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We describe an unusual case of posttransplant tuberculosis reactivation in a man who underwent allogeneic hematopoietic cell transplant. Concomitant with disseminated adenovirus infection, reactivation of tuberculosis manifested as disseminated, nonfollicular pustules on day +49. Skin biopsy was obtained on day +50. Initial histopathologic evaluation did not suggest mycobacterial infection, but tissue stain showed acid-fast organisms, which were subsequently identified as Mycobacterium tuberculosis. Shortly after the cutaneous presentation of tuberculosis, the patient died on day +52. Our case is among a paucity of reports describing tuberculosis reactivation in hematopoietic cell transplant patients in the early posttransplant period. It highlights the difficulty of diagnosing contemporaneous systemic infections, and it presents a rare and atypical cutaneous manifestation of tuberculosis in a hematopoietic cell transplant patient. Our case and review of the literature emphasize the need for further research to elucidate risk factors associated with early posttransplant reactivation of tuberculosis, and the importance of remaining vigilant for active tuberculosis in hematopoietic cell transplant patients with epidemiologic risk factors.

End-organ cytomegalovirus (CMV) disease can be life threatening to solid organ transplant recipients. Diagnosis is often complicated by variation in amount of CMV DNA in plasma and the need for an invasive procedure to obtain a biopsy of the suspected affected organ, which can delay recognition and treatment. Several inflammatory cytokines are elevated in CMV disease, and the purpose of this study was to determine if they could be used to distinguish solid organ transplant recipients with CMV DNAemia alone from those with possible end-organ CMV disease. We found that regardless of pre-transplant CMV serostatus, plasma interleukin (IL)-18, tumor necrosis factor-α (TNF-α), and amount of CMV DNA in plasma were increased in possible end-organ CMV disease, with elevated IL-18 associated with increased odds of possible end-organ CMV disease even after adjusting for amount of CMV DNA. These findings highlight IL-18 and TNF-α as potential non-invasive markers of possible end-organ CMV disease regardless of transplanted organ or serostatus in solid organ transplant recipients.

We present here an evidence-based review of the utility, timing, and indications for laboratory test use in the domains of inflammation, cardiology, hematology, nephrology and co-infection for clinicians managing the care of hospitalized COVID-19 patients. Levels of IL-6, CRP, absolute lymphocyte count, neutrophils and neutrophil-to-lymphocyte ratio obtained upon admission may help predict the severity of COVID-19. Elevated lactate dehydrogenase, ferritin, aspartate aminotransferase, and ᴅ-dimer are associated with severe illness and mortality. Elevated cardiac troponin at hospital admission can alert clinicians to patients at risk for cardiac complications. Elevated proBNP may help distinguish a cardiac complication from noncardiac etiologies. Evaluation for co-infection is typically unnecessary in nonsevere cases but is essential in severe COVID-19, intensive care unit patients, and immunocompromised patients.

Introduction : CMV infection is associated with direct and indirect morbidities in BMT recipients. Understanding cumulative morbidity associated with infections is difficult, as time-to-first event analyses do not represent recurrent events. We characterized infectious outcomes and non-relapse mortality (NRM) in a large cohort of haploidentical BMT recipients at Johns Hopkins Hospital (JHH) using novel analytic methods to detail recurrent events and estimate cumulative risks. Material and Methods : Demographics, transplant variables, CMV reactivation (DNAemia) and disease, and other outcomes (infections, GVHD and hospitalizations) were collected on sequential haploidentical BMT recipients at JHH (2004-2015). Infectious events were longitudinally depicted. Cox proportional hazards models were used to estimate effects of infections on 1-year survival, adjusted for age, disease related index (DRI), GVHD, time to engraftment, and transplant year. Survival and NRM differences were assessed by Kaplan Meier and competing risks functions, respectively. Results:683 people who received non-myeloablative haploidentical BMT using PTCy, mycophenolate and tacrolimus were included. CMV reactivation occurred in 268 (39%), with organ disease documented in 19 (2.8%). Recurrent reactivation was recorded in 83 (12% of cohort), predominating in seropositive recipients of negative donors (D-/R+). Neutropenia occurred in 24/123 (28%) of subjects with ganciclovir-treated 1st reactivation, increasing to 41% and 60% with 2nd and 3rd episodes. Patients who had CMV reactivation had higher mean numbers of bacteremias (0.48 vs. 0.36, p=0.006), clinical pneumonias (0.24 vs. 0.18, p= 0.03) invasive fungal infections (IFI, 0.23 vs. 0.15, p= 0.05), non-CMV viral infections (0.53 vs. 0.39, p=0.008), and hospitalizations (1.68 vs. 1.27, p=0.001). Patients with CMV reactivation had lower 1-year survival (68% vs. 76%, p=0.016), with higher NRM in competing risk analyses. Associations between CMV reactivation and other infections were appreciated in longitudinal analyses. In regression analysis, risks for death were associated with DRI (HR 4.3 - 2.5, p Conclusion: CMV reactivation and recurrence is common in seropositive haploidentical BMT recipients, especially with seronegative donors, but disease is rare. Longitudinal modeling of reactivation and treatment-associated neutropenia suggests that reactivation is implicated in secondary infections that increase risks for death. These findings may instruct better-targeted prophylaxis strategies. Disclosures Marr: MycoMed Technologies: Consultancy, Equity Ownership, Patents & Royalties.