Infectious Disease Alert Updates
By Carol A. Kemper, MD, FACP
Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases, Santa Clara Valley Medical Center
Recovering from Critical COVID
SOURCE: Heesakkers H, van der Hoeven JG, Corsten S, et al. Clinical outcomes among patients with 1-year survival following intensive care unit treatment for COVID-19. JAMA 2022;327:559-565.
Several studies have described the frequency of physical and neurological complaints in patients recovering from COVID-19 infection. Even a group of relatively young, healthier adults with COVID-19 (with a mean age of 42 years), who were followed in the outpatient setting, experienced a surprising frequency (39%) of residual complaints at seven to nine months following their acute infection.1 These included fatigue (20.7%), loss of taste and/or smell (16.8%), dyspnea (11.7%), headaches (10%), difficulty concentrating (5.9%), insomnia (5.7%), and memory loss (5.6%). Women were more likely than men to have persistent symptoms at seven to nine months following their infection (43.2% vs. 31.1%), and increasing age was associated with a greater frequency of residual symptoms.
This problem becomes magnified in those requiring hospitalization and intensive care unit (ICU) care. From February 2020 through June 2021, 24% of patients with COVID-19 infection hospitalized at our facility in California required critical care, and one-fourth of these died during their hospitalization. Survivors experienced many problems, including frequent rehospitalization.
These authors prospectively followed a cohort of patients admitted to one of 11 ICUs in the Netherlands from March 1, 2020, to July 1, 2020. Those who survived their hospitalization were followed for up to one year, at which point they completed a detailed survey of self-reported physical and neuropsychiatric symptoms. A total of 301 patients were included, 246 (81%) of whom completed the one-year survey (46 patients either did not provide sufficient baseline information or complete the follow-up, five declined to participate, three died, and two were lost to follow-up). The mean age was 61.2 years, the majority were male (71%), the median ICU stay was 18.5 days (range, 11 to 32), and the mean duration of hospitalization was 30 days (range, 20 to 46). A total of 132 patients required mechanical ventilation for a median of 14 days (range, eight to 22 days).
At one year following their ICU care, 182/245 (74.3%) participants reported one or more physical complaints, most commonly excessive fatigue in 56%. Anywhere from 21% to 39% of individuals experienced muscle weakness, joint stiffness, and myalgia, and 6.1% were considered frail. Further, cognitive and mental complaints were reported by 39% and 26.2% of respondents, respectively, including anxiety (17.9%), depression (18.3%), and symptoms of post-traumatic stress disorder (9.8%). Respiratory symptoms, such as dyspnea (20.8%) and persistent loss of taste/smell (6.9%), still were frequent one year later.
While these physical and neuropsychiatric problems were self-reported and, therefore, may not be substantiated by medical or laboratory findings, their frequency is significant, and clearly many of these individuals have residual impairment. It would have been interesting to see what portion had participated in physical therapy or rehabilitation programs during their recovery, and whether that care had made a difference in their outcomes. Despite the severity of their acute COVID illness, the number of apparent deaths occurring in this cohort during the one-year recovery period was remarkably small (1%).
REFERENCE
- Nehme M, Braillard O, Chappuis F, et al. Prevalence of symptoms more than seven months after diagnosis of symptomatic COVID-19 in an outpatient setting. Ann Intern 2021;174:1252-1260.
Oral and Anal Transmission of Syphilis
SOURCE: Nieuwenburg SA, Zondag HCA, Bruisten SM, et al. Detection of Treponema pallidum DNA during early syphilis stages in peripheral blood, oropharynx, ano-rectum and urine as a proxy for transmissibility. Clin Infect Dis 2022; Jan 25;ciac056. [Online ahead of print].
From 2015 to 2019, cases of syphilis in the United States increased 70%, with more than 129,800 cases of syphilis reported in 2019, including 1,870 cases of congenital syphilis. And then COVID-19 occurred, and public health funding for sexually transmitted disease (STD) clinics and contact tracing was diverted. Based on early reports, it is estimated that we are going to see a 100% increase in syphilis cases from 2020 to 2021; and some authors predict an explosion of STDs in the next five years — the result of a nightmarish storm of diminished public health funding and lots of people “sheltering” for COVID-19 but apparently not for sex.
What’s the problem? Most estimates of syphilis transmissibility suggest an R0 of ~1, which is far less than that for gonorrhea (R0 ~25). It is generally believed that only those individuals with primary or secondary syphilis with obvious sores, mucous membrane involvement, or rash may be contagious. So, why are we seeing so many cases? The answer may be similar to that for other infectious diseases: Transmission may occur in the absence of visible disease.
These authors examined the frequency of Treponema pallidum (TP) deoxyribonucleic acid (DNA) detected by real-time polymerase chain reaction (PCR) (targeting the polA gene) in blood, pharyngeal and anal specimens, and urine (as a proxy for urethra) as a marker of infectivity. Specimens were collected from a group of 293 men who have sex with men (MSM) with various stages of syphilis; 103 of these were human immunodeficiency virus (HIV)-positive and 90% of those were receiving antiretroviral therapy. The group was divided fairly evenly among those with primary syphilis with apparent oral or ano-genital disease (24%) with positive dark field microscopy; those with secondary syphilis with a rash, with or without lymphadenopathy, or with condyloma lata, and a rapid plasma reagin (RPR) ≥ 1:4 (25%); those with early latent syphilis, with either documented seroconversion, a four-fold rise in RPR, or an RPR ≥ 1:32 (29%); or those with latent syphilis and an RPR titer < 1:32 (5%). In addition, a number of MSM with previously treated syphilis (n = 23 [8%]) or without syphilis (n = 27 [9%]) served as controls. Specimens of blood and urine, and swabs of the pharynx and anus, were collected.
Detection of TP-DNA from patients with secondary syphilis was amazingly frequent: 85% of participants had one or more positive specimens, including positive pharyngeal swabs (64%), anal swabs (51%), urine (36%), and peripheral blood (21%). Fifty percent of those with primary syphilis had TP-DNA detected from one or more specimens, including positive urine (34%), anal (19%), and pharyngeal specimens (10%), but only rarely were peripheral blood specimens positive (3%). Patients with early latent syphilis had one or more positive specimens 34% of the time, including pharyngeal (24%), anal (13%), urine (7%), and blood specimens (6%). No DNA was detected in persons with late latent disease, those previously treated for syphilis, or those without syphilis. Fortunately, none of the individuals with late latent disease were positive — something we get asked about repeatedly.
Among those with primary syphilis without a visible penile ulcer, 8/28 (28%) had a positive urine specimen. Among those with secondary syphilis without a visible penile lesion, 22/68 (39%) had a positive urine specimen. Similarly, in those individuals with primary or secondary disease without an apparent oral lesion, 9% and 65%, respectively, had positive pharyngeal specimens.
Even in the absence of a visible lesion, TP-DNA was frequently detected, indicating frequent shedding of the organism from the oropharynx, anus, and urethra. Nearly two-thirds of pharyngeal specimens from patients with secondary syphilis were positive — suggesting ready transmission may occur even with simple oral contact. I remember a story of a Bay Area grandmother who gave pre-masticated food to a baby — unwittingly giving syphilis to the child. In other studies, TP-DNA has been found in semen. These data provide a stark picture of the infectivity of both primary and especially secondary syphilis, even in the absence of visible disease. Detection of syphilis in peripheral blood specimens was infrequent.
Recovering from Critical COVID; Oral and Anal Transmission of Syphilis
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