Letter to the Editor The successful management of an elderly Covid-19 infected patient by plasmapheresis Dear Editor, Coronavirus disease 2019 (COVID-19) is a pneumonia caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in Wuhan, China since December 2019. The epidemic spread rapidly worldwide, became a global threat and was characterized as a pandemic on March 11, 2020 by World Health Organization (WHO) [1]. It is not just a viral pneumonia, it can also cause a multisystemic disorder called COVID-19 immune syndrome [2]. In severe COVID-19 patients it was reported that the pro-inflammatory cytokins, mainly IL-6, IL-10, TNF-α were significantly increased around 7-14 days after onset, named as cytokine storm, which is also associated with the aggravation of disease and higher mortality [3,4]. Furthermore, most of these patients have already been in an induced-hypercoagulable state and predisposed to thrombosis. Currently, there isn't any specific effective and approved antiviral treatment for COVID-19 [5]. There aren't sufficient randomized controlled trials and so strong recommendations for the management of COVID-19 even from the international societies [2]. For better results and lower mortality rates, clinicians must both control the viral replication and also optimize the immun response. Plasmapheresis can take place successfully in the management of these patients with the use of anticoagulants and removal of both the inflammatory molecules and high molecular weight viscous components [6]. We want to emphasize the role of plasmapheresis by a critically ill Covid-19 patient whose clinical status worsen despite antiviral and tocilizumab treatments and who was successfully managed via performing plasmapheresis. A 65 year old female patient complaining of cough, myalgia and fatigue was admitted to our clinic who had a history of contact with a confirmed Covid-19 case. She had 3 comorbities: asthma, hypertension and type 2 Diabetes Mellitus. Her SARS-CoV-2 PCR test resulted negative, but her chest computed thomography(CT) revealed two small ground glass opacities in both lungs, which indicated COVID-19 pneumonia. According to our national Covid-19 treatment guidelines provided by the Ministry of Health, she was given hydroxychloroquine, azitromycine and oseltamivir. During hospital follow up, her maximum body temperature was 37.8 • C; all other vital signs were normal. Laboratory findings are summarized in Table 1. She completed the treatment schedule and was discharged from hospital after 5 days. On 10th day of the symptom onset she was readmitted to hospital with fever, cough, sputum and shortness of breath. Her fever was 38.5 • C, hearth rate was 118beats/min, respiratory rate was 26/min, blood pressure was 156/84 mmHg and oxygen saturation was 88 % at room air with intermittent prone positioning. Her thorax CT revealed bilateral multiple ground glass infiltrations (Fig. 1). Favipravir, enoxaparine prophylaxis, ceftriaxone and oxygen supplementation of 3 L/min were initiated. Laborat...

Purpose Klebsiella pneumoniae is the most common endogen agent for nosocomial infections. In this study, mortality markers were investigated in patients with nosocomial K. pneumoniae blood stream infection (NKp BSI).MethodsThe characteristics of patients >16 years who had NKp BSI diagnosis by daily active surveillance between January 2012 and January 2016 were retrospectively evaluated. Patients who died until 28th day of the clinical follow up and those who survived until this time were statistically compared in terms of various risk factors.ResultsOne hundred ninety patients were included into the study. Mortality rate was 47.9%, carbapenem resistance was 43.2%. Statistical analysis have shown that in presence of post-NKp BSI sepsis, septic shock, following in intensive care unit (ICU), meropenem resistance, kidney failure, NKp BSI secondary to pneumonia, use of invasive instruments such as central venous catheter (CVC), urinary catheter (UC) and mechanical ventilator (MV), colostomy, transfusion and hemodialysis mortality was significantly higher. In patients admitted into the hospital for neurological disorders, pancreaticobiliary tract (PBT) diseases and patients who have undergone endoscopic retrograde cholangiopancreatography (ERCP) and patients in whom NKp BSI secondary to PBT infection mortality rate was lower.ConclusionsSepsis, septic shock, clinical conditions requiring ICU treatment and meropenem resistance increase mortality rates in NKp BSI significantly. Mortality was higher also in patients with NKp BSI secondary to pneumonia, in kidney failure and when invasive instruments were used. On the other hand, in patients who were admitted to the hospital for neurological disorders and PBT diseases mortality rate was lower.

The recent pandemic of COVID-19 has caused a tremendous alarm around the world. Details of the infection process in the host have significant bearings on both recovery from the disease and on the correlates of the protection from the future exposures. One of these factors is the presence and titers of neutralizing Abs (NAbs) in infected people. In the current study, we set out to investigate NAbs in the recovered subjects discharged from the hospital in full health. Serum samples from a total of 49 documented consecutive COVID-19 subjects were included in the study. All the subjects were adults, and serum samples collected during the discharge were tested in viral neutralization, enzyme immunoassay (EIA), and Western immunoblot tests against viral Ags. Even though a majority of the recovered subjects had raised significant NAb titers, there is a substantial number of recovered patients (10 out of 49) with no or low titers of NAbs against the virus. In these cohorts as well as in patients with high NAb titers, viral Ag binding Abs were detectable in EIA tests. Both NAb titers and EIA detectable Abs are increased in patients experiencing a severe form of the disease, and in older patients the Ab titers were heightened. The main conclusion is that the recovery from SARS-CoV-2 infection is not solely dependent on high NAb titers in affected subjects, and this recovery process is probably produced by a complex interplay between many factors, including immune response, age of the subjects, and viral pathology.

Background: Serum cytokine levels over the course of HIV infection usually increase with immunosuppression and decrease after antiretroviral treatment (ART). Objectives: Compare cytokine levels between HIV-infected patients (HIP) and controls and investigate the relationship between CD4+T cell count, HIV-RNA levels, and cytokine levels. Methods: The study subjects comprised ART-naive HIP (n=30) with no comorbidities and age-and sex-matched healthy controls. We measured levels of IL-6, IL-1β, TNF-α, and IFN-γ in serum samples of HIP at the beginning and at month 6 of ART and in controls. Results: The mean age of the study subjects was 38.7 ±10.3 years, with men making up 86.7% of the study subjects (n=26). IL-6, IL-1β, and TNF-α levels were significantly higher in both ART-naive (p<0.001, p=0.002, p=0.001) and ARTexperienced HIP (p<0.001) than controls. The IFN-γ level was lower in both ART-naive and ART-experienced HIP compared to controls (p=0.082 and p=0.002). There was a positive correlation between the CD4+T cell count and serum concentration of IFN-γ(r=0.320, p<0.05). While the serum IFN-γ concentration showed a negative correlation with the HIV-RNA level(r=-0.412, p<0.001), the serum IL-1β, IL-6, and TNF-α concentrations showed a positive correlation with the HIVRNA level (r=0.349, p<0.001; r:0.54, p<0.001; r:0.438, p<0.00). Conclusions: Althugh serum concentrations of IL-6, IL-1β and TNF-a showed significant decrease after ART, they were still significantly higher than the controls. IFN-γ responded differently to ART compared to the other cytokines, indicating that it may play a distinct and important role in the pathogenesis of HIV infection.

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