infection with fungal pathogens. Case definitions have been proposed for IAPA [6,19] which can be modified for early recognition of CAPA. The occurrence of multi-triazole resistance in this case emphasises the urgent need for antifungal drug susceptibility testing of Aspergillus isolates using a rapid and simple phenotypic method and/or by detection of Cyp51 gene associated triazole resistance mutations directly on respiratory samples. Funding sources This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declaration of competing interestCOI T.R.Rogers has received grants and personal fees from 10.13039/100005564 Gilead Sciences , personal fees from 10.13039/100015278 Pfizer Healthcare Ireland , personal fees from Menarini Pharma outside the submitted work, A.F.Talento has received grant and personal fees from 10.13039/100005564 Gilead Sciences and personal fees from 10.13039/100015278 Pfizer Healthcare Ireland outside the submitted work. The other authors have no conflict of interests.	Oral	DrugAdministrationRoute	CC BY-NC-ND	32837879	19,468,704	2021-03
What was the administration route of drug 'MEROPENEM'?	Multi-triazole-resistant Aspergillus fumigatus and SARS-CoV-2 co-infection: A lethal combination. We report a case of severe COVID-19 pneumonia complicated by fatal co-infection with a multi-triazole resistant Aspergillus fumigatus and highlight the importance of recognising the significance of Aspergillus sp. isolation from respiratory samples. Early diagnosis and detection of triazole resistance are essential for appropriate antifungal therapy to improve outcome in patients with coronavirus associated invasive aspergillosis. 1 Introduction Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causing COVID-19 infection, is a newly recognised pathogen that has been traced to Wuhan (Hubei province) in China [1]. The clinical spectrum of COVID-19 varies from asymptomatic infection to severe pneumonia requiring mechanical ventilation. The overall case fatality rate is estimated to be 2.7%, which increases to 4.5% in those ≥ 60 years old [2]. Secondary infections with bacterial and fungal pathogens have been reported in patients with COVID-19 pneumonia which may be due to virus induced mucosal damage and/or the dysregulated immune response seen in patients with acute respiratory distress syndrome [3,4]. We report severe COVID-19 pneumonia with multi-triazole-resistant Aspergillus fumigatus co-infection in a patient not known to be immunocompromised to highlight the importance of early diagnosis and detection of triazole resistance. 2 Case A 66-year-old male presented to the emergency department with a history of progressive shortness of breath (SOB), myalgia, headaches, non-productive cough and fever. Two days previously, he had contacted his general practitioner (GP) describing a seven-day history of fever and cough. He had returned from the United Kingdom eight days earlier after visiting a relative who was subsequently diagnosed with COVID-19. He was advised to self-isolate and monitor his symptoms. Due to progressive SOB, he re-presented to his GP who referred him to the hospital for further management. The patient had Type 2 diabetes mellitus, hypertension, hyperlipidaemia and obesity with a body mass index of 35.5 (weight 90kg) with no hospital admissions in the past eight years. His medications included metformin, aspirin, simvastatin and ramipril. He had no history of prior triazole antifungal therapy. He was an ex-smoker but had not been previously diagnosed to have chronic lung disease. He works as a ground maintenance personnel where he is exposed to fungicides daily. On presentation, a portable chest radiograph was performed which showed unilateral peripheral left basal airspace shadowing (Fig. 1A). In view of the clinical presentation, radiographic findings and the recent exposure history, the patient was admitted under contact and droplet precautions.Fig. 1 A. Portable chest radiograph taken on day of admission showing unilateral peripheral left basal airspace shadowing. B. Portable chest radiograph taken on Day 12 of hospitalization (Day 20 of COVID-19 infection). The endotracheal tube and bilateral central lines are in satisfactory position. There has been interval progression of the left peripheral airspace shadowing with additional right upper and lower zone peripheral airspace shadowing with no evidence of cavitation. Fig. 1 On admission (Day 7 of COVID-19 illness), the patient was noted to be pyrexial (temperature of 38.6 °C), tachycardic (pulse rate of 174 beats per minute) with new onset atrial fibrillation, normotensive (BP 117/69 mmHg), tachypnic (24 breaths per minute) with oxygen saturation of 84% on room air. He was commenced on a trial of continuous positive airway pressure with oxygen therapy. Preliminary laboratory results revealed white cell count of 4.7 × 109/L (reference range 4.0–11.0 × 109/L), neutrophil count 3.0 × 109/L (reference range 2.0–7.0 × 109/L), lymphocyte count 0.8 × 109/L (reference range 1.0–3.0 × 109/L) and C-reactive protein of 118 mg/L (reference range < 5.0 mg/L). Nasopharyngeal and oropharyngeal swabs detected SARS-CoV-2 using real-time reverse transcriptase polymerase chain reaction on day 3. He was commenced on azithromycin (500 mg on day 1 and 250 once daily on days 2 and 3) and hydroxychloroquine (200 mg twice daily) orally as per our local protocol at that time. On day 4 (Day 11 of COVID-19 illness) he developed worsening hypoxic respiratory failure with a Sequential Organ Failure Assessment (SOFA) score of 6 necessitating intensive care unit (ICU) admission for ventilatory support. The patient was proned initially for 15 hours which did not improve his oxygenation. This, combined with significant hemodynamic instability, were contraindications for further proning. His condition continued to deteriorate progressing to multi-organ failure on day 7 (Day 14 of COVID-19 illness) which included acute respiratory failure, acute kidney injury requiring continuous renal replacement therapy and vasopressor support due to septic shock. His SOFA score increased to 12. He had continuing pyrexia and copious amounts of purulent respiratory secretions prompting a repeat septic screen which included culture of blood and endotracheal aspirate (ETA). Empiric antimicrobial therapy for hospital-acquired pneumonia with intravenous (IV) piperacillin-tazobactam (4.5g three times a day) was started. Subsequently, ETA culture grew Klebsiella varicola (susceptible to piperacillin-tazobactam), Aspergillus sp. and Candida albicans. Antifungal therapy with IV liposomal amphotericin B (3 mg per kg once daily) was commenced due to the patients rapidly deteriorating status and uncertainty of the full identification of the mould isolate which may be resistant to triazoles. The Aspergillus sp. was referred for further identification and antifungal susceptibility testing, as were serum samples for detection of 1–3, β-d-glucan (BDG) antigen and galactomannan (GM) antigen and ETA for GM antigen. His SOFA score on day 11 (Day 18 of COVID-19 illness) increased to 16. Antibiotic therapy was escalated to IV meropenem (1g twice daily) and vancomycin, with dosing based on renal function, due to ongoing pyrexia and deteriorating status. He was not prescribed systemic steroids at any time during his critical illness. A repeat portable chest radiograph on day 12 (Day 20 of COVID-19 illness) showed progression to additional right upper and lower zone peripheral airspace shadowing with no evidence of cavitation (Fig. 1B). He remained haemodynamically unstable which precluded further radiological investigations. In view of his non-responsive multi-organ failure, and after discussion with his family, the patient's life-support was withdrawn. He died on day 14 of hospitalization (Day 22 of COVID-19 illness). The Aspergillus sp. isolated from the ETA was confirmed to be A. fumigatus. Phenotypic testing utilising a 4-well triazole resistance screen (VIP check™, Mediaproducts BV, The Netherlands) (Fig. 2A and B) as well as determination of minimum inhibitory concentrations (MIC) utilising gradient strips (Liofilchem, Waltham MA, USA) were suggestive of triazole resistance (Table 1) [5]. The MIC to amphotericin was 0.125 mg/L (susceptible ≤ 1 mg/L) [5]. Genotypic testing utilising a commercial assay (Aspergenius™, Pathonostics B.V. The Netherlands) on the ETA detected A. fumigati complex with the TR34L98H resistance mutation in the cyp51A gene, the most common mutation in triazole-resistant A. fumigatus originating from an environmental source. The serum and ETA GM optical density index (ODI) were 1.1 and 5.5 respectively (Platelia™ Aspergillus Ag EIA, WA, USA). Serum BDG was 202 pg per milliliter (Fungitell™ Assay, Associates of Cape Cod, USA). These results (Table 1) were consistent with severe COVID-19 pneumonia and triazole-resistant invasive pulmonary aspergillus co-infection.Fig. 2 A and B VIPcheck™ plate, a four well triazole resistance screen plate which contains itraconazole (I) 4 mg per liter, voriconazole (V) 2 mg per liter, posaconazole. (P) 0.5 mg per liter, and growth control (GC). This is a simple phenotypic test used to screen for triazole resistance due to the common mutations in the cyp51A gene in A. fumigatus from an environmental source. The photos show a susceptible control strain AF293 (2A) where growth is only seen on GC well and the patient's isolate (2B) with growth in all wells consistent with findings seen in A. fumigatus with the cyp51A TR34/L98H mutation. Fig. 2 Table 1 Laboratory results. Table 1 Patient's Isolate A. fumigatus aClinical breakpoint > Resistant Antifungal Susceptibility Test Minimum inhibitory concentration (MIC) mg/L Voriconazole 2.0 1 Itraconazole >32 1 Posaconazole 1.0 0.25 Amphotericin B 0.125 1 Fungal antigensb Patient's results Cut-off Galactomannan Optical Density Index (ODI) Serum 1.1 ≥ 0.5 Tracheal aspirate 5.5 N/A 1,3 β-d-glucan pg/mL Serum 202 ≥ 80 a Based on the European Committee on Antimicrobial Susceptibility testing guidelines. b Fungal antigens: Galactomannan cut-off based on Platelia™ Aspergillus Ag EIA and 1–3 β-d-glucan cut-off based on Fungitell™ assay. 3 Discussion Previously known to cause infections in severely immunocompromised patients, A. fumigatus is now recognised as an emerging pathogen in critical care patients suffering chronic respiratory disorders and as a complication of severe influenza infection [6]. Aspergillus colonisation can rapidly lead to invasive aspergillosis following severe influenza infection due to multiple pathways including structural lung damage coupled with disruption of mucociliary clearance, leukopenia, Th1/Th2 imbalance and diffuse damage to the respiratory mucosa [7]. In addition, severe respiratory viral infections such as influenza have been identified as an independent risk factor for IPA with high mortality [6]. Although our patient did not receive steroids, their use in critical care patients is linked to increased risk of invasive fungal infections [6]. Like other causes of viral pneumonias, SARS-CoV-2 may impair local mucosal and systemic immune defenses [3]. Thirty-four cases of COVID-19 associated invasive aspergillosis (CAPA) have been reported to date [[8], [9], [10], [11], [12], [13], [14], [15], [16], [17]]. These were all patients with severe pneumonia with adult respiratory distress symdome, most of whom had no known history of immunocompromise. These has led to challenges in early diagnosis since most of them do not have the classical risk factors for invasive aspergillosis. Histopathology and culture from sterile site samples and biopsy remain the gold standard for proven IPA however the definition of probable or “putative” IPA has expanded but remains to be a composite of the host factors, clinical features and mycological evidence [6,18]. Although severe viral pneumonia is not considered a risk factor for IPA or other invasive mould disease according to the European Organisation for Research and Treatment of Cancer/Mycoses Study Group definitions, the structural damage to the lung parenchyma, in addition to the dysregulated immune response, can lead to IPA [6]. Recently a panel of experts proposed a case definition for influenza associated invasive aspergillosis (IAPA) which may be useful to classify COVID-19 patients with invasive aspergillosis. Following this case definition a patient with COVID-19 detected in respiratory sample by PCR, pulmonary infiltrates and a positive serum or bronchoalveolar lavage galactomannan has criteria consistent with probable CAPA [19]. Our patient had radiographic findings consistent with COVID-19 pneumonia. Unfortunately, his clinical status did not allow for computed tomography (CT) to be performed. Other mycological evidence of IPA include culture of Aspergillus sp. from non-sterile sites or detection of fungal antigens such as serum BDG. Our patient had COVID-19 pneumonia, A. fumigatus from a tracheal aspirate with elevated serum BDG and GM and elevated ETA GM, findings consistent with COVID-19 and probable IPA co-infection. Multi-triazole resistance in A. fumigatus has recently emerged and is linked to the use of triazole-containing compounds as agricultural fungicides or less commonly prolonged triazole use [20]. The former mechanism of resistance typically affects azole näive patients and is characterised by elevated MICs to itraconazole, voriconazole and posaconazole as was found in our patient. This is of serious concern since triazoles are recommended as the first-line and most effective treatment for IPA [21]. Of the 34 cases reported so far, only 7 cases had reported susceptibility results of which one was triazole resistant A. fumigatus [16] similar to our case. Our patient's exposure to fungicides daily in his work has most likely led to exposure and colonisation with triazole-resistant A. fumigatus which was further supported by detection of cyp51A TR34L98H mutation from our patient's ETA, the most prevalent triazole resistance mutation from environmental source [20]. This case highlights the importance of early evaluation of patients with COVID-19 pneumonia because of the risk of secondary or co-infection with fungal pathogens. Case definitions have been proposed for IAPA [6,19] which can be modified for early recognition of CAPA. The occurrence of multi-triazole resistance in this case emphasises the urgent need for antifungal drug susceptibility testing of Aspergillus isolates using a rapid and simple phenotypic method and/or by detection of Cyp51 gene associated triazole resistance mutations directly on respiratory samples. Funding sources This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declaration of competing interestCOI T.R.Rogers has received grants and personal fees from 10.13039/100005564 Gilead Sciences , personal fees from 10.13039/100015278 Pfizer Healthcare Ireland , personal fees from Menarini Pharma outside the submitted work, A.F.Talento has received grant and personal fees from 10.13039/100005564 Gilead Sciences and personal fees from 10.13039/100015278 Pfizer Healthcare Ireland outside the submitted work. The other authors have no conflict of interests.	Intravenous (not otherwise specified)	DrugAdministrationRoute	CC BY-NC-ND	32837879	19,468,704	2021-03
What was the administration route of drug 'PIPERACILLIN SODIUM\TAZOBACTAM SODIUM'?	Multi-triazole-resistant Aspergillus fumigatus and SARS-CoV-2 co-infection: A lethal combination. We report a case of severe COVID-19 pneumonia complicated by fatal co-infection with a multi-triazole resistant Aspergillus fumigatus and highlight the importance of recognising the significance of Aspergillus sp. isolation from respiratory samples. Early diagnosis and detection of triazole resistance are essential for appropriate antifungal therapy to improve outcome in patients with coronavirus associated invasive aspergillosis. 1 Introduction Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causing COVID-19 infection, is a newly recognised pathogen that has been traced to Wuhan (Hubei province) in China [1]. The clinical spectrum of COVID-19 varies from asymptomatic infection to severe pneumonia requiring mechanical ventilation. The overall case fatality rate is estimated to be 2.7%, which increases to 4.5% in those ≥ 60 years old [2]. Secondary infections with bacterial and fungal pathogens have been reported in patients with COVID-19 pneumonia which may be due to virus induced mucosal damage and/or the dysregulated immune response seen in patients with acute respiratory distress syndrome [3,4]. We report severe COVID-19 pneumonia with multi-triazole-resistant Aspergillus fumigatus co-infection in a patient not known to be immunocompromised to highlight the importance of early diagnosis and detection of triazole resistance. 2 Case A 66-year-old male presented to the emergency department with a history of progressive shortness of breath (SOB), myalgia, headaches, non-productive cough and fever. Two days previously, he had contacted his general practitioner (GP) describing a seven-day history of fever and cough. He had returned from the United Kingdom eight days earlier after visiting a relative who was subsequently diagnosed with COVID-19. He was advised to self-isolate and monitor his symptoms. Due to progressive SOB, he re-presented to his GP who referred him to the hospital for further management. The patient had Type 2 diabetes mellitus, hypertension, hyperlipidaemia and obesity with a body mass index of 35.5 (weight 90kg) with no hospital admissions in the past eight years. His medications included metformin, aspirin, simvastatin and ramipril. He had no history of prior triazole antifungal therapy. He was an ex-smoker but had not been previously diagnosed to have chronic lung disease. He works as a ground maintenance personnel where he is exposed to fungicides daily. On presentation, a portable chest radiograph was performed which showed unilateral peripheral left basal airspace shadowing (Fig. 1A). In view of the clinical presentation, radiographic findings and the recent exposure history, the patient was admitted under contact and droplet precautions.Fig. 1 A. Portable chest radiograph taken on day of admission showing unilateral peripheral left basal airspace shadowing. B. Portable chest radiograph taken on Day 12 of hospitalization (Day 20 of COVID-19 infection). The endotracheal tube and bilateral central lines are in satisfactory position. There has been interval progression of the left peripheral airspace shadowing with additional right upper and lower zone peripheral airspace shadowing with no evidence of cavitation. Fig. 1 On admission (Day 7 of COVID-19 illness), the patient was noted to be pyrexial (temperature of 38.6 °C), tachycardic (pulse rate of 174 beats per minute) with new onset atrial fibrillation, normotensive (BP 117/69 mmHg), tachypnic (24 breaths per minute) with oxygen saturation of 84% on room air. He was commenced on a trial of continuous positive airway pressure with oxygen therapy. Preliminary laboratory results revealed white cell count of 4.7 × 109/L (reference range 4.0–11.0 × 109/L), neutrophil count 3.0 × 109/L (reference range 2.0–7.0 × 109/L), lymphocyte count 0.8 × 109/L (reference range 1.0–3.0 × 109/L) and C-reactive protein of 118 mg/L (reference range < 5.0 mg/L). Nasopharyngeal and oropharyngeal swabs detected SARS-CoV-2 using real-time reverse transcriptase polymerase chain reaction on day 3. He was commenced on azithromycin (500 mg on day 1 and 250 once daily on days 2 and 3) and hydroxychloroquine (200 mg twice daily) orally as per our local protocol at that time. On day 4 (Day 11 of COVID-19 illness) he developed worsening hypoxic respiratory failure with a Sequential Organ Failure Assessment (SOFA) score of 6 necessitating intensive care unit (ICU) admission for ventilatory support. The patient was proned initially for 15 hours which did not improve his oxygenation. This, combined with significant hemodynamic instability, were contraindications for further proning. His condition continued to deteriorate progressing to multi-organ failure on day 7 (Day 14 of COVID-19 illness) which included acute respiratory failure, acute kidney injury requiring continuous renal replacement therapy and vasopressor support due to septic shock. His SOFA score increased to 12. He had continuing pyrexia and copious amounts of purulent respiratory secretions prompting a repeat septic screen which included culture of blood and endotracheal aspirate (ETA). Empiric antimicrobial therapy for hospital-acquired pneumonia with intravenous (IV) piperacillin-tazobactam (4.5g three times a day) was started. Subsequently, ETA culture grew Klebsiella varicola (susceptible to piperacillin-tazobactam), Aspergillus sp. and Candida albicans. Antifungal therapy with IV liposomal amphotericin B (3 mg per kg once daily) was commenced due to the patients rapidly deteriorating status and uncertainty of the full identification of the mould isolate which may be resistant to triazoles. The Aspergillus sp. was referred for further identification and antifungal susceptibility testing, as were serum samples for detection of 1–3, β-d-glucan (BDG) antigen and galactomannan (GM) antigen and ETA for GM antigen. His SOFA score on day 11 (Day 18 of COVID-19 illness) increased to 16. Antibiotic therapy was escalated to IV meropenem (1g twice daily) and vancomycin, with dosing based on renal function, due to ongoing pyrexia and deteriorating status. He was not prescribed systemic steroids at any time during his critical illness. A repeat portable chest radiograph on day 12 (Day 20 of COVID-19 illness) showed progression to additional right upper and lower zone peripheral airspace shadowing with no evidence of cavitation (Fig. 1B). He remained haemodynamically unstable which precluded further radiological investigations. In view of his non-responsive multi-organ failure, and after discussion with his family, the patient's life-support was withdrawn. He died on day 14 of hospitalization (Day 22 of COVID-19 illness). The Aspergillus sp. isolated from the ETA was confirmed to be A. fumigatus. Phenotypic testing utilising a 4-well triazole resistance screen (VIP check™, Mediaproducts BV, The Netherlands) (Fig. 2A and B) as well as determination of minimum inhibitory concentrations (MIC) utilising gradient strips (Liofilchem, Waltham MA, USA) were suggestive of triazole resistance (Table 1) [5]. The MIC to amphotericin was 0.125 mg/L (susceptible ≤ 1 mg/L) [5]. Genotypic testing utilising a commercial assay (Aspergenius™, Pathonostics B.V. The Netherlands) on the ETA detected A. fumigati complex with the TR34L98H resistance mutation in the cyp51A gene, the most common mutation in triazole-resistant A. fumigatus originating from an environmental source. The serum and ETA GM optical density index (ODI) were 1.1 and 5.5 respectively (Platelia™ Aspergillus Ag EIA, WA, USA). Serum BDG was 202 pg per milliliter (Fungitell™ Assay, Associates of Cape Cod, USA). These results (Table 1) were consistent with severe COVID-19 pneumonia and triazole-resistant invasive pulmonary aspergillus co-infection.Fig. 2 A and B VIPcheck™ plate, a four well triazole resistance screen plate which contains itraconazole (I) 4 mg per liter, voriconazole (V) 2 mg per liter, posaconazole. (P) 0.5 mg per liter, and growth control (GC). This is a simple phenotypic test used to screen for triazole resistance due to the common mutations in the cyp51A gene in A. fumigatus from an environmental source. The photos show a susceptible control strain AF293 (2A) where growth is only seen on GC well and the patient's isolate (2B) with growth in all wells consistent with findings seen in A. fumigatus with the cyp51A TR34/L98H mutation. Fig. 2 Table 1 Laboratory results. Table 1 Patient's Isolate A. fumigatus aClinical breakpoint > Resistant Antifungal Susceptibility Test Minimum inhibitory concentration (MIC) mg/L Voriconazole 2.0 1 Itraconazole >32 1 Posaconazole 1.0 0.25 Amphotericin B 0.125 1 Fungal antigensb Patient's results Cut-off Galactomannan Optical Density Index (ODI) Serum 1.1 ≥ 0.5 Tracheal aspirate 5.5 N/A 1,3 β-d-glucan pg/mL Serum 202 ≥ 80 a Based on the European Committee on Antimicrobial Susceptibility testing guidelines. b Fungal antigens: Galactomannan cut-off based on Platelia™ Aspergillus Ag EIA and 1–3 β-d-glucan cut-off based on Fungitell™ assay. 3 Discussion Previously known to cause infections in severely immunocompromised patients, A. fumigatus is now recognised as an emerging pathogen in critical care patients suffering chronic respiratory disorders and as a complication of severe influenza infection [6]. Aspergillus colonisation can rapidly lead to invasive aspergillosis following severe influenza infection due to multiple pathways including structural lung damage coupled with disruption of mucociliary clearance, leukopenia, Th1/Th2 imbalance and diffuse damage to the respiratory mucosa [7]. In addition, severe respiratory viral infections such as influenza have been identified as an independent risk factor for IPA with high mortality [6]. Although our patient did not receive steroids, their use in critical care patients is linked to increased risk of invasive fungal infections [6]. Like other causes of viral pneumonias, SARS-CoV-2 may impair local mucosal and systemic immune defenses [3]. Thirty-four cases of COVID-19 associated invasive aspergillosis (CAPA) have been reported to date [[8], [9], [10], [11], [12], [13], [14], [15], [16], [17]]. These were all patients with severe pneumonia with adult respiratory distress symdome, most of whom had no known history of immunocompromise. These has led to challenges in early diagnosis since most of them do not have the classical risk factors for invasive aspergillosis. Histopathology and culture from sterile site samples and biopsy remain the gold standard for proven IPA however the definition of probable or “putative” IPA has expanded but remains to be a composite of the host factors, clinical features and mycological evidence [6,18]. Although severe viral pneumonia is not considered a risk factor for IPA or other invasive mould disease according to the European Organisation for Research and Treatment of Cancer/Mycoses Study Group definitions, the structural damage to the lung parenchyma, in addition to the dysregulated immune response, can lead to IPA [6]. Recently a panel of experts proposed a case definition for influenza associated invasive aspergillosis (IAPA) which may be useful to classify COVID-19 patients with invasive aspergillosis. Following this case definition a patient with COVID-19 detected in respiratory sample by PCR, pulmonary infiltrates and a positive serum or bronchoalveolar lavage galactomannan has criteria consistent with probable CAPA [19]. Our patient had radiographic findings consistent with COVID-19 pneumonia. Unfortunately, his clinical status did not allow for computed tomography (CT) to be performed. Other mycological evidence of IPA include culture of Aspergillus sp. from non-sterile sites or detection of fungal antigens such as serum BDG. Our patient had COVID-19 pneumonia, A. fumigatus from a tracheal aspirate with elevated serum BDG and GM and elevated ETA GM, findings consistent with COVID-19 and probable IPA co-infection. Multi-triazole resistance in A. fumigatus has recently emerged and is linked to the use of triazole-containing compounds as agricultural fungicides or less commonly prolonged triazole use [20]. The former mechanism of resistance typically affects azole näive patients and is characterised by elevated MICs to itraconazole, voriconazole and posaconazole as was found in our patient. This is of serious concern since triazoles are recommended as the first-line and most effective treatment for IPA [21]. Of the 34 cases reported so far, only 7 cases had reported susceptibility results of which one was triazole resistant A. fumigatus [16] similar to our case. Our patient's exposure to fungicides daily in his work has most likely led to exposure and colonisation with triazole-resistant A. fumigatus which was further supported by detection of cyp51A TR34L98H mutation from our patient's ETA, the most prevalent triazole resistance mutation from environmental source [20]. This case highlights the importance of early evaluation of patients with COVID-19 pneumonia because of the risk of secondary or co-infection with fungal pathogens. Case definitions have been proposed for IAPA [6,19] which can be modified for early recognition of CAPA. The occurrence of multi-triazole resistance in this case emphasises the urgent need for antifungal drug susceptibility testing of Aspergillus isolates using a rapid and simple phenotypic method and/or by detection of Cyp51 gene associated triazole resistance mutations directly on respiratory samples. Funding sources This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declaration of competing interestCOI T.R.Rogers has received grants and personal fees from 10.13039/100005564 Gilead Sciences , personal fees from 10.13039/100015278 Pfizer Healthcare Ireland , personal fees from Menarini Pharma outside the submitted work, A.F.Talento has received grant and personal fees from 10.13039/100005564 Gilead Sciences and personal fees from 10.13039/100015278 Pfizer Healthcare Ireland outside the submitted work. The other authors have no conflict of interests.	Intravenous (not otherwise specified)	DrugAdministrationRoute	CC BY-NC-ND	32837879	19,468,704	2021-03
What was the dosage of drug 'MEROPENEM'?	Multi-triazole-resistant Aspergillus fumigatus and SARS-CoV-2 co-infection: A lethal combination. We report a case of severe COVID-19 pneumonia complicated by fatal co-infection with a multi-triazole resistant Aspergillus fumigatus and highlight the importance of recognising the significance of Aspergillus sp. isolation from respiratory samples. Early diagnosis and detection of triazole resistance are essential for appropriate antifungal therapy to improve outcome in patients with coronavirus associated invasive aspergillosis. 1 Introduction Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causing COVID-19 infection, is a newly recognised pathogen that has been traced to Wuhan (Hubei province) in China [1]. The clinical spectrum of COVID-19 varies from asymptomatic infection to severe pneumonia requiring mechanical ventilation. The overall case fatality rate is estimated to be 2.7%, which increases to 4.5% in those ≥ 60 years old [2]. Secondary infections with bacterial and fungal pathogens have been reported in patients with COVID-19 pneumonia which may be due to virus induced mucosal damage and/or the dysregulated immune response seen in patients with acute respiratory distress syndrome [3,4]. We report severe COVID-19 pneumonia with multi-triazole-resistant Aspergillus fumigatus co-infection in a patient not known to be immunocompromised to highlight the importance of early diagnosis and detection of triazole resistance. 2 Case A 66-year-old male presented to the emergency department with a history of progressive shortness of breath (SOB), myalgia, headaches, non-productive cough and fever. Two days previously, he had contacted his general practitioner (GP) describing a seven-day history of fever and cough. He had returned from the United Kingdom eight days earlier after visiting a relative who was subsequently diagnosed with COVID-19. He was advised to self-isolate and monitor his symptoms. Due to progressive SOB, he re-presented to his GP who referred him to the hospital for further management. The patient had Type 2 diabetes mellitus, hypertension, hyperlipidaemia and obesity with a body mass index of 35.5 (weight 90kg) with no hospital admissions in the past eight years. His medications included metformin, aspirin, simvastatin and ramipril. He had no history of prior triazole antifungal therapy. He was an ex-smoker but had not been previously diagnosed to have chronic lung disease. He works as a ground maintenance personnel where he is exposed to fungicides daily. On presentation, a portable chest radiograph was performed which showed unilateral peripheral left basal airspace shadowing (Fig. 1A). In view of the clinical presentation, radiographic findings and the recent exposure history, the patient was admitted under contact and droplet precautions.Fig. 1 A. Portable chest radiograph taken on day of admission showing unilateral peripheral left basal airspace shadowing. B. Portable chest radiograph taken on Day 12 of hospitalization (Day 20 of COVID-19 infection). The endotracheal tube and bilateral central lines are in satisfactory position. There has been interval progression of the left peripheral airspace shadowing with additional right upper and lower zone peripheral airspace shadowing with no evidence of cavitation. Fig. 1 On admission (Day 7 of COVID-19 illness), the patient was noted to be pyrexial (temperature of 38.6 °C), tachycardic (pulse rate of 174 beats per minute) with new onset atrial fibrillation, normotensive (BP 117/69 mmHg), tachypnic (24 breaths per minute) with oxygen saturation of 84% on room air. He was commenced on a trial of continuous positive airway pressure with oxygen therapy. Preliminary laboratory results revealed white cell count of 4.7 × 109/L (reference range 4.0–11.0 × 109/L), neutrophil count 3.0 × 109/L (reference range 2.0–7.0 × 109/L), lymphocyte count 0.8 × 109/L (reference range 1.0–3.0 × 109/L) and C-reactive protein of 118 mg/L (reference range < 5.0 mg/L). Nasopharyngeal and oropharyngeal swabs detected SARS-CoV-2 using real-time reverse transcriptase polymerase chain reaction on day 3. He was commenced on azithromycin (500 mg on day 1 and 250 once daily on days 2 and 3) and hydroxychloroquine (200 mg twice daily) orally as per our local protocol at that time. On day 4 (Day 11 of COVID-19 illness) he developed worsening hypoxic respiratory failure with a Sequential Organ Failure Assessment (SOFA) score of 6 necessitating intensive care unit (ICU) admission for ventilatory support. The patient was proned initially for 15 hours which did not improve his oxygenation. This, combined with significant hemodynamic instability, were contraindications for further proning. His condition continued to deteriorate progressing to multi-organ failure on day 7 (Day 14 of COVID-19 illness) which included acute respiratory failure, acute kidney injury requiring continuous renal replacement therapy and vasopressor support due to septic shock. His SOFA score increased to 12. He had continuing pyrexia and copious amounts of purulent respiratory secretions prompting a repeat septic screen which included culture of blood and endotracheal aspirate (ETA). Empiric antimicrobial therapy for hospital-acquired pneumonia with intravenous (IV) piperacillin-tazobactam (4.5g three times a day) was started. Subsequently, ETA culture grew Klebsiella varicola (susceptible to piperacillin-tazobactam), Aspergillus sp. and Candida albicans. Antifungal therapy with IV liposomal amphotericin B (3 mg per kg once daily) was commenced due to the patients rapidly deteriorating status and uncertainty of the full identification of the mould isolate which may be resistant to triazoles. The Aspergillus sp. was referred for further identification and antifungal susceptibility testing, as were serum samples for detection of 1–3, β-d-glucan (BDG) antigen and galactomannan (GM) antigen and ETA for GM antigen. His SOFA score on day 11 (Day 18 of COVID-19 illness) increased to 16. Antibiotic therapy was escalated to IV meropenem (1g twice daily) and vancomycin, with dosing based on renal function, due to ongoing pyrexia and deteriorating status. He was not prescribed systemic steroids at any time during his critical illness. A repeat portable chest radiograph on day 12 (Day 20 of COVID-19 illness) showed progression to additional right upper and lower zone peripheral airspace shadowing with no evidence of cavitation (Fig. 1B). He remained haemodynamically unstable which precluded further radiological investigations. In view of his non-responsive multi-organ failure, and after discussion with his family, the patient's life-support was withdrawn. He died on day 14 of hospitalization (Day 22 of COVID-19 illness). The Aspergillus sp. isolated from the ETA was confirmed to be A. fumigatus. Phenotypic testing utilising a 4-well triazole resistance screen (VIP check™, Mediaproducts BV, The Netherlands) (Fig. 2A and B) as well as determination of minimum inhibitory concentrations (MIC) utilising gradient strips (Liofilchem, Waltham MA, USA) were suggestive of triazole resistance (Table 1) [5]. The MIC to amphotericin was 0.125 mg/L (susceptible ≤ 1 mg/L) [5]. Genotypic testing utilising a commercial assay (Aspergenius™, Pathonostics B.V. The Netherlands) on the ETA detected A. fumigati complex with the TR34L98H resistance mutation in the cyp51A gene, the most common mutation in triazole-resistant A. fumigatus originating from an environmental source. The serum and ETA GM optical density index (ODI) were 1.1 and 5.5 respectively (Platelia™ Aspergillus Ag EIA, WA, USA). Serum BDG was 202 pg per milliliter (Fungitell™ Assay, Associates of Cape Cod, USA). These results (Table 1) were consistent with severe COVID-19 pneumonia and triazole-resistant invasive pulmonary aspergillus co-infection.Fig. 2 A and B VIPcheck™ plate, a four well triazole resistance screen plate which contains itraconazole (I) 4 mg per liter, voriconazole (V) 2 mg per liter, posaconazole. (P) 0.5 mg per liter, and growth control (GC). This is a simple phenotypic test used to screen for triazole resistance due to the common mutations in the cyp51A gene in A. fumigatus from an environmental source. The photos show a susceptible control strain AF293 (2A) where growth is only seen on GC well and the patient's isolate (2B) with growth in all wells consistent with findings seen in A. fumigatus with the cyp51A TR34/L98H mutation. Fig. 2 Table 1 Laboratory results. Table 1 Patient's Isolate A. fumigatus aClinical breakpoint > Resistant Antifungal Susceptibility Test Minimum inhibitory concentration (MIC) mg/L Voriconazole 2.0 1 Itraconazole >32 1 Posaconazole 1.0 0.25 Amphotericin B 0.125 1 Fungal antigensb Patient's results Cut-off Galactomannan Optical Density Index (ODI) Serum 1.1 ≥ 0.5 Tracheal aspirate 5.5 N/A 1,3 β-d-glucan pg/mL Serum 202 ≥ 80 a Based on the European Committee on Antimicrobial Susceptibility testing guidelines. b Fungal antigens: Galactomannan cut-off based on Platelia™ Aspergillus Ag EIA and 1–3 β-d-glucan cut-off based on Fungitell™ assay. 3 Discussion Previously known to cause infections in severely immunocompromised patients, A. fumigatus is now recognised as an emerging pathogen in critical care patients suffering chronic respiratory disorders and as a complication of severe influenza infection [6]. Aspergillus colonisation can rapidly lead to invasive aspergillosis following severe influenza infection due to multiple pathways including structural lung damage coupled with disruption of mucociliary clearance, leukopenia, Th1/Th2 imbalance and diffuse damage to the respiratory mucosa [7]. In addition, severe respiratory viral infections such as influenza have been identified as an independent risk factor for IPA with high mortality [6]. Although our patient did not receive steroids, their use in critical care patients is linked to increased risk of invasive fungal infections [6]. Like other causes of viral pneumonias, SARS-CoV-2 may impair local mucosal and systemic immune defenses [3]. Thirty-four cases of COVID-19 associated invasive aspergillosis (CAPA) have been reported to date [[8], [9], [10], [11], [12], [13], [14], [15], [16], [17]]. These were all patients with severe pneumonia with adult respiratory distress symdome, most of whom had no known history of immunocompromise. These has led to challenges in early diagnosis since most of them do not have the classical risk factors for invasive aspergillosis. Histopathology and culture from sterile site samples and biopsy remain the gold standard for proven IPA however the definition of probable or “putative” IPA has expanded but remains to be a composite of the host factors, clinical features and mycological evidence [6,18]. Although severe viral pneumonia is not considered a risk factor for IPA or other invasive mould disease according to the European Organisation for Research and Treatment of Cancer/Mycoses Study Group definitions, the structural damage to the lung parenchyma, in addition to the dysregulated immune response, can lead to IPA [6]. Recently a panel of experts proposed a case definition for influenza associated invasive aspergillosis (IAPA) which may be useful to classify COVID-19 patients with invasive aspergillosis. Following this case definition a patient with COVID-19 detected in respiratory sample by PCR, pulmonary infiltrates and a positive serum or bronchoalveolar lavage galactomannan has criteria consistent with probable CAPA [19]. Our patient had radiographic findings consistent with COVID-19 pneumonia. Unfortunately, his clinical status did not allow for computed tomography (CT) to be performed. Other mycological evidence of IPA include culture of Aspergillus sp. from non-sterile sites or detection of fungal antigens such as serum BDG. Our patient had COVID-19 pneumonia, A. fumigatus from a tracheal aspirate with elevated serum BDG and GM and elevated ETA GM, findings consistent with COVID-19 and probable IPA co-infection. Multi-triazole resistance in A. fumigatus has recently emerged and is linked to the use of triazole-containing compounds as agricultural fungicides or less commonly prolonged triazole use [20]. The former mechanism of resistance typically affects azole näive patients and is characterised by elevated MICs to itraconazole, voriconazole and posaconazole as was found in our patient. This is of serious concern since triazoles are recommended as the first-line and most effective treatment for IPA [21]. Of the 34 cases reported so far, only 7 cases had reported susceptibility results of which one was triazole resistant A. fumigatus [16] similar to our case. Our patient's exposure to fungicides daily in his work has most likely led to exposure and colonisation with triazole-resistant A. fumigatus which was further supported by detection of cyp51A TR34L98H mutation from our patient's ETA, the most prevalent triazole resistance mutation from environmental source [20]. This case highlights the importance of early evaluation of patients with COVID-19 pneumonia because of the risk of secondary or co-infection with fungal pathogens. Case definitions have been proposed for IAPA [6,19] which can be modified for early recognition of CAPA. The occurrence of multi-triazole resistance in this case emphasises the urgent need for antifungal drug susceptibility testing of Aspergillus isolates using a rapid and simple phenotypic method and/or by detection of Cyp51 gene associated triazole resistance mutations directly on respiratory samples. Funding sources This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declaration of competing interestCOI T.R.Rogers has received grants and personal fees from 10.13039/100005564 Gilead Sciences , personal fees from 10.13039/100015278 Pfizer Healthcare Ireland , personal fees from Menarini Pharma outside the submitted work, A.F.Talento has received grant and personal fees from 10.13039/100005564 Gilead Sciences and personal fees from 10.13039/100015278 Pfizer Healthcare Ireland outside the submitted work. The other authors have no conflict of interests.	1 G, 2X/DAY	DrugDosageText	CC BY-NC-ND	32837879	19,458,392	2021-03
What was the outcome of reaction 'Drug ineffective'?	Multi-triazole-resistant Aspergillus fumigatus and SARS-CoV-2 co-infection: A lethal combination. We report a case of severe COVID-19 pneumonia complicated by fatal co-infection with a multi-triazole resistant Aspergillus fumigatus and highlight the importance of recognising the significance of Aspergillus sp. isolation from respiratory samples. Early diagnosis and detection of triazole resistance are essential for appropriate antifungal therapy to improve outcome in patients with coronavirus associated invasive aspergillosis. 1 Introduction Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causing COVID-19 infection, is a newly recognised pathogen that has been traced to Wuhan (Hubei province) in China [1]. The clinical spectrum of COVID-19 varies from asymptomatic infection to severe pneumonia requiring mechanical ventilation. The overall case fatality rate is estimated to be 2.7%, which increases to 4.5% in those ≥ 60 years old [2]. Secondary infections with bacterial and fungal pathogens have been reported in patients with COVID-19 pneumonia which may be due to virus induced mucosal damage and/or the dysregulated immune response seen in patients with acute respiratory distress syndrome [3,4]. We report severe COVID-19 pneumonia with multi-triazole-resistant Aspergillus fumigatus co-infection in a patient not known to be immunocompromised to highlight the importance of early diagnosis and detection of triazole resistance. 2 Case A 66-year-old male presented to the emergency department with a history of progressive shortness of breath (SOB), myalgia, headaches, non-productive cough and fever. Two days previously, he had contacted his general practitioner (GP) describing a seven-day history of fever and cough. He had returned from the United Kingdom eight days earlier after visiting a relative who was subsequently diagnosed with COVID-19. He was advised to self-isolate and monitor his symptoms. Due to progressive SOB, he re-presented to his GP who referred him to the hospital for further management. The patient had Type 2 diabetes mellitus, hypertension, hyperlipidaemia and obesity with a body mass index of 35.5 (weight 90kg) with no hospital admissions in the past eight years. His medications included metformin, aspirin, simvastatin and ramipril. He had no history of prior triazole antifungal therapy. He was an ex-smoker but had not been previously diagnosed to have chronic lung disease. He works as a ground maintenance personnel where he is exposed to fungicides daily. On presentation, a portable chest radiograph was performed which showed unilateral peripheral left basal airspace shadowing (Fig. 1A). In view of the clinical presentation, radiographic findings and the recent exposure history, the patient was admitted under contact and droplet precautions.Fig. 1 A. Portable chest radiograph taken on day of admission showing unilateral peripheral left basal airspace shadowing. B. Portable chest radiograph taken on Day 12 of hospitalization (Day 20 of COVID-19 infection). The endotracheal tube and bilateral central lines are in satisfactory position. There has been interval progression of the left peripheral airspace shadowing with additional right upper and lower zone peripheral airspace shadowing with no evidence of cavitation. Fig. 1 On admission (Day 7 of COVID-19 illness), the patient was noted to be pyrexial (temperature of 38.6 °C), tachycardic (pulse rate of 174 beats per minute) with new onset atrial fibrillation, normotensive (BP 117/69 mmHg), tachypnic (24 breaths per minute) with oxygen saturation of 84% on room air. He was commenced on a trial of continuous positive airway pressure with oxygen therapy. Preliminary laboratory results revealed white cell count of 4.7 × 109/L (reference range 4.0–11.0 × 109/L), neutrophil count 3.0 × 109/L (reference range 2.0–7.0 × 109/L), lymphocyte count 0.8 × 109/L (reference range 1.0–3.0 × 109/L) and C-reactive protein of 118 mg/L (reference range < 5.0 mg/L). Nasopharyngeal and oropharyngeal swabs detected SARS-CoV-2 using real-time reverse transcriptase polymerase chain reaction on day 3. He was commenced on azithromycin (500 mg on day 1 and 250 once daily on days 2 and 3) and hydroxychloroquine (200 mg twice daily) orally as per our local protocol at that time. On day 4 (Day 11 of COVID-19 illness) he developed worsening hypoxic respiratory failure with a Sequential Organ Failure Assessment (SOFA) score of 6 necessitating intensive care unit (ICU) admission for ventilatory support. The patient was proned initially for 15 hours which did not improve his oxygenation. This, combined with significant hemodynamic instability, were contraindications for further proning. His condition continued to deteriorate progressing to multi-organ failure on day 7 (Day 14 of COVID-19 illness) which included acute respiratory failure, acute kidney injury requiring continuous renal replacement therapy and vasopressor support due to septic shock. His SOFA score increased to 12. He had continuing pyrexia and copious amounts of purulent respiratory secretions prompting a repeat septic screen which included culture of blood and endotracheal aspirate (ETA). Empiric antimicrobial therapy for hospital-acquired pneumonia with intravenous (IV) piperacillin-tazobactam (4.5g three times a day) was started. Subsequently, ETA culture grew Klebsiella varicola (susceptible to piperacillin-tazobactam), Aspergillus sp. and Candida albicans. Antifungal therapy with IV liposomal amphotericin B (3 mg per kg once daily) was commenced due to the patients rapidly deteriorating status and uncertainty of the full identification of the mould isolate which may be resistant to triazoles. The Aspergillus sp. was referred for further identification and antifungal susceptibility testing, as were serum samples for detection of 1–3, β-d-glucan (BDG) antigen and galactomannan (GM) antigen and ETA for GM antigen. His SOFA score on day 11 (Day 18 of COVID-19 illness) increased to 16. Antibiotic therapy was escalated to IV meropenem (1g twice daily) and vancomycin, with dosing based on renal function, due to ongoing pyrexia and deteriorating status. He was not prescribed systemic steroids at any time during his critical illness. A repeat portable chest radiograph on day 12 (Day 20 of COVID-19 illness) showed progression to additional right upper and lower zone peripheral airspace shadowing with no evidence of cavitation (Fig. 1B). He remained haemodynamically unstable which precluded further radiological investigations. In view of his non-responsive multi-organ failure, and after discussion with his family, the patient's life-support was withdrawn. He died on day 14 of hospitalization (Day 22 of COVID-19 illness). The Aspergillus sp. isolated from the ETA was confirmed to be A. fumigatus. Phenotypic testing utilising a 4-well triazole resistance screen (VIP check™, Mediaproducts BV, The Netherlands) (Fig. 2A and B) as well as determination of minimum inhibitory concentrations (MIC) utilising gradient strips (Liofilchem, Waltham MA, USA) were suggestive of triazole resistance (Table 1) [5]. The MIC to amphotericin was 0.125 mg/L (susceptible ≤ 1 mg/L) [5]. Genotypic testing utilising a commercial assay (Aspergenius™, Pathonostics B.V. The Netherlands) on the ETA detected A. fumigati complex with the TR34L98H resistance mutation in the cyp51A gene, the most common mutation in triazole-resistant A. fumigatus originating from an environmental source. The serum and ETA GM optical density index (ODI) were 1.1 and 5.5 respectively (Platelia™ Aspergillus Ag EIA, WA, USA). Serum BDG was 202 pg per milliliter (Fungitell™ Assay, Associates of Cape Cod, USA). These results (Table 1) were consistent with severe COVID-19 pneumonia and triazole-resistant invasive pulmonary aspergillus co-infection.Fig. 2 A and B VIPcheck™ plate, a four well triazole resistance screen plate which contains itraconazole (I) 4 mg per liter, voriconazole (V) 2 mg per liter, posaconazole. (P) 0.5 mg per liter, and growth control (GC). This is a simple phenotypic test used to screen for triazole resistance due to the common mutations in the cyp51A gene in A. fumigatus from an environmental source. The photos show a susceptible control strain AF293 (2A) where growth is only seen on GC well and the patient's isolate (2B) with growth in all wells consistent with findings seen in A. fumigatus with the cyp51A TR34/L98H mutation. Fig. 2 Table 1 Laboratory results. Table 1 Patient's Isolate A. fumigatus aClinical breakpoint > Resistant Antifungal Susceptibility Test Minimum inhibitory concentration (MIC) mg/L Voriconazole 2.0 1 Itraconazole >32 1 Posaconazole 1.0 0.25 Amphotericin B 0.125 1 Fungal antigensb Patient's results Cut-off Galactomannan Optical Density Index (ODI) Serum 1.1 ≥ 0.5 Tracheal aspirate 5.5 N/A 1,3 β-d-glucan pg/mL Serum 202 ≥ 80 a Based on the European Committee on Antimicrobial Susceptibility testing guidelines. b Fungal antigens: Galactomannan cut-off based on Platelia™ Aspergillus Ag EIA and 1–3 β-d-glucan cut-off based on Fungitell™ assay. 3 Discussion Previously known to cause infections in severely immunocompromised patients, A. fumigatus is now recognised as an emerging pathogen in critical care patients suffering chronic respiratory disorders and as a complication of severe influenza infection [6]. Aspergillus colonisation can rapidly lead to invasive aspergillosis following severe influenza infection due to multiple pathways including structural lung damage coupled with disruption of mucociliary clearance, leukopenia, Th1/Th2 imbalance and diffuse damage to the respiratory mucosa [7]. In addition, severe respiratory viral infections such as influenza have been identified as an independent risk factor for IPA with high mortality [6]. Although our patient did not receive steroids, their use in critical care patients is linked to increased risk of invasive fungal infections [6]. Like other causes of viral pneumonias, SARS-CoV-2 may impair local mucosal and systemic immune defenses [3]. Thirty-four cases of COVID-19 associated invasive aspergillosis (CAPA) have been reported to date [[8], [9], [10], [11], [12], [13], [14], [15], [16], [17]]. These were all patients with severe pneumonia with adult respiratory distress symdome, most of whom had no known history of immunocompromise. These has led to challenges in early diagnosis since most of them do not have the classical risk factors for invasive aspergillosis. Histopathology and culture from sterile site samples and biopsy remain the gold standard for proven IPA however the definition of probable or “putative” IPA has expanded but remains to be a composite of the host factors, clinical features and mycological evidence [6,18]. Although severe viral pneumonia is not considered a risk factor for IPA or other invasive mould disease according to the European Organisation for Research and Treatment of Cancer/Mycoses Study Group definitions, the structural damage to the lung parenchyma, in addition to the dysregulated immune response, can lead to IPA [6]. Recently a panel of experts proposed a case definition for influenza associated invasive aspergillosis (IAPA) which may be useful to classify COVID-19 patients with invasive aspergillosis. Following this case definition a patient with COVID-19 detected in respiratory sample by PCR, pulmonary infiltrates and a positive serum or bronchoalveolar lavage galactomannan has criteria consistent with probable CAPA [19]. Our patient had radiographic findings consistent with COVID-19 pneumonia. Unfortunately, his clinical status did not allow for computed tomography (CT) to be performed. Other mycological evidence of IPA include culture of Aspergillus sp. from non-sterile sites or detection of fungal antigens such as serum BDG. Our patient had COVID-19 pneumonia, A. fumigatus from a tracheal aspirate with elevated serum BDG and GM and elevated ETA GM, findings consistent with COVID-19 and probable IPA co-infection. Multi-triazole resistance in A. fumigatus has recently emerged and is linked to the use of triazole-containing compounds as agricultural fungicides or less commonly prolonged triazole use [20]. The former mechanism of resistance typically affects azole näive patients and is characterised by elevated MICs to itraconazole, voriconazole and posaconazole as was found in our patient. This is of serious concern since triazoles are recommended as the first-line and most effective treatment for IPA [21]. Of the 34 cases reported so far, only 7 cases had reported susceptibility results of which one was triazole resistant A. fumigatus [16] similar to our case. Our patient's exposure to fungicides daily in his work has most likely led to exposure and colonisation with triazole-resistant A. fumigatus which was further supported by detection of cyp51A TR34L98H mutation from our patient's ETA, the most prevalent triazole resistance mutation from environmental source [20]. This case highlights the importance of early evaluation of patients with COVID-19 pneumonia because of the risk of secondary or co-infection with fungal pathogens. Case definitions have been proposed for IAPA [6,19] which can be modified for early recognition of CAPA. The occurrence of multi-triazole resistance in this case emphasises the urgent need for antifungal drug susceptibility testing of Aspergillus isolates using a rapid and simple phenotypic method and/or by detection of Cyp51 gene associated triazole resistance mutations directly on respiratory samples. Funding sources This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declaration of competing interestCOI T.R.Rogers has received grants and personal fees from 10.13039/100005564 Gilead Sciences , personal fees from 10.13039/100015278 Pfizer Healthcare Ireland , personal fees from Menarini Pharma outside the submitted work, A.F.Talento has received grant and personal fees from 10.13039/100005564 Gilead Sciences and personal fees from 10.13039/100015278 Pfizer Healthcare Ireland outside the submitted work. The other authors have no conflict of interests.	Fatal	ReactionOutcome	CC BY-NC-ND	32837879	19,458,392	2021-03
What was the outcome of reaction 'Off label use'?	Multi-triazole-resistant Aspergillus fumigatus and SARS-CoV-2 co-infection: A lethal combination. We report a case of severe COVID-19 pneumonia complicated by fatal co-infection with a multi-triazole resistant Aspergillus fumigatus and highlight the importance of recognising the significance of Aspergillus sp. isolation from respiratory samples. Early diagnosis and detection of triazole resistance are essential for appropriate antifungal therapy to improve outcome in patients with coronavirus associated invasive aspergillosis. 1 Introduction Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causing COVID-19 infection, is a newly recognised pathogen that has been traced to Wuhan (Hubei province) in China [1]. The clinical spectrum of COVID-19 varies from asymptomatic infection to severe pneumonia requiring mechanical ventilation. The overall case fatality rate is estimated to be 2.7%, which increases to 4.5% in those ≥ 60 years old [2]. Secondary infections with bacterial and fungal pathogens have been reported in patients with COVID-19 pneumonia which may be due to virus induced mucosal damage and/or the dysregulated immune response seen in patients with acute respiratory distress syndrome [3,4]. We report severe COVID-19 pneumonia with multi-triazole-resistant Aspergillus fumigatus co-infection in a patient not known to be immunocompromised to highlight the importance of early diagnosis and detection of triazole resistance. 2 Case A 66-year-old male presented to the emergency department with a history of progressive shortness of breath (SOB), myalgia, headaches, non-productive cough and fever. Two days previously, he had contacted his general practitioner (GP) describing a seven-day history of fever and cough. He had returned from the United Kingdom eight days earlier after visiting a relative who was subsequently diagnosed with COVID-19. He was advised to self-isolate and monitor his symptoms. Due to progressive SOB, he re-presented to his GP who referred him to the hospital for further management. The patient had Type 2 diabetes mellitus, hypertension, hyperlipidaemia and obesity with a body mass index of 35.5 (weight 90kg) with no hospital admissions in the past eight years. His medications included metformin, aspirin, simvastatin and ramipril. He had no history of prior triazole antifungal therapy. He was an ex-smoker but had not been previously diagnosed to have chronic lung disease. He works as a ground maintenance personnel where he is exposed to fungicides daily. On presentation, a portable chest radiograph was performed which showed unilateral peripheral left basal airspace shadowing (Fig. 1A). In view of the clinical presentation, radiographic findings and the recent exposure history, the patient was admitted under contact and droplet precautions.Fig. 1 A. Portable chest radiograph taken on day of admission showing unilateral peripheral left basal airspace shadowing. B. Portable chest radiograph taken on Day 12 of hospitalization (Day 20 of COVID-19 infection). The endotracheal tube and bilateral central lines are in satisfactory position. There has been interval progression of the left peripheral airspace shadowing with additional right upper and lower zone peripheral airspace shadowing with no evidence of cavitation. Fig. 1 On admission (Day 7 of COVID-19 illness), the patient was noted to be pyrexial (temperature of 38.6 °C), tachycardic (pulse rate of 174 beats per minute) with new onset atrial fibrillation, normotensive (BP 117/69 mmHg), tachypnic (24 breaths per minute) with oxygen saturation of 84% on room air. He was commenced on a trial of continuous positive airway pressure with oxygen therapy. Preliminary laboratory results revealed white cell count of 4.7 × 109/L (reference range 4.0–11.0 × 109/L), neutrophil count 3.0 × 109/L (reference range 2.0–7.0 × 109/L), lymphocyte count 0.8 × 109/L (reference range 1.0–3.0 × 109/L) and C-reactive protein of 118 mg/L (reference range < 5.0 mg/L). Nasopharyngeal and oropharyngeal swabs detected SARS-CoV-2 using real-time reverse transcriptase polymerase chain reaction on day 3. He was commenced on azithromycin (500 mg on day 1 and 250 once daily on days 2 and 3) and hydroxychloroquine (200 mg twice daily) orally as per our local protocol at that time. On day 4 (Day 11 of COVID-19 illness) he developed worsening hypoxic respiratory failure with a Sequential Organ Failure Assessment (SOFA) score of 6 necessitating intensive care unit (ICU) admission for ventilatory support. The patient was proned initially for 15 hours which did not improve his oxygenation. This, combined with significant hemodynamic instability, were contraindications for further proning. His condition continued to deteriorate progressing to multi-organ failure on day 7 (Day 14 of COVID-19 illness) which included acute respiratory failure, acute kidney injury requiring continuous renal replacement therapy and vasopressor support due to septic shock. His SOFA score increased to 12. He had continuing pyrexia and copious amounts of purulent respiratory secretions prompting a repeat septic screen which included culture of blood and endotracheal aspirate (ETA). Empiric antimicrobial therapy for hospital-acquired pneumonia with intravenous (IV) piperacillin-tazobactam (4.5g three times a day) was started. Subsequently, ETA culture grew Klebsiella varicola (susceptible to piperacillin-tazobactam), Aspergillus sp. and Candida albicans. Antifungal therapy with IV liposomal amphotericin B (3 mg per kg once daily) was commenced due to the patients rapidly deteriorating status and uncertainty of the full identification of the mould isolate which may be resistant to triazoles. The Aspergillus sp. was referred for further identification and antifungal susceptibility testing, as were serum samples for detection of 1–3, β-d-glucan (BDG) antigen and galactomannan (GM) antigen and ETA for GM antigen. His SOFA score on day 11 (Day 18 of COVID-19 illness) increased to 16. Antibiotic therapy was escalated to IV meropenem (1g twice daily) and vancomycin, with dosing based on renal function, due to ongoing pyrexia and deteriorating status. He was not prescribed systemic steroids at any time during his critical illness. A repeat portable chest radiograph on day 12 (Day 20 of COVID-19 illness) showed progression to additional right upper and lower zone peripheral airspace shadowing with no evidence of cavitation (Fig. 1B). He remained haemodynamically unstable which precluded further radiological investigations. In view of his non-responsive multi-organ failure, and after discussion with his family, the patient's life-support was withdrawn. He died on day 14 of hospitalization (Day 22 of COVID-19 illness). The Aspergillus sp. isolated from the ETA was confirmed to be A. fumigatus. Phenotypic testing utilising a 4-well triazole resistance screen (VIP check™, Mediaproducts BV, The Netherlands) (Fig. 2A and B) as well as determination of minimum inhibitory concentrations (MIC) utilising gradient strips (Liofilchem, Waltham MA, USA) were suggestive of triazole resistance (Table 1) [5]. The MIC to amphotericin was 0.125 mg/L (susceptible ≤ 1 mg/L) [5]. Genotypic testing utilising a commercial assay (Aspergenius™, Pathonostics B.V. The Netherlands) on the ETA detected A. fumigati complex with the TR34L98H resistance mutation in the cyp51A gene, the most common mutation in triazole-resistant A. fumigatus originating from an environmental source. The serum and ETA GM optical density index (ODI) were 1.1 and 5.5 respectively (Platelia™ Aspergillus Ag EIA, WA, USA). Serum BDG was 202 pg per milliliter (Fungitell™ Assay, Associates of Cape Cod, USA). These results (Table 1) were consistent with severe COVID-19 pneumonia and triazole-resistant invasive pulmonary aspergillus co-infection.Fig. 2 A and B VIPcheck™ plate, a four well triazole resistance screen plate which contains itraconazole (I) 4 mg per liter, voriconazole (V) 2 mg per liter, posaconazole. (P) 0.5 mg per liter, and growth control (GC). This is a simple phenotypic test used to screen for triazole resistance due to the common mutations in the cyp51A gene in A. fumigatus from an environmental source. The photos show a susceptible control strain AF293 (2A) where growth is only seen on GC well and the patient's isolate (2B) with growth in all wells consistent with findings seen in A. fumigatus with the cyp51A TR34/L98H mutation. Fig. 2 Table 1 Laboratory results. Table 1 Patient's Isolate A. fumigatus aClinical breakpoint > Resistant Antifungal Susceptibility Test Minimum inhibitory concentration (MIC) mg/L Voriconazole 2.0 1 Itraconazole >32 1 Posaconazole 1.0 0.25 Amphotericin B 0.125 1 Fungal antigensb Patient's results Cut-off Galactomannan Optical Density Index (ODI) Serum 1.1 ≥ 0.5 Tracheal aspirate 5.5 N/A 1,3 β-d-glucan pg/mL Serum 202 ≥ 80 a Based on the European Committee on Antimicrobial Susceptibility testing guidelines. b Fungal antigens: Galactomannan cut-off based on Platelia™ Aspergillus Ag EIA and 1–3 β-d-glucan cut-off based on Fungitell™ assay. 3 Discussion Previously known to cause infections in severely immunocompromised patients, A. fumigatus is now recognised as an emerging pathogen in critical care patients suffering chronic respiratory disorders and as a complication of severe influenza infection [6]. Aspergillus colonisation can rapidly lead to invasive aspergillosis following severe influenza infection due to multiple pathways including structural lung damage coupled with disruption of mucociliary clearance, leukopenia, Th1/Th2 imbalance and diffuse damage to the respiratory mucosa [7]. In addition, severe respiratory viral infections such as influenza have been identified as an independent risk factor for IPA with high mortality [6]. Although our patient did not receive steroids, their use in critical care patients is linked to increased risk of invasive fungal infections [6]. Like other causes of viral pneumonias, SARS-CoV-2 may impair local mucosal and systemic immune defenses [3]. Thirty-four cases of COVID-19 associated invasive aspergillosis (CAPA) have been reported to date [[8], [9], [10], [11], [12], [13], [14], [15], [16], [17]]. These were all patients with severe pneumonia with adult respiratory distress symdome, most of whom had no known history of immunocompromise. These has led to challenges in early diagnosis since most of them do not have the classical risk factors for invasive aspergillosis. Histopathology and culture from sterile site samples and biopsy remain the gold standard for proven IPA however the definition of probable or “putative” IPA has expanded but remains to be a composite of the host factors, clinical features and mycological evidence [6,18]. Although severe viral pneumonia is not considered a risk factor for IPA or other invasive mould disease according to the European Organisation for Research and Treatment of Cancer/Mycoses Study Group definitions, the structural damage to the lung parenchyma, in addition to the dysregulated immune response, can lead to IPA [6]. Recently a panel of experts proposed a case definition for influenza associated invasive aspergillosis (IAPA) which may be useful to classify COVID-19 patients with invasive aspergillosis. Following this case definition a patient with COVID-19 detected in respiratory sample by PCR, pulmonary infiltrates and a positive serum or bronchoalveolar lavage galactomannan has criteria consistent with probable CAPA [19]. Our patient had radiographic findings consistent with COVID-19 pneumonia. Unfortunately, his clinical status did not allow for computed tomography (CT) to be performed. Other mycological evidence of IPA include culture of Aspergillus sp. from non-sterile sites or detection of fungal antigens such as serum BDG. Our patient had COVID-19 pneumonia, A. fumigatus from a tracheal aspirate with elevated serum BDG and GM and elevated ETA GM, findings consistent with COVID-19 and probable IPA co-infection. Multi-triazole resistance in A. fumigatus has recently emerged and is linked to the use of triazole-containing compounds as agricultural fungicides or less commonly prolonged triazole use [20]. The former mechanism of resistance typically affects azole näive patients and is characterised by elevated MICs to itraconazole, voriconazole and posaconazole as was found in our patient. This is of serious concern since triazoles are recommended as the first-line and most effective treatment for IPA [21]. Of the 34 cases reported so far, only 7 cases had reported susceptibility results of which one was triazole resistant A. fumigatus [16] similar to our case. Our patient's exposure to fungicides daily in his work has most likely led to exposure and colonisation with triazole-resistant A. fumigatus which was further supported by detection of cyp51A TR34L98H mutation from our patient's ETA, the most prevalent triazole resistance mutation from environmental source [20]. This case highlights the importance of early evaluation of patients with COVID-19 pneumonia because of the risk of secondary or co-infection with fungal pathogens. Case definitions have been proposed for IAPA [6,19] which can be modified for early recognition of CAPA. The occurrence of multi-triazole resistance in this case emphasises the urgent need for antifungal drug susceptibility testing of Aspergillus isolates using a rapid and simple phenotypic method and/or by detection of Cyp51 gene associated triazole resistance mutations directly on respiratory samples. Funding sources This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declaration of competing interestCOI T.R.Rogers has received grants and personal fees from 10.13039/100005564 Gilead Sciences , personal fees from 10.13039/100015278 Pfizer Healthcare Ireland , personal fees from Menarini Pharma outside the submitted work, A.F.Talento has received grant and personal fees from 10.13039/100005564 Gilead Sciences and personal fees from 10.13039/100015278 Pfizer Healthcare Ireland outside the submitted work. The other authors have no conflict of interests.	Fatal	ReactionOutcome	CC BY-NC-ND	32837879	19,458,392	2021-03
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Acute kidney injury'.	Ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Coronavirus disease 2019 (COVID-19), caused by the novel coronavirus SARS-CoV-2, emerged in Wuhan, China, in December 2019 and rapidly spread around the world. Invasive aspergillosis has been reported as a complication of severe influenza pneumonia among intensive care patients. Similarities between COVID-19 and influenza pneumonia, together with limited published case series, suggest that aspergillosis may be an important complication of COVID-19. This report describes a case of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 from Buenos Aires, Argentina. 1 Introduction SARS-CoV-2 is the novel coronavirus that causes coronavirus disease 2019 (COVID‐19), which was first reported in December 2019 in Wuhan, China, and has rapidly spread worldwide [1]. On March 11th, 2020, the World Health Organization (WHO) declared a pandemic, and by June 30th, 2020, a total of 10,185,374 cases and 503,862 deaths were reported in 216 locations around the world [2]. In Argentina, on June 30th, 2020, the Argentinean Ministry of Health (AMOH) reported 62,268 cases and 1283 deaths [3]. Invasive pulmonary aspergillosis (IPA) is a known complication in patients with severe influenza pneumonia. Case series from the Netherlands and Belgium reported an incidence of 19% in patients with influenza pneumonia and acute respiratory distress syndrome (ARDS) hospitalized in the intensive care unit (ICU) [4], although these high incidences have not been confirmed in other studies [4]. There is concern that critically ill COVID-19 patients might also be at increased risk of pulmonary aspergillosis co-infection [5]. Here we describe a report of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 and ARDS in Argentina. 2 Case presentation In late April 2020, an 85-year-old man with a history of hypertension was admitted to the ICU with a history of six days of fever and dyspnea, at home. The patient had close household contact with two COVID-19 cases, and nasopharyngeal (NP) swab samples collected on the day of ICU admission tested positive for SARS-CoV-2 using molecular testing. On ICU admission (day 1) the patient presented with bilateral infiltrates (ground-glass opacities) on chest radiograph, respiratory rate of 40 breaths per minute, heart rate of 82 beats per minute, and a blood pressure 150/85 mm Hg. Laboratory tests showed a white blood cell count of 11,600 cells/mm3, with lymphopenia, normal serum creatinine (1.02 mg/dL), low albumin (2.8 g/dL), and normal lactate (1.4 mmol/L), as well as elevated ferritin (1840 ng/mL), D-dimer (17.1 ng/mL), procalcitonin (2.89 ng/mL), and fibrinogen (702 mg/dl). The patient also presented with deep vein thrombosis in the right subclavian vein and in the right internal jugular vein; anticoagulation was initiated with heparin due to the hypercoagulable state. Empirical treatment for pneumonia was started with oseltamivir, ceftriaxone, and azithromycin, and hydroxychloroquine, ritonavir/lopinavir were started for COVID-19, according to the Argentinean Ministry of Health (AMOH) national guidelines [6]. After 3 days of hospitalization, the patient required ventilator support (orotracheal intubation and mechanical ventilation) and was given a corticosteroid (dexamethasone, 20 mg/day). Influenza antigen testing yielded a negative result, prompting cessation of empirical influenza treatment (Fig. 1).Fig. 1 Case timeline: ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Fig. 1 On day 10 of hospitalization, the patient developed a new fever (38 °C). Urinary culture and pneumococcal urine antigen test were negative; tracheal aspirate and blood culture were positive for Enterococcus faecalis, and imipenem and vancomycin were added to hydroxychloroquine and ritonavir/lopinavir. Two days later polymyxin was added, and blood cultures turned negative after seven days of treatment. On day 17, urinary analysis showed evidence of acute tubular necrosis with metabolic acidosis (low pH, PaCO2 and HCO3), and treatment was subsequently changed to meropenem and colistin. On day 19, tracheal aspirate, urine and blood culture remained negative for bacteria, and a second SARS-CoV-2 PCR test from a NP swab was positive. On day 23, the patient was again febrile, and urinary, tracheal aspirate, blood and catheter tip cultures were repeated; a third SARS-CoV-2 PCR test on day 24 from a NP swab was positive (Fig. 1). On day 25 the patient developed multiple organ failure, including acute renal failure. Aspergillus flavus, identified by MALDI-TOF (Fig. 2), and Acinetobacter baumanii (>106 CFU) were cultured from tracheal aspirate. Staphylococcus capitis was isolated from blood culture, and E. faecalis and Staphylococcus epidermidis were isolated from the central venous catheter tip culture. Candida lusitaniae was isolated from urine. The patient's antimicrobial regimen was updated to include vancomycin, meropenem, and colistin. Anidulafungin was added to control candidiasis, but azole therapy for the A. flavus finding was not started due to initial clinical suspicion of colonization versus infection. On day 26 a tracheostomy was placed as a result of prolonged ventilation, ARDS (PaO2/FiO2 ratio <200), and sepsis. Chest radiograph continued to show bilateral infiltrates (Fig. 3). Aspergillus galactomannan antigen (GM) was positive in serum (GM index: 1.4; Platelia Aspergillus; Bio-Rad, Marnes-La-Coquette, France) (Fig. 1).Fig. 2 Aspergillus flavus isolate: (A and B) Macroscopic: rapid growth olive green colonies, with woolly texture, on Sabouraud agar incubated at 28 °C (A) and 37 °C (B). (C) Microscopic: hyaline septate hyphae, radiate biseriate conidial head with finely roughened conidiophore. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.) Fig. 2 Fig. 3 Chest X-ray evidenced bilateral heterogeneous infiltrates on day 26 of hospitalization: picture from the COVID-19 associated pulmonary aspergillosis (CAPA) described on this report. Fig. 3 On day 28, laboratory testing showed increased white blood cells (16,930 cells/mm3; lymphocytes 45%), D-dimer (7.3 ng/mL), ferritin (3691 ng/mL) and C-reactive protein (31.8 mg/L). Blood and central venous catheter cultures were negative, and anidulafungin was replaced with voriconazole (400 mg first day, and then 300 mg daily) after the GM test returned positive. Colistin, vancomycin, and meropenem were continued. On day 30, hydroxychloroquine, ritonavir/lopinavir were suspended (following recommendation of AMOH), and on day 35, serum GM index decreased to 0.8. On day 44, the patient died in the ICU while on ventilatory support (Fig. 1). 3 Discussion COVID-19 associated pulmonary aspergillosis (CAPA) has been recently reported in European countries [[7], [8], [9], [10], [11], [12], [13]], including four case series covering 27 patients from France (n = 9), Belgium (n = 7), The Netherlands (n = 6), and Germany (n = 5) [[7], [8], [9], [10]]. Our case has similar clinical features compared with those previously reported. Among these four case series, all 27 patients were admitted to the ICU and developed ARDS. Most were male, >50 years old, and 25 (89%) of 27 had potential risk factors for severe COVID-19. Three (60%) of five patients from the German case series, seven (78%) of nine from the French case series, and three (43%) of seven patients from the Belgium case series had hypertension. All five patients from Germany had acute kidney injury, and three (33%) of nine patients from France and two (29%) of seven from Belgium received renal replacement therapy [[7], [8], [9], [10]]. Abnormal chest radiologic findings were reported in all of the patients from Germany (n = 5) and France (n = 9) [7,8]. Twelve (44%) of 27 patients received corticosteroids during their ICU stay, and 19 (70%) of 27 were treated with mold-active antifungal medication, eight (42%) of these 19 patients received corticosteroid simultaneous with antifungal treatment. Fifteen (55%) of the 27 case series patients died. Our patient received corticosteroids for 22 days before initial A. flavus culture and was treated with voriconazole starting 3 days after the initial fungal culture. Unlike influenza-associated pulmonary aspergillosis (IAPA), which commonly occurs early after ICU admission [4], our patient developed CAPA 25 days after ICU admission. COVID-19 associated pulmonary aspergillosis case series from Belgium and The Netherlands, showed variable time on development of were aspergillosis (range: 2–28 days) [9,10]. Making the diagnosis of IPA can be challenging, especially among patients not considered classically at greatest risk (e.g., hematologic malignancy and stem cell transplant patients). Among the four European CAPA case series discussed, Aspergillus species were cultured in 78% of respiratory specimens; positive specimens included: 14 bronchoalveolar lavage, six tracheal aspirate and one sputum [[7], [8], [9], [10]]. Bronchoscopy in COVID-19 patients is often not performed due to the risk of aerosol generation. Further complicating IPA diagnosis, serum GM testing is often negative among COVID-19 patients, and sensitivity is low among ICU patients in general; in the published cases series, of the 22 cases tested, only three (14%) had positive serum GM tests [14,15]. Most COVID-19 patients lack known risk factors for IPA [4]. Thus, isolation of Aspergillus from a non-sterile site and negative serum GM should not rule out invasive disease. Clinicians may want to consider mold-active azole therapy at first indication of aspergillosis in COVID-19 patients. Our patient had a high serum GM index (>1.0), which is the recommended cutoff, and mycological criteria for probable IPA classification by the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium [16]. Challenges in selecting a case definition for CAPA are also shared by the similar IAPA. For this reason, an expert panel recently proposed a new case definition for IAPA [17,18]. The definitions distinguish between invasive Aspergillus tracheobronchitis and other pulmonary manifestations and mainly rely on culture and GM to identify IPA. The expert panel stated that the IAPA case definition might also be useful to classify CAPA cases. Using this new definition, our case would be classified as probable CAPA [17]. A follow-up serum GM showed decreasing antigen titer which is consistent with antifungal treatment response. Little is known about the pathogenesis of CAPA, and there is a need to characterize risk factors for the development of IPA. Although influenza infection was found to be an independent risk factor for IPA [4], the use of corticosteroids in patients with influenza is also a risk factor for IAPA [19]. A recent preliminary report suggested that dexamethasone was associated with reduced mortality in COVID-19 patients [20]. However, corticosteroids might be associated with adverse effects such as delayed viral clearance and secondary infections. Notably, of the four proven IPA cases reported during the previous severe acute respiratory syndrome (SARS) epidemic, all were associated with concomitant corticosteroid therapy [5,21]. In our COVID-19 case with probable CAPA, we observed co-infections with bacterial and additional fungal pathogens (E. faecalis, A. baumanii, coagulase-negative staphylococci, and C. lusitaniae), which complicated patient treatment. Previous reports of CAPA cases did not describe the presence of other microbial co-infections [[7], [8], [9], [10], [11], [12], [13]], although these are commonly encountered in patients with influenza. Previous reports of ICU patients with severe influenza frequently reported secondary bacterial infection, and these were significantly associated with IAPA in studies comparing severe influenza patients with and without IAPA (61% vs 31%; p < 0.01) [22]. Co-infections were reported in up to 50% of patients with severe coronavirus infections causing both SARS and Middle East respiratory syndrome (MERS) [23]. However, early data suggest that coinfection frequency might be lower in COVID-19 [[23], [24], [25]]. We present a case of COVID-19 associated pulmonary aspergillosis from Argentina, with a clinical course and attributes similar to previously reported cases, that highlights the challenges in diagnosing and treating these CAPA patients. The use of a clinical algorithm to discriminate Aspergillus respiratory tract colonization from invasive pulmonary aspergillosis in critically ill patients is warranted, such as the one developed for IAPA [17,18]. This is the first report of ventilator-associated pneumonia involving A. flavus in a patient with COVID-19 and ARDS in the Americas. Awareness of CAPA and accessibility to appropriate diagnostic tests are necessary for accurate and timely identification of this co-infection [26,27]. Ethical considerations Publication of this case report was approved by the Hospital de Clínicas “José de San Martin” IRB. Declaration of competing interest All authors no reported conflicts of interest. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC. Acknowledgements Claudia Barberis, Marisa Almuzara, and the staff of the infectious disease division and the intensive care unit, at Hospital de Clínicas “José de San Martin”. Universidad de Buenos Aires. Diego H. Caceres acknowledges Oak Ridge Institute for Science and Education (ORISE).	AZITHROMYCIN ANHYDROUS, CEFTRIAXONE, DEXAMETHASONE, HEPARIN SODIUM, HYDROXYCHLOROQUINE, IMIPENEM, LOPINAVIR\RITONAVIR, OSELTAMIVIR, VANCOMYCIN	DrugsGivenReaction	CC BY	32837881	19,203,398	2021-03
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Metabolic acidosis'.	Ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Coronavirus disease 2019 (COVID-19), caused by the novel coronavirus SARS-CoV-2, emerged in Wuhan, China, in December 2019 and rapidly spread around the world. Invasive aspergillosis has been reported as a complication of severe influenza pneumonia among intensive care patients. Similarities between COVID-19 and influenza pneumonia, together with limited published case series, suggest that aspergillosis may be an important complication of COVID-19. This report describes a case of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 from Buenos Aires, Argentina. 1 Introduction SARS-CoV-2 is the novel coronavirus that causes coronavirus disease 2019 (COVID‐19), which was first reported in December 2019 in Wuhan, China, and has rapidly spread worldwide [1]. On March 11th, 2020, the World Health Organization (WHO) declared a pandemic, and by June 30th, 2020, a total of 10,185,374 cases and 503,862 deaths were reported in 216 locations around the world [2]. In Argentina, on June 30th, 2020, the Argentinean Ministry of Health (AMOH) reported 62,268 cases and 1283 deaths [3]. Invasive pulmonary aspergillosis (IPA) is a known complication in patients with severe influenza pneumonia. Case series from the Netherlands and Belgium reported an incidence of 19% in patients with influenza pneumonia and acute respiratory distress syndrome (ARDS) hospitalized in the intensive care unit (ICU) [4], although these high incidences have not been confirmed in other studies [4]. There is concern that critically ill COVID-19 patients might also be at increased risk of pulmonary aspergillosis co-infection [5]. Here we describe a report of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 and ARDS in Argentina. 2 Case presentation In late April 2020, an 85-year-old man with a history of hypertension was admitted to the ICU with a history of six days of fever and dyspnea, at home. The patient had close household contact with two COVID-19 cases, and nasopharyngeal (NP) swab samples collected on the day of ICU admission tested positive for SARS-CoV-2 using molecular testing. On ICU admission (day 1) the patient presented with bilateral infiltrates (ground-glass opacities) on chest radiograph, respiratory rate of 40 breaths per minute, heart rate of 82 beats per minute, and a blood pressure 150/85 mm Hg. Laboratory tests showed a white blood cell count of 11,600 cells/mm3, with lymphopenia, normal serum creatinine (1.02 mg/dL), low albumin (2.8 g/dL), and normal lactate (1.4 mmol/L), as well as elevated ferritin (1840 ng/mL), D-dimer (17.1 ng/mL), procalcitonin (2.89 ng/mL), and fibrinogen (702 mg/dl). The patient also presented with deep vein thrombosis in the right subclavian vein and in the right internal jugular vein; anticoagulation was initiated with heparin due to the hypercoagulable state. Empirical treatment for pneumonia was started with oseltamivir, ceftriaxone, and azithromycin, and hydroxychloroquine, ritonavir/lopinavir were started for COVID-19, according to the Argentinean Ministry of Health (AMOH) national guidelines [6]. After 3 days of hospitalization, the patient required ventilator support (orotracheal intubation and mechanical ventilation) and was given a corticosteroid (dexamethasone, 20 mg/day). Influenza antigen testing yielded a negative result, prompting cessation of empirical influenza treatment (Fig. 1).Fig. 1 Case timeline: ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Fig. 1 On day 10 of hospitalization, the patient developed a new fever (38 °C). Urinary culture and pneumococcal urine antigen test were negative; tracheal aspirate and blood culture were positive for Enterococcus faecalis, and imipenem and vancomycin were added to hydroxychloroquine and ritonavir/lopinavir. Two days later polymyxin was added, and blood cultures turned negative after seven days of treatment. On day 17, urinary analysis showed evidence of acute tubular necrosis with metabolic acidosis (low pH, PaCO2 and HCO3), and treatment was subsequently changed to meropenem and colistin. On day 19, tracheal aspirate, urine and blood culture remained negative for bacteria, and a second SARS-CoV-2 PCR test from a NP swab was positive. On day 23, the patient was again febrile, and urinary, tracheal aspirate, blood and catheter tip cultures were repeated; a third SARS-CoV-2 PCR test on day 24 from a NP swab was positive (Fig. 1). On day 25 the patient developed multiple organ failure, including acute renal failure. Aspergillus flavus, identified by MALDI-TOF (Fig. 2), and Acinetobacter baumanii (>106 CFU) were cultured from tracheal aspirate. Staphylococcus capitis was isolated from blood culture, and E. faecalis and Staphylococcus epidermidis were isolated from the central venous catheter tip culture. Candida lusitaniae was isolated from urine. The patient's antimicrobial regimen was updated to include vancomycin, meropenem, and colistin. Anidulafungin was added to control candidiasis, but azole therapy for the A. flavus finding was not started due to initial clinical suspicion of colonization versus infection. On day 26 a tracheostomy was placed as a result of prolonged ventilation, ARDS (PaO2/FiO2 ratio <200), and sepsis. Chest radiograph continued to show bilateral infiltrates (Fig. 3). Aspergillus galactomannan antigen (GM) was positive in serum (GM index: 1.4; Platelia Aspergillus; Bio-Rad, Marnes-La-Coquette, France) (Fig. 1).Fig. 2 Aspergillus flavus isolate: (A and B) Macroscopic: rapid growth olive green colonies, with woolly texture, on Sabouraud agar incubated at 28 °C (A) and 37 °C (B). (C) Microscopic: hyaline septate hyphae, radiate biseriate conidial head with finely roughened conidiophore. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.) Fig. 2 Fig. 3 Chest X-ray evidenced bilateral heterogeneous infiltrates on day 26 of hospitalization: picture from the COVID-19 associated pulmonary aspergillosis (CAPA) described on this report. Fig. 3 On day 28, laboratory testing showed increased white blood cells (16,930 cells/mm3; lymphocytes 45%), D-dimer (7.3 ng/mL), ferritin (3691 ng/mL) and C-reactive protein (31.8 mg/L). Blood and central venous catheter cultures were negative, and anidulafungin was replaced with voriconazole (400 mg first day, and then 300 mg daily) after the GM test returned positive. Colistin, vancomycin, and meropenem were continued. On day 30, hydroxychloroquine, ritonavir/lopinavir were suspended (following recommendation of AMOH), and on day 35, serum GM index decreased to 0.8. On day 44, the patient died in the ICU while on ventilatory support (Fig. 1). 3 Discussion COVID-19 associated pulmonary aspergillosis (CAPA) has been recently reported in European countries [[7], [8], [9], [10], [11], [12], [13]], including four case series covering 27 patients from France (n = 9), Belgium (n = 7), The Netherlands (n = 6), and Germany (n = 5) [[7], [8], [9], [10]]. Our case has similar clinical features compared with those previously reported. Among these four case series, all 27 patients were admitted to the ICU and developed ARDS. Most were male, >50 years old, and 25 (89%) of 27 had potential risk factors for severe COVID-19. Three (60%) of five patients from the German case series, seven (78%) of nine from the French case series, and three (43%) of seven patients from the Belgium case series had hypertension. All five patients from Germany had acute kidney injury, and three (33%) of nine patients from France and two (29%) of seven from Belgium received renal replacement therapy [[7], [8], [9], [10]]. Abnormal chest radiologic findings were reported in all of the patients from Germany (n = 5) and France (n = 9) [7,8]. Twelve (44%) of 27 patients received corticosteroids during their ICU stay, and 19 (70%) of 27 were treated with mold-active antifungal medication, eight (42%) of these 19 patients received corticosteroid simultaneous with antifungal treatment. Fifteen (55%) of the 27 case series patients died. Our patient received corticosteroids for 22 days before initial A. flavus culture and was treated with voriconazole starting 3 days after the initial fungal culture. Unlike influenza-associated pulmonary aspergillosis (IAPA), which commonly occurs early after ICU admission [4], our patient developed CAPA 25 days after ICU admission. COVID-19 associated pulmonary aspergillosis case series from Belgium and The Netherlands, showed variable time on development of were aspergillosis (range: 2–28 days) [9,10]. Making the diagnosis of IPA can be challenging, especially among patients not considered classically at greatest risk (e.g., hematologic malignancy and stem cell transplant patients). Among the four European CAPA case series discussed, Aspergillus species were cultured in 78% of respiratory specimens; positive specimens included: 14 bronchoalveolar lavage, six tracheal aspirate and one sputum [[7], [8], [9], [10]]. Bronchoscopy in COVID-19 patients is often not performed due to the risk of aerosol generation. Further complicating IPA diagnosis, serum GM testing is often negative among COVID-19 patients, and sensitivity is low among ICU patients in general; in the published cases series, of the 22 cases tested, only three (14%) had positive serum GM tests [14,15]. Most COVID-19 patients lack known risk factors for IPA [4]. Thus, isolation of Aspergillus from a non-sterile site and negative serum GM should not rule out invasive disease. Clinicians may want to consider mold-active azole therapy at first indication of aspergillosis in COVID-19 patients. Our patient had a high serum GM index (>1.0), which is the recommended cutoff, and mycological criteria for probable IPA classification by the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium [16]. Challenges in selecting a case definition for CAPA are also shared by the similar IAPA. For this reason, an expert panel recently proposed a new case definition for IAPA [17,18]. The definitions distinguish between invasive Aspergillus tracheobronchitis and other pulmonary manifestations and mainly rely on culture and GM to identify IPA. The expert panel stated that the IAPA case definition might also be useful to classify CAPA cases. Using this new definition, our case would be classified as probable CAPA [17]. A follow-up serum GM showed decreasing antigen titer which is consistent with antifungal treatment response. Little is known about the pathogenesis of CAPA, and there is a need to characterize risk factors for the development of IPA. Although influenza infection was found to be an independent risk factor for IPA [4], the use of corticosteroids in patients with influenza is also a risk factor for IAPA [19]. A recent preliminary report suggested that dexamethasone was associated with reduced mortality in COVID-19 patients [20]. However, corticosteroids might be associated with adverse effects such as delayed viral clearance and secondary infections. Notably, of the four proven IPA cases reported during the previous severe acute respiratory syndrome (SARS) epidemic, all were associated with concomitant corticosteroid therapy [5,21]. In our COVID-19 case with probable CAPA, we observed co-infections with bacterial and additional fungal pathogens (E. faecalis, A. baumanii, coagulase-negative staphylococci, and C. lusitaniae), which complicated patient treatment. Previous reports of CAPA cases did not describe the presence of other microbial co-infections [[7], [8], [9], [10], [11], [12], [13]], although these are commonly encountered in patients with influenza. Previous reports of ICU patients with severe influenza frequently reported secondary bacterial infection, and these were significantly associated with IAPA in studies comparing severe influenza patients with and without IAPA (61% vs 31%; p < 0.01) [22]. Co-infections were reported in up to 50% of patients with severe coronavirus infections causing both SARS and Middle East respiratory syndrome (MERS) [23]. However, early data suggest that coinfection frequency might be lower in COVID-19 [[23], [24], [25]]. We present a case of COVID-19 associated pulmonary aspergillosis from Argentina, with a clinical course and attributes similar to previously reported cases, that highlights the challenges in diagnosing and treating these CAPA patients. The use of a clinical algorithm to discriminate Aspergillus respiratory tract colonization from invasive pulmonary aspergillosis in critically ill patients is warranted, such as the one developed for IAPA [17,18]. This is the first report of ventilator-associated pneumonia involving A. flavus in a patient with COVID-19 and ARDS in the Americas. Awareness of CAPA and accessibility to appropriate diagnostic tests are necessary for accurate and timely identification of this co-infection [26,27]. Ethical considerations Publication of this case report was approved by the Hospital de Clínicas “José de San Martin” IRB. Declaration of competing interest All authors no reported conflicts of interest. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC. Acknowledgements Claudia Barberis, Marisa Almuzara, and the staff of the infectious disease division and the intensive care unit, at Hospital de Clínicas “José de San Martin”. Universidad de Buenos Aires. Diego H. Caceres acknowledges Oak Ridge Institute for Science and Education (ORISE).	AZITHROMYCIN ANHYDROUS, CEFTRIAXONE, DEXAMETHASONE, HEPARIN SODIUM, HYDROXYCHLOROQUINE, IMIPENEM, LOPINAVIR\RITONAVIR, OSELTAMIVIR, VANCOMYCIN	DrugsGivenReaction	CC BY	32837881	19,203,398	2021-03
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Off label use'.	Ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Coronavirus disease 2019 (COVID-19), caused by the novel coronavirus SARS-CoV-2, emerged in Wuhan, China, in December 2019 and rapidly spread around the world. Invasive aspergillosis has been reported as a complication of severe influenza pneumonia among intensive care patients. Similarities between COVID-19 and influenza pneumonia, together with limited published case series, suggest that aspergillosis may be an important complication of COVID-19. This report describes a case of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 from Buenos Aires, Argentina. 1 Introduction SARS-CoV-2 is the novel coronavirus that causes coronavirus disease 2019 (COVID‐19), which was first reported in December 2019 in Wuhan, China, and has rapidly spread worldwide [1]. On March 11th, 2020, the World Health Organization (WHO) declared a pandemic, and by June 30th, 2020, a total of 10,185,374 cases and 503,862 deaths were reported in 216 locations around the world [2]. In Argentina, on June 30th, 2020, the Argentinean Ministry of Health (AMOH) reported 62,268 cases and 1283 deaths [3]. Invasive pulmonary aspergillosis (IPA) is a known complication in patients with severe influenza pneumonia. Case series from the Netherlands and Belgium reported an incidence of 19% in patients with influenza pneumonia and acute respiratory distress syndrome (ARDS) hospitalized in the intensive care unit (ICU) [4], although these high incidences have not been confirmed in other studies [4]. There is concern that critically ill COVID-19 patients might also be at increased risk of pulmonary aspergillosis co-infection [5]. Here we describe a report of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 and ARDS in Argentina. 2 Case presentation In late April 2020, an 85-year-old man with a history of hypertension was admitted to the ICU with a history of six days of fever and dyspnea, at home. The patient had close household contact with two COVID-19 cases, and nasopharyngeal (NP) swab samples collected on the day of ICU admission tested positive for SARS-CoV-2 using molecular testing. On ICU admission (day 1) the patient presented with bilateral infiltrates (ground-glass opacities) on chest radiograph, respiratory rate of 40 breaths per minute, heart rate of 82 beats per minute, and a blood pressure 150/85 mm Hg. Laboratory tests showed a white blood cell count of 11,600 cells/mm3, with lymphopenia, normal serum creatinine (1.02 mg/dL), low albumin (2.8 g/dL), and normal lactate (1.4 mmol/L), as well as elevated ferritin (1840 ng/mL), D-dimer (17.1 ng/mL), procalcitonin (2.89 ng/mL), and fibrinogen (702 mg/dl). The patient also presented with deep vein thrombosis in the right subclavian vein and in the right internal jugular vein; anticoagulation was initiated with heparin due to the hypercoagulable state. Empirical treatment for pneumonia was started with oseltamivir, ceftriaxone, and azithromycin, and hydroxychloroquine, ritonavir/lopinavir were started for COVID-19, according to the Argentinean Ministry of Health (AMOH) national guidelines [6]. After 3 days of hospitalization, the patient required ventilator support (orotracheal intubation and mechanical ventilation) and was given a corticosteroid (dexamethasone, 20 mg/day). Influenza antigen testing yielded a negative result, prompting cessation of empirical influenza treatment (Fig. 1).Fig. 1 Case timeline: ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Fig. 1 On day 10 of hospitalization, the patient developed a new fever (38 °C). Urinary culture and pneumococcal urine antigen test were negative; tracheal aspirate and blood culture were positive for Enterococcus faecalis, and imipenem and vancomycin were added to hydroxychloroquine and ritonavir/lopinavir. Two days later polymyxin was added, and blood cultures turned negative after seven days of treatment. On day 17, urinary analysis showed evidence of acute tubular necrosis with metabolic acidosis (low pH, PaCO2 and HCO3), and treatment was subsequently changed to meropenem and colistin. On day 19, tracheal aspirate, urine and blood culture remained negative for bacteria, and a second SARS-CoV-2 PCR test from a NP swab was positive. On day 23, the patient was again febrile, and urinary, tracheal aspirate, blood and catheter tip cultures were repeated; a third SARS-CoV-2 PCR test on day 24 from a NP swab was positive (Fig. 1). On day 25 the patient developed multiple organ failure, including acute renal failure. Aspergillus flavus, identified by MALDI-TOF (Fig. 2), and Acinetobacter baumanii (>106 CFU) were cultured from tracheal aspirate. Staphylococcus capitis was isolated from blood culture, and E. faecalis and Staphylococcus epidermidis were isolated from the central venous catheter tip culture. Candida lusitaniae was isolated from urine. The patient's antimicrobial regimen was updated to include vancomycin, meropenem, and colistin. Anidulafungin was added to control candidiasis, but azole therapy for the A. flavus finding was not started due to initial clinical suspicion of colonization versus infection. On day 26 a tracheostomy was placed as a result of prolonged ventilation, ARDS (PaO2/FiO2 ratio <200), and sepsis. Chest radiograph continued to show bilateral infiltrates (Fig. 3). Aspergillus galactomannan antigen (GM) was positive in serum (GM index: 1.4; Platelia Aspergillus; Bio-Rad, Marnes-La-Coquette, France) (Fig. 1).Fig. 2 Aspergillus flavus isolate: (A and B) Macroscopic: rapid growth olive green colonies, with woolly texture, on Sabouraud agar incubated at 28 °C (A) and 37 °C (B). (C) Microscopic: hyaline septate hyphae, radiate biseriate conidial head with finely roughened conidiophore. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.) Fig. 2 Fig. 3 Chest X-ray evidenced bilateral heterogeneous infiltrates on day 26 of hospitalization: picture from the COVID-19 associated pulmonary aspergillosis (CAPA) described on this report. Fig. 3 On day 28, laboratory testing showed increased white blood cells (16,930 cells/mm3; lymphocytes 45%), D-dimer (7.3 ng/mL), ferritin (3691 ng/mL) and C-reactive protein (31.8 mg/L). Blood and central venous catheter cultures were negative, and anidulafungin was replaced with voriconazole (400 mg first day, and then 300 mg daily) after the GM test returned positive. Colistin, vancomycin, and meropenem were continued. On day 30, hydroxychloroquine, ritonavir/lopinavir were suspended (following recommendation of AMOH), and on day 35, serum GM index decreased to 0.8. On day 44, the patient died in the ICU while on ventilatory support (Fig. 1). 3 Discussion COVID-19 associated pulmonary aspergillosis (CAPA) has been recently reported in European countries [[7], [8], [9], [10], [11], [12], [13]], including four case series covering 27 patients from France (n = 9), Belgium (n = 7), The Netherlands (n = 6), and Germany (n = 5) [[7], [8], [9], [10]]. Our case has similar clinical features compared with those previously reported. Among these four case series, all 27 patients were admitted to the ICU and developed ARDS. Most were male, >50 years old, and 25 (89%) of 27 had potential risk factors for severe COVID-19. Three (60%) of five patients from the German case series, seven (78%) of nine from the French case series, and three (43%) of seven patients from the Belgium case series had hypertension. All five patients from Germany had acute kidney injury, and three (33%) of nine patients from France and two (29%) of seven from Belgium received renal replacement therapy [[7], [8], [9], [10]]. Abnormal chest radiologic findings were reported in all of the patients from Germany (n = 5) and France (n = 9) [7,8]. Twelve (44%) of 27 patients received corticosteroids during their ICU stay, and 19 (70%) of 27 were treated with mold-active antifungal medication, eight (42%) of these 19 patients received corticosteroid simultaneous with antifungal treatment. Fifteen (55%) of the 27 case series patients died. Our patient received corticosteroids for 22 days before initial A. flavus culture and was treated with voriconazole starting 3 days after the initial fungal culture. Unlike influenza-associated pulmonary aspergillosis (IAPA), which commonly occurs early after ICU admission [4], our patient developed CAPA 25 days after ICU admission. COVID-19 associated pulmonary aspergillosis case series from Belgium and The Netherlands, showed variable time on development of were aspergillosis (range: 2–28 days) [9,10]. Making the diagnosis of IPA can be challenging, especially among patients not considered classically at greatest risk (e.g., hematologic malignancy and stem cell transplant patients). Among the four European CAPA case series discussed, Aspergillus species were cultured in 78% of respiratory specimens; positive specimens included: 14 bronchoalveolar lavage, six tracheal aspirate and one sputum [[7], [8], [9], [10]]. Bronchoscopy in COVID-19 patients is often not performed due to the risk of aerosol generation. Further complicating IPA diagnosis, serum GM testing is often negative among COVID-19 patients, and sensitivity is low among ICU patients in general; in the published cases series, of the 22 cases tested, only three (14%) had positive serum GM tests [14,15]. Most COVID-19 patients lack known risk factors for IPA [4]. Thus, isolation of Aspergillus from a non-sterile site and negative serum GM should not rule out invasive disease. Clinicians may want to consider mold-active azole therapy at first indication of aspergillosis in COVID-19 patients. Our patient had a high serum GM index (>1.0), which is the recommended cutoff, and mycological criteria for probable IPA classification by the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium [16]. Challenges in selecting a case definition for CAPA are also shared by the similar IAPA. For this reason, an expert panel recently proposed a new case definition for IAPA [17,18]. The definitions distinguish between invasive Aspergillus tracheobronchitis and other pulmonary manifestations and mainly rely on culture and GM to identify IPA. The expert panel stated that the IAPA case definition might also be useful to classify CAPA cases. Using this new definition, our case would be classified as probable CAPA [17]. A follow-up serum GM showed decreasing antigen titer which is consistent with antifungal treatment response. Little is known about the pathogenesis of CAPA, and there is a need to characterize risk factors for the development of IPA. Although influenza infection was found to be an independent risk factor for IPA [4], the use of corticosteroids in patients with influenza is also a risk factor for IAPA [19]. A recent preliminary report suggested that dexamethasone was associated with reduced mortality in COVID-19 patients [20]. However, corticosteroids might be associated with adverse effects such as delayed viral clearance and secondary infections. Notably, of the four proven IPA cases reported during the previous severe acute respiratory syndrome (SARS) epidemic, all were associated with concomitant corticosteroid therapy [5,21]. In our COVID-19 case with probable CAPA, we observed co-infections with bacterial and additional fungal pathogens (E. faecalis, A. baumanii, coagulase-negative staphylococci, and C. lusitaniae), which complicated patient treatment. Previous reports of CAPA cases did not describe the presence of other microbial co-infections [[7], [8], [9], [10], [11], [12], [13]], although these are commonly encountered in patients with influenza. Previous reports of ICU patients with severe influenza frequently reported secondary bacterial infection, and these were significantly associated with IAPA in studies comparing severe influenza patients with and without IAPA (61% vs 31%; p < 0.01) [22]. Co-infections were reported in up to 50% of patients with severe coronavirus infections causing both SARS and Middle East respiratory syndrome (MERS) [23]. However, early data suggest that coinfection frequency might be lower in COVID-19 [[23], [24], [25]]. We present a case of COVID-19 associated pulmonary aspergillosis from Argentina, with a clinical course and attributes similar to previously reported cases, that highlights the challenges in diagnosing and treating these CAPA patients. The use of a clinical algorithm to discriminate Aspergillus respiratory tract colonization from invasive pulmonary aspergillosis in critically ill patients is warranted, such as the one developed for IAPA [17,18]. This is the first report of ventilator-associated pneumonia involving A. flavus in a patient with COVID-19 and ARDS in the Americas. Awareness of CAPA and accessibility to appropriate diagnostic tests are necessary for accurate and timely identification of this co-infection [26,27]. Ethical considerations Publication of this case report was approved by the Hospital de Clínicas “José de San Martin” IRB. Declaration of competing interest All authors no reported conflicts of interest. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC. Acknowledgements Claudia Barberis, Marisa Almuzara, and the staff of the infectious disease division and the intensive care unit, at Hospital de Clínicas “José de San Martin”. Universidad de Buenos Aires. Diego H. Caceres acknowledges Oak Ridge Institute for Science and Education (ORISE).	AZITHROMYCIN ANHYDROUS, CEFTRIAXONE, DEXAMETHASONE, HEPARIN SODIUM, HYDROXYCHLOROQUINE, IMIPENEM, LOPINAVIR\RITONAVIR, OSELTAMIVIR, VANCOMYCIN	DrugsGivenReaction	CC BY	32837881	19,203,398	2021-03
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Product use in unapproved indication'.	Ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Coronavirus disease 2019 (COVID-19), caused by the novel coronavirus SARS-CoV-2, emerged in Wuhan, China, in December 2019 and rapidly spread around the world. Invasive aspergillosis has been reported as a complication of severe influenza pneumonia among intensive care patients. Similarities between COVID-19 and influenza pneumonia, together with limited published case series, suggest that aspergillosis may be an important complication of COVID-19. This report describes a case of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 from Buenos Aires, Argentina. 1 Introduction SARS-CoV-2 is the novel coronavirus that causes coronavirus disease 2019 (COVID‐19), which was first reported in December 2019 in Wuhan, China, and has rapidly spread worldwide [1]. On March 11th, 2020, the World Health Organization (WHO) declared a pandemic, and by June 30th, 2020, a total of 10,185,374 cases and 503,862 deaths were reported in 216 locations around the world [2]. In Argentina, on June 30th, 2020, the Argentinean Ministry of Health (AMOH) reported 62,268 cases and 1283 deaths [3]. Invasive pulmonary aspergillosis (IPA) is a known complication in patients with severe influenza pneumonia. Case series from the Netherlands and Belgium reported an incidence of 19% in patients with influenza pneumonia and acute respiratory distress syndrome (ARDS) hospitalized in the intensive care unit (ICU) [4], although these high incidences have not been confirmed in other studies [4]. There is concern that critically ill COVID-19 patients might also be at increased risk of pulmonary aspergillosis co-infection [5]. Here we describe a report of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 and ARDS in Argentina. 2 Case presentation In late April 2020, an 85-year-old man with a history of hypertension was admitted to the ICU with a history of six days of fever and dyspnea, at home. The patient had close household contact with two COVID-19 cases, and nasopharyngeal (NP) swab samples collected on the day of ICU admission tested positive for SARS-CoV-2 using molecular testing. On ICU admission (day 1) the patient presented with bilateral infiltrates (ground-glass opacities) on chest radiograph, respiratory rate of 40 breaths per minute, heart rate of 82 beats per minute, and a blood pressure 150/85 mm Hg. Laboratory tests showed a white blood cell count of 11,600 cells/mm3, with lymphopenia, normal serum creatinine (1.02 mg/dL), low albumin (2.8 g/dL), and normal lactate (1.4 mmol/L), as well as elevated ferritin (1840 ng/mL), D-dimer (17.1 ng/mL), procalcitonin (2.89 ng/mL), and fibrinogen (702 mg/dl). The patient also presented with deep vein thrombosis in the right subclavian vein and in the right internal jugular vein; anticoagulation was initiated with heparin due to the hypercoagulable state. Empirical treatment for pneumonia was started with oseltamivir, ceftriaxone, and azithromycin, and hydroxychloroquine, ritonavir/lopinavir were started for COVID-19, according to the Argentinean Ministry of Health (AMOH) national guidelines [6]. After 3 days of hospitalization, the patient required ventilator support (orotracheal intubation and mechanical ventilation) and was given a corticosteroid (dexamethasone, 20 mg/day). Influenza antigen testing yielded a negative result, prompting cessation of empirical influenza treatment (Fig. 1).Fig. 1 Case timeline: ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Fig. 1 On day 10 of hospitalization, the patient developed a new fever (38 °C). Urinary culture and pneumococcal urine antigen test were negative; tracheal aspirate and blood culture were positive for Enterococcus faecalis, and imipenem and vancomycin were added to hydroxychloroquine and ritonavir/lopinavir. Two days later polymyxin was added, and blood cultures turned negative after seven days of treatment. On day 17, urinary analysis showed evidence of acute tubular necrosis with metabolic acidosis (low pH, PaCO2 and HCO3), and treatment was subsequently changed to meropenem and colistin. On day 19, tracheal aspirate, urine and blood culture remained negative for bacteria, and a second SARS-CoV-2 PCR test from a NP swab was positive. On day 23, the patient was again febrile, and urinary, tracheal aspirate, blood and catheter tip cultures were repeated; a third SARS-CoV-2 PCR test on day 24 from a NP swab was positive (Fig. 1). On day 25 the patient developed multiple organ failure, including acute renal failure. Aspergillus flavus, identified by MALDI-TOF (Fig. 2), and Acinetobacter baumanii (>106 CFU) were cultured from tracheal aspirate. Staphylococcus capitis was isolated from blood culture, and E. faecalis and Staphylococcus epidermidis were isolated from the central venous catheter tip culture. Candida lusitaniae was isolated from urine. The patient's antimicrobial regimen was updated to include vancomycin, meropenem, and colistin. Anidulafungin was added to control candidiasis, but azole therapy for the A. flavus finding was not started due to initial clinical suspicion of colonization versus infection. On day 26 a tracheostomy was placed as a result of prolonged ventilation, ARDS (PaO2/FiO2 ratio <200), and sepsis. Chest radiograph continued to show bilateral infiltrates (Fig. 3). Aspergillus galactomannan antigen (GM) was positive in serum (GM index: 1.4; Platelia Aspergillus; Bio-Rad, Marnes-La-Coquette, France) (Fig. 1).Fig. 2 Aspergillus flavus isolate: (A and B) Macroscopic: rapid growth olive green colonies, with woolly texture, on Sabouraud agar incubated at 28 °C (A) and 37 °C (B). (C) Microscopic: hyaline septate hyphae, radiate biseriate conidial head with finely roughened conidiophore. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.) Fig. 2 Fig. 3 Chest X-ray evidenced bilateral heterogeneous infiltrates on day 26 of hospitalization: picture from the COVID-19 associated pulmonary aspergillosis (CAPA) described on this report. Fig. 3 On day 28, laboratory testing showed increased white blood cells (16,930 cells/mm3; lymphocytes 45%), D-dimer (7.3 ng/mL), ferritin (3691 ng/mL) and C-reactive protein (31.8 mg/L). Blood and central venous catheter cultures were negative, and anidulafungin was replaced with voriconazole (400 mg first day, and then 300 mg daily) after the GM test returned positive. Colistin, vancomycin, and meropenem were continued. On day 30, hydroxychloroquine, ritonavir/lopinavir were suspended (following recommendation of AMOH), and on day 35, serum GM index decreased to 0.8. On day 44, the patient died in the ICU while on ventilatory support (Fig. 1). 3 Discussion COVID-19 associated pulmonary aspergillosis (CAPA) has been recently reported in European countries [[7], [8], [9], [10], [11], [12], [13]], including four case series covering 27 patients from France (n = 9), Belgium (n = 7), The Netherlands (n = 6), and Germany (n = 5) [[7], [8], [9], [10]]. Our case has similar clinical features compared with those previously reported. Among these four case series, all 27 patients were admitted to the ICU and developed ARDS. Most were male, >50 years old, and 25 (89%) of 27 had potential risk factors for severe COVID-19. Three (60%) of five patients from the German case series, seven (78%) of nine from the French case series, and three (43%) of seven patients from the Belgium case series had hypertension. All five patients from Germany had acute kidney injury, and three (33%) of nine patients from France and two (29%) of seven from Belgium received renal replacement therapy [[7], [8], [9], [10]]. Abnormal chest radiologic findings were reported in all of the patients from Germany (n = 5) and France (n = 9) [7,8]. Twelve (44%) of 27 patients received corticosteroids during their ICU stay, and 19 (70%) of 27 were treated with mold-active antifungal medication, eight (42%) of these 19 patients received corticosteroid simultaneous with antifungal treatment. Fifteen (55%) of the 27 case series patients died. Our patient received corticosteroids for 22 days before initial A. flavus culture and was treated with voriconazole starting 3 days after the initial fungal culture. Unlike influenza-associated pulmonary aspergillosis (IAPA), which commonly occurs early after ICU admission [4], our patient developed CAPA 25 days after ICU admission. COVID-19 associated pulmonary aspergillosis case series from Belgium and The Netherlands, showed variable time on development of were aspergillosis (range: 2–28 days) [9,10]. Making the diagnosis of IPA can be challenging, especially among patients not considered classically at greatest risk (e.g., hematologic malignancy and stem cell transplant patients). Among the four European CAPA case series discussed, Aspergillus species were cultured in 78% of respiratory specimens; positive specimens included: 14 bronchoalveolar lavage, six tracheal aspirate and one sputum [[7], [8], [9], [10]]. Bronchoscopy in COVID-19 patients is often not performed due to the risk of aerosol generation. Further complicating IPA diagnosis, serum GM testing is often negative among COVID-19 patients, and sensitivity is low among ICU patients in general; in the published cases series, of the 22 cases tested, only three (14%) had positive serum GM tests [14,15]. Most COVID-19 patients lack known risk factors for IPA [4]. Thus, isolation of Aspergillus from a non-sterile site and negative serum GM should not rule out invasive disease. Clinicians may want to consider mold-active azole therapy at first indication of aspergillosis in COVID-19 patients. Our patient had a high serum GM index (>1.0), which is the recommended cutoff, and mycological criteria for probable IPA classification by the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium [16]. Challenges in selecting a case definition for CAPA are also shared by the similar IAPA. For this reason, an expert panel recently proposed a new case definition for IAPA [17,18]. The definitions distinguish between invasive Aspergillus tracheobronchitis and other pulmonary manifestations and mainly rely on culture and GM to identify IPA. The expert panel stated that the IAPA case definition might also be useful to classify CAPA cases. Using this new definition, our case would be classified as probable CAPA [17]. A follow-up serum GM showed decreasing antigen titer which is consistent with antifungal treatment response. Little is known about the pathogenesis of CAPA, and there is a need to characterize risk factors for the development of IPA. Although influenza infection was found to be an independent risk factor for IPA [4], the use of corticosteroids in patients with influenza is also a risk factor for IAPA [19]. A recent preliminary report suggested that dexamethasone was associated with reduced mortality in COVID-19 patients [20]. However, corticosteroids might be associated with adverse effects such as delayed viral clearance and secondary infections. Notably, of the four proven IPA cases reported during the previous severe acute respiratory syndrome (SARS) epidemic, all were associated with concomitant corticosteroid therapy [5,21]. In our COVID-19 case with probable CAPA, we observed co-infections with bacterial and additional fungal pathogens (E. faecalis, A. baumanii, coagulase-negative staphylococci, and C. lusitaniae), which complicated patient treatment. Previous reports of CAPA cases did not describe the presence of other microbial co-infections [[7], [8], [9], [10], [11], [12], [13]], although these are commonly encountered in patients with influenza. Previous reports of ICU patients with severe influenza frequently reported secondary bacterial infection, and these were significantly associated with IAPA in studies comparing severe influenza patients with and without IAPA (61% vs 31%; p < 0.01) [22]. Co-infections were reported in up to 50% of patients with severe coronavirus infections causing both SARS and Middle East respiratory syndrome (MERS) [23]. However, early data suggest that coinfection frequency might be lower in COVID-19 [[23], [24], [25]]. We present a case of COVID-19 associated pulmonary aspergillosis from Argentina, with a clinical course and attributes similar to previously reported cases, that highlights the challenges in diagnosing and treating these CAPA patients. The use of a clinical algorithm to discriminate Aspergillus respiratory tract colonization from invasive pulmonary aspergillosis in critically ill patients is warranted, such as the one developed for IAPA [17,18]. This is the first report of ventilator-associated pneumonia involving A. flavus in a patient with COVID-19 and ARDS in the Americas. Awareness of CAPA and accessibility to appropriate diagnostic tests are necessary for accurate and timely identification of this co-infection [26,27]. Ethical considerations Publication of this case report was approved by the Hospital de Clínicas “José de San Martin” IRB. Declaration of competing interest All authors no reported conflicts of interest. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC. Acknowledgements Claudia Barberis, Marisa Almuzara, and the staff of the infectious disease division and the intensive care unit, at Hospital de Clínicas “José de San Martin”. Universidad de Buenos Aires. Diego H. Caceres acknowledges Oak Ridge Institute for Science and Education (ORISE).	AZITHROMYCIN ANHYDROUS, CEFTRIAXONE, DEXAMETHASONE, HEPARIN SODIUM, HYDROXYCHLOROQUINE, LOPINAVIR\RITONAVIR, OSELTAMIVIR	DrugsGivenReaction	CC BY	32837881	19,079,816	2021-03
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Renal tubular necrosis'.	Ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Coronavirus disease 2019 (COVID-19), caused by the novel coronavirus SARS-CoV-2, emerged in Wuhan, China, in December 2019 and rapidly spread around the world. Invasive aspergillosis has been reported as a complication of severe influenza pneumonia among intensive care patients. Similarities between COVID-19 and influenza pneumonia, together with limited published case series, suggest that aspergillosis may be an important complication of COVID-19. This report describes a case of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 from Buenos Aires, Argentina. 1 Introduction SARS-CoV-2 is the novel coronavirus that causes coronavirus disease 2019 (COVID‐19), which was first reported in December 2019 in Wuhan, China, and has rapidly spread worldwide [1]. On March 11th, 2020, the World Health Organization (WHO) declared a pandemic, and by June 30th, 2020, a total of 10,185,374 cases and 503,862 deaths were reported in 216 locations around the world [2]. In Argentina, on June 30th, 2020, the Argentinean Ministry of Health (AMOH) reported 62,268 cases and 1283 deaths [3]. Invasive pulmonary aspergillosis (IPA) is a known complication in patients with severe influenza pneumonia. Case series from the Netherlands and Belgium reported an incidence of 19% in patients with influenza pneumonia and acute respiratory distress syndrome (ARDS) hospitalized in the intensive care unit (ICU) [4], although these high incidences have not been confirmed in other studies [4]. There is concern that critically ill COVID-19 patients might also be at increased risk of pulmonary aspergillosis co-infection [5]. Here we describe a report of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 and ARDS in Argentina. 2 Case presentation In late April 2020, an 85-year-old man with a history of hypertension was admitted to the ICU with a history of six days of fever and dyspnea, at home. The patient had close household contact with two COVID-19 cases, and nasopharyngeal (NP) swab samples collected on the day of ICU admission tested positive for SARS-CoV-2 using molecular testing. On ICU admission (day 1) the patient presented with bilateral infiltrates (ground-glass opacities) on chest radiograph, respiratory rate of 40 breaths per minute, heart rate of 82 beats per minute, and a blood pressure 150/85 mm Hg. Laboratory tests showed a white blood cell count of 11,600 cells/mm3, with lymphopenia, normal serum creatinine (1.02 mg/dL), low albumin (2.8 g/dL), and normal lactate (1.4 mmol/L), as well as elevated ferritin (1840 ng/mL), D-dimer (17.1 ng/mL), procalcitonin (2.89 ng/mL), and fibrinogen (702 mg/dl). The patient also presented with deep vein thrombosis in the right subclavian vein and in the right internal jugular vein; anticoagulation was initiated with heparin due to the hypercoagulable state. Empirical treatment for pneumonia was started with oseltamivir, ceftriaxone, and azithromycin, and hydroxychloroquine, ritonavir/lopinavir were started for COVID-19, according to the Argentinean Ministry of Health (AMOH) national guidelines [6]. After 3 days of hospitalization, the patient required ventilator support (orotracheal intubation and mechanical ventilation) and was given a corticosteroid (dexamethasone, 20 mg/day). Influenza antigen testing yielded a negative result, prompting cessation of empirical influenza treatment (Fig. 1).Fig. 1 Case timeline: ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Fig. 1 On day 10 of hospitalization, the patient developed a new fever (38 °C). Urinary culture and pneumococcal urine antigen test were negative; tracheal aspirate and blood culture were positive for Enterococcus faecalis, and imipenem and vancomycin were added to hydroxychloroquine and ritonavir/lopinavir. Two days later polymyxin was added, and blood cultures turned negative after seven days of treatment. On day 17, urinary analysis showed evidence of acute tubular necrosis with metabolic acidosis (low pH, PaCO2 and HCO3), and treatment was subsequently changed to meropenem and colistin. On day 19, tracheal aspirate, urine and blood culture remained negative for bacteria, and a second SARS-CoV-2 PCR test from a NP swab was positive. On day 23, the patient was again febrile, and urinary, tracheal aspirate, blood and catheter tip cultures were repeated; a third SARS-CoV-2 PCR test on day 24 from a NP swab was positive (Fig. 1). On day 25 the patient developed multiple organ failure, including acute renal failure. Aspergillus flavus, identified by MALDI-TOF (Fig. 2), and Acinetobacter baumanii (>106 CFU) were cultured from tracheal aspirate. Staphylococcus capitis was isolated from blood culture, and E. faecalis and Staphylococcus epidermidis were isolated from the central venous catheter tip culture. Candida lusitaniae was isolated from urine. The patient's antimicrobial regimen was updated to include vancomycin, meropenem, and colistin. Anidulafungin was added to control candidiasis, but azole therapy for the A. flavus finding was not started due to initial clinical suspicion of colonization versus infection. On day 26 a tracheostomy was placed as a result of prolonged ventilation, ARDS (PaO2/FiO2 ratio <200), and sepsis. Chest radiograph continued to show bilateral infiltrates (Fig. 3). Aspergillus galactomannan antigen (GM) was positive in serum (GM index: 1.4; Platelia Aspergillus; Bio-Rad, Marnes-La-Coquette, France) (Fig. 1).Fig. 2 Aspergillus flavus isolate: (A and B) Macroscopic: rapid growth olive green colonies, with woolly texture, on Sabouraud agar incubated at 28 °C (A) and 37 °C (B). (C) Microscopic: hyaline septate hyphae, radiate biseriate conidial head with finely roughened conidiophore. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.) Fig. 2 Fig. 3 Chest X-ray evidenced bilateral heterogeneous infiltrates on day 26 of hospitalization: picture from the COVID-19 associated pulmonary aspergillosis (CAPA) described on this report. Fig. 3 On day 28, laboratory testing showed increased white blood cells (16,930 cells/mm3; lymphocytes 45%), D-dimer (7.3 ng/mL), ferritin (3691 ng/mL) and C-reactive protein (31.8 mg/L). Blood and central venous catheter cultures were negative, and anidulafungin was replaced with voriconazole (400 mg first day, and then 300 mg daily) after the GM test returned positive. Colistin, vancomycin, and meropenem were continued. On day 30, hydroxychloroquine, ritonavir/lopinavir were suspended (following recommendation of AMOH), and on day 35, serum GM index decreased to 0.8. On day 44, the patient died in the ICU while on ventilatory support (Fig. 1). 3 Discussion COVID-19 associated pulmonary aspergillosis (CAPA) has been recently reported in European countries [[7], [8], [9], [10], [11], [12], [13]], including four case series covering 27 patients from France (n = 9), Belgium (n = 7), The Netherlands (n = 6), and Germany (n = 5) [[7], [8], [9], [10]]. Our case has similar clinical features compared with those previously reported. Among these four case series, all 27 patients were admitted to the ICU and developed ARDS. Most were male, >50 years old, and 25 (89%) of 27 had potential risk factors for severe COVID-19. Three (60%) of five patients from the German case series, seven (78%) of nine from the French case series, and three (43%) of seven patients from the Belgium case series had hypertension. All five patients from Germany had acute kidney injury, and three (33%) of nine patients from France and two (29%) of seven from Belgium received renal replacement therapy [[7], [8], [9], [10]]. Abnormal chest radiologic findings were reported in all of the patients from Germany (n = 5) and France (n = 9) [7,8]. Twelve (44%) of 27 patients received corticosteroids during their ICU stay, and 19 (70%) of 27 were treated with mold-active antifungal medication, eight (42%) of these 19 patients received corticosteroid simultaneous with antifungal treatment. Fifteen (55%) of the 27 case series patients died. Our patient received corticosteroids for 22 days before initial A. flavus culture and was treated with voriconazole starting 3 days after the initial fungal culture. Unlike influenza-associated pulmonary aspergillosis (IAPA), which commonly occurs early after ICU admission [4], our patient developed CAPA 25 days after ICU admission. COVID-19 associated pulmonary aspergillosis case series from Belgium and The Netherlands, showed variable time on development of were aspergillosis (range: 2–28 days) [9,10]. Making the diagnosis of IPA can be challenging, especially among patients not considered classically at greatest risk (e.g., hematologic malignancy and stem cell transplant patients). Among the four European CAPA case series discussed, Aspergillus species were cultured in 78% of respiratory specimens; positive specimens included: 14 bronchoalveolar lavage, six tracheal aspirate and one sputum [[7], [8], [9], [10]]. Bronchoscopy in COVID-19 patients is often not performed due to the risk of aerosol generation. Further complicating IPA diagnosis, serum GM testing is often negative among COVID-19 patients, and sensitivity is low among ICU patients in general; in the published cases series, of the 22 cases tested, only three (14%) had positive serum GM tests [14,15]. Most COVID-19 patients lack known risk factors for IPA [4]. Thus, isolation of Aspergillus from a non-sterile site and negative serum GM should not rule out invasive disease. Clinicians may want to consider mold-active azole therapy at first indication of aspergillosis in COVID-19 patients. Our patient had a high serum GM index (>1.0), which is the recommended cutoff, and mycological criteria for probable IPA classification by the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium [16]. Challenges in selecting a case definition for CAPA are also shared by the similar IAPA. For this reason, an expert panel recently proposed a new case definition for IAPA [17,18]. The definitions distinguish between invasive Aspergillus tracheobronchitis and other pulmonary manifestations and mainly rely on culture and GM to identify IPA. The expert panel stated that the IAPA case definition might also be useful to classify CAPA cases. Using this new definition, our case would be classified as probable CAPA [17]. A follow-up serum GM showed decreasing antigen titer which is consistent with antifungal treatment response. Little is known about the pathogenesis of CAPA, and there is a need to characterize risk factors for the development of IPA. Although influenza infection was found to be an independent risk factor for IPA [4], the use of corticosteroids in patients with influenza is also a risk factor for IAPA [19]. A recent preliminary report suggested that dexamethasone was associated with reduced mortality in COVID-19 patients [20]. However, corticosteroids might be associated with adverse effects such as delayed viral clearance and secondary infections. Notably, of the four proven IPA cases reported during the previous severe acute respiratory syndrome (SARS) epidemic, all were associated with concomitant corticosteroid therapy [5,21]. In our COVID-19 case with probable CAPA, we observed co-infections with bacterial and additional fungal pathogens (E. faecalis, A. baumanii, coagulase-negative staphylococci, and C. lusitaniae), which complicated patient treatment. Previous reports of CAPA cases did not describe the presence of other microbial co-infections [[7], [8], [9], [10], [11], [12], [13]], although these are commonly encountered in patients with influenza. Previous reports of ICU patients with severe influenza frequently reported secondary bacterial infection, and these were significantly associated with IAPA in studies comparing severe influenza patients with and without IAPA (61% vs 31%; p < 0.01) [22]. Co-infections were reported in up to 50% of patients with severe coronavirus infections causing both SARS and Middle East respiratory syndrome (MERS) [23]. However, early data suggest that coinfection frequency might be lower in COVID-19 [[23], [24], [25]]. We present a case of COVID-19 associated pulmonary aspergillosis from Argentina, with a clinical course and attributes similar to previously reported cases, that highlights the challenges in diagnosing and treating these CAPA patients. The use of a clinical algorithm to discriminate Aspergillus respiratory tract colonization from invasive pulmonary aspergillosis in critically ill patients is warranted, such as the one developed for IAPA [17,18]. This is the first report of ventilator-associated pneumonia involving A. flavus in a patient with COVID-19 and ARDS in the Americas. Awareness of CAPA and accessibility to appropriate diagnostic tests are necessary for accurate and timely identification of this co-infection [26,27]. Ethical considerations Publication of this case report was approved by the Hospital de Clínicas “José de San Martin” IRB. Declaration of competing interest All authors no reported conflicts of interest. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC. Acknowledgements Claudia Barberis, Marisa Almuzara, and the staff of the infectious disease division and the intensive care unit, at Hospital de Clínicas “José de San Martin”. Universidad de Buenos Aires. Diego H. Caceres acknowledges Oak Ridge Institute for Science and Education (ORISE).	AZITHROMYCIN ANHYDROUS, CEFTRIAXONE, DEXAMETHASONE, HEPARIN SODIUM, HYDROXYCHLOROQUINE, IMIPENEM, LOPINAVIR\RITONAVIR, OSELTAMIVIR, VANCOMYCIN	DrugsGivenReaction	CC BY	32837881	19,203,398	2021-03
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'SARS-CoV-2 test positive'.	Ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Coronavirus disease 2019 (COVID-19), caused by the novel coronavirus SARS-CoV-2, emerged in Wuhan, China, in December 2019 and rapidly spread around the world. Invasive aspergillosis has been reported as a complication of severe influenza pneumonia among intensive care patients. Similarities between COVID-19 and influenza pneumonia, together with limited published case series, suggest that aspergillosis may be an important complication of COVID-19. This report describes a case of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 from Buenos Aires, Argentina. 1 Introduction SARS-CoV-2 is the novel coronavirus that causes coronavirus disease 2019 (COVID‐19), which was first reported in December 2019 in Wuhan, China, and has rapidly spread worldwide [1]. On March 11th, 2020, the World Health Organization (WHO) declared a pandemic, and by June 30th, 2020, a total of 10,185,374 cases and 503,862 deaths were reported in 216 locations around the world [2]. In Argentina, on June 30th, 2020, the Argentinean Ministry of Health (AMOH) reported 62,268 cases and 1283 deaths [3]. Invasive pulmonary aspergillosis (IPA) is a known complication in patients with severe influenza pneumonia. Case series from the Netherlands and Belgium reported an incidence of 19% in patients with influenza pneumonia and acute respiratory distress syndrome (ARDS) hospitalized in the intensive care unit (ICU) [4], although these high incidences have not been confirmed in other studies [4]. There is concern that critically ill COVID-19 patients might also be at increased risk of pulmonary aspergillosis co-infection [5]. Here we describe a report of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 and ARDS in Argentina. 2 Case presentation In late April 2020, an 85-year-old man with a history of hypertension was admitted to the ICU with a history of six days of fever and dyspnea, at home. The patient had close household contact with two COVID-19 cases, and nasopharyngeal (NP) swab samples collected on the day of ICU admission tested positive for SARS-CoV-2 using molecular testing. On ICU admission (day 1) the patient presented with bilateral infiltrates (ground-glass opacities) on chest radiograph, respiratory rate of 40 breaths per minute, heart rate of 82 beats per minute, and a blood pressure 150/85 mm Hg. Laboratory tests showed a white blood cell count of 11,600 cells/mm3, with lymphopenia, normal serum creatinine (1.02 mg/dL), low albumin (2.8 g/dL), and normal lactate (1.4 mmol/L), as well as elevated ferritin (1840 ng/mL), D-dimer (17.1 ng/mL), procalcitonin (2.89 ng/mL), and fibrinogen (702 mg/dl). The patient also presented with deep vein thrombosis in the right subclavian vein and in the right internal jugular vein; anticoagulation was initiated with heparin due to the hypercoagulable state. Empirical treatment for pneumonia was started with oseltamivir, ceftriaxone, and azithromycin, and hydroxychloroquine, ritonavir/lopinavir were started for COVID-19, according to the Argentinean Ministry of Health (AMOH) national guidelines [6]. After 3 days of hospitalization, the patient required ventilator support (orotracheal intubation and mechanical ventilation) and was given a corticosteroid (dexamethasone, 20 mg/day). Influenza antigen testing yielded a negative result, prompting cessation of empirical influenza treatment (Fig. 1).Fig. 1 Case timeline: ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Fig. 1 On day 10 of hospitalization, the patient developed a new fever (38 °C). Urinary culture and pneumococcal urine antigen test were negative; tracheal aspirate and blood culture were positive for Enterococcus faecalis, and imipenem and vancomycin were added to hydroxychloroquine and ritonavir/lopinavir. Two days later polymyxin was added, and blood cultures turned negative after seven days of treatment. On day 17, urinary analysis showed evidence of acute tubular necrosis with metabolic acidosis (low pH, PaCO2 and HCO3), and treatment was subsequently changed to meropenem and colistin. On day 19, tracheal aspirate, urine and blood culture remained negative for bacteria, and a second SARS-CoV-2 PCR test from a NP swab was positive. On day 23, the patient was again febrile, and urinary, tracheal aspirate, blood and catheter tip cultures were repeated; a third SARS-CoV-2 PCR test on day 24 from a NP swab was positive (Fig. 1). On day 25 the patient developed multiple organ failure, including acute renal failure. Aspergillus flavus, identified by MALDI-TOF (Fig. 2), and Acinetobacter baumanii (>106 CFU) were cultured from tracheal aspirate. Staphylococcus capitis was isolated from blood culture, and E. faecalis and Staphylococcus epidermidis were isolated from the central venous catheter tip culture. Candida lusitaniae was isolated from urine. The patient's antimicrobial regimen was updated to include vancomycin, meropenem, and colistin. Anidulafungin was added to control candidiasis, but azole therapy for the A. flavus finding was not started due to initial clinical suspicion of colonization versus infection. On day 26 a tracheostomy was placed as a result of prolonged ventilation, ARDS (PaO2/FiO2 ratio <200), and sepsis. Chest radiograph continued to show bilateral infiltrates (Fig. 3). Aspergillus galactomannan antigen (GM) was positive in serum (GM index: 1.4; Platelia Aspergillus; Bio-Rad, Marnes-La-Coquette, France) (Fig. 1).Fig. 2 Aspergillus flavus isolate: (A and B) Macroscopic: rapid growth olive green colonies, with woolly texture, on Sabouraud agar incubated at 28 °C (A) and 37 °C (B). (C) Microscopic: hyaline septate hyphae, radiate biseriate conidial head with finely roughened conidiophore. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.) Fig. 2 Fig. 3 Chest X-ray evidenced bilateral heterogeneous infiltrates on day 26 of hospitalization: picture from the COVID-19 associated pulmonary aspergillosis (CAPA) described on this report. Fig. 3 On day 28, laboratory testing showed increased white blood cells (16,930 cells/mm3; lymphocytes 45%), D-dimer (7.3 ng/mL), ferritin (3691 ng/mL) and C-reactive protein (31.8 mg/L). Blood and central venous catheter cultures were negative, and anidulafungin was replaced with voriconazole (400 mg first day, and then 300 mg daily) after the GM test returned positive. Colistin, vancomycin, and meropenem were continued. On day 30, hydroxychloroquine, ritonavir/lopinavir were suspended (following recommendation of AMOH), and on day 35, serum GM index decreased to 0.8. On day 44, the patient died in the ICU while on ventilatory support (Fig. 1). 3 Discussion COVID-19 associated pulmonary aspergillosis (CAPA) has been recently reported in European countries [[7], [8], [9], [10], [11], [12], [13]], including four case series covering 27 patients from France (n = 9), Belgium (n = 7), The Netherlands (n = 6), and Germany (n = 5) [[7], [8], [9], [10]]. Our case has similar clinical features compared with those previously reported. Among these four case series, all 27 patients were admitted to the ICU and developed ARDS. Most were male, >50 years old, and 25 (89%) of 27 had potential risk factors for severe COVID-19. Three (60%) of five patients from the German case series, seven (78%) of nine from the French case series, and three (43%) of seven patients from the Belgium case series had hypertension. All five patients from Germany had acute kidney injury, and three (33%) of nine patients from France and two (29%) of seven from Belgium received renal replacement therapy [[7], [8], [9], [10]]. Abnormal chest radiologic findings were reported in all of the patients from Germany (n = 5) and France (n = 9) [7,8]. Twelve (44%) of 27 patients received corticosteroids during their ICU stay, and 19 (70%) of 27 were treated with mold-active antifungal medication, eight (42%) of these 19 patients received corticosteroid simultaneous with antifungal treatment. Fifteen (55%) of the 27 case series patients died. Our patient received corticosteroids for 22 days before initial A. flavus culture and was treated with voriconazole starting 3 days after the initial fungal culture. Unlike influenza-associated pulmonary aspergillosis (IAPA), which commonly occurs early after ICU admission [4], our patient developed CAPA 25 days after ICU admission. COVID-19 associated pulmonary aspergillosis case series from Belgium and The Netherlands, showed variable time on development of were aspergillosis (range: 2–28 days) [9,10]. Making the diagnosis of IPA can be challenging, especially among patients not considered classically at greatest risk (e.g., hematologic malignancy and stem cell transplant patients). Among the four European CAPA case series discussed, Aspergillus species were cultured in 78% of respiratory specimens; positive specimens included: 14 bronchoalveolar lavage, six tracheal aspirate and one sputum [[7], [8], [9], [10]]. Bronchoscopy in COVID-19 patients is often not performed due to the risk of aerosol generation. Further complicating IPA diagnosis, serum GM testing is often negative among COVID-19 patients, and sensitivity is low among ICU patients in general; in the published cases series, of the 22 cases tested, only three (14%) had positive serum GM tests [14,15]. Most COVID-19 patients lack known risk factors for IPA [4]. Thus, isolation of Aspergillus from a non-sterile site and negative serum GM should not rule out invasive disease. Clinicians may want to consider mold-active azole therapy at first indication of aspergillosis in COVID-19 patients. Our patient had a high serum GM index (>1.0), which is the recommended cutoff, and mycological criteria for probable IPA classification by the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium [16]. Challenges in selecting a case definition for CAPA are also shared by the similar IAPA. For this reason, an expert panel recently proposed a new case definition for IAPA [17,18]. The definitions distinguish between invasive Aspergillus tracheobronchitis and other pulmonary manifestations and mainly rely on culture and GM to identify IPA. The expert panel stated that the IAPA case definition might also be useful to classify CAPA cases. Using this new definition, our case would be classified as probable CAPA [17]. A follow-up serum GM showed decreasing antigen titer which is consistent with antifungal treatment response. Little is known about the pathogenesis of CAPA, and there is a need to characterize risk factors for the development of IPA. Although influenza infection was found to be an independent risk factor for IPA [4], the use of corticosteroids in patients with influenza is also a risk factor for IAPA [19]. A recent preliminary report suggested that dexamethasone was associated with reduced mortality in COVID-19 patients [20]. However, corticosteroids might be associated with adverse effects such as delayed viral clearance and secondary infections. Notably, of the four proven IPA cases reported during the previous severe acute respiratory syndrome (SARS) epidemic, all were associated with concomitant corticosteroid therapy [5,21]. In our COVID-19 case with probable CAPA, we observed co-infections with bacterial and additional fungal pathogens (E. faecalis, A. baumanii, coagulase-negative staphylococci, and C. lusitaniae), which complicated patient treatment. Previous reports of CAPA cases did not describe the presence of other microbial co-infections [[7], [8], [9], [10], [11], [12], [13]], although these are commonly encountered in patients with influenza. Previous reports of ICU patients with severe influenza frequently reported secondary bacterial infection, and these were significantly associated with IAPA in studies comparing severe influenza patients with and without IAPA (61% vs 31%; p < 0.01) [22]. Co-infections were reported in up to 50% of patients with severe coronavirus infections causing both SARS and Middle East respiratory syndrome (MERS) [23]. However, early data suggest that coinfection frequency might be lower in COVID-19 [[23], [24], [25]]. We present a case of COVID-19 associated pulmonary aspergillosis from Argentina, with a clinical course and attributes similar to previously reported cases, that highlights the challenges in diagnosing and treating these CAPA patients. The use of a clinical algorithm to discriminate Aspergillus respiratory tract colonization from invasive pulmonary aspergillosis in critically ill patients is warranted, such as the one developed for IAPA [17,18]. This is the first report of ventilator-associated pneumonia involving A. flavus in a patient with COVID-19 and ARDS in the Americas. Awareness of CAPA and accessibility to appropriate diagnostic tests are necessary for accurate and timely identification of this co-infection [26,27]. Ethical considerations Publication of this case report was approved by the Hospital de Clínicas “José de San Martin” IRB. Declaration of competing interest All authors no reported conflicts of interest. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC. Acknowledgements Claudia Barberis, Marisa Almuzara, and the staff of the infectious disease division and the intensive care unit, at Hospital de Clínicas “José de San Martin”. Universidad de Buenos Aires. Diego H. Caceres acknowledges Oak Ridge Institute for Science and Education (ORISE).	AZITHROMYCIN ANHYDROUS, CEFTRIAXONE, DEXAMETHASONE, HEPARIN SODIUM, HYDROXYCHLOROQUINE, IMIPENEM, LOPINAVIR\RITONAVIR, OSELTAMIVIR, VANCOMYCIN	DrugsGivenReaction	CC BY	32837881	19,203,398	2021-03
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Vascular device infection'.	Ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Coronavirus disease 2019 (COVID-19), caused by the novel coronavirus SARS-CoV-2, emerged in Wuhan, China, in December 2019 and rapidly spread around the world. Invasive aspergillosis has been reported as a complication of severe influenza pneumonia among intensive care patients. Similarities between COVID-19 and influenza pneumonia, together with limited published case series, suggest that aspergillosis may be an important complication of COVID-19. This report describes a case of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 from Buenos Aires, Argentina. 1 Introduction SARS-CoV-2 is the novel coronavirus that causes coronavirus disease 2019 (COVID‐19), which was first reported in December 2019 in Wuhan, China, and has rapidly spread worldwide [1]. On March 11th, 2020, the World Health Organization (WHO) declared a pandemic, and by June 30th, 2020, a total of 10,185,374 cases and 503,862 deaths were reported in 216 locations around the world [2]. In Argentina, on June 30th, 2020, the Argentinean Ministry of Health (AMOH) reported 62,268 cases and 1283 deaths [3]. Invasive pulmonary aspergillosis (IPA) is a known complication in patients with severe influenza pneumonia. Case series from the Netherlands and Belgium reported an incidence of 19% in patients with influenza pneumonia and acute respiratory distress syndrome (ARDS) hospitalized in the intensive care unit (ICU) [4], although these high incidences have not been confirmed in other studies [4]. There is concern that critically ill COVID-19 patients might also be at increased risk of pulmonary aspergillosis co-infection [5]. Here we describe a report of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 and ARDS in Argentina. 2 Case presentation In late April 2020, an 85-year-old man with a history of hypertension was admitted to the ICU with a history of six days of fever and dyspnea, at home. The patient had close household contact with two COVID-19 cases, and nasopharyngeal (NP) swab samples collected on the day of ICU admission tested positive for SARS-CoV-2 using molecular testing. On ICU admission (day 1) the patient presented with bilateral infiltrates (ground-glass opacities) on chest radiograph, respiratory rate of 40 breaths per minute, heart rate of 82 beats per minute, and a blood pressure 150/85 mm Hg. Laboratory tests showed a white blood cell count of 11,600 cells/mm3, with lymphopenia, normal serum creatinine (1.02 mg/dL), low albumin (2.8 g/dL), and normal lactate (1.4 mmol/L), as well as elevated ferritin (1840 ng/mL), D-dimer (17.1 ng/mL), procalcitonin (2.89 ng/mL), and fibrinogen (702 mg/dl). The patient also presented with deep vein thrombosis in the right subclavian vein and in the right internal jugular vein; anticoagulation was initiated with heparin due to the hypercoagulable state. Empirical treatment for pneumonia was started with oseltamivir, ceftriaxone, and azithromycin, and hydroxychloroquine, ritonavir/lopinavir were started for COVID-19, according to the Argentinean Ministry of Health (AMOH) national guidelines [6]. After 3 days of hospitalization, the patient required ventilator support (orotracheal intubation and mechanical ventilation) and was given a corticosteroid (dexamethasone, 20 mg/day). Influenza antigen testing yielded a negative result, prompting cessation of empirical influenza treatment (Fig. 1).Fig. 1 Case timeline: ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Fig. 1 On day 10 of hospitalization, the patient developed a new fever (38 °C). Urinary culture and pneumococcal urine antigen test were negative; tracheal aspirate and blood culture were positive for Enterococcus faecalis, and imipenem and vancomycin were added to hydroxychloroquine and ritonavir/lopinavir. Two days later polymyxin was added, and blood cultures turned negative after seven days of treatment. On day 17, urinary analysis showed evidence of acute tubular necrosis with metabolic acidosis (low pH, PaCO2 and HCO3), and treatment was subsequently changed to meropenem and colistin. On day 19, tracheal aspirate, urine and blood culture remained negative for bacteria, and a second SARS-CoV-2 PCR test from a NP swab was positive. On day 23, the patient was again febrile, and urinary, tracheal aspirate, blood and catheter tip cultures were repeated; a third SARS-CoV-2 PCR test on day 24 from a NP swab was positive (Fig. 1). On day 25 the patient developed multiple organ failure, including acute renal failure. Aspergillus flavus, identified by MALDI-TOF (Fig. 2), and Acinetobacter baumanii (>106 CFU) were cultured from tracheal aspirate. Staphylococcus capitis was isolated from blood culture, and E. faecalis and Staphylococcus epidermidis were isolated from the central venous catheter tip culture. Candida lusitaniae was isolated from urine. The patient's antimicrobial regimen was updated to include vancomycin, meropenem, and colistin. Anidulafungin was added to control candidiasis, but azole therapy for the A. flavus finding was not started due to initial clinical suspicion of colonization versus infection. On day 26 a tracheostomy was placed as a result of prolonged ventilation, ARDS (PaO2/FiO2 ratio <200), and sepsis. Chest radiograph continued to show bilateral infiltrates (Fig. 3). Aspergillus galactomannan antigen (GM) was positive in serum (GM index: 1.4; Platelia Aspergillus; Bio-Rad, Marnes-La-Coquette, France) (Fig. 1).Fig. 2 Aspergillus flavus isolate: (A and B) Macroscopic: rapid growth olive green colonies, with woolly texture, on Sabouraud agar incubated at 28 °C (A) and 37 °C (B). (C) Microscopic: hyaline septate hyphae, radiate biseriate conidial head with finely roughened conidiophore. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.) Fig. 2 Fig. 3 Chest X-ray evidenced bilateral heterogeneous infiltrates on day 26 of hospitalization: picture from the COVID-19 associated pulmonary aspergillosis (CAPA) described on this report. Fig. 3 On day 28, laboratory testing showed increased white blood cells (16,930 cells/mm3; lymphocytes 45%), D-dimer (7.3 ng/mL), ferritin (3691 ng/mL) and C-reactive protein (31.8 mg/L). Blood and central venous catheter cultures were negative, and anidulafungin was replaced with voriconazole (400 mg first day, and then 300 mg daily) after the GM test returned positive. Colistin, vancomycin, and meropenem were continued. On day 30, hydroxychloroquine, ritonavir/lopinavir were suspended (following recommendation of AMOH), and on day 35, serum GM index decreased to 0.8. On day 44, the patient died in the ICU while on ventilatory support (Fig. 1). 3 Discussion COVID-19 associated pulmonary aspergillosis (CAPA) has been recently reported in European countries [[7], [8], [9], [10], [11], [12], [13]], including four case series covering 27 patients from France (n = 9), Belgium (n = 7), The Netherlands (n = 6), and Germany (n = 5) [[7], [8], [9], [10]]. Our case has similar clinical features compared with those previously reported. Among these four case series, all 27 patients were admitted to the ICU and developed ARDS. Most were male, >50 years old, and 25 (89%) of 27 had potential risk factors for severe COVID-19. Three (60%) of five patients from the German case series, seven (78%) of nine from the French case series, and three (43%) of seven patients from the Belgium case series had hypertension. All five patients from Germany had acute kidney injury, and three (33%) of nine patients from France and two (29%) of seven from Belgium received renal replacement therapy [[7], [8], [9], [10]]. Abnormal chest radiologic findings were reported in all of the patients from Germany (n = 5) and France (n = 9) [7,8]. Twelve (44%) of 27 patients received corticosteroids during their ICU stay, and 19 (70%) of 27 were treated with mold-active antifungal medication, eight (42%) of these 19 patients received corticosteroid simultaneous with antifungal treatment. Fifteen (55%) of the 27 case series patients died. Our patient received corticosteroids for 22 days before initial A. flavus culture and was treated with voriconazole starting 3 days after the initial fungal culture. Unlike influenza-associated pulmonary aspergillosis (IAPA), which commonly occurs early after ICU admission [4], our patient developed CAPA 25 days after ICU admission. COVID-19 associated pulmonary aspergillosis case series from Belgium and The Netherlands, showed variable time on development of were aspergillosis (range: 2–28 days) [9,10]. Making the diagnosis of IPA can be challenging, especially among patients not considered classically at greatest risk (e.g., hematologic malignancy and stem cell transplant patients). Among the four European CAPA case series discussed, Aspergillus species were cultured in 78% of respiratory specimens; positive specimens included: 14 bronchoalveolar lavage, six tracheal aspirate and one sputum [[7], [8], [9], [10]]. Bronchoscopy in COVID-19 patients is often not performed due to the risk of aerosol generation. Further complicating IPA diagnosis, serum GM testing is often negative among COVID-19 patients, and sensitivity is low among ICU patients in general; in the published cases series, of the 22 cases tested, only three (14%) had positive serum GM tests [14,15]. Most COVID-19 patients lack known risk factors for IPA [4]. Thus, isolation of Aspergillus from a non-sterile site and negative serum GM should not rule out invasive disease. Clinicians may want to consider mold-active azole therapy at first indication of aspergillosis in COVID-19 patients. Our patient had a high serum GM index (>1.0), which is the recommended cutoff, and mycological criteria for probable IPA classification by the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium [16]. Challenges in selecting a case definition for CAPA are also shared by the similar IAPA. For this reason, an expert panel recently proposed a new case definition for IAPA [17,18]. The definitions distinguish between invasive Aspergillus tracheobronchitis and other pulmonary manifestations and mainly rely on culture and GM to identify IPA. The expert panel stated that the IAPA case definition might also be useful to classify CAPA cases. Using this new definition, our case would be classified as probable CAPA [17]. A follow-up serum GM showed decreasing antigen titer which is consistent with antifungal treatment response. Little is known about the pathogenesis of CAPA, and there is a need to characterize risk factors for the development of IPA. Although influenza infection was found to be an independent risk factor for IPA [4], the use of corticosteroids in patients with influenza is also a risk factor for IAPA [19]. A recent preliminary report suggested that dexamethasone was associated with reduced mortality in COVID-19 patients [20]. However, corticosteroids might be associated with adverse effects such as delayed viral clearance and secondary infections. Notably, of the four proven IPA cases reported during the previous severe acute respiratory syndrome (SARS) epidemic, all were associated with concomitant corticosteroid therapy [5,21]. In our COVID-19 case with probable CAPA, we observed co-infections with bacterial and additional fungal pathogens (E. faecalis, A. baumanii, coagulase-negative staphylococci, and C. lusitaniae), which complicated patient treatment. Previous reports of CAPA cases did not describe the presence of other microbial co-infections [[7], [8], [9], [10], [11], [12], [13]], although these are commonly encountered in patients with influenza. Previous reports of ICU patients with severe influenza frequently reported secondary bacterial infection, and these were significantly associated with IAPA in studies comparing severe influenza patients with and without IAPA (61% vs 31%; p < 0.01) [22]. Co-infections were reported in up to 50% of patients with severe coronavirus infections causing both SARS and Middle East respiratory syndrome (MERS) [23]. However, early data suggest that coinfection frequency might be lower in COVID-19 [[23], [24], [25]]. We present a case of COVID-19 associated pulmonary aspergillosis from Argentina, with a clinical course and attributes similar to previously reported cases, that highlights the challenges in diagnosing and treating these CAPA patients. The use of a clinical algorithm to discriminate Aspergillus respiratory tract colonization from invasive pulmonary aspergillosis in critically ill patients is warranted, such as the one developed for IAPA [17,18]. This is the first report of ventilator-associated pneumonia involving A. flavus in a patient with COVID-19 and ARDS in the Americas. Awareness of CAPA and accessibility to appropriate diagnostic tests are necessary for accurate and timely identification of this co-infection [26,27]. Ethical considerations Publication of this case report was approved by the Hospital de Clínicas “José de San Martin” IRB. Declaration of competing interest All authors no reported conflicts of interest. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC. Acknowledgements Claudia Barberis, Marisa Almuzara, and the staff of the infectious disease division and the intensive care unit, at Hospital de Clínicas “José de San Martin”. Universidad de Buenos Aires. Diego H. Caceres acknowledges Oak Ridge Institute for Science and Education (ORISE).	AZITHROMYCIN ANHYDROUS, CEFTRIAXONE, DEXAMETHASONE, HEPARIN SODIUM, HYDROXYCHLOROQUINE, IMIPENEM, LOPINAVIR\RITONAVIR, OSELTAMIVIR, VANCOMYCIN	DrugsGivenReaction	CC BY	32837881	19,203,398	2021-03
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Viral load increased'.	Ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Coronavirus disease 2019 (COVID-19), caused by the novel coronavirus SARS-CoV-2, emerged in Wuhan, China, in December 2019 and rapidly spread around the world. Invasive aspergillosis has been reported as a complication of severe influenza pneumonia among intensive care patients. Similarities between COVID-19 and influenza pneumonia, together with limited published case series, suggest that aspergillosis may be an important complication of COVID-19. This report describes a case of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 from Buenos Aires, Argentina. 1 Introduction SARS-CoV-2 is the novel coronavirus that causes coronavirus disease 2019 (COVID‐19), which was first reported in December 2019 in Wuhan, China, and has rapidly spread worldwide [1]. On March 11th, 2020, the World Health Organization (WHO) declared a pandemic, and by June 30th, 2020, a total of 10,185,374 cases and 503,862 deaths were reported in 216 locations around the world [2]. In Argentina, on June 30th, 2020, the Argentinean Ministry of Health (AMOH) reported 62,268 cases and 1283 deaths [3]. Invasive pulmonary aspergillosis (IPA) is a known complication in patients with severe influenza pneumonia. Case series from the Netherlands and Belgium reported an incidence of 19% in patients with influenza pneumonia and acute respiratory distress syndrome (ARDS) hospitalized in the intensive care unit (ICU) [4], although these high incidences have not been confirmed in other studies [4]. There is concern that critically ill COVID-19 patients might also be at increased risk of pulmonary aspergillosis co-infection [5]. Here we describe a report of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 and ARDS in Argentina. 2 Case presentation In late April 2020, an 85-year-old man with a history of hypertension was admitted to the ICU with a history of six days of fever and dyspnea, at home. The patient had close household contact with two COVID-19 cases, and nasopharyngeal (NP) swab samples collected on the day of ICU admission tested positive for SARS-CoV-2 using molecular testing. On ICU admission (day 1) the patient presented with bilateral infiltrates (ground-glass opacities) on chest radiograph, respiratory rate of 40 breaths per minute, heart rate of 82 beats per minute, and a blood pressure 150/85 mm Hg. Laboratory tests showed a white blood cell count of 11,600 cells/mm3, with lymphopenia, normal serum creatinine (1.02 mg/dL), low albumin (2.8 g/dL), and normal lactate (1.4 mmol/L), as well as elevated ferritin (1840 ng/mL), D-dimer (17.1 ng/mL), procalcitonin (2.89 ng/mL), and fibrinogen (702 mg/dl). The patient also presented with deep vein thrombosis in the right subclavian vein and in the right internal jugular vein; anticoagulation was initiated with heparin due to the hypercoagulable state. Empirical treatment for pneumonia was started with oseltamivir, ceftriaxone, and azithromycin, and hydroxychloroquine, ritonavir/lopinavir were started for COVID-19, according to the Argentinean Ministry of Health (AMOH) national guidelines [6]. After 3 days of hospitalization, the patient required ventilator support (orotracheal intubation and mechanical ventilation) and was given a corticosteroid (dexamethasone, 20 mg/day). Influenza antigen testing yielded a negative result, prompting cessation of empirical influenza treatment (Fig. 1).Fig. 1 Case timeline: ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Fig. 1 On day 10 of hospitalization, the patient developed a new fever (38 °C). Urinary culture and pneumococcal urine antigen test were negative; tracheal aspirate and blood culture were positive for Enterococcus faecalis, and imipenem and vancomycin were added to hydroxychloroquine and ritonavir/lopinavir. Two days later polymyxin was added, and blood cultures turned negative after seven days of treatment. On day 17, urinary analysis showed evidence of acute tubular necrosis with metabolic acidosis (low pH, PaCO2 and HCO3), and treatment was subsequently changed to meropenem and colistin. On day 19, tracheal aspirate, urine and blood culture remained negative for bacteria, and a second SARS-CoV-2 PCR test from a NP swab was positive. On day 23, the patient was again febrile, and urinary, tracheal aspirate, blood and catheter tip cultures were repeated; a third SARS-CoV-2 PCR test on day 24 from a NP swab was positive (Fig. 1). On day 25 the patient developed multiple organ failure, including acute renal failure. Aspergillus flavus, identified by MALDI-TOF (Fig. 2), and Acinetobacter baumanii (>106 CFU) were cultured from tracheal aspirate. Staphylococcus capitis was isolated from blood culture, and E. faecalis and Staphylococcus epidermidis were isolated from the central venous catheter tip culture. Candida lusitaniae was isolated from urine. The patient's antimicrobial regimen was updated to include vancomycin, meropenem, and colistin. Anidulafungin was added to control candidiasis, but azole therapy for the A. flavus finding was not started due to initial clinical suspicion of colonization versus infection. On day 26 a tracheostomy was placed as a result of prolonged ventilation, ARDS (PaO2/FiO2 ratio <200), and sepsis. Chest radiograph continued to show bilateral infiltrates (Fig. 3). Aspergillus galactomannan antigen (GM) was positive in serum (GM index: 1.4; Platelia Aspergillus; Bio-Rad, Marnes-La-Coquette, France) (Fig. 1).Fig. 2 Aspergillus flavus isolate: (A and B) Macroscopic: rapid growth olive green colonies, with woolly texture, on Sabouraud agar incubated at 28 °C (A) and 37 °C (B). (C) Microscopic: hyaline septate hyphae, radiate biseriate conidial head with finely roughened conidiophore. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.) Fig. 2 Fig. 3 Chest X-ray evidenced bilateral heterogeneous infiltrates on day 26 of hospitalization: picture from the COVID-19 associated pulmonary aspergillosis (CAPA) described on this report. Fig. 3 On day 28, laboratory testing showed increased white blood cells (16,930 cells/mm3; lymphocytes 45%), D-dimer (7.3 ng/mL), ferritin (3691 ng/mL) and C-reactive protein (31.8 mg/L). Blood and central venous catheter cultures were negative, and anidulafungin was replaced with voriconazole (400 mg first day, and then 300 mg daily) after the GM test returned positive. Colistin, vancomycin, and meropenem were continued. On day 30, hydroxychloroquine, ritonavir/lopinavir were suspended (following recommendation of AMOH), and on day 35, serum GM index decreased to 0.8. On day 44, the patient died in the ICU while on ventilatory support (Fig. 1). 3 Discussion COVID-19 associated pulmonary aspergillosis (CAPA) has been recently reported in European countries [[7], [8], [9], [10], [11], [12], [13]], including four case series covering 27 patients from France (n = 9), Belgium (n = 7), The Netherlands (n = 6), and Germany (n = 5) [[7], [8], [9], [10]]. Our case has similar clinical features compared with those previously reported. Among these four case series, all 27 patients were admitted to the ICU and developed ARDS. Most were male, >50 years old, and 25 (89%) of 27 had potential risk factors for severe COVID-19. Three (60%) of five patients from the German case series, seven (78%) of nine from the French case series, and three (43%) of seven patients from the Belgium case series had hypertension. All five patients from Germany had acute kidney injury, and three (33%) of nine patients from France and two (29%) of seven from Belgium received renal replacement therapy [[7], [8], [9], [10]]. Abnormal chest radiologic findings were reported in all of the patients from Germany (n = 5) and France (n = 9) [7,8]. Twelve (44%) of 27 patients received corticosteroids during their ICU stay, and 19 (70%) of 27 were treated with mold-active antifungal medication, eight (42%) of these 19 patients received corticosteroid simultaneous with antifungal treatment. Fifteen (55%) of the 27 case series patients died. Our patient received corticosteroids for 22 days before initial A. flavus culture and was treated with voriconazole starting 3 days after the initial fungal culture. Unlike influenza-associated pulmonary aspergillosis (IAPA), which commonly occurs early after ICU admission [4], our patient developed CAPA 25 days after ICU admission. COVID-19 associated pulmonary aspergillosis case series from Belgium and The Netherlands, showed variable time on development of were aspergillosis (range: 2–28 days) [9,10]. Making the diagnosis of IPA can be challenging, especially among patients not considered classically at greatest risk (e.g., hematologic malignancy and stem cell transplant patients). Among the four European CAPA case series discussed, Aspergillus species were cultured in 78% of respiratory specimens; positive specimens included: 14 bronchoalveolar lavage, six tracheal aspirate and one sputum [[7], [8], [9], [10]]. Bronchoscopy in COVID-19 patients is often not performed due to the risk of aerosol generation. Further complicating IPA diagnosis, serum GM testing is often negative among COVID-19 patients, and sensitivity is low among ICU patients in general; in the published cases series, of the 22 cases tested, only three (14%) had positive serum GM tests [14,15]. Most COVID-19 patients lack known risk factors for IPA [4]. Thus, isolation of Aspergillus from a non-sterile site and negative serum GM should not rule out invasive disease. Clinicians may want to consider mold-active azole therapy at first indication of aspergillosis in COVID-19 patients. Our patient had a high serum GM index (>1.0), which is the recommended cutoff, and mycological criteria for probable IPA classification by the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium [16]. Challenges in selecting a case definition for CAPA are also shared by the similar IAPA. For this reason, an expert panel recently proposed a new case definition for IAPA [17,18]. The definitions distinguish between invasive Aspergillus tracheobronchitis and other pulmonary manifestations and mainly rely on culture and GM to identify IPA. The expert panel stated that the IAPA case definition might also be useful to classify CAPA cases. Using this new definition, our case would be classified as probable CAPA [17]. A follow-up serum GM showed decreasing antigen titer which is consistent with antifungal treatment response. Little is known about the pathogenesis of CAPA, and there is a need to characterize risk factors for the development of IPA. Although influenza infection was found to be an independent risk factor for IPA [4], the use of corticosteroids in patients with influenza is also a risk factor for IAPA [19]. A recent preliminary report suggested that dexamethasone was associated with reduced mortality in COVID-19 patients [20]. However, corticosteroids might be associated with adverse effects such as delayed viral clearance and secondary infections. Notably, of the four proven IPA cases reported during the previous severe acute respiratory syndrome (SARS) epidemic, all were associated with concomitant corticosteroid therapy [5,21]. In our COVID-19 case with probable CAPA, we observed co-infections with bacterial and additional fungal pathogens (E. faecalis, A. baumanii, coagulase-negative staphylococci, and C. lusitaniae), which complicated patient treatment. Previous reports of CAPA cases did not describe the presence of other microbial co-infections [[7], [8], [9], [10], [11], [12], [13]], although these are commonly encountered in patients with influenza. Previous reports of ICU patients with severe influenza frequently reported secondary bacterial infection, and these were significantly associated with IAPA in studies comparing severe influenza patients with and without IAPA (61% vs 31%; p < 0.01) [22]. Co-infections were reported in up to 50% of patients with severe coronavirus infections causing both SARS and Middle East respiratory syndrome (MERS) [23]. However, early data suggest that coinfection frequency might be lower in COVID-19 [[23], [24], [25]]. We present a case of COVID-19 associated pulmonary aspergillosis from Argentina, with a clinical course and attributes similar to previously reported cases, that highlights the challenges in diagnosing and treating these CAPA patients. The use of a clinical algorithm to discriminate Aspergillus respiratory tract colonization from invasive pulmonary aspergillosis in critically ill patients is warranted, such as the one developed for IAPA [17,18]. This is the first report of ventilator-associated pneumonia involving A. flavus in a patient with COVID-19 and ARDS in the Americas. Awareness of CAPA and accessibility to appropriate diagnostic tests are necessary for accurate and timely identification of this co-infection [26,27]. Ethical considerations Publication of this case report was approved by the Hospital de Clínicas “José de San Martin” IRB. Declaration of competing interest All authors no reported conflicts of interest. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC. Acknowledgements Claudia Barberis, Marisa Almuzara, and the staff of the infectious disease division and the intensive care unit, at Hospital de Clínicas “José de San Martin”. Universidad de Buenos Aires. Diego H. Caceres acknowledges Oak Ridge Institute for Science and Education (ORISE).	AZITHROMYCIN ANHYDROUS, CEFTRIAXONE, DEXAMETHASONE, HEPARIN SODIUM, HYDROXYCHLOROQUINE, IMIPENEM, LOPINAVIR\RITONAVIR, OSELTAMIVIR, VANCOMYCIN	DrugsGivenReaction	CC BY	32837881	19,203,398	2021-03
What was the outcome of reaction 'Acinetobacter infection'?	Ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Coronavirus disease 2019 (COVID-19), caused by the novel coronavirus SARS-CoV-2, emerged in Wuhan, China, in December 2019 and rapidly spread around the world. Invasive aspergillosis has been reported as a complication of severe influenza pneumonia among intensive care patients. Similarities between COVID-19 and influenza pneumonia, together with limited published case series, suggest that aspergillosis may be an important complication of COVID-19. This report describes a case of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 from Buenos Aires, Argentina. 1 Introduction SARS-CoV-2 is the novel coronavirus that causes coronavirus disease 2019 (COVID‐19), which was first reported in December 2019 in Wuhan, China, and has rapidly spread worldwide [1]. On March 11th, 2020, the World Health Organization (WHO) declared a pandemic, and by June 30th, 2020, a total of 10,185,374 cases and 503,862 deaths were reported in 216 locations around the world [2]. In Argentina, on June 30th, 2020, the Argentinean Ministry of Health (AMOH) reported 62,268 cases and 1283 deaths [3]. Invasive pulmonary aspergillosis (IPA) is a known complication in patients with severe influenza pneumonia. Case series from the Netherlands and Belgium reported an incidence of 19% in patients with influenza pneumonia and acute respiratory distress syndrome (ARDS) hospitalized in the intensive care unit (ICU) [4], although these high incidences have not been confirmed in other studies [4]. There is concern that critically ill COVID-19 patients might also be at increased risk of pulmonary aspergillosis co-infection [5]. Here we describe a report of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 and ARDS in Argentina. 2 Case presentation In late April 2020, an 85-year-old man with a history of hypertension was admitted to the ICU with a history of six days of fever and dyspnea, at home. The patient had close household contact with two COVID-19 cases, and nasopharyngeal (NP) swab samples collected on the day of ICU admission tested positive for SARS-CoV-2 using molecular testing. On ICU admission (day 1) the patient presented with bilateral infiltrates (ground-glass opacities) on chest radiograph, respiratory rate of 40 breaths per minute, heart rate of 82 beats per minute, and a blood pressure 150/85 mm Hg. Laboratory tests showed a white blood cell count of 11,600 cells/mm3, with lymphopenia, normal serum creatinine (1.02 mg/dL), low albumin (2.8 g/dL), and normal lactate (1.4 mmol/L), as well as elevated ferritin (1840 ng/mL), D-dimer (17.1 ng/mL), procalcitonin (2.89 ng/mL), and fibrinogen (702 mg/dl). The patient also presented with deep vein thrombosis in the right subclavian vein and in the right internal jugular vein; anticoagulation was initiated with heparin due to the hypercoagulable state. Empirical treatment for pneumonia was started with oseltamivir, ceftriaxone, and azithromycin, and hydroxychloroquine, ritonavir/lopinavir were started for COVID-19, according to the Argentinean Ministry of Health (AMOH) national guidelines [6]. After 3 days of hospitalization, the patient required ventilator support (orotracheal intubation and mechanical ventilation) and was given a corticosteroid (dexamethasone, 20 mg/day). Influenza antigen testing yielded a negative result, prompting cessation of empirical influenza treatment (Fig. 1).Fig. 1 Case timeline: ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Fig. 1 On day 10 of hospitalization, the patient developed a new fever (38 °C). Urinary culture and pneumococcal urine antigen test were negative; tracheal aspirate and blood culture were positive for Enterococcus faecalis, and imipenem and vancomycin were added to hydroxychloroquine and ritonavir/lopinavir. Two days later polymyxin was added, and blood cultures turned negative after seven days of treatment. On day 17, urinary analysis showed evidence of acute tubular necrosis with metabolic acidosis (low pH, PaCO2 and HCO3), and treatment was subsequently changed to meropenem and colistin. On day 19, tracheal aspirate, urine and blood culture remained negative for bacteria, and a second SARS-CoV-2 PCR test from a NP swab was positive. On day 23, the patient was again febrile, and urinary, tracheal aspirate, blood and catheter tip cultures were repeated; a third SARS-CoV-2 PCR test on day 24 from a NP swab was positive (Fig. 1). On day 25 the patient developed multiple organ failure, including acute renal failure. Aspergillus flavus, identified by MALDI-TOF (Fig. 2), and Acinetobacter baumanii (>106 CFU) were cultured from tracheal aspirate. Staphylococcus capitis was isolated from blood culture, and E. faecalis and Staphylococcus epidermidis were isolated from the central venous catheter tip culture. Candida lusitaniae was isolated from urine. The patient's antimicrobial regimen was updated to include vancomycin, meropenem, and colistin. Anidulafungin was added to control candidiasis, but azole therapy for the A. flavus finding was not started due to initial clinical suspicion of colonization versus infection. On day 26 a tracheostomy was placed as a result of prolonged ventilation, ARDS (PaO2/FiO2 ratio <200), and sepsis. Chest radiograph continued to show bilateral infiltrates (Fig. 3). Aspergillus galactomannan antigen (GM) was positive in serum (GM index: 1.4; Platelia Aspergillus; Bio-Rad, Marnes-La-Coquette, France) (Fig. 1).Fig. 2 Aspergillus flavus isolate: (A and B) Macroscopic: rapid growth olive green colonies, with woolly texture, on Sabouraud agar incubated at 28 °C (A) and 37 °C (B). (C) Microscopic: hyaline septate hyphae, radiate biseriate conidial head with finely roughened conidiophore. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.) Fig. 2 Fig. 3 Chest X-ray evidenced bilateral heterogeneous infiltrates on day 26 of hospitalization: picture from the COVID-19 associated pulmonary aspergillosis (CAPA) described on this report. Fig. 3 On day 28, laboratory testing showed increased white blood cells (16,930 cells/mm3; lymphocytes 45%), D-dimer (7.3 ng/mL), ferritin (3691 ng/mL) and C-reactive protein (31.8 mg/L). Blood and central venous catheter cultures were negative, and anidulafungin was replaced with voriconazole (400 mg first day, and then 300 mg daily) after the GM test returned positive. Colistin, vancomycin, and meropenem were continued. On day 30, hydroxychloroquine, ritonavir/lopinavir were suspended (following recommendation of AMOH), and on day 35, serum GM index decreased to 0.8. On day 44, the patient died in the ICU while on ventilatory support (Fig. 1). 3 Discussion COVID-19 associated pulmonary aspergillosis (CAPA) has been recently reported in European countries [[7], [8], [9], [10], [11], [12], [13]], including four case series covering 27 patients from France (n = 9), Belgium (n = 7), The Netherlands (n = 6), and Germany (n = 5) [[7], [8], [9], [10]]. Our case has similar clinical features compared with those previously reported. Among these four case series, all 27 patients were admitted to the ICU and developed ARDS. Most were male, >50 years old, and 25 (89%) of 27 had potential risk factors for severe COVID-19. Three (60%) of five patients from the German case series, seven (78%) of nine from the French case series, and three (43%) of seven patients from the Belgium case series had hypertension. All five patients from Germany had acute kidney injury, and three (33%) of nine patients from France and two (29%) of seven from Belgium received renal replacement therapy [[7], [8], [9], [10]]. Abnormal chest radiologic findings were reported in all of the patients from Germany (n = 5) and France (n = 9) [7,8]. Twelve (44%) of 27 patients received corticosteroids during their ICU stay, and 19 (70%) of 27 were treated with mold-active antifungal medication, eight (42%) of these 19 patients received corticosteroid simultaneous with antifungal treatment. Fifteen (55%) of the 27 case series patients died. Our patient received corticosteroids for 22 days before initial A. flavus culture and was treated with voriconazole starting 3 days after the initial fungal culture. Unlike influenza-associated pulmonary aspergillosis (IAPA), which commonly occurs early after ICU admission [4], our patient developed CAPA 25 days after ICU admission. COVID-19 associated pulmonary aspergillosis case series from Belgium and The Netherlands, showed variable time on development of were aspergillosis (range: 2–28 days) [9,10]. Making the diagnosis of IPA can be challenging, especially among patients not considered classically at greatest risk (e.g., hematologic malignancy and stem cell transplant patients). Among the four European CAPA case series discussed, Aspergillus species were cultured in 78% of respiratory specimens; positive specimens included: 14 bronchoalveolar lavage, six tracheal aspirate and one sputum [[7], [8], [9], [10]]. Bronchoscopy in COVID-19 patients is often not performed due to the risk of aerosol generation. Further complicating IPA diagnosis, serum GM testing is often negative among COVID-19 patients, and sensitivity is low among ICU patients in general; in the published cases series, of the 22 cases tested, only three (14%) had positive serum GM tests [14,15]. Most COVID-19 patients lack known risk factors for IPA [4]. Thus, isolation of Aspergillus from a non-sterile site and negative serum GM should not rule out invasive disease. Clinicians may want to consider mold-active azole therapy at first indication of aspergillosis in COVID-19 patients. Our patient had a high serum GM index (>1.0), which is the recommended cutoff, and mycological criteria for probable IPA classification by the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium [16]. Challenges in selecting a case definition for CAPA are also shared by the similar IAPA. For this reason, an expert panel recently proposed a new case definition for IAPA [17,18]. The definitions distinguish between invasive Aspergillus tracheobronchitis and other pulmonary manifestations and mainly rely on culture and GM to identify IPA. The expert panel stated that the IAPA case definition might also be useful to classify CAPA cases. Using this new definition, our case would be classified as probable CAPA [17]. A follow-up serum GM showed decreasing antigen titer which is consistent with antifungal treatment response. Little is known about the pathogenesis of CAPA, and there is a need to characterize risk factors for the development of IPA. Although influenza infection was found to be an independent risk factor for IPA [4], the use of corticosteroids in patients with influenza is also a risk factor for IAPA [19]. A recent preliminary report suggested that dexamethasone was associated with reduced mortality in COVID-19 patients [20]. However, corticosteroids might be associated with adverse effects such as delayed viral clearance and secondary infections. Notably, of the four proven IPA cases reported during the previous severe acute respiratory syndrome (SARS) epidemic, all were associated with concomitant corticosteroid therapy [5,21]. In our COVID-19 case with probable CAPA, we observed co-infections with bacterial and additional fungal pathogens (E. faecalis, A. baumanii, coagulase-negative staphylococci, and C. lusitaniae), which complicated patient treatment. Previous reports of CAPA cases did not describe the presence of other microbial co-infections [[7], [8], [9], [10], [11], [12], [13]], although these are commonly encountered in patients with influenza. Previous reports of ICU patients with severe influenza frequently reported secondary bacterial infection, and these were significantly associated with IAPA in studies comparing severe influenza patients with and without IAPA (61% vs 31%; p < 0.01) [22]. Co-infections were reported in up to 50% of patients with severe coronavirus infections causing both SARS and Middle East respiratory syndrome (MERS) [23]. However, early data suggest that coinfection frequency might be lower in COVID-19 [[23], [24], [25]]. We present a case of COVID-19 associated pulmonary aspergillosis from Argentina, with a clinical course and attributes similar to previously reported cases, that highlights the challenges in diagnosing and treating these CAPA patients. The use of a clinical algorithm to discriminate Aspergillus respiratory tract colonization from invasive pulmonary aspergillosis in critically ill patients is warranted, such as the one developed for IAPA [17,18]. This is the first report of ventilator-associated pneumonia involving A. flavus in a patient with COVID-19 and ARDS in the Americas. Awareness of CAPA and accessibility to appropriate diagnostic tests are necessary for accurate and timely identification of this co-infection [26,27]. Ethical considerations Publication of this case report was approved by the Hospital de Clínicas “José de San Martin” IRB. Declaration of competing interest All authors no reported conflicts of interest. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC. Acknowledgements Claudia Barberis, Marisa Almuzara, and the staff of the infectious disease division and the intensive care unit, at Hospital de Clínicas “José de San Martin”. Universidad de Buenos Aires. Diego H. Caceres acknowledges Oak Ridge Institute for Science and Education (ORISE).	Recovered	ReactionOutcome	CC BY	32837881	19,154,617	2021-03
What was the outcome of reaction 'Acute respiratory distress syndrome'?	Ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Coronavirus disease 2019 (COVID-19), caused by the novel coronavirus SARS-CoV-2, emerged in Wuhan, China, in December 2019 and rapidly spread around the world. Invasive aspergillosis has been reported as a complication of severe influenza pneumonia among intensive care patients. Similarities between COVID-19 and influenza pneumonia, together with limited published case series, suggest that aspergillosis may be an important complication of COVID-19. This report describes a case of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 from Buenos Aires, Argentina. 1 Introduction SARS-CoV-2 is the novel coronavirus that causes coronavirus disease 2019 (COVID‐19), which was first reported in December 2019 in Wuhan, China, and has rapidly spread worldwide [1]. On March 11th, 2020, the World Health Organization (WHO) declared a pandemic, and by June 30th, 2020, a total of 10,185,374 cases and 503,862 deaths were reported in 216 locations around the world [2]. In Argentina, on June 30th, 2020, the Argentinean Ministry of Health (AMOH) reported 62,268 cases and 1283 deaths [3]. Invasive pulmonary aspergillosis (IPA) is a known complication in patients with severe influenza pneumonia. Case series from the Netherlands and Belgium reported an incidence of 19% in patients with influenza pneumonia and acute respiratory distress syndrome (ARDS) hospitalized in the intensive care unit (ICU) [4], although these high incidences have not been confirmed in other studies [4]. There is concern that critically ill COVID-19 patients might also be at increased risk of pulmonary aspergillosis co-infection [5]. Here we describe a report of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 and ARDS in Argentina. 2 Case presentation In late April 2020, an 85-year-old man with a history of hypertension was admitted to the ICU with a history of six days of fever and dyspnea, at home. The patient had close household contact with two COVID-19 cases, and nasopharyngeal (NP) swab samples collected on the day of ICU admission tested positive for SARS-CoV-2 using molecular testing. On ICU admission (day 1) the patient presented with bilateral infiltrates (ground-glass opacities) on chest radiograph, respiratory rate of 40 breaths per minute, heart rate of 82 beats per minute, and a blood pressure 150/85 mm Hg. Laboratory tests showed a white blood cell count of 11,600 cells/mm3, with lymphopenia, normal serum creatinine (1.02 mg/dL), low albumin (2.8 g/dL), and normal lactate (1.4 mmol/L), as well as elevated ferritin (1840 ng/mL), D-dimer (17.1 ng/mL), procalcitonin (2.89 ng/mL), and fibrinogen (702 mg/dl). The patient also presented with deep vein thrombosis in the right subclavian vein and in the right internal jugular vein; anticoagulation was initiated with heparin due to the hypercoagulable state. Empirical treatment for pneumonia was started with oseltamivir, ceftriaxone, and azithromycin, and hydroxychloroquine, ritonavir/lopinavir were started for COVID-19, according to the Argentinean Ministry of Health (AMOH) national guidelines [6]. After 3 days of hospitalization, the patient required ventilator support (orotracheal intubation and mechanical ventilation) and was given a corticosteroid (dexamethasone, 20 mg/day). Influenza antigen testing yielded a negative result, prompting cessation of empirical influenza treatment (Fig. 1).Fig. 1 Case timeline: ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Fig. 1 On day 10 of hospitalization, the patient developed a new fever (38 °C). Urinary culture and pneumococcal urine antigen test were negative; tracheal aspirate and blood culture were positive for Enterococcus faecalis, and imipenem and vancomycin were added to hydroxychloroquine and ritonavir/lopinavir. Two days later polymyxin was added, and blood cultures turned negative after seven days of treatment. On day 17, urinary analysis showed evidence of acute tubular necrosis with metabolic acidosis (low pH, PaCO2 and HCO3), and treatment was subsequently changed to meropenem and colistin. On day 19, tracheal aspirate, urine and blood culture remained negative for bacteria, and a second SARS-CoV-2 PCR test from a NP swab was positive. On day 23, the patient was again febrile, and urinary, tracheal aspirate, blood and catheter tip cultures were repeated; a third SARS-CoV-2 PCR test on day 24 from a NP swab was positive (Fig. 1). On day 25 the patient developed multiple organ failure, including acute renal failure. Aspergillus flavus, identified by MALDI-TOF (Fig. 2), and Acinetobacter baumanii (>106 CFU) were cultured from tracheal aspirate. Staphylococcus capitis was isolated from blood culture, and E. faecalis and Staphylococcus epidermidis were isolated from the central venous catheter tip culture. Candida lusitaniae was isolated from urine. The patient's antimicrobial regimen was updated to include vancomycin, meropenem, and colistin. Anidulafungin was added to control candidiasis, but azole therapy for the A. flavus finding was not started due to initial clinical suspicion of colonization versus infection. On day 26 a tracheostomy was placed as a result of prolonged ventilation, ARDS (PaO2/FiO2 ratio <200), and sepsis. Chest radiograph continued to show bilateral infiltrates (Fig. 3). Aspergillus galactomannan antigen (GM) was positive in serum (GM index: 1.4; Platelia Aspergillus; Bio-Rad, Marnes-La-Coquette, France) (Fig. 1).Fig. 2 Aspergillus flavus isolate: (A and B) Macroscopic: rapid growth olive green colonies, with woolly texture, on Sabouraud agar incubated at 28 °C (A) and 37 °C (B). (C) Microscopic: hyaline septate hyphae, radiate biseriate conidial head with finely roughened conidiophore. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.) Fig. 2 Fig. 3 Chest X-ray evidenced bilateral heterogeneous infiltrates on day 26 of hospitalization: picture from the COVID-19 associated pulmonary aspergillosis (CAPA) described on this report. Fig. 3 On day 28, laboratory testing showed increased white blood cells (16,930 cells/mm3; lymphocytes 45%), D-dimer (7.3 ng/mL), ferritin (3691 ng/mL) and C-reactive protein (31.8 mg/L). Blood and central venous catheter cultures were negative, and anidulafungin was replaced with voriconazole (400 mg first day, and then 300 mg daily) after the GM test returned positive. Colistin, vancomycin, and meropenem were continued. On day 30, hydroxychloroquine, ritonavir/lopinavir were suspended (following recommendation of AMOH), and on day 35, serum GM index decreased to 0.8. On day 44, the patient died in the ICU while on ventilatory support (Fig. 1). 3 Discussion COVID-19 associated pulmonary aspergillosis (CAPA) has been recently reported in European countries [[7], [8], [9], [10], [11], [12], [13]], including four case series covering 27 patients from France (n = 9), Belgium (n = 7), The Netherlands (n = 6), and Germany (n = 5) [[7], [8], [9], [10]]. Our case has similar clinical features compared with those previously reported. Among these four case series, all 27 patients were admitted to the ICU and developed ARDS. Most were male, >50 years old, and 25 (89%) of 27 had potential risk factors for severe COVID-19. Three (60%) of five patients from the German case series, seven (78%) of nine from the French case series, and three (43%) of seven patients from the Belgium case series had hypertension. All five patients from Germany had acute kidney injury, and three (33%) of nine patients from France and two (29%) of seven from Belgium received renal replacement therapy [[7], [8], [9], [10]]. Abnormal chest radiologic findings were reported in all of the patients from Germany (n = 5) and France (n = 9) [7,8]. Twelve (44%) of 27 patients received corticosteroids during their ICU stay, and 19 (70%) of 27 were treated with mold-active antifungal medication, eight (42%) of these 19 patients received corticosteroid simultaneous with antifungal treatment. Fifteen (55%) of the 27 case series patients died. Our patient received corticosteroids for 22 days before initial A. flavus culture and was treated with voriconazole starting 3 days after the initial fungal culture. Unlike influenza-associated pulmonary aspergillosis (IAPA), which commonly occurs early after ICU admission [4], our patient developed CAPA 25 days after ICU admission. COVID-19 associated pulmonary aspergillosis case series from Belgium and The Netherlands, showed variable time on development of were aspergillosis (range: 2–28 days) [9,10]. Making the diagnosis of IPA can be challenging, especially among patients not considered classically at greatest risk (e.g., hematologic malignancy and stem cell transplant patients). Among the four European CAPA case series discussed, Aspergillus species were cultured in 78% of respiratory specimens; positive specimens included: 14 bronchoalveolar lavage, six tracheal aspirate and one sputum [[7], [8], [9], [10]]. Bronchoscopy in COVID-19 patients is often not performed due to the risk of aerosol generation. Further complicating IPA diagnosis, serum GM testing is often negative among COVID-19 patients, and sensitivity is low among ICU patients in general; in the published cases series, of the 22 cases tested, only three (14%) had positive serum GM tests [14,15]. Most COVID-19 patients lack known risk factors for IPA [4]. Thus, isolation of Aspergillus from a non-sterile site and negative serum GM should not rule out invasive disease. Clinicians may want to consider mold-active azole therapy at first indication of aspergillosis in COVID-19 patients. Our patient had a high serum GM index (>1.0), which is the recommended cutoff, and mycological criteria for probable IPA classification by the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium [16]. Challenges in selecting a case definition for CAPA are also shared by the similar IAPA. For this reason, an expert panel recently proposed a new case definition for IAPA [17,18]. The definitions distinguish between invasive Aspergillus tracheobronchitis and other pulmonary manifestations and mainly rely on culture and GM to identify IPA. The expert panel stated that the IAPA case definition might also be useful to classify CAPA cases. Using this new definition, our case would be classified as probable CAPA [17]. A follow-up serum GM showed decreasing antigen titer which is consistent with antifungal treatment response. Little is known about the pathogenesis of CAPA, and there is a need to characterize risk factors for the development of IPA. Although influenza infection was found to be an independent risk factor for IPA [4], the use of corticosteroids in patients with influenza is also a risk factor for IAPA [19]. A recent preliminary report suggested that dexamethasone was associated with reduced mortality in COVID-19 patients [20]. However, corticosteroids might be associated with adverse effects such as delayed viral clearance and secondary infections. Notably, of the four proven IPA cases reported during the previous severe acute respiratory syndrome (SARS) epidemic, all were associated with concomitant corticosteroid therapy [5,21]. In our COVID-19 case with probable CAPA, we observed co-infections with bacterial and additional fungal pathogens (E. faecalis, A. baumanii, coagulase-negative staphylococci, and C. lusitaniae), which complicated patient treatment. Previous reports of CAPA cases did not describe the presence of other microbial co-infections [[7], [8], [9], [10], [11], [12], [13]], although these are commonly encountered in patients with influenza. Previous reports of ICU patients with severe influenza frequently reported secondary bacterial infection, and these were significantly associated with IAPA in studies comparing severe influenza patients with and without IAPA (61% vs 31%; p < 0.01) [22]. Co-infections were reported in up to 50% of patients with severe coronavirus infections causing both SARS and Middle East respiratory syndrome (MERS) [23]. However, early data suggest that coinfection frequency might be lower in COVID-19 [[23], [24], [25]]. We present a case of COVID-19 associated pulmonary aspergillosis from Argentina, with a clinical course and attributes similar to previously reported cases, that highlights the challenges in diagnosing and treating these CAPA patients. The use of a clinical algorithm to discriminate Aspergillus respiratory tract colonization from invasive pulmonary aspergillosis in critically ill patients is warranted, such as the one developed for IAPA [17,18]. This is the first report of ventilator-associated pneumonia involving A. flavus in a patient with COVID-19 and ARDS in the Americas. Awareness of CAPA and accessibility to appropriate diagnostic tests are necessary for accurate and timely identification of this co-infection [26,27]. Ethical considerations Publication of this case report was approved by the Hospital de Clínicas “José de San Martin” IRB. Declaration of competing interest All authors no reported conflicts of interest. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC. Acknowledgements Claudia Barberis, Marisa Almuzara, and the staff of the infectious disease division and the intensive care unit, at Hospital de Clínicas “José de San Martin”. Universidad de Buenos Aires. Diego H. Caceres acknowledges Oak Ridge Institute for Science and Education (ORISE).	Fatal	ReactionOutcome	CC BY	32837881	19,154,617	2021-03
What was the outcome of reaction 'Aspergillus infection'?	Ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Coronavirus disease 2019 (COVID-19), caused by the novel coronavirus SARS-CoV-2, emerged in Wuhan, China, in December 2019 and rapidly spread around the world. Invasive aspergillosis has been reported as a complication of severe influenza pneumonia among intensive care patients. Similarities between COVID-19 and influenza pneumonia, together with limited published case series, suggest that aspergillosis may be an important complication of COVID-19. This report describes a case of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 from Buenos Aires, Argentina. 1 Introduction SARS-CoV-2 is the novel coronavirus that causes coronavirus disease 2019 (COVID‐19), which was first reported in December 2019 in Wuhan, China, and has rapidly spread worldwide [1]. On March 11th, 2020, the World Health Organization (WHO) declared a pandemic, and by June 30th, 2020, a total of 10,185,374 cases and 503,862 deaths were reported in 216 locations around the world [2]. In Argentina, on June 30th, 2020, the Argentinean Ministry of Health (AMOH) reported 62,268 cases and 1283 deaths [3]. Invasive pulmonary aspergillosis (IPA) is a known complication in patients with severe influenza pneumonia. Case series from the Netherlands and Belgium reported an incidence of 19% in patients with influenza pneumonia and acute respiratory distress syndrome (ARDS) hospitalized in the intensive care unit (ICU) [4], although these high incidences have not been confirmed in other studies [4]. There is concern that critically ill COVID-19 patients might also be at increased risk of pulmonary aspergillosis co-infection [5]. Here we describe a report of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 and ARDS in Argentina. 2 Case presentation In late April 2020, an 85-year-old man with a history of hypertension was admitted to the ICU with a history of six days of fever and dyspnea, at home. The patient had close household contact with two COVID-19 cases, and nasopharyngeal (NP) swab samples collected on the day of ICU admission tested positive for SARS-CoV-2 using molecular testing. On ICU admission (day 1) the patient presented with bilateral infiltrates (ground-glass opacities) on chest radiograph, respiratory rate of 40 breaths per minute, heart rate of 82 beats per minute, and a blood pressure 150/85 mm Hg. Laboratory tests showed a white blood cell count of 11,600 cells/mm3, with lymphopenia, normal serum creatinine (1.02 mg/dL), low albumin (2.8 g/dL), and normal lactate (1.4 mmol/L), as well as elevated ferritin (1840 ng/mL), D-dimer (17.1 ng/mL), procalcitonin (2.89 ng/mL), and fibrinogen (702 mg/dl). The patient also presented with deep vein thrombosis in the right subclavian vein and in the right internal jugular vein; anticoagulation was initiated with heparin due to the hypercoagulable state. Empirical treatment for pneumonia was started with oseltamivir, ceftriaxone, and azithromycin, and hydroxychloroquine, ritonavir/lopinavir were started for COVID-19, according to the Argentinean Ministry of Health (AMOH) national guidelines [6]. After 3 days of hospitalization, the patient required ventilator support (orotracheal intubation and mechanical ventilation) and was given a corticosteroid (dexamethasone, 20 mg/day). Influenza antigen testing yielded a negative result, prompting cessation of empirical influenza treatment (Fig. 1).Fig. 1 Case timeline: ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Fig. 1 On day 10 of hospitalization, the patient developed a new fever (38 °C). Urinary culture and pneumococcal urine antigen test were negative; tracheal aspirate and blood culture were positive for Enterococcus faecalis, and imipenem and vancomycin were added to hydroxychloroquine and ritonavir/lopinavir. Two days later polymyxin was added, and blood cultures turned negative after seven days of treatment. On day 17, urinary analysis showed evidence of acute tubular necrosis with metabolic acidosis (low pH, PaCO2 and HCO3), and treatment was subsequently changed to meropenem and colistin. On day 19, tracheal aspirate, urine and blood culture remained negative for bacteria, and a second SARS-CoV-2 PCR test from a NP swab was positive. On day 23, the patient was again febrile, and urinary, tracheal aspirate, blood and catheter tip cultures were repeated; a third SARS-CoV-2 PCR test on day 24 from a NP swab was positive (Fig. 1). On day 25 the patient developed multiple organ failure, including acute renal failure. Aspergillus flavus, identified by MALDI-TOF (Fig. 2), and Acinetobacter baumanii (>106 CFU) were cultured from tracheal aspirate. Staphylococcus capitis was isolated from blood culture, and E. faecalis and Staphylococcus epidermidis were isolated from the central venous catheter tip culture. Candida lusitaniae was isolated from urine. The patient's antimicrobial regimen was updated to include vancomycin, meropenem, and colistin. Anidulafungin was added to control candidiasis, but azole therapy for the A. flavus finding was not started due to initial clinical suspicion of colonization versus infection. On day 26 a tracheostomy was placed as a result of prolonged ventilation, ARDS (PaO2/FiO2 ratio <200), and sepsis. Chest radiograph continued to show bilateral infiltrates (Fig. 3). Aspergillus galactomannan antigen (GM) was positive in serum (GM index: 1.4; Platelia Aspergillus; Bio-Rad, Marnes-La-Coquette, France) (Fig. 1).Fig. 2 Aspergillus flavus isolate: (A and B) Macroscopic: rapid growth olive green colonies, with woolly texture, on Sabouraud agar incubated at 28 °C (A) and 37 °C (B). (C) Microscopic: hyaline septate hyphae, radiate biseriate conidial head with finely roughened conidiophore. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.) Fig. 2 Fig. 3 Chest X-ray evidenced bilateral heterogeneous infiltrates on day 26 of hospitalization: picture from the COVID-19 associated pulmonary aspergillosis (CAPA) described on this report. Fig. 3 On day 28, laboratory testing showed increased white blood cells (16,930 cells/mm3; lymphocytes 45%), D-dimer (7.3 ng/mL), ferritin (3691 ng/mL) and C-reactive protein (31.8 mg/L). Blood and central venous catheter cultures were negative, and anidulafungin was replaced with voriconazole (400 mg first day, and then 300 mg daily) after the GM test returned positive. Colistin, vancomycin, and meropenem were continued. On day 30, hydroxychloroquine, ritonavir/lopinavir were suspended (following recommendation of AMOH), and on day 35, serum GM index decreased to 0.8. On day 44, the patient died in the ICU while on ventilatory support (Fig. 1). 3 Discussion COVID-19 associated pulmonary aspergillosis (CAPA) has been recently reported in European countries [[7], [8], [9], [10], [11], [12], [13]], including four case series covering 27 patients from France (n = 9), Belgium (n = 7), The Netherlands (n = 6), and Germany (n = 5) [[7], [8], [9], [10]]. Our case has similar clinical features compared with those previously reported. Among these four case series, all 27 patients were admitted to the ICU and developed ARDS. Most were male, >50 years old, and 25 (89%) of 27 had potential risk factors for severe COVID-19. Three (60%) of five patients from the German case series, seven (78%) of nine from the French case series, and three (43%) of seven patients from the Belgium case series had hypertension. All five patients from Germany had acute kidney injury, and three (33%) of nine patients from France and two (29%) of seven from Belgium received renal replacement therapy [[7], [8], [9], [10]]. Abnormal chest radiologic findings were reported in all of the patients from Germany (n = 5) and France (n = 9) [7,8]. Twelve (44%) of 27 patients received corticosteroids during their ICU stay, and 19 (70%) of 27 were treated with mold-active antifungal medication, eight (42%) of these 19 patients received corticosteroid simultaneous with antifungal treatment. Fifteen (55%) of the 27 case series patients died. Our patient received corticosteroids for 22 days before initial A. flavus culture and was treated with voriconazole starting 3 days after the initial fungal culture. Unlike influenza-associated pulmonary aspergillosis (IAPA), which commonly occurs early after ICU admission [4], our patient developed CAPA 25 days after ICU admission. COVID-19 associated pulmonary aspergillosis case series from Belgium and The Netherlands, showed variable time on development of were aspergillosis (range: 2–28 days) [9,10]. Making the diagnosis of IPA can be challenging, especially among patients not considered classically at greatest risk (e.g., hematologic malignancy and stem cell transplant patients). Among the four European CAPA case series discussed, Aspergillus species were cultured in 78% of respiratory specimens; positive specimens included: 14 bronchoalveolar lavage, six tracheal aspirate and one sputum [[7], [8], [9], [10]]. Bronchoscopy in COVID-19 patients is often not performed due to the risk of aerosol generation. Further complicating IPA diagnosis, serum GM testing is often negative among COVID-19 patients, and sensitivity is low among ICU patients in general; in the published cases series, of the 22 cases tested, only three (14%) had positive serum GM tests [14,15]. Most COVID-19 patients lack known risk factors for IPA [4]. Thus, isolation of Aspergillus from a non-sterile site and negative serum GM should not rule out invasive disease. Clinicians may want to consider mold-active azole therapy at first indication of aspergillosis in COVID-19 patients. Our patient had a high serum GM index (>1.0), which is the recommended cutoff, and mycological criteria for probable IPA classification by the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium [16]. Challenges in selecting a case definition for CAPA are also shared by the similar IAPA. For this reason, an expert panel recently proposed a new case definition for IAPA [17,18]. The definitions distinguish between invasive Aspergillus tracheobronchitis and other pulmonary manifestations and mainly rely on culture and GM to identify IPA. The expert panel stated that the IAPA case definition might also be useful to classify CAPA cases. Using this new definition, our case would be classified as probable CAPA [17]. A follow-up serum GM showed decreasing antigen titer which is consistent with antifungal treatment response. Little is known about the pathogenesis of CAPA, and there is a need to characterize risk factors for the development of IPA. Although influenza infection was found to be an independent risk factor for IPA [4], the use of corticosteroids in patients with influenza is also a risk factor for IAPA [19]. A recent preliminary report suggested that dexamethasone was associated with reduced mortality in COVID-19 patients [20]. However, corticosteroids might be associated with adverse effects such as delayed viral clearance and secondary infections. Notably, of the four proven IPA cases reported during the previous severe acute respiratory syndrome (SARS) epidemic, all were associated with concomitant corticosteroid therapy [5,21]. In our COVID-19 case with probable CAPA, we observed co-infections with bacterial and additional fungal pathogens (E. faecalis, A. baumanii, coagulase-negative staphylococci, and C. lusitaniae), which complicated patient treatment. Previous reports of CAPA cases did not describe the presence of other microbial co-infections [[7], [8], [9], [10], [11], [12], [13]], although these are commonly encountered in patients with influenza. Previous reports of ICU patients with severe influenza frequently reported secondary bacterial infection, and these were significantly associated with IAPA in studies comparing severe influenza patients with and without IAPA (61% vs 31%; p < 0.01) [22]. Co-infections were reported in up to 50% of patients with severe coronavirus infections causing both SARS and Middle East respiratory syndrome (MERS) [23]. However, early data suggest that coinfection frequency might be lower in COVID-19 [[23], [24], [25]]. We present a case of COVID-19 associated pulmonary aspergillosis from Argentina, with a clinical course and attributes similar to previously reported cases, that highlights the challenges in diagnosing and treating these CAPA patients. The use of a clinical algorithm to discriminate Aspergillus respiratory tract colonization from invasive pulmonary aspergillosis in critically ill patients is warranted, such as the one developed for IAPA [17,18]. This is the first report of ventilator-associated pneumonia involving A. flavus in a patient with COVID-19 and ARDS in the Americas. Awareness of CAPA and accessibility to appropriate diagnostic tests are necessary for accurate and timely identification of this co-infection [26,27]. Ethical considerations Publication of this case report was approved by the Hospital de Clínicas “José de San Martin” IRB. Declaration of competing interest All authors no reported conflicts of interest. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC. Acknowledgements Claudia Barberis, Marisa Almuzara, and the staff of the infectious disease division and the intensive care unit, at Hospital de Clínicas “José de San Martin”. Universidad de Buenos Aires. Diego H. Caceres acknowledges Oak Ridge Institute for Science and Education (ORISE).	Fatal	ReactionOutcome	CC BY	32837881	19,203,398	2021-03
What was the outcome of reaction 'Bronchopulmonary aspergillosis'?	Ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Coronavirus disease 2019 (COVID-19), caused by the novel coronavirus SARS-CoV-2, emerged in Wuhan, China, in December 2019 and rapidly spread around the world. Invasive aspergillosis has been reported as a complication of severe influenza pneumonia among intensive care patients. Similarities between COVID-19 and influenza pneumonia, together with limited published case series, suggest that aspergillosis may be an important complication of COVID-19. This report describes a case of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 from Buenos Aires, Argentina. 1 Introduction SARS-CoV-2 is the novel coronavirus that causes coronavirus disease 2019 (COVID‐19), which was first reported in December 2019 in Wuhan, China, and has rapidly spread worldwide [1]. On March 11th, 2020, the World Health Organization (WHO) declared a pandemic, and by June 30th, 2020, a total of 10,185,374 cases and 503,862 deaths were reported in 216 locations around the world [2]. In Argentina, on June 30th, 2020, the Argentinean Ministry of Health (AMOH) reported 62,268 cases and 1283 deaths [3]. Invasive pulmonary aspergillosis (IPA) is a known complication in patients with severe influenza pneumonia. Case series from the Netherlands and Belgium reported an incidence of 19% in patients with influenza pneumonia and acute respiratory distress syndrome (ARDS) hospitalized in the intensive care unit (ICU) [4], although these high incidences have not been confirmed in other studies [4]. There is concern that critically ill COVID-19 patients might also be at increased risk of pulmonary aspergillosis co-infection [5]. Here we describe a report of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 and ARDS in Argentina. 2 Case presentation In late April 2020, an 85-year-old man with a history of hypertension was admitted to the ICU with a history of six days of fever and dyspnea, at home. The patient had close household contact with two COVID-19 cases, and nasopharyngeal (NP) swab samples collected on the day of ICU admission tested positive for SARS-CoV-2 using molecular testing. On ICU admission (day 1) the patient presented with bilateral infiltrates (ground-glass opacities) on chest radiograph, respiratory rate of 40 breaths per minute, heart rate of 82 beats per minute, and a blood pressure 150/85 mm Hg. Laboratory tests showed a white blood cell count of 11,600 cells/mm3, with lymphopenia, normal serum creatinine (1.02 mg/dL), low albumin (2.8 g/dL), and normal lactate (1.4 mmol/L), as well as elevated ferritin (1840 ng/mL), D-dimer (17.1 ng/mL), procalcitonin (2.89 ng/mL), and fibrinogen (702 mg/dl). The patient also presented with deep vein thrombosis in the right subclavian vein and in the right internal jugular vein; anticoagulation was initiated with heparin due to the hypercoagulable state. Empirical treatment for pneumonia was started with oseltamivir, ceftriaxone, and azithromycin, and hydroxychloroquine, ritonavir/lopinavir were started for COVID-19, according to the Argentinean Ministry of Health (AMOH) national guidelines [6]. After 3 days of hospitalization, the patient required ventilator support (orotracheal intubation and mechanical ventilation) and was given a corticosteroid (dexamethasone, 20 mg/day). Influenza antigen testing yielded a negative result, prompting cessation of empirical influenza treatment (Fig. 1).Fig. 1 Case timeline: ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Fig. 1 On day 10 of hospitalization, the patient developed a new fever (38 °C). Urinary culture and pneumococcal urine antigen test were negative; tracheal aspirate and blood culture were positive for Enterococcus faecalis, and imipenem and vancomycin were added to hydroxychloroquine and ritonavir/lopinavir. Two days later polymyxin was added, and blood cultures turned negative after seven days of treatment. On day 17, urinary analysis showed evidence of acute tubular necrosis with metabolic acidosis (low pH, PaCO2 and HCO3), and treatment was subsequently changed to meropenem and colistin. On day 19, tracheal aspirate, urine and blood culture remained negative for bacteria, and a second SARS-CoV-2 PCR test from a NP swab was positive. On day 23, the patient was again febrile, and urinary, tracheal aspirate, blood and catheter tip cultures were repeated; a third SARS-CoV-2 PCR test on day 24 from a NP swab was positive (Fig. 1). On day 25 the patient developed multiple organ failure, including acute renal failure. Aspergillus flavus, identified by MALDI-TOF (Fig. 2), and Acinetobacter baumanii (>106 CFU) were cultured from tracheal aspirate. Staphylococcus capitis was isolated from blood culture, and E. faecalis and Staphylococcus epidermidis were isolated from the central venous catheter tip culture. Candida lusitaniae was isolated from urine. The patient's antimicrobial regimen was updated to include vancomycin, meropenem, and colistin. Anidulafungin was added to control candidiasis, but azole therapy for the A. flavus finding was not started due to initial clinical suspicion of colonization versus infection. On day 26 a tracheostomy was placed as a result of prolonged ventilation, ARDS (PaO2/FiO2 ratio <200), and sepsis. Chest radiograph continued to show bilateral infiltrates (Fig. 3). Aspergillus galactomannan antigen (GM) was positive in serum (GM index: 1.4; Platelia Aspergillus; Bio-Rad, Marnes-La-Coquette, France) (Fig. 1).Fig. 2 Aspergillus flavus isolate: (A and B) Macroscopic: rapid growth olive green colonies, with woolly texture, on Sabouraud agar incubated at 28 °C (A) and 37 °C (B). (C) Microscopic: hyaline septate hyphae, radiate biseriate conidial head with finely roughened conidiophore. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.) Fig. 2 Fig. 3 Chest X-ray evidenced bilateral heterogeneous infiltrates on day 26 of hospitalization: picture from the COVID-19 associated pulmonary aspergillosis (CAPA) described on this report. Fig. 3 On day 28, laboratory testing showed increased white blood cells (16,930 cells/mm3; lymphocytes 45%), D-dimer (7.3 ng/mL), ferritin (3691 ng/mL) and C-reactive protein (31.8 mg/L). Blood and central venous catheter cultures were negative, and anidulafungin was replaced with voriconazole (400 mg first day, and then 300 mg daily) after the GM test returned positive. Colistin, vancomycin, and meropenem were continued. On day 30, hydroxychloroquine, ritonavir/lopinavir were suspended (following recommendation of AMOH), and on day 35, serum GM index decreased to 0.8. On day 44, the patient died in the ICU while on ventilatory support (Fig. 1). 3 Discussion COVID-19 associated pulmonary aspergillosis (CAPA) has been recently reported in European countries [[7], [8], [9], [10], [11], [12], [13]], including four case series covering 27 patients from France (n = 9), Belgium (n = 7), The Netherlands (n = 6), and Germany (n = 5) [[7], [8], [9], [10]]. Our case has similar clinical features compared with those previously reported. Among these four case series, all 27 patients were admitted to the ICU and developed ARDS. Most were male, >50 years old, and 25 (89%) of 27 had potential risk factors for severe COVID-19. Three (60%) of five patients from the German case series, seven (78%) of nine from the French case series, and three (43%) of seven patients from the Belgium case series had hypertension. All five patients from Germany had acute kidney injury, and three (33%) of nine patients from France and two (29%) of seven from Belgium received renal replacement therapy [[7], [8], [9], [10]]. Abnormal chest radiologic findings were reported in all of the patients from Germany (n = 5) and France (n = 9) [7,8]. Twelve (44%) of 27 patients received corticosteroids during their ICU stay, and 19 (70%) of 27 were treated with mold-active antifungal medication, eight (42%) of these 19 patients received corticosteroid simultaneous with antifungal treatment. Fifteen (55%) of the 27 case series patients died. Our patient received corticosteroids for 22 days before initial A. flavus culture and was treated with voriconazole starting 3 days after the initial fungal culture. Unlike influenza-associated pulmonary aspergillosis (IAPA), which commonly occurs early after ICU admission [4], our patient developed CAPA 25 days after ICU admission. COVID-19 associated pulmonary aspergillosis case series from Belgium and The Netherlands, showed variable time on development of were aspergillosis (range: 2–28 days) [9,10]. Making the diagnosis of IPA can be challenging, especially among patients not considered classically at greatest risk (e.g., hematologic malignancy and stem cell transplant patients). Among the four European CAPA case series discussed, Aspergillus species were cultured in 78% of respiratory specimens; positive specimens included: 14 bronchoalveolar lavage, six tracheal aspirate and one sputum [[7], [8], [9], [10]]. Bronchoscopy in COVID-19 patients is often not performed due to the risk of aerosol generation. Further complicating IPA diagnosis, serum GM testing is often negative among COVID-19 patients, and sensitivity is low among ICU patients in general; in the published cases series, of the 22 cases tested, only three (14%) had positive serum GM tests [14,15]. Most COVID-19 patients lack known risk factors for IPA [4]. Thus, isolation of Aspergillus from a non-sterile site and negative serum GM should not rule out invasive disease. Clinicians may want to consider mold-active azole therapy at first indication of aspergillosis in COVID-19 patients. Our patient had a high serum GM index (>1.0), which is the recommended cutoff, and mycological criteria for probable IPA classification by the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium [16]. Challenges in selecting a case definition for CAPA are also shared by the similar IAPA. For this reason, an expert panel recently proposed a new case definition for IAPA [17,18]. The definitions distinguish between invasive Aspergillus tracheobronchitis and other pulmonary manifestations and mainly rely on culture and GM to identify IPA. The expert panel stated that the IAPA case definition might also be useful to classify CAPA cases. Using this new definition, our case would be classified as probable CAPA [17]. A follow-up serum GM showed decreasing antigen titer which is consistent with antifungal treatment response. Little is known about the pathogenesis of CAPA, and there is a need to characterize risk factors for the development of IPA. Although influenza infection was found to be an independent risk factor for IPA [4], the use of corticosteroids in patients with influenza is also a risk factor for IAPA [19]. A recent preliminary report suggested that dexamethasone was associated with reduced mortality in COVID-19 patients [20]. However, corticosteroids might be associated with adverse effects such as delayed viral clearance and secondary infections. Notably, of the four proven IPA cases reported during the previous severe acute respiratory syndrome (SARS) epidemic, all were associated with concomitant corticosteroid therapy [5,21]. In our COVID-19 case with probable CAPA, we observed co-infections with bacterial and additional fungal pathogens (E. faecalis, A. baumanii, coagulase-negative staphylococci, and C. lusitaniae), which complicated patient treatment. Previous reports of CAPA cases did not describe the presence of other microbial co-infections [[7], [8], [9], [10], [11], [12], [13]], although these are commonly encountered in patients with influenza. Previous reports of ICU patients with severe influenza frequently reported secondary bacterial infection, and these were significantly associated with IAPA in studies comparing severe influenza patients with and without IAPA (61% vs 31%; p < 0.01) [22]. Co-infections were reported in up to 50% of patients with severe coronavirus infections causing both SARS and Middle East respiratory syndrome (MERS) [23]. However, early data suggest that coinfection frequency might be lower in COVID-19 [[23], [24], [25]]. We present a case of COVID-19 associated pulmonary aspergillosis from Argentina, with a clinical course and attributes similar to previously reported cases, that highlights the challenges in diagnosing and treating these CAPA patients. The use of a clinical algorithm to discriminate Aspergillus respiratory tract colonization from invasive pulmonary aspergillosis in critically ill patients is warranted, such as the one developed for IAPA [17,18]. This is the first report of ventilator-associated pneumonia involving A. flavus in a patient with COVID-19 and ARDS in the Americas. Awareness of CAPA and accessibility to appropriate diagnostic tests are necessary for accurate and timely identification of this co-infection [26,27]. Ethical considerations Publication of this case report was approved by the Hospital de Clínicas “José de San Martin” IRB. Declaration of competing interest All authors no reported conflicts of interest. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC. Acknowledgements Claudia Barberis, Marisa Almuzara, and the staff of the infectious disease division and the intensive care unit, at Hospital de Clínicas “José de San Martin”. Universidad de Buenos Aires. Diego H. Caceres acknowledges Oak Ridge Institute for Science and Education (ORISE).	Fatal	ReactionOutcome	CC BY	32837881	19,154,617	2021-03
What was the outcome of reaction 'Candida infection'?	Ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Coronavirus disease 2019 (COVID-19), caused by the novel coronavirus SARS-CoV-2, emerged in Wuhan, China, in December 2019 and rapidly spread around the world. Invasive aspergillosis has been reported as a complication of severe influenza pneumonia among intensive care patients. Similarities between COVID-19 and influenza pneumonia, together with limited published case series, suggest that aspergillosis may be an important complication of COVID-19. This report describes a case of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 from Buenos Aires, Argentina. 1 Introduction SARS-CoV-2 is the novel coronavirus that causes coronavirus disease 2019 (COVID‐19), which was first reported in December 2019 in Wuhan, China, and has rapidly spread worldwide [1]. On March 11th, 2020, the World Health Organization (WHO) declared a pandemic, and by June 30th, 2020, a total of 10,185,374 cases and 503,862 deaths were reported in 216 locations around the world [2]. In Argentina, on June 30th, 2020, the Argentinean Ministry of Health (AMOH) reported 62,268 cases and 1283 deaths [3]. Invasive pulmonary aspergillosis (IPA) is a known complication in patients with severe influenza pneumonia. Case series from the Netherlands and Belgium reported an incidence of 19% in patients with influenza pneumonia and acute respiratory distress syndrome (ARDS) hospitalized in the intensive care unit (ICU) [4], although these high incidences have not been confirmed in other studies [4]. There is concern that critically ill COVID-19 patients might also be at increased risk of pulmonary aspergillosis co-infection [5]. Here we describe a report of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 and ARDS in Argentina. 2 Case presentation In late April 2020, an 85-year-old man with a history of hypertension was admitted to the ICU with a history of six days of fever and dyspnea, at home. The patient had close household contact with two COVID-19 cases, and nasopharyngeal (NP) swab samples collected on the day of ICU admission tested positive for SARS-CoV-2 using molecular testing. On ICU admission (day 1) the patient presented with bilateral infiltrates (ground-glass opacities) on chest radiograph, respiratory rate of 40 breaths per minute, heart rate of 82 beats per minute, and a blood pressure 150/85 mm Hg. Laboratory tests showed a white blood cell count of 11,600 cells/mm3, with lymphopenia, normal serum creatinine (1.02 mg/dL), low albumin (2.8 g/dL), and normal lactate (1.4 mmol/L), as well as elevated ferritin (1840 ng/mL), D-dimer (17.1 ng/mL), procalcitonin (2.89 ng/mL), and fibrinogen (702 mg/dl). The patient also presented with deep vein thrombosis in the right subclavian vein and in the right internal jugular vein; anticoagulation was initiated with heparin due to the hypercoagulable state. Empirical treatment for pneumonia was started with oseltamivir, ceftriaxone, and azithromycin, and hydroxychloroquine, ritonavir/lopinavir were started for COVID-19, according to the Argentinean Ministry of Health (AMOH) national guidelines [6]. After 3 days of hospitalization, the patient required ventilator support (orotracheal intubation and mechanical ventilation) and was given a corticosteroid (dexamethasone, 20 mg/day). Influenza antigen testing yielded a negative result, prompting cessation of empirical influenza treatment (Fig. 1).Fig. 1 Case timeline: ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Fig. 1 On day 10 of hospitalization, the patient developed a new fever (38 °C). Urinary culture and pneumococcal urine antigen test were negative; tracheal aspirate and blood culture were positive for Enterococcus faecalis, and imipenem and vancomycin were added to hydroxychloroquine and ritonavir/lopinavir. Two days later polymyxin was added, and blood cultures turned negative after seven days of treatment. On day 17, urinary analysis showed evidence of acute tubular necrosis with metabolic acidosis (low pH, PaCO2 and HCO3), and treatment was subsequently changed to meropenem and colistin. On day 19, tracheal aspirate, urine and blood culture remained negative for bacteria, and a second SARS-CoV-2 PCR test from a NP swab was positive. On day 23, the patient was again febrile, and urinary, tracheal aspirate, blood and catheter tip cultures were repeated; a third SARS-CoV-2 PCR test on day 24 from a NP swab was positive (Fig. 1). On day 25 the patient developed multiple organ failure, including acute renal failure. Aspergillus flavus, identified by MALDI-TOF (Fig. 2), and Acinetobacter baumanii (>106 CFU) were cultured from tracheal aspirate. Staphylococcus capitis was isolated from blood culture, and E. faecalis and Staphylococcus epidermidis were isolated from the central venous catheter tip culture. Candida lusitaniae was isolated from urine. The patient's antimicrobial regimen was updated to include vancomycin, meropenem, and colistin. Anidulafungin was added to control candidiasis, but azole therapy for the A. flavus finding was not started due to initial clinical suspicion of colonization versus infection. On day 26 a tracheostomy was placed as a result of prolonged ventilation, ARDS (PaO2/FiO2 ratio <200), and sepsis. Chest radiograph continued to show bilateral infiltrates (Fig. 3). Aspergillus galactomannan antigen (GM) was positive in serum (GM index: 1.4; Platelia Aspergillus; Bio-Rad, Marnes-La-Coquette, France) (Fig. 1).Fig. 2 Aspergillus flavus isolate: (A and B) Macroscopic: rapid growth olive green colonies, with woolly texture, on Sabouraud agar incubated at 28 °C (A) and 37 °C (B). (C) Microscopic: hyaline septate hyphae, radiate biseriate conidial head with finely roughened conidiophore. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.) Fig. 2 Fig. 3 Chest X-ray evidenced bilateral heterogeneous infiltrates on day 26 of hospitalization: picture from the COVID-19 associated pulmonary aspergillosis (CAPA) described on this report. Fig. 3 On day 28, laboratory testing showed increased white blood cells (16,930 cells/mm3; lymphocytes 45%), D-dimer (7.3 ng/mL), ferritin (3691 ng/mL) and C-reactive protein (31.8 mg/L). Blood and central venous catheter cultures were negative, and anidulafungin was replaced with voriconazole (400 mg first day, and then 300 mg daily) after the GM test returned positive. Colistin, vancomycin, and meropenem were continued. On day 30, hydroxychloroquine, ritonavir/lopinavir were suspended (following recommendation of AMOH), and on day 35, serum GM index decreased to 0.8. On day 44, the patient died in the ICU while on ventilatory support (Fig. 1). 3 Discussion COVID-19 associated pulmonary aspergillosis (CAPA) has been recently reported in European countries [[7], [8], [9], [10], [11], [12], [13]], including four case series covering 27 patients from France (n = 9), Belgium (n = 7), The Netherlands (n = 6), and Germany (n = 5) [[7], [8], [9], [10]]. Our case has similar clinical features compared with those previously reported. Among these four case series, all 27 patients were admitted to the ICU and developed ARDS. Most were male, >50 years old, and 25 (89%) of 27 had potential risk factors for severe COVID-19. Three (60%) of five patients from the German case series, seven (78%) of nine from the French case series, and three (43%) of seven patients from the Belgium case series had hypertension. All five patients from Germany had acute kidney injury, and three (33%) of nine patients from France and two (29%) of seven from Belgium received renal replacement therapy [[7], [8], [9], [10]]. Abnormal chest radiologic findings were reported in all of the patients from Germany (n = 5) and France (n = 9) [7,8]. Twelve (44%) of 27 patients received corticosteroids during their ICU stay, and 19 (70%) of 27 were treated with mold-active antifungal medication, eight (42%) of these 19 patients received corticosteroid simultaneous with antifungal treatment. Fifteen (55%) of the 27 case series patients died. Our patient received corticosteroids for 22 days before initial A. flavus culture and was treated with voriconazole starting 3 days after the initial fungal culture. Unlike influenza-associated pulmonary aspergillosis (IAPA), which commonly occurs early after ICU admission [4], our patient developed CAPA 25 days after ICU admission. COVID-19 associated pulmonary aspergillosis case series from Belgium and The Netherlands, showed variable time on development of were aspergillosis (range: 2–28 days) [9,10]. Making the diagnosis of IPA can be challenging, especially among patients not considered classically at greatest risk (e.g., hematologic malignancy and stem cell transplant patients). Among the four European CAPA case series discussed, Aspergillus species were cultured in 78% of respiratory specimens; positive specimens included: 14 bronchoalveolar lavage, six tracheal aspirate and one sputum [[7], [8], [9], [10]]. Bronchoscopy in COVID-19 patients is often not performed due to the risk of aerosol generation. Further complicating IPA diagnosis, serum GM testing is often negative among COVID-19 patients, and sensitivity is low among ICU patients in general; in the published cases series, of the 22 cases tested, only three (14%) had positive serum GM tests [14,15]. Most COVID-19 patients lack known risk factors for IPA [4]. Thus, isolation of Aspergillus from a non-sterile site and negative serum GM should not rule out invasive disease. Clinicians may want to consider mold-active azole therapy at first indication of aspergillosis in COVID-19 patients. Our patient had a high serum GM index (>1.0), which is the recommended cutoff, and mycological criteria for probable IPA classification by the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium [16]. Challenges in selecting a case definition for CAPA are also shared by the similar IAPA. For this reason, an expert panel recently proposed a new case definition for IAPA [17,18]. The definitions distinguish between invasive Aspergillus tracheobronchitis and other pulmonary manifestations and mainly rely on culture and GM to identify IPA. The expert panel stated that the IAPA case definition might also be useful to classify CAPA cases. Using this new definition, our case would be classified as probable CAPA [17]. A follow-up serum GM showed decreasing antigen titer which is consistent with antifungal treatment response. Little is known about the pathogenesis of CAPA, and there is a need to characterize risk factors for the development of IPA. Although influenza infection was found to be an independent risk factor for IPA [4], the use of corticosteroids in patients with influenza is also a risk factor for IAPA [19]. A recent preliminary report suggested that dexamethasone was associated with reduced mortality in COVID-19 patients [20]. However, corticosteroids might be associated with adverse effects such as delayed viral clearance and secondary infections. Notably, of the four proven IPA cases reported during the previous severe acute respiratory syndrome (SARS) epidemic, all were associated with concomitant corticosteroid therapy [5,21]. In our COVID-19 case with probable CAPA, we observed co-infections with bacterial and additional fungal pathogens (E. faecalis, A. baumanii, coagulase-negative staphylococci, and C. lusitaniae), which complicated patient treatment. Previous reports of CAPA cases did not describe the presence of other microbial co-infections [[7], [8], [9], [10], [11], [12], [13]], although these are commonly encountered in patients with influenza. Previous reports of ICU patients with severe influenza frequently reported secondary bacterial infection, and these were significantly associated with IAPA in studies comparing severe influenza patients with and without IAPA (61% vs 31%; p < 0.01) [22]. Co-infections were reported in up to 50% of patients with severe coronavirus infections causing both SARS and Middle East respiratory syndrome (MERS) [23]. However, early data suggest that coinfection frequency might be lower in COVID-19 [[23], [24], [25]]. We present a case of COVID-19 associated pulmonary aspergillosis from Argentina, with a clinical course and attributes similar to previously reported cases, that highlights the challenges in diagnosing and treating these CAPA patients. The use of a clinical algorithm to discriminate Aspergillus respiratory tract colonization from invasive pulmonary aspergillosis in critically ill patients is warranted, such as the one developed for IAPA [17,18]. This is the first report of ventilator-associated pneumonia involving A. flavus in a patient with COVID-19 and ARDS in the Americas. Awareness of CAPA and accessibility to appropriate diagnostic tests are necessary for accurate and timely identification of this co-infection [26,27]. Ethical considerations Publication of this case report was approved by the Hospital de Clínicas “José de San Martin” IRB. Declaration of competing interest All authors no reported conflicts of interest. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC. Acknowledgements Claudia Barberis, Marisa Almuzara, and the staff of the infectious disease division and the intensive care unit, at Hospital de Clínicas “José de San Martin”. Universidad de Buenos Aires. Diego H. Caceres acknowledges Oak Ridge Institute for Science and Education (ORISE).	Recovered	ReactionOutcome	CC BY	32837881	19,203,398	2021-03
What was the outcome of reaction 'Enterococcal infection'?	Ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Coronavirus disease 2019 (COVID-19), caused by the novel coronavirus SARS-CoV-2, emerged in Wuhan, China, in December 2019 and rapidly spread around the world. Invasive aspergillosis has been reported as a complication of severe influenza pneumonia among intensive care patients. Similarities between COVID-19 and influenza pneumonia, together with limited published case series, suggest that aspergillosis may be an important complication of COVID-19. This report describes a case of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 from Buenos Aires, Argentina. 1 Introduction SARS-CoV-2 is the novel coronavirus that causes coronavirus disease 2019 (COVID‐19), which was first reported in December 2019 in Wuhan, China, and has rapidly spread worldwide [1]. On March 11th, 2020, the World Health Organization (WHO) declared a pandemic, and by June 30th, 2020, a total of 10,185,374 cases and 503,862 deaths were reported in 216 locations around the world [2]. In Argentina, on June 30th, 2020, the Argentinean Ministry of Health (AMOH) reported 62,268 cases and 1283 deaths [3]. Invasive pulmonary aspergillosis (IPA) is a known complication in patients with severe influenza pneumonia. Case series from the Netherlands and Belgium reported an incidence of 19% in patients with influenza pneumonia and acute respiratory distress syndrome (ARDS) hospitalized in the intensive care unit (ICU) [4], although these high incidences have not been confirmed in other studies [4]. There is concern that critically ill COVID-19 patients might also be at increased risk of pulmonary aspergillosis co-infection [5]. Here we describe a report of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 and ARDS in Argentina. 2 Case presentation In late April 2020, an 85-year-old man with a history of hypertension was admitted to the ICU with a history of six days of fever and dyspnea, at home. The patient had close household contact with two COVID-19 cases, and nasopharyngeal (NP) swab samples collected on the day of ICU admission tested positive for SARS-CoV-2 using molecular testing. On ICU admission (day 1) the patient presented with bilateral infiltrates (ground-glass opacities) on chest radiograph, respiratory rate of 40 breaths per minute, heart rate of 82 beats per minute, and a blood pressure 150/85 mm Hg. Laboratory tests showed a white blood cell count of 11,600 cells/mm3, with lymphopenia, normal serum creatinine (1.02 mg/dL), low albumin (2.8 g/dL), and normal lactate (1.4 mmol/L), as well as elevated ferritin (1840 ng/mL), D-dimer (17.1 ng/mL), procalcitonin (2.89 ng/mL), and fibrinogen (702 mg/dl). The patient also presented with deep vein thrombosis in the right subclavian vein and in the right internal jugular vein; anticoagulation was initiated with heparin due to the hypercoagulable state. Empirical treatment for pneumonia was started with oseltamivir, ceftriaxone, and azithromycin, and hydroxychloroquine, ritonavir/lopinavir were started for COVID-19, according to the Argentinean Ministry of Health (AMOH) national guidelines [6]. After 3 days of hospitalization, the patient required ventilator support (orotracheal intubation and mechanical ventilation) and was given a corticosteroid (dexamethasone, 20 mg/day). Influenza antigen testing yielded a negative result, prompting cessation of empirical influenza treatment (Fig. 1).Fig. 1 Case timeline: ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Fig. 1 On day 10 of hospitalization, the patient developed a new fever (38 °C). Urinary culture and pneumococcal urine antigen test were negative; tracheal aspirate and blood culture were positive for Enterococcus faecalis, and imipenem and vancomycin were added to hydroxychloroquine and ritonavir/lopinavir. Two days later polymyxin was added, and blood cultures turned negative after seven days of treatment. On day 17, urinary analysis showed evidence of acute tubular necrosis with metabolic acidosis (low pH, PaCO2 and HCO3), and treatment was subsequently changed to meropenem and colistin. On day 19, tracheal aspirate, urine and blood culture remained negative for bacteria, and a second SARS-CoV-2 PCR test from a NP swab was positive. On day 23, the patient was again febrile, and urinary, tracheal aspirate, blood and catheter tip cultures were repeated; a third SARS-CoV-2 PCR test on day 24 from a NP swab was positive (Fig. 1). On day 25 the patient developed multiple organ failure, including acute renal failure. Aspergillus flavus, identified by MALDI-TOF (Fig. 2), and Acinetobacter baumanii (>106 CFU) were cultured from tracheal aspirate. Staphylococcus capitis was isolated from blood culture, and E. faecalis and Staphylococcus epidermidis were isolated from the central venous catheter tip culture. Candida lusitaniae was isolated from urine. The patient's antimicrobial regimen was updated to include vancomycin, meropenem, and colistin. Anidulafungin was added to control candidiasis, but azole therapy for the A. flavus finding was not started due to initial clinical suspicion of colonization versus infection. On day 26 a tracheostomy was placed as a result of prolonged ventilation, ARDS (PaO2/FiO2 ratio <200), and sepsis. Chest radiograph continued to show bilateral infiltrates (Fig. 3). Aspergillus galactomannan antigen (GM) was positive in serum (GM index: 1.4; Platelia Aspergillus; Bio-Rad, Marnes-La-Coquette, France) (Fig. 1).Fig. 2 Aspergillus flavus isolate: (A and B) Macroscopic: rapid growth olive green colonies, with woolly texture, on Sabouraud agar incubated at 28 °C (A) and 37 °C (B). (C) Microscopic: hyaline septate hyphae, radiate biseriate conidial head with finely roughened conidiophore. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.) Fig. 2 Fig. 3 Chest X-ray evidenced bilateral heterogeneous infiltrates on day 26 of hospitalization: picture from the COVID-19 associated pulmonary aspergillosis (CAPA) described on this report. Fig. 3 On day 28, laboratory testing showed increased white blood cells (16,930 cells/mm3; lymphocytes 45%), D-dimer (7.3 ng/mL), ferritin (3691 ng/mL) and C-reactive protein (31.8 mg/L). Blood and central venous catheter cultures were negative, and anidulafungin was replaced with voriconazole (400 mg first day, and then 300 mg daily) after the GM test returned positive. Colistin, vancomycin, and meropenem were continued. On day 30, hydroxychloroquine, ritonavir/lopinavir were suspended (following recommendation of AMOH), and on day 35, serum GM index decreased to 0.8. On day 44, the patient died in the ICU while on ventilatory support (Fig. 1). 3 Discussion COVID-19 associated pulmonary aspergillosis (CAPA) has been recently reported in European countries [[7], [8], [9], [10], [11], [12], [13]], including four case series covering 27 patients from France (n = 9), Belgium (n = 7), The Netherlands (n = 6), and Germany (n = 5) [[7], [8], [9], [10]]. Our case has similar clinical features compared with those previously reported. Among these four case series, all 27 patients were admitted to the ICU and developed ARDS. Most were male, >50 years old, and 25 (89%) of 27 had potential risk factors for severe COVID-19. Three (60%) of five patients from the German case series, seven (78%) of nine from the French case series, and three (43%) of seven patients from the Belgium case series had hypertension. All five patients from Germany had acute kidney injury, and three (33%) of nine patients from France and two (29%) of seven from Belgium received renal replacement therapy [[7], [8], [9], [10]]. Abnormal chest radiologic findings were reported in all of the patients from Germany (n = 5) and France (n = 9) [7,8]. Twelve (44%) of 27 patients received corticosteroids during their ICU stay, and 19 (70%) of 27 were treated with mold-active antifungal medication, eight (42%) of these 19 patients received corticosteroid simultaneous with antifungal treatment. Fifteen (55%) of the 27 case series patients died. Our patient received corticosteroids for 22 days before initial A. flavus culture and was treated with voriconazole starting 3 days after the initial fungal culture. Unlike influenza-associated pulmonary aspergillosis (IAPA), which commonly occurs early after ICU admission [4], our patient developed CAPA 25 days after ICU admission. COVID-19 associated pulmonary aspergillosis case series from Belgium and The Netherlands, showed variable time on development of were aspergillosis (range: 2–28 days) [9,10]. Making the diagnosis of IPA can be challenging, especially among patients not considered classically at greatest risk (e.g., hematologic malignancy and stem cell transplant patients). Among the four European CAPA case series discussed, Aspergillus species were cultured in 78% of respiratory specimens; positive specimens included: 14 bronchoalveolar lavage, six tracheal aspirate and one sputum [[7], [8], [9], [10]]. Bronchoscopy in COVID-19 patients is often not performed due to the risk of aerosol generation. Further complicating IPA diagnosis, serum GM testing is often negative among COVID-19 patients, and sensitivity is low among ICU patients in general; in the published cases series, of the 22 cases tested, only three (14%) had positive serum GM tests [14,15]. Most COVID-19 patients lack known risk factors for IPA [4]. Thus, isolation of Aspergillus from a non-sterile site and negative serum GM should not rule out invasive disease. Clinicians may want to consider mold-active azole therapy at first indication of aspergillosis in COVID-19 patients. Our patient had a high serum GM index (>1.0), which is the recommended cutoff, and mycological criteria for probable IPA classification by the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium [16]. Challenges in selecting a case definition for CAPA are also shared by the similar IAPA. For this reason, an expert panel recently proposed a new case definition for IAPA [17,18]. The definitions distinguish between invasive Aspergillus tracheobronchitis and other pulmonary manifestations and mainly rely on culture and GM to identify IPA. The expert panel stated that the IAPA case definition might also be useful to classify CAPA cases. Using this new definition, our case would be classified as probable CAPA [17]. A follow-up serum GM showed decreasing antigen titer which is consistent with antifungal treatment response. Little is known about the pathogenesis of CAPA, and there is a need to characterize risk factors for the development of IPA. Although influenza infection was found to be an independent risk factor for IPA [4], the use of corticosteroids in patients with influenza is also a risk factor for IAPA [19]. A recent preliminary report suggested that dexamethasone was associated with reduced mortality in COVID-19 patients [20]. However, corticosteroids might be associated with adverse effects such as delayed viral clearance and secondary infections. Notably, of the four proven IPA cases reported during the previous severe acute respiratory syndrome (SARS) epidemic, all were associated with concomitant corticosteroid therapy [5,21]. In our COVID-19 case with probable CAPA, we observed co-infections with bacterial and additional fungal pathogens (E. faecalis, A. baumanii, coagulase-negative staphylococci, and C. lusitaniae), which complicated patient treatment. Previous reports of CAPA cases did not describe the presence of other microbial co-infections [[7], [8], [9], [10], [11], [12], [13]], although these are commonly encountered in patients with influenza. Previous reports of ICU patients with severe influenza frequently reported secondary bacterial infection, and these were significantly associated with IAPA in studies comparing severe influenza patients with and without IAPA (61% vs 31%; p < 0.01) [22]. Co-infections were reported in up to 50% of patients with severe coronavirus infections causing both SARS and Middle East respiratory syndrome (MERS) [23]. However, early data suggest that coinfection frequency might be lower in COVID-19 [[23], [24], [25]]. We present a case of COVID-19 associated pulmonary aspergillosis from Argentina, with a clinical course and attributes similar to previously reported cases, that highlights the challenges in diagnosing and treating these CAPA patients. The use of a clinical algorithm to discriminate Aspergillus respiratory tract colonization from invasive pulmonary aspergillosis in critically ill patients is warranted, such as the one developed for IAPA [17,18]. This is the first report of ventilator-associated pneumonia involving A. flavus in a patient with COVID-19 and ARDS in the Americas. Awareness of CAPA and accessibility to appropriate diagnostic tests are necessary for accurate and timely identification of this co-infection [26,27]. Ethical considerations Publication of this case report was approved by the Hospital de Clínicas “José de San Martin” IRB. Declaration of competing interest All authors no reported conflicts of interest. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC. Acknowledgements Claudia Barberis, Marisa Almuzara, and the staff of the infectious disease division and the intensive care unit, at Hospital de Clínicas “José de San Martin”. Universidad de Buenos Aires. Diego H. Caceres acknowledges Oak Ridge Institute for Science and Education (ORISE).	Recovered	ReactionOutcome	CC BY	32837881	19,154,617	2021-03
What was the outcome of reaction 'Multiple organ dysfunction syndrome'?	Ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Coronavirus disease 2019 (COVID-19), caused by the novel coronavirus SARS-CoV-2, emerged in Wuhan, China, in December 2019 and rapidly spread around the world. Invasive aspergillosis has been reported as a complication of severe influenza pneumonia among intensive care patients. Similarities between COVID-19 and influenza pneumonia, together with limited published case series, suggest that aspergillosis may be an important complication of COVID-19. This report describes a case of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 from Buenos Aires, Argentina. 1 Introduction SARS-CoV-2 is the novel coronavirus that causes coronavirus disease 2019 (COVID‐19), which was first reported in December 2019 in Wuhan, China, and has rapidly spread worldwide [1]. On March 11th, 2020, the World Health Organization (WHO) declared a pandemic, and by June 30th, 2020, a total of 10,185,374 cases and 503,862 deaths were reported in 216 locations around the world [2]. In Argentina, on June 30th, 2020, the Argentinean Ministry of Health (AMOH) reported 62,268 cases and 1283 deaths [3]. Invasive pulmonary aspergillosis (IPA) is a known complication in patients with severe influenza pneumonia. Case series from the Netherlands and Belgium reported an incidence of 19% in patients with influenza pneumonia and acute respiratory distress syndrome (ARDS) hospitalized in the intensive care unit (ICU) [4], although these high incidences have not been confirmed in other studies [4]. There is concern that critically ill COVID-19 patients might also be at increased risk of pulmonary aspergillosis co-infection [5]. Here we describe a report of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 and ARDS in Argentina. 2 Case presentation In late April 2020, an 85-year-old man with a history of hypertension was admitted to the ICU with a history of six days of fever and dyspnea, at home. The patient had close household contact with two COVID-19 cases, and nasopharyngeal (NP) swab samples collected on the day of ICU admission tested positive for SARS-CoV-2 using molecular testing. On ICU admission (day 1) the patient presented with bilateral infiltrates (ground-glass opacities) on chest radiograph, respiratory rate of 40 breaths per minute, heart rate of 82 beats per minute, and a blood pressure 150/85 mm Hg. Laboratory tests showed a white blood cell count of 11,600 cells/mm3, with lymphopenia, normal serum creatinine (1.02 mg/dL), low albumin (2.8 g/dL), and normal lactate (1.4 mmol/L), as well as elevated ferritin (1840 ng/mL), D-dimer (17.1 ng/mL), procalcitonin (2.89 ng/mL), and fibrinogen (702 mg/dl). The patient also presented with deep vein thrombosis in the right subclavian vein and in the right internal jugular vein; anticoagulation was initiated with heparin due to the hypercoagulable state. Empirical treatment for pneumonia was started with oseltamivir, ceftriaxone, and azithromycin, and hydroxychloroquine, ritonavir/lopinavir were started for COVID-19, according to the Argentinean Ministry of Health (AMOH) national guidelines [6]. After 3 days of hospitalization, the patient required ventilator support (orotracheal intubation and mechanical ventilation) and was given a corticosteroid (dexamethasone, 20 mg/day). Influenza antigen testing yielded a negative result, prompting cessation of empirical influenza treatment (Fig. 1).Fig. 1 Case timeline: ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Fig. 1 On day 10 of hospitalization, the patient developed a new fever (38 °C). Urinary culture and pneumococcal urine antigen test were negative; tracheal aspirate and blood culture were positive for Enterococcus faecalis, and imipenem and vancomycin were added to hydroxychloroquine and ritonavir/lopinavir. Two days later polymyxin was added, and blood cultures turned negative after seven days of treatment. On day 17, urinary analysis showed evidence of acute tubular necrosis with metabolic acidosis (low pH, PaCO2 and HCO3), and treatment was subsequently changed to meropenem and colistin. On day 19, tracheal aspirate, urine and blood culture remained negative for bacteria, and a second SARS-CoV-2 PCR test from a NP swab was positive. On day 23, the patient was again febrile, and urinary, tracheal aspirate, blood and catheter tip cultures were repeated; a third SARS-CoV-2 PCR test on day 24 from a NP swab was positive (Fig. 1). On day 25 the patient developed multiple organ failure, including acute renal failure. Aspergillus flavus, identified by MALDI-TOF (Fig. 2), and Acinetobacter baumanii (>106 CFU) were cultured from tracheal aspirate. Staphylococcus capitis was isolated from blood culture, and E. faecalis and Staphylococcus epidermidis were isolated from the central venous catheter tip culture. Candida lusitaniae was isolated from urine. The patient's antimicrobial regimen was updated to include vancomycin, meropenem, and colistin. Anidulafungin was added to control candidiasis, but azole therapy for the A. flavus finding was not started due to initial clinical suspicion of colonization versus infection. On day 26 a tracheostomy was placed as a result of prolonged ventilation, ARDS (PaO2/FiO2 ratio <200), and sepsis. Chest radiograph continued to show bilateral infiltrates (Fig. 3). Aspergillus galactomannan antigen (GM) was positive in serum (GM index: 1.4; Platelia Aspergillus; Bio-Rad, Marnes-La-Coquette, France) (Fig. 1).Fig. 2 Aspergillus flavus isolate: (A and B) Macroscopic: rapid growth olive green colonies, with woolly texture, on Sabouraud agar incubated at 28 °C (A) and 37 °C (B). (C) Microscopic: hyaline septate hyphae, radiate biseriate conidial head with finely roughened conidiophore. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.) Fig. 2 Fig. 3 Chest X-ray evidenced bilateral heterogeneous infiltrates on day 26 of hospitalization: picture from the COVID-19 associated pulmonary aspergillosis (CAPA) described on this report. Fig. 3 On day 28, laboratory testing showed increased white blood cells (16,930 cells/mm3; lymphocytes 45%), D-dimer (7.3 ng/mL), ferritin (3691 ng/mL) and C-reactive protein (31.8 mg/L). Blood and central venous catheter cultures were negative, and anidulafungin was replaced with voriconazole (400 mg first day, and then 300 mg daily) after the GM test returned positive. Colistin, vancomycin, and meropenem were continued. On day 30, hydroxychloroquine, ritonavir/lopinavir were suspended (following recommendation of AMOH), and on day 35, serum GM index decreased to 0.8. On day 44, the patient died in the ICU while on ventilatory support (Fig. 1). 3 Discussion COVID-19 associated pulmonary aspergillosis (CAPA) has been recently reported in European countries [[7], [8], [9], [10], [11], [12], [13]], including four case series covering 27 patients from France (n = 9), Belgium (n = 7), The Netherlands (n = 6), and Germany (n = 5) [[7], [8], [9], [10]]. Our case has similar clinical features compared with those previously reported. Among these four case series, all 27 patients were admitted to the ICU and developed ARDS. Most were male, >50 years old, and 25 (89%) of 27 had potential risk factors for severe COVID-19. Three (60%) of five patients from the German case series, seven (78%) of nine from the French case series, and three (43%) of seven patients from the Belgium case series had hypertension. All five patients from Germany had acute kidney injury, and three (33%) of nine patients from France and two (29%) of seven from Belgium received renal replacement therapy [[7], [8], [9], [10]]. Abnormal chest radiologic findings were reported in all of the patients from Germany (n = 5) and France (n = 9) [7,8]. Twelve (44%) of 27 patients received corticosteroids during their ICU stay, and 19 (70%) of 27 were treated with mold-active antifungal medication, eight (42%) of these 19 patients received corticosteroid simultaneous with antifungal treatment. Fifteen (55%) of the 27 case series patients died. Our patient received corticosteroids for 22 days before initial A. flavus culture and was treated with voriconazole starting 3 days after the initial fungal culture. Unlike influenza-associated pulmonary aspergillosis (IAPA), which commonly occurs early after ICU admission [4], our patient developed CAPA 25 days after ICU admission. COVID-19 associated pulmonary aspergillosis case series from Belgium and The Netherlands, showed variable time on development of were aspergillosis (range: 2–28 days) [9,10]. Making the diagnosis of IPA can be challenging, especially among patients not considered classically at greatest risk (e.g., hematologic malignancy and stem cell transplant patients). Among the four European CAPA case series discussed, Aspergillus species were cultured in 78% of respiratory specimens; positive specimens included: 14 bronchoalveolar lavage, six tracheal aspirate and one sputum [[7], [8], [9], [10]]. Bronchoscopy in COVID-19 patients is often not performed due to the risk of aerosol generation. Further complicating IPA diagnosis, serum GM testing is often negative among COVID-19 patients, and sensitivity is low among ICU patients in general; in the published cases series, of the 22 cases tested, only three (14%) had positive serum GM tests [14,15]. Most COVID-19 patients lack known risk factors for IPA [4]. Thus, isolation of Aspergillus from a non-sterile site and negative serum GM should not rule out invasive disease. Clinicians may want to consider mold-active azole therapy at first indication of aspergillosis in COVID-19 patients. Our patient had a high serum GM index (>1.0), which is the recommended cutoff, and mycological criteria for probable IPA classification by the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium [16]. Challenges in selecting a case definition for CAPA are also shared by the similar IAPA. For this reason, an expert panel recently proposed a new case definition for IAPA [17,18]. The definitions distinguish between invasive Aspergillus tracheobronchitis and other pulmonary manifestations and mainly rely on culture and GM to identify IPA. The expert panel stated that the IAPA case definition might also be useful to classify CAPA cases. Using this new definition, our case would be classified as probable CAPA [17]. A follow-up serum GM showed decreasing antigen titer which is consistent with antifungal treatment response. Little is known about the pathogenesis of CAPA, and there is a need to characterize risk factors for the development of IPA. Although influenza infection was found to be an independent risk factor for IPA [4], the use of corticosteroids in patients with influenza is also a risk factor for IAPA [19]. A recent preliminary report suggested that dexamethasone was associated with reduced mortality in COVID-19 patients [20]. However, corticosteroids might be associated with adverse effects such as delayed viral clearance and secondary infections. Notably, of the four proven IPA cases reported during the previous severe acute respiratory syndrome (SARS) epidemic, all were associated with concomitant corticosteroid therapy [5,21]. In our COVID-19 case with probable CAPA, we observed co-infections with bacterial and additional fungal pathogens (E. faecalis, A. baumanii, coagulase-negative staphylococci, and C. lusitaniae), which complicated patient treatment. Previous reports of CAPA cases did not describe the presence of other microbial co-infections [[7], [8], [9], [10], [11], [12], [13]], although these are commonly encountered in patients with influenza. Previous reports of ICU patients with severe influenza frequently reported secondary bacterial infection, and these were significantly associated with IAPA in studies comparing severe influenza patients with and without IAPA (61% vs 31%; p < 0.01) [22]. Co-infections were reported in up to 50% of patients with severe coronavirus infections causing both SARS and Middle East respiratory syndrome (MERS) [23]. However, early data suggest that coinfection frequency might be lower in COVID-19 [[23], [24], [25]]. We present a case of COVID-19 associated pulmonary aspergillosis from Argentina, with a clinical course and attributes similar to previously reported cases, that highlights the challenges in diagnosing and treating these CAPA patients. The use of a clinical algorithm to discriminate Aspergillus respiratory tract colonization from invasive pulmonary aspergillosis in critically ill patients is warranted, such as the one developed for IAPA [17,18]. This is the first report of ventilator-associated pneumonia involving A. flavus in a patient with COVID-19 and ARDS in the Americas. Awareness of CAPA and accessibility to appropriate diagnostic tests are necessary for accurate and timely identification of this co-infection [26,27]. Ethical considerations Publication of this case report was approved by the Hospital de Clínicas “José de San Martin” IRB. Declaration of competing interest All authors no reported conflicts of interest. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC. Acknowledgements Claudia Barberis, Marisa Almuzara, and the staff of the infectious disease division and the intensive care unit, at Hospital de Clínicas “José de San Martin”. Universidad de Buenos Aires. Diego H. Caceres acknowledges Oak Ridge Institute for Science and Education (ORISE).	Fatal	ReactionOutcome	CC BY	32837881	19,203,398	2021-03
What was the outcome of reaction 'Pneumonia'?	Ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Coronavirus disease 2019 (COVID-19), caused by the novel coronavirus SARS-CoV-2, emerged in Wuhan, China, in December 2019 and rapidly spread around the world. Invasive aspergillosis has been reported as a complication of severe influenza pneumonia among intensive care patients. Similarities between COVID-19 and influenza pneumonia, together with limited published case series, suggest that aspergillosis may be an important complication of COVID-19. This report describes a case of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 from Buenos Aires, Argentina. 1 Introduction SARS-CoV-2 is the novel coronavirus that causes coronavirus disease 2019 (COVID‐19), which was first reported in December 2019 in Wuhan, China, and has rapidly spread worldwide [1]. On March 11th, 2020, the World Health Organization (WHO) declared a pandemic, and by June 30th, 2020, a total of 10,185,374 cases and 503,862 deaths were reported in 216 locations around the world [2]. In Argentina, on June 30th, 2020, the Argentinean Ministry of Health (AMOH) reported 62,268 cases and 1283 deaths [3]. Invasive pulmonary aspergillosis (IPA) is a known complication in patients with severe influenza pneumonia. Case series from the Netherlands and Belgium reported an incidence of 19% in patients with influenza pneumonia and acute respiratory distress syndrome (ARDS) hospitalized in the intensive care unit (ICU) [4], although these high incidences have not been confirmed in other studies [4]. There is concern that critically ill COVID-19 patients might also be at increased risk of pulmonary aspergillosis co-infection [5]. Here we describe a report of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 and ARDS in Argentina. 2 Case presentation In late April 2020, an 85-year-old man with a history of hypertension was admitted to the ICU with a history of six days of fever and dyspnea, at home. The patient had close household contact with two COVID-19 cases, and nasopharyngeal (NP) swab samples collected on the day of ICU admission tested positive for SARS-CoV-2 using molecular testing. On ICU admission (day 1) the patient presented with bilateral infiltrates (ground-glass opacities) on chest radiograph, respiratory rate of 40 breaths per minute, heart rate of 82 beats per minute, and a blood pressure 150/85 mm Hg. Laboratory tests showed a white blood cell count of 11,600 cells/mm3, with lymphopenia, normal serum creatinine (1.02 mg/dL), low albumin (2.8 g/dL), and normal lactate (1.4 mmol/L), as well as elevated ferritin (1840 ng/mL), D-dimer (17.1 ng/mL), procalcitonin (2.89 ng/mL), and fibrinogen (702 mg/dl). The patient also presented with deep vein thrombosis in the right subclavian vein and in the right internal jugular vein; anticoagulation was initiated with heparin due to the hypercoagulable state. Empirical treatment for pneumonia was started with oseltamivir, ceftriaxone, and azithromycin, and hydroxychloroquine, ritonavir/lopinavir were started for COVID-19, according to the Argentinean Ministry of Health (AMOH) national guidelines [6]. After 3 days of hospitalization, the patient required ventilator support (orotracheal intubation and mechanical ventilation) and was given a corticosteroid (dexamethasone, 20 mg/day). Influenza antigen testing yielded a negative result, prompting cessation of empirical influenza treatment (Fig. 1).Fig. 1 Case timeline: ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Fig. 1 On day 10 of hospitalization, the patient developed a new fever (38 °C). Urinary culture and pneumococcal urine antigen test were negative; tracheal aspirate and blood culture were positive for Enterococcus faecalis, and imipenem and vancomycin were added to hydroxychloroquine and ritonavir/lopinavir. Two days later polymyxin was added, and blood cultures turned negative after seven days of treatment. On day 17, urinary analysis showed evidence of acute tubular necrosis with metabolic acidosis (low pH, PaCO2 and HCO3), and treatment was subsequently changed to meropenem and colistin. On day 19, tracheal aspirate, urine and blood culture remained negative for bacteria, and a second SARS-CoV-2 PCR test from a NP swab was positive. On day 23, the patient was again febrile, and urinary, tracheal aspirate, blood and catheter tip cultures were repeated; a third SARS-CoV-2 PCR test on day 24 from a NP swab was positive (Fig. 1). On day 25 the patient developed multiple organ failure, including acute renal failure. Aspergillus flavus, identified by MALDI-TOF (Fig. 2), and Acinetobacter baumanii (>106 CFU) were cultured from tracheal aspirate. Staphylococcus capitis was isolated from blood culture, and E. faecalis and Staphylococcus epidermidis were isolated from the central venous catheter tip culture. Candida lusitaniae was isolated from urine. The patient's antimicrobial regimen was updated to include vancomycin, meropenem, and colistin. Anidulafungin was added to control candidiasis, but azole therapy for the A. flavus finding was not started due to initial clinical suspicion of colonization versus infection. On day 26 a tracheostomy was placed as a result of prolonged ventilation, ARDS (PaO2/FiO2 ratio <200), and sepsis. Chest radiograph continued to show bilateral infiltrates (Fig. 3). Aspergillus galactomannan antigen (GM) was positive in serum (GM index: 1.4; Platelia Aspergillus; Bio-Rad, Marnes-La-Coquette, France) (Fig. 1).Fig. 2 Aspergillus flavus isolate: (A and B) Macroscopic: rapid growth olive green colonies, with woolly texture, on Sabouraud agar incubated at 28 °C (A) and 37 °C (B). (C) Microscopic: hyaline septate hyphae, radiate biseriate conidial head with finely roughened conidiophore. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.) Fig. 2 Fig. 3 Chest X-ray evidenced bilateral heterogeneous infiltrates on day 26 of hospitalization: picture from the COVID-19 associated pulmonary aspergillosis (CAPA) described on this report. Fig. 3 On day 28, laboratory testing showed increased white blood cells (16,930 cells/mm3; lymphocytes 45%), D-dimer (7.3 ng/mL), ferritin (3691 ng/mL) and C-reactive protein (31.8 mg/L). Blood and central venous catheter cultures were negative, and anidulafungin was replaced with voriconazole (400 mg first day, and then 300 mg daily) after the GM test returned positive. Colistin, vancomycin, and meropenem were continued. On day 30, hydroxychloroquine, ritonavir/lopinavir were suspended (following recommendation of AMOH), and on day 35, serum GM index decreased to 0.8. On day 44, the patient died in the ICU while on ventilatory support (Fig. 1). 3 Discussion COVID-19 associated pulmonary aspergillosis (CAPA) has been recently reported in European countries [[7], [8], [9], [10], [11], [12], [13]], including four case series covering 27 patients from France (n = 9), Belgium (n = 7), The Netherlands (n = 6), and Germany (n = 5) [[7], [8], [9], [10]]. Our case has similar clinical features compared with those previously reported. Among these four case series, all 27 patients were admitted to the ICU and developed ARDS. Most were male, >50 years old, and 25 (89%) of 27 had potential risk factors for severe COVID-19. Three (60%) of five patients from the German case series, seven (78%) of nine from the French case series, and three (43%) of seven patients from the Belgium case series had hypertension. All five patients from Germany had acute kidney injury, and three (33%) of nine patients from France and two (29%) of seven from Belgium received renal replacement therapy [[7], [8], [9], [10]]. Abnormal chest radiologic findings were reported in all of the patients from Germany (n = 5) and France (n = 9) [7,8]. Twelve (44%) of 27 patients received corticosteroids during their ICU stay, and 19 (70%) of 27 were treated with mold-active antifungal medication, eight (42%) of these 19 patients received corticosteroid simultaneous with antifungal treatment. Fifteen (55%) of the 27 case series patients died. Our patient received corticosteroids for 22 days before initial A. flavus culture and was treated with voriconazole starting 3 days after the initial fungal culture. Unlike influenza-associated pulmonary aspergillosis (IAPA), which commonly occurs early after ICU admission [4], our patient developed CAPA 25 days after ICU admission. COVID-19 associated pulmonary aspergillosis case series from Belgium and The Netherlands, showed variable time on development of were aspergillosis (range: 2–28 days) [9,10]. Making the diagnosis of IPA can be challenging, especially among patients not considered classically at greatest risk (e.g., hematologic malignancy and stem cell transplant patients). Among the four European CAPA case series discussed, Aspergillus species were cultured in 78% of respiratory specimens; positive specimens included: 14 bronchoalveolar lavage, six tracheal aspirate and one sputum [[7], [8], [9], [10]]. Bronchoscopy in COVID-19 patients is often not performed due to the risk of aerosol generation. Further complicating IPA diagnosis, serum GM testing is often negative among COVID-19 patients, and sensitivity is low among ICU patients in general; in the published cases series, of the 22 cases tested, only three (14%) had positive serum GM tests [14,15]. Most COVID-19 patients lack known risk factors for IPA [4]. Thus, isolation of Aspergillus from a non-sterile site and negative serum GM should not rule out invasive disease. Clinicians may want to consider mold-active azole therapy at first indication of aspergillosis in COVID-19 patients. Our patient had a high serum GM index (>1.0), which is the recommended cutoff, and mycological criteria for probable IPA classification by the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium [16]. Challenges in selecting a case definition for CAPA are also shared by the similar IAPA. For this reason, an expert panel recently proposed a new case definition for IAPA [17,18]. The definitions distinguish between invasive Aspergillus tracheobronchitis and other pulmonary manifestations and mainly rely on culture and GM to identify IPA. The expert panel stated that the IAPA case definition might also be useful to classify CAPA cases. Using this new definition, our case would be classified as probable CAPA [17]. A follow-up serum GM showed decreasing antigen titer which is consistent with antifungal treatment response. Little is known about the pathogenesis of CAPA, and there is a need to characterize risk factors for the development of IPA. Although influenza infection was found to be an independent risk factor for IPA [4], the use of corticosteroids in patients with influenza is also a risk factor for IAPA [19]. A recent preliminary report suggested that dexamethasone was associated with reduced mortality in COVID-19 patients [20]. However, corticosteroids might be associated with adverse effects such as delayed viral clearance and secondary infections. Notably, of the four proven IPA cases reported during the previous severe acute respiratory syndrome (SARS) epidemic, all were associated with concomitant corticosteroid therapy [5,21]. In our COVID-19 case with probable CAPA, we observed co-infections with bacterial and additional fungal pathogens (E. faecalis, A. baumanii, coagulase-negative staphylococci, and C. lusitaniae), which complicated patient treatment. Previous reports of CAPA cases did not describe the presence of other microbial co-infections [[7], [8], [9], [10], [11], [12], [13]], although these are commonly encountered in patients with influenza. Previous reports of ICU patients with severe influenza frequently reported secondary bacterial infection, and these were significantly associated with IAPA in studies comparing severe influenza patients with and without IAPA (61% vs 31%; p < 0.01) [22]. Co-infections were reported in up to 50% of patients with severe coronavirus infections causing both SARS and Middle East respiratory syndrome (MERS) [23]. However, early data suggest that coinfection frequency might be lower in COVID-19 [[23], [24], [25]]. We present a case of COVID-19 associated pulmonary aspergillosis from Argentina, with a clinical course and attributes similar to previously reported cases, that highlights the challenges in diagnosing and treating these CAPA patients. The use of a clinical algorithm to discriminate Aspergillus respiratory tract colonization from invasive pulmonary aspergillosis in critically ill patients is warranted, such as the one developed for IAPA [17,18]. This is the first report of ventilator-associated pneumonia involving A. flavus in a patient with COVID-19 and ARDS in the Americas. Awareness of CAPA and accessibility to appropriate diagnostic tests are necessary for accurate and timely identification of this co-infection [26,27]. Ethical considerations Publication of this case report was approved by the Hospital de Clínicas “José de San Martin” IRB. Declaration of competing interest All authors no reported conflicts of interest. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC. Acknowledgements Claudia Barberis, Marisa Almuzara, and the staff of the infectious disease division and the intensive care unit, at Hospital de Clínicas “José de San Martin”. Universidad de Buenos Aires. Diego H. Caceres acknowledges Oak Ridge Institute for Science and Education (ORISE).	Fatal	ReactionOutcome	CC BY	32837881	19,154,617	2021-03
What was the outcome of reaction 'SARS-CoV-2 test positive'?	Ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Coronavirus disease 2019 (COVID-19), caused by the novel coronavirus SARS-CoV-2, emerged in Wuhan, China, in December 2019 and rapidly spread around the world. Invasive aspergillosis has been reported as a complication of severe influenza pneumonia among intensive care patients. Similarities between COVID-19 and influenza pneumonia, together with limited published case series, suggest that aspergillosis may be an important complication of COVID-19. This report describes a case of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 from Buenos Aires, Argentina. 1 Introduction SARS-CoV-2 is the novel coronavirus that causes coronavirus disease 2019 (COVID‐19), which was first reported in December 2019 in Wuhan, China, and has rapidly spread worldwide [1]. On March 11th, 2020, the World Health Organization (WHO) declared a pandemic, and by June 30th, 2020, a total of 10,185,374 cases and 503,862 deaths were reported in 216 locations around the world [2]. In Argentina, on June 30th, 2020, the Argentinean Ministry of Health (AMOH) reported 62,268 cases and 1283 deaths [3]. Invasive pulmonary aspergillosis (IPA) is a known complication in patients with severe influenza pneumonia. Case series from the Netherlands and Belgium reported an incidence of 19% in patients with influenza pneumonia and acute respiratory distress syndrome (ARDS) hospitalized in the intensive care unit (ICU) [4], although these high incidences have not been confirmed in other studies [4]. There is concern that critically ill COVID-19 patients might also be at increased risk of pulmonary aspergillosis co-infection [5]. Here we describe a report of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 and ARDS in Argentina. 2 Case presentation In late April 2020, an 85-year-old man with a history of hypertension was admitted to the ICU with a history of six days of fever and dyspnea, at home. The patient had close household contact with two COVID-19 cases, and nasopharyngeal (NP) swab samples collected on the day of ICU admission tested positive for SARS-CoV-2 using molecular testing. On ICU admission (day 1) the patient presented with bilateral infiltrates (ground-glass opacities) on chest radiograph, respiratory rate of 40 breaths per minute, heart rate of 82 beats per minute, and a blood pressure 150/85 mm Hg. Laboratory tests showed a white blood cell count of 11,600 cells/mm3, with lymphopenia, normal serum creatinine (1.02 mg/dL), low albumin (2.8 g/dL), and normal lactate (1.4 mmol/L), as well as elevated ferritin (1840 ng/mL), D-dimer (17.1 ng/mL), procalcitonin (2.89 ng/mL), and fibrinogen (702 mg/dl). The patient also presented with deep vein thrombosis in the right subclavian vein and in the right internal jugular vein; anticoagulation was initiated with heparin due to the hypercoagulable state. Empirical treatment for pneumonia was started with oseltamivir, ceftriaxone, and azithromycin, and hydroxychloroquine, ritonavir/lopinavir were started for COVID-19, according to the Argentinean Ministry of Health (AMOH) national guidelines [6]. After 3 days of hospitalization, the patient required ventilator support (orotracheal intubation and mechanical ventilation) and was given a corticosteroid (dexamethasone, 20 mg/day). Influenza antigen testing yielded a negative result, prompting cessation of empirical influenza treatment (Fig. 1).Fig. 1 Case timeline: ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Fig. 1 On day 10 of hospitalization, the patient developed a new fever (38 °C). Urinary culture and pneumococcal urine antigen test were negative; tracheal aspirate and blood culture were positive for Enterococcus faecalis, and imipenem and vancomycin were added to hydroxychloroquine and ritonavir/lopinavir. Two days later polymyxin was added, and blood cultures turned negative after seven days of treatment. On day 17, urinary analysis showed evidence of acute tubular necrosis with metabolic acidosis (low pH, PaCO2 and HCO3), and treatment was subsequently changed to meropenem and colistin. On day 19, tracheal aspirate, urine and blood culture remained negative for bacteria, and a second SARS-CoV-2 PCR test from a NP swab was positive. On day 23, the patient was again febrile, and urinary, tracheal aspirate, blood and catheter tip cultures were repeated; a third SARS-CoV-2 PCR test on day 24 from a NP swab was positive (Fig. 1). On day 25 the patient developed multiple organ failure, including acute renal failure. Aspergillus flavus, identified by MALDI-TOF (Fig. 2), and Acinetobacter baumanii (>106 CFU) were cultured from tracheal aspirate. Staphylococcus capitis was isolated from blood culture, and E. faecalis and Staphylococcus epidermidis were isolated from the central venous catheter tip culture. Candida lusitaniae was isolated from urine. The patient's antimicrobial regimen was updated to include vancomycin, meropenem, and colistin. Anidulafungin was added to control candidiasis, but azole therapy for the A. flavus finding was not started due to initial clinical suspicion of colonization versus infection. On day 26 a tracheostomy was placed as a result of prolonged ventilation, ARDS (PaO2/FiO2 ratio <200), and sepsis. Chest radiograph continued to show bilateral infiltrates (Fig. 3). Aspergillus galactomannan antigen (GM) was positive in serum (GM index: 1.4; Platelia Aspergillus; Bio-Rad, Marnes-La-Coquette, France) (Fig. 1).Fig. 2 Aspergillus flavus isolate: (A and B) Macroscopic: rapid growth olive green colonies, with woolly texture, on Sabouraud agar incubated at 28 °C (A) and 37 °C (B). (C) Microscopic: hyaline septate hyphae, radiate biseriate conidial head with finely roughened conidiophore. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.) Fig. 2 Fig. 3 Chest X-ray evidenced bilateral heterogeneous infiltrates on day 26 of hospitalization: picture from the COVID-19 associated pulmonary aspergillosis (CAPA) described on this report. Fig. 3 On day 28, laboratory testing showed increased white blood cells (16,930 cells/mm3; lymphocytes 45%), D-dimer (7.3 ng/mL), ferritin (3691 ng/mL) and C-reactive protein (31.8 mg/L). Blood and central venous catheter cultures were negative, and anidulafungin was replaced with voriconazole (400 mg first day, and then 300 mg daily) after the GM test returned positive. Colistin, vancomycin, and meropenem were continued. On day 30, hydroxychloroquine, ritonavir/lopinavir were suspended (following recommendation of AMOH), and on day 35, serum GM index decreased to 0.8. On day 44, the patient died in the ICU while on ventilatory support (Fig. 1). 3 Discussion COVID-19 associated pulmonary aspergillosis (CAPA) has been recently reported in European countries [[7], [8], [9], [10], [11], [12], [13]], including four case series covering 27 patients from France (n = 9), Belgium (n = 7), The Netherlands (n = 6), and Germany (n = 5) [[7], [8], [9], [10]]. Our case has similar clinical features compared with those previously reported. Among these four case series, all 27 patients were admitted to the ICU and developed ARDS. Most were male, >50 years old, and 25 (89%) of 27 had potential risk factors for severe COVID-19. Three (60%) of five patients from the German case series, seven (78%) of nine from the French case series, and three (43%) of seven patients from the Belgium case series had hypertension. All five patients from Germany had acute kidney injury, and three (33%) of nine patients from France and two (29%) of seven from Belgium received renal replacement therapy [[7], [8], [9], [10]]. Abnormal chest radiologic findings were reported in all of the patients from Germany (n = 5) and France (n = 9) [7,8]. Twelve (44%) of 27 patients received corticosteroids during their ICU stay, and 19 (70%) of 27 were treated with mold-active antifungal medication, eight (42%) of these 19 patients received corticosteroid simultaneous with antifungal treatment. Fifteen (55%) of the 27 case series patients died. Our patient received corticosteroids for 22 days before initial A. flavus culture and was treated with voriconazole starting 3 days after the initial fungal culture. Unlike influenza-associated pulmonary aspergillosis (IAPA), which commonly occurs early after ICU admission [4], our patient developed CAPA 25 days after ICU admission. COVID-19 associated pulmonary aspergillosis case series from Belgium and The Netherlands, showed variable time on development of were aspergillosis (range: 2–28 days) [9,10]. Making the diagnosis of IPA can be challenging, especially among patients not considered classically at greatest risk (e.g., hematologic malignancy and stem cell transplant patients). Among the four European CAPA case series discussed, Aspergillus species were cultured in 78% of respiratory specimens; positive specimens included: 14 bronchoalveolar lavage, six tracheal aspirate and one sputum [[7], [8], [9], [10]]. Bronchoscopy in COVID-19 patients is often not performed due to the risk of aerosol generation. Further complicating IPA diagnosis, serum GM testing is often negative among COVID-19 patients, and sensitivity is low among ICU patients in general; in the published cases series, of the 22 cases tested, only three (14%) had positive serum GM tests [14,15]. Most COVID-19 patients lack known risk factors for IPA [4]. Thus, isolation of Aspergillus from a non-sterile site and negative serum GM should not rule out invasive disease. Clinicians may want to consider mold-active azole therapy at first indication of aspergillosis in COVID-19 patients. Our patient had a high serum GM index (>1.0), which is the recommended cutoff, and mycological criteria for probable IPA classification by the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium [16]. Challenges in selecting a case definition for CAPA are also shared by the similar IAPA. For this reason, an expert panel recently proposed a new case definition for IAPA [17,18]. The definitions distinguish between invasive Aspergillus tracheobronchitis and other pulmonary manifestations and mainly rely on culture and GM to identify IPA. The expert panel stated that the IAPA case definition might also be useful to classify CAPA cases. Using this new definition, our case would be classified as probable CAPA [17]. A follow-up serum GM showed decreasing antigen titer which is consistent with antifungal treatment response. Little is known about the pathogenesis of CAPA, and there is a need to characterize risk factors for the development of IPA. Although influenza infection was found to be an independent risk factor for IPA [4], the use of corticosteroids in patients with influenza is also a risk factor for IAPA [19]. A recent preliminary report suggested that dexamethasone was associated with reduced mortality in COVID-19 patients [20]. However, corticosteroids might be associated with adverse effects such as delayed viral clearance and secondary infections. Notably, of the four proven IPA cases reported during the previous severe acute respiratory syndrome (SARS) epidemic, all were associated with concomitant corticosteroid therapy [5,21]. In our COVID-19 case with probable CAPA, we observed co-infections with bacterial and additional fungal pathogens (E. faecalis, A. baumanii, coagulase-negative staphylococci, and C. lusitaniae), which complicated patient treatment. Previous reports of CAPA cases did not describe the presence of other microbial co-infections [[7], [8], [9], [10], [11], [12], [13]], although these are commonly encountered in patients with influenza. Previous reports of ICU patients with severe influenza frequently reported secondary bacterial infection, and these were significantly associated with IAPA in studies comparing severe influenza patients with and without IAPA (61% vs 31%; p < 0.01) [22]. Co-infections were reported in up to 50% of patients with severe coronavirus infections causing both SARS and Middle East respiratory syndrome (MERS) [23]. However, early data suggest that coinfection frequency might be lower in COVID-19 [[23], [24], [25]]. We present a case of COVID-19 associated pulmonary aspergillosis from Argentina, with a clinical course and attributes similar to previously reported cases, that highlights the challenges in diagnosing and treating these CAPA patients. The use of a clinical algorithm to discriminate Aspergillus respiratory tract colonization from invasive pulmonary aspergillosis in critically ill patients is warranted, such as the one developed for IAPA [17,18]. This is the first report of ventilator-associated pneumonia involving A. flavus in a patient with COVID-19 and ARDS in the Americas. Awareness of CAPA and accessibility to appropriate diagnostic tests are necessary for accurate and timely identification of this co-infection [26,27]. Ethical considerations Publication of this case report was approved by the Hospital de Clínicas “José de San Martin” IRB. Declaration of competing interest All authors no reported conflicts of interest. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC. Acknowledgements Claudia Barberis, Marisa Almuzara, and the staff of the infectious disease division and the intensive care unit, at Hospital de Clínicas “José de San Martin”. Universidad de Buenos Aires. Diego H. Caceres acknowledges Oak Ridge Institute for Science and Education (ORISE).	Fatal	ReactionOutcome	CC BY	32837881	19,203,398	2021-03
What was the outcome of reaction 'Sepsis'?	Ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Coronavirus disease 2019 (COVID-19), caused by the novel coronavirus SARS-CoV-2, emerged in Wuhan, China, in December 2019 and rapidly spread around the world. Invasive aspergillosis has been reported as a complication of severe influenza pneumonia among intensive care patients. Similarities between COVID-19 and influenza pneumonia, together with limited published case series, suggest that aspergillosis may be an important complication of COVID-19. This report describes a case of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 from Buenos Aires, Argentina. 1 Introduction SARS-CoV-2 is the novel coronavirus that causes coronavirus disease 2019 (COVID‐19), which was first reported in December 2019 in Wuhan, China, and has rapidly spread worldwide [1]. On March 11th, 2020, the World Health Organization (WHO) declared a pandemic, and by June 30th, 2020, a total of 10,185,374 cases and 503,862 deaths were reported in 216 locations around the world [2]. In Argentina, on June 30th, 2020, the Argentinean Ministry of Health (AMOH) reported 62,268 cases and 1283 deaths [3]. Invasive pulmonary aspergillosis (IPA) is a known complication in patients with severe influenza pneumonia. Case series from the Netherlands and Belgium reported an incidence of 19% in patients with influenza pneumonia and acute respiratory distress syndrome (ARDS) hospitalized in the intensive care unit (ICU) [4], although these high incidences have not been confirmed in other studies [4]. There is concern that critically ill COVID-19 patients might also be at increased risk of pulmonary aspergillosis co-infection [5]. Here we describe a report of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 and ARDS in Argentina. 2 Case presentation In late April 2020, an 85-year-old man with a history of hypertension was admitted to the ICU with a history of six days of fever and dyspnea, at home. The patient had close household contact with two COVID-19 cases, and nasopharyngeal (NP) swab samples collected on the day of ICU admission tested positive for SARS-CoV-2 using molecular testing. On ICU admission (day 1) the patient presented with bilateral infiltrates (ground-glass opacities) on chest radiograph, respiratory rate of 40 breaths per minute, heart rate of 82 beats per minute, and a blood pressure 150/85 mm Hg. Laboratory tests showed a white blood cell count of 11,600 cells/mm3, with lymphopenia, normal serum creatinine (1.02 mg/dL), low albumin (2.8 g/dL), and normal lactate (1.4 mmol/L), as well as elevated ferritin (1840 ng/mL), D-dimer (17.1 ng/mL), procalcitonin (2.89 ng/mL), and fibrinogen (702 mg/dl). The patient also presented with deep vein thrombosis in the right subclavian vein and in the right internal jugular vein; anticoagulation was initiated with heparin due to the hypercoagulable state. Empirical treatment for pneumonia was started with oseltamivir, ceftriaxone, and azithromycin, and hydroxychloroquine, ritonavir/lopinavir were started for COVID-19, according to the Argentinean Ministry of Health (AMOH) national guidelines [6]. After 3 days of hospitalization, the patient required ventilator support (orotracheal intubation and mechanical ventilation) and was given a corticosteroid (dexamethasone, 20 mg/day). Influenza antigen testing yielded a negative result, prompting cessation of empirical influenza treatment (Fig. 1).Fig. 1 Case timeline: ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Fig. 1 On day 10 of hospitalization, the patient developed a new fever (38 °C). Urinary culture and pneumococcal urine antigen test were negative; tracheal aspirate and blood culture were positive for Enterococcus faecalis, and imipenem and vancomycin were added to hydroxychloroquine and ritonavir/lopinavir. Two days later polymyxin was added, and blood cultures turned negative after seven days of treatment. On day 17, urinary analysis showed evidence of acute tubular necrosis with metabolic acidosis (low pH, PaCO2 and HCO3), and treatment was subsequently changed to meropenem and colistin. On day 19, tracheal aspirate, urine and blood culture remained negative for bacteria, and a second SARS-CoV-2 PCR test from a NP swab was positive. On day 23, the patient was again febrile, and urinary, tracheal aspirate, blood and catheter tip cultures were repeated; a third SARS-CoV-2 PCR test on day 24 from a NP swab was positive (Fig. 1). On day 25 the patient developed multiple organ failure, including acute renal failure. Aspergillus flavus, identified by MALDI-TOF (Fig. 2), and Acinetobacter baumanii (>106 CFU) were cultured from tracheal aspirate. Staphylococcus capitis was isolated from blood culture, and E. faecalis and Staphylococcus epidermidis were isolated from the central venous catheter tip culture. Candida lusitaniae was isolated from urine. The patient's antimicrobial regimen was updated to include vancomycin, meropenem, and colistin. Anidulafungin was added to control candidiasis, but azole therapy for the A. flavus finding was not started due to initial clinical suspicion of colonization versus infection. On day 26 a tracheostomy was placed as a result of prolonged ventilation, ARDS (PaO2/FiO2 ratio <200), and sepsis. Chest radiograph continued to show bilateral infiltrates (Fig. 3). Aspergillus galactomannan antigen (GM) was positive in serum (GM index: 1.4; Platelia Aspergillus; Bio-Rad, Marnes-La-Coquette, France) (Fig. 1).Fig. 2 Aspergillus flavus isolate: (A and B) Macroscopic: rapid growth olive green colonies, with woolly texture, on Sabouraud agar incubated at 28 °C (A) and 37 °C (B). (C) Microscopic: hyaline septate hyphae, radiate biseriate conidial head with finely roughened conidiophore. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.) Fig. 2 Fig. 3 Chest X-ray evidenced bilateral heterogeneous infiltrates on day 26 of hospitalization: picture from the COVID-19 associated pulmonary aspergillosis (CAPA) described on this report. Fig. 3 On day 28, laboratory testing showed increased white blood cells (16,930 cells/mm3; lymphocytes 45%), D-dimer (7.3 ng/mL), ferritin (3691 ng/mL) and C-reactive protein (31.8 mg/L). Blood and central venous catheter cultures were negative, and anidulafungin was replaced with voriconazole (400 mg first day, and then 300 mg daily) after the GM test returned positive. Colistin, vancomycin, and meropenem were continued. On day 30, hydroxychloroquine, ritonavir/lopinavir were suspended (following recommendation of AMOH), and on day 35, serum GM index decreased to 0.8. On day 44, the patient died in the ICU while on ventilatory support (Fig. 1). 3 Discussion COVID-19 associated pulmonary aspergillosis (CAPA) has been recently reported in European countries [[7], [8], [9], [10], [11], [12], [13]], including four case series covering 27 patients from France (n = 9), Belgium (n = 7), The Netherlands (n = 6), and Germany (n = 5) [[7], [8], [9], [10]]. Our case has similar clinical features compared with those previously reported. Among these four case series, all 27 patients were admitted to the ICU and developed ARDS. Most were male, >50 years old, and 25 (89%) of 27 had potential risk factors for severe COVID-19. Three (60%) of five patients from the German case series, seven (78%) of nine from the French case series, and three (43%) of seven patients from the Belgium case series had hypertension. All five patients from Germany had acute kidney injury, and three (33%) of nine patients from France and two (29%) of seven from Belgium received renal replacement therapy [[7], [8], [9], [10]]. Abnormal chest radiologic findings were reported in all of the patients from Germany (n = 5) and France (n = 9) [7,8]. Twelve (44%) of 27 patients received corticosteroids during their ICU stay, and 19 (70%) of 27 were treated with mold-active antifungal medication, eight (42%) of these 19 patients received corticosteroid simultaneous with antifungal treatment. Fifteen (55%) of the 27 case series patients died. Our patient received corticosteroids for 22 days before initial A. flavus culture and was treated with voriconazole starting 3 days after the initial fungal culture. Unlike influenza-associated pulmonary aspergillosis (IAPA), which commonly occurs early after ICU admission [4], our patient developed CAPA 25 days after ICU admission. COVID-19 associated pulmonary aspergillosis case series from Belgium and The Netherlands, showed variable time on development of were aspergillosis (range: 2–28 days) [9,10]. Making the diagnosis of IPA can be challenging, especially among patients not considered classically at greatest risk (e.g., hematologic malignancy and stem cell transplant patients). Among the four European CAPA case series discussed, Aspergillus species were cultured in 78% of respiratory specimens; positive specimens included: 14 bronchoalveolar lavage, six tracheal aspirate and one sputum [[7], [8], [9], [10]]. Bronchoscopy in COVID-19 patients is often not performed due to the risk of aerosol generation. Further complicating IPA diagnosis, serum GM testing is often negative among COVID-19 patients, and sensitivity is low among ICU patients in general; in the published cases series, of the 22 cases tested, only three (14%) had positive serum GM tests [14,15]. Most COVID-19 patients lack known risk factors for IPA [4]. Thus, isolation of Aspergillus from a non-sterile site and negative serum GM should not rule out invasive disease. Clinicians may want to consider mold-active azole therapy at first indication of aspergillosis in COVID-19 patients. Our patient had a high serum GM index (>1.0), which is the recommended cutoff, and mycological criteria for probable IPA classification by the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium [16]. Challenges in selecting a case definition for CAPA are also shared by the similar IAPA. For this reason, an expert panel recently proposed a new case definition for IAPA [17,18]. The definitions distinguish between invasive Aspergillus tracheobronchitis and other pulmonary manifestations and mainly rely on culture and GM to identify IPA. The expert panel stated that the IAPA case definition might also be useful to classify CAPA cases. Using this new definition, our case would be classified as probable CAPA [17]. A follow-up serum GM showed decreasing antigen titer which is consistent with antifungal treatment response. Little is known about the pathogenesis of CAPA, and there is a need to characterize risk factors for the development of IPA. Although influenza infection was found to be an independent risk factor for IPA [4], the use of corticosteroids in patients with influenza is also a risk factor for IAPA [19]. A recent preliminary report suggested that dexamethasone was associated with reduced mortality in COVID-19 patients [20]. However, corticosteroids might be associated with adverse effects such as delayed viral clearance and secondary infections. Notably, of the four proven IPA cases reported during the previous severe acute respiratory syndrome (SARS) epidemic, all were associated with concomitant corticosteroid therapy [5,21]. In our COVID-19 case with probable CAPA, we observed co-infections with bacterial and additional fungal pathogens (E. faecalis, A. baumanii, coagulase-negative staphylococci, and C. lusitaniae), which complicated patient treatment. Previous reports of CAPA cases did not describe the presence of other microbial co-infections [[7], [8], [9], [10], [11], [12], [13]], although these are commonly encountered in patients with influenza. Previous reports of ICU patients with severe influenza frequently reported secondary bacterial infection, and these were significantly associated with IAPA in studies comparing severe influenza patients with and without IAPA (61% vs 31%; p < 0.01) [22]. Co-infections were reported in up to 50% of patients with severe coronavirus infections causing both SARS and Middle East respiratory syndrome (MERS) [23]. However, early data suggest that coinfection frequency might be lower in COVID-19 [[23], [24], [25]]. We present a case of COVID-19 associated pulmonary aspergillosis from Argentina, with a clinical course and attributes similar to previously reported cases, that highlights the challenges in diagnosing and treating these CAPA patients. The use of a clinical algorithm to discriminate Aspergillus respiratory tract colonization from invasive pulmonary aspergillosis in critically ill patients is warranted, such as the one developed for IAPA [17,18]. This is the first report of ventilator-associated pneumonia involving A. flavus in a patient with COVID-19 and ARDS in the Americas. Awareness of CAPA and accessibility to appropriate diagnostic tests are necessary for accurate and timely identification of this co-infection [26,27]. Ethical considerations Publication of this case report was approved by the Hospital de Clínicas “José de San Martin” IRB. Declaration of competing interest All authors no reported conflicts of interest. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC. Acknowledgements Claudia Barberis, Marisa Almuzara, and the staff of the infectious disease division and the intensive care unit, at Hospital de Clínicas “José de San Martin”. Universidad de Buenos Aires. Diego H. Caceres acknowledges Oak Ridge Institute for Science and Education (ORISE).	Fatal	ReactionOutcome	CC BY	32837881	19,203,398	2021-03
What was the outcome of reaction 'Staphylococcal infection'?	Ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Coronavirus disease 2019 (COVID-19), caused by the novel coronavirus SARS-CoV-2, emerged in Wuhan, China, in December 2019 and rapidly spread around the world. Invasive aspergillosis has been reported as a complication of severe influenza pneumonia among intensive care patients. Similarities between COVID-19 and influenza pneumonia, together with limited published case series, suggest that aspergillosis may be an important complication of COVID-19. This report describes a case of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 from Buenos Aires, Argentina. 1 Introduction SARS-CoV-2 is the novel coronavirus that causes coronavirus disease 2019 (COVID‐19), which was first reported in December 2019 in Wuhan, China, and has rapidly spread worldwide [1]. On March 11th, 2020, the World Health Organization (WHO) declared a pandemic, and by June 30th, 2020, a total of 10,185,374 cases and 503,862 deaths were reported in 216 locations around the world [2]. In Argentina, on June 30th, 2020, the Argentinean Ministry of Health (AMOH) reported 62,268 cases and 1283 deaths [3]. Invasive pulmonary aspergillosis (IPA) is a known complication in patients with severe influenza pneumonia. Case series from the Netherlands and Belgium reported an incidence of 19% in patients with influenza pneumonia and acute respiratory distress syndrome (ARDS) hospitalized in the intensive care unit (ICU) [4], although these high incidences have not been confirmed in other studies [4]. There is concern that critically ill COVID-19 patients might also be at increased risk of pulmonary aspergillosis co-infection [5]. Here we describe a report of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 and ARDS in Argentina. 2 Case presentation In late April 2020, an 85-year-old man with a history of hypertension was admitted to the ICU with a history of six days of fever and dyspnea, at home. The patient had close household contact with two COVID-19 cases, and nasopharyngeal (NP) swab samples collected on the day of ICU admission tested positive for SARS-CoV-2 using molecular testing. On ICU admission (day 1) the patient presented with bilateral infiltrates (ground-glass opacities) on chest radiograph, respiratory rate of 40 breaths per minute, heart rate of 82 beats per minute, and a blood pressure 150/85 mm Hg. Laboratory tests showed a white blood cell count of 11,600 cells/mm3, with lymphopenia, normal serum creatinine (1.02 mg/dL), low albumin (2.8 g/dL), and normal lactate (1.4 mmol/L), as well as elevated ferritin (1840 ng/mL), D-dimer (17.1 ng/mL), procalcitonin (2.89 ng/mL), and fibrinogen (702 mg/dl). The patient also presented with deep vein thrombosis in the right subclavian vein and in the right internal jugular vein; anticoagulation was initiated with heparin due to the hypercoagulable state. Empirical treatment for pneumonia was started with oseltamivir, ceftriaxone, and azithromycin, and hydroxychloroquine, ritonavir/lopinavir were started for COVID-19, according to the Argentinean Ministry of Health (AMOH) national guidelines [6]. After 3 days of hospitalization, the patient required ventilator support (orotracheal intubation and mechanical ventilation) and was given a corticosteroid (dexamethasone, 20 mg/day). Influenza antigen testing yielded a negative result, prompting cessation of empirical influenza treatment (Fig. 1).Fig. 1 Case timeline: ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Fig. 1 On day 10 of hospitalization, the patient developed a new fever (38 °C). Urinary culture and pneumococcal urine antigen test were negative; tracheal aspirate and blood culture were positive for Enterococcus faecalis, and imipenem and vancomycin were added to hydroxychloroquine and ritonavir/lopinavir. Two days later polymyxin was added, and blood cultures turned negative after seven days of treatment. On day 17, urinary analysis showed evidence of acute tubular necrosis with metabolic acidosis (low pH, PaCO2 and HCO3), and treatment was subsequently changed to meropenem and colistin. On day 19, tracheal aspirate, urine and blood culture remained negative for bacteria, and a second SARS-CoV-2 PCR test from a NP swab was positive. On day 23, the patient was again febrile, and urinary, tracheal aspirate, blood and catheter tip cultures were repeated; a third SARS-CoV-2 PCR test on day 24 from a NP swab was positive (Fig. 1). On day 25 the patient developed multiple organ failure, including acute renal failure. Aspergillus flavus, identified by MALDI-TOF (Fig. 2), and Acinetobacter baumanii (>106 CFU) were cultured from tracheal aspirate. Staphylococcus capitis was isolated from blood culture, and E. faecalis and Staphylococcus epidermidis were isolated from the central venous catheter tip culture. Candida lusitaniae was isolated from urine. The patient's antimicrobial regimen was updated to include vancomycin, meropenem, and colistin. Anidulafungin was added to control candidiasis, but azole therapy for the A. flavus finding was not started due to initial clinical suspicion of colonization versus infection. On day 26 a tracheostomy was placed as a result of prolonged ventilation, ARDS (PaO2/FiO2 ratio <200), and sepsis. Chest radiograph continued to show bilateral infiltrates (Fig. 3). Aspergillus galactomannan antigen (GM) was positive in serum (GM index: 1.4; Platelia Aspergillus; Bio-Rad, Marnes-La-Coquette, France) (Fig. 1).Fig. 2 Aspergillus flavus isolate: (A and B) Macroscopic: rapid growth olive green colonies, with woolly texture, on Sabouraud agar incubated at 28 °C (A) and 37 °C (B). (C) Microscopic: hyaline septate hyphae, radiate biseriate conidial head with finely roughened conidiophore. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.) Fig. 2 Fig. 3 Chest X-ray evidenced bilateral heterogeneous infiltrates on day 26 of hospitalization: picture from the COVID-19 associated pulmonary aspergillosis (CAPA) described on this report. Fig. 3 On day 28, laboratory testing showed increased white blood cells (16,930 cells/mm3; lymphocytes 45%), D-dimer (7.3 ng/mL), ferritin (3691 ng/mL) and C-reactive protein (31.8 mg/L). Blood and central venous catheter cultures were negative, and anidulafungin was replaced with voriconazole (400 mg first day, and then 300 mg daily) after the GM test returned positive. Colistin, vancomycin, and meropenem were continued. On day 30, hydroxychloroquine, ritonavir/lopinavir were suspended (following recommendation of AMOH), and on day 35, serum GM index decreased to 0.8. On day 44, the patient died in the ICU while on ventilatory support (Fig. 1). 3 Discussion COVID-19 associated pulmonary aspergillosis (CAPA) has been recently reported in European countries [[7], [8], [9], [10], [11], [12], [13]], including four case series covering 27 patients from France (n = 9), Belgium (n = 7), The Netherlands (n = 6), and Germany (n = 5) [[7], [8], [9], [10]]. Our case has similar clinical features compared with those previously reported. Among these four case series, all 27 patients were admitted to the ICU and developed ARDS. Most were male, >50 years old, and 25 (89%) of 27 had potential risk factors for severe COVID-19. Three (60%) of five patients from the German case series, seven (78%) of nine from the French case series, and three (43%) of seven patients from the Belgium case series had hypertension. All five patients from Germany had acute kidney injury, and three (33%) of nine patients from France and two (29%) of seven from Belgium received renal replacement therapy [[7], [8], [9], [10]]. Abnormal chest radiologic findings were reported in all of the patients from Germany (n = 5) and France (n = 9) [7,8]. Twelve (44%) of 27 patients received corticosteroids during their ICU stay, and 19 (70%) of 27 were treated with mold-active antifungal medication, eight (42%) of these 19 patients received corticosteroid simultaneous with antifungal treatment. Fifteen (55%) of the 27 case series patients died. Our patient received corticosteroids for 22 days before initial A. flavus culture and was treated with voriconazole starting 3 days after the initial fungal culture. Unlike influenza-associated pulmonary aspergillosis (IAPA), which commonly occurs early after ICU admission [4], our patient developed CAPA 25 days after ICU admission. COVID-19 associated pulmonary aspergillosis case series from Belgium and The Netherlands, showed variable time on development of were aspergillosis (range: 2–28 days) [9,10]. Making the diagnosis of IPA can be challenging, especially among patients not considered classically at greatest risk (e.g., hematologic malignancy and stem cell transplant patients). Among the four European CAPA case series discussed, Aspergillus species were cultured in 78% of respiratory specimens; positive specimens included: 14 bronchoalveolar lavage, six tracheal aspirate and one sputum [[7], [8], [9], [10]]. Bronchoscopy in COVID-19 patients is often not performed due to the risk of aerosol generation. Further complicating IPA diagnosis, serum GM testing is often negative among COVID-19 patients, and sensitivity is low among ICU patients in general; in the published cases series, of the 22 cases tested, only three (14%) had positive serum GM tests [14,15]. Most COVID-19 patients lack known risk factors for IPA [4]. Thus, isolation of Aspergillus from a non-sterile site and negative serum GM should not rule out invasive disease. Clinicians may want to consider mold-active azole therapy at first indication of aspergillosis in COVID-19 patients. Our patient had a high serum GM index (>1.0), which is the recommended cutoff, and mycological criteria for probable IPA classification by the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium [16]. Challenges in selecting a case definition for CAPA are also shared by the similar IAPA. For this reason, an expert panel recently proposed a new case definition for IAPA [17,18]. The definitions distinguish between invasive Aspergillus tracheobronchitis and other pulmonary manifestations and mainly rely on culture and GM to identify IPA. The expert panel stated that the IAPA case definition might also be useful to classify CAPA cases. Using this new definition, our case would be classified as probable CAPA [17]. A follow-up serum GM showed decreasing antigen titer which is consistent with antifungal treatment response. Little is known about the pathogenesis of CAPA, and there is a need to characterize risk factors for the development of IPA. Although influenza infection was found to be an independent risk factor for IPA [4], the use of corticosteroids in patients with influenza is also a risk factor for IAPA [19]. A recent preliminary report suggested that dexamethasone was associated with reduced mortality in COVID-19 patients [20]. However, corticosteroids might be associated with adverse effects such as delayed viral clearance and secondary infections. Notably, of the four proven IPA cases reported during the previous severe acute respiratory syndrome (SARS) epidemic, all were associated with concomitant corticosteroid therapy [5,21]. In our COVID-19 case with probable CAPA, we observed co-infections with bacterial and additional fungal pathogens (E. faecalis, A. baumanii, coagulase-negative staphylococci, and C. lusitaniae), which complicated patient treatment. Previous reports of CAPA cases did not describe the presence of other microbial co-infections [[7], [8], [9], [10], [11], [12], [13]], although these are commonly encountered in patients with influenza. Previous reports of ICU patients with severe influenza frequently reported secondary bacterial infection, and these were significantly associated with IAPA in studies comparing severe influenza patients with and without IAPA (61% vs 31%; p < 0.01) [22]. Co-infections were reported in up to 50% of patients with severe coronavirus infections causing both SARS and Middle East respiratory syndrome (MERS) [23]. However, early data suggest that coinfection frequency might be lower in COVID-19 [[23], [24], [25]]. We present a case of COVID-19 associated pulmonary aspergillosis from Argentina, with a clinical course and attributes similar to previously reported cases, that highlights the challenges in diagnosing and treating these CAPA patients. The use of a clinical algorithm to discriminate Aspergillus respiratory tract colonization from invasive pulmonary aspergillosis in critically ill patients is warranted, such as the one developed for IAPA [17,18]. This is the first report of ventilator-associated pneumonia involving A. flavus in a patient with COVID-19 and ARDS in the Americas. Awareness of CAPA and accessibility to appropriate diagnostic tests are necessary for accurate and timely identification of this co-infection [26,27]. Ethical considerations Publication of this case report was approved by the Hospital de Clínicas “José de San Martin” IRB. Declaration of competing interest All authors no reported conflicts of interest. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC. Acknowledgements Claudia Barberis, Marisa Almuzara, and the staff of the infectious disease division and the intensive care unit, at Hospital de Clínicas “José de San Martin”. Universidad de Buenos Aires. Diego H. Caceres acknowledges Oak Ridge Institute for Science and Education (ORISE).	Recovered	ReactionOutcome	CC BY	32837881	19,154,617	2021-03
What was the outcome of reaction 'Vascular device infection'?	Ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Coronavirus disease 2019 (COVID-19), caused by the novel coronavirus SARS-CoV-2, emerged in Wuhan, China, in December 2019 and rapidly spread around the world. Invasive aspergillosis has been reported as a complication of severe influenza pneumonia among intensive care patients. Similarities between COVID-19 and influenza pneumonia, together with limited published case series, suggest that aspergillosis may be an important complication of COVID-19. This report describes a case of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 from Buenos Aires, Argentina. 1 Introduction SARS-CoV-2 is the novel coronavirus that causes coronavirus disease 2019 (COVID‐19), which was first reported in December 2019 in Wuhan, China, and has rapidly spread worldwide [1]. On March 11th, 2020, the World Health Organization (WHO) declared a pandemic, and by June 30th, 2020, a total of 10,185,374 cases and 503,862 deaths were reported in 216 locations around the world [2]. In Argentina, on June 30th, 2020, the Argentinean Ministry of Health (AMOH) reported 62,268 cases and 1283 deaths [3]. Invasive pulmonary aspergillosis (IPA) is a known complication in patients with severe influenza pneumonia. Case series from the Netherlands and Belgium reported an incidence of 19% in patients with influenza pneumonia and acute respiratory distress syndrome (ARDS) hospitalized in the intensive care unit (ICU) [4], although these high incidences have not been confirmed in other studies [4]. There is concern that critically ill COVID-19 patients might also be at increased risk of pulmonary aspergillosis co-infection [5]. Here we describe a report of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 and ARDS in Argentina. 2 Case presentation In late April 2020, an 85-year-old man with a history of hypertension was admitted to the ICU with a history of six days of fever and dyspnea, at home. The patient had close household contact with two COVID-19 cases, and nasopharyngeal (NP) swab samples collected on the day of ICU admission tested positive for SARS-CoV-2 using molecular testing. On ICU admission (day 1) the patient presented with bilateral infiltrates (ground-glass opacities) on chest radiograph, respiratory rate of 40 breaths per minute, heart rate of 82 beats per minute, and a blood pressure 150/85 mm Hg. Laboratory tests showed a white blood cell count of 11,600 cells/mm3, with lymphopenia, normal serum creatinine (1.02 mg/dL), low albumin (2.8 g/dL), and normal lactate (1.4 mmol/L), as well as elevated ferritin (1840 ng/mL), D-dimer (17.1 ng/mL), procalcitonin (2.89 ng/mL), and fibrinogen (702 mg/dl). The patient also presented with deep vein thrombosis in the right subclavian vein and in the right internal jugular vein; anticoagulation was initiated with heparin due to the hypercoagulable state. Empirical treatment for pneumonia was started with oseltamivir, ceftriaxone, and azithromycin, and hydroxychloroquine, ritonavir/lopinavir were started for COVID-19, according to the Argentinean Ministry of Health (AMOH) national guidelines [6]. After 3 days of hospitalization, the patient required ventilator support (orotracheal intubation and mechanical ventilation) and was given a corticosteroid (dexamethasone, 20 mg/day). Influenza antigen testing yielded a negative result, prompting cessation of empirical influenza treatment (Fig. 1).Fig. 1 Case timeline: ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Fig. 1 On day 10 of hospitalization, the patient developed a new fever (38 °C). Urinary culture and pneumococcal urine antigen test were negative; tracheal aspirate and blood culture were positive for Enterococcus faecalis, and imipenem and vancomycin were added to hydroxychloroquine and ritonavir/lopinavir. Two days later polymyxin was added, and blood cultures turned negative after seven days of treatment. On day 17, urinary analysis showed evidence of acute tubular necrosis with metabolic acidosis (low pH, PaCO2 and HCO3), and treatment was subsequently changed to meropenem and colistin. On day 19, tracheal aspirate, urine and blood culture remained negative for bacteria, and a second SARS-CoV-2 PCR test from a NP swab was positive. On day 23, the patient was again febrile, and urinary, tracheal aspirate, blood and catheter tip cultures were repeated; a third SARS-CoV-2 PCR test on day 24 from a NP swab was positive (Fig. 1). On day 25 the patient developed multiple organ failure, including acute renal failure. Aspergillus flavus, identified by MALDI-TOF (Fig. 2), and Acinetobacter baumanii (>106 CFU) were cultured from tracheal aspirate. Staphylococcus capitis was isolated from blood culture, and E. faecalis and Staphylococcus epidermidis were isolated from the central venous catheter tip culture. Candida lusitaniae was isolated from urine. The patient's antimicrobial regimen was updated to include vancomycin, meropenem, and colistin. Anidulafungin was added to control candidiasis, but azole therapy for the A. flavus finding was not started due to initial clinical suspicion of colonization versus infection. On day 26 a tracheostomy was placed as a result of prolonged ventilation, ARDS (PaO2/FiO2 ratio <200), and sepsis. Chest radiograph continued to show bilateral infiltrates (Fig. 3). Aspergillus galactomannan antigen (GM) was positive in serum (GM index: 1.4; Platelia Aspergillus; Bio-Rad, Marnes-La-Coquette, France) (Fig. 1).Fig. 2 Aspergillus flavus isolate: (A and B) Macroscopic: rapid growth olive green colonies, with woolly texture, on Sabouraud agar incubated at 28 °C (A) and 37 °C (B). (C) Microscopic: hyaline septate hyphae, radiate biseriate conidial head with finely roughened conidiophore. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.) Fig. 2 Fig. 3 Chest X-ray evidenced bilateral heterogeneous infiltrates on day 26 of hospitalization: picture from the COVID-19 associated pulmonary aspergillosis (CAPA) described on this report. Fig. 3 On day 28, laboratory testing showed increased white blood cells (16,930 cells/mm3; lymphocytes 45%), D-dimer (7.3 ng/mL), ferritin (3691 ng/mL) and C-reactive protein (31.8 mg/L). Blood and central venous catheter cultures were negative, and anidulafungin was replaced with voriconazole (400 mg first day, and then 300 mg daily) after the GM test returned positive. Colistin, vancomycin, and meropenem were continued. On day 30, hydroxychloroquine, ritonavir/lopinavir were suspended (following recommendation of AMOH), and on day 35, serum GM index decreased to 0.8. On day 44, the patient died in the ICU while on ventilatory support (Fig. 1). 3 Discussion COVID-19 associated pulmonary aspergillosis (CAPA) has been recently reported in European countries [[7], [8], [9], [10], [11], [12], [13]], including four case series covering 27 patients from France (n = 9), Belgium (n = 7), The Netherlands (n = 6), and Germany (n = 5) [[7], [8], [9], [10]]. Our case has similar clinical features compared with those previously reported. Among these four case series, all 27 patients were admitted to the ICU and developed ARDS. Most were male, >50 years old, and 25 (89%) of 27 had potential risk factors for severe COVID-19. Three (60%) of five patients from the German case series, seven (78%) of nine from the French case series, and three (43%) of seven patients from the Belgium case series had hypertension. All five patients from Germany had acute kidney injury, and three (33%) of nine patients from France and two (29%) of seven from Belgium received renal replacement therapy [[7], [8], [9], [10]]. Abnormal chest radiologic findings were reported in all of the patients from Germany (n = 5) and France (n = 9) [7,8]. Twelve (44%) of 27 patients received corticosteroids during their ICU stay, and 19 (70%) of 27 were treated with mold-active antifungal medication, eight (42%) of these 19 patients received corticosteroid simultaneous with antifungal treatment. Fifteen (55%) of the 27 case series patients died. Our patient received corticosteroids for 22 days before initial A. flavus culture and was treated with voriconazole starting 3 days after the initial fungal culture. Unlike influenza-associated pulmonary aspergillosis (IAPA), which commonly occurs early after ICU admission [4], our patient developed CAPA 25 days after ICU admission. COVID-19 associated pulmonary aspergillosis case series from Belgium and The Netherlands, showed variable time on development of were aspergillosis (range: 2–28 days) [9,10]. Making the diagnosis of IPA can be challenging, especially among patients not considered classically at greatest risk (e.g., hematologic malignancy and stem cell transplant patients). Among the four European CAPA case series discussed, Aspergillus species were cultured in 78% of respiratory specimens; positive specimens included: 14 bronchoalveolar lavage, six tracheal aspirate and one sputum [[7], [8], [9], [10]]. Bronchoscopy in COVID-19 patients is often not performed due to the risk of aerosol generation. Further complicating IPA diagnosis, serum GM testing is often negative among COVID-19 patients, and sensitivity is low among ICU patients in general; in the published cases series, of the 22 cases tested, only three (14%) had positive serum GM tests [14,15]. Most COVID-19 patients lack known risk factors for IPA [4]. Thus, isolation of Aspergillus from a non-sterile site and negative serum GM should not rule out invasive disease. Clinicians may want to consider mold-active azole therapy at first indication of aspergillosis in COVID-19 patients. Our patient had a high serum GM index (>1.0), which is the recommended cutoff, and mycological criteria for probable IPA classification by the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium [16]. Challenges in selecting a case definition for CAPA are also shared by the similar IAPA. For this reason, an expert panel recently proposed a new case definition for IAPA [17,18]. The definitions distinguish between invasive Aspergillus tracheobronchitis and other pulmonary manifestations and mainly rely on culture and GM to identify IPA. The expert panel stated that the IAPA case definition might also be useful to classify CAPA cases. Using this new definition, our case would be classified as probable CAPA [17]. A follow-up serum GM showed decreasing antigen titer which is consistent with antifungal treatment response. Little is known about the pathogenesis of CAPA, and there is a need to characterize risk factors for the development of IPA. Although influenza infection was found to be an independent risk factor for IPA [4], the use of corticosteroids in patients with influenza is also a risk factor for IAPA [19]. A recent preliminary report suggested that dexamethasone was associated with reduced mortality in COVID-19 patients [20]. However, corticosteroids might be associated with adverse effects such as delayed viral clearance and secondary infections. Notably, of the four proven IPA cases reported during the previous severe acute respiratory syndrome (SARS) epidemic, all were associated with concomitant corticosteroid therapy [5,21]. In our COVID-19 case with probable CAPA, we observed co-infections with bacterial and additional fungal pathogens (E. faecalis, A. baumanii, coagulase-negative staphylococci, and C. lusitaniae), which complicated patient treatment. Previous reports of CAPA cases did not describe the presence of other microbial co-infections [[7], [8], [9], [10], [11], [12], [13]], although these are commonly encountered in patients with influenza. Previous reports of ICU patients with severe influenza frequently reported secondary bacterial infection, and these were significantly associated with IAPA in studies comparing severe influenza patients with and without IAPA (61% vs 31%; p < 0.01) [22]. Co-infections were reported in up to 50% of patients with severe coronavirus infections causing both SARS and Middle East respiratory syndrome (MERS) [23]. However, early data suggest that coinfection frequency might be lower in COVID-19 [[23], [24], [25]]. We present a case of COVID-19 associated pulmonary aspergillosis from Argentina, with a clinical course and attributes similar to previously reported cases, that highlights the challenges in diagnosing and treating these CAPA patients. The use of a clinical algorithm to discriminate Aspergillus respiratory tract colonization from invasive pulmonary aspergillosis in critically ill patients is warranted, such as the one developed for IAPA [17,18]. This is the first report of ventilator-associated pneumonia involving A. flavus in a patient with COVID-19 and ARDS in the Americas. Awareness of CAPA and accessibility to appropriate diagnostic tests are necessary for accurate and timely identification of this co-infection [26,27]. Ethical considerations Publication of this case report was approved by the Hospital de Clínicas “José de San Martin” IRB. Declaration of competing interest All authors no reported conflicts of interest. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC. Acknowledgements Claudia Barberis, Marisa Almuzara, and the staff of the infectious disease division and the intensive care unit, at Hospital de Clínicas “José de San Martin”. Universidad de Buenos Aires. Diego H. Caceres acknowledges Oak Ridge Institute for Science and Education (ORISE).	Recovered	ReactionOutcome	CC BY	32837881	19,203,398	2021-03
What was the outcome of reaction 'Viral load increased'?	Ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Coronavirus disease 2019 (COVID-19), caused by the novel coronavirus SARS-CoV-2, emerged in Wuhan, China, in December 2019 and rapidly spread around the world. Invasive aspergillosis has been reported as a complication of severe influenza pneumonia among intensive care patients. Similarities between COVID-19 and influenza pneumonia, together with limited published case series, suggest that aspergillosis may be an important complication of COVID-19. This report describes a case of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 from Buenos Aires, Argentina. 1 Introduction SARS-CoV-2 is the novel coronavirus that causes coronavirus disease 2019 (COVID‐19), which was first reported in December 2019 in Wuhan, China, and has rapidly spread worldwide [1]. On March 11th, 2020, the World Health Organization (WHO) declared a pandemic, and by June 30th, 2020, a total of 10,185,374 cases and 503,862 deaths were reported in 216 locations around the world [2]. In Argentina, on June 30th, 2020, the Argentinean Ministry of Health (AMOH) reported 62,268 cases and 1283 deaths [3]. Invasive pulmonary aspergillosis (IPA) is a known complication in patients with severe influenza pneumonia. Case series from the Netherlands and Belgium reported an incidence of 19% in patients with influenza pneumonia and acute respiratory distress syndrome (ARDS) hospitalized in the intensive care unit (ICU) [4], although these high incidences have not been confirmed in other studies [4]. There is concern that critically ill COVID-19 patients might also be at increased risk of pulmonary aspergillosis co-infection [5]. Here we describe a report of ventilator-associated pneumonia involving Aspergillus flavus in a patient with COVID-19 and ARDS in Argentina. 2 Case presentation In late April 2020, an 85-year-old man with a history of hypertension was admitted to the ICU with a history of six days of fever and dyspnea, at home. The patient had close household contact with two COVID-19 cases, and nasopharyngeal (NP) swab samples collected on the day of ICU admission tested positive for SARS-CoV-2 using molecular testing. On ICU admission (day 1) the patient presented with bilateral infiltrates (ground-glass opacities) on chest radiograph, respiratory rate of 40 breaths per minute, heart rate of 82 beats per minute, and a blood pressure 150/85 mm Hg. Laboratory tests showed a white blood cell count of 11,600 cells/mm3, with lymphopenia, normal serum creatinine (1.02 mg/dL), low albumin (2.8 g/dL), and normal lactate (1.4 mmol/L), as well as elevated ferritin (1840 ng/mL), D-dimer (17.1 ng/mL), procalcitonin (2.89 ng/mL), and fibrinogen (702 mg/dl). The patient also presented with deep vein thrombosis in the right subclavian vein and in the right internal jugular vein; anticoagulation was initiated with heparin due to the hypercoagulable state. Empirical treatment for pneumonia was started with oseltamivir, ceftriaxone, and azithromycin, and hydroxychloroquine, ritonavir/lopinavir were started for COVID-19, according to the Argentinean Ministry of Health (AMOH) national guidelines [6]. After 3 days of hospitalization, the patient required ventilator support (orotracheal intubation and mechanical ventilation) and was given a corticosteroid (dexamethasone, 20 mg/day). Influenza antigen testing yielded a negative result, prompting cessation of empirical influenza treatment (Fig. 1).Fig. 1 Case timeline: ventilator-associated pneumonia involving Aspergillus flavus in a patient with coronavirus disease 2019 (COVID-19) from Argentina. Fig. 1 On day 10 of hospitalization, the patient developed a new fever (38 °C). Urinary culture and pneumococcal urine antigen test were negative; tracheal aspirate and blood culture were positive for Enterococcus faecalis, and imipenem and vancomycin were added to hydroxychloroquine and ritonavir/lopinavir. Two days later polymyxin was added, and blood cultures turned negative after seven days of treatment. On day 17, urinary analysis showed evidence of acute tubular necrosis with metabolic acidosis (low pH, PaCO2 and HCO3), and treatment was subsequently changed to meropenem and colistin. On day 19, tracheal aspirate, urine and blood culture remained negative for bacteria, and a second SARS-CoV-2 PCR test from a NP swab was positive. On day 23, the patient was again febrile, and urinary, tracheal aspirate, blood and catheter tip cultures were repeated; a third SARS-CoV-2 PCR test on day 24 from a NP swab was positive (Fig. 1). On day 25 the patient developed multiple organ failure, including acute renal failure. Aspergillus flavus, identified by MALDI-TOF (Fig. 2), and Acinetobacter baumanii (>106 CFU) were cultured from tracheal aspirate. Staphylococcus capitis was isolated from blood culture, and E. faecalis and Staphylococcus epidermidis were isolated from the central venous catheter tip culture. Candida lusitaniae was isolated from urine. The patient's antimicrobial regimen was updated to include vancomycin, meropenem, and colistin. Anidulafungin was added to control candidiasis, but azole therapy for the A. flavus finding was not started due to initial clinical suspicion of colonization versus infection. On day 26 a tracheostomy was placed as a result of prolonged ventilation, ARDS (PaO2/FiO2 ratio <200), and sepsis. Chest radiograph continued to show bilateral infiltrates (Fig. 3). Aspergillus galactomannan antigen (GM) was positive in serum (GM index: 1.4; Platelia Aspergillus; Bio-Rad, Marnes-La-Coquette, France) (Fig. 1).Fig. 2 Aspergillus flavus isolate: (A and B) Macroscopic: rapid growth olive green colonies, with woolly texture, on Sabouraud agar incubated at 28 °C (A) and 37 °C (B). (C) Microscopic: hyaline septate hyphae, radiate biseriate conidial head with finely roughened conidiophore. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.) Fig. 2 Fig. 3 Chest X-ray evidenced bilateral heterogeneous infiltrates on day 26 of hospitalization: picture from the COVID-19 associated pulmonary aspergillosis (CAPA) described on this report. Fig. 3 On day 28, laboratory testing showed increased white blood cells (16,930 cells/mm3; lymphocytes 45%), D-dimer (7.3 ng/mL), ferritin (3691 ng/mL) and C-reactive protein (31.8 mg/L). Blood and central venous catheter cultures were negative, and anidulafungin was replaced with voriconazole (400 mg first day, and then 300 mg daily) after the GM test returned positive. Colistin, vancomycin, and meropenem were continued. On day 30, hydroxychloroquine, ritonavir/lopinavir were suspended (following recommendation of AMOH), and on day 35, serum GM index decreased to 0.8. On day 44, the patient died in the ICU while on ventilatory support (Fig. 1). 3 Discussion COVID-19 associated pulmonary aspergillosis (CAPA) has been recently reported in European countries [[7], [8], [9], [10], [11], [12], [13]], including four case series covering 27 patients from France (n = 9), Belgium (n = 7), The Netherlands (n = 6), and Germany (n = 5) [[7], [8], [9], [10]]. Our case has similar clinical features compared with those previously reported. Among these four case series, all 27 patients were admitted to the ICU and developed ARDS. Most were male, >50 years old, and 25 (89%) of 27 had potential risk factors for severe COVID-19. Three (60%) of five patients from the German case series, seven (78%) of nine from the French case series, and three (43%) of seven patients from the Belgium case series had hypertension. All five patients from Germany had acute kidney injury, and three (33%) of nine patients from France and two (29%) of seven from Belgium received renal replacement therapy [[7], [8], [9], [10]]. Abnormal chest radiologic findings were reported in all of the patients from Germany (n = 5) and France (n = 9) [7,8]. Twelve (44%) of 27 patients received corticosteroids during their ICU stay, and 19 (70%) of 27 were treated with mold-active antifungal medication, eight (42%) of these 19 patients received corticosteroid simultaneous with antifungal treatment. Fifteen (55%) of the 27 case series patients died. Our patient received corticosteroids for 22 days before initial A. flavus culture and was treated with voriconazole starting 3 days after the initial fungal culture. Unlike influenza-associated pulmonary aspergillosis (IAPA), which commonly occurs early after ICU admission [4], our patient developed CAPA 25 days after ICU admission. COVID-19 associated pulmonary aspergillosis case series from Belgium and The Netherlands, showed variable time on development of were aspergillosis (range: 2–28 days) [9,10]. Making the diagnosis of IPA can be challenging, especially among patients not considered classically at greatest risk (e.g., hematologic malignancy and stem cell transplant patients). Among the four European CAPA case series discussed, Aspergillus species were cultured in 78% of respiratory specimens; positive specimens included: 14 bronchoalveolar lavage, six tracheal aspirate and one sputum [[7], [8], [9], [10]]. Bronchoscopy in COVID-19 patients is often not performed due to the risk of aerosol generation. Further complicating IPA diagnosis, serum GM testing is often negative among COVID-19 patients, and sensitivity is low among ICU patients in general; in the published cases series, of the 22 cases tested, only three (14%) had positive serum GM tests [14,15]. Most COVID-19 patients lack known risk factors for IPA [4]. Thus, isolation of Aspergillus from a non-sterile site and negative serum GM should not rule out invasive disease. Clinicians may want to consider mold-active azole therapy at first indication of aspergillosis in COVID-19 patients. Our patient had a high serum GM index (>1.0), which is the recommended cutoff, and mycological criteria for probable IPA classification by the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium [16]. Challenges in selecting a case definition for CAPA are also shared by the similar IAPA. For this reason, an expert panel recently proposed a new case definition for IAPA [17,18]. The definitions distinguish between invasive Aspergillus tracheobronchitis and other pulmonary manifestations and mainly rely on culture and GM to identify IPA. The expert panel stated that the IAPA case definition might also be useful to classify CAPA cases. Using this new definition, our case would be classified as probable CAPA [17]. A follow-up serum GM showed decreasing antigen titer which is consistent with antifungal treatment response. Little is known about the pathogenesis of CAPA, and there is a need to characterize risk factors for the development of IPA. Although influenza infection was found to be an independent risk factor for IPA [4], the use of corticosteroids in patients with influenza is also a risk factor for IAPA [19]. A recent preliminary report suggested that dexamethasone was associated with reduced mortality in COVID-19 patients [20]. However, corticosteroids might be associated with adverse effects such as delayed viral clearance and secondary infections. Notably, of the four proven IPA cases reported during the previous severe acute respiratory syndrome (SARS) epidemic, all were associated with concomitant corticosteroid therapy [5,21]. In our COVID-19 case with probable CAPA, we observed co-infections with bacterial and additional fungal pathogens (E. faecalis, A. baumanii, coagulase-negative staphylococci, and C. lusitaniae), which complicated patient treatment. Previous reports of CAPA cases did not describe the presence of other microbial co-infections [[7], [8], [9], [10], [11], [12], [13]], although these are commonly encountered in patients with influenza. Previous reports of ICU patients with severe influenza frequently reported secondary bacterial infection, and these were significantly associated with IAPA in studies comparing severe influenza patients with and without IAPA (61% vs 31%; p < 0.01) [22]. Co-infections were reported in up to 50% of patients with severe coronavirus infections causing both SARS and Middle East respiratory syndrome (MERS) [23]. However, early data suggest that coinfection frequency might be lower in COVID-19 [[23], [24], [25]]. We present a case of COVID-19 associated pulmonary aspergillosis from Argentina, with a clinical course and attributes similar to previously reported cases, that highlights the challenges in diagnosing and treating these CAPA patients. The use of a clinical algorithm to discriminate Aspergillus respiratory tract colonization from invasive pulmonary aspergillosis in critically ill patients is warranted, such as the one developed for IAPA [17,18]. This is the first report of ventilator-associated pneumonia involving A. flavus in a patient with COVID-19 and ARDS in the Americas. Awareness of CAPA and accessibility to appropriate diagnostic tests are necessary for accurate and timely identification of this co-infection [26,27]. Ethical considerations Publication of this case report was approved by the Hospital de Clínicas “José de San Martin” IRB. Declaration of competing interest All authors no reported conflicts of interest. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC. Acknowledgements Claudia Barberis, Marisa Almuzara, and the staff of the infectious disease division and the intensive care unit, at Hospital de Clínicas “José de San Martin”. Universidad de Buenos Aires. Diego H. Caceres acknowledges Oak Ridge Institute for Science and Education (ORISE).	Fatal	ReactionOutcome	CC BY	32837881	19,203,398	2021-03
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Drug ineffective'.	Ischemic Necrosis of Lower Extremity in COVID-19: A Case Report. Coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is an acute infectious disease that spreads mainly via the respiratory route. Elderly patients or those with underlying diseases are more seriously affected. We report a case of COVID-19 infection in a geriatric patient with arteriovenous thrombosis of the right lower limb. Despite persistent anticoagulant therapy, the patient's arterial thrombosis continued to progress and presented with ischemic necrosis of the lower extremity. After amputation in this case, the levels of D-dimer and inflammatory cytokine increased progressively, and he presented with acute myocardial infarction, which progressed rapidly to multisystem organ failure. However, whether coronavirus can directly cause the damage of the cardiovascular system and thrombosis needs further investigation. Introduction In December 2019, there was an outbreak of SARS-CoV-2 infection disease in Wuhan, China1). On February 11, 2020, the World Health Organization has termed this disease as the coronavirus disease 2019 (COVID-19) and decla red it as pandemic on March 11, 2020. COVID-19 is highly contagious and has rapidly spread to many countries around the world. By May 14, 2020, there were 4,248,389 confirmed cases with 294,046 related deaths2). Wuhan Union Hospital is one of the hospitals in China designated for the treatment of critically ill COVID-19 patients. During the outbreak, we treated several COVID-19 patients in Wuhan Union Hospital. We now report the first operative amputation case of COVID-19 that manifested ischemic necrosis in the world. Case Report A 70-year-old man who resided in Wuhan, China, felt the first symptoms of chest discomfort on January 17, 2020, and had chest x-rays that showed mild pulmonary infection. At that time, he did not have diarrhea, cough, or subjective fever. He refused to be hospitalized, and he took oral anti-infective drug by himself at home. He did not have direct exposure to the Huanan seafood market in Wuhan, but he had a history of left lung cancer surgery 4 years ago. There was no tumor metastasis or recurrence. He had no history of previous arteriovenous thromboembolic disease, hypertension, diabetes, or heart disease. On January 27, 2020, he suffered from muscle pain and bruise in the lower right limb. Gradually, he developed fatigue, anorexia, and ecchymosis of the right lower limb and was then hospitalized in a local community hospital on February 3, 2020. Despite antibiotic treatment in the community hospital, his condition continued to deteriorate. On February 8, 2020, he was transferred to the Wuhan Steel Hospital. An ultrasound examination showed the presence of multiple emboli at the right femoral artery and superficial femoral artery. Laboratory tests revealed that D-dimer was 22.43 mg/L (normal < 0.5 mg/L). The chest computed tomography (CT) images showed multiple infectious lesions in both lungs with partial fibrosis, highly suspicious of SARS-CoV-2 infection (see Supplementary Fig. 1). Further laboratory testing using novel coronavirus nucleic acid test confirmed this case as positive COVID-19. On February 8, 2020, enoxaparin sodium (4000 IU once every 12 h subcutaneous injection) was used for antithrombotic treatment (see Supplementary Fig. 2A). However, after 12 days of antithrombotic and antiviral treatment, his arterial circulation was not restored. On February 19, 2020, the ultrasound examination showed thrombosis in the middle and lower segments of the common femoral vein in the right lower limb. Supplementary Fig. 1. Transverse chest CT images showing bilateral ground-glass opacity on day 13 after symptom onset Supplementary Fig. 2. The antithrombotic course demonstrates changes over time in APTT and D-dimer A. Antithrombotic therapy and changes in APTT and D-dimer in other hospital. B. Antithrombotic therapy and changes in APTT and D-dimer in our hospital. DVT: deep vein thrombosis, APTT: activated partial thromboplastin time, ASA: aspirin, CLP: clopidogrel, AMI: acute myocardial infarction. On February 20, 2020, the patient was transferred to our Wuhan Union Hospital. On admission, he reported cough and expectoration. However, the phlegm culture was all negative. Physical examination revealed obvious, bluish-purple swelling, and pain to palpation of the lower right limb, but the pulsation of the right dorsalis pedis arteries disappeared (Fig. 1). On February 21, 2020, an inferior vena cava filter was done via the left common femoral vein to prevent pulmonary thrombosis before surgery by a vascular surgeon. Afterward, lower right limb amputation was conducted under general anesthesia. Fig. 1. Lower right limb of the patient, showing that the lower limb is bluish-purple with apparent swelling (Photo taken at on admission) Postoperatively, the patient stayed in an intensive care unit, and enoxaparin sodium (4000 IU once daily by subcutaneous injection) was commenced for deep vein thrombosis (DVT) prophylaxis (see Supplementary Fig. 2B). His consciousness was clear and his vital signs were normal. On day 2 postoperative, he was transferred to a general quarantine ward. On day 3 after surgery, his axillary body temperature was 36.3 °C −38.4°C; heart rate, 64–72 beats/min; respiratory rate, 15–20 breaths/min; blood pressure, 99/145–65/88 mmHg; and arterial oxygen saturation (SaO2) 95%–98% (nasal oxygen breath, 3 L/min). On day 4 postoperative, he developed chest oppression and nausea. The SaO2 was 94% (nasal oxygen breath, 5 L/min), and respiratory rate was 20–23 breaths/min. On day 6 postoperative, his symptoms had not improved, and he developed bloody sputum (Fig. 2). The SaO2 decreased to 88%–98% (non-invasive ventilation, 10 L/min). On day 7 postoperative, his hypoxemia and shortness of breath worsened. Arterial blood gas analysis indicated an oxygenation index of 40 mmHg, an SaO2 of 67%, and a pH of 7.28. He was immediately given invasive ventilation. Electrocardiogram showed atrial fibrillation and acute myocardial infarction. Hypersensitive troponin I level was 10025.4 ng/L (normal ≤ 26.2 ng/L), brain natriuretic peptide level was 508.9 pg/mL (normal ≤ 100 pg/mL), and echocardiogram demonstrated an ejection fraction of 43%. Despite receiving invasive ventilation, his SaO2 decreased to 74%–85%. The condition progressed rapidly to multisystem organ failure (MSOF), including acute heart failure, acute kidney injury, acute liver failure, and acute hypoxic respiratory failure (Table 1). On day 9 postoperative, his SaO2 decreased to 60%–66%. He was immediately given chest compression and adrenaline injection. Unfortunately, the rescue was not successful, and the patient died on March 1, 2020. Fig. 2. Maximum Body Temperatures, Minimum oxygen saturation and Symptoms by Day of hospitalization AMI: acute myocardial infarction. Table 1. Laboratory findings of the patient on admission to Wuhan Union Hospital Normal range Feb 20 (pre-op) Feb 22 (1 day post-op) Feb 23 (2 day post-op) Feb 25 (4 day post-op) Feb 26 (5 day post-op) Feb 28 (7 day post-op) Feb 29 (8 day post-op) Mar 1 (9 day post-op) White blood cell count, × 10 9/L (3.5–9.5) 9.83 6.22 11.31 11.42 11.58 11.67 5.76 8.24 Lymphocyte count, × 10 9/L (1.1–3.2) 1.32 0.52 1.37 0.68 0.64 0.45 0.81 0.48 CRP. mg/L (0–8) 79.08 65.79 79.08 122.24 132.75 151.4 151.82 189.95 Procalcitonin, ng/mL (0–0.05) 0.16 0.17 0.21 0.65 15.77 37.5 IL-6, pg/mL (0–7) 336.2 D-dimer, ug/mL (0–0.5) 6.55 5.67 > 8 5.19 2.85 7.62 > 8 > 8 Fibrinogen, g/L (2–4) 5.6 5.25 5.32 6.07 5.75 6.16 4.53 3.9 PT, s (11–16) 14.5 14.1 13.6 14.5 14.8 15.7 19 18.1 APTT, s (27–45) 57.2 51.5 42.8 44.1 43.5 40.4 47.9 49.4 Platelet count, × 10 9/L (125–350) 282 233 224 275 249 271 215 60 Aspartate aminotransferase, U/L (8–40) 65 82 65 63 28 34 488 840 Alanine aminotransferase, U/L (5–40) 68 92 68 73 39 27 232 367 Creatinine, umol/L (57–111) 62.3 59 62.3 62.1 54.9 46.1 173.8 207.3 Urea nitrogen, umol/L (2.9–8.2) 4.5 5.09 4.5 4.48 3.4 66.4 10.1 12.86 Hypersensitive troponin I, ng/L (0–26.2) 5.9 25.7 22.4 1002.5 > 50000 > 50000 BNP, pg/mL (0–100) 122.4 88.5 235.2 508.9 1641.5 > 5000 COVID-19 IgM, AU/mL (0–10) 41.46 COVID-19 IgG, AU/mL (0–10) 118.36 C-reactive protein (CRP), Interleukin-6 (IL-6), Prothrombin time (PT), Activated partial thromboplastin time (APTT), Brain natriuretic peptide(BNP) Discussion COVID-19 has become a serious global health problem. The most common symptoms of SARS-COV-2 infection are fever, cough, and myalgia or fatigue. Most patients had normal white blood cell counts but leukopenia, elevated levels of C-reactive protein (CRP), and abnormal chest CT images showing ground glass opacity1, 3). As shown in this case, the elderly patient demonstrated most of the common symptoms but afebrile in the early stage. SARS-CoV-2 can be transmitted by droplets, via direct contact, and possibly by aerosols. Thus, operating room personnel should wear personal protective equipment (PPE), including disposable cap, goggles, face shield, N95 mask, disposable latex gloves, and waterproof boot. To avoid cross contamination, the operation should be conducted in a negative-pressure surgery room. PPE and respirators should be discarded before leaving the operating room. Studies indicated that DVT and pulmonary embolism in SARS patients who were infected by another coronavirus was 20.5% and 11.4%, respectively4). It has been clinically recognized that COVID-19 patients are prone to thrombotic dysfunction, and COVID-19 patients, especially those with severe symptoms, had a higher D-dimer value and risk of thrombosis1, 3, 5, 6). Furthermore, COVID-19 patients may exhibit many risk factors of thrombosis such as blood concentration, vascular endothelial injury, blood hypercoagulation, bed rest, advanced age, and history of surgery. In this case, the elderly patient first developed chest discomfort and lung infection 10 days before thrombosis symptom occurred in the lower extremity. Despite 12 days of persistent anticoagulant therapy in the hospital, the patient's arterial thrombosis continued to progress, and he was presented with ischemic necrosis of the lower extremity. Therefore, we speculate that there is a high correlation between COVID-19 infection and thrombosis. Recent studies have demonstrated that SARS-CoV-2 uses the SARS-CoV receptor angiotensin-converting enzyme 2 (ACE2) for host cell entry7). ACE2 protein is highly expressed in cardiovascular tissues8). According to the Diagnosis and Treatment Program of 2019 New Coronavirus Pneumonia (trial seventh version), the vascular pathological changes of COVID-19 were mainly partial vascular endothelial shedding, vascular intimal inflammation, and thrombosis9). Additionally, the endotheliitis has been reported to be correlated with SARS-CoV-2 infection, which may promote the development of thrombosis in COVID-19 10, 11). This patient suffered from a sudden worsening of condition on the fourth day after operation, followed by abnormal electrocardiogram (atrial fibrillation and acute myocardial infarction) and then extremely high hypersensitive troponin I level. Therefore, it appears that SARS-CoV-2 could attack cardiovascular tissue directly or indirectly via inducing inflammation storm. Previous studies have shown that CRP and procalcitonin (PCT) are correlated and can successfully predict mortality in patients with community-acquired pneumonia (CAP)12). D-dimer levels are elevated in patients with CAP and are associated with the severity of CAP and clinical outcomes13). As shown in this case, the level of D-dimer, CRP, and PCT increased progressively after surgery and the patient progressed rapidly with acute respiratory distress syndrome and acute myocardial infarction, which was eventually followed by MSOF. Furthermore, recent research has shown that increased amounts of proinflammatory cytokines in serum were associated with disease severity in COVID-19 1). In SARS patients, the cytokine storm was associated with pulmonary inflammation and extensive lung damage14). Therefore, elevations of D-dimer and inflammatory cytokine might account for the sudden progression of disease in this patient. His serum cytokine IL-6 had a 50-fold increase (Table 1). Additionally, surgery represents a major stress event for the patient, which may aggravate the body's inflammatory response. Those probably indicated poor prognosis of this patient. In conclusion, the pathogenesis of this patient's lower limb arterial thrombosis is unknown. Whether the coronavirus can directly cause thrombosis needs further investigation. However, COVID-19 infection not only can induce various proinflammatory immune mediators that might damage the lungs but also is enough to activate the coagulation system. This case highlights the importance of timely diagnosis of COVID-19 and appropriate management of thrombosis. Acknowledgement This work was supported by grants from the National Natural Science Foundation of China (No. 81702157, to Wei Tong). Declaration of Interests The authors declare that they have no competing interest.	ASPIRIN, CLOPIDOGREL BISULFATE, ENOXAPARIN SODIUM, EPINEPHRINE	DrugsGivenReaction	CC BY-NC-SA	32863298	18,902,435	2021-01-01
What was the administration route of drug 'ENOXAPARIN SODIUM'?	Ischemic Necrosis of Lower Extremity in COVID-19: A Case Report. Coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is an acute infectious disease that spreads mainly via the respiratory route. Elderly patients or those with underlying diseases are more seriously affected. We report a case of COVID-19 infection in a geriatric patient with arteriovenous thrombosis of the right lower limb. Despite persistent anticoagulant therapy, the patient's arterial thrombosis continued to progress and presented with ischemic necrosis of the lower extremity. After amputation in this case, the levels of D-dimer and inflammatory cytokine increased progressively, and he presented with acute myocardial infarction, which progressed rapidly to multisystem organ failure. However, whether coronavirus can directly cause the damage of the cardiovascular system and thrombosis needs further investigation. Introduction In December 2019, there was an outbreak of SARS-CoV-2 infection disease in Wuhan, China1). On February 11, 2020, the World Health Organization has termed this disease as the coronavirus disease 2019 (COVID-19) and decla red it as pandemic on March 11, 2020. COVID-19 is highly contagious and has rapidly spread to many countries around the world. By May 14, 2020, there were 4,248,389 confirmed cases with 294,046 related deaths2). Wuhan Union Hospital is one of the hospitals in China designated for the treatment of critically ill COVID-19 patients. During the outbreak, we treated several COVID-19 patients in Wuhan Union Hospital. We now report the first operative amputation case of COVID-19 that manifested ischemic necrosis in the world. Case Report A 70-year-old man who resided in Wuhan, China, felt the first symptoms of chest discomfort on January 17, 2020, and had chest x-rays that showed mild pulmonary infection. At that time, he did not have diarrhea, cough, or subjective fever. He refused to be hospitalized, and he took oral anti-infective drug by himself at home. He did not have direct exposure to the Huanan seafood market in Wuhan, but he had a history of left lung cancer surgery 4 years ago. There was no tumor metastasis or recurrence. He had no history of previous arteriovenous thromboembolic disease, hypertension, diabetes, or heart disease. On January 27, 2020, he suffered from muscle pain and bruise in the lower right limb. Gradually, he developed fatigue, anorexia, and ecchymosis of the right lower limb and was then hospitalized in a local community hospital on February 3, 2020. Despite antibiotic treatment in the community hospital, his condition continued to deteriorate. On February 8, 2020, he was transferred to the Wuhan Steel Hospital. An ultrasound examination showed the presence of multiple emboli at the right femoral artery and superficial femoral artery. Laboratory tests revealed that D-dimer was 22.43 mg/L (normal < 0.5 mg/L). The chest computed tomography (CT) images showed multiple infectious lesions in both lungs with partial fibrosis, highly suspicious of SARS-CoV-2 infection (see Supplementary Fig. 1). Further laboratory testing using novel coronavirus nucleic acid test confirmed this case as positive COVID-19. On February 8, 2020, enoxaparin sodium (4000 IU once every 12 h subcutaneous injection) was used for antithrombotic treatment (see Supplementary Fig. 2A). However, after 12 days of antithrombotic and antiviral treatment, his arterial circulation was not restored. On February 19, 2020, the ultrasound examination showed thrombosis in the middle and lower segments of the common femoral vein in the right lower limb. Supplementary Fig. 1. Transverse chest CT images showing bilateral ground-glass opacity on day 13 after symptom onset Supplementary Fig. 2. The antithrombotic course demonstrates changes over time in APTT and D-dimer A. Antithrombotic therapy and changes in APTT and D-dimer in other hospital. B. Antithrombotic therapy and changes in APTT and D-dimer in our hospital. DVT: deep vein thrombosis, APTT: activated partial thromboplastin time, ASA: aspirin, CLP: clopidogrel, AMI: acute myocardial infarction. On February 20, 2020, the patient was transferred to our Wuhan Union Hospital. On admission, he reported cough and expectoration. However, the phlegm culture was all negative. Physical examination revealed obvious, bluish-purple swelling, and pain to palpation of the lower right limb, but the pulsation of the right dorsalis pedis arteries disappeared (Fig. 1). On February 21, 2020, an inferior vena cava filter was done via the left common femoral vein to prevent pulmonary thrombosis before surgery by a vascular surgeon. Afterward, lower right limb amputation was conducted under general anesthesia. Fig. 1. Lower right limb of the patient, showing that the lower limb is bluish-purple with apparent swelling (Photo taken at on admission) Postoperatively, the patient stayed in an intensive care unit, and enoxaparin sodium (4000 IU once daily by subcutaneous injection) was commenced for deep vein thrombosis (DVT) prophylaxis (see Supplementary Fig. 2B). His consciousness was clear and his vital signs were normal. On day 2 postoperative, he was transferred to a general quarantine ward. On day 3 after surgery, his axillary body temperature was 36.3 °C −38.4°C; heart rate, 64–72 beats/min; respiratory rate, 15–20 breaths/min; blood pressure, 99/145–65/88 mmHg; and arterial oxygen saturation (SaO2) 95%–98% (nasal oxygen breath, 3 L/min). On day 4 postoperative, he developed chest oppression and nausea. The SaO2 was 94% (nasal oxygen breath, 5 L/min), and respiratory rate was 20–23 breaths/min. On day 6 postoperative, his symptoms had not improved, and he developed bloody sputum (Fig. 2). The SaO2 decreased to 88%–98% (non-invasive ventilation, 10 L/min). On day 7 postoperative, his hypoxemia and shortness of breath worsened. Arterial blood gas analysis indicated an oxygenation index of 40 mmHg, an SaO2 of 67%, and a pH of 7.28. He was immediately given invasive ventilation. Electrocardiogram showed atrial fibrillation and acute myocardial infarction. Hypersensitive troponin I level was 10025.4 ng/L (normal ≤ 26.2 ng/L), brain natriuretic peptide level was 508.9 pg/mL (normal ≤ 100 pg/mL), and echocardiogram demonstrated an ejection fraction of 43%. Despite receiving invasive ventilation, his SaO2 decreased to 74%–85%. The condition progressed rapidly to multisystem organ failure (MSOF), including acute heart failure, acute kidney injury, acute liver failure, and acute hypoxic respiratory failure (Table 1). On day 9 postoperative, his SaO2 decreased to 60%–66%. He was immediately given chest compression and adrenaline injection. Unfortunately, the rescue was not successful, and the patient died on March 1, 2020. Fig. 2. Maximum Body Temperatures, Minimum oxygen saturation and Symptoms by Day of hospitalization AMI: acute myocardial infarction. Table 1. Laboratory findings of the patient on admission to Wuhan Union Hospital Normal range Feb 20 (pre-op) Feb 22 (1 day post-op) Feb 23 (2 day post-op) Feb 25 (4 day post-op) Feb 26 (5 day post-op) Feb 28 (7 day post-op) Feb 29 (8 day post-op) Mar 1 (9 day post-op) White blood cell count, × 10 9/L (3.5–9.5) 9.83 6.22 11.31 11.42 11.58 11.67 5.76 8.24 Lymphocyte count, × 10 9/L (1.1–3.2) 1.32 0.52 1.37 0.68 0.64 0.45 0.81 0.48 CRP. mg/L (0–8) 79.08 65.79 79.08 122.24 132.75 151.4 151.82 189.95 Procalcitonin, ng/mL (0–0.05) 0.16 0.17 0.21 0.65 15.77 37.5 IL-6, pg/mL (0–7) 336.2 D-dimer, ug/mL (0–0.5) 6.55 5.67 > 8 5.19 2.85 7.62 > 8 > 8 Fibrinogen, g/L (2–4) 5.6 5.25 5.32 6.07 5.75 6.16 4.53 3.9 PT, s (11–16) 14.5 14.1 13.6 14.5 14.8 15.7 19 18.1 APTT, s (27–45) 57.2 51.5 42.8 44.1 43.5 40.4 47.9 49.4 Platelet count, × 10 9/L (125–350) 282 233 224 275 249 271 215 60 Aspartate aminotransferase, U/L (8–40) 65 82 65 63 28 34 488 840 Alanine aminotransferase, U/L (5–40) 68 92 68 73 39 27 232 367 Creatinine, umol/L (57–111) 62.3 59 62.3 62.1 54.9 46.1 173.8 207.3 Urea nitrogen, umol/L (2.9–8.2) 4.5 5.09 4.5 4.48 3.4 66.4 10.1 12.86 Hypersensitive troponin I, ng/L (0–26.2) 5.9 25.7 22.4 1002.5 > 50000 > 50000 BNP, pg/mL (0–100) 122.4 88.5 235.2 508.9 1641.5 > 5000 COVID-19 IgM, AU/mL (0–10) 41.46 COVID-19 IgG, AU/mL (0–10) 118.36 C-reactive protein (CRP), Interleukin-6 (IL-6), Prothrombin time (PT), Activated partial thromboplastin time (APTT), Brain natriuretic peptide(BNP) Discussion COVID-19 has become a serious global health problem. The most common symptoms of SARS-COV-2 infection are fever, cough, and myalgia or fatigue. Most patients had normal white blood cell counts but leukopenia, elevated levels of C-reactive protein (CRP), and abnormal chest CT images showing ground glass opacity1, 3). As shown in this case, the elderly patient demonstrated most of the common symptoms but afebrile in the early stage. SARS-CoV-2 can be transmitted by droplets, via direct contact, and possibly by aerosols. Thus, operating room personnel should wear personal protective equipment (PPE), including disposable cap, goggles, face shield, N95 mask, disposable latex gloves, and waterproof boot. To avoid cross contamination, the operation should be conducted in a negative-pressure surgery room. PPE and respirators should be discarded before leaving the operating room. Studies indicated that DVT and pulmonary embolism in SARS patients who were infected by another coronavirus was 20.5% and 11.4%, respectively4). It has been clinically recognized that COVID-19 patients are prone to thrombotic dysfunction, and COVID-19 patients, especially those with severe symptoms, had a higher D-dimer value and risk of thrombosis1, 3, 5, 6). Furthermore, COVID-19 patients may exhibit many risk factors of thrombosis such as blood concentration, vascular endothelial injury, blood hypercoagulation, bed rest, advanced age, and history of surgery. In this case, the elderly patient first developed chest discomfort and lung infection 10 days before thrombosis symptom occurred in the lower extremity. Despite 12 days of persistent anticoagulant therapy in the hospital, the patient's arterial thrombosis continued to progress, and he was presented with ischemic necrosis of the lower extremity. Therefore, we speculate that there is a high correlation between COVID-19 infection and thrombosis. Recent studies have demonstrated that SARS-CoV-2 uses the SARS-CoV receptor angiotensin-converting enzyme 2 (ACE2) for host cell entry7). ACE2 protein is highly expressed in cardiovascular tissues8). According to the Diagnosis and Treatment Program of 2019 New Coronavirus Pneumonia (trial seventh version), the vascular pathological changes of COVID-19 were mainly partial vascular endothelial shedding, vascular intimal inflammation, and thrombosis9). Additionally, the endotheliitis has been reported to be correlated with SARS-CoV-2 infection, which may promote the development of thrombosis in COVID-19 10, 11). This patient suffered from a sudden worsening of condition on the fourth day after operation, followed by abnormal electrocardiogram (atrial fibrillation and acute myocardial infarction) and then extremely high hypersensitive troponin I level. Therefore, it appears that SARS-CoV-2 could attack cardiovascular tissue directly or indirectly via inducing inflammation storm. Previous studies have shown that CRP and procalcitonin (PCT) are correlated and can successfully predict mortality in patients with community-acquired pneumonia (CAP)12). D-dimer levels are elevated in patients with CAP and are associated with the severity of CAP and clinical outcomes13). As shown in this case, the level of D-dimer, CRP, and PCT increased progressively after surgery and the patient progressed rapidly with acute respiratory distress syndrome and acute myocardial infarction, which was eventually followed by MSOF. Furthermore, recent research has shown that increased amounts of proinflammatory cytokines in serum were associated with disease severity in COVID-19 1). In SARS patients, the cytokine storm was associated with pulmonary inflammation and extensive lung damage14). Therefore, elevations of D-dimer and inflammatory cytokine might account for the sudden progression of disease in this patient. His serum cytokine IL-6 had a 50-fold increase (Table 1). Additionally, surgery represents a major stress event for the patient, which may aggravate the body's inflammatory response. Those probably indicated poor prognosis of this patient. In conclusion, the pathogenesis of this patient's lower limb arterial thrombosis is unknown. Whether the coronavirus can directly cause thrombosis needs further investigation. However, COVID-19 infection not only can induce various proinflammatory immune mediators that might damage the lungs but also is enough to activate the coagulation system. This case highlights the importance of timely diagnosis of COVID-19 and appropriate management of thrombosis. Acknowledgement This work was supported by grants from the National Natural Science Foundation of China (No. 81702157, to Wei Tong). Declaration of Interests The authors declare that they have no competing interest.	Subcutaneous	DrugAdministrationRoute	CC BY-NC-SA	32863298	18,902,435	2021-01-01
What was the outcome of reaction 'Drug ineffective'?	Ischemic Necrosis of Lower Extremity in COVID-19: A Case Report. Coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is an acute infectious disease that spreads mainly via the respiratory route. Elderly patients or those with underlying diseases are more seriously affected. We report a case of COVID-19 infection in a geriatric patient with arteriovenous thrombosis of the right lower limb. Despite persistent anticoagulant therapy, the patient's arterial thrombosis continued to progress and presented with ischemic necrosis of the lower extremity. After amputation in this case, the levels of D-dimer and inflammatory cytokine increased progressively, and he presented with acute myocardial infarction, which progressed rapidly to multisystem organ failure. However, whether coronavirus can directly cause the damage of the cardiovascular system and thrombosis needs further investigation. Introduction In December 2019, there was an outbreak of SARS-CoV-2 infection disease in Wuhan, China1). On February 11, 2020, the World Health Organization has termed this disease as the coronavirus disease 2019 (COVID-19) and decla red it as pandemic on March 11, 2020. COVID-19 is highly contagious and has rapidly spread to many countries around the world. By May 14, 2020, there were 4,248,389 confirmed cases with 294,046 related deaths2). Wuhan Union Hospital is one of the hospitals in China designated for the treatment of critically ill COVID-19 patients. During the outbreak, we treated several COVID-19 patients in Wuhan Union Hospital. We now report the first operative amputation case of COVID-19 that manifested ischemic necrosis in the world. Case Report A 70-year-old man who resided in Wuhan, China, felt the first symptoms of chest discomfort on January 17, 2020, and had chest x-rays that showed mild pulmonary infection. At that time, he did not have diarrhea, cough, or subjective fever. He refused to be hospitalized, and he took oral anti-infective drug by himself at home. He did not have direct exposure to the Huanan seafood market in Wuhan, but he had a history of left lung cancer surgery 4 years ago. There was no tumor metastasis or recurrence. He had no history of previous arteriovenous thromboembolic disease, hypertension, diabetes, or heart disease. On January 27, 2020, he suffered from muscle pain and bruise in the lower right limb. Gradually, he developed fatigue, anorexia, and ecchymosis of the right lower limb and was then hospitalized in a local community hospital on February 3, 2020. Despite antibiotic treatment in the community hospital, his condition continued to deteriorate. On February 8, 2020, he was transferred to the Wuhan Steel Hospital. An ultrasound examination showed the presence of multiple emboli at the right femoral artery and superficial femoral artery. Laboratory tests revealed that D-dimer was 22.43 mg/L (normal < 0.5 mg/L). The chest computed tomography (CT) images showed multiple infectious lesions in both lungs with partial fibrosis, highly suspicious of SARS-CoV-2 infection (see Supplementary Fig. 1). Further laboratory testing using novel coronavirus nucleic acid test confirmed this case as positive COVID-19. On February 8, 2020, enoxaparin sodium (4000 IU once every 12 h subcutaneous injection) was used for antithrombotic treatment (see Supplementary Fig. 2A). However, after 12 days of antithrombotic and antiviral treatment, his arterial circulation was not restored. On February 19, 2020, the ultrasound examination showed thrombosis in the middle and lower segments of the common femoral vein in the right lower limb. Supplementary Fig. 1. Transverse chest CT images showing bilateral ground-glass opacity on day 13 after symptom onset Supplementary Fig. 2. The antithrombotic course demonstrates changes over time in APTT and D-dimer A. Antithrombotic therapy and changes in APTT and D-dimer in other hospital. B. Antithrombotic therapy and changes in APTT and D-dimer in our hospital. DVT: deep vein thrombosis, APTT: activated partial thromboplastin time, ASA: aspirin, CLP: clopidogrel, AMI: acute myocardial infarction. On February 20, 2020, the patient was transferred to our Wuhan Union Hospital. On admission, he reported cough and expectoration. However, the phlegm culture was all negative. Physical examination revealed obvious, bluish-purple swelling, and pain to palpation of the lower right limb, but the pulsation of the right dorsalis pedis arteries disappeared (Fig. 1). On February 21, 2020, an inferior vena cava filter was done via the left common femoral vein to prevent pulmonary thrombosis before surgery by a vascular surgeon. Afterward, lower right limb amputation was conducted under general anesthesia. Fig. 1. Lower right limb of the patient, showing that the lower limb is bluish-purple with apparent swelling (Photo taken at on admission) Postoperatively, the patient stayed in an intensive care unit, and enoxaparin sodium (4000 IU once daily by subcutaneous injection) was commenced for deep vein thrombosis (DVT) prophylaxis (see Supplementary Fig. 2B). His consciousness was clear and his vital signs were normal. On day 2 postoperative, he was transferred to a general quarantine ward. On day 3 after surgery, his axillary body temperature was 36.3 °C −38.4°C; heart rate, 64–72 beats/min; respiratory rate, 15–20 breaths/min; blood pressure, 99/145–65/88 mmHg; and arterial oxygen saturation (SaO2) 95%–98% (nasal oxygen breath, 3 L/min). On day 4 postoperative, he developed chest oppression and nausea. The SaO2 was 94% (nasal oxygen breath, 5 L/min), and respiratory rate was 20–23 breaths/min. On day 6 postoperative, his symptoms had not improved, and he developed bloody sputum (Fig. 2). The SaO2 decreased to 88%–98% (non-invasive ventilation, 10 L/min). On day 7 postoperative, his hypoxemia and shortness of breath worsened. Arterial blood gas analysis indicated an oxygenation index of 40 mmHg, an SaO2 of 67%, and a pH of 7.28. He was immediately given invasive ventilation. Electrocardiogram showed atrial fibrillation and acute myocardial infarction. Hypersensitive troponin I level was 10025.4 ng/L (normal ≤ 26.2 ng/L), brain natriuretic peptide level was 508.9 pg/mL (normal ≤ 100 pg/mL), and echocardiogram demonstrated an ejection fraction of 43%. Despite receiving invasive ventilation, his SaO2 decreased to 74%–85%. The condition progressed rapidly to multisystem organ failure (MSOF), including acute heart failure, acute kidney injury, acute liver failure, and acute hypoxic respiratory failure (Table 1). On day 9 postoperative, his SaO2 decreased to 60%–66%. He was immediately given chest compression and adrenaline injection. Unfortunately, the rescue was not successful, and the patient died on March 1, 2020. Fig. 2. Maximum Body Temperatures, Minimum oxygen saturation and Symptoms by Day of hospitalization AMI: acute myocardial infarction. Table 1. Laboratory findings of the patient on admission to Wuhan Union Hospital Normal range Feb 20 (pre-op) Feb 22 (1 day post-op) Feb 23 (2 day post-op) Feb 25 (4 day post-op) Feb 26 (5 day post-op) Feb 28 (7 day post-op) Feb 29 (8 day post-op) Mar 1 (9 day post-op) White blood cell count, × 10 9/L (3.5–9.5) 9.83 6.22 11.31 11.42 11.58 11.67 5.76 8.24 Lymphocyte count, × 10 9/L (1.1–3.2) 1.32 0.52 1.37 0.68 0.64 0.45 0.81 0.48 CRP. mg/L (0–8) 79.08 65.79 79.08 122.24 132.75 151.4 151.82 189.95 Procalcitonin, ng/mL (0–0.05) 0.16 0.17 0.21 0.65 15.77 37.5 IL-6, pg/mL (0–7) 336.2 D-dimer, ug/mL (0–0.5) 6.55 5.67 > 8 5.19 2.85 7.62 > 8 > 8 Fibrinogen, g/L (2–4) 5.6 5.25 5.32 6.07 5.75 6.16 4.53 3.9 PT, s (11–16) 14.5 14.1 13.6 14.5 14.8 15.7 19 18.1 APTT, s (27–45) 57.2 51.5 42.8 44.1 43.5 40.4 47.9 49.4 Platelet count, × 10 9/L (125–350) 282 233 224 275 249 271 215 60 Aspartate aminotransferase, U/L (8–40) 65 82 65 63 28 34 488 840 Alanine aminotransferase, U/L (5–40) 68 92 68 73 39 27 232 367 Creatinine, umol/L (57–111) 62.3 59 62.3 62.1 54.9 46.1 173.8 207.3 Urea nitrogen, umol/L (2.9–8.2) 4.5 5.09 4.5 4.48 3.4 66.4 10.1 12.86 Hypersensitive troponin I, ng/L (0–26.2) 5.9 25.7 22.4 1002.5 > 50000 > 50000 BNP, pg/mL (0–100) 122.4 88.5 235.2 508.9 1641.5 > 5000 COVID-19 IgM, AU/mL (0–10) 41.46 COVID-19 IgG, AU/mL (0–10) 118.36 C-reactive protein (CRP), Interleukin-6 (IL-6), Prothrombin time (PT), Activated partial thromboplastin time (APTT), Brain natriuretic peptide(BNP) Discussion COVID-19 has become a serious global health problem. The most common symptoms of SARS-COV-2 infection are fever, cough, and myalgia or fatigue. Most patients had normal white blood cell counts but leukopenia, elevated levels of C-reactive protein (CRP), and abnormal chest CT images showing ground glass opacity1, 3). As shown in this case, the elderly patient demonstrated most of the common symptoms but afebrile in the early stage. SARS-CoV-2 can be transmitted by droplets, via direct contact, and possibly by aerosols. Thus, operating room personnel should wear personal protective equipment (PPE), including disposable cap, goggles, face shield, N95 mask, disposable latex gloves, and waterproof boot. To avoid cross contamination, the operation should be conducted in a negative-pressure surgery room. PPE and respirators should be discarded before leaving the operating room. Studies indicated that DVT and pulmonary embolism in SARS patients who were infected by another coronavirus was 20.5% and 11.4%, respectively4). It has been clinically recognized that COVID-19 patients are prone to thrombotic dysfunction, and COVID-19 patients, especially those with severe symptoms, had a higher D-dimer value and risk of thrombosis1, 3, 5, 6). Furthermore, COVID-19 patients may exhibit many risk factors of thrombosis such as blood concentration, vascular endothelial injury, blood hypercoagulation, bed rest, advanced age, and history of surgery. In this case, the elderly patient first developed chest discomfort and lung infection 10 days before thrombosis symptom occurred in the lower extremity. Despite 12 days of persistent anticoagulant therapy in the hospital, the patient's arterial thrombosis continued to progress, and he was presented with ischemic necrosis of the lower extremity. Therefore, we speculate that there is a high correlation between COVID-19 infection and thrombosis. Recent studies have demonstrated that SARS-CoV-2 uses the SARS-CoV receptor angiotensin-converting enzyme 2 (ACE2) for host cell entry7). ACE2 protein is highly expressed in cardiovascular tissues8). According to the Diagnosis and Treatment Program of 2019 New Coronavirus Pneumonia (trial seventh version), the vascular pathological changes of COVID-19 were mainly partial vascular endothelial shedding, vascular intimal inflammation, and thrombosis9). Additionally, the endotheliitis has been reported to be correlated with SARS-CoV-2 infection, which may promote the development of thrombosis in COVID-19 10, 11). This patient suffered from a sudden worsening of condition on the fourth day after operation, followed by abnormal electrocardiogram (atrial fibrillation and acute myocardial infarction) and then extremely high hypersensitive troponin I level. Therefore, it appears that SARS-CoV-2 could attack cardiovascular tissue directly or indirectly via inducing inflammation storm. Previous studies have shown that CRP and procalcitonin (PCT) are correlated and can successfully predict mortality in patients with community-acquired pneumonia (CAP)12). D-dimer levels are elevated in patients with CAP and are associated with the severity of CAP and clinical outcomes13). As shown in this case, the level of D-dimer, CRP, and PCT increased progressively after surgery and the patient progressed rapidly with acute respiratory distress syndrome and acute myocardial infarction, which was eventually followed by MSOF. Furthermore, recent research has shown that increased amounts of proinflammatory cytokines in serum were associated with disease severity in COVID-19 1). In SARS patients, the cytokine storm was associated with pulmonary inflammation and extensive lung damage14). Therefore, elevations of D-dimer and inflammatory cytokine might account for the sudden progression of disease in this patient. His serum cytokine IL-6 had a 50-fold increase (Table 1). Additionally, surgery represents a major stress event for the patient, which may aggravate the body's inflammatory response. Those probably indicated poor prognosis of this patient. In conclusion, the pathogenesis of this patient's lower limb arterial thrombosis is unknown. Whether the coronavirus can directly cause thrombosis needs further investigation. However, COVID-19 infection not only can induce various proinflammatory immune mediators that might damage the lungs but also is enough to activate the coagulation system. This case highlights the importance of timely diagnosis of COVID-19 and appropriate management of thrombosis. Acknowledgement This work was supported by grants from the National Natural Science Foundation of China (No. 81702157, to Wei Tong). Declaration of Interests The authors declare that they have no competing interest.	Fatal	ReactionOutcome	CC BY-NC-SA	32863298	18,902,435	2021-01-01
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Pneumonia viral'.	Two Cases of Primary Rhinovirus Pneumonia with Multiple Pulmonary Nodules. Two patients, a 60-year-old man and 43-year-old woman, presented to our hospital with symptoms of respiratory tract infection. These patients showed imaging findings of multiple small nodules, ground-glass opacities, and consolidations. In case 1, although antibiotics were started, bilateral shadows spread widely, which made us suspect interstitial pneumonia. The condition improved after steroid administration, and there has been no recurrence since completing this treatment. In case 2, the patient recovered rapidly with antibiotics only. In both cases, we performed bronchoalveolar lavage, in which only human rhinovirus infection was detected by multiplex polymerase chain reaction testing, and primary rhinovirus pneumonia was diagnosed. Introduction Human rhinovirus (HRV), which is the most common pathogen of the common cold, is a member of the enterovirus genus, family Picornaviridae. In recent years, HRV has been reported to cause not only upper but also lower respiratory tract infection including primary viral pneumonia (1). Some studies of community-acquired pneumonia have reported that HRV is the most common virus in viral pneumonia (2,3). We herein report two cases of HRV pneumonia diagnosed by multiplex polymerase chain reaction (PCR) from bronchoalveolar lavage (BAL) fluid. Our two cases showed computed tomography (CT) findings of multiple nodules, which are rare in HRV. Some nodules were randomly distributed, as in case 1, while others showed a centrilobular distribution, as in case 2. We describe these cases and review the clinical and radiological features of HRV pneumonia. Case Reports Case 1 A 60-year-old man who worked as a dentist presented to our hospital with a 1-week history of general fatigue, a fever, and a cough in mid-January 2019. He did not have rhinorrhea or a sore throat. His history included bronchial asthma for 30 years, and he had received corticosteroid administration (prednisolone 20 mg daily for 2 weeks) for treatment of an asthma attack until 10 days before admission to our hospital. Arthralgia, myalgia, and a fever of 38.7°C also developed one day before his presentation, and he was admitted for a further evaluation. Although he had had no evident contact with sick people, he treated about 30 patients a day at his dental clinic. He had never smoked or drank, had never been exposed to dust, and had no relevant family medical history. His vital signs included a blood pressure of 100/68 mmHg, heart rate of 78 beats/min, and respiratory rate of 20/min. His body mass index was 24.2 kg/m2. Arterial blood gasses under ambient air showed a pH of 7.49, PaCO2 of 37.2 Torr, PaO2 of 72.1 Torr, and HCO3- of 27.4 mmol/L. Laboratory tests showed a white blood cell (WBC) count of 9,800/mm3 (neutrophils, 5,500/mm3; lymphocytes, 3,400/mm3; eosinophils, 200/mm3; and monocytes, 700/mm3), hemoglobin, 16.0 g/dL; platelet count, 13.1×104/mm3; aspartate aminotransferase (AST), 31 IU/L; lactate dehydrogenase (LDH), 253 IU/L; blood urea nitrogen, 7 mg/dL; creatinine, 0.7 mg/dL; C-reactive protein, 3.2 mg/dL; and procalcitonin, 0.069 ng/mL. Autoantibodies were negative. Rapid nasopharyngeal or oropharyngeal diagnostic test and urinary antigen testing for influenza virus, Streptococcus pneumoniae, Legionella spp., and M. pneumoniae were all negative, as was cytomegalovirus antigenemia determined by the C7-horseradish peroxidase (HRP) method. Chest X-ray showed nodules in the bilateral lung fields (Fig. 1a). CT showed diffuse bronchial wall thickening and bilateral small nodules existing along the airways, but some nodules were randomly distributed (Fig. 1b). We suspected pulmonary septic emboli, but a repeat blood culture was negative, and no focus of infection outside the lung was found by systemic surveys. Figure 1. Chest imaging findings of case 1. Chest X-ray on admission showed nodules in the bilateral lung fields (a). Computed tomography showed diffuse bronchial wall thickening and bilateral small nodules that existed along the airways, but some nodules were randomly distributed (arrows) (b1, 2). Chest X-ray performed on hospital day 10 showed increased bilateral shadows (c). Computed tomography on hospital day 10 showed bilateral consolidations and shrinkage change with bronchodilation and distortion (d). We started piperacillin/tazobactam, but his respiratory condition worsened, and bilateral shadows had increased on hospital day 10 (Fig. 1c). CT showed bilateral ground-glass opacities (GGOs), consolidations, and shrinkage change with bronchodilation and distortion (Fig. 1d). We performed BAL from the anterior segment of the right upper lobe (49 of 150 mL recovered), which showed 10.0×105 cells/mL (neutrophils, 23.5%; lymphocytes, 74.1%; eosinophils, 2.0%; and basophils, 0.4%). A transbronchial lung biopsy from the anterior basal segment of the right upper lobe revealed the accumulation of macrophages with few eosinophils and neutrophils, and exudates of fibrins and mild alveolitis were also found (Fig. 2). Figure 2. Histological findings of case 1. A transbronchial lung biopsy showed the accumulation of macrophages with few eosinophils and neutrophils. Exudates of fibrins and mild alveolitis were also found. We initially suspected interstitial pneumonia and started methylprednisolone 1 g daily for 3 days, followed by 60 mg daily, which improved his condition. BAL fluid showed positive results for HRV on multiplex PCR [FTD Resp 21 Kit (Fast Track Diagnostics, Silema, Malta), which detects the following respiratory pathogens: influenza A and B viruses; coronaviruses NL63, 229E, OC43, and HKU1; human parainfluenza viruses 1-4; human metapneumovirus A/B; respiratory syncytial virus A/B; adenovirus; enterovirus; human parechovirus; bocavirus; and Mycoplasma pneumoniae] but negative results for other viruses and M. pneumoniae. Cultures of BAL fluid, blood, and bronchial aspirates were also negative for bacteria including M. pneumoniae. The methylprednisolone was then decreased. His fever abated on hospital day 13, and his respiratory condition improved. Specific antibody titers against M. pneumoniae, Chlamydophila pneumoniae, C. psittaci, Legionella spp., influenza virus, adenovirus, respiratory syncytial virus, and parainfluenza virus (serotypes 1-4) in paired sera did not increase. Bilateral GGOs, consolidations, and shrinkage change with bronchodilation and distortion improved on CT at 40 days after discharge. The methylprednisolone was gradually tapered and discontinued six months after discharge, and there has been no recurrence in the five months since discontinuing steroids. Case 2 A 43-year-old housewife presented to our hospital with rhinorrhea, sore throat, chills, a fever of 39-40°C, and dyspnea for 10 days at the end of November 2018. She had visited a local physician who started her on levofloxacin, but her body temperature did not decrease, and she developed a dyspneic cough for which she was referred to our hospital. She had never smoked or drank, had no apparent personal or family medical history, and had no evident contact with sick people. Her body mass index was 18.7 kg/m2. A physical examination revealed bilateral fine crackles, and arterial blood gases under O2 of 1 L/min by nasal cannula showed a pH of 7.49, PaCO2 of 34.2 Torr, PaO2 of 144.0 Torr, and HCO3- of 25.3 mmol/L. Laboratory tests showed a WBC of 5,400/mm3 (neutrophils, 3,900/mm3; lymphocytes, 700/mm3; eosinophils, 500/mm3; and monocytes, 300/mm3), hemoglobin, 12.9 g/dL; platelets, 22.1×104/mm3; AST, 22 IU/L; LDH, 220 IU/L; blood urea nitrogen, 5 mg/dL; creatinine, 0.6 mg/dL; C-reactive protein; 7.1 mg/dL; and procalcitonin, 0.266 ng/mL. Autoantibodies were negative. A rapid influenza diagnostic test and urinary antigen testing for S. pneumoniae, Legionella spp., and M. pneumoniae were negative. Chest X-ray showed bilateral consolidations (Fig. 3a), and CT showed bilateral GGOs and bilateral small centrilobular nodules (Fig. 3b, c). We performed BAL (84 of 150 mL recovered) from the lateral segment of the right middle lobe, which showed 11.8×105 cells/mL (macrophages, 37.2%; neutrophils, 3.6%; lymphocytes, 40.0%, and eosinophils, 19.2%). BAL fluid did not yield significant pathogens. Multiplex PCR (FTD21 Resp Kit) of the BAL fluid showed positive results only for HRV. Figure 3. Chest imaging findings of case 2. Chest X-ray showed bilateral consolidation (a). Computed tomography showed bilateral ground-glass opacities and centrilobular nodules (b, c). Once ceftriaxone was administered, her fever abated by hospital day 3, and she was discharged on hospital day 10. Specific antibody titers against M. pneumoniae, C. pneumoniae, C. psittaci, Legionella spp., influenza virus, adenovirus, respiratory syncytial virus, and parainfluenza virus (serotypes 1-4) in paired sera did not increase. Her chest imaging findings improved quickly, and the bilateral GGOs had disappeared by two weeks after discharge. Discussion As the one of the most common pathogens to infect humans and the most important cause of the common cold (4), HRV has been implicated in 30% to 50% of all cases of acute respiratory disease. In recent years, HRV has been reported to be a major cause of exacerbations of asthma and other chronic pulmonary diseases (5,6) and has also been found to cause lower respiratory tract infections, including pneumonia (1). Our patient in case 2 showed symptoms of upper respiratory tract infection, such as rhinorrhea and sore throat, whereas the patient in case 1 had no such symptoms, which indicates that HRV pneumonia should not be ruled out when patients do not have symptoms of upper respiratory tract infection. A previous study reported that, in patients with primary viral pneumonia, only 20.8% had sore throat and 3.8% had rhinorrhea (7). In the study of the pathogens of community-acquired pneumonia requiring hospitalization conducted by the Centers for Disease Control and Prevention in 2015, respiratory viruses were detected more frequently than bacteria. The most common pathogen was HRV, which accounted for 9% of the total patients (8). Neither of our two cases was associated with severe respiratory failure, but some severe cases have been reported. Of 49 mechanically ventilated patients with severe community-acquired pneumonia, 24 had viral infection (49%), and HRV was the most common virus, accounting for 58% of the infections (3). In another report of 20 patients with HRV-associated community-acquired pneumonia, 14 developed respiratory failure, and 13 required mechanical ventilation (9). The CT findings of HRV pneumonia include bilateral multifocal patchy consolidations, multiple GGOs, interlobular septal thickening, and pleural effusion, but nodules are rare (9-11). Our two cases showed bilateral nodules, with case 1 showing randomly distributed nodules and case 2 showing centrilobular nodules. In case 1, although viral culture of blood was not performed and viremia was not proven, the imaging findings suggested hematological spread. In a previous report on 356 children and 146 adults with HRV pneumonia, 57 patients showed HRV viremia, all children (12). In another study, HRV viremia was found in 10 (11.4%) of 88 HRV-infected children: 7 of 28 children with an asthma attack, 2 of 26 with a common cold, and 1 of 25 with bronchiolitis (13). Factors associated with HRV viremia were sampling within 24 hours from the onset of symptoms and asthma. The increased susceptibility of individuals with asthma to viral, particularly HRV, infections has been considered (14). Although why the present case 1 showed viremia is unclear, we suspect that the immunocompromised state caused by systemic steroids for the asthma attack experienced before developing pneumonia might have been involved. To our knowledge, there have been no reports of HRV viremia in adults, but our experience showed that HRV viremia in adults can develop under such conditions. In contrast, Case 2 suggested transbronchial spread. Various histologic patterns of lung injury have been described in viral pneumonia. Some viruses produce specific nuclear changes or characteristic cytoplasmic inclusions (15). However, the histologic characteristics of HRV pneumonia are not well known. Case 1 in the present study showed an accumulation of macrophages with few eosinophils and neutrophils, exudates of fibrins, and mild alveolitis, which reflect the GGOs and consolidations on CT. However, pulmonary nodules were also found on CT in this patient. Minute necrotic nodules can be found in some cases with Varicella pneumonia (16). Multiple necrotic and hemorrhagic lesions with interstitial edema and mononuclear cell infiltration in chickenpox pneumonia have also been reported (17). However, we were unable to detect such histologic lesions in our patient with HRV viremia. Treatment of HRV infection generally consists of supportive care. Some studies have reported the efficacy of interferon-α, blockade of the intercellular adhesion molecule (ICAM)-1 receptor, capsid-binding agents, and 3C protease inhibitors for HRV infection (4), but these therapies have not been approved for use in Japan. In case 1, we initially suspected hematogenous infection, such as septic pulmonary embolism, and started antibiotics, but they were not effective, and no significant pathogens were isolated, including from blood cultures. We subsequently administered systemic corticosteroid because this patient's condition deteriorated rapidly, and CT findings showed expanding GGOs in the lung fields, which suggested acute progressive interstitial pneumonia. About half of cases of suspected acute progressive interstitial pneumonia are reportedly viral pneumonia (7). The effectiveness of steroids in viral pneumonia has been suggested only in limited viruses (18,19), and the efficacy of steroids for HRV pneumonia has been reported only in a limited number of cases (20). However, our patient's respiratory condition improved after the administration of steroids. Proinflammatory cytokines and chemokines have been shown to play a role in the disease course (4). It is worth keeping track of whether or not blocking these proteins affects the clinical outcome. Corticosteroids may have alleviated the excessive inflammatory response in case 1. In contrast, the patient in case 2 did not receive corticosteroids but instead antibiotics, and her condition also improved. Significant pathogens were not detected by culture and paired sera, indicating that her recovery was primarily due to supportive care. A treatment strategy for HRV pneumonia has not been established yet, and further studies are needed. In conclusion, we presented two cases of HRV pneumonia with prominent multiple nodules. Each pattern of progression was suggested to be hematogenous and by transbronchial spreading, although such an image pattern seems to be rare in HRV pneumonia. Multiplex PCR was useful for diagnosing these cases. Further cases are needed to establish effective treatment strategies for HRV pneumonia. The authors state that they have no Conflict of Interest (COI). Financial Support A part of this study was supported by a Research Fund from Saitama Cardiovascular and Respiratory Center under Grant Nos. 16ES, 17ES, and 18ES.	PREDNISOLONE	DrugsGivenReaction	CC BY-NC-ND	32863361	19,777,698	2021-02-01
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Rhinovirus infection'.	Two Cases of Primary Rhinovirus Pneumonia with Multiple Pulmonary Nodules. Two patients, a 60-year-old man and 43-year-old woman, presented to our hospital with symptoms of respiratory tract infection. These patients showed imaging findings of multiple small nodules, ground-glass opacities, and consolidations. In case 1, although antibiotics were started, bilateral shadows spread widely, which made us suspect interstitial pneumonia. The condition improved after steroid administration, and there has been no recurrence since completing this treatment. In case 2, the patient recovered rapidly with antibiotics only. In both cases, we performed bronchoalveolar lavage, in which only human rhinovirus infection was detected by multiplex polymerase chain reaction testing, and primary rhinovirus pneumonia was diagnosed. Introduction Human rhinovirus (HRV), which is the most common pathogen of the common cold, is a member of the enterovirus genus, family Picornaviridae. In recent years, HRV has been reported to cause not only upper but also lower respiratory tract infection including primary viral pneumonia (1). Some studies of community-acquired pneumonia have reported that HRV is the most common virus in viral pneumonia (2,3). We herein report two cases of HRV pneumonia diagnosed by multiplex polymerase chain reaction (PCR) from bronchoalveolar lavage (BAL) fluid. Our two cases showed computed tomography (CT) findings of multiple nodules, which are rare in HRV. Some nodules were randomly distributed, as in case 1, while others showed a centrilobular distribution, as in case 2. We describe these cases and review the clinical and radiological features of HRV pneumonia. Case Reports Case 1 A 60-year-old man who worked as a dentist presented to our hospital with a 1-week history of general fatigue, a fever, and a cough in mid-January 2019. He did not have rhinorrhea or a sore throat. His history included bronchial asthma for 30 years, and he had received corticosteroid administration (prednisolone 20 mg daily for 2 weeks) for treatment of an asthma attack until 10 days before admission to our hospital. Arthralgia, myalgia, and a fever of 38.7°C also developed one day before his presentation, and he was admitted for a further evaluation. Although he had had no evident contact with sick people, he treated about 30 patients a day at his dental clinic. He had never smoked or drank, had never been exposed to dust, and had no relevant family medical history. His vital signs included a blood pressure of 100/68 mmHg, heart rate of 78 beats/min, and respiratory rate of 20/min. His body mass index was 24.2 kg/m2. Arterial blood gasses under ambient air showed a pH of 7.49, PaCO2 of 37.2 Torr, PaO2 of 72.1 Torr, and HCO3- of 27.4 mmol/L. Laboratory tests showed a white blood cell (WBC) count of 9,800/mm3 (neutrophils, 5,500/mm3; lymphocytes, 3,400/mm3; eosinophils, 200/mm3; and monocytes, 700/mm3), hemoglobin, 16.0 g/dL; platelet count, 13.1×104/mm3; aspartate aminotransferase (AST), 31 IU/L; lactate dehydrogenase (LDH), 253 IU/L; blood urea nitrogen, 7 mg/dL; creatinine, 0.7 mg/dL; C-reactive protein, 3.2 mg/dL; and procalcitonin, 0.069 ng/mL. Autoantibodies were negative. Rapid nasopharyngeal or oropharyngeal diagnostic test and urinary antigen testing for influenza virus, Streptococcus pneumoniae, Legionella spp., and M. pneumoniae were all negative, as was cytomegalovirus antigenemia determined by the C7-horseradish peroxidase (HRP) method. Chest X-ray showed nodules in the bilateral lung fields (Fig. 1a). CT showed diffuse bronchial wall thickening and bilateral small nodules existing along the airways, but some nodules were randomly distributed (Fig. 1b). We suspected pulmonary septic emboli, but a repeat blood culture was negative, and no focus of infection outside the lung was found by systemic surveys. Figure 1. Chest imaging findings of case 1. Chest X-ray on admission showed nodules in the bilateral lung fields (a). Computed tomography showed diffuse bronchial wall thickening and bilateral small nodules that existed along the airways, but some nodules were randomly distributed (arrows) (b1, 2). Chest X-ray performed on hospital day 10 showed increased bilateral shadows (c). Computed tomography on hospital day 10 showed bilateral consolidations and shrinkage change with bronchodilation and distortion (d). We started piperacillin/tazobactam, but his respiratory condition worsened, and bilateral shadows had increased on hospital day 10 (Fig. 1c). CT showed bilateral ground-glass opacities (GGOs), consolidations, and shrinkage change with bronchodilation and distortion (Fig. 1d). We performed BAL from the anterior segment of the right upper lobe (49 of 150 mL recovered), which showed 10.0×105 cells/mL (neutrophils, 23.5%; lymphocytes, 74.1%; eosinophils, 2.0%; and basophils, 0.4%). A transbronchial lung biopsy from the anterior basal segment of the right upper lobe revealed the accumulation of macrophages with few eosinophils and neutrophils, and exudates of fibrins and mild alveolitis were also found (Fig. 2). Figure 2. Histological findings of case 1. A transbronchial lung biopsy showed the accumulation of macrophages with few eosinophils and neutrophils. Exudates of fibrins and mild alveolitis were also found. We initially suspected interstitial pneumonia and started methylprednisolone 1 g daily for 3 days, followed by 60 mg daily, which improved his condition. BAL fluid showed positive results for HRV on multiplex PCR [FTD Resp 21 Kit (Fast Track Diagnostics, Silema, Malta), which detects the following respiratory pathogens: influenza A and B viruses; coronaviruses NL63, 229E, OC43, and HKU1; human parainfluenza viruses 1-4; human metapneumovirus A/B; respiratory syncytial virus A/B; adenovirus; enterovirus; human parechovirus; bocavirus; and Mycoplasma pneumoniae] but negative results for other viruses and M. pneumoniae. Cultures of BAL fluid, blood, and bronchial aspirates were also negative for bacteria including M. pneumoniae. The methylprednisolone was then decreased. His fever abated on hospital day 13, and his respiratory condition improved. Specific antibody titers against M. pneumoniae, Chlamydophila pneumoniae, C. psittaci, Legionella spp., influenza virus, adenovirus, respiratory syncytial virus, and parainfluenza virus (serotypes 1-4) in paired sera did not increase. Bilateral GGOs, consolidations, and shrinkage change with bronchodilation and distortion improved on CT at 40 days after discharge. The methylprednisolone was gradually tapered and discontinued six months after discharge, and there has been no recurrence in the five months since discontinuing steroids. Case 2 A 43-year-old housewife presented to our hospital with rhinorrhea, sore throat, chills, a fever of 39-40°C, and dyspnea for 10 days at the end of November 2018. She had visited a local physician who started her on levofloxacin, but her body temperature did not decrease, and she developed a dyspneic cough for which she was referred to our hospital. She had never smoked or drank, had no apparent personal or family medical history, and had no evident contact with sick people. Her body mass index was 18.7 kg/m2. A physical examination revealed bilateral fine crackles, and arterial blood gases under O2 of 1 L/min by nasal cannula showed a pH of 7.49, PaCO2 of 34.2 Torr, PaO2 of 144.0 Torr, and HCO3- of 25.3 mmol/L. Laboratory tests showed a WBC of 5,400/mm3 (neutrophils, 3,900/mm3; lymphocytes, 700/mm3; eosinophils, 500/mm3; and monocytes, 300/mm3), hemoglobin, 12.9 g/dL; platelets, 22.1×104/mm3; AST, 22 IU/L; LDH, 220 IU/L; blood urea nitrogen, 5 mg/dL; creatinine, 0.6 mg/dL; C-reactive protein; 7.1 mg/dL; and procalcitonin, 0.266 ng/mL. Autoantibodies were negative. A rapid influenza diagnostic test and urinary antigen testing for S. pneumoniae, Legionella spp., and M. pneumoniae were negative. Chest X-ray showed bilateral consolidations (Fig. 3a), and CT showed bilateral GGOs and bilateral small centrilobular nodules (Fig. 3b, c). We performed BAL (84 of 150 mL recovered) from the lateral segment of the right middle lobe, which showed 11.8×105 cells/mL (macrophages, 37.2%; neutrophils, 3.6%; lymphocytes, 40.0%, and eosinophils, 19.2%). BAL fluid did not yield significant pathogens. Multiplex PCR (FTD21 Resp Kit) of the BAL fluid showed positive results only for HRV. Figure 3. Chest imaging findings of case 2. Chest X-ray showed bilateral consolidation (a). Computed tomography showed bilateral ground-glass opacities and centrilobular nodules (b, c). Once ceftriaxone was administered, her fever abated by hospital day 3, and she was discharged on hospital day 10. Specific antibody titers against M. pneumoniae, C. pneumoniae, C. psittaci, Legionella spp., influenza virus, adenovirus, respiratory syncytial virus, and parainfluenza virus (serotypes 1-4) in paired sera did not increase. Her chest imaging findings improved quickly, and the bilateral GGOs had disappeared by two weeks after discharge. Discussion As the one of the most common pathogens to infect humans and the most important cause of the common cold (4), HRV has been implicated in 30% to 50% of all cases of acute respiratory disease. In recent years, HRV has been reported to be a major cause of exacerbations of asthma and other chronic pulmonary diseases (5,6) and has also been found to cause lower respiratory tract infections, including pneumonia (1). Our patient in case 2 showed symptoms of upper respiratory tract infection, such as rhinorrhea and sore throat, whereas the patient in case 1 had no such symptoms, which indicates that HRV pneumonia should not be ruled out when patients do not have symptoms of upper respiratory tract infection. A previous study reported that, in patients with primary viral pneumonia, only 20.8% had sore throat and 3.8% had rhinorrhea (7). In the study of the pathogens of community-acquired pneumonia requiring hospitalization conducted by the Centers for Disease Control and Prevention in 2015, respiratory viruses were detected more frequently than bacteria. The most common pathogen was HRV, which accounted for 9% of the total patients (8). Neither of our two cases was associated with severe respiratory failure, but some severe cases have been reported. Of 49 mechanically ventilated patients with severe community-acquired pneumonia, 24 had viral infection (49%), and HRV was the most common virus, accounting for 58% of the infections (3). In another report of 20 patients with HRV-associated community-acquired pneumonia, 14 developed respiratory failure, and 13 required mechanical ventilation (9). The CT findings of HRV pneumonia include bilateral multifocal patchy consolidations, multiple GGOs, interlobular septal thickening, and pleural effusion, but nodules are rare (9-11). Our two cases showed bilateral nodules, with case 1 showing randomly distributed nodules and case 2 showing centrilobular nodules. In case 1, although viral culture of blood was not performed and viremia was not proven, the imaging findings suggested hematological spread. In a previous report on 356 children and 146 adults with HRV pneumonia, 57 patients showed HRV viremia, all children (12). In another study, HRV viremia was found in 10 (11.4%) of 88 HRV-infected children: 7 of 28 children with an asthma attack, 2 of 26 with a common cold, and 1 of 25 with bronchiolitis (13). Factors associated with HRV viremia were sampling within 24 hours from the onset of symptoms and asthma. The increased susceptibility of individuals with asthma to viral, particularly HRV, infections has been considered (14). Although why the present case 1 showed viremia is unclear, we suspect that the immunocompromised state caused by systemic steroids for the asthma attack experienced before developing pneumonia might have been involved. To our knowledge, there have been no reports of HRV viremia in adults, but our experience showed that HRV viremia in adults can develop under such conditions. In contrast, Case 2 suggested transbronchial spread. Various histologic patterns of lung injury have been described in viral pneumonia. Some viruses produce specific nuclear changes or characteristic cytoplasmic inclusions (15). However, the histologic characteristics of HRV pneumonia are not well known. Case 1 in the present study showed an accumulation of macrophages with few eosinophils and neutrophils, exudates of fibrins, and mild alveolitis, which reflect the GGOs and consolidations on CT. However, pulmonary nodules were also found on CT in this patient. Minute necrotic nodules can be found in some cases with Varicella pneumonia (16). Multiple necrotic and hemorrhagic lesions with interstitial edema and mononuclear cell infiltration in chickenpox pneumonia have also been reported (17). However, we were unable to detect such histologic lesions in our patient with HRV viremia. Treatment of HRV infection generally consists of supportive care. Some studies have reported the efficacy of interferon-α, blockade of the intercellular adhesion molecule (ICAM)-1 receptor, capsid-binding agents, and 3C protease inhibitors for HRV infection (4), but these therapies have not been approved for use in Japan. In case 1, we initially suspected hematogenous infection, such as septic pulmonary embolism, and started antibiotics, but they were not effective, and no significant pathogens were isolated, including from blood cultures. We subsequently administered systemic corticosteroid because this patient's condition deteriorated rapidly, and CT findings showed expanding GGOs in the lung fields, which suggested acute progressive interstitial pneumonia. About half of cases of suspected acute progressive interstitial pneumonia are reportedly viral pneumonia (7). The effectiveness of steroids in viral pneumonia has been suggested only in limited viruses (18,19), and the efficacy of steroids for HRV pneumonia has been reported only in a limited number of cases (20). However, our patient's respiratory condition improved after the administration of steroids. Proinflammatory cytokines and chemokines have been shown to play a role in the disease course (4). It is worth keeping track of whether or not blocking these proteins affects the clinical outcome. Corticosteroids may have alleviated the excessive inflammatory response in case 1. In contrast, the patient in case 2 did not receive corticosteroids but instead antibiotics, and her condition also improved. Significant pathogens were not detected by culture and paired sera, indicating that her recovery was primarily due to supportive care. A treatment strategy for HRV pneumonia has not been established yet, and further studies are needed. In conclusion, we presented two cases of HRV pneumonia with prominent multiple nodules. Each pattern of progression was suggested to be hematogenous and by transbronchial spreading, although such an image pattern seems to be rare in HRV pneumonia. Multiplex PCR was useful for diagnosing these cases. Further cases are needed to establish effective treatment strategies for HRV pneumonia. The authors state that they have no Conflict of Interest (COI). Financial Support A part of this study was supported by a Research Fund from Saitama Cardiovascular and Respiratory Center under Grant Nos. 16ES, 17ES, and 18ES.	PREDNISOLONE	DrugsGivenReaction	CC BY-NC-ND	32863361	19,777,698	2021-02-01
What was the outcome of reaction 'Pneumonia viral'?	Two Cases of Primary Rhinovirus Pneumonia with Multiple Pulmonary Nodules. Two patients, a 60-year-old man and 43-year-old woman, presented to our hospital with symptoms of respiratory tract infection. These patients showed imaging findings of multiple small nodules, ground-glass opacities, and consolidations. In case 1, although antibiotics were started, bilateral shadows spread widely, which made us suspect interstitial pneumonia. The condition improved after steroid administration, and there has been no recurrence since completing this treatment. In case 2, the patient recovered rapidly with antibiotics only. In both cases, we performed bronchoalveolar lavage, in which only human rhinovirus infection was detected by multiplex polymerase chain reaction testing, and primary rhinovirus pneumonia was diagnosed. Introduction Human rhinovirus (HRV), which is the most common pathogen of the common cold, is a member of the enterovirus genus, family Picornaviridae. In recent years, HRV has been reported to cause not only upper but also lower respiratory tract infection including primary viral pneumonia (1). Some studies of community-acquired pneumonia have reported that HRV is the most common virus in viral pneumonia (2,3). We herein report two cases of HRV pneumonia diagnosed by multiplex polymerase chain reaction (PCR) from bronchoalveolar lavage (BAL) fluid. Our two cases showed computed tomography (CT) findings of multiple nodules, which are rare in HRV. Some nodules were randomly distributed, as in case 1, while others showed a centrilobular distribution, as in case 2. We describe these cases and review the clinical and radiological features of HRV pneumonia. Case Reports Case 1 A 60-year-old man who worked as a dentist presented to our hospital with a 1-week history of general fatigue, a fever, and a cough in mid-January 2019. He did not have rhinorrhea or a sore throat. His history included bronchial asthma for 30 years, and he had received corticosteroid administration (prednisolone 20 mg daily for 2 weeks) for treatment of an asthma attack until 10 days before admission to our hospital. Arthralgia, myalgia, and a fever of 38.7°C also developed one day before his presentation, and he was admitted for a further evaluation. Although he had had no evident contact with sick people, he treated about 30 patients a day at his dental clinic. He had never smoked or drank, had never been exposed to dust, and had no relevant family medical history. His vital signs included a blood pressure of 100/68 mmHg, heart rate of 78 beats/min, and respiratory rate of 20/min. His body mass index was 24.2 kg/m2. Arterial blood gasses under ambient air showed a pH of 7.49, PaCO2 of 37.2 Torr, PaO2 of 72.1 Torr, and HCO3- of 27.4 mmol/L. Laboratory tests showed a white blood cell (WBC) count of 9,800/mm3 (neutrophils, 5,500/mm3; lymphocytes, 3,400/mm3; eosinophils, 200/mm3; and monocytes, 700/mm3), hemoglobin, 16.0 g/dL; platelet count, 13.1×104/mm3; aspartate aminotransferase (AST), 31 IU/L; lactate dehydrogenase (LDH), 253 IU/L; blood urea nitrogen, 7 mg/dL; creatinine, 0.7 mg/dL; C-reactive protein, 3.2 mg/dL; and procalcitonin, 0.069 ng/mL. Autoantibodies were negative. Rapid nasopharyngeal or oropharyngeal diagnostic test and urinary antigen testing for influenza virus, Streptococcus pneumoniae, Legionella spp., and M. pneumoniae were all negative, as was cytomegalovirus antigenemia determined by the C7-horseradish peroxidase (HRP) method. Chest X-ray showed nodules in the bilateral lung fields (Fig. 1a). CT showed diffuse bronchial wall thickening and bilateral small nodules existing along the airways, but some nodules were randomly distributed (Fig. 1b). We suspected pulmonary septic emboli, but a repeat blood culture was negative, and no focus of infection outside the lung was found by systemic surveys. Figure 1. Chest imaging findings of case 1. Chest X-ray on admission showed nodules in the bilateral lung fields (a). Computed tomography showed diffuse bronchial wall thickening and bilateral small nodules that existed along the airways, but some nodules were randomly distributed (arrows) (b1, 2). Chest X-ray performed on hospital day 10 showed increased bilateral shadows (c). Computed tomography on hospital day 10 showed bilateral consolidations and shrinkage change with bronchodilation and distortion (d). We started piperacillin/tazobactam, but his respiratory condition worsened, and bilateral shadows had increased on hospital day 10 (Fig. 1c). CT showed bilateral ground-glass opacities (GGOs), consolidations, and shrinkage change with bronchodilation and distortion (Fig. 1d). We performed BAL from the anterior segment of the right upper lobe (49 of 150 mL recovered), which showed 10.0×105 cells/mL (neutrophils, 23.5%; lymphocytes, 74.1%; eosinophils, 2.0%; and basophils, 0.4%). A transbronchial lung biopsy from the anterior basal segment of the right upper lobe revealed the accumulation of macrophages with few eosinophils and neutrophils, and exudates of fibrins and mild alveolitis were also found (Fig. 2). Figure 2. Histological findings of case 1. A transbronchial lung biopsy showed the accumulation of macrophages with few eosinophils and neutrophils. Exudates of fibrins and mild alveolitis were also found. We initially suspected interstitial pneumonia and started methylprednisolone 1 g daily for 3 days, followed by 60 mg daily, which improved his condition. BAL fluid showed positive results for HRV on multiplex PCR [FTD Resp 21 Kit (Fast Track Diagnostics, Silema, Malta), which detects the following respiratory pathogens: influenza A and B viruses; coronaviruses NL63, 229E, OC43, and HKU1; human parainfluenza viruses 1-4; human metapneumovirus A/B; respiratory syncytial virus A/B; adenovirus; enterovirus; human parechovirus; bocavirus; and Mycoplasma pneumoniae] but negative results for other viruses and M. pneumoniae. Cultures of BAL fluid, blood, and bronchial aspirates were also negative for bacteria including M. pneumoniae. The methylprednisolone was then decreased. His fever abated on hospital day 13, and his respiratory condition improved. Specific antibody titers against M. pneumoniae, Chlamydophila pneumoniae, C. psittaci, Legionella spp., influenza virus, adenovirus, respiratory syncytial virus, and parainfluenza virus (serotypes 1-4) in paired sera did not increase. Bilateral GGOs, consolidations, and shrinkage change with bronchodilation and distortion improved on CT at 40 days after discharge. The methylprednisolone was gradually tapered and discontinued six months after discharge, and there has been no recurrence in the five months since discontinuing steroids. Case 2 A 43-year-old housewife presented to our hospital with rhinorrhea, sore throat, chills, a fever of 39-40°C, and dyspnea for 10 days at the end of November 2018. She had visited a local physician who started her on levofloxacin, but her body temperature did not decrease, and she developed a dyspneic cough for which she was referred to our hospital. She had never smoked or drank, had no apparent personal or family medical history, and had no evident contact with sick people. Her body mass index was 18.7 kg/m2. A physical examination revealed bilateral fine crackles, and arterial blood gases under O2 of 1 L/min by nasal cannula showed a pH of 7.49, PaCO2 of 34.2 Torr, PaO2 of 144.0 Torr, and HCO3- of 25.3 mmol/L. Laboratory tests showed a WBC of 5,400/mm3 (neutrophils, 3,900/mm3; lymphocytes, 700/mm3; eosinophils, 500/mm3; and monocytes, 300/mm3), hemoglobin, 12.9 g/dL; platelets, 22.1×104/mm3; AST, 22 IU/L; LDH, 220 IU/L; blood urea nitrogen, 5 mg/dL; creatinine, 0.6 mg/dL; C-reactive protein; 7.1 mg/dL; and procalcitonin, 0.266 ng/mL. Autoantibodies were negative. A rapid influenza diagnostic test and urinary antigen testing for S. pneumoniae, Legionella spp., and M. pneumoniae were negative. Chest X-ray showed bilateral consolidations (Fig. 3a), and CT showed bilateral GGOs and bilateral small centrilobular nodules (Fig. 3b, c). We performed BAL (84 of 150 mL recovered) from the lateral segment of the right middle lobe, which showed 11.8×105 cells/mL (macrophages, 37.2%; neutrophils, 3.6%; lymphocytes, 40.0%, and eosinophils, 19.2%). BAL fluid did not yield significant pathogens. Multiplex PCR (FTD21 Resp Kit) of the BAL fluid showed positive results only for HRV. Figure 3. Chest imaging findings of case 2. Chest X-ray showed bilateral consolidation (a). Computed tomography showed bilateral ground-glass opacities and centrilobular nodules (b, c). Once ceftriaxone was administered, her fever abated by hospital day 3, and she was discharged on hospital day 10. Specific antibody titers against M. pneumoniae, C. pneumoniae, C. psittaci, Legionella spp., influenza virus, adenovirus, respiratory syncytial virus, and parainfluenza virus (serotypes 1-4) in paired sera did not increase. Her chest imaging findings improved quickly, and the bilateral GGOs had disappeared by two weeks after discharge. Discussion As the one of the most common pathogens to infect humans and the most important cause of the common cold (4), HRV has been implicated in 30% to 50% of all cases of acute respiratory disease. In recent years, HRV has been reported to be a major cause of exacerbations of asthma and other chronic pulmonary diseases (5,6) and has also been found to cause lower respiratory tract infections, including pneumonia (1). Our patient in case 2 showed symptoms of upper respiratory tract infection, such as rhinorrhea and sore throat, whereas the patient in case 1 had no such symptoms, which indicates that HRV pneumonia should not be ruled out when patients do not have symptoms of upper respiratory tract infection. A previous study reported that, in patients with primary viral pneumonia, only 20.8% had sore throat and 3.8% had rhinorrhea (7). In the study of the pathogens of community-acquired pneumonia requiring hospitalization conducted by the Centers for Disease Control and Prevention in 2015, respiratory viruses were detected more frequently than bacteria. The most common pathogen was HRV, which accounted for 9% of the total patients (8). Neither of our two cases was associated with severe respiratory failure, but some severe cases have been reported. Of 49 mechanically ventilated patients with severe community-acquired pneumonia, 24 had viral infection (49%), and HRV was the most common virus, accounting for 58% of the infections (3). In another report of 20 patients with HRV-associated community-acquired pneumonia, 14 developed respiratory failure, and 13 required mechanical ventilation (9). The CT findings of HRV pneumonia include bilateral multifocal patchy consolidations, multiple GGOs, interlobular septal thickening, and pleural effusion, but nodules are rare (9-11). Our two cases showed bilateral nodules, with case 1 showing randomly distributed nodules and case 2 showing centrilobular nodules. In case 1, although viral culture of blood was not performed and viremia was not proven, the imaging findings suggested hematological spread. In a previous report on 356 children and 146 adults with HRV pneumonia, 57 patients showed HRV viremia, all children (12). In another study, HRV viremia was found in 10 (11.4%) of 88 HRV-infected children: 7 of 28 children with an asthma attack, 2 of 26 with a common cold, and 1 of 25 with bronchiolitis (13). Factors associated with HRV viremia were sampling within 24 hours from the onset of symptoms and asthma. The increased susceptibility of individuals with asthma to viral, particularly HRV, infections has been considered (14). Although why the present case 1 showed viremia is unclear, we suspect that the immunocompromised state caused by systemic steroids for the asthma attack experienced before developing pneumonia might have been involved. To our knowledge, there have been no reports of HRV viremia in adults, but our experience showed that HRV viremia in adults can develop under such conditions. In contrast, Case 2 suggested transbronchial spread. Various histologic patterns of lung injury have been described in viral pneumonia. Some viruses produce specific nuclear changes or characteristic cytoplasmic inclusions (15). However, the histologic characteristics of HRV pneumonia are not well known. Case 1 in the present study showed an accumulation of macrophages with few eosinophils and neutrophils, exudates of fibrins, and mild alveolitis, which reflect the GGOs and consolidations on CT. However, pulmonary nodules were also found on CT in this patient. Minute necrotic nodules can be found in some cases with Varicella pneumonia (16). Multiple necrotic and hemorrhagic lesions with interstitial edema and mononuclear cell infiltration in chickenpox pneumonia have also been reported (17). However, we were unable to detect such histologic lesions in our patient with HRV viremia. Treatment of HRV infection generally consists of supportive care. Some studies have reported the efficacy of interferon-α, blockade of the intercellular adhesion molecule (ICAM)-1 receptor, capsid-binding agents, and 3C protease inhibitors for HRV infection (4), but these therapies have not been approved for use in Japan. In case 1, we initially suspected hematogenous infection, such as septic pulmonary embolism, and started antibiotics, but they were not effective, and no significant pathogens were isolated, including from blood cultures. We subsequently administered systemic corticosteroid because this patient's condition deteriorated rapidly, and CT findings showed expanding GGOs in the lung fields, which suggested acute progressive interstitial pneumonia. About half of cases of suspected acute progressive interstitial pneumonia are reportedly viral pneumonia (7). The effectiveness of steroids in viral pneumonia has been suggested only in limited viruses (18,19), and the efficacy of steroids for HRV pneumonia has been reported only in a limited number of cases (20). However, our patient's respiratory condition improved after the administration of steroids. Proinflammatory cytokines and chemokines have been shown to play a role in the disease course (4). It is worth keeping track of whether or not blocking these proteins affects the clinical outcome. Corticosteroids may have alleviated the excessive inflammatory response in case 1. In contrast, the patient in case 2 did not receive corticosteroids but instead antibiotics, and her condition also improved. Significant pathogens were not detected by culture and paired sera, indicating that her recovery was primarily due to supportive care. A treatment strategy for HRV pneumonia has not been established yet, and further studies are needed. In conclusion, we presented two cases of HRV pneumonia with prominent multiple nodules. Each pattern of progression was suggested to be hematogenous and by transbronchial spreading, although such an image pattern seems to be rare in HRV pneumonia. Multiplex PCR was useful for diagnosing these cases. Further cases are needed to establish effective treatment strategies for HRV pneumonia. The authors state that they have no Conflict of Interest (COI). Financial Support A part of this study was supported by a Research Fund from Saitama Cardiovascular and Respiratory Center under Grant Nos. 16ES, 17ES, and 18ES.	Recovered	ReactionOutcome	CC BY-NC-ND	32863361	19,777,698	2021-02-01
What was the outcome of reaction 'Rhinovirus infection'?	Two Cases of Primary Rhinovirus Pneumonia with Multiple Pulmonary Nodules. Two patients, a 60-year-old man and 43-year-old woman, presented to our hospital with symptoms of respiratory tract infection. These patients showed imaging findings of multiple small nodules, ground-glass opacities, and consolidations. In case 1, although antibiotics were started, bilateral shadows spread widely, which made us suspect interstitial pneumonia. The condition improved after steroid administration, and there has been no recurrence since completing this treatment. In case 2, the patient recovered rapidly with antibiotics only. In both cases, we performed bronchoalveolar lavage, in which only human rhinovirus infection was detected by multiplex polymerase chain reaction testing, and primary rhinovirus pneumonia was diagnosed. Introduction Human rhinovirus (HRV), which is the most common pathogen of the common cold, is a member of the enterovirus genus, family Picornaviridae. In recent years, HRV has been reported to cause not only upper but also lower respiratory tract infection including primary viral pneumonia (1). Some studies of community-acquired pneumonia have reported that HRV is the most common virus in viral pneumonia (2,3). We herein report two cases of HRV pneumonia diagnosed by multiplex polymerase chain reaction (PCR) from bronchoalveolar lavage (BAL) fluid. Our two cases showed computed tomography (CT) findings of multiple nodules, which are rare in HRV. Some nodules were randomly distributed, as in case 1, while others showed a centrilobular distribution, as in case 2. We describe these cases and review the clinical and radiological features of HRV pneumonia. Case Reports Case 1 A 60-year-old man who worked as a dentist presented to our hospital with a 1-week history of general fatigue, a fever, and a cough in mid-January 2019. He did not have rhinorrhea or a sore throat. His history included bronchial asthma for 30 years, and he had received corticosteroid administration (prednisolone 20 mg daily for 2 weeks) for treatment of an asthma attack until 10 days before admission to our hospital. Arthralgia, myalgia, and a fever of 38.7°C also developed one day before his presentation, and he was admitted for a further evaluation. Although he had had no evident contact with sick people, he treated about 30 patients a day at his dental clinic. He had never smoked or drank, had never been exposed to dust, and had no relevant family medical history. His vital signs included a blood pressure of 100/68 mmHg, heart rate of 78 beats/min, and respiratory rate of 20/min. His body mass index was 24.2 kg/m2. Arterial blood gasses under ambient air showed a pH of 7.49, PaCO2 of 37.2 Torr, PaO2 of 72.1 Torr, and HCO3- of 27.4 mmol/L. Laboratory tests showed a white blood cell (WBC) count of 9,800/mm3 (neutrophils, 5,500/mm3; lymphocytes, 3,400/mm3; eosinophils, 200/mm3; and monocytes, 700/mm3), hemoglobin, 16.0 g/dL; platelet count, 13.1×104/mm3; aspartate aminotransferase (AST), 31 IU/L; lactate dehydrogenase (LDH), 253 IU/L; blood urea nitrogen, 7 mg/dL; creatinine, 0.7 mg/dL; C-reactive protein, 3.2 mg/dL; and procalcitonin, 0.069 ng/mL. Autoantibodies were negative. Rapid nasopharyngeal or oropharyngeal diagnostic test and urinary antigen testing for influenza virus, Streptococcus pneumoniae, Legionella spp., and M. pneumoniae were all negative, as was cytomegalovirus antigenemia determined by the C7-horseradish peroxidase (HRP) method. Chest X-ray showed nodules in the bilateral lung fields (Fig. 1a). CT showed diffuse bronchial wall thickening and bilateral small nodules existing along the airways, but some nodules were randomly distributed (Fig. 1b). We suspected pulmonary septic emboli, but a repeat blood culture was negative, and no focus of infection outside the lung was found by systemic surveys. Figure 1. Chest imaging findings of case 1. Chest X-ray on admission showed nodules in the bilateral lung fields (a). Computed tomography showed diffuse bronchial wall thickening and bilateral small nodules that existed along the airways, but some nodules were randomly distributed (arrows) (b1, 2). Chest X-ray performed on hospital day 10 showed increased bilateral shadows (c). Computed tomography on hospital day 10 showed bilateral consolidations and shrinkage change with bronchodilation and distortion (d). We started piperacillin/tazobactam, but his respiratory condition worsened, and bilateral shadows had increased on hospital day 10 (Fig. 1c). CT showed bilateral ground-glass opacities (GGOs), consolidations, and shrinkage change with bronchodilation and distortion (Fig. 1d). We performed BAL from the anterior segment of the right upper lobe (49 of 150 mL recovered), which showed 10.0×105 cells/mL (neutrophils, 23.5%; lymphocytes, 74.1%; eosinophils, 2.0%; and basophils, 0.4%). A transbronchial lung biopsy from the anterior basal segment of the right upper lobe revealed the accumulation of macrophages with few eosinophils and neutrophils, and exudates of fibrins and mild alveolitis were also found (Fig. 2). Figure 2. Histological findings of case 1. A transbronchial lung biopsy showed the accumulation of macrophages with few eosinophils and neutrophils. Exudates of fibrins and mild alveolitis were also found. We initially suspected interstitial pneumonia and started methylprednisolone 1 g daily for 3 days, followed by 60 mg daily, which improved his condition. BAL fluid showed positive results for HRV on multiplex PCR [FTD Resp 21 Kit (Fast Track Diagnostics, Silema, Malta), which detects the following respiratory pathogens: influenza A and B viruses; coronaviruses NL63, 229E, OC43, and HKU1; human parainfluenza viruses 1-4; human metapneumovirus A/B; respiratory syncytial virus A/B; adenovirus; enterovirus; human parechovirus; bocavirus; and Mycoplasma pneumoniae] but negative results for other viruses and M. pneumoniae. Cultures of BAL fluid, blood, and bronchial aspirates were also negative for bacteria including M. pneumoniae. The methylprednisolone was then decreased. His fever abated on hospital day 13, and his respiratory condition improved. Specific antibody titers against M. pneumoniae, Chlamydophila pneumoniae, C. psittaci, Legionella spp., influenza virus, adenovirus, respiratory syncytial virus, and parainfluenza virus (serotypes 1-4) in paired sera did not increase. Bilateral GGOs, consolidations, and shrinkage change with bronchodilation and distortion improved on CT at 40 days after discharge. The methylprednisolone was gradually tapered and discontinued six months after discharge, and there has been no recurrence in the five months since discontinuing steroids. Case 2 A 43-year-old housewife presented to our hospital with rhinorrhea, sore throat, chills, a fever of 39-40°C, and dyspnea for 10 days at the end of November 2018. She had visited a local physician who started her on levofloxacin, but her body temperature did not decrease, and she developed a dyspneic cough for which she was referred to our hospital. She had never smoked or drank, had no apparent personal or family medical history, and had no evident contact with sick people. Her body mass index was 18.7 kg/m2. A physical examination revealed bilateral fine crackles, and arterial blood gases under O2 of 1 L/min by nasal cannula showed a pH of 7.49, PaCO2 of 34.2 Torr, PaO2 of 144.0 Torr, and HCO3- of 25.3 mmol/L. Laboratory tests showed a WBC of 5,400/mm3 (neutrophils, 3,900/mm3; lymphocytes, 700/mm3; eosinophils, 500/mm3; and monocytes, 300/mm3), hemoglobin, 12.9 g/dL; platelets, 22.1×104/mm3; AST, 22 IU/L; LDH, 220 IU/L; blood urea nitrogen, 5 mg/dL; creatinine, 0.6 mg/dL; C-reactive protein; 7.1 mg/dL; and procalcitonin, 0.266 ng/mL. Autoantibodies were negative. A rapid influenza diagnostic test and urinary antigen testing for S. pneumoniae, Legionella spp., and M. pneumoniae were negative. Chest X-ray showed bilateral consolidations (Fig. 3a), and CT showed bilateral GGOs and bilateral small centrilobular nodules (Fig. 3b, c). We performed BAL (84 of 150 mL recovered) from the lateral segment of the right middle lobe, which showed 11.8×105 cells/mL (macrophages, 37.2%; neutrophils, 3.6%; lymphocytes, 40.0%, and eosinophils, 19.2%). BAL fluid did not yield significant pathogens. Multiplex PCR (FTD21 Resp Kit) of the BAL fluid showed positive results only for HRV. Figure 3. Chest imaging findings of case 2. Chest X-ray showed bilateral consolidation (a). Computed tomography showed bilateral ground-glass opacities and centrilobular nodules (b, c). Once ceftriaxone was administered, her fever abated by hospital day 3, and she was discharged on hospital day 10. Specific antibody titers against M. pneumoniae, C. pneumoniae, C. psittaci, Legionella spp., influenza virus, adenovirus, respiratory syncytial virus, and parainfluenza virus (serotypes 1-4) in paired sera did not increase. Her chest imaging findings improved quickly, and the bilateral GGOs had disappeared by two weeks after discharge. Discussion As the one of the most common pathogens to infect humans and the most important cause of the common cold (4), HRV has been implicated in 30% to 50% of all cases of acute respiratory disease. In recent years, HRV has been reported to be a major cause of exacerbations of asthma and other chronic pulmonary diseases (5,6) and has also been found to cause lower respiratory tract infections, including pneumonia (1). Our patient in case 2 showed symptoms of upper respiratory tract infection, such as rhinorrhea and sore throat, whereas the patient in case 1 had no such symptoms, which indicates that HRV pneumonia should not be ruled out when patients do not have symptoms of upper respiratory tract infection. A previous study reported that, in patients with primary viral pneumonia, only 20.8% had sore throat and 3.8% had rhinorrhea (7). In the study of the pathogens of community-acquired pneumonia requiring hospitalization conducted by the Centers for Disease Control and Prevention in 2015, respiratory viruses were detected more frequently than bacteria. The most common pathogen was HRV, which accounted for 9% of the total patients (8). Neither of our two cases was associated with severe respiratory failure, but some severe cases have been reported. Of 49 mechanically ventilated patients with severe community-acquired pneumonia, 24 had viral infection (49%), and HRV was the most common virus, accounting for 58% of the infections (3). In another report of 20 patients with HRV-associated community-acquired pneumonia, 14 developed respiratory failure, and 13 required mechanical ventilation (9). The CT findings of HRV pneumonia include bilateral multifocal patchy consolidations, multiple GGOs, interlobular septal thickening, and pleural effusion, but nodules are rare (9-11). Our two cases showed bilateral nodules, with case 1 showing randomly distributed nodules and case 2 showing centrilobular nodules. In case 1, although viral culture of blood was not performed and viremia was not proven, the imaging findings suggested hematological spread. In a previous report on 356 children and 146 adults with HRV pneumonia, 57 patients showed HRV viremia, all children (12). In another study, HRV viremia was found in 10 (11.4%) of 88 HRV-infected children: 7 of 28 children with an asthma attack, 2 of 26 with a common cold, and 1 of 25 with bronchiolitis (13). Factors associated with HRV viremia were sampling within 24 hours from the onset of symptoms and asthma. The increased susceptibility of individuals with asthma to viral, particularly HRV, infections has been considered (14). Although why the present case 1 showed viremia is unclear, we suspect that the immunocompromised state caused by systemic steroids for the asthma attack experienced before developing pneumonia might have been involved. To our knowledge, there have been no reports of HRV viremia in adults, but our experience showed that HRV viremia in adults can develop under such conditions. In contrast, Case 2 suggested transbronchial spread. Various histologic patterns of lung injury have been described in viral pneumonia. Some viruses produce specific nuclear changes or characteristic cytoplasmic inclusions (15). However, the histologic characteristics of HRV pneumonia are not well known. Case 1 in the present study showed an accumulation of macrophages with few eosinophils and neutrophils, exudates of fibrins, and mild alveolitis, which reflect the GGOs and consolidations on CT. However, pulmonary nodules were also found on CT in this patient. Minute necrotic nodules can be found in some cases with Varicella pneumonia (16). Multiple necrotic and hemorrhagic lesions with interstitial edema and mononuclear cell infiltration in chickenpox pneumonia have also been reported (17). However, we were unable to detect such histologic lesions in our patient with HRV viremia. Treatment of HRV infection generally consists of supportive care. Some studies have reported the efficacy of interferon-α, blockade of the intercellular adhesion molecule (ICAM)-1 receptor, capsid-binding agents, and 3C protease inhibitors for HRV infection (4), but these therapies have not been approved for use in Japan. In case 1, we initially suspected hematogenous infection, such as septic pulmonary embolism, and started antibiotics, but they were not effective, and no significant pathogens were isolated, including from blood cultures. We subsequently administered systemic corticosteroid because this patient's condition deteriorated rapidly, and CT findings showed expanding GGOs in the lung fields, which suggested acute progressive interstitial pneumonia. About half of cases of suspected acute progressive interstitial pneumonia are reportedly viral pneumonia (7). The effectiveness of steroids in viral pneumonia has been suggested only in limited viruses (18,19), and the efficacy of steroids for HRV pneumonia has been reported only in a limited number of cases (20). However, our patient's respiratory condition improved after the administration of steroids. Proinflammatory cytokines and chemokines have been shown to play a role in the disease course (4). It is worth keeping track of whether or not blocking these proteins affects the clinical outcome. Corticosteroids may have alleviated the excessive inflammatory response in case 1. In contrast, the patient in case 2 did not receive corticosteroids but instead antibiotics, and her condition also improved. Significant pathogens were not detected by culture and paired sera, indicating that her recovery was primarily due to supportive care. A treatment strategy for HRV pneumonia has not been established yet, and further studies are needed. In conclusion, we presented two cases of HRV pneumonia with prominent multiple nodules. Each pattern of progression was suggested to be hematogenous and by transbronchial spreading, although such an image pattern seems to be rare in HRV pneumonia. Multiplex PCR was useful for diagnosing these cases. Further cases are needed to establish effective treatment strategies for HRV pneumonia. The authors state that they have no Conflict of Interest (COI). Financial Support A part of this study was supported by a Research Fund from Saitama Cardiovascular and Respiratory Center under Grant Nos. 16ES, 17ES, and 18ES.	Recovered	ReactionOutcome	CC BY-NC-ND	32863361	19,777,698	2021-02-01
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Cytomegalovirus viraemia'.	Rapid Virologic Response to Brincidofovir in Children with Disseminated Adenovirus Infection. Disseminated adenovirus infections (d-ADV) after hematopoietic cell transplant (HCT) are often fatal with limited treatment options. Brincidofovir (BCV) a lipid ester of cidofovir is developed for this indication. We report four pediatric HCT recipients with d-ADV treated successfully with BCV. pmcIntroduction Adenovirus (ADV) infections may occur in up to 40% of pediatric HCT recipients [1]. T-cell depletion (TCD) (ex vivo CD34+ or serotherapy with antithymocyte globulin or alemtuzumab), or severe graft-versus-host disease (GVHD) are associated with ADV infection post-HCT [2]. Recovery of ADV specific T-lymphocytes (ADV-CTLs) confers protection against ADV [3], whereas lymphopenia is a risk factor for disseminated ADV infection (d-ADV) [4]. Ex vivo by CD34+ selection (Miltenyi Biotec, Gladbach, Germany) achieves a 5-log depletion of T-lymphocytes in the allograft [5]. D-ADV infections after TCD HCT are often fatal with mortality rates ranging from 50 - 100% [678]. There is currently no approved treatment for ADV. Intravenous cidofovir (CDV) is commonly used; however its utility is limited by associated nephrotoxicity [9]. Adoptive transfer of ADV-CTLs has shown efficacy in single center studies [2]. Brincidofovir (BCV) is a lipid-linked derivative of CDV with high potency against all clinically significant ADV subtypes and no evidence of renal or hematological toxicity to date [1011]. In lymphocyte-depleted pediatric HCT recipients with ADV infections, treatment with BCV resulted in faster and greater virologic responses to BCV compared with CDV [12]. BCV has been associated with gastrointestinal toxicity with typical onset after 4 - 6 doses of BCV [11]. Children may tolerate BCV better than adults possibly due to a more rapid turnover of gastrointestinal mucosa compared with adults [10]. We describe 4 pediatric TCD HCT recipients with d-ADV infection treated successfully with oral BCV 2 mg/kg twice per week under Emergency Investigational New Drug from 9/2015 and 5/2016. The study was reviewed and approved by the Memorial Sloan Kettering Cancer Center Institutional Review and Privavy Board and granted a waiver of authorization (IRB #16-844). Table 1 shows the clinical and virologic characteristics. Virologic responses to BCV are shown in Figure 1A-1D. Table 1 Characteristics and outcome of disseminated adenovirus cases Case Age/sex Dx Transplant type, donor Post-transplant complications before onset of ADV viremia, immunosuppressant First ADV viremiaa, days post-HCT (D) Max ADV viremia, D Sites of ADV ADV disease, D ADV viremia at first CDV Tx ADV viremia at first BCV Tx BCV initiation, D Anti-viral Tx Time to virologic clearance from BCV, days ALC / CD4+ (cell/mcL) at BCV Tx Outcome A 19m/F SCID 1st HCT: BMT, haplo mother (graft failure) Autoimmune Hemolytic Anemia, Rituximab, Prednisolone 2.1 × 105, D+192 2.1 × 105, D+192 Blood, Stool, Urine Probable Enterocolitis, D+207 4.3 × 104 <190 D+193 CDV IV 5 mg/kg × 5 doses 3 ALC 400 CD4+ 30 Alive 2nd HCT: CD34+ TCD PBSCT, MUD BCV PO 2 mg/kg TIW × 17 doses B 4y/M ALL CD34+ TCD PBSCT, 9/10 MUD 469, D+10 4.7 × 106, D+69 Blood, Stool, Liver, RESP, Pleural Fluid Definite Pneumonitis, D+84; Definite Hepatitis, D+88 5.8 × 104 3.3 × 105 D+25 CDV IV 5 mg/kg × 14 doses N/A ALC 400 CD4+ 0 Alive BCV PO 2 mg/kg TIW × 5 doses DLI, ADV CTLs C 3y/M Familial HLH CD34+ TCD PBSCT, Haplo mother Skin Grade 3 GVHD and GI Grade 1 GVHD, Mesenchymal stem cell infusion, Alemtuzumab, CNI and Prednisolone 9.8 × 105, D+841 6.7 × 106, D+1026 Blood, Stool, RESP Possible Enterocolitis, D+870 N/A 4.1 × 105 D+848 BCV PO 2 mg/kg TIW × 29 doses 1st course: 14 1st course: ALC 100 CD4+ 0 Death, D+1088, MSOF 2nd course: 20 2nd course: ALC 100 CD4+ 0 D 3y/F ALL 1st HCT: CD34+ TCD PBSCT, MUD Acute Rejection of first allo-graft 2 × 103, D+38 (From 2nd HCT) 1.9 × 107, D+42 (From 2nd HCT) Blood, Stool, Liver Possible Enterocolitis, D+65 (From 2nd HCT) 2.8 × 105 1.6 × 107 D+57 (From 2nd HCT) CDV IV 5 mg/kg × 2 doses 34 ALC 300 CD4+ 19 Death, D+539 (From 2nd HCT), relapse of primary disease 2nd HCT: CD34+ TCD PBSCT, MUD 2nd HCT: Alemtuzumab 1 mg/kg divided in 5 doses after 2nd HCT BCV PO 2 mg/kg TIW × 26 doses aADV PCR in blood was performed by Viraco Eurofins (Lee's Summit, MO, USA). Values are copies/ml. m, months-old; F, female; y, years-old; M, male; Dx, diagnosis; SCID, severe combined immune deficiency; ALL, acute lymphoblastic leukemia; HLH, hemophagocytic lymphohistiocytosis; HCT, hematopoietic cell transplant; BMT, bone marrow transplant; Haplo, Haploidentical; TCD, T Cell-depleted; PBSCT, peripheral blood stem cell transplant; MUD, matched unrelated donor; ADV, adenovirus; GVHD, graft-versus-host disease; GI, gastrointestinal; CNI, calcineurin inhibitors; D, day from transplant; max, maximum, RESP, respiratory specimens (bronchoalveolar lavage, nasopharyngeal swab); CDV, cidofovir; Tx, treatment; N/A, not applicable; BCV, brincidofovir; IV, intravenous; PO, orally; TIW, three times per week; DLI, donor lymphocyte infusion; CTLs, cytotoxic T lymphocytes, ALC, absolute lymphocyte counts; MSOF, multisystem organ failure. Figure 1 Plasma adenovirus viral load and treatment in 4 pediatric hematopoietic cell transplant recipients with disseminated adenovirus infection. CD4+ count: cell/mcL. CDV, cidofovir; BCV, brincidofovir; ADV, adenovirus; VL, viral load; DLI, donor lymphocyte infusion; CTL, cytotoxic T-lymphocyte; PCR, polymerase chain reaction. Case report ADV PCR was performed by Viracor-Eurofins (Lee's Summit, MO, USA). The linear range of quantification of ADV PCR in the blood was 100 – 1 × 1010 copies/mL. D-ADV was defined as previously defined [7]. 1. Case A A 19-month-old girl with severe combined immunodeficiency syndrome received a TCD HCT from a matched unrelated donor (MUD). Her post-transplant course was complicated by autoimmune hemolytic anemia treated with prednisolone and 6 doses of rituximab. Six months post-transplant she presented for hypoactivity, irritability and watery diarrhea. On admission, stool ADV PCR was positive and ADV viremia was 2.1 × 105copies/ml. She was treated with CDV and intravenous immunoglobulin. After 2 weeks of CDV, colonoscopy was performed. Pathology showed friable colonic mucosa. Viral culture from tissues was positive for ADV. Because of persistent diarrhea after 5 doses of CDV, BCV was started. ADV viremia became undetectable after 2 doses of BCV. BCV was stopped at 8 weeks after BCV initiation. 2. Case B A 4-year-old boy with acute lymphoblastic leukemia (ALL) received a TCD HCT from a MUD. On Day 0, stool ADV PCR was positive and ADV viremia was negative. On Day +10, ADV viremia was 469 copies/ml and on Day +17 ADV viremia rose to 5.8 × 104copies/ml. On Day +25, CDV was started due to persistent fever, diarrhea and rising ADV viremia. After 2 doses of CDV, CDV was switched to BCV due to increased ADV viremia (3.3 × 105copies/ml). On Day +39, BCV was discontinued after 5 doses due to persistent diarrhea. CDV was resumed, however ADV viremia increased to 4.7 × 106copies/ml on Day +69 and transaminitis was noted. Liver biopsy on Day +84 confirmed GVHD with ADV hepatitis (positive ADV stain). Concurrently, he developed respiratory distress and a nasopharyngeal swab was positive for ADV by PCR. On Day +88, thoracentesis was performed due to worsening pleural effusion. Pleural fluid was positive for ADV (1.8 × 105copies/ml). He was treated with donor lymphocyte infusion (DLI) and subsequently with ADV-CTLs with virologic response. 3. Case C A 3-year-old boy with familial hemophagocytic lymphohistiocytosis was admitted with fever, diarrhea and vomiting 2 years post-transplant. He received a TCD HCT from his haploidentical mother. His post-transplant course was complicated by poor graft function, refractory skin and gastrointestinal GVHD, human herpesvirus-6 viremia and chronic renal dysfunction. He received cyclosporine, tacrolimus, steroids and mesenchymal stem cells infusion for GVHD. On admission, cefepime and vancomycin were empirically started. Stool was negative for Clostridioides difficile. Symptoms persisted during admission. On hospital day 21, stool ADV PCR was positive and ADV viremia was 9.8 × 105copies/ml. BCV was initiated. Viral clearance was achieved after 5 doses BCV and BCV was continued for 4 weeks. One week after BCV discontinuation, ADV viremia recrudesced to 1.0 × 107copies/ml. BCV was reinitiated and continued for 10 weeks with good virologic control. Due to persistent diarrhea, colonoscopy was performed and pathology showed persistent gut GVHD. The tissue was positive for ADV by PCR. He received a stem cell boost 2 months after stopping BCV for poor graft function. He subsequently developed relapse of ADV viremia (6.7 × 106copies/ml), thus BCV was resumed and ADV viremia became undectable after 7 doses of BCV. His hospital stay was further complicated by hospital-acquired pneumonia with respiratory failure. Despite resolving ADV viremia, he died due to multi-organ failure. 4. Case D A 3-year-old girl with ALL received a TCD HCT from a MUD complicated by graft rejection and followed by a second TCD HCT from a different MUD one month after the first HCT. Her post-transplant course was complicated by Epstein-Barr virus (EBV) viremia treated with rituximab and cytomegalovirus viremia. On Day +38 post-transplant, she was found to have ADV viremia (2.0 × 103copies/ml). On Day +42, ADV viremia increased to 1.9 × 107copies/ml. On Day +53, she developed watery diarrhea and nausea. Stool ADV PCR was positive. On Day +56, colonoscopy was performed. The tissue was positive for ADV by PCR. On Day +56, ADV viremia was 2.8 × 105copies/ml and CDV was started. After two doses of CDV, ADV viremia was 1.1 × 105copies/ml. She developed worsening hepatic function. Computed tomography of the chest and abdomen on Day +65 showed a necrotic liver lesion and a necrotic lung mass. ADV viremia rose up to 2.3 × 107copies/ml on Day +66 despite CDV. Lung and liver biopsies performed on Day +67 yielded Legionella pneumophila serotype 1 by culture and liver biopsy was positive for EBV and ADV by PCR. ADV viremia was 1.6 × 107 copies/mL on Day +69. On Day +71, levofloxacin was started for Legionella pneumonia and BCV for d-ADV infection. ADV viremia became undectable 34 days after initiation. She received BCV for 80 days as outpatient. Discussion We report 4 pediatric TCD HCT recipients (overall 6 episodes of ADV viremia) with d-ADV treated with BCV. All patients were highly immunosuppressed, with profound lymphopenia and/or very low CD4 counts. Despite high ADV viremia (median 3.7 × 105 copies/mL) at BCV initiation, 3 of 4 patients cleared ADV viremia at a median of 14 days (range, 1 - 34) of BCV treatment. Two patients (cases A and C) were on high dose steroids. Two patients had received prior CDV treatment (case A and C) without response prior to BCV treatment. Three patients tolerated prolonged doses of BCV (range, 17 - 29 doses). Case C had lymphopenia (100 cell/mm3) and CD4+ count was 0 cell/mm3 during ADV infection. Despite a rapid virologic response to BCV, ADV recurred after discontinuation of BCV highlighting the importance of immune recovery for control of ADV infection. Importantly the patient responded rapidly after 2 short subsequent courses of BCV suggesting that repeated episodic treatment with BCV guided by ADV viral load (VL) remains effective even in the setting of persistent lymphopenia. D-ADV infections are associated with substantial morbidity and mortality in HCT recipients [678]. Cases A, C and D with ADV colitis cleared ADV viremia with BCV. Case B did not tolerate BCV. BCV was discontinued after 5 doses concerning for gastrointestinal toxicity. Case B developed ADV hepatitis and ADV pneumonitis while on CDV. Case B responded to DLI and ADV-CTLs. While ADV-CTLs have shown safety and efficacy in small series (reviewed in reference 2), at present several hurdles preclude the broad applicability of this potentially effective therapy [2]. The virologic responses in our cases confirms the virologic activity of BCV even in lymphopenic patients and are in agreement with results of the recent BCV trial [11]. In that trial virologic responses were better, if BCV treatment was initiated at low VL and was associated with improved survival [11]. Our patients had high VL at BCV initiation despite which, 3 of 4 patients achieved virologic responses. One patient discontinued BCV due to gastrointestinal symptoms. Gastrointestinal toxicity is a known side effect of BCV [10]. Management of gastrointestinal toxicity due to BCV like case B is particularly challenging in patients with ADV in the gastrointestinal tract as symptoms may be related to ADV enteritis/colitis and/or BCV. Case B had diarrhea prior to BCV initiation and had persistent diarrhea while on BCV which led a clinician to stop BCV. An intravenous formulation of BCV is currently in development and may alleviate concerns for gastrointestinal toxicity. In conclusion, our small case series show rapid virologic responses after short courses of oral BCV in 3 of 4 pediatric patients with d-ADV. Repeated short courses of BCV were effective in a patient with recurrent ADV viremia. Our data supports the study design of short-course oral BCV treatment in pediatric HCT recipients with ADV infection. ACKNOWLEDGEMENT This research was funded in part through the NIH/NCI Cancer Center Support Grant P30 CA008748. Conflict of Interest: GAP has been an investigator for Shire, Merck, Chimerix and Astellas and has received consulting fees from Shire, Merck, Chimerix and Astellas. Author Contributions: Conceptualization: GAP, YJL. Data curation: SYC, SEP, FB, GAP, YJL, YJL. Writing - original draft: SEP, FB, GAP, YJL.	ALEMTUZUMAB, RITUXIMAB	DrugsGivenReaction	CC BY-NC	32869551	19,460,124	2021-09
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Epstein-Barr viraemia'.	Rapid Virologic Response to Brincidofovir in Children with Disseminated Adenovirus Infection. Disseminated adenovirus infections (d-ADV) after hematopoietic cell transplant (HCT) are often fatal with limited treatment options. Brincidofovir (BCV) a lipid ester of cidofovir is developed for this indication. We report four pediatric HCT recipients with d-ADV treated successfully with BCV. pmcIntroduction Adenovirus (ADV) infections may occur in up to 40% of pediatric HCT recipients [1]. T-cell depletion (TCD) (ex vivo CD34+ or serotherapy with antithymocyte globulin or alemtuzumab), or severe graft-versus-host disease (GVHD) are associated with ADV infection post-HCT [2]. Recovery of ADV specific T-lymphocytes (ADV-CTLs) confers protection against ADV [3], whereas lymphopenia is a risk factor for disseminated ADV infection (d-ADV) [4]. Ex vivo by CD34+ selection (Miltenyi Biotec, Gladbach, Germany) achieves a 5-log depletion of T-lymphocytes in the allograft [5]. D-ADV infections after TCD HCT are often fatal with mortality rates ranging from 50 - 100% [678]. There is currently no approved treatment for ADV. Intravenous cidofovir (CDV) is commonly used; however its utility is limited by associated nephrotoxicity [9]. Adoptive transfer of ADV-CTLs has shown efficacy in single center studies [2]. Brincidofovir (BCV) is a lipid-linked derivative of CDV with high potency against all clinically significant ADV subtypes and no evidence of renal or hematological toxicity to date [1011]. In lymphocyte-depleted pediatric HCT recipients with ADV infections, treatment with BCV resulted in faster and greater virologic responses to BCV compared with CDV [12]. BCV has been associated with gastrointestinal toxicity with typical onset after 4 - 6 doses of BCV [11]. Children may tolerate BCV better than adults possibly due to a more rapid turnover of gastrointestinal mucosa compared with adults [10]. We describe 4 pediatric TCD HCT recipients with d-ADV infection treated successfully with oral BCV 2 mg/kg twice per week under Emergency Investigational New Drug from 9/2015 and 5/2016. The study was reviewed and approved by the Memorial Sloan Kettering Cancer Center Institutional Review and Privavy Board and granted a waiver of authorization (IRB #16-844). Table 1 shows the clinical and virologic characteristics. Virologic responses to BCV are shown in Figure 1A-1D. Table 1 Characteristics and outcome of disseminated adenovirus cases Case Age/sex Dx Transplant type, donor Post-transplant complications before onset of ADV viremia, immunosuppressant First ADV viremiaa, days post-HCT (D) Max ADV viremia, D Sites of ADV ADV disease, D ADV viremia at first CDV Tx ADV viremia at first BCV Tx BCV initiation, D Anti-viral Tx Time to virologic clearance from BCV, days ALC / CD4+ (cell/mcL) at BCV Tx Outcome A 19m/F SCID 1st HCT: BMT, haplo mother (graft failure) Autoimmune Hemolytic Anemia, Rituximab, Prednisolone 2.1 × 105, D+192 2.1 × 105, D+192 Blood, Stool, Urine Probable Enterocolitis, D+207 4.3 × 104 <190 D+193 CDV IV 5 mg/kg × 5 doses 3 ALC 400 CD4+ 30 Alive 2nd HCT: CD34+ TCD PBSCT, MUD BCV PO 2 mg/kg TIW × 17 doses B 4y/M ALL CD34+ TCD PBSCT, 9/10 MUD 469, D+10 4.7 × 106, D+69 Blood, Stool, Liver, RESP, Pleural Fluid Definite Pneumonitis, D+84; Definite Hepatitis, D+88 5.8 × 104 3.3 × 105 D+25 CDV IV 5 mg/kg × 14 doses N/A ALC 400 CD4+ 0 Alive BCV PO 2 mg/kg TIW × 5 doses DLI, ADV CTLs C 3y/M Familial HLH CD34+ TCD PBSCT, Haplo mother Skin Grade 3 GVHD and GI Grade 1 GVHD, Mesenchymal stem cell infusion, Alemtuzumab, CNI and Prednisolone 9.8 × 105, D+841 6.7 × 106, D+1026 Blood, Stool, RESP Possible Enterocolitis, D+870 N/A 4.1 × 105 D+848 BCV PO 2 mg/kg TIW × 29 doses 1st course: 14 1st course: ALC 100 CD4+ 0 Death, D+1088, MSOF 2nd course: 20 2nd course: ALC 100 CD4+ 0 D 3y/F ALL 1st HCT: CD34+ TCD PBSCT, MUD Acute Rejection of first allo-graft 2 × 103, D+38 (From 2nd HCT) 1.9 × 107, D+42 (From 2nd HCT) Blood, Stool, Liver Possible Enterocolitis, D+65 (From 2nd HCT) 2.8 × 105 1.6 × 107 D+57 (From 2nd HCT) CDV IV 5 mg/kg × 2 doses 34 ALC 300 CD4+ 19 Death, D+539 (From 2nd HCT), relapse of primary disease 2nd HCT: CD34+ TCD PBSCT, MUD 2nd HCT: Alemtuzumab 1 mg/kg divided in 5 doses after 2nd HCT BCV PO 2 mg/kg TIW × 26 doses aADV PCR in blood was performed by Viraco Eurofins (Lee's Summit, MO, USA). Values are copies/ml. m, months-old; F, female; y, years-old; M, male; Dx, diagnosis; SCID, severe combined immune deficiency; ALL, acute lymphoblastic leukemia; HLH, hemophagocytic lymphohistiocytosis; HCT, hematopoietic cell transplant; BMT, bone marrow transplant; Haplo, Haploidentical; TCD, T Cell-depleted; PBSCT, peripheral blood stem cell transplant; MUD, matched unrelated donor; ADV, adenovirus; GVHD, graft-versus-host disease; GI, gastrointestinal; CNI, calcineurin inhibitors; D, day from transplant; max, maximum, RESP, respiratory specimens (bronchoalveolar lavage, nasopharyngeal swab); CDV, cidofovir; Tx, treatment; N/A, not applicable; BCV, brincidofovir; IV, intravenous; PO, orally; TIW, three times per week; DLI, donor lymphocyte infusion; CTLs, cytotoxic T lymphocytes, ALC, absolute lymphocyte counts; MSOF, multisystem organ failure. Figure 1 Plasma adenovirus viral load and treatment in 4 pediatric hematopoietic cell transplant recipients with disseminated adenovirus infection. CD4+ count: cell/mcL. CDV, cidofovir; BCV, brincidofovir; ADV, adenovirus; VL, viral load; DLI, donor lymphocyte infusion; CTL, cytotoxic T-lymphocyte; PCR, polymerase chain reaction. Case report ADV PCR was performed by Viracor-Eurofins (Lee's Summit, MO, USA). The linear range of quantification of ADV PCR in the blood was 100 – 1 × 1010 copies/mL. D-ADV was defined as previously defined [7]. 1. Case A A 19-month-old girl with severe combined immunodeficiency syndrome received a TCD HCT from a matched unrelated donor (MUD). Her post-transplant course was complicated by autoimmune hemolytic anemia treated with prednisolone and 6 doses of rituximab. Six months post-transplant she presented for hypoactivity, irritability and watery diarrhea. On admission, stool ADV PCR was positive and ADV viremia was 2.1 × 105copies/ml. She was treated with CDV and intravenous immunoglobulin. After 2 weeks of CDV, colonoscopy was performed. Pathology showed friable colonic mucosa. Viral culture from tissues was positive for ADV. Because of persistent diarrhea after 5 doses of CDV, BCV was started. ADV viremia became undetectable after 2 doses of BCV. BCV was stopped at 8 weeks after BCV initiation. 2. Case B A 4-year-old boy with acute lymphoblastic leukemia (ALL) received a TCD HCT from a MUD. On Day 0, stool ADV PCR was positive and ADV viremia was negative. On Day +10, ADV viremia was 469 copies/ml and on Day +17 ADV viremia rose to 5.8 × 104copies/ml. On Day +25, CDV was started due to persistent fever, diarrhea and rising ADV viremia. After 2 doses of CDV, CDV was switched to BCV due to increased ADV viremia (3.3 × 105copies/ml). On Day +39, BCV was discontinued after 5 doses due to persistent diarrhea. CDV was resumed, however ADV viremia increased to 4.7 × 106copies/ml on Day +69 and transaminitis was noted. Liver biopsy on Day +84 confirmed GVHD with ADV hepatitis (positive ADV stain). Concurrently, he developed respiratory distress and a nasopharyngeal swab was positive for ADV by PCR. On Day +88, thoracentesis was performed due to worsening pleural effusion. Pleural fluid was positive for ADV (1.8 × 105copies/ml). He was treated with donor lymphocyte infusion (DLI) and subsequently with ADV-CTLs with virologic response. 3. Case C A 3-year-old boy with familial hemophagocytic lymphohistiocytosis was admitted with fever, diarrhea and vomiting 2 years post-transplant. He received a TCD HCT from his haploidentical mother. His post-transplant course was complicated by poor graft function, refractory skin and gastrointestinal GVHD, human herpesvirus-6 viremia and chronic renal dysfunction. He received cyclosporine, tacrolimus, steroids and mesenchymal stem cells infusion for GVHD. On admission, cefepime and vancomycin were empirically started. Stool was negative for Clostridioides difficile. Symptoms persisted during admission. On hospital day 21, stool ADV PCR was positive and ADV viremia was 9.8 × 105copies/ml. BCV was initiated. Viral clearance was achieved after 5 doses BCV and BCV was continued for 4 weeks. One week after BCV discontinuation, ADV viremia recrudesced to 1.0 × 107copies/ml. BCV was reinitiated and continued for 10 weeks with good virologic control. Due to persistent diarrhea, colonoscopy was performed and pathology showed persistent gut GVHD. The tissue was positive for ADV by PCR. He received a stem cell boost 2 months after stopping BCV for poor graft function. He subsequently developed relapse of ADV viremia (6.7 × 106copies/ml), thus BCV was resumed and ADV viremia became undectable after 7 doses of BCV. His hospital stay was further complicated by hospital-acquired pneumonia with respiratory failure. Despite resolving ADV viremia, he died due to multi-organ failure. 4. Case D A 3-year-old girl with ALL received a TCD HCT from a MUD complicated by graft rejection and followed by a second TCD HCT from a different MUD one month after the first HCT. Her post-transplant course was complicated by Epstein-Barr virus (EBV) viremia treated with rituximab and cytomegalovirus viremia. On Day +38 post-transplant, she was found to have ADV viremia (2.0 × 103copies/ml). On Day +42, ADV viremia increased to 1.9 × 107copies/ml. On Day +53, she developed watery diarrhea and nausea. Stool ADV PCR was positive. On Day +56, colonoscopy was performed. The tissue was positive for ADV by PCR. On Day +56, ADV viremia was 2.8 × 105copies/ml and CDV was started. After two doses of CDV, ADV viremia was 1.1 × 105copies/ml. She developed worsening hepatic function. Computed tomography of the chest and abdomen on Day +65 showed a necrotic liver lesion and a necrotic lung mass. ADV viremia rose up to 2.3 × 107copies/ml on Day +66 despite CDV. Lung and liver biopsies performed on Day +67 yielded Legionella pneumophila serotype 1 by culture and liver biopsy was positive for EBV and ADV by PCR. ADV viremia was 1.6 × 107 copies/mL on Day +69. On Day +71, levofloxacin was started for Legionella pneumonia and BCV for d-ADV infection. ADV viremia became undectable 34 days after initiation. She received BCV for 80 days as outpatient. Discussion We report 4 pediatric TCD HCT recipients (overall 6 episodes of ADV viremia) with d-ADV treated with BCV. All patients were highly immunosuppressed, with profound lymphopenia and/or very low CD4 counts. Despite high ADV viremia (median 3.7 × 105 copies/mL) at BCV initiation, 3 of 4 patients cleared ADV viremia at a median of 14 days (range, 1 - 34) of BCV treatment. Two patients (cases A and C) were on high dose steroids. Two patients had received prior CDV treatment (case A and C) without response prior to BCV treatment. Three patients tolerated prolonged doses of BCV (range, 17 - 29 doses). Case C had lymphopenia (100 cell/mm3) and CD4+ count was 0 cell/mm3 during ADV infection. Despite a rapid virologic response to BCV, ADV recurred after discontinuation of BCV highlighting the importance of immune recovery for control of ADV infection. Importantly the patient responded rapidly after 2 short subsequent courses of BCV suggesting that repeated episodic treatment with BCV guided by ADV viral load (VL) remains effective even in the setting of persistent lymphopenia. D-ADV infections are associated with substantial morbidity and mortality in HCT recipients [678]. Cases A, C and D with ADV colitis cleared ADV viremia with BCV. Case B did not tolerate BCV. BCV was discontinued after 5 doses concerning for gastrointestinal toxicity. Case B developed ADV hepatitis and ADV pneumonitis while on CDV. Case B responded to DLI and ADV-CTLs. While ADV-CTLs have shown safety and efficacy in small series (reviewed in reference 2), at present several hurdles preclude the broad applicability of this potentially effective therapy [2]. The virologic responses in our cases confirms the virologic activity of BCV even in lymphopenic patients and are in agreement with results of the recent BCV trial [11]. In that trial virologic responses were better, if BCV treatment was initiated at low VL and was associated with improved survival [11]. Our patients had high VL at BCV initiation despite which, 3 of 4 patients achieved virologic responses. One patient discontinued BCV due to gastrointestinal symptoms. Gastrointestinal toxicity is a known side effect of BCV [10]. Management of gastrointestinal toxicity due to BCV like case B is particularly challenging in patients with ADV in the gastrointestinal tract as symptoms may be related to ADV enteritis/colitis and/or BCV. Case B had diarrhea prior to BCV initiation and had persistent diarrhea while on BCV which led a clinician to stop BCV. An intravenous formulation of BCV is currently in development and may alleviate concerns for gastrointestinal toxicity. In conclusion, our small case series show rapid virologic responses after short courses of oral BCV in 3 of 4 pediatric patients with d-ADV. Repeated short courses of BCV were effective in a patient with recurrent ADV viremia. Our data supports the study design of short-course oral BCV treatment in pediatric HCT recipients with ADV infection. ACKNOWLEDGEMENT This research was funded in part through the NIH/NCI Cancer Center Support Grant P30 CA008748. Conflict of Interest: GAP has been an investigator for Shire, Merck, Chimerix and Astellas and has received consulting fees from Shire, Merck, Chimerix and Astellas. Author Contributions: Conceptualization: GAP, YJL. Data curation: SYC, SEP, FB, GAP, YJL, YJL. Writing - original draft: SEP, FB, GAP, YJL.	ALEMTUZUMAB, RITUXIMAB	DrugsGivenReaction	CC BY-NC	32869551	19,460,124	2021-09
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Human herpesvirus 6 infection'.	Rapid Virologic Response to Brincidofovir in Children with Disseminated Adenovirus Infection. Disseminated adenovirus infections (d-ADV) after hematopoietic cell transplant (HCT) are often fatal with limited treatment options. Brincidofovir (BCV) a lipid ester of cidofovir is developed for this indication. We report four pediatric HCT recipients with d-ADV treated successfully with BCV. pmcIntroduction Adenovirus (ADV) infections may occur in up to 40% of pediatric HCT recipients [1]. T-cell depletion (TCD) (ex vivo CD34+ or serotherapy with antithymocyte globulin or alemtuzumab), or severe graft-versus-host disease (GVHD) are associated with ADV infection post-HCT [2]. Recovery of ADV specific T-lymphocytes (ADV-CTLs) confers protection against ADV [3], whereas lymphopenia is a risk factor for disseminated ADV infection (d-ADV) [4]. Ex vivo by CD34+ selection (Miltenyi Biotec, Gladbach, Germany) achieves a 5-log depletion of T-lymphocytes in the allograft [5]. D-ADV infections after TCD HCT are often fatal with mortality rates ranging from 50 - 100% [678]. There is currently no approved treatment for ADV. Intravenous cidofovir (CDV) is commonly used; however its utility is limited by associated nephrotoxicity [9]. Adoptive transfer of ADV-CTLs has shown efficacy in single center studies [2]. Brincidofovir (BCV) is a lipid-linked derivative of CDV with high potency against all clinically significant ADV subtypes and no evidence of renal or hematological toxicity to date [1011]. In lymphocyte-depleted pediatric HCT recipients with ADV infections, treatment with BCV resulted in faster and greater virologic responses to BCV compared with CDV [12]. BCV has been associated with gastrointestinal toxicity with typical onset after 4 - 6 doses of BCV [11]. Children may tolerate BCV better than adults possibly due to a more rapid turnover of gastrointestinal mucosa compared with adults [10]. We describe 4 pediatric TCD HCT recipients with d-ADV infection treated successfully with oral BCV 2 mg/kg twice per week under Emergency Investigational New Drug from 9/2015 and 5/2016. The study was reviewed and approved by the Memorial Sloan Kettering Cancer Center Institutional Review and Privavy Board and granted a waiver of authorization (IRB #16-844). Table 1 shows the clinical and virologic characteristics. Virologic responses to BCV are shown in Figure 1A-1D. Table 1 Characteristics and outcome of disseminated adenovirus cases Case Age/sex Dx Transplant type, donor Post-transplant complications before onset of ADV viremia, immunosuppressant First ADV viremiaa, days post-HCT (D) Max ADV viremia, D Sites of ADV ADV disease, D ADV viremia at first CDV Tx ADV viremia at first BCV Tx BCV initiation, D Anti-viral Tx Time to virologic clearance from BCV, days ALC / CD4+ (cell/mcL) at BCV Tx Outcome A 19m/F SCID 1st HCT: BMT, haplo mother (graft failure) Autoimmune Hemolytic Anemia, Rituximab, Prednisolone 2.1 × 105, D+192 2.1 × 105, D+192 Blood, Stool, Urine Probable Enterocolitis, D+207 4.3 × 104 <190 D+193 CDV IV 5 mg/kg × 5 doses 3 ALC 400 CD4+ 30 Alive 2nd HCT: CD34+ TCD PBSCT, MUD BCV PO 2 mg/kg TIW × 17 doses B 4y/M ALL CD34+ TCD PBSCT, 9/10 MUD 469, D+10 4.7 × 106, D+69 Blood, Stool, Liver, RESP, Pleural Fluid Definite Pneumonitis, D+84; Definite Hepatitis, D+88 5.8 × 104 3.3 × 105 D+25 CDV IV 5 mg/kg × 14 doses N/A ALC 400 CD4+ 0 Alive BCV PO 2 mg/kg TIW × 5 doses DLI, ADV CTLs C 3y/M Familial HLH CD34+ TCD PBSCT, Haplo mother Skin Grade 3 GVHD and GI Grade 1 GVHD, Mesenchymal stem cell infusion, Alemtuzumab, CNI and Prednisolone 9.8 × 105, D+841 6.7 × 106, D+1026 Blood, Stool, RESP Possible Enterocolitis, D+870 N/A 4.1 × 105 D+848 BCV PO 2 mg/kg TIW × 29 doses 1st course: 14 1st course: ALC 100 CD4+ 0 Death, D+1088, MSOF 2nd course: 20 2nd course: ALC 100 CD4+ 0 D 3y/F ALL 1st HCT: CD34+ TCD PBSCT, MUD Acute Rejection of first allo-graft 2 × 103, D+38 (From 2nd HCT) 1.9 × 107, D+42 (From 2nd HCT) Blood, Stool, Liver Possible Enterocolitis, D+65 (From 2nd HCT) 2.8 × 105 1.6 × 107 D+57 (From 2nd HCT) CDV IV 5 mg/kg × 2 doses 34 ALC 300 CD4+ 19 Death, D+539 (From 2nd HCT), relapse of primary disease 2nd HCT: CD34+ TCD PBSCT, MUD 2nd HCT: Alemtuzumab 1 mg/kg divided in 5 doses after 2nd HCT BCV PO 2 mg/kg TIW × 26 doses aADV PCR in blood was performed by Viraco Eurofins (Lee's Summit, MO, USA). Values are copies/ml. m, months-old; F, female; y, years-old; M, male; Dx, diagnosis; SCID, severe combined immune deficiency; ALL, acute lymphoblastic leukemia; HLH, hemophagocytic lymphohistiocytosis; HCT, hematopoietic cell transplant; BMT, bone marrow transplant; Haplo, Haploidentical; TCD, T Cell-depleted; PBSCT, peripheral blood stem cell transplant; MUD, matched unrelated donor; ADV, adenovirus; GVHD, graft-versus-host disease; GI, gastrointestinal; CNI, calcineurin inhibitors; D, day from transplant; max, maximum, RESP, respiratory specimens (bronchoalveolar lavage, nasopharyngeal swab); CDV, cidofovir; Tx, treatment; N/A, not applicable; BCV, brincidofovir; IV, intravenous; PO, orally; TIW, three times per week; DLI, donor lymphocyte infusion; CTLs, cytotoxic T lymphocytes, ALC, absolute lymphocyte counts; MSOF, multisystem organ failure. Figure 1 Plasma adenovirus viral load and treatment in 4 pediatric hematopoietic cell transplant recipients with disseminated adenovirus infection. CD4+ count: cell/mcL. CDV, cidofovir; BCV, brincidofovir; ADV, adenovirus; VL, viral load; DLI, donor lymphocyte infusion; CTL, cytotoxic T-lymphocyte; PCR, polymerase chain reaction. Case report ADV PCR was performed by Viracor-Eurofins (Lee's Summit, MO, USA). The linear range of quantification of ADV PCR in the blood was 100 – 1 × 1010 copies/mL. D-ADV was defined as previously defined [7]. 1. Case A A 19-month-old girl with severe combined immunodeficiency syndrome received a TCD HCT from a matched unrelated donor (MUD). Her post-transplant course was complicated by autoimmune hemolytic anemia treated with prednisolone and 6 doses of rituximab. Six months post-transplant she presented for hypoactivity, irritability and watery diarrhea. On admission, stool ADV PCR was positive and ADV viremia was 2.1 × 105copies/ml. She was treated with CDV and intravenous immunoglobulin. After 2 weeks of CDV, colonoscopy was performed. Pathology showed friable colonic mucosa. Viral culture from tissues was positive for ADV. Because of persistent diarrhea after 5 doses of CDV, BCV was started. ADV viremia became undetectable after 2 doses of BCV. BCV was stopped at 8 weeks after BCV initiation. 2. Case B A 4-year-old boy with acute lymphoblastic leukemia (ALL) received a TCD HCT from a MUD. On Day 0, stool ADV PCR was positive and ADV viremia was negative. On Day +10, ADV viremia was 469 copies/ml and on Day +17 ADV viremia rose to 5.8 × 104copies/ml. On Day +25, CDV was started due to persistent fever, diarrhea and rising ADV viremia. After 2 doses of CDV, CDV was switched to BCV due to increased ADV viremia (3.3 × 105copies/ml). On Day +39, BCV was discontinued after 5 doses due to persistent diarrhea. CDV was resumed, however ADV viremia increased to 4.7 × 106copies/ml on Day +69 and transaminitis was noted. Liver biopsy on Day +84 confirmed GVHD with ADV hepatitis (positive ADV stain). Concurrently, he developed respiratory distress and a nasopharyngeal swab was positive for ADV by PCR. On Day +88, thoracentesis was performed due to worsening pleural effusion. Pleural fluid was positive for ADV (1.8 × 105copies/ml). He was treated with donor lymphocyte infusion (DLI) and subsequently with ADV-CTLs with virologic response. 3. Case C A 3-year-old boy with familial hemophagocytic lymphohistiocytosis was admitted with fever, diarrhea and vomiting 2 years post-transplant. He received a TCD HCT from his haploidentical mother. His post-transplant course was complicated by poor graft function, refractory skin and gastrointestinal GVHD, human herpesvirus-6 viremia and chronic renal dysfunction. He received cyclosporine, tacrolimus, steroids and mesenchymal stem cells infusion for GVHD. On admission, cefepime and vancomycin were empirically started. Stool was negative for Clostridioides difficile. Symptoms persisted during admission. On hospital day 21, stool ADV PCR was positive and ADV viremia was 9.8 × 105copies/ml. BCV was initiated. Viral clearance was achieved after 5 doses BCV and BCV was continued for 4 weeks. One week after BCV discontinuation, ADV viremia recrudesced to 1.0 × 107copies/ml. BCV was reinitiated and continued for 10 weeks with good virologic control. Due to persistent diarrhea, colonoscopy was performed and pathology showed persistent gut GVHD. The tissue was positive for ADV by PCR. He received a stem cell boost 2 months after stopping BCV for poor graft function. He subsequently developed relapse of ADV viremia (6.7 × 106copies/ml), thus BCV was resumed and ADV viremia became undectable after 7 doses of BCV. His hospital stay was further complicated by hospital-acquired pneumonia with respiratory failure. Despite resolving ADV viremia, he died due to multi-organ failure. 4. Case D A 3-year-old girl with ALL received a TCD HCT from a MUD complicated by graft rejection and followed by a second TCD HCT from a different MUD one month after the first HCT. Her post-transplant course was complicated by Epstein-Barr virus (EBV) viremia treated with rituximab and cytomegalovirus viremia. On Day +38 post-transplant, she was found to have ADV viremia (2.0 × 103copies/ml). On Day +42, ADV viremia increased to 1.9 × 107copies/ml. On Day +53, she developed watery diarrhea and nausea. Stool ADV PCR was positive. On Day +56, colonoscopy was performed. The tissue was positive for ADV by PCR. On Day +56, ADV viremia was 2.8 × 105copies/ml and CDV was started. After two doses of CDV, ADV viremia was 1.1 × 105copies/ml. She developed worsening hepatic function. Computed tomography of the chest and abdomen on Day +65 showed a necrotic liver lesion and a necrotic lung mass. ADV viremia rose up to 2.3 × 107copies/ml on Day +66 despite CDV. Lung and liver biopsies performed on Day +67 yielded Legionella pneumophila serotype 1 by culture and liver biopsy was positive for EBV and ADV by PCR. ADV viremia was 1.6 × 107 copies/mL on Day +69. On Day +71, levofloxacin was started for Legionella pneumonia and BCV for d-ADV infection. ADV viremia became undectable 34 days after initiation. She received BCV for 80 days as outpatient. Discussion We report 4 pediatric TCD HCT recipients (overall 6 episodes of ADV viremia) with d-ADV treated with BCV. All patients were highly immunosuppressed, with profound lymphopenia and/or very low CD4 counts. Despite high ADV viremia (median 3.7 × 105 copies/mL) at BCV initiation, 3 of 4 patients cleared ADV viremia at a median of 14 days (range, 1 - 34) of BCV treatment. Two patients (cases A and C) were on high dose steroids. Two patients had received prior CDV treatment (case A and C) without response prior to BCV treatment. Three patients tolerated prolonged doses of BCV (range, 17 - 29 doses). Case C had lymphopenia (100 cell/mm3) and CD4+ count was 0 cell/mm3 during ADV infection. Despite a rapid virologic response to BCV, ADV recurred after discontinuation of BCV highlighting the importance of immune recovery for control of ADV infection. Importantly the patient responded rapidly after 2 short subsequent courses of BCV suggesting that repeated episodic treatment with BCV guided by ADV viral load (VL) remains effective even in the setting of persistent lymphopenia. D-ADV infections are associated with substantial morbidity and mortality in HCT recipients [678]. Cases A, C and D with ADV colitis cleared ADV viremia with BCV. Case B did not tolerate BCV. BCV was discontinued after 5 doses concerning for gastrointestinal toxicity. Case B developed ADV hepatitis and ADV pneumonitis while on CDV. Case B responded to DLI and ADV-CTLs. While ADV-CTLs have shown safety and efficacy in small series (reviewed in reference 2), at present several hurdles preclude the broad applicability of this potentially effective therapy [2]. The virologic responses in our cases confirms the virologic activity of BCV even in lymphopenic patients and are in agreement with results of the recent BCV trial [11]. In that trial virologic responses were better, if BCV treatment was initiated at low VL and was associated with improved survival [11]. Our patients had high VL at BCV initiation despite which, 3 of 4 patients achieved virologic responses. One patient discontinued BCV due to gastrointestinal symptoms. Gastrointestinal toxicity is a known side effect of BCV [10]. Management of gastrointestinal toxicity due to BCV like case B is particularly challenging in patients with ADV in the gastrointestinal tract as symptoms may be related to ADV enteritis/colitis and/or BCV. Case B had diarrhea prior to BCV initiation and had persistent diarrhea while on BCV which led a clinician to stop BCV. An intravenous formulation of BCV is currently in development and may alleviate concerns for gastrointestinal toxicity. In conclusion, our small case series show rapid virologic responses after short courses of oral BCV in 3 of 4 pediatric patients with d-ADV. Repeated short courses of BCV were effective in a patient with recurrent ADV viremia. Our data supports the study design of short-course oral BCV treatment in pediatric HCT recipients with ADV infection. ACKNOWLEDGEMENT This research was funded in part through the NIH/NCI Cancer Center Support Grant P30 CA008748. Conflict of Interest: GAP has been an investigator for Shire, Merck, Chimerix and Astellas and has received consulting fees from Shire, Merck, Chimerix and Astellas. Author Contributions: Conceptualization: GAP, YJL. Data curation: SYC, SEP, FB, GAP, YJL, YJL. Writing - original draft: SEP, FB, GAP, YJL.	ALEMTUZUMAB, PREDNISOLONE	DrugsGivenReaction	CC BY-NC	32869551	19,446,308	2021-09
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Legionella infection'.	Rapid Virologic Response to Brincidofovir in Children with Disseminated Adenovirus Infection. Disseminated adenovirus infections (d-ADV) after hematopoietic cell transplant (HCT) are often fatal with limited treatment options. Brincidofovir (BCV) a lipid ester of cidofovir is developed for this indication. We report four pediatric HCT recipients with d-ADV treated successfully with BCV. pmcIntroduction Adenovirus (ADV) infections may occur in up to 40% of pediatric HCT recipients [1]. T-cell depletion (TCD) (ex vivo CD34+ or serotherapy with antithymocyte globulin or alemtuzumab), or severe graft-versus-host disease (GVHD) are associated with ADV infection post-HCT [2]. Recovery of ADV specific T-lymphocytes (ADV-CTLs) confers protection against ADV [3], whereas lymphopenia is a risk factor for disseminated ADV infection (d-ADV) [4]. Ex vivo by CD34+ selection (Miltenyi Biotec, Gladbach, Germany) achieves a 5-log depletion of T-lymphocytes in the allograft [5]. D-ADV infections after TCD HCT are often fatal with mortality rates ranging from 50 - 100% [678]. There is currently no approved treatment for ADV. Intravenous cidofovir (CDV) is commonly used; however its utility is limited by associated nephrotoxicity [9]. Adoptive transfer of ADV-CTLs has shown efficacy in single center studies [2]. Brincidofovir (BCV) is a lipid-linked derivative of CDV with high potency against all clinically significant ADV subtypes and no evidence of renal or hematological toxicity to date [1011]. In lymphocyte-depleted pediatric HCT recipients with ADV infections, treatment with BCV resulted in faster and greater virologic responses to BCV compared with CDV [12]. BCV has been associated with gastrointestinal toxicity with typical onset after 4 - 6 doses of BCV [11]. Children may tolerate BCV better than adults possibly due to a more rapid turnover of gastrointestinal mucosa compared with adults [10]. We describe 4 pediatric TCD HCT recipients with d-ADV infection treated successfully with oral BCV 2 mg/kg twice per week under Emergency Investigational New Drug from 9/2015 and 5/2016. The study was reviewed and approved by the Memorial Sloan Kettering Cancer Center Institutional Review and Privavy Board and granted a waiver of authorization (IRB #16-844). Table 1 shows the clinical and virologic characteristics. Virologic responses to BCV are shown in Figure 1A-1D. Table 1 Characteristics and outcome of disseminated adenovirus cases Case Age/sex Dx Transplant type, donor Post-transplant complications before onset of ADV viremia, immunosuppressant First ADV viremiaa, days post-HCT (D) Max ADV viremia, D Sites of ADV ADV disease, D ADV viremia at first CDV Tx ADV viremia at first BCV Tx BCV initiation, D Anti-viral Tx Time to virologic clearance from BCV, days ALC / CD4+ (cell/mcL) at BCV Tx Outcome A 19m/F SCID 1st HCT: BMT, haplo mother (graft failure) Autoimmune Hemolytic Anemia, Rituximab, Prednisolone 2.1 × 105, D+192 2.1 × 105, D+192 Blood, Stool, Urine Probable Enterocolitis, D+207 4.3 × 104 <190 D+193 CDV IV 5 mg/kg × 5 doses 3 ALC 400 CD4+ 30 Alive 2nd HCT: CD34+ TCD PBSCT, MUD BCV PO 2 mg/kg TIW × 17 doses B 4y/M ALL CD34+ TCD PBSCT, 9/10 MUD 469, D+10 4.7 × 106, D+69 Blood, Stool, Liver, RESP, Pleural Fluid Definite Pneumonitis, D+84; Definite Hepatitis, D+88 5.8 × 104 3.3 × 105 D+25 CDV IV 5 mg/kg × 14 doses N/A ALC 400 CD4+ 0 Alive BCV PO 2 mg/kg TIW × 5 doses DLI, ADV CTLs C 3y/M Familial HLH CD34+ TCD PBSCT, Haplo mother Skin Grade 3 GVHD and GI Grade 1 GVHD, Mesenchymal stem cell infusion, Alemtuzumab, CNI and Prednisolone 9.8 × 105, D+841 6.7 × 106, D+1026 Blood, Stool, RESP Possible Enterocolitis, D+870 N/A 4.1 × 105 D+848 BCV PO 2 mg/kg TIW × 29 doses 1st course: 14 1st course: ALC 100 CD4+ 0 Death, D+1088, MSOF 2nd course: 20 2nd course: ALC 100 CD4+ 0 D 3y/F ALL 1st HCT: CD34+ TCD PBSCT, MUD Acute Rejection of first allo-graft 2 × 103, D+38 (From 2nd HCT) 1.9 × 107, D+42 (From 2nd HCT) Blood, Stool, Liver Possible Enterocolitis, D+65 (From 2nd HCT) 2.8 × 105 1.6 × 107 D+57 (From 2nd HCT) CDV IV 5 mg/kg × 2 doses 34 ALC 300 CD4+ 19 Death, D+539 (From 2nd HCT), relapse of primary disease 2nd HCT: CD34+ TCD PBSCT, MUD 2nd HCT: Alemtuzumab 1 mg/kg divided in 5 doses after 2nd HCT BCV PO 2 mg/kg TIW × 26 doses aADV PCR in blood was performed by Viraco Eurofins (Lee's Summit, MO, USA). Values are copies/ml. m, months-old; F, female; y, years-old; M, male; Dx, diagnosis; SCID, severe combined immune deficiency; ALL, acute lymphoblastic leukemia; HLH, hemophagocytic lymphohistiocytosis; HCT, hematopoietic cell transplant; BMT, bone marrow transplant; Haplo, Haploidentical; TCD, T Cell-depleted; PBSCT, peripheral blood stem cell transplant; MUD, matched unrelated donor; ADV, adenovirus; GVHD, graft-versus-host disease; GI, gastrointestinal; CNI, calcineurin inhibitors; D, day from transplant; max, maximum, RESP, respiratory specimens (bronchoalveolar lavage, nasopharyngeal swab); CDV, cidofovir; Tx, treatment; N/A, not applicable; BCV, brincidofovir; IV, intravenous; PO, orally; TIW, three times per week; DLI, donor lymphocyte infusion; CTLs, cytotoxic T lymphocytes, ALC, absolute lymphocyte counts; MSOF, multisystem organ failure. Figure 1 Plasma adenovirus viral load and treatment in 4 pediatric hematopoietic cell transplant recipients with disseminated adenovirus infection. CD4+ count: cell/mcL. CDV, cidofovir; BCV, brincidofovir; ADV, adenovirus; VL, viral load; DLI, donor lymphocyte infusion; CTL, cytotoxic T-lymphocyte; PCR, polymerase chain reaction. Case report ADV PCR was performed by Viracor-Eurofins (Lee's Summit, MO, USA). The linear range of quantification of ADV PCR in the blood was 100 – 1 × 1010 copies/mL. D-ADV was defined as previously defined [7]. 1. Case A A 19-month-old girl with severe combined immunodeficiency syndrome received a TCD HCT from a matched unrelated donor (MUD). Her post-transplant course was complicated by autoimmune hemolytic anemia treated with prednisolone and 6 doses of rituximab. Six months post-transplant she presented for hypoactivity, irritability and watery diarrhea. On admission, stool ADV PCR was positive and ADV viremia was 2.1 × 105copies/ml. She was treated with CDV and intravenous immunoglobulin. After 2 weeks of CDV, colonoscopy was performed. Pathology showed friable colonic mucosa. Viral culture from tissues was positive for ADV. Because of persistent diarrhea after 5 doses of CDV, BCV was started. ADV viremia became undetectable after 2 doses of BCV. BCV was stopped at 8 weeks after BCV initiation. 2. Case B A 4-year-old boy with acute lymphoblastic leukemia (ALL) received a TCD HCT from a MUD. On Day 0, stool ADV PCR was positive and ADV viremia was negative. On Day +10, ADV viremia was 469 copies/ml and on Day +17 ADV viremia rose to 5.8 × 104copies/ml. On Day +25, CDV was started due to persistent fever, diarrhea and rising ADV viremia. After 2 doses of CDV, CDV was switched to BCV due to increased ADV viremia (3.3 × 105copies/ml). On Day +39, BCV was discontinued after 5 doses due to persistent diarrhea. CDV was resumed, however ADV viremia increased to 4.7 × 106copies/ml on Day +69 and transaminitis was noted. Liver biopsy on Day +84 confirmed GVHD with ADV hepatitis (positive ADV stain). Concurrently, he developed respiratory distress and a nasopharyngeal swab was positive for ADV by PCR. On Day +88, thoracentesis was performed due to worsening pleural effusion. Pleural fluid was positive for ADV (1.8 × 105copies/ml). He was treated with donor lymphocyte infusion (DLI) and subsequently with ADV-CTLs with virologic response. 3. Case C A 3-year-old boy with familial hemophagocytic lymphohistiocytosis was admitted with fever, diarrhea and vomiting 2 years post-transplant. He received a TCD HCT from his haploidentical mother. His post-transplant course was complicated by poor graft function, refractory skin and gastrointestinal GVHD, human herpesvirus-6 viremia and chronic renal dysfunction. He received cyclosporine, tacrolimus, steroids and mesenchymal stem cells infusion for GVHD. On admission, cefepime and vancomycin were empirically started. Stool was negative for Clostridioides difficile. Symptoms persisted during admission. On hospital day 21, stool ADV PCR was positive and ADV viremia was 9.8 × 105copies/ml. BCV was initiated. Viral clearance was achieved after 5 doses BCV and BCV was continued for 4 weeks. One week after BCV discontinuation, ADV viremia recrudesced to 1.0 × 107copies/ml. BCV was reinitiated and continued for 10 weeks with good virologic control. Due to persistent diarrhea, colonoscopy was performed and pathology showed persistent gut GVHD. The tissue was positive for ADV by PCR. He received a stem cell boost 2 months after stopping BCV for poor graft function. He subsequently developed relapse of ADV viremia (6.7 × 106copies/ml), thus BCV was resumed and ADV viremia became undectable after 7 doses of BCV. His hospital stay was further complicated by hospital-acquired pneumonia with respiratory failure. Despite resolving ADV viremia, he died due to multi-organ failure. 4. Case D A 3-year-old girl with ALL received a TCD HCT from a MUD complicated by graft rejection and followed by a second TCD HCT from a different MUD one month after the first HCT. Her post-transplant course was complicated by Epstein-Barr virus (EBV) viremia treated with rituximab and cytomegalovirus viremia. On Day +38 post-transplant, she was found to have ADV viremia (2.0 × 103copies/ml). On Day +42, ADV viremia increased to 1.9 × 107copies/ml. On Day +53, she developed watery diarrhea and nausea. Stool ADV PCR was positive. On Day +56, colonoscopy was performed. The tissue was positive for ADV by PCR. On Day +56, ADV viremia was 2.8 × 105copies/ml and CDV was started. After two doses of CDV, ADV viremia was 1.1 × 105copies/ml. She developed worsening hepatic function. Computed tomography of the chest and abdomen on Day +65 showed a necrotic liver lesion and a necrotic lung mass. ADV viremia rose up to 2.3 × 107copies/ml on Day +66 despite CDV. Lung and liver biopsies performed on Day +67 yielded Legionella pneumophila serotype 1 by culture and liver biopsy was positive for EBV and ADV by PCR. ADV viremia was 1.6 × 107 copies/mL on Day +69. On Day +71, levofloxacin was started for Legionella pneumonia and BCV for d-ADV infection. ADV viremia became undectable 34 days after initiation. She received BCV for 80 days as outpatient. Discussion We report 4 pediatric TCD HCT recipients (overall 6 episodes of ADV viremia) with d-ADV treated with BCV. All patients were highly immunosuppressed, with profound lymphopenia and/or very low CD4 counts. Despite high ADV viremia (median 3.7 × 105 copies/mL) at BCV initiation, 3 of 4 patients cleared ADV viremia at a median of 14 days (range, 1 - 34) of BCV treatment. Two patients (cases A and C) were on high dose steroids. Two patients had received prior CDV treatment (case A and C) without response prior to BCV treatment. Three patients tolerated prolonged doses of BCV (range, 17 - 29 doses). Case C had lymphopenia (100 cell/mm3) and CD4+ count was 0 cell/mm3 during ADV infection. Despite a rapid virologic response to BCV, ADV recurred after discontinuation of BCV highlighting the importance of immune recovery for control of ADV infection. Importantly the patient responded rapidly after 2 short subsequent courses of BCV suggesting that repeated episodic treatment with BCV guided by ADV viral load (VL) remains effective even in the setting of persistent lymphopenia. D-ADV infections are associated with substantial morbidity and mortality in HCT recipients [678]. Cases A, C and D with ADV colitis cleared ADV viremia with BCV. Case B did not tolerate BCV. BCV was discontinued after 5 doses concerning for gastrointestinal toxicity. Case B developed ADV hepatitis and ADV pneumonitis while on CDV. Case B responded to DLI and ADV-CTLs. While ADV-CTLs have shown safety and efficacy in small series (reviewed in reference 2), at present several hurdles preclude the broad applicability of this potentially effective therapy [2]. The virologic responses in our cases confirms the virologic activity of BCV even in lymphopenic patients and are in agreement with results of the recent BCV trial [11]. In that trial virologic responses were better, if BCV treatment was initiated at low VL and was associated with improved survival [11]. Our patients had high VL at BCV initiation despite which, 3 of 4 patients achieved virologic responses. One patient discontinued BCV due to gastrointestinal symptoms. Gastrointestinal toxicity is a known side effect of BCV [10]. Management of gastrointestinal toxicity due to BCV like case B is particularly challenging in patients with ADV in the gastrointestinal tract as symptoms may be related to ADV enteritis/colitis and/or BCV. Case B had diarrhea prior to BCV initiation and had persistent diarrhea while on BCV which led a clinician to stop BCV. An intravenous formulation of BCV is currently in development and may alleviate concerns for gastrointestinal toxicity. In conclusion, our small case series show rapid virologic responses after short courses of oral BCV in 3 of 4 pediatric patients with d-ADV. Repeated short courses of BCV were effective in a patient with recurrent ADV viremia. Our data supports the study design of short-course oral BCV treatment in pediatric HCT recipients with ADV infection. ACKNOWLEDGEMENT This research was funded in part through the NIH/NCI Cancer Center Support Grant P30 CA008748. Conflict of Interest: GAP has been an investigator for Shire, Merck, Chimerix and Astellas and has received consulting fees from Shire, Merck, Chimerix and Astellas. Author Contributions: Conceptualization: GAP, YJL. Data curation: SYC, SEP, FB, GAP, YJL, YJL. Writing - original draft: SEP, FB, GAP, YJL.	ALEMTUZUMAB, RITUXIMAB	DrugsGivenReaction	CC BY-NC	32869551	19,460,124	2021-09
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Lymphopenia'.	Rapid Virologic Response to Brincidofovir in Children with Disseminated Adenovirus Infection. Disseminated adenovirus infections (d-ADV) after hematopoietic cell transplant (HCT) are often fatal with limited treatment options. Brincidofovir (BCV) a lipid ester of cidofovir is developed for this indication. We report four pediatric HCT recipients with d-ADV treated successfully with BCV. pmcIntroduction Adenovirus (ADV) infections may occur in up to 40% of pediatric HCT recipients [1]. T-cell depletion (TCD) (ex vivo CD34+ or serotherapy with antithymocyte globulin or alemtuzumab), or severe graft-versus-host disease (GVHD) are associated with ADV infection post-HCT [2]. Recovery of ADV specific T-lymphocytes (ADV-CTLs) confers protection against ADV [3], whereas lymphopenia is a risk factor for disseminated ADV infection (d-ADV) [4]. Ex vivo by CD34+ selection (Miltenyi Biotec, Gladbach, Germany) achieves a 5-log depletion of T-lymphocytes in the allograft [5]. D-ADV infections after TCD HCT are often fatal with mortality rates ranging from 50 - 100% [678]. There is currently no approved treatment for ADV. Intravenous cidofovir (CDV) is commonly used; however its utility is limited by associated nephrotoxicity [9]. Adoptive transfer of ADV-CTLs has shown efficacy in single center studies [2]. Brincidofovir (BCV) is a lipid-linked derivative of CDV with high potency against all clinically significant ADV subtypes and no evidence of renal or hematological toxicity to date [1011]. In lymphocyte-depleted pediatric HCT recipients with ADV infections, treatment with BCV resulted in faster and greater virologic responses to BCV compared with CDV [12]. BCV has been associated with gastrointestinal toxicity with typical onset after 4 - 6 doses of BCV [11]. Children may tolerate BCV better than adults possibly due to a more rapid turnover of gastrointestinal mucosa compared with adults [10]. We describe 4 pediatric TCD HCT recipients with d-ADV infection treated successfully with oral BCV 2 mg/kg twice per week under Emergency Investigational New Drug from 9/2015 and 5/2016. The study was reviewed and approved by the Memorial Sloan Kettering Cancer Center Institutional Review and Privavy Board and granted a waiver of authorization (IRB #16-844). Table 1 shows the clinical and virologic characteristics. Virologic responses to BCV are shown in Figure 1A-1D. Table 1 Characteristics and outcome of disseminated adenovirus cases Case Age/sex Dx Transplant type, donor Post-transplant complications before onset of ADV viremia, immunosuppressant First ADV viremiaa, days post-HCT (D) Max ADV viremia, D Sites of ADV ADV disease, D ADV viremia at first CDV Tx ADV viremia at first BCV Tx BCV initiation, D Anti-viral Tx Time to virologic clearance from BCV, days ALC / CD4+ (cell/mcL) at BCV Tx Outcome A 19m/F SCID 1st HCT: BMT, haplo mother (graft failure) Autoimmune Hemolytic Anemia, Rituximab, Prednisolone 2.1 × 105, D+192 2.1 × 105, D+192 Blood, Stool, Urine Probable Enterocolitis, D+207 4.3 × 104 <190 D+193 CDV IV 5 mg/kg × 5 doses 3 ALC 400 CD4+ 30 Alive 2nd HCT: CD34+ TCD PBSCT, MUD BCV PO 2 mg/kg TIW × 17 doses B 4y/M ALL CD34+ TCD PBSCT, 9/10 MUD 469, D+10 4.7 × 106, D+69 Blood, Stool, Liver, RESP, Pleural Fluid Definite Pneumonitis, D+84; Definite Hepatitis, D+88 5.8 × 104 3.3 × 105 D+25 CDV IV 5 mg/kg × 14 doses N/A ALC 400 CD4+ 0 Alive BCV PO 2 mg/kg TIW × 5 doses DLI, ADV CTLs C 3y/M Familial HLH CD34+ TCD PBSCT, Haplo mother Skin Grade 3 GVHD and GI Grade 1 GVHD, Mesenchymal stem cell infusion, Alemtuzumab, CNI and Prednisolone 9.8 × 105, D+841 6.7 × 106, D+1026 Blood, Stool, RESP Possible Enterocolitis, D+870 N/A 4.1 × 105 D+848 BCV PO 2 mg/kg TIW × 29 doses 1st course: 14 1st course: ALC 100 CD4+ 0 Death, D+1088, MSOF 2nd course: 20 2nd course: ALC 100 CD4+ 0 D 3y/F ALL 1st HCT: CD34+ TCD PBSCT, MUD Acute Rejection of first allo-graft 2 × 103, D+38 (From 2nd HCT) 1.9 × 107, D+42 (From 2nd HCT) Blood, Stool, Liver Possible Enterocolitis, D+65 (From 2nd HCT) 2.8 × 105 1.6 × 107 D+57 (From 2nd HCT) CDV IV 5 mg/kg × 2 doses 34 ALC 300 CD4+ 19 Death, D+539 (From 2nd HCT), relapse of primary disease 2nd HCT: CD34+ TCD PBSCT, MUD 2nd HCT: Alemtuzumab 1 mg/kg divided in 5 doses after 2nd HCT BCV PO 2 mg/kg TIW × 26 doses aADV PCR in blood was performed by Viraco Eurofins (Lee's Summit, MO, USA). Values are copies/ml. m, months-old; F, female; y, years-old; M, male; Dx, diagnosis; SCID, severe combined immune deficiency; ALL, acute lymphoblastic leukemia; HLH, hemophagocytic lymphohistiocytosis; HCT, hematopoietic cell transplant; BMT, bone marrow transplant; Haplo, Haploidentical; TCD, T Cell-depleted; PBSCT, peripheral blood stem cell transplant; MUD, matched unrelated donor; ADV, adenovirus; GVHD, graft-versus-host disease; GI, gastrointestinal; CNI, calcineurin inhibitors; D, day from transplant; max, maximum, RESP, respiratory specimens (bronchoalveolar lavage, nasopharyngeal swab); CDV, cidofovir; Tx, treatment; N/A, not applicable; BCV, brincidofovir; IV, intravenous; PO, orally; TIW, three times per week; DLI, donor lymphocyte infusion; CTLs, cytotoxic T lymphocytes, ALC, absolute lymphocyte counts; MSOF, multisystem organ failure. Figure 1 Plasma adenovirus viral load and treatment in 4 pediatric hematopoietic cell transplant recipients with disseminated adenovirus infection. CD4+ count: cell/mcL. CDV, cidofovir; BCV, brincidofovir; ADV, adenovirus; VL, viral load; DLI, donor lymphocyte infusion; CTL, cytotoxic T-lymphocyte; PCR, polymerase chain reaction. Case report ADV PCR was performed by Viracor-Eurofins (Lee's Summit, MO, USA). The linear range of quantification of ADV PCR in the blood was 100 – 1 × 1010 copies/mL. D-ADV was defined as previously defined [7]. 1. Case A A 19-month-old girl with severe combined immunodeficiency syndrome received a TCD HCT from a matched unrelated donor (MUD). Her post-transplant course was complicated by autoimmune hemolytic anemia treated with prednisolone and 6 doses of rituximab. Six months post-transplant she presented for hypoactivity, irritability and watery diarrhea. On admission, stool ADV PCR was positive and ADV viremia was 2.1 × 105copies/ml. She was treated with CDV and intravenous immunoglobulin. After 2 weeks of CDV, colonoscopy was performed. Pathology showed friable colonic mucosa. Viral culture from tissues was positive for ADV. Because of persistent diarrhea after 5 doses of CDV, BCV was started. ADV viremia became undetectable after 2 doses of BCV. BCV was stopped at 8 weeks after BCV initiation. 2. Case B A 4-year-old boy with acute lymphoblastic leukemia (ALL) received a TCD HCT from a MUD. On Day 0, stool ADV PCR was positive and ADV viremia was negative. On Day +10, ADV viremia was 469 copies/ml and on Day +17 ADV viremia rose to 5.8 × 104copies/ml. On Day +25, CDV was started due to persistent fever, diarrhea and rising ADV viremia. After 2 doses of CDV, CDV was switched to BCV due to increased ADV viremia (3.3 × 105copies/ml). On Day +39, BCV was discontinued after 5 doses due to persistent diarrhea. CDV was resumed, however ADV viremia increased to 4.7 × 106copies/ml on Day +69 and transaminitis was noted. Liver biopsy on Day +84 confirmed GVHD with ADV hepatitis (positive ADV stain). Concurrently, he developed respiratory distress and a nasopharyngeal swab was positive for ADV by PCR. On Day +88, thoracentesis was performed due to worsening pleural effusion. Pleural fluid was positive for ADV (1.8 × 105copies/ml). He was treated with donor lymphocyte infusion (DLI) and subsequently with ADV-CTLs with virologic response. 3. Case C A 3-year-old boy with familial hemophagocytic lymphohistiocytosis was admitted with fever, diarrhea and vomiting 2 years post-transplant. He received a TCD HCT from his haploidentical mother. His post-transplant course was complicated by poor graft function, refractory skin and gastrointestinal GVHD, human herpesvirus-6 viremia and chronic renal dysfunction. He received cyclosporine, tacrolimus, steroids and mesenchymal stem cells infusion for GVHD. On admission, cefepime and vancomycin were empirically started. Stool was negative for Clostridioides difficile. Symptoms persisted during admission. On hospital day 21, stool ADV PCR was positive and ADV viremia was 9.8 × 105copies/ml. BCV was initiated. Viral clearance was achieved after 5 doses BCV and BCV was continued for 4 weeks. One week after BCV discontinuation, ADV viremia recrudesced to 1.0 × 107copies/ml. BCV was reinitiated and continued for 10 weeks with good virologic control. Due to persistent diarrhea, colonoscopy was performed and pathology showed persistent gut GVHD. The tissue was positive for ADV by PCR. He received a stem cell boost 2 months after stopping BCV for poor graft function. He subsequently developed relapse of ADV viremia (6.7 × 106copies/ml), thus BCV was resumed and ADV viremia became undectable after 7 doses of BCV. His hospital stay was further complicated by hospital-acquired pneumonia with respiratory failure. Despite resolving ADV viremia, he died due to multi-organ failure. 4. Case D A 3-year-old girl with ALL received a TCD HCT from a MUD complicated by graft rejection and followed by a second TCD HCT from a different MUD one month after the first HCT. Her post-transplant course was complicated by Epstein-Barr virus (EBV) viremia treated with rituximab and cytomegalovirus viremia. On Day +38 post-transplant, she was found to have ADV viremia (2.0 × 103copies/ml). On Day +42, ADV viremia increased to 1.9 × 107copies/ml. On Day +53, she developed watery diarrhea and nausea. Stool ADV PCR was positive. On Day +56, colonoscopy was performed. The tissue was positive for ADV by PCR. On Day +56, ADV viremia was 2.8 × 105copies/ml and CDV was started. After two doses of CDV, ADV viremia was 1.1 × 105copies/ml. She developed worsening hepatic function. Computed tomography of the chest and abdomen on Day +65 showed a necrotic liver lesion and a necrotic lung mass. ADV viremia rose up to 2.3 × 107copies/ml on Day +66 despite CDV. Lung and liver biopsies performed on Day +67 yielded Legionella pneumophila serotype 1 by culture and liver biopsy was positive for EBV and ADV by PCR. ADV viremia was 1.6 × 107 copies/mL on Day +69. On Day +71, levofloxacin was started for Legionella pneumonia and BCV for d-ADV infection. ADV viremia became undectable 34 days after initiation. She received BCV for 80 days as outpatient. Discussion We report 4 pediatric TCD HCT recipients (overall 6 episodes of ADV viremia) with d-ADV treated with BCV. All patients were highly immunosuppressed, with profound lymphopenia and/or very low CD4 counts. Despite high ADV viremia (median 3.7 × 105 copies/mL) at BCV initiation, 3 of 4 patients cleared ADV viremia at a median of 14 days (range, 1 - 34) of BCV treatment. Two patients (cases A and C) were on high dose steroids. Two patients had received prior CDV treatment (case A and C) without response prior to BCV treatment. Three patients tolerated prolonged doses of BCV (range, 17 - 29 doses). Case C had lymphopenia (100 cell/mm3) and CD4+ count was 0 cell/mm3 during ADV infection. Despite a rapid virologic response to BCV, ADV recurred after discontinuation of BCV highlighting the importance of immune recovery for control of ADV infection. Importantly the patient responded rapidly after 2 short subsequent courses of BCV suggesting that repeated episodic treatment with BCV guided by ADV viral load (VL) remains effective even in the setting of persistent lymphopenia. D-ADV infections are associated with substantial morbidity and mortality in HCT recipients [678]. Cases A, C and D with ADV colitis cleared ADV viremia with BCV. Case B did not tolerate BCV. BCV was discontinued after 5 doses concerning for gastrointestinal toxicity. Case B developed ADV hepatitis and ADV pneumonitis while on CDV. Case B responded to DLI and ADV-CTLs. While ADV-CTLs have shown safety and efficacy in small series (reviewed in reference 2), at present several hurdles preclude the broad applicability of this potentially effective therapy [2]. The virologic responses in our cases confirms the virologic activity of BCV even in lymphopenic patients and are in agreement with results of the recent BCV trial [11]. In that trial virologic responses were better, if BCV treatment was initiated at low VL and was associated with improved survival [11]. Our patients had high VL at BCV initiation despite which, 3 of 4 patients achieved virologic responses. One patient discontinued BCV due to gastrointestinal symptoms. Gastrointestinal toxicity is a known side effect of BCV [10]. Management of gastrointestinal toxicity due to BCV like case B is particularly challenging in patients with ADV in the gastrointestinal tract as symptoms may be related to ADV enteritis/colitis and/or BCV. Case B had diarrhea prior to BCV initiation and had persistent diarrhea while on BCV which led a clinician to stop BCV. An intravenous formulation of BCV is currently in development and may alleviate concerns for gastrointestinal toxicity. In conclusion, our small case series show rapid virologic responses after short courses of oral BCV in 3 of 4 pediatric patients with d-ADV. Repeated short courses of BCV were effective in a patient with recurrent ADV viremia. Our data supports the study design of short-course oral BCV treatment in pediatric HCT recipients with ADV infection. ACKNOWLEDGEMENT This research was funded in part through the NIH/NCI Cancer Center Support Grant P30 CA008748. Conflict of Interest: GAP has been an investigator for Shire, Merck, Chimerix and Astellas and has received consulting fees from Shire, Merck, Chimerix and Astellas. Author Contributions: Conceptualization: GAP, YJL. Data curation: SYC, SEP, FB, GAP, YJL, YJL. Writing - original draft: SEP, FB, GAP, YJL.	ALEMTUZUMAB, PREDNISOLONE	DrugsGivenReaction	CC BY-NC	32869551	19,446,308	2021-09
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Multiple organ dysfunction syndrome'.	Rapid Virologic Response to Brincidofovir in Children with Disseminated Adenovirus Infection. Disseminated adenovirus infections (d-ADV) after hematopoietic cell transplant (HCT) are often fatal with limited treatment options. Brincidofovir (BCV) a lipid ester of cidofovir is developed for this indication. We report four pediatric HCT recipients with d-ADV treated successfully with BCV. pmcIntroduction Adenovirus (ADV) infections may occur in up to 40% of pediatric HCT recipients [1]. T-cell depletion (TCD) (ex vivo CD34+ or serotherapy with antithymocyte globulin or alemtuzumab), or severe graft-versus-host disease (GVHD) are associated with ADV infection post-HCT [2]. Recovery of ADV specific T-lymphocytes (ADV-CTLs) confers protection against ADV [3], whereas lymphopenia is a risk factor for disseminated ADV infection (d-ADV) [4]. Ex vivo by CD34+ selection (Miltenyi Biotec, Gladbach, Germany) achieves a 5-log depletion of T-lymphocytes in the allograft [5]. D-ADV infections after TCD HCT are often fatal with mortality rates ranging from 50 - 100% [678]. There is currently no approved treatment for ADV. Intravenous cidofovir (CDV) is commonly used; however its utility is limited by associated nephrotoxicity [9]. Adoptive transfer of ADV-CTLs has shown efficacy in single center studies [2]. Brincidofovir (BCV) is a lipid-linked derivative of CDV with high potency against all clinically significant ADV subtypes and no evidence of renal or hematological toxicity to date [1011]. In lymphocyte-depleted pediatric HCT recipients with ADV infections, treatment with BCV resulted in faster and greater virologic responses to BCV compared with CDV [12]. BCV has been associated with gastrointestinal toxicity with typical onset after 4 - 6 doses of BCV [11]. Children may tolerate BCV better than adults possibly due to a more rapid turnover of gastrointestinal mucosa compared with adults [10]. We describe 4 pediatric TCD HCT recipients with d-ADV infection treated successfully with oral BCV 2 mg/kg twice per week under Emergency Investigational New Drug from 9/2015 and 5/2016. The study was reviewed and approved by the Memorial Sloan Kettering Cancer Center Institutional Review and Privavy Board and granted a waiver of authorization (IRB #16-844). Table 1 shows the clinical and virologic characteristics. Virologic responses to BCV are shown in Figure 1A-1D. Table 1 Characteristics and outcome of disseminated adenovirus cases Case Age/sex Dx Transplant type, donor Post-transplant complications before onset of ADV viremia, immunosuppressant First ADV viremiaa, days post-HCT (D) Max ADV viremia, D Sites of ADV ADV disease, D ADV viremia at first CDV Tx ADV viremia at first BCV Tx BCV initiation, D Anti-viral Tx Time to virologic clearance from BCV, days ALC / CD4+ (cell/mcL) at BCV Tx Outcome A 19m/F SCID 1st HCT: BMT, haplo mother (graft failure) Autoimmune Hemolytic Anemia, Rituximab, Prednisolone 2.1 × 105, D+192 2.1 × 105, D+192 Blood, Stool, Urine Probable Enterocolitis, D+207 4.3 × 104 <190 D+193 CDV IV 5 mg/kg × 5 doses 3 ALC 400 CD4+ 30 Alive 2nd HCT: CD34+ TCD PBSCT, MUD BCV PO 2 mg/kg TIW × 17 doses B 4y/M ALL CD34+ TCD PBSCT, 9/10 MUD 469, D+10 4.7 × 106, D+69 Blood, Stool, Liver, RESP, Pleural Fluid Definite Pneumonitis, D+84; Definite Hepatitis, D+88 5.8 × 104 3.3 × 105 D+25 CDV IV 5 mg/kg × 14 doses N/A ALC 400 CD4+ 0 Alive BCV PO 2 mg/kg TIW × 5 doses DLI, ADV CTLs C 3y/M Familial HLH CD34+ TCD PBSCT, Haplo mother Skin Grade 3 GVHD and GI Grade 1 GVHD, Mesenchymal stem cell infusion, Alemtuzumab, CNI and Prednisolone 9.8 × 105, D+841 6.7 × 106, D+1026 Blood, Stool, RESP Possible Enterocolitis, D+870 N/A 4.1 × 105 D+848 BCV PO 2 mg/kg TIW × 29 doses 1st course: 14 1st course: ALC 100 CD4+ 0 Death, D+1088, MSOF 2nd course: 20 2nd course: ALC 100 CD4+ 0 D 3y/F ALL 1st HCT: CD34+ TCD PBSCT, MUD Acute Rejection of first allo-graft 2 × 103, D+38 (From 2nd HCT) 1.9 × 107, D+42 (From 2nd HCT) Blood, Stool, Liver Possible Enterocolitis, D+65 (From 2nd HCT) 2.8 × 105 1.6 × 107 D+57 (From 2nd HCT) CDV IV 5 mg/kg × 2 doses 34 ALC 300 CD4+ 19 Death, D+539 (From 2nd HCT), relapse of primary disease 2nd HCT: CD34+ TCD PBSCT, MUD 2nd HCT: Alemtuzumab 1 mg/kg divided in 5 doses after 2nd HCT BCV PO 2 mg/kg TIW × 26 doses aADV PCR in blood was performed by Viraco Eurofins (Lee's Summit, MO, USA). Values are copies/ml. m, months-old; F, female; y, years-old; M, male; Dx, diagnosis; SCID, severe combined immune deficiency; ALL, acute lymphoblastic leukemia; HLH, hemophagocytic lymphohistiocytosis; HCT, hematopoietic cell transplant; BMT, bone marrow transplant; Haplo, Haploidentical; TCD, T Cell-depleted; PBSCT, peripheral blood stem cell transplant; MUD, matched unrelated donor; ADV, adenovirus; GVHD, graft-versus-host disease; GI, gastrointestinal; CNI, calcineurin inhibitors; D, day from transplant; max, maximum, RESP, respiratory specimens (bronchoalveolar lavage, nasopharyngeal swab); CDV, cidofovir; Tx, treatment; N/A, not applicable; BCV, brincidofovir; IV, intravenous; PO, orally; TIW, three times per week; DLI, donor lymphocyte infusion; CTLs, cytotoxic T lymphocytes, ALC, absolute lymphocyte counts; MSOF, multisystem organ failure. Figure 1 Plasma adenovirus viral load and treatment in 4 pediatric hematopoietic cell transplant recipients with disseminated adenovirus infection. CD4+ count: cell/mcL. CDV, cidofovir; BCV, brincidofovir; ADV, adenovirus; VL, viral load; DLI, donor lymphocyte infusion; CTL, cytotoxic T-lymphocyte; PCR, polymerase chain reaction. Case report ADV PCR was performed by Viracor-Eurofins (Lee's Summit, MO, USA). The linear range of quantification of ADV PCR in the blood was 100 – 1 × 1010 copies/mL. D-ADV was defined as previously defined [7]. 1. Case A A 19-month-old girl with severe combined immunodeficiency syndrome received a TCD HCT from a matched unrelated donor (MUD). Her post-transplant course was complicated by autoimmune hemolytic anemia treated with prednisolone and 6 doses of rituximab. Six months post-transplant she presented for hypoactivity, irritability and watery diarrhea. On admission, stool ADV PCR was positive and ADV viremia was 2.1 × 105copies/ml. She was treated with CDV and intravenous immunoglobulin. After 2 weeks of CDV, colonoscopy was performed. Pathology showed friable colonic mucosa. Viral culture from tissues was positive for ADV. Because of persistent diarrhea after 5 doses of CDV, BCV was started. ADV viremia became undetectable after 2 doses of BCV. BCV was stopped at 8 weeks after BCV initiation. 2. Case B A 4-year-old boy with acute lymphoblastic leukemia (ALL) received a TCD HCT from a MUD. On Day 0, stool ADV PCR was positive and ADV viremia was negative. On Day +10, ADV viremia was 469 copies/ml and on Day +17 ADV viremia rose to 5.8 × 104copies/ml. On Day +25, CDV was started due to persistent fever, diarrhea and rising ADV viremia. After 2 doses of CDV, CDV was switched to BCV due to increased ADV viremia (3.3 × 105copies/ml). On Day +39, BCV was discontinued after 5 doses due to persistent diarrhea. CDV was resumed, however ADV viremia increased to 4.7 × 106copies/ml on Day +69 and transaminitis was noted. Liver biopsy on Day +84 confirmed GVHD with ADV hepatitis (positive ADV stain). Concurrently, he developed respiratory distress and a nasopharyngeal swab was positive for ADV by PCR. On Day +88, thoracentesis was performed due to worsening pleural effusion. Pleural fluid was positive for ADV (1.8 × 105copies/ml). He was treated with donor lymphocyte infusion (DLI) and subsequently with ADV-CTLs with virologic response. 3. Case C A 3-year-old boy with familial hemophagocytic lymphohistiocytosis was admitted with fever, diarrhea and vomiting 2 years post-transplant. He received a TCD HCT from his haploidentical mother. His post-transplant course was complicated by poor graft function, refractory skin and gastrointestinal GVHD, human herpesvirus-6 viremia and chronic renal dysfunction. He received cyclosporine, tacrolimus, steroids and mesenchymal stem cells infusion for GVHD. On admission, cefepime and vancomycin were empirically started. Stool was negative for Clostridioides difficile. Symptoms persisted during admission. On hospital day 21, stool ADV PCR was positive and ADV viremia was 9.8 × 105copies/ml. BCV was initiated. Viral clearance was achieved after 5 doses BCV and BCV was continued for 4 weeks. One week after BCV discontinuation, ADV viremia recrudesced to 1.0 × 107copies/ml. BCV was reinitiated and continued for 10 weeks with good virologic control. Due to persistent diarrhea, colonoscopy was performed and pathology showed persistent gut GVHD. The tissue was positive for ADV by PCR. He received a stem cell boost 2 months after stopping BCV for poor graft function. He subsequently developed relapse of ADV viremia (6.7 × 106copies/ml), thus BCV was resumed and ADV viremia became undectable after 7 doses of BCV. His hospital stay was further complicated by hospital-acquired pneumonia with respiratory failure. Despite resolving ADV viremia, he died due to multi-organ failure. 4. Case D A 3-year-old girl with ALL received a TCD HCT from a MUD complicated by graft rejection and followed by a second TCD HCT from a different MUD one month after the first HCT. Her post-transplant course was complicated by Epstein-Barr virus (EBV) viremia treated with rituximab and cytomegalovirus viremia. On Day +38 post-transplant, she was found to have ADV viremia (2.0 × 103copies/ml). On Day +42, ADV viremia increased to 1.9 × 107copies/ml. On Day +53, she developed watery diarrhea and nausea. Stool ADV PCR was positive. On Day +56, colonoscopy was performed. The tissue was positive for ADV by PCR. On Day +56, ADV viremia was 2.8 × 105copies/ml and CDV was started. After two doses of CDV, ADV viremia was 1.1 × 105copies/ml. She developed worsening hepatic function. Computed tomography of the chest and abdomen on Day +65 showed a necrotic liver lesion and a necrotic lung mass. ADV viremia rose up to 2.3 × 107copies/ml on Day +66 despite CDV. Lung and liver biopsies performed on Day +67 yielded Legionella pneumophila serotype 1 by culture and liver biopsy was positive for EBV and ADV by PCR. ADV viremia was 1.6 × 107 copies/mL on Day +69. On Day +71, levofloxacin was started for Legionella pneumonia and BCV for d-ADV infection. ADV viremia became undectable 34 days after initiation. She received BCV for 80 days as outpatient. Discussion We report 4 pediatric TCD HCT recipients (overall 6 episodes of ADV viremia) with d-ADV treated with BCV. All patients were highly immunosuppressed, with profound lymphopenia and/or very low CD4 counts. Despite high ADV viremia (median 3.7 × 105 copies/mL) at BCV initiation, 3 of 4 patients cleared ADV viremia at a median of 14 days (range, 1 - 34) of BCV treatment. Two patients (cases A and C) were on high dose steroids. Two patients had received prior CDV treatment (case A and C) without response prior to BCV treatment. Three patients tolerated prolonged doses of BCV (range, 17 - 29 doses). Case C had lymphopenia (100 cell/mm3) and CD4+ count was 0 cell/mm3 during ADV infection. Despite a rapid virologic response to BCV, ADV recurred after discontinuation of BCV highlighting the importance of immune recovery for control of ADV infection. Importantly the patient responded rapidly after 2 short subsequent courses of BCV suggesting that repeated episodic treatment with BCV guided by ADV viral load (VL) remains effective even in the setting of persistent lymphopenia. D-ADV infections are associated with substantial morbidity and mortality in HCT recipients [678]. Cases A, C and D with ADV colitis cleared ADV viremia with BCV. Case B did not tolerate BCV. BCV was discontinued after 5 doses concerning for gastrointestinal toxicity. Case B developed ADV hepatitis and ADV pneumonitis while on CDV. Case B responded to DLI and ADV-CTLs. While ADV-CTLs have shown safety and efficacy in small series (reviewed in reference 2), at present several hurdles preclude the broad applicability of this potentially effective therapy [2]. The virologic responses in our cases confirms the virologic activity of BCV even in lymphopenic patients and are in agreement with results of the recent BCV trial [11]. In that trial virologic responses were better, if BCV treatment was initiated at low VL and was associated with improved survival [11]. Our patients had high VL at BCV initiation despite which, 3 of 4 patients achieved virologic responses. One patient discontinued BCV due to gastrointestinal symptoms. Gastrointestinal toxicity is a known side effect of BCV [10]. Management of gastrointestinal toxicity due to BCV like case B is particularly challenging in patients with ADV in the gastrointestinal tract as symptoms may be related to ADV enteritis/colitis and/or BCV. Case B had diarrhea prior to BCV initiation and had persistent diarrhea while on BCV which led a clinician to stop BCV. An intravenous formulation of BCV is currently in development and may alleviate concerns for gastrointestinal toxicity. In conclusion, our small case series show rapid virologic responses after short courses of oral BCV in 3 of 4 pediatric patients with d-ADV. Repeated short courses of BCV were effective in a patient with recurrent ADV viremia. Our data supports the study design of short-course oral BCV treatment in pediatric HCT recipients with ADV infection. ACKNOWLEDGEMENT This research was funded in part through the NIH/NCI Cancer Center Support Grant P30 CA008748. Conflict of Interest: GAP has been an investigator for Shire, Merck, Chimerix and Astellas and has received consulting fees from Shire, Merck, Chimerix and Astellas. Author Contributions: Conceptualization: GAP, YJL. Data curation: SYC, SEP, FB, GAP, YJL, YJL. Writing - original draft: SEP, FB, GAP, YJL.	ALEMTUZUMAB, PREDNISOLONE	DrugsGivenReaction	CC BY-NC	32869551	19,446,308	2021-09
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Nausea'.	Rapid Virologic Response to Brincidofovir in Children with Disseminated Adenovirus Infection. Disseminated adenovirus infections (d-ADV) after hematopoietic cell transplant (HCT) are often fatal with limited treatment options. Brincidofovir (BCV) a lipid ester of cidofovir is developed for this indication. We report four pediatric HCT recipients with d-ADV treated successfully with BCV. pmcIntroduction Adenovirus (ADV) infections may occur in up to 40% of pediatric HCT recipients [1]. T-cell depletion (TCD) (ex vivo CD34+ or serotherapy with antithymocyte globulin or alemtuzumab), or severe graft-versus-host disease (GVHD) are associated with ADV infection post-HCT [2]. Recovery of ADV specific T-lymphocytes (ADV-CTLs) confers protection against ADV [3], whereas lymphopenia is a risk factor for disseminated ADV infection (d-ADV) [4]. Ex vivo by CD34+ selection (Miltenyi Biotec, Gladbach, Germany) achieves a 5-log depletion of T-lymphocytes in the allograft [5]. D-ADV infections after TCD HCT are often fatal with mortality rates ranging from 50 - 100% [678]. There is currently no approved treatment for ADV. Intravenous cidofovir (CDV) is commonly used; however its utility is limited by associated nephrotoxicity [9]. Adoptive transfer of ADV-CTLs has shown efficacy in single center studies [2]. Brincidofovir (BCV) is a lipid-linked derivative of CDV with high potency against all clinically significant ADV subtypes and no evidence of renal or hematological toxicity to date [1011]. In lymphocyte-depleted pediatric HCT recipients with ADV infections, treatment with BCV resulted in faster and greater virologic responses to BCV compared with CDV [12]. BCV has been associated with gastrointestinal toxicity with typical onset after 4 - 6 doses of BCV [11]. Children may tolerate BCV better than adults possibly due to a more rapid turnover of gastrointestinal mucosa compared with adults [10]. We describe 4 pediatric TCD HCT recipients with d-ADV infection treated successfully with oral BCV 2 mg/kg twice per week under Emergency Investigational New Drug from 9/2015 and 5/2016. The study was reviewed and approved by the Memorial Sloan Kettering Cancer Center Institutional Review and Privavy Board and granted a waiver of authorization (IRB #16-844). Table 1 shows the clinical and virologic characteristics. Virologic responses to BCV are shown in Figure 1A-1D. Table 1 Characteristics and outcome of disseminated adenovirus cases Case Age/sex Dx Transplant type, donor Post-transplant complications before onset of ADV viremia, immunosuppressant First ADV viremiaa, days post-HCT (D) Max ADV viremia, D Sites of ADV ADV disease, D ADV viremia at first CDV Tx ADV viremia at first BCV Tx BCV initiation, D Anti-viral Tx Time to virologic clearance from BCV, days ALC / CD4+ (cell/mcL) at BCV Tx Outcome A 19m/F SCID 1st HCT: BMT, haplo mother (graft failure) Autoimmune Hemolytic Anemia, Rituximab, Prednisolone 2.1 × 105, D+192 2.1 × 105, D+192 Blood, Stool, Urine Probable Enterocolitis, D+207 4.3 × 104 <190 D+193 CDV IV 5 mg/kg × 5 doses 3 ALC 400 CD4+ 30 Alive 2nd HCT: CD34+ TCD PBSCT, MUD BCV PO 2 mg/kg TIW × 17 doses B 4y/M ALL CD34+ TCD PBSCT, 9/10 MUD 469, D+10 4.7 × 106, D+69 Blood, Stool, Liver, RESP, Pleural Fluid Definite Pneumonitis, D+84; Definite Hepatitis, D+88 5.8 × 104 3.3 × 105 D+25 CDV IV 5 mg/kg × 14 doses N/A ALC 400 CD4+ 0 Alive BCV PO 2 mg/kg TIW × 5 doses DLI, ADV CTLs C 3y/M Familial HLH CD34+ TCD PBSCT, Haplo mother Skin Grade 3 GVHD and GI Grade 1 GVHD, Mesenchymal stem cell infusion, Alemtuzumab, CNI and Prednisolone 9.8 × 105, D+841 6.7 × 106, D+1026 Blood, Stool, RESP Possible Enterocolitis, D+870 N/A 4.1 × 105 D+848 BCV PO 2 mg/kg TIW × 29 doses 1st course: 14 1st course: ALC 100 CD4+ 0 Death, D+1088, MSOF 2nd course: 20 2nd course: ALC 100 CD4+ 0 D 3y/F ALL 1st HCT: CD34+ TCD PBSCT, MUD Acute Rejection of first allo-graft 2 × 103, D+38 (From 2nd HCT) 1.9 × 107, D+42 (From 2nd HCT) Blood, Stool, Liver Possible Enterocolitis, D+65 (From 2nd HCT) 2.8 × 105 1.6 × 107 D+57 (From 2nd HCT) CDV IV 5 mg/kg × 2 doses 34 ALC 300 CD4+ 19 Death, D+539 (From 2nd HCT), relapse of primary disease 2nd HCT: CD34+ TCD PBSCT, MUD 2nd HCT: Alemtuzumab 1 mg/kg divided in 5 doses after 2nd HCT BCV PO 2 mg/kg TIW × 26 doses aADV PCR in blood was performed by Viraco Eurofins (Lee's Summit, MO, USA). Values are copies/ml. m, months-old; F, female; y, years-old; M, male; Dx, diagnosis; SCID, severe combined immune deficiency; ALL, acute lymphoblastic leukemia; HLH, hemophagocytic lymphohistiocytosis; HCT, hematopoietic cell transplant; BMT, bone marrow transplant; Haplo, Haploidentical; TCD, T Cell-depleted; PBSCT, peripheral blood stem cell transplant; MUD, matched unrelated donor; ADV, adenovirus; GVHD, graft-versus-host disease; GI, gastrointestinal; CNI, calcineurin inhibitors; D, day from transplant; max, maximum, RESP, respiratory specimens (bronchoalveolar lavage, nasopharyngeal swab); CDV, cidofovir; Tx, treatment; N/A, not applicable; BCV, brincidofovir; IV, intravenous; PO, orally; TIW, three times per week; DLI, donor lymphocyte infusion; CTLs, cytotoxic T lymphocytes, ALC, absolute lymphocyte counts; MSOF, multisystem organ failure. Figure 1 Plasma adenovirus viral load and treatment in 4 pediatric hematopoietic cell transplant recipients with disseminated adenovirus infection. CD4+ count: cell/mcL. CDV, cidofovir; BCV, brincidofovir; ADV, adenovirus; VL, viral load; DLI, donor lymphocyte infusion; CTL, cytotoxic T-lymphocyte; PCR, polymerase chain reaction. Case report ADV PCR was performed by Viracor-Eurofins (Lee's Summit, MO, USA). The linear range of quantification of ADV PCR in the blood was 100 – 1 × 1010 copies/mL. D-ADV was defined as previously defined [7]. 1. Case A A 19-month-old girl with severe combined immunodeficiency syndrome received a TCD HCT from a matched unrelated donor (MUD). Her post-transplant course was complicated by autoimmune hemolytic anemia treated with prednisolone and 6 doses of rituximab. Six months post-transplant she presented for hypoactivity, irritability and watery diarrhea. On admission, stool ADV PCR was positive and ADV viremia was 2.1 × 105copies/ml. She was treated with CDV and intravenous immunoglobulin. After 2 weeks of CDV, colonoscopy was performed. Pathology showed friable colonic mucosa. Viral culture from tissues was positive for ADV. Because of persistent diarrhea after 5 doses of CDV, BCV was started. ADV viremia became undetectable after 2 doses of BCV. BCV was stopped at 8 weeks after BCV initiation. 2. Case B A 4-year-old boy with acute lymphoblastic leukemia (ALL) received a TCD HCT from a MUD. On Day 0, stool ADV PCR was positive and ADV viremia was negative. On Day +10, ADV viremia was 469 copies/ml and on Day +17 ADV viremia rose to 5.8 × 104copies/ml. On Day +25, CDV was started due to persistent fever, diarrhea and rising ADV viremia. After 2 doses of CDV, CDV was switched to BCV due to increased ADV viremia (3.3 × 105copies/ml). On Day +39, BCV was discontinued after 5 doses due to persistent diarrhea. CDV was resumed, however ADV viremia increased to 4.7 × 106copies/ml on Day +69 and transaminitis was noted. Liver biopsy on Day +84 confirmed GVHD with ADV hepatitis (positive ADV stain). Concurrently, he developed respiratory distress and a nasopharyngeal swab was positive for ADV by PCR. On Day +88, thoracentesis was performed due to worsening pleural effusion. Pleural fluid was positive for ADV (1.8 × 105copies/ml). He was treated with donor lymphocyte infusion (DLI) and subsequently with ADV-CTLs with virologic response. 3. Case C A 3-year-old boy with familial hemophagocytic lymphohistiocytosis was admitted with fever, diarrhea and vomiting 2 years post-transplant. He received a TCD HCT from his haploidentical mother. His post-transplant course was complicated by poor graft function, refractory skin and gastrointestinal GVHD, human herpesvirus-6 viremia and chronic renal dysfunction. He received cyclosporine, tacrolimus, steroids and mesenchymal stem cells infusion for GVHD. On admission, cefepime and vancomycin were empirically started. Stool was negative for Clostridioides difficile. Symptoms persisted during admission. On hospital day 21, stool ADV PCR was positive and ADV viremia was 9.8 × 105copies/ml. BCV was initiated. Viral clearance was achieved after 5 doses BCV and BCV was continued for 4 weeks. One week after BCV discontinuation, ADV viremia recrudesced to 1.0 × 107copies/ml. BCV was reinitiated and continued for 10 weeks with good virologic control. Due to persistent diarrhea, colonoscopy was performed and pathology showed persistent gut GVHD. The tissue was positive for ADV by PCR. He received a stem cell boost 2 months after stopping BCV for poor graft function. He subsequently developed relapse of ADV viremia (6.7 × 106copies/ml), thus BCV was resumed and ADV viremia became undectable after 7 doses of BCV. His hospital stay was further complicated by hospital-acquired pneumonia with respiratory failure. Despite resolving ADV viremia, he died due to multi-organ failure. 4. Case D A 3-year-old girl with ALL received a TCD HCT from a MUD complicated by graft rejection and followed by a second TCD HCT from a different MUD one month after the first HCT. Her post-transplant course was complicated by Epstein-Barr virus (EBV) viremia treated with rituximab and cytomegalovirus viremia. On Day +38 post-transplant, she was found to have ADV viremia (2.0 × 103copies/ml). On Day +42, ADV viremia increased to 1.9 × 107copies/ml. On Day +53, she developed watery diarrhea and nausea. Stool ADV PCR was positive. On Day +56, colonoscopy was performed. The tissue was positive for ADV by PCR. On Day +56, ADV viremia was 2.8 × 105copies/ml and CDV was started. After two doses of CDV, ADV viremia was 1.1 × 105copies/ml. She developed worsening hepatic function. Computed tomography of the chest and abdomen on Day +65 showed a necrotic liver lesion and a necrotic lung mass. ADV viremia rose up to 2.3 × 107copies/ml on Day +66 despite CDV. Lung and liver biopsies performed on Day +67 yielded Legionella pneumophila serotype 1 by culture and liver biopsy was positive for EBV and ADV by PCR. ADV viremia was 1.6 × 107 copies/mL on Day +69. On Day +71, levofloxacin was started for Legionella pneumonia and BCV for d-ADV infection. ADV viremia became undectable 34 days after initiation. She received BCV for 80 days as outpatient. Discussion We report 4 pediatric TCD HCT recipients (overall 6 episodes of ADV viremia) with d-ADV treated with BCV. All patients were highly immunosuppressed, with profound lymphopenia and/or very low CD4 counts. Despite high ADV viremia (median 3.7 × 105 copies/mL) at BCV initiation, 3 of 4 patients cleared ADV viremia at a median of 14 days (range, 1 - 34) of BCV treatment. Two patients (cases A and C) were on high dose steroids. Two patients had received prior CDV treatment (case A and C) without response prior to BCV treatment. Three patients tolerated prolonged doses of BCV (range, 17 - 29 doses). Case C had lymphopenia (100 cell/mm3) and CD4+ count was 0 cell/mm3 during ADV infection. Despite a rapid virologic response to BCV, ADV recurred after discontinuation of BCV highlighting the importance of immune recovery for control of ADV infection. Importantly the patient responded rapidly after 2 short subsequent courses of BCV suggesting that repeated episodic treatment with BCV guided by ADV viral load (VL) remains effective even in the setting of persistent lymphopenia. D-ADV infections are associated with substantial morbidity and mortality in HCT recipients [678]. Cases A, C and D with ADV colitis cleared ADV viremia with BCV. Case B did not tolerate BCV. BCV was discontinued after 5 doses concerning for gastrointestinal toxicity. Case B developed ADV hepatitis and ADV pneumonitis while on CDV. Case B responded to DLI and ADV-CTLs. While ADV-CTLs have shown safety and efficacy in small series (reviewed in reference 2), at present several hurdles preclude the broad applicability of this potentially effective therapy [2]. The virologic responses in our cases confirms the virologic activity of BCV even in lymphopenic patients and are in agreement with results of the recent BCV trial [11]. In that trial virologic responses were better, if BCV treatment was initiated at low VL and was associated with improved survival [11]. Our patients had high VL at BCV initiation despite which, 3 of 4 patients achieved virologic responses. One patient discontinued BCV due to gastrointestinal symptoms. Gastrointestinal toxicity is a known side effect of BCV [10]. Management of gastrointestinal toxicity due to BCV like case B is particularly challenging in patients with ADV in the gastrointestinal tract as symptoms may be related to ADV enteritis/colitis and/or BCV. Case B had diarrhea prior to BCV initiation and had persistent diarrhea while on BCV which led a clinician to stop BCV. An intravenous formulation of BCV is currently in development and may alleviate concerns for gastrointestinal toxicity. In conclusion, our small case series show rapid virologic responses after short courses of oral BCV in 3 of 4 pediatric patients with d-ADV. Repeated short courses of BCV were effective in a patient with recurrent ADV viremia. Our data supports the study design of short-course oral BCV treatment in pediatric HCT recipients with ADV infection. ACKNOWLEDGEMENT This research was funded in part through the NIH/NCI Cancer Center Support Grant P30 CA008748. Conflict of Interest: GAP has been an investigator for Shire, Merck, Chimerix and Astellas and has received consulting fees from Shire, Merck, Chimerix and Astellas. Author Contributions: Conceptualization: GAP, YJL. Data curation: SYC, SEP, FB, GAP, YJL, YJL. Writing - original draft: SEP, FB, GAP, YJL.	ALEMTUZUMAB, RITUXIMAB	DrugsGivenReaction	CC BY-NC	32869551	19,460,124	2021-09
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Pneumonia'.	Rapid Virologic Response to Brincidofovir in Children with Disseminated Adenovirus Infection. Disseminated adenovirus infections (d-ADV) after hematopoietic cell transplant (HCT) are often fatal with limited treatment options. Brincidofovir (BCV) a lipid ester of cidofovir is developed for this indication. We report four pediatric HCT recipients with d-ADV treated successfully with BCV. pmcIntroduction Adenovirus (ADV) infections may occur in up to 40% of pediatric HCT recipients [1]. T-cell depletion (TCD) (ex vivo CD34+ or serotherapy with antithymocyte globulin or alemtuzumab), or severe graft-versus-host disease (GVHD) are associated with ADV infection post-HCT [2]. Recovery of ADV specific T-lymphocytes (ADV-CTLs) confers protection against ADV [3], whereas lymphopenia is a risk factor for disseminated ADV infection (d-ADV) [4]. Ex vivo by CD34+ selection (Miltenyi Biotec, Gladbach, Germany) achieves a 5-log depletion of T-lymphocytes in the allograft [5]. D-ADV infections after TCD HCT are often fatal with mortality rates ranging from 50 - 100% [678]. There is currently no approved treatment for ADV. Intravenous cidofovir (CDV) is commonly used; however its utility is limited by associated nephrotoxicity [9]. Adoptive transfer of ADV-CTLs has shown efficacy in single center studies [2]. Brincidofovir (BCV) is a lipid-linked derivative of CDV with high potency against all clinically significant ADV subtypes and no evidence of renal or hematological toxicity to date [1011]. In lymphocyte-depleted pediatric HCT recipients with ADV infections, treatment with BCV resulted in faster and greater virologic responses to BCV compared with CDV [12]. BCV has been associated with gastrointestinal toxicity with typical onset after 4 - 6 doses of BCV [11]. Children may tolerate BCV better than adults possibly due to a more rapid turnover of gastrointestinal mucosa compared with adults [10]. We describe 4 pediatric TCD HCT recipients with d-ADV infection treated successfully with oral BCV 2 mg/kg twice per week under Emergency Investigational New Drug from 9/2015 and 5/2016. The study was reviewed and approved by the Memorial Sloan Kettering Cancer Center Institutional Review and Privavy Board and granted a waiver of authorization (IRB #16-844). Table 1 shows the clinical and virologic characteristics. Virologic responses to BCV are shown in Figure 1A-1D. Table 1 Characteristics and outcome of disseminated adenovirus cases Case Age/sex Dx Transplant type, donor Post-transplant complications before onset of ADV viremia, immunosuppressant First ADV viremiaa, days post-HCT (D) Max ADV viremia, D Sites of ADV ADV disease, D ADV viremia at first CDV Tx ADV viremia at first BCV Tx BCV initiation, D Anti-viral Tx Time to virologic clearance from BCV, days ALC / CD4+ (cell/mcL) at BCV Tx Outcome A 19m/F SCID 1st HCT: BMT, haplo mother (graft failure) Autoimmune Hemolytic Anemia, Rituximab, Prednisolone 2.1 × 105, D+192 2.1 × 105, D+192 Blood, Stool, Urine Probable Enterocolitis, D+207 4.3 × 104 <190 D+193 CDV IV 5 mg/kg × 5 doses 3 ALC 400 CD4+ 30 Alive 2nd HCT: CD34+ TCD PBSCT, MUD BCV PO 2 mg/kg TIW × 17 doses B 4y/M ALL CD34+ TCD PBSCT, 9/10 MUD 469, D+10 4.7 × 106, D+69 Blood, Stool, Liver, RESP, Pleural Fluid Definite Pneumonitis, D+84; Definite Hepatitis, D+88 5.8 × 104 3.3 × 105 D+25 CDV IV 5 mg/kg × 14 doses N/A ALC 400 CD4+ 0 Alive BCV PO 2 mg/kg TIW × 5 doses DLI, ADV CTLs C 3y/M Familial HLH CD34+ TCD PBSCT, Haplo mother Skin Grade 3 GVHD and GI Grade 1 GVHD, Mesenchymal stem cell infusion, Alemtuzumab, CNI and Prednisolone 9.8 × 105, D+841 6.7 × 106, D+1026 Blood, Stool, RESP Possible Enterocolitis, D+870 N/A 4.1 × 105 D+848 BCV PO 2 mg/kg TIW × 29 doses 1st course: 14 1st course: ALC 100 CD4+ 0 Death, D+1088, MSOF 2nd course: 20 2nd course: ALC 100 CD4+ 0 D 3y/F ALL 1st HCT: CD34+ TCD PBSCT, MUD Acute Rejection of first allo-graft 2 × 103, D+38 (From 2nd HCT) 1.9 × 107, D+42 (From 2nd HCT) Blood, Stool, Liver Possible Enterocolitis, D+65 (From 2nd HCT) 2.8 × 105 1.6 × 107 D+57 (From 2nd HCT) CDV IV 5 mg/kg × 2 doses 34 ALC 300 CD4+ 19 Death, D+539 (From 2nd HCT), relapse of primary disease 2nd HCT: CD34+ TCD PBSCT, MUD 2nd HCT: Alemtuzumab 1 mg/kg divided in 5 doses after 2nd HCT BCV PO 2 mg/kg TIW × 26 doses aADV PCR in blood was performed by Viraco Eurofins (Lee's Summit, MO, USA). Values are copies/ml. m, months-old; F, female; y, years-old; M, male; Dx, diagnosis; SCID, severe combined immune deficiency; ALL, acute lymphoblastic leukemia; HLH, hemophagocytic lymphohistiocytosis; HCT, hematopoietic cell transplant; BMT, bone marrow transplant; Haplo, Haploidentical; TCD, T Cell-depleted; PBSCT, peripheral blood stem cell transplant; MUD, matched unrelated donor; ADV, adenovirus; GVHD, graft-versus-host disease; GI, gastrointestinal; CNI, calcineurin inhibitors; D, day from transplant; max, maximum, RESP, respiratory specimens (bronchoalveolar lavage, nasopharyngeal swab); CDV, cidofovir; Tx, treatment; N/A, not applicable; BCV, brincidofovir; IV, intravenous; PO, orally; TIW, three times per week; DLI, donor lymphocyte infusion; CTLs, cytotoxic T lymphocytes, ALC, absolute lymphocyte counts; MSOF, multisystem organ failure. Figure 1 Plasma adenovirus viral load and treatment in 4 pediatric hematopoietic cell transplant recipients with disseminated adenovirus infection. CD4+ count: cell/mcL. CDV, cidofovir; BCV, brincidofovir; ADV, adenovirus; VL, viral load; DLI, donor lymphocyte infusion; CTL, cytotoxic T-lymphocyte; PCR, polymerase chain reaction. Case report ADV PCR was performed by Viracor-Eurofins (Lee's Summit, MO, USA). The linear range of quantification of ADV PCR in the blood was 100 – 1 × 1010 copies/mL. D-ADV was defined as previously defined [7]. 1. Case A A 19-month-old girl with severe combined immunodeficiency syndrome received a TCD HCT from a matched unrelated donor (MUD). Her post-transplant course was complicated by autoimmune hemolytic anemia treated with prednisolone and 6 doses of rituximab. Six months post-transplant she presented for hypoactivity, irritability and watery diarrhea. On admission, stool ADV PCR was positive and ADV viremia was 2.1 × 105copies/ml. She was treated with CDV and intravenous immunoglobulin. After 2 weeks of CDV, colonoscopy was performed. Pathology showed friable colonic mucosa. Viral culture from tissues was positive for ADV. Because of persistent diarrhea after 5 doses of CDV, BCV was started. ADV viremia became undetectable after 2 doses of BCV. BCV was stopped at 8 weeks after BCV initiation. 2. Case B A 4-year-old boy with acute lymphoblastic leukemia (ALL) received a TCD HCT from a MUD. On Day 0, stool ADV PCR was positive and ADV viremia was negative. On Day +10, ADV viremia was 469 copies/ml and on Day +17 ADV viremia rose to 5.8 × 104copies/ml. On Day +25, CDV was started due to persistent fever, diarrhea and rising ADV viremia. After 2 doses of CDV, CDV was switched to BCV due to increased ADV viremia (3.3 × 105copies/ml). On Day +39, BCV was discontinued after 5 doses due to persistent diarrhea. CDV was resumed, however ADV viremia increased to 4.7 × 106copies/ml on Day +69 and transaminitis was noted. Liver biopsy on Day +84 confirmed GVHD with ADV hepatitis (positive ADV stain). Concurrently, he developed respiratory distress and a nasopharyngeal swab was positive for ADV by PCR. On Day +88, thoracentesis was performed due to worsening pleural effusion. Pleural fluid was positive for ADV (1.8 × 105copies/ml). He was treated with donor lymphocyte infusion (DLI) and subsequently with ADV-CTLs with virologic response. 3. Case C A 3-year-old boy with familial hemophagocytic lymphohistiocytosis was admitted with fever, diarrhea and vomiting 2 years post-transplant. He received a TCD HCT from his haploidentical mother. His post-transplant course was complicated by poor graft function, refractory skin and gastrointestinal GVHD, human herpesvirus-6 viremia and chronic renal dysfunction. He received cyclosporine, tacrolimus, steroids and mesenchymal stem cells infusion for GVHD. On admission, cefepime and vancomycin were empirically started. Stool was negative for Clostridioides difficile. Symptoms persisted during admission. On hospital day 21, stool ADV PCR was positive and ADV viremia was 9.8 × 105copies/ml. BCV was initiated. Viral clearance was achieved after 5 doses BCV and BCV was continued for 4 weeks. One week after BCV discontinuation, ADV viremia recrudesced to 1.0 × 107copies/ml. BCV was reinitiated and continued for 10 weeks with good virologic control. Due to persistent diarrhea, colonoscopy was performed and pathology showed persistent gut GVHD. The tissue was positive for ADV by PCR. He received a stem cell boost 2 months after stopping BCV for poor graft function. He subsequently developed relapse of ADV viremia (6.7 × 106copies/ml), thus BCV was resumed and ADV viremia became undectable after 7 doses of BCV. His hospital stay was further complicated by hospital-acquired pneumonia with respiratory failure. Despite resolving ADV viremia, he died due to multi-organ failure. 4. Case D A 3-year-old girl with ALL received a TCD HCT from a MUD complicated by graft rejection and followed by a second TCD HCT from a different MUD one month after the first HCT. Her post-transplant course was complicated by Epstein-Barr virus (EBV) viremia treated with rituximab and cytomegalovirus viremia. On Day +38 post-transplant, she was found to have ADV viremia (2.0 × 103copies/ml). On Day +42, ADV viremia increased to 1.9 × 107copies/ml. On Day +53, she developed watery diarrhea and nausea. Stool ADV PCR was positive. On Day +56, colonoscopy was performed. The tissue was positive for ADV by PCR. On Day +56, ADV viremia was 2.8 × 105copies/ml and CDV was started. After two doses of CDV, ADV viremia was 1.1 × 105copies/ml. She developed worsening hepatic function. Computed tomography of the chest and abdomen on Day +65 showed a necrotic liver lesion and a necrotic lung mass. ADV viremia rose up to 2.3 × 107copies/ml on Day +66 despite CDV. Lung and liver biopsies performed on Day +67 yielded Legionella pneumophila serotype 1 by culture and liver biopsy was positive for EBV and ADV by PCR. ADV viremia was 1.6 × 107 copies/mL on Day +69. On Day +71, levofloxacin was started for Legionella pneumonia and BCV for d-ADV infection. ADV viremia became undectable 34 days after initiation. She received BCV for 80 days as outpatient. Discussion We report 4 pediatric TCD HCT recipients (overall 6 episodes of ADV viremia) with d-ADV treated with BCV. All patients were highly immunosuppressed, with profound lymphopenia and/or very low CD4 counts. Despite high ADV viremia (median 3.7 × 105 copies/mL) at BCV initiation, 3 of 4 patients cleared ADV viremia at a median of 14 days (range, 1 - 34) of BCV treatment. Two patients (cases A and C) were on high dose steroids. Two patients had received prior CDV treatment (case A and C) without response prior to BCV treatment. Three patients tolerated prolonged doses of BCV (range, 17 - 29 doses). Case C had lymphopenia (100 cell/mm3) and CD4+ count was 0 cell/mm3 during ADV infection. Despite a rapid virologic response to BCV, ADV recurred after discontinuation of BCV highlighting the importance of immune recovery for control of ADV infection. Importantly the patient responded rapidly after 2 short subsequent courses of BCV suggesting that repeated episodic treatment with BCV guided by ADV viral load (VL) remains effective even in the setting of persistent lymphopenia. D-ADV infections are associated with substantial morbidity and mortality in HCT recipients [678]. Cases A, C and D with ADV colitis cleared ADV viremia with BCV. Case B did not tolerate BCV. BCV was discontinued after 5 doses concerning for gastrointestinal toxicity. Case B developed ADV hepatitis and ADV pneumonitis while on CDV. Case B responded to DLI and ADV-CTLs. While ADV-CTLs have shown safety and efficacy in small series (reviewed in reference 2), at present several hurdles preclude the broad applicability of this potentially effective therapy [2]. The virologic responses in our cases confirms the virologic activity of BCV even in lymphopenic patients and are in agreement with results of the recent BCV trial [11]. In that trial virologic responses were better, if BCV treatment was initiated at low VL and was associated with improved survival [11]. Our patients had high VL at BCV initiation despite which, 3 of 4 patients achieved virologic responses. One patient discontinued BCV due to gastrointestinal symptoms. Gastrointestinal toxicity is a known side effect of BCV [10]. Management of gastrointestinal toxicity due to BCV like case B is particularly challenging in patients with ADV in the gastrointestinal tract as symptoms may be related to ADV enteritis/colitis and/or BCV. Case B had diarrhea prior to BCV initiation and had persistent diarrhea while on BCV which led a clinician to stop BCV. An intravenous formulation of BCV is currently in development and may alleviate concerns for gastrointestinal toxicity. In conclusion, our small case series show rapid virologic responses after short courses of oral BCV in 3 of 4 pediatric patients with d-ADV. Repeated short courses of BCV were effective in a patient with recurrent ADV viremia. Our data supports the study design of short-course oral BCV treatment in pediatric HCT recipients with ADV infection. ACKNOWLEDGEMENT This research was funded in part through the NIH/NCI Cancer Center Support Grant P30 CA008748. Conflict of Interest: GAP has been an investigator for Shire, Merck, Chimerix and Astellas and has received consulting fees from Shire, Merck, Chimerix and Astellas. Author Contributions: Conceptualization: GAP, YJL. Data curation: SYC, SEP, FB, GAP, YJL, YJL. Writing - original draft: SEP, FB, GAP, YJL.	ALEMTUZUMAB, PREDNISOLONE	DrugsGivenReaction	CC BY-NC	32869551	19,446,308	2021-09
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Pulmonary mass'.	Rapid Virologic Response to Brincidofovir in Children with Disseminated Adenovirus Infection. Disseminated adenovirus infections (d-ADV) after hematopoietic cell transplant (HCT) are often fatal with limited treatment options. Brincidofovir (BCV) a lipid ester of cidofovir is developed for this indication. We report four pediatric HCT recipients with d-ADV treated successfully with BCV. pmcIntroduction Adenovirus (ADV) infections may occur in up to 40% of pediatric HCT recipients [1]. T-cell depletion (TCD) (ex vivo CD34+ or serotherapy with antithymocyte globulin or alemtuzumab), or severe graft-versus-host disease (GVHD) are associated with ADV infection post-HCT [2]. Recovery of ADV specific T-lymphocytes (ADV-CTLs) confers protection against ADV [3], whereas lymphopenia is a risk factor for disseminated ADV infection (d-ADV) [4]. Ex vivo by CD34+ selection (Miltenyi Biotec, Gladbach, Germany) achieves a 5-log depletion of T-lymphocytes in the allograft [5]. D-ADV infections after TCD HCT are often fatal with mortality rates ranging from 50 - 100% [678]. There is currently no approved treatment for ADV. Intravenous cidofovir (CDV) is commonly used; however its utility is limited by associated nephrotoxicity [9]. Adoptive transfer of ADV-CTLs has shown efficacy in single center studies [2]. Brincidofovir (BCV) is a lipid-linked derivative of CDV with high potency against all clinically significant ADV subtypes and no evidence of renal or hematological toxicity to date [1011]. In lymphocyte-depleted pediatric HCT recipients with ADV infections, treatment with BCV resulted in faster and greater virologic responses to BCV compared with CDV [12]. BCV has been associated with gastrointestinal toxicity with typical onset after 4 - 6 doses of BCV [11]. Children may tolerate BCV better than adults possibly due to a more rapid turnover of gastrointestinal mucosa compared with adults [10]. We describe 4 pediatric TCD HCT recipients with d-ADV infection treated successfully with oral BCV 2 mg/kg twice per week under Emergency Investigational New Drug from 9/2015 and 5/2016. The study was reviewed and approved by the Memorial Sloan Kettering Cancer Center Institutional Review and Privavy Board and granted a waiver of authorization (IRB #16-844). Table 1 shows the clinical and virologic characteristics. Virologic responses to BCV are shown in Figure 1A-1D. Table 1 Characteristics and outcome of disseminated adenovirus cases Case Age/sex Dx Transplant type, donor Post-transplant complications before onset of ADV viremia, immunosuppressant First ADV viremiaa, days post-HCT (D) Max ADV viremia, D Sites of ADV ADV disease, D ADV viremia at first CDV Tx ADV viremia at first BCV Tx BCV initiation, D Anti-viral Tx Time to virologic clearance from BCV, days ALC / CD4+ (cell/mcL) at BCV Tx Outcome A 19m/F SCID 1st HCT: BMT, haplo mother (graft failure) Autoimmune Hemolytic Anemia, Rituximab, Prednisolone 2.1 × 105, D+192 2.1 × 105, D+192 Blood, Stool, Urine Probable Enterocolitis, D+207 4.3 × 104 <190 D+193 CDV IV 5 mg/kg × 5 doses 3 ALC 400 CD4+ 30 Alive 2nd HCT: CD34+ TCD PBSCT, MUD BCV PO 2 mg/kg TIW × 17 doses B 4y/M ALL CD34+ TCD PBSCT, 9/10 MUD 469, D+10 4.7 × 106, D+69 Blood, Stool, Liver, RESP, Pleural Fluid Definite Pneumonitis, D+84; Definite Hepatitis, D+88 5.8 × 104 3.3 × 105 D+25 CDV IV 5 mg/kg × 14 doses N/A ALC 400 CD4+ 0 Alive BCV PO 2 mg/kg TIW × 5 doses DLI, ADV CTLs C 3y/M Familial HLH CD34+ TCD PBSCT, Haplo mother Skin Grade 3 GVHD and GI Grade 1 GVHD, Mesenchymal stem cell infusion, Alemtuzumab, CNI and Prednisolone 9.8 × 105, D+841 6.7 × 106, D+1026 Blood, Stool, RESP Possible Enterocolitis, D+870 N/A 4.1 × 105 D+848 BCV PO 2 mg/kg TIW × 29 doses 1st course: 14 1st course: ALC 100 CD4+ 0 Death, D+1088, MSOF 2nd course: 20 2nd course: ALC 100 CD4+ 0 D 3y/F ALL 1st HCT: CD34+ TCD PBSCT, MUD Acute Rejection of first allo-graft 2 × 103, D+38 (From 2nd HCT) 1.9 × 107, D+42 (From 2nd HCT) Blood, Stool, Liver Possible Enterocolitis, D+65 (From 2nd HCT) 2.8 × 105 1.6 × 107 D+57 (From 2nd HCT) CDV IV 5 mg/kg × 2 doses 34 ALC 300 CD4+ 19 Death, D+539 (From 2nd HCT), relapse of primary disease 2nd HCT: CD34+ TCD PBSCT, MUD 2nd HCT: Alemtuzumab 1 mg/kg divided in 5 doses after 2nd HCT BCV PO 2 mg/kg TIW × 26 doses aADV PCR in blood was performed by Viraco Eurofins (Lee's Summit, MO, USA). Values are copies/ml. m, months-old; F, female; y, years-old; M, male; Dx, diagnosis; SCID, severe combined immune deficiency; ALL, acute lymphoblastic leukemia; HLH, hemophagocytic lymphohistiocytosis; HCT, hematopoietic cell transplant; BMT, bone marrow transplant; Haplo, Haploidentical; TCD, T Cell-depleted; PBSCT, peripheral blood stem cell transplant; MUD, matched unrelated donor; ADV, adenovirus; GVHD, graft-versus-host disease; GI, gastrointestinal; CNI, calcineurin inhibitors; D, day from transplant; max, maximum, RESP, respiratory specimens (bronchoalveolar lavage, nasopharyngeal swab); CDV, cidofovir; Tx, treatment; N/A, not applicable; BCV, brincidofovir; IV, intravenous; PO, orally; TIW, three times per week; DLI, donor lymphocyte infusion; CTLs, cytotoxic T lymphocytes, ALC, absolute lymphocyte counts; MSOF, multisystem organ failure. Figure 1 Plasma adenovirus viral load and treatment in 4 pediatric hematopoietic cell transplant recipients with disseminated adenovirus infection. CD4+ count: cell/mcL. CDV, cidofovir; BCV, brincidofovir; ADV, adenovirus; VL, viral load; DLI, donor lymphocyte infusion; CTL, cytotoxic T-lymphocyte; PCR, polymerase chain reaction. Case report ADV PCR was performed by Viracor-Eurofins (Lee's Summit, MO, USA). The linear range of quantification of ADV PCR in the blood was 100 – 1 × 1010 copies/mL. D-ADV was defined as previously defined [7]. 1. Case A A 19-month-old girl with severe combined immunodeficiency syndrome received a TCD HCT from a matched unrelated donor (MUD). Her post-transplant course was complicated by autoimmune hemolytic anemia treated with prednisolone and 6 doses of rituximab. Six months post-transplant she presented for hypoactivity, irritability and watery diarrhea. On admission, stool ADV PCR was positive and ADV viremia was 2.1 × 105copies/ml. She was treated with CDV and intravenous immunoglobulin. After 2 weeks of CDV, colonoscopy was performed. Pathology showed friable colonic mucosa. Viral culture from tissues was positive for ADV. Because of persistent diarrhea after 5 doses of CDV, BCV was started. ADV viremia became undetectable after 2 doses of BCV. BCV was stopped at 8 weeks after BCV initiation. 2. Case B A 4-year-old boy with acute lymphoblastic leukemia (ALL) received a TCD HCT from a MUD. On Day 0, stool ADV PCR was positive and ADV viremia was negative. On Day +10, ADV viremia was 469 copies/ml and on Day +17 ADV viremia rose to 5.8 × 104copies/ml. On Day +25, CDV was started due to persistent fever, diarrhea and rising ADV viremia. After 2 doses of CDV, CDV was switched to BCV due to increased ADV viremia (3.3 × 105copies/ml). On Day +39, BCV was discontinued after 5 doses due to persistent diarrhea. CDV was resumed, however ADV viremia increased to 4.7 × 106copies/ml on Day +69 and transaminitis was noted. Liver biopsy on Day +84 confirmed GVHD with ADV hepatitis (positive ADV stain). Concurrently, he developed respiratory distress and a nasopharyngeal swab was positive for ADV by PCR. On Day +88, thoracentesis was performed due to worsening pleural effusion. Pleural fluid was positive for ADV (1.8 × 105copies/ml). He was treated with donor lymphocyte infusion (DLI) and subsequently with ADV-CTLs with virologic response. 3. Case C A 3-year-old boy with familial hemophagocytic lymphohistiocytosis was admitted with fever, diarrhea and vomiting 2 years post-transplant. He received a TCD HCT from his haploidentical mother. His post-transplant course was complicated by poor graft function, refractory skin and gastrointestinal GVHD, human herpesvirus-6 viremia and chronic renal dysfunction. He received cyclosporine, tacrolimus, steroids and mesenchymal stem cells infusion for GVHD. On admission, cefepime and vancomycin were empirically started. Stool was negative for Clostridioides difficile. Symptoms persisted during admission. On hospital day 21, stool ADV PCR was positive and ADV viremia was 9.8 × 105copies/ml. BCV was initiated. Viral clearance was achieved after 5 doses BCV and BCV was continued for 4 weeks. One week after BCV discontinuation, ADV viremia recrudesced to 1.0 × 107copies/ml. BCV was reinitiated and continued for 10 weeks with good virologic control. Due to persistent diarrhea, colonoscopy was performed and pathology showed persistent gut GVHD. The tissue was positive for ADV by PCR. He received a stem cell boost 2 months after stopping BCV for poor graft function. He subsequently developed relapse of ADV viremia (6.7 × 106copies/ml), thus BCV was resumed and ADV viremia became undectable after 7 doses of BCV. His hospital stay was further complicated by hospital-acquired pneumonia with respiratory failure. Despite resolving ADV viremia, he died due to multi-organ failure. 4. Case D A 3-year-old girl with ALL received a TCD HCT from a MUD complicated by graft rejection and followed by a second TCD HCT from a different MUD one month after the first HCT. Her post-transplant course was complicated by Epstein-Barr virus (EBV) viremia treated with rituximab and cytomegalovirus viremia. On Day +38 post-transplant, she was found to have ADV viremia (2.0 × 103copies/ml). On Day +42, ADV viremia increased to 1.9 × 107copies/ml. On Day +53, she developed watery diarrhea and nausea. Stool ADV PCR was positive. On Day +56, colonoscopy was performed. The tissue was positive for ADV by PCR. On Day +56, ADV viremia was 2.8 × 105copies/ml and CDV was started. After two doses of CDV, ADV viremia was 1.1 × 105copies/ml. She developed worsening hepatic function. Computed tomography of the chest and abdomen on Day +65 showed a necrotic liver lesion and a necrotic lung mass. ADV viremia rose up to 2.3 × 107copies/ml on Day +66 despite CDV. Lung and liver biopsies performed on Day +67 yielded Legionella pneumophila serotype 1 by culture and liver biopsy was positive for EBV and ADV by PCR. ADV viremia was 1.6 × 107 copies/mL on Day +69. On Day +71, levofloxacin was started for Legionella pneumonia and BCV for d-ADV infection. ADV viremia became undectable 34 days after initiation. She received BCV for 80 days as outpatient. Discussion We report 4 pediatric TCD HCT recipients (overall 6 episodes of ADV viremia) with d-ADV treated with BCV. All patients were highly immunosuppressed, with profound lymphopenia and/or very low CD4 counts. Despite high ADV viremia (median 3.7 × 105 copies/mL) at BCV initiation, 3 of 4 patients cleared ADV viremia at a median of 14 days (range, 1 - 34) of BCV treatment. Two patients (cases A and C) were on high dose steroids. Two patients had received prior CDV treatment (case A and C) without response prior to BCV treatment. Three patients tolerated prolonged doses of BCV (range, 17 - 29 doses). Case C had lymphopenia (100 cell/mm3) and CD4+ count was 0 cell/mm3 during ADV infection. Despite a rapid virologic response to BCV, ADV recurred after discontinuation of BCV highlighting the importance of immune recovery for control of ADV infection. Importantly the patient responded rapidly after 2 short subsequent courses of BCV suggesting that repeated episodic treatment with BCV guided by ADV viral load (VL) remains effective even in the setting of persistent lymphopenia. D-ADV infections are associated with substantial morbidity and mortality in HCT recipients [678]. Cases A, C and D with ADV colitis cleared ADV viremia with BCV. Case B did not tolerate BCV. BCV was discontinued after 5 doses concerning for gastrointestinal toxicity. Case B developed ADV hepatitis and ADV pneumonitis while on CDV. Case B responded to DLI and ADV-CTLs. While ADV-CTLs have shown safety and efficacy in small series (reviewed in reference 2), at present several hurdles preclude the broad applicability of this potentially effective therapy [2]. The virologic responses in our cases confirms the virologic activity of BCV even in lymphopenic patients and are in agreement with results of the recent BCV trial [11]. In that trial virologic responses were better, if BCV treatment was initiated at low VL and was associated with improved survival [11]. Our patients had high VL at BCV initiation despite which, 3 of 4 patients achieved virologic responses. One patient discontinued BCV due to gastrointestinal symptoms. Gastrointestinal toxicity is a known side effect of BCV [10]. Management of gastrointestinal toxicity due to BCV like case B is particularly challenging in patients with ADV in the gastrointestinal tract as symptoms may be related to ADV enteritis/colitis and/or BCV. Case B had diarrhea prior to BCV initiation and had persistent diarrhea while on BCV which led a clinician to stop BCV. An intravenous formulation of BCV is currently in development and may alleviate concerns for gastrointestinal toxicity. In conclusion, our small case series show rapid virologic responses after short courses of oral BCV in 3 of 4 pediatric patients with d-ADV. Repeated short courses of BCV were effective in a patient with recurrent ADV viremia. Our data supports the study design of short-course oral BCV treatment in pediatric HCT recipients with ADV infection. ACKNOWLEDGEMENT This research was funded in part through the NIH/NCI Cancer Center Support Grant P30 CA008748. Conflict of Interest: GAP has been an investigator for Shire, Merck, Chimerix and Astellas and has received consulting fees from Shire, Merck, Chimerix and Astellas. Author Contributions: Conceptualization: GAP, YJL. Data curation: SYC, SEP, FB, GAP, YJL, YJL. Writing - original draft: SEP, FB, GAP, YJL.	ALEMTUZUMAB, RITUXIMAB	DrugsGivenReaction	CC BY-NC	32869551	19,460,124	2021-09
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Pulmonary necrosis'.	Rapid Virologic Response to Brincidofovir in Children with Disseminated Adenovirus Infection. Disseminated adenovirus infections (d-ADV) after hematopoietic cell transplant (HCT) are often fatal with limited treatment options. Brincidofovir (BCV) a lipid ester of cidofovir is developed for this indication. We report four pediatric HCT recipients with d-ADV treated successfully with BCV. pmcIntroduction Adenovirus (ADV) infections may occur in up to 40% of pediatric HCT recipients [1]. T-cell depletion (TCD) (ex vivo CD34+ or serotherapy with antithymocyte globulin or alemtuzumab), or severe graft-versus-host disease (GVHD) are associated with ADV infection post-HCT [2]. Recovery of ADV specific T-lymphocytes (ADV-CTLs) confers protection against ADV [3], whereas lymphopenia is a risk factor for disseminated ADV infection (d-ADV) [4]. Ex vivo by CD34+ selection (Miltenyi Biotec, Gladbach, Germany) achieves a 5-log depletion of T-lymphocytes in the allograft [5]. D-ADV infections after TCD HCT are often fatal with mortality rates ranging from 50 - 100% [678]. There is currently no approved treatment for ADV. Intravenous cidofovir (CDV) is commonly used; however its utility is limited by associated nephrotoxicity [9]. Adoptive transfer of ADV-CTLs has shown efficacy in single center studies [2]. Brincidofovir (BCV) is a lipid-linked derivative of CDV with high potency against all clinically significant ADV subtypes and no evidence of renal or hematological toxicity to date [1011]. In lymphocyte-depleted pediatric HCT recipients with ADV infections, treatment with BCV resulted in faster and greater virologic responses to BCV compared with CDV [12]. BCV has been associated with gastrointestinal toxicity with typical onset after 4 - 6 doses of BCV [11]. Children may tolerate BCV better than adults possibly due to a more rapid turnover of gastrointestinal mucosa compared with adults [10]. We describe 4 pediatric TCD HCT recipients with d-ADV infection treated successfully with oral BCV 2 mg/kg twice per week under Emergency Investigational New Drug from 9/2015 and 5/2016. The study was reviewed and approved by the Memorial Sloan Kettering Cancer Center Institutional Review and Privavy Board and granted a waiver of authorization (IRB #16-844). Table 1 shows the clinical and virologic characteristics. Virologic responses to BCV are shown in Figure 1A-1D. Table 1 Characteristics and outcome of disseminated adenovirus cases Case Age/sex Dx Transplant type, donor Post-transplant complications before onset of ADV viremia, immunosuppressant First ADV viremiaa, days post-HCT (D) Max ADV viremia, D Sites of ADV ADV disease, D ADV viremia at first CDV Tx ADV viremia at first BCV Tx BCV initiation, D Anti-viral Tx Time to virologic clearance from BCV, days ALC / CD4+ (cell/mcL) at BCV Tx Outcome A 19m/F SCID 1st HCT: BMT, haplo mother (graft failure) Autoimmune Hemolytic Anemia, Rituximab, Prednisolone 2.1 × 105, D+192 2.1 × 105, D+192 Blood, Stool, Urine Probable Enterocolitis, D+207 4.3 × 104 <190 D+193 CDV IV 5 mg/kg × 5 doses 3 ALC 400 CD4+ 30 Alive 2nd HCT: CD34+ TCD PBSCT, MUD BCV PO 2 mg/kg TIW × 17 doses B 4y/M ALL CD34+ TCD PBSCT, 9/10 MUD 469, D+10 4.7 × 106, D+69 Blood, Stool, Liver, RESP, Pleural Fluid Definite Pneumonitis, D+84; Definite Hepatitis, D+88 5.8 × 104 3.3 × 105 D+25 CDV IV 5 mg/kg × 14 doses N/A ALC 400 CD4+ 0 Alive BCV PO 2 mg/kg TIW × 5 doses DLI, ADV CTLs C 3y/M Familial HLH CD34+ TCD PBSCT, Haplo mother Skin Grade 3 GVHD and GI Grade 1 GVHD, Mesenchymal stem cell infusion, Alemtuzumab, CNI and Prednisolone 9.8 × 105, D+841 6.7 × 106, D+1026 Blood, Stool, RESP Possible Enterocolitis, D+870 N/A 4.1 × 105 D+848 BCV PO 2 mg/kg TIW × 29 doses 1st course: 14 1st course: ALC 100 CD4+ 0 Death, D+1088, MSOF 2nd course: 20 2nd course: ALC 100 CD4+ 0 D 3y/F ALL 1st HCT: CD34+ TCD PBSCT, MUD Acute Rejection of first allo-graft 2 × 103, D+38 (From 2nd HCT) 1.9 × 107, D+42 (From 2nd HCT) Blood, Stool, Liver Possible Enterocolitis, D+65 (From 2nd HCT) 2.8 × 105 1.6 × 107 D+57 (From 2nd HCT) CDV IV 5 mg/kg × 2 doses 34 ALC 300 CD4+ 19 Death, D+539 (From 2nd HCT), relapse of primary disease 2nd HCT: CD34+ TCD PBSCT, MUD 2nd HCT: Alemtuzumab 1 mg/kg divided in 5 doses after 2nd HCT BCV PO 2 mg/kg TIW × 26 doses aADV PCR in blood was performed by Viraco Eurofins (Lee's Summit, MO, USA). Values are copies/ml. m, months-old; F, female; y, years-old; M, male; Dx, diagnosis; SCID, severe combined immune deficiency; ALL, acute lymphoblastic leukemia; HLH, hemophagocytic lymphohistiocytosis; HCT, hematopoietic cell transplant; BMT, bone marrow transplant; Haplo, Haploidentical; TCD, T Cell-depleted; PBSCT, peripheral blood stem cell transplant; MUD, matched unrelated donor; ADV, adenovirus; GVHD, graft-versus-host disease; GI, gastrointestinal; CNI, calcineurin inhibitors; D, day from transplant; max, maximum, RESP, respiratory specimens (bronchoalveolar lavage, nasopharyngeal swab); CDV, cidofovir; Tx, treatment; N/A, not applicable; BCV, brincidofovir; IV, intravenous; PO, orally; TIW, three times per week; DLI, donor lymphocyte infusion; CTLs, cytotoxic T lymphocytes, ALC, absolute lymphocyte counts; MSOF, multisystem organ failure. Figure 1 Plasma adenovirus viral load and treatment in 4 pediatric hematopoietic cell transplant recipients with disseminated adenovirus infection. CD4+ count: cell/mcL. CDV, cidofovir; BCV, brincidofovir; ADV, adenovirus; VL, viral load; DLI, donor lymphocyte infusion; CTL, cytotoxic T-lymphocyte; PCR, polymerase chain reaction. Case report ADV PCR was performed by Viracor-Eurofins (Lee's Summit, MO, USA). The linear range of quantification of ADV PCR in the blood was 100 – 1 × 1010 copies/mL. D-ADV was defined as previously defined [7]. 1. Case A A 19-month-old girl with severe combined immunodeficiency syndrome received a TCD HCT from a matched unrelated donor (MUD). Her post-transplant course was complicated by autoimmune hemolytic anemia treated with prednisolone and 6 doses of rituximab. Six months post-transplant she presented for hypoactivity, irritability and watery diarrhea. On admission, stool ADV PCR was positive and ADV viremia was 2.1 × 105copies/ml. She was treated with CDV and intravenous immunoglobulin. After 2 weeks of CDV, colonoscopy was performed. Pathology showed friable colonic mucosa. Viral culture from tissues was positive for ADV. Because of persistent diarrhea after 5 doses of CDV, BCV was started. ADV viremia became undetectable after 2 doses of BCV. BCV was stopped at 8 weeks after BCV initiation. 2. Case B A 4-year-old boy with acute lymphoblastic leukemia (ALL) received a TCD HCT from a MUD. On Day 0, stool ADV PCR was positive and ADV viremia was negative. On Day +10, ADV viremia was 469 copies/ml and on Day +17 ADV viremia rose to 5.8 × 104copies/ml. On Day +25, CDV was started due to persistent fever, diarrhea and rising ADV viremia. After 2 doses of CDV, CDV was switched to BCV due to increased ADV viremia (3.3 × 105copies/ml). On Day +39, BCV was discontinued after 5 doses due to persistent diarrhea. CDV was resumed, however ADV viremia increased to 4.7 × 106copies/ml on Day +69 and transaminitis was noted. Liver biopsy on Day +84 confirmed GVHD with ADV hepatitis (positive ADV stain). Concurrently, he developed respiratory distress and a nasopharyngeal swab was positive for ADV by PCR. On Day +88, thoracentesis was performed due to worsening pleural effusion. Pleural fluid was positive for ADV (1.8 × 105copies/ml). He was treated with donor lymphocyte infusion (DLI) and subsequently with ADV-CTLs with virologic response. 3. Case C A 3-year-old boy with familial hemophagocytic lymphohistiocytosis was admitted with fever, diarrhea and vomiting 2 years post-transplant. He received a TCD HCT from his haploidentical mother. His post-transplant course was complicated by poor graft function, refractory skin and gastrointestinal GVHD, human herpesvirus-6 viremia and chronic renal dysfunction. He received cyclosporine, tacrolimus, steroids and mesenchymal stem cells infusion for GVHD. On admission, cefepime and vancomycin were empirically started. Stool was negative for Clostridioides difficile. Symptoms persisted during admission. On hospital day 21, stool ADV PCR was positive and ADV viremia was 9.8 × 105copies/ml. BCV was initiated. Viral clearance was achieved after 5 doses BCV and BCV was continued for 4 weeks. One week after BCV discontinuation, ADV viremia recrudesced to 1.0 × 107copies/ml. BCV was reinitiated and continued for 10 weeks with good virologic control. Due to persistent diarrhea, colonoscopy was performed and pathology showed persistent gut GVHD. The tissue was positive for ADV by PCR. He received a stem cell boost 2 months after stopping BCV for poor graft function. He subsequently developed relapse of ADV viremia (6.7 × 106copies/ml), thus BCV was resumed and ADV viremia became undectable after 7 doses of BCV. His hospital stay was further complicated by hospital-acquired pneumonia with respiratory failure. Despite resolving ADV viremia, he died due to multi-organ failure. 4. Case D A 3-year-old girl with ALL received a TCD HCT from a MUD complicated by graft rejection and followed by a second TCD HCT from a different MUD one month after the first HCT. Her post-transplant course was complicated by Epstein-Barr virus (EBV) viremia treated with rituximab and cytomegalovirus viremia. On Day +38 post-transplant, she was found to have ADV viremia (2.0 × 103copies/ml). On Day +42, ADV viremia increased to 1.9 × 107copies/ml. On Day +53, she developed watery diarrhea and nausea. Stool ADV PCR was positive. On Day +56, colonoscopy was performed. The tissue was positive for ADV by PCR. On Day +56, ADV viremia was 2.8 × 105copies/ml and CDV was started. After two doses of CDV, ADV viremia was 1.1 × 105copies/ml. She developed worsening hepatic function. Computed tomography of the chest and abdomen on Day +65 showed a necrotic liver lesion and a necrotic lung mass. ADV viremia rose up to 2.3 × 107copies/ml on Day +66 despite CDV. Lung and liver biopsies performed on Day +67 yielded Legionella pneumophila serotype 1 by culture and liver biopsy was positive for EBV and ADV by PCR. ADV viremia was 1.6 × 107 copies/mL on Day +69. On Day +71, levofloxacin was started for Legionella pneumonia and BCV for d-ADV infection. ADV viremia became undectable 34 days after initiation. She received BCV for 80 days as outpatient. Discussion We report 4 pediatric TCD HCT recipients (overall 6 episodes of ADV viremia) with d-ADV treated with BCV. All patients were highly immunosuppressed, with profound lymphopenia and/or very low CD4 counts. Despite high ADV viremia (median 3.7 × 105 copies/mL) at BCV initiation, 3 of 4 patients cleared ADV viremia at a median of 14 days (range, 1 - 34) of BCV treatment. Two patients (cases A and C) were on high dose steroids. Two patients had received prior CDV treatment (case A and C) without response prior to BCV treatment. Three patients tolerated prolonged doses of BCV (range, 17 - 29 doses). Case C had lymphopenia (100 cell/mm3) and CD4+ count was 0 cell/mm3 during ADV infection. Despite a rapid virologic response to BCV, ADV recurred after discontinuation of BCV highlighting the importance of immune recovery for control of ADV infection. Importantly the patient responded rapidly after 2 short subsequent courses of BCV suggesting that repeated episodic treatment with BCV guided by ADV viral load (VL) remains effective even in the setting of persistent lymphopenia. D-ADV infections are associated with substantial morbidity and mortality in HCT recipients [678]. Cases A, C and D with ADV colitis cleared ADV viremia with BCV. Case B did not tolerate BCV. BCV was discontinued after 5 doses concerning for gastrointestinal toxicity. Case B developed ADV hepatitis and ADV pneumonitis while on CDV. Case B responded to DLI and ADV-CTLs. While ADV-CTLs have shown safety and efficacy in small series (reviewed in reference 2), at present several hurdles preclude the broad applicability of this potentially effective therapy [2]. The virologic responses in our cases confirms the virologic activity of BCV even in lymphopenic patients and are in agreement with results of the recent BCV trial [11]. In that trial virologic responses were better, if BCV treatment was initiated at low VL and was associated with improved survival [11]. Our patients had high VL at BCV initiation despite which, 3 of 4 patients achieved virologic responses. One patient discontinued BCV due to gastrointestinal symptoms. Gastrointestinal toxicity is a known side effect of BCV [10]. Management of gastrointestinal toxicity due to BCV like case B is particularly challenging in patients with ADV in the gastrointestinal tract as symptoms may be related to ADV enteritis/colitis and/or BCV. Case B had diarrhea prior to BCV initiation and had persistent diarrhea while on BCV which led a clinician to stop BCV. An intravenous formulation of BCV is currently in development and may alleviate concerns for gastrointestinal toxicity. In conclusion, our small case series show rapid virologic responses after short courses of oral BCV in 3 of 4 pediatric patients with d-ADV. Repeated short courses of BCV were effective in a patient with recurrent ADV viremia. Our data supports the study design of short-course oral BCV treatment in pediatric HCT recipients with ADV infection. ACKNOWLEDGEMENT This research was funded in part through the NIH/NCI Cancer Center Support Grant P30 CA008748. Conflict of Interest: GAP has been an investigator for Shire, Merck, Chimerix and Astellas and has received consulting fees from Shire, Merck, Chimerix and Astellas. Author Contributions: Conceptualization: GAP, YJL. Data curation: SYC, SEP, FB, GAP, YJL, YJL. Writing - original draft: SEP, FB, GAP, YJL.	ALEMTUZUMAB, RITUXIMAB	DrugsGivenReaction	CC BY-NC	32869551	19,460,124	2021-09
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Pyrexia'.	Rapid Virologic Response to Brincidofovir in Children with Disseminated Adenovirus Infection. Disseminated adenovirus infections (d-ADV) after hematopoietic cell transplant (HCT) are often fatal with limited treatment options. Brincidofovir (BCV) a lipid ester of cidofovir is developed for this indication. We report four pediatric HCT recipients with d-ADV treated successfully with BCV. pmcIntroduction Adenovirus (ADV) infections may occur in up to 40% of pediatric HCT recipients [1]. T-cell depletion (TCD) (ex vivo CD34+ or serotherapy with antithymocyte globulin or alemtuzumab), or severe graft-versus-host disease (GVHD) are associated with ADV infection post-HCT [2]. Recovery of ADV specific T-lymphocytes (ADV-CTLs) confers protection against ADV [3], whereas lymphopenia is a risk factor for disseminated ADV infection (d-ADV) [4]. Ex vivo by CD34+ selection (Miltenyi Biotec, Gladbach, Germany) achieves a 5-log depletion of T-lymphocytes in the allograft [5]. D-ADV infections after TCD HCT are often fatal with mortality rates ranging from 50 - 100% [678]. There is currently no approved treatment for ADV. Intravenous cidofovir (CDV) is commonly used; however its utility is limited by associated nephrotoxicity [9]. Adoptive transfer of ADV-CTLs has shown efficacy in single center studies [2]. Brincidofovir (BCV) is a lipid-linked derivative of CDV with high potency against all clinically significant ADV subtypes and no evidence of renal or hematological toxicity to date [1011]. In lymphocyte-depleted pediatric HCT recipients with ADV infections, treatment with BCV resulted in faster and greater virologic responses to BCV compared with CDV [12]. BCV has been associated with gastrointestinal toxicity with typical onset after 4 - 6 doses of BCV [11]. Children may tolerate BCV better than adults possibly due to a more rapid turnover of gastrointestinal mucosa compared with adults [10]. We describe 4 pediatric TCD HCT recipients with d-ADV infection treated successfully with oral BCV 2 mg/kg twice per week under Emergency Investigational New Drug from 9/2015 and 5/2016. The study was reviewed and approved by the Memorial Sloan Kettering Cancer Center Institutional Review and Privavy Board and granted a waiver of authorization (IRB #16-844). Table 1 shows the clinical and virologic characteristics. Virologic responses to BCV are shown in Figure 1A-1D. Table 1 Characteristics and outcome of disseminated adenovirus cases Case Age/sex Dx Transplant type, donor Post-transplant complications before onset of ADV viremia, immunosuppressant First ADV viremiaa, days post-HCT (D) Max ADV viremia, D Sites of ADV ADV disease, D ADV viremia at first CDV Tx ADV viremia at first BCV Tx BCV initiation, D Anti-viral Tx Time to virologic clearance from BCV, days ALC / CD4+ (cell/mcL) at BCV Tx Outcome A 19m/F SCID 1st HCT: BMT, haplo mother (graft failure) Autoimmune Hemolytic Anemia, Rituximab, Prednisolone 2.1 × 105, D+192 2.1 × 105, D+192 Blood, Stool, Urine Probable Enterocolitis, D+207 4.3 × 104 <190 D+193 CDV IV 5 mg/kg × 5 doses 3 ALC 400 CD4+ 30 Alive 2nd HCT: CD34+ TCD PBSCT, MUD BCV PO 2 mg/kg TIW × 17 doses B 4y/M ALL CD34+ TCD PBSCT, 9/10 MUD 469, D+10 4.7 × 106, D+69 Blood, Stool, Liver, RESP, Pleural Fluid Definite Pneumonitis, D+84; Definite Hepatitis, D+88 5.8 × 104 3.3 × 105 D+25 CDV IV 5 mg/kg × 14 doses N/A ALC 400 CD4+ 0 Alive BCV PO 2 mg/kg TIW × 5 doses DLI, ADV CTLs C 3y/M Familial HLH CD34+ TCD PBSCT, Haplo mother Skin Grade 3 GVHD and GI Grade 1 GVHD, Mesenchymal stem cell infusion, Alemtuzumab, CNI and Prednisolone 9.8 × 105, D+841 6.7 × 106, D+1026 Blood, Stool, RESP Possible Enterocolitis, D+870 N/A 4.1 × 105 D+848 BCV PO 2 mg/kg TIW × 29 doses 1st course: 14 1st course: ALC 100 CD4+ 0 Death, D+1088, MSOF 2nd course: 20 2nd course: ALC 100 CD4+ 0 D 3y/F ALL 1st HCT: CD34+ TCD PBSCT, MUD Acute Rejection of first allo-graft 2 × 103, D+38 (From 2nd HCT) 1.9 × 107, D+42 (From 2nd HCT) Blood, Stool, Liver Possible Enterocolitis, D+65 (From 2nd HCT) 2.8 × 105 1.6 × 107 D+57 (From 2nd HCT) CDV IV 5 mg/kg × 2 doses 34 ALC 300 CD4+ 19 Death, D+539 (From 2nd HCT), relapse of primary disease 2nd HCT: CD34+ TCD PBSCT, MUD 2nd HCT: Alemtuzumab 1 mg/kg divided in 5 doses after 2nd HCT BCV PO 2 mg/kg TIW × 26 doses aADV PCR in blood was performed by Viraco Eurofins (Lee's Summit, MO, USA). Values are copies/ml. m, months-old; F, female; y, years-old; M, male; Dx, diagnosis; SCID, severe combined immune deficiency; ALL, acute lymphoblastic leukemia; HLH, hemophagocytic lymphohistiocytosis; HCT, hematopoietic cell transplant; BMT, bone marrow transplant; Haplo, Haploidentical; TCD, T Cell-depleted; PBSCT, peripheral blood stem cell transplant; MUD, matched unrelated donor; ADV, adenovirus; GVHD, graft-versus-host disease; GI, gastrointestinal; CNI, calcineurin inhibitors; D, day from transplant; max, maximum, RESP, respiratory specimens (bronchoalveolar lavage, nasopharyngeal swab); CDV, cidofovir; Tx, treatment; N/A, not applicable; BCV, brincidofovir; IV, intravenous; PO, orally; TIW, three times per week; DLI, donor lymphocyte infusion; CTLs, cytotoxic T lymphocytes, ALC, absolute lymphocyte counts; MSOF, multisystem organ failure. Figure 1 Plasma adenovirus viral load and treatment in 4 pediatric hematopoietic cell transplant recipients with disseminated adenovirus infection. CD4+ count: cell/mcL. CDV, cidofovir; BCV, brincidofovir; ADV, adenovirus; VL, viral load; DLI, donor lymphocyte infusion; CTL, cytotoxic T-lymphocyte; PCR, polymerase chain reaction. Case report ADV PCR was performed by Viracor-Eurofins (Lee's Summit, MO, USA). The linear range of quantification of ADV PCR in the blood was 100 – 1 × 1010 copies/mL. D-ADV was defined as previously defined [7]. 1. Case A A 19-month-old girl with severe combined immunodeficiency syndrome received a TCD HCT from a matched unrelated donor (MUD). Her post-transplant course was complicated by autoimmune hemolytic anemia treated with prednisolone and 6 doses of rituximab. Six months post-transplant she presented for hypoactivity, irritability and watery diarrhea. On admission, stool ADV PCR was positive and ADV viremia was 2.1 × 105copies/ml. She was treated with CDV and intravenous immunoglobulin. After 2 weeks of CDV, colonoscopy was performed. Pathology showed friable colonic mucosa. Viral culture from tissues was positive for ADV. Because of persistent diarrhea after 5 doses of CDV, BCV was started. ADV viremia became undetectable after 2 doses of BCV. BCV was stopped at 8 weeks after BCV initiation. 2. Case B A 4-year-old boy with acute lymphoblastic leukemia (ALL) received a TCD HCT from a MUD. On Day 0, stool ADV PCR was positive and ADV viremia was negative. On Day +10, ADV viremia was 469 copies/ml and on Day +17 ADV viremia rose to 5.8 × 104copies/ml. On Day +25, CDV was started due to persistent fever, diarrhea and rising ADV viremia. After 2 doses of CDV, CDV was switched to BCV due to increased ADV viremia (3.3 × 105copies/ml). On Day +39, BCV was discontinued after 5 doses due to persistent diarrhea. CDV was resumed, however ADV viremia increased to 4.7 × 106copies/ml on Day +69 and transaminitis was noted. Liver biopsy on Day +84 confirmed GVHD with ADV hepatitis (positive ADV stain). Concurrently, he developed respiratory distress and a nasopharyngeal swab was positive for ADV by PCR. On Day +88, thoracentesis was performed due to worsening pleural effusion. Pleural fluid was positive for ADV (1.8 × 105copies/ml). He was treated with donor lymphocyte infusion (DLI) and subsequently with ADV-CTLs with virologic response. 3. Case C A 3-year-old boy with familial hemophagocytic lymphohistiocytosis was admitted with fever, diarrhea and vomiting 2 years post-transplant. He received a TCD HCT from his haploidentical mother. His post-transplant course was complicated by poor graft function, refractory skin and gastrointestinal GVHD, human herpesvirus-6 viremia and chronic renal dysfunction. He received cyclosporine, tacrolimus, steroids and mesenchymal stem cells infusion for GVHD. On admission, cefepime and vancomycin were empirically started. Stool was negative for Clostridioides difficile. Symptoms persisted during admission. On hospital day 21, stool ADV PCR was positive and ADV viremia was 9.8 × 105copies/ml. BCV was initiated. Viral clearance was achieved after 5 doses BCV and BCV was continued for 4 weeks. One week after BCV discontinuation, ADV viremia recrudesced to 1.0 × 107copies/ml. BCV was reinitiated and continued for 10 weeks with good virologic control. Due to persistent diarrhea, colonoscopy was performed and pathology showed persistent gut GVHD. The tissue was positive for ADV by PCR. He received a stem cell boost 2 months after stopping BCV for poor graft function. He subsequently developed relapse of ADV viremia (6.7 × 106copies/ml), thus BCV was resumed and ADV viremia became undectable after 7 doses of BCV. His hospital stay was further complicated by hospital-acquired pneumonia with respiratory failure. Despite resolving ADV viremia, he died due to multi-organ failure. 4. Case D A 3-year-old girl with ALL received a TCD HCT from a MUD complicated by graft rejection and followed by a second TCD HCT from a different MUD one month after the first HCT. Her post-transplant course was complicated by Epstein-Barr virus (EBV) viremia treated with rituximab and cytomegalovirus viremia. On Day +38 post-transplant, she was found to have ADV viremia (2.0 × 103copies/ml). On Day +42, ADV viremia increased to 1.9 × 107copies/ml. On Day +53, she developed watery diarrhea and nausea. Stool ADV PCR was positive. On Day +56, colonoscopy was performed. The tissue was positive for ADV by PCR. On Day +56, ADV viremia was 2.8 × 105copies/ml and CDV was started. After two doses of CDV, ADV viremia was 1.1 × 105copies/ml. She developed worsening hepatic function. Computed tomography of the chest and abdomen on Day +65 showed a necrotic liver lesion and a necrotic lung mass. ADV viremia rose up to 2.3 × 107copies/ml on Day +66 despite CDV. Lung and liver biopsies performed on Day +67 yielded Legionella pneumophila serotype 1 by culture and liver biopsy was positive for EBV and ADV by PCR. ADV viremia was 1.6 × 107 copies/mL on Day +69. On Day +71, levofloxacin was started for Legionella pneumonia and BCV for d-ADV infection. ADV viremia became undectable 34 days after initiation. She received BCV for 80 days as outpatient. Discussion We report 4 pediatric TCD HCT recipients (overall 6 episodes of ADV viremia) with d-ADV treated with BCV. All patients were highly immunosuppressed, with profound lymphopenia and/or very low CD4 counts. Despite high ADV viremia (median 3.7 × 105 copies/mL) at BCV initiation, 3 of 4 patients cleared ADV viremia at a median of 14 days (range, 1 - 34) of BCV treatment. Two patients (cases A and C) were on high dose steroids. Two patients had received prior CDV treatment (case A and C) without response prior to BCV treatment. Three patients tolerated prolonged doses of BCV (range, 17 - 29 doses). Case C had lymphopenia (100 cell/mm3) and CD4+ count was 0 cell/mm3 during ADV infection. Despite a rapid virologic response to BCV, ADV recurred after discontinuation of BCV highlighting the importance of immune recovery for control of ADV infection. Importantly the patient responded rapidly after 2 short subsequent courses of BCV suggesting that repeated episodic treatment with BCV guided by ADV viral load (VL) remains effective even in the setting of persistent lymphopenia. D-ADV infections are associated with substantial morbidity and mortality in HCT recipients [678]. Cases A, C and D with ADV colitis cleared ADV viremia with BCV. Case B did not tolerate BCV. BCV was discontinued after 5 doses concerning for gastrointestinal toxicity. Case B developed ADV hepatitis and ADV pneumonitis while on CDV. Case B responded to DLI and ADV-CTLs. While ADV-CTLs have shown safety and efficacy in small series (reviewed in reference 2), at present several hurdles preclude the broad applicability of this potentially effective therapy [2]. The virologic responses in our cases confirms the virologic activity of BCV even in lymphopenic patients and are in agreement with results of the recent BCV trial [11]. In that trial virologic responses were better, if BCV treatment was initiated at low VL and was associated with improved survival [11]. Our patients had high VL at BCV initiation despite which, 3 of 4 patients achieved virologic responses. One patient discontinued BCV due to gastrointestinal symptoms. Gastrointestinal toxicity is a known side effect of BCV [10]. Management of gastrointestinal toxicity due to BCV like case B is particularly challenging in patients with ADV in the gastrointestinal tract as symptoms may be related to ADV enteritis/colitis and/or BCV. Case B had diarrhea prior to BCV initiation and had persistent diarrhea while on BCV which led a clinician to stop BCV. An intravenous formulation of BCV is currently in development and may alleviate concerns for gastrointestinal toxicity. In conclusion, our small case series show rapid virologic responses after short courses of oral BCV in 3 of 4 pediatric patients with d-ADV. Repeated short courses of BCV were effective in a patient with recurrent ADV viremia. Our data supports the study design of short-course oral BCV treatment in pediatric HCT recipients with ADV infection. ACKNOWLEDGEMENT This research was funded in part through the NIH/NCI Cancer Center Support Grant P30 CA008748. Conflict of Interest: GAP has been an investigator for Shire, Merck, Chimerix and Astellas and has received consulting fees from Shire, Merck, Chimerix and Astellas. Author Contributions: Conceptualization: GAP, YJL. Data curation: SYC, SEP, FB, GAP, YJL, YJL. Writing - original draft: SEP, FB, GAP, YJL.	ALEMTUZUMAB, PREDNISOLONE	DrugsGivenReaction	CC BY-NC	32869551	19,446,308	2021-09
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Renal impairment'.	Rapid Virologic Response to Brincidofovir in Children with Disseminated Adenovirus Infection. Disseminated adenovirus infections (d-ADV) after hematopoietic cell transplant (HCT) are often fatal with limited treatment options. Brincidofovir (BCV) a lipid ester of cidofovir is developed for this indication. We report four pediatric HCT recipients with d-ADV treated successfully with BCV. pmcIntroduction Adenovirus (ADV) infections may occur in up to 40% of pediatric HCT recipients [1]. T-cell depletion (TCD) (ex vivo CD34+ or serotherapy with antithymocyte globulin or alemtuzumab), or severe graft-versus-host disease (GVHD) are associated with ADV infection post-HCT [2]. Recovery of ADV specific T-lymphocytes (ADV-CTLs) confers protection against ADV [3], whereas lymphopenia is a risk factor for disseminated ADV infection (d-ADV) [4]. Ex vivo by CD34+ selection (Miltenyi Biotec, Gladbach, Germany) achieves a 5-log depletion of T-lymphocytes in the allograft [5]. D-ADV infections after TCD HCT are often fatal with mortality rates ranging from 50 - 100% [678]. There is currently no approved treatment for ADV. Intravenous cidofovir (CDV) is commonly used; however its utility is limited by associated nephrotoxicity [9]. Adoptive transfer of ADV-CTLs has shown efficacy in single center studies [2]. Brincidofovir (BCV) is a lipid-linked derivative of CDV with high potency against all clinically significant ADV subtypes and no evidence of renal or hematological toxicity to date [1011]. In lymphocyte-depleted pediatric HCT recipients with ADV infections, treatment with BCV resulted in faster and greater virologic responses to BCV compared with CDV [12]. BCV has been associated with gastrointestinal toxicity with typical onset after 4 - 6 doses of BCV [11]. Children may tolerate BCV better than adults possibly due to a more rapid turnover of gastrointestinal mucosa compared with adults [10]. We describe 4 pediatric TCD HCT recipients with d-ADV infection treated successfully with oral BCV 2 mg/kg twice per week under Emergency Investigational New Drug from 9/2015 and 5/2016. The study was reviewed and approved by the Memorial Sloan Kettering Cancer Center Institutional Review and Privavy Board and granted a waiver of authorization (IRB #16-844). Table 1 shows the clinical and virologic characteristics. Virologic responses to BCV are shown in Figure 1A-1D. Table 1 Characteristics and outcome of disseminated adenovirus cases Case Age/sex Dx Transplant type, donor Post-transplant complications before onset of ADV viremia, immunosuppressant First ADV viremiaa, days post-HCT (D) Max ADV viremia, D Sites of ADV ADV disease, D ADV viremia at first CDV Tx ADV viremia at first BCV Tx BCV initiation, D Anti-viral Tx Time to virologic clearance from BCV, days ALC / CD4+ (cell/mcL) at BCV Tx Outcome A 19m/F SCID 1st HCT: BMT, haplo mother (graft failure) Autoimmune Hemolytic Anemia, Rituximab, Prednisolone 2.1 × 105, D+192 2.1 × 105, D+192 Blood, Stool, Urine Probable Enterocolitis, D+207 4.3 × 104 <190 D+193 CDV IV 5 mg/kg × 5 doses 3 ALC 400 CD4+ 30 Alive 2nd HCT: CD34+ TCD PBSCT, MUD BCV PO 2 mg/kg TIW × 17 doses B 4y/M ALL CD34+ TCD PBSCT, 9/10 MUD 469, D+10 4.7 × 106, D+69 Blood, Stool, Liver, RESP, Pleural Fluid Definite Pneumonitis, D+84; Definite Hepatitis, D+88 5.8 × 104 3.3 × 105 D+25 CDV IV 5 mg/kg × 14 doses N/A ALC 400 CD4+ 0 Alive BCV PO 2 mg/kg TIW × 5 doses DLI, ADV CTLs C 3y/M Familial HLH CD34+ TCD PBSCT, Haplo mother Skin Grade 3 GVHD and GI Grade 1 GVHD, Mesenchymal stem cell infusion, Alemtuzumab, CNI and Prednisolone 9.8 × 105, D+841 6.7 × 106, D+1026 Blood, Stool, RESP Possible Enterocolitis, D+870 N/A 4.1 × 105 D+848 BCV PO 2 mg/kg TIW × 29 doses 1st course: 14 1st course: ALC 100 CD4+ 0 Death, D+1088, MSOF 2nd course: 20 2nd course: ALC 100 CD4+ 0 D 3y/F ALL 1st HCT: CD34+ TCD PBSCT, MUD Acute Rejection of first allo-graft 2 × 103, D+38 (From 2nd HCT) 1.9 × 107, D+42 (From 2nd HCT) Blood, Stool, Liver Possible Enterocolitis, D+65 (From 2nd HCT) 2.8 × 105 1.6 × 107 D+57 (From 2nd HCT) CDV IV 5 mg/kg × 2 doses 34 ALC 300 CD4+ 19 Death, D+539 (From 2nd HCT), relapse of primary disease 2nd HCT: CD34+ TCD PBSCT, MUD 2nd HCT: Alemtuzumab 1 mg/kg divided in 5 doses after 2nd HCT BCV PO 2 mg/kg TIW × 26 doses aADV PCR in blood was performed by Viraco Eurofins (Lee's Summit, MO, USA). Values are copies/ml. m, months-old; F, female; y, years-old; M, male; Dx, diagnosis; SCID, severe combined immune deficiency; ALL, acute lymphoblastic leukemia; HLH, hemophagocytic lymphohistiocytosis; HCT, hematopoietic cell transplant; BMT, bone marrow transplant; Haplo, Haploidentical; TCD, T Cell-depleted; PBSCT, peripheral blood stem cell transplant; MUD, matched unrelated donor; ADV, adenovirus; GVHD, graft-versus-host disease; GI, gastrointestinal; CNI, calcineurin inhibitors; D, day from transplant; max, maximum, RESP, respiratory specimens (bronchoalveolar lavage, nasopharyngeal swab); CDV, cidofovir; Tx, treatment; N/A, not applicable; BCV, brincidofovir; IV, intravenous; PO, orally; TIW, three times per week; DLI, donor lymphocyte infusion; CTLs, cytotoxic T lymphocytes, ALC, absolute lymphocyte counts; MSOF, multisystem organ failure. Figure 1 Plasma adenovirus viral load and treatment in 4 pediatric hematopoietic cell transplant recipients with disseminated adenovirus infection. CD4+ count: cell/mcL. CDV, cidofovir; BCV, brincidofovir; ADV, adenovirus; VL, viral load; DLI, donor lymphocyte infusion; CTL, cytotoxic T-lymphocyte; PCR, polymerase chain reaction. Case report ADV PCR was performed by Viracor-Eurofins (Lee's Summit, MO, USA). The linear range of quantification of ADV PCR in the blood was 100 – 1 × 1010 copies/mL. D-ADV was defined as previously defined [7]. 1. Case A A 19-month-old girl with severe combined immunodeficiency syndrome received a TCD HCT from a matched unrelated donor (MUD). Her post-transplant course was complicated by autoimmune hemolytic anemia treated with prednisolone and 6 doses of rituximab. Six months post-transplant she presented for hypoactivity, irritability and watery diarrhea. On admission, stool ADV PCR was positive and ADV viremia was 2.1 × 105copies/ml. She was treated with CDV and intravenous immunoglobulin. After 2 weeks of CDV, colonoscopy was performed. Pathology showed friable colonic mucosa. Viral culture from tissues was positive for ADV. Because of persistent diarrhea after 5 doses of CDV, BCV was started. ADV viremia became undetectable after 2 doses of BCV. BCV was stopped at 8 weeks after BCV initiation. 2. Case B A 4-year-old boy with acute lymphoblastic leukemia (ALL) received a TCD HCT from a MUD. On Day 0, stool ADV PCR was positive and ADV viremia was negative. On Day +10, ADV viremia was 469 copies/ml and on Day +17 ADV viremia rose to 5.8 × 104copies/ml. On Day +25, CDV was started due to persistent fever, diarrhea and rising ADV viremia. After 2 doses of CDV, CDV was switched to BCV due to increased ADV viremia (3.3 × 105copies/ml). On Day +39, BCV was discontinued after 5 doses due to persistent diarrhea. CDV was resumed, however ADV viremia increased to 4.7 × 106copies/ml on Day +69 and transaminitis was noted. Liver biopsy on Day +84 confirmed GVHD with ADV hepatitis (positive ADV stain). Concurrently, he developed respiratory distress and a nasopharyngeal swab was positive for ADV by PCR. On Day +88, thoracentesis was performed due to worsening pleural effusion. Pleural fluid was positive for ADV (1.8 × 105copies/ml). He was treated with donor lymphocyte infusion (DLI) and subsequently with ADV-CTLs with virologic response. 3. Case C A 3-year-old boy with familial hemophagocytic lymphohistiocytosis was admitted with fever, diarrhea and vomiting 2 years post-transplant. He received a TCD HCT from his haploidentical mother. His post-transplant course was complicated by poor graft function, refractory skin and gastrointestinal GVHD, human herpesvirus-6 viremia and chronic renal dysfunction. He received cyclosporine, tacrolimus, steroids and mesenchymal stem cells infusion for GVHD. On admission, cefepime and vancomycin were empirically started. Stool was negative for Clostridioides difficile. Symptoms persisted during admission. On hospital day 21, stool ADV PCR was positive and ADV viremia was 9.8 × 105copies/ml. BCV was initiated. Viral clearance was achieved after 5 doses BCV and BCV was continued for 4 weeks. One week after BCV discontinuation, ADV viremia recrudesced to 1.0 × 107copies/ml. BCV was reinitiated and continued for 10 weeks with good virologic control. Due to persistent diarrhea, colonoscopy was performed and pathology showed persistent gut GVHD. The tissue was positive for ADV by PCR. He received a stem cell boost 2 months after stopping BCV for poor graft function. He subsequently developed relapse of ADV viremia (6.7 × 106copies/ml), thus BCV was resumed and ADV viremia became undectable after 7 doses of BCV. His hospital stay was further complicated by hospital-acquired pneumonia with respiratory failure. Despite resolving ADV viremia, he died due to multi-organ failure. 4. Case D A 3-year-old girl with ALL received a TCD HCT from a MUD complicated by graft rejection and followed by a second TCD HCT from a different MUD one month after the first HCT. Her post-transplant course was complicated by Epstein-Barr virus (EBV) viremia treated with rituximab and cytomegalovirus viremia. On Day +38 post-transplant, she was found to have ADV viremia (2.0 × 103copies/ml). On Day +42, ADV viremia increased to 1.9 × 107copies/ml. On Day +53, she developed watery diarrhea and nausea. Stool ADV PCR was positive. On Day +56, colonoscopy was performed. The tissue was positive for ADV by PCR. On Day +56, ADV viremia was 2.8 × 105copies/ml and CDV was started. After two doses of CDV, ADV viremia was 1.1 × 105copies/ml. She developed worsening hepatic function. Computed tomography of the chest and abdomen on Day +65 showed a necrotic liver lesion and a necrotic lung mass. ADV viremia rose up to 2.3 × 107copies/ml on Day +66 despite CDV. Lung and liver biopsies performed on Day +67 yielded Legionella pneumophila serotype 1 by culture and liver biopsy was positive for EBV and ADV by PCR. ADV viremia was 1.6 × 107 copies/mL on Day +69. On Day +71, levofloxacin was started for Legionella pneumonia and BCV for d-ADV infection. ADV viremia became undectable 34 days after initiation. She received BCV for 80 days as outpatient. Discussion We report 4 pediatric TCD HCT recipients (overall 6 episodes of ADV viremia) with d-ADV treated with BCV. All patients were highly immunosuppressed, with profound lymphopenia and/or very low CD4 counts. Despite high ADV viremia (median 3.7 × 105 copies/mL) at BCV initiation, 3 of 4 patients cleared ADV viremia at a median of 14 days (range, 1 - 34) of BCV treatment. Two patients (cases A and C) were on high dose steroids. Two patients had received prior CDV treatment (case A and C) without response prior to BCV treatment. Three patients tolerated prolonged doses of BCV (range, 17 - 29 doses). Case C had lymphopenia (100 cell/mm3) and CD4+ count was 0 cell/mm3 during ADV infection. Despite a rapid virologic response to BCV, ADV recurred after discontinuation of BCV highlighting the importance of immune recovery for control of ADV infection. Importantly the patient responded rapidly after 2 short subsequent courses of BCV suggesting that repeated episodic treatment with BCV guided by ADV viral load (VL) remains effective even in the setting of persistent lymphopenia. D-ADV infections are associated with substantial morbidity and mortality in HCT recipients [678]. Cases A, C and D with ADV colitis cleared ADV viremia with BCV. Case B did not tolerate BCV. BCV was discontinued after 5 doses concerning for gastrointestinal toxicity. Case B developed ADV hepatitis and ADV pneumonitis while on CDV. Case B responded to DLI and ADV-CTLs. While ADV-CTLs have shown safety and efficacy in small series (reviewed in reference 2), at present several hurdles preclude the broad applicability of this potentially effective therapy [2]. The virologic responses in our cases confirms the virologic activity of BCV even in lymphopenic patients and are in agreement with results of the recent BCV trial [11]. In that trial virologic responses were better, if BCV treatment was initiated at low VL and was associated with improved survival [11]. Our patients had high VL at BCV initiation despite which, 3 of 4 patients achieved virologic responses. One patient discontinued BCV due to gastrointestinal symptoms. Gastrointestinal toxicity is a known side effect of BCV [10]. Management of gastrointestinal toxicity due to BCV like case B is particularly challenging in patients with ADV in the gastrointestinal tract as symptoms may be related to ADV enteritis/colitis and/or BCV. Case B had diarrhea prior to BCV initiation and had persistent diarrhea while on BCV which led a clinician to stop BCV. An intravenous formulation of BCV is currently in development and may alleviate concerns for gastrointestinal toxicity. In conclusion, our small case series show rapid virologic responses after short courses of oral BCV in 3 of 4 pediatric patients with d-ADV. Repeated short courses of BCV were effective in a patient with recurrent ADV viremia. Our data supports the study design of short-course oral BCV treatment in pediatric HCT recipients with ADV infection. ACKNOWLEDGEMENT This research was funded in part through the NIH/NCI Cancer Center Support Grant P30 CA008748. Conflict of Interest: GAP has been an investigator for Shire, Merck, Chimerix and Astellas and has received consulting fees from Shire, Merck, Chimerix and Astellas. Author Contributions: Conceptualization: GAP, YJL. Data curation: SYC, SEP, FB, GAP, YJL, YJL. Writing - original draft: SEP, FB, GAP, YJL.	ALEMTUZUMAB, PREDNISOLONE	DrugsGivenReaction	CC BY-NC	32869551	19,446,308	2021-09
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Respiratory failure'.	Rapid Virologic Response to Brincidofovir in Children with Disseminated Adenovirus Infection. Disseminated adenovirus infections (d-ADV) after hematopoietic cell transplant (HCT) are often fatal with limited treatment options. Brincidofovir (BCV) a lipid ester of cidofovir is developed for this indication. We report four pediatric HCT recipients with d-ADV treated successfully with BCV. pmcIntroduction Adenovirus (ADV) infections may occur in up to 40% of pediatric HCT recipients [1]. T-cell depletion (TCD) (ex vivo CD34+ or serotherapy with antithymocyte globulin or alemtuzumab), or severe graft-versus-host disease (GVHD) are associated with ADV infection post-HCT [2]. Recovery of ADV specific T-lymphocytes (ADV-CTLs) confers protection against ADV [3], whereas lymphopenia is a risk factor for disseminated ADV infection (d-ADV) [4]. Ex vivo by CD34+ selection (Miltenyi Biotec, Gladbach, Germany) achieves a 5-log depletion of T-lymphocytes in the allograft [5]. D-ADV infections after TCD HCT are often fatal with mortality rates ranging from 50 - 100% [678]. There is currently no approved treatment for ADV. Intravenous cidofovir (CDV) is commonly used; however its utility is limited by associated nephrotoxicity [9]. Adoptive transfer of ADV-CTLs has shown efficacy in single center studies [2]. Brincidofovir (BCV) is a lipid-linked derivative of CDV with high potency against all clinically significant ADV subtypes and no evidence of renal or hematological toxicity to date [1011]. In lymphocyte-depleted pediatric HCT recipients with ADV infections, treatment with BCV resulted in faster and greater virologic responses to BCV compared with CDV [12]. BCV has been associated with gastrointestinal toxicity with typical onset after 4 - 6 doses of BCV [11]. Children may tolerate BCV better than adults possibly due to a more rapid turnover of gastrointestinal mucosa compared with adults [10]. We describe 4 pediatric TCD HCT recipients with d-ADV infection treated successfully with oral BCV 2 mg/kg twice per week under Emergency Investigational New Drug from 9/2015 and 5/2016. The study was reviewed and approved by the Memorial Sloan Kettering Cancer Center Institutional Review and Privavy Board and granted a waiver of authorization (IRB #16-844). Table 1 shows the clinical and virologic characteristics. Virologic responses to BCV are shown in Figure 1A-1D. Table 1 Characteristics and outcome of disseminated adenovirus cases Case Age/sex Dx Transplant type, donor Post-transplant complications before onset of ADV viremia, immunosuppressant First ADV viremiaa, days post-HCT (D) Max ADV viremia, D Sites of ADV ADV disease, D ADV viremia at first CDV Tx ADV viremia at first BCV Tx BCV initiation, D Anti-viral Tx Time to virologic clearance from BCV, days ALC / CD4+ (cell/mcL) at BCV Tx Outcome A 19m/F SCID 1st HCT: BMT, haplo mother (graft failure) Autoimmune Hemolytic Anemia, Rituximab, Prednisolone 2.1 × 105, D+192 2.1 × 105, D+192 Blood, Stool, Urine Probable Enterocolitis, D+207 4.3 × 104 <190 D+193 CDV IV 5 mg/kg × 5 doses 3 ALC 400 CD4+ 30 Alive 2nd HCT: CD34+ TCD PBSCT, MUD BCV PO 2 mg/kg TIW × 17 doses B 4y/M ALL CD34+ TCD PBSCT, 9/10 MUD 469, D+10 4.7 × 106, D+69 Blood, Stool, Liver, RESP, Pleural Fluid Definite Pneumonitis, D+84; Definite Hepatitis, D+88 5.8 × 104 3.3 × 105 D+25 CDV IV 5 mg/kg × 14 doses N/A ALC 400 CD4+ 0 Alive BCV PO 2 mg/kg TIW × 5 doses DLI, ADV CTLs C 3y/M Familial HLH CD34+ TCD PBSCT, Haplo mother Skin Grade 3 GVHD and GI Grade 1 GVHD, Mesenchymal stem cell infusion, Alemtuzumab, CNI and Prednisolone 9.8 × 105, D+841 6.7 × 106, D+1026 Blood, Stool, RESP Possible Enterocolitis, D+870 N/A 4.1 × 105 D+848 BCV PO 2 mg/kg TIW × 29 doses 1st course: 14 1st course: ALC 100 CD4+ 0 Death, D+1088, MSOF 2nd course: 20 2nd course: ALC 100 CD4+ 0 D 3y/F ALL 1st HCT: CD34+ TCD PBSCT, MUD Acute Rejection of first allo-graft 2 × 103, D+38 (From 2nd HCT) 1.9 × 107, D+42 (From 2nd HCT) Blood, Stool, Liver Possible Enterocolitis, D+65 (From 2nd HCT) 2.8 × 105 1.6 × 107 D+57 (From 2nd HCT) CDV IV 5 mg/kg × 2 doses 34 ALC 300 CD4+ 19 Death, D+539 (From 2nd HCT), relapse of primary disease 2nd HCT: CD34+ TCD PBSCT, MUD 2nd HCT: Alemtuzumab 1 mg/kg divided in 5 doses after 2nd HCT BCV PO 2 mg/kg TIW × 26 doses aADV PCR in blood was performed by Viraco Eurofins (Lee's Summit, MO, USA). Values are copies/ml. m, months-old; F, female; y, years-old; M, male; Dx, diagnosis; SCID, severe combined immune deficiency; ALL, acute lymphoblastic leukemia; HLH, hemophagocytic lymphohistiocytosis; HCT, hematopoietic cell transplant; BMT, bone marrow transplant; Haplo, Haploidentical; TCD, T Cell-depleted; PBSCT, peripheral blood stem cell transplant; MUD, matched unrelated donor; ADV, adenovirus; GVHD, graft-versus-host disease; GI, gastrointestinal; CNI, calcineurin inhibitors; D, day from transplant; max, maximum, RESP, respiratory specimens (bronchoalveolar lavage, nasopharyngeal swab); CDV, cidofovir; Tx, treatment; N/A, not applicable; BCV, brincidofovir; IV, intravenous; PO, orally; TIW, three times per week; DLI, donor lymphocyte infusion; CTLs, cytotoxic T lymphocytes, ALC, absolute lymphocyte counts; MSOF, multisystem organ failure. Figure 1 Plasma adenovirus viral load and treatment in 4 pediatric hematopoietic cell transplant recipients with disseminated adenovirus infection. CD4+ count: cell/mcL. CDV, cidofovir; BCV, brincidofovir; ADV, adenovirus; VL, viral load; DLI, donor lymphocyte infusion; CTL, cytotoxic T-lymphocyte; PCR, polymerase chain reaction. Case report ADV PCR was performed by Viracor-Eurofins (Lee's Summit, MO, USA). The linear range of quantification of ADV PCR in the blood was 100 – 1 × 1010 copies/mL. D-ADV was defined as previously defined [7]. 1. Case A A 19-month-old girl with severe combined immunodeficiency syndrome received a TCD HCT from a matched unrelated donor (MUD). Her post-transplant course was complicated by autoimmune hemolytic anemia treated with prednisolone and 6 doses of rituximab. Six months post-transplant she presented for hypoactivity, irritability and watery diarrhea. On admission, stool ADV PCR was positive and ADV viremia was 2.1 × 105copies/ml. She was treated with CDV and intravenous immunoglobulin. After 2 weeks of CDV, colonoscopy was performed. Pathology showed friable colonic mucosa. Viral culture from tissues was positive for ADV. Because of persistent diarrhea after 5 doses of CDV, BCV was started. ADV viremia became undetectable after 2 doses of BCV. BCV was stopped at 8 weeks after BCV initiation. 2. Case B A 4-year-old boy with acute lymphoblastic leukemia (ALL) received a TCD HCT from a MUD. On Day 0, stool ADV PCR was positive and ADV viremia was negative. On Day +10, ADV viremia was 469 copies/ml and on Day +17 ADV viremia rose to 5.8 × 104copies/ml. On Day +25, CDV was started due to persistent fever, diarrhea and rising ADV viremia. After 2 doses of CDV, CDV was switched to BCV due to increased ADV viremia (3.3 × 105copies/ml). On Day +39, BCV was discontinued after 5 doses due to persistent diarrhea. CDV was resumed, however ADV viremia increased to 4.7 × 106copies/ml on Day +69 and transaminitis was noted. Liver biopsy on Day +84 confirmed GVHD with ADV hepatitis (positive ADV stain). Concurrently, he developed respiratory distress and a nasopharyngeal swab was positive for ADV by PCR. On Day +88, thoracentesis was performed due to worsening pleural effusion. Pleural fluid was positive for ADV (1.8 × 105copies/ml). He was treated with donor lymphocyte infusion (DLI) and subsequently with ADV-CTLs with virologic response. 3. Case C A 3-year-old boy with familial hemophagocytic lymphohistiocytosis was admitted with fever, diarrhea and vomiting 2 years post-transplant. He received a TCD HCT from his haploidentical mother. His post-transplant course was complicated by poor graft function, refractory skin and gastrointestinal GVHD, human herpesvirus-6 viremia and chronic renal dysfunction. He received cyclosporine, tacrolimus, steroids and mesenchymal stem cells infusion for GVHD. On admission, cefepime and vancomycin were empirically started. Stool was negative for Clostridioides difficile. Symptoms persisted during admission. On hospital day 21, stool ADV PCR was positive and ADV viremia was 9.8 × 105copies/ml. BCV was initiated. Viral clearance was achieved after 5 doses BCV and BCV was continued for 4 weeks. One week after BCV discontinuation, ADV viremia recrudesced to 1.0 × 107copies/ml. BCV was reinitiated and continued for 10 weeks with good virologic control. Due to persistent diarrhea, colonoscopy was performed and pathology showed persistent gut GVHD. The tissue was positive for ADV by PCR. He received a stem cell boost 2 months after stopping BCV for poor graft function. He subsequently developed relapse of ADV viremia (6.7 × 106copies/ml), thus BCV was resumed and ADV viremia became undectable after 7 doses of BCV. His hospital stay was further complicated by hospital-acquired pneumonia with respiratory failure. Despite resolving ADV viremia, he died due to multi-organ failure. 4. Case D A 3-year-old girl with ALL received a TCD HCT from a MUD complicated by graft rejection and followed by a second TCD HCT from a different MUD one month after the first HCT. Her post-transplant course was complicated by Epstein-Barr virus (EBV) viremia treated with rituximab and cytomegalovirus viremia. On Day +38 post-transplant, she was found to have ADV viremia (2.0 × 103copies/ml). On Day +42, ADV viremia increased to 1.9 × 107copies/ml. On Day +53, she developed watery diarrhea and nausea. Stool ADV PCR was positive. On Day +56, colonoscopy was performed. The tissue was positive for ADV by PCR. On Day +56, ADV viremia was 2.8 × 105copies/ml and CDV was started. After two doses of CDV, ADV viremia was 1.1 × 105copies/ml. She developed worsening hepatic function. Computed tomography of the chest and abdomen on Day +65 showed a necrotic liver lesion and a necrotic lung mass. ADV viremia rose up to 2.3 × 107copies/ml on Day +66 despite CDV. Lung and liver biopsies performed on Day +67 yielded Legionella pneumophila serotype 1 by culture and liver biopsy was positive for EBV and ADV by PCR. ADV viremia was 1.6 × 107 copies/mL on Day +69. On Day +71, levofloxacin was started for Legionella pneumonia and BCV for d-ADV infection. ADV viremia became undectable 34 days after initiation. She received BCV for 80 days as outpatient. Discussion We report 4 pediatric TCD HCT recipients (overall 6 episodes of ADV viremia) with d-ADV treated with BCV. All patients were highly immunosuppressed, with profound lymphopenia and/or very low CD4 counts. Despite high ADV viremia (median 3.7 × 105 copies/mL) at BCV initiation, 3 of 4 patients cleared ADV viremia at a median of 14 days (range, 1 - 34) of BCV treatment. Two patients (cases A and C) were on high dose steroids. Two patients had received prior CDV treatment (case A and C) without response prior to BCV treatment. Three patients tolerated prolonged doses of BCV (range, 17 - 29 doses). Case C had lymphopenia (100 cell/mm3) and CD4+ count was 0 cell/mm3 during ADV infection. Despite a rapid virologic response to BCV, ADV recurred after discontinuation of BCV highlighting the importance of immune recovery for control of ADV infection. Importantly the patient responded rapidly after 2 short subsequent courses of BCV suggesting that repeated episodic treatment with BCV guided by ADV viral load (VL) remains effective even in the setting of persistent lymphopenia. D-ADV infections are associated with substantial morbidity and mortality in HCT recipients [678]. Cases A, C and D with ADV colitis cleared ADV viremia with BCV. Case B did not tolerate BCV. BCV was discontinued after 5 doses concerning for gastrointestinal toxicity. Case B developed ADV hepatitis and ADV pneumonitis while on CDV. Case B responded to DLI and ADV-CTLs. While ADV-CTLs have shown safety and efficacy in small series (reviewed in reference 2), at present several hurdles preclude the broad applicability of this potentially effective therapy [2]. The virologic responses in our cases confirms the virologic activity of BCV even in lymphopenic patients and are in agreement with results of the recent BCV trial [11]. In that trial virologic responses were better, if BCV treatment was initiated at low VL and was associated with improved survival [11]. Our patients had high VL at BCV initiation despite which, 3 of 4 patients achieved virologic responses. One patient discontinued BCV due to gastrointestinal symptoms. Gastrointestinal toxicity is a known side effect of BCV [10]. Management of gastrointestinal toxicity due to BCV like case B is particularly challenging in patients with ADV in the gastrointestinal tract as symptoms may be related to ADV enteritis/colitis and/or BCV. Case B had diarrhea prior to BCV initiation and had persistent diarrhea while on BCV which led a clinician to stop BCV. An intravenous formulation of BCV is currently in development and may alleviate concerns for gastrointestinal toxicity. In conclusion, our small case series show rapid virologic responses after short courses of oral BCV in 3 of 4 pediatric patients with d-ADV. Repeated short courses of BCV were effective in a patient with recurrent ADV viremia. Our data supports the study design of short-course oral BCV treatment in pediatric HCT recipients with ADV infection. ACKNOWLEDGEMENT This research was funded in part through the NIH/NCI Cancer Center Support Grant P30 CA008748. Conflict of Interest: GAP has been an investigator for Shire, Merck, Chimerix and Astellas and has received consulting fees from Shire, Merck, Chimerix and Astellas. Author Contributions: Conceptualization: GAP, YJL. Data curation: SYC, SEP, FB, GAP, YJL, YJL. Writing - original draft: SEP, FB, GAP, YJL.	ALEMTUZUMAB, PREDNISOLONE	DrugsGivenReaction	CC BY-NC	32869551	19,446,308	2021-09
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Vomiting'.	Rapid Virologic Response to Brincidofovir in Children with Disseminated Adenovirus Infection. Disseminated adenovirus infections (d-ADV) after hematopoietic cell transplant (HCT) are often fatal with limited treatment options. Brincidofovir (BCV) a lipid ester of cidofovir is developed for this indication. We report four pediatric HCT recipients with d-ADV treated successfully with BCV. pmcIntroduction Adenovirus (ADV) infections may occur in up to 40% of pediatric HCT recipients [1]. T-cell depletion (TCD) (ex vivo CD34+ or serotherapy with antithymocyte globulin or alemtuzumab), or severe graft-versus-host disease (GVHD) are associated with ADV infection post-HCT [2]. Recovery of ADV specific T-lymphocytes (ADV-CTLs) confers protection against ADV [3], whereas lymphopenia is a risk factor for disseminated ADV infection (d-ADV) [4]. Ex vivo by CD34+ selection (Miltenyi Biotec, Gladbach, Germany) achieves a 5-log depletion of T-lymphocytes in the allograft [5]. D-ADV infections after TCD HCT are often fatal with mortality rates ranging from 50 - 100% [678]. There is currently no approved treatment for ADV. Intravenous cidofovir (CDV) is commonly used; however its utility is limited by associated nephrotoxicity [9]. Adoptive transfer of ADV-CTLs has shown efficacy in single center studies [2]. Brincidofovir (BCV) is a lipid-linked derivative of CDV with high potency against all clinically significant ADV subtypes and no evidence of renal or hematological toxicity to date [1011]. In lymphocyte-depleted pediatric HCT recipients with ADV infections, treatment with BCV resulted in faster and greater virologic responses to BCV compared with CDV [12]. BCV has been associated with gastrointestinal toxicity with typical onset after 4 - 6 doses of BCV [11]. Children may tolerate BCV better than adults possibly due to a more rapid turnover of gastrointestinal mucosa compared with adults [10]. We describe 4 pediatric TCD HCT recipients with d-ADV infection treated successfully with oral BCV 2 mg/kg twice per week under Emergency Investigational New Drug from 9/2015 and 5/2016. The study was reviewed and approved by the Memorial Sloan Kettering Cancer Center Institutional Review and Privavy Board and granted a waiver of authorization (IRB #16-844). Table 1 shows the clinical and virologic characteristics. Virologic responses to BCV are shown in Figure 1A-1D. Table 1 Characteristics and outcome of disseminated adenovirus cases Case Age/sex Dx Transplant type, donor Post-transplant complications before onset of ADV viremia, immunosuppressant First ADV viremiaa, days post-HCT (D) Max ADV viremia, D Sites of ADV ADV disease, D ADV viremia at first CDV Tx ADV viremia at first BCV Tx BCV initiation, D Anti-viral Tx Time to virologic clearance from BCV, days ALC / CD4+ (cell/mcL) at BCV Tx Outcome A 19m/F SCID 1st HCT: BMT, haplo mother (graft failure) Autoimmune Hemolytic Anemia, Rituximab, Prednisolone 2.1 × 105, D+192 2.1 × 105, D+192 Blood, Stool, Urine Probable Enterocolitis, D+207 4.3 × 104 <190 D+193 CDV IV 5 mg/kg × 5 doses 3 ALC 400 CD4+ 30 Alive 2nd HCT: CD34+ TCD PBSCT, MUD BCV PO 2 mg/kg TIW × 17 doses B 4y/M ALL CD34+ TCD PBSCT, 9/10 MUD 469, D+10 4.7 × 106, D+69 Blood, Stool, Liver, RESP, Pleural Fluid Definite Pneumonitis, D+84; Definite Hepatitis, D+88 5.8 × 104 3.3 × 105 D+25 CDV IV 5 mg/kg × 14 doses N/A ALC 400 CD4+ 0 Alive BCV PO 2 mg/kg TIW × 5 doses DLI, ADV CTLs C 3y/M Familial HLH CD34+ TCD PBSCT, Haplo mother Skin Grade 3 GVHD and GI Grade 1 GVHD, Mesenchymal stem cell infusion, Alemtuzumab, CNI and Prednisolone 9.8 × 105, D+841 6.7 × 106, D+1026 Blood, Stool, RESP Possible Enterocolitis, D+870 N/A 4.1 × 105 D+848 BCV PO 2 mg/kg TIW × 29 doses 1st course: 14 1st course: ALC 100 CD4+ 0 Death, D+1088, MSOF 2nd course: 20 2nd course: ALC 100 CD4+ 0 D 3y/F ALL 1st HCT: CD34+ TCD PBSCT, MUD Acute Rejection of first allo-graft 2 × 103, D+38 (From 2nd HCT) 1.9 × 107, D+42 (From 2nd HCT) Blood, Stool, Liver Possible Enterocolitis, D+65 (From 2nd HCT) 2.8 × 105 1.6 × 107 D+57 (From 2nd HCT) CDV IV 5 mg/kg × 2 doses 34 ALC 300 CD4+ 19 Death, D+539 (From 2nd HCT), relapse of primary disease 2nd HCT: CD34+ TCD PBSCT, MUD 2nd HCT: Alemtuzumab 1 mg/kg divided in 5 doses after 2nd HCT BCV PO 2 mg/kg TIW × 26 doses aADV PCR in blood was performed by Viraco Eurofins (Lee's Summit, MO, USA). Values are copies/ml. m, months-old; F, female; y, years-old; M, male; Dx, diagnosis; SCID, severe combined immune deficiency; ALL, acute lymphoblastic leukemia; HLH, hemophagocytic lymphohistiocytosis; HCT, hematopoietic cell transplant; BMT, bone marrow transplant; Haplo, Haploidentical; TCD, T Cell-depleted; PBSCT, peripheral blood stem cell transplant; MUD, matched unrelated donor; ADV, adenovirus; GVHD, graft-versus-host disease; GI, gastrointestinal; CNI, calcineurin inhibitors; D, day from transplant; max, maximum, RESP, respiratory specimens (bronchoalveolar lavage, nasopharyngeal swab); CDV, cidofovir; Tx, treatment; N/A, not applicable; BCV, brincidofovir; IV, intravenous; PO, orally; TIW, three times per week; DLI, donor lymphocyte infusion; CTLs, cytotoxic T lymphocytes, ALC, absolute lymphocyte counts; MSOF, multisystem organ failure. Figure 1 Plasma adenovirus viral load and treatment in 4 pediatric hematopoietic cell transplant recipients with disseminated adenovirus infection. CD4+ count: cell/mcL. CDV, cidofovir; BCV, brincidofovir; ADV, adenovirus; VL, viral load; DLI, donor lymphocyte infusion; CTL, cytotoxic T-lymphocyte; PCR, polymerase chain reaction. Case report ADV PCR was performed by Viracor-Eurofins (Lee's Summit, MO, USA). The linear range of quantification of ADV PCR in the blood was 100 – 1 × 1010 copies/mL. D-ADV was defined as previously defined [7]. 1. Case A A 19-month-old girl with severe combined immunodeficiency syndrome received a TCD HCT from a matched unrelated donor (MUD). Her post-transplant course was complicated by autoimmune hemolytic anemia treated with prednisolone and 6 doses of rituximab. Six months post-transplant she presented for hypoactivity, irritability and watery diarrhea. On admission, stool ADV PCR was positive and ADV viremia was 2.1 × 105copies/ml. She was treated with CDV and intravenous immunoglobulin. After 2 weeks of CDV, colonoscopy was performed. Pathology showed friable colonic mucosa. Viral culture from tissues was positive for ADV. Because of persistent diarrhea after 5 doses of CDV, BCV was started. ADV viremia became undetectable after 2 doses of BCV. BCV was stopped at 8 weeks after BCV initiation. 2. Case B A 4-year-old boy with acute lymphoblastic leukemia (ALL) received a TCD HCT from a MUD. On Day 0, stool ADV PCR was positive and ADV viremia was negative. On Day +10, ADV viremia was 469 copies/ml and on Day +17 ADV viremia rose to 5.8 × 104copies/ml. On Day +25, CDV was started due to persistent fever, diarrhea and rising ADV viremia. After 2 doses of CDV, CDV was switched to BCV due to increased ADV viremia (3.3 × 105copies/ml). On Day +39, BCV was discontinued after 5 doses due to persistent diarrhea. CDV was resumed, however ADV viremia increased to 4.7 × 106copies/ml on Day +69 and transaminitis was noted. Liver biopsy on Day +84 confirmed GVHD with ADV hepatitis (positive ADV stain). Concurrently, he developed respiratory distress and a nasopharyngeal swab was positive for ADV by PCR. On Day +88, thoracentesis was performed due to worsening pleural effusion. Pleural fluid was positive for ADV (1.8 × 105copies/ml). He was treated with donor lymphocyte infusion (DLI) and subsequently with ADV-CTLs with virologic response. 3. Case C A 3-year-old boy with familial hemophagocytic lymphohistiocytosis was admitted with fever, diarrhea and vomiting 2 years post-transplant. He received a TCD HCT from his haploidentical mother. His post-transplant course was complicated by poor graft function, refractory skin and gastrointestinal GVHD, human herpesvirus-6 viremia and chronic renal dysfunction. He received cyclosporine, tacrolimus, steroids and mesenchymal stem cells infusion for GVHD. On admission, cefepime and vancomycin were empirically started. Stool was negative for Clostridioides difficile. Symptoms persisted during admission. On hospital day 21, stool ADV PCR was positive and ADV viremia was 9.8 × 105copies/ml. BCV was initiated. Viral clearance was achieved after 5 doses BCV and BCV was continued for 4 weeks. One week after BCV discontinuation, ADV viremia recrudesced to 1.0 × 107copies/ml. BCV was reinitiated and continued for 10 weeks with good virologic control. Due to persistent diarrhea, colonoscopy was performed and pathology showed persistent gut GVHD. The tissue was positive for ADV by PCR. He received a stem cell boost 2 months after stopping BCV for poor graft function. He subsequently developed relapse of ADV viremia (6.7 × 106copies/ml), thus BCV was resumed and ADV viremia became undectable after 7 doses of BCV. His hospital stay was further complicated by hospital-acquired pneumonia with respiratory failure. Despite resolving ADV viremia, he died due to multi-organ failure. 4. Case D A 3-year-old girl with ALL received a TCD HCT from a MUD complicated by graft rejection and followed by a second TCD HCT from a different MUD one month after the first HCT. Her post-transplant course was complicated by Epstein-Barr virus (EBV) viremia treated with rituximab and cytomegalovirus viremia. On Day +38 post-transplant, she was found to have ADV viremia (2.0 × 103copies/ml). On Day +42, ADV viremia increased to 1.9 × 107copies/ml. On Day +53, she developed watery diarrhea and nausea. Stool ADV PCR was positive. On Day +56, colonoscopy was performed. The tissue was positive for ADV by PCR. On Day +56, ADV viremia was 2.8 × 105copies/ml and CDV was started. After two doses of CDV, ADV viremia was 1.1 × 105copies/ml. She developed worsening hepatic function. Computed tomography of the chest and abdomen on Day +65 showed a necrotic liver lesion and a necrotic lung mass. ADV viremia rose up to 2.3 × 107copies/ml on Day +66 despite CDV. Lung and liver biopsies performed on Day +67 yielded Legionella pneumophila serotype 1 by culture and liver biopsy was positive for EBV and ADV by PCR. ADV viremia was 1.6 × 107 copies/mL on Day +69. On Day +71, levofloxacin was started for Legionella pneumonia and BCV for d-ADV infection. ADV viremia became undectable 34 days after initiation. She received BCV for 80 days as outpatient. Discussion We report 4 pediatric TCD HCT recipients (overall 6 episodes of ADV viremia) with d-ADV treated with BCV. All patients were highly immunosuppressed, with profound lymphopenia and/or very low CD4 counts. Despite high ADV viremia (median 3.7 × 105 copies/mL) at BCV initiation, 3 of 4 patients cleared ADV viremia at a median of 14 days (range, 1 - 34) of BCV treatment. Two patients (cases A and C) were on high dose steroids. Two patients had received prior CDV treatment (case A and C) without response prior to BCV treatment. Three patients tolerated prolonged doses of BCV (range, 17 - 29 doses). Case C had lymphopenia (100 cell/mm3) and CD4+ count was 0 cell/mm3 during ADV infection. Despite a rapid virologic response to BCV, ADV recurred after discontinuation of BCV highlighting the importance of immune recovery for control of ADV infection. Importantly the patient responded rapidly after 2 short subsequent courses of BCV suggesting that repeated episodic treatment with BCV guided by ADV viral load (VL) remains effective even in the setting of persistent lymphopenia. D-ADV infections are associated with substantial morbidity and mortality in HCT recipients [678]. Cases A, C and D with ADV colitis cleared ADV viremia with BCV. Case B did not tolerate BCV. BCV was discontinued after 5 doses concerning for gastrointestinal toxicity. Case B developed ADV hepatitis and ADV pneumonitis while on CDV. Case B responded to DLI and ADV-CTLs. While ADV-CTLs have shown safety and efficacy in small series (reviewed in reference 2), at present several hurdles preclude the broad applicability of this potentially effective therapy [2]. The virologic responses in our cases confirms the virologic activity of BCV even in lymphopenic patients and are in agreement with results of the recent BCV trial [11]. In that trial virologic responses were better, if BCV treatment was initiated at low VL and was associated with improved survival [11]. Our patients had high VL at BCV initiation despite which, 3 of 4 patients achieved virologic responses. One patient discontinued BCV due to gastrointestinal symptoms. Gastrointestinal toxicity is a known side effect of BCV [10]. Management of gastrointestinal toxicity due to BCV like case B is particularly challenging in patients with ADV in the gastrointestinal tract as symptoms may be related to ADV enteritis/colitis and/or BCV. Case B had diarrhea prior to BCV initiation and had persistent diarrhea while on BCV which led a clinician to stop BCV. An intravenous formulation of BCV is currently in development and may alleviate concerns for gastrointestinal toxicity. In conclusion, our small case series show rapid virologic responses after short courses of oral BCV in 3 of 4 pediatric patients with d-ADV. Repeated short courses of BCV were effective in a patient with recurrent ADV viremia. Our data supports the study design of short-course oral BCV treatment in pediatric HCT recipients with ADV infection. ACKNOWLEDGEMENT This research was funded in part through the NIH/NCI Cancer Center Support Grant P30 CA008748. Conflict of Interest: GAP has been an investigator for Shire, Merck, Chimerix and Astellas and has received consulting fees from Shire, Merck, Chimerix and Astellas. Author Contributions: Conceptualization: GAP, YJL. Data curation: SYC, SEP, FB, GAP, YJL, YJL. Writing - original draft: SEP, FB, GAP, YJL.	ALEMTUZUMAB, PREDNISOLONE	DrugsGivenReaction	CC BY-NC	32869551	19,446,308	2021-09
What was the dosage of drug 'ALEMTUZUMAB'?	Rapid Virologic Response to Brincidofovir in Children with Disseminated Adenovirus Infection. Disseminated adenovirus infections (d-ADV) after hematopoietic cell transplant (HCT) are often fatal with limited treatment options. Brincidofovir (BCV) a lipid ester of cidofovir is developed for this indication. We report four pediatric HCT recipients with d-ADV treated successfully with BCV. pmcIntroduction Adenovirus (ADV) infections may occur in up to 40% of pediatric HCT recipients [1]. T-cell depletion (TCD) (ex vivo CD34+ or serotherapy with antithymocyte globulin or alemtuzumab), or severe graft-versus-host disease (GVHD) are associated with ADV infection post-HCT [2]. Recovery of ADV specific T-lymphocytes (ADV-CTLs) confers protection against ADV [3], whereas lymphopenia is a risk factor for disseminated ADV infection (d-ADV) [4]. Ex vivo by CD34+ selection (Miltenyi Biotec, Gladbach, Germany) achieves a 5-log depletion of T-lymphocytes in the allograft [5]. D-ADV infections after TCD HCT are often fatal with mortality rates ranging from 50 - 100% [678]. There is currently no approved treatment for ADV. Intravenous cidofovir (CDV) is commonly used; however its utility is limited by associated nephrotoxicity [9]. Adoptive transfer of ADV-CTLs has shown efficacy in single center studies [2]. Brincidofovir (BCV) is a lipid-linked derivative of CDV with high potency against all clinically significant ADV subtypes and no evidence of renal or hematological toxicity to date [1011]. In lymphocyte-depleted pediatric HCT recipients with ADV infections, treatment with BCV resulted in faster and greater virologic responses to BCV compared with CDV [12]. BCV has been associated with gastrointestinal toxicity with typical onset after 4 - 6 doses of BCV [11]. Children may tolerate BCV better than adults possibly due to a more rapid turnover of gastrointestinal mucosa compared with adults [10]. We describe 4 pediatric TCD HCT recipients with d-ADV infection treated successfully with oral BCV 2 mg/kg twice per week under Emergency Investigational New Drug from 9/2015 and 5/2016. The study was reviewed and approved by the Memorial Sloan Kettering Cancer Center Institutional Review and Privavy Board and granted a waiver of authorization (IRB #16-844). Table 1 shows the clinical and virologic characteristics. Virologic responses to BCV are shown in Figure 1A-1D. Table 1 Characteristics and outcome of disseminated adenovirus cases Case Age/sex Dx Transplant type, donor Post-transplant complications before onset of ADV viremia, immunosuppressant First ADV viremiaa, days post-HCT (D) Max ADV viremia, D Sites of ADV ADV disease, D ADV viremia at first CDV Tx ADV viremia at first BCV Tx BCV initiation, D Anti-viral Tx Time to virologic clearance from BCV, days ALC / CD4+ (cell/mcL) at BCV Tx Outcome A 19m/F SCID 1st HCT: BMT, haplo mother (graft failure) Autoimmune Hemolytic Anemia, Rituximab, Prednisolone 2.1 × 105, D+192 2.1 × 105, D+192 Blood, Stool, Urine Probable Enterocolitis, D+207 4.3 × 104 <190 D+193 CDV IV 5 mg/kg × 5 doses 3 ALC 400 CD4+ 30 Alive 2nd HCT: CD34+ TCD PBSCT, MUD BCV PO 2 mg/kg TIW × 17 doses B 4y/M ALL CD34+ TCD PBSCT, 9/10 MUD 469, D+10 4.7 × 106, D+69 Blood, Stool, Liver, RESP, Pleural Fluid Definite Pneumonitis, D+84; Definite Hepatitis, D+88 5.8 × 104 3.3 × 105 D+25 CDV IV 5 mg/kg × 14 doses N/A ALC 400 CD4+ 0 Alive BCV PO 2 mg/kg TIW × 5 doses DLI, ADV CTLs C 3y/M Familial HLH CD34+ TCD PBSCT, Haplo mother Skin Grade 3 GVHD and GI Grade 1 GVHD, Mesenchymal stem cell infusion, Alemtuzumab, CNI and Prednisolone 9.8 × 105, D+841 6.7 × 106, D+1026 Blood, Stool, RESP Possible Enterocolitis, D+870 N/A 4.1 × 105 D+848 BCV PO 2 mg/kg TIW × 29 doses 1st course: 14 1st course: ALC 100 CD4+ 0 Death, D+1088, MSOF 2nd course: 20 2nd course: ALC 100 CD4+ 0 D 3y/F ALL 1st HCT: CD34+ TCD PBSCT, MUD Acute Rejection of first allo-graft 2 × 103, D+38 (From 2nd HCT) 1.9 × 107, D+42 (From 2nd HCT) Blood, Stool, Liver Possible Enterocolitis, D+65 (From 2nd HCT) 2.8 × 105 1.6 × 107 D+57 (From 2nd HCT) CDV IV 5 mg/kg × 2 doses 34 ALC 300 CD4+ 19 Death, D+539 (From 2nd HCT), relapse of primary disease 2nd HCT: CD34+ TCD PBSCT, MUD 2nd HCT: Alemtuzumab 1 mg/kg divided in 5 doses after 2nd HCT BCV PO 2 mg/kg TIW × 26 doses aADV PCR in blood was performed by Viraco Eurofins (Lee's Summit, MO, USA). Values are copies/ml. m, months-old; F, female; y, years-old; M, male; Dx, diagnosis; SCID, severe combined immune deficiency; ALL, acute lymphoblastic leukemia; HLH, hemophagocytic lymphohistiocytosis; HCT, hematopoietic cell transplant; BMT, bone marrow transplant; Haplo, Haploidentical; TCD, T Cell-depleted; PBSCT, peripheral blood stem cell transplant; MUD, matched unrelated donor; ADV, adenovirus; GVHD, graft-versus-host disease; GI, gastrointestinal; CNI, calcineurin inhibitors; D, day from transplant; max, maximum, RESP, respiratory specimens (bronchoalveolar lavage, nasopharyngeal swab); CDV, cidofovir; Tx, treatment; N/A, not applicable; BCV, brincidofovir; IV, intravenous; PO, orally; TIW, three times per week; DLI, donor lymphocyte infusion; CTLs, cytotoxic T lymphocytes, ALC, absolute lymphocyte counts; MSOF, multisystem organ failure. Figure 1 Plasma adenovirus viral load and treatment in 4 pediatric hematopoietic cell transplant recipients with disseminated adenovirus infection. CD4+ count: cell/mcL. CDV, cidofovir; BCV, brincidofovir; ADV, adenovirus; VL, viral load; DLI, donor lymphocyte infusion; CTL, cytotoxic T-lymphocyte; PCR, polymerase chain reaction. Case report ADV PCR was performed by Viracor-Eurofins (Lee's Summit, MO, USA). The linear range of quantification of ADV PCR in the blood was 100 – 1 × 1010 copies/mL. D-ADV was defined as previously defined [7]. 1. Case A A 19-month-old girl with severe combined immunodeficiency syndrome received a TCD HCT from a matched unrelated donor (MUD). Her post-transplant course was complicated by autoimmune hemolytic anemia treated with prednisolone and 6 doses of rituximab. Six months post-transplant she presented for hypoactivity, irritability and watery diarrhea. On admission, stool ADV PCR was positive and ADV viremia was 2.1 × 105copies/ml. She was treated with CDV and intravenous immunoglobulin. After 2 weeks of CDV, colonoscopy was performed. Pathology showed friable colonic mucosa. Viral culture from tissues was positive for ADV. Because of persistent diarrhea after 5 doses of CDV, BCV was started. ADV viremia became undetectable after 2 doses of BCV. BCV was stopped at 8 weeks after BCV initiation. 2. Case B A 4-year-old boy with acute lymphoblastic leukemia (ALL) received a TCD HCT from a MUD. On Day 0, stool ADV PCR was positive and ADV viremia was negative. On Day +10, ADV viremia was 469 copies/ml and on Day +17 ADV viremia rose to 5.8 × 104copies/ml. On Day +25, CDV was started due to persistent fever, diarrhea and rising ADV viremia. After 2 doses of CDV, CDV was switched to BCV due to increased ADV viremia (3.3 × 105copies/ml). On Day +39, BCV was discontinued after 5 doses due to persistent diarrhea. CDV was resumed, however ADV viremia increased to 4.7 × 106copies/ml on Day +69 and transaminitis was noted. Liver biopsy on Day +84 confirmed GVHD with ADV hepatitis (positive ADV stain). Concurrently, he developed respiratory distress and a nasopharyngeal swab was positive for ADV by PCR. On Day +88, thoracentesis was performed due to worsening pleural effusion. Pleural fluid was positive for ADV (1.8 × 105copies/ml). He was treated with donor lymphocyte infusion (DLI) and subsequently with ADV-CTLs with virologic response. 3. Case C A 3-year-old boy with familial hemophagocytic lymphohistiocytosis was admitted with fever, diarrhea and vomiting 2 years post-transplant. He received a TCD HCT from his haploidentical mother. His post-transplant course was complicated by poor graft function, refractory skin and gastrointestinal GVHD, human herpesvirus-6 viremia and chronic renal dysfunction. He received cyclosporine, tacrolimus, steroids and mesenchymal stem cells infusion for GVHD. On admission, cefepime and vancomycin were empirically started. Stool was negative for Clostridioides difficile. Symptoms persisted during admission. On hospital day 21, stool ADV PCR was positive and ADV viremia was 9.8 × 105copies/ml. BCV was initiated. Viral clearance was achieved after 5 doses BCV and BCV was continued for 4 weeks. One week after BCV discontinuation, ADV viremia recrudesced to 1.0 × 107copies/ml. BCV was reinitiated and continued for 10 weeks with good virologic control. Due to persistent diarrhea, colonoscopy was performed and pathology showed persistent gut GVHD. The tissue was positive for ADV by PCR. He received a stem cell boost 2 months after stopping BCV for poor graft function. He subsequently developed relapse of ADV viremia (6.7 × 106copies/ml), thus BCV was resumed and ADV viremia became undectable after 7 doses of BCV. His hospital stay was further complicated by hospital-acquired pneumonia with respiratory failure. Despite resolving ADV viremia, he died due to multi-organ failure. 4. Case D A 3-year-old girl with ALL received a TCD HCT from a MUD complicated by graft rejection and followed by a second TCD HCT from a different MUD one month after the first HCT. Her post-transplant course was complicated by Epstein-Barr virus (EBV) viremia treated with rituximab and cytomegalovirus viremia. On Day +38 post-transplant, she was found to have ADV viremia (2.0 × 103copies/ml). On Day +42, ADV viremia increased to 1.9 × 107copies/ml. On Day +53, she developed watery diarrhea and nausea. Stool ADV PCR was positive. On Day +56, colonoscopy was performed. The tissue was positive for ADV by PCR. On Day +56, ADV viremia was 2.8 × 105copies/ml and CDV was started. After two doses of CDV, ADV viremia was 1.1 × 105copies/ml. She developed worsening hepatic function. Computed tomography of the chest and abdomen on Day +65 showed a necrotic liver lesion and a necrotic lung mass. ADV viremia rose up to 2.3 × 107copies/ml on Day +66 despite CDV. Lung and liver biopsies performed on Day +67 yielded Legionella pneumophila serotype 1 by culture and liver biopsy was positive for EBV and ADV by PCR. ADV viremia was 1.6 × 107 copies/mL on Day +69. On Day +71, levofloxacin was started for Legionella pneumonia and BCV for d-ADV infection. ADV viremia became undectable 34 days after initiation. She received BCV for 80 days as outpatient. Discussion We report 4 pediatric TCD HCT recipients (overall 6 episodes of ADV viremia) with d-ADV treated with BCV. All patients were highly immunosuppressed, with profound lymphopenia and/or very low CD4 counts. Despite high ADV viremia (median 3.7 × 105 copies/mL) at BCV initiation, 3 of 4 patients cleared ADV viremia at a median of 14 days (range, 1 - 34) of BCV treatment. Two patients (cases A and C) were on high dose steroids. Two patients had received prior CDV treatment (case A and C) without response prior to BCV treatment. Three patients tolerated prolonged doses of BCV (range, 17 - 29 doses). Case C had lymphopenia (100 cell/mm3) and CD4+ count was 0 cell/mm3 during ADV infection. Despite a rapid virologic response to BCV, ADV recurred after discontinuation of BCV highlighting the importance of immune recovery for control of ADV infection. Importantly the patient responded rapidly after 2 short subsequent courses of BCV suggesting that repeated episodic treatment with BCV guided by ADV viral load (VL) remains effective even in the setting of persistent lymphopenia. D-ADV infections are associated with substantial morbidity and mortality in HCT recipients [678]. Cases A, C and D with ADV colitis cleared ADV viremia with BCV. Case B did not tolerate BCV. BCV was discontinued after 5 doses concerning for gastrointestinal toxicity. Case B developed ADV hepatitis and ADV pneumonitis while on CDV. Case B responded to DLI and ADV-CTLs. While ADV-CTLs have shown safety and efficacy in small series (reviewed in reference 2), at present several hurdles preclude the broad applicability of this potentially effective therapy [2]. The virologic responses in our cases confirms the virologic activity of BCV even in lymphopenic patients and are in agreement with results of the recent BCV trial [11]. In that trial virologic responses were better, if BCV treatment was initiated at low VL and was associated with improved survival [11]. Our patients had high VL at BCV initiation despite which, 3 of 4 patients achieved virologic responses. One patient discontinued BCV due to gastrointestinal symptoms. Gastrointestinal toxicity is a known side effect of BCV [10]. Management of gastrointestinal toxicity due to BCV like case B is particularly challenging in patients with ADV in the gastrointestinal tract as symptoms may be related to ADV enteritis/colitis and/or BCV. Case B had diarrhea prior to BCV initiation and had persistent diarrhea while on BCV which led a clinician to stop BCV. An intravenous formulation of BCV is currently in development and may alleviate concerns for gastrointestinal toxicity. In conclusion, our small case series show rapid virologic responses after short courses of oral BCV in 3 of 4 pediatric patients with d-ADV. Repeated short courses of BCV were effective in a patient with recurrent ADV viremia. Our data supports the study design of short-course oral BCV treatment in pediatric HCT recipients with ADV infection. ACKNOWLEDGEMENT This research was funded in part through the NIH/NCI Cancer Center Support Grant P30 CA008748. Conflict of Interest: GAP has been an investigator for Shire, Merck, Chimerix and Astellas and has received consulting fees from Shire, Merck, Chimerix and Astellas. Author Contributions: Conceptualization: GAP, YJL. Data curation: SYC, SEP, FB, GAP, YJL, YJL. Writing - original draft: SEP, FB, GAP, YJL.	1 MG/KG	DrugDosageText	CC BY-NC	32869551	19,460,124	2021-09
What was the outcome of reaction 'Lymphopenia'?	Rapid Virologic Response to Brincidofovir in Children with Disseminated Adenovirus Infection. Disseminated adenovirus infections (d-ADV) after hematopoietic cell transplant (HCT) are often fatal with limited treatment options. Brincidofovir (BCV) a lipid ester of cidofovir is developed for this indication. We report four pediatric HCT recipients with d-ADV treated successfully with BCV. pmcIntroduction Adenovirus (ADV) infections may occur in up to 40% of pediatric HCT recipients [1]. T-cell depletion (TCD) (ex vivo CD34+ or serotherapy with antithymocyte globulin or alemtuzumab), or severe graft-versus-host disease (GVHD) are associated with ADV infection post-HCT [2]. Recovery of ADV specific T-lymphocytes (ADV-CTLs) confers protection against ADV [3], whereas lymphopenia is a risk factor for disseminated ADV infection (d-ADV) [4]. Ex vivo by CD34+ selection (Miltenyi Biotec, Gladbach, Germany) achieves a 5-log depletion of T-lymphocytes in the allograft [5]. D-ADV infections after TCD HCT are often fatal with mortality rates ranging from 50 - 100% [678]. There is currently no approved treatment for ADV. Intravenous cidofovir (CDV) is commonly used; however its utility is limited by associated nephrotoxicity [9]. Adoptive transfer of ADV-CTLs has shown efficacy in single center studies [2]. Brincidofovir (BCV) is a lipid-linked derivative of CDV with high potency against all clinically significant ADV subtypes and no evidence of renal or hematological toxicity to date [1011]. In lymphocyte-depleted pediatric HCT recipients with ADV infections, treatment with BCV resulted in faster and greater virologic responses to BCV compared with CDV [12]. BCV has been associated with gastrointestinal toxicity with typical onset after 4 - 6 doses of BCV [11]. Children may tolerate BCV better than adults possibly due to a more rapid turnover of gastrointestinal mucosa compared with adults [10]. We describe 4 pediatric TCD HCT recipients with d-ADV infection treated successfully with oral BCV 2 mg/kg twice per week under Emergency Investigational New Drug from 9/2015 and 5/2016. The study was reviewed and approved by the Memorial Sloan Kettering Cancer Center Institutional Review and Privavy Board and granted a waiver of authorization (IRB #16-844). Table 1 shows the clinical and virologic characteristics. Virologic responses to BCV are shown in Figure 1A-1D. Table 1 Characteristics and outcome of disseminated adenovirus cases Case Age/sex Dx Transplant type, donor Post-transplant complications before onset of ADV viremia, immunosuppressant First ADV viremiaa, days post-HCT (D) Max ADV viremia, D Sites of ADV ADV disease, D ADV viremia at first CDV Tx ADV viremia at first BCV Tx BCV initiation, D Anti-viral Tx Time to virologic clearance from BCV, days ALC / CD4+ (cell/mcL) at BCV Tx Outcome A 19m/F SCID 1st HCT: BMT, haplo mother (graft failure) Autoimmune Hemolytic Anemia, Rituximab, Prednisolone 2.1 × 105, D+192 2.1 × 105, D+192 Blood, Stool, Urine Probable Enterocolitis, D+207 4.3 × 104 <190 D+193 CDV IV 5 mg/kg × 5 doses 3 ALC 400 CD4+ 30 Alive 2nd HCT: CD34+ TCD PBSCT, MUD BCV PO 2 mg/kg TIW × 17 doses B 4y/M ALL CD34+ TCD PBSCT, 9/10 MUD 469, D+10 4.7 × 106, D+69 Blood, Stool, Liver, RESP, Pleural Fluid Definite Pneumonitis, D+84; Definite Hepatitis, D+88 5.8 × 104 3.3 × 105 D+25 CDV IV 5 mg/kg × 14 doses N/A ALC 400 CD4+ 0 Alive BCV PO 2 mg/kg TIW × 5 doses DLI, ADV CTLs C 3y/M Familial HLH CD34+ TCD PBSCT, Haplo mother Skin Grade 3 GVHD and GI Grade 1 GVHD, Mesenchymal stem cell infusion, Alemtuzumab, CNI and Prednisolone 9.8 × 105, D+841 6.7 × 106, D+1026 Blood, Stool, RESP Possible Enterocolitis, D+870 N/A 4.1 × 105 D+848 BCV PO 2 mg/kg TIW × 29 doses 1st course: 14 1st course: ALC 100 CD4+ 0 Death, D+1088, MSOF 2nd course: 20 2nd course: ALC 100 CD4+ 0 D 3y/F ALL 1st HCT: CD34+ TCD PBSCT, MUD Acute Rejection of first allo-graft 2 × 103, D+38 (From 2nd HCT) 1.9 × 107, D+42 (From 2nd HCT) Blood, Stool, Liver Possible Enterocolitis, D+65 (From 2nd HCT) 2.8 × 105 1.6 × 107 D+57 (From 2nd HCT) CDV IV 5 mg/kg × 2 doses 34 ALC 300 CD4+ 19 Death, D+539 (From 2nd HCT), relapse of primary disease 2nd HCT: CD34+ TCD PBSCT, MUD 2nd HCT: Alemtuzumab 1 mg/kg divided in 5 doses after 2nd HCT BCV PO 2 mg/kg TIW × 26 doses aADV PCR in blood was performed by Viraco Eurofins (Lee's Summit, MO, USA). Values are copies/ml. m, months-old; F, female; y, years-old; M, male; Dx, diagnosis; SCID, severe combined immune deficiency; ALL, acute lymphoblastic leukemia; HLH, hemophagocytic lymphohistiocytosis; HCT, hematopoietic cell transplant; BMT, bone marrow transplant; Haplo, Haploidentical; TCD, T Cell-depleted; PBSCT, peripheral blood stem cell transplant; MUD, matched unrelated donor; ADV, adenovirus; GVHD, graft-versus-host disease; GI, gastrointestinal; CNI, calcineurin inhibitors; D, day from transplant; max, maximum, RESP, respiratory specimens (bronchoalveolar lavage, nasopharyngeal swab); CDV, cidofovir; Tx, treatment; N/A, not applicable; BCV, brincidofovir; IV, intravenous; PO, orally; TIW, three times per week; DLI, donor lymphocyte infusion; CTLs, cytotoxic T lymphocytes, ALC, absolute lymphocyte counts; MSOF, multisystem organ failure. Figure 1 Plasma adenovirus viral load and treatment in 4 pediatric hematopoietic cell transplant recipients with disseminated adenovirus infection. CD4+ count: cell/mcL. CDV, cidofovir; BCV, brincidofovir; ADV, adenovirus; VL, viral load; DLI, donor lymphocyte infusion; CTL, cytotoxic T-lymphocyte; PCR, polymerase chain reaction. Case report ADV PCR was performed by Viracor-Eurofins (Lee's Summit, MO, USA). The linear range of quantification of ADV PCR in the blood was 100 – 1 × 1010 copies/mL. D-ADV was defined as previously defined [7]. 1. Case A A 19-month-old girl with severe combined immunodeficiency syndrome received a TCD HCT from a matched unrelated donor (MUD). Her post-transplant course was complicated by autoimmune hemolytic anemia treated with prednisolone and 6 doses of rituximab. Six months post-transplant she presented for hypoactivity, irritability and watery diarrhea. On admission, stool ADV PCR was positive and ADV viremia was 2.1 × 105copies/ml. She was treated with CDV and intravenous immunoglobulin. After 2 weeks of CDV, colonoscopy was performed. Pathology showed friable colonic mucosa. Viral culture from tissues was positive for ADV. Because of persistent diarrhea after 5 doses of CDV, BCV was started. ADV viremia became undetectable after 2 doses of BCV. BCV was stopped at 8 weeks after BCV initiation. 2. Case B A 4-year-old boy with acute lymphoblastic leukemia (ALL) received a TCD HCT from a MUD. On Day 0, stool ADV PCR was positive and ADV viremia was negative. On Day +10, ADV viremia was 469 copies/ml and on Day +17 ADV viremia rose to 5.8 × 104copies/ml. On Day +25, CDV was started due to persistent fever, diarrhea and rising ADV viremia. After 2 doses of CDV, CDV was switched to BCV due to increased ADV viremia (3.3 × 105copies/ml). On Day +39, BCV was discontinued after 5 doses due to persistent diarrhea. CDV was resumed, however ADV viremia increased to 4.7 × 106copies/ml on Day +69 and transaminitis was noted. Liver biopsy on Day +84 confirmed GVHD with ADV hepatitis (positive ADV stain). Concurrently, he developed respiratory distress and a nasopharyngeal swab was positive for ADV by PCR. On Day +88, thoracentesis was performed due to worsening pleural effusion. Pleural fluid was positive for ADV (1.8 × 105copies/ml). He was treated with donor lymphocyte infusion (DLI) and subsequently with ADV-CTLs with virologic response. 3. Case C A 3-year-old boy with familial hemophagocytic lymphohistiocytosis was admitted with fever, diarrhea and vomiting 2 years post-transplant. He received a TCD HCT from his haploidentical mother. His post-transplant course was complicated by poor graft function, refractory skin and gastrointestinal GVHD, human herpesvirus-6 viremia and chronic renal dysfunction. He received cyclosporine, tacrolimus, steroids and mesenchymal stem cells infusion for GVHD. On admission, cefepime and vancomycin were empirically started. Stool was negative for Clostridioides difficile. Symptoms persisted during admission. On hospital day 21, stool ADV PCR was positive and ADV viremia was 9.8 × 105copies/ml. BCV was initiated. Viral clearance was achieved after 5 doses BCV and BCV was continued for 4 weeks. One week after BCV discontinuation, ADV viremia recrudesced to 1.0 × 107copies/ml. BCV was reinitiated and continued for 10 weeks with good virologic control. Due to persistent diarrhea, colonoscopy was performed and pathology showed persistent gut GVHD. The tissue was positive for ADV by PCR. He received a stem cell boost 2 months after stopping BCV for poor graft function. He subsequently developed relapse of ADV viremia (6.7 × 106copies/ml), thus BCV was resumed and ADV viremia became undectable after 7 doses of BCV. His hospital stay was further complicated by hospital-acquired pneumonia with respiratory failure. Despite resolving ADV viremia, he died due to multi-organ failure. 4. Case D A 3-year-old girl with ALL received a TCD HCT from a MUD complicated by graft rejection and followed by a second TCD HCT from a different MUD one month after the first HCT. Her post-transplant course was complicated by Epstein-Barr virus (EBV) viremia treated with rituximab and cytomegalovirus viremia. On Day +38 post-transplant, she was found to have ADV viremia (2.0 × 103copies/ml). On Day +42, ADV viremia increased to 1.9 × 107copies/ml. On Day +53, she developed watery diarrhea and nausea. Stool ADV PCR was positive. On Day +56, colonoscopy was performed. The tissue was positive for ADV by PCR. On Day +56, ADV viremia was 2.8 × 105copies/ml and CDV was started. After two doses of CDV, ADV viremia was 1.1 × 105copies/ml. She developed worsening hepatic function. Computed tomography of the chest and abdomen on Day +65 showed a necrotic liver lesion and a necrotic lung mass. ADV viremia rose up to 2.3 × 107copies/ml on Day +66 despite CDV. Lung and liver biopsies performed on Day +67 yielded Legionella pneumophila serotype 1 by culture and liver biopsy was positive for EBV and ADV by PCR. ADV viremia was 1.6 × 107 copies/mL on Day +69. On Day +71, levofloxacin was started for Legionella pneumonia and BCV for d-ADV infection. ADV viremia became undectable 34 days after initiation. She received BCV for 80 days as outpatient. Discussion We report 4 pediatric TCD HCT recipients (overall 6 episodes of ADV viremia) with d-ADV treated with BCV. All patients were highly immunosuppressed, with profound lymphopenia and/or very low CD4 counts. Despite high ADV viremia (median 3.7 × 105 copies/mL) at BCV initiation, 3 of 4 patients cleared ADV viremia at a median of 14 days (range, 1 - 34) of BCV treatment. Two patients (cases A and C) were on high dose steroids. Two patients had received prior CDV treatment (case A and C) without response prior to BCV treatment. Three patients tolerated prolonged doses of BCV (range, 17 - 29 doses). Case C had lymphopenia (100 cell/mm3) and CD4+ count was 0 cell/mm3 during ADV infection. Despite a rapid virologic response to BCV, ADV recurred after discontinuation of BCV highlighting the importance of immune recovery for control of ADV infection. Importantly the patient responded rapidly after 2 short subsequent courses of BCV suggesting that repeated episodic treatment with BCV guided by ADV viral load (VL) remains effective even in the setting of persistent lymphopenia. D-ADV infections are associated with substantial morbidity and mortality in HCT recipients [678]. Cases A, C and D with ADV colitis cleared ADV viremia with BCV. Case B did not tolerate BCV. BCV was discontinued after 5 doses concerning for gastrointestinal toxicity. Case B developed ADV hepatitis and ADV pneumonitis while on CDV. Case B responded to DLI and ADV-CTLs. While ADV-CTLs have shown safety and efficacy in small series (reviewed in reference 2), at present several hurdles preclude the broad applicability of this potentially effective therapy [2]. The virologic responses in our cases confirms the virologic activity of BCV even in lymphopenic patients and are in agreement with results of the recent BCV trial [11]. In that trial virologic responses were better, if BCV treatment was initiated at low VL and was associated with improved survival [11]. Our patients had high VL at BCV initiation despite which, 3 of 4 patients achieved virologic responses. One patient discontinued BCV due to gastrointestinal symptoms. Gastrointestinal toxicity is a known side effect of BCV [10]. Management of gastrointestinal toxicity due to BCV like case B is particularly challenging in patients with ADV in the gastrointestinal tract as symptoms may be related to ADV enteritis/colitis and/or BCV. Case B had diarrhea prior to BCV initiation and had persistent diarrhea while on BCV which led a clinician to stop BCV. An intravenous formulation of BCV is currently in development and may alleviate concerns for gastrointestinal toxicity. In conclusion, our small case series show rapid virologic responses after short courses of oral BCV in 3 of 4 pediatric patients with d-ADV. Repeated short courses of BCV were effective in a patient with recurrent ADV viremia. Our data supports the study design of short-course oral BCV treatment in pediatric HCT recipients with ADV infection. ACKNOWLEDGEMENT This research was funded in part through the NIH/NCI Cancer Center Support Grant P30 CA008748. Conflict of Interest: GAP has been an investigator for Shire, Merck, Chimerix and Astellas and has received consulting fees from Shire, Merck, Chimerix and Astellas. Author Contributions: Conceptualization: GAP, YJL. Data curation: SYC, SEP, FB, GAP, YJL, YJL. Writing - original draft: SEP, FB, GAP, YJL.	Fatal	ReactionOutcome	CC BY-NC	32869551	19,446,308	2021-09
What was the outcome of reaction 'Multiple organ dysfunction syndrome'?	Rapid Virologic Response to Brincidofovir in Children with Disseminated Adenovirus Infection. Disseminated adenovirus infections (d-ADV) after hematopoietic cell transplant (HCT) are often fatal with limited treatment options. Brincidofovir (BCV) a lipid ester of cidofovir is developed for this indication. We report four pediatric HCT recipients with d-ADV treated successfully with BCV. pmcIntroduction Adenovirus (ADV) infections may occur in up to 40% of pediatric HCT recipients [1]. T-cell depletion (TCD) (ex vivo CD34+ or serotherapy with antithymocyte globulin or alemtuzumab), or severe graft-versus-host disease (GVHD) are associated with ADV infection post-HCT [2]. Recovery of ADV specific T-lymphocytes (ADV-CTLs) confers protection against ADV [3], whereas lymphopenia is a risk factor for disseminated ADV infection (d-ADV) [4]. Ex vivo by CD34+ selection (Miltenyi Biotec, Gladbach, Germany) achieves a 5-log depletion of T-lymphocytes in the allograft [5]. D-ADV infections after TCD HCT are often fatal with mortality rates ranging from 50 - 100% [678]. There is currently no approved treatment for ADV. Intravenous cidofovir (CDV) is commonly used; however its utility is limited by associated nephrotoxicity [9]. Adoptive transfer of ADV-CTLs has shown efficacy in single center studies [2]. Brincidofovir (BCV) is a lipid-linked derivative of CDV with high potency against all clinically significant ADV subtypes and no evidence of renal or hematological toxicity to date [1011]. In lymphocyte-depleted pediatric HCT recipients with ADV infections, treatment with BCV resulted in faster and greater virologic responses to BCV compared with CDV [12]. BCV has been associated with gastrointestinal toxicity with typical onset after 4 - 6 doses of BCV [11]. Children may tolerate BCV better than adults possibly due to a more rapid turnover of gastrointestinal mucosa compared with adults [10]. We describe 4 pediatric TCD HCT recipients with d-ADV infection treated successfully with oral BCV 2 mg/kg twice per week under Emergency Investigational New Drug from 9/2015 and 5/2016. The study was reviewed and approved by the Memorial Sloan Kettering Cancer Center Institutional Review and Privavy Board and granted a waiver of authorization (IRB #16-844). Table 1 shows the clinical and virologic characteristics. Virologic responses to BCV are shown in Figure 1A-1D. Table 1 Characteristics and outcome of disseminated adenovirus cases Case Age/sex Dx Transplant type, donor Post-transplant complications before onset of ADV viremia, immunosuppressant First ADV viremiaa, days post-HCT (D) Max ADV viremia, D Sites of ADV ADV disease, D ADV viremia at first CDV Tx ADV viremia at first BCV Tx BCV initiation, D Anti-viral Tx Time to virologic clearance from BCV, days ALC / CD4+ (cell/mcL) at BCV Tx Outcome A 19m/F SCID 1st HCT: BMT, haplo mother (graft failure) Autoimmune Hemolytic Anemia, Rituximab, Prednisolone 2.1 × 105, D+192 2.1 × 105, D+192 Blood, Stool, Urine Probable Enterocolitis, D+207 4.3 × 104 <190 D+193 CDV IV 5 mg/kg × 5 doses 3 ALC 400 CD4+ 30 Alive 2nd HCT: CD34+ TCD PBSCT, MUD BCV PO 2 mg/kg TIW × 17 doses B 4y/M ALL CD34+ TCD PBSCT, 9/10 MUD 469, D+10 4.7 × 106, D+69 Blood, Stool, Liver, RESP, Pleural Fluid Definite Pneumonitis, D+84; Definite Hepatitis, D+88 5.8 × 104 3.3 × 105 D+25 CDV IV 5 mg/kg × 14 doses N/A ALC 400 CD4+ 0 Alive BCV PO 2 mg/kg TIW × 5 doses DLI, ADV CTLs C 3y/M Familial HLH CD34+ TCD PBSCT, Haplo mother Skin Grade 3 GVHD and GI Grade 1 GVHD, Mesenchymal stem cell infusion, Alemtuzumab, CNI and Prednisolone 9.8 × 105, D+841 6.7 × 106, D+1026 Blood, Stool, RESP Possible Enterocolitis, D+870 N/A 4.1 × 105 D+848 BCV PO 2 mg/kg TIW × 29 doses 1st course: 14 1st course: ALC 100 CD4+ 0 Death, D+1088, MSOF 2nd course: 20 2nd course: ALC 100 CD4+ 0 D 3y/F ALL 1st HCT: CD34+ TCD PBSCT, MUD Acute Rejection of first allo-graft 2 × 103, D+38 (From 2nd HCT) 1.9 × 107, D+42 (From 2nd HCT) Blood, Stool, Liver Possible Enterocolitis, D+65 (From 2nd HCT) 2.8 × 105 1.6 × 107 D+57 (From 2nd HCT) CDV IV 5 mg/kg × 2 doses 34 ALC 300 CD4+ 19 Death, D+539 (From 2nd HCT), relapse of primary disease 2nd HCT: CD34+ TCD PBSCT, MUD 2nd HCT: Alemtuzumab 1 mg/kg divided in 5 doses after 2nd HCT BCV PO 2 mg/kg TIW × 26 doses aADV PCR in blood was performed by Viraco Eurofins (Lee's Summit, MO, USA). Values are copies/ml. m, months-old; F, female; y, years-old; M, male; Dx, diagnosis; SCID, severe combined immune deficiency; ALL, acute lymphoblastic leukemia; HLH, hemophagocytic lymphohistiocytosis; HCT, hematopoietic cell transplant; BMT, bone marrow transplant; Haplo, Haploidentical; TCD, T Cell-depleted; PBSCT, peripheral blood stem cell transplant; MUD, matched unrelated donor; ADV, adenovirus; GVHD, graft-versus-host disease; GI, gastrointestinal; CNI, calcineurin inhibitors; D, day from transplant; max, maximum, RESP, respiratory specimens (bronchoalveolar lavage, nasopharyngeal swab); CDV, cidofovir; Tx, treatment; N/A, not applicable; BCV, brincidofovir; IV, intravenous; PO, orally; TIW, three times per week; DLI, donor lymphocyte infusion; CTLs, cytotoxic T lymphocytes, ALC, absolute lymphocyte counts; MSOF, multisystem organ failure. Figure 1 Plasma adenovirus viral load and treatment in 4 pediatric hematopoietic cell transplant recipients with disseminated adenovirus infection. CD4+ count: cell/mcL. CDV, cidofovir; BCV, brincidofovir; ADV, adenovirus; VL, viral load; DLI, donor lymphocyte infusion; CTL, cytotoxic T-lymphocyte; PCR, polymerase chain reaction. Case report ADV PCR was performed by Viracor-Eurofins (Lee's Summit, MO, USA). The linear range of quantification of ADV PCR in the blood was 100 – 1 × 1010 copies/mL. D-ADV was defined as previously defined [7]. 1. Case A A 19-month-old girl with severe combined immunodeficiency syndrome received a TCD HCT from a matched unrelated donor (MUD). Her post-transplant course was complicated by autoimmune hemolytic anemia treated with prednisolone and 6 doses of rituximab. Six months post-transplant she presented for hypoactivity, irritability and watery diarrhea. On admission, stool ADV PCR was positive and ADV viremia was 2.1 × 105copies/ml. She was treated with CDV and intravenous immunoglobulin. After 2 weeks of CDV, colonoscopy was performed. Pathology showed friable colonic mucosa. Viral culture from tissues was positive for ADV. Because of persistent diarrhea after 5 doses of CDV, BCV was started. ADV viremia became undetectable after 2 doses of BCV. BCV was stopped at 8 weeks after BCV initiation. 2. Case B A 4-year-old boy with acute lymphoblastic leukemia (ALL) received a TCD HCT from a MUD. On Day 0, stool ADV PCR was positive and ADV viremia was negative. On Day +10, ADV viremia was 469 copies/ml and on Day +17 ADV viremia rose to 5.8 × 104copies/ml. On Day +25, CDV was started due to persistent fever, diarrhea and rising ADV viremia. After 2 doses of CDV, CDV was switched to BCV due to increased ADV viremia (3.3 × 105copies/ml). On Day +39, BCV was discontinued after 5 doses due to persistent diarrhea. CDV was resumed, however ADV viremia increased to 4.7 × 106copies/ml on Day +69 and transaminitis was noted. Liver biopsy on Day +84 confirmed GVHD with ADV hepatitis (positive ADV stain). Concurrently, he developed respiratory distress and a nasopharyngeal swab was positive for ADV by PCR. On Day +88, thoracentesis was performed due to worsening pleural effusion. Pleural fluid was positive for ADV (1.8 × 105copies/ml). He was treated with donor lymphocyte infusion (DLI) and subsequently with ADV-CTLs with virologic response. 3. Case C A 3-year-old boy with familial hemophagocytic lymphohistiocytosis was admitted with fever, diarrhea and vomiting 2 years post-transplant. He received a TCD HCT from his haploidentical mother. His post-transplant course was complicated by poor graft function, refractory skin and gastrointestinal GVHD, human herpesvirus-6 viremia and chronic renal dysfunction. He received cyclosporine, tacrolimus, steroids and mesenchymal stem cells infusion for GVHD. On admission, cefepime and vancomycin were empirically started. Stool was negative for Clostridioides difficile. Symptoms persisted during admission. On hospital day 21, stool ADV PCR was positive and ADV viremia was 9.8 × 105copies/ml. BCV was initiated. Viral clearance was achieved after 5 doses BCV and BCV was continued for 4 weeks. One week after BCV discontinuation, ADV viremia recrudesced to 1.0 × 107copies/ml. BCV was reinitiated and continued for 10 weeks with good virologic control. Due to persistent diarrhea, colonoscopy was performed and pathology showed persistent gut GVHD. The tissue was positive for ADV by PCR. He received a stem cell boost 2 months after stopping BCV for poor graft function. He subsequently developed relapse of ADV viremia (6.7 × 106copies/ml), thus BCV was resumed and ADV viremia became undectable after 7 doses of BCV. His hospital stay was further complicated by hospital-acquired pneumonia with respiratory failure. Despite resolving ADV viremia, he died due to multi-organ failure. 4. Case D A 3-year-old girl with ALL received a TCD HCT from a MUD complicated by graft rejection and followed by a second TCD HCT from a different MUD one month after the first HCT. Her post-transplant course was complicated by Epstein-Barr virus (EBV) viremia treated with rituximab and cytomegalovirus viremia. On Day +38 post-transplant, she was found to have ADV viremia (2.0 × 103copies/ml). On Day +42, ADV viremia increased to 1.9 × 107copies/ml. On Day +53, she developed watery diarrhea and nausea. Stool ADV PCR was positive. On Day +56, colonoscopy was performed. The tissue was positive for ADV by PCR. On Day +56, ADV viremia was 2.8 × 105copies/ml and CDV was started. After two doses of CDV, ADV viremia was 1.1 × 105copies/ml. She developed worsening hepatic function. Computed tomography of the chest and abdomen on Day +65 showed a necrotic liver lesion and a necrotic lung mass. ADV viremia rose up to 2.3 × 107copies/ml on Day +66 despite CDV. Lung and liver biopsies performed on Day +67 yielded Legionella pneumophila serotype 1 by culture and liver biopsy was positive for EBV and ADV by PCR. ADV viremia was 1.6 × 107 copies/mL on Day +69. On Day +71, levofloxacin was started for Legionella pneumonia and BCV for d-ADV infection. ADV viremia became undectable 34 days after initiation. She received BCV for 80 days as outpatient. Discussion We report 4 pediatric TCD HCT recipients (overall 6 episodes of ADV viremia) with d-ADV treated with BCV. All patients were highly immunosuppressed, with profound lymphopenia and/or very low CD4 counts. Despite high ADV viremia (median 3.7 × 105 copies/mL) at BCV initiation, 3 of 4 patients cleared ADV viremia at a median of 14 days (range, 1 - 34) of BCV treatment. Two patients (cases A and C) were on high dose steroids. Two patients had received prior CDV treatment (case A and C) without response prior to BCV treatment. Three patients tolerated prolonged doses of BCV (range, 17 - 29 doses). Case C had lymphopenia (100 cell/mm3) and CD4+ count was 0 cell/mm3 during ADV infection. Despite a rapid virologic response to BCV, ADV recurred after discontinuation of BCV highlighting the importance of immune recovery for control of ADV infection. Importantly the patient responded rapidly after 2 short subsequent courses of BCV suggesting that repeated episodic treatment with BCV guided by ADV viral load (VL) remains effective even in the setting of persistent lymphopenia. D-ADV infections are associated with substantial morbidity and mortality in HCT recipients [678]. Cases A, C and D with ADV colitis cleared ADV viremia with BCV. Case B did not tolerate BCV. BCV was discontinued after 5 doses concerning for gastrointestinal toxicity. Case B developed ADV hepatitis and ADV pneumonitis while on CDV. Case B responded to DLI and ADV-CTLs. While ADV-CTLs have shown safety and efficacy in small series (reviewed in reference 2), at present several hurdles preclude the broad applicability of this potentially effective therapy [2]. The virologic responses in our cases confirms the virologic activity of BCV even in lymphopenic patients and are in agreement with results of the recent BCV trial [11]. In that trial virologic responses were better, if BCV treatment was initiated at low VL and was associated with improved survival [11]. Our patients had high VL at BCV initiation despite which, 3 of 4 patients achieved virologic responses. One patient discontinued BCV due to gastrointestinal symptoms. Gastrointestinal toxicity is a known side effect of BCV [10]. Management of gastrointestinal toxicity due to BCV like case B is particularly challenging in patients with ADV in the gastrointestinal tract as symptoms may be related to ADV enteritis/colitis and/or BCV. Case B had diarrhea prior to BCV initiation and had persistent diarrhea while on BCV which led a clinician to stop BCV. An intravenous formulation of BCV is currently in development and may alleviate concerns for gastrointestinal toxicity. In conclusion, our small case series show rapid virologic responses after short courses of oral BCV in 3 of 4 pediatric patients with d-ADV. Repeated short courses of BCV were effective in a patient with recurrent ADV viremia. Our data supports the study design of short-course oral BCV treatment in pediatric HCT recipients with ADV infection. ACKNOWLEDGEMENT This research was funded in part through the NIH/NCI Cancer Center Support Grant P30 CA008748. Conflict of Interest: GAP has been an investigator for Shire, Merck, Chimerix and Astellas and has received consulting fees from Shire, Merck, Chimerix and Astellas. Author Contributions: Conceptualization: GAP, YJL. Data curation: SYC, SEP, FB, GAP, YJL, YJL. Writing - original draft: SEP, FB, GAP, YJL.	Fatal	ReactionOutcome	CC BY-NC	32869551	19,446,308	2021-09
What was the outcome of reaction 'Nausea'?	Rapid Virologic Response to Brincidofovir in Children with Disseminated Adenovirus Infection. Disseminated adenovirus infections (d-ADV) after hematopoietic cell transplant (HCT) are often fatal with limited treatment options. Brincidofovir (BCV) a lipid ester of cidofovir is developed for this indication. We report four pediatric HCT recipients with d-ADV treated successfully with BCV. pmcIntroduction Adenovirus (ADV) infections may occur in up to 40% of pediatric HCT recipients [1]. T-cell depletion (TCD) (ex vivo CD34+ or serotherapy with antithymocyte globulin or alemtuzumab), or severe graft-versus-host disease (GVHD) are associated with ADV infection post-HCT [2]. Recovery of ADV specific T-lymphocytes (ADV-CTLs) confers protection against ADV [3], whereas lymphopenia is a risk factor for disseminated ADV infection (d-ADV) [4]. Ex vivo by CD34+ selection (Miltenyi Biotec, Gladbach, Germany) achieves a 5-log depletion of T-lymphocytes in the allograft [5]. D-ADV infections after TCD HCT are often fatal with mortality rates ranging from 50 - 100% [678]. There is currently no approved treatment for ADV. Intravenous cidofovir (CDV) is commonly used; however its utility is limited by associated nephrotoxicity [9]. Adoptive transfer of ADV-CTLs has shown efficacy in single center studies [2]. Brincidofovir (BCV) is a lipid-linked derivative of CDV with high potency against all clinically significant ADV subtypes and no evidence of renal or hematological toxicity to date [1011]. In lymphocyte-depleted pediatric HCT recipients with ADV infections, treatment with BCV resulted in faster and greater virologic responses to BCV compared with CDV [12]. BCV has been associated with gastrointestinal toxicity with typical onset after 4 - 6 doses of BCV [11]. Children may tolerate BCV better than adults possibly due to a more rapid turnover of gastrointestinal mucosa compared with adults [10]. We describe 4 pediatric TCD HCT recipients with d-ADV infection treated successfully with oral BCV 2 mg/kg twice per week under Emergency Investigational New Drug from 9/2015 and 5/2016. The study was reviewed and approved by the Memorial Sloan Kettering Cancer Center Institutional Review and Privavy Board and granted a waiver of authorization (IRB #16-844). Table 1 shows the clinical and virologic characteristics. Virologic responses to BCV are shown in Figure 1A-1D. Table 1 Characteristics and outcome of disseminated adenovirus cases Case Age/sex Dx Transplant type, donor Post-transplant complications before onset of ADV viremia, immunosuppressant First ADV viremiaa, days post-HCT (D) Max ADV viremia, D Sites of ADV ADV disease, D ADV viremia at first CDV Tx ADV viremia at first BCV Tx BCV initiation, D Anti-viral Tx Time to virologic clearance from BCV, days ALC / CD4+ (cell/mcL) at BCV Tx Outcome A 19m/F SCID 1st HCT: BMT, haplo mother (graft failure) Autoimmune Hemolytic Anemia, Rituximab, Prednisolone 2.1 × 105, D+192 2.1 × 105, D+192 Blood, Stool, Urine Probable Enterocolitis, D+207 4.3 × 104 <190 D+193 CDV IV 5 mg/kg × 5 doses 3 ALC 400 CD4+ 30 Alive 2nd HCT: CD34+ TCD PBSCT, MUD BCV PO 2 mg/kg TIW × 17 doses B 4y/M ALL CD34+ TCD PBSCT, 9/10 MUD 469, D+10 4.7 × 106, D+69 Blood, Stool, Liver, RESP, Pleural Fluid Definite Pneumonitis, D+84; Definite Hepatitis, D+88 5.8 × 104 3.3 × 105 D+25 CDV IV 5 mg/kg × 14 doses N/A ALC 400 CD4+ 0 Alive BCV PO 2 mg/kg TIW × 5 doses DLI, ADV CTLs C 3y/M Familial HLH CD34+ TCD PBSCT, Haplo mother Skin Grade 3 GVHD and GI Grade 1 GVHD, Mesenchymal stem cell infusion, Alemtuzumab, CNI and Prednisolone 9.8 × 105, D+841 6.7 × 106, D+1026 Blood, Stool, RESP Possible Enterocolitis, D+870 N/A 4.1 × 105 D+848 BCV PO 2 mg/kg TIW × 29 doses 1st course: 14 1st course: ALC 100 CD4+ 0 Death, D+1088, MSOF 2nd course: 20 2nd course: ALC 100 CD4+ 0 D 3y/F ALL 1st HCT: CD34+ TCD PBSCT, MUD Acute Rejection of first allo-graft 2 × 103, D+38 (From 2nd HCT) 1.9 × 107, D+42 (From 2nd HCT) Blood, Stool, Liver Possible Enterocolitis, D+65 (From 2nd HCT) 2.8 × 105 1.6 × 107 D+57 (From 2nd HCT) CDV IV 5 mg/kg × 2 doses 34 ALC 300 CD4+ 19 Death, D+539 (From 2nd HCT), relapse of primary disease 2nd HCT: CD34+ TCD PBSCT, MUD 2nd HCT: Alemtuzumab 1 mg/kg divided in 5 doses after 2nd HCT BCV PO 2 mg/kg TIW × 26 doses aADV PCR in blood was performed by Viraco Eurofins (Lee's Summit, MO, USA). Values are copies/ml. m, months-old; F, female; y, years-old; M, male; Dx, diagnosis; SCID, severe combined immune deficiency; ALL, acute lymphoblastic leukemia; HLH, hemophagocytic lymphohistiocytosis; HCT, hematopoietic cell transplant; BMT, bone marrow transplant; Haplo, Haploidentical; TCD, T Cell-depleted; PBSCT, peripheral blood stem cell transplant; MUD, matched unrelated donor; ADV, adenovirus; GVHD, graft-versus-host disease; GI, gastrointestinal; CNI, calcineurin inhibitors; D, day from transplant; max, maximum, RESP, respiratory specimens (bronchoalveolar lavage, nasopharyngeal swab); CDV, cidofovir; Tx, treatment; N/A, not applicable; BCV, brincidofovir; IV, intravenous; PO, orally; TIW, three times per week; DLI, donor lymphocyte infusion; CTLs, cytotoxic T lymphocytes, ALC, absolute lymphocyte counts; MSOF, multisystem organ failure. Figure 1 Plasma adenovirus viral load and treatment in 4 pediatric hematopoietic cell transplant recipients with disseminated adenovirus infection. CD4+ count: cell/mcL. CDV, cidofovir; BCV, brincidofovir; ADV, adenovirus; VL, viral load; DLI, donor lymphocyte infusion; CTL, cytotoxic T-lymphocyte; PCR, polymerase chain reaction. Case report ADV PCR was performed by Viracor-Eurofins (Lee's Summit, MO, USA). The linear range of quantification of ADV PCR in the blood was 100 – 1 × 1010 copies/mL. D-ADV was defined as previously defined [7]. 1. Case A A 19-month-old girl with severe combined immunodeficiency syndrome received a TCD HCT from a matched unrelated donor (MUD). Her post-transplant course was complicated by autoimmune hemolytic anemia treated with prednisolone and 6 doses of rituximab. Six months post-transplant she presented for hypoactivity, irritability and watery diarrhea. On admission, stool ADV PCR was positive and ADV viremia was 2.1 × 105copies/ml. She was treated with CDV and intravenous immunoglobulin. After 2 weeks of CDV, colonoscopy was performed. Pathology showed friable colonic mucosa. Viral culture from tissues was positive for ADV. Because of persistent diarrhea after 5 doses of CDV, BCV was started. ADV viremia became undetectable after 2 doses of BCV. BCV was stopped at 8 weeks after BCV initiation. 2. Case B A 4-year-old boy with acute lymphoblastic leukemia (ALL) received a TCD HCT from a MUD. On Day 0, stool ADV PCR was positive and ADV viremia was negative. On Day +10, ADV viremia was 469 copies/ml and on Day +17 ADV viremia rose to 5.8 × 104copies/ml. On Day +25, CDV was started due to persistent fever, diarrhea and rising ADV viremia. After 2 doses of CDV, CDV was switched to BCV due to increased ADV viremia (3.3 × 105copies/ml). On Day +39, BCV was discontinued after 5 doses due to persistent diarrhea. CDV was resumed, however ADV viremia increased to 4.7 × 106copies/ml on Day +69 and transaminitis was noted. Liver biopsy on Day +84 confirmed GVHD with ADV hepatitis (positive ADV stain). Concurrently, he developed respiratory distress and a nasopharyngeal swab was positive for ADV by PCR. On Day +88, thoracentesis was performed due to worsening pleural effusion. Pleural fluid was positive for ADV (1.8 × 105copies/ml). He was treated with donor lymphocyte infusion (DLI) and subsequently with ADV-CTLs with virologic response. 3. Case C A 3-year-old boy with familial hemophagocytic lymphohistiocytosis was admitted with fever, diarrhea and vomiting 2 years post-transplant. He received a TCD HCT from his haploidentical mother. His post-transplant course was complicated by poor graft function, refractory skin and gastrointestinal GVHD, human herpesvirus-6 viremia and chronic renal dysfunction. He received cyclosporine, tacrolimus, steroids and mesenchymal stem cells infusion for GVHD. On admission, cefepime and vancomycin were empirically started. Stool was negative for Clostridioides difficile. Symptoms persisted during admission. On hospital day 21, stool ADV PCR was positive and ADV viremia was 9.8 × 105copies/ml. BCV was initiated. Viral clearance was achieved after 5 doses BCV and BCV was continued for 4 weeks. One week after BCV discontinuation, ADV viremia recrudesced to 1.0 × 107copies/ml. BCV was reinitiated and continued for 10 weeks with good virologic control. Due to persistent diarrhea, colonoscopy was performed and pathology showed persistent gut GVHD. The tissue was positive for ADV by PCR. He received a stem cell boost 2 months after stopping BCV for poor graft function. He subsequently developed relapse of ADV viremia (6.7 × 106copies/ml), thus BCV was resumed and ADV viremia became undectable after 7 doses of BCV. His hospital stay was further complicated by hospital-acquired pneumonia with respiratory failure. Despite resolving ADV viremia, he died due to multi-organ failure. 4. Case D A 3-year-old girl with ALL received a TCD HCT from a MUD complicated by graft rejection and followed by a second TCD HCT from a different MUD one month after the first HCT. Her post-transplant course was complicated by Epstein-Barr virus (EBV) viremia treated with rituximab and cytomegalovirus viremia. On Day +38 post-transplant, she was found to have ADV viremia (2.0 × 103copies/ml). On Day +42, ADV viremia increased to 1.9 × 107copies/ml. On Day +53, she developed watery diarrhea and nausea. Stool ADV PCR was positive. On Day +56, colonoscopy was performed. The tissue was positive for ADV by PCR. On Day +56, ADV viremia was 2.8 × 105copies/ml and CDV was started. After two doses of CDV, ADV viremia was 1.1 × 105copies/ml. She developed worsening hepatic function. Computed tomography of the chest and abdomen on Day +65 showed a necrotic liver lesion and a necrotic lung mass. ADV viremia rose up to 2.3 × 107copies/ml on Day +66 despite CDV. Lung and liver biopsies performed on Day +67 yielded Legionella pneumophila serotype 1 by culture and liver biopsy was positive for EBV and ADV by PCR. ADV viremia was 1.6 × 107 copies/mL on Day +69. On Day +71, levofloxacin was started for Legionella pneumonia and BCV for d-ADV infection. ADV viremia became undectable 34 days after initiation. She received BCV for 80 days as outpatient. Discussion We report 4 pediatric TCD HCT recipients (overall 6 episodes of ADV viremia) with d-ADV treated with BCV. All patients were highly immunosuppressed, with profound lymphopenia and/or very low CD4 counts. Despite high ADV viremia (median 3.7 × 105 copies/mL) at BCV initiation, 3 of 4 patients cleared ADV viremia at a median of 14 days (range, 1 - 34) of BCV treatment. Two patients (cases A and C) were on high dose steroids. Two patients had received prior CDV treatment (case A and C) without response prior to BCV treatment. Three patients tolerated prolonged doses of BCV (range, 17 - 29 doses). Case C had lymphopenia (100 cell/mm3) and CD4+ count was 0 cell/mm3 during ADV infection. Despite a rapid virologic response to BCV, ADV recurred after discontinuation of BCV highlighting the importance of immune recovery for control of ADV infection. Importantly the patient responded rapidly after 2 short subsequent courses of BCV suggesting that repeated episodic treatment with BCV guided by ADV viral load (VL) remains effective even in the setting of persistent lymphopenia. D-ADV infections are associated with substantial morbidity and mortality in HCT recipients [678]. Cases A, C and D with ADV colitis cleared ADV viremia with BCV. Case B did not tolerate BCV. BCV was discontinued after 5 doses concerning for gastrointestinal toxicity. Case B developed ADV hepatitis and ADV pneumonitis while on CDV. Case B responded to DLI and ADV-CTLs. While ADV-CTLs have shown safety and efficacy in small series (reviewed in reference 2), at present several hurdles preclude the broad applicability of this potentially effective therapy [2]. The virologic responses in our cases confirms the virologic activity of BCV even in lymphopenic patients and are in agreement with results of the recent BCV trial [11]. In that trial virologic responses were better, if BCV treatment was initiated at low VL and was associated with improved survival [11]. Our patients had high VL at BCV initiation despite which, 3 of 4 patients achieved virologic responses. One patient discontinued BCV due to gastrointestinal symptoms. Gastrointestinal toxicity is a known side effect of BCV [10]. Management of gastrointestinal toxicity due to BCV like case B is particularly challenging in patients with ADV in the gastrointestinal tract as symptoms may be related to ADV enteritis/colitis and/or BCV. Case B had diarrhea prior to BCV initiation and had persistent diarrhea while on BCV which led a clinician to stop BCV. An intravenous formulation of BCV is currently in development and may alleviate concerns for gastrointestinal toxicity. In conclusion, our small case series show rapid virologic responses after short courses of oral BCV in 3 of 4 pediatric patients with d-ADV. Repeated short courses of BCV were effective in a patient with recurrent ADV viremia. Our data supports the study design of short-course oral BCV treatment in pediatric HCT recipients with ADV infection. ACKNOWLEDGEMENT This research was funded in part through the NIH/NCI Cancer Center Support Grant P30 CA008748. Conflict of Interest: GAP has been an investigator for Shire, Merck, Chimerix and Astellas and has received consulting fees from Shire, Merck, Chimerix and Astellas. Author Contributions: Conceptualization: GAP, YJL. Data curation: SYC, SEP, FB, GAP, YJL, YJL. Writing - original draft: SEP, FB, GAP, YJL.	Recovered	ReactionOutcome	CC BY-NC	32869551	19,460,124	2021-09
What was the outcome of reaction 'Pyrexia'?	Rapid Virologic Response to Brincidofovir in Children with Disseminated Adenovirus Infection. Disseminated adenovirus infections (d-ADV) after hematopoietic cell transplant (HCT) are often fatal with limited treatment options. Brincidofovir (BCV) a lipid ester of cidofovir is developed for this indication. We report four pediatric HCT recipients with d-ADV treated successfully with BCV. pmcIntroduction Adenovirus (ADV) infections may occur in up to 40% of pediatric HCT recipients [1]. T-cell depletion (TCD) (ex vivo CD34+ or serotherapy with antithymocyte globulin or alemtuzumab), or severe graft-versus-host disease (GVHD) are associated with ADV infection post-HCT [2]. Recovery of ADV specific T-lymphocytes (ADV-CTLs) confers protection against ADV [3], whereas lymphopenia is a risk factor for disseminated ADV infection (d-ADV) [4]. Ex vivo by CD34+ selection (Miltenyi Biotec, Gladbach, Germany) achieves a 5-log depletion of T-lymphocytes in the allograft [5]. D-ADV infections after TCD HCT are often fatal with mortality rates ranging from 50 - 100% [678]. There is currently no approved treatment for ADV. Intravenous cidofovir (CDV) is commonly used; however its utility is limited by associated nephrotoxicity [9]. Adoptive transfer of ADV-CTLs has shown efficacy in single center studies [2]. Brincidofovir (BCV) is a lipid-linked derivative of CDV with high potency against all clinically significant ADV subtypes and no evidence of renal or hematological toxicity to date [1011]. In lymphocyte-depleted pediatric HCT recipients with ADV infections, treatment with BCV resulted in faster and greater virologic responses to BCV compared with CDV [12]. BCV has been associated with gastrointestinal toxicity with typical onset after 4 - 6 doses of BCV [11]. Children may tolerate BCV better than adults possibly due to a more rapid turnover of gastrointestinal mucosa compared with adults [10]. We describe 4 pediatric TCD HCT recipients with d-ADV infection treated successfully with oral BCV 2 mg/kg twice per week under Emergency Investigational New Drug from 9/2015 and 5/2016. The study was reviewed and approved by the Memorial Sloan Kettering Cancer Center Institutional Review and Privavy Board and granted a waiver of authorization (IRB #16-844). Table 1 shows the clinical and virologic characteristics. Virologic responses to BCV are shown in Figure 1A-1D. Table 1 Characteristics and outcome of disseminated adenovirus cases Case Age/sex Dx Transplant type, donor Post-transplant complications before onset of ADV viremia, immunosuppressant First ADV viremiaa, days post-HCT (D) Max ADV viremia, D Sites of ADV ADV disease, D ADV viremia at first CDV Tx ADV viremia at first BCV Tx BCV initiation, D Anti-viral Tx Time to virologic clearance from BCV, days ALC / CD4+ (cell/mcL) at BCV Tx Outcome A 19m/F SCID 1st HCT: BMT, haplo mother (graft failure) Autoimmune Hemolytic Anemia, Rituximab, Prednisolone 2.1 × 105, D+192 2.1 × 105, D+192 Blood, Stool, Urine Probable Enterocolitis, D+207 4.3 × 104 <190 D+193 CDV IV 5 mg/kg × 5 doses 3 ALC 400 CD4+ 30 Alive 2nd HCT: CD34+ TCD PBSCT, MUD BCV PO 2 mg/kg TIW × 17 doses B 4y/M ALL CD34+ TCD PBSCT, 9/10 MUD 469, D+10 4.7 × 106, D+69 Blood, Stool, Liver, RESP, Pleural Fluid Definite Pneumonitis, D+84; Definite Hepatitis, D+88 5.8 × 104 3.3 × 105 D+25 CDV IV 5 mg/kg × 14 doses N/A ALC 400 CD4+ 0 Alive BCV PO 2 mg/kg TIW × 5 doses DLI, ADV CTLs C 3y/M Familial HLH CD34+ TCD PBSCT, Haplo mother Skin Grade 3 GVHD and GI Grade 1 GVHD, Mesenchymal stem cell infusion, Alemtuzumab, CNI and Prednisolone 9.8 × 105, D+841 6.7 × 106, D+1026 Blood, Stool, RESP Possible Enterocolitis, D+870 N/A 4.1 × 105 D+848 BCV PO 2 mg/kg TIW × 29 doses 1st course: 14 1st course: ALC 100 CD4+ 0 Death, D+1088, MSOF 2nd course: 20 2nd course: ALC 100 CD4+ 0 D 3y/F ALL 1st HCT: CD34+ TCD PBSCT, MUD Acute Rejection of first allo-graft 2 × 103, D+38 (From 2nd HCT) 1.9 × 107, D+42 (From 2nd HCT) Blood, Stool, Liver Possible Enterocolitis, D+65 (From 2nd HCT) 2.8 × 105 1.6 × 107 D+57 (From 2nd HCT) CDV IV 5 mg/kg × 2 doses 34 ALC 300 CD4+ 19 Death, D+539 (From 2nd HCT), relapse of primary disease 2nd HCT: CD34+ TCD PBSCT, MUD 2nd HCT: Alemtuzumab 1 mg/kg divided in 5 doses after 2nd HCT BCV PO 2 mg/kg TIW × 26 doses aADV PCR in blood was performed by Viraco Eurofins (Lee's Summit, MO, USA). Values are copies/ml. m, months-old; F, female; y, years-old; M, male; Dx, diagnosis; SCID, severe combined immune deficiency; ALL, acute lymphoblastic leukemia; HLH, hemophagocytic lymphohistiocytosis; HCT, hematopoietic cell transplant; BMT, bone marrow transplant; Haplo, Haploidentical; TCD, T Cell-depleted; PBSCT, peripheral blood stem cell transplant; MUD, matched unrelated donor; ADV, adenovirus; GVHD, graft-versus-host disease; GI, gastrointestinal; CNI, calcineurin inhibitors; D, day from transplant; max, maximum, RESP, respiratory specimens (bronchoalveolar lavage, nasopharyngeal swab); CDV, cidofovir; Tx, treatment; N/A, not applicable; BCV, brincidofovir; IV, intravenous; PO, orally; TIW, three times per week; DLI, donor lymphocyte infusion; CTLs, cytotoxic T lymphocytes, ALC, absolute lymphocyte counts; MSOF, multisystem organ failure. Figure 1 Plasma adenovirus viral load and treatment in 4 pediatric hematopoietic cell transplant recipients with disseminated adenovirus infection. CD4+ count: cell/mcL. CDV, cidofovir; BCV, brincidofovir; ADV, adenovirus; VL, viral load; DLI, donor lymphocyte infusion; CTL, cytotoxic T-lymphocyte; PCR, polymerase chain reaction. Case report ADV PCR was performed by Viracor-Eurofins (Lee's Summit, MO, USA). The linear range of quantification of ADV PCR in the blood was 100 – 1 × 1010 copies/mL. D-ADV was defined as previously defined [7]. 1. Case A A 19-month-old girl with severe combined immunodeficiency syndrome received a TCD HCT from a matched unrelated donor (MUD). Her post-transplant course was complicated by autoimmune hemolytic anemia treated with prednisolone and 6 doses of rituximab. Six months post-transplant she presented for hypoactivity, irritability and watery diarrhea. On admission, stool ADV PCR was positive and ADV viremia was 2.1 × 105copies/ml. She was treated with CDV and intravenous immunoglobulin. After 2 weeks of CDV, colonoscopy was performed. Pathology showed friable colonic mucosa. Viral culture from tissues was positive for ADV. Because of persistent diarrhea after 5 doses of CDV, BCV was started. ADV viremia became undetectable after 2 doses of BCV. BCV was stopped at 8 weeks after BCV initiation. 2. Case B A 4-year-old boy with acute lymphoblastic leukemia (ALL) received a TCD HCT from a MUD. On Day 0, stool ADV PCR was positive and ADV viremia was negative. On Day +10, ADV viremia was 469 copies/ml and on Day +17 ADV viremia rose to 5.8 × 104copies/ml. On Day +25, CDV was started due to persistent fever, diarrhea and rising ADV viremia. After 2 doses of CDV, CDV was switched to BCV due to increased ADV viremia (3.3 × 105copies/ml). On Day +39, BCV was discontinued after 5 doses due to persistent diarrhea. CDV was resumed, however ADV viremia increased to 4.7 × 106copies/ml on Day +69 and transaminitis was noted. Liver biopsy on Day +84 confirmed GVHD with ADV hepatitis (positive ADV stain). Concurrently, he developed respiratory distress and a nasopharyngeal swab was positive for ADV by PCR. On Day +88, thoracentesis was performed due to worsening pleural effusion. Pleural fluid was positive for ADV (1.8 × 105copies/ml). He was treated with donor lymphocyte infusion (DLI) and subsequently with ADV-CTLs with virologic response. 3. Case C A 3-year-old boy with familial hemophagocytic lymphohistiocytosis was admitted with fever, diarrhea and vomiting 2 years post-transplant. He received a TCD HCT from his haploidentical mother. His post-transplant course was complicated by poor graft function, refractory skin and gastrointestinal GVHD, human herpesvirus-6 viremia and chronic renal dysfunction. He received cyclosporine, tacrolimus, steroids and mesenchymal stem cells infusion for GVHD. On admission, cefepime and vancomycin were empirically started. Stool was negative for Clostridioides difficile. Symptoms persisted during admission. On hospital day 21, stool ADV PCR was positive and ADV viremia was 9.8 × 105copies/ml. BCV was initiated. Viral clearance was achieved after 5 doses BCV and BCV was continued for 4 weeks. One week after BCV discontinuation, ADV viremia recrudesced to 1.0 × 107copies/ml. BCV was reinitiated and continued for 10 weeks with good virologic control. Due to persistent diarrhea, colonoscopy was performed and pathology showed persistent gut GVHD. The tissue was positive for ADV by PCR. He received a stem cell boost 2 months after stopping BCV for poor graft function. He subsequently developed relapse of ADV viremia (6.7 × 106copies/ml), thus BCV was resumed and ADV viremia became undectable after 7 doses of BCV. His hospital stay was further complicated by hospital-acquired pneumonia with respiratory failure. Despite resolving ADV viremia, he died due to multi-organ failure. 4. Case D A 3-year-old girl with ALL received a TCD HCT from a MUD complicated by graft rejection and followed by a second TCD HCT from a different MUD one month after the first HCT. Her post-transplant course was complicated by Epstein-Barr virus (EBV) viremia treated with rituximab and cytomegalovirus viremia. On Day +38 post-transplant, she was found to have ADV viremia (2.0 × 103copies/ml). On Day +42, ADV viremia increased to 1.9 × 107copies/ml. On Day +53, she developed watery diarrhea and nausea. Stool ADV PCR was positive. On Day +56, colonoscopy was performed. The tissue was positive for ADV by PCR. On Day +56, ADV viremia was 2.8 × 105copies/ml and CDV was started. After two doses of CDV, ADV viremia was 1.1 × 105copies/ml. She developed worsening hepatic function. Computed tomography of the chest and abdomen on Day +65 showed a necrotic liver lesion and a necrotic lung mass. ADV viremia rose up to 2.3 × 107copies/ml on Day +66 despite CDV. Lung and liver biopsies performed on Day +67 yielded Legionella pneumophila serotype 1 by culture and liver biopsy was positive for EBV and ADV by PCR. ADV viremia was 1.6 × 107 copies/mL on Day +69. On Day +71, levofloxacin was started for Legionella pneumonia and BCV for d-ADV infection. ADV viremia became undectable 34 days after initiation. She received BCV for 80 days as outpatient. Discussion We report 4 pediatric TCD HCT recipients (overall 6 episodes of ADV viremia) with d-ADV treated with BCV. All patients were highly immunosuppressed, with profound lymphopenia and/or very low CD4 counts. Despite high ADV viremia (median 3.7 × 105 copies/mL) at BCV initiation, 3 of 4 patients cleared ADV viremia at a median of 14 days (range, 1 - 34) of BCV treatment. Two patients (cases A and C) were on high dose steroids. Two patients had received prior CDV treatment (case A and C) without response prior to BCV treatment. Three patients tolerated prolonged doses of BCV (range, 17 - 29 doses). Case C had lymphopenia (100 cell/mm3) and CD4+ count was 0 cell/mm3 during ADV infection. Despite a rapid virologic response to BCV, ADV recurred after discontinuation of BCV highlighting the importance of immune recovery for control of ADV infection. Importantly the patient responded rapidly after 2 short subsequent courses of BCV suggesting that repeated episodic treatment with BCV guided by ADV viral load (VL) remains effective even in the setting of persistent lymphopenia. D-ADV infections are associated with substantial morbidity and mortality in HCT recipients [678]. Cases A, C and D with ADV colitis cleared ADV viremia with BCV. Case B did not tolerate BCV. BCV was discontinued after 5 doses concerning for gastrointestinal toxicity. Case B developed ADV hepatitis and ADV pneumonitis while on CDV. Case B responded to DLI and ADV-CTLs. While ADV-CTLs have shown safety and efficacy in small series (reviewed in reference 2), at present several hurdles preclude the broad applicability of this potentially effective therapy [2]. The virologic responses in our cases confirms the virologic activity of BCV even in lymphopenic patients and are in agreement with results of the recent BCV trial [11]. In that trial virologic responses were better, if BCV treatment was initiated at low VL and was associated with improved survival [11]. Our patients had high VL at BCV initiation despite which, 3 of 4 patients achieved virologic responses. One patient discontinued BCV due to gastrointestinal symptoms. Gastrointestinal toxicity is a known side effect of BCV [10]. Management of gastrointestinal toxicity due to BCV like case B is particularly challenging in patients with ADV in the gastrointestinal tract as symptoms may be related to ADV enteritis/colitis and/or BCV. Case B had diarrhea prior to BCV initiation and had persistent diarrhea while on BCV which led a clinician to stop BCV. An intravenous formulation of BCV is currently in development and may alleviate concerns for gastrointestinal toxicity. In conclusion, our small case series show rapid virologic responses after short courses of oral BCV in 3 of 4 pediatric patients with d-ADV. Repeated short courses of BCV were effective in a patient with recurrent ADV viremia. Our data supports the study design of short-course oral BCV treatment in pediatric HCT recipients with ADV infection. ACKNOWLEDGEMENT This research was funded in part through the NIH/NCI Cancer Center Support Grant P30 CA008748. Conflict of Interest: GAP has been an investigator for Shire, Merck, Chimerix and Astellas and has received consulting fees from Shire, Merck, Chimerix and Astellas. Author Contributions: Conceptualization: GAP, YJL. Data curation: SYC, SEP, FB, GAP, YJL, YJL. Writing - original draft: SEP, FB, GAP, YJL.	Fatal	ReactionOutcome	CC BY-NC	32869551	19,446,308	2021-09
What was the outcome of reaction 'Vomiting'?	Rapid Virologic Response to Brincidofovir in Children with Disseminated Adenovirus Infection. Disseminated adenovirus infections (d-ADV) after hematopoietic cell transplant (HCT) are often fatal with limited treatment options. Brincidofovir (BCV) a lipid ester of cidofovir is developed for this indication. We report four pediatric HCT recipients with d-ADV treated successfully with BCV. pmcIntroduction Adenovirus (ADV) infections may occur in up to 40% of pediatric HCT recipients [1]. T-cell depletion (TCD) (ex vivo CD34+ or serotherapy with antithymocyte globulin or alemtuzumab), or severe graft-versus-host disease (GVHD) are associated with ADV infection post-HCT [2]. Recovery of ADV specific T-lymphocytes (ADV-CTLs) confers protection against ADV [3], whereas lymphopenia is a risk factor for disseminated ADV infection (d-ADV) [4]. Ex vivo by CD34+ selection (Miltenyi Biotec, Gladbach, Germany) achieves a 5-log depletion of T-lymphocytes in the allograft [5]. D-ADV infections after TCD HCT are often fatal with mortality rates ranging from 50 - 100% [678]. There is currently no approved treatment for ADV. Intravenous cidofovir (CDV) is commonly used; however its utility is limited by associated nephrotoxicity [9]. Adoptive transfer of ADV-CTLs has shown efficacy in single center studies [2]. Brincidofovir (BCV) is a lipid-linked derivative of CDV with high potency against all clinically significant ADV subtypes and no evidence of renal or hematological toxicity to date [1011]. In lymphocyte-depleted pediatric HCT recipients with ADV infections, treatment with BCV resulted in faster and greater virologic responses to BCV compared with CDV [12]. BCV has been associated with gastrointestinal toxicity with typical onset after 4 - 6 doses of BCV [11]. Children may tolerate BCV better than adults possibly due to a more rapid turnover of gastrointestinal mucosa compared with adults [10]. We describe 4 pediatric TCD HCT recipients with d-ADV infection treated successfully with oral BCV 2 mg/kg twice per week under Emergency Investigational New Drug from 9/2015 and 5/2016. The study was reviewed and approved by the Memorial Sloan Kettering Cancer Center Institutional Review and Privavy Board and granted a waiver of authorization (IRB #16-844). Table 1 shows the clinical and virologic characteristics. Virologic responses to BCV are shown in Figure 1A-1D. Table 1 Characteristics and outcome of disseminated adenovirus cases Case Age/sex Dx Transplant type, donor Post-transplant complications before onset of ADV viremia, immunosuppressant First ADV viremiaa, days post-HCT (D) Max ADV viremia, D Sites of ADV ADV disease, D ADV viremia at first CDV Tx ADV viremia at first BCV Tx BCV initiation, D Anti-viral Tx Time to virologic clearance from BCV, days ALC / CD4+ (cell/mcL) at BCV Tx Outcome A 19m/F SCID 1st HCT: BMT, haplo mother (graft failure) Autoimmune Hemolytic Anemia, Rituximab, Prednisolone 2.1 × 105, D+192 2.1 × 105, D+192 Blood, Stool, Urine Probable Enterocolitis, D+207 4.3 × 104 <190 D+193 CDV IV 5 mg/kg × 5 doses 3 ALC 400 CD4+ 30 Alive 2nd HCT: CD34+ TCD PBSCT, MUD BCV PO 2 mg/kg TIW × 17 doses B 4y/M ALL CD34+ TCD PBSCT, 9/10 MUD 469, D+10 4.7 × 106, D+69 Blood, Stool, Liver, RESP, Pleural Fluid Definite Pneumonitis, D+84; Definite Hepatitis, D+88 5.8 × 104 3.3 × 105 D+25 CDV IV 5 mg/kg × 14 doses N/A ALC 400 CD4+ 0 Alive BCV PO 2 mg/kg TIW × 5 doses DLI, ADV CTLs C 3y/M Familial HLH CD34+ TCD PBSCT, Haplo mother Skin Grade 3 GVHD and GI Grade 1 GVHD, Mesenchymal stem cell infusion, Alemtuzumab, CNI and Prednisolone 9.8 × 105, D+841 6.7 × 106, D+1026 Blood, Stool, RESP Possible Enterocolitis, D+870 N/A 4.1 × 105 D+848 BCV PO 2 mg/kg TIW × 29 doses 1st course: 14 1st course: ALC 100 CD4+ 0 Death, D+1088, MSOF 2nd course: 20 2nd course: ALC 100 CD4+ 0 D 3y/F ALL 1st HCT: CD34+ TCD PBSCT, MUD Acute Rejection of first allo-graft 2 × 103, D+38 (From 2nd HCT) 1.9 × 107, D+42 (From 2nd HCT) Blood, Stool, Liver Possible Enterocolitis, D+65 (From 2nd HCT) 2.8 × 105 1.6 × 107 D+57 (From 2nd HCT) CDV IV 5 mg/kg × 2 doses 34 ALC 300 CD4+ 19 Death, D+539 (From 2nd HCT), relapse of primary disease 2nd HCT: CD34+ TCD PBSCT, MUD 2nd HCT: Alemtuzumab 1 mg/kg divided in 5 doses after 2nd HCT BCV PO 2 mg/kg TIW × 26 doses aADV PCR in blood was performed by Viraco Eurofins (Lee's Summit, MO, USA). Values are copies/ml. m, months-old; F, female; y, years-old; M, male; Dx, diagnosis; SCID, severe combined immune deficiency; ALL, acute lymphoblastic leukemia; HLH, hemophagocytic lymphohistiocytosis; HCT, hematopoietic cell transplant; BMT, bone marrow transplant; Haplo, Haploidentical; TCD, T Cell-depleted; PBSCT, peripheral blood stem cell transplant; MUD, matched unrelated donor; ADV, adenovirus; GVHD, graft-versus-host disease; GI, gastrointestinal; CNI, calcineurin inhibitors; D, day from transplant; max, maximum, RESP, respiratory specimens (bronchoalveolar lavage, nasopharyngeal swab); CDV, cidofovir; Tx, treatment; N/A, not applicable; BCV, brincidofovir; IV, intravenous; PO, orally; TIW, three times per week; DLI, donor lymphocyte infusion; CTLs, cytotoxic T lymphocytes, ALC, absolute lymphocyte counts; MSOF, multisystem organ failure. Figure 1 Plasma adenovirus viral load and treatment in 4 pediatric hematopoietic cell transplant recipients with disseminated adenovirus infection. CD4+ count: cell/mcL. CDV, cidofovir; BCV, brincidofovir; ADV, adenovirus; VL, viral load; DLI, donor lymphocyte infusion; CTL, cytotoxic T-lymphocyte; PCR, polymerase chain reaction. Case report ADV PCR was performed by Viracor-Eurofins (Lee's Summit, MO, USA). The linear range of quantification of ADV PCR in the blood was 100 – 1 × 1010 copies/mL. D-ADV was defined as previously defined [7]. 1. Case A A 19-month-old girl with severe combined immunodeficiency syndrome received a TCD HCT from a matched unrelated donor (MUD). Her post-transplant course was complicated by autoimmune hemolytic anemia treated with prednisolone and 6 doses of rituximab. Six months post-transplant she presented for hypoactivity, irritability and watery diarrhea. On admission, stool ADV PCR was positive and ADV viremia was 2.1 × 105copies/ml. She was treated with CDV and intravenous immunoglobulin. After 2 weeks of CDV, colonoscopy was performed. Pathology showed friable colonic mucosa. Viral culture from tissues was positive for ADV. Because of persistent diarrhea after 5 doses of CDV, BCV was started. ADV viremia became undetectable after 2 doses of BCV. BCV was stopped at 8 weeks after BCV initiation. 2. Case B A 4-year-old boy with acute lymphoblastic leukemia (ALL) received a TCD HCT from a MUD. On Day 0, stool ADV PCR was positive and ADV viremia was negative. On Day +10, ADV viremia was 469 copies/ml and on Day +17 ADV viremia rose to 5.8 × 104copies/ml. On Day +25, CDV was started due to persistent fever, diarrhea and rising ADV viremia. After 2 doses of CDV, CDV was switched to BCV due to increased ADV viremia (3.3 × 105copies/ml). On Day +39, BCV was discontinued after 5 doses due to persistent diarrhea. CDV was resumed, however ADV viremia increased to 4.7 × 106copies/ml on Day +69 and transaminitis was noted. Liver biopsy on Day +84 confirmed GVHD with ADV hepatitis (positive ADV stain). Concurrently, he developed respiratory distress and a nasopharyngeal swab was positive for ADV by PCR. On Day +88, thoracentesis was performed due to worsening pleural effusion. Pleural fluid was positive for ADV (1.8 × 105copies/ml). He was treated with donor lymphocyte infusion (DLI) and subsequently with ADV-CTLs with virologic response. 3. Case C A 3-year-old boy with familial hemophagocytic lymphohistiocytosis was admitted with fever, diarrhea and vomiting 2 years post-transplant. He received a TCD HCT from his haploidentical mother. His post-transplant course was complicated by poor graft function, refractory skin and gastrointestinal GVHD, human herpesvirus-6 viremia and chronic renal dysfunction. He received cyclosporine, tacrolimus, steroids and mesenchymal stem cells infusion for GVHD. On admission, cefepime and vancomycin were empirically started. Stool was negative for Clostridioides difficile. Symptoms persisted during admission. On hospital day 21, stool ADV PCR was positive and ADV viremia was 9.8 × 105copies/ml. BCV was initiated. Viral clearance was achieved after 5 doses BCV and BCV was continued for 4 weeks. One week after BCV discontinuation, ADV viremia recrudesced to 1.0 × 107copies/ml. BCV was reinitiated and continued for 10 weeks with good virologic control. Due to persistent diarrhea, colonoscopy was performed and pathology showed persistent gut GVHD. The tissue was positive for ADV by PCR. He received a stem cell boost 2 months after stopping BCV for poor graft function. He subsequently developed relapse of ADV viremia (6.7 × 106copies/ml), thus BCV was resumed and ADV viremia became undectable after 7 doses of BCV. His hospital stay was further complicated by hospital-acquired pneumonia with respiratory failure. Despite resolving ADV viremia, he died due to multi-organ failure. 4. Case D A 3-year-old girl with ALL received a TCD HCT from a MUD complicated by graft rejection and followed by a second TCD HCT from a different MUD one month after the first HCT. Her post-transplant course was complicated by Epstein-Barr virus (EBV) viremia treated with rituximab and cytomegalovirus viremia. On Day +38 post-transplant, she was found to have ADV viremia (2.0 × 103copies/ml). On Day +42, ADV viremia increased to 1.9 × 107copies/ml. On Day +53, she developed watery diarrhea and nausea. Stool ADV PCR was positive. On Day +56, colonoscopy was performed. The tissue was positive for ADV by PCR. On Day +56, ADV viremia was 2.8 × 105copies/ml and CDV was started. After two doses of CDV, ADV viremia was 1.1 × 105copies/ml. She developed worsening hepatic function. Computed tomography of the chest and abdomen on Day +65 showed a necrotic liver lesion and a necrotic lung mass. ADV viremia rose up to 2.3 × 107copies/ml on Day +66 despite CDV. Lung and liver biopsies performed on Day +67 yielded Legionella pneumophila serotype 1 by culture and liver biopsy was positive for EBV and ADV by PCR. ADV viremia was 1.6 × 107 copies/mL on Day +69. On Day +71, levofloxacin was started for Legionella pneumonia and BCV for d-ADV infection. ADV viremia became undectable 34 days after initiation. She received BCV for 80 days as outpatient. Discussion We report 4 pediatric TCD HCT recipients (overall 6 episodes of ADV viremia) with d-ADV treated with BCV. All patients were highly immunosuppressed, with profound lymphopenia and/or very low CD4 counts. Despite high ADV viremia (median 3.7 × 105 copies/mL) at BCV initiation, 3 of 4 patients cleared ADV viremia at a median of 14 days (range, 1 - 34) of BCV treatment. Two patients (cases A and C) were on high dose steroids. Two patients had received prior CDV treatment (case A and C) without response prior to BCV treatment. Three patients tolerated prolonged doses of BCV (range, 17 - 29 doses). Case C had lymphopenia (100 cell/mm3) and CD4+ count was 0 cell/mm3 during ADV infection. Despite a rapid virologic response to BCV, ADV recurred after discontinuation of BCV highlighting the importance of immune recovery for control of ADV infection. Importantly the patient responded rapidly after 2 short subsequent courses of BCV suggesting that repeated episodic treatment with BCV guided by ADV viral load (VL) remains effective even in the setting of persistent lymphopenia. D-ADV infections are associated with substantial morbidity and mortality in HCT recipients [678]. Cases A, C and D with ADV colitis cleared ADV viremia with BCV. Case B did not tolerate BCV. BCV was discontinued after 5 doses concerning for gastrointestinal toxicity. Case B developed ADV hepatitis and ADV pneumonitis while on CDV. Case B responded to DLI and ADV-CTLs. While ADV-CTLs have shown safety and efficacy in small series (reviewed in reference 2), at present several hurdles preclude the broad applicability of this potentially effective therapy [2]. The virologic responses in our cases confirms the virologic activity of BCV even in lymphopenic patients and are in agreement with results of the recent BCV trial [11]. In that trial virologic responses were better, if BCV treatment was initiated at low VL and was associated with improved survival [11]. Our patients had high VL at BCV initiation despite which, 3 of 4 patients achieved virologic responses. One patient discontinued BCV due to gastrointestinal symptoms. Gastrointestinal toxicity is a known side effect of BCV [10]. Management of gastrointestinal toxicity due to BCV like case B is particularly challenging in patients with ADV in the gastrointestinal tract as symptoms may be related to ADV enteritis/colitis and/or BCV. Case B had diarrhea prior to BCV initiation and had persistent diarrhea while on BCV which led a clinician to stop BCV. An intravenous formulation of BCV is currently in development and may alleviate concerns for gastrointestinal toxicity. In conclusion, our small case series show rapid virologic responses after short courses of oral BCV in 3 of 4 pediatric patients with d-ADV. Repeated short courses of BCV were effective in a patient with recurrent ADV viremia. Our data supports the study design of short-course oral BCV treatment in pediatric HCT recipients with ADV infection. ACKNOWLEDGEMENT This research was funded in part through the NIH/NCI Cancer Center Support Grant P30 CA008748. Conflict of Interest: GAP has been an investigator for Shire, Merck, Chimerix and Astellas and has received consulting fees from Shire, Merck, Chimerix and Astellas. Author Contributions: Conceptualization: GAP, YJL. Data curation: SYC, SEP, FB, GAP, YJL, YJL. Writing - original draft: SEP, FB, GAP, YJL.	Fatal	ReactionOutcome	CC BY-NC	32869551	19,446,308	2021-09
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Basedow^s disease'.	Graves' Disease after Adrenalectomy for Cushing's Syndrome. A 44-year-old woman presented with a 3-month history of back pain, gait disturbance, and insomnia. She had moon face and central obesity but no goiter. Cushing's syndrome due to left adrenal adenoma was diagnosed. She also had low triiodothyronine syndrome and central hypothyroidism. Treatment involved adrenalectomy followed by 30 mg/day of hydrocortisone. Inappropriate secretion of thyroid-stimulating hormone occurred postoperatively. She developed Graves' disease nine months postoperatively and was treated with methimazole. Excess glucocorticoids followed by their withdrawal may influence the hypothalamic-pituitary-thyroid axis and immune system. Therefore, a careful evaluation of the thyroid function and antibodies is important after surgery for Cushing's syndrome. Introduction Cushing's syndrome is a disorder caused by chronic glucocorticoid excess, resulting in various symptoms, such as moon face, central obesity, a “buffalo hump,” red striae, and fatigue (1). The excess glucocorticoid affects the hypothalamic-pituitary-thyroid axis and results in central hypothyroidism and low triiodothyronine (T3) syndrome (2,3). The excess glucocorticoid also suppresses the immune system (4). Rapid withdrawal of glucocorticoid sometimes causes steroid withdrawal syndrome (SWS) and syndrome of inappropriate secretion of thyroid-stimulating hormone (SITSH) despite treatment with physiological doses of hydrocortisone (5,6). The resolution of hypercortisolism may also trigger the development of autoimmune disorders, including autoimmune thyroid diseases (1,7-14). We herein report a case of Graves' disease after unilateral adrenalectomy for Cushing's syndrome. Case Report A 44-year-old woman presented to our hospital with a 3-month history of back pain, gait disturbance, insomnia, and depression. She had moon face, central obesity, hypertrichosis, and pitting edema on her legs and feet. She also had a 2-year history of hypertension. The patient had no family history of thyroid disease or other autoimmune diseases. Her height was 172.7 cm, and her body weight was 71.5 kg. Her blood pressure was 132/107 mmHg. No goiter, exophthalmos, Graefe's sign, or Dalrymple's sign was present. Laboratory tests showed leukocytosis [white blood cell count, 10,900 cells/mL (neutrophils, 82.5%; eosinophils, 0.5%)] and hypokalemia (potassium, 3.4 mmol/L). Her serum free thyroxine (FT4) level was normal (0.82 ng/dL; reference range, 0.76-1.65 ng/dL), but her thyroid-stimulating hormone (TSH) level (0.377 IU/mL; reference range, 0.541-4.261 IU/mL) and free T3 (FT3) level (1.65 pg/mL; reference range, 2.39-4.06 pg/mL) were low. Her plasma adrenocorticotropic hormone (ACTH) level (<2.0 pg/mL; reference range, 7.2-63.3 pg/mL) was suppressed, and her plasma cortisol level (17.2 μg/dL; reference range, 6.24-18.0 μg/dL) and 24-h urinary free cortisol level (967 μg/day) were elevated. Loss of diurnal variation of plasma ACTH and cortisol was observed. The oral administration of 1 mg of dexamethasone at 11:00 PM did not suppress the plasma cortisol level at 8:00 AM the following morning (17.9 μg/dL). Computed tomography revealed a 30-mm tumor in the left adrenal gland (Fig. 1A). Magnetic resonance imaging did not show a pituitary tumor. 99mTc-methylene diphosphonate (MDP) scintigraphy indicated multiple fractures in the seventh to ninth right ribs, fourth and fifth lumbar vertebrae, bilateral sacroiliac joints, and left ilium (Fig. 1B). The patient was diagnosed with Cushing's syndrome due to a left adrenal adenoma. She also had low T3 syndrome and central hypothyroidism. Figure 1. Computed tomography (CT) and whole-body 99mTc-methylene diphosphonate bone scintigraphy. (A) CT revealed a 30-mm left adrenal tumor (arrow). (B) A bone scan showed a significant abnormal isotope uptake in multiple ribs and vertebrae, the sacroiliac joints, and the right ileum. Unilateral adrenalectomy was performed 5 months after the first visit to our hospital, and oral hydrocortisone was administered at 30 mg/day after surgery. She had general malaise and hypotension for 3 months despite medication with 30 mg/day hydrocortisone. Five months after surgery, the dose of hydrocortisone was reduced to 20 mg/day. Inappropriate secretion of TSH had been observed from 1 month after surgery (FT3, 4.16 pg/mL; TSH, 0.575 IU/mL) to 7 months after surgery (FT3, 4.12 pg/mL; TSH, 1.361 IU/mL). The patient developed tachycardia and diffuse goiter 9 months after the adrenalectomy and was diagnosed with Graves' disease [FT3, 10.27 pg/mL; FT4, 3.16 ng/dL; TSH, <0.003 IU/mL; anti-thyroglobulin antibody, 1,063.2 IU/mL (reference range, <40.6 IU/mL); anti-thyroid peroxidase antibody, 225.5 IU/mL (reference range, <9.4 IU/mL); anti-TSH receptor antibody (third-generation TRAb electrochemiluminescence immunoassay), 7.4 IU/L (reference range, <2.0 IU/L); and thyroid-stimulating antibody (TSAb Bioassay Enzyme Immunoassay; Yamasa, Choshi, Japan), 1,196% (reference range, <120%)]. Ultrasonography showed the diffuse enlargement of her thyroid glands with increased blood flow. She was started on oral methimazole at 15 mg/day. She remained euthyroid on oral methimazole at 5 mg/day for 15 months after adrenalectomy. The serum thyroid-stimulating antibody level gradually decreased to 216% 17 months after adrenalectomy and 149% 23 months after surgery (Fig. 2). Figure 2. Clinical course. FT3: free triiodothyronine, FT4: free thyroxine, TSH: thyroid-stimulating hormone, TRAb: anti-TSH receptor antibody, TSAb: thyroid-stimulating antibody Discussion Excess glucocorticoid followed by its withdrawal may influence the hypothalamic-pituitary-thyroid axis and immune system (1-14). In our case, low T3 syndrome and TSH suppression were present before adrenalectomy. The patient developed SITSH one month after surgery and Graves' disease nine months after adrenalectomy. The serum TSH level is suppressed in patients with Cushing's syndrome. Hypercortisolemia decreases the TSH pulse amplitude and nocturnal surge (15,16) and suppresses TSH secretion through the suppression of the thyrotropin-releasing hormone gene expression (17) or through the direct suppression of TSH secretion via leptin, dopamine, annexin 1, and somatostatin (18-21). Increased activity of type II deiodinase by glucocorticoids also causes increased local T3 levels, eventually leading to suppression of thyrotropin-releasing hormone and TSH secretion (6,22). Although the FT4 level was within the reference range in our case, central hypothyroidism with a reduced T4 level is sometimes present in patients with Cushing's syndrome. The prevalence of central hypothyroidism ranges from 18% to 26% (2,23). In our patient, SWS was observed after adrenalectomy despite supplementation with oral hydrocortisone at 30 mg/day. She also complained of anorexia and fatigue. Her serum TSH and FT3 levels were higher than the upper limit of normal, which indicated SITSH. A recent report described SITSH as a clinical condition with the presence of normal or elevated TSH secretion despite inappropriately high levels of thyroid hormones in patients who receive insufficient hydrocortisone replacement following surgery for Cushing's syndrome (6). Because the symptoms of hyperthyroidism due to SITSH overlap with those of SWS, SITSH is considered the main cause of SWS (23). Tamada et al. (6) reported that SITSH was detected in the first month of follow-up when the daily hydrocortisone replacement doses were <20 mg. SITSH was present in 75% of patients with Cushing's syndrome up to 6 months after surgery and disappeared by 12 months after surgery (6). In contrast, Dogansen et al. (2) failed to detect SITSH in the early postoperative period with their prednisolone replacement doses. Several reports have described the exacerbation or development of autoimmune disorders, including thyroid diseases, after surgery for Cushing's syndrome (7-14). Although the pathogenesis underlying the exacerbation of autoimmune thyroid disease is not well known, rebound immunity and activation of latent autoimmune thyroid disease have been postulated. In previous studies, the prevalence of autoimmune dysfunction after surgery for Cushing's syndrome was 16.7% in adults (24) and 7.8% in children (25). The prevalence of autoimmune thyroid disease after surgery for Cushing's syndrome reportedly ranges from 10% to 35% (9,13,26). Colao et al. (14) reported an increased prevalence of positive thyroglobulin and thyroid peroxidase antibody titers in patients after Cushing's syndrome remission than during active Cushing's syndrome (60% vs. 20%). Niepomniszcze et al. (27) reported that thyroid autoimmunity was detected in 21.7% of patients at the time of diagnosis of Cushing's syndrome and in 65.2% of patients after remission of hypercortisolism. Several case reports have described Graves' disease after surgery for Cushing's syndrome (24,25,27-29), reporting prevalence rates of 0.8% to 8.5% (Table). Most patients developed autoimmune thyroid disorders 7 to 10 months after surgery. Graves' disease developed 3 to 100 months after surgery for Cushing's syndrome. Therefore, physicians need to be aware of this possible outcome. Table. Previous Reports on Exacerbation or Development of Graves’ Disease after Adrenalectomy for Cushing’s Syndrome. Reference Sex Age Time of presentation of Graves’ disease after surgery TSH receptor antibody and iodine uptake Prevalence of Graves’ disease Treatment used 27 - - 3 M, 14 M, 18 M, 100 M, -20 Y - 8.5% (5/59) 28 Male 49 80 D TRAb-, TSAb- positive - Remission without treatment 29 Female 50 9 M TRAb 30 IU/L, I uptake 31% at 2 hr - PTU 24 Female 58 27 M TRAb 9.8 IU/L, I uptake 37.8% at 24 hr 1.5% (1/66) MMI 25 Female 15 12 M - 0.8% (1/127) present study Female 44 9 M TRAb 7.4 IU/L, TSAb 1196% - MMI TSH: thyroid-stimulating hormone, D: days, M: months, Y: years, TRAb: anti-TSH receptor antibody, TSAb: thyroid-stimulating antibody, PTU: propylthiouracil, MMI: methimazole It is reasonable to hypothesize that predisposed patients are protected from autoimmune attack by immunologic tolerance related to steroid excess and overt thyroid dysfunction that develops after the decline in glucocorticoid concentration (9). However, the possibility of other mechanisms precipitating the occurrence of the disease, such as iodine excess, cannot be ruled out. The present case had SITSH for a six-month period until two months before the diagnosis of Graves' disease, although the role of SITSH in the development of Graves' disease is unclear. In conclusion, this study suggests that the thyroid function and antibody tests should be carefully evaluated before and after surgery for Cushing's syndrome. The authors state that they have no Conflict of Interest (COI). Acknowledgement We thank Angela Morben, DVM, ELS for editing a draft of this manuscript.	HYDROCORTISONE	DrugsGivenReaction	CC BY-NC-ND	32893226	19,236,992	2021-01-01
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Goitre'.	Graves' Disease after Adrenalectomy for Cushing's Syndrome. A 44-year-old woman presented with a 3-month history of back pain, gait disturbance, and insomnia. She had moon face and central obesity but no goiter. Cushing's syndrome due to left adrenal adenoma was diagnosed. She also had low triiodothyronine syndrome and central hypothyroidism. Treatment involved adrenalectomy followed by 30 mg/day of hydrocortisone. Inappropriate secretion of thyroid-stimulating hormone occurred postoperatively. She developed Graves' disease nine months postoperatively and was treated with methimazole. Excess glucocorticoids followed by their withdrawal may influence the hypothalamic-pituitary-thyroid axis and immune system. Therefore, a careful evaluation of the thyroid function and antibodies is important after surgery for Cushing's syndrome. Introduction Cushing's syndrome is a disorder caused by chronic glucocorticoid excess, resulting in various symptoms, such as moon face, central obesity, a “buffalo hump,” red striae, and fatigue (1). The excess glucocorticoid affects the hypothalamic-pituitary-thyroid axis and results in central hypothyroidism and low triiodothyronine (T3) syndrome (2,3). The excess glucocorticoid also suppresses the immune system (4). Rapid withdrawal of glucocorticoid sometimes causes steroid withdrawal syndrome (SWS) and syndrome of inappropriate secretion of thyroid-stimulating hormone (SITSH) despite treatment with physiological doses of hydrocortisone (5,6). The resolution of hypercortisolism may also trigger the development of autoimmune disorders, including autoimmune thyroid diseases (1,7-14). We herein report a case of Graves' disease after unilateral adrenalectomy for Cushing's syndrome. Case Report A 44-year-old woman presented to our hospital with a 3-month history of back pain, gait disturbance, insomnia, and depression. She had moon face, central obesity, hypertrichosis, and pitting edema on her legs and feet. She also had a 2-year history of hypertension. The patient had no family history of thyroid disease or other autoimmune diseases. Her height was 172.7 cm, and her body weight was 71.5 kg. Her blood pressure was 132/107 mmHg. No goiter, exophthalmos, Graefe's sign, or Dalrymple's sign was present. Laboratory tests showed leukocytosis [white blood cell count, 10,900 cells/mL (neutrophils, 82.5%; eosinophils, 0.5%)] and hypokalemia (potassium, 3.4 mmol/L). Her serum free thyroxine (FT4) level was normal (0.82 ng/dL; reference range, 0.76-1.65 ng/dL), but her thyroid-stimulating hormone (TSH) level (0.377 IU/mL; reference range, 0.541-4.261 IU/mL) and free T3 (FT3) level (1.65 pg/mL; reference range, 2.39-4.06 pg/mL) were low. Her plasma adrenocorticotropic hormone (ACTH) level (<2.0 pg/mL; reference range, 7.2-63.3 pg/mL) was suppressed, and her plasma cortisol level (17.2 μg/dL; reference range, 6.24-18.0 μg/dL) and 24-h urinary free cortisol level (967 μg/day) were elevated. Loss of diurnal variation of plasma ACTH and cortisol was observed. The oral administration of 1 mg of dexamethasone at 11:00 PM did not suppress the plasma cortisol level at 8:00 AM the following morning (17.9 μg/dL). Computed tomography revealed a 30-mm tumor in the left adrenal gland (Fig. 1A). Magnetic resonance imaging did not show a pituitary tumor. 99mTc-methylene diphosphonate (MDP) scintigraphy indicated multiple fractures in the seventh to ninth right ribs, fourth and fifth lumbar vertebrae, bilateral sacroiliac joints, and left ilium (Fig. 1B). The patient was diagnosed with Cushing's syndrome due to a left adrenal adenoma. She also had low T3 syndrome and central hypothyroidism. Figure 1. Computed tomography (CT) and whole-body 99mTc-methylene diphosphonate bone scintigraphy. (A) CT revealed a 30-mm left adrenal tumor (arrow). (B) A bone scan showed a significant abnormal isotope uptake in multiple ribs and vertebrae, the sacroiliac joints, and the right ileum. Unilateral adrenalectomy was performed 5 months after the first visit to our hospital, and oral hydrocortisone was administered at 30 mg/day after surgery. She had general malaise and hypotension for 3 months despite medication with 30 mg/day hydrocortisone. Five months after surgery, the dose of hydrocortisone was reduced to 20 mg/day. Inappropriate secretion of TSH had been observed from 1 month after surgery (FT3, 4.16 pg/mL; TSH, 0.575 IU/mL) to 7 months after surgery (FT3, 4.12 pg/mL; TSH, 1.361 IU/mL). The patient developed tachycardia and diffuse goiter 9 months after the adrenalectomy and was diagnosed with Graves' disease [FT3, 10.27 pg/mL; FT4, 3.16 ng/dL; TSH, <0.003 IU/mL; anti-thyroglobulin antibody, 1,063.2 IU/mL (reference range, <40.6 IU/mL); anti-thyroid peroxidase antibody, 225.5 IU/mL (reference range, <9.4 IU/mL); anti-TSH receptor antibody (third-generation TRAb electrochemiluminescence immunoassay), 7.4 IU/L (reference range, <2.0 IU/L); and thyroid-stimulating antibody (TSAb Bioassay Enzyme Immunoassay; Yamasa, Choshi, Japan), 1,196% (reference range, <120%)]. Ultrasonography showed the diffuse enlargement of her thyroid glands with increased blood flow. She was started on oral methimazole at 15 mg/day. She remained euthyroid on oral methimazole at 5 mg/day for 15 months after adrenalectomy. The serum thyroid-stimulating antibody level gradually decreased to 216% 17 months after adrenalectomy and 149% 23 months after surgery (Fig. 2). Figure 2. Clinical course. FT3: free triiodothyronine, FT4: free thyroxine, TSH: thyroid-stimulating hormone, TRAb: anti-TSH receptor antibody, TSAb: thyroid-stimulating antibody Discussion Excess glucocorticoid followed by its withdrawal may influence the hypothalamic-pituitary-thyroid axis and immune system (1-14). In our case, low T3 syndrome and TSH suppression were present before adrenalectomy. The patient developed SITSH one month after surgery and Graves' disease nine months after adrenalectomy. The serum TSH level is suppressed in patients with Cushing's syndrome. Hypercortisolemia decreases the TSH pulse amplitude and nocturnal surge (15,16) and suppresses TSH secretion through the suppression of the thyrotropin-releasing hormone gene expression (17) or through the direct suppression of TSH secretion via leptin, dopamine, annexin 1, and somatostatin (18-21). Increased activity of type II deiodinase by glucocorticoids also causes increased local T3 levels, eventually leading to suppression of thyrotropin-releasing hormone and TSH secretion (6,22). Although the FT4 level was within the reference range in our case, central hypothyroidism with a reduced T4 level is sometimes present in patients with Cushing's syndrome. The prevalence of central hypothyroidism ranges from 18% to 26% (2,23). In our patient, SWS was observed after adrenalectomy despite supplementation with oral hydrocortisone at 30 mg/day. She also complained of anorexia and fatigue. Her serum TSH and FT3 levels were higher than the upper limit of normal, which indicated SITSH. A recent report described SITSH as a clinical condition with the presence of normal or elevated TSH secretion despite inappropriately high levels of thyroid hormones in patients who receive insufficient hydrocortisone replacement following surgery for Cushing's syndrome (6). Because the symptoms of hyperthyroidism due to SITSH overlap with those of SWS, SITSH is considered the main cause of SWS (23). Tamada et al. (6) reported that SITSH was detected in the first month of follow-up when the daily hydrocortisone replacement doses were <20 mg. SITSH was present in 75% of patients with Cushing's syndrome up to 6 months after surgery and disappeared by 12 months after surgery (6). In contrast, Dogansen et al. (2) failed to detect SITSH in the early postoperative period with their prednisolone replacement doses. Several reports have described the exacerbation or development of autoimmune disorders, including thyroid diseases, after surgery for Cushing's syndrome (7-14). Although the pathogenesis underlying the exacerbation of autoimmune thyroid disease is not well known, rebound immunity and activation of latent autoimmune thyroid disease have been postulated. In previous studies, the prevalence of autoimmune dysfunction after surgery for Cushing's syndrome was 16.7% in adults (24) and 7.8% in children (25). The prevalence of autoimmune thyroid disease after surgery for Cushing's syndrome reportedly ranges from 10% to 35% (9,13,26). Colao et al. (14) reported an increased prevalence of positive thyroglobulin and thyroid peroxidase antibody titers in patients after Cushing's syndrome remission than during active Cushing's syndrome (60% vs. 20%). Niepomniszcze et al. (27) reported that thyroid autoimmunity was detected in 21.7% of patients at the time of diagnosis of Cushing's syndrome and in 65.2% of patients after remission of hypercortisolism. Several case reports have described Graves' disease after surgery for Cushing's syndrome (24,25,27-29), reporting prevalence rates of 0.8% to 8.5% (Table). Most patients developed autoimmune thyroid disorders 7 to 10 months after surgery. Graves' disease developed 3 to 100 months after surgery for Cushing's syndrome. Therefore, physicians need to be aware of this possible outcome. Table. Previous Reports on Exacerbation or Development of Graves’ Disease after Adrenalectomy for Cushing’s Syndrome. Reference Sex Age Time of presentation of Graves’ disease after surgery TSH receptor antibody and iodine uptake Prevalence of Graves’ disease Treatment used 27 - - 3 M, 14 M, 18 M, 100 M, -20 Y - 8.5% (5/59) 28 Male 49 80 D TRAb-, TSAb- positive - Remission without treatment 29 Female 50 9 M TRAb 30 IU/L, I uptake 31% at 2 hr - PTU 24 Female 58 27 M TRAb 9.8 IU/L, I uptake 37.8% at 24 hr 1.5% (1/66) MMI 25 Female 15 12 M - 0.8% (1/127) present study Female 44 9 M TRAb 7.4 IU/L, TSAb 1196% - MMI TSH: thyroid-stimulating hormone, D: days, M: months, Y: years, TRAb: anti-TSH receptor antibody, TSAb: thyroid-stimulating antibody, PTU: propylthiouracil, MMI: methimazole It is reasonable to hypothesize that predisposed patients are protected from autoimmune attack by immunologic tolerance related to steroid excess and overt thyroid dysfunction that develops after the decline in glucocorticoid concentration (9). However, the possibility of other mechanisms precipitating the occurrence of the disease, such as iodine excess, cannot be ruled out. The present case had SITSH for a six-month period until two months before the diagnosis of Graves' disease, although the role of SITSH in the development of Graves' disease is unclear. In conclusion, this study suggests that the thyroid function and antibody tests should be carefully evaluated before and after surgery for Cushing's syndrome. The authors state that they have no Conflict of Interest (COI). Acknowledgement We thank Angela Morben, DVM, ELS for editing a draft of this manuscript.	HYDROCORTISONE	DrugsGivenReaction	CC BY-NC-ND	32893226	19,236,992	2021-01-01
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Hypotension'.	Graves' Disease after Adrenalectomy for Cushing's Syndrome. A 44-year-old woman presented with a 3-month history of back pain, gait disturbance, and insomnia. She had moon face and central obesity but no goiter. Cushing's syndrome due to left adrenal adenoma was diagnosed. She also had low triiodothyronine syndrome and central hypothyroidism. Treatment involved adrenalectomy followed by 30 mg/day of hydrocortisone. Inappropriate secretion of thyroid-stimulating hormone occurred postoperatively. She developed Graves' disease nine months postoperatively and was treated with methimazole. Excess glucocorticoids followed by their withdrawal may influence the hypothalamic-pituitary-thyroid axis and immune system. Therefore, a careful evaluation of the thyroid function and antibodies is important after surgery for Cushing's syndrome. Introduction Cushing's syndrome is a disorder caused by chronic glucocorticoid excess, resulting in various symptoms, such as moon face, central obesity, a “buffalo hump,” red striae, and fatigue (1). The excess glucocorticoid affects the hypothalamic-pituitary-thyroid axis and results in central hypothyroidism and low triiodothyronine (T3) syndrome (2,3). The excess glucocorticoid also suppresses the immune system (4). Rapid withdrawal of glucocorticoid sometimes causes steroid withdrawal syndrome (SWS) and syndrome of inappropriate secretion of thyroid-stimulating hormone (SITSH) despite treatment with physiological doses of hydrocortisone (5,6). The resolution of hypercortisolism may also trigger the development of autoimmune disorders, including autoimmune thyroid diseases (1,7-14). We herein report a case of Graves' disease after unilateral adrenalectomy for Cushing's syndrome. Case Report A 44-year-old woman presented to our hospital with a 3-month history of back pain, gait disturbance, insomnia, and depression. She had moon face, central obesity, hypertrichosis, and pitting edema on her legs and feet. She also had a 2-year history of hypertension. The patient had no family history of thyroid disease or other autoimmune diseases. Her height was 172.7 cm, and her body weight was 71.5 kg. Her blood pressure was 132/107 mmHg. No goiter, exophthalmos, Graefe's sign, or Dalrymple's sign was present. Laboratory tests showed leukocytosis [white blood cell count, 10,900 cells/mL (neutrophils, 82.5%; eosinophils, 0.5%)] and hypokalemia (potassium, 3.4 mmol/L). Her serum free thyroxine (FT4) level was normal (0.82 ng/dL; reference range, 0.76-1.65 ng/dL), but her thyroid-stimulating hormone (TSH) level (0.377 IU/mL; reference range, 0.541-4.261 IU/mL) and free T3 (FT3) level (1.65 pg/mL; reference range, 2.39-4.06 pg/mL) were low. Her plasma adrenocorticotropic hormone (ACTH) level (<2.0 pg/mL; reference range, 7.2-63.3 pg/mL) was suppressed, and her plasma cortisol level (17.2 μg/dL; reference range, 6.24-18.0 μg/dL) and 24-h urinary free cortisol level (967 μg/day) were elevated. Loss of diurnal variation of plasma ACTH and cortisol was observed. The oral administration of 1 mg of dexamethasone at 11:00 PM did not suppress the plasma cortisol level at 8:00 AM the following morning (17.9 μg/dL). Computed tomography revealed a 30-mm tumor in the left adrenal gland (Fig. 1A). Magnetic resonance imaging did not show a pituitary tumor. 99mTc-methylene diphosphonate (MDP) scintigraphy indicated multiple fractures in the seventh to ninth right ribs, fourth and fifth lumbar vertebrae, bilateral sacroiliac joints, and left ilium (Fig. 1B). The patient was diagnosed with Cushing's syndrome due to a left adrenal adenoma. She also had low T3 syndrome and central hypothyroidism. Figure 1. Computed tomography (CT) and whole-body 99mTc-methylene diphosphonate bone scintigraphy. (A) CT revealed a 30-mm left adrenal tumor (arrow). (B) A bone scan showed a significant abnormal isotope uptake in multiple ribs and vertebrae, the sacroiliac joints, and the right ileum. Unilateral adrenalectomy was performed 5 months after the first visit to our hospital, and oral hydrocortisone was administered at 30 mg/day after surgery. She had general malaise and hypotension for 3 months despite medication with 30 mg/day hydrocortisone. Five months after surgery, the dose of hydrocortisone was reduced to 20 mg/day. Inappropriate secretion of TSH had been observed from 1 month after surgery (FT3, 4.16 pg/mL; TSH, 0.575 IU/mL) to 7 months after surgery (FT3, 4.12 pg/mL; TSH, 1.361 IU/mL). The patient developed tachycardia and diffuse goiter 9 months after the adrenalectomy and was diagnosed with Graves' disease [FT3, 10.27 pg/mL; FT4, 3.16 ng/dL; TSH, <0.003 IU/mL; anti-thyroglobulin antibody, 1,063.2 IU/mL (reference range, <40.6 IU/mL); anti-thyroid peroxidase antibody, 225.5 IU/mL (reference range, <9.4 IU/mL); anti-TSH receptor antibody (third-generation TRAb electrochemiluminescence immunoassay), 7.4 IU/L (reference range, <2.0 IU/L); and thyroid-stimulating antibody (TSAb Bioassay Enzyme Immunoassay; Yamasa, Choshi, Japan), 1,196% (reference range, <120%)]. Ultrasonography showed the diffuse enlargement of her thyroid glands with increased blood flow. She was started on oral methimazole at 15 mg/day. She remained euthyroid on oral methimazole at 5 mg/day for 15 months after adrenalectomy. The serum thyroid-stimulating antibody level gradually decreased to 216% 17 months after adrenalectomy and 149% 23 months after surgery (Fig. 2). Figure 2. Clinical course. FT3: free triiodothyronine, FT4: free thyroxine, TSH: thyroid-stimulating hormone, TRAb: anti-TSH receptor antibody, TSAb: thyroid-stimulating antibody Discussion Excess glucocorticoid followed by its withdrawal may influence the hypothalamic-pituitary-thyroid axis and immune system (1-14). In our case, low T3 syndrome and TSH suppression were present before adrenalectomy. The patient developed SITSH one month after surgery and Graves' disease nine months after adrenalectomy. The serum TSH level is suppressed in patients with Cushing's syndrome. Hypercortisolemia decreases the TSH pulse amplitude and nocturnal surge (15,16) and suppresses TSH secretion through the suppression of the thyrotropin-releasing hormone gene expression (17) or through the direct suppression of TSH secretion via leptin, dopamine, annexin 1, and somatostatin (18-21). Increased activity of type II deiodinase by glucocorticoids also causes increased local T3 levels, eventually leading to suppression of thyrotropin-releasing hormone and TSH secretion (6,22). Although the FT4 level was within the reference range in our case, central hypothyroidism with a reduced T4 level is sometimes present in patients with Cushing's syndrome. The prevalence of central hypothyroidism ranges from 18% to 26% (2,23). In our patient, SWS was observed after adrenalectomy despite supplementation with oral hydrocortisone at 30 mg/day. She also complained of anorexia and fatigue. Her serum TSH and FT3 levels were higher than the upper limit of normal, which indicated SITSH. A recent report described SITSH as a clinical condition with the presence of normal or elevated TSH secretion despite inappropriately high levels of thyroid hormones in patients who receive insufficient hydrocortisone replacement following surgery for Cushing's syndrome (6). Because the symptoms of hyperthyroidism due to SITSH overlap with those of SWS, SITSH is considered the main cause of SWS (23). Tamada et al. (6) reported that SITSH was detected in the first month of follow-up when the daily hydrocortisone replacement doses were <20 mg. SITSH was present in 75% of patients with Cushing's syndrome up to 6 months after surgery and disappeared by 12 months after surgery (6). In contrast, Dogansen et al. (2) failed to detect SITSH in the early postoperative period with their prednisolone replacement doses. Several reports have described the exacerbation or development of autoimmune disorders, including thyroid diseases, after surgery for Cushing's syndrome (7-14). Although the pathogenesis underlying the exacerbation of autoimmune thyroid disease is not well known, rebound immunity and activation of latent autoimmune thyroid disease have been postulated. In previous studies, the prevalence of autoimmune dysfunction after surgery for Cushing's syndrome was 16.7% in adults (24) and 7.8% in children (25). The prevalence of autoimmune thyroid disease after surgery for Cushing's syndrome reportedly ranges from 10% to 35% (9,13,26). Colao et al. (14) reported an increased prevalence of positive thyroglobulin and thyroid peroxidase antibody titers in patients after Cushing's syndrome remission than during active Cushing's syndrome (60% vs. 20%). Niepomniszcze et al. (27) reported that thyroid autoimmunity was detected in 21.7% of patients at the time of diagnosis of Cushing's syndrome and in 65.2% of patients after remission of hypercortisolism. Several case reports have described Graves' disease after surgery for Cushing's syndrome (24,25,27-29), reporting prevalence rates of 0.8% to 8.5% (Table). Most patients developed autoimmune thyroid disorders 7 to 10 months after surgery. Graves' disease developed 3 to 100 months after surgery for Cushing's syndrome. Therefore, physicians need to be aware of this possible outcome. Table. Previous Reports on Exacerbation or Development of Graves’ Disease after Adrenalectomy for Cushing’s Syndrome. Reference Sex Age Time of presentation of Graves’ disease after surgery TSH receptor antibody and iodine uptake Prevalence of Graves’ disease Treatment used 27 - - 3 M, 14 M, 18 M, 100 M, -20 Y - 8.5% (5/59) 28 Male 49 80 D TRAb-, TSAb- positive - Remission without treatment 29 Female 50 9 M TRAb 30 IU/L, I uptake 31% at 2 hr - PTU 24 Female 58 27 M TRAb 9.8 IU/L, I uptake 37.8% at 24 hr 1.5% (1/66) MMI 25 Female 15 12 M - 0.8% (1/127) present study Female 44 9 M TRAb 7.4 IU/L, TSAb 1196% - MMI TSH: thyroid-stimulating hormone, D: days, M: months, Y: years, TRAb: anti-TSH receptor antibody, TSAb: thyroid-stimulating antibody, PTU: propylthiouracil, MMI: methimazole It is reasonable to hypothesize that predisposed patients are protected from autoimmune attack by immunologic tolerance related to steroid excess and overt thyroid dysfunction that develops after the decline in glucocorticoid concentration (9). However, the possibility of other mechanisms precipitating the occurrence of the disease, such as iodine excess, cannot be ruled out. The present case had SITSH for a six-month period until two months before the diagnosis of Graves' disease, although the role of SITSH in the development of Graves' disease is unclear. In conclusion, this study suggests that the thyroid function and antibody tests should be carefully evaluated before and after surgery for Cushing's syndrome. The authors state that they have no Conflict of Interest (COI). Acknowledgement We thank Angela Morben, DVM, ELS for editing a draft of this manuscript.	HYDROCORTISONE	DrugsGivenReaction	CC BY-NC-ND	32893226	19,236,992	2021-01-01
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Hypothalamic pituitary adrenal axis suppression'.	Graves' Disease after Adrenalectomy for Cushing's Syndrome. A 44-year-old woman presented with a 3-month history of back pain, gait disturbance, and insomnia. She had moon face and central obesity but no goiter. Cushing's syndrome due to left adrenal adenoma was diagnosed. She also had low triiodothyronine syndrome and central hypothyroidism. Treatment involved adrenalectomy followed by 30 mg/day of hydrocortisone. Inappropriate secretion of thyroid-stimulating hormone occurred postoperatively. She developed Graves' disease nine months postoperatively and was treated with methimazole. Excess glucocorticoids followed by their withdrawal may influence the hypothalamic-pituitary-thyroid axis and immune system. Therefore, a careful evaluation of the thyroid function and antibodies is important after surgery for Cushing's syndrome. Introduction Cushing's syndrome is a disorder caused by chronic glucocorticoid excess, resulting in various symptoms, such as moon face, central obesity, a “buffalo hump,” red striae, and fatigue (1). The excess glucocorticoid affects the hypothalamic-pituitary-thyroid axis and results in central hypothyroidism and low triiodothyronine (T3) syndrome (2,3). The excess glucocorticoid also suppresses the immune system (4). Rapid withdrawal of glucocorticoid sometimes causes steroid withdrawal syndrome (SWS) and syndrome of inappropriate secretion of thyroid-stimulating hormone (SITSH) despite treatment with physiological doses of hydrocortisone (5,6). The resolution of hypercortisolism may also trigger the development of autoimmune disorders, including autoimmune thyroid diseases (1,7-14). We herein report a case of Graves' disease after unilateral adrenalectomy for Cushing's syndrome. Case Report A 44-year-old woman presented to our hospital with a 3-month history of back pain, gait disturbance, insomnia, and depression. She had moon face, central obesity, hypertrichosis, and pitting edema on her legs and feet. She also had a 2-year history of hypertension. The patient had no family history of thyroid disease or other autoimmune diseases. Her height was 172.7 cm, and her body weight was 71.5 kg. Her blood pressure was 132/107 mmHg. No goiter, exophthalmos, Graefe's sign, or Dalrymple's sign was present. Laboratory tests showed leukocytosis [white blood cell count, 10,900 cells/mL (neutrophils, 82.5%; eosinophils, 0.5%)] and hypokalemia (potassium, 3.4 mmol/L). Her serum free thyroxine (FT4) level was normal (0.82 ng/dL; reference range, 0.76-1.65 ng/dL), but her thyroid-stimulating hormone (TSH) level (0.377 IU/mL; reference range, 0.541-4.261 IU/mL) and free T3 (FT3) level (1.65 pg/mL; reference range, 2.39-4.06 pg/mL) were low. Her plasma adrenocorticotropic hormone (ACTH) level (<2.0 pg/mL; reference range, 7.2-63.3 pg/mL) was suppressed, and her plasma cortisol level (17.2 μg/dL; reference range, 6.24-18.0 μg/dL) and 24-h urinary free cortisol level (967 μg/day) were elevated. Loss of diurnal variation of plasma ACTH and cortisol was observed. The oral administration of 1 mg of dexamethasone at 11:00 PM did not suppress the plasma cortisol level at 8:00 AM the following morning (17.9 μg/dL). Computed tomography revealed a 30-mm tumor in the left adrenal gland (Fig. 1A). Magnetic resonance imaging did not show a pituitary tumor. 99mTc-methylene diphosphonate (MDP) scintigraphy indicated multiple fractures in the seventh to ninth right ribs, fourth and fifth lumbar vertebrae, bilateral sacroiliac joints, and left ilium (Fig. 1B). The patient was diagnosed with Cushing's syndrome due to a left adrenal adenoma. She also had low T3 syndrome and central hypothyroidism. Figure 1. Computed tomography (CT) and whole-body 99mTc-methylene diphosphonate bone scintigraphy. (A) CT revealed a 30-mm left adrenal tumor (arrow). (B) A bone scan showed a significant abnormal isotope uptake in multiple ribs and vertebrae, the sacroiliac joints, and the right ileum. Unilateral adrenalectomy was performed 5 months after the first visit to our hospital, and oral hydrocortisone was administered at 30 mg/day after surgery. She had general malaise and hypotension for 3 months despite medication with 30 mg/day hydrocortisone. Five months after surgery, the dose of hydrocortisone was reduced to 20 mg/day. Inappropriate secretion of TSH had been observed from 1 month after surgery (FT3, 4.16 pg/mL; TSH, 0.575 IU/mL) to 7 months after surgery (FT3, 4.12 pg/mL; TSH, 1.361 IU/mL). The patient developed tachycardia and diffuse goiter 9 months after the adrenalectomy and was diagnosed with Graves' disease [FT3, 10.27 pg/mL; FT4, 3.16 ng/dL; TSH, <0.003 IU/mL; anti-thyroglobulin antibody, 1,063.2 IU/mL (reference range, <40.6 IU/mL); anti-thyroid peroxidase antibody, 225.5 IU/mL (reference range, <9.4 IU/mL); anti-TSH receptor antibody (third-generation TRAb electrochemiluminescence immunoassay), 7.4 IU/L (reference range, <2.0 IU/L); and thyroid-stimulating antibody (TSAb Bioassay Enzyme Immunoassay; Yamasa, Choshi, Japan), 1,196% (reference range, <120%)]. Ultrasonography showed the diffuse enlargement of her thyroid glands with increased blood flow. She was started on oral methimazole at 15 mg/day. She remained euthyroid on oral methimazole at 5 mg/day for 15 months after adrenalectomy. The serum thyroid-stimulating antibody level gradually decreased to 216% 17 months after adrenalectomy and 149% 23 months after surgery (Fig. 2). Figure 2. Clinical course. FT3: free triiodothyronine, FT4: free thyroxine, TSH: thyroid-stimulating hormone, TRAb: anti-TSH receptor antibody, TSAb: thyroid-stimulating antibody Discussion Excess glucocorticoid followed by its withdrawal may influence the hypothalamic-pituitary-thyroid axis and immune system (1-14). In our case, low T3 syndrome and TSH suppression were present before adrenalectomy. The patient developed SITSH one month after surgery and Graves' disease nine months after adrenalectomy. The serum TSH level is suppressed in patients with Cushing's syndrome. Hypercortisolemia decreases the TSH pulse amplitude and nocturnal surge (15,16) and suppresses TSH secretion through the suppression of the thyrotropin-releasing hormone gene expression (17) or through the direct suppression of TSH secretion via leptin, dopamine, annexin 1, and somatostatin (18-21). Increased activity of type II deiodinase by glucocorticoids also causes increased local T3 levels, eventually leading to suppression of thyrotropin-releasing hormone and TSH secretion (6,22). Although the FT4 level was within the reference range in our case, central hypothyroidism with a reduced T4 level is sometimes present in patients with Cushing's syndrome. The prevalence of central hypothyroidism ranges from 18% to 26% (2,23). In our patient, SWS was observed after adrenalectomy despite supplementation with oral hydrocortisone at 30 mg/day. She also complained of anorexia and fatigue. Her serum TSH and FT3 levels were higher than the upper limit of normal, which indicated SITSH. A recent report described SITSH as a clinical condition with the presence of normal or elevated TSH secretion despite inappropriately high levels of thyroid hormones in patients who receive insufficient hydrocortisone replacement following surgery for Cushing's syndrome (6). Because the symptoms of hyperthyroidism due to SITSH overlap with those of SWS, SITSH is considered the main cause of SWS (23). Tamada et al. (6) reported that SITSH was detected in the first month of follow-up when the daily hydrocortisone replacement doses were <20 mg. SITSH was present in 75% of patients with Cushing's syndrome up to 6 months after surgery and disappeared by 12 months after surgery (6). In contrast, Dogansen et al. (2) failed to detect SITSH in the early postoperative period with their prednisolone replacement doses. Several reports have described the exacerbation or development of autoimmune disorders, including thyroid diseases, after surgery for Cushing's syndrome (7-14). Although the pathogenesis underlying the exacerbation of autoimmune thyroid disease is not well known, rebound immunity and activation of latent autoimmune thyroid disease have been postulated. In previous studies, the prevalence of autoimmune dysfunction after surgery for Cushing's syndrome was 16.7% in adults (24) and 7.8% in children (25). The prevalence of autoimmune thyroid disease after surgery for Cushing's syndrome reportedly ranges from 10% to 35% (9,13,26). Colao et al. (14) reported an increased prevalence of positive thyroglobulin and thyroid peroxidase antibody titers in patients after Cushing's syndrome remission than during active Cushing's syndrome (60% vs. 20%). Niepomniszcze et al. (27) reported that thyroid autoimmunity was detected in 21.7% of patients at the time of diagnosis of Cushing's syndrome and in 65.2% of patients after remission of hypercortisolism. Several case reports have described Graves' disease after surgery for Cushing's syndrome (24,25,27-29), reporting prevalence rates of 0.8% to 8.5% (Table). Most patients developed autoimmune thyroid disorders 7 to 10 months after surgery. Graves' disease developed 3 to 100 months after surgery for Cushing's syndrome. Therefore, physicians need to be aware of this possible outcome. Table. Previous Reports on Exacerbation or Development of Graves’ Disease after Adrenalectomy for Cushing’s Syndrome. Reference Sex Age Time of presentation of Graves’ disease after surgery TSH receptor antibody and iodine uptake Prevalence of Graves’ disease Treatment used 27 - - 3 M, 14 M, 18 M, 100 M, -20 Y - 8.5% (5/59) 28 Male 49 80 D TRAb-, TSAb- positive - Remission without treatment 29 Female 50 9 M TRAb 30 IU/L, I uptake 31% at 2 hr - PTU 24 Female 58 27 M TRAb 9.8 IU/L, I uptake 37.8% at 24 hr 1.5% (1/66) MMI 25 Female 15 12 M - 0.8% (1/127) present study Female 44 9 M TRAb 7.4 IU/L, TSAb 1196% - MMI TSH: thyroid-stimulating hormone, D: days, M: months, Y: years, TRAb: anti-TSH receptor antibody, TSAb: thyroid-stimulating antibody, PTU: propylthiouracil, MMI: methimazole It is reasonable to hypothesize that predisposed patients are protected from autoimmune attack by immunologic tolerance related to steroid excess and overt thyroid dysfunction that develops after the decline in glucocorticoid concentration (9). However, the possibility of other mechanisms precipitating the occurrence of the disease, such as iodine excess, cannot be ruled out. The present case had SITSH for a six-month period until two months before the diagnosis of Graves' disease, although the role of SITSH in the development of Graves' disease is unclear. In conclusion, this study suggests that the thyroid function and antibody tests should be carefully evaluated before and after surgery for Cushing's syndrome. The authors state that they have no Conflict of Interest (COI). Acknowledgement We thank Angela Morben, DVM, ELS for editing a draft of this manuscript.	HYDROCORTISONE	DrugsGivenReaction	CC BY-NC-ND	32893226	19,236,992	2021-01-01
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Inappropriate thyroid stimulating hormone secretion'.	Graves' Disease after Adrenalectomy for Cushing's Syndrome. A 44-year-old woman presented with a 3-month history of back pain, gait disturbance, and insomnia. She had moon face and central obesity but no goiter. Cushing's syndrome due to left adrenal adenoma was diagnosed. She also had low triiodothyronine syndrome and central hypothyroidism. Treatment involved adrenalectomy followed by 30 mg/day of hydrocortisone. Inappropriate secretion of thyroid-stimulating hormone occurred postoperatively. She developed Graves' disease nine months postoperatively and was treated with methimazole. Excess glucocorticoids followed by their withdrawal may influence the hypothalamic-pituitary-thyroid axis and immune system. Therefore, a careful evaluation of the thyroid function and antibodies is important after surgery for Cushing's syndrome. Introduction Cushing's syndrome is a disorder caused by chronic glucocorticoid excess, resulting in various symptoms, such as moon face, central obesity, a “buffalo hump,” red striae, and fatigue (1). The excess glucocorticoid affects the hypothalamic-pituitary-thyroid axis and results in central hypothyroidism and low triiodothyronine (T3) syndrome (2,3). The excess glucocorticoid also suppresses the immune system (4). Rapid withdrawal of glucocorticoid sometimes causes steroid withdrawal syndrome (SWS) and syndrome of inappropriate secretion of thyroid-stimulating hormone (SITSH) despite treatment with physiological doses of hydrocortisone (5,6). The resolution of hypercortisolism may also trigger the development of autoimmune disorders, including autoimmune thyroid diseases (1,7-14). We herein report a case of Graves' disease after unilateral adrenalectomy for Cushing's syndrome. Case Report A 44-year-old woman presented to our hospital with a 3-month history of back pain, gait disturbance, insomnia, and depression. She had moon face, central obesity, hypertrichosis, and pitting edema on her legs and feet. She also had a 2-year history of hypertension. The patient had no family history of thyroid disease or other autoimmune diseases. Her height was 172.7 cm, and her body weight was 71.5 kg. Her blood pressure was 132/107 mmHg. No goiter, exophthalmos, Graefe's sign, or Dalrymple's sign was present. Laboratory tests showed leukocytosis [white blood cell count, 10,900 cells/mL (neutrophils, 82.5%; eosinophils, 0.5%)] and hypokalemia (potassium, 3.4 mmol/L). Her serum free thyroxine (FT4) level was normal (0.82 ng/dL; reference range, 0.76-1.65 ng/dL), but her thyroid-stimulating hormone (TSH) level (0.377 IU/mL; reference range, 0.541-4.261 IU/mL) and free T3 (FT3) level (1.65 pg/mL; reference range, 2.39-4.06 pg/mL) were low. Her plasma adrenocorticotropic hormone (ACTH) level (<2.0 pg/mL; reference range, 7.2-63.3 pg/mL) was suppressed, and her plasma cortisol level (17.2 μg/dL; reference range, 6.24-18.0 μg/dL) and 24-h urinary free cortisol level (967 μg/day) were elevated. Loss of diurnal variation of plasma ACTH and cortisol was observed. The oral administration of 1 mg of dexamethasone at 11:00 PM did not suppress the plasma cortisol level at 8:00 AM the following morning (17.9 μg/dL). Computed tomography revealed a 30-mm tumor in the left adrenal gland (Fig. 1A). Magnetic resonance imaging did not show a pituitary tumor. 99mTc-methylene diphosphonate (MDP) scintigraphy indicated multiple fractures in the seventh to ninth right ribs, fourth and fifth lumbar vertebrae, bilateral sacroiliac joints, and left ilium (Fig. 1B). The patient was diagnosed with Cushing's syndrome due to a left adrenal adenoma. She also had low T3 syndrome and central hypothyroidism. Figure 1. Computed tomography (CT) and whole-body 99mTc-methylene diphosphonate bone scintigraphy. (A) CT revealed a 30-mm left adrenal tumor (arrow). (B) A bone scan showed a significant abnormal isotope uptake in multiple ribs and vertebrae, the sacroiliac joints, and the right ileum. Unilateral adrenalectomy was performed 5 months after the first visit to our hospital, and oral hydrocortisone was administered at 30 mg/day after surgery. She had general malaise and hypotension for 3 months despite medication with 30 mg/day hydrocortisone. Five months after surgery, the dose of hydrocortisone was reduced to 20 mg/day. Inappropriate secretion of TSH had been observed from 1 month after surgery (FT3, 4.16 pg/mL; TSH, 0.575 IU/mL) to 7 months after surgery (FT3, 4.12 pg/mL; TSH, 1.361 IU/mL). The patient developed tachycardia and diffuse goiter 9 months after the adrenalectomy and was diagnosed with Graves' disease [FT3, 10.27 pg/mL; FT4, 3.16 ng/dL; TSH, <0.003 IU/mL; anti-thyroglobulin antibody, 1,063.2 IU/mL (reference range, <40.6 IU/mL); anti-thyroid peroxidase antibody, 225.5 IU/mL (reference range, <9.4 IU/mL); anti-TSH receptor antibody (third-generation TRAb electrochemiluminescence immunoassay), 7.4 IU/L (reference range, <2.0 IU/L); and thyroid-stimulating antibody (TSAb Bioassay Enzyme Immunoassay; Yamasa, Choshi, Japan), 1,196% (reference range, <120%)]. Ultrasonography showed the diffuse enlargement of her thyroid glands with increased blood flow. She was started on oral methimazole at 15 mg/day. She remained euthyroid on oral methimazole at 5 mg/day for 15 months after adrenalectomy. The serum thyroid-stimulating antibody level gradually decreased to 216% 17 months after adrenalectomy and 149% 23 months after surgery (Fig. 2). Figure 2. Clinical course. FT3: free triiodothyronine, FT4: free thyroxine, TSH: thyroid-stimulating hormone, TRAb: anti-TSH receptor antibody, TSAb: thyroid-stimulating antibody Discussion Excess glucocorticoid followed by its withdrawal may influence the hypothalamic-pituitary-thyroid axis and immune system (1-14). In our case, low T3 syndrome and TSH suppression were present before adrenalectomy. The patient developed SITSH one month after surgery and Graves' disease nine months after adrenalectomy. The serum TSH level is suppressed in patients with Cushing's syndrome. Hypercortisolemia decreases the TSH pulse amplitude and nocturnal surge (15,16) and suppresses TSH secretion through the suppression of the thyrotropin-releasing hormone gene expression (17) or through the direct suppression of TSH secretion via leptin, dopamine, annexin 1, and somatostatin (18-21). Increased activity of type II deiodinase by glucocorticoids also causes increased local T3 levels, eventually leading to suppression of thyrotropin-releasing hormone and TSH secretion (6,22). Although the FT4 level was within the reference range in our case, central hypothyroidism with a reduced T4 level is sometimes present in patients with Cushing's syndrome. The prevalence of central hypothyroidism ranges from 18% to 26% (2,23). In our patient, SWS was observed after adrenalectomy despite supplementation with oral hydrocortisone at 30 mg/day. She also complained of anorexia and fatigue. Her serum TSH and FT3 levels were higher than the upper limit of normal, which indicated SITSH. A recent report described SITSH as a clinical condition with the presence of normal or elevated TSH secretion despite inappropriately high levels of thyroid hormones in patients who receive insufficient hydrocortisone replacement following surgery for Cushing's syndrome (6). Because the symptoms of hyperthyroidism due to SITSH overlap with those of SWS, SITSH is considered the main cause of SWS (23). Tamada et al. (6) reported that SITSH was detected in the first month of follow-up when the daily hydrocortisone replacement doses were <20 mg. SITSH was present in 75% of patients with Cushing's syndrome up to 6 months after surgery and disappeared by 12 months after surgery (6). In contrast, Dogansen et al. (2) failed to detect SITSH in the early postoperative period with their prednisolone replacement doses. Several reports have described the exacerbation or development of autoimmune disorders, including thyroid diseases, after surgery for Cushing's syndrome (7-14). Although the pathogenesis underlying the exacerbation of autoimmune thyroid disease is not well known, rebound immunity and activation of latent autoimmune thyroid disease have been postulated. In previous studies, the prevalence of autoimmune dysfunction after surgery for Cushing's syndrome was 16.7% in adults (24) and 7.8% in children (25). The prevalence of autoimmune thyroid disease after surgery for Cushing's syndrome reportedly ranges from 10% to 35% (9,13,26). Colao et al. (14) reported an increased prevalence of positive thyroglobulin and thyroid peroxidase antibody titers in patients after Cushing's syndrome remission than during active Cushing's syndrome (60% vs. 20%). Niepomniszcze et al. (27) reported that thyroid autoimmunity was detected in 21.7% of patients at the time of diagnosis of Cushing's syndrome and in 65.2% of patients after remission of hypercortisolism. Several case reports have described Graves' disease after surgery for Cushing's syndrome (24,25,27-29), reporting prevalence rates of 0.8% to 8.5% (Table). Most patients developed autoimmune thyroid disorders 7 to 10 months after surgery. Graves' disease developed 3 to 100 months after surgery for Cushing's syndrome. Therefore, physicians need to be aware of this possible outcome. Table. Previous Reports on Exacerbation or Development of Graves’ Disease after Adrenalectomy for Cushing’s Syndrome. Reference Sex Age Time of presentation of Graves’ disease after surgery TSH receptor antibody and iodine uptake Prevalence of Graves’ disease Treatment used 27 - - 3 M, 14 M, 18 M, 100 M, -20 Y - 8.5% (5/59) 28 Male 49 80 D TRAb-, TSAb- positive - Remission without treatment 29 Female 50 9 M TRAb 30 IU/L, I uptake 31% at 2 hr - PTU 24 Female 58 27 M TRAb 9.8 IU/L, I uptake 37.8% at 24 hr 1.5% (1/66) MMI 25 Female 15 12 M - 0.8% (1/127) present study Female 44 9 M TRAb 7.4 IU/L, TSAb 1196% - MMI TSH: thyroid-stimulating hormone, D: days, M: months, Y: years, TRAb: anti-TSH receptor antibody, TSAb: thyroid-stimulating antibody, PTU: propylthiouracil, MMI: methimazole It is reasonable to hypothesize that predisposed patients are protected from autoimmune attack by immunologic tolerance related to steroid excess and overt thyroid dysfunction that develops after the decline in glucocorticoid concentration (9). However, the possibility of other mechanisms precipitating the occurrence of the disease, such as iodine excess, cannot be ruled out. The present case had SITSH for a six-month period until two months before the diagnosis of Graves' disease, although the role of SITSH in the development of Graves' disease is unclear. In conclusion, this study suggests that the thyroid function and antibody tests should be carefully evaluated before and after surgery for Cushing's syndrome. The authors state that they have no Conflict of Interest (COI). Acknowledgement We thank Angela Morben, DVM, ELS for editing a draft of this manuscript.	HYDROCORTISONE	DrugsGivenReaction	CC BY-NC-ND	32893226	19,236,992	2021-01-01
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Malaise'.	Graves' Disease after Adrenalectomy for Cushing's Syndrome. A 44-year-old woman presented with a 3-month history of back pain, gait disturbance, and insomnia. She had moon face and central obesity but no goiter. Cushing's syndrome due to left adrenal adenoma was diagnosed. She also had low triiodothyronine syndrome and central hypothyroidism. Treatment involved adrenalectomy followed by 30 mg/day of hydrocortisone. Inappropriate secretion of thyroid-stimulating hormone occurred postoperatively. She developed Graves' disease nine months postoperatively and was treated with methimazole. Excess glucocorticoids followed by their withdrawal may influence the hypothalamic-pituitary-thyroid axis and immune system. Therefore, a careful evaluation of the thyroid function and antibodies is important after surgery for Cushing's syndrome. Introduction Cushing's syndrome is a disorder caused by chronic glucocorticoid excess, resulting in various symptoms, such as moon face, central obesity, a “buffalo hump,” red striae, and fatigue (1). The excess glucocorticoid affects the hypothalamic-pituitary-thyroid axis and results in central hypothyroidism and low triiodothyronine (T3) syndrome (2,3). The excess glucocorticoid also suppresses the immune system (4). Rapid withdrawal of glucocorticoid sometimes causes steroid withdrawal syndrome (SWS) and syndrome of inappropriate secretion of thyroid-stimulating hormone (SITSH) despite treatment with physiological doses of hydrocortisone (5,6). The resolution of hypercortisolism may also trigger the development of autoimmune disorders, including autoimmune thyroid diseases (1,7-14). We herein report a case of Graves' disease after unilateral adrenalectomy for Cushing's syndrome. Case Report A 44-year-old woman presented to our hospital with a 3-month history of back pain, gait disturbance, insomnia, and depression. She had moon face, central obesity, hypertrichosis, and pitting edema on her legs and feet. She also had a 2-year history of hypertension. The patient had no family history of thyroid disease or other autoimmune diseases. Her height was 172.7 cm, and her body weight was 71.5 kg. Her blood pressure was 132/107 mmHg. No goiter, exophthalmos, Graefe's sign, or Dalrymple's sign was present. Laboratory tests showed leukocytosis [white blood cell count, 10,900 cells/mL (neutrophils, 82.5%; eosinophils, 0.5%)] and hypokalemia (potassium, 3.4 mmol/L). Her serum free thyroxine (FT4) level was normal (0.82 ng/dL; reference range, 0.76-1.65 ng/dL), but her thyroid-stimulating hormone (TSH) level (0.377 IU/mL; reference range, 0.541-4.261 IU/mL) and free T3 (FT3) level (1.65 pg/mL; reference range, 2.39-4.06 pg/mL) were low. Her plasma adrenocorticotropic hormone (ACTH) level (<2.0 pg/mL; reference range, 7.2-63.3 pg/mL) was suppressed, and her plasma cortisol level (17.2 μg/dL; reference range, 6.24-18.0 μg/dL) and 24-h urinary free cortisol level (967 μg/day) were elevated. Loss of diurnal variation of plasma ACTH and cortisol was observed. The oral administration of 1 mg of dexamethasone at 11:00 PM did not suppress the plasma cortisol level at 8:00 AM the following morning (17.9 μg/dL). Computed tomography revealed a 30-mm tumor in the left adrenal gland (Fig. 1A). Magnetic resonance imaging did not show a pituitary tumor. 99mTc-methylene diphosphonate (MDP) scintigraphy indicated multiple fractures in the seventh to ninth right ribs, fourth and fifth lumbar vertebrae, bilateral sacroiliac joints, and left ilium (Fig. 1B). The patient was diagnosed with Cushing's syndrome due to a left adrenal adenoma. She also had low T3 syndrome and central hypothyroidism. Figure 1. Computed tomography (CT) and whole-body 99mTc-methylene diphosphonate bone scintigraphy. (A) CT revealed a 30-mm left adrenal tumor (arrow). (B) A bone scan showed a significant abnormal isotope uptake in multiple ribs and vertebrae, the sacroiliac joints, and the right ileum. Unilateral adrenalectomy was performed 5 months after the first visit to our hospital, and oral hydrocortisone was administered at 30 mg/day after surgery. She had general malaise and hypotension for 3 months despite medication with 30 mg/day hydrocortisone. Five months after surgery, the dose of hydrocortisone was reduced to 20 mg/day. Inappropriate secretion of TSH had been observed from 1 month after surgery (FT3, 4.16 pg/mL; TSH, 0.575 IU/mL) to 7 months after surgery (FT3, 4.12 pg/mL; TSH, 1.361 IU/mL). The patient developed tachycardia and diffuse goiter 9 months after the adrenalectomy and was diagnosed with Graves' disease [FT3, 10.27 pg/mL; FT4, 3.16 ng/dL; TSH, <0.003 IU/mL; anti-thyroglobulin antibody, 1,063.2 IU/mL (reference range, <40.6 IU/mL); anti-thyroid peroxidase antibody, 225.5 IU/mL (reference range, <9.4 IU/mL); anti-TSH receptor antibody (third-generation TRAb electrochemiluminescence immunoassay), 7.4 IU/L (reference range, <2.0 IU/L); and thyroid-stimulating antibody (TSAb Bioassay Enzyme Immunoassay; Yamasa, Choshi, Japan), 1,196% (reference range, <120%)]. Ultrasonography showed the diffuse enlargement of her thyroid glands with increased blood flow. She was started on oral methimazole at 15 mg/day. She remained euthyroid on oral methimazole at 5 mg/day for 15 months after adrenalectomy. The serum thyroid-stimulating antibody level gradually decreased to 216% 17 months after adrenalectomy and 149% 23 months after surgery (Fig. 2). Figure 2. Clinical course. FT3: free triiodothyronine, FT4: free thyroxine, TSH: thyroid-stimulating hormone, TRAb: anti-TSH receptor antibody, TSAb: thyroid-stimulating antibody Discussion Excess glucocorticoid followed by its withdrawal may influence the hypothalamic-pituitary-thyroid axis and immune system (1-14). In our case, low T3 syndrome and TSH suppression were present before adrenalectomy. The patient developed SITSH one month after surgery and Graves' disease nine months after adrenalectomy. The serum TSH level is suppressed in patients with Cushing's syndrome. Hypercortisolemia decreases the TSH pulse amplitude and nocturnal surge (15,16) and suppresses TSH secretion through the suppression of the thyrotropin-releasing hormone gene expression (17) or through the direct suppression of TSH secretion via leptin, dopamine, annexin 1, and somatostatin (18-21). Increased activity of type II deiodinase by glucocorticoids also causes increased local T3 levels, eventually leading to suppression of thyrotropin-releasing hormone and TSH secretion (6,22). Although the FT4 level was within the reference range in our case, central hypothyroidism with a reduced T4 level is sometimes present in patients with Cushing's syndrome. The prevalence of central hypothyroidism ranges from 18% to 26% (2,23). In our patient, SWS was observed after adrenalectomy despite supplementation with oral hydrocortisone at 30 mg/day. She also complained of anorexia and fatigue. Her serum TSH and FT3 levels were higher than the upper limit of normal, which indicated SITSH. A recent report described SITSH as a clinical condition with the presence of normal or elevated TSH secretion despite inappropriately high levels of thyroid hormones in patients who receive insufficient hydrocortisone replacement following surgery for Cushing's syndrome (6). Because the symptoms of hyperthyroidism due to SITSH overlap with those of SWS, SITSH is considered the main cause of SWS (23). Tamada et al. (6) reported that SITSH was detected in the first month of follow-up when the daily hydrocortisone replacement doses were <20 mg. SITSH was present in 75% of patients with Cushing's syndrome up to 6 months after surgery and disappeared by 12 months after surgery (6). In contrast, Dogansen et al. (2) failed to detect SITSH in the early postoperative period with their prednisolone replacement doses. Several reports have described the exacerbation or development of autoimmune disorders, including thyroid diseases, after surgery for Cushing's syndrome (7-14). Although the pathogenesis underlying the exacerbation of autoimmune thyroid disease is not well known, rebound immunity and activation of latent autoimmune thyroid disease have been postulated. In previous studies, the prevalence of autoimmune dysfunction after surgery for Cushing's syndrome was 16.7% in adults (24) and 7.8% in children (25). The prevalence of autoimmune thyroid disease after surgery for Cushing's syndrome reportedly ranges from 10% to 35% (9,13,26). Colao et al. (14) reported an increased prevalence of positive thyroglobulin and thyroid peroxidase antibody titers in patients after Cushing's syndrome remission than during active Cushing's syndrome (60% vs. 20%). Niepomniszcze et al. (27) reported that thyroid autoimmunity was detected in 21.7% of patients at the time of diagnosis of Cushing's syndrome and in 65.2% of patients after remission of hypercortisolism. Several case reports have described Graves' disease after surgery for Cushing's syndrome (24,25,27-29), reporting prevalence rates of 0.8% to 8.5% (Table). Most patients developed autoimmune thyroid disorders 7 to 10 months after surgery. Graves' disease developed 3 to 100 months after surgery for Cushing's syndrome. Therefore, physicians need to be aware of this possible outcome. Table. Previous Reports on Exacerbation or Development of Graves’ Disease after Adrenalectomy for Cushing’s Syndrome. Reference Sex Age Time of presentation of Graves’ disease after surgery TSH receptor antibody and iodine uptake Prevalence of Graves’ disease Treatment used 27 - - 3 M, 14 M, 18 M, 100 M, -20 Y - 8.5% (5/59) 28 Male 49 80 D TRAb-, TSAb- positive - Remission without treatment 29 Female 50 9 M TRAb 30 IU/L, I uptake 31% at 2 hr - PTU 24 Female 58 27 M TRAb 9.8 IU/L, I uptake 37.8% at 24 hr 1.5% (1/66) MMI 25 Female 15 12 M - 0.8% (1/127) present study Female 44 9 M TRAb 7.4 IU/L, TSAb 1196% - MMI TSH: thyroid-stimulating hormone, D: days, M: months, Y: years, TRAb: anti-TSH receptor antibody, TSAb: thyroid-stimulating antibody, PTU: propylthiouracil, MMI: methimazole It is reasonable to hypothesize that predisposed patients are protected from autoimmune attack by immunologic tolerance related to steroid excess and overt thyroid dysfunction that develops after the decline in glucocorticoid concentration (9). However, the possibility of other mechanisms precipitating the occurrence of the disease, such as iodine excess, cannot be ruled out. The present case had SITSH for a six-month period until two months before the diagnosis of Graves' disease, although the role of SITSH in the development of Graves' disease is unclear. In conclusion, this study suggests that the thyroid function and antibody tests should be carefully evaluated before and after surgery for Cushing's syndrome. The authors state that they have no Conflict of Interest (COI). Acknowledgement We thank Angela Morben, DVM, ELS for editing a draft of this manuscript.	HYDROCORTISONE	DrugsGivenReaction	CC BY-NC-ND	32893226	19,236,992	2021-01-01
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Parathyroid gland enlargement'.	Graves' Disease after Adrenalectomy for Cushing's Syndrome. A 44-year-old woman presented with a 3-month history of back pain, gait disturbance, and insomnia. She had moon face and central obesity but no goiter. Cushing's syndrome due to left adrenal adenoma was diagnosed. She also had low triiodothyronine syndrome and central hypothyroidism. Treatment involved adrenalectomy followed by 30 mg/day of hydrocortisone. Inappropriate secretion of thyroid-stimulating hormone occurred postoperatively. She developed Graves' disease nine months postoperatively and was treated with methimazole. Excess glucocorticoids followed by their withdrawal may influence the hypothalamic-pituitary-thyroid axis and immune system. Therefore, a careful evaluation of the thyroid function and antibodies is important after surgery for Cushing's syndrome. Introduction Cushing's syndrome is a disorder caused by chronic glucocorticoid excess, resulting in various symptoms, such as moon face, central obesity, a “buffalo hump,” red striae, and fatigue (1). The excess glucocorticoid affects the hypothalamic-pituitary-thyroid axis and results in central hypothyroidism and low triiodothyronine (T3) syndrome (2,3). The excess glucocorticoid also suppresses the immune system (4). Rapid withdrawal of glucocorticoid sometimes causes steroid withdrawal syndrome (SWS) and syndrome of inappropriate secretion of thyroid-stimulating hormone (SITSH) despite treatment with physiological doses of hydrocortisone (5,6). The resolution of hypercortisolism may also trigger the development of autoimmune disorders, including autoimmune thyroid diseases (1,7-14). We herein report a case of Graves' disease after unilateral adrenalectomy for Cushing's syndrome. Case Report A 44-year-old woman presented to our hospital with a 3-month history of back pain, gait disturbance, insomnia, and depression. She had moon face, central obesity, hypertrichosis, and pitting edema on her legs and feet. She also had a 2-year history of hypertension. The patient had no family history of thyroid disease or other autoimmune diseases. Her height was 172.7 cm, and her body weight was 71.5 kg. Her blood pressure was 132/107 mmHg. No goiter, exophthalmos, Graefe's sign, or Dalrymple's sign was present. Laboratory tests showed leukocytosis [white blood cell count, 10,900 cells/mL (neutrophils, 82.5%; eosinophils, 0.5%)] and hypokalemia (potassium, 3.4 mmol/L). Her serum free thyroxine (FT4) level was normal (0.82 ng/dL; reference range, 0.76-1.65 ng/dL), but her thyroid-stimulating hormone (TSH) level (0.377 IU/mL; reference range, 0.541-4.261 IU/mL) and free T3 (FT3) level (1.65 pg/mL; reference range, 2.39-4.06 pg/mL) were low. Her plasma adrenocorticotropic hormone (ACTH) level (<2.0 pg/mL; reference range, 7.2-63.3 pg/mL) was suppressed, and her plasma cortisol level (17.2 μg/dL; reference range, 6.24-18.0 μg/dL) and 24-h urinary free cortisol level (967 μg/day) were elevated. Loss of diurnal variation of plasma ACTH and cortisol was observed. The oral administration of 1 mg of dexamethasone at 11:00 PM did not suppress the plasma cortisol level at 8:00 AM the following morning (17.9 μg/dL). Computed tomography revealed a 30-mm tumor in the left adrenal gland (Fig. 1A). Magnetic resonance imaging did not show a pituitary tumor. 99mTc-methylene diphosphonate (MDP) scintigraphy indicated multiple fractures in the seventh to ninth right ribs, fourth and fifth lumbar vertebrae, bilateral sacroiliac joints, and left ilium (Fig. 1B). The patient was diagnosed with Cushing's syndrome due to a left adrenal adenoma. She also had low T3 syndrome and central hypothyroidism. Figure 1. Computed tomography (CT) and whole-body 99mTc-methylene diphosphonate bone scintigraphy. (A) CT revealed a 30-mm left adrenal tumor (arrow). (B) A bone scan showed a significant abnormal isotope uptake in multiple ribs and vertebrae, the sacroiliac joints, and the right ileum. Unilateral adrenalectomy was performed 5 months after the first visit to our hospital, and oral hydrocortisone was administered at 30 mg/day after surgery. She had general malaise and hypotension for 3 months despite medication with 30 mg/day hydrocortisone. Five months after surgery, the dose of hydrocortisone was reduced to 20 mg/day. Inappropriate secretion of TSH had been observed from 1 month after surgery (FT3, 4.16 pg/mL; TSH, 0.575 IU/mL) to 7 months after surgery (FT3, 4.12 pg/mL; TSH, 1.361 IU/mL). The patient developed tachycardia and diffuse goiter 9 months after the adrenalectomy and was diagnosed with Graves' disease [FT3, 10.27 pg/mL; FT4, 3.16 ng/dL; TSH, <0.003 IU/mL; anti-thyroglobulin antibody, 1,063.2 IU/mL (reference range, <40.6 IU/mL); anti-thyroid peroxidase antibody, 225.5 IU/mL (reference range, <9.4 IU/mL); anti-TSH receptor antibody (third-generation TRAb electrochemiluminescence immunoassay), 7.4 IU/L (reference range, <2.0 IU/L); and thyroid-stimulating antibody (TSAb Bioassay Enzyme Immunoassay; Yamasa, Choshi, Japan), 1,196% (reference range, <120%)]. Ultrasonography showed the diffuse enlargement of her thyroid glands with increased blood flow. She was started on oral methimazole at 15 mg/day. She remained euthyroid on oral methimazole at 5 mg/day for 15 months after adrenalectomy. The serum thyroid-stimulating antibody level gradually decreased to 216% 17 months after adrenalectomy and 149% 23 months after surgery (Fig. 2). Figure 2. Clinical course. FT3: free triiodothyronine, FT4: free thyroxine, TSH: thyroid-stimulating hormone, TRAb: anti-TSH receptor antibody, TSAb: thyroid-stimulating antibody Discussion Excess glucocorticoid followed by its withdrawal may influence the hypothalamic-pituitary-thyroid axis and immune system (1-14). In our case, low T3 syndrome and TSH suppression were present before adrenalectomy. The patient developed SITSH one month after surgery and Graves' disease nine months after adrenalectomy. The serum TSH level is suppressed in patients with Cushing's syndrome. Hypercortisolemia decreases the TSH pulse amplitude and nocturnal surge (15,16) and suppresses TSH secretion through the suppression of the thyrotropin-releasing hormone gene expression (17) or through the direct suppression of TSH secretion via leptin, dopamine, annexin 1, and somatostatin (18-21). Increased activity of type II deiodinase by glucocorticoids also causes increased local T3 levels, eventually leading to suppression of thyrotropin-releasing hormone and TSH secretion (6,22). Although the FT4 level was within the reference range in our case, central hypothyroidism with a reduced T4 level is sometimes present in patients with Cushing's syndrome. The prevalence of central hypothyroidism ranges from 18% to 26% (2,23). In our patient, SWS was observed after adrenalectomy despite supplementation with oral hydrocortisone at 30 mg/day. She also complained of anorexia and fatigue. Her serum TSH and FT3 levels were higher than the upper limit of normal, which indicated SITSH. A recent report described SITSH as a clinical condition with the presence of normal or elevated TSH secretion despite inappropriately high levels of thyroid hormones in patients who receive insufficient hydrocortisone replacement following surgery for Cushing's syndrome (6). Because the symptoms of hyperthyroidism due to SITSH overlap with those of SWS, SITSH is considered the main cause of SWS (23). Tamada et al. (6) reported that SITSH was detected in the first month of follow-up when the daily hydrocortisone replacement doses were <20 mg. SITSH was present in 75% of patients with Cushing's syndrome up to 6 months after surgery and disappeared by 12 months after surgery (6). In contrast, Dogansen et al. (2) failed to detect SITSH in the early postoperative period with their prednisolone replacement doses. Several reports have described the exacerbation or development of autoimmune disorders, including thyroid diseases, after surgery for Cushing's syndrome (7-14). Although the pathogenesis underlying the exacerbation of autoimmune thyroid disease is not well known, rebound immunity and activation of latent autoimmune thyroid disease have been postulated. In previous studies, the prevalence of autoimmune dysfunction after surgery for Cushing's syndrome was 16.7% in adults (24) and 7.8% in children (25). The prevalence of autoimmune thyroid disease after surgery for Cushing's syndrome reportedly ranges from 10% to 35% (9,13,26). Colao et al. (14) reported an increased prevalence of positive thyroglobulin and thyroid peroxidase antibody titers in patients after Cushing's syndrome remission than during active Cushing's syndrome (60% vs. 20%). Niepomniszcze et al. (27) reported that thyroid autoimmunity was detected in 21.7% of patients at the time of diagnosis of Cushing's syndrome and in 65.2% of patients after remission of hypercortisolism. Several case reports have described Graves' disease after surgery for Cushing's syndrome (24,25,27-29), reporting prevalence rates of 0.8% to 8.5% (Table). Most patients developed autoimmune thyroid disorders 7 to 10 months after surgery. Graves' disease developed 3 to 100 months after surgery for Cushing's syndrome. Therefore, physicians need to be aware of this possible outcome. Table. Previous Reports on Exacerbation or Development of Graves’ Disease after Adrenalectomy for Cushing’s Syndrome. Reference Sex Age Time of presentation of Graves’ disease after surgery TSH receptor antibody and iodine uptake Prevalence of Graves’ disease Treatment used 27 - - 3 M, 14 M, 18 M, 100 M, -20 Y - 8.5% (5/59) 28 Male 49 80 D TRAb-, TSAb- positive - Remission without treatment 29 Female 50 9 M TRAb 30 IU/L, I uptake 31% at 2 hr - PTU 24 Female 58 27 M TRAb 9.8 IU/L, I uptake 37.8% at 24 hr 1.5% (1/66) MMI 25 Female 15 12 M - 0.8% (1/127) present study Female 44 9 M TRAb 7.4 IU/L, TSAb 1196% - MMI TSH: thyroid-stimulating hormone, D: days, M: months, Y: years, TRAb: anti-TSH receptor antibody, TSAb: thyroid-stimulating antibody, PTU: propylthiouracil, MMI: methimazole It is reasonable to hypothesize that predisposed patients are protected from autoimmune attack by immunologic tolerance related to steroid excess and overt thyroid dysfunction that develops after the decline in glucocorticoid concentration (9). However, the possibility of other mechanisms precipitating the occurrence of the disease, such as iodine excess, cannot be ruled out. The present case had SITSH for a six-month period until two months before the diagnosis of Graves' disease, although the role of SITSH in the development of Graves' disease is unclear. In conclusion, this study suggests that the thyroid function and antibody tests should be carefully evaluated before and after surgery for Cushing's syndrome. The authors state that they have no Conflict of Interest (COI). Acknowledgement We thank Angela Morben, DVM, ELS for editing a draft of this manuscript.	HYDROCORTISONE	DrugsGivenReaction	CC BY-NC-ND	32893226	19,236,992	2021-01-01
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Tachycardia'.	Graves' Disease after Adrenalectomy for Cushing's Syndrome. A 44-year-old woman presented with a 3-month history of back pain, gait disturbance, and insomnia. She had moon face and central obesity but no goiter. Cushing's syndrome due to left adrenal adenoma was diagnosed. She also had low triiodothyronine syndrome and central hypothyroidism. Treatment involved adrenalectomy followed by 30 mg/day of hydrocortisone. Inappropriate secretion of thyroid-stimulating hormone occurred postoperatively. She developed Graves' disease nine months postoperatively and was treated with methimazole. Excess glucocorticoids followed by their withdrawal may influence the hypothalamic-pituitary-thyroid axis and immune system. Therefore, a careful evaluation of the thyroid function and antibodies is important after surgery for Cushing's syndrome. Introduction Cushing's syndrome is a disorder caused by chronic glucocorticoid excess, resulting in various symptoms, such as moon face, central obesity, a “buffalo hump,” red striae, and fatigue (1). The excess glucocorticoid affects the hypothalamic-pituitary-thyroid axis and results in central hypothyroidism and low triiodothyronine (T3) syndrome (2,3). The excess glucocorticoid also suppresses the immune system (4). Rapid withdrawal of glucocorticoid sometimes causes steroid withdrawal syndrome (SWS) and syndrome of inappropriate secretion of thyroid-stimulating hormone (SITSH) despite treatment with physiological doses of hydrocortisone (5,6). The resolution of hypercortisolism may also trigger the development of autoimmune disorders, including autoimmune thyroid diseases (1,7-14). We herein report a case of Graves' disease after unilateral adrenalectomy for Cushing's syndrome. Case Report A 44-year-old woman presented to our hospital with a 3-month history of back pain, gait disturbance, insomnia, and depression. She had moon face, central obesity, hypertrichosis, and pitting edema on her legs and feet. She also had a 2-year history of hypertension. The patient had no family history of thyroid disease or other autoimmune diseases. Her height was 172.7 cm, and her body weight was 71.5 kg. Her blood pressure was 132/107 mmHg. No goiter, exophthalmos, Graefe's sign, or Dalrymple's sign was present. Laboratory tests showed leukocytosis [white blood cell count, 10,900 cells/mL (neutrophils, 82.5%; eosinophils, 0.5%)] and hypokalemia (potassium, 3.4 mmol/L). Her serum free thyroxine (FT4) level was normal (0.82 ng/dL; reference range, 0.76-1.65 ng/dL), but her thyroid-stimulating hormone (TSH) level (0.377 IU/mL; reference range, 0.541-4.261 IU/mL) and free T3 (FT3) level (1.65 pg/mL; reference range, 2.39-4.06 pg/mL) were low. Her plasma adrenocorticotropic hormone (ACTH) level (<2.0 pg/mL; reference range, 7.2-63.3 pg/mL) was suppressed, and her plasma cortisol level (17.2 μg/dL; reference range, 6.24-18.0 μg/dL) and 24-h urinary free cortisol level (967 μg/day) were elevated. Loss of diurnal variation of plasma ACTH and cortisol was observed. The oral administration of 1 mg of dexamethasone at 11:00 PM did not suppress the plasma cortisol level at 8:00 AM the following morning (17.9 μg/dL). Computed tomography revealed a 30-mm tumor in the left adrenal gland (Fig. 1A). Magnetic resonance imaging did not show a pituitary tumor. 99mTc-methylene diphosphonate (MDP) scintigraphy indicated multiple fractures in the seventh to ninth right ribs, fourth and fifth lumbar vertebrae, bilateral sacroiliac joints, and left ilium (Fig. 1B). The patient was diagnosed with Cushing's syndrome due to a left adrenal adenoma. She also had low T3 syndrome and central hypothyroidism. Figure 1. Computed tomography (CT) and whole-body 99mTc-methylene diphosphonate bone scintigraphy. (A) CT revealed a 30-mm left adrenal tumor (arrow). (B) A bone scan showed a significant abnormal isotope uptake in multiple ribs and vertebrae, the sacroiliac joints, and the right ileum. Unilateral adrenalectomy was performed 5 months after the first visit to our hospital, and oral hydrocortisone was administered at 30 mg/day after surgery. She had general malaise and hypotension for 3 months despite medication with 30 mg/day hydrocortisone. Five months after surgery, the dose of hydrocortisone was reduced to 20 mg/day. Inappropriate secretion of TSH had been observed from 1 month after surgery (FT3, 4.16 pg/mL; TSH, 0.575 IU/mL) to 7 months after surgery (FT3, 4.12 pg/mL; TSH, 1.361 IU/mL). The patient developed tachycardia and diffuse goiter 9 months after the adrenalectomy and was diagnosed with Graves' disease [FT3, 10.27 pg/mL; FT4, 3.16 ng/dL; TSH, <0.003 IU/mL; anti-thyroglobulin antibody, 1,063.2 IU/mL (reference range, <40.6 IU/mL); anti-thyroid peroxidase antibody, 225.5 IU/mL (reference range, <9.4 IU/mL); anti-TSH receptor antibody (third-generation TRAb electrochemiluminescence immunoassay), 7.4 IU/L (reference range, <2.0 IU/L); and thyroid-stimulating antibody (TSAb Bioassay Enzyme Immunoassay; Yamasa, Choshi, Japan), 1,196% (reference range, <120%)]. Ultrasonography showed the diffuse enlargement of her thyroid glands with increased blood flow. She was started on oral methimazole at 15 mg/day. She remained euthyroid on oral methimazole at 5 mg/day for 15 months after adrenalectomy. The serum thyroid-stimulating antibody level gradually decreased to 216% 17 months after adrenalectomy and 149% 23 months after surgery (Fig. 2). Figure 2. Clinical course. FT3: free triiodothyronine, FT4: free thyroxine, TSH: thyroid-stimulating hormone, TRAb: anti-TSH receptor antibody, TSAb: thyroid-stimulating antibody Discussion Excess glucocorticoid followed by its withdrawal may influence the hypothalamic-pituitary-thyroid axis and immune system (1-14). In our case, low T3 syndrome and TSH suppression were present before adrenalectomy. The patient developed SITSH one month after surgery and Graves' disease nine months after adrenalectomy. The serum TSH level is suppressed in patients with Cushing's syndrome. Hypercortisolemia decreases the TSH pulse amplitude and nocturnal surge (15,16) and suppresses TSH secretion through the suppression of the thyrotropin-releasing hormone gene expression (17) or through the direct suppression of TSH secretion via leptin, dopamine, annexin 1, and somatostatin (18-21). Increased activity of type II deiodinase by glucocorticoids also causes increased local T3 levels, eventually leading to suppression of thyrotropin-releasing hormone and TSH secretion (6,22). Although the FT4 level was within the reference range in our case, central hypothyroidism with a reduced T4 level is sometimes present in patients with Cushing's syndrome. The prevalence of central hypothyroidism ranges from 18% to 26% (2,23). In our patient, SWS was observed after adrenalectomy despite supplementation with oral hydrocortisone at 30 mg/day. She also complained of anorexia and fatigue. Her serum TSH and FT3 levels were higher than the upper limit of normal, which indicated SITSH. A recent report described SITSH as a clinical condition with the presence of normal or elevated TSH secretion despite inappropriately high levels of thyroid hormones in patients who receive insufficient hydrocortisone replacement following surgery for Cushing's syndrome (6). Because the symptoms of hyperthyroidism due to SITSH overlap with those of SWS, SITSH is considered the main cause of SWS (23). Tamada et al. (6) reported that SITSH was detected in the first month of follow-up when the daily hydrocortisone replacement doses were <20 mg. SITSH was present in 75% of patients with Cushing's syndrome up to 6 months after surgery and disappeared by 12 months after surgery (6). In contrast, Dogansen et al. (2) failed to detect SITSH in the early postoperative period with their prednisolone replacement doses. Several reports have described the exacerbation or development of autoimmune disorders, including thyroid diseases, after surgery for Cushing's syndrome (7-14). Although the pathogenesis underlying the exacerbation of autoimmune thyroid disease is not well known, rebound immunity and activation of latent autoimmune thyroid disease have been postulated. In previous studies, the prevalence of autoimmune dysfunction after surgery for Cushing's syndrome was 16.7% in adults (24) and 7.8% in children (25). The prevalence of autoimmune thyroid disease after surgery for Cushing's syndrome reportedly ranges from 10% to 35% (9,13,26). Colao et al. (14) reported an increased prevalence of positive thyroglobulin and thyroid peroxidase antibody titers in patients after Cushing's syndrome remission than during active Cushing's syndrome (60% vs. 20%). Niepomniszcze et al. (27) reported that thyroid autoimmunity was detected in 21.7% of patients at the time of diagnosis of Cushing's syndrome and in 65.2% of patients after remission of hypercortisolism. Several case reports have described Graves' disease after surgery for Cushing's syndrome (24,25,27-29), reporting prevalence rates of 0.8% to 8.5% (Table). Most patients developed autoimmune thyroid disorders 7 to 10 months after surgery. Graves' disease developed 3 to 100 months after surgery for Cushing's syndrome. Therefore, physicians need to be aware of this possible outcome. Table. Previous Reports on Exacerbation or Development of Graves’ Disease after Adrenalectomy for Cushing’s Syndrome. Reference Sex Age Time of presentation of Graves’ disease after surgery TSH receptor antibody and iodine uptake Prevalence of Graves’ disease Treatment used 27 - - 3 M, 14 M, 18 M, 100 M, -20 Y - 8.5% (5/59) 28 Male 49 80 D TRAb-, TSAb- positive - Remission without treatment 29 Female 50 9 M TRAb 30 IU/L, I uptake 31% at 2 hr - PTU 24 Female 58 27 M TRAb 9.8 IU/L, I uptake 37.8% at 24 hr 1.5% (1/66) MMI 25 Female 15 12 M - 0.8% (1/127) present study Female 44 9 M TRAb 7.4 IU/L, TSAb 1196% - MMI TSH: thyroid-stimulating hormone, D: days, M: months, Y: years, TRAb: anti-TSH receptor antibody, TSAb: thyroid-stimulating antibody, PTU: propylthiouracil, MMI: methimazole It is reasonable to hypothesize that predisposed patients are protected from autoimmune attack by immunologic tolerance related to steroid excess and overt thyroid dysfunction that develops after the decline in glucocorticoid concentration (9). However, the possibility of other mechanisms precipitating the occurrence of the disease, such as iodine excess, cannot be ruled out. The present case had SITSH for a six-month period until two months before the diagnosis of Graves' disease, although the role of SITSH in the development of Graves' disease is unclear. In conclusion, this study suggests that the thyroid function and antibody tests should be carefully evaluated before and after surgery for Cushing's syndrome. The authors state that they have no Conflict of Interest (COI). Acknowledgement We thank Angela Morben, DVM, ELS for editing a draft of this manuscript.	HYDROCORTISONE	DrugsGivenReaction	CC BY-NC-ND	32893226	19,236,992	2021-01-01
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Gastric ulcer'.	Bevacizumab plus cisplatin/pemetrexed then bevacizumab alone for unresectable malignant pleural mesothelioma: A Japanese safety study. OBJECTIVE Malignant pleural mesothelioma (MPM) is an aggressive malignancy with poor prognosis and limited treatment options. Cisplatin plus pemetrexed is the only approved first-line treatment for patients with unresectable MPM. Recently, promising outcomes were observed with first-line bevacizumab combined with cisplatin/pemetrexed, leading to the recommendation of this regimen as a first-line treatment option for patients with MPM. Bevacizumab plus cisplatin/pemetrexed has been shown to be safe and effective in non-small cell lung cancer, however, there are no efficacy or safety data in Japanese patients with MPM treated with this regimen. We conducted a multicenter study to evaluate tolerability and safety for Japanese patients with chemotherapy-naïve, unresectable MPM. METHODS Eligible patients (n = 7) received bevacizumab plus cisplatin/pemetrexed (up to six cycles), then single-agent bevacizumab until disease progression or onset of unacceptable adverse events (AEs), according to the 3+3 design analogy. RESULTS One patient (14.3%) reported an AE (gastric ulcer) meeting tolerability criteria. All patients experienced gastrointestinal disorders, including nausea (grade 1/2 only, n = 6, 85.7%) and constipation (grade 1/2 only, n = 5, 71.4%). Five patients (71.4%) had grade 3 hypertension. Two patients discontinued treatment due to gastric ulcer (n = 1) and proteinuria (n = 1). At data cut-off, four patients had stable disease, two had partial response and one had non-complete response/non-progressive disease due to the absence of target lesions. CONCLUSIONS Bevacizumab plus cisplatin/pemetrexed then bevacizumab was well tolerated in Japanese patients with MPM. 1 INTRODUCTION Malignant pleural mesothelioma (MPM) is a rare, aggressive neoplasm with poor prognosis, which originates in the mesothelial cells lining the thoracic cavity. 1 Development of MPM is strongly associated with inhalational exposure to asbestos, and is usually caused by occupational asbestos exposure, but it can also occur from low‐level exposure in the general environment. 2 Despite regulatory action against, and prohibition of the use of asbestos, the number of patients with MPM is increasing substantially in many countries where asbestos has been widely used historically. 3 Its incidence is increasing rapidly worldwide, and the annual number of MPM deaths in Japan has risen from 500 in 1995 to 1555 in 2017. 4 Asia has become the largest consumer of asbestos in the world and is responsible for two‐thirds of global use. 5 China continues to use asbestos and is the top consumer in the world, with an increasing trend of MPM during 2000–2013 and 1659 MPM cases in 2013, but its incidence is low compared with industrialized countries. 5 Newly diagnosed patients with unresectable disease have a median overall survival (OS) of ∼12 months when treated with the standard of care, cisplatin plus pemetrexed. 6 The combination of cisplatin plus pemetrexed is the only currently approved regimen for unresectable first‐line MPM, with approvals gained in 2004 in the USA and European Union, and in 2007 in Japan. Phase II studies demonstrated that pemetrexed in combination with carboplatin might be an alternative regimen with similar treatment outcomes. 7 There have been no new first‐line therapies approved for MPM for more than a decade. Furthermore, there is no US Food and Drug Administration (FDA)‐approved or European Medicines Agency (EMA)‐approved second‐line treatment for MPM. In 2018, anti‐programmed death‐1 (PD‐1) antibody nivolumab was approved in Japan for salvage use. The National Comprehensive Cancer Network (NCCN) guidelines revised their recommendation for nivolumab use with or without ipilimumab from category 2B to 2A, on the basis of recent clinical trial data for subsequent systemic MPM treatment. 8 In view of the poor prognosis and limited approved therapies, there is an unmet need for new treatment options that further improve outcomes for patients with MPM. A broad range of therapeutic targets exist in MPM, including angiogenesis, immune checkpoints, mesothelin and chemotherapeutic agents. Vascular endothelial growth factor (VEGF) is known to be a key regulator of MPM because it is an autocrine growth factor of MPM. 9 Significantly higher serum levels of VEGF have been identified in patients with MPM compared with other tumor types 10 and high VEGF level in serum or pleural effusion is a poor prognostic factor in MPM. 11 , 12 Because VEGF signaling is essential for mesothelioma cell physiopathology, 9 VEGF targeting therapy, such as the recombinant humanized monoclonal antibody bevacizumab, is a rational approach for the treatment of MPM. 13 , 14 Preclinical evaluation of the therapeutic efficacy of bevacizumab in combination with pemetrexed against mesothelioma has shown a synergy for the combination, compared with pemetrexed or bevacizumab alone. 15 Bevacizumab, when added to standard chemotherapy, has demonstrated effectiveness in non–small cell lung cancer (NSCLC) 16 and other tumor types such as breast cancer, 17 colorectal cancer 18 and renal cell carcinoma. 19 Bevacizumab has been evaluated as a combination therapy for MPM in randomized phase II and III clinical trials. 20 , 21 Prior to the approval of pemetrexed, gemcitabine plus cisplatin was a common treatment regimen for MPM. In a randomized phase II US trial in patients with previously untreated MPM, the addition of bevacizumab to gemcitabine/cisplatin did not improve progression‐free survival (PFS) or OS. 20 It was postulated that the trial failed to show positive results due to a potential negative interaction between bevacizumab and gemcitabine in preclinical studies. 22 Therefore, other chemotherapy backbones with bevacizumab, including cisplatin plus pemetrexed, have been investigated. The phase III Mesothelioma Avastin Cisplatin Pemetrexed Study (MAPS), which evaluated the addition of bevacizumab to cisplatin/pemetrexed followed by bevacizumab maintenance, was the first trial to demonstrate improved outcomes versus the standard of care. 21 In MAPS, the addition of bevacizumab to cisplatin/pemetrexed significantly improved PFS and OS compared with cisplatin/pemetrexed alone (OS = 18.8 months vs 16.1 months; hazard ratio [HR] = 0.77; P = 0.0167; PFS = 9.2 months vs 7.3 months, HR = 0.61, P < 0.0001). Additionally, adverse events (AEs) reported in MAPS were consistent with the known safety profile of bevacizumab plus chemotherapy. Based on these outcomes, 21 bevacizumab in combination with cisplatin/pemetrexed was included as a category 1 recommended first‐line treatment for unresectable MPM in the NCCN guidelines. 8 Although MAPS was conducted by the French Cooperative Thoracic Intergroup and data were from French patients only, the results confirm that first‐line bevacizumab‐based therapy can improve outcomes for patients with newly diagnosed MPM. Bevacizumab plus cisplatin/pemetrexed has been shown to be safe and effective in Japanese patients with NSCLC; however, there are no data showing tolerability and safety in Japanese patients with MPM treated with this triplet regimen. This article reports results from a single‐arm, multicenter study evaluating the tolerability, safety and efficacy of first‐line bevacizumab together with cisplatin/pemetrexed, followed by single‐agent bevacizumab, in Japanese patients with unresectable MPM. 2 PATIENTS AND METHODS 2.1 Study design JO39183 (JapicCTI‐163294) was a multicenter, open‐label, single‐arm, phase II study evaluating the tolerability, safety and efficacy of bevacizumab combined with cisplatin/pemetrexed followed by single‐agent bevacizumab in patients with unresectable MPM who had not previously received chemotherapy (Figure 1). The replacement of cisplatin by carboplatin was allowed in cases where a patient developed nephrotoxicity (creatinine clearance <45 mL/min, 6 weeks after administration) or ototoxicity. The target sample size for the study was six patients, which is determined as an analogy for 3+3 design, according to the methods of official recommendation issued by the Pharmaceutical and Food Safety Bureau, Ministry of Health, Labour and Welfare, Japan. 23 However, it was permissible to enroll more than six patients because the main purpose of the study was to evaluate tolerability and safety in Japanese patients. Following enrollment, each patient received up to six cycles of bevacizumab, cisplatin and pemetrexed (induction period), with cycles repeated every 3 weeks. Patients then continued to receive bevacizumab monotherapy every 3 weeks during the maintenance period until disease progression or the onset of unacceptable AEs. FIGURE 1 Study design The study was conducted in accordance with the principles of the Declaration of Helsinki and Good Clinical Practice. All appropriate ethical approval was received from Institutional Review Boards or Independent Ethics Committees at each of the sites. All patients provided written informed consent prior to any study‐related procedures, and agreed to their individual data being published. 2.2 Eligibility criteria Key inclusion criteria for patients included: age ≥20 years with histologically confirmed pleural mesothelioma, not considered amendable to resection; an Eastern Cooperative Oncology Group performance status (ECOG PS) of 0–2; life expectancy of ≥12 weeks from the time of enrollment; no previous chemotherapy for MPM (including adjuvant and neoadjuvant therapy); and radiographically evident lesions. Patients with central nervous system metastases were excluded. Further exclusion criteria are detailed in the Supporting Information. 2.3 Treatment Patients received combination therapy with bevacizumab, cisplatin and pemetrexed, administered for up to six cycles with cycles being repeated every 3 weeks in the induction period. Pemetrexed 500 mg/m2 was administered intravenously (IV) over 10 min, then 30 min later cisplatin 75 mg/m2 IV was administered over 2 h. Following the cisplatin infusion, bevacizumab 15 mg/kg IV was administered over 30–90 min. If carboplatin was used in place of cisplatin, it was administered at a dose at which the target area under the curve was 5 mg/mL/min (as calculated based on the Calvert formula) over 30–60 min on Day 1 of each cycle. Following six cycles of the combination, bevacizumab 15 mg/kg was administered every 3 weeks in the maintenance period until disease progression or the onset of unacceptable AEs. The combination therapy could be discontinued before completion of six cycles; in this case, patients continued on bevacizumab monotherapy. The study duration for each patient was from the day of consent to the last observation day (observation or assessment day that was 28 ± 7 days after the last dose of study drug). 2.4 Study endpoints The primary purpose was to evaluate the tolerability of bevacizumab combined with cisplatin/pemetrexed. Secondary purposes were to evaluate the safety and efficacy of bevacizumab combined with cisplatin/pemetrexed followed by single‐agent bevacizumab. 2.5 Study assessments The evaluation period for tolerability was from Day 1 of Cycle 1 until immediately prior to the start of study drug administration on Day 1 of Cycle 2. AEs predefined for tolerability criteria included grade 4 neutropenia persisting for ≥7 days, febrile neutropenia, grade 3/4 reductions in platelet counts and any nonhematologic toxicity with severity of grade 3 or higher (further details are provided in the Supporting Information), occurring during the tolerability evaluation period and for which a causal relationship to the combination therapy could not be ruled out. The study treatment was considered tolerable if these AEs were reported in ≤34% (two out of six patients) of all enrolled patients considered evaluable for tolerability. The severity of AEs was graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.03. An Efficacy and Safety Evaluation Committee decided whether to continue the study and/or to amend the protocol if any AEs meeting the tolerability criteria were reported in three patients during the study period. If the occurrence of AEs meeting the criteria was estimated to be in ≤34% of the target number of patients (e.g. corresponding AEs were not reported in the first four patients, excluding patients who were considered nonevaluable for tolerability), the Efficacy and Safety Evaluation Committee had the option of closing enrollment. Safety was assessed using data collected until the point at which the observation period in Cycle 1 was completed for the last patient. AEs were coded using the Medical Dictionary for Regulatory Activities (version 19.0) and summarized by system organ class and preferred term. Best overall response and median PFS were assessed in accordance with Response Evaluation Criteria in Solid Tumors version 1.1. PFS was defined as the time from the first day of study drug administration to the first documented disease progression or death, whichever occurred first. 3 RESULTS 3.1 Patient population Seven patients, from four centers, were enrolled into the study and all received bevacizumab combination therapy. After four cycles of treatment with bevacizumab, cisplatin and pemetrexed, one patient changed from cisplatin to carboplatin due to reduced kidney function. Baseline patient characteristics are shown in Table 1. Patients had a median age of 66 years (range 47–73) and 57.1% were male. Although patients with an ECOG PS of 0–2 were eligible, all patients had an ECOG PS of 0 or 1. The tolerability and safety analysis sets included all seven patients. The data cut‐off was September 15, 2016, for tolerability and July 6, 2017, for safety and efficacy. TABLE 1 Patient characteristics at baseline Patient characteristics Patients (n = 7) Sex, n (%) Male 4 (57.1) Female 3 (42.9) Median age (range), years 66 (47–73) Histology, n (%) Epithelioid 6 (85.7) Sarcomatoid or mixed 1 (14.3) ECOG PS, n (%) 0 5 (71.4) 1 2 (28.6) Smoking status, n (%) Smoker 4 (57.1) Never smoker 3 (42.9) Abbreviation: ECOG PS, Eastern Cooperative Oncology Group performance status. John Wiley & Sons, Ltd. 3.2 Treatment exposure A summary of treatment exposure is shown in Figure 2. Overall, a median of nine cycles of bevacizumab were administered, with a median treatment duration of 188 days. Dose intensity was defined as the proportion of actual doses received to planned dose. For pemetrexed and cisplatin, planned dose was defined as the initial dose for six cycles completed without dose delay or dose reduction. For bevacizumab, planned dose was defined as the initial dose for actual cycles completed without dose delay or dose reduction. The mean dose intensities of bevacizumab, pemetrexed and cisplatin were 94%, 72% and 65%, respectively. FIGURE 2 Treatment exposure. †, Cisplatin was replaced with carboplatin for Cycles 5 and 6. ‡, Ongoing At the time of data cut‐off (July 6, 2017), four patients had discontinued treatment and three were continuing to receive single‐agent bevacizumab. One patient discontinued combination therapy due to a gastric ulcer and another due to proteinuria. The remaining two patients discontinued combination therapy due to disease progression. Three out of seven patients did not complete six cycles of chemotherapy; in addition, one patient received carboplatin instead of cisplatin for Cycles 5 and 6 due to reduced creatinine clearance. In the three patients who did not complete six cycles of chemotherapy, the reasons for chemotherapy discontinuation were gastric ulcer, proteinuria (as mentioned above), systemic rash and dyspnea. 3.3 Tolerability During the tolerability evaluation period, one of the seven patients (14.3%) experienced an AE (gastric ulcer), which met the definition criteria for tolerability. 3.4 Safety All seven patients (100%) experienced at least one AE (any grade) and a total of 74 AEs were reported. All patients experienced gastrointestinal disorders (any grade), with the most common being nausea (any grade, n = 6, 85.7%) and constipation (any grade, n = 5, 71.4%). Six different grade 3 AEs were reported: hypertension occurred in five patients (71.4%), and elevated amylase, elevated γ‐glutamyltransferase, hyponatremia, anemia and proteinuria each occurred in one patient (14.3%). There were no grade 4/5 AEs. Two patients had AEs that led to treatment discontinuation; one had a gastric ulcer (n = 1; 14.3%) and the other had proteinuria (n = 1; 14.3%). No deaths were reported. Treatment‐related AEs are detailed in Table 2. TABLE 2 Treatment‐related adverse events (n = 7) Any grade, n (%) Grade 1, n (%) Grade 2, n (%) Grade 3, n (%) Nausea 6 (85.7) 3 (42.9) 3 (42.9) 0 Hypertension 6 (85.7) 0 1 (14.3) 5 (71.4) Constipation 4 (57.1) 3 (42.9) 1 (14.3) 0 Edema peripheral 1 (14.3) 1 (14.3) 0 0 Malaise 2 (28.6) 1 (14.3) 1 (14.3) 0 Rash generalized 2 (28.6) 0 2 (28.6) 0 Epistaxis 2 (28.6) 2 (28.6) 0 0 Dysgeusia 2 (28.6) 2 (28.6) 0 0 Headache 1 (14.3) 0 1 (14.3) 0 Hiccups 1 (14.3) 1 (14.3) 0 0 Amylase increased 1 (14.3) 0 0 1 (14.3) Gastric ulcer 1 (14.3) 0 1 (14.3) 0 Eyelid edema 1 (14.3) 1 (14.3) 0 0 Blood creatinine increased 1 (14.3) 1 (14.3) 0 0 Dyspnea 1 (14.3) 0 1 (14.3) 0 Oropharyngeal pain 1 (14.3) 1 (14.3) 0 0 Stomatitis 1 (14.3) 1 (14.3) 0 0 Neutrophil count decreased 1 (14.3) 0 1 (14.3) 0 Periodontal disease 1 (14.3) 0 1 (14.3) 0 Carpal tunnel syndrome 1 (14.3) 1 (14.3) 0 0 Pigmentation disorder 1 (14.3) 1 (14.3) 0 0 Decreased appetite 1 (14.3) 0 1 (14.3) 0 Creatinine renal clearance decreased 1 (14.3) 0 1 (14.3) 0 Bodyweight increased 1 (14.3) 1 (14.3) 0 0 Proteinuria 1 (14.3) 0 0 1 (14.3) Injection site pain 1 (14.3) 1 (14.3) 0 0 Flushing 1 (14.3) 1 (14.3) 0 0 Hyponatremia 1 (14.3) 0 0 1 (14.3) Protein urine present 1 (14.3) 0 1 (14.3) 0 White blood cell count decreased 1 (14.3) 0 1 (14.3) 0 Rash 1 (14.3) 1 (14.3) 0 0 Pyrexia 1 (14.3) 1 (14.3) 0 0 Abdominal distension 1 (14.3) 0 1 (14.3) 0 Peripheral neuropathy 1 (14.3) 1 (14.3) 0 0 Vomiting 1 (14.3) 0 1 (14.3) 0 No grade 4/5 treatment‐related adverse events were reported. John Wiley & Sons, Ltd. 3.5 Efficacy Best overall response and PFS data are shown in Table 3. At the time of data cut‐off (July 6, 2017), four patients had stable disease, two had a partial response and one had non‐complete response/non‐progressive disease (non‐CR/non‐PD). The four patients who had stable disease had PFS of 0.9, 2.7, 6.7 and 6.8 months, respectively; and the two patients with a partial response had censored PFS durations of 10.4 and 11.1 months, respectively. The partial response in one of the patients is illustrated in Figure 3. The non‐CR/non‐PD patient had a PFS of 9.4 months (censored). Three patients who had either a partial response (n = 2) or a non‐CR/non‐PD (n = 1) remained on treatment at the time of data cut‐off. TABLE 3 Summary of efficacy Patient number Status Best overall response PFS (months) 1 Withdrawal at C1 SD a 0.9 2 Withdrawal at C3 SD 2.7 3 Withdrawal at C9 SD 6.7 4 Withdrawal at C9 SD 6.8 5 Ongoing PR 10.4 b 6 Ongoing Non‐CR/non‐PD 9.4 b 7 Ongoing PR 11.1 b Abbreviations: C, cycle; CR, complete response; PD, progressive disease; PFS, progression‐free survival; PR, partial response; SD, stable disease. a The period from baseline to best overall response evaluation was ≥6 weeks. b Censored observation, treatment ongoing. John Wiley & Sons, Ltd. FIGURE 3 Patient case: Computed tomography scan after Cycle 7 in a 47‐year‐old, female patient who was diagnosed with stage III MPM, and experienced a partial response after receiving treatment without dose modification, other than cisplatin at Cycle 6, when treatment with cisplatin was discontinued mid‐treatment due to the occurrence of a systemic rash (patient #5) 4 DISCUSSION This is the first study to report tolerability and safety data for Japanese patients with MPM treated with bevacizumab plus cisplatin/pemetrexed. Our results demonstrate that bevacizumab added to cisplatin/pemetrexed, followed by single‐agent bevacizumab is tolerable as a first‐line treatment in Japanese patients with MPM. No new safety concerns were identified for bevacizumab either in combination with cisplatin/pemetrexed or as single‐agent maintenance treatment. The overall safety profile in this study was consistent with data published for MAPS. 21 All patients in our study experienced gastrointestinal AEs, the most common being nausea (85.7%; any grade), which was similar to the incidence reported in MAPS (78.4%). Notably, 71.4% of patients experienced grade 3 hypertension compared with only 23% of patients in MAPS. 21 However, hypertension was manageable with administration of antihypertensive medications, allowing patients to continue receiving bevacizumab. Other grade 3 AEs included elevated amylase, elevated γ‐glutamyltransferase, anemia, proteinuria and hyponatremia. The toxicity profile of bevacizumab plus cisplatin/pemetrexed was also similar to that reported in Japanese patients with NSCLC 24 and with advanced cervical cancer. 25 Although it is difficult to make cross‐trial comparisons due to differences in study designs, methods of assessment and patient populations, our safety data appear to be consistent with previous reports on bevacizumab‐based therapy for MPM, and did not identify any previously unknown toxicities. 21 , 22 One patient changed from cisplatin to carboplatin due to reduced kidney function but, since there is a wealth of safety and efficacy data for carboplatin‐based chemotherapy, it is unlikely that this would significantly impact the safety profile. 16 , 26 , 27 One patient withdrew from the study due to a gastric ulcer, which was confirmed by the investigator as being associated with bevacizumab; however, because gastroendoscopy was not conducted prior to study enrollment, it is unknown whether this was present at baseline. Another patient experienced pleural effusion but continued to receive bevacizumab for ∼1.5 years (as of January 31, 2018). Similarly, results from the multicenter, phase II, NEJ013A trial showed that bevacizumab may be active in patients with malignant pleural effusion. 28 Median PFS was 6.8 months in this study, which is similar to two phase II studies in MPM that both reported median PFS of 6.9 months with the addition of bevacizumab to standard of care: the multicenter study by Dowell et al. 29 (n = 52) evaluated the same regimen as our study, and the randomized trial by Kindler et al. 20 (n = 108) added bevacizumab to cisplatin/gemcitabine. In contrast, two patients with a partial response had a longer PFS of 10.4 and 11.1 months in our study. The phase III MAPS, with a larger population of 448 patients, reported median PFS and OS durations of 9.2 and 18.8 months, respectively, with bevacizumab plus cisplatin/pemetrexed. 21 At the data cut‐off, three patients remained on treatment with bevacizumab and continue to be monitored. Patients can continue treatment for about a year, so there is potential to observe ongoing responses in these patients. As of January 31, 2018, two patients had continued to receive treatment for ∼1.5 years and no new toxicity had been observed. The combination of anti‐angiogenic agents, such as bevacizumab, nintedanib and cediranib, with cisplatin/pemetrexed has been evaluated in the first‐line MPM treatment setting. The most promising results have been obtained with the addition of bevacizumab to cisplatin/pemetrexed. 21 Nintedanib is a triple angiokinase inhibitor with activity against VEGF receptor 1−3, platelet‐derived growth factor (PDGF) receptors α and ß, fibroblast growth factors receptors 1−3 and Src and Abl kinases. Addition of nintedanib to cisplatin/pemetrexed in the phase II LUME‐Meso study improved PFS in patients with unresectable nonsarcomatoid MPM compared with the addition of placebo (median PFS 9.4 months vs 5.7 months, respectively). 30 However, the double‐blind, randomized, placebo‐controlled phase III LUME‐Meso study in unresectable epithelioid MPM failed to meet its primary PFS endpoint (median PFS 6.8 months in the nintedanib arm vs 7.0 months in the placebo arm; P = 0.91). 31 Cediranib is an inhibitor of VEGF receptor, PDGF receptor and stem cell factor receptor. In a phase I trial, the addition of cediranib to cisplatin/pemetrexed demonstrated promising preliminary outcomes in patients with chemotherapy‐naïve MPM (median PFS = 8.6 months; median OS = 16.2 months). 32 Results from the ongoing phase II study of cediranib in combination with cisplatin/pemetrexed (NCT01064648) are awaited. Recently, nivolumab was approved in Japan as salvage therapy in MPM patients, and is now being evaluated in the first‐line setting in combination with standard of care treatment in Japan. 33 Preclinical studies suggest that combining anti‐angiogenic agents with immunotherapy may have a synergistic effect, enhancing the efficacy of both treatments. 34 A phase I trial is currently assessing nintedanib in combination with the PD‐1 inhibitor pembrolizumab in patients with various tumors including MPM (NCT02856425), whereas a phase II study is evaluating bevacizumab in combination with atezolizumab in MPM and peritoneal mesothelioma (NCT03074513). We reported safety and efficacy data for first‐line bevacizumab in combination with cisplatin/pemetrexed in Japanese patients with MPM, for whom data are currently limited. Our safety data are comparable with other similar studies and show that the addition of bevacizumab to the current standard of care is tolerable. 5 CONCLUSION The combination of bevacizumab, cisplatin and pemetrexed followed by maintenance treatment with bevacizumab was well tolerated and had satisfactory efficacy in this small patient dataset, warranting its first‐line use in Japanese patients with MPM, on the basis of the phase III study in France. In terms of systematic chemotherapy for MPM, cisplatin plus pemetrexed is the only approved regimen in the untreated setting. Data from this single‐arm trial are encouraging for patients with unresectable MPM; the addition of bevacizumab to standard chemotherapy would offer an alternative treatment option and may extend survival in patients with this aggressive neoplasm. CONFLICTS OF INTEREST Takashi Nakano has received honoraria from MSD, Olympus Corporation, ISHIHARA Sangyo, KYORIN Pharmaceutical, Nippon Boehringer Ingelheim and ONO Pharmaceutical; acted in a consulting or advisory role for Nippon Boehringer Ingelheim; and reports personal fees from Cancer and Chemotherapy Publishers, Ishiyaku Publishers, IGAKU‐SHOIN, Elsevier Japan K.K., Asakura Publishing, Ministry of the Environment Japan and Amagasaki City, outside the submitted work. Kozo Kuribayashi has received honoraria from AstraZeneca, Astellas Pharma, Boehringer Ingelheim, Chugai Pharmaceutical, Kyowa Hakko Kirin, KYORIN Pharmaceutical, Meiji‐Seika‐Pharma, Novartis, Ono Pharmaceutical and Taiho Pharmaceutical. Masashi Kondo has received honoraria from Eli Lilly, MSD, Chugai Pharmaceutical, Pfizer, Novartis, AstraZeneca, Nippon Boehringer Ingelheim, Taiho Pharmaceutical and Kyowa Hakko Kirin. Masahiro Morise has received honoraria from Chugai Pharmaceutical, Eli Lilly Japan K.K., Ono Pharmaceutical, Bristol‐Myers Squibb, Pfizer, AstraZeneca, Boehringer Ingelheim, Merck Serono and Novartis. Yuji Tada has received honoraria from Chugai Pharmaceutical. Katsuya Hirano reports personal fees from AstraZeneca K.K., Chugai Pharmaceutical, Eli Lilly, Nippon Boehringer Ingelheim, Ono Pharmaceutical, Pfizer, Taiho Pharmaceutical and Novartis, outside the submitted work. Morihiko Hayashi and Misa Tanaka are employees of Chugai Pharmaceutical, and Misa Tanaka owns stock in Chugai Pharmaceutical. Masataka Hirabayashi has received honoraria from AstraZeneca K.K., Ono Pharmaceutical, KYORIN Pharmaceutical, Taiho Pharmaceutical, MSD, Chugai Pharmaceutical, Pfizer, Boehringer Ingelheim and Eli Lilly. Supporting information Supporting Information Click here for additional data file. ACKNOWLEDGMENTS This study was supported by Chugai Pharmaceutical Co., Ltd. We thank the patients who participated in this study. We also express our thanks to Kosei Tajima of Chugai Pharmaceutical Co., Ltd., and Professor Takashi Kijima, Hyogo College of Medicine, for drafting and reviewing the manuscript. Third‐party medical writing assistance, under the direction of the authors, was provided by Nathalie Robinson, PhD, and Rachel Hubbard, MSc, of Gardiner‐Caldwell Communications, and was funded by Chugai Pharmaceutical Co., Ltd. Trial registration number: JapicCTI‐163294. DATA AVAILABILITY STATEMENT Chugai Pharmaceutical Co., Ltd. provide qualified researchers access to individual patient‐level data through the clinical study data request platform (www.clinicalstudydatarequest.com). Further details of Chugai's Data Sharing Policy are available here (https://www.chugai‐pharm.co.jp/english/profile/rd/ctds_request.html).	BEVACIZUMAB, CISPLATIN, PEMETREXED	DrugsGivenReaction	CC BY-NC	32893992	18,306,165	2021-06
What was the administration route of drug 'BEVACIZUMAB'?	Bevacizumab plus cisplatin/pemetrexed then bevacizumab alone for unresectable malignant pleural mesothelioma: A Japanese safety study. OBJECTIVE Malignant pleural mesothelioma (MPM) is an aggressive malignancy with poor prognosis and limited treatment options. Cisplatin plus pemetrexed is the only approved first-line treatment for patients with unresectable MPM. Recently, promising outcomes were observed with first-line bevacizumab combined with cisplatin/pemetrexed, leading to the recommendation of this regimen as a first-line treatment option for patients with MPM. Bevacizumab plus cisplatin/pemetrexed has been shown to be safe and effective in non-small cell lung cancer, however, there are no efficacy or safety data in Japanese patients with MPM treated with this regimen. We conducted a multicenter study to evaluate tolerability and safety for Japanese patients with chemotherapy-naïve, unresectable MPM. METHODS Eligible patients (n = 7) received bevacizumab plus cisplatin/pemetrexed (up to six cycles), then single-agent bevacizumab until disease progression or onset of unacceptable adverse events (AEs), according to the 3+3 design analogy. RESULTS One patient (14.3%) reported an AE (gastric ulcer) meeting tolerability criteria. All patients experienced gastrointestinal disorders, including nausea (grade 1/2 only, n = 6, 85.7%) and constipation (grade 1/2 only, n = 5, 71.4%). Five patients (71.4%) had grade 3 hypertension. Two patients discontinued treatment due to gastric ulcer (n = 1) and proteinuria (n = 1). At data cut-off, four patients had stable disease, two had partial response and one had non-complete response/non-progressive disease due to the absence of target lesions. CONCLUSIONS Bevacizumab plus cisplatin/pemetrexed then bevacizumab was well tolerated in Japanese patients with MPM. 1 INTRODUCTION Malignant pleural mesothelioma (MPM) is a rare, aggressive neoplasm with poor prognosis, which originates in the mesothelial cells lining the thoracic cavity. 1 Development of MPM is strongly associated with inhalational exposure to asbestos, and is usually caused by occupational asbestos exposure, but it can also occur from low‐level exposure in the general environment. 2 Despite regulatory action against, and prohibition of the use of asbestos, the number of patients with MPM is increasing substantially in many countries where asbestos has been widely used historically. 3 Its incidence is increasing rapidly worldwide, and the annual number of MPM deaths in Japan has risen from 500 in 1995 to 1555 in 2017. 4 Asia has become the largest consumer of asbestos in the world and is responsible for two‐thirds of global use. 5 China continues to use asbestos and is the top consumer in the world, with an increasing trend of MPM during 2000–2013 and 1659 MPM cases in 2013, but its incidence is low compared with industrialized countries. 5 Newly diagnosed patients with unresectable disease have a median overall survival (OS) of ∼12 months when treated with the standard of care, cisplatin plus pemetrexed. 6 The combination of cisplatin plus pemetrexed is the only currently approved regimen for unresectable first‐line MPM, with approvals gained in 2004 in the USA and European Union, and in 2007 in Japan. Phase II studies demonstrated that pemetrexed in combination with carboplatin might be an alternative regimen with similar treatment outcomes. 7 There have been no new first‐line therapies approved for MPM for more than a decade. Furthermore, there is no US Food and Drug Administration (FDA)‐approved or European Medicines Agency (EMA)‐approved second‐line treatment for MPM. In 2018, anti‐programmed death‐1 (PD‐1) antibody nivolumab was approved in Japan for salvage use. The National Comprehensive Cancer Network (NCCN) guidelines revised their recommendation for nivolumab use with or without ipilimumab from category 2B to 2A, on the basis of recent clinical trial data for subsequent systemic MPM treatment. 8 In view of the poor prognosis and limited approved therapies, there is an unmet need for new treatment options that further improve outcomes for patients with MPM. A broad range of therapeutic targets exist in MPM, including angiogenesis, immune checkpoints, mesothelin and chemotherapeutic agents. Vascular endothelial growth factor (VEGF) is known to be a key regulator of MPM because it is an autocrine growth factor of MPM. 9 Significantly higher serum levels of VEGF have been identified in patients with MPM compared with other tumor types 10 and high VEGF level in serum or pleural effusion is a poor prognostic factor in MPM. 11 , 12 Because VEGF signaling is essential for mesothelioma cell physiopathology, 9 VEGF targeting therapy, such as the recombinant humanized monoclonal antibody bevacizumab, is a rational approach for the treatment of MPM. 13 , 14 Preclinical evaluation of the therapeutic efficacy of bevacizumab in combination with pemetrexed against mesothelioma has shown a synergy for the combination, compared with pemetrexed or bevacizumab alone. 15 Bevacizumab, when added to standard chemotherapy, has demonstrated effectiveness in non–small cell lung cancer (NSCLC) 16 and other tumor types such as breast cancer, 17 colorectal cancer 18 and renal cell carcinoma. 19 Bevacizumab has been evaluated as a combination therapy for MPM in randomized phase II and III clinical trials. 20 , 21 Prior to the approval of pemetrexed, gemcitabine plus cisplatin was a common treatment regimen for MPM. In a randomized phase II US trial in patients with previously untreated MPM, the addition of bevacizumab to gemcitabine/cisplatin did not improve progression‐free survival (PFS) or OS. 20 It was postulated that the trial failed to show positive results due to a potential negative interaction between bevacizumab and gemcitabine in preclinical studies. 22 Therefore, other chemotherapy backbones with bevacizumab, including cisplatin plus pemetrexed, have been investigated. The phase III Mesothelioma Avastin Cisplatin Pemetrexed Study (MAPS), which evaluated the addition of bevacizumab to cisplatin/pemetrexed followed by bevacizumab maintenance, was the first trial to demonstrate improved outcomes versus the standard of care. 21 In MAPS, the addition of bevacizumab to cisplatin/pemetrexed significantly improved PFS and OS compared with cisplatin/pemetrexed alone (OS = 18.8 months vs 16.1 months; hazard ratio [HR] = 0.77; P = 0.0167; PFS = 9.2 months vs 7.3 months, HR = 0.61, P < 0.0001). Additionally, adverse events (AEs) reported in MAPS were consistent with the known safety profile of bevacizumab plus chemotherapy. Based on these outcomes, 21 bevacizumab in combination with cisplatin/pemetrexed was included as a category 1 recommended first‐line treatment for unresectable MPM in the NCCN guidelines. 8 Although MAPS was conducted by the French Cooperative Thoracic Intergroup and data were from French patients only, the results confirm that first‐line bevacizumab‐based therapy can improve outcomes for patients with newly diagnosed MPM. Bevacizumab plus cisplatin/pemetrexed has been shown to be safe and effective in Japanese patients with NSCLC; however, there are no data showing tolerability and safety in Japanese patients with MPM treated with this triplet regimen. This article reports results from a single‐arm, multicenter study evaluating the tolerability, safety and efficacy of first‐line bevacizumab together with cisplatin/pemetrexed, followed by single‐agent bevacizumab, in Japanese patients with unresectable MPM. 2 PATIENTS AND METHODS 2.1 Study design JO39183 (JapicCTI‐163294) was a multicenter, open‐label, single‐arm, phase II study evaluating the tolerability, safety and efficacy of bevacizumab combined with cisplatin/pemetrexed followed by single‐agent bevacizumab in patients with unresectable MPM who had not previously received chemotherapy (Figure 1). The replacement of cisplatin by carboplatin was allowed in cases where a patient developed nephrotoxicity (creatinine clearance <45 mL/min, 6 weeks after administration) or ototoxicity. The target sample size for the study was six patients, which is determined as an analogy for 3+3 design, according to the methods of official recommendation issued by the Pharmaceutical and Food Safety Bureau, Ministry of Health, Labour and Welfare, Japan. 23 However, it was permissible to enroll more than six patients because the main purpose of the study was to evaluate tolerability and safety in Japanese patients. Following enrollment, each patient received up to six cycles of bevacizumab, cisplatin and pemetrexed (induction period), with cycles repeated every 3 weeks. Patients then continued to receive bevacizumab monotherapy every 3 weeks during the maintenance period until disease progression or the onset of unacceptable AEs. FIGURE 1 Study design The study was conducted in accordance with the principles of the Declaration of Helsinki and Good Clinical Practice. All appropriate ethical approval was received from Institutional Review Boards or Independent Ethics Committees at each of the sites. All patients provided written informed consent prior to any study‐related procedures, and agreed to their individual data being published. 2.2 Eligibility criteria Key inclusion criteria for patients included: age ≥20 years with histologically confirmed pleural mesothelioma, not considered amendable to resection; an Eastern Cooperative Oncology Group performance status (ECOG PS) of 0–2; life expectancy of ≥12 weeks from the time of enrollment; no previous chemotherapy for MPM (including adjuvant and neoadjuvant therapy); and radiographically evident lesions. Patients with central nervous system metastases were excluded. Further exclusion criteria are detailed in the Supporting Information. 2.3 Treatment Patients received combination therapy with bevacizumab, cisplatin and pemetrexed, administered for up to six cycles with cycles being repeated every 3 weeks in the induction period. Pemetrexed 500 mg/m2 was administered intravenously (IV) over 10 min, then 30 min later cisplatin 75 mg/m2 IV was administered over 2 h. Following the cisplatin infusion, bevacizumab 15 mg/kg IV was administered over 30–90 min. If carboplatin was used in place of cisplatin, it was administered at a dose at which the target area under the curve was 5 mg/mL/min (as calculated based on the Calvert formula) over 30–60 min on Day 1 of each cycle. Following six cycles of the combination, bevacizumab 15 mg/kg was administered every 3 weeks in the maintenance period until disease progression or the onset of unacceptable AEs. The combination therapy could be discontinued before completion of six cycles; in this case, patients continued on bevacizumab monotherapy. The study duration for each patient was from the day of consent to the last observation day (observation or assessment day that was 28 ± 7 days after the last dose of study drug). 2.4 Study endpoints The primary purpose was to evaluate the tolerability of bevacizumab combined with cisplatin/pemetrexed. Secondary purposes were to evaluate the safety and efficacy of bevacizumab combined with cisplatin/pemetrexed followed by single‐agent bevacizumab. 2.5 Study assessments The evaluation period for tolerability was from Day 1 of Cycle 1 until immediately prior to the start of study drug administration on Day 1 of Cycle 2. AEs predefined for tolerability criteria included grade 4 neutropenia persisting for ≥7 days, febrile neutropenia, grade 3/4 reductions in platelet counts and any nonhematologic toxicity with severity of grade 3 or higher (further details are provided in the Supporting Information), occurring during the tolerability evaluation period and for which a causal relationship to the combination therapy could not be ruled out. The study treatment was considered tolerable if these AEs were reported in ≤34% (two out of six patients) of all enrolled patients considered evaluable for tolerability. The severity of AEs was graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.03. An Efficacy and Safety Evaluation Committee decided whether to continue the study and/or to amend the protocol if any AEs meeting the tolerability criteria were reported in three patients during the study period. If the occurrence of AEs meeting the criteria was estimated to be in ≤34% of the target number of patients (e.g. corresponding AEs were not reported in the first four patients, excluding patients who were considered nonevaluable for tolerability), the Efficacy and Safety Evaluation Committee had the option of closing enrollment. Safety was assessed using data collected until the point at which the observation period in Cycle 1 was completed for the last patient. AEs were coded using the Medical Dictionary for Regulatory Activities (version 19.0) and summarized by system organ class and preferred term. Best overall response and median PFS were assessed in accordance with Response Evaluation Criteria in Solid Tumors version 1.1. PFS was defined as the time from the first day of study drug administration to the first documented disease progression or death, whichever occurred first. 3 RESULTS 3.1 Patient population Seven patients, from four centers, were enrolled into the study and all received bevacizumab combination therapy. After four cycles of treatment with bevacizumab, cisplatin and pemetrexed, one patient changed from cisplatin to carboplatin due to reduced kidney function. Baseline patient characteristics are shown in Table 1. Patients had a median age of 66 years (range 47–73) and 57.1% were male. Although patients with an ECOG PS of 0–2 were eligible, all patients had an ECOG PS of 0 or 1. The tolerability and safety analysis sets included all seven patients. The data cut‐off was September 15, 2016, for tolerability and July 6, 2017, for safety and efficacy. TABLE 1 Patient characteristics at baseline Patient characteristics Patients (n = 7) Sex, n (%) Male 4 (57.1) Female 3 (42.9) Median age (range), years 66 (47–73) Histology, n (%) Epithelioid 6 (85.7) Sarcomatoid or mixed 1 (14.3) ECOG PS, n (%) 0 5 (71.4) 1 2 (28.6) Smoking status, n (%) Smoker 4 (57.1) Never smoker 3 (42.9) Abbreviation: ECOG PS, Eastern Cooperative Oncology Group performance status. John Wiley & Sons, Ltd. 3.2 Treatment exposure A summary of treatment exposure is shown in Figure 2. Overall, a median of nine cycles of bevacizumab were administered, with a median treatment duration of 188 days. Dose intensity was defined as the proportion of actual doses received to planned dose. For pemetrexed and cisplatin, planned dose was defined as the initial dose for six cycles completed without dose delay or dose reduction. For bevacizumab, planned dose was defined as the initial dose for actual cycles completed without dose delay or dose reduction. The mean dose intensities of bevacizumab, pemetrexed and cisplatin were 94%, 72% and 65%, respectively. FIGURE 2 Treatment exposure. †, Cisplatin was replaced with carboplatin for Cycles 5 and 6. ‡, Ongoing At the time of data cut‐off (July 6, 2017), four patients had discontinued treatment and three were continuing to receive single‐agent bevacizumab. One patient discontinued combination therapy due to a gastric ulcer and another due to proteinuria. The remaining two patients discontinued combination therapy due to disease progression. Three out of seven patients did not complete six cycles of chemotherapy; in addition, one patient received carboplatin instead of cisplatin for Cycles 5 and 6 due to reduced creatinine clearance. In the three patients who did not complete six cycles of chemotherapy, the reasons for chemotherapy discontinuation were gastric ulcer, proteinuria (as mentioned above), systemic rash and dyspnea. 3.3 Tolerability During the tolerability evaluation period, one of the seven patients (14.3%) experienced an AE (gastric ulcer), which met the definition criteria for tolerability. 3.4 Safety All seven patients (100%) experienced at least one AE (any grade) and a total of 74 AEs were reported. All patients experienced gastrointestinal disorders (any grade), with the most common being nausea (any grade, n = 6, 85.7%) and constipation (any grade, n = 5, 71.4%). Six different grade 3 AEs were reported: hypertension occurred in five patients (71.4%), and elevated amylase, elevated γ‐glutamyltransferase, hyponatremia, anemia and proteinuria each occurred in one patient (14.3%). There were no grade 4/5 AEs. Two patients had AEs that led to treatment discontinuation; one had a gastric ulcer (n = 1; 14.3%) and the other had proteinuria (n = 1; 14.3%). No deaths were reported. Treatment‐related AEs are detailed in Table 2. TABLE 2 Treatment‐related adverse events (n = 7) Any grade, n (%) Grade 1, n (%) Grade 2, n (%) Grade 3, n (%) Nausea 6 (85.7) 3 (42.9) 3 (42.9) 0 Hypertension 6 (85.7) 0 1 (14.3) 5 (71.4) Constipation 4 (57.1) 3 (42.9) 1 (14.3) 0 Edema peripheral 1 (14.3) 1 (14.3) 0 0 Malaise 2 (28.6) 1 (14.3) 1 (14.3) 0 Rash generalized 2 (28.6) 0 2 (28.6) 0 Epistaxis 2 (28.6) 2 (28.6) 0 0 Dysgeusia 2 (28.6) 2 (28.6) 0 0 Headache 1 (14.3) 0 1 (14.3) 0 Hiccups 1 (14.3) 1 (14.3) 0 0 Amylase increased 1 (14.3) 0 0 1 (14.3) Gastric ulcer 1 (14.3) 0 1 (14.3) 0 Eyelid edema 1 (14.3) 1 (14.3) 0 0 Blood creatinine increased 1 (14.3) 1 (14.3) 0 0 Dyspnea 1 (14.3) 0 1 (14.3) 0 Oropharyngeal pain 1 (14.3) 1 (14.3) 0 0 Stomatitis 1 (14.3) 1 (14.3) 0 0 Neutrophil count decreased 1 (14.3) 0 1 (14.3) 0 Periodontal disease 1 (14.3) 0 1 (14.3) 0 Carpal tunnel syndrome 1 (14.3) 1 (14.3) 0 0 Pigmentation disorder 1 (14.3) 1 (14.3) 0 0 Decreased appetite 1 (14.3) 0 1 (14.3) 0 Creatinine renal clearance decreased 1 (14.3) 0 1 (14.3) 0 Bodyweight increased 1 (14.3) 1 (14.3) 0 0 Proteinuria 1 (14.3) 0 0 1 (14.3) Injection site pain 1 (14.3) 1 (14.3) 0 0 Flushing 1 (14.3) 1 (14.3) 0 0 Hyponatremia 1 (14.3) 0 0 1 (14.3) Protein urine present 1 (14.3) 0 1 (14.3) 0 White blood cell count decreased 1 (14.3) 0 1 (14.3) 0 Rash 1 (14.3) 1 (14.3) 0 0 Pyrexia 1 (14.3) 1 (14.3) 0 0 Abdominal distension 1 (14.3) 0 1 (14.3) 0 Peripheral neuropathy 1 (14.3) 1 (14.3) 0 0 Vomiting 1 (14.3) 0 1 (14.3) 0 No grade 4/5 treatment‐related adverse events were reported. John Wiley & Sons, Ltd. 3.5 Efficacy Best overall response and PFS data are shown in Table 3. At the time of data cut‐off (July 6, 2017), four patients had stable disease, two had a partial response and one had non‐complete response/non‐progressive disease (non‐CR/non‐PD). The four patients who had stable disease had PFS of 0.9, 2.7, 6.7 and 6.8 months, respectively; and the two patients with a partial response had censored PFS durations of 10.4 and 11.1 months, respectively. The partial response in one of the patients is illustrated in Figure 3. The non‐CR/non‐PD patient had a PFS of 9.4 months (censored). Three patients who had either a partial response (n = 2) or a non‐CR/non‐PD (n = 1) remained on treatment at the time of data cut‐off. TABLE 3 Summary of efficacy Patient number Status Best overall response PFS (months) 1 Withdrawal at C1 SD a 0.9 2 Withdrawal at C3 SD 2.7 3 Withdrawal at C9 SD 6.7 4 Withdrawal at C9 SD 6.8 5 Ongoing PR 10.4 b 6 Ongoing Non‐CR/non‐PD 9.4 b 7 Ongoing PR 11.1 b Abbreviations: C, cycle; CR, complete response; PD, progressive disease; PFS, progression‐free survival; PR, partial response; SD, stable disease. a The period from baseline to best overall response evaluation was ≥6 weeks. b Censored observation, treatment ongoing. John Wiley & Sons, Ltd. FIGURE 3 Patient case: Computed tomography scan after Cycle 7 in a 47‐year‐old, female patient who was diagnosed with stage III MPM, and experienced a partial response after receiving treatment without dose modification, other than cisplatin at Cycle 6, when treatment with cisplatin was discontinued mid‐treatment due to the occurrence of a systemic rash (patient #5) 4 DISCUSSION This is the first study to report tolerability and safety data for Japanese patients with MPM treated with bevacizumab plus cisplatin/pemetrexed. Our results demonstrate that bevacizumab added to cisplatin/pemetrexed, followed by single‐agent bevacizumab is tolerable as a first‐line treatment in Japanese patients with MPM. No new safety concerns were identified for bevacizumab either in combination with cisplatin/pemetrexed or as single‐agent maintenance treatment. The overall safety profile in this study was consistent with data published for MAPS. 21 All patients in our study experienced gastrointestinal AEs, the most common being nausea (85.7%; any grade), which was similar to the incidence reported in MAPS (78.4%). Notably, 71.4% of patients experienced grade 3 hypertension compared with only 23% of patients in MAPS. 21 However, hypertension was manageable with administration of antihypertensive medications, allowing patients to continue receiving bevacizumab. Other grade 3 AEs included elevated amylase, elevated γ‐glutamyltransferase, anemia, proteinuria and hyponatremia. The toxicity profile of bevacizumab plus cisplatin/pemetrexed was also similar to that reported in Japanese patients with NSCLC 24 and with advanced cervical cancer. 25 Although it is difficult to make cross‐trial comparisons due to differences in study designs, methods of assessment and patient populations, our safety data appear to be consistent with previous reports on bevacizumab‐based therapy for MPM, and did not identify any previously unknown toxicities. 21 , 22 One patient changed from cisplatin to carboplatin due to reduced kidney function but, since there is a wealth of safety and efficacy data for carboplatin‐based chemotherapy, it is unlikely that this would significantly impact the safety profile. 16 , 26 , 27 One patient withdrew from the study due to a gastric ulcer, which was confirmed by the investigator as being associated with bevacizumab; however, because gastroendoscopy was not conducted prior to study enrollment, it is unknown whether this was present at baseline. Another patient experienced pleural effusion but continued to receive bevacizumab for ∼1.5 years (as of January 31, 2018). Similarly, results from the multicenter, phase II, NEJ013A trial showed that bevacizumab may be active in patients with malignant pleural effusion. 28 Median PFS was 6.8 months in this study, which is similar to two phase II studies in MPM that both reported median PFS of 6.9 months with the addition of bevacizumab to standard of care: the multicenter study by Dowell et al. 29 (n = 52) evaluated the same regimen as our study, and the randomized trial by Kindler et al. 20 (n = 108) added bevacizumab to cisplatin/gemcitabine. In contrast, two patients with a partial response had a longer PFS of 10.4 and 11.1 months in our study. The phase III MAPS, with a larger population of 448 patients, reported median PFS and OS durations of 9.2 and 18.8 months, respectively, with bevacizumab plus cisplatin/pemetrexed. 21 At the data cut‐off, three patients remained on treatment with bevacizumab and continue to be monitored. Patients can continue treatment for about a year, so there is potential to observe ongoing responses in these patients. As of January 31, 2018, two patients had continued to receive treatment for ∼1.5 years and no new toxicity had been observed. The combination of anti‐angiogenic agents, such as bevacizumab, nintedanib and cediranib, with cisplatin/pemetrexed has been evaluated in the first‐line MPM treatment setting. The most promising results have been obtained with the addition of bevacizumab to cisplatin/pemetrexed. 21 Nintedanib is a triple angiokinase inhibitor with activity against VEGF receptor 1−3, platelet‐derived growth factor (PDGF) receptors α and ß, fibroblast growth factors receptors 1−3 and Src and Abl kinases. Addition of nintedanib to cisplatin/pemetrexed in the phase II LUME‐Meso study improved PFS in patients with unresectable nonsarcomatoid MPM compared with the addition of placebo (median PFS 9.4 months vs 5.7 months, respectively). 30 However, the double‐blind, randomized, placebo‐controlled phase III LUME‐Meso study in unresectable epithelioid MPM failed to meet its primary PFS endpoint (median PFS 6.8 months in the nintedanib arm vs 7.0 months in the placebo arm; P = 0.91). 31 Cediranib is an inhibitor of VEGF receptor, PDGF receptor and stem cell factor receptor. In a phase I trial, the addition of cediranib to cisplatin/pemetrexed demonstrated promising preliminary outcomes in patients with chemotherapy‐naïve MPM (median PFS = 8.6 months; median OS = 16.2 months). 32 Results from the ongoing phase II study of cediranib in combination with cisplatin/pemetrexed (NCT01064648) are awaited. Recently, nivolumab was approved in Japan as salvage therapy in MPM patients, and is now being evaluated in the first‐line setting in combination with standard of care treatment in Japan. 33 Preclinical studies suggest that combining anti‐angiogenic agents with immunotherapy may have a synergistic effect, enhancing the efficacy of both treatments. 34 A phase I trial is currently assessing nintedanib in combination with the PD‐1 inhibitor pembrolizumab in patients with various tumors including MPM (NCT02856425), whereas a phase II study is evaluating bevacizumab in combination with atezolizumab in MPM and peritoneal mesothelioma (NCT03074513). We reported safety and efficacy data for first‐line bevacizumab in combination with cisplatin/pemetrexed in Japanese patients with MPM, for whom data are currently limited. Our safety data are comparable with other similar studies and show that the addition of bevacizumab to the current standard of care is tolerable. 5 CONCLUSION The combination of bevacizumab, cisplatin and pemetrexed followed by maintenance treatment with bevacizumab was well tolerated and had satisfactory efficacy in this small patient dataset, warranting its first‐line use in Japanese patients with MPM, on the basis of the phase III study in France. In terms of systematic chemotherapy for MPM, cisplatin plus pemetrexed is the only approved regimen in the untreated setting. Data from this single‐arm trial are encouraging for patients with unresectable MPM; the addition of bevacizumab to standard chemotherapy would offer an alternative treatment option and may extend survival in patients with this aggressive neoplasm. CONFLICTS OF INTEREST Takashi Nakano has received honoraria from MSD, Olympus Corporation, ISHIHARA Sangyo, KYORIN Pharmaceutical, Nippon Boehringer Ingelheim and ONO Pharmaceutical; acted in a consulting or advisory role for Nippon Boehringer Ingelheim; and reports personal fees from Cancer and Chemotherapy Publishers, Ishiyaku Publishers, IGAKU‐SHOIN, Elsevier Japan K.K., Asakura Publishing, Ministry of the Environment Japan and Amagasaki City, outside the submitted work. Kozo Kuribayashi has received honoraria from AstraZeneca, Astellas Pharma, Boehringer Ingelheim, Chugai Pharmaceutical, Kyowa Hakko Kirin, KYORIN Pharmaceutical, Meiji‐Seika‐Pharma, Novartis, Ono Pharmaceutical and Taiho Pharmaceutical. Masashi Kondo has received honoraria from Eli Lilly, MSD, Chugai Pharmaceutical, Pfizer, Novartis, AstraZeneca, Nippon Boehringer Ingelheim, Taiho Pharmaceutical and Kyowa Hakko Kirin. Masahiro Morise has received honoraria from Chugai Pharmaceutical, Eli Lilly Japan K.K., Ono Pharmaceutical, Bristol‐Myers Squibb, Pfizer, AstraZeneca, Boehringer Ingelheim, Merck Serono and Novartis. Yuji Tada has received honoraria from Chugai Pharmaceutical. Katsuya Hirano reports personal fees from AstraZeneca K.K., Chugai Pharmaceutical, Eli Lilly, Nippon Boehringer Ingelheim, Ono Pharmaceutical, Pfizer, Taiho Pharmaceutical and Novartis, outside the submitted work. Morihiko Hayashi and Misa Tanaka are employees of Chugai Pharmaceutical, and Misa Tanaka owns stock in Chugai Pharmaceutical. Masataka Hirabayashi has received honoraria from AstraZeneca K.K., Ono Pharmaceutical, KYORIN Pharmaceutical, Taiho Pharmaceutical, MSD, Chugai Pharmaceutical, Pfizer, Boehringer Ingelheim and Eli Lilly. Supporting information Supporting Information Click here for additional data file. ACKNOWLEDGMENTS This study was supported by Chugai Pharmaceutical Co., Ltd. We thank the patients who participated in this study. We also express our thanks to Kosei Tajima of Chugai Pharmaceutical Co., Ltd., and Professor Takashi Kijima, Hyogo College of Medicine, for drafting and reviewing the manuscript. Third‐party medical writing assistance, under the direction of the authors, was provided by Nathalie Robinson, PhD, and Rachel Hubbard, MSc, of Gardiner‐Caldwell Communications, and was funded by Chugai Pharmaceutical Co., Ltd. Trial registration number: JapicCTI‐163294. DATA AVAILABILITY STATEMENT Chugai Pharmaceutical Co., Ltd. provide qualified researchers access to individual patient‐level data through the clinical study data request platform (www.clinicalstudydatarequest.com). Further details of Chugai's Data Sharing Policy are available here (https://www.chugai‐pharm.co.jp/english/profile/rd/ctds_request.html).	Intravenous (not otherwise specified)	DrugAdministrationRoute	CC BY-NC	32893992	18,306,165	2021-06
What was the administration route of drug 'CISPLATIN'?	Bevacizumab plus cisplatin/pemetrexed then bevacizumab alone for unresectable malignant pleural mesothelioma: A Japanese safety study. OBJECTIVE Malignant pleural mesothelioma (MPM) is an aggressive malignancy with poor prognosis and limited treatment options. Cisplatin plus pemetrexed is the only approved first-line treatment for patients with unresectable MPM. Recently, promising outcomes were observed with first-line bevacizumab combined with cisplatin/pemetrexed, leading to the recommendation of this regimen as a first-line treatment option for patients with MPM. Bevacizumab plus cisplatin/pemetrexed has been shown to be safe and effective in non-small cell lung cancer, however, there are no efficacy or safety data in Japanese patients with MPM treated with this regimen. We conducted a multicenter study to evaluate tolerability and safety for Japanese patients with chemotherapy-naïve, unresectable MPM. METHODS Eligible patients (n = 7) received bevacizumab plus cisplatin/pemetrexed (up to six cycles), then single-agent bevacizumab until disease progression or onset of unacceptable adverse events (AEs), according to the 3+3 design analogy. RESULTS One patient (14.3%) reported an AE (gastric ulcer) meeting tolerability criteria. All patients experienced gastrointestinal disorders, including nausea (grade 1/2 only, n = 6, 85.7%) and constipation (grade 1/2 only, n = 5, 71.4%). Five patients (71.4%) had grade 3 hypertension. Two patients discontinued treatment due to gastric ulcer (n = 1) and proteinuria (n = 1). At data cut-off, four patients had stable disease, two had partial response and one had non-complete response/non-progressive disease due to the absence of target lesions. CONCLUSIONS Bevacizumab plus cisplatin/pemetrexed then bevacizumab was well tolerated in Japanese patients with MPM. 1 INTRODUCTION Malignant pleural mesothelioma (MPM) is a rare, aggressive neoplasm with poor prognosis, which originates in the mesothelial cells lining the thoracic cavity. 1 Development of MPM is strongly associated with inhalational exposure to asbestos, and is usually caused by occupational asbestos exposure, but it can also occur from low‐level exposure in the general environment. 2 Despite regulatory action against, and prohibition of the use of asbestos, the number of patients with MPM is increasing substantially in many countries where asbestos has been widely used historically. 3 Its incidence is increasing rapidly worldwide, and the annual number of MPM deaths in Japan has risen from 500 in 1995 to 1555 in 2017. 4 Asia has become the largest consumer of asbestos in the world and is responsible for two‐thirds of global use. 5 China continues to use asbestos and is the top consumer in the world, with an increasing trend of MPM during 2000–2013 and 1659 MPM cases in 2013, but its incidence is low compared with industrialized countries. 5 Newly diagnosed patients with unresectable disease have a median overall survival (OS) of ∼12 months when treated with the standard of care, cisplatin plus pemetrexed. 6 The combination of cisplatin plus pemetrexed is the only currently approved regimen for unresectable first‐line MPM, with approvals gained in 2004 in the USA and European Union, and in 2007 in Japan. Phase II studies demonstrated that pemetrexed in combination with carboplatin might be an alternative regimen with similar treatment outcomes. 7 There have been no new first‐line therapies approved for MPM for more than a decade. Furthermore, there is no US Food and Drug Administration (FDA)‐approved or European Medicines Agency (EMA)‐approved second‐line treatment for MPM. In 2018, anti‐programmed death‐1 (PD‐1) antibody nivolumab was approved in Japan for salvage use. The National Comprehensive Cancer Network (NCCN) guidelines revised their recommendation for nivolumab use with or without ipilimumab from category 2B to 2A, on the basis of recent clinical trial data for subsequent systemic MPM treatment. 8 In view of the poor prognosis and limited approved therapies, there is an unmet need for new treatment options that further improve outcomes for patients with MPM. A broad range of therapeutic targets exist in MPM, including angiogenesis, immune checkpoints, mesothelin and chemotherapeutic agents. Vascular endothelial growth factor (VEGF) is known to be a key regulator of MPM because it is an autocrine growth factor of MPM. 9 Significantly higher serum levels of VEGF have been identified in patients with MPM compared with other tumor types 10 and high VEGF level in serum or pleural effusion is a poor prognostic factor in MPM. 11 , 12 Because VEGF signaling is essential for mesothelioma cell physiopathology, 9 VEGF targeting therapy, such as the recombinant humanized monoclonal antibody bevacizumab, is a rational approach for the treatment of MPM. 13 , 14 Preclinical evaluation of the therapeutic efficacy of bevacizumab in combination with pemetrexed against mesothelioma has shown a synergy for the combination, compared with pemetrexed or bevacizumab alone. 15 Bevacizumab, when added to standard chemotherapy, has demonstrated effectiveness in non–small cell lung cancer (NSCLC) 16 and other tumor types such as breast cancer, 17 colorectal cancer 18 and renal cell carcinoma. 19 Bevacizumab has been evaluated as a combination therapy for MPM in randomized phase II and III clinical trials. 20 , 21 Prior to the approval of pemetrexed, gemcitabine plus cisplatin was a common treatment regimen for MPM. In a randomized phase II US trial in patients with previously untreated MPM, the addition of bevacizumab to gemcitabine/cisplatin did not improve progression‐free survival (PFS) or OS. 20 It was postulated that the trial failed to show positive results due to a potential negative interaction between bevacizumab and gemcitabine in preclinical studies. 22 Therefore, other chemotherapy backbones with bevacizumab, including cisplatin plus pemetrexed, have been investigated. The phase III Mesothelioma Avastin Cisplatin Pemetrexed Study (MAPS), which evaluated the addition of bevacizumab to cisplatin/pemetrexed followed by bevacizumab maintenance, was the first trial to demonstrate improved outcomes versus the standard of care. 21 In MAPS, the addition of bevacizumab to cisplatin/pemetrexed significantly improved PFS and OS compared with cisplatin/pemetrexed alone (OS = 18.8 months vs 16.1 months; hazard ratio [HR] = 0.77; P = 0.0167; PFS = 9.2 months vs 7.3 months, HR = 0.61, P < 0.0001). Additionally, adverse events (AEs) reported in MAPS were consistent with the known safety profile of bevacizumab plus chemotherapy. Based on these outcomes, 21 bevacizumab in combination with cisplatin/pemetrexed was included as a category 1 recommended first‐line treatment for unresectable MPM in the NCCN guidelines. 8 Although MAPS was conducted by the French Cooperative Thoracic Intergroup and data were from French patients only, the results confirm that first‐line bevacizumab‐based therapy can improve outcomes for patients with newly diagnosed MPM. Bevacizumab plus cisplatin/pemetrexed has been shown to be safe and effective in Japanese patients with NSCLC; however, there are no data showing tolerability and safety in Japanese patients with MPM treated with this triplet regimen. This article reports results from a single‐arm, multicenter study evaluating the tolerability, safety and efficacy of first‐line bevacizumab together with cisplatin/pemetrexed, followed by single‐agent bevacizumab, in Japanese patients with unresectable MPM. 2 PATIENTS AND METHODS 2.1 Study design JO39183 (JapicCTI‐163294) was a multicenter, open‐label, single‐arm, phase II study evaluating the tolerability, safety and efficacy of bevacizumab combined with cisplatin/pemetrexed followed by single‐agent bevacizumab in patients with unresectable MPM who had not previously received chemotherapy (Figure 1). The replacement of cisplatin by carboplatin was allowed in cases where a patient developed nephrotoxicity (creatinine clearance <45 mL/min, 6 weeks after administration) or ototoxicity. The target sample size for the study was six patients, which is determined as an analogy for 3+3 design, according to the methods of official recommendation issued by the Pharmaceutical and Food Safety Bureau, Ministry of Health, Labour and Welfare, Japan. 23 However, it was permissible to enroll more than six patients because the main purpose of the study was to evaluate tolerability and safety in Japanese patients. Following enrollment, each patient received up to six cycles of bevacizumab, cisplatin and pemetrexed (induction period), with cycles repeated every 3 weeks. Patients then continued to receive bevacizumab monotherapy every 3 weeks during the maintenance period until disease progression or the onset of unacceptable AEs. FIGURE 1 Study design The study was conducted in accordance with the principles of the Declaration of Helsinki and Good Clinical Practice. All appropriate ethical approval was received from Institutional Review Boards or Independent Ethics Committees at each of the sites. All patients provided written informed consent prior to any study‐related procedures, and agreed to their individual data being published. 2.2 Eligibility criteria Key inclusion criteria for patients included: age ≥20 years with histologically confirmed pleural mesothelioma, not considered amendable to resection; an Eastern Cooperative Oncology Group performance status (ECOG PS) of 0–2; life expectancy of ≥12 weeks from the time of enrollment; no previous chemotherapy for MPM (including adjuvant and neoadjuvant therapy); and radiographically evident lesions. Patients with central nervous system metastases were excluded. Further exclusion criteria are detailed in the Supporting Information. 2.3 Treatment Patients received combination therapy with bevacizumab, cisplatin and pemetrexed, administered for up to six cycles with cycles being repeated every 3 weeks in the induction period. Pemetrexed 500 mg/m2 was administered intravenously (IV) over 10 min, then 30 min later cisplatin 75 mg/m2 IV was administered over 2 h. Following the cisplatin infusion, bevacizumab 15 mg/kg IV was administered over 30–90 min. If carboplatin was used in place of cisplatin, it was administered at a dose at which the target area under the curve was 5 mg/mL/min (as calculated based on the Calvert formula) over 30–60 min on Day 1 of each cycle. Following six cycles of the combination, bevacizumab 15 mg/kg was administered every 3 weeks in the maintenance period until disease progression or the onset of unacceptable AEs. The combination therapy could be discontinued before completion of six cycles; in this case, patients continued on bevacizumab monotherapy. The study duration for each patient was from the day of consent to the last observation day (observation or assessment day that was 28 ± 7 days after the last dose of study drug). 2.4 Study endpoints The primary purpose was to evaluate the tolerability of bevacizumab combined with cisplatin/pemetrexed. Secondary purposes were to evaluate the safety and efficacy of bevacizumab combined with cisplatin/pemetrexed followed by single‐agent bevacizumab. 2.5 Study assessments The evaluation period for tolerability was from Day 1 of Cycle 1 until immediately prior to the start of study drug administration on Day 1 of Cycle 2. AEs predefined for tolerability criteria included grade 4 neutropenia persisting for ≥7 days, febrile neutropenia, grade 3/4 reductions in platelet counts and any nonhematologic toxicity with severity of grade 3 or higher (further details are provided in the Supporting Information), occurring during the tolerability evaluation period and for which a causal relationship to the combination therapy could not be ruled out. The study treatment was considered tolerable if these AEs were reported in ≤34% (two out of six patients) of all enrolled patients considered evaluable for tolerability. The severity of AEs was graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.03. An Efficacy and Safety Evaluation Committee decided whether to continue the study and/or to amend the protocol if any AEs meeting the tolerability criteria were reported in three patients during the study period. If the occurrence of AEs meeting the criteria was estimated to be in ≤34% of the target number of patients (e.g. corresponding AEs were not reported in the first four patients, excluding patients who were considered nonevaluable for tolerability), the Efficacy and Safety Evaluation Committee had the option of closing enrollment. Safety was assessed using data collected until the point at which the observation period in Cycle 1 was completed for the last patient. AEs were coded using the Medical Dictionary for Regulatory Activities (version 19.0) and summarized by system organ class and preferred term. Best overall response and median PFS were assessed in accordance with Response Evaluation Criteria in Solid Tumors version 1.1. PFS was defined as the time from the first day of study drug administration to the first documented disease progression or death, whichever occurred first. 3 RESULTS 3.1 Patient population Seven patients, from four centers, were enrolled into the study and all received bevacizumab combination therapy. After four cycles of treatment with bevacizumab, cisplatin and pemetrexed, one patient changed from cisplatin to carboplatin due to reduced kidney function. Baseline patient characteristics are shown in Table 1. Patients had a median age of 66 years (range 47–73) and 57.1% were male. Although patients with an ECOG PS of 0–2 were eligible, all patients had an ECOG PS of 0 or 1. The tolerability and safety analysis sets included all seven patients. The data cut‐off was September 15, 2016, for tolerability and July 6, 2017, for safety and efficacy. TABLE 1 Patient characteristics at baseline Patient characteristics Patients (n = 7) Sex, n (%) Male 4 (57.1) Female 3 (42.9) Median age (range), years 66 (47–73) Histology, n (%) Epithelioid 6 (85.7) Sarcomatoid or mixed 1 (14.3) ECOG PS, n (%) 0 5 (71.4) 1 2 (28.6) Smoking status, n (%) Smoker 4 (57.1) Never smoker 3 (42.9) Abbreviation: ECOG PS, Eastern Cooperative Oncology Group performance status. John Wiley & Sons, Ltd. 3.2 Treatment exposure A summary of treatment exposure is shown in Figure 2. Overall, a median of nine cycles of bevacizumab were administered, with a median treatment duration of 188 days. Dose intensity was defined as the proportion of actual doses received to planned dose. For pemetrexed and cisplatin, planned dose was defined as the initial dose for six cycles completed without dose delay or dose reduction. For bevacizumab, planned dose was defined as the initial dose for actual cycles completed without dose delay or dose reduction. The mean dose intensities of bevacizumab, pemetrexed and cisplatin were 94%, 72% and 65%, respectively. FIGURE 2 Treatment exposure. †, Cisplatin was replaced with carboplatin for Cycles 5 and 6. ‡, Ongoing At the time of data cut‐off (July 6, 2017), four patients had discontinued treatment and three were continuing to receive single‐agent bevacizumab. One patient discontinued combination therapy due to a gastric ulcer and another due to proteinuria. The remaining two patients discontinued combination therapy due to disease progression. Three out of seven patients did not complete six cycles of chemotherapy; in addition, one patient received carboplatin instead of cisplatin for Cycles 5 and 6 due to reduced creatinine clearance. In the three patients who did not complete six cycles of chemotherapy, the reasons for chemotherapy discontinuation were gastric ulcer, proteinuria (as mentioned above), systemic rash and dyspnea. 3.3 Tolerability During the tolerability evaluation period, one of the seven patients (14.3%) experienced an AE (gastric ulcer), which met the definition criteria for tolerability. 3.4 Safety All seven patients (100%) experienced at least one AE (any grade) and a total of 74 AEs were reported. All patients experienced gastrointestinal disorders (any grade), with the most common being nausea (any grade, n = 6, 85.7%) and constipation (any grade, n = 5, 71.4%). Six different grade 3 AEs were reported: hypertension occurred in five patients (71.4%), and elevated amylase, elevated γ‐glutamyltransferase, hyponatremia, anemia and proteinuria each occurred in one patient (14.3%). There were no grade 4/5 AEs. Two patients had AEs that led to treatment discontinuation; one had a gastric ulcer (n = 1; 14.3%) and the other had proteinuria (n = 1; 14.3%). No deaths were reported. Treatment‐related AEs are detailed in Table 2. TABLE 2 Treatment‐related adverse events (n = 7) Any grade, n (%) Grade 1, n (%) Grade 2, n (%) Grade 3, n (%) Nausea 6 (85.7) 3 (42.9) 3 (42.9) 0 Hypertension 6 (85.7) 0 1 (14.3) 5 (71.4) Constipation 4 (57.1) 3 (42.9) 1 (14.3) 0 Edema peripheral 1 (14.3) 1 (14.3) 0 0 Malaise 2 (28.6) 1 (14.3) 1 (14.3) 0 Rash generalized 2 (28.6) 0 2 (28.6) 0 Epistaxis 2 (28.6) 2 (28.6) 0 0 Dysgeusia 2 (28.6) 2 (28.6) 0 0 Headache 1 (14.3) 0 1 (14.3) 0 Hiccups 1 (14.3) 1 (14.3) 0 0 Amylase increased 1 (14.3) 0 0 1 (14.3) Gastric ulcer 1 (14.3) 0 1 (14.3) 0 Eyelid edema 1 (14.3) 1 (14.3) 0 0 Blood creatinine increased 1 (14.3) 1 (14.3) 0 0 Dyspnea 1 (14.3) 0 1 (14.3) 0 Oropharyngeal pain 1 (14.3) 1 (14.3) 0 0 Stomatitis 1 (14.3) 1 (14.3) 0 0 Neutrophil count decreased 1 (14.3) 0 1 (14.3) 0 Periodontal disease 1 (14.3) 0 1 (14.3) 0 Carpal tunnel syndrome 1 (14.3) 1 (14.3) 0 0 Pigmentation disorder 1 (14.3) 1 (14.3) 0 0 Decreased appetite 1 (14.3) 0 1 (14.3) 0 Creatinine renal clearance decreased 1 (14.3) 0 1 (14.3) 0 Bodyweight increased 1 (14.3) 1 (14.3) 0 0 Proteinuria 1 (14.3) 0 0 1 (14.3) Injection site pain 1 (14.3) 1 (14.3) 0 0 Flushing 1 (14.3) 1 (14.3) 0 0 Hyponatremia 1 (14.3) 0 0 1 (14.3) Protein urine present 1 (14.3) 0 1 (14.3) 0 White blood cell count decreased 1 (14.3) 0 1 (14.3) 0 Rash 1 (14.3) 1 (14.3) 0 0 Pyrexia 1 (14.3) 1 (14.3) 0 0 Abdominal distension 1 (14.3) 0 1 (14.3) 0 Peripheral neuropathy 1 (14.3) 1 (14.3) 0 0 Vomiting 1 (14.3) 0 1 (14.3) 0 No grade 4/5 treatment‐related adverse events were reported. John Wiley & Sons, Ltd. 3.5 Efficacy Best overall response and PFS data are shown in Table 3. At the time of data cut‐off (July 6, 2017), four patients had stable disease, two had a partial response and one had non‐complete response/non‐progressive disease (non‐CR/non‐PD). The four patients who had stable disease had PFS of 0.9, 2.7, 6.7 and 6.8 months, respectively; and the two patients with a partial response had censored PFS durations of 10.4 and 11.1 months, respectively. The partial response in one of the patients is illustrated in Figure 3. The non‐CR/non‐PD patient had a PFS of 9.4 months (censored). Three patients who had either a partial response (n = 2) or a non‐CR/non‐PD (n = 1) remained on treatment at the time of data cut‐off. TABLE 3 Summary of efficacy Patient number Status Best overall response PFS (months) 1 Withdrawal at C1 SD a 0.9 2 Withdrawal at C3 SD 2.7 3 Withdrawal at C9 SD 6.7 4 Withdrawal at C9 SD 6.8 5 Ongoing PR 10.4 b 6 Ongoing Non‐CR/non‐PD 9.4 b 7 Ongoing PR 11.1 b Abbreviations: C, cycle; CR, complete response; PD, progressive disease; PFS, progression‐free survival; PR, partial response; SD, stable disease. a The period from baseline to best overall response evaluation was ≥6 weeks. b Censored observation, treatment ongoing. John Wiley & Sons, Ltd. FIGURE 3 Patient case: Computed tomography scan after Cycle 7 in a 47‐year‐old, female patient who was diagnosed with stage III MPM, and experienced a partial response after receiving treatment without dose modification, other than cisplatin at Cycle 6, when treatment with cisplatin was discontinued mid‐treatment due to the occurrence of a systemic rash (patient #5) 4 DISCUSSION This is the first study to report tolerability and safety data for Japanese patients with MPM treated with bevacizumab plus cisplatin/pemetrexed. Our results demonstrate that bevacizumab added to cisplatin/pemetrexed, followed by single‐agent bevacizumab is tolerable as a first‐line treatment in Japanese patients with MPM. No new safety concerns were identified for bevacizumab either in combination with cisplatin/pemetrexed or as single‐agent maintenance treatment. The overall safety profile in this study was consistent with data published for MAPS. 21 All patients in our study experienced gastrointestinal AEs, the most common being nausea (85.7%; any grade), which was similar to the incidence reported in MAPS (78.4%). Notably, 71.4% of patients experienced grade 3 hypertension compared with only 23% of patients in MAPS. 21 However, hypertension was manageable with administration of antihypertensive medications, allowing patients to continue receiving bevacizumab. Other grade 3 AEs included elevated amylase, elevated γ‐glutamyltransferase, anemia, proteinuria and hyponatremia. The toxicity profile of bevacizumab plus cisplatin/pemetrexed was also similar to that reported in Japanese patients with NSCLC 24 and with advanced cervical cancer. 25 Although it is difficult to make cross‐trial comparisons due to differences in study designs, methods of assessment and patient populations, our safety data appear to be consistent with previous reports on bevacizumab‐based therapy for MPM, and did not identify any previously unknown toxicities. 21 , 22 One patient changed from cisplatin to carboplatin due to reduced kidney function but, since there is a wealth of safety and efficacy data for carboplatin‐based chemotherapy, it is unlikely that this would significantly impact the safety profile. 16 , 26 , 27 One patient withdrew from the study due to a gastric ulcer, which was confirmed by the investigator as being associated with bevacizumab; however, because gastroendoscopy was not conducted prior to study enrollment, it is unknown whether this was present at baseline. Another patient experienced pleural effusion but continued to receive bevacizumab for ∼1.5 years (as of January 31, 2018). Similarly, results from the multicenter, phase II, NEJ013A trial showed that bevacizumab may be active in patients with malignant pleural effusion. 28 Median PFS was 6.8 months in this study, which is similar to two phase II studies in MPM that both reported median PFS of 6.9 months with the addition of bevacizumab to standard of care: the multicenter study by Dowell et al. 29 (n = 52) evaluated the same regimen as our study, and the randomized trial by Kindler et al. 20 (n = 108) added bevacizumab to cisplatin/gemcitabine. In contrast, two patients with a partial response had a longer PFS of 10.4 and 11.1 months in our study. The phase III MAPS, with a larger population of 448 patients, reported median PFS and OS durations of 9.2 and 18.8 months, respectively, with bevacizumab plus cisplatin/pemetrexed. 21 At the data cut‐off, three patients remained on treatment with bevacizumab and continue to be monitored. Patients can continue treatment for about a year, so there is potential to observe ongoing responses in these patients. As of January 31, 2018, two patients had continued to receive treatment for ∼1.5 years and no new toxicity had been observed. The combination of anti‐angiogenic agents, such as bevacizumab, nintedanib and cediranib, with cisplatin/pemetrexed has been evaluated in the first‐line MPM treatment setting. The most promising results have been obtained with the addition of bevacizumab to cisplatin/pemetrexed. 21 Nintedanib is a triple angiokinase inhibitor with activity against VEGF receptor 1−3, platelet‐derived growth factor (PDGF) receptors α and ß, fibroblast growth factors receptors 1−3 and Src and Abl kinases. Addition of nintedanib to cisplatin/pemetrexed in the phase II LUME‐Meso study improved PFS in patients with unresectable nonsarcomatoid MPM compared with the addition of placebo (median PFS 9.4 months vs 5.7 months, respectively). 30 However, the double‐blind, randomized, placebo‐controlled phase III LUME‐Meso study in unresectable epithelioid MPM failed to meet its primary PFS endpoint (median PFS 6.8 months in the nintedanib arm vs 7.0 months in the placebo arm; P = 0.91). 31 Cediranib is an inhibitor of VEGF receptor, PDGF receptor and stem cell factor receptor. In a phase I trial, the addition of cediranib to cisplatin/pemetrexed demonstrated promising preliminary outcomes in patients with chemotherapy‐naïve MPM (median PFS = 8.6 months; median OS = 16.2 months). 32 Results from the ongoing phase II study of cediranib in combination with cisplatin/pemetrexed (NCT01064648) are awaited. Recently, nivolumab was approved in Japan as salvage therapy in MPM patients, and is now being evaluated in the first‐line setting in combination with standard of care treatment in Japan. 33 Preclinical studies suggest that combining anti‐angiogenic agents with immunotherapy may have a synergistic effect, enhancing the efficacy of both treatments. 34 A phase I trial is currently assessing nintedanib in combination with the PD‐1 inhibitor pembrolizumab in patients with various tumors including MPM (NCT02856425), whereas a phase II study is evaluating bevacizumab in combination with atezolizumab in MPM and peritoneal mesothelioma (NCT03074513). We reported safety and efficacy data for first‐line bevacizumab in combination with cisplatin/pemetrexed in Japanese patients with MPM, for whom data are currently limited. Our safety data are comparable with other similar studies and show that the addition of bevacizumab to the current standard of care is tolerable. 5 CONCLUSION The combination of bevacizumab, cisplatin and pemetrexed followed by maintenance treatment with bevacizumab was well tolerated and had satisfactory efficacy in this small patient dataset, warranting its first‐line use in Japanese patients with MPM, on the basis of the phase III study in France. In terms of systematic chemotherapy for MPM, cisplatin plus pemetrexed is the only approved regimen in the untreated setting. Data from this single‐arm trial are encouraging for patients with unresectable MPM; the addition of bevacizumab to standard chemotherapy would offer an alternative treatment option and may extend survival in patients with this aggressive neoplasm. CONFLICTS OF INTEREST Takashi Nakano has received honoraria from MSD, Olympus Corporation, ISHIHARA Sangyo, KYORIN Pharmaceutical, Nippon Boehringer Ingelheim and ONO Pharmaceutical; acted in a consulting or advisory role for Nippon Boehringer Ingelheim; and reports personal fees from Cancer and Chemotherapy Publishers, Ishiyaku Publishers, IGAKU‐SHOIN, Elsevier Japan K.K., Asakura Publishing, Ministry of the Environment Japan and Amagasaki City, outside the submitted work. Kozo Kuribayashi has received honoraria from AstraZeneca, Astellas Pharma, Boehringer Ingelheim, Chugai Pharmaceutical, Kyowa Hakko Kirin, KYORIN Pharmaceutical, Meiji‐Seika‐Pharma, Novartis, Ono Pharmaceutical and Taiho Pharmaceutical. Masashi Kondo has received honoraria from Eli Lilly, MSD, Chugai Pharmaceutical, Pfizer, Novartis, AstraZeneca, Nippon Boehringer Ingelheim, Taiho Pharmaceutical and Kyowa Hakko Kirin. Masahiro Morise has received honoraria from Chugai Pharmaceutical, Eli Lilly Japan K.K., Ono Pharmaceutical, Bristol‐Myers Squibb, Pfizer, AstraZeneca, Boehringer Ingelheim, Merck Serono and Novartis. Yuji Tada has received honoraria from Chugai Pharmaceutical. Katsuya Hirano reports personal fees from AstraZeneca K.K., Chugai Pharmaceutical, Eli Lilly, Nippon Boehringer Ingelheim, Ono Pharmaceutical, Pfizer, Taiho Pharmaceutical and Novartis, outside the submitted work. Morihiko Hayashi and Misa Tanaka are employees of Chugai Pharmaceutical, and Misa Tanaka owns stock in Chugai Pharmaceutical. Masataka Hirabayashi has received honoraria from AstraZeneca K.K., Ono Pharmaceutical, KYORIN Pharmaceutical, Taiho Pharmaceutical, MSD, Chugai Pharmaceutical, Pfizer, Boehringer Ingelheim and Eli Lilly. Supporting information Supporting Information Click here for additional data file. ACKNOWLEDGMENTS This study was supported by Chugai Pharmaceutical Co., Ltd. We thank the patients who participated in this study. We also express our thanks to Kosei Tajima of Chugai Pharmaceutical Co., Ltd., and Professor Takashi Kijima, Hyogo College of Medicine, for drafting and reviewing the manuscript. Third‐party medical writing assistance, under the direction of the authors, was provided by Nathalie Robinson, PhD, and Rachel Hubbard, MSc, of Gardiner‐Caldwell Communications, and was funded by Chugai Pharmaceutical Co., Ltd. Trial registration number: JapicCTI‐163294. DATA AVAILABILITY STATEMENT Chugai Pharmaceutical Co., Ltd. provide qualified researchers access to individual patient‐level data through the clinical study data request platform (www.clinicalstudydatarequest.com). Further details of Chugai's Data Sharing Policy are available here (https://www.chugai‐pharm.co.jp/english/profile/rd/ctds_request.html).	Intravenous (not otherwise specified)	DrugAdministrationRoute	CC BY-NC	32893992	18,306,165	2021-06
What was the administration route of drug 'PEMETREXED'?	Bevacizumab plus cisplatin/pemetrexed then bevacizumab alone for unresectable malignant pleural mesothelioma: A Japanese safety study. OBJECTIVE Malignant pleural mesothelioma (MPM) is an aggressive malignancy with poor prognosis and limited treatment options. Cisplatin plus pemetrexed is the only approved first-line treatment for patients with unresectable MPM. Recently, promising outcomes were observed with first-line bevacizumab combined with cisplatin/pemetrexed, leading to the recommendation of this regimen as a first-line treatment option for patients with MPM. Bevacizumab plus cisplatin/pemetrexed has been shown to be safe and effective in non-small cell lung cancer, however, there are no efficacy or safety data in Japanese patients with MPM treated with this regimen. We conducted a multicenter study to evaluate tolerability and safety for Japanese patients with chemotherapy-naïve, unresectable MPM. METHODS Eligible patients (n = 7) received bevacizumab plus cisplatin/pemetrexed (up to six cycles), then single-agent bevacizumab until disease progression or onset of unacceptable adverse events (AEs), according to the 3+3 design analogy. RESULTS One patient (14.3%) reported an AE (gastric ulcer) meeting tolerability criteria. All patients experienced gastrointestinal disorders, including nausea (grade 1/2 only, n = 6, 85.7%) and constipation (grade 1/2 only, n = 5, 71.4%). Five patients (71.4%) had grade 3 hypertension. Two patients discontinued treatment due to gastric ulcer (n = 1) and proteinuria (n = 1). At data cut-off, four patients had stable disease, two had partial response and one had non-complete response/non-progressive disease due to the absence of target lesions. CONCLUSIONS Bevacizumab plus cisplatin/pemetrexed then bevacizumab was well tolerated in Japanese patients with MPM. 1 INTRODUCTION Malignant pleural mesothelioma (MPM) is a rare, aggressive neoplasm with poor prognosis, which originates in the mesothelial cells lining the thoracic cavity. 1 Development of MPM is strongly associated with inhalational exposure to asbestos, and is usually caused by occupational asbestos exposure, but it can also occur from low‐level exposure in the general environment. 2 Despite regulatory action against, and prohibition of the use of asbestos, the number of patients with MPM is increasing substantially in many countries where asbestos has been widely used historically. 3 Its incidence is increasing rapidly worldwide, and the annual number of MPM deaths in Japan has risen from 500 in 1995 to 1555 in 2017. 4 Asia has become the largest consumer of asbestos in the world and is responsible for two‐thirds of global use. 5 China continues to use asbestos and is the top consumer in the world, with an increasing trend of MPM during 2000–2013 and 1659 MPM cases in 2013, but its incidence is low compared with industrialized countries. 5 Newly diagnosed patients with unresectable disease have a median overall survival (OS) of ∼12 months when treated with the standard of care, cisplatin plus pemetrexed. 6 The combination of cisplatin plus pemetrexed is the only currently approved regimen for unresectable first‐line MPM, with approvals gained in 2004 in the USA and European Union, and in 2007 in Japan. Phase II studies demonstrated that pemetrexed in combination with carboplatin might be an alternative regimen with similar treatment outcomes. 7 There have been no new first‐line therapies approved for MPM for more than a decade. Furthermore, there is no US Food and Drug Administration (FDA)‐approved or European Medicines Agency (EMA)‐approved second‐line treatment for MPM. In 2018, anti‐programmed death‐1 (PD‐1) antibody nivolumab was approved in Japan for salvage use. The National Comprehensive Cancer Network (NCCN) guidelines revised their recommendation for nivolumab use with or without ipilimumab from category 2B to 2A, on the basis of recent clinical trial data for subsequent systemic MPM treatment. 8 In view of the poor prognosis and limited approved therapies, there is an unmet need for new treatment options that further improve outcomes for patients with MPM. A broad range of therapeutic targets exist in MPM, including angiogenesis, immune checkpoints, mesothelin and chemotherapeutic agents. Vascular endothelial growth factor (VEGF) is known to be a key regulator of MPM because it is an autocrine growth factor of MPM. 9 Significantly higher serum levels of VEGF have been identified in patients with MPM compared with other tumor types 10 and high VEGF level in serum or pleural effusion is a poor prognostic factor in MPM. 11 , 12 Because VEGF signaling is essential for mesothelioma cell physiopathology, 9 VEGF targeting therapy, such as the recombinant humanized monoclonal antibody bevacizumab, is a rational approach for the treatment of MPM. 13 , 14 Preclinical evaluation of the therapeutic efficacy of bevacizumab in combination with pemetrexed against mesothelioma has shown a synergy for the combination, compared with pemetrexed or bevacizumab alone. 15 Bevacizumab, when added to standard chemotherapy, has demonstrated effectiveness in non–small cell lung cancer (NSCLC) 16 and other tumor types such as breast cancer, 17 colorectal cancer 18 and renal cell carcinoma. 19 Bevacizumab has been evaluated as a combination therapy for MPM in randomized phase II and III clinical trials. 20 , 21 Prior to the approval of pemetrexed, gemcitabine plus cisplatin was a common treatment regimen for MPM. In a randomized phase II US trial in patients with previously untreated MPM, the addition of bevacizumab to gemcitabine/cisplatin did not improve progression‐free survival (PFS) or OS. 20 It was postulated that the trial failed to show positive results due to a potential negative interaction between bevacizumab and gemcitabine in preclinical studies. 22 Therefore, other chemotherapy backbones with bevacizumab, including cisplatin plus pemetrexed, have been investigated. The phase III Mesothelioma Avastin Cisplatin Pemetrexed Study (MAPS), which evaluated the addition of bevacizumab to cisplatin/pemetrexed followed by bevacizumab maintenance, was the first trial to demonstrate improved outcomes versus the standard of care. 21 In MAPS, the addition of bevacizumab to cisplatin/pemetrexed significantly improved PFS and OS compared with cisplatin/pemetrexed alone (OS = 18.8 months vs 16.1 months; hazard ratio [HR] = 0.77; P = 0.0167; PFS = 9.2 months vs 7.3 months, HR = 0.61, P < 0.0001). Additionally, adverse events (AEs) reported in MAPS were consistent with the known safety profile of bevacizumab plus chemotherapy. Based on these outcomes, 21 bevacizumab in combination with cisplatin/pemetrexed was included as a category 1 recommended first‐line treatment for unresectable MPM in the NCCN guidelines. 8 Although MAPS was conducted by the French Cooperative Thoracic Intergroup and data were from French patients only, the results confirm that first‐line bevacizumab‐based therapy can improve outcomes for patients with newly diagnosed MPM. Bevacizumab plus cisplatin/pemetrexed has been shown to be safe and effective in Japanese patients with NSCLC; however, there are no data showing tolerability and safety in Japanese patients with MPM treated with this triplet regimen. This article reports results from a single‐arm, multicenter study evaluating the tolerability, safety and efficacy of first‐line bevacizumab together with cisplatin/pemetrexed, followed by single‐agent bevacizumab, in Japanese patients with unresectable MPM. 2 PATIENTS AND METHODS 2.1 Study design JO39183 (JapicCTI‐163294) was a multicenter, open‐label, single‐arm, phase II study evaluating the tolerability, safety and efficacy of bevacizumab combined with cisplatin/pemetrexed followed by single‐agent bevacizumab in patients with unresectable MPM who had not previously received chemotherapy (Figure 1). The replacement of cisplatin by carboplatin was allowed in cases where a patient developed nephrotoxicity (creatinine clearance <45 mL/min, 6 weeks after administration) or ototoxicity. The target sample size for the study was six patients, which is determined as an analogy for 3+3 design, according to the methods of official recommendation issued by the Pharmaceutical and Food Safety Bureau, Ministry of Health, Labour and Welfare, Japan. 23 However, it was permissible to enroll more than six patients because the main purpose of the study was to evaluate tolerability and safety in Japanese patients. Following enrollment, each patient received up to six cycles of bevacizumab, cisplatin and pemetrexed (induction period), with cycles repeated every 3 weeks. Patients then continued to receive bevacizumab monotherapy every 3 weeks during the maintenance period until disease progression or the onset of unacceptable AEs. FIGURE 1 Study design The study was conducted in accordance with the principles of the Declaration of Helsinki and Good Clinical Practice. All appropriate ethical approval was received from Institutional Review Boards or Independent Ethics Committees at each of the sites. All patients provided written informed consent prior to any study‐related procedures, and agreed to their individual data being published. 2.2 Eligibility criteria Key inclusion criteria for patients included: age ≥20 years with histologically confirmed pleural mesothelioma, not considered amendable to resection; an Eastern Cooperative Oncology Group performance status (ECOG PS) of 0–2; life expectancy of ≥12 weeks from the time of enrollment; no previous chemotherapy for MPM (including adjuvant and neoadjuvant therapy); and radiographically evident lesions. Patients with central nervous system metastases were excluded. Further exclusion criteria are detailed in the Supporting Information. 2.3 Treatment Patients received combination therapy with bevacizumab, cisplatin and pemetrexed, administered for up to six cycles with cycles being repeated every 3 weeks in the induction period. Pemetrexed 500 mg/m2 was administered intravenously (IV) over 10 min, then 30 min later cisplatin 75 mg/m2 IV was administered over 2 h. Following the cisplatin infusion, bevacizumab 15 mg/kg IV was administered over 30–90 min. If carboplatin was used in place of cisplatin, it was administered at a dose at which the target area under the curve was 5 mg/mL/min (as calculated based on the Calvert formula) over 30–60 min on Day 1 of each cycle. Following six cycles of the combination, bevacizumab 15 mg/kg was administered every 3 weeks in the maintenance period until disease progression or the onset of unacceptable AEs. The combination therapy could be discontinued before completion of six cycles; in this case, patients continued on bevacizumab monotherapy. The study duration for each patient was from the day of consent to the last observation day (observation or assessment day that was 28 ± 7 days after the last dose of study drug). 2.4 Study endpoints The primary purpose was to evaluate the tolerability of bevacizumab combined with cisplatin/pemetrexed. Secondary purposes were to evaluate the safety and efficacy of bevacizumab combined with cisplatin/pemetrexed followed by single‐agent bevacizumab. 2.5 Study assessments The evaluation period for tolerability was from Day 1 of Cycle 1 until immediately prior to the start of study drug administration on Day 1 of Cycle 2. AEs predefined for tolerability criteria included grade 4 neutropenia persisting for ≥7 days, febrile neutropenia, grade 3/4 reductions in platelet counts and any nonhematologic toxicity with severity of grade 3 or higher (further details are provided in the Supporting Information), occurring during the tolerability evaluation period and for which a causal relationship to the combination therapy could not be ruled out. The study treatment was considered tolerable if these AEs were reported in ≤34% (two out of six patients) of all enrolled patients considered evaluable for tolerability. The severity of AEs was graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.03. An Efficacy and Safety Evaluation Committee decided whether to continue the study and/or to amend the protocol if any AEs meeting the tolerability criteria were reported in three patients during the study period. If the occurrence of AEs meeting the criteria was estimated to be in ≤34% of the target number of patients (e.g. corresponding AEs were not reported in the first four patients, excluding patients who were considered nonevaluable for tolerability), the Efficacy and Safety Evaluation Committee had the option of closing enrollment. Safety was assessed using data collected until the point at which the observation period in Cycle 1 was completed for the last patient. AEs were coded using the Medical Dictionary for Regulatory Activities (version 19.0) and summarized by system organ class and preferred term. Best overall response and median PFS were assessed in accordance with Response Evaluation Criteria in Solid Tumors version 1.1. PFS was defined as the time from the first day of study drug administration to the first documented disease progression or death, whichever occurred first. 3 RESULTS 3.1 Patient population Seven patients, from four centers, were enrolled into the study and all received bevacizumab combination therapy. After four cycles of treatment with bevacizumab, cisplatin and pemetrexed, one patient changed from cisplatin to carboplatin due to reduced kidney function. Baseline patient characteristics are shown in Table 1. Patients had a median age of 66 years (range 47–73) and 57.1% were male. Although patients with an ECOG PS of 0–2 were eligible, all patients had an ECOG PS of 0 or 1. The tolerability and safety analysis sets included all seven patients. The data cut‐off was September 15, 2016, for tolerability and July 6, 2017, for safety and efficacy. TABLE 1 Patient characteristics at baseline Patient characteristics Patients (n = 7) Sex, n (%) Male 4 (57.1) Female 3 (42.9) Median age (range), years 66 (47–73) Histology, n (%) Epithelioid 6 (85.7) Sarcomatoid or mixed 1 (14.3) ECOG PS, n (%) 0 5 (71.4) 1 2 (28.6) Smoking status, n (%) Smoker 4 (57.1) Never smoker 3 (42.9) Abbreviation: ECOG PS, Eastern Cooperative Oncology Group performance status. John Wiley & Sons, Ltd. 3.2 Treatment exposure A summary of treatment exposure is shown in Figure 2. Overall, a median of nine cycles of bevacizumab were administered, with a median treatment duration of 188 days. Dose intensity was defined as the proportion of actual doses received to planned dose. For pemetrexed and cisplatin, planned dose was defined as the initial dose for six cycles completed without dose delay or dose reduction. For bevacizumab, planned dose was defined as the initial dose for actual cycles completed without dose delay or dose reduction. The mean dose intensities of bevacizumab, pemetrexed and cisplatin were 94%, 72% and 65%, respectively. FIGURE 2 Treatment exposure. †, Cisplatin was replaced with carboplatin for Cycles 5 and 6. ‡, Ongoing At the time of data cut‐off (July 6, 2017), four patients had discontinued treatment and three were continuing to receive single‐agent bevacizumab. One patient discontinued combination therapy due to a gastric ulcer and another due to proteinuria. The remaining two patients discontinued combination therapy due to disease progression. Three out of seven patients did not complete six cycles of chemotherapy; in addition, one patient received carboplatin instead of cisplatin for Cycles 5 and 6 due to reduced creatinine clearance. In the three patients who did not complete six cycles of chemotherapy, the reasons for chemotherapy discontinuation were gastric ulcer, proteinuria (as mentioned above), systemic rash and dyspnea. 3.3 Tolerability During the tolerability evaluation period, one of the seven patients (14.3%) experienced an AE (gastric ulcer), which met the definition criteria for tolerability. 3.4 Safety All seven patients (100%) experienced at least one AE (any grade) and a total of 74 AEs were reported. All patients experienced gastrointestinal disorders (any grade), with the most common being nausea (any grade, n = 6, 85.7%) and constipation (any grade, n = 5, 71.4%). Six different grade 3 AEs were reported: hypertension occurred in five patients (71.4%), and elevated amylase, elevated γ‐glutamyltransferase, hyponatremia, anemia and proteinuria each occurred in one patient (14.3%). There were no grade 4/5 AEs. Two patients had AEs that led to treatment discontinuation; one had a gastric ulcer (n = 1; 14.3%) and the other had proteinuria (n = 1; 14.3%). No deaths were reported. Treatment‐related AEs are detailed in Table 2. TABLE 2 Treatment‐related adverse events (n = 7) Any grade, n (%) Grade 1, n (%) Grade 2, n (%) Grade 3, n (%) Nausea 6 (85.7) 3 (42.9) 3 (42.9) 0 Hypertension 6 (85.7) 0 1 (14.3) 5 (71.4) Constipation 4 (57.1) 3 (42.9) 1 (14.3) 0 Edema peripheral 1 (14.3) 1 (14.3) 0 0 Malaise 2 (28.6) 1 (14.3) 1 (14.3) 0 Rash generalized 2 (28.6) 0 2 (28.6) 0 Epistaxis 2 (28.6) 2 (28.6) 0 0 Dysgeusia 2 (28.6) 2 (28.6) 0 0 Headache 1 (14.3) 0 1 (14.3) 0 Hiccups 1 (14.3) 1 (14.3) 0 0 Amylase increased 1 (14.3) 0 0 1 (14.3) Gastric ulcer 1 (14.3) 0 1 (14.3) 0 Eyelid edema 1 (14.3) 1 (14.3) 0 0 Blood creatinine increased 1 (14.3) 1 (14.3) 0 0 Dyspnea 1 (14.3) 0 1 (14.3) 0 Oropharyngeal pain 1 (14.3) 1 (14.3) 0 0 Stomatitis 1 (14.3) 1 (14.3) 0 0 Neutrophil count decreased 1 (14.3) 0 1 (14.3) 0 Periodontal disease 1 (14.3) 0 1 (14.3) 0 Carpal tunnel syndrome 1 (14.3) 1 (14.3) 0 0 Pigmentation disorder 1 (14.3) 1 (14.3) 0 0 Decreased appetite 1 (14.3) 0 1 (14.3) 0 Creatinine renal clearance decreased 1 (14.3) 0 1 (14.3) 0 Bodyweight increased 1 (14.3) 1 (14.3) 0 0 Proteinuria 1 (14.3) 0 0 1 (14.3) Injection site pain 1 (14.3) 1 (14.3) 0 0 Flushing 1 (14.3) 1 (14.3) 0 0 Hyponatremia 1 (14.3) 0 0 1 (14.3) Protein urine present 1 (14.3) 0 1 (14.3) 0 White blood cell count decreased 1 (14.3) 0 1 (14.3) 0 Rash 1 (14.3) 1 (14.3) 0 0 Pyrexia 1 (14.3) 1 (14.3) 0 0 Abdominal distension 1 (14.3) 0 1 (14.3) 0 Peripheral neuropathy 1 (14.3) 1 (14.3) 0 0 Vomiting 1 (14.3) 0 1 (14.3) 0 No grade 4/5 treatment‐related adverse events were reported. John Wiley & Sons, Ltd. 3.5 Efficacy Best overall response and PFS data are shown in Table 3. At the time of data cut‐off (July 6, 2017), four patients had stable disease, two had a partial response and one had non‐complete response/non‐progressive disease (non‐CR/non‐PD). The four patients who had stable disease had PFS of 0.9, 2.7, 6.7 and 6.8 months, respectively; and the two patients with a partial response had censored PFS durations of 10.4 and 11.1 months, respectively. The partial response in one of the patients is illustrated in Figure 3. The non‐CR/non‐PD patient had a PFS of 9.4 months (censored). Three patients who had either a partial response (n = 2) or a non‐CR/non‐PD (n = 1) remained on treatment at the time of data cut‐off. TABLE 3 Summary of efficacy Patient number Status Best overall response PFS (months) 1 Withdrawal at C1 SD a 0.9 2 Withdrawal at C3 SD 2.7 3 Withdrawal at C9 SD 6.7 4 Withdrawal at C9 SD 6.8 5 Ongoing PR 10.4 b 6 Ongoing Non‐CR/non‐PD 9.4 b 7 Ongoing PR 11.1 b Abbreviations: C, cycle; CR, complete response; PD, progressive disease; PFS, progression‐free survival; PR, partial response; SD, stable disease. a The period from baseline to best overall response evaluation was ≥6 weeks. b Censored observation, treatment ongoing. John Wiley & Sons, Ltd. FIGURE 3 Patient case: Computed tomography scan after Cycle 7 in a 47‐year‐old, female patient who was diagnosed with stage III MPM, and experienced a partial response after receiving treatment without dose modification, other than cisplatin at Cycle 6, when treatment with cisplatin was discontinued mid‐treatment due to the occurrence of a systemic rash (patient #5) 4 DISCUSSION This is the first study to report tolerability and safety data for Japanese patients with MPM treated with bevacizumab plus cisplatin/pemetrexed. Our results demonstrate that bevacizumab added to cisplatin/pemetrexed, followed by single‐agent bevacizumab is tolerable as a first‐line treatment in Japanese patients with MPM. No new safety concerns were identified for bevacizumab either in combination with cisplatin/pemetrexed or as single‐agent maintenance treatment. The overall safety profile in this study was consistent with data published for MAPS. 21 All patients in our study experienced gastrointestinal AEs, the most common being nausea (85.7%; any grade), which was similar to the incidence reported in MAPS (78.4%). Notably, 71.4% of patients experienced grade 3 hypertension compared with only 23% of patients in MAPS. 21 However, hypertension was manageable with administration of antihypertensive medications, allowing patients to continue receiving bevacizumab. Other grade 3 AEs included elevated amylase, elevated γ‐glutamyltransferase, anemia, proteinuria and hyponatremia. The toxicity profile of bevacizumab plus cisplatin/pemetrexed was also similar to that reported in Japanese patients with NSCLC 24 and with advanced cervical cancer. 25 Although it is difficult to make cross‐trial comparisons due to differences in study designs, methods of assessment and patient populations, our safety data appear to be consistent with previous reports on bevacizumab‐based therapy for MPM, and did not identify any previously unknown toxicities. 21 , 22 One patient changed from cisplatin to carboplatin due to reduced kidney function but, since there is a wealth of safety and efficacy data for carboplatin‐based chemotherapy, it is unlikely that this would significantly impact the safety profile. 16 , 26 , 27 One patient withdrew from the study due to a gastric ulcer, which was confirmed by the investigator as being associated with bevacizumab; however, because gastroendoscopy was not conducted prior to study enrollment, it is unknown whether this was present at baseline. Another patient experienced pleural effusion but continued to receive bevacizumab for ∼1.5 years (as of January 31, 2018). Similarly, results from the multicenter, phase II, NEJ013A trial showed that bevacizumab may be active in patients with malignant pleural effusion. 28 Median PFS was 6.8 months in this study, which is similar to two phase II studies in MPM that both reported median PFS of 6.9 months with the addition of bevacizumab to standard of care: the multicenter study by Dowell et al. 29 (n = 52) evaluated the same regimen as our study, and the randomized trial by Kindler et al. 20 (n = 108) added bevacizumab to cisplatin/gemcitabine. In contrast, two patients with a partial response had a longer PFS of 10.4 and 11.1 months in our study. The phase III MAPS, with a larger population of 448 patients, reported median PFS and OS durations of 9.2 and 18.8 months, respectively, with bevacizumab plus cisplatin/pemetrexed. 21 At the data cut‐off, three patients remained on treatment with bevacizumab and continue to be monitored. Patients can continue treatment for about a year, so there is potential to observe ongoing responses in these patients. As of January 31, 2018, two patients had continued to receive treatment for ∼1.5 years and no new toxicity had been observed. The combination of anti‐angiogenic agents, such as bevacizumab, nintedanib and cediranib, with cisplatin/pemetrexed has been evaluated in the first‐line MPM treatment setting. The most promising results have been obtained with the addition of bevacizumab to cisplatin/pemetrexed. 21 Nintedanib is a triple angiokinase inhibitor with activity against VEGF receptor 1−3, platelet‐derived growth factor (PDGF) receptors α and ß, fibroblast growth factors receptors 1−3 and Src and Abl kinases. Addition of nintedanib to cisplatin/pemetrexed in the phase II LUME‐Meso study improved PFS in patients with unresectable nonsarcomatoid MPM compared with the addition of placebo (median PFS 9.4 months vs 5.7 months, respectively). 30 However, the double‐blind, randomized, placebo‐controlled phase III LUME‐Meso study in unresectable epithelioid MPM failed to meet its primary PFS endpoint (median PFS 6.8 months in the nintedanib arm vs 7.0 months in the placebo arm; P = 0.91). 31 Cediranib is an inhibitor of VEGF receptor, PDGF receptor and stem cell factor receptor. In a phase I trial, the addition of cediranib to cisplatin/pemetrexed demonstrated promising preliminary outcomes in patients with chemotherapy‐naïve MPM (median PFS = 8.6 months; median OS = 16.2 months). 32 Results from the ongoing phase II study of cediranib in combination with cisplatin/pemetrexed (NCT01064648) are awaited. Recently, nivolumab was approved in Japan as salvage therapy in MPM patients, and is now being evaluated in the first‐line setting in combination with standard of care treatment in Japan. 33 Preclinical studies suggest that combining anti‐angiogenic agents with immunotherapy may have a synergistic effect, enhancing the efficacy of both treatments. 34 A phase I trial is currently assessing nintedanib in combination with the PD‐1 inhibitor pembrolizumab in patients with various tumors including MPM (NCT02856425), whereas a phase II study is evaluating bevacizumab in combination with atezolizumab in MPM and peritoneal mesothelioma (NCT03074513). We reported safety and efficacy data for first‐line bevacizumab in combination with cisplatin/pemetrexed in Japanese patients with MPM, for whom data are currently limited. Our safety data are comparable with other similar studies and show that the addition of bevacizumab to the current standard of care is tolerable. 5 CONCLUSION The combination of bevacizumab, cisplatin and pemetrexed followed by maintenance treatment with bevacizumab was well tolerated and had satisfactory efficacy in this small patient dataset, warranting its first‐line use in Japanese patients with MPM, on the basis of the phase III study in France. In terms of systematic chemotherapy for MPM, cisplatin plus pemetrexed is the only approved regimen in the untreated setting. Data from this single‐arm trial are encouraging for patients with unresectable MPM; the addition of bevacizumab to standard chemotherapy would offer an alternative treatment option and may extend survival in patients with this aggressive neoplasm. CONFLICTS OF INTEREST Takashi Nakano has received honoraria from MSD, Olympus Corporation, ISHIHARA Sangyo, KYORIN Pharmaceutical, Nippon Boehringer Ingelheim and ONO Pharmaceutical; acted in a consulting or advisory role for Nippon Boehringer Ingelheim; and reports personal fees from Cancer and Chemotherapy Publishers, Ishiyaku Publishers, IGAKU‐SHOIN, Elsevier Japan K.K., Asakura Publishing, Ministry of the Environment Japan and Amagasaki City, outside the submitted work. Kozo Kuribayashi has received honoraria from AstraZeneca, Astellas Pharma, Boehringer Ingelheim, Chugai Pharmaceutical, Kyowa Hakko Kirin, KYORIN Pharmaceutical, Meiji‐Seika‐Pharma, Novartis, Ono Pharmaceutical and Taiho Pharmaceutical. Masashi Kondo has received honoraria from Eli Lilly, MSD, Chugai Pharmaceutical, Pfizer, Novartis, AstraZeneca, Nippon Boehringer Ingelheim, Taiho Pharmaceutical and Kyowa Hakko Kirin. Masahiro Morise has received honoraria from Chugai Pharmaceutical, Eli Lilly Japan K.K., Ono Pharmaceutical, Bristol‐Myers Squibb, Pfizer, AstraZeneca, Boehringer Ingelheim, Merck Serono and Novartis. Yuji Tada has received honoraria from Chugai Pharmaceutical. Katsuya Hirano reports personal fees from AstraZeneca K.K., Chugai Pharmaceutical, Eli Lilly, Nippon Boehringer Ingelheim, Ono Pharmaceutical, Pfizer, Taiho Pharmaceutical and Novartis, outside the submitted work. Morihiko Hayashi and Misa Tanaka are employees of Chugai Pharmaceutical, and Misa Tanaka owns stock in Chugai Pharmaceutical. Masataka Hirabayashi has received honoraria from AstraZeneca K.K., Ono Pharmaceutical, KYORIN Pharmaceutical, Taiho Pharmaceutical, MSD, Chugai Pharmaceutical, Pfizer, Boehringer Ingelheim and Eli Lilly. Supporting information Supporting Information Click here for additional data file. ACKNOWLEDGMENTS This study was supported by Chugai Pharmaceutical Co., Ltd. We thank the patients who participated in this study. We also express our thanks to Kosei Tajima of Chugai Pharmaceutical Co., Ltd., and Professor Takashi Kijima, Hyogo College of Medicine, for drafting and reviewing the manuscript. Third‐party medical writing assistance, under the direction of the authors, was provided by Nathalie Robinson, PhD, and Rachel Hubbard, MSc, of Gardiner‐Caldwell Communications, and was funded by Chugai Pharmaceutical Co., Ltd. Trial registration number: JapicCTI‐163294. DATA AVAILABILITY STATEMENT Chugai Pharmaceutical Co., Ltd. provide qualified researchers access to individual patient‐level data through the clinical study data request platform (www.clinicalstudydatarequest.com). Further details of Chugai's Data Sharing Policy are available here (https://www.chugai‐pharm.co.jp/english/profile/rd/ctds_request.html).	Intravenous (not otherwise specified)	DrugAdministrationRoute	CC BY-NC	32893992	18,306,165	2021-06
What was the dosage of drug 'BEVACIZUMAB'?	Bevacizumab plus cisplatin/pemetrexed then bevacizumab alone for unresectable malignant pleural mesothelioma: A Japanese safety study. OBJECTIVE Malignant pleural mesothelioma (MPM) is an aggressive malignancy with poor prognosis and limited treatment options. Cisplatin plus pemetrexed is the only approved first-line treatment for patients with unresectable MPM. Recently, promising outcomes were observed with first-line bevacizumab combined with cisplatin/pemetrexed, leading to the recommendation of this regimen as a first-line treatment option for patients with MPM. Bevacizumab plus cisplatin/pemetrexed has been shown to be safe and effective in non-small cell lung cancer, however, there are no efficacy or safety data in Japanese patients with MPM treated with this regimen. We conducted a multicenter study to evaluate tolerability and safety for Japanese patients with chemotherapy-naïve, unresectable MPM. METHODS Eligible patients (n = 7) received bevacizumab plus cisplatin/pemetrexed (up to six cycles), then single-agent bevacizumab until disease progression or onset of unacceptable adverse events (AEs), according to the 3+3 design analogy. RESULTS One patient (14.3%) reported an AE (gastric ulcer) meeting tolerability criteria. All patients experienced gastrointestinal disorders, including nausea (grade 1/2 only, n = 6, 85.7%) and constipation (grade 1/2 only, n = 5, 71.4%). Five patients (71.4%) had grade 3 hypertension. Two patients discontinued treatment due to gastric ulcer (n = 1) and proteinuria (n = 1). At data cut-off, four patients had stable disease, two had partial response and one had non-complete response/non-progressive disease due to the absence of target lesions. CONCLUSIONS Bevacizumab plus cisplatin/pemetrexed then bevacizumab was well tolerated in Japanese patients with MPM. 1 INTRODUCTION Malignant pleural mesothelioma (MPM) is a rare, aggressive neoplasm with poor prognosis, which originates in the mesothelial cells lining the thoracic cavity. 1 Development of MPM is strongly associated with inhalational exposure to asbestos, and is usually caused by occupational asbestos exposure, but it can also occur from low‐level exposure in the general environment. 2 Despite regulatory action against, and prohibition of the use of asbestos, the number of patients with MPM is increasing substantially in many countries where asbestos has been widely used historically. 3 Its incidence is increasing rapidly worldwide, and the annual number of MPM deaths in Japan has risen from 500 in 1995 to 1555 in 2017. 4 Asia has become the largest consumer of asbestos in the world and is responsible for two‐thirds of global use. 5 China continues to use asbestos and is the top consumer in the world, with an increasing trend of MPM during 2000–2013 and 1659 MPM cases in 2013, but its incidence is low compared with industrialized countries. 5 Newly diagnosed patients with unresectable disease have a median overall survival (OS) of ∼12 months when treated with the standard of care, cisplatin plus pemetrexed. 6 The combination of cisplatin plus pemetrexed is the only currently approved regimen for unresectable first‐line MPM, with approvals gained in 2004 in the USA and European Union, and in 2007 in Japan. Phase II studies demonstrated that pemetrexed in combination with carboplatin might be an alternative regimen with similar treatment outcomes. 7 There have been no new first‐line therapies approved for MPM for more than a decade. Furthermore, there is no US Food and Drug Administration (FDA)‐approved or European Medicines Agency (EMA)‐approved second‐line treatment for MPM. In 2018, anti‐programmed death‐1 (PD‐1) antibody nivolumab was approved in Japan for salvage use. The National Comprehensive Cancer Network (NCCN) guidelines revised their recommendation for nivolumab use with or without ipilimumab from category 2B to 2A, on the basis of recent clinical trial data for subsequent systemic MPM treatment. 8 In view of the poor prognosis and limited approved therapies, there is an unmet need for new treatment options that further improve outcomes for patients with MPM. A broad range of therapeutic targets exist in MPM, including angiogenesis, immune checkpoints, mesothelin and chemotherapeutic agents. Vascular endothelial growth factor (VEGF) is known to be a key regulator of MPM because it is an autocrine growth factor of MPM. 9 Significantly higher serum levels of VEGF have been identified in patients with MPM compared with other tumor types 10 and high VEGF level in serum or pleural effusion is a poor prognostic factor in MPM. 11 , 12 Because VEGF signaling is essential for mesothelioma cell physiopathology, 9 VEGF targeting therapy, such as the recombinant humanized monoclonal antibody bevacizumab, is a rational approach for the treatment of MPM. 13 , 14 Preclinical evaluation of the therapeutic efficacy of bevacizumab in combination with pemetrexed against mesothelioma has shown a synergy for the combination, compared with pemetrexed or bevacizumab alone. 15 Bevacizumab, when added to standard chemotherapy, has demonstrated effectiveness in non–small cell lung cancer (NSCLC) 16 and other tumor types such as breast cancer, 17 colorectal cancer 18 and renal cell carcinoma. 19 Bevacizumab has been evaluated as a combination therapy for MPM in randomized phase II and III clinical trials. 20 , 21 Prior to the approval of pemetrexed, gemcitabine plus cisplatin was a common treatment regimen for MPM. In a randomized phase II US trial in patients with previously untreated MPM, the addition of bevacizumab to gemcitabine/cisplatin did not improve progression‐free survival (PFS) or OS. 20 It was postulated that the trial failed to show positive results due to a potential negative interaction between bevacizumab and gemcitabine in preclinical studies. 22 Therefore, other chemotherapy backbones with bevacizumab, including cisplatin plus pemetrexed, have been investigated. The phase III Mesothelioma Avastin Cisplatin Pemetrexed Study (MAPS), which evaluated the addition of bevacizumab to cisplatin/pemetrexed followed by bevacizumab maintenance, was the first trial to demonstrate improved outcomes versus the standard of care. 21 In MAPS, the addition of bevacizumab to cisplatin/pemetrexed significantly improved PFS and OS compared with cisplatin/pemetrexed alone (OS = 18.8 months vs 16.1 months; hazard ratio [HR] = 0.77; P = 0.0167; PFS = 9.2 months vs 7.3 months, HR = 0.61, P < 0.0001). Additionally, adverse events (AEs) reported in MAPS were consistent with the known safety profile of bevacizumab plus chemotherapy. Based on these outcomes, 21 bevacizumab in combination with cisplatin/pemetrexed was included as a category 1 recommended first‐line treatment for unresectable MPM in the NCCN guidelines. 8 Although MAPS was conducted by the French Cooperative Thoracic Intergroup and data were from French patients only, the results confirm that first‐line bevacizumab‐based therapy can improve outcomes for patients with newly diagnosed MPM. Bevacizumab plus cisplatin/pemetrexed has been shown to be safe and effective in Japanese patients with NSCLC; however, there are no data showing tolerability and safety in Japanese patients with MPM treated with this triplet regimen. This article reports results from a single‐arm, multicenter study evaluating the tolerability, safety and efficacy of first‐line bevacizumab together with cisplatin/pemetrexed, followed by single‐agent bevacizumab, in Japanese patients with unresectable MPM. 2 PATIENTS AND METHODS 2.1 Study design JO39183 (JapicCTI‐163294) was a multicenter, open‐label, single‐arm, phase II study evaluating the tolerability, safety and efficacy of bevacizumab combined with cisplatin/pemetrexed followed by single‐agent bevacizumab in patients with unresectable MPM who had not previously received chemotherapy (Figure 1). The replacement of cisplatin by carboplatin was allowed in cases where a patient developed nephrotoxicity (creatinine clearance <45 mL/min, 6 weeks after administration) or ototoxicity. The target sample size for the study was six patients, which is determined as an analogy for 3+3 design, according to the methods of official recommendation issued by the Pharmaceutical and Food Safety Bureau, Ministry of Health, Labour and Welfare, Japan. 23 However, it was permissible to enroll more than six patients because the main purpose of the study was to evaluate tolerability and safety in Japanese patients. Following enrollment, each patient received up to six cycles of bevacizumab, cisplatin and pemetrexed (induction period), with cycles repeated every 3 weeks. Patients then continued to receive bevacizumab monotherapy every 3 weeks during the maintenance period until disease progression or the onset of unacceptable AEs. FIGURE 1 Study design The study was conducted in accordance with the principles of the Declaration of Helsinki and Good Clinical Practice. All appropriate ethical approval was received from Institutional Review Boards or Independent Ethics Committees at each of the sites. All patients provided written informed consent prior to any study‐related procedures, and agreed to their individual data being published. 2.2 Eligibility criteria Key inclusion criteria for patients included: age ≥20 years with histologically confirmed pleural mesothelioma, not considered amendable to resection; an Eastern Cooperative Oncology Group performance status (ECOG PS) of 0–2; life expectancy of ≥12 weeks from the time of enrollment; no previous chemotherapy for MPM (including adjuvant and neoadjuvant therapy); and radiographically evident lesions. Patients with central nervous system metastases were excluded. Further exclusion criteria are detailed in the Supporting Information. 2.3 Treatment Patients received combination therapy with bevacizumab, cisplatin and pemetrexed, administered for up to six cycles with cycles being repeated every 3 weeks in the induction period. Pemetrexed 500 mg/m2 was administered intravenously (IV) over 10 min, then 30 min later cisplatin 75 mg/m2 IV was administered over 2 h. Following the cisplatin infusion, bevacizumab 15 mg/kg IV was administered over 30–90 min. If carboplatin was used in place of cisplatin, it was administered at a dose at which the target area under the curve was 5 mg/mL/min (as calculated based on the Calvert formula) over 30–60 min on Day 1 of each cycle. Following six cycles of the combination, bevacizumab 15 mg/kg was administered every 3 weeks in the maintenance period until disease progression or the onset of unacceptable AEs. The combination therapy could be discontinued before completion of six cycles; in this case, patients continued on bevacizumab monotherapy. The study duration for each patient was from the day of consent to the last observation day (observation or assessment day that was 28 ± 7 days after the last dose of study drug). 2.4 Study endpoints The primary purpose was to evaluate the tolerability of bevacizumab combined with cisplatin/pemetrexed. Secondary purposes were to evaluate the safety and efficacy of bevacizumab combined with cisplatin/pemetrexed followed by single‐agent bevacizumab. 2.5 Study assessments The evaluation period for tolerability was from Day 1 of Cycle 1 until immediately prior to the start of study drug administration on Day 1 of Cycle 2. AEs predefined for tolerability criteria included grade 4 neutropenia persisting for ≥7 days, febrile neutropenia, grade 3/4 reductions in platelet counts and any nonhematologic toxicity with severity of grade 3 or higher (further details are provided in the Supporting Information), occurring during the tolerability evaluation period and for which a causal relationship to the combination therapy could not be ruled out. The study treatment was considered tolerable if these AEs were reported in ≤34% (two out of six patients) of all enrolled patients considered evaluable for tolerability. The severity of AEs was graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.03. An Efficacy and Safety Evaluation Committee decided whether to continue the study and/or to amend the protocol if any AEs meeting the tolerability criteria were reported in three patients during the study period. If the occurrence of AEs meeting the criteria was estimated to be in ≤34% of the target number of patients (e.g. corresponding AEs were not reported in the first four patients, excluding patients who were considered nonevaluable for tolerability), the Efficacy and Safety Evaluation Committee had the option of closing enrollment. Safety was assessed using data collected until the point at which the observation period in Cycle 1 was completed for the last patient. AEs were coded using the Medical Dictionary for Regulatory Activities (version 19.0) and summarized by system organ class and preferred term. Best overall response and median PFS were assessed in accordance with Response Evaluation Criteria in Solid Tumors version 1.1. PFS was defined as the time from the first day of study drug administration to the first documented disease progression or death, whichever occurred first. 3 RESULTS 3.1 Patient population Seven patients, from four centers, were enrolled into the study and all received bevacizumab combination therapy. After four cycles of treatment with bevacizumab, cisplatin and pemetrexed, one patient changed from cisplatin to carboplatin due to reduced kidney function. Baseline patient characteristics are shown in Table 1. Patients had a median age of 66 years (range 47–73) and 57.1% were male. Although patients with an ECOG PS of 0–2 were eligible, all patients had an ECOG PS of 0 or 1. The tolerability and safety analysis sets included all seven patients. The data cut‐off was September 15, 2016, for tolerability and July 6, 2017, for safety and efficacy. TABLE 1 Patient characteristics at baseline Patient characteristics Patients (n = 7) Sex, n (%) Male 4 (57.1) Female 3 (42.9) Median age (range), years 66 (47–73) Histology, n (%) Epithelioid 6 (85.7) Sarcomatoid or mixed 1 (14.3) ECOG PS, n (%) 0 5 (71.4) 1 2 (28.6) Smoking status, n (%) Smoker 4 (57.1) Never smoker 3 (42.9) Abbreviation: ECOG PS, Eastern Cooperative Oncology Group performance status. John Wiley & Sons, Ltd. 3.2 Treatment exposure A summary of treatment exposure is shown in Figure 2. Overall, a median of nine cycles of bevacizumab were administered, with a median treatment duration of 188 days. Dose intensity was defined as the proportion of actual doses received to planned dose. For pemetrexed and cisplatin, planned dose was defined as the initial dose for six cycles completed without dose delay or dose reduction. For bevacizumab, planned dose was defined as the initial dose for actual cycles completed without dose delay or dose reduction. The mean dose intensities of bevacizumab, pemetrexed and cisplatin were 94%, 72% and 65%, respectively. FIGURE 2 Treatment exposure. †, Cisplatin was replaced with carboplatin for Cycles 5 and 6. ‡, Ongoing At the time of data cut‐off (July 6, 2017), four patients had discontinued treatment and three were continuing to receive single‐agent bevacizumab. One patient discontinued combination therapy due to a gastric ulcer and another due to proteinuria. The remaining two patients discontinued combination therapy due to disease progression. Three out of seven patients did not complete six cycles of chemotherapy; in addition, one patient received carboplatin instead of cisplatin for Cycles 5 and 6 due to reduced creatinine clearance. In the three patients who did not complete six cycles of chemotherapy, the reasons for chemotherapy discontinuation were gastric ulcer, proteinuria (as mentioned above), systemic rash and dyspnea. 3.3 Tolerability During the tolerability evaluation period, one of the seven patients (14.3%) experienced an AE (gastric ulcer), which met the definition criteria for tolerability. 3.4 Safety All seven patients (100%) experienced at least one AE (any grade) and a total of 74 AEs were reported. All patients experienced gastrointestinal disorders (any grade), with the most common being nausea (any grade, n = 6, 85.7%) and constipation (any grade, n = 5, 71.4%). Six different grade 3 AEs were reported: hypertension occurred in five patients (71.4%), and elevated amylase, elevated γ‐glutamyltransferase, hyponatremia, anemia and proteinuria each occurred in one patient (14.3%). There were no grade 4/5 AEs. Two patients had AEs that led to treatment discontinuation; one had a gastric ulcer (n = 1; 14.3%) and the other had proteinuria (n = 1; 14.3%). No deaths were reported. Treatment‐related AEs are detailed in Table 2. TABLE 2 Treatment‐related adverse events (n = 7) Any grade, n (%) Grade 1, n (%) Grade 2, n (%) Grade 3, n (%) Nausea 6 (85.7) 3 (42.9) 3 (42.9) 0 Hypertension 6 (85.7) 0 1 (14.3) 5 (71.4) Constipation 4 (57.1) 3 (42.9) 1 (14.3) 0 Edema peripheral 1 (14.3) 1 (14.3) 0 0 Malaise 2 (28.6) 1 (14.3) 1 (14.3) 0 Rash generalized 2 (28.6) 0 2 (28.6) 0 Epistaxis 2 (28.6) 2 (28.6) 0 0 Dysgeusia 2 (28.6) 2 (28.6) 0 0 Headache 1 (14.3) 0 1 (14.3) 0 Hiccups 1 (14.3) 1 (14.3) 0 0 Amylase increased 1 (14.3) 0 0 1 (14.3) Gastric ulcer 1 (14.3) 0 1 (14.3) 0 Eyelid edema 1 (14.3) 1 (14.3) 0 0 Blood creatinine increased 1 (14.3) 1 (14.3) 0 0 Dyspnea 1 (14.3) 0 1 (14.3) 0 Oropharyngeal pain 1 (14.3) 1 (14.3) 0 0 Stomatitis 1 (14.3) 1 (14.3) 0 0 Neutrophil count decreased 1 (14.3) 0 1 (14.3) 0 Periodontal disease 1 (14.3) 0 1 (14.3) 0 Carpal tunnel syndrome 1 (14.3) 1 (14.3) 0 0 Pigmentation disorder 1 (14.3) 1 (14.3) 0 0 Decreased appetite 1 (14.3) 0 1 (14.3) 0 Creatinine renal clearance decreased 1 (14.3) 0 1 (14.3) 0 Bodyweight increased 1 (14.3) 1 (14.3) 0 0 Proteinuria 1 (14.3) 0 0 1 (14.3) Injection site pain 1 (14.3) 1 (14.3) 0 0 Flushing 1 (14.3) 1 (14.3) 0 0 Hyponatremia 1 (14.3) 0 0 1 (14.3) Protein urine present 1 (14.3) 0 1 (14.3) 0 White blood cell count decreased 1 (14.3) 0 1 (14.3) 0 Rash 1 (14.3) 1 (14.3) 0 0 Pyrexia 1 (14.3) 1 (14.3) 0 0 Abdominal distension 1 (14.3) 0 1 (14.3) 0 Peripheral neuropathy 1 (14.3) 1 (14.3) 0 0 Vomiting 1 (14.3) 0 1 (14.3) 0 No grade 4/5 treatment‐related adverse events were reported. John Wiley & Sons, Ltd. 3.5 Efficacy Best overall response and PFS data are shown in Table 3. At the time of data cut‐off (July 6, 2017), four patients had stable disease, two had a partial response and one had non‐complete response/non‐progressive disease (non‐CR/non‐PD). The four patients who had stable disease had PFS of 0.9, 2.7, 6.7 and 6.8 months, respectively; and the two patients with a partial response had censored PFS durations of 10.4 and 11.1 months, respectively. The partial response in one of the patients is illustrated in Figure 3. The non‐CR/non‐PD patient had a PFS of 9.4 months (censored). Three patients who had either a partial response (n = 2) or a non‐CR/non‐PD (n = 1) remained on treatment at the time of data cut‐off. TABLE 3 Summary of efficacy Patient number Status Best overall response PFS (months) 1 Withdrawal at C1 SD a 0.9 2 Withdrawal at C3 SD 2.7 3 Withdrawal at C9 SD 6.7 4 Withdrawal at C9 SD 6.8 5 Ongoing PR 10.4 b 6 Ongoing Non‐CR/non‐PD 9.4 b 7 Ongoing PR 11.1 b Abbreviations: C, cycle; CR, complete response; PD, progressive disease; PFS, progression‐free survival; PR, partial response; SD, stable disease. a The period from baseline to best overall response evaluation was ≥6 weeks. b Censored observation, treatment ongoing. John Wiley & Sons, Ltd. FIGURE 3 Patient case: Computed tomography scan after Cycle 7 in a 47‐year‐old, female patient who was diagnosed with stage III MPM, and experienced a partial response after receiving treatment without dose modification, other than cisplatin at Cycle 6, when treatment with cisplatin was discontinued mid‐treatment due to the occurrence of a systemic rash (patient #5) 4 DISCUSSION This is the first study to report tolerability and safety data for Japanese patients with MPM treated with bevacizumab plus cisplatin/pemetrexed. Our results demonstrate that bevacizumab added to cisplatin/pemetrexed, followed by single‐agent bevacizumab is tolerable as a first‐line treatment in Japanese patients with MPM. No new safety concerns were identified for bevacizumab either in combination with cisplatin/pemetrexed or as single‐agent maintenance treatment. The overall safety profile in this study was consistent with data published for MAPS. 21 All patients in our study experienced gastrointestinal AEs, the most common being nausea (85.7%; any grade), which was similar to the incidence reported in MAPS (78.4%). Notably, 71.4% of patients experienced grade 3 hypertension compared with only 23% of patients in MAPS. 21 However, hypertension was manageable with administration of antihypertensive medications, allowing patients to continue receiving bevacizumab. Other grade 3 AEs included elevated amylase, elevated γ‐glutamyltransferase, anemia, proteinuria and hyponatremia. The toxicity profile of bevacizumab plus cisplatin/pemetrexed was also similar to that reported in Japanese patients with NSCLC 24 and with advanced cervical cancer. 25 Although it is difficult to make cross‐trial comparisons due to differences in study designs, methods of assessment and patient populations, our safety data appear to be consistent with previous reports on bevacizumab‐based therapy for MPM, and did not identify any previously unknown toxicities. 21 , 22 One patient changed from cisplatin to carboplatin due to reduced kidney function but, since there is a wealth of safety and efficacy data for carboplatin‐based chemotherapy, it is unlikely that this would significantly impact the safety profile. 16 , 26 , 27 One patient withdrew from the study due to a gastric ulcer, which was confirmed by the investigator as being associated with bevacizumab; however, because gastroendoscopy was not conducted prior to study enrollment, it is unknown whether this was present at baseline. Another patient experienced pleural effusion but continued to receive bevacizumab for ∼1.5 years (as of January 31, 2018). Similarly, results from the multicenter, phase II, NEJ013A trial showed that bevacizumab may be active in patients with malignant pleural effusion. 28 Median PFS was 6.8 months in this study, which is similar to two phase II studies in MPM that both reported median PFS of 6.9 months with the addition of bevacizumab to standard of care: the multicenter study by Dowell et al. 29 (n = 52) evaluated the same regimen as our study, and the randomized trial by Kindler et al. 20 (n = 108) added bevacizumab to cisplatin/gemcitabine. In contrast, two patients with a partial response had a longer PFS of 10.4 and 11.1 months in our study. The phase III MAPS, with a larger population of 448 patients, reported median PFS and OS durations of 9.2 and 18.8 months, respectively, with bevacizumab plus cisplatin/pemetrexed. 21 At the data cut‐off, three patients remained on treatment with bevacizumab and continue to be monitored. Patients can continue treatment for about a year, so there is potential to observe ongoing responses in these patients. As of January 31, 2018, two patients had continued to receive treatment for ∼1.5 years and no new toxicity had been observed. The combination of anti‐angiogenic agents, such as bevacizumab, nintedanib and cediranib, with cisplatin/pemetrexed has been evaluated in the first‐line MPM treatment setting. The most promising results have been obtained with the addition of bevacizumab to cisplatin/pemetrexed. 21 Nintedanib is a triple angiokinase inhibitor with activity against VEGF receptor 1−3, platelet‐derived growth factor (PDGF) receptors α and ß, fibroblast growth factors receptors 1−3 and Src and Abl kinases. Addition of nintedanib to cisplatin/pemetrexed in the phase II LUME‐Meso study improved PFS in patients with unresectable nonsarcomatoid MPM compared with the addition of placebo (median PFS 9.4 months vs 5.7 months, respectively). 30 However, the double‐blind, randomized, placebo‐controlled phase III LUME‐Meso study in unresectable epithelioid MPM failed to meet its primary PFS endpoint (median PFS 6.8 months in the nintedanib arm vs 7.0 months in the placebo arm; P = 0.91). 31 Cediranib is an inhibitor of VEGF receptor, PDGF receptor and stem cell factor receptor. In a phase I trial, the addition of cediranib to cisplatin/pemetrexed demonstrated promising preliminary outcomes in patients with chemotherapy‐naïve MPM (median PFS = 8.6 months; median OS = 16.2 months). 32 Results from the ongoing phase II study of cediranib in combination with cisplatin/pemetrexed (NCT01064648) are awaited. Recently, nivolumab was approved in Japan as salvage therapy in MPM patients, and is now being evaluated in the first‐line setting in combination with standard of care treatment in Japan. 33 Preclinical studies suggest that combining anti‐angiogenic agents with immunotherapy may have a synergistic effect, enhancing the efficacy of both treatments. 34 A phase I trial is currently assessing nintedanib in combination with the PD‐1 inhibitor pembrolizumab in patients with various tumors including MPM (NCT02856425), whereas a phase II study is evaluating bevacizumab in combination with atezolizumab in MPM and peritoneal mesothelioma (NCT03074513). We reported safety and efficacy data for first‐line bevacizumab in combination with cisplatin/pemetrexed in Japanese patients with MPM, for whom data are currently limited. Our safety data are comparable with other similar studies and show that the addition of bevacizumab to the current standard of care is tolerable. 5 CONCLUSION The combination of bevacizumab, cisplatin and pemetrexed followed by maintenance treatment with bevacizumab was well tolerated and had satisfactory efficacy in this small patient dataset, warranting its first‐line use in Japanese patients with MPM, on the basis of the phase III study in France. In terms of systematic chemotherapy for MPM, cisplatin plus pemetrexed is the only approved regimen in the untreated setting. Data from this single‐arm trial are encouraging for patients with unresectable MPM; the addition of bevacizumab to standard chemotherapy would offer an alternative treatment option and may extend survival in patients with this aggressive neoplasm. CONFLICTS OF INTEREST Takashi Nakano has received honoraria from MSD, Olympus Corporation, ISHIHARA Sangyo, KYORIN Pharmaceutical, Nippon Boehringer Ingelheim and ONO Pharmaceutical; acted in a consulting or advisory role for Nippon Boehringer Ingelheim; and reports personal fees from Cancer and Chemotherapy Publishers, Ishiyaku Publishers, IGAKU‐SHOIN, Elsevier Japan K.K., Asakura Publishing, Ministry of the Environment Japan and Amagasaki City, outside the submitted work. Kozo Kuribayashi has received honoraria from AstraZeneca, Astellas Pharma, Boehringer Ingelheim, Chugai Pharmaceutical, Kyowa Hakko Kirin, KYORIN Pharmaceutical, Meiji‐Seika‐Pharma, Novartis, Ono Pharmaceutical and Taiho Pharmaceutical. Masashi Kondo has received honoraria from Eli Lilly, MSD, Chugai Pharmaceutical, Pfizer, Novartis, AstraZeneca, Nippon Boehringer Ingelheim, Taiho Pharmaceutical and Kyowa Hakko Kirin. Masahiro Morise has received honoraria from Chugai Pharmaceutical, Eli Lilly Japan K.K., Ono Pharmaceutical, Bristol‐Myers Squibb, Pfizer, AstraZeneca, Boehringer Ingelheim, Merck Serono and Novartis. Yuji Tada has received honoraria from Chugai Pharmaceutical. Katsuya Hirano reports personal fees from AstraZeneca K.K., Chugai Pharmaceutical, Eli Lilly, Nippon Boehringer Ingelheim, Ono Pharmaceutical, Pfizer, Taiho Pharmaceutical and Novartis, outside the submitted work. Morihiko Hayashi and Misa Tanaka are employees of Chugai Pharmaceutical, and Misa Tanaka owns stock in Chugai Pharmaceutical. Masataka Hirabayashi has received honoraria from AstraZeneca K.K., Ono Pharmaceutical, KYORIN Pharmaceutical, Taiho Pharmaceutical, MSD, Chugai Pharmaceutical, Pfizer, Boehringer Ingelheim and Eli Lilly. Supporting information Supporting Information Click here for additional data file. ACKNOWLEDGMENTS This study was supported by Chugai Pharmaceutical Co., Ltd. We thank the patients who participated in this study. We also express our thanks to Kosei Tajima of Chugai Pharmaceutical Co., Ltd., and Professor Takashi Kijima, Hyogo College of Medicine, for drafting and reviewing the manuscript. Third‐party medical writing assistance, under the direction of the authors, was provided by Nathalie Robinson, PhD, and Rachel Hubbard, MSc, of Gardiner‐Caldwell Communications, and was funded by Chugai Pharmaceutical Co., Ltd. Trial registration number: JapicCTI‐163294. DATA AVAILABILITY STATEMENT Chugai Pharmaceutical Co., Ltd. provide qualified researchers access to individual patient‐level data through the clinical study data request platform (www.clinicalstudydatarequest.com). Further details of Chugai's Data Sharing Policy are available here (https://www.chugai‐pharm.co.jp/english/profile/rd/ctds_request.html).	WAS ADMINISTERED OVER 30-90 MIN	DrugDosageText	CC BY-NC	32893992	18,306,165	2021-06
What was the dosage of drug 'CISPLATIN'?	Bevacizumab plus cisplatin/pemetrexed then bevacizumab alone for unresectable malignant pleural mesothelioma: A Japanese safety study. OBJECTIVE Malignant pleural mesothelioma (MPM) is an aggressive malignancy with poor prognosis and limited treatment options. Cisplatin plus pemetrexed is the only approved first-line treatment for patients with unresectable MPM. Recently, promising outcomes were observed with first-line bevacizumab combined with cisplatin/pemetrexed, leading to the recommendation of this regimen as a first-line treatment option for patients with MPM. Bevacizumab plus cisplatin/pemetrexed has been shown to be safe and effective in non-small cell lung cancer, however, there are no efficacy or safety data in Japanese patients with MPM treated with this regimen. We conducted a multicenter study to evaluate tolerability and safety for Japanese patients with chemotherapy-naïve, unresectable MPM. METHODS Eligible patients (n = 7) received bevacizumab plus cisplatin/pemetrexed (up to six cycles), then single-agent bevacizumab until disease progression or onset of unacceptable adverse events (AEs), according to the 3+3 design analogy. RESULTS One patient (14.3%) reported an AE (gastric ulcer) meeting tolerability criteria. All patients experienced gastrointestinal disorders, including nausea (grade 1/2 only, n = 6, 85.7%) and constipation (grade 1/2 only, n = 5, 71.4%). Five patients (71.4%) had grade 3 hypertension. Two patients discontinued treatment due to gastric ulcer (n = 1) and proteinuria (n = 1). At data cut-off, four patients had stable disease, two had partial response and one had non-complete response/non-progressive disease due to the absence of target lesions. CONCLUSIONS Bevacizumab plus cisplatin/pemetrexed then bevacizumab was well tolerated in Japanese patients with MPM. 1 INTRODUCTION Malignant pleural mesothelioma (MPM) is a rare, aggressive neoplasm with poor prognosis, which originates in the mesothelial cells lining the thoracic cavity. 1 Development of MPM is strongly associated with inhalational exposure to asbestos, and is usually caused by occupational asbestos exposure, but it can also occur from low‐level exposure in the general environment. 2 Despite regulatory action against, and prohibition of the use of asbestos, the number of patients with MPM is increasing substantially in many countries where asbestos has been widely used historically. 3 Its incidence is increasing rapidly worldwide, and the annual number of MPM deaths in Japan has risen from 500 in 1995 to 1555 in 2017. 4 Asia has become the largest consumer of asbestos in the world and is responsible for two‐thirds of global use. 5 China continues to use asbestos and is the top consumer in the world, with an increasing trend of MPM during 2000–2013 and 1659 MPM cases in 2013, but its incidence is low compared with industrialized countries. 5 Newly diagnosed patients with unresectable disease have a median overall survival (OS) of ∼12 months when treated with the standard of care, cisplatin plus pemetrexed. 6 The combination of cisplatin plus pemetrexed is the only currently approved regimen for unresectable first‐line MPM, with approvals gained in 2004 in the USA and European Union, and in 2007 in Japan. Phase II studies demonstrated that pemetrexed in combination with carboplatin might be an alternative regimen with similar treatment outcomes. 7 There have been no new first‐line therapies approved for MPM for more than a decade. Furthermore, there is no US Food and Drug Administration (FDA)‐approved or European Medicines Agency (EMA)‐approved second‐line treatment for MPM. In 2018, anti‐programmed death‐1 (PD‐1) antibody nivolumab was approved in Japan for salvage use. The National Comprehensive Cancer Network (NCCN) guidelines revised their recommendation for nivolumab use with or without ipilimumab from category 2B to 2A, on the basis of recent clinical trial data for subsequent systemic MPM treatment. 8 In view of the poor prognosis and limited approved therapies, there is an unmet need for new treatment options that further improve outcomes for patients with MPM. A broad range of therapeutic targets exist in MPM, including angiogenesis, immune checkpoints, mesothelin and chemotherapeutic agents. Vascular endothelial growth factor (VEGF) is known to be a key regulator of MPM because it is an autocrine growth factor of MPM. 9 Significantly higher serum levels of VEGF have been identified in patients with MPM compared with other tumor types 10 and high VEGF level in serum or pleural effusion is a poor prognostic factor in MPM. 11 , 12 Because VEGF signaling is essential for mesothelioma cell physiopathology, 9 VEGF targeting therapy, such as the recombinant humanized monoclonal antibody bevacizumab, is a rational approach for the treatment of MPM. 13 , 14 Preclinical evaluation of the therapeutic efficacy of bevacizumab in combination with pemetrexed against mesothelioma has shown a synergy for the combination, compared with pemetrexed or bevacizumab alone. 15 Bevacizumab, when added to standard chemotherapy, has demonstrated effectiveness in non–small cell lung cancer (NSCLC) 16 and other tumor types such as breast cancer, 17 colorectal cancer 18 and renal cell carcinoma. 19 Bevacizumab has been evaluated as a combination therapy for MPM in randomized phase II and III clinical trials. 20 , 21 Prior to the approval of pemetrexed, gemcitabine plus cisplatin was a common treatment regimen for MPM. In a randomized phase II US trial in patients with previously untreated MPM, the addition of bevacizumab to gemcitabine/cisplatin did not improve progression‐free survival (PFS) or OS. 20 It was postulated that the trial failed to show positive results due to a potential negative interaction between bevacizumab and gemcitabine in preclinical studies. 22 Therefore, other chemotherapy backbones with bevacizumab, including cisplatin plus pemetrexed, have been investigated. The phase III Mesothelioma Avastin Cisplatin Pemetrexed Study (MAPS), which evaluated the addition of bevacizumab to cisplatin/pemetrexed followed by bevacizumab maintenance, was the first trial to demonstrate improved outcomes versus the standard of care. 21 In MAPS, the addition of bevacizumab to cisplatin/pemetrexed significantly improved PFS and OS compared with cisplatin/pemetrexed alone (OS = 18.8 months vs 16.1 months; hazard ratio [HR] = 0.77; P = 0.0167; PFS = 9.2 months vs 7.3 months, HR = 0.61, P < 0.0001). Additionally, adverse events (AEs) reported in MAPS were consistent with the known safety profile of bevacizumab plus chemotherapy. Based on these outcomes, 21 bevacizumab in combination with cisplatin/pemetrexed was included as a category 1 recommended first‐line treatment for unresectable MPM in the NCCN guidelines. 8 Although MAPS was conducted by the French Cooperative Thoracic Intergroup and data were from French patients only, the results confirm that first‐line bevacizumab‐based therapy can improve outcomes for patients with newly diagnosed MPM. Bevacizumab plus cisplatin/pemetrexed has been shown to be safe and effective in Japanese patients with NSCLC; however, there are no data showing tolerability and safety in Japanese patients with MPM treated with this triplet regimen. This article reports results from a single‐arm, multicenter study evaluating the tolerability, safety and efficacy of first‐line bevacizumab together with cisplatin/pemetrexed, followed by single‐agent bevacizumab, in Japanese patients with unresectable MPM. 2 PATIENTS AND METHODS 2.1 Study design JO39183 (JapicCTI‐163294) was a multicenter, open‐label, single‐arm, phase II study evaluating the tolerability, safety and efficacy of bevacizumab combined with cisplatin/pemetrexed followed by single‐agent bevacizumab in patients with unresectable MPM who had not previously received chemotherapy (Figure 1). The replacement of cisplatin by carboplatin was allowed in cases where a patient developed nephrotoxicity (creatinine clearance <45 mL/min, 6 weeks after administration) or ototoxicity. The target sample size for the study was six patients, which is determined as an analogy for 3+3 design, according to the methods of official recommendation issued by the Pharmaceutical and Food Safety Bureau, Ministry of Health, Labour and Welfare, Japan. 23 However, it was permissible to enroll more than six patients because the main purpose of the study was to evaluate tolerability and safety in Japanese patients. Following enrollment, each patient received up to six cycles of bevacizumab, cisplatin and pemetrexed (induction period), with cycles repeated every 3 weeks. Patients then continued to receive bevacizumab monotherapy every 3 weeks during the maintenance period until disease progression or the onset of unacceptable AEs. FIGURE 1 Study design The study was conducted in accordance with the principles of the Declaration of Helsinki and Good Clinical Practice. All appropriate ethical approval was received from Institutional Review Boards or Independent Ethics Committees at each of the sites. All patients provided written informed consent prior to any study‐related procedures, and agreed to their individual data being published. 2.2 Eligibility criteria Key inclusion criteria for patients included: age ≥20 years with histologically confirmed pleural mesothelioma, not considered amendable to resection; an Eastern Cooperative Oncology Group performance status (ECOG PS) of 0–2; life expectancy of ≥12 weeks from the time of enrollment; no previous chemotherapy for MPM (including adjuvant and neoadjuvant therapy); and radiographically evident lesions. Patients with central nervous system metastases were excluded. Further exclusion criteria are detailed in the Supporting Information. 2.3 Treatment Patients received combination therapy with bevacizumab, cisplatin and pemetrexed, administered for up to six cycles with cycles being repeated every 3 weeks in the induction period. Pemetrexed 500 mg/m2 was administered intravenously (IV) over 10 min, then 30 min later cisplatin 75 mg/m2 IV was administered over 2 h. Following the cisplatin infusion, bevacizumab 15 mg/kg IV was administered over 30–90 min. If carboplatin was used in place of cisplatin, it was administered at a dose at which the target area under the curve was 5 mg/mL/min (as calculated based on the Calvert formula) over 30–60 min on Day 1 of each cycle. Following six cycles of the combination, bevacizumab 15 mg/kg was administered every 3 weeks in the maintenance period until disease progression or the onset of unacceptable AEs. The combination therapy could be discontinued before completion of six cycles; in this case, patients continued on bevacizumab monotherapy. The study duration for each patient was from the day of consent to the last observation day (observation or assessment day that was 28 ± 7 days after the last dose of study drug). 2.4 Study endpoints The primary purpose was to evaluate the tolerability of bevacizumab combined with cisplatin/pemetrexed. Secondary purposes were to evaluate the safety and efficacy of bevacizumab combined with cisplatin/pemetrexed followed by single‐agent bevacizumab. 2.5 Study assessments The evaluation period for tolerability was from Day 1 of Cycle 1 until immediately prior to the start of study drug administration on Day 1 of Cycle 2. AEs predefined for tolerability criteria included grade 4 neutropenia persisting for ≥7 days, febrile neutropenia, grade 3/4 reductions in platelet counts and any nonhematologic toxicity with severity of grade 3 or higher (further details are provided in the Supporting Information), occurring during the tolerability evaluation period and for which a causal relationship to the combination therapy could not be ruled out. The study treatment was considered tolerable if these AEs were reported in ≤34% (two out of six patients) of all enrolled patients considered evaluable for tolerability. The severity of AEs was graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.03. An Efficacy and Safety Evaluation Committee decided whether to continue the study and/or to amend the protocol if any AEs meeting the tolerability criteria were reported in three patients during the study period. If the occurrence of AEs meeting the criteria was estimated to be in ≤34% of the target number of patients (e.g. corresponding AEs were not reported in the first four patients, excluding patients who were considered nonevaluable for tolerability), the Efficacy and Safety Evaluation Committee had the option of closing enrollment. Safety was assessed using data collected until the point at which the observation period in Cycle 1 was completed for the last patient. AEs were coded using the Medical Dictionary for Regulatory Activities (version 19.0) and summarized by system organ class and preferred term. Best overall response and median PFS were assessed in accordance with Response Evaluation Criteria in Solid Tumors version 1.1. PFS was defined as the time from the first day of study drug administration to the first documented disease progression or death, whichever occurred first. 3 RESULTS 3.1 Patient population Seven patients, from four centers, were enrolled into the study and all received bevacizumab combination therapy. After four cycles of treatment with bevacizumab, cisplatin and pemetrexed, one patient changed from cisplatin to carboplatin due to reduced kidney function. Baseline patient characteristics are shown in Table 1. Patients had a median age of 66 years (range 47–73) and 57.1% were male. Although patients with an ECOG PS of 0–2 were eligible, all patients had an ECOG PS of 0 or 1. The tolerability and safety analysis sets included all seven patients. The data cut‐off was September 15, 2016, for tolerability and July 6, 2017, for safety and efficacy. TABLE 1 Patient characteristics at baseline Patient characteristics Patients (n = 7) Sex, n (%) Male 4 (57.1) Female 3 (42.9) Median age (range), years 66 (47–73) Histology, n (%) Epithelioid 6 (85.7) Sarcomatoid or mixed 1 (14.3) ECOG PS, n (%) 0 5 (71.4) 1 2 (28.6) Smoking status, n (%) Smoker 4 (57.1) Never smoker 3 (42.9) Abbreviation: ECOG PS, Eastern Cooperative Oncology Group performance status. John Wiley & Sons, Ltd. 3.2 Treatment exposure A summary of treatment exposure is shown in Figure 2. Overall, a median of nine cycles of bevacizumab were administered, with a median treatment duration of 188 days. Dose intensity was defined as the proportion of actual doses received to planned dose. For pemetrexed and cisplatin, planned dose was defined as the initial dose for six cycles completed without dose delay or dose reduction. For bevacizumab, planned dose was defined as the initial dose for actual cycles completed without dose delay or dose reduction. The mean dose intensities of bevacizumab, pemetrexed and cisplatin were 94%, 72% and 65%, respectively. FIGURE 2 Treatment exposure. †, Cisplatin was replaced with carboplatin for Cycles 5 and 6. ‡, Ongoing At the time of data cut‐off (July 6, 2017), four patients had discontinued treatment and three were continuing to receive single‐agent bevacizumab. One patient discontinued combination therapy due to a gastric ulcer and another due to proteinuria. The remaining two patients discontinued combination therapy due to disease progression. Three out of seven patients did not complete six cycles of chemotherapy; in addition, one patient received carboplatin instead of cisplatin for Cycles 5 and 6 due to reduced creatinine clearance. In the three patients who did not complete six cycles of chemotherapy, the reasons for chemotherapy discontinuation were gastric ulcer, proteinuria (as mentioned above), systemic rash and dyspnea. 3.3 Tolerability During the tolerability evaluation period, one of the seven patients (14.3%) experienced an AE (gastric ulcer), which met the definition criteria for tolerability. 3.4 Safety All seven patients (100%) experienced at least one AE (any grade) and a total of 74 AEs were reported. All patients experienced gastrointestinal disorders (any grade), with the most common being nausea (any grade, n = 6, 85.7%) and constipation (any grade, n = 5, 71.4%). Six different grade 3 AEs were reported: hypertension occurred in five patients (71.4%), and elevated amylase, elevated γ‐glutamyltransferase, hyponatremia, anemia and proteinuria each occurred in one patient (14.3%). There were no grade 4/5 AEs. Two patients had AEs that led to treatment discontinuation; one had a gastric ulcer (n = 1; 14.3%) and the other had proteinuria (n = 1; 14.3%). No deaths were reported. Treatment‐related AEs are detailed in Table 2. TABLE 2 Treatment‐related adverse events (n = 7) Any grade, n (%) Grade 1, n (%) Grade 2, n (%) Grade 3, n (%) Nausea 6 (85.7) 3 (42.9) 3 (42.9) 0 Hypertension 6 (85.7) 0 1 (14.3) 5 (71.4) Constipation 4 (57.1) 3 (42.9) 1 (14.3) 0 Edema peripheral 1 (14.3) 1 (14.3) 0 0 Malaise 2 (28.6) 1 (14.3) 1 (14.3) 0 Rash generalized 2 (28.6) 0 2 (28.6) 0 Epistaxis 2 (28.6) 2 (28.6) 0 0 Dysgeusia 2 (28.6) 2 (28.6) 0 0 Headache 1 (14.3) 0 1 (14.3) 0 Hiccups 1 (14.3) 1 (14.3) 0 0 Amylase increased 1 (14.3) 0 0 1 (14.3) Gastric ulcer 1 (14.3) 0 1 (14.3) 0 Eyelid edema 1 (14.3) 1 (14.3) 0 0 Blood creatinine increased 1 (14.3) 1 (14.3) 0 0 Dyspnea 1 (14.3) 0 1 (14.3) 0 Oropharyngeal pain 1 (14.3) 1 (14.3) 0 0 Stomatitis 1 (14.3) 1 (14.3) 0 0 Neutrophil count decreased 1 (14.3) 0 1 (14.3) 0 Periodontal disease 1 (14.3) 0 1 (14.3) 0 Carpal tunnel syndrome 1 (14.3) 1 (14.3) 0 0 Pigmentation disorder 1 (14.3) 1 (14.3) 0 0 Decreased appetite 1 (14.3) 0 1 (14.3) 0 Creatinine renal clearance decreased 1 (14.3) 0 1 (14.3) 0 Bodyweight increased 1 (14.3) 1 (14.3) 0 0 Proteinuria 1 (14.3) 0 0 1 (14.3) Injection site pain 1 (14.3) 1 (14.3) 0 0 Flushing 1 (14.3) 1 (14.3) 0 0 Hyponatremia 1 (14.3) 0 0 1 (14.3) Protein urine present 1 (14.3) 0 1 (14.3) 0 White blood cell count decreased 1 (14.3) 0 1 (14.3) 0 Rash 1 (14.3) 1 (14.3) 0 0 Pyrexia 1 (14.3) 1 (14.3) 0 0 Abdominal distension 1 (14.3) 0 1 (14.3) 0 Peripheral neuropathy 1 (14.3) 1 (14.3) 0 0 Vomiting 1 (14.3) 0 1 (14.3) 0 No grade 4/5 treatment‐related adverse events were reported. John Wiley & Sons, Ltd. 3.5 Efficacy Best overall response and PFS data are shown in Table 3. At the time of data cut‐off (July 6, 2017), four patients had stable disease, two had a partial response and one had non‐complete response/non‐progressive disease (non‐CR/non‐PD). The four patients who had stable disease had PFS of 0.9, 2.7, 6.7 and 6.8 months, respectively; and the two patients with a partial response had censored PFS durations of 10.4 and 11.1 months, respectively. The partial response in one of the patients is illustrated in Figure 3. The non‐CR/non‐PD patient had a PFS of 9.4 months (censored). Three patients who had either a partial response (n = 2) or a non‐CR/non‐PD (n = 1) remained on treatment at the time of data cut‐off. TABLE 3 Summary of efficacy Patient number Status Best overall response PFS (months) 1 Withdrawal at C1 SD a 0.9 2 Withdrawal at C3 SD 2.7 3 Withdrawal at C9 SD 6.7 4 Withdrawal at C9 SD 6.8 5 Ongoing PR 10.4 b 6 Ongoing Non‐CR/non‐PD 9.4 b 7 Ongoing PR 11.1 b Abbreviations: C, cycle; CR, complete response; PD, progressive disease; PFS, progression‐free survival; PR, partial response; SD, stable disease. a The period from baseline to best overall response evaluation was ≥6 weeks. b Censored observation, treatment ongoing. John Wiley & Sons, Ltd. FIGURE 3 Patient case: Computed tomography scan after Cycle 7 in a 47‐year‐old, female patient who was diagnosed with stage III MPM, and experienced a partial response after receiving treatment without dose modification, other than cisplatin at Cycle 6, when treatment with cisplatin was discontinued mid‐treatment due to the occurrence of a systemic rash (patient #5) 4 DISCUSSION This is the first study to report tolerability and safety data for Japanese patients with MPM treated with bevacizumab plus cisplatin/pemetrexed. Our results demonstrate that bevacizumab added to cisplatin/pemetrexed, followed by single‐agent bevacizumab is tolerable as a first‐line treatment in Japanese patients with MPM. No new safety concerns were identified for bevacizumab either in combination with cisplatin/pemetrexed or as single‐agent maintenance treatment. The overall safety profile in this study was consistent with data published for MAPS. 21 All patients in our study experienced gastrointestinal AEs, the most common being nausea (85.7%; any grade), which was similar to the incidence reported in MAPS (78.4%). Notably, 71.4% of patients experienced grade 3 hypertension compared with only 23% of patients in MAPS. 21 However, hypertension was manageable with administration of antihypertensive medications, allowing patients to continue receiving bevacizumab. Other grade 3 AEs included elevated amylase, elevated γ‐glutamyltransferase, anemia, proteinuria and hyponatremia. The toxicity profile of bevacizumab plus cisplatin/pemetrexed was also similar to that reported in Japanese patients with NSCLC 24 and with advanced cervical cancer. 25 Although it is difficult to make cross‐trial comparisons due to differences in study designs, methods of assessment and patient populations, our safety data appear to be consistent with previous reports on bevacizumab‐based therapy for MPM, and did not identify any previously unknown toxicities. 21 , 22 One patient changed from cisplatin to carboplatin due to reduced kidney function but, since there is a wealth of safety and efficacy data for carboplatin‐based chemotherapy, it is unlikely that this would significantly impact the safety profile. 16 , 26 , 27 One patient withdrew from the study due to a gastric ulcer, which was confirmed by the investigator as being associated with bevacizumab; however, because gastroendoscopy was not conducted prior to study enrollment, it is unknown whether this was present at baseline. Another patient experienced pleural effusion but continued to receive bevacizumab for ∼1.5 years (as of January 31, 2018). Similarly, results from the multicenter, phase II, NEJ013A trial showed that bevacizumab may be active in patients with malignant pleural effusion. 28 Median PFS was 6.8 months in this study, which is similar to two phase II studies in MPM that both reported median PFS of 6.9 months with the addition of bevacizumab to standard of care: the multicenter study by Dowell et al. 29 (n = 52) evaluated the same regimen as our study, and the randomized trial by Kindler et al. 20 (n = 108) added bevacizumab to cisplatin/gemcitabine. In contrast, two patients with a partial response had a longer PFS of 10.4 and 11.1 months in our study. The phase III MAPS, with a larger population of 448 patients, reported median PFS and OS durations of 9.2 and 18.8 months, respectively, with bevacizumab plus cisplatin/pemetrexed. 21 At the data cut‐off, three patients remained on treatment with bevacizumab and continue to be monitored. Patients can continue treatment for about a year, so there is potential to observe ongoing responses in these patients. As of January 31, 2018, two patients had continued to receive treatment for ∼1.5 years and no new toxicity had been observed. The combination of anti‐angiogenic agents, such as bevacizumab, nintedanib and cediranib, with cisplatin/pemetrexed has been evaluated in the first‐line MPM treatment setting. The most promising results have been obtained with the addition of bevacizumab to cisplatin/pemetrexed. 21 Nintedanib is a triple angiokinase inhibitor with activity against VEGF receptor 1−3, platelet‐derived growth factor (PDGF) receptors α and ß, fibroblast growth factors receptors 1−3 and Src and Abl kinases. Addition of nintedanib to cisplatin/pemetrexed in the phase II LUME‐Meso study improved PFS in patients with unresectable nonsarcomatoid MPM compared with the addition of placebo (median PFS 9.4 months vs 5.7 months, respectively). 30 However, the double‐blind, randomized, placebo‐controlled phase III LUME‐Meso study in unresectable epithelioid MPM failed to meet its primary PFS endpoint (median PFS 6.8 months in the nintedanib arm vs 7.0 months in the placebo arm; P = 0.91). 31 Cediranib is an inhibitor of VEGF receptor, PDGF receptor and stem cell factor receptor. In a phase I trial, the addition of cediranib to cisplatin/pemetrexed demonstrated promising preliminary outcomes in patients with chemotherapy‐naïve MPM (median PFS = 8.6 months; median OS = 16.2 months). 32 Results from the ongoing phase II study of cediranib in combination with cisplatin/pemetrexed (NCT01064648) are awaited. Recently, nivolumab was approved in Japan as salvage therapy in MPM patients, and is now being evaluated in the first‐line setting in combination with standard of care treatment in Japan. 33 Preclinical studies suggest that combining anti‐angiogenic agents with immunotherapy may have a synergistic effect, enhancing the efficacy of both treatments. 34 A phase I trial is currently assessing nintedanib in combination with the PD‐1 inhibitor pembrolizumab in patients with various tumors including MPM (NCT02856425), whereas a phase II study is evaluating bevacizumab in combination with atezolizumab in MPM and peritoneal mesothelioma (NCT03074513). We reported safety and efficacy data for first‐line bevacizumab in combination with cisplatin/pemetrexed in Japanese patients with MPM, for whom data are currently limited. Our safety data are comparable with other similar studies and show that the addition of bevacizumab to the current standard of care is tolerable. 5 CONCLUSION The combination of bevacizumab, cisplatin and pemetrexed followed by maintenance treatment with bevacizumab was well tolerated and had satisfactory efficacy in this small patient dataset, warranting its first‐line use in Japanese patients with MPM, on the basis of the phase III study in France. In terms of systematic chemotherapy for MPM, cisplatin plus pemetrexed is the only approved regimen in the untreated setting. Data from this single‐arm trial are encouraging for patients with unresectable MPM; the addition of bevacizumab to standard chemotherapy would offer an alternative treatment option and may extend survival in patients with this aggressive neoplasm. CONFLICTS OF INTEREST Takashi Nakano has received honoraria from MSD, Olympus Corporation, ISHIHARA Sangyo, KYORIN Pharmaceutical, Nippon Boehringer Ingelheim and ONO Pharmaceutical; acted in a consulting or advisory role for Nippon Boehringer Ingelheim; and reports personal fees from Cancer and Chemotherapy Publishers, Ishiyaku Publishers, IGAKU‐SHOIN, Elsevier Japan K.K., Asakura Publishing, Ministry of the Environment Japan and Amagasaki City, outside the submitted work. Kozo Kuribayashi has received honoraria from AstraZeneca, Astellas Pharma, Boehringer Ingelheim, Chugai Pharmaceutical, Kyowa Hakko Kirin, KYORIN Pharmaceutical, Meiji‐Seika‐Pharma, Novartis, Ono Pharmaceutical and Taiho Pharmaceutical. Masashi Kondo has received honoraria from Eli Lilly, MSD, Chugai Pharmaceutical, Pfizer, Novartis, AstraZeneca, Nippon Boehringer Ingelheim, Taiho Pharmaceutical and Kyowa Hakko Kirin. Masahiro Morise has received honoraria from Chugai Pharmaceutical, Eli Lilly Japan K.K., Ono Pharmaceutical, Bristol‐Myers Squibb, Pfizer, AstraZeneca, Boehringer Ingelheim, Merck Serono and Novartis. Yuji Tada has received honoraria from Chugai Pharmaceutical. Katsuya Hirano reports personal fees from AstraZeneca K.K., Chugai Pharmaceutical, Eli Lilly, Nippon Boehringer Ingelheim, Ono Pharmaceutical, Pfizer, Taiho Pharmaceutical and Novartis, outside the submitted work. Morihiko Hayashi and Misa Tanaka are employees of Chugai Pharmaceutical, and Misa Tanaka owns stock in Chugai Pharmaceutical. Masataka Hirabayashi has received honoraria from AstraZeneca K.K., Ono Pharmaceutical, KYORIN Pharmaceutical, Taiho Pharmaceutical, MSD, Chugai Pharmaceutical, Pfizer, Boehringer Ingelheim and Eli Lilly. Supporting information Supporting Information Click here for additional data file. ACKNOWLEDGMENTS This study was supported by Chugai Pharmaceutical Co., Ltd. We thank the patients who participated in this study. We also express our thanks to Kosei Tajima of Chugai Pharmaceutical Co., Ltd., and Professor Takashi Kijima, Hyogo College of Medicine, for drafting and reviewing the manuscript. Third‐party medical writing assistance, under the direction of the authors, was provided by Nathalie Robinson, PhD, and Rachel Hubbard, MSc, of Gardiner‐Caldwell Communications, and was funded by Chugai Pharmaceutical Co., Ltd. Trial registration number: JapicCTI‐163294. DATA AVAILABILITY STATEMENT Chugai Pharmaceutical Co., Ltd. provide qualified researchers access to individual patient‐level data through the clinical study data request platform (www.clinicalstudydatarequest.com). Further details of Chugai's Data Sharing Policy are available here (https://www.chugai‐pharm.co.jp/english/profile/rd/ctds_request.html).	ADMINISTERED OVER 2 H , CYCLES BEING REPEATED EVERY 3 WEEKS	DrugDosageText	CC BY-NC	32893992	18,306,165	2021-06
What was the dosage of drug 'PEMETREXED'?	Bevacizumab plus cisplatin/pemetrexed then bevacizumab alone for unresectable malignant pleural mesothelioma: A Japanese safety study. OBJECTIVE Malignant pleural mesothelioma (MPM) is an aggressive malignancy with poor prognosis and limited treatment options. Cisplatin plus pemetrexed is the only approved first-line treatment for patients with unresectable MPM. Recently, promising outcomes were observed with first-line bevacizumab combined with cisplatin/pemetrexed, leading to the recommendation of this regimen as a first-line treatment option for patients with MPM. Bevacizumab plus cisplatin/pemetrexed has been shown to be safe and effective in non-small cell lung cancer, however, there are no efficacy or safety data in Japanese patients with MPM treated with this regimen. We conducted a multicenter study to evaluate tolerability and safety for Japanese patients with chemotherapy-naïve, unresectable MPM. METHODS Eligible patients (n = 7) received bevacizumab plus cisplatin/pemetrexed (up to six cycles), then single-agent bevacizumab until disease progression or onset of unacceptable adverse events (AEs), according to the 3+3 design analogy. RESULTS One patient (14.3%) reported an AE (gastric ulcer) meeting tolerability criteria. All patients experienced gastrointestinal disorders, including nausea (grade 1/2 only, n = 6, 85.7%) and constipation (grade 1/2 only, n = 5, 71.4%). Five patients (71.4%) had grade 3 hypertension. Two patients discontinued treatment due to gastric ulcer (n = 1) and proteinuria (n = 1). At data cut-off, four patients had stable disease, two had partial response and one had non-complete response/non-progressive disease due to the absence of target lesions. CONCLUSIONS Bevacizumab plus cisplatin/pemetrexed then bevacizumab was well tolerated in Japanese patients with MPM. 1 INTRODUCTION Malignant pleural mesothelioma (MPM) is a rare, aggressive neoplasm with poor prognosis, which originates in the mesothelial cells lining the thoracic cavity. 1 Development of MPM is strongly associated with inhalational exposure to asbestos, and is usually caused by occupational asbestos exposure, but it can also occur from low‐level exposure in the general environment. 2 Despite regulatory action against, and prohibition of the use of asbestos, the number of patients with MPM is increasing substantially in many countries where asbestos has been widely used historically. 3 Its incidence is increasing rapidly worldwide, and the annual number of MPM deaths in Japan has risen from 500 in 1995 to 1555 in 2017. 4 Asia has become the largest consumer of asbestos in the world and is responsible for two‐thirds of global use. 5 China continues to use asbestos and is the top consumer in the world, with an increasing trend of MPM during 2000–2013 and 1659 MPM cases in 2013, but its incidence is low compared with industrialized countries. 5 Newly diagnosed patients with unresectable disease have a median overall survival (OS) of ∼12 months when treated with the standard of care, cisplatin plus pemetrexed. 6 The combination of cisplatin plus pemetrexed is the only currently approved regimen for unresectable first‐line MPM, with approvals gained in 2004 in the USA and European Union, and in 2007 in Japan. Phase II studies demonstrated that pemetrexed in combination with carboplatin might be an alternative regimen with similar treatment outcomes. 7 There have been no new first‐line therapies approved for MPM for more than a decade. Furthermore, there is no US Food and Drug Administration (FDA)‐approved or European Medicines Agency (EMA)‐approved second‐line treatment for MPM. In 2018, anti‐programmed death‐1 (PD‐1) antibody nivolumab was approved in Japan for salvage use. The National Comprehensive Cancer Network (NCCN) guidelines revised their recommendation for nivolumab use with or without ipilimumab from category 2B to 2A, on the basis of recent clinical trial data for subsequent systemic MPM treatment. 8 In view of the poor prognosis and limited approved therapies, there is an unmet need for new treatment options that further improve outcomes for patients with MPM. A broad range of therapeutic targets exist in MPM, including angiogenesis, immune checkpoints, mesothelin and chemotherapeutic agents. Vascular endothelial growth factor (VEGF) is known to be a key regulator of MPM because it is an autocrine growth factor of MPM. 9 Significantly higher serum levels of VEGF have been identified in patients with MPM compared with other tumor types 10 and high VEGF level in serum or pleural effusion is a poor prognostic factor in MPM. 11 , 12 Because VEGF signaling is essential for mesothelioma cell physiopathology, 9 VEGF targeting therapy, such as the recombinant humanized monoclonal antibody bevacizumab, is a rational approach for the treatment of MPM. 13 , 14 Preclinical evaluation of the therapeutic efficacy of bevacizumab in combination with pemetrexed against mesothelioma has shown a synergy for the combination, compared with pemetrexed or bevacizumab alone. 15 Bevacizumab, when added to standard chemotherapy, has demonstrated effectiveness in non–small cell lung cancer (NSCLC) 16 and other tumor types such as breast cancer, 17 colorectal cancer 18 and renal cell carcinoma. 19 Bevacizumab has been evaluated as a combination therapy for MPM in randomized phase II and III clinical trials. 20 , 21 Prior to the approval of pemetrexed, gemcitabine plus cisplatin was a common treatment regimen for MPM. In a randomized phase II US trial in patients with previously untreated MPM, the addition of bevacizumab to gemcitabine/cisplatin did not improve progression‐free survival (PFS) or OS. 20 It was postulated that the trial failed to show positive results due to a potential negative interaction between bevacizumab and gemcitabine in preclinical studies. 22 Therefore, other chemotherapy backbones with bevacizumab, including cisplatin plus pemetrexed, have been investigated. The phase III Mesothelioma Avastin Cisplatin Pemetrexed Study (MAPS), which evaluated the addition of bevacizumab to cisplatin/pemetrexed followed by bevacizumab maintenance, was the first trial to demonstrate improved outcomes versus the standard of care. 21 In MAPS, the addition of bevacizumab to cisplatin/pemetrexed significantly improved PFS and OS compared with cisplatin/pemetrexed alone (OS = 18.8 months vs 16.1 months; hazard ratio [HR] = 0.77; P = 0.0167; PFS = 9.2 months vs 7.3 months, HR = 0.61, P < 0.0001). Additionally, adverse events (AEs) reported in MAPS were consistent with the known safety profile of bevacizumab plus chemotherapy. Based on these outcomes, 21 bevacizumab in combination with cisplatin/pemetrexed was included as a category 1 recommended first‐line treatment for unresectable MPM in the NCCN guidelines. 8 Although MAPS was conducted by the French Cooperative Thoracic Intergroup and data were from French patients only, the results confirm that first‐line bevacizumab‐based therapy can improve outcomes for patients with newly diagnosed MPM. Bevacizumab plus cisplatin/pemetrexed has been shown to be safe and effective in Japanese patients with NSCLC; however, there are no data showing tolerability and safety in Japanese patients with MPM treated with this triplet regimen. This article reports results from a single‐arm, multicenter study evaluating the tolerability, safety and efficacy of first‐line bevacizumab together with cisplatin/pemetrexed, followed by single‐agent bevacizumab, in Japanese patients with unresectable MPM. 2 PATIENTS AND METHODS 2.1 Study design JO39183 (JapicCTI‐163294) was a multicenter, open‐label, single‐arm, phase II study evaluating the tolerability, safety and efficacy of bevacizumab combined with cisplatin/pemetrexed followed by single‐agent bevacizumab in patients with unresectable MPM who had not previously received chemotherapy (Figure 1). The replacement of cisplatin by carboplatin was allowed in cases where a patient developed nephrotoxicity (creatinine clearance <45 mL/min, 6 weeks after administration) or ototoxicity. The target sample size for the study was six patients, which is determined as an analogy for 3+3 design, according to the methods of official recommendation issued by the Pharmaceutical and Food Safety Bureau, Ministry of Health, Labour and Welfare, Japan. 23 However, it was permissible to enroll more than six patients because the main purpose of the study was to evaluate tolerability and safety in Japanese patients. Following enrollment, each patient received up to six cycles of bevacizumab, cisplatin and pemetrexed (induction period), with cycles repeated every 3 weeks. Patients then continued to receive bevacizumab monotherapy every 3 weeks during the maintenance period until disease progression or the onset of unacceptable AEs. FIGURE 1 Study design The study was conducted in accordance with the principles of the Declaration of Helsinki and Good Clinical Practice. All appropriate ethical approval was received from Institutional Review Boards or Independent Ethics Committees at each of the sites. All patients provided written informed consent prior to any study‐related procedures, and agreed to their individual data being published. 2.2 Eligibility criteria Key inclusion criteria for patients included: age ≥20 years with histologically confirmed pleural mesothelioma, not considered amendable to resection; an Eastern Cooperative Oncology Group performance status (ECOG PS) of 0–2; life expectancy of ≥12 weeks from the time of enrollment; no previous chemotherapy for MPM (including adjuvant and neoadjuvant therapy); and radiographically evident lesions. Patients with central nervous system metastases were excluded. Further exclusion criteria are detailed in the Supporting Information. 2.3 Treatment Patients received combination therapy with bevacizumab, cisplatin and pemetrexed, administered for up to six cycles with cycles being repeated every 3 weeks in the induction period. Pemetrexed 500 mg/m2 was administered intravenously (IV) over 10 min, then 30 min later cisplatin 75 mg/m2 IV was administered over 2 h. Following the cisplatin infusion, bevacizumab 15 mg/kg IV was administered over 30–90 min. If carboplatin was used in place of cisplatin, it was administered at a dose at which the target area under the curve was 5 mg/mL/min (as calculated based on the Calvert formula) over 30–60 min on Day 1 of each cycle. Following six cycles of the combination, bevacizumab 15 mg/kg was administered every 3 weeks in the maintenance period until disease progression or the onset of unacceptable AEs. The combination therapy could be discontinued before completion of six cycles; in this case, patients continued on bevacizumab monotherapy. The study duration for each patient was from the day of consent to the last observation day (observation or assessment day that was 28 ± 7 days after the last dose of study drug). 2.4 Study endpoints The primary purpose was to evaluate the tolerability of bevacizumab combined with cisplatin/pemetrexed. Secondary purposes were to evaluate the safety and efficacy of bevacizumab combined with cisplatin/pemetrexed followed by single‐agent bevacizumab. 2.5 Study assessments The evaluation period for tolerability was from Day 1 of Cycle 1 until immediately prior to the start of study drug administration on Day 1 of Cycle 2. AEs predefined for tolerability criteria included grade 4 neutropenia persisting for ≥7 days, febrile neutropenia, grade 3/4 reductions in platelet counts and any nonhematologic toxicity with severity of grade 3 or higher (further details are provided in the Supporting Information), occurring during the tolerability evaluation period and for which a causal relationship to the combination therapy could not be ruled out. The study treatment was considered tolerable if these AEs were reported in ≤34% (two out of six patients) of all enrolled patients considered evaluable for tolerability. The severity of AEs was graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.03. An Efficacy and Safety Evaluation Committee decided whether to continue the study and/or to amend the protocol if any AEs meeting the tolerability criteria were reported in three patients during the study period. If the occurrence of AEs meeting the criteria was estimated to be in ≤34% of the target number of patients (e.g. corresponding AEs were not reported in the first four patients, excluding patients who were considered nonevaluable for tolerability), the Efficacy and Safety Evaluation Committee had the option of closing enrollment. Safety was assessed using data collected until the point at which the observation period in Cycle 1 was completed for the last patient. AEs were coded using the Medical Dictionary for Regulatory Activities (version 19.0) and summarized by system organ class and preferred term. Best overall response and median PFS were assessed in accordance with Response Evaluation Criteria in Solid Tumors version 1.1. PFS was defined as the time from the first day of study drug administration to the first documented disease progression or death, whichever occurred first. 3 RESULTS 3.1 Patient population Seven patients, from four centers, were enrolled into the study and all received bevacizumab combination therapy. After four cycles of treatment with bevacizumab, cisplatin and pemetrexed, one patient changed from cisplatin to carboplatin due to reduced kidney function. Baseline patient characteristics are shown in Table 1. Patients had a median age of 66 years (range 47–73) and 57.1% were male. Although patients with an ECOG PS of 0–2 were eligible, all patients had an ECOG PS of 0 or 1. The tolerability and safety analysis sets included all seven patients. The data cut‐off was September 15, 2016, for tolerability and July 6, 2017, for safety and efficacy. TABLE 1 Patient characteristics at baseline Patient characteristics Patients (n = 7) Sex, n (%) Male 4 (57.1) Female 3 (42.9) Median age (range), years 66 (47–73) Histology, n (%) Epithelioid 6 (85.7) Sarcomatoid or mixed 1 (14.3) ECOG PS, n (%) 0 5 (71.4) 1 2 (28.6) Smoking status, n (%) Smoker 4 (57.1) Never smoker 3 (42.9) Abbreviation: ECOG PS, Eastern Cooperative Oncology Group performance status. John Wiley & Sons, Ltd. 3.2 Treatment exposure A summary of treatment exposure is shown in Figure 2. Overall, a median of nine cycles of bevacizumab were administered, with a median treatment duration of 188 days. Dose intensity was defined as the proportion of actual doses received to planned dose. For pemetrexed and cisplatin, planned dose was defined as the initial dose for six cycles completed without dose delay or dose reduction. For bevacizumab, planned dose was defined as the initial dose for actual cycles completed without dose delay or dose reduction. The mean dose intensities of bevacizumab, pemetrexed and cisplatin were 94%, 72% and 65%, respectively. FIGURE 2 Treatment exposure. †, Cisplatin was replaced with carboplatin for Cycles 5 and 6. ‡, Ongoing At the time of data cut‐off (July 6, 2017), four patients had discontinued treatment and three were continuing to receive single‐agent bevacizumab. One patient discontinued combination therapy due to a gastric ulcer and another due to proteinuria. The remaining two patients discontinued combination therapy due to disease progression. Three out of seven patients did not complete six cycles of chemotherapy; in addition, one patient received carboplatin instead of cisplatin for Cycles 5 and 6 due to reduced creatinine clearance. In the three patients who did not complete six cycles of chemotherapy, the reasons for chemotherapy discontinuation were gastric ulcer, proteinuria (as mentioned above), systemic rash and dyspnea. 3.3 Tolerability During the tolerability evaluation period, one of the seven patients (14.3%) experienced an AE (gastric ulcer), which met the definition criteria for tolerability. 3.4 Safety All seven patients (100%) experienced at least one AE (any grade) and a total of 74 AEs were reported. All patients experienced gastrointestinal disorders (any grade), with the most common being nausea (any grade, n = 6, 85.7%) and constipation (any grade, n = 5, 71.4%). Six different grade 3 AEs were reported: hypertension occurred in five patients (71.4%), and elevated amylase, elevated γ‐glutamyltransferase, hyponatremia, anemia and proteinuria each occurred in one patient (14.3%). There were no grade 4/5 AEs. Two patients had AEs that led to treatment discontinuation; one had a gastric ulcer (n = 1; 14.3%) and the other had proteinuria (n = 1; 14.3%). No deaths were reported. Treatment‐related AEs are detailed in Table 2. TABLE 2 Treatment‐related adverse events (n = 7) Any grade, n (%) Grade 1, n (%) Grade 2, n (%) Grade 3, n (%) Nausea 6 (85.7) 3 (42.9) 3 (42.9) 0 Hypertension 6 (85.7) 0 1 (14.3) 5 (71.4) Constipation 4 (57.1) 3 (42.9) 1 (14.3) 0 Edema peripheral 1 (14.3) 1 (14.3) 0 0 Malaise 2 (28.6) 1 (14.3) 1 (14.3) 0 Rash generalized 2 (28.6) 0 2 (28.6) 0 Epistaxis 2 (28.6) 2 (28.6) 0 0 Dysgeusia 2 (28.6) 2 (28.6) 0 0 Headache 1 (14.3) 0 1 (14.3) 0 Hiccups 1 (14.3) 1 (14.3) 0 0 Amylase increased 1 (14.3) 0 0 1 (14.3) Gastric ulcer 1 (14.3) 0 1 (14.3) 0 Eyelid edema 1 (14.3) 1 (14.3) 0 0 Blood creatinine increased 1 (14.3) 1 (14.3) 0 0 Dyspnea 1 (14.3) 0 1 (14.3) 0 Oropharyngeal pain 1 (14.3) 1 (14.3) 0 0 Stomatitis 1 (14.3) 1 (14.3) 0 0 Neutrophil count decreased 1 (14.3) 0 1 (14.3) 0 Periodontal disease 1 (14.3) 0 1 (14.3) 0 Carpal tunnel syndrome 1 (14.3) 1 (14.3) 0 0 Pigmentation disorder 1 (14.3) 1 (14.3) 0 0 Decreased appetite 1 (14.3) 0 1 (14.3) 0 Creatinine renal clearance decreased 1 (14.3) 0 1 (14.3) 0 Bodyweight increased 1 (14.3) 1 (14.3) 0 0 Proteinuria 1 (14.3) 0 0 1 (14.3) Injection site pain 1 (14.3) 1 (14.3) 0 0 Flushing 1 (14.3) 1 (14.3) 0 0 Hyponatremia 1 (14.3) 0 0 1 (14.3) Protein urine present 1 (14.3) 0 1 (14.3) 0 White blood cell count decreased 1 (14.3) 0 1 (14.3) 0 Rash 1 (14.3) 1 (14.3) 0 0 Pyrexia 1 (14.3) 1 (14.3) 0 0 Abdominal distension 1 (14.3) 0 1 (14.3) 0 Peripheral neuropathy 1 (14.3) 1 (14.3) 0 0 Vomiting 1 (14.3) 0 1 (14.3) 0 No grade 4/5 treatment‐related adverse events were reported. John Wiley & Sons, Ltd. 3.5 Efficacy Best overall response and PFS data are shown in Table 3. At the time of data cut‐off (July 6, 2017), four patients had stable disease, two had a partial response and one had non‐complete response/non‐progressive disease (non‐CR/non‐PD). The four patients who had stable disease had PFS of 0.9, 2.7, 6.7 and 6.8 months, respectively; and the two patients with a partial response had censored PFS durations of 10.4 and 11.1 months, respectively. The partial response in one of the patients is illustrated in Figure 3. The non‐CR/non‐PD patient had a PFS of 9.4 months (censored). Three patients who had either a partial response (n = 2) or a non‐CR/non‐PD (n = 1) remained on treatment at the time of data cut‐off. TABLE 3 Summary of efficacy Patient number Status Best overall response PFS (months) 1 Withdrawal at C1 SD a 0.9 2 Withdrawal at C3 SD 2.7 3 Withdrawal at C9 SD 6.7 4 Withdrawal at C9 SD 6.8 5 Ongoing PR 10.4 b 6 Ongoing Non‐CR/non‐PD 9.4 b 7 Ongoing PR 11.1 b Abbreviations: C, cycle; CR, complete response; PD, progressive disease; PFS, progression‐free survival; PR, partial response; SD, stable disease. a The period from baseline to best overall response evaluation was ≥6 weeks. b Censored observation, treatment ongoing. John Wiley & Sons, Ltd. FIGURE 3 Patient case: Computed tomography scan after Cycle 7 in a 47‐year‐old, female patient who was diagnosed with stage III MPM, and experienced a partial response after receiving treatment without dose modification, other than cisplatin at Cycle 6, when treatment with cisplatin was discontinued mid‐treatment due to the occurrence of a systemic rash (patient #5) 4 DISCUSSION This is the first study to report tolerability and safety data for Japanese patients with MPM treated with bevacizumab plus cisplatin/pemetrexed. Our results demonstrate that bevacizumab added to cisplatin/pemetrexed, followed by single‐agent bevacizumab is tolerable as a first‐line treatment in Japanese patients with MPM. No new safety concerns were identified for bevacizumab either in combination with cisplatin/pemetrexed or as single‐agent maintenance treatment. The overall safety profile in this study was consistent with data published for MAPS. 21 All patients in our study experienced gastrointestinal AEs, the most common being nausea (85.7%; any grade), which was similar to the incidence reported in MAPS (78.4%). Notably, 71.4% of patients experienced grade 3 hypertension compared with only 23% of patients in MAPS. 21 However, hypertension was manageable with administration of antihypertensive medications, allowing patients to continue receiving bevacizumab. Other grade 3 AEs included elevated amylase, elevated γ‐glutamyltransferase, anemia, proteinuria and hyponatremia. The toxicity profile of bevacizumab plus cisplatin/pemetrexed was also similar to that reported in Japanese patients with NSCLC 24 and with advanced cervical cancer. 25 Although it is difficult to make cross‐trial comparisons due to differences in study designs, methods of assessment and patient populations, our safety data appear to be consistent with previous reports on bevacizumab‐based therapy for MPM, and did not identify any previously unknown toxicities. 21 , 22 One patient changed from cisplatin to carboplatin due to reduced kidney function but, since there is a wealth of safety and efficacy data for carboplatin‐based chemotherapy, it is unlikely that this would significantly impact the safety profile. 16 , 26 , 27 One patient withdrew from the study due to a gastric ulcer, which was confirmed by the investigator as being associated with bevacizumab; however, because gastroendoscopy was not conducted prior to study enrollment, it is unknown whether this was present at baseline. Another patient experienced pleural effusion but continued to receive bevacizumab for ∼1.5 years (as of January 31, 2018). Similarly, results from the multicenter, phase II, NEJ013A trial showed that bevacizumab may be active in patients with malignant pleural effusion. 28 Median PFS was 6.8 months in this study, which is similar to two phase II studies in MPM that both reported median PFS of 6.9 months with the addition of bevacizumab to standard of care: the multicenter study by Dowell et al. 29 (n = 52) evaluated the same regimen as our study, and the randomized trial by Kindler et al. 20 (n = 108) added bevacizumab to cisplatin/gemcitabine. In contrast, two patients with a partial response had a longer PFS of 10.4 and 11.1 months in our study. The phase III MAPS, with a larger population of 448 patients, reported median PFS and OS durations of 9.2 and 18.8 months, respectively, with bevacizumab plus cisplatin/pemetrexed. 21 At the data cut‐off, three patients remained on treatment with bevacizumab and continue to be monitored. Patients can continue treatment for about a year, so there is potential to observe ongoing responses in these patients. As of January 31, 2018, two patients had continued to receive treatment for ∼1.5 years and no new toxicity had been observed. The combination of anti‐angiogenic agents, such as bevacizumab, nintedanib and cediranib, with cisplatin/pemetrexed has been evaluated in the first‐line MPM treatment setting. The most promising results have been obtained with the addition of bevacizumab to cisplatin/pemetrexed. 21 Nintedanib is a triple angiokinase inhibitor with activity against VEGF receptor 1−3, platelet‐derived growth factor (PDGF) receptors α and ß, fibroblast growth factors receptors 1−3 and Src and Abl kinases. Addition of nintedanib to cisplatin/pemetrexed in the phase II LUME‐Meso study improved PFS in patients with unresectable nonsarcomatoid MPM compared with the addition of placebo (median PFS 9.4 months vs 5.7 months, respectively). 30 However, the double‐blind, randomized, placebo‐controlled phase III LUME‐Meso study in unresectable epithelioid MPM failed to meet its primary PFS endpoint (median PFS 6.8 months in the nintedanib arm vs 7.0 months in the placebo arm; P = 0.91). 31 Cediranib is an inhibitor of VEGF receptor, PDGF receptor and stem cell factor receptor. In a phase I trial, the addition of cediranib to cisplatin/pemetrexed demonstrated promising preliminary outcomes in patients with chemotherapy‐naïve MPM (median PFS = 8.6 months; median OS = 16.2 months). 32 Results from the ongoing phase II study of cediranib in combination with cisplatin/pemetrexed (NCT01064648) are awaited. Recently, nivolumab was approved in Japan as salvage therapy in MPM patients, and is now being evaluated in the first‐line setting in combination with standard of care treatment in Japan. 33 Preclinical studies suggest that combining anti‐angiogenic agents with immunotherapy may have a synergistic effect, enhancing the efficacy of both treatments. 34 A phase I trial is currently assessing nintedanib in combination with the PD‐1 inhibitor pembrolizumab in patients with various tumors including MPM (NCT02856425), whereas a phase II study is evaluating bevacizumab in combination with atezolizumab in MPM and peritoneal mesothelioma (NCT03074513). We reported safety and efficacy data for first‐line bevacizumab in combination with cisplatin/pemetrexed in Japanese patients with MPM, for whom data are currently limited. Our safety data are comparable with other similar studies and show that the addition of bevacizumab to the current standard of care is tolerable. 5 CONCLUSION The combination of bevacizumab, cisplatin and pemetrexed followed by maintenance treatment with bevacizumab was well tolerated and had satisfactory efficacy in this small patient dataset, warranting its first‐line use in Japanese patients with MPM, on the basis of the phase III study in France. In terms of systematic chemotherapy for MPM, cisplatin plus pemetrexed is the only approved regimen in the untreated setting. Data from this single‐arm trial are encouraging for patients with unresectable MPM; the addition of bevacizumab to standard chemotherapy would offer an alternative treatment option and may extend survival in patients with this aggressive neoplasm. CONFLICTS OF INTEREST Takashi Nakano has received honoraria from MSD, Olympus Corporation, ISHIHARA Sangyo, KYORIN Pharmaceutical, Nippon Boehringer Ingelheim and ONO Pharmaceutical; acted in a consulting or advisory role for Nippon Boehringer Ingelheim; and reports personal fees from Cancer and Chemotherapy Publishers, Ishiyaku Publishers, IGAKU‐SHOIN, Elsevier Japan K.K., Asakura Publishing, Ministry of the Environment Japan and Amagasaki City, outside the submitted work. Kozo Kuribayashi has received honoraria from AstraZeneca, Astellas Pharma, Boehringer Ingelheim, Chugai Pharmaceutical, Kyowa Hakko Kirin, KYORIN Pharmaceutical, Meiji‐Seika‐Pharma, Novartis, Ono Pharmaceutical and Taiho Pharmaceutical. Masashi Kondo has received honoraria from Eli Lilly, MSD, Chugai Pharmaceutical, Pfizer, Novartis, AstraZeneca, Nippon Boehringer Ingelheim, Taiho Pharmaceutical and Kyowa Hakko Kirin. Masahiro Morise has received honoraria from Chugai Pharmaceutical, Eli Lilly Japan K.K., Ono Pharmaceutical, Bristol‐Myers Squibb, Pfizer, AstraZeneca, Boehringer Ingelheim, Merck Serono and Novartis. Yuji Tada has received honoraria from Chugai Pharmaceutical. Katsuya Hirano reports personal fees from AstraZeneca K.K., Chugai Pharmaceutical, Eli Lilly, Nippon Boehringer Ingelheim, Ono Pharmaceutical, Pfizer, Taiho Pharmaceutical and Novartis, outside the submitted work. Morihiko Hayashi and Misa Tanaka are employees of Chugai Pharmaceutical, and Misa Tanaka owns stock in Chugai Pharmaceutical. Masataka Hirabayashi has received honoraria from AstraZeneca K.K., Ono Pharmaceutical, KYORIN Pharmaceutical, Taiho Pharmaceutical, MSD, Chugai Pharmaceutical, Pfizer, Boehringer Ingelheim and Eli Lilly. Supporting information Supporting Information Click here for additional data file. ACKNOWLEDGMENTS This study was supported by Chugai Pharmaceutical Co., Ltd. We thank the patients who participated in this study. We also express our thanks to Kosei Tajima of Chugai Pharmaceutical Co., Ltd., and Professor Takashi Kijima, Hyogo College of Medicine, for drafting and reviewing the manuscript. Third‐party medical writing assistance, under the direction of the authors, was provided by Nathalie Robinson, PhD, and Rachel Hubbard, MSc, of Gardiner‐Caldwell Communications, and was funded by Chugai Pharmaceutical Co., Ltd. Trial registration number: JapicCTI‐163294. DATA AVAILABILITY STATEMENT Chugai Pharmaceutical Co., Ltd. provide qualified researchers access to individual patient‐level data through the clinical study data request platform (www.clinicalstudydatarequest.com). Further details of Chugai's Data Sharing Policy are available here (https://www.chugai‐pharm.co.jp/english/profile/rd/ctds_request.html).	ADMINISTERED OVER 10 MIN., CYCLES BEING REPEATED EVERY 3 WEEKS	DrugDosageText	CC BY-NC	32893992	18,306,165	2021-06
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Depressed level of consciousness'.	Hyperammonemic Encephalopathy Mimicking Ornithine Transcarbamylase Deficiency in Fibrolamellar Hepatocellular Carcinoma: Successful Treatment with Continuous Venovenous Hemofiltration and Ammonia Scavengers. Fibrolamellar hepatocellular carcinoma (FLHCC) is a rare liver cancer affecting adolescents and young adults without any pre existing liver disease. Hyperammonemic encephalopathy (HAE) is a serious paraneoplastic syndrome, and several cases of HAE have been reported in patients with FLHCC. This condition is rare; hence, there are currently no management guidelines for cancer-related HAE. Herein, we report a case of an 18-year-old man with advanced FLHCC who developed HAE during the first course of chemotherapy consisting of cisplatin, doxorubicin, 5-fluorouracil, and interferon-α. He was successfully treated with continuous venovenous hemofiltration, sodium benzoate, sodium phenylbutyrate, and amino acid supplementation for HAE. After the second course of chemotherapy, he underwent surgery, and thereafter, his ammonia levels were normal without any ammonia scavenger therapy. Treatments for HAE described here will be helpful for this rare, but serious metabolic complication of FLHCC and could partially applied to HAE related to any malignancies. Introduction Fibrolamellar hepatocellular carcinoma (FLHCC) is different from conventional hepatocellular carcinoma (HCC) [1]. The incidence of FLHCC is very low, and it affects adolescents and young adults without any pre existing liver disease [1]. Recent studies suggest that FLHCC is an independent entity, showing distinctive molecular profile [2]. Several case reports described paraneoplastic syndrome of FLHCC with symptoms such as hyperammonemia [3–6], gynecomastia [7], and venous thrombosis [8]. Hyperammonemic encephalopathy (HAE) is the most serious paraneoplastic syndrome. However, owing to its rarity, no management guidelines exist for cancer-related HAE. Herein, we report a case of an 18-year-old male patient with FLHCC who developed HAE during the first course of chemotherapy. He was successfully treated with hemofiltration, sodium benzoate, and sodium phenylbutyrate. He underwent surgery and successive chemotherapy, and his ammonia levels were maintained in the normal range without ammonia scavenger therapy. Case Report An 18-year-old boy presented with a history of fatigue, vomiting, abdominal pain, and distension. Computed tomography (CT) revealed a huge mass (13.7×10.7 cm) occupying the left liver and two masses (8.7×7.3 cm, 3.9×2.9 cm) in the pelvic cavity. Multiple lymph nodes were enlarged in right anterior and posterior cardiophrenic angles (Fig. 1). An initial laboratory investigation showed normal bilirubin, slightly elevated aminotransferase levels (aspartate aminotransferase [AST], 85 U/L; alanine aminotransferase [ALT], 154 U/L) and α-fetoprotein (27.2 ng/mL). He was previously healthy with no signs of chronic liver disease and had negative results on serologic testing for hepatitis B (hepatitis B virus surface antigen, hepatitis B virus surface antibody) and hepatitis C (anti–hepatitis C virus). He underwent fine needle biopsy and was diagnosed with FLHCC (Fig. 2). Considering the extent of the tumor, the patient was not considered a candidate for surgical resection. Systemic chemotherapy was initiated with cisplatin (80 mg/m2 on day 1), doxorubicin (30 mg/m2 on days 1 and 2), 5-fluorouracil (5-FU; 400 mg/m2 on days 1–4), and interferon-α (5×108 U/m2 on days 1–4). At midnight on day 3 of chemotherapy, the patient became agitated and was walking and running around the ward, not responding to verbal stimuli. Laboratory testing revealed a serum ammonia level of 393 μg/dL, AST/ALT level of 201/126 U/L, and total bilirubin level of 0.3 mg/dL. Head CT did not reveal any significant findings. He was diagnosed as HAE, and chemotherapy (4th dose of 5-FU and interferon-α) was stopped. Treatment with rifaximin and lactulose was initiated. However, his serum ammonia level rapidly increased to 500 μg/dL, and his mental status deteriorated to the semicoma state. The patient was transferred to the intensive care unit (ICU) and was on mechanical ventilator support under sedation using midazolam, remifentanil, and vecuronium. The metabolic and genetics department was consulted, and treatment for hyperammonemia was started as follows: (1) continuous venovenous hemofiltration, (2) intravenous infusion of sodium benzoate at a loading dose of 8.8 g (170 mg/kg), followed by continuous infusion (8.8 g/day) and sodium phenylbutyrate (5 g four times a day, via Levin tube), (3) 20% dextrose for caloric intake (6 mg/kg/min), and (4) administration of lactulose and rifaximin via Levin tube. His ammonia level decreased to 164 μg/dL but rebounded to 442 μg/dL on the third day of ICU care. Sodium benzoate (8.8 g) was loaded again, and his ammonia level decreased to 135 μg/dL. On the sixth day of the above-mentioned treatment, continuous venovenous hemofiltration was discontinued. On the eighth day, the patient was extubated, and sodium benzoate/sodium phenylbutyrate administration was changed to an intermittent schedule, with sodium benzoate 1.8 g administered as intravenously every 8 hours, sodium phenylbutyrate 3 g four times a day, and arginine 2.5 g twice a day. He was started on a low-protein diet (1 g/kg/day) through a Levin tube. Two days later (10th day of ICU care), he became disoriented and could not properly respond to verbal stimuli, with an ammonia level of 173 μg/dL. The low-protein diet was discontinued, and a continuous infusion of sodium benzoate (5.5 g/day, after a loading dose of 5.5 g) was started again, as well as citrulline (5 g three times a day). There were no focal neurologic signs, and brain magnetic resonance imaging (MRI) did not reveal any abnormality. As the serum ammonia level started decreasing (59 μg/dL), his conscious level improved. On the 12th day, he started Levin tube feeding and oral medications (sodium phenylbutyrate 6 g/day, L-carnitine 2,550 mg/day); citrulline was discontinued. On the 14th day of ICU care, sodium benzoate infusion was changed to an intermittent schedule (1.8 g every 8 hours). He resumed the low-protein diet (0.5 g/kg/day), and his ammonia level was maintained in the range of 90–100 μg/dL. He was transferred to a general ward on the 16th day of ICU care, and sodium benzoate was changed to an oral form (3 g three times a day). With sodium benzoate, sodium phenylbutyrate (3 g three times a day), arginine (2.5 g twice a day), and L-carnitine (660 mg once daily), his ammonia level further decreased to 50–60 μg/dL (Fig. 3). On the ninth day at the general ward, laboratory analyses were performed to identify the underlying mechanism of his HAE. The patient’s serum amino acid analysis revealed the following findings: decreased citrulline and ornithine, normal alanine and glutamine. His urine orotic acid level was elevated, and serum acylcarnitine was slightly elevated. These results suggested impaired activity of ornithine transcarbamylase (OTC). However, polymerase chain reaction (PCR) and direct sequencing of the OTC gene did not reveal any pathogenic variant, deletion, or duplication. On the 20th day at the general ward, the patient underwent a second course of chemotherapy involving cisplatin+doxorubicin+5-fluorouracil+interferon-α. One month later, he underwent extended left hemihepatectomy en bloc with the caudate lobe, excision of pelvic mass, and peritoneal seeding. Extensive lymph node dissection was also performed at the hepatoduodenal, cardiophrenic, para-aortic, and pelvic lymph nodes. Immunohistochemical staining confirmed a profile consistent with that of FLHCC, that is, positive for cytokeratin 7, glypican 3, and CD68. We did not test for the DNAJB1-PRKACA fusion. Next-generation sequencing (NGS) was performed to identify actionable therapeutic targets but only revealed APC mutation (c.4666delA, p.T1556fs), with an allele frequency of 15.53%. His postoperative period was uneventful and the ammonia level further decreased (30–40 μg/dL). One month after the surgery, treatment for hyperammonemia was discontinued. He received two additional courses of chemotherapy involving cisplatin+doxorubicin+5-FU+interferon-α. However, CT and MRI obtained 3 months after the surgery revealed enlarged left external iliac lymph nodes and multiple enhancing nodules at the perihepatic, perigastric, mesentery, omentum, and pelvic cavity. The chemotherapy regimen was changed to vincristine (1.5 mg/m2 on days 1, 8)+irinotecan (50 mg/m2 on days 1–5) and then to gemcitabine (1,000 mg/m2 on day 1)+cisplatin (20 mg/m2 on days 1–5). CT performed after three courses of gemcitabine+cisplatin showed a decrease in the size of the peritoneal nodules and iliac lymph node. Furthermore, the patient experienced severe, recurrent abdominal pain with vomiting, and CT images suggested obstructive ileus. Exploratory laparotomy was performed, and multiple adhesive bands were dissected off the small intestine and excised. Additionally, two metastatic nodules were resected. At the time of this report writing, the patient had just completed the sixth course of gemcitabine-cisplatin, and his disease was stable. He is on normal regular diet and his ammonia level remains normal (30–40 μg/dL). Discussion We report an 18-year-old male patient with advanced FLHCC who developed HAE during the first course of chemotherapy comprising o cisplatin, doxorubicin, 5-FU, and interferon-α. His HAE was successfully treated with continuous venovenous hemofiltration, ammonium scavengers, and amino acid supplementation. Serum amino acid and urine organic acid analyses suggested urea cycle dysfunction. However, PCR and direct sequencing of the OTC gene did not reveal any pathogenic variants. Intriguingly, APC gene mutation was detected from NGS of the tumor tissue, suggesting a possible relation to the development of HAE. After tumor excision, serum ammonia levels were maintained in the normal range without treatment with ammonium scavengers. HAE in FLHCC was first reported in 2009 [3]. This condition is very rare, and approximately 10 cases are reported thus far; many of the patients present HAE at the time of diagnosis of FLHCC [3–6]. One of them recovered from HAE after liver transplantation [4]. Similar to our case, a 31-year-old man developed HAE on the third day of gemcitabine+oxaliplatin chemotherapy [5]. Several mechanisms were proposed on the development of HAE in patients with FLHCC. Some studies suggest that urea cycle dysfunction is caused by an imbalance in the activities and ratios of OTC and ornithine decarboxylase (ODC) [6]. Reduced activity of OTC or augmented activation of ODC results in ornithine consumption and urea cycle disturbance, thereby causing hyperammonemia [6,9]. A recent study suggested that the molecular pathogenesis of FLHCC may contribute to urea cycle dysfunction [6]. Heterozygous deletion of chromosome 19 results in chimeric DNAJB1-PRKACA kinase, which is frequently identified in FLHCC [10]. This chimeric DNAJB1-PRKACA kinase increases the expression of Aurora kinase A, leading to the overexpression of c-Myc that upregulates ODC function [6,10]. The precise mechanism of the development of HAE in our case is unclear. Initially, there were no specific findings in his metal or neurologic status, and his serum ammonia level was not tested. He developed HAE on the third day of chemotherapy, which suggests a causal relationship between chemotherapeutic agents and HAE. There are case reports about chemotherapy-associated hyperammonemia. For example, patients with acute lymphoblastic leukemia receiving corticosteroids [11] and L-asparaginase [12] show a transient increase in the serum ammonia level. Several case reports described HAE in patients receiving 5-FU, cytarabine, cyclophosphamide, oxaliplatin, vincristine, etoposide, anthracycline, busulfan, methotrexate, topotecan, gemcitabine, and tyrosine kinase inhibitors [5]. Our patient received steroids (as antiemetics) and 5-FU. Another culprit that might have contributed to HAE is APC tumor suppressor gene mutation identified by the NGS assay of the tumor. Unfortunately, our case was not tested for heterozygous deletion of chromosome 19 or chimeric DNAJB1-PRKACA kinase. APC mutation was identified by NGS assay of the tumor with an allele frequency of 15.53%. Several in vitro studies suggest that APC mediates ODC expression through a c-Myc– dependent mechanism, thereby affecting ODC transcription [13]. Tumor cells with truncated APC exhibit high levels of β-catenin, leading to increased expression of c-Myc [13]. We presume that both APC mutation and chemotherapy might have caused HAE resembling OTC deficiency. There are no management guidelines for cancer- or chemotherapy-associated hyperammonemia or HAE. Therefore, treatment of hyperammonemia or HAE is extrapolated from that for hepatic encephalopathy or OTC deficiency [14]. Clinical features of hyperammonemia can deteriorate from irritability, confusion to seizure, coma, and even death [14]. Ammonia scavenger therapy should be initiated when ammonia levels are greater than 100 μg/dL [5]. When the serum ammonia level is extremely high (500 μg/dL), dialysis/rapid hemofiltration should be started immediately [5]. In our case, the patient developed HAE during the first course of chemotherapy. Ammonia scavenger therapy normalized his ammonia level and was maintained until the second course of chemotherapy and surgery. After surgery, his ammonia level remained normal without ammonia scavenger therapy, suggesting that his HAE was a paraneoplastic phenomenon of FLHCC. While HCC is prevalent in Asia, the incidence of FLHCC is similar across different ethnic groups [1]. FLHCC comprises less than 1% of all primary liver cancer cases in the United States [1]. Recent studies suggest that FLHCC has a distinctive molecular profile, with focal deletion leading to DNAJB1-PRKACA gene fusion [2]. There are limited studies on the treatment outcome of patients with FLHCC. Despite the large tumor size and advanced stage at presentation, FLHCC patients exhibit significantly better 5-year relative survival than those with conventional HCC [1]. It is unclear whether biologic difference or absence of pre existing liver disease in FLHCC attributes to better survival. Except for surgery, no consensus exists for the treatment of FLHCC. Chemotherapy regimens for unresectable cases include cytotoxic agents, bevacizumab, and tyrosine kinase inhibitors [5]. A phase II trial involving nine cases of FLHCC suggested a potential benefit of 5-FU and interferon [15]. Our patient received perioperative chemotherapy including 5-FU and interferon. Generally, surgical resection is not considered for case like ours, even after systemic chemotherapy. However, there are several reports favoring aggressive cytoreductive surgery prolongs the survival of HCC patients with peritoneal metastases [16,17]. Our case received surgery for the following reasons: (1) the patient was young without any underlying disease, (2) tumors, including liver mass, peritoneal and pelvic metastases appeared to be feasible for resection without compromising patient’s safety, (3) to alleviate clinical symptom (HAE, early satiety, nausea, abdominal discomfort and pain) caused by the multiple large tumors. In the absence of any evidence-based treatment options for aggressive FLHCC, disappearance of HAE after surgery showed that our decision was appropriate. However, the size of the peritoneal nodule increased 3 months after the surgery and combination chemotherapy. The chemotherapy regimen was changed, and the patient was on third-line chemotherapy consisting of cisplatin and gemcitabine, and the patient has been alive for 12 months since the diagnosis of FLHCC. In conclusion, a young boy with FLHCC presenting HAE, which mimicks OTC deficiency, was successfully treated with hemofiltration and ammonia scavenger therapy. Lack of significant findings in OTC gene analysis and the normal ammonia level after surgery imply that FLHCC directly caused urea cycle dysfunction. We assume that APC mutation might be partially related to the development of HAE in our case. Oncologists should be aware about the HAE, a rare but serious metabolic complication of FLHCC. Treatments extrapolated from OTC deficiency, such as continuous venovenous hemofiltration and ammonia scavengers, will be helpful and could partially applied to HAE related to any malignancies. Ethical Statement The present study was approved by the Institutional Review Board of National Cancer Center in Korea (NCC2020-0175), who waived the requirement for informed consent because of the retrospective nature of the study. Author Contributions Conceived and designed the analysis: Lee JA. Collected the data: Lee JS, Han N, Lee JA. Contributed data or analysis tools: Jin HY, Ko JM, Kim SH, Park BK, Park M, Park HJ. Performed the analysis: Lee JS, Lee JA. Wrote the paper: Lee JA, Kim SH, Lee JS. Conflicts of Interest Conflicts of interest relevant to this article was not reported. Fig. 1 Dynamic liver computed tomography at the time of diagnosis of fibrolamellar hepatocellular carcinoma (coronal view, portal phase). Fig. 2 Photographs of the fine needle biopsy and surgical resection specimen. (A) Histologic features of fibrolamellar hepatocellular carcinoma (FLHCC). Large, polygonal tumor cells with abundant oncocytic cytoplasm in background of dense collagen bundles (H&E, ×100). Cytokeratin 7 (B) and CD68 (C) protein expression were noted in FLHCC evaluated by immunohistochemistry (×100). (D) Representative image of surgical specimen. Bulging, large mass with well-circumscribed border was observed. Fibrous bands and central stellate scar are noted. Fig. 3 Change of the serum ammonia levels with ammonia scavengers and hemofiltration. HF, hemofiltration; IV, intravenously; PO, orally.	CISPLATIN, DEXTROSE, DOXORUBICIN, FLUOROURACIL, INTERFERON ALFA-2A OR INTERFERON ALFA-2B, LACTULOSE, RIFAXIMIN, SODIUM BENZOATE, SODIUM PHENYLBUTYRATE	DrugsGivenReaction	CC BY-NC	32898940	18,380,427	2021-01
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Rebound effect'.	Hyperammonemic Encephalopathy Mimicking Ornithine Transcarbamylase Deficiency in Fibrolamellar Hepatocellular Carcinoma: Successful Treatment with Continuous Venovenous Hemofiltration and Ammonia Scavengers. Fibrolamellar hepatocellular carcinoma (FLHCC) is a rare liver cancer affecting adolescents and young adults without any pre existing liver disease. Hyperammonemic encephalopathy (HAE) is a serious paraneoplastic syndrome, and several cases of HAE have been reported in patients with FLHCC. This condition is rare; hence, there are currently no management guidelines for cancer-related HAE. Herein, we report a case of an 18-year-old man with advanced FLHCC who developed HAE during the first course of chemotherapy consisting of cisplatin, doxorubicin, 5-fluorouracil, and interferon-α. He was successfully treated with continuous venovenous hemofiltration, sodium benzoate, sodium phenylbutyrate, and amino acid supplementation for HAE. After the second course of chemotherapy, he underwent surgery, and thereafter, his ammonia levels were normal without any ammonia scavenger therapy. Treatments for HAE described here will be helpful for this rare, but serious metabolic complication of FLHCC and could partially applied to HAE related to any malignancies. Introduction Fibrolamellar hepatocellular carcinoma (FLHCC) is different from conventional hepatocellular carcinoma (HCC) [1]. The incidence of FLHCC is very low, and it affects adolescents and young adults without any pre existing liver disease [1]. Recent studies suggest that FLHCC is an independent entity, showing distinctive molecular profile [2]. Several case reports described paraneoplastic syndrome of FLHCC with symptoms such as hyperammonemia [3–6], gynecomastia [7], and venous thrombosis [8]. Hyperammonemic encephalopathy (HAE) is the most serious paraneoplastic syndrome. However, owing to its rarity, no management guidelines exist for cancer-related HAE. Herein, we report a case of an 18-year-old male patient with FLHCC who developed HAE during the first course of chemotherapy. He was successfully treated with hemofiltration, sodium benzoate, and sodium phenylbutyrate. He underwent surgery and successive chemotherapy, and his ammonia levels were maintained in the normal range without ammonia scavenger therapy. Case Report An 18-year-old boy presented with a history of fatigue, vomiting, abdominal pain, and distension. Computed tomography (CT) revealed a huge mass (13.7×10.7 cm) occupying the left liver and two masses (8.7×7.3 cm, 3.9×2.9 cm) in the pelvic cavity. Multiple lymph nodes were enlarged in right anterior and posterior cardiophrenic angles (Fig. 1). An initial laboratory investigation showed normal bilirubin, slightly elevated aminotransferase levels (aspartate aminotransferase [AST], 85 U/L; alanine aminotransferase [ALT], 154 U/L) and α-fetoprotein (27.2 ng/mL). He was previously healthy with no signs of chronic liver disease and had negative results on serologic testing for hepatitis B (hepatitis B virus surface antigen, hepatitis B virus surface antibody) and hepatitis C (anti–hepatitis C virus). He underwent fine needle biopsy and was diagnosed with FLHCC (Fig. 2). Considering the extent of the tumor, the patient was not considered a candidate for surgical resection. Systemic chemotherapy was initiated with cisplatin (80 mg/m2 on day 1), doxorubicin (30 mg/m2 on days 1 and 2), 5-fluorouracil (5-FU; 400 mg/m2 on days 1–4), and interferon-α (5×108 U/m2 on days 1–4). At midnight on day 3 of chemotherapy, the patient became agitated and was walking and running around the ward, not responding to verbal stimuli. Laboratory testing revealed a serum ammonia level of 393 μg/dL, AST/ALT level of 201/126 U/L, and total bilirubin level of 0.3 mg/dL. Head CT did not reveal any significant findings. He was diagnosed as HAE, and chemotherapy (4th dose of 5-FU and interferon-α) was stopped. Treatment with rifaximin and lactulose was initiated. However, his serum ammonia level rapidly increased to 500 μg/dL, and his mental status deteriorated to the semicoma state. The patient was transferred to the intensive care unit (ICU) and was on mechanical ventilator support under sedation using midazolam, remifentanil, and vecuronium. The metabolic and genetics department was consulted, and treatment for hyperammonemia was started as follows: (1) continuous venovenous hemofiltration, (2) intravenous infusion of sodium benzoate at a loading dose of 8.8 g (170 mg/kg), followed by continuous infusion (8.8 g/day) and sodium phenylbutyrate (5 g four times a day, via Levin tube), (3) 20% dextrose for caloric intake (6 mg/kg/min), and (4) administration of lactulose and rifaximin via Levin tube. His ammonia level decreased to 164 μg/dL but rebounded to 442 μg/dL on the third day of ICU care. Sodium benzoate (8.8 g) was loaded again, and his ammonia level decreased to 135 μg/dL. On the sixth day of the above-mentioned treatment, continuous venovenous hemofiltration was discontinued. On the eighth day, the patient was extubated, and sodium benzoate/sodium phenylbutyrate administration was changed to an intermittent schedule, with sodium benzoate 1.8 g administered as intravenously every 8 hours, sodium phenylbutyrate 3 g four times a day, and arginine 2.5 g twice a day. He was started on a low-protein diet (1 g/kg/day) through a Levin tube. Two days later (10th day of ICU care), he became disoriented and could not properly respond to verbal stimuli, with an ammonia level of 173 μg/dL. The low-protein diet was discontinued, and a continuous infusion of sodium benzoate (5.5 g/day, after a loading dose of 5.5 g) was started again, as well as citrulline (5 g three times a day). There were no focal neurologic signs, and brain magnetic resonance imaging (MRI) did not reveal any abnormality. As the serum ammonia level started decreasing (59 μg/dL), his conscious level improved. On the 12th day, he started Levin tube feeding and oral medications (sodium phenylbutyrate 6 g/day, L-carnitine 2,550 mg/day); citrulline was discontinued. On the 14th day of ICU care, sodium benzoate infusion was changed to an intermittent schedule (1.8 g every 8 hours). He resumed the low-protein diet (0.5 g/kg/day), and his ammonia level was maintained in the range of 90–100 μg/dL. He was transferred to a general ward on the 16th day of ICU care, and sodium benzoate was changed to an oral form (3 g three times a day). With sodium benzoate, sodium phenylbutyrate (3 g three times a day), arginine (2.5 g twice a day), and L-carnitine (660 mg once daily), his ammonia level further decreased to 50–60 μg/dL (Fig. 3). On the ninth day at the general ward, laboratory analyses were performed to identify the underlying mechanism of his HAE. The patient’s serum amino acid analysis revealed the following findings: decreased citrulline and ornithine, normal alanine and glutamine. His urine orotic acid level was elevated, and serum acylcarnitine was slightly elevated. These results suggested impaired activity of ornithine transcarbamylase (OTC). However, polymerase chain reaction (PCR) and direct sequencing of the OTC gene did not reveal any pathogenic variant, deletion, or duplication. On the 20th day at the general ward, the patient underwent a second course of chemotherapy involving cisplatin+doxorubicin+5-fluorouracil+interferon-α. One month later, he underwent extended left hemihepatectomy en bloc with the caudate lobe, excision of pelvic mass, and peritoneal seeding. Extensive lymph node dissection was also performed at the hepatoduodenal, cardiophrenic, para-aortic, and pelvic lymph nodes. Immunohistochemical staining confirmed a profile consistent with that of FLHCC, that is, positive for cytokeratin 7, glypican 3, and CD68. We did not test for the DNAJB1-PRKACA fusion. Next-generation sequencing (NGS) was performed to identify actionable therapeutic targets but only revealed APC mutation (c.4666delA, p.T1556fs), with an allele frequency of 15.53%. His postoperative period was uneventful and the ammonia level further decreased (30–40 μg/dL). One month after the surgery, treatment for hyperammonemia was discontinued. He received two additional courses of chemotherapy involving cisplatin+doxorubicin+5-FU+interferon-α. However, CT and MRI obtained 3 months after the surgery revealed enlarged left external iliac lymph nodes and multiple enhancing nodules at the perihepatic, perigastric, mesentery, omentum, and pelvic cavity. The chemotherapy regimen was changed to vincristine (1.5 mg/m2 on days 1, 8)+irinotecan (50 mg/m2 on days 1–5) and then to gemcitabine (1,000 mg/m2 on day 1)+cisplatin (20 mg/m2 on days 1–5). CT performed after three courses of gemcitabine+cisplatin showed a decrease in the size of the peritoneal nodules and iliac lymph node. Furthermore, the patient experienced severe, recurrent abdominal pain with vomiting, and CT images suggested obstructive ileus. Exploratory laparotomy was performed, and multiple adhesive bands were dissected off the small intestine and excised. Additionally, two metastatic nodules were resected. At the time of this report writing, the patient had just completed the sixth course of gemcitabine-cisplatin, and his disease was stable. He is on normal regular diet and his ammonia level remains normal (30–40 μg/dL). Discussion We report an 18-year-old male patient with advanced FLHCC who developed HAE during the first course of chemotherapy comprising o cisplatin, doxorubicin, 5-FU, and interferon-α. His HAE was successfully treated with continuous venovenous hemofiltration, ammonium scavengers, and amino acid supplementation. Serum amino acid and urine organic acid analyses suggested urea cycle dysfunction. However, PCR and direct sequencing of the OTC gene did not reveal any pathogenic variants. Intriguingly, APC gene mutation was detected from NGS of the tumor tissue, suggesting a possible relation to the development of HAE. After tumor excision, serum ammonia levels were maintained in the normal range without treatment with ammonium scavengers. HAE in FLHCC was first reported in 2009 [3]. This condition is very rare, and approximately 10 cases are reported thus far; many of the patients present HAE at the time of diagnosis of FLHCC [3–6]. One of them recovered from HAE after liver transplantation [4]. Similar to our case, a 31-year-old man developed HAE on the third day of gemcitabine+oxaliplatin chemotherapy [5]. Several mechanisms were proposed on the development of HAE in patients with FLHCC. Some studies suggest that urea cycle dysfunction is caused by an imbalance in the activities and ratios of OTC and ornithine decarboxylase (ODC) [6]. Reduced activity of OTC or augmented activation of ODC results in ornithine consumption and urea cycle disturbance, thereby causing hyperammonemia [6,9]. A recent study suggested that the molecular pathogenesis of FLHCC may contribute to urea cycle dysfunction [6]. Heterozygous deletion of chromosome 19 results in chimeric DNAJB1-PRKACA kinase, which is frequently identified in FLHCC [10]. This chimeric DNAJB1-PRKACA kinase increases the expression of Aurora kinase A, leading to the overexpression of c-Myc that upregulates ODC function [6,10]. The precise mechanism of the development of HAE in our case is unclear. Initially, there were no specific findings in his metal or neurologic status, and his serum ammonia level was not tested. He developed HAE on the third day of chemotherapy, which suggests a causal relationship between chemotherapeutic agents and HAE. There are case reports about chemotherapy-associated hyperammonemia. For example, patients with acute lymphoblastic leukemia receiving corticosteroids [11] and L-asparaginase [12] show a transient increase in the serum ammonia level. Several case reports described HAE in patients receiving 5-FU, cytarabine, cyclophosphamide, oxaliplatin, vincristine, etoposide, anthracycline, busulfan, methotrexate, topotecan, gemcitabine, and tyrosine kinase inhibitors [5]. Our patient received steroids (as antiemetics) and 5-FU. Another culprit that might have contributed to HAE is APC tumor suppressor gene mutation identified by the NGS assay of the tumor. Unfortunately, our case was not tested for heterozygous deletion of chromosome 19 or chimeric DNAJB1-PRKACA kinase. APC mutation was identified by NGS assay of the tumor with an allele frequency of 15.53%. Several in vitro studies suggest that APC mediates ODC expression through a c-Myc– dependent mechanism, thereby affecting ODC transcription [13]. Tumor cells with truncated APC exhibit high levels of β-catenin, leading to increased expression of c-Myc [13]. We presume that both APC mutation and chemotherapy might have caused HAE resembling OTC deficiency. There are no management guidelines for cancer- or chemotherapy-associated hyperammonemia or HAE. Therefore, treatment of hyperammonemia or HAE is extrapolated from that for hepatic encephalopathy or OTC deficiency [14]. Clinical features of hyperammonemia can deteriorate from irritability, confusion to seizure, coma, and even death [14]. Ammonia scavenger therapy should be initiated when ammonia levels are greater than 100 μg/dL [5]. When the serum ammonia level is extremely high (500 μg/dL), dialysis/rapid hemofiltration should be started immediately [5]. In our case, the patient developed HAE during the first course of chemotherapy. Ammonia scavenger therapy normalized his ammonia level and was maintained until the second course of chemotherapy and surgery. After surgery, his ammonia level remained normal without ammonia scavenger therapy, suggesting that his HAE was a paraneoplastic phenomenon of FLHCC. While HCC is prevalent in Asia, the incidence of FLHCC is similar across different ethnic groups [1]. FLHCC comprises less than 1% of all primary liver cancer cases in the United States [1]. Recent studies suggest that FLHCC has a distinctive molecular profile, with focal deletion leading to DNAJB1-PRKACA gene fusion [2]. There are limited studies on the treatment outcome of patients with FLHCC. Despite the large tumor size and advanced stage at presentation, FLHCC patients exhibit significantly better 5-year relative survival than those with conventional HCC [1]. It is unclear whether biologic difference or absence of pre existing liver disease in FLHCC attributes to better survival. Except for surgery, no consensus exists for the treatment of FLHCC. Chemotherapy regimens for unresectable cases include cytotoxic agents, bevacizumab, and tyrosine kinase inhibitors [5]. A phase II trial involving nine cases of FLHCC suggested a potential benefit of 5-FU and interferon [15]. Our patient received perioperative chemotherapy including 5-FU and interferon. Generally, surgical resection is not considered for case like ours, even after systemic chemotherapy. However, there are several reports favoring aggressive cytoreductive surgery prolongs the survival of HCC patients with peritoneal metastases [16,17]. Our case received surgery for the following reasons: (1) the patient was young without any underlying disease, (2) tumors, including liver mass, peritoneal and pelvic metastases appeared to be feasible for resection without compromising patient’s safety, (3) to alleviate clinical symptom (HAE, early satiety, nausea, abdominal discomfort and pain) caused by the multiple large tumors. In the absence of any evidence-based treatment options for aggressive FLHCC, disappearance of HAE after surgery showed that our decision was appropriate. However, the size of the peritoneal nodule increased 3 months after the surgery and combination chemotherapy. The chemotherapy regimen was changed, and the patient was on third-line chemotherapy consisting of cisplatin and gemcitabine, and the patient has been alive for 12 months since the diagnosis of FLHCC. In conclusion, a young boy with FLHCC presenting HAE, which mimicks OTC deficiency, was successfully treated with hemofiltration and ammonia scavenger therapy. Lack of significant findings in OTC gene analysis and the normal ammonia level after surgery imply that FLHCC directly caused urea cycle dysfunction. We assume that APC mutation might be partially related to the development of HAE in our case. Oncologists should be aware about the HAE, a rare but serious metabolic complication of FLHCC. Treatments extrapolated from OTC deficiency, such as continuous venovenous hemofiltration and ammonia scavengers, will be helpful and could partially applied to HAE related to any malignancies. Ethical Statement The present study was approved by the Institutional Review Board of National Cancer Center in Korea (NCC2020-0175), who waived the requirement for informed consent because of the retrospective nature of the study. Author Contributions Conceived and designed the analysis: Lee JA. Collected the data: Lee JS, Han N, Lee JA. Contributed data or analysis tools: Jin HY, Ko JM, Kim SH, Park BK, Park M, Park HJ. Performed the analysis: Lee JS, Lee JA. Wrote the paper: Lee JA, Kim SH, Lee JS. Conflicts of Interest Conflicts of interest relevant to this article was not reported. Fig. 1 Dynamic liver computed tomography at the time of diagnosis of fibrolamellar hepatocellular carcinoma (coronal view, portal phase). Fig. 2 Photographs of the fine needle biopsy and surgical resection specimen. (A) Histologic features of fibrolamellar hepatocellular carcinoma (FLHCC). Large, polygonal tumor cells with abundant oncocytic cytoplasm in background of dense collagen bundles (H&E, ×100). Cytokeratin 7 (B) and CD68 (C) protein expression were noted in FLHCC evaluated by immunohistochemistry (×100). (D) Representative image of surgical specimen. Bulging, large mass with well-circumscribed border was observed. Fibrous bands and central stellate scar are noted. Fig. 3 Change of the serum ammonia levels with ammonia scavengers and hemofiltration. HF, hemofiltration; IV, intravenously; PO, orally.	CISPLATIN, DEXTROSE, DOXORUBICIN, FLUOROURACIL, INTERFERON ALFA-2A OR INTERFERON ALFA-2B, LACTULOSE, RIFAXIMIN, SODIUM BENZOATE, SODIUM PHENYLBUTYRATE	DrugsGivenReaction	CC BY-NC	32898940	18,380,427	2021-01
What was the administration route of drug 'SODIUM BENZOATE'?	Hyperammonemic Encephalopathy Mimicking Ornithine Transcarbamylase Deficiency in Fibrolamellar Hepatocellular Carcinoma: Successful Treatment with Continuous Venovenous Hemofiltration and Ammonia Scavengers. Fibrolamellar hepatocellular carcinoma (FLHCC) is a rare liver cancer affecting adolescents and young adults without any pre existing liver disease. Hyperammonemic encephalopathy (HAE) is a serious paraneoplastic syndrome, and several cases of HAE have been reported in patients with FLHCC. This condition is rare; hence, there are currently no management guidelines for cancer-related HAE. Herein, we report a case of an 18-year-old man with advanced FLHCC who developed HAE during the first course of chemotherapy consisting of cisplatin, doxorubicin, 5-fluorouracil, and interferon-α. He was successfully treated with continuous venovenous hemofiltration, sodium benzoate, sodium phenylbutyrate, and amino acid supplementation for HAE. After the second course of chemotherapy, he underwent surgery, and thereafter, his ammonia levels were normal without any ammonia scavenger therapy. Treatments for HAE described here will be helpful for this rare, but serious metabolic complication of FLHCC and could partially applied to HAE related to any malignancies. Introduction Fibrolamellar hepatocellular carcinoma (FLHCC) is different from conventional hepatocellular carcinoma (HCC) [1]. The incidence of FLHCC is very low, and it affects adolescents and young adults without any pre existing liver disease [1]. Recent studies suggest that FLHCC is an independent entity, showing distinctive molecular profile [2]. Several case reports described paraneoplastic syndrome of FLHCC with symptoms such as hyperammonemia [3–6], gynecomastia [7], and venous thrombosis [8]. Hyperammonemic encephalopathy (HAE) is the most serious paraneoplastic syndrome. However, owing to its rarity, no management guidelines exist for cancer-related HAE. Herein, we report a case of an 18-year-old male patient with FLHCC who developed HAE during the first course of chemotherapy. He was successfully treated with hemofiltration, sodium benzoate, and sodium phenylbutyrate. He underwent surgery and successive chemotherapy, and his ammonia levels were maintained in the normal range without ammonia scavenger therapy. Case Report An 18-year-old boy presented with a history of fatigue, vomiting, abdominal pain, and distension. Computed tomography (CT) revealed a huge mass (13.7×10.7 cm) occupying the left liver and two masses (8.7×7.3 cm, 3.9×2.9 cm) in the pelvic cavity. Multiple lymph nodes were enlarged in right anterior and posterior cardiophrenic angles (Fig. 1). An initial laboratory investigation showed normal bilirubin, slightly elevated aminotransferase levels (aspartate aminotransferase [AST], 85 U/L; alanine aminotransferase [ALT], 154 U/L) and α-fetoprotein (27.2 ng/mL). He was previously healthy with no signs of chronic liver disease and had negative results on serologic testing for hepatitis B (hepatitis B virus surface antigen, hepatitis B virus surface antibody) and hepatitis C (anti–hepatitis C virus). He underwent fine needle biopsy and was diagnosed with FLHCC (Fig. 2). Considering the extent of the tumor, the patient was not considered a candidate for surgical resection. Systemic chemotherapy was initiated with cisplatin (80 mg/m2 on day 1), doxorubicin (30 mg/m2 on days 1 and 2), 5-fluorouracil (5-FU; 400 mg/m2 on days 1–4), and interferon-α (5×108 U/m2 on days 1–4). At midnight on day 3 of chemotherapy, the patient became agitated and was walking and running around the ward, not responding to verbal stimuli. Laboratory testing revealed a serum ammonia level of 393 μg/dL, AST/ALT level of 201/126 U/L, and total bilirubin level of 0.3 mg/dL. Head CT did not reveal any significant findings. He was diagnosed as HAE, and chemotherapy (4th dose of 5-FU and interferon-α) was stopped. Treatment with rifaximin and lactulose was initiated. However, his serum ammonia level rapidly increased to 500 μg/dL, and his mental status deteriorated to the semicoma state. The patient was transferred to the intensive care unit (ICU) and was on mechanical ventilator support under sedation using midazolam, remifentanil, and vecuronium. The metabolic and genetics department was consulted, and treatment for hyperammonemia was started as follows: (1) continuous venovenous hemofiltration, (2) intravenous infusion of sodium benzoate at a loading dose of 8.8 g (170 mg/kg), followed by continuous infusion (8.8 g/day) and sodium phenylbutyrate (5 g four times a day, via Levin tube), (3) 20% dextrose for caloric intake (6 mg/kg/min), and (4) administration of lactulose and rifaximin via Levin tube. His ammonia level decreased to 164 μg/dL but rebounded to 442 μg/dL on the third day of ICU care. Sodium benzoate (8.8 g) was loaded again, and his ammonia level decreased to 135 μg/dL. On the sixth day of the above-mentioned treatment, continuous venovenous hemofiltration was discontinued. On the eighth day, the patient was extubated, and sodium benzoate/sodium phenylbutyrate administration was changed to an intermittent schedule, with sodium benzoate 1.8 g administered as intravenously every 8 hours, sodium phenylbutyrate 3 g four times a day, and arginine 2.5 g twice a day. He was started on a low-protein diet (1 g/kg/day) through a Levin tube. Two days later (10th day of ICU care), he became disoriented and could not properly respond to verbal stimuli, with an ammonia level of 173 μg/dL. The low-protein diet was discontinued, and a continuous infusion of sodium benzoate (5.5 g/day, after a loading dose of 5.5 g) was started again, as well as citrulline (5 g three times a day). There were no focal neurologic signs, and brain magnetic resonance imaging (MRI) did not reveal any abnormality. As the serum ammonia level started decreasing (59 μg/dL), his conscious level improved. On the 12th day, he started Levin tube feeding and oral medications (sodium phenylbutyrate 6 g/day, L-carnitine 2,550 mg/day); citrulline was discontinued. On the 14th day of ICU care, sodium benzoate infusion was changed to an intermittent schedule (1.8 g every 8 hours). He resumed the low-protein diet (0.5 g/kg/day), and his ammonia level was maintained in the range of 90–100 μg/dL. He was transferred to a general ward on the 16th day of ICU care, and sodium benzoate was changed to an oral form (3 g three times a day). With sodium benzoate, sodium phenylbutyrate (3 g three times a day), arginine (2.5 g twice a day), and L-carnitine (660 mg once daily), his ammonia level further decreased to 50–60 μg/dL (Fig. 3). On the ninth day at the general ward, laboratory analyses were performed to identify the underlying mechanism of his HAE. The patient’s serum amino acid analysis revealed the following findings: decreased citrulline and ornithine, normal alanine and glutamine. His urine orotic acid level was elevated, and serum acylcarnitine was slightly elevated. These results suggested impaired activity of ornithine transcarbamylase (OTC). However, polymerase chain reaction (PCR) and direct sequencing of the OTC gene did not reveal any pathogenic variant, deletion, or duplication. On the 20th day at the general ward, the patient underwent a second course of chemotherapy involving cisplatin+doxorubicin+5-fluorouracil+interferon-α. One month later, he underwent extended left hemihepatectomy en bloc with the caudate lobe, excision of pelvic mass, and peritoneal seeding. Extensive lymph node dissection was also performed at the hepatoduodenal, cardiophrenic, para-aortic, and pelvic lymph nodes. Immunohistochemical staining confirmed a profile consistent with that of FLHCC, that is, positive for cytokeratin 7, glypican 3, and CD68. We did not test for the DNAJB1-PRKACA fusion. Next-generation sequencing (NGS) was performed to identify actionable therapeutic targets but only revealed APC mutation (c.4666delA, p.T1556fs), with an allele frequency of 15.53%. His postoperative period was uneventful and the ammonia level further decreased (30–40 μg/dL). One month after the surgery, treatment for hyperammonemia was discontinued. He received two additional courses of chemotherapy involving cisplatin+doxorubicin+5-FU+interferon-α. However, CT and MRI obtained 3 months after the surgery revealed enlarged left external iliac lymph nodes and multiple enhancing nodules at the perihepatic, perigastric, mesentery, omentum, and pelvic cavity. The chemotherapy regimen was changed to vincristine (1.5 mg/m2 on days 1, 8)+irinotecan (50 mg/m2 on days 1–5) and then to gemcitabine (1,000 mg/m2 on day 1)+cisplatin (20 mg/m2 on days 1–5). CT performed after three courses of gemcitabine+cisplatin showed a decrease in the size of the peritoneal nodules and iliac lymph node. Furthermore, the patient experienced severe, recurrent abdominal pain with vomiting, and CT images suggested obstructive ileus. Exploratory laparotomy was performed, and multiple adhesive bands were dissected off the small intestine and excised. Additionally, two metastatic nodules were resected. At the time of this report writing, the patient had just completed the sixth course of gemcitabine-cisplatin, and his disease was stable. He is on normal regular diet and his ammonia level remains normal (30–40 μg/dL). Discussion We report an 18-year-old male patient with advanced FLHCC who developed HAE during the first course of chemotherapy comprising o cisplatin, doxorubicin, 5-FU, and interferon-α. His HAE was successfully treated with continuous venovenous hemofiltration, ammonium scavengers, and amino acid supplementation. Serum amino acid and urine organic acid analyses suggested urea cycle dysfunction. However, PCR and direct sequencing of the OTC gene did not reveal any pathogenic variants. Intriguingly, APC gene mutation was detected from NGS of the tumor tissue, suggesting a possible relation to the development of HAE. After tumor excision, serum ammonia levels were maintained in the normal range without treatment with ammonium scavengers. HAE in FLHCC was first reported in 2009 [3]. This condition is very rare, and approximately 10 cases are reported thus far; many of the patients present HAE at the time of diagnosis of FLHCC [3–6]. One of them recovered from HAE after liver transplantation [4]. Similar to our case, a 31-year-old man developed HAE on the third day of gemcitabine+oxaliplatin chemotherapy [5]. Several mechanisms were proposed on the development of HAE in patients with FLHCC. Some studies suggest that urea cycle dysfunction is caused by an imbalance in the activities and ratios of OTC and ornithine decarboxylase (ODC) [6]. Reduced activity of OTC or augmented activation of ODC results in ornithine consumption and urea cycle disturbance, thereby causing hyperammonemia [6,9]. A recent study suggested that the molecular pathogenesis of FLHCC may contribute to urea cycle dysfunction [6]. Heterozygous deletion of chromosome 19 results in chimeric DNAJB1-PRKACA kinase, which is frequently identified in FLHCC [10]. This chimeric DNAJB1-PRKACA kinase increases the expression of Aurora kinase A, leading to the overexpression of c-Myc that upregulates ODC function [6,10]. The precise mechanism of the development of HAE in our case is unclear. Initially, there were no specific findings in his metal or neurologic status, and his serum ammonia level was not tested. He developed HAE on the third day of chemotherapy, which suggests a causal relationship between chemotherapeutic agents and HAE. There are case reports about chemotherapy-associated hyperammonemia. For example, patients with acute lymphoblastic leukemia receiving corticosteroids [11] and L-asparaginase [12] show a transient increase in the serum ammonia level. Several case reports described HAE in patients receiving 5-FU, cytarabine, cyclophosphamide, oxaliplatin, vincristine, etoposide, anthracycline, busulfan, methotrexate, topotecan, gemcitabine, and tyrosine kinase inhibitors [5]. Our patient received steroids (as antiemetics) and 5-FU. Another culprit that might have contributed to HAE is APC tumor suppressor gene mutation identified by the NGS assay of the tumor. Unfortunately, our case was not tested for heterozygous deletion of chromosome 19 or chimeric DNAJB1-PRKACA kinase. APC mutation was identified by NGS assay of the tumor with an allele frequency of 15.53%. Several in vitro studies suggest that APC mediates ODC expression through a c-Myc– dependent mechanism, thereby affecting ODC transcription [13]. Tumor cells with truncated APC exhibit high levels of β-catenin, leading to increased expression of c-Myc [13]. We presume that both APC mutation and chemotherapy might have caused HAE resembling OTC deficiency. There are no management guidelines for cancer- or chemotherapy-associated hyperammonemia or HAE. Therefore, treatment of hyperammonemia or HAE is extrapolated from that for hepatic encephalopathy or OTC deficiency [14]. Clinical features of hyperammonemia can deteriorate from irritability, confusion to seizure, coma, and even death [14]. Ammonia scavenger therapy should be initiated when ammonia levels are greater than 100 μg/dL [5]. When the serum ammonia level is extremely high (500 μg/dL), dialysis/rapid hemofiltration should be started immediately [5]. In our case, the patient developed HAE during the first course of chemotherapy. Ammonia scavenger therapy normalized his ammonia level and was maintained until the second course of chemotherapy and surgery. After surgery, his ammonia level remained normal without ammonia scavenger therapy, suggesting that his HAE was a paraneoplastic phenomenon of FLHCC. While HCC is prevalent in Asia, the incidence of FLHCC is similar across different ethnic groups [1]. FLHCC comprises less than 1% of all primary liver cancer cases in the United States [1]. Recent studies suggest that FLHCC has a distinctive molecular profile, with focal deletion leading to DNAJB1-PRKACA gene fusion [2]. There are limited studies on the treatment outcome of patients with FLHCC. Despite the large tumor size and advanced stage at presentation, FLHCC patients exhibit significantly better 5-year relative survival than those with conventional HCC [1]. It is unclear whether biologic difference or absence of pre existing liver disease in FLHCC attributes to better survival. Except for surgery, no consensus exists for the treatment of FLHCC. Chemotherapy regimens for unresectable cases include cytotoxic agents, bevacizumab, and tyrosine kinase inhibitors [5]. A phase II trial involving nine cases of FLHCC suggested a potential benefit of 5-FU and interferon [15]. Our patient received perioperative chemotherapy including 5-FU and interferon. Generally, surgical resection is not considered for case like ours, even after systemic chemotherapy. However, there are several reports favoring aggressive cytoreductive surgery prolongs the survival of HCC patients with peritoneal metastases [16,17]. Our case received surgery for the following reasons: (1) the patient was young without any underlying disease, (2) tumors, including liver mass, peritoneal and pelvic metastases appeared to be feasible for resection without compromising patient’s safety, (3) to alleviate clinical symptom (HAE, early satiety, nausea, abdominal discomfort and pain) caused by the multiple large tumors. In the absence of any evidence-based treatment options for aggressive FLHCC, disappearance of HAE after surgery showed that our decision was appropriate. However, the size of the peritoneal nodule increased 3 months after the surgery and combination chemotherapy. The chemotherapy regimen was changed, and the patient was on third-line chemotherapy consisting of cisplatin and gemcitabine, and the patient has been alive for 12 months since the diagnosis of FLHCC. In conclusion, a young boy with FLHCC presenting HAE, which mimicks OTC deficiency, was successfully treated with hemofiltration and ammonia scavenger therapy. Lack of significant findings in OTC gene analysis and the normal ammonia level after surgery imply that FLHCC directly caused urea cycle dysfunction. We assume that APC mutation might be partially related to the development of HAE in our case. Oncologists should be aware about the HAE, a rare but serious metabolic complication of FLHCC. Treatments extrapolated from OTC deficiency, such as continuous venovenous hemofiltration and ammonia scavengers, will be helpful and could partially applied to HAE related to any malignancies. Ethical Statement The present study was approved by the Institutional Review Board of National Cancer Center in Korea (NCC2020-0175), who waived the requirement for informed consent because of the retrospective nature of the study. Author Contributions Conceived and designed the analysis: Lee JA. Collected the data: Lee JS, Han N, Lee JA. Contributed data or analysis tools: Jin HY, Ko JM, Kim SH, Park BK, Park M, Park HJ. Performed the analysis: Lee JS, Lee JA. Wrote the paper: Lee JA, Kim SH, Lee JS. Conflicts of Interest Conflicts of interest relevant to this article was not reported. Fig. 1 Dynamic liver computed tomography at the time of diagnosis of fibrolamellar hepatocellular carcinoma (coronal view, portal phase). Fig. 2 Photographs of the fine needle biopsy and surgical resection specimen. (A) Histologic features of fibrolamellar hepatocellular carcinoma (FLHCC). Large, polygonal tumor cells with abundant oncocytic cytoplasm in background of dense collagen bundles (H&E, ×100). Cytokeratin 7 (B) and CD68 (C) protein expression were noted in FLHCC evaluated by immunohistochemistry (×100). (D) Representative image of surgical specimen. Bulging, large mass with well-circumscribed border was observed. Fibrous bands and central stellate scar are noted. Fig. 3 Change of the serum ammonia levels with ammonia scavengers and hemofiltration. HF, hemofiltration; IV, intravenously; PO, orally.	Intravenous drip	DrugAdministrationRoute	CC BY-NC	32898940	18,380,427	2021-01
What was the dosage of drug 'DEXTROSE'?	Hyperammonemic Encephalopathy Mimicking Ornithine Transcarbamylase Deficiency in Fibrolamellar Hepatocellular Carcinoma: Successful Treatment with Continuous Venovenous Hemofiltration and Ammonia Scavengers. Fibrolamellar hepatocellular carcinoma (FLHCC) is a rare liver cancer affecting adolescents and young adults without any pre existing liver disease. Hyperammonemic encephalopathy (HAE) is a serious paraneoplastic syndrome, and several cases of HAE have been reported in patients with FLHCC. This condition is rare; hence, there are currently no management guidelines for cancer-related HAE. Herein, we report a case of an 18-year-old man with advanced FLHCC who developed HAE during the first course of chemotherapy consisting of cisplatin, doxorubicin, 5-fluorouracil, and interferon-α. He was successfully treated with continuous venovenous hemofiltration, sodium benzoate, sodium phenylbutyrate, and amino acid supplementation for HAE. After the second course of chemotherapy, he underwent surgery, and thereafter, his ammonia levels were normal without any ammonia scavenger therapy. Treatments for HAE described here will be helpful for this rare, but serious metabolic complication of FLHCC and could partially applied to HAE related to any malignancies. Introduction Fibrolamellar hepatocellular carcinoma (FLHCC) is different from conventional hepatocellular carcinoma (HCC) [1]. The incidence of FLHCC is very low, and it affects adolescents and young adults without any pre existing liver disease [1]. Recent studies suggest that FLHCC is an independent entity, showing distinctive molecular profile [2]. Several case reports described paraneoplastic syndrome of FLHCC with symptoms such as hyperammonemia [3–6], gynecomastia [7], and venous thrombosis [8]. Hyperammonemic encephalopathy (HAE) is the most serious paraneoplastic syndrome. However, owing to its rarity, no management guidelines exist for cancer-related HAE. Herein, we report a case of an 18-year-old male patient with FLHCC who developed HAE during the first course of chemotherapy. He was successfully treated with hemofiltration, sodium benzoate, and sodium phenylbutyrate. He underwent surgery and successive chemotherapy, and his ammonia levels were maintained in the normal range without ammonia scavenger therapy. Case Report An 18-year-old boy presented with a history of fatigue, vomiting, abdominal pain, and distension. Computed tomography (CT) revealed a huge mass (13.7×10.7 cm) occupying the left liver and two masses (8.7×7.3 cm, 3.9×2.9 cm) in the pelvic cavity. Multiple lymph nodes were enlarged in right anterior and posterior cardiophrenic angles (Fig. 1). An initial laboratory investigation showed normal bilirubin, slightly elevated aminotransferase levels (aspartate aminotransferase [AST], 85 U/L; alanine aminotransferase [ALT], 154 U/L) and α-fetoprotein (27.2 ng/mL). He was previously healthy with no signs of chronic liver disease and had negative results on serologic testing for hepatitis B (hepatitis B virus surface antigen, hepatitis B virus surface antibody) and hepatitis C (anti–hepatitis C virus). He underwent fine needle biopsy and was diagnosed with FLHCC (Fig. 2). Considering the extent of the tumor, the patient was not considered a candidate for surgical resection. Systemic chemotherapy was initiated with cisplatin (80 mg/m2 on day 1), doxorubicin (30 mg/m2 on days 1 and 2), 5-fluorouracil (5-FU; 400 mg/m2 on days 1–4), and interferon-α (5×108 U/m2 on days 1–4). At midnight on day 3 of chemotherapy, the patient became agitated and was walking and running around the ward, not responding to verbal stimuli. Laboratory testing revealed a serum ammonia level of 393 μg/dL, AST/ALT level of 201/126 U/L, and total bilirubin level of 0.3 mg/dL. Head CT did not reveal any significant findings. He was diagnosed as HAE, and chemotherapy (4th dose of 5-FU and interferon-α) was stopped. Treatment with rifaximin and lactulose was initiated. However, his serum ammonia level rapidly increased to 500 μg/dL, and his mental status deteriorated to the semicoma state. The patient was transferred to the intensive care unit (ICU) and was on mechanical ventilator support under sedation using midazolam, remifentanil, and vecuronium. The metabolic and genetics department was consulted, and treatment for hyperammonemia was started as follows: (1) continuous venovenous hemofiltration, (2) intravenous infusion of sodium benzoate at a loading dose of 8.8 g (170 mg/kg), followed by continuous infusion (8.8 g/day) and sodium phenylbutyrate (5 g four times a day, via Levin tube), (3) 20% dextrose for caloric intake (6 mg/kg/min), and (4) administration of lactulose and rifaximin via Levin tube. His ammonia level decreased to 164 μg/dL but rebounded to 442 μg/dL on the third day of ICU care. Sodium benzoate (8.8 g) was loaded again, and his ammonia level decreased to 135 μg/dL. On the sixth day of the above-mentioned treatment, continuous venovenous hemofiltration was discontinued. On the eighth day, the patient was extubated, and sodium benzoate/sodium phenylbutyrate administration was changed to an intermittent schedule, with sodium benzoate 1.8 g administered as intravenously every 8 hours, sodium phenylbutyrate 3 g four times a day, and arginine 2.5 g twice a day. He was started on a low-protein diet (1 g/kg/day) through a Levin tube. Two days later (10th day of ICU care), he became disoriented and could not properly respond to verbal stimuli, with an ammonia level of 173 μg/dL. The low-protein diet was discontinued, and a continuous infusion of sodium benzoate (5.5 g/day, after a loading dose of 5.5 g) was started again, as well as citrulline (5 g three times a day). There were no focal neurologic signs, and brain magnetic resonance imaging (MRI) did not reveal any abnormality. As the serum ammonia level started decreasing (59 μg/dL), his conscious level improved. On the 12th day, he started Levin tube feeding and oral medications (sodium phenylbutyrate 6 g/day, L-carnitine 2,550 mg/day); citrulline was discontinued. On the 14th day of ICU care, sodium benzoate infusion was changed to an intermittent schedule (1.8 g every 8 hours). He resumed the low-protein diet (0.5 g/kg/day), and his ammonia level was maintained in the range of 90–100 μg/dL. He was transferred to a general ward on the 16th day of ICU care, and sodium benzoate was changed to an oral form (3 g three times a day). With sodium benzoate, sodium phenylbutyrate (3 g three times a day), arginine (2.5 g twice a day), and L-carnitine (660 mg once daily), his ammonia level further decreased to 50–60 μg/dL (Fig. 3). On the ninth day at the general ward, laboratory analyses were performed to identify the underlying mechanism of his HAE. The patient’s serum amino acid analysis revealed the following findings: decreased citrulline and ornithine, normal alanine and glutamine. His urine orotic acid level was elevated, and serum acylcarnitine was slightly elevated. These results suggested impaired activity of ornithine transcarbamylase (OTC). However, polymerase chain reaction (PCR) and direct sequencing of the OTC gene did not reveal any pathogenic variant, deletion, or duplication. On the 20th day at the general ward, the patient underwent a second course of chemotherapy involving cisplatin+doxorubicin+5-fluorouracil+interferon-α. One month later, he underwent extended left hemihepatectomy en bloc with the caudate lobe, excision of pelvic mass, and peritoneal seeding. Extensive lymph node dissection was also performed at the hepatoduodenal, cardiophrenic, para-aortic, and pelvic lymph nodes. Immunohistochemical staining confirmed a profile consistent with that of FLHCC, that is, positive for cytokeratin 7, glypican 3, and CD68. We did not test for the DNAJB1-PRKACA fusion. Next-generation sequencing (NGS) was performed to identify actionable therapeutic targets but only revealed APC mutation (c.4666delA, p.T1556fs), with an allele frequency of 15.53%. His postoperative period was uneventful and the ammonia level further decreased (30–40 μg/dL). One month after the surgery, treatment for hyperammonemia was discontinued. He received two additional courses of chemotherapy involving cisplatin+doxorubicin+5-FU+interferon-α. However, CT and MRI obtained 3 months after the surgery revealed enlarged left external iliac lymph nodes and multiple enhancing nodules at the perihepatic, perigastric, mesentery, omentum, and pelvic cavity. The chemotherapy regimen was changed to vincristine (1.5 mg/m2 on days 1, 8)+irinotecan (50 mg/m2 on days 1–5) and then to gemcitabine (1,000 mg/m2 on day 1)+cisplatin (20 mg/m2 on days 1–5). CT performed after three courses of gemcitabine+cisplatin showed a decrease in the size of the peritoneal nodules and iliac lymph node. Furthermore, the patient experienced severe, recurrent abdominal pain with vomiting, and CT images suggested obstructive ileus. Exploratory laparotomy was performed, and multiple adhesive bands were dissected off the small intestine and excised. Additionally, two metastatic nodules were resected. At the time of this report writing, the patient had just completed the sixth course of gemcitabine-cisplatin, and his disease was stable. He is on normal regular diet and his ammonia level remains normal (30–40 μg/dL). Discussion We report an 18-year-old male patient with advanced FLHCC who developed HAE during the first course of chemotherapy comprising o cisplatin, doxorubicin, 5-FU, and interferon-α. His HAE was successfully treated with continuous venovenous hemofiltration, ammonium scavengers, and amino acid supplementation. Serum amino acid and urine organic acid analyses suggested urea cycle dysfunction. However, PCR and direct sequencing of the OTC gene did not reveal any pathogenic variants. Intriguingly, APC gene mutation was detected from NGS of the tumor tissue, suggesting a possible relation to the development of HAE. After tumor excision, serum ammonia levels were maintained in the normal range without treatment with ammonium scavengers. HAE in FLHCC was first reported in 2009 [3]. This condition is very rare, and approximately 10 cases are reported thus far; many of the patients present HAE at the time of diagnosis of FLHCC [3–6]. One of them recovered from HAE after liver transplantation [4]. Similar to our case, a 31-year-old man developed HAE on the third day of gemcitabine+oxaliplatin chemotherapy [5]. Several mechanisms were proposed on the development of HAE in patients with FLHCC. Some studies suggest that urea cycle dysfunction is caused by an imbalance in the activities and ratios of OTC and ornithine decarboxylase (ODC) [6]. Reduced activity of OTC or augmented activation of ODC results in ornithine consumption and urea cycle disturbance, thereby causing hyperammonemia [6,9]. A recent study suggested that the molecular pathogenesis of FLHCC may contribute to urea cycle dysfunction [6]. Heterozygous deletion of chromosome 19 results in chimeric DNAJB1-PRKACA kinase, which is frequently identified in FLHCC [10]. This chimeric DNAJB1-PRKACA kinase increases the expression of Aurora kinase A, leading to the overexpression of c-Myc that upregulates ODC function [6,10]. The precise mechanism of the development of HAE in our case is unclear. Initially, there were no specific findings in his metal or neurologic status, and his serum ammonia level was not tested. He developed HAE on the third day of chemotherapy, which suggests a causal relationship between chemotherapeutic agents and HAE. There are case reports about chemotherapy-associated hyperammonemia. For example, patients with acute lymphoblastic leukemia receiving corticosteroids [11] and L-asparaginase [12] show a transient increase in the serum ammonia level. Several case reports described HAE in patients receiving 5-FU, cytarabine, cyclophosphamide, oxaliplatin, vincristine, etoposide, anthracycline, busulfan, methotrexate, topotecan, gemcitabine, and tyrosine kinase inhibitors [5]. Our patient received steroids (as antiemetics) and 5-FU. Another culprit that might have contributed to HAE is APC tumor suppressor gene mutation identified by the NGS assay of the tumor. Unfortunately, our case was not tested for heterozygous deletion of chromosome 19 or chimeric DNAJB1-PRKACA kinase. APC mutation was identified by NGS assay of the tumor with an allele frequency of 15.53%. Several in vitro studies suggest that APC mediates ODC expression through a c-Myc– dependent mechanism, thereby affecting ODC transcription [13]. Tumor cells with truncated APC exhibit high levels of β-catenin, leading to increased expression of c-Myc [13]. We presume that both APC mutation and chemotherapy might have caused HAE resembling OTC deficiency. There are no management guidelines for cancer- or chemotherapy-associated hyperammonemia or HAE. Therefore, treatment of hyperammonemia or HAE is extrapolated from that for hepatic encephalopathy or OTC deficiency [14]. Clinical features of hyperammonemia can deteriorate from irritability, confusion to seizure, coma, and even death [14]. Ammonia scavenger therapy should be initiated when ammonia levels are greater than 100 μg/dL [5]. When the serum ammonia level is extremely high (500 μg/dL), dialysis/rapid hemofiltration should be started immediately [5]. In our case, the patient developed HAE during the first course of chemotherapy. Ammonia scavenger therapy normalized his ammonia level and was maintained until the second course of chemotherapy and surgery. After surgery, his ammonia level remained normal without ammonia scavenger therapy, suggesting that his HAE was a paraneoplastic phenomenon of FLHCC. While HCC is prevalent in Asia, the incidence of FLHCC is similar across different ethnic groups [1]. FLHCC comprises less than 1% of all primary liver cancer cases in the United States [1]. Recent studies suggest that FLHCC has a distinctive molecular profile, with focal deletion leading to DNAJB1-PRKACA gene fusion [2]. There are limited studies on the treatment outcome of patients with FLHCC. Despite the large tumor size and advanced stage at presentation, FLHCC patients exhibit significantly better 5-year relative survival than those with conventional HCC [1]. It is unclear whether biologic difference or absence of pre existing liver disease in FLHCC attributes to better survival. Except for surgery, no consensus exists for the treatment of FLHCC. Chemotherapy regimens for unresectable cases include cytotoxic agents, bevacizumab, and tyrosine kinase inhibitors [5]. A phase II trial involving nine cases of FLHCC suggested a potential benefit of 5-FU and interferon [15]. Our patient received perioperative chemotherapy including 5-FU and interferon. Generally, surgical resection is not considered for case like ours, even after systemic chemotherapy. However, there are several reports favoring aggressive cytoreductive surgery prolongs the survival of HCC patients with peritoneal metastases [16,17]. Our case received surgery for the following reasons: (1) the patient was young without any underlying disease, (2) tumors, including liver mass, peritoneal and pelvic metastases appeared to be feasible for resection without compromising patient’s safety, (3) to alleviate clinical symptom (HAE, early satiety, nausea, abdominal discomfort and pain) caused by the multiple large tumors. In the absence of any evidence-based treatment options for aggressive FLHCC, disappearance of HAE after surgery showed that our decision was appropriate. However, the size of the peritoneal nodule increased 3 months after the surgery and combination chemotherapy. The chemotherapy regimen was changed, and the patient was on third-line chemotherapy consisting of cisplatin and gemcitabine, and the patient has been alive for 12 months since the diagnosis of FLHCC. In conclusion, a young boy with FLHCC presenting HAE, which mimicks OTC deficiency, was successfully treated with hemofiltration and ammonia scavenger therapy. Lack of significant findings in OTC gene analysis and the normal ammonia level after surgery imply that FLHCC directly caused urea cycle dysfunction. We assume that APC mutation might be partially related to the development of HAE in our case. Oncologists should be aware about the HAE, a rare but serious metabolic complication of FLHCC. Treatments extrapolated from OTC deficiency, such as continuous venovenous hemofiltration and ammonia scavengers, will be helpful and could partially applied to HAE related to any malignancies. Ethical Statement The present study was approved by the Institutional Review Board of National Cancer Center in Korea (NCC2020-0175), who waived the requirement for informed consent because of the retrospective nature of the study. Author Contributions Conceived and designed the analysis: Lee JA. Collected the data: Lee JS, Han N, Lee JA. Contributed data or analysis tools: Jin HY, Ko JM, Kim SH, Park BK, Park M, Park HJ. Performed the analysis: Lee JS, Lee JA. Wrote the paper: Lee JA, Kim SH, Lee JS. Conflicts of Interest Conflicts of interest relevant to this article was not reported. Fig. 1 Dynamic liver computed tomography at the time of diagnosis of fibrolamellar hepatocellular carcinoma (coronal view, portal phase). Fig. 2 Photographs of the fine needle biopsy and surgical resection specimen. (A) Histologic features of fibrolamellar hepatocellular carcinoma (FLHCC). Large, polygonal tumor cells with abundant oncocytic cytoplasm in background of dense collagen bundles (H&E, ×100). Cytokeratin 7 (B) and CD68 (C) protein expression were noted in FLHCC evaluated by immunohistochemistry (×100). (D) Representative image of surgical specimen. Bulging, large mass with well-circumscribed border was observed. Fibrous bands and central stellate scar are noted. Fig. 3 Change of the serum ammonia levels with ammonia scavengers and hemofiltration. HF, hemofiltration; IV, intravenously; PO, orally.	20 GRAM DAILY;	DrugDosageText	CC BY-NC	32898940	18,380,427	2021-01
What was the dosage of drug 'DOXORUBICIN HYDROCHLORIDE'?	Hyperammonemic Encephalopathy Mimicking Ornithine Transcarbamylase Deficiency in Fibrolamellar Hepatocellular Carcinoma: Successful Treatment with Continuous Venovenous Hemofiltration and Ammonia Scavengers. Fibrolamellar hepatocellular carcinoma (FLHCC) is a rare liver cancer affecting adolescents and young adults without any pre existing liver disease. Hyperammonemic encephalopathy (HAE) is a serious paraneoplastic syndrome, and several cases of HAE have been reported in patients with FLHCC. This condition is rare; hence, there are currently no management guidelines for cancer-related HAE. Herein, we report a case of an 18-year-old man with advanced FLHCC who developed HAE during the first course of chemotherapy consisting of cisplatin, doxorubicin, 5-fluorouracil, and interferon-α. He was successfully treated with continuous venovenous hemofiltration, sodium benzoate, sodium phenylbutyrate, and amino acid supplementation for HAE. After the second course of chemotherapy, he underwent surgery, and thereafter, his ammonia levels were normal without any ammonia scavenger therapy. Treatments for HAE described here will be helpful for this rare, but serious metabolic complication of FLHCC and could partially applied to HAE related to any malignancies. Introduction Fibrolamellar hepatocellular carcinoma (FLHCC) is different from conventional hepatocellular carcinoma (HCC) [1]. The incidence of FLHCC is very low, and it affects adolescents and young adults without any pre existing liver disease [1]. Recent studies suggest that FLHCC is an independent entity, showing distinctive molecular profile [2]. Several case reports described paraneoplastic syndrome of FLHCC with symptoms such as hyperammonemia [3–6], gynecomastia [7], and venous thrombosis [8]. Hyperammonemic encephalopathy (HAE) is the most serious paraneoplastic syndrome. However, owing to its rarity, no management guidelines exist for cancer-related HAE. Herein, we report a case of an 18-year-old male patient with FLHCC who developed HAE during the first course of chemotherapy. He was successfully treated with hemofiltration, sodium benzoate, and sodium phenylbutyrate. He underwent surgery and successive chemotherapy, and his ammonia levels were maintained in the normal range without ammonia scavenger therapy. Case Report An 18-year-old boy presented with a history of fatigue, vomiting, abdominal pain, and distension. Computed tomography (CT) revealed a huge mass (13.7×10.7 cm) occupying the left liver and two masses (8.7×7.3 cm, 3.9×2.9 cm) in the pelvic cavity. Multiple lymph nodes were enlarged in right anterior and posterior cardiophrenic angles (Fig. 1). An initial laboratory investigation showed normal bilirubin, slightly elevated aminotransferase levels (aspartate aminotransferase [AST], 85 U/L; alanine aminotransferase [ALT], 154 U/L) and α-fetoprotein (27.2 ng/mL). He was previously healthy with no signs of chronic liver disease and had negative results on serologic testing for hepatitis B (hepatitis B virus surface antigen, hepatitis B virus surface antibody) and hepatitis C (anti–hepatitis C virus). He underwent fine needle biopsy and was diagnosed with FLHCC (Fig. 2). Considering the extent of the tumor, the patient was not considered a candidate for surgical resection. Systemic chemotherapy was initiated with cisplatin (80 mg/m2 on day 1), doxorubicin (30 mg/m2 on days 1 and 2), 5-fluorouracil (5-FU; 400 mg/m2 on days 1–4), and interferon-α (5×108 U/m2 on days 1–4). At midnight on day 3 of chemotherapy, the patient became agitated and was walking and running around the ward, not responding to verbal stimuli. Laboratory testing revealed a serum ammonia level of 393 μg/dL, AST/ALT level of 201/126 U/L, and total bilirubin level of 0.3 mg/dL. Head CT did not reveal any significant findings. He was diagnosed as HAE, and chemotherapy (4th dose of 5-FU and interferon-α) was stopped. Treatment with rifaximin and lactulose was initiated. However, his serum ammonia level rapidly increased to 500 μg/dL, and his mental status deteriorated to the semicoma state. The patient was transferred to the intensive care unit (ICU) and was on mechanical ventilator support under sedation using midazolam, remifentanil, and vecuronium. The metabolic and genetics department was consulted, and treatment for hyperammonemia was started as follows: (1) continuous venovenous hemofiltration, (2) intravenous infusion of sodium benzoate at a loading dose of 8.8 g (170 mg/kg), followed by continuous infusion (8.8 g/day) and sodium phenylbutyrate (5 g four times a day, via Levin tube), (3) 20% dextrose for caloric intake (6 mg/kg/min), and (4) administration of lactulose and rifaximin via Levin tube. His ammonia level decreased to 164 μg/dL but rebounded to 442 μg/dL on the third day of ICU care. Sodium benzoate (8.8 g) was loaded again, and his ammonia level decreased to 135 μg/dL. On the sixth day of the above-mentioned treatment, continuous venovenous hemofiltration was discontinued. On the eighth day, the patient was extubated, and sodium benzoate/sodium phenylbutyrate administration was changed to an intermittent schedule, with sodium benzoate 1.8 g administered as intravenously every 8 hours, sodium phenylbutyrate 3 g four times a day, and arginine 2.5 g twice a day. He was started on a low-protein diet (1 g/kg/day) through a Levin tube. Two days later (10th day of ICU care), he became disoriented and could not properly respond to verbal stimuli, with an ammonia level of 173 μg/dL. The low-protein diet was discontinued, and a continuous infusion of sodium benzoate (5.5 g/day, after a loading dose of 5.5 g) was started again, as well as citrulline (5 g three times a day). There were no focal neurologic signs, and brain magnetic resonance imaging (MRI) did not reveal any abnormality. As the serum ammonia level started decreasing (59 μg/dL), his conscious level improved. On the 12th day, he started Levin tube feeding and oral medications (sodium phenylbutyrate 6 g/day, L-carnitine 2,550 mg/day); citrulline was discontinued. On the 14th day of ICU care, sodium benzoate infusion was changed to an intermittent schedule (1.8 g every 8 hours). He resumed the low-protein diet (0.5 g/kg/day), and his ammonia level was maintained in the range of 90–100 μg/dL. He was transferred to a general ward on the 16th day of ICU care, and sodium benzoate was changed to an oral form (3 g three times a day). With sodium benzoate, sodium phenylbutyrate (3 g three times a day), arginine (2.5 g twice a day), and L-carnitine (660 mg once daily), his ammonia level further decreased to 50–60 μg/dL (Fig. 3). On the ninth day at the general ward, laboratory analyses were performed to identify the underlying mechanism of his HAE. The patient’s serum amino acid analysis revealed the following findings: decreased citrulline and ornithine, normal alanine and glutamine. His urine orotic acid level was elevated, and serum acylcarnitine was slightly elevated. These results suggested impaired activity of ornithine transcarbamylase (OTC). However, polymerase chain reaction (PCR) and direct sequencing of the OTC gene did not reveal any pathogenic variant, deletion, or duplication. On the 20th day at the general ward, the patient underwent a second course of chemotherapy involving cisplatin+doxorubicin+5-fluorouracil+interferon-α. One month later, he underwent extended left hemihepatectomy en bloc with the caudate lobe, excision of pelvic mass, and peritoneal seeding. Extensive lymph node dissection was also performed at the hepatoduodenal, cardiophrenic, para-aortic, and pelvic lymph nodes. Immunohistochemical staining confirmed a profile consistent with that of FLHCC, that is, positive for cytokeratin 7, glypican 3, and CD68. We did not test for the DNAJB1-PRKACA fusion. Next-generation sequencing (NGS) was performed to identify actionable therapeutic targets but only revealed APC mutation (c.4666delA, p.T1556fs), with an allele frequency of 15.53%. His postoperative period was uneventful and the ammonia level further decreased (30–40 μg/dL). One month after the surgery, treatment for hyperammonemia was discontinued. He received two additional courses of chemotherapy involving cisplatin+doxorubicin+5-FU+interferon-α. However, CT and MRI obtained 3 months after the surgery revealed enlarged left external iliac lymph nodes and multiple enhancing nodules at the perihepatic, perigastric, mesentery, omentum, and pelvic cavity. The chemotherapy regimen was changed to vincristine (1.5 mg/m2 on days 1, 8)+irinotecan (50 mg/m2 on days 1–5) and then to gemcitabine (1,000 mg/m2 on day 1)+cisplatin (20 mg/m2 on days 1–5). CT performed after three courses of gemcitabine+cisplatin showed a decrease in the size of the peritoneal nodules and iliac lymph node. Furthermore, the patient experienced severe, recurrent abdominal pain with vomiting, and CT images suggested obstructive ileus. Exploratory laparotomy was performed, and multiple adhesive bands were dissected off the small intestine and excised. Additionally, two metastatic nodules were resected. At the time of this report writing, the patient had just completed the sixth course of gemcitabine-cisplatin, and his disease was stable. He is on normal regular diet and his ammonia level remains normal (30–40 μg/dL). Discussion We report an 18-year-old male patient with advanced FLHCC who developed HAE during the first course of chemotherapy comprising o cisplatin, doxorubicin, 5-FU, and interferon-α. His HAE was successfully treated with continuous venovenous hemofiltration, ammonium scavengers, and amino acid supplementation. Serum amino acid and urine organic acid analyses suggested urea cycle dysfunction. However, PCR and direct sequencing of the OTC gene did not reveal any pathogenic variants. Intriguingly, APC gene mutation was detected from NGS of the tumor tissue, suggesting a possible relation to the development of HAE. After tumor excision, serum ammonia levels were maintained in the normal range without treatment with ammonium scavengers. HAE in FLHCC was first reported in 2009 [3]. This condition is very rare, and approximately 10 cases are reported thus far; many of the patients present HAE at the time of diagnosis of FLHCC [3–6]. One of them recovered from HAE after liver transplantation [4]. Similar to our case, a 31-year-old man developed HAE on the third day of gemcitabine+oxaliplatin chemotherapy [5]. Several mechanisms were proposed on the development of HAE in patients with FLHCC. Some studies suggest that urea cycle dysfunction is caused by an imbalance in the activities and ratios of OTC and ornithine decarboxylase (ODC) [6]. Reduced activity of OTC or augmented activation of ODC results in ornithine consumption and urea cycle disturbance, thereby causing hyperammonemia [6,9]. A recent study suggested that the molecular pathogenesis of FLHCC may contribute to urea cycle dysfunction [6]. Heterozygous deletion of chromosome 19 results in chimeric DNAJB1-PRKACA kinase, which is frequently identified in FLHCC [10]. This chimeric DNAJB1-PRKACA kinase increases the expression of Aurora kinase A, leading to the overexpression of c-Myc that upregulates ODC function [6,10]. The precise mechanism of the development of HAE in our case is unclear. Initially, there were no specific findings in his metal or neurologic status, and his serum ammonia level was not tested. He developed HAE on the third day of chemotherapy, which suggests a causal relationship between chemotherapeutic agents and HAE. There are case reports about chemotherapy-associated hyperammonemia. For example, patients with acute lymphoblastic leukemia receiving corticosteroids [11] and L-asparaginase [12] show a transient increase in the serum ammonia level. Several case reports described HAE in patients receiving 5-FU, cytarabine, cyclophosphamide, oxaliplatin, vincristine, etoposide, anthracycline, busulfan, methotrexate, topotecan, gemcitabine, and tyrosine kinase inhibitors [5]. Our patient received steroids (as antiemetics) and 5-FU. Another culprit that might have contributed to HAE is APC tumor suppressor gene mutation identified by the NGS assay of the tumor. Unfortunately, our case was not tested for heterozygous deletion of chromosome 19 or chimeric DNAJB1-PRKACA kinase. APC mutation was identified by NGS assay of the tumor with an allele frequency of 15.53%. Several in vitro studies suggest that APC mediates ODC expression through a c-Myc– dependent mechanism, thereby affecting ODC transcription [13]. Tumor cells with truncated APC exhibit high levels of β-catenin, leading to increased expression of c-Myc [13]. We presume that both APC mutation and chemotherapy might have caused HAE resembling OTC deficiency. There are no management guidelines for cancer- or chemotherapy-associated hyperammonemia or HAE. Therefore, treatment of hyperammonemia or HAE is extrapolated from that for hepatic encephalopathy or OTC deficiency [14]. Clinical features of hyperammonemia can deteriorate from irritability, confusion to seizure, coma, and even death [14]. Ammonia scavenger therapy should be initiated when ammonia levels are greater than 100 μg/dL [5]. When the serum ammonia level is extremely high (500 μg/dL), dialysis/rapid hemofiltration should be started immediately [5]. In our case, the patient developed HAE during the first course of chemotherapy. Ammonia scavenger therapy normalized his ammonia level and was maintained until the second course of chemotherapy and surgery. After surgery, his ammonia level remained normal without ammonia scavenger therapy, suggesting that his HAE was a paraneoplastic phenomenon of FLHCC. While HCC is prevalent in Asia, the incidence of FLHCC is similar across different ethnic groups [1]. FLHCC comprises less than 1% of all primary liver cancer cases in the United States [1]. Recent studies suggest that FLHCC has a distinctive molecular profile, with focal deletion leading to DNAJB1-PRKACA gene fusion [2]. There are limited studies on the treatment outcome of patients with FLHCC. Despite the large tumor size and advanced stage at presentation, FLHCC patients exhibit significantly better 5-year relative survival than those with conventional HCC [1]. It is unclear whether biologic difference or absence of pre existing liver disease in FLHCC attributes to better survival. Except for surgery, no consensus exists for the treatment of FLHCC. Chemotherapy regimens for unresectable cases include cytotoxic agents, bevacizumab, and tyrosine kinase inhibitors [5]. A phase II trial involving nine cases of FLHCC suggested a potential benefit of 5-FU and interferon [15]. Our patient received perioperative chemotherapy including 5-FU and interferon. Generally, surgical resection is not considered for case like ours, even after systemic chemotherapy. However, there are several reports favoring aggressive cytoreductive surgery prolongs the survival of HCC patients with peritoneal metastases [16,17]. Our case received surgery for the following reasons: (1) the patient was young without any underlying disease, (2) tumors, including liver mass, peritoneal and pelvic metastases appeared to be feasible for resection without compromising patient’s safety, (3) to alleviate clinical symptom (HAE, early satiety, nausea, abdominal discomfort and pain) caused by the multiple large tumors. In the absence of any evidence-based treatment options for aggressive FLHCC, disappearance of HAE after surgery showed that our decision was appropriate. However, the size of the peritoneal nodule increased 3 months after the surgery and combination chemotherapy. The chemotherapy regimen was changed, and the patient was on third-line chemotherapy consisting of cisplatin and gemcitabine, and the patient has been alive for 12 months since the diagnosis of FLHCC. In conclusion, a young boy with FLHCC presenting HAE, which mimicks OTC deficiency, was successfully treated with hemofiltration and ammonia scavenger therapy. Lack of significant findings in OTC gene analysis and the normal ammonia level after surgery imply that FLHCC directly caused urea cycle dysfunction. We assume that APC mutation might be partially related to the development of HAE in our case. Oncologists should be aware about the HAE, a rare but serious metabolic complication of FLHCC. Treatments extrapolated from OTC deficiency, such as continuous venovenous hemofiltration and ammonia scavengers, will be helpful and could partially applied to HAE related to any malignancies. Ethical Statement The present study was approved by the Institutional Review Board of National Cancer Center in Korea (NCC2020-0175), who waived the requirement for informed consent because of the retrospective nature of the study. Author Contributions Conceived and designed the analysis: Lee JA. Collected the data: Lee JS, Han N, Lee JA. Contributed data or analysis tools: Jin HY, Ko JM, Kim SH, Park BK, Park M, Park HJ. Performed the analysis: Lee JS, Lee JA. Wrote the paper: Lee JA, Kim SH, Lee JS. Conflicts of Interest Conflicts of interest relevant to this article was not reported. Fig. 1 Dynamic liver computed tomography at the time of diagnosis of fibrolamellar hepatocellular carcinoma (coronal view, portal phase). Fig. 2 Photographs of the fine needle biopsy and surgical resection specimen. (A) Histologic features of fibrolamellar hepatocellular carcinoma (FLHCC). Large, polygonal tumor cells with abundant oncocytic cytoplasm in background of dense collagen bundles (H&E, ×100). Cytokeratin 7 (B) and CD68 (C) protein expression were noted in FLHCC evaluated by immunohistochemistry (×100). (D) Representative image of surgical specimen. Bulging, large mass with well-circumscribed border was observed. Fibrous bands and central stellate scar are noted. Fig. 3 Change of the serum ammonia levels with ammonia scavengers and hemofiltration. HF, hemofiltration; IV, intravenously; PO, orally.	DAYS 1 AND 2 (30 MG/M2)	DrugDosageText	CC BY-NC	32898940	18,812,291	2021-01
What was the dosage of drug 'SODIUM PHENYLBUTYRATE'?	Hyperammonemic Encephalopathy Mimicking Ornithine Transcarbamylase Deficiency in Fibrolamellar Hepatocellular Carcinoma: Successful Treatment with Continuous Venovenous Hemofiltration and Ammonia Scavengers. Fibrolamellar hepatocellular carcinoma (FLHCC) is a rare liver cancer affecting adolescents and young adults without any pre existing liver disease. Hyperammonemic encephalopathy (HAE) is a serious paraneoplastic syndrome, and several cases of HAE have been reported in patients with FLHCC. This condition is rare; hence, there are currently no management guidelines for cancer-related HAE. Herein, we report a case of an 18-year-old man with advanced FLHCC who developed HAE during the first course of chemotherapy consisting of cisplatin, doxorubicin, 5-fluorouracil, and interferon-α. He was successfully treated with continuous venovenous hemofiltration, sodium benzoate, sodium phenylbutyrate, and amino acid supplementation for HAE. After the second course of chemotherapy, he underwent surgery, and thereafter, his ammonia levels were normal without any ammonia scavenger therapy. Treatments for HAE described here will be helpful for this rare, but serious metabolic complication of FLHCC and could partially applied to HAE related to any malignancies. Introduction Fibrolamellar hepatocellular carcinoma (FLHCC) is different from conventional hepatocellular carcinoma (HCC) [1]. The incidence of FLHCC is very low, and it affects adolescents and young adults without any pre existing liver disease [1]. Recent studies suggest that FLHCC is an independent entity, showing distinctive molecular profile [2]. Several case reports described paraneoplastic syndrome of FLHCC with symptoms such as hyperammonemia [3–6], gynecomastia [7], and venous thrombosis [8]. Hyperammonemic encephalopathy (HAE) is the most serious paraneoplastic syndrome. However, owing to its rarity, no management guidelines exist for cancer-related HAE. Herein, we report a case of an 18-year-old male patient with FLHCC who developed HAE during the first course of chemotherapy. He was successfully treated with hemofiltration, sodium benzoate, and sodium phenylbutyrate. He underwent surgery and successive chemotherapy, and his ammonia levels were maintained in the normal range without ammonia scavenger therapy. Case Report An 18-year-old boy presented with a history of fatigue, vomiting, abdominal pain, and distension. Computed tomography (CT) revealed a huge mass (13.7×10.7 cm) occupying the left liver and two masses (8.7×7.3 cm, 3.9×2.9 cm) in the pelvic cavity. Multiple lymph nodes were enlarged in right anterior and posterior cardiophrenic angles (Fig. 1). An initial laboratory investigation showed normal bilirubin, slightly elevated aminotransferase levels (aspartate aminotransferase [AST], 85 U/L; alanine aminotransferase [ALT], 154 U/L) and α-fetoprotein (27.2 ng/mL). He was previously healthy with no signs of chronic liver disease and had negative results on serologic testing for hepatitis B (hepatitis B virus surface antigen, hepatitis B virus surface antibody) and hepatitis C (anti–hepatitis C virus). He underwent fine needle biopsy and was diagnosed with FLHCC (Fig. 2). Considering the extent of the tumor, the patient was not considered a candidate for surgical resection. Systemic chemotherapy was initiated with cisplatin (80 mg/m2 on day 1), doxorubicin (30 mg/m2 on days 1 and 2), 5-fluorouracil (5-FU; 400 mg/m2 on days 1–4), and interferon-α (5×108 U/m2 on days 1–4). At midnight on day 3 of chemotherapy, the patient became agitated and was walking and running around the ward, not responding to verbal stimuli. Laboratory testing revealed a serum ammonia level of 393 μg/dL, AST/ALT level of 201/126 U/L, and total bilirubin level of 0.3 mg/dL. Head CT did not reveal any significant findings. He was diagnosed as HAE, and chemotherapy (4th dose of 5-FU and interferon-α) was stopped. Treatment with rifaximin and lactulose was initiated. However, his serum ammonia level rapidly increased to 500 μg/dL, and his mental status deteriorated to the semicoma state. The patient was transferred to the intensive care unit (ICU) and was on mechanical ventilator support under sedation using midazolam, remifentanil, and vecuronium. The metabolic and genetics department was consulted, and treatment for hyperammonemia was started as follows: (1) continuous venovenous hemofiltration, (2) intravenous infusion of sodium benzoate at a loading dose of 8.8 g (170 mg/kg), followed by continuous infusion (8.8 g/day) and sodium phenylbutyrate (5 g four times a day, via Levin tube), (3) 20% dextrose for caloric intake (6 mg/kg/min), and (4) administration of lactulose and rifaximin via Levin tube. His ammonia level decreased to 164 μg/dL but rebounded to 442 μg/dL on the third day of ICU care. Sodium benzoate (8.8 g) was loaded again, and his ammonia level decreased to 135 μg/dL. On the sixth day of the above-mentioned treatment, continuous venovenous hemofiltration was discontinued. On the eighth day, the patient was extubated, and sodium benzoate/sodium phenylbutyrate administration was changed to an intermittent schedule, with sodium benzoate 1.8 g administered as intravenously every 8 hours, sodium phenylbutyrate 3 g four times a day, and arginine 2.5 g twice a day. He was started on a low-protein diet (1 g/kg/day) through a Levin tube. Two days later (10th day of ICU care), he became disoriented and could not properly respond to verbal stimuli, with an ammonia level of 173 μg/dL. The low-protein diet was discontinued, and a continuous infusion of sodium benzoate (5.5 g/day, after a loading dose of 5.5 g) was started again, as well as citrulline (5 g three times a day). There were no focal neurologic signs, and brain magnetic resonance imaging (MRI) did not reveal any abnormality. As the serum ammonia level started decreasing (59 μg/dL), his conscious level improved. On the 12th day, he started Levin tube feeding and oral medications (sodium phenylbutyrate 6 g/day, L-carnitine 2,550 mg/day); citrulline was discontinued. On the 14th day of ICU care, sodium benzoate infusion was changed to an intermittent schedule (1.8 g every 8 hours). He resumed the low-protein diet (0.5 g/kg/day), and his ammonia level was maintained in the range of 90–100 μg/dL. He was transferred to a general ward on the 16th day of ICU care, and sodium benzoate was changed to an oral form (3 g three times a day). With sodium benzoate, sodium phenylbutyrate (3 g three times a day), arginine (2.5 g twice a day), and L-carnitine (660 mg once daily), his ammonia level further decreased to 50–60 μg/dL (Fig. 3). On the ninth day at the general ward, laboratory analyses were performed to identify the underlying mechanism of his HAE. The patient’s serum amino acid analysis revealed the following findings: decreased citrulline and ornithine, normal alanine and glutamine. His urine orotic acid level was elevated, and serum acylcarnitine was slightly elevated. These results suggested impaired activity of ornithine transcarbamylase (OTC). However, polymerase chain reaction (PCR) and direct sequencing of the OTC gene did not reveal any pathogenic variant, deletion, or duplication. On the 20th day at the general ward, the patient underwent a second course of chemotherapy involving cisplatin+doxorubicin+5-fluorouracil+interferon-α. One month later, he underwent extended left hemihepatectomy en bloc with the caudate lobe, excision of pelvic mass, and peritoneal seeding. Extensive lymph node dissection was also performed at the hepatoduodenal, cardiophrenic, para-aortic, and pelvic lymph nodes. Immunohistochemical staining confirmed a profile consistent with that of FLHCC, that is, positive for cytokeratin 7, glypican 3, and CD68. We did not test for the DNAJB1-PRKACA fusion. Next-generation sequencing (NGS) was performed to identify actionable therapeutic targets but only revealed APC mutation (c.4666delA, p.T1556fs), with an allele frequency of 15.53%. His postoperative period was uneventful and the ammonia level further decreased (30–40 μg/dL). One month after the surgery, treatment for hyperammonemia was discontinued. He received two additional courses of chemotherapy involving cisplatin+doxorubicin+5-FU+interferon-α. However, CT and MRI obtained 3 months after the surgery revealed enlarged left external iliac lymph nodes and multiple enhancing nodules at the perihepatic, perigastric, mesentery, omentum, and pelvic cavity. The chemotherapy regimen was changed to vincristine (1.5 mg/m2 on days 1, 8)+irinotecan (50 mg/m2 on days 1–5) and then to gemcitabine (1,000 mg/m2 on day 1)+cisplatin (20 mg/m2 on days 1–5). CT performed after three courses of gemcitabine+cisplatin showed a decrease in the size of the peritoneal nodules and iliac lymph node. Furthermore, the patient experienced severe, recurrent abdominal pain with vomiting, and CT images suggested obstructive ileus. Exploratory laparotomy was performed, and multiple adhesive bands were dissected off the small intestine and excised. Additionally, two metastatic nodules were resected. At the time of this report writing, the patient had just completed the sixth course of gemcitabine-cisplatin, and his disease was stable. He is on normal regular diet and his ammonia level remains normal (30–40 μg/dL). Discussion We report an 18-year-old male patient with advanced FLHCC who developed HAE during the first course of chemotherapy comprising o cisplatin, doxorubicin, 5-FU, and interferon-α. His HAE was successfully treated with continuous venovenous hemofiltration, ammonium scavengers, and amino acid supplementation. Serum amino acid and urine organic acid analyses suggested urea cycle dysfunction. However, PCR and direct sequencing of the OTC gene did not reveal any pathogenic variants. Intriguingly, APC gene mutation was detected from NGS of the tumor tissue, suggesting a possible relation to the development of HAE. After tumor excision, serum ammonia levels were maintained in the normal range without treatment with ammonium scavengers. HAE in FLHCC was first reported in 2009 [3]. This condition is very rare, and approximately 10 cases are reported thus far; many of the patients present HAE at the time of diagnosis of FLHCC [3–6]. One of them recovered from HAE after liver transplantation [4]. Similar to our case, a 31-year-old man developed HAE on the third day of gemcitabine+oxaliplatin chemotherapy [5]. Several mechanisms were proposed on the development of HAE in patients with FLHCC. Some studies suggest that urea cycle dysfunction is caused by an imbalance in the activities and ratios of OTC and ornithine decarboxylase (ODC) [6]. Reduced activity of OTC or augmented activation of ODC results in ornithine consumption and urea cycle disturbance, thereby causing hyperammonemia [6,9]. A recent study suggested that the molecular pathogenesis of FLHCC may contribute to urea cycle dysfunction [6]. Heterozygous deletion of chromosome 19 results in chimeric DNAJB1-PRKACA kinase, which is frequently identified in FLHCC [10]. This chimeric DNAJB1-PRKACA kinase increases the expression of Aurora kinase A, leading to the overexpression of c-Myc that upregulates ODC function [6,10]. The precise mechanism of the development of HAE in our case is unclear. Initially, there were no specific findings in his metal or neurologic status, and his serum ammonia level was not tested. He developed HAE on the third day of chemotherapy, which suggests a causal relationship between chemotherapeutic agents and HAE. There are case reports about chemotherapy-associated hyperammonemia. For example, patients with acute lymphoblastic leukemia receiving corticosteroids [11] and L-asparaginase [12] show a transient increase in the serum ammonia level. Several case reports described HAE in patients receiving 5-FU, cytarabine, cyclophosphamide, oxaliplatin, vincristine, etoposide, anthracycline, busulfan, methotrexate, topotecan, gemcitabine, and tyrosine kinase inhibitors [5]. Our patient received steroids (as antiemetics) and 5-FU. Another culprit that might have contributed to HAE is APC tumor suppressor gene mutation identified by the NGS assay of the tumor. Unfortunately, our case was not tested for heterozygous deletion of chromosome 19 or chimeric DNAJB1-PRKACA kinase. APC mutation was identified by NGS assay of the tumor with an allele frequency of 15.53%. Several in vitro studies suggest that APC mediates ODC expression through a c-Myc– dependent mechanism, thereby affecting ODC transcription [13]. Tumor cells with truncated APC exhibit high levels of β-catenin, leading to increased expression of c-Myc [13]. We presume that both APC mutation and chemotherapy might have caused HAE resembling OTC deficiency. There are no management guidelines for cancer- or chemotherapy-associated hyperammonemia or HAE. Therefore, treatment of hyperammonemia or HAE is extrapolated from that for hepatic encephalopathy or OTC deficiency [14]. Clinical features of hyperammonemia can deteriorate from irritability, confusion to seizure, coma, and even death [14]. Ammonia scavenger therapy should be initiated when ammonia levels are greater than 100 μg/dL [5]. When the serum ammonia level is extremely high (500 μg/dL), dialysis/rapid hemofiltration should be started immediately [5]. In our case, the patient developed HAE during the first course of chemotherapy. Ammonia scavenger therapy normalized his ammonia level and was maintained until the second course of chemotherapy and surgery. After surgery, his ammonia level remained normal without ammonia scavenger therapy, suggesting that his HAE was a paraneoplastic phenomenon of FLHCC. While HCC is prevalent in Asia, the incidence of FLHCC is similar across different ethnic groups [1]. FLHCC comprises less than 1% of all primary liver cancer cases in the United States [1]. Recent studies suggest that FLHCC has a distinctive molecular profile, with focal deletion leading to DNAJB1-PRKACA gene fusion [2]. There are limited studies on the treatment outcome of patients with FLHCC. Despite the large tumor size and advanced stage at presentation, FLHCC patients exhibit significantly better 5-year relative survival than those with conventional HCC [1]. It is unclear whether biologic difference or absence of pre existing liver disease in FLHCC attributes to better survival. Except for surgery, no consensus exists for the treatment of FLHCC. Chemotherapy regimens for unresectable cases include cytotoxic agents, bevacizumab, and tyrosine kinase inhibitors [5]. A phase II trial involving nine cases of FLHCC suggested a potential benefit of 5-FU and interferon [15]. Our patient received perioperative chemotherapy including 5-FU and interferon. Generally, surgical resection is not considered for case like ours, even after systemic chemotherapy. However, there are several reports favoring aggressive cytoreductive surgery prolongs the survival of HCC patients with peritoneal metastases [16,17]. Our case received surgery for the following reasons: (1) the patient was young without any underlying disease, (2) tumors, including liver mass, peritoneal and pelvic metastases appeared to be feasible for resection without compromising patient’s safety, (3) to alleviate clinical symptom (HAE, early satiety, nausea, abdominal discomfort and pain) caused by the multiple large tumors. In the absence of any evidence-based treatment options for aggressive FLHCC, disappearance of HAE after surgery showed that our decision was appropriate. However, the size of the peritoneal nodule increased 3 months after the surgery and combination chemotherapy. The chemotherapy regimen was changed, and the patient was on third-line chemotherapy consisting of cisplatin and gemcitabine, and the patient has been alive for 12 months since the diagnosis of FLHCC. In conclusion, a young boy with FLHCC presenting HAE, which mimicks OTC deficiency, was successfully treated with hemofiltration and ammonia scavenger therapy. Lack of significant findings in OTC gene analysis and the normal ammonia level after surgery imply that FLHCC directly caused urea cycle dysfunction. We assume that APC mutation might be partially related to the development of HAE in our case. Oncologists should be aware about the HAE, a rare but serious metabolic complication of FLHCC. Treatments extrapolated from OTC deficiency, such as continuous venovenous hemofiltration and ammonia scavengers, will be helpful and could partially applied to HAE related to any malignancies. Ethical Statement The present study was approved by the Institutional Review Board of National Cancer Center in Korea (NCC2020-0175), who waived the requirement for informed consent because of the retrospective nature of the study. Author Contributions Conceived and designed the analysis: Lee JA. Collected the data: Lee JS, Han N, Lee JA. Contributed data or analysis tools: Jin HY, Ko JM, Kim SH, Park BK, Park M, Park HJ. Performed the analysis: Lee JS, Lee JA. Wrote the paper: Lee JA, Kim SH, Lee JS. Conflicts of Interest Conflicts of interest relevant to this article was not reported. Fig. 1 Dynamic liver computed tomography at the time of diagnosis of fibrolamellar hepatocellular carcinoma (coronal view, portal phase). Fig. 2 Photographs of the fine needle biopsy and surgical resection specimen. (A) Histologic features of fibrolamellar hepatocellular carcinoma (FLHCC). Large, polygonal tumor cells with abundant oncocytic cytoplasm in background of dense collagen bundles (H&E, ×100). Cytokeratin 7 (B) and CD68 (C) protein expression were noted in FLHCC evaluated by immunohistochemistry (×100). (D) Representative image of surgical specimen. Bulging, large mass with well-circumscribed border was observed. Fibrous bands and central stellate scar are noted. Fig. 3 Change of the serum ammonia levels with ammonia scavengers and hemofiltration. HF, hemofiltration; IV, intravenously; PO, orally.	20 GRAM DAILY;	DrugDosageText	CC BY-NC	32898940	18,380,427	2021-01
What was the outcome of reaction 'Depressed level of consciousness'?	Hyperammonemic Encephalopathy Mimicking Ornithine Transcarbamylase Deficiency in Fibrolamellar Hepatocellular Carcinoma: Successful Treatment with Continuous Venovenous Hemofiltration and Ammonia Scavengers. Fibrolamellar hepatocellular carcinoma (FLHCC) is a rare liver cancer affecting adolescents and young adults without any pre existing liver disease. Hyperammonemic encephalopathy (HAE) is a serious paraneoplastic syndrome, and several cases of HAE have been reported in patients with FLHCC. This condition is rare; hence, there are currently no management guidelines for cancer-related HAE. Herein, we report a case of an 18-year-old man with advanced FLHCC who developed HAE during the first course of chemotherapy consisting of cisplatin, doxorubicin, 5-fluorouracil, and interferon-α. He was successfully treated with continuous venovenous hemofiltration, sodium benzoate, sodium phenylbutyrate, and amino acid supplementation for HAE. After the second course of chemotherapy, he underwent surgery, and thereafter, his ammonia levels were normal without any ammonia scavenger therapy. Treatments for HAE described here will be helpful for this rare, but serious metabolic complication of FLHCC and could partially applied to HAE related to any malignancies. Introduction Fibrolamellar hepatocellular carcinoma (FLHCC) is different from conventional hepatocellular carcinoma (HCC) [1]. The incidence of FLHCC is very low, and it affects adolescents and young adults without any pre existing liver disease [1]. Recent studies suggest that FLHCC is an independent entity, showing distinctive molecular profile [2]. Several case reports described paraneoplastic syndrome of FLHCC with symptoms such as hyperammonemia [3–6], gynecomastia [7], and venous thrombosis [8]. Hyperammonemic encephalopathy (HAE) is the most serious paraneoplastic syndrome. However, owing to its rarity, no management guidelines exist for cancer-related HAE. Herein, we report a case of an 18-year-old male patient with FLHCC who developed HAE during the first course of chemotherapy. He was successfully treated with hemofiltration, sodium benzoate, and sodium phenylbutyrate. He underwent surgery and successive chemotherapy, and his ammonia levels were maintained in the normal range without ammonia scavenger therapy. Case Report An 18-year-old boy presented with a history of fatigue, vomiting, abdominal pain, and distension. Computed tomography (CT) revealed a huge mass (13.7×10.7 cm) occupying the left liver and two masses (8.7×7.3 cm, 3.9×2.9 cm) in the pelvic cavity. Multiple lymph nodes were enlarged in right anterior and posterior cardiophrenic angles (Fig. 1). An initial laboratory investigation showed normal bilirubin, slightly elevated aminotransferase levels (aspartate aminotransferase [AST], 85 U/L; alanine aminotransferase [ALT], 154 U/L) and α-fetoprotein (27.2 ng/mL). He was previously healthy with no signs of chronic liver disease and had negative results on serologic testing for hepatitis B (hepatitis B virus surface antigen, hepatitis B virus surface antibody) and hepatitis C (anti–hepatitis C virus). He underwent fine needle biopsy and was diagnosed with FLHCC (Fig. 2). Considering the extent of the tumor, the patient was not considered a candidate for surgical resection. Systemic chemotherapy was initiated with cisplatin (80 mg/m2 on day 1), doxorubicin (30 mg/m2 on days 1 and 2), 5-fluorouracil (5-FU; 400 mg/m2 on days 1–4), and interferon-α (5×108 U/m2 on days 1–4). At midnight on day 3 of chemotherapy, the patient became agitated and was walking and running around the ward, not responding to verbal stimuli. Laboratory testing revealed a serum ammonia level of 393 μg/dL, AST/ALT level of 201/126 U/L, and total bilirubin level of 0.3 mg/dL. Head CT did not reveal any significant findings. He was diagnosed as HAE, and chemotherapy (4th dose of 5-FU and interferon-α) was stopped. Treatment with rifaximin and lactulose was initiated. However, his serum ammonia level rapidly increased to 500 μg/dL, and his mental status deteriorated to the semicoma state. The patient was transferred to the intensive care unit (ICU) and was on mechanical ventilator support under sedation using midazolam, remifentanil, and vecuronium. The metabolic and genetics department was consulted, and treatment for hyperammonemia was started as follows: (1) continuous venovenous hemofiltration, (2) intravenous infusion of sodium benzoate at a loading dose of 8.8 g (170 mg/kg), followed by continuous infusion (8.8 g/day) and sodium phenylbutyrate (5 g four times a day, via Levin tube), (3) 20% dextrose for caloric intake (6 mg/kg/min), and (4) administration of lactulose and rifaximin via Levin tube. His ammonia level decreased to 164 μg/dL but rebounded to 442 μg/dL on the third day of ICU care. Sodium benzoate (8.8 g) was loaded again, and his ammonia level decreased to 135 μg/dL. On the sixth day of the above-mentioned treatment, continuous venovenous hemofiltration was discontinued. On the eighth day, the patient was extubated, and sodium benzoate/sodium phenylbutyrate administration was changed to an intermittent schedule, with sodium benzoate 1.8 g administered as intravenously every 8 hours, sodium phenylbutyrate 3 g four times a day, and arginine 2.5 g twice a day. He was started on a low-protein diet (1 g/kg/day) through a Levin tube. Two days later (10th day of ICU care), he became disoriented and could not properly respond to verbal stimuli, with an ammonia level of 173 μg/dL. The low-protein diet was discontinued, and a continuous infusion of sodium benzoate (5.5 g/day, after a loading dose of 5.5 g) was started again, as well as citrulline (5 g three times a day). There were no focal neurologic signs, and brain magnetic resonance imaging (MRI) did not reveal any abnormality. As the serum ammonia level started decreasing (59 μg/dL), his conscious level improved. On the 12th day, he started Levin tube feeding and oral medications (sodium phenylbutyrate 6 g/day, L-carnitine 2,550 mg/day); citrulline was discontinued. On the 14th day of ICU care, sodium benzoate infusion was changed to an intermittent schedule (1.8 g every 8 hours). He resumed the low-protein diet (0.5 g/kg/day), and his ammonia level was maintained in the range of 90–100 μg/dL. He was transferred to a general ward on the 16th day of ICU care, and sodium benzoate was changed to an oral form (3 g three times a day). With sodium benzoate, sodium phenylbutyrate (3 g three times a day), arginine (2.5 g twice a day), and L-carnitine (660 mg once daily), his ammonia level further decreased to 50–60 μg/dL (Fig. 3). On the ninth day at the general ward, laboratory analyses were performed to identify the underlying mechanism of his HAE. The patient’s serum amino acid analysis revealed the following findings: decreased citrulline and ornithine, normal alanine and glutamine. His urine orotic acid level was elevated, and serum acylcarnitine was slightly elevated. These results suggested impaired activity of ornithine transcarbamylase (OTC). However, polymerase chain reaction (PCR) and direct sequencing of the OTC gene did not reveal any pathogenic variant, deletion, or duplication. On the 20th day at the general ward, the patient underwent a second course of chemotherapy involving cisplatin+doxorubicin+5-fluorouracil+interferon-α. One month later, he underwent extended left hemihepatectomy en bloc with the caudate lobe, excision of pelvic mass, and peritoneal seeding. Extensive lymph node dissection was also performed at the hepatoduodenal, cardiophrenic, para-aortic, and pelvic lymph nodes. Immunohistochemical staining confirmed a profile consistent with that of FLHCC, that is, positive for cytokeratin 7, glypican 3, and CD68. We did not test for the DNAJB1-PRKACA fusion. Next-generation sequencing (NGS) was performed to identify actionable therapeutic targets but only revealed APC mutation (c.4666delA, p.T1556fs), with an allele frequency of 15.53%. His postoperative period was uneventful and the ammonia level further decreased (30–40 μg/dL). One month after the surgery, treatment for hyperammonemia was discontinued. He received two additional courses of chemotherapy involving cisplatin+doxorubicin+5-FU+interferon-α. However, CT and MRI obtained 3 months after the surgery revealed enlarged left external iliac lymph nodes and multiple enhancing nodules at the perihepatic, perigastric, mesentery, omentum, and pelvic cavity. The chemotherapy regimen was changed to vincristine (1.5 mg/m2 on days 1, 8)+irinotecan (50 mg/m2 on days 1–5) and then to gemcitabine (1,000 mg/m2 on day 1)+cisplatin (20 mg/m2 on days 1–5). CT performed after three courses of gemcitabine+cisplatin showed a decrease in the size of the peritoneal nodules and iliac lymph node. Furthermore, the patient experienced severe, recurrent abdominal pain with vomiting, and CT images suggested obstructive ileus. Exploratory laparotomy was performed, and multiple adhesive bands were dissected off the small intestine and excised. Additionally, two metastatic nodules were resected. At the time of this report writing, the patient had just completed the sixth course of gemcitabine-cisplatin, and his disease was stable. He is on normal regular diet and his ammonia level remains normal (30–40 μg/dL). Discussion We report an 18-year-old male patient with advanced FLHCC who developed HAE during the first course of chemotherapy comprising o cisplatin, doxorubicin, 5-FU, and interferon-α. His HAE was successfully treated with continuous venovenous hemofiltration, ammonium scavengers, and amino acid supplementation. Serum amino acid and urine organic acid analyses suggested urea cycle dysfunction. However, PCR and direct sequencing of the OTC gene did not reveal any pathogenic variants. Intriguingly, APC gene mutation was detected from NGS of the tumor tissue, suggesting a possible relation to the development of HAE. After tumor excision, serum ammonia levels were maintained in the normal range without treatment with ammonium scavengers. HAE in FLHCC was first reported in 2009 [3]. This condition is very rare, and approximately 10 cases are reported thus far; many of the patients present HAE at the time of diagnosis of FLHCC [3–6]. One of them recovered from HAE after liver transplantation [4]. Similar to our case, a 31-year-old man developed HAE on the third day of gemcitabine+oxaliplatin chemotherapy [5]. Several mechanisms were proposed on the development of HAE in patients with FLHCC. Some studies suggest that urea cycle dysfunction is caused by an imbalance in the activities and ratios of OTC and ornithine decarboxylase (ODC) [6]. Reduced activity of OTC or augmented activation of ODC results in ornithine consumption and urea cycle disturbance, thereby causing hyperammonemia [6,9]. A recent study suggested that the molecular pathogenesis of FLHCC may contribute to urea cycle dysfunction [6]. Heterozygous deletion of chromosome 19 results in chimeric DNAJB1-PRKACA kinase, which is frequently identified in FLHCC [10]. This chimeric DNAJB1-PRKACA kinase increases the expression of Aurora kinase A, leading to the overexpression of c-Myc that upregulates ODC function [6,10]. The precise mechanism of the development of HAE in our case is unclear. Initially, there were no specific findings in his metal or neurologic status, and his serum ammonia level was not tested. He developed HAE on the third day of chemotherapy, which suggests a causal relationship between chemotherapeutic agents and HAE. There are case reports about chemotherapy-associated hyperammonemia. For example, patients with acute lymphoblastic leukemia receiving corticosteroids [11] and L-asparaginase [12] show a transient increase in the serum ammonia level. Several case reports described HAE in patients receiving 5-FU, cytarabine, cyclophosphamide, oxaliplatin, vincristine, etoposide, anthracycline, busulfan, methotrexate, topotecan, gemcitabine, and tyrosine kinase inhibitors [5]. Our patient received steroids (as antiemetics) and 5-FU. Another culprit that might have contributed to HAE is APC tumor suppressor gene mutation identified by the NGS assay of the tumor. Unfortunately, our case was not tested for heterozygous deletion of chromosome 19 or chimeric DNAJB1-PRKACA kinase. APC mutation was identified by NGS assay of the tumor with an allele frequency of 15.53%. Several in vitro studies suggest that APC mediates ODC expression through a c-Myc– dependent mechanism, thereby affecting ODC transcription [13]. Tumor cells with truncated APC exhibit high levels of β-catenin, leading to increased expression of c-Myc [13]. We presume that both APC mutation and chemotherapy might have caused HAE resembling OTC deficiency. There are no management guidelines for cancer- or chemotherapy-associated hyperammonemia or HAE. Therefore, treatment of hyperammonemia or HAE is extrapolated from that for hepatic encephalopathy or OTC deficiency [14]. Clinical features of hyperammonemia can deteriorate from irritability, confusion to seizure, coma, and even death [14]. Ammonia scavenger therapy should be initiated when ammonia levels are greater than 100 μg/dL [5]. When the serum ammonia level is extremely high (500 μg/dL), dialysis/rapid hemofiltration should be started immediately [5]. In our case, the patient developed HAE during the first course of chemotherapy. Ammonia scavenger therapy normalized his ammonia level and was maintained until the second course of chemotherapy and surgery. After surgery, his ammonia level remained normal without ammonia scavenger therapy, suggesting that his HAE was a paraneoplastic phenomenon of FLHCC. While HCC is prevalent in Asia, the incidence of FLHCC is similar across different ethnic groups [1]. FLHCC comprises less than 1% of all primary liver cancer cases in the United States [1]. Recent studies suggest that FLHCC has a distinctive molecular profile, with focal deletion leading to DNAJB1-PRKACA gene fusion [2]. There are limited studies on the treatment outcome of patients with FLHCC. Despite the large tumor size and advanced stage at presentation, FLHCC patients exhibit significantly better 5-year relative survival than those with conventional HCC [1]. It is unclear whether biologic difference or absence of pre existing liver disease in FLHCC attributes to better survival. Except for surgery, no consensus exists for the treatment of FLHCC. Chemotherapy regimens for unresectable cases include cytotoxic agents, bevacizumab, and tyrosine kinase inhibitors [5]. A phase II trial involving nine cases of FLHCC suggested a potential benefit of 5-FU and interferon [15]. Our patient received perioperative chemotherapy including 5-FU and interferon. Generally, surgical resection is not considered for case like ours, even after systemic chemotherapy. However, there are several reports favoring aggressive cytoreductive surgery prolongs the survival of HCC patients with peritoneal metastases [16,17]. Our case received surgery for the following reasons: (1) the patient was young without any underlying disease, (2) tumors, including liver mass, peritoneal and pelvic metastases appeared to be feasible for resection without compromising patient’s safety, (3) to alleviate clinical symptom (HAE, early satiety, nausea, abdominal discomfort and pain) caused by the multiple large tumors. In the absence of any evidence-based treatment options for aggressive FLHCC, disappearance of HAE after surgery showed that our decision was appropriate. However, the size of the peritoneal nodule increased 3 months after the surgery and combination chemotherapy. The chemotherapy regimen was changed, and the patient was on third-line chemotherapy consisting of cisplatin and gemcitabine, and the patient has been alive for 12 months since the diagnosis of FLHCC. In conclusion, a young boy with FLHCC presenting HAE, which mimicks OTC deficiency, was successfully treated with hemofiltration and ammonia scavenger therapy. Lack of significant findings in OTC gene analysis and the normal ammonia level after surgery imply that FLHCC directly caused urea cycle dysfunction. We assume that APC mutation might be partially related to the development of HAE in our case. Oncologists should be aware about the HAE, a rare but serious metabolic complication of FLHCC. Treatments extrapolated from OTC deficiency, such as continuous venovenous hemofiltration and ammonia scavengers, will be helpful and could partially applied to HAE related to any malignancies. Ethical Statement The present study was approved by the Institutional Review Board of National Cancer Center in Korea (NCC2020-0175), who waived the requirement for informed consent because of the retrospective nature of the study. Author Contributions Conceived and designed the analysis: Lee JA. Collected the data: Lee JS, Han N, Lee JA. Contributed data or analysis tools: Jin HY, Ko JM, Kim SH, Park BK, Park M, Park HJ. Performed the analysis: Lee JS, Lee JA. Wrote the paper: Lee JA, Kim SH, Lee JS. Conflicts of Interest Conflicts of interest relevant to this article was not reported. Fig. 1 Dynamic liver computed tomography at the time of diagnosis of fibrolamellar hepatocellular carcinoma (coronal view, portal phase). Fig. 2 Photographs of the fine needle biopsy and surgical resection specimen. (A) Histologic features of fibrolamellar hepatocellular carcinoma (FLHCC). Large, polygonal tumor cells with abundant oncocytic cytoplasm in background of dense collagen bundles (H&E, ×100). Cytokeratin 7 (B) and CD68 (C) protein expression were noted in FLHCC evaluated by immunohistochemistry (×100). (D) Representative image of surgical specimen. Bulging, large mass with well-circumscribed border was observed. Fibrous bands and central stellate scar are noted. Fig. 3 Change of the serum ammonia levels with ammonia scavengers and hemofiltration. HF, hemofiltration; IV, intravenously; PO, orally.	Recovered	ReactionOutcome	CC BY-NC	32898940	18,380,427	2021-01
What was the outcome of reaction 'Hyperammonaemic encephalopathy'?	Hyperammonemic Encephalopathy Mimicking Ornithine Transcarbamylase Deficiency in Fibrolamellar Hepatocellular Carcinoma: Successful Treatment with Continuous Venovenous Hemofiltration and Ammonia Scavengers. Fibrolamellar hepatocellular carcinoma (FLHCC) is a rare liver cancer affecting adolescents and young adults without any pre existing liver disease. Hyperammonemic encephalopathy (HAE) is a serious paraneoplastic syndrome, and several cases of HAE have been reported in patients with FLHCC. This condition is rare; hence, there are currently no management guidelines for cancer-related HAE. Herein, we report a case of an 18-year-old man with advanced FLHCC who developed HAE during the first course of chemotherapy consisting of cisplatin, doxorubicin, 5-fluorouracil, and interferon-α. He was successfully treated with continuous venovenous hemofiltration, sodium benzoate, sodium phenylbutyrate, and amino acid supplementation for HAE. After the second course of chemotherapy, he underwent surgery, and thereafter, his ammonia levels were normal without any ammonia scavenger therapy. Treatments for HAE described here will be helpful for this rare, but serious metabolic complication of FLHCC and could partially applied to HAE related to any malignancies. Introduction Fibrolamellar hepatocellular carcinoma (FLHCC) is different from conventional hepatocellular carcinoma (HCC) [1]. The incidence of FLHCC is very low, and it affects adolescents and young adults without any pre existing liver disease [1]. Recent studies suggest that FLHCC is an independent entity, showing distinctive molecular profile [2]. Several case reports described paraneoplastic syndrome of FLHCC with symptoms such as hyperammonemia [3–6], gynecomastia [7], and venous thrombosis [8]. Hyperammonemic encephalopathy (HAE) is the most serious paraneoplastic syndrome. However, owing to its rarity, no management guidelines exist for cancer-related HAE. Herein, we report a case of an 18-year-old male patient with FLHCC who developed HAE during the first course of chemotherapy. He was successfully treated with hemofiltration, sodium benzoate, and sodium phenylbutyrate. He underwent surgery and successive chemotherapy, and his ammonia levels were maintained in the normal range without ammonia scavenger therapy. Case Report An 18-year-old boy presented with a history of fatigue, vomiting, abdominal pain, and distension. Computed tomography (CT) revealed a huge mass (13.7×10.7 cm) occupying the left liver and two masses (8.7×7.3 cm, 3.9×2.9 cm) in the pelvic cavity. Multiple lymph nodes were enlarged in right anterior and posterior cardiophrenic angles (Fig. 1). An initial laboratory investigation showed normal bilirubin, slightly elevated aminotransferase levels (aspartate aminotransferase [AST], 85 U/L; alanine aminotransferase [ALT], 154 U/L) and α-fetoprotein (27.2 ng/mL). He was previously healthy with no signs of chronic liver disease and had negative results on serologic testing for hepatitis B (hepatitis B virus surface antigen, hepatitis B virus surface antibody) and hepatitis C (anti–hepatitis C virus). He underwent fine needle biopsy and was diagnosed with FLHCC (Fig. 2). Considering the extent of the tumor, the patient was not considered a candidate for surgical resection. Systemic chemotherapy was initiated with cisplatin (80 mg/m2 on day 1), doxorubicin (30 mg/m2 on days 1 and 2), 5-fluorouracil (5-FU; 400 mg/m2 on days 1–4), and interferon-α (5×108 U/m2 on days 1–4). At midnight on day 3 of chemotherapy, the patient became agitated and was walking and running around the ward, not responding to verbal stimuli. Laboratory testing revealed a serum ammonia level of 393 μg/dL, AST/ALT level of 201/126 U/L, and total bilirubin level of 0.3 mg/dL. Head CT did not reveal any significant findings. He was diagnosed as HAE, and chemotherapy (4th dose of 5-FU and interferon-α) was stopped. Treatment with rifaximin and lactulose was initiated. However, his serum ammonia level rapidly increased to 500 μg/dL, and his mental status deteriorated to the semicoma state. The patient was transferred to the intensive care unit (ICU) and was on mechanical ventilator support under sedation using midazolam, remifentanil, and vecuronium. The metabolic and genetics department was consulted, and treatment for hyperammonemia was started as follows: (1) continuous venovenous hemofiltration, (2) intravenous infusion of sodium benzoate at a loading dose of 8.8 g (170 mg/kg), followed by continuous infusion (8.8 g/day) and sodium phenylbutyrate (5 g four times a day, via Levin tube), (3) 20% dextrose for caloric intake (6 mg/kg/min), and (4) administration of lactulose and rifaximin via Levin tube. His ammonia level decreased to 164 μg/dL but rebounded to 442 μg/dL on the third day of ICU care. Sodium benzoate (8.8 g) was loaded again, and his ammonia level decreased to 135 μg/dL. On the sixth day of the above-mentioned treatment, continuous venovenous hemofiltration was discontinued. On the eighth day, the patient was extubated, and sodium benzoate/sodium phenylbutyrate administration was changed to an intermittent schedule, with sodium benzoate 1.8 g administered as intravenously every 8 hours, sodium phenylbutyrate 3 g four times a day, and arginine 2.5 g twice a day. He was started on a low-protein diet (1 g/kg/day) through a Levin tube. Two days later (10th day of ICU care), he became disoriented and could not properly respond to verbal stimuli, with an ammonia level of 173 μg/dL. The low-protein diet was discontinued, and a continuous infusion of sodium benzoate (5.5 g/day, after a loading dose of 5.5 g) was started again, as well as citrulline (5 g three times a day). There were no focal neurologic signs, and brain magnetic resonance imaging (MRI) did not reveal any abnormality. As the serum ammonia level started decreasing (59 μg/dL), his conscious level improved. On the 12th day, he started Levin tube feeding and oral medications (sodium phenylbutyrate 6 g/day, L-carnitine 2,550 mg/day); citrulline was discontinued. On the 14th day of ICU care, sodium benzoate infusion was changed to an intermittent schedule (1.8 g every 8 hours). He resumed the low-protein diet (0.5 g/kg/day), and his ammonia level was maintained in the range of 90–100 μg/dL. He was transferred to a general ward on the 16th day of ICU care, and sodium benzoate was changed to an oral form (3 g three times a day). With sodium benzoate, sodium phenylbutyrate (3 g three times a day), arginine (2.5 g twice a day), and L-carnitine (660 mg once daily), his ammonia level further decreased to 50–60 μg/dL (Fig. 3). On the ninth day at the general ward, laboratory analyses were performed to identify the underlying mechanism of his HAE. The patient’s serum amino acid analysis revealed the following findings: decreased citrulline and ornithine, normal alanine and glutamine. His urine orotic acid level was elevated, and serum acylcarnitine was slightly elevated. These results suggested impaired activity of ornithine transcarbamylase (OTC). However, polymerase chain reaction (PCR) and direct sequencing of the OTC gene did not reveal any pathogenic variant, deletion, or duplication. On the 20th day at the general ward, the patient underwent a second course of chemotherapy involving cisplatin+doxorubicin+5-fluorouracil+interferon-α. One month later, he underwent extended left hemihepatectomy en bloc with the caudate lobe, excision of pelvic mass, and peritoneal seeding. Extensive lymph node dissection was also performed at the hepatoduodenal, cardiophrenic, para-aortic, and pelvic lymph nodes. Immunohistochemical staining confirmed a profile consistent with that of FLHCC, that is, positive for cytokeratin 7, glypican 3, and CD68. We did not test for the DNAJB1-PRKACA fusion. Next-generation sequencing (NGS) was performed to identify actionable therapeutic targets but only revealed APC mutation (c.4666delA, p.T1556fs), with an allele frequency of 15.53%. His postoperative period was uneventful and the ammonia level further decreased (30–40 μg/dL). One month after the surgery, treatment for hyperammonemia was discontinued. He received two additional courses of chemotherapy involving cisplatin+doxorubicin+5-FU+interferon-α. However, CT and MRI obtained 3 months after the surgery revealed enlarged left external iliac lymph nodes and multiple enhancing nodules at the perihepatic, perigastric, mesentery, omentum, and pelvic cavity. The chemotherapy regimen was changed to vincristine (1.5 mg/m2 on days 1, 8)+irinotecan (50 mg/m2 on days 1–5) and then to gemcitabine (1,000 mg/m2 on day 1)+cisplatin (20 mg/m2 on days 1–5). CT performed after three courses of gemcitabine+cisplatin showed a decrease in the size of the peritoneal nodules and iliac lymph node. Furthermore, the patient experienced severe, recurrent abdominal pain with vomiting, and CT images suggested obstructive ileus. Exploratory laparotomy was performed, and multiple adhesive bands were dissected off the small intestine and excised. Additionally, two metastatic nodules were resected. At the time of this report writing, the patient had just completed the sixth course of gemcitabine-cisplatin, and his disease was stable. He is on normal regular diet and his ammonia level remains normal (30–40 μg/dL). Discussion We report an 18-year-old male patient with advanced FLHCC who developed HAE during the first course of chemotherapy comprising o cisplatin, doxorubicin, 5-FU, and interferon-α. His HAE was successfully treated with continuous venovenous hemofiltration, ammonium scavengers, and amino acid supplementation. Serum amino acid and urine organic acid analyses suggested urea cycle dysfunction. However, PCR and direct sequencing of the OTC gene did not reveal any pathogenic variants. Intriguingly, APC gene mutation was detected from NGS of the tumor tissue, suggesting a possible relation to the development of HAE. After tumor excision, serum ammonia levels were maintained in the normal range without treatment with ammonium scavengers. HAE in FLHCC was first reported in 2009 [3]. This condition is very rare, and approximately 10 cases are reported thus far; many of the patients present HAE at the time of diagnosis of FLHCC [3–6]. One of them recovered from HAE after liver transplantation [4]. Similar to our case, a 31-year-old man developed HAE on the third day of gemcitabine+oxaliplatin chemotherapy [5]. Several mechanisms were proposed on the development of HAE in patients with FLHCC. Some studies suggest that urea cycle dysfunction is caused by an imbalance in the activities and ratios of OTC and ornithine decarboxylase (ODC) [6]. Reduced activity of OTC or augmented activation of ODC results in ornithine consumption and urea cycle disturbance, thereby causing hyperammonemia [6,9]. A recent study suggested that the molecular pathogenesis of FLHCC may contribute to urea cycle dysfunction [6]. Heterozygous deletion of chromosome 19 results in chimeric DNAJB1-PRKACA kinase, which is frequently identified in FLHCC [10]. This chimeric DNAJB1-PRKACA kinase increases the expression of Aurora kinase A, leading to the overexpression of c-Myc that upregulates ODC function [6,10]. The precise mechanism of the development of HAE in our case is unclear. Initially, there were no specific findings in his metal or neurologic status, and his serum ammonia level was not tested. He developed HAE on the third day of chemotherapy, which suggests a causal relationship between chemotherapeutic agents and HAE. There are case reports about chemotherapy-associated hyperammonemia. For example, patients with acute lymphoblastic leukemia receiving corticosteroids [11] and L-asparaginase [12] show a transient increase in the serum ammonia level. Several case reports described HAE in patients receiving 5-FU, cytarabine, cyclophosphamide, oxaliplatin, vincristine, etoposide, anthracycline, busulfan, methotrexate, topotecan, gemcitabine, and tyrosine kinase inhibitors [5]. Our patient received steroids (as antiemetics) and 5-FU. Another culprit that might have contributed to HAE is APC tumor suppressor gene mutation identified by the NGS assay of the tumor. Unfortunately, our case was not tested for heterozygous deletion of chromosome 19 or chimeric DNAJB1-PRKACA kinase. APC mutation was identified by NGS assay of the tumor with an allele frequency of 15.53%. Several in vitro studies suggest that APC mediates ODC expression through a c-Myc– dependent mechanism, thereby affecting ODC transcription [13]. Tumor cells with truncated APC exhibit high levels of β-catenin, leading to increased expression of c-Myc [13]. We presume that both APC mutation and chemotherapy might have caused HAE resembling OTC deficiency. There are no management guidelines for cancer- or chemotherapy-associated hyperammonemia or HAE. Therefore, treatment of hyperammonemia or HAE is extrapolated from that for hepatic encephalopathy or OTC deficiency [14]. Clinical features of hyperammonemia can deteriorate from irritability, confusion to seizure, coma, and even death [14]. Ammonia scavenger therapy should be initiated when ammonia levels are greater than 100 μg/dL [5]. When the serum ammonia level is extremely high (500 μg/dL), dialysis/rapid hemofiltration should be started immediately [5]. In our case, the patient developed HAE during the first course of chemotherapy. Ammonia scavenger therapy normalized his ammonia level and was maintained until the second course of chemotherapy and surgery. After surgery, his ammonia level remained normal without ammonia scavenger therapy, suggesting that his HAE was a paraneoplastic phenomenon of FLHCC. While HCC is prevalent in Asia, the incidence of FLHCC is similar across different ethnic groups [1]. FLHCC comprises less than 1% of all primary liver cancer cases in the United States [1]. Recent studies suggest that FLHCC has a distinctive molecular profile, with focal deletion leading to DNAJB1-PRKACA gene fusion [2]. There are limited studies on the treatment outcome of patients with FLHCC. Despite the large tumor size and advanced stage at presentation, FLHCC patients exhibit significantly better 5-year relative survival than those with conventional HCC [1]. It is unclear whether biologic difference or absence of pre existing liver disease in FLHCC attributes to better survival. Except for surgery, no consensus exists for the treatment of FLHCC. Chemotherapy regimens for unresectable cases include cytotoxic agents, bevacizumab, and tyrosine kinase inhibitors [5]. A phase II trial involving nine cases of FLHCC suggested a potential benefit of 5-FU and interferon [15]. Our patient received perioperative chemotherapy including 5-FU and interferon. Generally, surgical resection is not considered for case like ours, even after systemic chemotherapy. However, there are several reports favoring aggressive cytoreductive surgery prolongs the survival of HCC patients with peritoneal metastases [16,17]. Our case received surgery for the following reasons: (1) the patient was young without any underlying disease, (2) tumors, including liver mass, peritoneal and pelvic metastases appeared to be feasible for resection without compromising patient’s safety, (3) to alleviate clinical symptom (HAE, early satiety, nausea, abdominal discomfort and pain) caused by the multiple large tumors. In the absence of any evidence-based treatment options for aggressive FLHCC, disappearance of HAE after surgery showed that our decision was appropriate. However, the size of the peritoneal nodule increased 3 months after the surgery and combination chemotherapy. The chemotherapy regimen was changed, and the patient was on third-line chemotherapy consisting of cisplatin and gemcitabine, and the patient has been alive for 12 months since the diagnosis of FLHCC. In conclusion, a young boy with FLHCC presenting HAE, which mimicks OTC deficiency, was successfully treated with hemofiltration and ammonia scavenger therapy. Lack of significant findings in OTC gene analysis and the normal ammonia level after surgery imply that FLHCC directly caused urea cycle dysfunction. We assume that APC mutation might be partially related to the development of HAE in our case. Oncologists should be aware about the HAE, a rare but serious metabolic complication of FLHCC. Treatments extrapolated from OTC deficiency, such as continuous venovenous hemofiltration and ammonia scavengers, will be helpful and could partially applied to HAE related to any malignancies. Ethical Statement The present study was approved by the Institutional Review Board of National Cancer Center in Korea (NCC2020-0175), who waived the requirement for informed consent because of the retrospective nature of the study. Author Contributions Conceived and designed the analysis: Lee JA. Collected the data: Lee JS, Han N, Lee JA. Contributed data or analysis tools: Jin HY, Ko JM, Kim SH, Park BK, Park M, Park HJ. Performed the analysis: Lee JS, Lee JA. Wrote the paper: Lee JA, Kim SH, Lee JS. Conflicts of Interest Conflicts of interest relevant to this article was not reported. Fig. 1 Dynamic liver computed tomography at the time of diagnosis of fibrolamellar hepatocellular carcinoma (coronal view, portal phase). Fig. 2 Photographs of the fine needle biopsy and surgical resection specimen. (A) Histologic features of fibrolamellar hepatocellular carcinoma (FLHCC). Large, polygonal tumor cells with abundant oncocytic cytoplasm in background of dense collagen bundles (H&E, ×100). Cytokeratin 7 (B) and CD68 (C) protein expression were noted in FLHCC evaluated by immunohistochemistry (×100). (D) Representative image of surgical specimen. Bulging, large mass with well-circumscribed border was observed. Fibrous bands and central stellate scar are noted. Fig. 3 Change of the serum ammonia levels with ammonia scavengers and hemofiltration. HF, hemofiltration; IV, intravenously; PO, orally.	Recovered	ReactionOutcome	CC BY-NC	32898940	18,380,427	2021-01

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