Background Since its appearance in late 2019, infections caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have created unprecedented challenges for health systems worldwide. Multiple therapeutic options have been explored including corticosteroids (CS); preliminary results of CS in coronavirus disease 2019 (COVID-19) are encouraging, however, the role of CS is still controversial. Research Question What is the impact of CS in mortality, ICU admission, mechanical ventilation and viral shedding in COVID-19 cases? Study Design and Methods We conducted a systematic review of literature on CS and COVID-19 in major databases (PubMed, MEDLINE, and EMBASE) of published literature until July 22, 2020, that report outcomes of interest in COVID-19 patients receiving CS with a comparative group. Results A total of 73 studies with 21,350 COVID-19 cases were identified. CS use was widely reported in mechanically ventilated (35.3%), ICU (51.3%) and severe COVID-19 cases (40%). CS showed mortality benefit in severelly ill COVID-19 cases (OR 0.65, 95%CI 0.51-0.83, P=0.0006), however, no beneficial or harmful effects were noted amongst high- or low-dose CS regimens. Emerging evidence shows that low-dose CS do not have a significant impact in the duration of SARS-CoV-2 viral shedding. The analysis was limited by highly heterogeneous literature for high- and low-dose CS regimens. Interpretation Our results show evidence of mortality benefit in severely-ill COVID-19 treated with CS. CS are widely used in COVID-19 cases worldwide and a rapidly developing global pandemic warrants further high-quality clinical trials to define the most beneficial timing and dosing for CS.

Background Nocardial brain abscesses are rare, and published literature describing brain abscesses due to Nocardia species is limited to individual case reports or small series. We report one of the largest contemporary retrospective studies describing risk factors, diagnostic evaluation, management, and outcomes of nocardial brain abscess. Methods Retrospective review of all adults with brain abscess due to culture-confirmed Nocardia species at our institution between January 1, 2009, and June 30, 2020. Results Overall, 24 patients had nocardial brain abscesses during the study period. The median age at presentation was 64 years, and 62.5% were immunocompromised. Pulmonary and cutaneous infections were the most common primary sites of nocardial infection. All 24 patients had magnetic resonance imaging performed, and the frontal lobe was the most commonly involved. The most common organism isolated was Nocardia farcinica, followed by Nocardia wallacei and Nocardia cyriacigeorgica. Thirteen patients were managed with antimicrobial therapy alone, while 11 had both medical and surgical management. In all patients, dual therapy was recommended for the initial 6 weeks of treatment, and 22 patients received at least 1 oral agent as part of their final antibiotic regimen, predominantly trimethoprim-sulfamethoxazole and linezolid. Fourteen patients achieved complete clinical and radiographic resolution of infection. Conclusions Nocardia is an important cause of brain abscess in the immunocompromised host. Early diagnostic and therapeutic aspiration may help health care providers confirm the diagnosis, choose an appropriate antimicrobial regimen, and achieve source control.

Highlights Molecular detection of SARS-CoV-2 is critical in the diagnosis of COVID-19. The persistence of SARS-CoV-2 RNA shedding in the context of clinical features and comorbidities is understudied. The cumulative cessation of viral shedding rate at 3 weeks from symptom-onset is 44%. Repeating a SARS-CoV-2 PCR test within 21 days of a laboratory-confirmed COVID-19 diagnosis is considered unnecessary.

Current guidelines recommend deferring liver transplantation (LT) in patients with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection until clinical improvement occurs and two PCR tests collected at least 24 hours apart are negative. We report a case of an 18‐year‐old, previously healthy African‐American woman diagnosed with COVID‐19, who presents with acute liver failure (ALF) requiring urgent LT in the context of SARS‐CoV‐2 polymerase chain reaction (PCR) positivity. The patient was thought to have acute Wilsonian crisis on the basis of hemolytic anemia, alkaline phosphatase:bilirubin ratio <4, AST:ALT ratio >2.2, elevated serum copper, and low uric acid, although an unusual presentation of COVID‐19 causing ALF could not be excluded. After meeting criteria for status 1a listing, the patient underwent successful LT, despite ongoing SARS‐CoV‐2 PCR positivity. Remdesivir was given immediately posttransplant, and mycophenolate mofetil was withheld initially and the SARS‐CoV‐2 PCR test eventually became negative. Three months following transplantation, the patient has made a near‐complete recovery. This case highlights that COVID‐19 with SARS‐CoV‐2 PCR positivity may not be an absolute contraindication for transplantation in ALF. Criteria for patient selection and timing of LT amid the COVID‐19 pandemic need to be validated in future studies.

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