Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.
1. A third dose of COVID-19 vaccine increased antibody levels in organ transplant recipients with a suboptimal response following standard 2-dose vaccination
Study is the first to report on response to a third vaccine dose
Abstract: https://www.acpjournals.org/doi/10.7326/L21-0282
URL goes live when the embargo lifts
A case series published in Annals of Internal Medicine found that a third dose of vaccine increased antibody levels in organ transplant recipients who had suboptimal response to standard vaccination. These findings suggest that clinical trials are warranted to determine whether booster doses should be incorporated into clinical practice for transplant patients, just as they have been for hepatitis B and influenza vaccinations. This is the first study to report on response to a third vaccine dose.
The antibody response after 2 doses of an mRNA vaccine against the SARS-CoV-2 virus is excellent in the general population, yet the antibody responses in transplant recipients may be markedly attenuated. In addition, reports of COVID-19 breakthrough infections in vaccinated transplant recipients have prompted interest in administering additional doses of vaccine.
Researchers from Johns Hopkins University School of Medicine studied 30 organ transplant recipients who received a third dose of COVID-19 vaccine to describe antibody responses and vaccine reactions after the booster. They found that a third of the patients who had negative antibody levels and all patients who had low levels of antibody before the booster increased their antibody levels after the third dose of vaccine. Self-reported reactions to the booster were relatively minor, including injection site reactions, fever, chills, headache, myalgia, and diarrhea. The authors could not say for sure whether one case of mild rejection was related to the vaccine, but conclude that the benefits of vaccination likely outweigh the cons. Also, this study was examined only antibody levels and future studies are needed to show if those antibody levels were associated with lower infection rates in those who received a third vaccine dose.
Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Dorry Segev, MD, PhD, please contact Michael Newman at mnewma25@jhmi.edu.
2. History of systemic capillary leak syndrome may put patients at risk for severe adverse reaction to COVID-19 vaccination
Abstract: https://www.acpjournals.org/doi/10.7326/L21-0250
URL goes live when the embargo lifts
Experts warn that severe systemic capillary leak syndrome-like (SCLS) events are a rare but serious potential side effect of COVID-19 vaccination for some patients with a history suggestive of SCLS. They recommend that patients with a diagnosis or a suspected diagnosis of SCLS should receive intravenous immunoglobulin (IVIG) prophylaxis before vaccination. Findings from 3 case reports are published in Annals of Internal Medicine.
Flares of SCLS release plasma into peripheral tissues, which typically leads to hypotensive shock and multiple organ dysfunction. Between episodes, patients are typically asymptomatic and the diagnosis of SCLS attacks is based on characteristic clinical findings that include hypotension, hemoconcentration, and hypoalbuminemia. Prophylaxis with IVIG can prevent flares and improve survival.
Researchers from the National Institute of Allergy and Infectious Diseases (NAID) describe 3 cases of a patient with SCLS or a history suggestive of SCLS who developed a life-threatening flare 1 to 2 days after COVID-19 vaccination. The events were classified as non-dose-related, unexpected, and serious adverse events according to the World Health Organization. While the researchers could not rule out other causes of the patients' flares, they were unable to identify any other trigger, suggesting that SCLS was the culprit. As such, the researchers warn that SCLS-like events could occur in some patients after vaccination and clinicians should be aware of the risk factors so that they can advise patients and take proper precautions prior to vaccination.
Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Kirk Druey, MD, please contact Jennifer Routh at Niaidnews@niaid.nih.gov.
3. Metagenomic sequencing used to diagnose rare, lethal bacterial infection in patient with nonspecific symptoms
Abstract: https://www.acpjournals.org/doi/10.7326/L20-1470
URL goes live when the embargo lifts
Metagenomic sequencing successfully detected T whipplei bacterium, a lethal pathogen that causes Whipple disease, in a patient who presented with ocular symptoms not typical to the condition. This is important because Whipple disease is often difficult to diagnose and lack of prompt treatment can result in serious issues, such as rapidly progressive dementia and death. The findings are published in Annals of Internal Medicine.
Whipple disease, a rare but serious bacterial infection often causes gastrointestinal, lymphatic, and neurologic infection and inflammation. It is so uncommonly seen in ophthalmology that it is rarely on the differential diagnosis when a patient shows ocular symptoms. Furthermore, directed molecular diagnostics for T whipplei do not exist for ocular tissues outside of research laboratories, making timely diagnosis even more challenging.
Researchers from the Proctor Foundation at the University of California, San Francisco describe the case of a 45-year-old man with gradual vision loss in both eyes and subsequent neurological deficits. Imaging revealed a localized mass in his brain which prompted concerns for malignancy, but an exhaustive work-up using conventional diagnostics did not reveal an infectious etiology. The researchers report that metagenomic sequencing was conducted on a tiny volume of ocular fluid just as the patient was exhibiting progressively devastating neurologic dysfunction. The positive result directed appropriate antimicrobial therapy just in time to prevent death.
According to the authors, these findings suggest that unbiased molecular testing with metagenomic sequencing can be especially helpful in situations where a patient presents with nebulous ocular symptoms and time is of the essence. Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Thuy Doan, MD, PhD, please contact her directly at Thuy.Doan@ucsf.edu.
Also new in this issue:
"We do not want him because he is a Jew": The Montreal Interns' Strike of 1934
Halperin
History of Medicine
Abstract: https://www.acpjournals.org/doi/10.7326/M20-7121
Editorial: https://www.acpjournals.org/doi/10.7326/M21-0648
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Journal
Annals of Internal Medicine